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Context: There are two ways that digital media may influence alcohol use. The first is commercial alcohol marketing. The second is user-created alcohol promotion, defined as content distributed through new media that promotes consumption, but independent of commercial marketing. This thesis explores how both types of content promote alcohol, what association there is between exposure and alcohol-related attitudes and behaviour, and the differences between marketing and user-created promotion. Method: A mixed method design was employed, divided into two studies. The first was a content analysis of the design features, topical references, and messages suggested about alcohol in digital marketing and user-created promotion on Facebook, Twitter, and YouTube. The second was a cross-sectional survey with young adults (n = 405). This measured awareness of, and participation with, digital marketing and user-created promotion, and the association with consumption, higher-risk drinking, brand recall, expectancies, and drinking motives. Results: The content analysis found that digital marketing had personalised designs which contained subtle and positive messages about consumption, whereas user-created promotion had simpler designs, displayed little ethical practice, and contained overt messages about higher-risk drinking. The cross-sectional survey found that young adults were aware of, and participating with, both digital marketing and user-created promotion, with exposure greater for the latter. Exposure to both types of content was positively associated with alcohol use, higher-risk consumption, and drinking intentions. User-created promotion had a stronger association with all outcomes than marketing. The association between exposure and consumption, for both types of content, was mediated through drinking motives and expectancies. Conclusion: Young adults are aware of, and participating with, a range of digital marketing and user-created promotion. That such exposure is associated with alcohol-related attitudes and behaviour highlights the potential of new media to influence alcohol consumption. Further research is required to better understand young people’s experience with digital media and the challenges of addressing online health risk messages.

The aim of this multi-disciplinary research was to explore the power of digital, interactive or participatory storytelling to influence human behaviour in the context of public health. It addressed three related questions: RQ1: Does digital storytelling have the power to influence human behaviour? RQ2: If digital storytelling can influence human behaviour then how might it do so? RQ3: Is a ‘digital storytelling framework’ feasible as an approach to behaviour change? Four linked qualitative studies were conducted: a scoping review, in-depth interviews with 11 international ‘digital storytellers’, two case studies of ‘digital storytelling designed to influence human behaviour’ and six focus groups with 35 adolescent ‘digital story participants’. The research found that: RA1: Digital storytelling appears to influence human behaviour. RA2: Digital storytelling appears to influence by engaging at ever deepening emotional and non-conscious levels. Commerce appears to understand and embrace this power: But public health appears to rely on traditional uni-directional, non-participatory message led approaches and appeals to cognition. This presents threats and opportunities to public health. RA3: The proposed ‘digital storytelling framework’ is feasible and desirable as a behaviour change paradigm. The thesis concludes that Digital Storytelling appears to influence human behaviour. It appears to derive its power to influence by facilitating unprecedented depths of emotional engagement potentially en route to behaviour change. The current imbalance in how commerce and public health corral the power of digital storytelling suggests that the latter might embrace its potential; and tougher regulation might constrain how the former uses it to market harmful products. The proposed digital storytelling framework makes a valuable creative, analytical and critical contribution to both of these ends. Its core principles have informed the design of numerous story-led digital health interventions; and they now sit at the core of a counter-marketing campaign to reduce harmful effects of marketing on children’s health.

There has been substantial scientific debate about the impact of alcohol marketing on consumption. Relying mainly on econometric studies, the alcohol industry has traditionally maintained that alcohol marketing does not influence consumption, but is merely limited to brand level effects. Public health advocates, on the other hand, point to consumer-level research that shows a relationship between exposure to marketing and alcohol consumption, especially amongst the young. Recent longitudinal research has firmly established a causal relationship between alcohol marketing and alcohol consumption, giving the upper hand to the public health critics of alcohol marketing. The new consensus forged by these recent cohort studies has led to two separate, but related, debates. In the first instance, having answered the question of whether marketing influences drinking behaviour, there is a need to establish how and when such effects occur. Secondly, in the face of the mounting longitudinal evidence on the effects of marketing, representatives of the alcohol industry have sought to move the debate away from marketing by explicitly highlighting peer influence as a more significant causal factor in problematic youth alcohol consumption. This thesis tackles both of these new questions simultaneously by harnessing insights developed from social norms theory. An online survey (N = 1,071) was administered to undergraduates of the Dublin Institute of Technology in Ireland, and mediation relationships were tested with logistic and multiple linear regression methods as appropriate. Amongst other findings, the main contributions of this thesis are: (1) that marketing may play a key role in establishing perceived social norms around alcohol consumption, and that these perceived norms may act as an indirect pathway for the influence of marketing on behaviour and (2) that the association between alcohol marketing and consumption may increase as levels of engagement with marketing increase; this engagement appears to be at its most potent when marketing facilitates simultaneous interaction between the consumer, the brand and the consumer’s peers in an online social media environment. This thesis helps to move the field of alcohol marketing scholarship beyond questions of whether marketing influences alcohol consumption to how and when that influence occurs. By showing how peers may act as perpetuators and magnifiers of marketing influence it also undermines the argument that peers matter more than marketing, and suggests that peer norms can act as a powerful marketing tool.

Plain packaging first appeared on the UK policy agenda in the Department of Health’s 2008 ‘Consultation on the Future of Tobacco Control’. Since then, plain (or standardised) packaging has been framed through the potential benefit to young people. Within the period of this thesis, plain packaging has been actively debated and draft plain packaging regulations were published in June 2014. An extended literature review of academic and practitioner marketing literature, internal tobacco company documents and public health packaging research, establishes that the research informing the policy debate, while consistent in its approach and findings, fails to recognise the strategic nature of pack design, the full extent of the influence that branded design can have on consumer responses, and the importance of product design as a marketing tool. This thesis attempts to address these gaps in the plain packaging evidence base. It explores if, and how, adolescents engage with different styles of packaging and product design, whether or not an association between tobacco packaging and adolescent smoking exists, and whether it is possible to observe cognitive, affective and behavioural responses to packaging. The study uses a sequential exploratory mixed methodology design with two stages of research. First, focus groups were conducted with 15 year olds (n=48) to explore adolescent responses to tobacco packaging and product design. The findings show that adolescents are most appreciative of ‘novelty’ pack designs. These ‘novelty’ packs, for instance with innovative structures or distinctive designs and colours, generated positive user imagery and influenced affective feelings among participants. Cigarettes with slim diameters, white tips and decorative designs increased appeal and communicated a weaker tasting and less harmful product. Conversely, a plain pack eliminated positive perceptions and feelings, and exposed tobacco as harmful, dirty and not for young people. The qualitative findings were used to develop measures and hypotheses which were tested in a quantitative survey. The second stage of research utilised a cross-sectional in-home survey (n=1373) with 11 to 16 year olds. Respondents were asked to rate three different pack styles - ‘novelty’, ‘regular’ and ‘plain’ - on 11 pack ratings items and four pack feelings items. The findings show adolescents hold ‘novelty’ packaging in higher regard than ‘regular’ packaging across pack ratings items. There were fewer differences between ‘novelty’ and ‘regular’ packaging for the pack feelings items. Plain packaging was consistently rated most negatively across all survey items. Logistic regressions, controlling for factors known to influence youth smoking, showed that susceptibility to smoke was associated with positive appraisal and also receptivity for ‘novelty’ packaging. There was no association with pack appraisal or receptivity for the plain pack. While susceptibility is not a direct behavioural response it is a reasonable predictor of future tobacco use. Collectively the findings show that ‘novelty’ packaging and product design holds greatest appeal for adolescents. Plain packaging limits the opportunity for tobacco companies to communicate with, mislead and influence consumers. Based upon the role of packaging for consumer goods in general, and tobacco in particular, plain packaging would effectively reduce the promotional role of packaging.

In 2005, the House of Commons (HoC) Health Committee produced a report on The Influence of the Pharmaceutical Industry – the first of its kind since 1914. The inquiry concluded that there were ‘over-riding concerns about the volume, extent and intensity of the industry’s influence, not only on clinical medicine and research but also on patients, regulators, the media, civil servants and politicians’, and stressed the need ‘to examine critically the industry’s impact on health to guard against excessive and damaging dependencies’ (HoC 2005, p. 97). It also noted that it is important to comprehensively analyse pharmaceutical regulation in order to ascertain whether there are systemic problems: In some circumstances, one particular item of influence may be of relatively little importance. Only when it is viewed as part of a larger package of influences is the true effect of the company’s activity recognised and the potential for distortion seen. The possibility that certain components of any such campaign are covert and their source undeclared is particularly worrying. (HoC 2005, p. 97) This study addresses this recommendation and was primarily conducted to examine whether recognised concerns are merely ad hoc or as a result of systemic flaws in the current system of pharmaceutical regulation. The work addresses a gap in the academic literature by drawing on the fragmented criticisms of the pharmaceutical industry in order to produce a model to illustrate how various stakeholders collaborate with drug companies to promote licensed products, and to explore the nature of the relationships between these elite stakeholders. The thesis begins with a literature review which determines who is involved in pharmaceutical regulation; how the regulatory system works; and explores the key role of communication in this process (Chapters 1 to 3). The recurrent theme is the neglect or exclusion of the patient/consumer, which leads to the development a model of intra-elite communication in drug regulation called Pharmaffiliation (Chapter 3). The thesis then looks for evidence to support or refute this model, using multiple methods (Chapter 4). Four case studies (with specific selection criteria) are chosen to test the model’s constructs and indicators (Chapters 5 to 8). The research uncovers systemic problems in the current system of pharmaceutical regulation which can ultimately harm the patient/consumer, and the implications of these findings are discussed (Chapter 9). Solutions on a micro-level include consumer involvement in decision making processes, which can be enhanced through public education and awareness campaigns and the instigation of public inquiries whenever drugs are withdrawn from the market (HoC 2005, p. 105). On a macro-level, however, this will involve critically exploring neoliberal capitalism and the empowerment of the citizenry (Street 2001).

The social norms concept provides a fresh basis for thinking about how public health policies and campaigns impact health behaviour. Social norms offer much promise to the field of public health, nonetheless, the potential role of norms in changing health behaviour have not been fully embraced. This thesis demonstrates that one of the mechanisms by which national level policies (e.g. tobacco control) can promote health behaviour change, such as an increase in quit intentions, is by making smoking less normative and an undesirable behaviour. This study is vital as it provides a broad conceptualization of tobacco denormalisation and shows how its reasoning is able to influence normative beliefs and smoking behaviour. A review of literature was carried out to establish the generic origins of denormalisation as well as demonstrate that this approach (i.e. social norms) has been widely adopted in schools and college settings to influence health behaviour. As a broader perspective of this thinking was imperative to address public health issues at a societal level, tobacco control was employed to investigate how individual polices influence behaviour and normative beliefs. The research methodology used was pluralistic in nature, given that the majority of past tobacco control policy studies employed either quantitative or qualitative methods. Thus adopting both methods a richer amount of data would be obtained in order to generate an improved understanding of how public policy affects norms and smoking behaviour. To empirically examine the relationship between public policy, social norms and smoking behaviour a broad conceptualization was developed to investigate the normative pathways between national level tobacco policy effects on youth and adults’ smoking behaviour. Quantitative results from the longitudinal study, the International Tobacco Control (ITC) Scotland/UK survey, indicate that a comprehensive smoke-free law that covers, without exception, an entire nation (i.e. Scotland) has increased adult smokers’ perceived social unacceptability of smoking, to some extent higher in Scotland than rest of the UK which, in turn, is associated with quit intentions at follow-up, in both countries. The examination of data from the UK Youth Tobacco Policy Study (YTPS) also demonstrated that the influence of tobacco marketing awareness on adolescents’ smoking intentions is mediated by perceived norms. Prior to the enactment of the UK Tobacco Advertising and Promotion Act (TAPA), higher levels of awareness of tobacco advertising and promotion were independently associated with higher levels of perceived sibling approval which, in turn, were positively related to smoking intentions. Independent paths from perceived smoking prevalence and benefits fully mediated the effects of advertising and promotion awareness on intentions, during and after the enactment of the TAPA. Results from the qualitative study generally supported the quantitative findings and provided new insights into how adolescents’ normative beliefs and smoking behaviour are influenced by tobacco control policies. The qualitative group discussion suggests that smoke-free legislation and anti-smoking ads influence perceptions of prevalence, acceptability and smoking behaviour. A number of theoretical implications were presented, including the belief that social norms campaigns and interventions must be focal and salient in individuals’ consciousness so as to effect the desired behaviour change. A theoretical framework of the various normative mechanisms should consequently be integrated into tobacco control policies and norm-based interventions to work in a synergistic manner to influence health-related behaviour. Practical implications of this conceptualization include the view that, instead of public health interventions focusing on conventional approaches (for example, scare tactics), an appropriate strategy would be to incorporate specific information that corrects normative misperceptions and ambiguities among referent populations at individual and societal levels, with consequential normative and health behaviour change. It is recommended that future research employing tobacco industry perceptions and possibly a descriptive norm as additional normative mediators, aside from unacceptability, would be of value to examine whether smoke-free legislation influences quitting partly via changing favourable tobacco industry perceptions, social acceptability of smoking and perceived prevalence of smoking. To sum up, the findings demonstrate that societal level policy measures such as smoke-free legislation and the TAPA are critical elements of a comprehensive tobacco control program that can significantly influence adult smokers’ quit intentions and reduce adolescents’ smoking intentions respectively, by signifying smoking to be less normative and to be socially unacceptable.

Relationship marketing provides a new foundation for thinking, genuine change in values and ethics and a new logic that sees consumers as the prime drivers of the value creation process. It seems to have a lot to offer to social marketing, however, despite its potential, the social marketing field is responding slowly to relational thinking. This research demonstrates that relationship marketing helps social marketing and that its absence seriously undermines the field. Our examination is critical because it de-constructs the transactional paradigm and shows how its logic is incapable of responding to the complexities of contemporary pluralist societies. From the literature, we have identified the principles, processes and constructs of relationship marketing that are transferable to social marketing. Further, we have identified the challenges and implications of that transference, given the particular characteristics of social marketing. To empirically examine the potential of relationship marketing in social marketing, we have conducted a process evaluation and developed a specific framework that incorporates and reflects relationship marketing principles, processes and constructs. This research makes an important methodological contribution because it goes beyond current frameworks and suggests alternative evaluation components. The process evaluation was applied through an explanatory, holistic and single case-study design. The case was a parent drugs prevention programme and to examine it we have predominantly used a mix of qualitative methods and a research design which enabled triangulation. Through the application of process evaluation to the case we have de-constructed the dominant paradigm of the programme and examined its consequences. The findings indicate that the programme did not widely applied the principles, processes and constructs of relationship marketing. Despite having successfully applied relationship marketing in specific parts of the programme, these correspond to technical rather than strategic aspects of relationship marketing and worked as isolated parts rather than as a whole. More fundamentally, rather than seeing consumers as partners, the programme saw consumers as targets, not recognizing them as the main drivers of the value creation process. The programme was therefore shaped by a transactional perspective which affected its assumptions and undermined its design and implementation. The main conclusion is that, despite its theoretical potential, it is challenging and difficult to transfer relationship marketing to real live social marketing programmes. In particular, social marketing needs to be more reflexive and self-critical in order to de-construct its prevailing paradigm and start re-constructing an alternative. This demands not only a new attitude, new values and new assumptions but also a focus on resources, competences and new and more flexible organizational structures.