Reinvigorating Public Support for Community Water Fluoridation

1. Reinvigorating Public Support for Community Water Fluoridation Matt Jacob Pew Children’s Dental Campaign June 8, 2012

2. Slow, steady growth for fluoridation Millions of Americans on Public Water Systems Who Receive Optimally Fluoridated Water 210 200 190 180 170 160 150 140 130 120 1988 1992 2000 2002 2004 2006 2008 2010 Year of Fluoridation Data CDC named community water fluoridation one of “10 great public health achievements of the 20th century.”

3. One of many health interventions • Vitamin D in milk • Iodine in table salt • Folic acid in breads and cereals • Chlorine in drinking water supplies and swimming pools

4. But this is no time to celebrate • 72 million Americans do not receive community water fluoridation (CWF). In many states, anti-fluoride activists are trying to stop CWF, ending a proven strategy to prevent tooth decay. Tennessee’s Speaker of the House publicly urged state officials in 2011 to stop promoting CWF. In Nebraska, 80% of the towns voting chose to opt out of a fluoridation law (2008-2010). One of Florida’s largest counties voted in 2011 to discontinue CWF. l l l

5. What we will cover • Why public health advocates face a vigorous challenge to preserve and expand CWF What insights Pew has learned about how the public views this issue How oral health advocates can advocate more effectively for CWF How the Campaign for Dental Health is working to reinvigorate the advocacy of water fluoridation l l l

6. A perfect storm • The growing distrust of government’s role in health or other issues • The sense of complacency within the public health community — CWF is a “been-there, done-that issue” • Opponents mostly avoid talk of a “conspiracy” and now package their arguments as science

7. Other factors shape the situation • Many Americans incorrectly assume their water is optimally fluoridated when it isn’t. • Oral health issues aren’t taken as seriously as they should be by policy makers and the media, which also means the public hears less about these issues.

8. A fertile environmental for junk science I bought this Vitamin C here yesterday .. I bought this Vitamin C from your store yesterday, but when I got home I noticed that it contained a strange ingredient called ascorbic acid. Are you trying to kill me?

9. Pew’s research on fluoridation • Media analysis of newspapers, social media and search-engine results • Research of opposition messages used online and in social media • Focus groups and interviews with stakeholders in communities where fluoridation has been hotly debated in recent years • Palm Beach, FL; Wichita, KS; York, PA; and San Diego, CA • National survey of the public • Message testing ofpro- and anti-fluoridation leafletswith groups of “active citizens” • Focus groups of water operators in Mississippi

10. Key Findings fromPew's Research

11. Public awareness is low • Only 58% of Maryland residents could identify the purpose for adjusting the fluoride in public drinking water. • 80% of Americans admit they have a low level of knowledge about fluoridation.

12. Public awareness is low • Only 58% of Maryland residents could identify the purpose for adjusting the fluoride in public drinking water. • 80% of Americans admit they have a low level of knowledge about fluoridation.

13. Media presents it as a “debate” • Media analysis: 4 out of 5 front-page newspaper stories about fluoride framed the issue as a “debate.” • Focus groups: Our side’s message was summed up as “We’re the experts — just trust us.” Health: Not in My Water Supply Somebody put a dead rat in Curtis Smith's mailbox. Someone else has made anonymous phone calls accusing him of trying to poison his neighbors. And all around the usually placid university town of Bellingham, Wash., activists from a group called Citizens Against Forced Fluoride have planted lawn signs adorned with skull and crossbones. "I had no idea it would get this intense," says Smith, 70, a retired dentist who is leading a Nov. 8 ballot initiative to add fluoride to the local drinking water. Fluoridation is still a hard sell in Mass. Massachusetts, the birthplace of public health, has long led the nation in disease-fighting crusades, vaccinating children at high rates and crafting antismoking campaigns exported around the world. But it ranks 36th when it comes to providing residents with fluoridated water.

14. Opponents: Persistent and web-savvy Opponents are aggressively posting web content, courting media coverage and circulating anti-fluoride videos.

15. A web of misinformation

16. Advocates must harness the web • 61% of Americans regularly go online for info about health and medical issues. • Four out of 10 Americans get most of their news from the Internet — a dramatic jump from the 1 out of 6 who said so in 2009. Young people, a key target audience for CWF advocates, are much more likely to seek news on the web. Support for CWF by the 18-34 age group is lower than for other age groups. l

17. Comparing each side’s tactics • They are speaking to the public and successfully targeting key audiences. • They use ordinarylanguage to spread fear and doubt. • They have a strongpresence on the web and in social media. • We are more likely to communicate through conferences and list-servs. • We often use clinicallanguage and don’t do much to correct distortions. • We have a relatively lowprofile on the web and in social media. Water Fluoridation: A Corporate-Inspired Scam

18. What we learned was missing • Advocates felt alone and isolated. The lack of a national network for local advocates meant they were rarely sharing ideas and experiences about what worked. • CDC and ADA are excellent advocates, but not always nimble enough to react quickly to breaking news or other events. Besides, their efforts need to be amplified by support that extends beyond the oral health field.

19. A Closer Look atthe Opposition

20. Leaders of the anti-fluoride movement Fluoride Action Network (FAN) • A staff of 5-6 people who are based in upstate New York • Led by Paul Connett, a retired chemistry professor, who co-wrote the book The Case Against Fluoride • FAN’s website cites flawed research and misrepresents valid research The Lillie Center • A small, low-profile group based in northern Georgia • Founded by Daniel Stockin, a former EPA employee who opposes water fluoridation • The Center has used the issue of fluorosis to try to build opposition among Atlanta’s black community Paul Connett Daniel Stockin

21. Using the web effectively Creating the false impression that a celebrity endorses the anti-fluoride position.

22. Posting claims that look like “news” Posted by the New York State Coalition Opposed to Fluoridation A 52-year-old American (New York) man's arthritic-like joint pain and immobility went away after he stopped brushing his teeth with fluoridated toothpaste, according to a study in the Journal of Bone and Mineral Research. PRESS RELEASE Another Study Links Fluoride to Bone Cancer It’s a press release, not a Reuters story, but the distinction is easy to miss

23. Raising unjustified fears What does mild fluorosis look like? Theysay: Children are being “overdosed” on fluoride, and that is causing fluorosis — which means “damaged teeth.” The Facts: • Nearly all fluorosis in the U.S. is very mild or mild— a cosmetic condition that leaves faint white streaks on teeth. It’s so subtle that is often takes a dentist to notice fluorosis. • Mild fluorosis does not cause pain, and it does not affect the health or function of the teeth. • Experts believe fluorosis in the U.S. is typically due to young children swallowing toothpaste. • The newly proposed optimal level for fluoridation is likely to reduce fluorosis.

24. Misrepresenting valid research • They say: “A National Research Council report showed that fluoride can be harmful.” • The Facts: • The NRC’s 2006 report examined health concerns in U.S. communities where the natural fluoride levels in well water or aquifers are unusually high. • These natural fluoride levels are far higher than the level used to fluoridate public water systems. • The NRC itself explained that its report was not an evaluation of water fluoridation.

25. Creating the veneer of science The publication Fluoride is presented to the public as a scientifically rigorous journal A New Hampshire architect claims that fluoridated water is linked to high crime rates in the U.S. His data came from crime stories that he collected based “on their content and on my intuition, from my routine daily reading, rather than from a methodical or exhaustive search …” l l

26. Distorting the facts

27. Distorting the facts Dr. Heyd was AMA president in 1936-37, many years before any U.S. city started fluoridating. His opposition is not “based on the latest medical research.” AMA supports community water fluoridation. In fact, AMA has urged states to “consider the value of required statewide fluoridation.” l l

28. Seeking to control the dialogue Anti-fluoride activists: • Circulate questionable “studies” and other information that are aimed at raising the public’s fear and doubt • Want oral health advocates to spend most of their time responding to the unsupported claims they make about fluoridation

29. A pro-fluoridation message wheel Preventing Decay Better Overall Health Kids and Adults Avoid Pain Eat and Smile with Dignity Healthy Reduce Health Care Costs Teeth Seniors Keep Their Teeth Kids Miss Fewer School Days Better Job Prospects

30. Opponents’ message wheel Fluorosis Lower IQs Cancer Bone Fractures Arthritis Harms Risks Hypo- thyroidism Kidney Problems & Alzheimer’s Migraines Nervous System Problems Violent Crime Autism

31. Lessons Learned for Guiding Our Advocacy

32. Lead with the need “… a solution needs a problem. If the people required to change do not perceive there is a problem, you can spend from now until the cows come home, but you will never convince them to change.” – James McGovern, technology guru • Fluoridation is a solution to a problem. • Establishing that problem is crucial before we can convince policy makers and the public that fluoridation deserves their support.

33. Lead with the need • A survey of parents found that roughly one out of seven children (ages 6-12) had suffered a toothache within the past six months. • Children with poor oral health are nearly three times more likely than their peers to miss school due to dental pain. • The average 50-year-old has had decay affecting 50 surfaces of his or her teeth.

34. The impact of clinical language Dental Health and Fluoride Treatment Debate Continues Over Fluoridation Wichita’s water supply has sparked a debate for decades that has pitted health professionals against every- day Kansans as to whether to flouridate it or not. “It's one of the most highly studied chemicals we've ever had," said Wichita dentist Dr. Brick Scheer. Using the word “chemical” plays into the fear-based message of anti-fluoride activists

35. Identify a diverse network of allies • The “healthy families” coalition • County health officers • Head Start directors • Rotary clubs or other civic groups • City or county chambers of commerce • PTAs and teacher organizations • Children’s advocacy groups • Civil rights organizations • Faith community leaders Proactively reach out to:

36. The Campaign forDental HealthiLikeMyTeeth.org

37. The campaign’s objectives • Create a network of fluoridation advocates who can share ideas, offer insights, and support one another • Improve the quality and accuracy of web content about oral health and CWF • Provide state and local advocates with fact sheets, PowerPoint slides and other helpful materials • Offer reporters and other media fact-based information on CWF and federal announcements related to fluoridation

38. Some of our campaign partners A campaign with diverse partners:

39. The web presence Framing CWF in the context of oral health (protecting teeth)

40. The web presence Allowing advocates to create a locally customized web presence for their CWF campaign

41. Separating science from myth A link to an affiliated website that provides a detailed analysis of research on CWF

42. Using social media • The Campaign has nearly 120 Twitter followers and almost 100 Facebook friends • Since March 1, the Campaign has sent more than 130 tweets about oral health and fluoridation • The iLikeMyTeeth.org website will be made more social media-friendly by allowing visitors to “like” its pages or content

43. Un-tilting the online dialogue A typical sequence of comments to an online news article about fluoridation

44. Purpose of the rapid response team • Mobilize a network of local advocates who can post comments quickly to online articles, ensuring the public receives clear, accurate info • Post comments to both pro- and anti-fluoride articles • Share reconnaissance on what opponents are saying and how their talking points may be changing

45. A whole lot is at stake There are real consequences when a group of activists is able to raise fear about proven public health interventions. In 2011, the U.S. experienced its biggest outbreak of measles in 15 years. JUNE 15, 2011 Preventable measles makes a comeback Landon Lewis, 4, was living in a Minneapolis homeless shelter when he fell ill, first with a fever of 104 degrees, and then with a red rash on his forehead. It took two visits to a doctor to diagnose a disease that clinic staff hadn’t seen in years: measles. The rash spread into Landon’s mouth and throat, so swallowingwastorture. He beganvomiting and then

46. We have a lot of work to do Editorial: June 25, 1988 “… It is absurd, given the record, that so many people, children and adults alike, must still be condemned to suffer tooth decay and avoidable pain because local officials refuse to add minute amounts of fluoride to the public water supplies.”

47. Questions? Comments? Matt Jacob Kelly Adams mjacob@pewtrusts.org kadams@pewtrusts.org