Social Media and Youth Substance Use

SOCIAL MEDIA FOR HEALTH PROMOTION WITH YOUTH
2012

AND YOUNG ADULT SUBSTANCE USE
A resource and evidence review

Prepared by Cameron D. Norman
CENSE Research + Design

SOCIAL MEDIA FOR HEALTH PROMOTION WITH YOUTH
AND YOUNG ADULT SUBSTANCE USE
A Resource and Evidence Review
April 25, 2012

Prepared by:

Cameron D. Norman PhD, Principal
Toronto, ON Canada

For Health Canada, Tobacco and Drugs Initiative

CENSE
Research + Design

Acknowledgements

The author wishes to acknowledge the contributions of Bruce Baskerville, Jack Boomer, Rebecca Haines-Saah, Tyler Janzen,
Jessica Patterson, Lisa Campbell Salazar, Andrea Yip and a community of Twitter users and online contributors for providing
expert opinion, key resource referrals, feedback and commentary on this topic in support of this report’s development.

Special thanks to The Public Health Studio for producing the graphical design elements for this report and formatting it for
production.

For more information about the contents of this report contact:

Cameron Norman PhD
Principal
info@cense.ca
www.cense.ca

Please cite as:
Norman, C.D. (2012). Social Media for Health Promotion with Youth and Young Adult Substance Use: A Resource and Evi-
dence Review. Report submitted to Health Canada (Tobacco and Drugs Initiative). Toronto, ON: CENSE Research + Design.

The views expressed herein do not necessarily represent the views of Health Canada.

TABLE OF CONTENTS

01 Executive Summary 01

02 Introduction 02

03 Context 03

04 Methods of Investigation 06

05 Review of the Scholarly Literature 08

06 Social Media Content Review 11

07 Practitioner Perspectives 20

08 Conclusions & Limitations 24

09 Recommendations 28

10 References 32

11 Appendix 1 37

01

EXECUTIVE SUMMARY
Social media has changed the way that youth and young adults communicate
with themselves and the world, and has opened up significant new opportunities
for health promotion on issues of substance use.

A multi-method review was undertaken to look at the application of social media to youth and young adult sub-
stance use with emphasis on Canadian examples. This included: 1) a search of applied health sciences databases;
2) a literature review; 3) a search of the open web and specific social media networks (e.g., Facebook, Twitter,
and YouTube) for examples of social media interventions; and 4) informal interviews conducted with practitio-
ners and researchers working in the field of social media and youth substance use to gain insight into issues not
captured elsewhere.

The review of the scholarly literature found few examples to illustrate effective interventions using social media
and offered little guidance on appropriate evaluation methods. Text messaging was the only intervention format
that had enough evidence to assess effectiveness, showing modest impact on tobacco and alcohol use.

Examination of examples of social media applications to youth and young adult substance use found a broad
field with varying levels of informational depth, opportunities for youth engagement, and quality. The design
features of these resources was also varied as some were visibly part of a larger integrated strategy, while others
were single pages or videos with limited to no connection to other resources or even the organization or program
responsible.

Practice and research experts were consulted to provide additional contextual information about the challenges,
opportunities and lessons learned from using social media for youth substance use prevention and treatment.
Experts emphasized the need to engage youth early on in the design process and keep them engaged in the
deployment of the social media strategy, to pay attention to equity issues and recognize the glocalized and mobile
nature of social media.

Recommendations include: 1) support health professionals in developing a social media strategy for substance
use issues using a ‘youth first’ approach that emphasizes health equity, person-centred design methodologies
and systems thinking, 2) creating a culture of innovation supported by appropriate research methods, and 3)
consideration of global and local networks in developing and evaluating interventions.

Social media presents a new opportunities and challenges for health promotion including a shift in mindset and
model for engagement. Systems and design thinking can facilitate this shift and when used with developmental
evaluation methods can produce innovative and responsive ways to address substance use with young people.

02

INTRODUCTION
How is social media What are the most What are the most
reducing the health effective ways to engage appropriate social media
burdens created by youth and young adults in tools to effectively reduce
substance use among health promotion using unhealthy use of drugs,
youth and young social media? tobacco and alcohol with
adults? youth and young adults?

The answer to these questions is the same: We don’t know.

Facebook. Twitter. YouTube. These are the tools of youth and young adults and represent examples of their
most power vehicle for information gathering and social engagement: social media.

Social media is an emergent set of tools and technologies that have transformed the way that people interact with
each other through the Internet, enabling active conversation about topics rather than serving as simply another
means of broadcasting. It facilitates real-time interactions between people from diverse contexts to connect
around common issues and develop novel solutions to problems. This peer-to-peer model of communication
is deeply personal and familiar while contributing to a global agora of dialogue and health knowledge. Through
social media anyone with Internet access can create, distribute and re-mix content for the same audience as
anyone else.

For youth and young adults seeking health information, treatment choices, or social support about substance
use, social media offers a panoply of options of which few are evidence-based or delivered as part of professional
public health services. It is that professional-focused part of the spectrum that this report seeks to illuminate by
reviewing the current state of evidence, provide examples of current practice, and suggest possible options for
future work.

Social media levels the playing field in a game that is open to everyone and is still defining its rules. As this
report will illustrate, these new rules are posing challenges for the way that evidence is generated, interventions
delivered, and communication strategies implemented. What this means for the prevention and treatment of
substance use for youth and young adults is unclear. However, by looking closely at what is being currently in
practice, health practitioners can better shape a future that best uses the opportunities that social media creates
to address substance use issues with youth and young adults in ways never before possible.

03

CONTEXT
Substance use among youth and young adults remains widespread and continues to challenge public health.
Although behaviours such as cigarette smoking have shown signs of decrease in recent years, the rates of use
among young people are still higher than any non-clinical population (Health Canada, 2010). Alcohol and drug
use among students remains a public health concern as substance use behaviours affect young people’s cur-
rent wellbeing and can be precursors to serious health problems later in life (Young et al., 2011). The legal and
potential social implications of substance use with youth has often been concealed from the eyes of adults, mak-
ing it a challenge for public health to deal with directly.

It is for this reason that Internet-enabled interventions for health promotion have found purchase among public
health professionals as a means of addressing substance use in a manner that is responsive to the needs of youth,
protective of their privacy, and attractive at the same time (Norman, Maley, Li, & Skinner, 2008; Norman &
Skinner, 2007). Social media represents an evolutionary step towards providing interventions at a distance for
youth that requires not only new networked tools, but new ways of thinking about how youth engage with those
tools (Norman & Yip, 2011). This report outlines the current state of evidence to support the use of social
media for substance use prevention and treatment with youth and young adults, reviews examples of social media
applications currently in use, and provides insight from researchers and practitioners engaged in social media
use with this population.

Included in this report is a review of social media, web applications, and websites in youth health promotion,
prevention, and cessation/treatment interventions with a focus on substance use; a scan of the recent literature
(past 5 years) related to evaluating social media initiatives that show health impact/ cost-effectiveness; a profile
of some of the current Canadian substance use-focused initiatives that use social media; and an identification of
specific challenges and recommendations based on demonstrated effective approaches associated with the evalu-
ation of eHealth promotion, prevention and treatment initiatives.

For this report websites promoting a product or providing static information content were not considered unless
the users of the site also produce and share content (with some exceptions to illustrate current examples of tra-
ditional Internet media applications as a reference point). For the purposes of this review, tools like Facebook,
Twitter, and YouTube will be the principal technologies of interest as they are the most widely used and popular
social media platforms in Canada.

3.1 Defining Social Media
The term Web 2.0 (http://en.wikipedia.org/wiki/Web_2.0), describes a set of tools and technologies that
reflect the terms illustrated in Figure 1. These terms reflect an active, interactive, and dynamic set of conditions
that shape the way content is generated, distributed, and redesigned.

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Figure 1: Web 2.0 Word Map

Source: http://en.wikipedia.org/wiki/File:Web_2.0_Map.svg

Social media falls within this realm of Web 2.0. For this review, social media is defined as any networked tool or
information technology that derives its principal value from user-generated content and engagement.

Social media represents a significant shift in the social and physical locations for interventions. Youth seek
engagement, dialogue, participation, immediacy and operate with a temporal flexibility to their lives that is
distinctive from older generations where messaging to people was acceptable and messaging with them was rare.
The peer-to-peer, many-to-many form of communication used in social media places those using the technolo-
gies on a similar footing with each other, which is different from traditional forms of communication where the
message was generated and transmitted solely by one party. This shift in power requires different styles of com-
munication.

From Facebook Pages to Tweet-ups to video broadcasts and interactive websites, social media provides youth
with ways to connect with public health professionals and each other immediately and wherever they are when
combined with mobile handsets or tablets. The mobility of social media provides opportunities for engagement
with youth anywhere they are and anytime they need services and support.

3.2 Social Media and Youth
Youth and young adults are using social media more than ever before. Although there is limited Canadian data,
research from United States suggest that over 70 per cent of youth and young adults are active on social network
sites and engage with them on a daily or weekly basis (Lenhart, Purcell, Smith, & Zickuhr, 2010). Tools such as
Facebook, Twitter and YouTube are everyday parts of the lives of youth and young adults and serve as a source
both healthy and unhealthy substance use information and resources (International Narcotics Control Board,
2012; Reifman, 2009; Seidenberg, Rodgers, Rees, & Connolly, 2011).

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This shift in the way that users interact with this new class of technologies has had fundamental implications for
the range and scope of opportunities for young people to create, share and engage content on health topics.
No longer is content creation restricted to those with the resources to develop a website or relegated to a com-
ment section of a web page, now young people can generate content from scratch and distribute it to their peers
without having knowledge of computer programming. For health professionals, this is a shift from broadcasting
information from a place of authority to co-creating knowledge and forming conversations around health topics.
It is as much about a mind-shift as it is a change in technology or media.

3.3 Terms
Youth is categorized as a person between the ages of 12 and 24 years, following the World Health Organiza-
tion’s operating definition (WHO/UNFPA/UNICEF Study Group on Programming for Adolescent Health,
1999). A young adult is defined as a person who is between the ages of 18 and 29 years drawing partly on
the debate in the academic literature on age classification in adolescent and youth health (Geiger & Castellino,
2011).

This shift translates into having professionals talk to youth to talking with youth and doing it in real-time, poten-
tially at any time and, with mobile devices, any location, has implications for the way that health promoters design
and think about their interventions.

For the purposes of this review, substance use was
considered within the broadly defined areas of tobacco,
alcohol, and drugs and referring to a psychoactive or
“Social media is defined as performance-enhancing compound for a non-thera-
any networked tool or peutic or non-medicinal effect.
information technology that
Social media is defined as any electronic, networked
derives its principal value resource that derives its principal value from user
from user-generated content participation. Thus, stand-alone websites without an
and engagement.” explicit social component were reviewed as separate
entities or not included.

Although social media encompasses a variety of different tools and technologies, for the purposes of this proj-
ect emphasis will be placed on three specific technologies: Facebook (http://www.facebook.com), YouTube
(http://www.youtube.com) and Twitter (http://twitter.com).

Social media websites and tools represent more than half of the top ten most visited websites in Canada accord-
ing to site ranking company Alexa.com (http://www.alexa.com/topsites/countries/CA, search March 16,
2012). Within the top ten, Facebook is the #3 website in Canada, Youtube is #4 and Twitter is #8. Wikipedia
(#7), LinkedIn (#9), and Blogspot (#10) were excluded as potential sources because of a lack of deep interactiv-
ity (Wikipedia and Blogspot) and a focus on solely professional networking (LinkedIn).

The term intervention will be used in the context of this report to describe any social media resource that
is focused toward youth that serves a public health interest. Any feed, page, or content source will be consid-
ered part of an intervention if it falls within this set of bounds.

06

METHODS OF
INVESTIGATION
This four-pronged review was executed using multiple, overlapping strategies in a phased approach:

A search of the scholarly literature was performed using multiple methods. An initial search of academic
1 applied health sciences databases was performed using the Scholars Portal / Web of Science databases,
which capture research from medical, allied health, behavioural science, education, and social science
literature. These are the fields where literature on social media, substance use is likely to reside. Key-
words derived from the current U.S. National Library of Medicine index of terms coupled with those
found in known articles in this area of work. The scholarly search strategy is listed in Appendix 1. A
modified version of the search was performed using Google Scholar and through a general Google web
search. Peer-reviewed, edited and grey literature resources were all considered.

Referrals from health practitioners, review of reference lists were also considered. Virtual ‘hand search-
es’ of the Cochrane and Campbell Collaboration databases and the leading journal specializing in social
media and eHealth: Journal of Medical Internet Research (JMIR). Database searches were restricted to
the years 2005 - 2012.

The literature was reviewed for content appropriateness, descriptive completeness (i.e., the interven-
2 tion was described in sufficient depth), audience, health topic(s) covered, evaluations (if information is
present or known), selected features, and overall medium of engagement. Particular attention was paid
to the methods of evaluation and assessment of behaviour change or preventive actions taken.

A similar search strategy was undertaken of the open web using Google to search for existing examples
3 of social media interventions including references drawn from the scholarly and grey literature. Inter-
ventions were identified through the search, through referrals from practitioners and researchers work-
ing in public health and health promotion, links provided from found resources and from the snowball
strategy performed of those links and referring pages. Resources were reviewed based on relevance,
appropriateness, country or province of origin (with emphasis on Canadian examples when possible),
scope of service, health topic, and medium of engagement.

The breadth, depth and poor indexing of social media in major search tools, has limited what resources
could be reviewed. Resource quality was considered by looking at issues of eHealth literacy and related
eHealth promotion recommended practices (Norman, 2011; Norman & Skinner, 2006). Resources
were compiled and reviewed for commonalities, exceptions and notable features. Emphasis was placed
on noting qualities and limitations that could be used to form the basis for actionable recommendations
to health promotion professionals and the public health and health sciences research community.

07

Informal interviews were conducted with practitioners and researchers working in the field of social
4 media and youth substance use. The aim of these interviews was to gain insight into details of service
delivery, recruitment, data collection, perceived intervention effectiveness and general operational
issues that were not captured in the literature or service profiles. Professionals were identified based
on their relationship with existing funded social media and health projects and through referrals from
known professionals working in this area. Due to the contextual nature of the funding and service deliv-
ery demands for these services, interviews were limited to Canadian-based professionals and youth.

Conversations with service providers working in public health developing or delivering social media
applications for health promotion were also used to supplement this data to provide contextual practice
information.

08

REVIEW OF THE SCHOLARLY
LITERATURE
What does the scholarly literature say about the effect of social media on
youth and young adult substance use?

Both academic (published) and relevant grey literature databases were searched for examples of social media
evaluations using keywords drawn from the NLM database, reviews of known published literature, and the incor-
poration of colloquial terms used in social media (e.g., tweets) (see Appendix 1 for the search strategy).

Execution of the search strategy found little evidence for the application of social media to any of the three topic
areas: tobacco, drugs or alcohol. The sole exception was limited to a single medium and two issues: text messag-
ing for tobacco or alcohol use. Although multiple articles discussed the challenges and opportunities associated
with social media and young people (e.g., Elkin, Thomson, & Wilson, 2010), few explicit intervention evalua-
tions were published in either the grey or peer-reviewed academic literature.

5.1 Seach Results
Of the articles found, only three explicitly used the term “social media” (Anderson & Speed, 2010; Seidenberg
et al., 2011; Thomson & Wilson, 2012) and just one had an explicit focus on youth-oriented interventions
(Seidenberg et al., 2011). The term social Internet was used in one article (Pujazon-Zazik & Park, 2010).
Explicit referral to a specific platform or technology was also rare, with one study citing Facebook (Mart, Mer-
gendoller, & Simon, 2009), one (indirectly) focused on Twitter (Pujazon-Zazik & Park, 2010), and four youth-
oriented studies that identified YouTube as a focus (Backinger et al., 2011; Elkin et al., 2010; Freeman &
Chapman, 2007b; Kim, Paek, & Lynn, 2010) in the title or abstract. Text messaging was the most clearly identi-
fied form of social media intervention with five cited studies or reviews that were relevant to youth substance use
(Free et al., 2009; Suffoletto, Callaway, Kristan, Kraemer, & Clark, 2012; Thurlow & McKay, 2003; Whittaker
et al., 2009; Whittaker, Maddison, McRobbie, & Bullen, 2008).

Upon executing the review, the principal challenge was determining whether an intervention was indeed a social
media intervention or something else from the descriptions provided in the abstract and article. Many interven-
tions that used highly interactive components appeared in the search (e.g., Norman et al., 2008), but were not
examples of social media. Absence of detail about interventions is common in the academic eHealth literature,
which typically favours research description over intervention description or related theoretical components
powering them (Webb, Joseph, Yardley, & Michie, 2010). For example, a 2010 systematic review of online
alcohol interventions, of which most were focused on youth or young adults, did not feature a single social media-
based intervention (White et al., 2010) even though the article came up in the search of the literature.

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The only formal literature review of social media applications for public health (broadly) located was conducted
by Schein et al. in 2010 as a non-published white paper prepared for the Peel Public Health Unit in Ontario
(Schein, Wilson, & Keelan, 2010). This review included academic content such as conference papers and peer-
reviewed journal articles and grey literature reports focused on any aspect of public health practice, including
commentaries on feasibility and implementation of social media as interventions. Despite broadly defined inclu-
sion criteria, not a single youth-focused intervention study looking at substance use was located and included in
the Schein, Wilson and Keelan (2010) review. Analyses of social marketing approaches to tobacco promotion
through social media were the only topical areas that looked at substance use and young people (Freeman &
Chapman, 2007, 2008, 2010).

A second review of ‘social internet’ applications was published in 2010 and focused on potential health out-
comes and gender differences (Pujazon-Zazik & Park, 2010), however the breadth of scope of the literature and
its different health and non-health-related studies yielded no transferrable insights on effectiveness or efficacy for
this review on substance use and youth. The only area where there was reasonable evidence of efficacy was on the
use of text messaging for support of tobacco use cessation and alcohol.

5.2 Text Messaging
Text messaging was the only social media technology that did have some explicit evidence behind it, that
included peer-reviewed studies (Free et al., 2009; Riley, Obermayer, & Jersino, 2008; Rodgers et al., 2005;
Suffoletto et al., 2012; Whittaker et al., 2008), a cross-disciplinary review of text messaging and youth (Porath,
2011) and a systematic review focused on tobacco use cessation for population health in general (Whittaker et
al., 2009). However, within even the published systematic review only one relevant article that had an explicit
intervention focus was found (Whittaker et al., 2008). A recently published study of text messaging demonstrat-
ed potential impact using a brief intervention added to a hospital discharge with young adults admitted for heavy
drinking-related problems (Suffoletto et al., 2012). The study found that the text-message intervention helped
assess problem drinking levels in young adults exposed to the intervention, helped them set goals for alcohol
reduction, and led to fewer heavy drinking days compared to a group that did not receive the intervention.

The systematic review on tobacco-related interventions with text-messaging found four trials that all yielded
significant positive changes in smoking behaviour attributed to the intervention (Whittaker et al., 2009). Both
short and long-term outcomes were positively affected, however the heterogeneity in long-term outcomes limits
what can be expected of such interventions. One of the principal challenges with this review – and that of other
eHealth interventions overall – is the thin description of the interventions themselves reported in the academic
papers. Interventions relied on automated text message systems that delivered personalized messages developed
from databases. Two trials (Rodgers, 2005 and Free, 2009) involved daily delivery of 5-6 messages up to a
planned quit day followed by a single message every two weeks.

Suffaletto and colleagues studied 45 young adults (aged 18-24 year) who were screened as hazardous drinkers
after presenting to one of three emergency departments (Suffaletto et al., 2012). Participants were randomly
assigned to receive weekly text message (TM) based feedback with goal setting, weekly TM-based assessments
without feedback, or a control for a period of three months. Measurements were taken at baseline and three
months post-intervention. The results showed that those with the text-message based interventions – with or
without a goal – led to fewer heavy drinking days post-admission to the emergency room than the control group.
The relatively small sample size limits the generalizations that can be made from this review, however it does
demonstrate the feasibility and potential efficacy of text messaging for alcohol use. Both the authors and others
suggest that more robust randomized trials are needed.

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Text messaging is a form of social media, however its absence of wider-scale participation opportunities relative
to other social media forms and the inability to adequately share content from text messages to others with ease
limits the lessons learned from it relative to tools such as Facebook, Twitter or YouTube. These other social
media forms also have features that enable them to easily link to other resources (e.g., webpages, other social
media) and embed rich media such as video, text and audio in a manner that text messaging largely is unable to
do well. These differences make some of the lessons from text messaging more challenging to transmit to other
social media forms.

Another missing component of the data was research on mobile applications beyond text-messaging such as
smart phone applications or apps.

5.3 Concluding Message
The concluding message from the review of the literature is that there is not enough research to provide suffi-
cient information to serve as evidence to support (or challenge) social media use for youth substance use beyond
text messaging.

With the exception of text messaging, which has shown some promise as a means of supporting substance use
reduction, no body of work has provided evidence to support or reasonably challenge the use of social media as
a resource for substance use prevention and cessation. The absence of sufficient research has further limited the
ability to identify suitable evaluation challenges arising from social media and substance use work with youth
and young adults emerging from the literature. No cost-effectiveness data was presented or found in any of the
reviews or original articles.

“The concluding message from the review of the literature
is that there is not enough research to provide sufficient
information to serve as evidence to support (or challenge)
social media use for youth substance use beyond text
messaging.”

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SOCIAL MEDIA
CONTENT REVIEW
What does the youth and young-adult focused social media landscape for
substance use intervention look like?

An online search of social media applications used to support substance use prevention, cessation and change
was undertaken using the Google search engine, referrals from health professionals, and linked references
obtained from resources located during the review. Additional searches within each social media environment
were undertaken to locate appropriate resources.

Social media exists in a largely dynamic and decentralized environment in the manner by which tools are indexed.
This limits the reach and scope of search engines such as Google and Bing to in locating and cataloguing social
media resources.

The practical limitations imposed by the way social media resources are indexed, generated and distributed pre-
vented an exhaustive review of the field. Further, initial searches revealed an incomplete, inconsistent and frag-
mented collection of resources that challenged efforts to conduct systematic, yet practical comparisons. Work-
ing with these limitations, a corpus of resources was located using the strategy above, selected and reviewed to
provide an illustrative example of social media interventions presently available.

The choice to profile different social media interventions was framed based on the various types of content and
forms reviewed. For example, some Facebook pages or YouTube sites had no ability to facilitate comments or
sharing, which limited their potential to engage their audience. In certain cases, the Facebook page was used as
a portal for other Internet sites connected to the program or campaign, while in others a Facebook wall was used
more like a bulletin board.

A profile the resources reviewed is in Table 1. The table includes Canadian examples except for particularly
notable non-Canadian examples.

Reviewing these resources finds a broad diversity in the manner by which public health and health promotion
services seek to engage youth and young adults and little consistency in the manner by which information is pre-
sented. This diversity reflects varying levels of engagement and content types. Facebook was the most popular
vehicle for health promotion among the various social media types reviewed. Twitter was the next most popular
tool (by number of resources), with YouTube being the third most popular social media tool.

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6.1 Profiling Social Media Interventions
One of the primary challenges with reviewing social media applications is the lack of consistent standards across
the interventions for identification and contact. Best practices for determining eHealth ownership and markers
for quality content (c.f., Charnock & Shepperd, 2004) were not typically followed. Although every social media
resource has some marker that indicates when content was posted, the date of content creation date is not always
clear given that material can be remixed multiple times.

Another feature absent from nearly every single resource reviewed was some form of identifiable contact consis-
tent with better practice guidelines. To illustrate, What’s With Weed (http;//www.whatswithweed.ca) had no
identifiers listed, only a reference to a funding sponsor. The only descriptor with contact information provided
was:

“WhatsWithWeed.ca is a Canadian educational resource developed with young people in Ontario who are both
marijuana users and non-users, in partnership with drug education specialists, drug treatment counsellors and
researchers with funding from Health Canada. It is not meant to replace advice from a health care professional.
Comments or questions can be sent to info@whatswithweed.ca”

No names, organizational affiliations or alternative contact points are listed on the website. This pattern was
common among the resources reviewed. Of the different media forms, websites were the most likely to provide
some form of contact information other than something self-referential (e.g., Facebook page referring to a Face-
book page for contact information).

More than half of the Facebook resources included in this review were devoid of contact information. One of the
best positive examples was the Drugs Not 4 Me page (http://www.facebook.com/drugsnot4me) that offered
multiple forms of contact for visitors to the page. A more typical example was Live, Play, Be Tobacco Free, that
has a hard to navigate collection of information about sponsorship and contact information, due in part to way
in which Facebook pages are designed, and partly due to a reliance on a secondary resource (a web page) as the
primary means of conveying information about the resource. The page features an About section that has no
discernible contact information, with a website link available on the Info tab.

A sample of Twitter profiles are listed drawing on examples from the review that use multiple platforms to pro-
vide a base for comparison across social media platforms. Thus, stand-alone Twitter accounts were not included.

6.2 Population of Focus
The population of interest was not evident in many social media interventions. While some were identified by
their name (e.g., YATI, Youth Voices Research Group), others did not have an explicit statement of focus on
youth even if there were identifiable youth resources (e.g., Quit Exchange).

6.3 Budget
Although the cost of social media platforms are (mostly) free. In discussion with public health and health promo-
tion professionals doing social media work, much of the costs are unknown, particularly because social media
is often seen as an ‘add-on’ to complement other forms of health communications. Tools like Facebook, Twit-
ter, and YouTube are all free to use with costs resting on the content development, distribution and time spent
monitoring these sites.

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For the development, deployment and sustainability of a social media platform based around a mobile applica-
tions, costs can be far higher. For example, the Crush the Crave Android app and related campaign (University of
Waterloo/Canadian Cancer Society) was developed from a budget of close to $300,000. The project, funded by
Health Canada, included costs for professional developers, graphic designers, marketing leaders, evaluation and
research expertise and data from the Propel Centre for Population Health, and soliciting feedback from young
adults.

Another example of social media use in youth substance use for tobacco control was the Access Project by The
Youth Voices Research Group at the University of Toronto. This short-term research project used participa-
tory video development and blogging to support youth discussions of tobacco treatment access and contraband
cigarettes. The project, which was funded by the Ontario Ministry of Health Promotion, ran for three months and
estimates for the social media portion of the project suggest it would cost $65,000 to operate at the same level
year round. This is based on having one staff member working at .6 full-time equivalent and costs for local youth
engagement activities and materials development.

The Youth Voices Research Group has conducted multiple health promotion projects using social media, includ-
ing one that had a comprehensive strategy involving Facebook, Twitter, Flickr, YouTube, a website and blogs
focused on youth health navigation run in 2010. Estimates from that project suggest that a fully-implemented,
multi-method social media strategy would cost $95,000 to create from scratch to run for a year with a full-time
social media staff person assigned to administer the strategy and work with youth and young adults to produce
and distribute content. The Youth Voices Research Groups’ Youth4Health project model represents the largest
known application of social media to youth health promotion.

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Table 1: Resource review

Resource Name Resource Locator Focus Description

FACEBOOK PAGES
Not4Me http://www.facebook.com/ Drug use Regular updates, links to other websites and YouTube videos. Nearly all
drugsnot4me self-referencing materials. Some critical discussion on the site, a lot of sup-
portive comments.
62518 likes
Ontario Lung http://www.facebook.com/ Tobacco use cessation Custom page with videos embedded in the site, looks like it was designed to
Association OntarioLungAssociation serve as a conduit to other web resources, not as a forum for discussion. No
threads or posts visible on front page. Embedded link to Twitter feed 2963
likes

In the Nic-o-time http://www.facebook.com/ Tobacco use cessation Regular updates, including links to others site on other issues facing youth
InTheNicotime such as the Pink Shirt Day 2012 campaign.
Hooked by Hol- http://www.facebook.com/ Tobacco use advocacy 1845 likes. Opens like a website with content focusing on new movies (con-
lywood hookedbyhollywood stantly updated every Thursday) that illustrate warnings based on tobacco
use in file.
Be Your Best Self http://www.facebook. Health Promotion Information on a variety of topics and posts using different media forms such
com/pages/Be-Your-Best- as YouTube videos, news articles, and general interest wellness resources.
Self/213777151982426 Most post likes are from Be Your Best Self. The page has 192 likes.
Quit Exchange http://www.facebook.com/ Tobacco use cessation No clear sense of what the website is about, where it is based and what kind
pages/Quit-Exchange/3 of outcomes it seeks.
07157932632220chan
ge/307157932632220

Leave the Pack http://www.facebook.com/ Tobacco use cessation Many user updates on the website filled with tips for quitting and other
Behind LeaveThePackBehind self-help resources. Some debate on the merits of different methods (e.g.,
Champix vs. mind-over-matter) Post-your-tip contest was run in March. 482
likes.

15
Table 1: Resource review, Continued


FACEBOOK PAGES
Quitters Unite http://www.facebook.com/ Tobacco use cessation Many updates and links to different tobacco use related resources for health
QuittersUnite promotion. Comments are varied in focus and depth from supportive quit
messages through to cross-promotions from partner organizations. QU team
responds to comments and engages audience.
1050 likes

YouthRISE http://www.facebook.com/ Drug use - harm reduc- Links to advocacy resources worldwide with most posts showing some
YouthRISE tion “likes”, yet relatively few comments, some debate. 1533 likes
Fuck Cancer (Van- http://www.facebook.com/ Cancer awareness 56870 likes. Highly active page with links to videos, magazine articles, user
couver, BC) letsfcancer comments and diversity of participants on the website
Campaign to http://www.facebook.com/ Cancer awareness 780 likes. Consistent, regular posts and updates with links to external sites
Control Cancer controlcancer from around the world. Many of the updates are focused on news articles on
(Toronto, ON / the science of cancers
Canada)
MADD Canada http://www.facebook.com/ Alcohol awareness 6198 likes. Regular updates and news stories from diverse media sources on
maddcanada.ca the problems associated with drinking and driving. Some post likes and a few
comments. Little direct-to-youth engagement visible.
Picture Me Smoke http://www.facebook.com/ Tobacco use prevention Little content on the Facebook page, although a well-designed landing. 306
Free Project (Van- PictureMeSmokefreeProject likes. Most information is delivered to users using the feed generated from
couver, BC) Likes.

Quit Now BC http://www.facebook.com/ Tobacco use cessation Major focus is on the quit now contest, virtually no conversation on the site,
QuitNowBC rather visitors are encouraged to visit QuitNow website. 2269 likes.

Expose’ http://www.facebook.com/ Tobacco use cessation 285 likes. Posts in French and English. Serious news stories mixed
exposeottawa with some humourous youth-oriented media shares (e.g., link to Glo-
balTV episode of American Dad that features ‘big tobacco’ angle)

16


FACEBOOK PAGES
Canadian Centre http://www.facebook.com/ Substance use Not updated regularly. One post in 2012 with little detail. Largely used for
on Substance CCSAcommunications promotion of events. 78 likes.
Abuse (Ottawa)

YATI http://www.facebook.com/ Tobacco use cessation 362 friends (organization page), no other content.
YATIYouthAdvocacy & prevention
Crush the Crave http://www.facebook.com/ Tobacco use cessation To-be-launched mobile app for smoking cessation. Already has 2380 likes.
CrushTheCrave Many photos and comments on the posts from a diverse group of page fol-
lowers.
Drugs Not 4 Me http://www.facebook.com/ Drug use prevention A Health Canada-sponsored information site on drug-related harms and
drugsnot4me risks.
YOU TUBE
Health Canada http://www.youtube.com/ Drug use Health Canada’s YouTube Channel features videos on a variety of health
user/healthcanada topics including many of the top videos found in a YouTube search of youth,
drugs, alcohol and tobacco. The channel has 834 subscribers and 480,881
views.
Leave The Pack http://www.youtube.com/ Tobacco use cessation This video is not part of a channel, but rather a single post from a single user.
Behind watch?v=Ho6iDSaq-CQ This user (nikionthego) who has 6 uploaded videos on completely different
topics.
Students for http://www.youtube.com/ Drug use An example of a U.S.-based organization using YouTube. The channel
Sensible Drug user/SSDP?ob=0&feature has 201 videos and more than 1.3 Million views. Videos focus mostly
Policy =results_main on public events and speeches by drug policy leaders with some adver-
tisements and humourous clips included.
Nic O Time http://www.youtube.com/ Tobacco use cessation Channel was developed and produced by Rocketship Productions,
Challenge 2012 watch?v=cfHdwSKrL3g& which does interactive marketing on different topics. Multiple videos
feature=youtu.be were produced for this campaign with more than 1100 views for the
most popular videos.

17


YOU TUBE
Saskatchewan http://www.youtube.com/ Alcohol awareness Three videos are part of this channels (1390 views) that focus on the poten-
Prevention user/PreventionInstitute1 tial harms of alcohol. This is an example of a prevention-oriented application
Institute of using video to connect to an audience.

Play Live Be http://www.youtube.com/ Tobacco prevention A tobacco-free contest page featuring youth-created videos promoting a
Tobacco Free user/playlivebe tobacco free lifestyle. The channel has 45 subscribers and 1552 video views.
MADD Canada http://www.youtube.com/ Alcohol awareness MADD has more than 85 videos from public service announcements to
user/maddcanada short films that feature messages warning of the negative consequences of
drinking and driving in French and English.
Portage Canada http://www.youtube.com/ Drugs and addiction Stories about addiction and treatment are shared in French and English in
user/PortageCanada 17 videos that have more than 6500 views.
National http://www.youtube.com/ Alcohol, drug and NAHO has videos on a variety of health topics that include youth and young
Aboriginal Health user/NAHOnews tobacco awareness adult substance use issues. Emphasis on aboriginal-focused treatment and
Organization prevention messages is the focus.

Youth Voices http://www.youtube.com/ Tobacco use advocacy, The former U of T research unit has a youth-developed series on access to
Research Group user/YouthVoicesResearch awareness and cessation cigarettes and access to treatment as part of a wider set of videos designed
for youth and youth-serving professionals. The channel has 29 videos and
more than 27,500 views.
WEBSITES
The Smoking http://www.smokingzine. Tobacco use cessation A recently retired intervention that features customizable personal
Zine org and prevention assessments, decision support tools, and interactive games to aid youth
in smoking cessation or supporting preventive efforts. The Smoking
Zine evaluated as part of a randomized controlled trial published in
2007.

18

WEBSITES
Quitters Unite http://www.quittersunite. Tobacco use cessation An interactive website that provides assessments and supports for young
com/ adults in quitting smoking. Links to contests and healthy lifestyle resources
are provided along with a blog, discussion forum and social media feeds.

Not4Me http://www.not4me.org/ Drug prevention This intervention developed by Canadian Students for Sensible Drug Policy
seeks to provide information on the health, social and legal risks associated
with drug use through a harm reduction and prevention lens.
NAHO Youth http://www.naho.ca/first- Youth substance use This aboriginal-focused page includes static content on the risks and harms
Substance Use nations/youth-substance- associated with substance abuse and provides links to other sites that can
Information Page abuse/ help a youth interested in further information about prevention and treat-
ment options.
YouthRise http://youthrise.org/ Drug use prevention A harm-reduction focused website featuring news, briefing papers, and links
and education to training resources.
Trip Project http://www.tripproject.ca/ Drug use education A Toronto-based youth-focused drug information and safe partying page and
trip/ related network for youth to connect to each other around issues of safe drug
use, treatment and prevention.
What’s With http://www.whatswithweed. Drug Use (Marijuana) A web resource focused on marijuana use including information, self-assess-
Weed ca/weed/ Prevention and ments, and links to other resources.
Cessation
XPeriment.ca http://www.xperiment.ca/ Drug Use prevention A multi-media interactive website that enables youth to explore the potential
index_en.html and cessation harms associated with drug use. Videos, interactive assessment tools and
information on drug-related harms are featured.
Quit4Life http://www.hc-sc.gc.ca/ Tobacco Use Cessation Quit4Life was once an interactive website for tobacco use cessa-
hc-ps/tobac-tabac/youth- tion and is now a static resource featuring a downloadable handbook.
jeunes/life-vie/index-eng. Quit4Life has been extensively evaluated over many years since its
php inception in the early 2000’s.
Health Canada http://www.nationalanti- Drug Use prevention Health Canada’s youth-directed drug prevention resource focuses on the
National Drug drugstrategy.gc.ca/preven- harmful effects of drug use by presenting information, testimonials, and
Strategy / Drugs tion/youth-jeunes/index. multi-media tools to connect youth to prevention messages.
Not 4 Me html

19

TWITTER FEEDS (SAMPLE)
Trip Project @tripproject Drug use & sexual Highly active posting focused on provoking questions, disseminating drug
health harm reduction information and sexual health resources. 3278 tweets, 1751
following, 1648 followers
Crush the Crave @crushthecrave Tobacco use cessation Resource dissemination for quit smoking including tips and news articles.
367 tweets, 177 following, 610 followers
Hooked By @hookedhollywood Tobacco use advocacy Resource dissemination, provocations for discussions on current movies,
Hollywood with lots of mentions of other Twitter users. 1672 tweets, 657 following,
487 followers
Quitters Unite @quittersunitebc Tobacco use cessation Consistent tweeting with dialogue with others. Uses questions to provoke
responses and takes a tone of conversationalist, rather than broadcaster.
1296 tweets, 423 following, 338 followers

YouthRISE @youthrise Drug use - harm reduc- Regular daily updates. Focus on dissemination of resources, provocative
tion stories, and conversation with followers. 1159 tweets, 506 following, 1292
followers
Fuck Cancer @letsfcancer Cancer awareness Announcements, tips and resource sharing as the focus. 3592 tweets,
(Vancouver, BC) 1311 following, 14697 followers.
MADD Canada @maddcanada Alcohol awareness Provides regular reports of alcohol-related or suspected traffic acci-
dents with some additional dissemination of resources; daily or mul-
tiple posts per day. 2533 tweets, 6 following, 1290 followers.
Picture Me @smokefreepx Tobacco use preven- Regular posts, dissemination of information plus highly conversational
Smoke Free Proj- tion with twitter users. 234 tweets, 264 following, 118 followers.
ect (Vancouver,
BC)
YATI @youth_advocacy Tobacco use preven- Regular daily tweets on tobacco prevention news, youth advocacy
tion & cessation stories, and health promotion information. 998 tweets, 1998 following,
859 followers

20

PRACTITIONER
PERSPECTIVES
What do professionals working with youth and young adults think about
the opportunities and challenges that social media brings to substance use
prevention, treatment and advocacy?

Considering the absence of solid evidence emerging from the literature or content review, expert opinion was
sought from practitioners and researchers working with youth, young adults and social media on issues of sub-
stance use. This informal review was conducted to generate practice-based evidence to assist in guiding the
overall recommendations for public health. As this review was designed to reflect the state of evidence and situate
that in Canada, Canadian-based expert practitioners with experience in social media, substance and public health
were sought to provide contextual knowledge of the challenges, opportunities, outcomes and processes associ-
ated with these forms of intervention. These conversations were intended to contextualize some of the findings
and provide additional insight into social media and substance use practice. Reflections, resources and comments
on the state of practice was obtained from two PhD-level principal investigators (researchers), two Masters level
health promoters who have served as project managers on social media-related projects with youth, and a front-
line community health project worker who has direct experience with youth substance use. In keeping with the
focus on social media, advice from a global network of health promoters and youth working within this area was
also sought and this report reflects those contributions.

Commentary was provided through face-to-face or telephone conversations in March 2012 after the literature
and content reviews were completed. The purpose of these discussions was to gain additional practice-based
experience to provide context to the review given that no clear findings emerged. The author of this report also
brings experience as a researcher and practitioner working with youth and eHealth for more than 15 years pro-
vided an additional set of insights to complement and compare with those from the others,

7.1 Text Messaging
Of the various areas of social media in use, only text-messaging has enough evidence to evaluate thoroughly.
While text messaging has shown promise as a medium for reaching young people, its popularity was questioned
given the emergence of new rapid-response methods of communication (e.g., Twitter). One expert pointed out
that text messaging in North America didn’t take off until used as a voting method on popular teen-oriented
talent shows, such as American Idol. Although universally available on any mobile phone, the proliferation of
‘smart’ phone handsets such as the iPhone, Android and Blackberry now offers options that are typically included
with a data plan. Shows like American Idol continue to use text messaging as a voting method while including
alternative communication options such as Twitter (e.g., @americanidol) to support voting and fan engagement.
Indeed, American Idol now issues a special Twitter account to all of its top finalists who are encouraged to engage
with fans during the series. There was speculation that the popularity of text messaging might wane as data costs
come down and the means to engage in rapid communication quickly expands. The investment in text messaging
as a medium for future health promotion should be considered with caution given these changing trends.

21

7.2 Youth Engagement
A consistent observation among the expert group is that the world of youth and their social media landscape
evolves quickly and that approaches to working with youth must keep pace in to order to maintain relevance.
Public health and health promotion professionals need to keep current and prepare to adapt their strategy to
these changes and experts mentioned the disconnection between adults and youth in the way that they approach
social media. Youth are far more flexible and connected to the media and each other and use it in ways that are
not consistent with the intervention approaches that many adult professionals envision.

Multiple experts asserted that youth cultural norms clash with the expectations of organizations seeking to devel-
op and deploy interventions aimed at youth that can be managed and controlled and feature messages that warn
youth of the dangers of drugs, tobacco or alcohol. This thinking produces interventions that youth “laugh at” or
ignore or attracts youth that are already adhering to the message of sobriety or abstinence. These adult-generated
interventions also avoid topics like harm reduction that are often seen as more relevant to youth, particularly on
issues of drug use.

Adults are not always the best or appropriate people to be delivering interventions directed to youth through
social media. Adult language, experience, and culture are not always conducive to the rhythms of social media.
These barriers to communication limit the accessibility and reach of certain interventions to young people.

7.3 Accessibility and Reach
Experts spoke to the challenges in making social
media interventions sustainable and attractive to
“Adult language, experience, and low-income and socially disadvantaged young people
culture are not always conducive to as an important challenge for health promotion. One
the rhythms of social media. These researcher commented on the missed opportunities
for health promotion that emerge because many youth
barriers to communication limit the who could benefit from social media do not have the
accessibility and reach of certain tools to take full advantage of it (e.g., reliable wi-fi,
interventions to young people.” multi-purpose mobile handset, digital cameras). This
exacerbates or creates health inequities.

Age and gender issues play a large role in shaping the expression of young people through social media interven-
tions and it was repeatedly noted that youth and young adults should not be viewed as a homogenous group, but
a multi-layered set of sub-populations. Experts pointed out distinct differences in preferences even among youth
of similar ages and sex on issues of design, content, and medium for engagement. Thus, younger girls may like
things that younger boys do not like, while these girls may also have quite different perspectives from ones just
slightly older in age. This ‘thin-slicing’ of the youth demographic was something remarked on by the experts who
had done formative research in developing interventions.

7.4 Mobility and Non-localized networks of support
Access is also tied to the physical space where youth and young adults engage social media material.
The proliferation of cloud-based services (that nearly all social media tools employ) means that youth
can use Facebook, Twitter and other tools anywhere without dependence on specific devices.

22

The devices that youth are using are increasingly mobile in nature. IPhones, Blackberry and Android handsets
are favoured means of youth to communicate. The privacy and portability afforded by these devices allows youth
to have ‘live’, real-time access to their peers and to information from anywhere. Mobile devices are shaping the
relationship that youth and young adults have with social media content and its context. Youth are attracted to
spaces where their peers are trust recommendations from this community about where to go and what informa-
tion to trust.

This community is both local and global in scope. When recalling the spaces that youth frequently cited as help-
ful and even the resources that professionals recommend to youth and young adults, only some of them are Cana-
dian. In a globalized Internet web, the physical home of a certain resource is becoming less relevant except for
material that is of a specific local nature (e.g., face-to-face counseling resources, local advocacy events). Youth
regularly engage with a peer network that includes young people who they have met online and may be physically
located anywhere on the global, yet also virtually close by.

7.5 Overcoming Stereotypes
There is much stigma to using substances and requiring
help. One expert commented on how this stigma is shaping
the way that youth use social media and sometimes chal- “There was wide agreement
lenges the idea that youth continually want to share their that traditional means of
experiences with others. Indeed, youth may want to share
their experiences with other youth who are experiencing
evaluation and assessment
the same issues as them, but not with their family and larger were not likely to reveal the
social network. The stereotype of the ‘oversharing’ youth true impact of social media
is something that creates a misperception about how social
media can work to support substance use prevention and
on youth substance use.”
treatment.

Encompassing a strategy for design that enables developers to explore the context of social engagement with
youth and shape social media messaging to that specific context. Some youth will want to have their substance
use and related support needs known within their more intimate personal networks, but many will not and these
preferences cannot be assumed. Ethical as well as design considerations must be taken to ensure that young
people are not made more vulnerable through engaging social media than before.

7.6 Effectiveness
There was wide agreement that traditional means of evaluation and assessment were not likely to reveal the true
impact of social media on youth substance use.

The non-standardized nature of social media tools (as illustrated in the content review) inhibits the level of
comparison between services at a level that would satisfy most researchers. Researchers and practitioners spoke
of the need to use multiple method designs to study and evaluate social media interventions. A strong emphasis
on both quantitative and qualitative data collection methods was made. The highly contextualized nature of social
media interactions suggested methods of observation would be useful along with quantitative outcomes-oriented
methods.

23

Focus is another problem. One expert spoke of how rapid communication tools like Twitter and Facebook were
used by youth to communicate about drug safety concerns in real-time. This enabled youth drug users to co-cre-
ate and deploy an emergent harm reduction strategy based on experience and data gained from other users. This
rapid-response system works because youth are connected directly to the problem and each other and are free to
use whatever language and terms they like to communicate. Traditional adult-delivered services are not set-up to
respond quickly to emergent problems like ‘bad batches’ of drugs, may be reluctant to consider harm reduction
as an option, and use language that doesn’t connect to youth. Thus, ‘success’ in these terms might be the number
of youth who take up and share a prevention message that adults might find less attractive.

While social media tools themselves may not produce change directly, their indirect effect could be significant. It
was suggested that social media’s benefit may be as a conduit to other interventions. One expert suggested that
social media tools like smartphone apps might do little on their own even when guided by evidence, but that their
true impact could be in how they highlight existing resources and drive traffic to them. For example, a quit smok-
ing app might draw attention to tools like a phone line or counseling by having a link embedded in the app. The
attraction to youth may initially be to the app, but the service’s effectiveness would come from connecting youth
to face-to-face counseling and phone helplines.

24

CONCLUSIONS &
LIMITATIONS
What is the state of our knowledge about social media and its role in substance
use-related health promotion with youth and young adults?

Social media presents challenges and opportunities for public health that are novel and offer a tremendous space
for innovation in dealing with substance use issues for youth and young adults. Within this space exist fundament
constraints on the way in which evidence is generated and the potential for drawing usable conclusions based on
such evidence. This review sought to make a definitive statement on the effect of social media on youth substance
use and comment on the evaluative strategies used to assess interventions delivered by these new media forms.

The statements that emerge are based on what is not present in the evidence, rather than what is missing. There
is not enough evidence to inform action based on the current knowledge base for any of the topic areas -- tobac-
co, alcohol or drug use – unless practice-based evidence is considered. Only with respect to text messaging can
any evidence-based statement be made and that is simply that the medium is promising and only for tobacco ces-
sation and potentially reducing alcohol intake.

8.1 Limitations
The rapidly evolving nature of the social media landscape poses specific challenges for a review of this nature.
The boundaries that befit social media are indeterminable and dynamic, thus completeness is not an achievable
goal. The social media sphere is still poorly indexed, limiting some of the utility of tools like Google and Bing to
locate specific resources. Within applications such as Facebook, the available search options provide a limited
perspective on the true size, shape and depth of a particular network and most pages found during this review
were located through snowball sampling or reputation, not the Facebook search feature. Twitter was better, but
the short-message nature of tweets introduced different limitations in determining a message focus and conduct-
ing a content review.

The content of social media itself is highly diverse in its structure and method of deployment even within the
same platform. For example, Facebook interventions included pages that were fully integrated with other web
resources (e.g., Quitters Unite), while other groups have different accounts for Facebook and other social media
resources, relying on their wall as the intervention (e.g., YATI Youth Advocacy). YouTube presents similar chal-
lenges in that there are organizations who have channels and develop a roster of videos distributed through that
from an organizational account (e.g., Health Canada), while others use individual accounts to distribute content
(e.g., Leave the Pack Behind).

25

For the reasons mentioned in previous sections, the diffusion of resources, the methods and indexes required to
search for such tools are not highly developed, nor is there a universal standard for even similar platform inter-
ventions. The rapid cycle of change that takes place with social media also places constraints on the data. Twitter,
for example, is a real-time source of communication and thus, changes in the way conversations are structured,
the individual sending the tweets on behalf of an organization, and the style of communication may change rap-
idly. Thus, the descriptions provided of the resources listed in this report require confirmation by the reader.

“There is not enough evidence to inform action based on
the current knowledge base for any of the topic areas
-- tobacco, alcohol or drug use – unless practice-based
evidence is considered.”

After the initial search strategy was implemented with the scholarly literature and refined, it was decided that
additional search terms for tobacco, alcohol or drug to provide a finer-grained analysis would not yield additional
actionable information. Further refined scoping of the search if run on all possible and relevant queries is highly
unlikely to yield research findings that would change the overall recommendations. Virtual hand searches of lead-
ing eHealth journals such as the Journal of Medical Internet Research and the International Journal of Medical
Informatics yielded little additional information beyond the initial review.

Practitioners provided an important contextual grounding for the data, however the recruitment and data
generated was done informally, drawing on recommendations from Health Canada, health practitioners, and
the authors’ knowledge of the field. Detailed consultations with experts resulted from the data itself and was
not originally part of the project, thus the sample was not representative. The anecdotal nature of the experts’
comments and that of the other public health practitioners’ experience using social media may unintentionally
exclude other relevant perspectives. Some of the feedback came from Twitter users and the web community with-
out attribution or expressed interest in being cited.

Social media messages exist in real-time and thus the findings from this review are highly bound by temporal con-
straints. Examples from the resource review are likely to change over time and the very structure of the platforms
themselves will evolve. Lessons learned must be considered within this context.

8.2 Issues
Is this absence of social media evidence an artifact of its ‘newness’, a lack of fit between social media and sub-
stance use issues with youth or is it due to something inherent in the technologies and the way they are used?
Although there is little evidence for use of social media with substance use issues, there is a growing, emergent
body of evidence to support the use of these tools and approaches with sexual health promotion. Considerably
more research has been done attempting to connect youth with health information and services in the sexual
health area than substance use.

26

Tools like Facebook are poorly indexed both within and outside of the site and are difficult to search. Other tools
like Twitter are much easier to search through, however only in a quantitative sense. Twitter can determine how
many times a particular content point (e.g., word, phrase or hashtag) has been mentioned, but it does not illus-
trate the context of how that content is used. The popularity of ‘retweeting’ and modifying tweets before sharing
them means that this missing contextual element is not trivial.

Due to the challenges with relying on conventional search strategies by themselves, snowballing and finding
reputation-based links to resources was used to complement the findings from the searches. This was effective at
locating resources that did not show up in conventional searches, however this method is both time consuming
and yields incomplete findings as it favours established, connected resources over newer or less connected ones.

8.3 Lessons from other areas of health promotion
Neiger et al (2012) reviewed the literature on social media use and general health promotion and found little
on social media interventions with even less on related evaluations. In outlining the possibilities for evalua-
tion, the authors recommend metrics that focus on four key performance indicators: insights, exposure, reach
and engagement. Examples of how these have been applied were not forthcoming. Another possible framing
for social media and Internet-related behaviour interventions was proposed by Lefebvre (2009), who suggests
applying a social marketing perspective and the four P’s (Products and Services, Price, Place and Promotion) to
the design and evaluation. The Spiral Technology Action Research (STAR) model proposed by Skinner, Maley
and Norman (2006) has been applied to youth-focused Internet interventions and their evaluation on issues such
as tobacco control, gambling, and sexual health promotion (see: Norman & Skinner, 2007). The latter area of
sexual health promotion is another area that has some emergent evidence supporting its use with youth and other
populations (Alamagno & Kenne, 2011).

Rice and colleagues (2010) looked at social networking, Internet use and HIV/AIDS risk for homeless ado-
lescents. This cross-sectional study found networks exacerbated harm and help depending on the type of con-
nection made through the Internet. When connected to home-based peers, social networks supported higher
HIV testing rates, while greater connections to street-based peers correlated with a higher rate of risky sexual
exchanges. Gold et al (2011) undertook a systematic examination of online social networking sites for sexual
health promotion and found 178 interventions (with one scholarly publication). Similar to this review, the
authors found social networking sites “are being used to deliver health promotion, although these activities have
not been described in the published scientific literature or evaluated for their effectiveness in improving health
outcomes” (p. e7).

Along with calls for more research to be undertaken in this area, the authors proposed the following recommen-
dations for what should be considered in that research:
“process and impact evaluations of individual health promotion activities using SNSs should
consider inclusion of measures such as:
• Characteristics of end-users: demographics, health knowledge, attitudes and behaviours;
• Quantity of interactions: number of interactions with end-users;
• Quality of interactions - content analysis of interactions to assess relevance and utility;
• Message spread: number of ‘shares’ and ‘retweets’ of site content (and characteristics of
secondary recipients of site content, if possible);
• Impact of activity on health knowledge, attitudes and behaviour; and
• Cost-effectiveness of activities, particularly in comparison to the cost and effectiveness of
delivering health promotion interventions via more traditional channels.” (p. e7)

27

Like youth substance use, much has been published on the process of developing and implementing Internet-
based or social media-focused interventions for sexual health promotion (e.g., Flicker et al., 2004; Hightow-
Weidman et al., 2011), but little on its impact. Nonetheless, examining these other fields of practice and study
can provide some further guidance on how to proceed within the field of youth substance use.

8.4 Conclusions
Given the relative youth of social media, it is perhaps premature to expect that there would be considerable
evidence to support its use for substance use prevention and treatment. Even areas like tobacco use cessation
(all methods) for youth have little high-quality evidence to guide them (e.g., Gervais et al., 2007). Areas such as
online alcohol interventions and tobacco cessation interventions have shown promise (White et al., 2010; Hut-
ton et al, 2011), however the absence of any solid empirical research and evaluation on social media has left a gap
in the evidence. This review parallels the 2011 findings of Gold and colleagues looking at sexual health promo-
tion who found most activity in the area was unreported with only a single published intervention (Moreno et al.
2009) that looked at a social network (MySpace) that is no longer popular with youth.

Sexual health promotion is a field that has experience using social media to engage youth. Unlike with substance
use, there are multiple examples of social media and web-based interventions for use with youth sexual health that
can provide guidance to health promotion professionals looking to bring these tools to alcohol, tobacco and drug
use prevention and treatment (e.g., Flicker et al, 2004, 2008a,b; Ralph, Berglas, Schwartz & Brindis, 2011,
Rice, Monro, Barman-Adhikari, & Young, 2011).

Tobacco and drug use had the most substantial variety of resources available across the different social media
platforms. Alcohol was comparatively less covered with few websites or social media interventions available for
youth and young adults. Of those that are available, most were prevention focused (e.g., MADD, Saskatchewan
Prevention Institute).

There are few solid evaluations and little consistent practice of social media for health promotion related to youth
and young adult substance use. The absence of standards in research and practice poses significant challenges for
a comparative review of social media, limiting the potential to generate or identify best practice indicators.

In discussion with the experts and other health promotion professionals, there is little observable dialogue
between those working within substance use and between it and other public health areas. Not only would taking
a systems approach produce more effective interventions on their own, it would create more effective knowledge
translation on social media –based health promotion more broadly.

28

RECOMMENDATIONS
What steps could public health and health promotion take to effectively
employ social media as a means of addressing substance use among youth
and young adults?

Based on the content reviewed, current practice and feedback from experts, the following recommendations are
suggested for advancing work in social media and substance use treatment and prevention.

Encourage and support the development of a social media strategy for organizations working on
1 substance use prevention and treatment with youth and young adults.

A survey of the current social media landscape for substance use health promotion finds a non-coherent set of
resources and approaches to dealing with youth and young adults. This results in certain social media representa-
tions that are transplanted versions of a regular website (e.g., static information provision) while others actively
use these forms to engage visitors in dialogue, rapidly update the content, and treat material in a more dynamic
manner. With a clearer sense of what social media is expected to do and deliver for organizations, it will be easier
in the future to assess when social media is being used as an intervention or as simply an extension of more tradi-
tional unidirectional health communications.

Although there were notable examples of organizations integrating their social media into a strategy, conversa-
tions with practitioners and examples reviewed suggest that this is an exception, rather than standard practice.
The dynamic, evolving nature of social media tools coupled with a fundamental shift from a broadcasting model
to a peer-to-peer conversation model of communication poses difficulties for public health professionals seeking
to craft ways to connect to youth and young adults. Practitioners are using social media out of a perceived need to
“go where youth are”, yet without a full grasp of the methods and implications associated with this new paradigm
of communication, public health is struggling to connect to youth.

Supporting health practitioners in developing a social media strategy that is consistent with their organization’s
goals and in the needs and interests of youth will contribute greatly to the development of relevant, high quality
and responsive social media resources for young people. By encouraging innovation and the necessary research
or evaluation models that can support strategic learning, such as Developmental Evaluation, this evolution of
programming will be guided by data rather than speculation.

29

2 Develop a ‘youth first’ approach to social media programming

In creation of strategy and development of specific interventions, youth and young adults need to play central
role. Simple consultation with youth and young adults is not sufficient, young people need to play tactical and
strategic roles in social media projects to ensure relevance and appropriateness. This approach further requires
a re-thinking of the language and types of messages that health promotion uses in delivering information. Youth
and young adults engage with social media using methods and at times and locations that differ greatly from adult
health professionals.

This shift includes the role of mobile applications and use of social media from handset devices and tablets.
For example, on issues such as drug safety, youth respond quickly and in real-time to threats, and social media
provides the means to do this. By developing resources and strategies that fit these behavioural patterns, public
health will be better able to produce the most appropriate and timely tools for substance use health promotion.

3 Expand focus beyond the media technology to include equity

Engaging youth in health promotion has unique challenges and social media adds to these by introducing a layer
of technology, which can create or amplify social inequities. Concerns were raised about the types of youth that
social media engages and how thought needs to be given to ways in which social media interventions can reach
those without the technologies best suited to using these tools effectively.

University and college students were most often cited as the demographic involved in the development of social
media tools (when youth were consulted) and apps and related campaigns, leaving potential gaps in access or
knowledge. Youth from communities of disadvantage and represent a diversity of perspectives – including
emphasis on current and past substance use users – are critical to engage and support in maintaining engage-
ment using social media.

Create connections within and between public health initiatives working with social media to look
4 beyond substance use to other domains for knowledge and support

Substance use prevention and treatment with youth and young adults is not a unified field of public health, yet
there is much in common between the way social media is being used to address the issues connected to it. Little
connection between the work in tobacco, alcohol, or drug use prevention and treatment was made in discussion
with practitioners or as part of the social media interventions themselves. With some exception, professional-
directed social media interventions were focused on a single topic.

Public health issues like youth sexual health have more established bodies of evidence on the use of eHealth
promotion and substance use prevention and treatment professionals could learn much from this area of public
health. With such little solid evidence and a rapidly changing field of research and practice, health promotion
could gain much from building better links between areas.

30

Foster a culture of innovation within the substance use practice community on issues of social media to
5 guide evaluation and program improvement.

Social media tools and the content delivered through them changes rapidly and traditional planning and evalua-
tion approaches to understanding their impact and creating program improvements are ill-fitted to this model.
To be effective in engaging youth, interventions must be designed in a manner that fits the dynamic youth
lifestyle that is accustomed to adopting and adapting to new technologies and ways of communicating. This is
an environment of complexity and innovation, thus the methods and tools to support social media development
needs to be considered as part of a larger effort to create a culture of innovation. A single method or tool will
not likely suffice given the rapid pace of change. For example, within the last 12 months Facebook has unveiled
its Timeline format to organize content in a linear manner, Skype integration (to enable video chat within the
site), and is allowing thousands of new apps to join its ecosystem; YouTube has completely restructured its look
and feel and the manner by which its channels are formatted; while Twitter has gone from being a niche tool to a
mainstream form of communication for many young people.

An organization seeking to develop for one version of a particular tool without the capacity to adapt to that tool’s
changes will find itself out of touch. Doing this requires developmental thinking and evaluation (Gamble, 2006;
Patton, 2011) and adaptive capabilities that come from developing a culture of innovation (c.f., Christensen &
Raynor, 2003) not single-shot attempts at creating new products or services. Use of traditional, linear planning
models are unlikely to support the innovation culture necessary to create adaptive strategies that allows organiza-
tions to respond to youth needs and demands in a timely manner. Without changing the way plans are developed
and executed there is a risk that health promotion will create tools that are always a step behind where youth want
to be and where they seek their information from.

To make this adaptation and to understand the implications of developing strategies to engage youth in this
dynamic context, systems and design thinking are recommended skills that public health professionals need to
develop or enlist in creating programs and evaluation plans (c.f., Brown & Wyatt, 2010; Norman, 2009; Patton,
2011). This approach also means paying attention to social networks and expanding the scope of attention for
evaluation and program design beyond the individuals that are reached directly, but also towards people within
those individuals’ networks (e.g., Weber & Monge, 2011). This may have implications for the type of success
indicators that organizations use to assess program impact and the way in which evaluation data is gathered and
used to support innovation, development and improvement.

Engagement with youth cannot be done piecemeal, but must be built into the fundamental design process used
in creating social media messages and strategies by having young people involved in program development at
the outset. Thinking in systems and applying participatory design methods appropriately will best enable public
health and health promotion to better support the foundation for a culture of innovation. Doing so will generate
more responsive designs of social media interventions that have greater impact on the knowledge, skills and atti-
tudes of youth on matters of substance use. Supporting organizations in developing or enhancing their systems
thinking and design thinking skills along with expanding their knowledge of youth engagement strategies is key
to implementing this recommendation.

31

6 Place social media within a ‘glocalized’ context

Youth and young adults function online as part of a global network of connections. Young people are motivated
to go where their peers are and use resources that are endorsed by that peer group and are seen as credible, fits
with their values and effective. They are less motivated by where these resources are produced. At the same time,
this attention to peers means that certain local activities will remain important to them as part of their social
networks.

Not every local health unit or substance use-related health promotion needs to have an in-depth social media
engagement plan. At the same time, there is an opportunity for health professionals to provide specific, targeted
interventions and to link these with other ones. It is worth considering how public health can direct youth to
existing interventions that are not their own where appropriate rather than seeking to (re)create social media
spaces locally. To do this, more substantial, robust practice networks and communication between professionals
working in social media and substance use (or public health more broadly) is needed within Canada and inter-
nationally. Systems thinking about the problem and designing strategies that fit these environments will enable
greater attention to local and global opportunities for health promotion.

32

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Free, C., Whittaker, R., Knight, R., Abramsky, T., Rodgers, A., & Roberts, I. G. (2009). Txt2stop: a pilot ran-
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