Social Marketing As Prevention: Uncovering Some Critical Assumptions

Lawrence Wallack, University of California, Berkeley
ABSTRACT - Social marketing may be a valuable approach to preventing public health problems. To be effective, however, social marketers must examine the basic assumptions on which prevention concepts are based. This paper explores some of these assumptions.
[ to cite ]:
Lawrence Wallack (1984) ,"Social Marketing As Prevention: Uncovering Some Critical Assumptions", in NA - Advances in Consumer Research Volume 11, eds. Thomas C. Kinnear, Provo, UT : Association for Consumer Research, Pages: 682-687.

Advances in Consumer Research Volume 11, 1984      Pages 682-687

SOCIAL MARKETING AS PREVENTION: UNCOVERING SOME CRITICAL ASSUMPTIONS

Lawrence Wallack, University of California, Berkeley

[I wish to thank Peter Fisher for his expert word processing work on this paper.]

[Dr. Wallack is an Assistant Professor in the School of Public health. In addition, he is the Scientific Director of the PRC: A National Center for the Study of Environmental Approaches to Prevention. Work on this paper was partially supported by a National Alcohol Research Center Grant (#1P50AA06282-01) from the National Institute on Alcohol Abuse and Alcoholism to the Pacific Institute for Research and Evaluation.]

ABSTRACT -

Social marketing may be a valuable approach to preventing public health problems. To be effective, however, social marketers must examine the basic assumptions on which prevention concepts are based. This paper explores some of these assumptions.

INTRODUCTION

Social marketing has been suggested as an approach to generating planned social change (Kotler and Zaltman 1971; Kotler 1982; Sheth and Frazier 1982; Fox and Kotler 1980). it has been noted that social marketing may be especially useful in efforts to change consumer behavior in health-related areas (Fox and Kotler 1980; Solomon 1979). The health policy direction emphasizing prevention that has emerged out of the 1970s provides an excellent opportunity for social marketing approaches to be brought to bear on significant public health problems. The definition of health problems as problems of individual consumption forms a strong rationale for the use of marketing techniques to "unsell" unhealthy behaviors or, conversely, to promote healthy behaviors. This paper explores the barriers that social marketing must address if it is to be successful.

The first part of this paper addresses the implications of the two major health policy documents that were published in the 1970s. Subsequent discussion focuses on the relationship of social marketing to prevention, and the major barriers to be addressed in prevention.

THE HEALTH POLICY BASIS FOR PREVENTION

The publication of two major health policy documents in the 1970s was heralded to be the opening shots in a new public health revolution. Both reports recognized the limits of the medical care system in increasing the health status of the general population. The reports, one on the health of Canadians (Lalonde 1574) and the other by the United States Surgeon General (USDHEW 1979), elaborated the need for a significant shift toward the prevention of disability and premature death and the general promotion of health.

The thrust of the reports was that health is a function of an interaction between the individual and the larger social and physical environment. The reports, however, while emphasizing individual lifestyle factors and environmental conditions as the primary determinants of health, have been used not as a starting point for a revolution but as a renaissance for individual-based behavior change strategies. An extensive critique of the American report, for example, found that the po]icy recommendations primarily addressed individual behavior change strategies. Strategies focussing on factors in the social arc economic environment that, to a large extent, determine individual behaviors were substantially ignored (Neubauer and Pratt 1981)

A critique of the Canadian report and the program experience that has emerged from it also pointed to a lack of attention to environmental factors that contribute extensively to the health status o, communities. Rather than being an impetus for significant change, the Canadian report was viewed as reinforcing a "victim blaming" ideology and supporting the notion that health is primarily dependent on the lifestyle choices made by individuals. Stated another way, the critique found that health promotion programs, in practice, are based on the assumption that individuals are responsible for choosing their own health status (Labonte and Penfold 1981).

In summary, the American and Canadian reports have contributed to a definition of health that is centered on the individual and based on a marketpLace ideology (Beauchamp 1976). health, it is implied by the reports, is primarily determined by the consumption choices that individuals make. The producers in the "marketplace" bear little if any responsibility for health or illness because they are only responding to the messages sent by the consumers. Galbraith (1975) notes how the economic system distances itself from assuming responsibility:

If the goods that it produces or the services that it renders are frivolous or lethal or do damage to air, water, landscape or the tranquility of life, the firm is not to blame. This reflects the public choice. If people are abused, it is because they choose self abuse (pp. 5-6).

In addition, the medical establishment, which has absorbed enormous levels of resources with relatively little return in increased health status for the general population (e.g., Haggerty 1972; Knowles 1977), similarly distanced itself from prevention. As then-Secretary of Health, Education and Welfare Joseph Califano noted in his introduction to the Surgeon General's Report:

You, the individual, can do more for your own health and well-being than any doctor, any hospital, any drug, any exotic medical device (USDHEW 1979).

The consumer, detached from the health care system and apparently responsible for the Unhealthy and unsafe environment in which s/he lives, is left to stand alone against the ongoing "commercial assault on health" (Crawford 1977). The problem resides in the choices that individuals make and hence, the solution is to change how individuals make choices. The consequence of this definition of the problem is that important variables that determine the range of choices that individuals can make about their health are ignored in the planning of policies and programs.

PREVENTION AND SOCIAL MARKETING

Social marketing, in general, is the application of marketing principles to the promotion of socially benefic al goods. These goods might be ideas, causes, behaviors, or perhaps specific services. Implicit in the concept of social marketing is the assumption that an exchange process between the producer and the consumer is facilitated by the provision of knowledge and product availability. Ideally, the exchange benefits the consumer and producer on a basis such that both obtain an acceptable level of satisfaction.

Social marketing of health issues fits well with a general concept of prevention. Effective social marketing regarding the package of behaviors that influence lifestyle factors presumed to contribute to various chronic diseases and acute problems may well prevent or minimize the incidence of disability and premature death. Social marketing, however, faces many of the same barriers to change as prevention programs ar,d policies. Before addressing these barriers it is useful to consider, in general, the nature or prevention and social marketing.

Prevention

Primary prevention is a public health term that can be defined as activities, programs, or policies designed to reduce the incidence or the number of new cases of a disease or problem. Based on the public health model, prevention can be accomplished by reducing exposure to the causal agent or altering the susceptibility of the person. [Marketing, on the other hand, seeks to increase exposure to the product and increase, rather than decrease, the susceptibility or the individual to the marketing goal (i.e., consumption).] Primary prevention efforts can be categorized in the following areas: health promotion, disease prevention, and health protection.

Health promotion strategies are based on the assumption that the most effective way of attaining a longer and healthier life is by continuing or adopting good personal health practices. These practices address cigarette smoking, alcohol consumption, diet, and exercise-related behaviors. Health promotion is targeted to a healthy population and provides knowledge, and sometimes specific skills, to help people lead a healthy lifestyle. Although, in theory, health promotion points to the need for a supportive environment to facilitate the choice of healthy behaviors, such attention to the environment is seldom seen in practice.

Disease prevention programs usually provide spec,tic preventive services to high risk populations in order to prevent or minimize the development of further problems. Disease prevention strategies are illustrated by stress reduction programs for police officers, screening for people from families with poor health histories, or counseling for children of alcoholics. Like health promotion approaches, disease prevention primarily focuses on the individual as the point of intervention.

Health promotion and disease prevention programs are closely related. t;any times the definitional lines disappear. For example, some programs described as health promotion in the workplace really provide services for at-risk workers and are more accurately described as disease prevention efforts. Some programs may use both types or approaches. Based on available data the success of health promotion/disease prevention programs, in general has yet to be demonstrated. Yet there can be little practical doubt that efforts to reduce the susceptibility of individuals to disease by providing information and education, or more intensive personal counseling services is an important part of a comprehensive prevention approach.

Health protection is the third approach to the primary prevention of public health problems. Health protection uses passive rather than active strategies and is targeted to the entire population. The strategies are considered passive because they do not require individuals to take any action to be protected--protection is automatic. While health promotion and disease prevention attempt to prevent problems by altering the individual, health protection attempts to reduce exposure to the cause of the problem by altering the environment around the individual.

Health protection strategies, historically, have proven to be the most effective public health prevention measures. Because these strategies emphasize regulatory measures that primarily place the burden of responsibility on producers, there is a long history of resistance associated with the promotion of such strategies. Health protection measures such as motorcycle helmet laws and product safety regulations continue to generate controversy today because of presumed conflicts with individual liberty and free market concepts. [Regulation of advertising for cigarettes or alcoholic beverages also represent a health protection approach.] The critical balance between the collective good and the rights of the individual has significant implications for prevention and social marketing approaches.

In summary, primary prevent- on encompasses a range of strategies directed toward various populations. Although prevention approaches are usually viewed as efforts to change individual behavior this need not be the case. The concept of prevention recognizes that health behavior and health problems are a function of the interaction between the individual and the larger environment. Prevention approaches, therefore, must necessarily be directed toward the many levels ,n the larger system including, but not limited to the individual.

Social Marketing

Primary prevention and social marketing both evolve from a broad conceptual base that understands individual behavior as it is linked to a larger environment. Social marketing can be seen as an alternative to existing prevention efforts; one that uses a special set of techniques and ways of analyzing problems. It appears that in the area of risk factors, such as cigarette use, alcohol consumption, diet and exercise, social marketing perspectives are merging with public health prevention approaches to develop innovative programs (e.g., Solomon 1979; Wallack and Barrows 1983). Thus, it appears appropriate to move toward an integration of these concepts.

Fox and Kotler have emphasized that, particularly in the area of smoking, social marketing can provide a framework to tie together and coordinate isolated and fragmented approaches to health problems (Fox and Kotler 1980-81). Social marketing takes the planning variables from marketing - product, promotion, place, and price-reinterprets these variables for a particular health or social issue, and frames the planning process in the context of a larger environment of economic, political, technological, cultural, and education factors. The planning process also includes selection of primary markets for targeting and identification of appropriate mass and interpersonal channels of communication (Kotler and Zaltman 19715.

The emphasis of social marketing on Product, price, Place, and promotion is consistent with the public health approach to prevention in both a general and specific sense. In a general sense, behavioral medicine programs have found that the product for helping change behavior has to be well packaged, attractive, and easy to use. The "product" might be an actual product such as a cookbook or a guide to initiating exercise, or it might be a service such as a weight reduction program. But, as Salomon (1579) points out, the product is the focal point of the exchange of information between the consumer and the marketer or program staff. The product is information.

The Place and price address the issue of availability of Socio-cultural and physical situations in which to act on the information or "use the product." If there is a social place (meaning a situation with supportive socio-cultural norms) or a physical place (e.g., legislated nonsmoking areas) then the product (information) is more likely to be used and the desired outcome to occur. The use of the product is linked to the price or, more appropriately, cost of using the product. Is there a loss of status from product use? Is product use time consuming? Does it lead to other problems? Is the price of obtaining the product, relative to obtaining other goods, consistent with the economic value system of the larger group?

The promotion of public health behaviors can be seen in two ways. First, is the desired behavior from the use of the product supported by the broader social institutions and the values these institutions communicate? Second, are alternative behaviors promoted through the larger environment that provide significant support for behaviors that are inconsistent with good individual and community health practices? Social marketing approaches might "kick off" a healthy diet effort by mounting an extensive promotion using various moss media and interpersonal approaches. This is an approach that public health and behavioral medicine are. of course, quite comfortable with. Public health professionals, however, also would likely want to remove or more tightly control the level of promotion supporting unhealthy dietary choices by working toward increased regulation of marketing activities.

In a specific sense, social marketing and public health approaches to such issues as cigarette smoking and alcohol use are quite similar. Fox and Kotler's presentation of tactics for a program to countermarket smoking includes many strategies for either making the product safer or lowering the availability and social support for the use of the product by focusing on price and place (Fox and Kotler 1980-81). This is easily translated into public health strategies that seek to protect the individual by decreasing exposure to significant causal factors in the larger environment (reducing availability) or by reducing the health hazard potential of the product. Other social marketing strategies for addressing cigarette smoking would focus on reducing promotional opportunities for cigarette companies and increasing promotional opportunities for anti-smoking groups.

Social marketing and public health can easily be seen as similar in what they hope to accomplish but will differ in the way data are used, arguments are constructed, and strategies elaborated. In terms of implementation, both approaches can easily blend together and often do. The purposes of both approaches are not dissimilar. The intention is to empower consumers with accurate information and ensure an environment that is conducive to using that information in an effective manner. Public health will tend to emphasize the importance of controlling the environment as a way of decreasing individual susceptibility to problems while social marketing will likely be more optimistic about being able to "outmarket" the existing "anti-health" factors in the environment, thereby downplaying the need for increased formal regulation and control. True to marketing principles, social marketing, no doubt, will view the consumer as in greater control and the environment as somewhat less important.

BARRIERS TO PREVENTION: THE INDIVIDUAL FOCUS

In theory, both public health and social marketing approaches to prevention place considerable emphasis on the need to alter the physical and social environment [Both approaches may define the various components of the environment differently. However, the awareness that the environment, no matter how defined, is important in understanding consumer and health behavior is common.] that significantly contributes to health status. in practice, however, efforts to alter risk factors associated with higher levels of problems often focus only on individual behavior and, for the most part, ignore the environment which influences these behaviors. The "new" health policy direction that emerged during the 1970s has served to reinforce individual oriented strategies and has failed to direct significant attention to environmental factors. This continued focus on changing individual behavior as perhaps the single greatest obstacle to the prevention of significant public health problems.

There are two reasons why the emphasis on individual factors is so great. First, it fits well with dominant research models that we use to define and understand problems. Second, it is consistent with a larger societal ethic that exalts individual responsibility. Increased understanding o the research and ethical issues that shape prevention and social marketing strategies is important .if we are to move beyond current, lower potential, approaches.

Research and Definitional Issues

The way that a problem is defined determines the types of strategies that we can use to address that problem (e.g., Powles 1979; Blum 1980). We tend to define problems in line with the methods we have to gain knowledge about them in a way that is considered "true" or "valid" and consistent with the interventions or solutions with which we are most skilled (Caplan and Nelson 1973) and which fit best with the values of the decision makers in the larger society (Beauchamp 1976). Research into health and social problems, like study in the biological sciences, tends to be based on the experimental approach or "scientific method" as the ideal way of gaining knowledge. Grant review panels that make recommendations for research and demonstration funding rely on a basic criteria that heavily weights conservative and traditional notions of what constitutes good science. Grant proposals that adhere more closely to the experimental approach tend to get funded; proposals that rely on less accepted methods or methods perceived as less rigorous (e.g., anthropological approaches) tend not to be funded.

The purpose of the experimental approach is to isolate a specific cause for every effect. The doctrine of specific etiology (the view that specific diseases had one specific isolatable cause) was the basis for 19th century medical discoveries that identified the causes of various infectious diseases. Yet the decline in the incidence of these diseases began before specific causes had been isolated. The biological causes were always necessary but never sufficient to cause a specific disease. The effective techniques to prevent infectious diseases were due primarily to increases in the quality of the social and physical environment and not through medical technology (Dubos 1955; McKeown 1579; Turshen 1979). Breakthroughs in prevention came from more holistic, naturalistic observational methods than from tightly controlled experimental approaches.

The experimental approach is best suited to study the individual and sub-individual level. The strength of the model, in part, is linked to the assumption that external variables can either be controlled or are not relevant to the problem. This assumption, particularly as relates to health, is not well founded. The experimental approach has been quite useful but the inherent limitations of this process, often not recognized by researchers and policy makers, can be quite serious:

The experimental approach . . . has led by necessity to the neglect and indeed has often delayed the recognition, of the many other factors that play a part in the causation of disease under conditions prevailing in the natural world for example, the physiological state of the infected individual and the impact of the environment in which he lives (Dubos 1959:106-107).

This individual based model has clear political and economic implications. Reverby (1972) points out that the biomedical model historically has allowed medical scientists to "'scientifically' ignore 'unscientific"' environmental and social factors." Thus, the research model supports a definition of the problem that reinforces individual-oriented approaches. This does not mean that individual explanations are "true," only that we are willing to define the problem based on the needs of the research model and not how the problem exists in natural settings.

In summary, the individual-based research model that attempts to explain larger social problems by examining individual behavior serves to reinforce "victim blaming" (Ryan 1976). The separation of the individual from the larger social, economic and political context results in ar understanding of the problem that car never be adequate for developing appropriate interventions. As Milton Terris noted in his 1967 Presidential Address to the American Public Health Association:

There is a strong current trend to divorce individual behavior from its social base. The social sciences are being redefined as "behavior" sciences, and emphasis is placed on the study of individual behavior per se. This general orientation is reflected in the tendency of public health theory to focus on individual behavior and lose sight of the larger social parameters that determine such behavior. The result is an impoverishment of the armamentarium of public health, which is thereby hindered from grasping the complex realities of the new problems and forging the necessary tools for their solution (1968:6).

Ethical Concerns

The second major reason that helps to explain why we continually focus on individual behavior is the larger social ethic that emphasizes and reinforces individual level responsibility.

The genera. principles that lead us to search for individual level factors to explain social and health problems also define the ethical dimension of the issue. Research and programming reflect a deeply held value in American society concerning the role of the individual and where the responsibility for personal and social well being resides. This is an ethical value. It makes a statement about fairness because it directs the allocation or responsibility for well-being or the change necessary to obtain such a state. In America the dominant ethical value that underlies most public health and medical care programs has been identified as market-justice.

Market-justice is solidly based on traditional American ideals of rugged individualism and self-determination. Lynd (1964) has identified a set of assumptions to which Americans are strongly committed. These assumptions, and the values they reflect, form the basis for the market-justice paradigm:

1. That people are rational, car and do know what is best for them, are free to choose, and will accordingly choose wisely.

2. That the 'greatest good to the greatest number' occurs when individual enterprise is left free from controls in the interest of any type of planned pattern.

3. That any design or unity in pattern which is useful can be depended on to develop automatically under the fractions of competing individual self interests (pp. 64-65)

These represent, in general, the classic economic assumptions regarding the marketplace. In short, they suggest health is the choice of the consumer and the freer the market-place is of restraints the greater the opportunity for people to maximize their health. This image of choice, so strong]7 put forth in economics and prevention, is also hinged on a fourth assumption implied by the first three. This fourth assumption is that major social and political institutions are neutral: in general, each person is seen to be without major disadvantage that cannot be overcome by individual effort. The final assumption is especially problematic because, as John Rawls (1971) notes, societal institutions greatly favor some starting places over others and reinforce deep inequities.

The manner in which market-justice forms the basis for public health programming has been elaborated by Dan Beauchamp (1976). He characterizes the market-justice ethic as ore which emphasizes individual responsibility and the pursuit of self-interest. People are seen as having a minimal responsibility to the collective good and all enjoy freedom from collective obligations except for the responsibility to observe the basic rights of others. Because behavior is seen as volitional in nature, the individual is viewed as responsible for all consequences of her/his behavior. Beauchamp has called the market-justice ethic the most critical barrier to prevention efforts.

The market-justice ethic can be seen in the way that the "fallacy of choice" is reinforced by the corporate economy. Public health and prevention programs that are based on the critical assumption that individuals make choices about their health that are essentially unfettered by environmental forces are misleading and often counterproductive in that attention is deflected away from important environmental factors that materially contribute to health and social problems. Action against advertising, for example, is seldom a focus of formal preventive efforts because it is seen as a corporate exercise of freedom of speech that in turn is intended to facilitate the freedom of choice by the consumer. This is strange indeed! Advertising is often justified on the grounds that it provides consumers with useful information about products. Yet, alcohol and tobacco advertising, (products strongly linked with excess mortality) seldom, if ever, contain any objective product information (Mosher and Wallack 1981; Wallack 1983a).

This individual level orientation is ethically and practically tolerable for two reasons. First, it is ethically tolerable because the person with the problem is seen to have gotten his/her just desserts: they have chosen their behavior knowing the risk of adverse consequences. This lengthy quote from John Kenneth Galbraith (1975) captures part of the reason that we see the individual problems and suffering as apart from the larger system:

The imagery of choice has a yet more important effect. It means that this choosing--the decision to purchase this product--is what, when aggregated controls the economic system. And if choice by the public is the source of power, the organizations that comprise the economic system cannot have power. They are merely instruments in the ultimate service of that choice. Perhaps the oldest and certainly the wisest strategy for the exercise of power is to deny that it is possessed. Monarchs, including the most inimical of despots, long pictured themselves as the mere projection of divine will. This is the established religion then affirmed. It followed that their behavior, however scandalous, expensive and damaging to health, life, livelihood or common decency, could not be questioned, at least by the true believer. It was in the service of higher will. The modern politician perpetuates the same instinct when he explains, however unconvincingly, that he is only the instrument of his constituents, the expression not of his own preferences but of the public good (p. 5).

On a practical level we accept such a system because we like to think that we have power over our environment. How frustrating to feel that our fate resides primarily in factors outside our control, factors imposed on us. In addition, this system often works for the majority, as it is usually a minority that suffers the social and health problems that prevention programs seek to address Our safety and health behavior has been likened to a lottery (Beauchamp 1981). Basically we bet that we will win and the other person will lose and usually we do win. The big losers are those who become disabled or die from the range of 'voluntary' behaviors that contribute to excess mortality. The big winners are those who gain considerable profit from the consumption of potentially harmful products. The rest, the large majority, escape the added costs of a few cents on a product or enjoy the minimal increase in convenience of not having to fiddle with a child-proof cap or put on a seat be,t. The winners don't want change, the losers are powerless to change, and the majority does not want to give up the small conveniences and do not relate their own behavior to the big losers anyway.

DISCUSSION

How we determine what is scientific in research and what is ethical and fair in distributing responsibility depends on the basic values that we as individuals and a society embrace. These basic values are important in understanding what prevention means as compared to what prevention is. Currently our societal values in this area reinforce a "blaming the victim" approach that has little chance of significantly reducing the serious public health problems we seek to address. Blaming the victim means that we understand and react to social problems as fa-lures of the individual to adequately adapt to the larger system. By focusing on the victim we fail to ques.ion the conditions outside the individual that give rise to and sustain these problems.

An important first step in moving toward more effective prevention policies and programs is to broaden the way that the problem is defined. This means de-emphasizing primarily individual level explanations of the problem and increasing the emphasis on community or societal level explanations. Along with this broader definition of the problem goes a broader distribution of responsibility for preventing the problem. The responsibility becomes shared more equitably across the various interests that have a stake in the problem. Because these problems ultimately or potentially effect the well-being of the entire community or society, the sacrifice for addressing public health problems should be borne collectively.

Social marketers can play an important role in the prevention of public health problems in several ways. First, they can continue to work with health education and communications people to increase the effectiveness of mass media efforts in providing much needed information and skills to the general population. Second, social marketers must turn their creative energies tow-and educating decision makers and gate keepers about the following principles:

1. health behavior and health problems are inextricably linked to a larger social and political environment and thus prevention approaches need to account for this in planning;

2. prevention strategies must address problems on several levels and not just one--health problems are complex and will inevitably require varied methods with different populations in different settings;

3. prevention is a collective responsibility that must be shared and not placed solely on the individual with the problem or at-risk;

4. prevention approaches need to have long-term support in order to address serious public health problems such as the consequences of alcohol and cigarette use--short-term, fragmented approaches which have characterized many previous efforts will never be adequate to create meaningful change.

If we are to see changes in the health status of the population it will be necessary to begin a serious re-examination of the basic assumptions on which prevention strategies are based. Hopefully, social marketers will lend their talents to help meet this challenge.

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