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With about 300 attendees and nearly thirty sessions, the 2003 National Social Norms Conference, held July 16-18 in Boston, MA, was both large and extremely varied. One of the real pleasures for the program selection committee was struggling to accommodate the large number of excellent proposals. It is a testament to how much the social norms approach has evolved in the last few years that so many people are doing so good work, and in so many areas. Unfortunately, given the limitations of space I can only discuss a fraction of the presentations in any detail. I therefore want to focus on the number of projects that reported positive outcome data, and close with a discussion of several innovative efforts.

Middle and High School Interventions: The Research Background

As we know, an increasing number of conference presentations, case studies, and published articles continue to show that the social norms approach can be an effective method of promoting health and reducing harm among college students, especially as it concerns heavy episodic alcohol consumption. Positive results have been documented at large schools and small, both public and private, and in all parts of the country. Inspired by the positive impact achieved in the higher education setting, a growing number of middle schools, high schools, and communities have begun to actively investigate the possibility of implementing their own social norms campaigns, most often focused on the prevention of adolescent alcohol and tobacco use. As is the case for all proposed norm interventions focused on substance use, one critical question is whether the target population possesses both a positive norm and exaggerated perceptions of peer use. This is a particularly important consideration as regards alcohol, where normative messages of moderate and responsible use—routinely disseminated in social norm campaigns on college campuses—are impermissible among middle and high school populations for whom abstinence is the only acceptable message.

One ongoing study presented at this year's conference continues to find clear norms of peer abstinence for tobacco and illicit drugs, as well as viable norms of nonuse of alcohol, among both middle and high school students in a range of schools across the nation. The work of Wes Perkins and David Craig (presented during the session "Using a Web-Survey Strategy to Expose Actual and Perceived Social Norms Among Middle and High School Students") has now grown to comprise a data base of over eight thousand students from thirty schools in states such as Massachusetts, New York, Colorado, Montana, and Washington. This important work documenting what they have termed "the imaginary life of peers" (Perkins and Craig, 2003) significantly extends the findings of other researchers who have also reported the overestimation of peer alcohol, tobacco, and illicit drug use among students of middle and high school age (Botvin et al., 2001; D'Amico et al., 2001; Sussman et al., 1988; Thombs, Wolcott, and Farkash, 1997; Bech and Treiman, 1996; Graham, Marks, and Hansen, 1991).

Interestingly, one of the presenters at this year's conference was among the very first researchers to report that adolescent onset of use can be significantly delayed by correcting overestimations of alcohol and cigarette use among peers. William Hansen's work on "norm setting," published more than twenty years ago (Hansen and Graham, 1991), pre-dated much if not all of the work that we now routinely think of as fundamental to the implementation of the social norms approach. In his conference presentation ("Lessons Learned about Norm Setting from Middle School Interventions") he reflected at length on the findings of his ongoing research project, the Adolescent Alcohol Prevention Trial, which is designed to test norm setting versus resistance skills training as an approach to alcohol use prevention. This research suggests that normative beliefs are highly correlated with three other variables among adolescent non-users and successful quitters: personal commitments to avoid drug use, strong beliefs about the social and personal consequences of drug use, and the belief that drug use is incongruent with one's desired lifestyle. In a sense, these findings suggest how correct our response has been to those critics who allege that the social norms approach simply promotes conformity. Hansen's analysis suggests that, quite to the contrary, the promotion of true norms actually empowers individuals to live and act in greater congruence with their personal beliefs and values.

Much of Hansen's current research is focused on infusing normative messages into curricula, blending them with other programmatic elements not obviously linked to norm setting, and attempting to measure the disparate impact of these variables on youth resilience. This is important work that, like his previous research, is sure to have important implications for those using social norms in college and community health as well.

High School Interventions: Three Case Studies

Building on some of the research described above, several presenters offered sessions relating their successful use of the social norms approach in reducing alcohol and cigarette use among high school students. These efforts represent important advances for the field of health promotion, since they confirm that the social norms approach can indeed be used effectively in a variety of normative contexts where substance use is concerned.

Two of these case studies were presented in tandem, since one is essentially a replication of the other. The DeKalb/Sycamore DCP SAFE high school project was the first to document positive impact in reducing alcohol and cigarette use among adolescents in a community-wide setting using a social norms media approach. It did so by correcting not only the misperceptions of students, but those of parents and teachers as well.

Based on data gathered during the marketing research stage of the project, various methods and media channels were employed to communicate accurate information about the student norms of nonuse to all three target populations. A number of basic messages were developed, market tested, and refined so as to be school specific. Newspaper ads and direct mailings on school letterhead were used to reach parents; institute days and inter-office mailings were used to communicate with teachers; and in-school posters, direct mail flyers and promotional postcards, as well as radio spots on one specific station were used to reach students.

After two years of campaign implementation, all of the data trends were in a positive direction:

• Parents, teachers, and students more accurately perceived the student norms of nonuse;
• Parents and teachers reported increasing use of true norm messages in their interactions with students;
• Students reported receiving more alcohol and tobacco-related information from parents, teachers, posters, flyers, and radio; and
• Students use of alcohol and tobacco declined significantly.

Specifically, the 30-day measure of alcohol use dropped from 43.7% at Time 1 (1999) to 30.4% at Time 2 (2001), a 13.3 percentage point decline that in effect represents a 30.4% reduction in prevalence. Similarly, the 30-day measure of cigarette use dropped from 25.6% at Time 1 to 16.8% at Time 2, an 8.8 percentage point drop that translates into a 34.4% reduction. These are astonishing results, especially given that prior to the implementation of the social norm campaign a number of traditional prevention programs, such as D.A.R.E., had been instituted at each of the high schools with no demonstrable positive impact.

Following the model established by the DCP SAFE project, the ETHS coalition embarked on a campaign to increase the accurate perception of student norms of nonuse by parents, school staff, and students. The primary objective of this intervention, stated as a specific, measurable and time-limited outcome, was:

• To increase the nonuse of alcohol and cigarettes among ETHS students by
  3-7% in year one and by 20% in year five (2006).

With approximately three thousand students and over three hundred teachers, staff, and administrators, Evanston Township High School is not only large but extremely diverse. Using a wide array of royalty-free, commercially purchased images of young people, project staff were able to create normative media reflective of the school's tremendous diversity and its inclusive ethos. Messages were specifically designed to support the concepts of power and choice—especially appealing notions to developing adolescents—and to promote the competence, care, and healthy behavior of the clear majority of students.

After the first year of implementation, most of the key data points had trended in the desired direction; after two years, the data trends were even more broadly positive, such that:

• School staff reported increasing use of true norm messages to students regarding alcohol and cigarettes
• School staff reported more accurate perceptions of the norms of nonuse by students
  Parents reported increasing use of true norm messages regarding alcohol to students
• Parents reported more accurate perceptions of the nonuse norms of students
• Student perceptions of peer use of alcohol and cigarettes consistently declined, and
• Student use of alcohol and cigarettes was reduced.

Specifically, the 30-day measure of alcohol use dropped from 46% at Time 1 baseline to 41% at Time 3 (2003), a 5 percentage point decline that represents an 11% reduction in prevalence. Similarly, student 30-day use of cigarettes went from 16% at baseline to 12% at Time 3, a 4 percentage point drop equaling a 25% reduction in prevalence.

Finally, in another session, the Naperville Social Norms Marketing Coalition presented information about its own successful intervention that is currently focused solely on the reduction of cigarette use. The Naperville Township system comprises four high schools with a combined enrollment of approximately 11,800 students. Baseline data from their Drug Perception and Use survey revealed the familiar finding of a misperceived norm of health regarding cigarette use. Specifically, while fully 75% of students reported that they never smoked, the students thought that only 9% of their peers never did so. Based on this data normative messages of non-use were developed and market tested. The Resulting "Reality is…" campaign featured a number of posters with slightly varying but thematically consistent messages.

After three years of implementing the social norm campaign, the data revealed the following statistically significant findings:

• Decrease in perceived peer use of cigarettes across as well as within grade levels.
• Decrease in cigarette use across grade levels.

With the three-year costs for printing posters and related items totaling $6500, this has been an extremely cost-effective method of achieving large-scale, positive results in four fairly large suburban high schools.

Together, the sessions devoted to these three projects provided a wealth of information to the many conference attendees seeking to broaden their understanding of how such interventions can be conducted effectively, and with fidelity to the model.

The Social Norms Model: Roadmaps for Positive Change

The theme of this year's conference—"Roadmaps for Positive Change"—was inspired in large part by the generous financial support provided by the Governor's Highway Safety Bureau of the Commonwealth of Massachusetts. Given that, it was especially appropriate that Robert Foss presented the findings from his 2 Out of 3 .00 BAC project at the University of North Carolina (UNC) at Chapel Hill, since this work was funded in part by that state's Governor's Highway Safety Program. The positive results of this study have garnered a great deal of press attention since the conference, and for good reason.

The innovative aspect of this work is that it is based, not on student self reports of drinking, but on breathalyzer readings gathered in the field as students returned home late in the evening or early morning. A preliminary study conducted in 1997 using this direct measurement of blood alcohol concentration (BAC) level found that fully two-thirds of UNC students returning home on traditional "party" nights registered .00 BACs, and this data generated the normative message that became the basis of the campaign:

• "Whether it's Thursday, Friday, or Saturday night, 2 out of 3 UNC students return home with a .00 blood alcohol concentration.

Initially targeted solely at freshmen, the campaign was subsequently expanded so as to address the entire student body.

Variations of this message were employed over the course of the campaign and delivered via a number of media channels, though posters were the principal mechanism. Evaluative data indicated a growing awareness of the campaign from 1999 to 2002, with increasing percentages of students understanding and believing the message. Breathalyzer samples gathered in the field in 1999 and 2002 showed a number of positive changes in student drinking, among the most notable (as detailed in the final project report: Foss et al., 2003):

• "Among respondents who had been drinking on the night of the interview, the proportion with a BAC above .05% decreased from 60% to 52%
• The percentage of respondents who could be classified as heavy drinkers on the night of the interview dropped from 14% to 10%
• Among those drinking on the night of the interview, the mean number of self-reported drinks consumed decreased from 5.1 to 4.3."

This is important work that provides further evidence of the effectiveness of the social norms approach. It also adds to the growing body of research revealing that the 5/4 measure inappropriately classifies large numbers of students (and others as well) as heavy episodic drinkers despite the fact that their BAC levels remain well within safe limits (Thombs, Olds, and Snyder, 2003; Perkins, DeJong, Linkenbach, 2001).

The Prevention Collaborative

A more traditional intervention with positive outcome data was described by David Hellstrom, who presented information about a group of seven colleges in the Twin Cities that formed a collaborative with the goal of achieving a quantifiable reduction in the number of students reporting impaired driving. This DWI prevention campaign—funded with a three-year grant from the Minnesota Department of Transportation—used the social norms approach to communicate the fact that the clear majority of students were making safe and healthy choices about drinking a driving. The Collaborative achieved a 13% reduction in student reported DWI over the course of the project.

Many of the methods employed to disseminate the very simple normative message—"Most students prevent DWI"—were very traditional: posters, table tents, stickers, etc. In the third year of the campaign, specific data about the reduced incidence of DWI were also incorporated into the media ("That's an 18% improvement. Way to go!"), as were specific tips for preventing DWI, such as walking home, calling a cab, and using a designated driver.

Interestingly, the outcome data also showed significant reductions in other measures as well, such as excessive drinking, underage drinking, and alcohol-related negative consequences. Such reductions occurred even though they were not stated objectives of the campaign and, more importantly, no messages were disseminated regarding these particular issues.

Most Valuable Players: Targeting A Sub-Population

A question that is frequently asked in the field concerns the possibility of conducting a social norms intervention that is targeted at a sub-population. One of the conference presentations provided an exemplary model of how such a project can be carried out in the context of an existing campus-wide campaign. Wes Perkins' and David Craig's "Most Valuable Players: Using Social Norms to Target Student-Athletes As a High-Risk Sub-Population" offered a comprehensive overview of a campaign whose express goal was to produce a new and more integrated athletic, academic, and social climate, where athletes and the general student body had a more realistic awareness of peer disapproval of alcohol abuse, a more responsible level of conversation about alcohol use norms, and a lower level of high-risk drinking among athletes.

Baseline data was gathered in November 2001 using a comprehensive and anonymous web-based survey of Hobart and William Smith (HWS) Colleges' student athlete population. A total of 414 athletes participated in the survey, which represents 86% of all intercollegiate athletes on the HWS campus. Among the numerous advantages of using this customized web-based survey is that it reduces data collection costs and greatly increases the rapidity with which data can be made available for use in the campaign.

A wide variety of normative messages were generated from the data. Here are some examples:

• 78% of HWS senior athletes, when thinking about a career, say "intellectual challenge" is very important to them.
• The majority of HWS athletes in season consume alcohol only once or twice a month or do not drink at all.
• Two-thirds of athletes participate in campus organizations other than their sport.
• 88% of athletes believe that one should never drink to an intoxicating level that interferes with academics or other responsibilities.
• Two-thirds of all HWS senior athletes participate in volunteer service each week with one-third contributing at least three hours weekly.

A variety of methods have been employed to promote these messages, including a print campaign that includes newspaper ads and an MVP Factoids column, a poster campaign, and a two-pronged electronic mass media campaign. One component of the latter campaign uses flat screen computers that have been mounted into 9 custom wall-mounted cabinets in high traffic areas of athletic facilities; each computer offers students access to athlete and general student data bases through the Campus Factoids and MVP Factoids software applications. The other component utilizes MVP E-Bits, which are brief summaries of results from recent surveys of student athletes.

A program media exposure survey revealed high levels of saturation. For example, 70% of respondents had seen a wall poster about student athletes multiple times, 65% had read an MVP Factoid on a screen saver multiple times, and 40% had read an MVP Factoid in a campus newspaper multiple times.

Post-test data was gathered the following year using the same comprehensive and anonymous web-based survey of the HWS student population. An analysis of this data shows reductions in the extent to which both male and female athletes misperceive team-mate drinking as being high in frequency (2 or more days per week). Concurrent significant reductions were also found in the percentage of male and female athletes drinking two or more days per week as well as numerous negative consequences due to drinking, such as inefficiency in homework, cutting class, and late papers/missed or poor exams. Additionally, female athletes reported significant reductions in injuries to self and others, whereas males reported significant reductions in unintended sexual activity as a result of drinking.

These are astonishing initial results from an intense and highly innovative intervention. What they clearly suggest is that the range of options for communicating normative messages to populations (or sub-groups thereof) is really quite broad: your ingenuity is the limit. And yet, as always, the basic principle remains the same: that correcting a misperception with consistently delivered normative messages can lead to positive behavior change.

College Student Drinkers: Celebrating Protection

Two presentations were fundamentally similar in their theoretical outlook, and they perhaps point to one of the ways in which the social norms approach may be evolving as it addresses the issue of college student drinking.

In one session ("The Personal Protective Behaviors of College Student Drinkers: Evidence of Indigenous Protective Norms"), Gregory Barker and Rich Rice presented evidence, based on an analysis of aggregate National College Health Assessment (NCHA) data, that college student drinkers regularly employ a number of strategies or behaviors in order to reduce their risk of injury and to promote personal safety when they consume alcohol. Our analysis reveals that a number of these behaviors correlate significantly with reduced harm; by contrast, a number of other behaviors do not appear to provide significant protection.

Interestingly, it appears that students regularly employ more than one protective behavior while drinking, and that this clustering of behaviors has an additive effect; i.e., the more protective behaviors one employs the less harm one incurs. Indeed, one of our most important findings is how normative it is for student drinkers to invoke protection. Nearly three-quarters (73%) of student drinkers in the sample regularly employ at least one protective behavior, and well over half (64%) of the students who use protective behaviors routinely employ two or more. Our analysis strongly suggests that these "indigenous protective norms" account, at least in part, for the relatively low incidence of alcohol-related harm among college student drinkers.

Another noteworthy finding is that fully 50% of college student drinkers choose "sometimes" not to drink alcohol when they socialize, while another 18% report that they "usually" choose not to do so. Thus, college student drinkers can be said to employ situational abstinence as an effective protective behavior, a phenomenon that does not appear to have been previously documented in the literature.

Of course, these findings are significant for those in college health who are already using various methods to model and promote effective safer drinking skills to students. Given their higher correlation with protection, certain behaviors warrant promotion, whereas others do not.

All of the behaviors included in the NCHA are consumption-based, and have therefore to do with limiting the quantity of alcohol consumed. Additional research has already begun to identify other, non-consumption based behaviors that appear to correlate with reduced harm as well, and another conference session ("Specialized Social Norm Message Strategies Focusing on Celebratory Drinking") conducted by Charles Atkin, Jasmine Greenamyer, and Dennis Martell, presented interesting information in this regard.

In examining the behaviors and motivations of student drinkers at Michigan State University (MSU) during certain celebratory events (such as Welcome Week, Halloween, St. Patrick's Day), these researches discovered the following:

• The top reasons MSU students gave for partying are to have fun (65 percent); to meet up with friends (60 percent); and to celebrate (40 percent).
• Only 5 percent of students said that the reason they party is to get drunk.
• Some 7% of student drinkers reported that they chose not to drink during the celebrations in question.
• Some actions that students take are likely to protect them when they drink: Go out as part of a group and stay with the same group; stay in one place the entire time while drinking; and drink only one kind of alcohol.

The work presented in both of these sessions suggests that there are many aspects of the competence, health, and resilience of college students that remain to be fully explored and effectively used in our social norm interventions.

The Social Norms Approach to Sexual Assault Prevention

An innovative application of this solution-focused approach to violence prevention was presented by Patricia Fabiano, Wes Perkins, Alan Berkowitz, and Jeff Linkenbach in their session "Ending Violence Against Women: Evidence for a Social Norms Approach." As these researchers pointed out, much is known in the sexual assault prevention field about "rape proclivity," whereas very little is understood about the attitudes and behaviors of the presumed majority of men who are unlikely to rape and are uncomfortable with stereotypical masculinity.

Based on a survey conducted at Western Washington University in spring 2002, these researchers made a number of findings that are sure to have important implications for the field. Their analysis revealed that:

• Both males and females show strong commitment to obtaining and honoring consent in sexual relationships;
• Men typically underestimate the importance to male and female peers of consent before sexual activity, with greater misperception of male peer norms;
• Men who perceive such consent to be highly normative for male and female peers are more likely to report that consent was necessary for them, but the strongest predictor of male's personal importance of consent was their perception of the women's norm for consent; and
• The sole predictor of men's willingness to intervene in a situation that may lead to sexual violence is the extent to which they perceived other men as willing to intervene.

These findings replicate those of other studies that have documented the extent to which men misperceive the norms of their peers regarding issues of sexual intimacy. They also clearly suggest that the necessary condition obtain for normative interventions to correct men's potentially rape-supportive misperceptions.

Sexual Risk-Taking among Urban Middle Schoolers

This summary of some of the key conference presentations began with an examination of three interventions targeted at high school students, a relatively new but quickly emerging area in the field. Indeed, it often seems that high schools and community-based interventions are now where college-based interventions were a decade ago: poised to create great interest and to expand rapidly. Given that, I wan to close with a brief look at a session that was devoted to an innovative intervention.

William Bacon and Tracy Smith's presentation "A Social Norms Approach to Reducing Sexual Risk-Taking Among Urban Middle Schoolers described an effort to extend the social norms approach into a domain with a target population that is quite different from one traditionally selected. As a component of its pregnancy prevention work, Planned Parenthood of New York City (PPNYC) has embarked on a well researched and implemented effort that uses the social norms approach to reduce adolescent sexual risk-taking (Bacon and Smith, 2003).

There is already evidence in the literature documenting misperceptions and correlative increased sexual risk-taking among adolescents (Robinson et al., 1999; Kinsman, 1998; Romer et al., 1994), and the PPNYC project's baseline data has confirmed these findings among its own target group of urban middle schoolers. Indeed, they have found misperceptions of both attitudinal (injunctive) and behavioral (descriptive) norms, suggesting that the necessary conditions exist for a normative, perception-correcting intervention.

The PPNYC project has adopted an essentially two-pronged approach. First, whenever possible, it has infused accurate norm-related information into the existing sex education curricula. Some of this work has included components that seek to define and clarify for the children the very concepts on which the intervention is based, i.e., actual norms ("What's really going on.") perceived norms ("What we think is going on."), and the potential harmfulness of misperceptions ("Because we might feel pressure to do things that go against our beliefs and values.") Second, they have researched, developed, and begun to implement a poster campaign to promote accurate norm information.

The experience of the PPNYC project staff has confirmed what other social norm projects have found to be the case as well: initial market data collection and message testing are critical. Focus groups with the children, parents and teachers yielded rich information that aided immeasurably in preliminary message development. The desire was to avoid a message such as "Most 8th graders aren't having sex." The resulting "Think Again…The Truth Is…" campaign focused instead on the clear attitudinal norm to delay sexual activity.

Initial process evaluation conducted thus far has indicated a high level of student exposure to the message, with impressive understanding of it and reasonably good levels of believability. At the time of the presentation, an analysis of the perception, attitude, and behavior change was still underway.

This presentation was compelling for its demonstration of how adaptable the social norms approach is to a wide variety of issues. But it also served to demonstrate the importance of the conference itself, since these two engaging and committed presenters had attended the previous year's conference, gaining enough insights and skills there to return to their own work with the fresh and health-based outlook that the social norms approach provides.

Conclusion

The sessions described here share a common focus on the analysis of health and protective behaviors of the clear majority of students. They incorporate a wide variety of issues and range across a number of different settings, including middle-schools, high schools, colleges and universities, and athletic programs. In their totality they provide impressive evidence for the importance of the social norms paradigm shift to the field of health promotion. An essentially solution-based methodology, the social norms approach seeks to consistently shift the focus to an ever sharper perception of the attitudinal and behavioral norms of health and safety. These studies add to the growing body of evidence suggesting that by doing so risk and harm are reduced and wellness grows.

(Note: A version of this article was originally published in The Report on Social Norms, Volume 3, Issue 4, Working Paper #13, in December 2003. Alan Berkowitz composed the section "The Social Norms Approach to Sexual Assault Prevention.")

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