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Social Media and Youth Substance Use
 

Social Media and Youth Substance Use

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How is social media being used to support health promotion efforts to engage young people? This review of the literature and active resources aimed at preventing substance use among youth and ...

How is social media being used to support health promotion efforts to engage young people? This review of the literature and active resources aimed at preventing substance use among youth and providing early intervention exposure was conducted for Health Canada in 2012. The purpose of the report is to explore the ways in which social media is being used, the challenges and opportunities it brings, and examine the evidence on what works, doesn't and consider what is needed.

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    Social Media and Youth Substance Use Social Media and Youth Substance Use Document Transcript

    • 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 CENSE Research + Design Toronto, ON Canada For Health Canada, Tobacco and Drugs Initiative CENSE Research + Design
    • AcknowledgementsThe 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 providingexpert 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 forproduction.For more information about the contents of this report contact:Cameron Norman PhDPrincipalCENSE Research + Designinfo@cense.cawww.cense.caPlease 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 CONTENTS01 Executive Summary 0102 Introduction 0203 Context 0304 Methods of Investigation 0605 Review of the Scholarly Literature 08
    • 06 Social Media Content Review 1107 Practitioner Perspectives 2008 Conclusions & Limitations 2409 Recommendations 2810 References 3211 Appendix 1 37
    • 01EXECUTIVE 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 notcaptured elsewhere.The review of the scholarly literature found few examples to illustrate effective interventions using social mediaand offered little guidance on appropriate evaluation methods. Text messaging was the only intervention formatthat 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 broadfield with varying levels of informational depth, opportunities for youth engagement, and quality. The designfeatures of these resources was also varied as some were visibly part of a larger integrated strategy, while otherswere single pages or videos with limited to no connection to other resources or even the organization or programresponsible.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 thedeployment of the social media strategy, to pay attention to equity issues and recognize the glocalized and mobilenature of social media.Recommendations include: 1) support health professionals in developing a social media strategy for substanceuse issues using a ‘youth first’ approach that emphasizes health equity, person-centred design methodologiesand 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 andmodel for engagement. Systems and design thinking can facilitate this shift and when used with developmentalevaluation methods can produce innovative and responsive ways to address substance use with young people.
    • 02INTRODUCTION 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 theirmost 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 witheach other through the Internet, enabling active conversation about topics rather than serving as simply anothermeans of broadcasting. It facilitates real-time interactions between people from diverse contexts to connectaround common issues and develop novel solutions to problems. This peer-to-peer model of communicationis deeply personal and familiar while contributing to a global agora of dialogue and health knowledge. Throughsocial media anyone with Internet access can create, distribute and re-mix content for the same audience asanyone else.For youth and young adults seeking health information, treatment choices, or social support about substanceuse, social media offers a panoply of options of which few are evidence-based or delivered as part of professionalpublic health services. It is that professional-focused part of the spectrum that this report seeks to illuminate byreviewing the current state of evidence, provide examples of current practice, and suggest possible options forfuture work.Social media levels the playing field in a game that is open to everyone and is still defining its rules. As thisreport will illustrate, these new rules are posing challenges for the way that evidence is generated, interventionsdelivered, and communication strategies implemented. What this means for the prevention and treatment ofsubstance use for youth and young adults is unclear. However, by looking closely at what is being currently inpractice, health practitioners can better shape a future that best uses the opportunities that social media createsto address substance use issues with youth and young adults in ways never before possible.
    • 03CONTEXTSubstance 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 useamong young people are still higher than any non-clinical population (Health Canada, 2010). Alcohol and druguse 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 andpotential 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 publichealth 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 foryouth that requires not only new networked tools, but new ways of thinking about how youth engage with thosetools (Norman & Yip, 2011). This report outlines the current state of evidence to support the use of socialmedia for substance use prevention and treatment with youth and young adults, reviews examples of social mediaapplications currently in use, and provides insight from researchers and practitioners engaged in social mediause 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 profileof some of the current Canadian substance use-focused initiatives that use social media; and an identification ofspecific 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 unlessthe 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 popularsocial media platforms in Canada.3.1 Defining Social MediaThe term Web 2.0 (http://en.wikipedia.org/wiki/Web_2.0), describes a set of tools and technologies thatreflect the terms illustrated in Figure 1. These terms reflect an active, interactive, and dynamic set of conditionsthat shape the way content is generated, distributed, and redesigned.
    • 04 Figure 1: Web 2.0 Word Map Source: http://en.wikipedia.org/wiki/File:Web_2.0_Map.svgSocial media falls within this realm of Web 2.0. For this review, social media is defined as any networked tool orinformation 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 seekengagement, dialogue, participation, immediacy and operate with a temporal flexibility to their lives that isdistinctive 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 themessage 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 youthwith ways to connect with public health professionals and each other immediately and wherever they are whencombined with mobile handsets or tablets. The mobility of social media provides opportunities for engagementwith youth anywhere they are and anytime they need services and support.3.2 Social Media and YouthYouth 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 networksites and engage with them on a daily or weekly basis (Lenhart, Purcell, Smith, & Zickuhr, 2010). Tools such asFacebook, Twitter and YouTube are everyday parts of the lives of youth and young adults and serve as a sourceboth healthy and unhealthy substance use information and resources (International Narcotics Control Board,2012; Reifman, 2009; Seidenberg, Rodgers, Rees, & Connolly, 2011).
    • 05This shift in the way that users interact with this new class of technologies has had fundamental implications forthe 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 peerswithout having knowledge of computer programming. For health professionals, this is a shift from broadcastinginformation 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 TermsYouth 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 onthe 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 designand 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 thatis 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.
    • 06METHODS OFINVESTIGATIONThis 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 social4 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.
    • 08REVIEW OF THE SCHOLARLYLITERATURE 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 mediaevaluations 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 topicareas: 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 associatedwith 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 ResultsOf the articles found, only three explicitly used the term “social media” (Anderson & Speed, 2010; Seidenberget 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; Whittakeret al., 2009; Whittaker, Maddison, McRobbie, & Bullen, 2008).Upon executing the review, the principal challenge was determining whether an intervention was indeed a socialmedia 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 notexamples 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 componentspowering them (Webb, Joseph, Yardley, & Michie, 2010). For example, a 2010 systematic review of onlinealcohol 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.
    • 09The only formal literature review of social media applications for public health (broadly) located was conductedby 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, includingcommentaries 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 inthe Schein, Wilson and Keelan (2010) review. Analyses of social marketing approaches to tobacco promotionthrough 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 andits different health and non-health-related studies yielded no transferrable insights on effectiveness or efficacy forthis review on substance use and youth. The only area where there was reasonable evidence of efficacy was on theuse of text messaging for support of tobacco use cessation and alcohol.5.2 Text MessagingText messaging was the only social media technology that did have some explicit evidence behind it, thatincluded 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 etal., 2009). However, within even the published systematic review only one relevant article that had an explicitintervention 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 heavydrinking-related problems (Suffoletto et al., 2012). The study found that the text-message intervention helpedassess problem drinking levels in young adults exposed to the intervention, helped them set goals for alcoholreduction, 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 yieldedsignificant positive changes in smoking behaviour attributed to the intervention (Whittaker et al., 2009). Bothshort and long-term outcomes were positively affected, however the heterogeneity in long-term outcomes limitswhat can be expected of such interventions. One of the principal challenges with this review – and that of othereHealth interventions overall – is the thin description of the interventions themselves reported in the academicpapers. Interventions relied on automated text message systems that delivered personalized messages developedfrom databases. Two trials (Rodgers, 2005 and Free, 2009) involved daily delivery of 5-6 messages up to aplanned 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 drinkersafter presenting to one of three emergency departments (Suffaletto et al., 2012). Participants were randomlyassigned to receive weekly text message (TM) based feedback with goal setting, weekly TM-based assessmentswithout feedback, or a control for a period of three months. Measurements were taken at baseline and threemonths post-intervention. The results showed that those with the text-message based interventions – with orwithout 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 doesdemonstrate the feasibility and potential efficacy of text messaging for alcohol use. Both the authors and otherssuggest that more robust randomized trials are needed.
    • 10Text messaging is a form of social media, however its absence of wider-scale participation opportunities relativeto other social media forms and the inability to adequately share content from text messages to others with easelimits the lessons learned from it relative to tools such as Facebook, Twitter or YouTube. These other socialmedia forms also have features that enable them to easily link to other resources (e.g., webpages, other socialmedia) and embed rich media such as video, text and audio in a manner that text messaging largely is unable todo well. These differences make some of the lessons from text messaging more challenging to transmit to othersocial media forms.Another missing component of the data was research on mobile applications beyond text-messaging such assmart phone applications or apps.5.3 Concluding MessageThe 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 beyondtext messaging.With the exception of text messaging, which has shown some promise as a means of supporting substance usereduction, no body of work has provided evidence to support or reasonably challenge the use of social media asa resource for substance use prevention and cessation. The absence of sufficient research has further limited theability to identify suitable evaluation challenges arising from social media and substance use work with youthand young adults emerging from the literature. No cost-effectiveness data was presented or found in any of thereviews 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.”
    • 11SOCIAL MEDIACONTENT 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 changewas undertaken using the Google search engine, referrals from health professionals, and linked referencesobtained from resources located during the review. Additional searches within each social media environmentwere 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 socialmedia 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 toprovide 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 andforms reviewed. For example, some Facebook pages or YouTube sites had no ability to facilitate comments orsharing, which limited their potential to engage their audience. In certain cases, the Facebook page was used asa portal for other Internet sites connected to the program or campaign, while in others a Facebook wall was usedmore like a bulletin board.A profile the resources reviewed is in Table 1. The table includes Canadian examples except for particularlynotable non-Canadian examples.Reviewing these resources finds a broad diversity in the manner by which public health and health promotionservices 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 popularvehicle for health promotion among the various social media types reviewed. Twitter was the next most populartool (by number of resources), with YouTube being the third most popular social media tool.
    • 126.1 Profiling Social Media InterventionsOne of the primary challenges with reviewing social media applications is the lack of consistent standards acrossthe interventions for identification and contact. Best practices for determining eHealth ownership and markersfor quality content (c.f., Charnock & Shepperd, 2004) were not typically followed. Although every social mediaresource has some marker that indicates when content was posted, the date of content creation date is not alwaysclear 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 noidentifiers listed, only a reference to a funding sponsor. The only descriptor with contact information providedwas:“WhatsWithWeed.ca is a Canadian educational resource developed with young people in Ontario who are bothmarijuana users and non-users, in partnership with drug education specialists, drug treatment counsellors andresearchers 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 wascommon among the resources reviewed. Of the different media forms, websites were the most likely to providesome 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 thebest positive examples was the Drugs Not 4 Me page (http://www.facebook.com/drugsnot4me) that offeredmultiple forms of contact for visitors to the page. A more typical example was Live, Play, Be Tobacco Free, thathas a hard to navigate collection of information about sponsorship and contact information, due in part to wayin which Facebook pages are designed, and partly due to a reliance on a secondary resource (a web page) as theprimary means of conveying information about the resource. The page features an About section that has nodiscernible 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 FocusThe population of interest was not evident in many social media interventions. While some were identified bytheir name (e.g., YATI, Youth Voices Research Group), others did not have an explicit statement of focus onyouth even if there were identifiable youth resources (e.g., Quit Exchange).6.3 BudgetAlthough 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 mediais 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 spentmonitoring these sites.
    • 13For 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 ofWaterloo/Canadian Cancer Society) was developed from a budget of close to $300,000. The project, funded byHealth Canada, included costs for professional developers, graphic designers, marketing leaders, evaluation andresearch expertise and data from the Propel Centre for Population Health, and soliciting feedback from youngadults.Another example of social media use in youth substance use for tobacco control was the Access Project by TheYouth 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 contrabandcigarettes. The project, which was funded by the Ontario Ministry of Health Promotion, ran for three months andestimates for the social media portion of the project suggest it would cost $65,000 to operate at the same levelyear round. This is based on having one staff member working at .6 full-time equivalent and costs for local youthengagement 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 blogsfocused 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-timesocial media staff person assigned to administer the strategy and work with youth and young adults to produceand distribute content. The Youth Voices Research Groups’ Youth4Health project model represents the largestknown application of social media to youth health promotion.
    • 14Table 1: Resource review Resource Name Resource Locator Focus DescriptionFACEBOOK PAGESNot4Me 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 likesOntario Lung http://www.facebook.com/ Tobacco use cessation Custom page with videos embedded in the site, looks like it was designed toAssociation 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 likesIn 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/307157932632220Leave the Pack http://www.facebook.com/ Tobacco use cessation Many user updates on the website filled with tips for quitting and otherBehind 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.
    • 15Table 1: Resource review, Continued Resource Name Resource Locator Focus DescriptionFACEBOOK PAGESQuitters 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 likesYouthRISE 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 likesFuck Cancer (Van- http://www.facebook.com/ Cancer awareness 56870 likes. Highly active page with links to videos, magazine articles, usercouver, BC) letsfcancer comments and diversity of participants on the websiteCampaign to http://www.facebook.com/ Cancer awareness 780 likes. Consistent, regular posts and updates with links to external sitesControl Cancer controlcancer from around the world. Many of the updates are focused on news articles on(Toronto, ON / the science of cancersCanada)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. 306Free Project (Van- PictureMeSmokefreeProject likes. Most information is delivered to users using the feed generated fromcouver, 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)
    • 16Table 1: Resource review, Continued Resource Name Resource Locator Focus DescriptionFACEBOOK PAGESCanadian Centre http://www.facebook.com/ Substance use Not updated regularly. One post in 2012 with little detail. Largely used foron 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 TUBEHealth 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 channelSensible Drug user/SSDP?ob=0&feature has 201 videos and more than 1.3 Million views. Videos focus mostlyPolicy =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.
    • 17Table 1: Resource review, Continued Resource Name Resource Locator Focus DescriptionYOU TUBESaskatchewan 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 applicationInstitute 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 aTobacco 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 youngAboriginal Health user/NAHOnews tobacco awareness adult substance use issues. Emphasis on aboriginal-focused treatment andOrganization 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 toResearch 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.WEBSITESThe Smoking http://www.smokingzine. Tobacco use cessation A recently retired intervention that features customizable personalZine 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.
    • 18Table 1: Resource review, Continued Resource Name Resource Locator Focus DescriptionWEBSITESQuitters 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 harmsSubstance Use nations/youth-substance- associated with substance abuse and provides links to other sites that canInformation 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. CessationXPeriment.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 theNational Drug drugstrategy.gc.ca/preven- harmful effects of drug use by presenting information, testimonials, andStrategy / Drugs tion/youth-jeunes/index. multi-media tools to connect youth to prevention messages.Not 4 Me html
    • 19Table 1: Resource review, Continued Resource Name Resource Locator Focus DescriptionTWITTER 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 followersCrush the Crave @crushthecrave Tobacco use cessation Resource dissemination for quit smoking including tips and news articles. 367 tweets, 177 following, 610 followersHooked 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 followersQuitters 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 followersYouthRISE @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 followersFuck 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 conversationalSmoke 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
    • 20PRACTITIONERPERSPECTIVES 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 wassought 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 theoverall recommendations for public health. As this review was designed to reflect the state of evidence and situatethat in Canada, Canadian-based expert practitioners with experience in social media, substance and public healthwere 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 findingsand provide additional insight into social media and substance use practice. Reflections, resources and commentson the state of practice was obtained from two PhD-level principal investigators (researchers), two Masters levelhealth 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 thefocus on social media, advice from a global network of health promoters and youth working within this area wasalso sought and this report reflects those contributions.Commentary was provided through face-to-face or telephone conversations in March 2012 after the literatureand content reviews were completed. The purpose of these discussions was to gain additional practice-basedexperience to provide context to the review given that no clear findings emerged. The author of this report alsobrings 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 MessagingOf 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 questionedgiven the emergence of new rapid-response methods of communication (e.g., Twitter). One expert pointed outthat text messaging in North America didn’t take off until used as a voting method on popular teen-orientedtalent 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 includedwith a data plan. Shows like American Idol continue to use text messaging as a voting method while includingalternative 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 engagewith fans during the series. There was speculation that the popularity of text messaging might wane as data costscome down and the means to engage in rapid communication quickly expands. The investment in text messagingas a medium for future health promotion should be considered with caution given these changing trends.
    • 217.2 Youth EngagementA consistent observation among the expert group is that the world of youth and their social media landscapeevolves 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 tothese changes and experts mentioned the disconnection between adults and youth in the way that they approachsocial media. Youth are far more flexible and connected to the media and each other and use it in ways that arenot 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 warnyouth of the dangers of drugs, tobacco or alcohol. This thinking produces interventions that youth “laugh at” orignore or attracts youth that are already adhering to the message of sobriety or abstinence. These adult-generatedinterventions also avoid topics like harm reduction that are often seen as more relevant to youth, particularly onissues of drug use.Adults are not always the best or appropriate people to be delivering interventions directed to youth throughsocial 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, buta multi-layered set of sub-populations. Experts pointed out distinct differences in preferences even among youthof similar ages and sex on issues of design, content, and medium for engagement. Thus, younger girls may likethings that younger boys do not like, while these girls may also have quite different perspectives from ones justslightly older in age. This ‘thin-slicing’ of the youth demographic was something remarked on by the experts whohad done formative research in developing interventions.7.4 Mobility and Non-localized networks of supportAccess 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 youthcan use Facebook, Twitter and other tools anywhere without dependence on specific devices.
    • 22The devices that youth are using are increasingly mobile in nature. IPhones, Blackberry and Android handsetsare favoured means of youth to communicate. The privacy and portability afforded by these devices allows youthto have ‘live’, real-time access to their peers and to information from anywhere. Mobile devices are shaping therelationship that youth and young adults have with social media content and its context. Youth are attracted tospaces 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 formaterial that is of a specific local nature (e.g., face-to-face counseling resources, local advocacy events). Youthregularly engage with a peer network that includes young people who they have met online and may be physicallylocated anywhere on the global, yet also virtually close by.7.5 Overcoming StereotypesThere is much stigma to using substances and requiringhelp. One expert commented on how this stigma is shapingthe way that youth use social media and sometimes chal- “There was wide agreementlenges the idea that youth continually want to share their that traditional means ofexperiences with others. Indeed, youth may want to sharetheir experiences with other youth who are experiencing evaluation and assessmentthe same issues as them, but not with their family and larger were not likely to reveal thesocial network. The stereotype of the ‘oversharing’ youth true impact of social mediais something that creates a misperception about how socialmedia 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 withyouth and shape social media messaging to that specific context. Some youth will want to have their substanceuse and related support needs known within their more intimate personal networks, but many will not and thesepreferences cannot be assumed. Ethical as well as design considerations must be taken to ensure that youngpeople are not made more vulnerable through engaging social media than before.7.6 EffectivenessThere was wide agreement that traditional means of evaluation and assessment were not likely to reveal the trueimpact of social media on youth substance use.The non-standardized nature of social media tools (as illustrated in the content review) inhibits the level ofcomparison between services at a level that would satisfy most researchers. Researchers and practitioners spokeof the need to use multiple method designs to study and evaluate social media interventions. A strong emphasison both quantitative and qualitative data collection methods was made. The highly contextualized nature of socialmedia interactions suggested methods of observation would be useful along with quantitative outcomes-orientedmethods.
    • 23Focus is another problem. One expert spoke of how rapid communication tools like Twitter and Facebook wereused 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. Thisrapid-response system works because youth are connected directly to the problem and each other and are free touse whatever language and terms they like to communicate. Traditional adult-delivered services are not set-up torespond quickly to emergent problems like ‘bad batches’ of drugs, may be reluctant to consider harm reductionas an option, and use language that doesn’t connect to youth. Thus, ‘success’ in these terms might be the numberof 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. Itwas suggested that social media’s benefit may be as a conduit to other interventions. One expert suggested thatsocial media tools like smartphone apps might do little on their own even when guided by evidence, but that theirtrue 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. Theattraction to youth may initially be to the app, but the service’s effectiveness would come from connecting youthto face-to-face counseling and phone helplines.
    • 24CONCLUSIONS &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 spacefor innovation in dealing with substance use issues for youth and young adults. Within this space exist fundamentconstraints on the way in which evidence is generated and the potential for drawing usable conclusions based onsuch evidence. This review sought to make a definitive statement on the effect of social media on youth substanceuse 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. Thereis 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 canany 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 LimitationsThe 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 achievablegoal. The social media sphere is still poorly indexed, limiting some of the utility of tools like Google and Bing tolocate specific resources. Within applications such as Facebook, the available search options provide a limitedperspective on the true size, shape and depth of a particular network and most pages found during this reviewwere located through snowball sampling or reputation, not the Facebook search feature. Twitter was better, butthe 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 thesame platform. For example, Facebook interventions included pages that were fully integrated with other webresources (e.g., Quitters Unite), while other groups have different accounts for Facebook and other social mediaresources, 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 thatfrom an organizational account (e.g., Health Canada), while others use individual accounts to distribute content(e.g., Leave the Pack Behind).
    • 25For the reasons mentioned in previous sections, the diffusion of resources, the methods and indexes required tosearch 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 thatadditional search terms for tobacco, alcohol or drug to provide a finer-grained analysis would not yield additionalactionable information. Further refined scoping of the search if run on all possible and relevant queries is highlyunlikely 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 MedicalInformatics yielded little additional information beyond the initial review.Practitioners provided an important contextual grounding for the data, however the recruitment and datagenerated was done informally, drawing on recommendations from Health Canada, health practitioners, andthe authors’ knowledge of the field. Detailed consultations with experts resulted from the data itself and wasnot 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 unintentionallyexclude 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 platformsthemselves will evolve. Lessons learned must be considered within this context.8.2 IssuesIs 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, emergentbody of evidence to support the use of these tools and approaches with sexual health promotion. Considerablymore research has been done attempting to connect youth with health information and services in the sexualhealth area than substance use.
    • 26Tools like Facebook are poorly indexed both within and outside of the site and are difficult to search. Other toolslike Twitter are much easier to search through, however only in a quantitative sense. Twitter can determine howmany 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 sharingthem means that this missing contextual element is not trivial.Due to the challenges with relying on conventional search strategies by themselves, snowballing and findingreputation-based links to resources was used to complement the findings from the searches. This was effective atlocating resources that did not show up in conventional searches, however this method is both time consumingand yields incomplete findings as it favours established, connected resources over newer or less connected ones.8.3 Lessons from other areas of health promotionNeiger et al (2012) reviewed the literature on social media use and general health promotion and found littleon 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, reachand engagement. Examples of how these have been applied were not forthcoming. Another possible framingfor social media and Internet-related behaviour interventions was proposed by Lefebvre (2009), who suggestsapplying a social marketing perspective and the four P’s (Products and Services, Price, Place and Promotion) tothe design and evaluation. The Spiral Technology Action Research (STAR) model proposed by Skinner, Maleyand Norman (2006) has been applied to youth-focused Internet interventions and their evaluation on issues suchas tobacco control, gambling, and sexual health promotion (see: Norman & Skinner, 2007). The latter area ofsexual health promotion is another area that has some emergent evidence supporting its use with youth and otherpopulations (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 higherHIV testing rates, while greater connections to street-based peers correlated with a higher rate of risky sexualexchanges. Gold et al (2011) undertook a systematic examination of online social networking sites for sexualhealth promotion and found 178 interventions (with one scholarly publication). Similar to this review, theauthors found social networking sites “are being used to deliver health promotion, although these activities havenot been described in the published scientific literature or evaluated for their effectiveness in improving healthoutcomes” (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)
    • 27Like 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 studycan provide some further guidance on how to proceed within the field of youth substance use.8.4 ConclusionsGiven the relative youth of social media, it is perhaps premature to expect that there would be considerableevidence 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 asonline 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 gapin 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 substanceuse, there are multiple examples of social media and web-based interventions for use with youth sexual health thatcan provide guidance to health promotion professionals looking to bring these tools to alcohol, tobacco and druguse 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 mediaplatforms. Alcohol was comparatively less covered with few websites or social media interventions available foryouth and young adults. Of those that are available, most were prevention focused (e.g., MADD, SaskatchewanPrevention Institute).There are few solid evaluations and little consistent practice of social media for health promotion related to youthand young adult substance use. The absence of standards in research and practice poses significant challenges fora 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 dialoguebetween those working within substance use and between it and other public health areas. Not only would takinga systems approach produce more effective interventions on their own, it would create more effective knowledgetranslation on social media –based health promotion more broadly.
    • 28RECOMMENDATIONS 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 aresuggested 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 ofresources 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 activelyuse these forms to engage visitors in dialogue, rapidly update the content, and treat material in a more dynamicmanner. With a clearer sense of what social media is expected to do and deliver for organizations, it will be easierin 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 modelto a peer-to-peer conversation model of communication poses difficulties for public health professionals seekingto 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 paradigmof communication, public health is struggling to connect to youth.Supporting health practitioners in developing a social media strategy that is consistent with their organization’sgoals and in the needs and interests of youth will contribute greatly to the development of relevant, high qualityand responsive social media resources for young people. By encouraging innovation and the necessary researchor evaluation models that can support strategic learning, such as Developmental Evaluation, this evolution ofprogramming will be guided by data rather than speculation.
    • 29 2 Develop a ‘youth first’ approach to social media programmingIn creation of strategy and development of specific interventions, youth and young adults need to play centralrole. Simple consultation with youth and young adults is not sufficient, young people need to play tactical andstrategic roles in social media projects to ensure relevance and appropriateness. This approach further requiresa re-thinking of the language and types of messages that health promotion uses in delivering information. Youthand young adults engage with social media using methods and at times and locations that differ greatly from adulthealth 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 mediaprovides the means to do this. By developing resources and strategies that fit these behavioural patterns, publichealth 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 equityEngaging youth in health promotion has unique challenges and social media adds to these by introducing a layerof technology, which can create or amplify social inequities. Concerns were raised about the types of youth thatsocial media engages and how thought needs to be given to ways in which social media interventions can reachthose 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 socialmedia tools (when youth were consulted) and apps and related campaigns, leaving potential gaps in access orknowledge. Youth from communities of disadvantage and represent a diversity of perspectives – includingemphasis 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 supportSubstance use prevention and treatment with youth and young adults is not a unified field of public health, yetthere is much in common between the way social media is being used to address the issues connected to it. Littleconnection between the work in tobacco, alcohol, or drug use prevention and treatment was made in discussionwith 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 eHealthpromotion and substance use prevention and treatment professionals could learn much from this area of publichealth. With such little solid evidence and a rapidly changing field of research and practice, health promotioncould 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 youthlifestyle that is accustomed to adopting and adapting to new technologies and ways of communicating. This isan environment of complexity and innovation, thus the methods and tools to support social media developmentneeds to be considered as part of a larger effort to create a culture of innovation. A single method or tool willnot likely suffice given the rapid pace of change. For example, within the last 12 months Facebook has unveiledits Timeline format to organize content in a linear manner, Skype integration (to enable video chat within thesite), and is allowing thousands of new apps to join its ecosystem; YouTube has completely restructured its lookand feel and the manner by which its channels are formatted; while Twitter has gone from being a niche tool to amainstream 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’schanges 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 planningmodels 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 developedand executed there is a risk that health promotion will create tools that are always a step behind where youth wantto be and where they seek their information from.To make this adaptation and to understand the implications of developing strategies to engage youth in thisdynamic context, systems and design thinking are recommended skills that public health professionals need todevelop 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 forevaluation and program design beyond the individuals that are reached directly, but also towards people withinthose individuals’ networks (e.g., Weber & Monge, 2011). This may have implications for the type of successindicators that organizations use to assess program impact and the way in which evaluation data is gathered andused to support innovation, development and improvement.Engagement with youth cannot be done piecemeal, but must be built into the fundamental design process usedin creating social media messages and strategies by having young people involved in program development atthe outset. Thinking in systems and applying participatory design methods appropriately will best enable publichealth and health promotion to better support the foundation for a culture of innovation. Doing so will generatemore 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 systemsthinking and design thinking skills along with expanding their knowledge of youth engagement strategies is keyto implementing this recommendation.
    • 31 6 Place social media within a ‘glocalized’ contextYouth and young adults function online as part of a global network of connections. Young people are motivatedto go where their peers are and use resources that are endorsed by that peer group and are seen as credible, fitswith 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 socialnetworks.Not every local health unit or substance use-related health promotion needs to have an in-depth social mediaengagement plan. At the same time, there is an opportunity for health professionals to provide specific, targetedinterventions and to link these with other ones. It is worth considering how public health can direct youth toexisting interventions that are not their own where appropriate rather than seeking to (re)create social mediaspaces locally. To do this, more substantial, robust practice networks and communication between professionalsworking 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 enablegreater attention to local and global opportunities for health promotion.
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    • 37APPENDIX 1Social media literature review search strategyHost: Scholars Portal / Web of Science2005 - CurrentEnglish OnlyAll publication typesDatabases: • Communication & Mass Media Index @ Scholars Portal • Communication Abstracts Indexes and Limits • PsycARTICLES • PsycCRITIQUES • PsychINFO • ASSIA: Applies Social Sciences – Index and Abstracts Indexes and Limits • BHI: British Humanities Indexes and Limits • LISA: Library and Information Science Abstract Indexes and LimitsSearch Strategy:1. (Teen* or youth or young people) and (social media and social networks)2. (Teen* or youth or young people) and (internet or web or world wide web or online)3. (Teen* or youth or young people) and 2 and 14. 3 and (innovation or new media)5. (Teen* or youth or young people) and (social space or social community)6. (Teen* or youth or young people) and (information technology)7. (Teen* or youth or young people) and (web 2.0)8. (Teen* or youth or young people) and (myspace or youtube or facebook or secondlife or gaming or twitter9. (Teen* or youth or young people) and (health) and (drug*) and (internet) or (web) or (world wide web) or (online)10. (Teen* or youth or young people) and (health) and (alcohol) and (internet) or (web) or (world wide web) or (online)11. (Teen* or youth or young people) and (health) and (tobacco or smoking or cigarette*) and (internet) or (web) or (world wide web) or (online)12. (Teen* or youth or young people) and (health) and (web2.0 or blog* or weblog or youtube or facebook or twitter or myspace or second life)13. (Teen* or youth or young people) and (health) and (tobacco) and (social media)14. (Teen* or youth or young people) and (health) and (drug*) and (social media)15. (Teen* or youth or young people) and (health) and (alcohol) and (social media)