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“Just not all ice users do that”: investigating perceptions and potential harms of Australia’s Ice Destroys Lives campaign in two studies

“Just not all ice users do that”: investigating perceptions and potential harms of Australia’s... Background: In 2015, the Australian government launched the media campaign Ice Destroys Lives targeting crystal methamphetamine use. Previous research indicates mass media campaigns may have harmful effects for people engaged in drug use. This study investigated perceptions and harms of Ice Destroys Lives among adults with a history of injecting drugs and young people. Methods: This analysis includes data from two studies: an online questionnaire with young people and in-depth interviews with adults who use crystal methamphetamine. Young people from Victoria, Australia, were recruited through Facebook. We collected data on drug use, campaign recognition and behaviours. Participants who recognised the campaign indicated whether they agreed with five statements related to Ice Destroys Lives.We compared campaign perceptions between young people who reported ever using crystal methamphetamine and those who did not. Adults who use crystal methamphetamine were sampled from the Melbourne injecting drug user cohort study. We asked participants if they recognised the campaign and whether it represented their experiences. Results: One thousand twenty-nine young people completed the questionnaire; 71% were female, 4% had used crystal methamphetamine and 69% recognised Ice Destroys Lives. Three quarters agreed the campaign made them not want to use ice. Ever using crystal methamphetamine was associated with disagreeing with three statements including this campaign makes you not want to use ice (adjusted odds ratio (AOR) = 4.3, confidence interval (CI) = 1.8–10.0), this campaign accurately portrays the risks of ice use (AOR = 3.2, CI = 1.4–7.6) and this campaign makes you think that people who use ice are dangerous (AOR = 6.6, CI = 2.2–19.8). We interviewed 14 people who used crystal methamphetamine; most were male, aged 29–39 years, and most recognised the campaign. Participants believed Ice Destroys Lives misrepresented their experiences and exaggerated “the nasty side” of drug use. Participants felt the campaign exacerbated negative labels and portrayed people who use crystal methamphetamine as “violent” and “crazy”. Conclusion: In our study, Ice Destroys Lives was widely recognised and delivered a prevention message to young people. However, for people with a history of crystal methamphetamine use, the campaign also reinforced negative stereotypes and did not encourage help seeking. Alternative evidence-based strategies are required to reduce crystal methamphetamine-related harms. Keywords: Injecting drug use, Australia, Media, Crystal methamphetamine, Young people * Correspondence: [email protected] Burnet Institute, 85 Commercial Road, Melbourne, Victoria 3004, Australia School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Victoria 3004, Australia Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Douglass et al. Harm Reduction Journal (2017) 14:45 Page 2 of 8 Background in the uptake of illicit drugs among young Australians” Australia has one of the highest rates of methamphetamine aged 14–25 years, to increase awareness of “arangeof use worldwide [1]. In 2013, an estimated 7% of Australians serious harms associated with the use of ice” among aged 14 years and over reported using methamphetamines young people and their parents and “to encourage and in their lifetime and 2% reported having done so in the past support decisions not to use illicit drugs” [17]. The 12 months [2]. Currently, crystal methamphetamine (“ice”) campaign used graphic advertisements to depict people is the purest and most commonly used form of the drug in who use crystal methamphetamine as violent, criminal Australia [2, 3]. There is evidence that methamphetamine- and psychotic [18]. For example, one video advertisement related harms (such as hospitalisations, mental health unit featured a male character stealing from and physically submissions for stimulant abuse and psychosis and arrests assaulting his mother in the presence of a young child. for possession or use) have increased in the state of Victoria The campaign was accompanied by a website which since 2010 [4] in the context of major market changes [5]. included educational information and links to a range of Reports of increased harm have resulted in considerable generalist support services such as Direct Line, Counsel- community concern as evidenced by increased coverage of ling Online and the Australian Drug Foundation [19]. methamphetamine use in the Australian media [6]. In The Department of Health commissioned an inde- 2013, 16% of Australians aged 14 years and over rated pendent evaluation of the campaign, which suggested methamphetamines as the drug of most concern in that Ice Destroys Lives increased both awareness of ice- Australia compared to 40% in 2016 [7]. Illicit drug use is related harms and negative attitudes towards ice among highly politicised in Australia with the majority of govern- young people and their parents [17]. A total of 2171 ment funding spent on law enforcement (64%) and treat- young people were interviewed for this evaluation; one ment (23%) compared to 10% on prevention [8]. third thought that the campaign was relevant to them, In 2015, the Australian government launched a 6-week and half indicated that they would “avoid using ice” as a $9 million media campaign, Ice Destroys Lives, to target result of seeing the campaign. However, the evaluation crystal methamphetamine use (referred to in the campaign did not report whether participants had previously used as “ice”) [9, 10]. Mass media campaigns can disseminate crystal methamphetamine or other illicit drugs which drug-related information at a population level [11]. may have influenced their opinion of the campaign. Im- However, these campaigns are rarely evaluated, and most portantly, the evaluation did not consider the effects of research has come from the USA [11–13]. An inter- the campaign for other audiences such as people who national systematic review investigating the effect of mass already use crystal methamphetamine. In the existing lit- media campaigns on illicit drug use found that eight stud- erature, there is only a small number of studies describ- ies demonstrated no effect of media campaigns on drug ing the impact of anti-drug campaigns on people who use, four studies had beneficial effects and two studies re- use drugs [14]. Given the indication within the literature ported increased drug use [12]. Generally, media cam- that these campaigns can be harmful, we analysed data paigns target young people in an attempt to prevent new from two ongoing studies (an online survey and a cohort uptake; however, their widespread nature means that they study) to investigate potential harms of media campaigns also reach other populations such as people who already targeting illicit drug use. The aims of this study were to: engage in drug use [14]. Anti-drug campaigns are often shock-based, reinforce negative stereotypes and portray 1. Investigate recognition, perceptions and potential people who use drugs as threats to the community [14]. harms of Ice Destroys Lives among young people. Adverse implications for people who use drugs include 2. Explore recognition, perceptions and potential isolation, low self-esteem and reduced access to treatment harms of Ice Destroys Lives among adults with a [14]. An evaluation of a US campaign—The Montana history of injecting drug use who report crystal Meth Project—suggested that graphic advertisements had methamphetamine use. no effect on methamphetamine use among young people [15]. It was criticised for using sexualised, racialised and Methods gendered advertisements that had the potential to influ- Design and setting ence policy, increase stigma and prevent the implementa- This study analysed data from two different studies with tion of harm reduction strategies [16]. People with two different population groups. We used data from a experience of methamphetamine dependency believed The large online questionnaire with young people that in- Montana Meth Project was “demonising” and exacerbated cluded a section of questions about the Ice Destroys their experiences of judgement, shame and rejection [14]. Lives campaign. We also analysed interviews conducted The tagline of Australia’s Ice Destroys Lives campaign as part of a cohort study with adults who had a history was “Ice destroys lives. Don’t let it destroy yours”.The of injecting drug use who report crystal methampheta- aims of the campaign were to contribute to “areduction mine use to gather in-depth information. Douglass et al. Harm Reduction Journal (2017) 14:45 Page 3 of 8 Online questionnaire with young people driven sampling. Participants complete an annual inter- The Sex, Drugs and Rock ‘n’ Roll study is an annual cross- view and provide in-depth information on drug use pat- sectional survey of young people conducted by the Burnet terns, health service utilisation and other social outcomes. Institute. Methods have been described previously [20]. In 2016, MIX had 757 participants; the majority were Briefly, we invited Victorians aged 15–29 years to complete male, the median age was 28 years, 59% had a history of an online questionnaire. Participants were recruited from incarceration and 6% reported that methamphetamine social network sites through advertisements on Facebook was the illicit drug they had used most in the past month and Instagram, and posts on Facebook pages that target [22]. Participants from MIX were eligible to complete an young people (such as university pages and community additional face to face in-depth interview focusing on their youth groups). We collected data on participants’ socio- use of crystal methamphetamine if they (1) reported that demographic characteristics, use of alcohol and other illicit they had used crystal methamphetamine more regularly drugs, and a range of other health domains. Upon than heroin or any other drug for a week or more since completion, participants entered into a draw to win a $250 their baseline study visit, (2) could be contacted by supermarket voucher. This study includes data from the telephone to arrange the interview and (3) provided writ- 2016 questionnaire. ten informed consent. Two trained interviewers (authors AP and PH) conducted these interviews, one section of Main outcome measures which explored recall and perceptions of the Ice Destroys We asked if participants recognised Ice Destroys Lives by Lives campaign. Interviews ran between 30 and 60 min providing five still images from the campaign. Those who and participants were reimbursed $40 for their time and recognised the campaign responded to five statements to travel expenses. Interviews with MIX participants were determine their perceptions of the campaign’s accuracy and audio-recorded and transcribed verbatim. effectiveness. Participants stated whether they strongly agreed, agreed, neither agreed nor disagreed, disagreed or Main outcome measures strongly disagreed with each statement. Levels of agreement Participants were asked if they recalled Ice Destroys Lives. were grouped in analysis in three categories: “agree” which Those who did not recall the campaign were shown an ex- combined “agree” and “strongly agree”, “neutral” (“neither cerpt of the advertisement on the interviewer’ssmartphone. agree nor disagree”), and “disagree” (“disagree” or “strongly All participants were asked open-ended questions about their disagree”). All statements were informed by drug experts perceptions of the campaign and whether it represented their and pilot-tested with young people. experiences and use of crystal methamphetamine. Analysis Analysis All quantitative data were analysed using Stata version 13.1. Interview transcripts were uploaded into NVivo 11 for Socio-demographic characteristics are presented as descrip- processing and coding in a de-identifiable form. Authors tive statistics. We used logistic regression to determine if CD and EE performed thematic analysis and used induct- any socio-demographic characteristics were associated with ive, iterative coding. Transcripts were initially coded with crystal methamphetamine use. We calculated the percent- broad open codes which were refined and converged age of participants who agreed, disagreed or remained during the process as deemed necessary. Researcher neutral with each statement on Ice Destroys Lives.Weused triangulation was also implemented, in which transcripts multinomial logistic regression to calculate whether ever were read by the interviewers (AP and PH) to confirm the using crystal methamphetamine was correlated with agree- themes that arose from the analysis. ing, disagreeing or remaining neutral to statements about the campaign. We used “agree” as our reference category to Results produce odds ratios, p values and 95% confidence intervals. Quantitative results from online questionnaire with We ran a second multinomial logistic regression model that young people adjusted for socio-demographic characteristics that we In 2016, we recruited 1029 young people. Their character- identified as significantly associated with using crystal istics appear in Table 1. The majority were female, and the methamphetamine. mean age was 23 years. In total, 54% of participants had ever used an illicit drug. Of all participants, 4% reported Interviews with people who use crystal that they had used crystal methamphetamine in their life- methamphetamine time and 1% had used it in the past month. Using crystal The Melbourne injecting drug user cohort study (MIX) methamphetamine was significantly associated with being was established in 2008, the detailed methods for which older, identifying as male, not living with parents, spend- have been described elsewhere [21]. Participants were ini- ing $120 or more per week for recreational purposes and tially recruited through street outreach and respondent- identifying as non-heterosexual. Douglass et al. Harm Reduction Journal (2017) 14:45 Page 4 of 8 Table 1 Characteristics of participants by crystal methamphetamine use Total Had never used crystal methamphetamine Had used crystal methamphetamine Odds Confidence (n = 1029) in lifetime (n = 955) in lifetime (n = 46) ratio interval n (%) n (%) n (%) Gender Male 278 (27.0) 250 (26.2) 18 (39.2) 1.0 Ref Female 731 (71.0) 688 (72.0) 25 (54.4) 0.5 0.3–0.9* Non-binary, trans or other 17 (1.7) 15 (1.6) 2 (4.4) 1.9 0.4–8.7 identity Born in Australia No 121 (11.8) 108 (11.3) 7 (15.2) 1.0 Ref Yes 891 (86.6) 834 (87.3) 38 (82.6) 0.7 0.3–1.6 Completed post-high school education No 606 (58.9) 573 (60.0) 23 (50.0) 1.0 Ref Yes 423 (41.1) 382 (40.0) 23 (50.0) 1.5 0.8–2.7 Live with parents No 498 (48.4) 446 (46.7) 36 (78.3) 1.0 Ref Yes 531 (51.6) 509 (53.3) 10 (21.7) 0.2 0.1–0.5** Money spent per week for recreation Less than $120 815 (79.2) 771 (80.7) 22 (47.8) 1.0 Ref $120 or more 207 (20.1) 178 (18.6) 24 (52.2) 4.8 2.6–8.6** Live in major city No 103 (10.0) 93 (9.7) 6 (13.0) 1.0 Ref Yes 914 (88.8) 851 (89.1) 39 (84.8) 0.7 0.3–1.7 Heterosexual No 273 (26.5) 240 (25.1) 23 (50.0) 1.0 Ref Yes 756 (73.5) 715 (74.9) 23 (50.0) 0.4 0.2–0.6** Mean age (years) 22.5 22.4 25.2 1.3 1.2–1.5** Percentages may not add up to 100% due to rounding. Numbers may not add up to total as participants who reported “I don’t wish to say” are not shown Ref reference *p < 0.05; **p < 0.001; Non-binary, trans and other identities have been combined due to small numbers Campaign recognition Perceptions of Ice Destroys Lives campaign by crystal The majority of participants recognised Ice Destroys Lives methamphetamine use from the still images provided (69%). Among participants Using crystal methamphetamine was associated with dis- who recognised the campaign, 71% were female and the agreeing with four of the five statements including this mean age was 23 years. Overall, 5% had ever used crystal campaign makes you not want to use ice (OR = 5.0, CI = methamphetamine (n = 33), and of these, 24% had used it 2.3–10.7), accurately portrays therisks of iceuse (OR = 7.0, in the past month (n = 8) (not shown in Table). CI = 3.2–15.4), makes you think that people who use ice are dangerous (OR = 9.6, CI = 3.7–25.2) and this campaign will scare young people off using ice (OR = 4.7, CI = 1.9–11.6) Perceptions of Ice Destroys Lives (Table 2). The exception was this campaign will encourage Participants’ perceptions of the Ice Destroys Lives cam- ice users to seek help; there was no significant association paign appear in Table 2. Of all participants, 75% agreed between disagreeing with this statement and reporting crys- the campaign made them not want to use ice, 55% tal methamphetamine use (OR = 2.7, CI = 0.9–8.0). agreed it accurately portrays the risk of ice use, 46% When we adjusted for age, gender, living arrangements, agreed the campaign will scare youngpeopleoff using money spent per week and sexual identity, disagreeing ice and 84% agreed that the campaign made them think with three of the five campaign statements remained sig- that people who use ice are dangerous. Overall, 47% nificantly associated with reporting crystal methampheta- disagreed that the campaign would encourage ice users mine use. However, the association between using crystal to seek help. methamphetamine and disagreeing with the statement Douglass et al. Harm Reduction Journal (2017) 14:45 Page 5 of 8 Table 2 Young people’s perceptions of Ice Destroys Lives by crystal methamphetamine use Statement Total (n = 711) Had never used crystal Had used crystal Odds 95% confidence Adjusted 95% confidence methamphetamine methamphetamine ratio interval odds ratio interval in lifetime (n = 678) in lifetime (n = 33) This campaign n (%) n (%) n (%) Makes you not want to use ice Agree 535 (75.4) 519 (76.7) 16 (48.5) 1.0 Ref 1.0 Ref Neutral 77 (10.9) 73 (10.8) 4 (12.1) 1.8 0.6–5.5 1.0 0.3–3.3 Disagree 98 (13.8) 85 (12.6) 13 (39.4) 5.0 2.3–10.7** 4.3 1.8–10.0** Accurately portrays the risks of ice use Agree 390 (55.3) 379 (56.4) 11 (33.3) 1.0 Ref 1.0 Ref Neutral 209 (29.7) 205 (30.5) 4 (12.1) 0.7 0.2–2.1 0.5 0.2–1.7 Disagree 106 (15.0) 88 (13.1) 18 (54.6) 7.0 3.2–15.4** 3.2 1.4–7.6* Makes you think that people who use ice are dangerous Agree 597 (84.1) 576 (85.1) 21 (63.6) 1.0 Ref 1.0 Ref Neutral 86 (12.1) 81 (12.0) 5 (15.2) 1.7 0.6–4.6 1.0 0.4–3.1 Disagree 27 (3.8) 20 (3.0) 7 (21.2) 9.6 3.7–25.2** 6.6 2.2–19.8** Will scare young people off using ice Agree 326 (46.0) 319 (47.2) 7 (21.2) 1.0 Ref 1.0 Ref Neutral 211 (29.8) 201 (29.7) 10 (30.3) 2.3 0.8–6.1 1.5 0.5–4.2 Disagree 172 (24.3) 156 (23.1) 16 (48.5) 4.7 1.9–11.6* 2.6 1.0–6.9 Will encourage ice users to seek help Agree 146 (20.6) 142 (21.0) 4 (12.1) 1.0 Ref 1.0 Ref Neutral 228 (32.1) 223 (32.9) 5 (15.2) 0.8 0.2–3.0 0.7 0.2–2.7 Disagree 336 (47.3) 312 (46.1) 24 (72.7) 2.7 0.9–8.0 1.8 0.6–5.5 Percentages may not add up to 100% due to rounding. Numbers may not add up to total as participants who reported “I don’t wish to say” are not shown Ref reference *p < 0.05; **p < 0.001 Adjusted for gender, living arrangements, money spent per week for recreational purposes, sexual identity and age this campaign will scare young people off using ice did not recalled seeing it, four reported they had not seen it and four remain significant (AOR = 2.6, CI = 1.0–6.9) (see Table 2). participants were unsure. After being shown an excerpt of the video advertisement, those participants who were ini- Qualitative results from in-depth interviews with adults tially unsure reported that they did recognise the campaign. who inject drugs Sixty participants from MIX were eligible to participate in Perceptions of Ice Destroys Lives campaign an in-depth interview focusing on crystal methampheta- The main theme that emerged during the interviews was mine use. When researchers attempted to contact eligible that Ice Destroys Lives misrepresented the experiences of participants, most phone numbers were disconnected. Of people who use crystal methamphetamine. However, participants who could be contacted, 14 consented to three participants acknowledged that some elements of participate and two declined. Most participants identified the Ice Destroys Lives campaign were accurate, including as male (n =12) and were aged 29–39 years. Almost all sleep deprivation, hallucinations and the portrayal of participants interviewed were unemployed and lived in gov- crystal methamphetamine as a “very destructive drug”. ernment housing. Approximately two thirds (n =10) were on opiate substitution therapy. Nine of the 14 participants Yeah, that’s pretty accurate…I’ve been in some reported that heroin was their drug of choice at the time of situations like that (male, 39 years). the interview, while the remaining five nominated crystal methamphetamine as their drug of choice. Alternatively, nine participants felt that Ice Destroys Lives was sensationalised and exaggerated “the nasty side” Campaign recognition and recall of crystal methamphetamine use. Terms used to describe Recall of the Ice Destroys Lives campaign among adults who the campaign included “confronting”, “jumping the gun” used crystal methamphetamine was mixed; six participants and “pretty wrong”. When asked, five participants stated Douglass et al. Harm Reduction Journal (2017) 14:45 Page 6 of 8 that the campaign was unlikely to prevent them from Young people’s perceptions of Ice Destroys Lives using crystal methamphetamine or encourage them to The main aim of Ice Destroys Lives was to “contribute to a seek help, with one participant suggesting that “There just reduction in the uptake of illicit drugs among young needs to be more help out there I think” (male, 35 years). Australians”. In our questionnaire, three quarters of Despite acknowledging the harms of ice, most partici- participants reported that the campaign made them not pants felt that Ice Destroys Lives did not accurately portray want to use ice and 46% agreed it would scare young their personal experiences or behaviours. Their criticisms people off using ice. This suggests that the campaign centred on the violence depicted in the campaign with reached its target population with a prevention message, seven participants stating that “it doesn’t apply to me”. reflecting results from the original evaluation report [17]. However, our findings show that the campaign also had Like sometimes when I’monitIgetabitrowdy butI adverse effects: 84% reported that the campaign made don’t go out there causing trouble. I don’twant to get them think that people who use ice are dangerous and 47% in trouble. I have my own things to do (male, 37 years). disagreed that the campaign encouraged help-seeking behaviours. This suggests that Ice Destroys Lives also deliv- While participants eagerly explained that the campaign ered stigmatised messages to its target audience. There misrepresented their personal circumstances and behav- were significant differences in young people’sperceptions iours, they also believed that Ice Destroys Lives did not of Ice Destroys Lives based on crystal methamphetamine represent other people who use crystal methampheta- use. Participants who had previously used crystal metham- mine. Ten participants mentioned that all people have phetamine were significantly less likely to believe that the different experiences when using the drug. campaign was accurate, helpful or effective. Alternatively, participants who had never used crystal methampheta- Just not all ice users do that. It’s basically saying that all mine were more likely to agree that the campaign made ice users are likely to do that, you know (male, 38 years). them think that people who use ice are dangerous. This reinforces the evidence that mass media campaigns such According to participants, Ice Destroys Lives depicted as Ice Destroys Lives contribute to negative stereotypes only the “worst case scenarios” to frame all people who and are unlikely to increase help seeking for people who use crystal methamphetamine in a negative light. Partici- use crystal methamphetamine [12]. This provides support pants felt that Ice Destroys Lives exacerbated negative for allocating funds to targeted prevention and evidence- stereotypes and created fear throughout the community. based strategies focusing on high-risk groups rather than They discussed the role of sensationalised media report- generalist mass media campaigns targeting all young ing contributing to assumptions and labels that commu- people [23]. nity members imposed upon them. Perceptions of the campaign among adults who use Just some people think that you are going to go crazy crystal methamphetamine or yeah. They just show so many people who have When interviewed, adults with a history of injecting drug gotten violent whilst using ice and that, bashing bus use who had used crystal methamphetamine generally did drivers and that. They think that everyone who uses it not identify with the violent behaviours depicted in Ice is going to get like that…They think that all ice users Destroys Lives. They distanced themselves from the deviant will, just you know, bash them or rob them or do characters that were portrayed; however, they felt that the something (male, 38 years). wider community still labelled them as “violent” and “crazy” based on the “worst case scenarios” shown. Participants felt that the campaign did not encourage them to seek help nor Discussion would it prevent them from using crystal methampheta- Recognition and recall mine in the future. Shock-based campaigns often frame This manuscript draws on data from two studies to crystal methamphetamine use as an individual-level prob- explore perceptions of Australia’s Ice Destroys Lives cam- lem [12, 14, 24] evidenced in this campaign by the tagline paign among young people and adults with a history of “Ice destroys lives. Don’t let it destroy yours”.Campaigns injecting drugs. Our results suggest that the majority of can also evoke fear throughout communities by linking young people surveyed recognised the campaign, aligning crystal methamphetamine use to violence, criminal activity with findings from the original evaluation of the campaign and immorality [25]. Language is important and can be [17]. Ice Destroys Lives was also highly recognised by stigmatising [26], and some suggest that use of aggressive participants who used crystal methamphetamine, suggest- and discriminatory language frames all people who use ing that it is important to consider the implications this crystal methamphetamine as worthless and problematic campaign had on other audiences. [23]. This attitude can subsequently act as a barrier for Douglass et al. Harm Reduction Journal (2017) 14:45 Page 7 of 8 treatment and increase stress and isolation among people information on the effects of media campaigns on adults who use crystal methamphetamine [26, 27]. Consumer with a history of injecting drugs. Initially, 60 MIX partici- representatives have encouraged the Australian government pants were eligible for interviews focusing on crystal to alter their approach to ensure that future strategies are methamphetamine; however, most of their telephone inclusive, evidence-based and cost-effective [23]. numbers were disconnected, and we were unable to con- tact them. Participants who were contactable by telephone Limitations may differ from the participants we were unable to reach. This study has some limitations. We recruited young However, of participants who were contacted, the re- people for the Sex, Drugs and Rock ‘n’ Roll survey through sponse rate was high and their socio-demographic charac- convenience sampling from Facebook and other social net- teristics reflected the MIX sample. work sites. This sampling technique generally recruits a higher proportion of females than males, people with Conclusions higher levels of education and individuals who have an Ice Destroys Lives was well recognised and delivered a pre- interest in the topic [28, 29]; it is unlikely our sample is rep- vention message to young people in our study; however, resentative of all young Victorians. Only 33 participants among young people who had ever used crystal metham- from the online survey who were included in logistic re- phetamine, the campaign was less well perceived. Our study gression had used crystal methamphetamine in their life- also provides important evidence that adults with a history time, and of these, 24% had used the drug in the past of injecting drug use recalled this shock-based campaign month. Consequently, confidence intervals lack precision, but did not identify with the behaviours portrayed. Implica- and results do not capture the perceptions of young people tions included feeling misrepresented and being negatively who have recently engaged in crystal methamphetamine labelled, likely contributing further to discrimination and use. Future studies should recruit a larger sample of young stigma within the community. The Australian government’s people engaged in drug use and differentiate results by aim of targeting methamphetamine-related harms is com- usage patterns. Although statements in our survey were mendable; funding for evidence-based strategies that are in- pilot-tested andinformedbyexperts, we did not usea formed by experts and high-risk groups in an inclusive validated tool to measure young people’sperceptionsof Ice manner wouldbeamoreeffectiveuse of future resources. Destroys Lives. In addition, although we adjusted for age, Abbreviations gender, living arrangements, money spent per week and MIX: Melbourne injecting drug user cohort study sexual identity, there may have been other variables that in- fluenced young people’sperceptions of Ice Destroys Lives Acknowledgements such as political orientation and social networks [30]. All The authors wish to thank all the participants who took part in the Sex, Drugs and Rock ‘n’ Roll and MIX studies. We gratefully acknowledge the MIX data were self-reported and may have been influenced by fieldwork team who assisted with initial participant recruitment, study design social desirability bias; however, this was minimised by the and follow-up. anonymity of the survey's online platform. Funding We recruited participants of the existing MIX study No specific funding was received for this study. Funding for the MIX study is who use crystal methamphetamine through purposive provided by National Health and Medical Research Council (NHMRC) and the sampling. Although this recruitment method does not Centre for Research Excellence on Injecting Drug Use. The 2016 Sex, Drugs and Rock ‘n’ Roll study was funded by the Burnet Institute. The authors gratefully capture a representative sample, it allowed us to access acknowledge the support of the Victorian Operational Infrastructure Support individuals who are typically hard-to-reach and could pro- Program received by Burnet Institute. Cassandra Wright is supported by an vide in-depth information for our research aims [21]. The Australian Government Research Training Program Scholarship. Megan Lim is supported by the Jim and Margaret Beever Foundation. Paul Dietze is participants we interviewed were a highly marginalised supported by an ARC Future Fellowship and has received funding from Gilead group; most were unemployed, lived in government hous- Sciences and Reckitt Benckiser for work unrelated to this study. The funding ing and involved in treatment programs. It is likely that bodies were not involved in study design, collection, analysis or interpretation of data or in writing the manuscript. their past experiences increased their negative perceptions of the campaign. The MIX participants were significantly Availability of data and materials older than the target population of Ice Destroys Lives and The datasets analysed during the current study from Sex, Drugs and had a history of injecting drugs; qualitative results are Rock’n’Roll and MIX study are not publicly available due to them containing information that could compromise participant privacy/consent. therefore not applicable to younger people who use crystal methamphetamine recreationally and may use by modes Authors’ contributions besides injecting. In future, it would be beneficial to evalu- CD was involved in online survey recruitment and data collection, data ate similar campaigns with younger people based on pat- analysis and led the writing of the manuscript. EE and CW were involved in quantitative and qualitative data analysis. PH was involved in study design terns of usage. However, one aim of this study was to and interviewing. AP conducted interviews and assisted with data analysis. assess impacts of the campaign on those outside the target BQ provided input into data collection and analysis for both studies. PD had group; therefore, our study provides important input into the data collection and leads the MIX study. ML conceived the Douglass et al. Harm Reduction Journal (2017) 14:45 Page 8 of 8 manuscript and leads the Sex, Drugs and Rock’n’Roll study. All authors have evidence. Drugs: Educ Prev Policy. 2004;12:247–8. doi:10.1080/ contributed to and approved the final manuscript. 09687630500070037. 14. Ferestad J, Thompson M. “I’m Not Gonna Be Like ‘That Guy’”: examining Ethics approval and consent to participate antidrug shock advertising through the eyes of “That Guy”. Deviant Behav. The Sex, Drugs and Rock ‘n’ Roll (Project number: 326/08) received ethical 2016;38:173–87. doi:10.1080/01639625.2016.1196971. approval from the Alfred Health Human Research Ethics Committee. 15. Anderson DM, Elsea D. 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National Drugs Campaign. 2016. http:// www.drugs.health.gov.au/internet/drugs/publishingcp.nsf/content/home. Publisher’sNote Accessed 30 Jan 2017. Springer Nature remains neutral with regard to jurisdictional claims in 19. Department of Health Victoria. Taking action stopping ice—facts and help. published maps and institutional. 2015. http://ice.vic.gov.au/facts-and-help/. Accessed 06 Apr 2017. 20. Carrotte ER, Dietze PM, Wright CJ, Lim MS. Who ‘likes’ alcohol? Young Author details Australians’ engagement with alcohol marketing via social media and Burnet Institute, 85 Commercial Road, Melbourne, Victoria 3004, Australia. related alcohol consumption patterns. Aust N Z J Public Health. 2016;40: School of Public Health and Preventive Medicine, Monash University, 553 St 474–9. doi:10.1111/1753-6405.12572. Kilda Road, Melbourne, Victoria 3004, Australia. Department of Public Health, 21. Horyniak D, Higgs P, Jenkinson R, Degenhardt L, Stoove M, Kerr T, et al. 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Submit your next manuscript to BioMed Central 9. Conifer D. Ice addiction: graphic ad campaign on dangers of ice launched by Federal Government. ABC News. 2015. http://www.abc.net.au/news/ and we will help you at every step: 2015-05-10/federal-government-launches-graphic-ice-ad-campaign/6457810. • We accept pre-submission inquiries Accessed 06 Apr 2017. 10. Department of Health Australia. Government response to the final report of the � Our selector tool helps you to find the most relevant journal National Ice Action Taskforce. 2015. http://www.health.gov.au/internet/main/ � We provide round the clock customer support publishing.nsf/Content/MC15-009596-national-ice-taskforce. Accessed 06 Apr 2017. � Convenient online submission 11. Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health behaviour. Lancet. 2010;376:1261–71. doi:10.1016/S0140-6736(10)60809-4. � Thorough peer review 12. Allara E, Ferri M, Bo A, Gasparrini A, Faggiano F. Are mass-media campaigns � Inclusion in PubMed and all major indexing services effective in preventing drug use? A Cochrane systematic review and meta- � Maximum visibility for your research analysis. BMJ Open. 2015;5:e007449. doi:10.1136/bmjopen-2014-007449. 13. Loxley W, Toumbourou J, Stockwell T, Haines B, Scott K, Godfrey C, et al. Submit your manuscript at The prevention of substance use, risk and harm in Australia: a review of the www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Harm Reduction Journal Springer Journals

“Just not all ice users do that”: investigating perceptions and potential harms of Australia’s Ice Destroys Lives campaign in two studies

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Medicine & Public Health; Health Promotion and Disease Prevention; Social Policy; Social Work; Health Psychology
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Abstract

Background: In 2015, the Australian government launched the media campaign Ice Destroys Lives targeting crystal methamphetamine use. Previous research indicates mass media campaigns may have harmful effects for people engaged in drug use. This study investigated perceptions and harms of Ice Destroys Lives among adults with a history of injecting drugs and young people. Methods: This analysis includes data from two studies: an online questionnaire with young people and in-depth interviews with adults who use crystal methamphetamine. Young people from Victoria, Australia, were recruited through Facebook. We collected data on drug use, campaign recognition and behaviours. Participants who recognised the campaign indicated whether they agreed with five statements related to Ice Destroys Lives.We compared campaign perceptions between young people who reported ever using crystal methamphetamine and those who did not. Adults who use crystal methamphetamine were sampled from the Melbourne injecting drug user cohort study. We asked participants if they recognised the campaign and whether it represented their experiences. Results: One thousand twenty-nine young people completed the questionnaire; 71% were female, 4% had used crystal methamphetamine and 69% recognised Ice Destroys Lives. Three quarters agreed the campaign made them not want to use ice. Ever using crystal methamphetamine was associated with disagreeing with three statements including this campaign makes you not want to use ice (adjusted odds ratio (AOR) = 4.3, confidence interval (CI) = 1.8–10.0), this campaign accurately portrays the risks of ice use (AOR = 3.2, CI = 1.4–7.6) and this campaign makes you think that people who use ice are dangerous (AOR = 6.6, CI = 2.2–19.8). We interviewed 14 people who used crystal methamphetamine; most were male, aged 29–39 years, and most recognised the campaign. Participants believed Ice Destroys Lives misrepresented their experiences and exaggerated “the nasty side” of drug use. Participants felt the campaign exacerbated negative labels and portrayed people who use crystal methamphetamine as “violent” and “crazy”. Conclusion: In our study, Ice Destroys Lives was widely recognised and delivered a prevention message to young people. However, for people with a history of crystal methamphetamine use, the campaign also reinforced negative stereotypes and did not encourage help seeking. Alternative evidence-based strategies are required to reduce crystal methamphetamine-related harms. Keywords: Injecting drug use, Australia, Media, Crystal methamphetamine, Young people * Correspondence: [email protected] Burnet Institute, 85 Commercial Road, Melbourne, Victoria 3004, Australia School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Victoria 3004, Australia Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Douglass et al. Harm Reduction Journal (2017) 14:45 Page 2 of 8 Background in the uptake of illicit drugs among young Australians” Australia has one of the highest rates of methamphetamine aged 14–25 years, to increase awareness of “arangeof use worldwide [1]. In 2013, an estimated 7% of Australians serious harms associated with the use of ice” among aged 14 years and over reported using methamphetamines young people and their parents and “to encourage and in their lifetime and 2% reported having done so in the past support decisions not to use illicit drugs” [17]. The 12 months [2]. Currently, crystal methamphetamine (“ice”) campaign used graphic advertisements to depict people is the purest and most commonly used form of the drug in who use crystal methamphetamine as violent, criminal Australia [2, 3]. There is evidence that methamphetamine- and psychotic [18]. For example, one video advertisement related harms (such as hospitalisations, mental health unit featured a male character stealing from and physically submissions for stimulant abuse and psychosis and arrests assaulting his mother in the presence of a young child. for possession or use) have increased in the state of Victoria The campaign was accompanied by a website which since 2010 [4] in the context of major market changes [5]. included educational information and links to a range of Reports of increased harm have resulted in considerable generalist support services such as Direct Line, Counsel- community concern as evidenced by increased coverage of ling Online and the Australian Drug Foundation [19]. methamphetamine use in the Australian media [6]. In The Department of Health commissioned an inde- 2013, 16% of Australians aged 14 years and over rated pendent evaluation of the campaign, which suggested methamphetamines as the drug of most concern in that Ice Destroys Lives increased both awareness of ice- Australia compared to 40% in 2016 [7]. Illicit drug use is related harms and negative attitudes towards ice among highly politicised in Australia with the majority of govern- young people and their parents [17]. A total of 2171 ment funding spent on law enforcement (64%) and treat- young people were interviewed for this evaluation; one ment (23%) compared to 10% on prevention [8]. third thought that the campaign was relevant to them, In 2015, the Australian government launched a 6-week and half indicated that they would “avoid using ice” as a $9 million media campaign, Ice Destroys Lives, to target result of seeing the campaign. However, the evaluation crystal methamphetamine use (referred to in the campaign did not report whether participants had previously used as “ice”) [9, 10]. Mass media campaigns can disseminate crystal methamphetamine or other illicit drugs which drug-related information at a population level [11]. may have influenced their opinion of the campaign. Im- However, these campaigns are rarely evaluated, and most portantly, the evaluation did not consider the effects of research has come from the USA [11–13]. An inter- the campaign for other audiences such as people who national systematic review investigating the effect of mass already use crystal methamphetamine. In the existing lit- media campaigns on illicit drug use found that eight stud- erature, there is only a small number of studies describ- ies demonstrated no effect of media campaigns on drug ing the impact of anti-drug campaigns on people who use, four studies had beneficial effects and two studies re- use drugs [14]. Given the indication within the literature ported increased drug use [12]. Generally, media cam- that these campaigns can be harmful, we analysed data paigns target young people in an attempt to prevent new from two ongoing studies (an online survey and a cohort uptake; however, their widespread nature means that they study) to investigate potential harms of media campaigns also reach other populations such as people who already targeting illicit drug use. The aims of this study were to: engage in drug use [14]. Anti-drug campaigns are often shock-based, reinforce negative stereotypes and portray 1. Investigate recognition, perceptions and potential people who use drugs as threats to the community [14]. harms of Ice Destroys Lives among young people. Adverse implications for people who use drugs include 2. Explore recognition, perceptions and potential isolation, low self-esteem and reduced access to treatment harms of Ice Destroys Lives among adults with a [14]. An evaluation of a US campaign—The Montana history of injecting drug use who report crystal Meth Project—suggested that graphic advertisements had methamphetamine use. no effect on methamphetamine use among young people [15]. It was criticised for using sexualised, racialised and Methods gendered advertisements that had the potential to influ- Design and setting ence policy, increase stigma and prevent the implementa- This study analysed data from two different studies with tion of harm reduction strategies [16]. People with two different population groups. We used data from a experience of methamphetamine dependency believed The large online questionnaire with young people that in- Montana Meth Project was “demonising” and exacerbated cluded a section of questions about the Ice Destroys their experiences of judgement, shame and rejection [14]. Lives campaign. We also analysed interviews conducted The tagline of Australia’s Ice Destroys Lives campaign as part of a cohort study with adults who had a history was “Ice destroys lives. Don’t let it destroy yours”.The of injecting drug use who report crystal methampheta- aims of the campaign were to contribute to “areduction mine use to gather in-depth information. Douglass et al. Harm Reduction Journal (2017) 14:45 Page 3 of 8 Online questionnaire with young people driven sampling. Participants complete an annual inter- The Sex, Drugs and Rock ‘n’ Roll study is an annual cross- view and provide in-depth information on drug use pat- sectional survey of young people conducted by the Burnet terns, health service utilisation and other social outcomes. Institute. Methods have been described previously [20]. In 2016, MIX had 757 participants; the majority were Briefly, we invited Victorians aged 15–29 years to complete male, the median age was 28 years, 59% had a history of an online questionnaire. Participants were recruited from incarceration and 6% reported that methamphetamine social network sites through advertisements on Facebook was the illicit drug they had used most in the past month and Instagram, and posts on Facebook pages that target [22]. Participants from MIX were eligible to complete an young people (such as university pages and community additional face to face in-depth interview focusing on their youth groups). We collected data on participants’ socio- use of crystal methamphetamine if they (1) reported that demographic characteristics, use of alcohol and other illicit they had used crystal methamphetamine more regularly drugs, and a range of other health domains. Upon than heroin or any other drug for a week or more since completion, participants entered into a draw to win a $250 their baseline study visit, (2) could be contacted by supermarket voucher. This study includes data from the telephone to arrange the interview and (3) provided writ- 2016 questionnaire. ten informed consent. Two trained interviewers (authors AP and PH) conducted these interviews, one section of Main outcome measures which explored recall and perceptions of the Ice Destroys We asked if participants recognised Ice Destroys Lives by Lives campaign. Interviews ran between 30 and 60 min providing five still images from the campaign. Those who and participants were reimbursed $40 for their time and recognised the campaign responded to five statements to travel expenses. Interviews with MIX participants were determine their perceptions of the campaign’s accuracy and audio-recorded and transcribed verbatim. effectiveness. Participants stated whether they strongly agreed, agreed, neither agreed nor disagreed, disagreed or Main outcome measures strongly disagreed with each statement. Levels of agreement Participants were asked if they recalled Ice Destroys Lives. were grouped in analysis in three categories: “agree” which Those who did not recall the campaign were shown an ex- combined “agree” and “strongly agree”, “neutral” (“neither cerpt of the advertisement on the interviewer’ssmartphone. agree nor disagree”), and “disagree” (“disagree” or “strongly All participants were asked open-ended questions about their disagree”). All statements were informed by drug experts perceptions of the campaign and whether it represented their and pilot-tested with young people. experiences and use of crystal methamphetamine. Analysis Analysis All quantitative data were analysed using Stata version 13.1. Interview transcripts were uploaded into NVivo 11 for Socio-demographic characteristics are presented as descrip- processing and coding in a de-identifiable form. Authors tive statistics. We used logistic regression to determine if CD and EE performed thematic analysis and used induct- any socio-demographic characteristics were associated with ive, iterative coding. Transcripts were initially coded with crystal methamphetamine use. We calculated the percent- broad open codes which were refined and converged age of participants who agreed, disagreed or remained during the process as deemed necessary. Researcher neutral with each statement on Ice Destroys Lives.Weused triangulation was also implemented, in which transcripts multinomial logistic regression to calculate whether ever were read by the interviewers (AP and PH) to confirm the using crystal methamphetamine was correlated with agree- themes that arose from the analysis. ing, disagreeing or remaining neutral to statements about the campaign. We used “agree” as our reference category to Results produce odds ratios, p values and 95% confidence intervals. Quantitative results from online questionnaire with We ran a second multinomial logistic regression model that young people adjusted for socio-demographic characteristics that we In 2016, we recruited 1029 young people. Their character- identified as significantly associated with using crystal istics appear in Table 1. The majority were female, and the methamphetamine. mean age was 23 years. In total, 54% of participants had ever used an illicit drug. Of all participants, 4% reported Interviews with people who use crystal that they had used crystal methamphetamine in their life- methamphetamine time and 1% had used it in the past month. Using crystal The Melbourne injecting drug user cohort study (MIX) methamphetamine was significantly associated with being was established in 2008, the detailed methods for which older, identifying as male, not living with parents, spend- have been described elsewhere [21]. Participants were ini- ing $120 or more per week for recreational purposes and tially recruited through street outreach and respondent- identifying as non-heterosexual. Douglass et al. Harm Reduction Journal (2017) 14:45 Page 4 of 8 Table 1 Characteristics of participants by crystal methamphetamine use Total Had never used crystal methamphetamine Had used crystal methamphetamine Odds Confidence (n = 1029) in lifetime (n = 955) in lifetime (n = 46) ratio interval n (%) n (%) n (%) Gender Male 278 (27.0) 250 (26.2) 18 (39.2) 1.0 Ref Female 731 (71.0) 688 (72.0) 25 (54.4) 0.5 0.3–0.9* Non-binary, trans or other 17 (1.7) 15 (1.6) 2 (4.4) 1.9 0.4–8.7 identity Born in Australia No 121 (11.8) 108 (11.3) 7 (15.2) 1.0 Ref Yes 891 (86.6) 834 (87.3) 38 (82.6) 0.7 0.3–1.6 Completed post-high school education No 606 (58.9) 573 (60.0) 23 (50.0) 1.0 Ref Yes 423 (41.1) 382 (40.0) 23 (50.0) 1.5 0.8–2.7 Live with parents No 498 (48.4) 446 (46.7) 36 (78.3) 1.0 Ref Yes 531 (51.6) 509 (53.3) 10 (21.7) 0.2 0.1–0.5** Money spent per week for recreation Less than $120 815 (79.2) 771 (80.7) 22 (47.8) 1.0 Ref $120 or more 207 (20.1) 178 (18.6) 24 (52.2) 4.8 2.6–8.6** Live in major city No 103 (10.0) 93 (9.7) 6 (13.0) 1.0 Ref Yes 914 (88.8) 851 (89.1) 39 (84.8) 0.7 0.3–1.7 Heterosexual No 273 (26.5) 240 (25.1) 23 (50.0) 1.0 Ref Yes 756 (73.5) 715 (74.9) 23 (50.0) 0.4 0.2–0.6** Mean age (years) 22.5 22.4 25.2 1.3 1.2–1.5** Percentages may not add up to 100% due to rounding. Numbers may not add up to total as participants who reported “I don’t wish to say” are not shown Ref reference *p < 0.05; **p < 0.001; Non-binary, trans and other identities have been combined due to small numbers Campaign recognition Perceptions of Ice Destroys Lives campaign by crystal The majority of participants recognised Ice Destroys Lives methamphetamine use from the still images provided (69%). Among participants Using crystal methamphetamine was associated with dis- who recognised the campaign, 71% were female and the agreeing with four of the five statements including this mean age was 23 years. Overall, 5% had ever used crystal campaign makes you not want to use ice (OR = 5.0, CI = methamphetamine (n = 33), and of these, 24% had used it 2.3–10.7), accurately portrays therisks of iceuse (OR = 7.0, in the past month (n = 8) (not shown in Table). CI = 3.2–15.4), makes you think that people who use ice are dangerous (OR = 9.6, CI = 3.7–25.2) and this campaign will scare young people off using ice (OR = 4.7, CI = 1.9–11.6) Perceptions of Ice Destroys Lives (Table 2). The exception was this campaign will encourage Participants’ perceptions of the Ice Destroys Lives cam- ice users to seek help; there was no significant association paign appear in Table 2. Of all participants, 75% agreed between disagreeing with this statement and reporting crys- the campaign made them not want to use ice, 55% tal methamphetamine use (OR = 2.7, CI = 0.9–8.0). agreed it accurately portrays the risk of ice use, 46% When we adjusted for age, gender, living arrangements, agreed the campaign will scare youngpeopleoff using money spent per week and sexual identity, disagreeing ice and 84% agreed that the campaign made them think with three of the five campaign statements remained sig- that people who use ice are dangerous. Overall, 47% nificantly associated with reporting crystal methampheta- disagreed that the campaign would encourage ice users mine use. However, the association between using crystal to seek help. methamphetamine and disagreeing with the statement Douglass et al. Harm Reduction Journal (2017) 14:45 Page 5 of 8 Table 2 Young people’s perceptions of Ice Destroys Lives by crystal methamphetamine use Statement Total (n = 711) Had never used crystal Had used crystal Odds 95% confidence Adjusted 95% confidence methamphetamine methamphetamine ratio interval odds ratio interval in lifetime (n = 678) in lifetime (n = 33) This campaign n (%) n (%) n (%) Makes you not want to use ice Agree 535 (75.4) 519 (76.7) 16 (48.5) 1.0 Ref 1.0 Ref Neutral 77 (10.9) 73 (10.8) 4 (12.1) 1.8 0.6–5.5 1.0 0.3–3.3 Disagree 98 (13.8) 85 (12.6) 13 (39.4) 5.0 2.3–10.7** 4.3 1.8–10.0** Accurately portrays the risks of ice use Agree 390 (55.3) 379 (56.4) 11 (33.3) 1.0 Ref 1.0 Ref Neutral 209 (29.7) 205 (30.5) 4 (12.1) 0.7 0.2–2.1 0.5 0.2–1.7 Disagree 106 (15.0) 88 (13.1) 18 (54.6) 7.0 3.2–15.4** 3.2 1.4–7.6* Makes you think that people who use ice are dangerous Agree 597 (84.1) 576 (85.1) 21 (63.6) 1.0 Ref 1.0 Ref Neutral 86 (12.1) 81 (12.0) 5 (15.2) 1.7 0.6–4.6 1.0 0.4–3.1 Disagree 27 (3.8) 20 (3.0) 7 (21.2) 9.6 3.7–25.2** 6.6 2.2–19.8** Will scare young people off using ice Agree 326 (46.0) 319 (47.2) 7 (21.2) 1.0 Ref 1.0 Ref Neutral 211 (29.8) 201 (29.7) 10 (30.3) 2.3 0.8–6.1 1.5 0.5–4.2 Disagree 172 (24.3) 156 (23.1) 16 (48.5) 4.7 1.9–11.6* 2.6 1.0–6.9 Will encourage ice users to seek help Agree 146 (20.6) 142 (21.0) 4 (12.1) 1.0 Ref 1.0 Ref Neutral 228 (32.1) 223 (32.9) 5 (15.2) 0.8 0.2–3.0 0.7 0.2–2.7 Disagree 336 (47.3) 312 (46.1) 24 (72.7) 2.7 0.9–8.0 1.8 0.6–5.5 Percentages may not add up to 100% due to rounding. Numbers may not add up to total as participants who reported “I don’t wish to say” are not shown Ref reference *p < 0.05; **p < 0.001 Adjusted for gender, living arrangements, money spent per week for recreational purposes, sexual identity and age this campaign will scare young people off using ice did not recalled seeing it, four reported they had not seen it and four remain significant (AOR = 2.6, CI = 1.0–6.9) (see Table 2). participants were unsure. After being shown an excerpt of the video advertisement, those participants who were ini- Qualitative results from in-depth interviews with adults tially unsure reported that they did recognise the campaign. who inject drugs Sixty participants from MIX were eligible to participate in Perceptions of Ice Destroys Lives campaign an in-depth interview focusing on crystal methampheta- The main theme that emerged during the interviews was mine use. When researchers attempted to contact eligible that Ice Destroys Lives misrepresented the experiences of participants, most phone numbers were disconnected. Of people who use crystal methamphetamine. However, participants who could be contacted, 14 consented to three participants acknowledged that some elements of participate and two declined. Most participants identified the Ice Destroys Lives campaign were accurate, including as male (n =12) and were aged 29–39 years. Almost all sleep deprivation, hallucinations and the portrayal of participants interviewed were unemployed and lived in gov- crystal methamphetamine as a “very destructive drug”. ernment housing. Approximately two thirds (n =10) were on opiate substitution therapy. Nine of the 14 participants Yeah, that’s pretty accurate…I’ve been in some reported that heroin was their drug of choice at the time of situations like that (male, 39 years). the interview, while the remaining five nominated crystal methamphetamine as their drug of choice. Alternatively, nine participants felt that Ice Destroys Lives was sensationalised and exaggerated “the nasty side” Campaign recognition and recall of crystal methamphetamine use. Terms used to describe Recall of the Ice Destroys Lives campaign among adults who the campaign included “confronting”, “jumping the gun” used crystal methamphetamine was mixed; six participants and “pretty wrong”. When asked, five participants stated Douglass et al. Harm Reduction Journal (2017) 14:45 Page 6 of 8 that the campaign was unlikely to prevent them from Young people’s perceptions of Ice Destroys Lives using crystal methamphetamine or encourage them to The main aim of Ice Destroys Lives was to “contribute to a seek help, with one participant suggesting that “There just reduction in the uptake of illicit drugs among young needs to be more help out there I think” (male, 35 years). Australians”. In our questionnaire, three quarters of Despite acknowledging the harms of ice, most partici- participants reported that the campaign made them not pants felt that Ice Destroys Lives did not accurately portray want to use ice and 46% agreed it would scare young their personal experiences or behaviours. Their criticisms people off using ice. This suggests that the campaign centred on the violence depicted in the campaign with reached its target population with a prevention message, seven participants stating that “it doesn’t apply to me”. reflecting results from the original evaluation report [17]. However, our findings show that the campaign also had Like sometimes when I’monitIgetabitrowdy butI adverse effects: 84% reported that the campaign made don’t go out there causing trouble. I don’twant to get them think that people who use ice are dangerous and 47% in trouble. I have my own things to do (male, 37 years). disagreed that the campaign encouraged help-seeking behaviours. This suggests that Ice Destroys Lives also deliv- While participants eagerly explained that the campaign ered stigmatised messages to its target audience. There misrepresented their personal circumstances and behav- were significant differences in young people’sperceptions iours, they also believed that Ice Destroys Lives did not of Ice Destroys Lives based on crystal methamphetamine represent other people who use crystal methampheta- use. Participants who had previously used crystal metham- mine. Ten participants mentioned that all people have phetamine were significantly less likely to believe that the different experiences when using the drug. campaign was accurate, helpful or effective. Alternatively, participants who had never used crystal methampheta- Just not all ice users do that. It’s basically saying that all mine were more likely to agree that the campaign made ice users are likely to do that, you know (male, 38 years). them think that people who use ice are dangerous. This reinforces the evidence that mass media campaigns such According to participants, Ice Destroys Lives depicted as Ice Destroys Lives contribute to negative stereotypes only the “worst case scenarios” to frame all people who and are unlikely to increase help seeking for people who use crystal methamphetamine in a negative light. Partici- use crystal methamphetamine [12]. This provides support pants felt that Ice Destroys Lives exacerbated negative for allocating funds to targeted prevention and evidence- stereotypes and created fear throughout the community. based strategies focusing on high-risk groups rather than They discussed the role of sensationalised media report- generalist mass media campaigns targeting all young ing contributing to assumptions and labels that commu- people [23]. nity members imposed upon them. Perceptions of the campaign among adults who use Just some people think that you are going to go crazy crystal methamphetamine or yeah. They just show so many people who have When interviewed, adults with a history of injecting drug gotten violent whilst using ice and that, bashing bus use who had used crystal methamphetamine generally did drivers and that. They think that everyone who uses it not identify with the violent behaviours depicted in Ice is going to get like that…They think that all ice users Destroys Lives. They distanced themselves from the deviant will, just you know, bash them or rob them or do characters that were portrayed; however, they felt that the something (male, 38 years). wider community still labelled them as “violent” and “crazy” based on the “worst case scenarios” shown. Participants felt that the campaign did not encourage them to seek help nor Discussion would it prevent them from using crystal methampheta- Recognition and recall mine in the future. Shock-based campaigns often frame This manuscript draws on data from two studies to crystal methamphetamine use as an individual-level prob- explore perceptions of Australia’s Ice Destroys Lives cam- lem [12, 14, 24] evidenced in this campaign by the tagline paign among young people and adults with a history of “Ice destroys lives. Don’t let it destroy yours”.Campaigns injecting drugs. Our results suggest that the majority of can also evoke fear throughout communities by linking young people surveyed recognised the campaign, aligning crystal methamphetamine use to violence, criminal activity with findings from the original evaluation of the campaign and immorality [25]. Language is important and can be [17]. Ice Destroys Lives was also highly recognised by stigmatising [26], and some suggest that use of aggressive participants who used crystal methamphetamine, suggest- and discriminatory language frames all people who use ing that it is important to consider the implications this crystal methamphetamine as worthless and problematic campaign had on other audiences. [23]. This attitude can subsequently act as a barrier for Douglass et al. Harm Reduction Journal (2017) 14:45 Page 7 of 8 treatment and increase stress and isolation among people information on the effects of media campaigns on adults who use crystal methamphetamine [26, 27]. Consumer with a history of injecting drugs. Initially, 60 MIX partici- representatives have encouraged the Australian government pants were eligible for interviews focusing on crystal to alter their approach to ensure that future strategies are methamphetamine; however, most of their telephone inclusive, evidence-based and cost-effective [23]. numbers were disconnected, and we were unable to con- tact them. Participants who were contactable by telephone Limitations may differ from the participants we were unable to reach. This study has some limitations. We recruited young However, of participants who were contacted, the re- people for the Sex, Drugs and Rock ‘n’ Roll survey through sponse rate was high and their socio-demographic charac- convenience sampling from Facebook and other social net- teristics reflected the MIX sample. work sites. This sampling technique generally recruits a higher proportion of females than males, people with Conclusions higher levels of education and individuals who have an Ice Destroys Lives was well recognised and delivered a pre- interest in the topic [28, 29]; it is unlikely our sample is rep- vention message to young people in our study; however, resentative of all young Victorians. Only 33 participants among young people who had ever used crystal metham- from the online survey who were included in logistic re- phetamine, the campaign was less well perceived. Our study gression had used crystal methamphetamine in their life- also provides important evidence that adults with a history time, and of these, 24% had used the drug in the past of injecting drug use recalled this shock-based campaign month. Consequently, confidence intervals lack precision, but did not identify with the behaviours portrayed. Implica- and results do not capture the perceptions of young people tions included feeling misrepresented and being negatively who have recently engaged in crystal methamphetamine labelled, likely contributing further to discrimination and use. Future studies should recruit a larger sample of young stigma within the community. The Australian government’s people engaged in drug use and differentiate results by aim of targeting methamphetamine-related harms is com- usage patterns. Although statements in our survey were mendable; funding for evidence-based strategies that are in- pilot-tested andinformedbyexperts, we did not usea formed by experts and high-risk groups in an inclusive validated tool to measure young people’sperceptionsof Ice manner wouldbeamoreeffectiveuse of future resources. Destroys Lives. In addition, although we adjusted for age, Abbreviations gender, living arrangements, money spent per week and MIX: Melbourne injecting drug user cohort study sexual identity, there may have been other variables that in- fluenced young people’sperceptions of Ice Destroys Lives Acknowledgements such as political orientation and social networks [30]. All The authors wish to thank all the participants who took part in the Sex, Drugs and Rock ‘n’ Roll and MIX studies. We gratefully acknowledge the MIX data were self-reported and may have been influenced by fieldwork team who assisted with initial participant recruitment, study design social desirability bias; however, this was minimised by the and follow-up. anonymity of the survey's online platform. Funding We recruited participants of the existing MIX study No specific funding was received for this study. Funding for the MIX study is who use crystal methamphetamine through purposive provided by National Health and Medical Research Council (NHMRC) and the sampling. Although this recruitment method does not Centre for Research Excellence on Injecting Drug Use. The 2016 Sex, Drugs and Rock ‘n’ Roll study was funded by the Burnet Institute. The authors gratefully capture a representative sample, it allowed us to access acknowledge the support of the Victorian Operational Infrastructure Support individuals who are typically hard-to-reach and could pro- Program received by Burnet Institute. Cassandra Wright is supported by an vide in-depth information for our research aims [21]. The Australian Government Research Training Program Scholarship. Megan Lim is supported by the Jim and Margaret Beever Foundation. Paul Dietze is participants we interviewed were a highly marginalised supported by an ARC Future Fellowship and has received funding from Gilead group; most were unemployed, lived in government hous- Sciences and Reckitt Benckiser for work unrelated to this study. The funding ing and involved in treatment programs. It is likely that bodies were not involved in study design, collection, analysis or interpretation of data or in writing the manuscript. their past experiences increased their negative perceptions of the campaign. The MIX participants were significantly Availability of data and materials older than the target population of Ice Destroys Lives and The datasets analysed during the current study from Sex, Drugs and had a history of injecting drugs; qualitative results are Rock’n’Roll and MIX study are not publicly available due to them containing information that could compromise participant privacy/consent. therefore not applicable to younger people who use crystal methamphetamine recreationally and may use by modes Authors’ contributions besides injecting. In future, it would be beneficial to evalu- CD was involved in online survey recruitment and data collection, data ate similar campaigns with younger people based on pat- analysis and led the writing of the manuscript. EE and CW were involved in quantitative and qualitative data analysis. PH was involved in study design terns of usage. However, one aim of this study was to and interviewing. AP conducted interviews and assisted with data analysis. assess impacts of the campaign on those outside the target BQ provided input into data collection and analysis for both studies. PD had group; therefore, our study provides important input into the data collection and leads the MIX study. ML conceived the Douglass et al. Harm Reduction Journal (2017) 14:45 Page 8 of 8 manuscript and leads the Sex, Drugs and Rock’n’Roll study. All authors have evidence. Drugs: Educ Prev Policy. 2004;12:247–8. doi:10.1080/ contributed to and approved the final manuscript. 09687630500070037. 14. Ferestad J, Thompson M. “I’m Not Gonna Be Like ‘That Guy’”: examining Ethics approval and consent to participate antidrug shock advertising through the eyes of “That Guy”. Deviant Behav. The Sex, Drugs and Rock ‘n’ Roll (Project number: 326/08) received ethical 2016;38:173–87. doi:10.1080/01639625.2016.1196971. approval from the Alfred Health Human Research Ethics Committee. 15. Anderson DM, Elsea D. 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Published: Jul 14, 2017

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