Warning Labels for Social Media Are A Terrible Idea.
That is a bad suggestion from a public health professional.
The NY Times featured— yesterday—a lukewarm op-ed by Vikek Murthy, M.D., MBA, the Surgeon General of the United States. My wife,
is of the opinion that a subscription to The NY Times is the kind of thing you just need to have as an adult. It’s like life insurance or buckling your seat belt. In that august pulication, Dr. Murthy is advocating for panicked responses to the mental health crisis… as public policy:One of the most important lessons I learned in medical school was that in an emergency, you don’t have the luxury to wait for perfect information. You assess the available facts, you use your best judgment, and you act quickly.
As I have previously opined…how to put this delicately? Ok…I’ll go with this is a Bad Idea (Owen Muir, M.D., in “The Mental Health Crisis…Crisis”):
We do not have a mental health crisis. We have a mental health crisis…crisis. We have become so panicked by the relentless onslaught of early, preventable death, loss, and sorrow that we cannot address it. The crisis frame creates panicked responses. Those responses have served up more death, suffering, and isolation.
Dr. Murthy is not a child psychiatrist or pediatric subspecialist. He’s an MD/MBA with training in internal medicine. He, however, promises us he has found the villain in the children’s mental health crisis:
The mental health crisis among young people is an emergency — and social media has emerged as an important contributor.
He goes on to remind us all that correlation and causation are not that important to disambiguate:
Adolescents who spend more than three hours a day on social media face double the risk of anxiety and depression symptoms, and the average daily use in this age group, as of the summer of 2023, was 4.8 hours. Additionally, nearly half of adolescents say social media makes them feel worse about their bodies.
These data are important but not causal, randomized, or a solid basis for public policy—according to me. According to the doctor who actually gets to set public health policy, they are a call to action to do…something. In this case, he takes to the Grey Lady to call for a Warning Label—a hammer in his belt as a Surgeon General:
It is time to require a surgeon general’s warning label on social media platforms, stating that social media is associated with significant mental health harms for adolescents. A surgeon general’s warning label, which requires congressional action, would regularly remind parents and adolescents that social media has not been proved safe.
As a child psychiatrist, I will take a moment to remind Dr. Murthy: This is a time-tested strategy! If we want less of a behavior in teens, we regularly remind them — that fun thing your friends are doing? STOP IT. It isn’t isn’t safe. Of course all adolescents stop doing it. They act in keeping with the stern rules of their par—wait a minute.
This has been considered before. One parent, Mr. Capulet— Juliet’s father—tried a similar technique. In Romeo and Juliet, he takes a firm stand in favor of marriage to a man who’s not Romeo:
“to go with Paris to Saint Peter’s Church, or I will drag thee on a hurdle thither” (III.V.154)
Juliet, famously, was not having it:
“he shall not make me there a joyful bride” (III.V.117)
Reminding adolescents that something—Murthy’s proposed plan— isn’t safe? This is an awesome strategy to encourage more of that behavior. Adolescent brains don’t work exactly like adult brains, and they are particularly sensitive to social context, a concept called approach sensitization”
That is, neural responses to positively valenced socioemotional stimuli—in this case, responses that do not even reach the level of conscious awareness—may sensitize approach responding to unrelated incentive cues.1
That is to say, the social approval of your friends makes you more likely to do it, even if you aren’t aware that is what is happening. I’ve previously noted that even walking isn’t proven safe. Maybe we can get a warning label on that? How about treatment for depression with oral medication in adolescents? That has a black box warning for suicidal ideation also. After that warning label went on, deaths among youth increased2:
Or what about antipsychotic medicines in youth on Medicaid? Oh, that also kills 127/100,000 more youth a year as well— 500% more deaths in that age group than fentanyl.
It’s also important to note that the data on how adolescents interpret warning labels indicates they are often more confused about what they mean than the label-makers might expect:3
He makes the assertion that warning labels about cigarettes are an effective public health intervention. There is some data to back this up, but it’s not unambiguous. Graphics on cigarettes that have low emotional content outperform text only in randomized trials (from Nicotine and Tobacco Research, October 2017), in which they were randomized to three groups: text warnings, low emotion pictures, and high emotion pictures:
Participants in the high-emotion condition reported greater emotional reaction than text-only participants (bAdult = 0.21; bTeen = 0.27, p’s < .004);4
While, on the contrary:
Those in the low-emotion condition reported lower emotional reaction than text-only participants (bAdult = −0.18; bTeen = −0.22, p’s < .018).
That is, some graphics underperformed text only warnings. Comparing teens and adults, again, the content of the warnings mattered:
Stronger emotional reaction was associated with increased risk perceptions in both samples (bAdult= 0.66; bTeen = 0.85, p’s < .001) and greater quit intentions among adults (bAdult = 1.00, p < .001).
It is worth noting that the intention to quit was only higher in adults, not youth. Low emotion warnings led to lower quit intentions in that tobacco warning study:
Compared to text-only warnings, low-emotion warnings were associated with reduced risk perceptions and quit intentions whereas high-emotion warnings were associated with increased risk perceptions and quit intentions.
In the world of tobacco warnings science, it’s not hard to imagine what kind of pictures one could use to warn—horrible cancers, blighted lungs, disgusting teeth, and more. What does Dr. Murthy imagine we will use as the content of the warning labels? Frightening pictures of posts with no likes? A TikTok video of your Gen X mother using Facebook to respond with an emoji she doesn’t understand? Cringe!
Perhaps we need a warning label on warning labels from regulators and surgeons general?
Warning: Unintended Consequences May Follow.
The irony is thick, in our cultural memory:
For fear of that I still will stay with thee
And never from this ⌜palace⌝ of dim night
Depart again.
—Romeo, Romeo and Juliet Act V, Scene 3, immediately prior to his suicide by poisoning.
It was a misunderstanding that killed Romeo. The lessons of history are ready for us to learn from— if only we cared to look.
Albert, D., Chein, J., & Steinberg, L. (2013). The teenage brain: Peer influences on adolescent decision making. Current directions in psychological science, 22(2), 114-120.
Lu, C. Y., Penfold, R. B., Wallace, J., Lupton, C., Libby, A. M., & Soumerai, S. B. (2020). Increases in suicide deaths among adolescents and young adults following US Food and Drug Administration antidepressant boxed warnings and declines in depression care. Psychiatric research and clinical practice, 2(2), 43-52.
Goldsworthy, R. C., Schwartz, N. C., & Mayhorn, C. B. (2008). Interpretation of pharmaceutical warnings among adolescents. Journal of adolescent health, 42(6), 617-625.
Abigail T Evans, Ellen Peters, Abigail B Shoben, Louise R Meilleur, Elizabeth G Klein, Mary Kate Tompkins, Daniel Romer, Martin Tusler, Cigarette Graphic Warning Labels Are Not Created Equal: They Can Increase or Decrease Smokers’ Quit Intentions Relative to Text-Only Warnings, Nicotine & Tobacco Research, Volume 19, Issue 10, October 2017, Pages 1155–1162, https://doi.org/10.1093/ntr/ntw389
I think Dr Murthy makes a great point regarding the success of cigarette warnings and subsequent decreases in usage over time. I’m not hopeful for the intervention but I think it would at least be an honest label.