# ![](media/image1.wmf){width="8.604861111111111in" height="11.125in"}  {#section .A1}

# Acknowledgements {#acknowledgements .A1}

## ORC Macro Report Authors {#orc-macro-report-authors .A2}

Amy Chadwick, M.A.

Tamara Lamia, M.P.H.

Jesse Zaro-Moore, B.A.

## ORC Macro Research Team {#orc-macro-research-team .A2}

Amy Chadwick, M.A.

Tamara Lamia, M.P.H.

Jesse Zaro-Moore, B.A.

Doryn Chervin, Dr.P.H.

Richard Wike, Ph.D.

Jennifer Farrell, B.A.

Bonnie Bates, M.A.

## Expert Panel  {#expert-panel .A2}

Richard N. Brandon, Ph.D., University of Washington

Frances Butterfoss, Ph.D, Center for Pediatric Research, Children's
Hospital of King's Daughter

Todd Donovan, Ph.D., Western Washington University

Lori Dorfman, Dr.P.H., Berkeley Media Studies Group

James H. Hyde, Jr., M.A., S.M., Tufts University School of Medicine

## CDC Technical Monitor {#cdc-technical-monitor .A2}

Claudia Vousden, R.N., M.P.H.

## CDC Division of Oral Health Advisors {#cdc-division-of-oral-health-advisors .A2}

Barbara Gooch, D.M.D., M.P.H.

Scott Presson, D.D.S., M.P.H.

*This publication was supported by Contract Number* 2002-Q-00523 (E-52)M
*from the Centers for Disease Control and Prevention. Its contents are
solely the responsibility of the authors and do not necessarily
represent the official views of the Centers for Disease Control and
Prevention, the Department of Health and Human Services, or the U.S.
government.*

Table of Contents

[I. Introduction 1](#i.-introduction)

[II. Fluoridation 1](#ii.-fluoridation)

[A. Fluoridation as a Health Issue
1](#a.-fluoridation-as-a-health-issue)

[B. Fluoridation as a Political Issue
1](#b.-fluoridation-as-a-political-issue)

[Antifluoridationists 1](#antifluoridationists)

[Direct v. Representative Democracy
1](#direct-v.-representative-democracy)

[Community Process for Making Fluoridation Decisions
1](#community-process-for-making-fluoridation-decisions)

[III. Perspectives on Communication and Campaign Outcomes
1](#iii.-perspectives-on-communication-and-campaign-outcomes)

[A. Structural Community Factors 1](#a.-structural-community-factors)

[B. Political Behavior 1](#b.-political-behavior)

[Voting in Low Information Campaigns
1](#voting-in-low-information-campaigns)

[Cues from Policy Elites 1](#cues-from-policy-elites)

[Self-interest 1](#self-interest)

[Risk Aversion 1](#risk-aversion)

[Alienation, Efficacy, and Trust 1](#alienation-efficacy-and-trust)

[C. Risk Perception 1](#c.-risk-perception)

[D. Media and Campaign Communication
1](#d.-media-and-campaign-communication)

[E. Diffusion of Innovations 1](#e.-diffusion-of-innovations)

[F. Other Campaign Variables 1](#f.-other-campaign-variables)

[Campaign Organization 1](#campaign-organization)

[Coalition Building 1](#coalition-building)

[Formative Research and Use of Data
1](#formative-research-and-use-of-data)

[Campaign Finance 1](#campaign-finance)

[Ballot Wording 1](#ballot-wording)

[Timing 1](#timing)

[IV. Discussion 1](#iv.-discussion)

[V. References 1](#v.-references)

# 

# I. Introduction

There is strong scientific evidence that community water fluoridation
has greatly improved the nation's oral health and that the benefits of
fluoridated water vastly outweigh any risks. The decisions to fluoridate
water systems are frequently made by local referendums and preceded by
activities carried out by both proponents and opponents of fluoridation
with unpredictable outcomes and around which little research has been
conducted.

The Centers for Disease Control and Prevention (CDC) frequently receives
requests for guidance or advice from states and communities that aspire
to inform, educate, and empower their citizens to make knowledgeable
decisions about fluoridation. To improve its ability to respond to such
requests, the CDC is conducting exploratory research to provide a better
understanding of the factors that affect outcomes of
fluoridation-related initiatives.

This literature review is the initial product of the research activities
conducted under contract by ORC Macro, Inc. To achieve an exploratory
research design inclusive of the broad array of factors likely to
influence community decisions about fluoridation, ORC Macro assembled an
expert panel of nationally known social scientists, academic
professionals and oral health practitioners with expertise in community
organizing, health communication, media advocacy, and political science
to provide guidance throughout the study. The expert panel was also
asked to identify useful theories and publications for inclusion in this
review of relevant literature and to help CDC integrate pertinent
concepts into the design of subsequent research activities.

The intent of this review is to provide background information on the
issue of fluoridation and to identify social scientific research that
may shed light on the factors that influence community decisions to
adopt or reject fluoridation. Although fluoridation has been a frequent
topic of social scientific inquiry, much of this literature specific to
fluoridation dates from the 1960s, 70s, and 80s, and may not reflect the
current thinking in the field. Therefore, in addition to these studies,
this document includes works from public health and other disciplines
such as sociology, political science, and communication that are
potentially relevant but not directly focused on fluoridation. Thus,
this information merges the different sets of literature to present a
more comprehensive view with inclusion of relevant social scientific
perspectives. It should be noted that this literature review is not, nor
was it intended to be an evidence-based review or necessarily a complete
review of the literature.

In addition to this Introduction, the literature review consists of
three major parts. Section II provides background on fluoridation, both
as a public health issue and as a political issue. Section III examines
a number of potentially relevant social scientific perspectives on
communication and the factors influencing campaign outcomes. Finally,
Section IV discusses potentially important variables relating to
fluoridation referendums identified in the literature, as well as the
next steps of the research process.

#  

# II. Fluoridation

## A. Fluoridation as a Health Issue

Since initiation of community water fluoridation[^1] in Grand Rapids,
Michigan, in 1945, fluoridation of public water supplies has
dramatically reduced the prevalence of dental caries in the United
States. Scientific evidence compiled over more than six decades
demonstrates that fluoridation is a safe, cost-effective, and equitable
intervention that benefits everyone in a given community regardless of
financial status. Early studies of fluoridated and non-fluoridated
communities illustrated the significant oral health benefits that
communities could realize through fluoridation. Evaluations published
between 1956 and 1979 showed that children in communities with
fluoridated water had a 50--70% reduction in dental caries in permanent
teeth. The reduction of caries in primary teeth was only slightly less
dramatic, with most studies finding a 40--60% reduction (Horowitz, 1996;
Ripa, 1993). The tremendous success of fluoridation has led CDC to label
it one of ten great public health achievements of the 20th century (CDC,
2000).

More recent estimates of reductions in tooth decay attributable to water
fluoridation have been lower---ranging from 18-40% (CDC, 2001). This is
likely related to fluoride exposure among residents in non-fluoridated
communities from other sources (Griffin et al., 2001). Once the benefits
of fluoride through community water fluoridation became clear,
researchers began to explore other methods to deliver fluoride and by
the 1960s manufacturers had developed additional methods to deliver
fluoride to the teeth. Exposure to other sources of fluoride, such as
fluoride toothpaste, rinses, supplements and professionally applied gels
and varnishes, has increased in all communities. In addition,
fluoridated water is diffused throughout the population as residents of
non-fluoridated communities increasingly consume foods and beverages
processed and bottled in fluoridated communities. Thus, many individuals
residing in non-fluoridated communities have benefited from fluoridation
policies. Although this improvement in oral health in non-fluoridated
communities is a positive outcome, it may lead to an underestimation of
community water fluoridation's benefits and thus to more difficulty in
promoting fluoridation (Griffin et al., 2001).

The percentage of the U.S. population living in areas with fluoridated
water grew steadily from 1945 to the mid-1970s. In recent years, the
rate of increase has tapered off (Horowitz, 1996; Hinman et al., 1996).
In 1975, 49% of the population had access to water with optimal levels
of fluoridation (Horowitz, 1996). By 1992, this figure had increased to
62.1% and by 2000 to 65.8%, still far short of the 75% fluoridation
target set in both the *Healthy People 2000* and *2010* objectives.
However, fluoridation has become the norm among the nation's largest
cities, as 48 of the 50 most populous cities either are fluoridated or
have approved fluoridation and are awaiting implementation. In 2000, San
Diego, San Antonio, Las Vegas, Sacramento, and Mesa all joined the ranks
of large cities with fluoridated water. To reach the 75% goal,
fluoridation advocates will need to focus on the next tier of cities,
those with populations of approximately 50,000--330,000.

## B. Fluoridation as a Political Issue

From its inception, fluoridation has been a political issue as well as a
scientific one. Although there is a strong scientific evidence that
fluoridation has greatly improved the nation's oral health and that the
benefits of fluoridated water vastly outweigh any risks, the public
debate over this issue has often been acrimonious, frequently plagued by
fears and claims supported by little or no scientific evidence.

##### 

### Antifluoridationists

Fears of fluoridation began to surface during the pioneering efforts of
Grand Rapids in the 1940s. Complaints about weight gain and skin rashes
as a result of fluoridation were reported in Grand Rapids in early
January 1945, despite the fact that, due to delays, fluoridation was not
even implemented in the area until January 25th (Newbrun, 1996). These
isolated complaints in Grand Rapids and elsewhere eventually grew into
local, national, and international networks of what are often labeled
"antifluoridationists." Numerous authors have analyzed the
characteristics of the antifluoridation movement and offered suggestions
on how to counter antifluoridationist claims and tactics (Block, 1986;
Easley, 1983, 1985, 1986, and 1990; Evans and Pickles, 1978; Hinman,
1996; Isman, 1983; Levallois et al., 1998; Lowry, 2000; Neenan, 1996;
Newbrun, 1996; Watson, 1985).

Antifluoridationists include activists from both the right and left of
the political spectrum. Often highly organized, opponents of
fluoridation have created organizations such as the National Health
Federation (NHF), the Safe Water Foundation (SWF), and the Center for
Health Action (CHA), which serve as centers for producing and
disseminating antifluoridation literature (Evans 1978, 1970; Easley,
1985; 1986; Isman, 1980). Antifluoridationists have exaggerated links
between community water fluoridation and bone fractures and erroneously
linked fluoridation to Alzheimer's, AIDS, and cancer. Although
relatively few in number, they have proven to be effective, often
successfully derailing fluoridation campaigns.

In addition to the health-related claims of some antifluoridationists,
opponents of fluoridation express concern that it poses an
unconstitutional infringement on individual choice and the right to
protect one's health (Block, 1986). Although the courts have upheld the
constitutionality of fluoridation, many oppose what they refer to as
"mass medication" and believe the decision to consume fluoride should be
left to the individual (Newbrun, 1996).

While traditional pro-fluoridation arguments are generally limited in
scope due to a simple and scientific message---that it has been shown
time and time again that optimally fluoridated water prevents dental
caries and has no harmful side effects---antifluoridationists have often
designed their messages to capitalize on prevalent societal fears.
Easley (1985, 2001) has summed up the connections between
antifluoridationist messages and corresponding societal concerns,
showing that during the 1950s antifluoridationists took advantage of
prevalent McCarthyist attitudes by connecting fluoridation to a national
communist plot. In the 1960s and 70s, antifluoridationists commandeered
buzzwords such as "toxic waste" and "pollutant" from the environmental
movement, and in the post-Vietnam era spoke to societal rejection and
mistrust of the government's motives. In the 1980s, arguments such as
those that tied fluoridation to the

breakdown of collagen, the production of wrinkles, and deterioration of
ligaments, muscles and tendons, were aimed at a health and
image-conscious public. Finally, the 1990s, which brought on a renewed
interest in health food and natural lifestyles, as well as heightened
awareness and fear of HIV infection and AIDS, provided
antifluoridationists with many opportunities to capitalize on public
anxiety by branding fluoride as an unnatural chemical and an immune
system suppressant. Similar observations have been made by Evans et al.
(1978, 1979) and Isman (1980), who suggest that antifluoridationists
have capitalized on factors such as distrust of government,
environmental concerns, and fears of additives or contaminants in food
and water.

Easley (1985) summarizes some of the main campaigning techniques of the
antifluoridationists:

+---------------+------------------------------------------------------+
| #             |                                                      |
| ### Table 1:  |                                                      |
| Antifluoridat |                                                      |
| ionist Campai |                                                      |
| gn Techniques |                                                      |
+---------------+------------------------------------------------------+
| ######        | Through intense letter writing campaigns and         |
| # Neutralizin | petitioning, antifluoridationists cause local        |
| g Politicians | politicians to shy away from making controversial    |
|               | decisions. As a result, fluoridation measures may be |
|               | determined by a referendum, where they often fail.   |
+---------------+------------------------------------------------------+
| #######       | In an attempt to create voter confusion and          |
| "The Big Lie" | opposition, antifluoridationists will claim that     |
|               | fluoridation causes cancer, is a communist plot, or  |
|               | that it is linked to any number of other negative    |
|               | outcomes.                                            |
+---------------+------------------------------------------------------+
| ######        | A technique of stating that fluoride is linked to    |
| # Half-Truths | negative health consequences, without qualifying the |
|               | statement to reflect that the link only exists when  |
|               | fluoride is administered at extremely high levels.   |
|               | This has little to do with public fluoridation,      |
|               | which is the adjustment of fluoride levels in        |
|               | drinking water to *optimal* levels (for caries       |
|               | prevention).                                         |
+---------------+------------------------------------------------------+
| ###           | Taking an idea such as *one cigarette wont kill you, |
| #### Innuendo | but over a lifetime...* and applying it to fluoride: |
|               | *one glass won't harm you, but who knows what many   |
|               | glasses could do...*                                 |
+---------------+------------------------------------------------------+
| Out of        | Many antifluoridationists have misquoted, or         |
| Context       | misrepresented quotes of, professionals to suit      |
| Statements    | their arguments.                                     |
+---------------+------------------------------------------------------+
| ####### "Ex   | Self-proclaimed fluoridation "experts" are made out  |
| perts" Quoted | to be true experts. Oftentimes these "experts" are   |
|               | scientists, although their area of study may be      |
|               | unrelated to fluoridation, or their arguments        |
|               | scientifically unfounded. The public often lacks the |
|               | necessary information to discriminate between        |
|               | qualified and unqualified experts, or to determine   |
|               | the validity of the information presented to them.   |
+---------------+------------------------------------------------------+
| #             | As with most conspiracy theories, those associated   |
| ###### Conspi | with fluoridation are hard to disprove, and play off |
| racy Theories | societal fears. For instance, in the 1950s           |
|               | fluoridation was often part of conspiracy theories   |
|               | regarding communist plots in the U.S.                |
+---------------+------------------------------------------------------+
| ######        | During a campaign, antifluoriationists often use     |
| # Scare Words | phrases such as "mandatory fluoridation" and "toxic  |
|               | waste byproduct" to create confusion and concern     |
|               | among voters.                                        |
+---------------+------------------------------------------------------+
| ##            | Public debates between pro- and                      |
| ##### Debates | antifluoridationsists often become personal,         |
|               | unscientific, overly political, and most of all,     |
|               | give the impression that both sides have equal       |
|               | standing and legitimacy (in light of the available   |
|               | science).                                            |
+---------------+------------------------------------------------------+

Fluoridation, of course, is not the only public health effort to evoke
such intense opposition. Public health proponents have had similar
experiences with issues such as milk pasteurization, drinking water
chlorination, and the immunization of children against diphtheria and
smallpox (Newbrun, 1996). Fluoridation, however, presents a different
kind of challenge because it is one of the few public health measures
often decided by voters at the ballot box.

##### 

### Direct v. Representative Democracy

In the United States, political decisions about fluoridation are made at
the state and local levels. There are two different methods for making
these decisions. First, a governing body or agency, such as a
legislature, city council, or local health department, may decide
fluoridation policy. Second, in many states voters determine such issues
through ballot measures, such as initiatives or referendums.[^2]
Overall, fluoridation referendum campaigns have had mixed success in the
U.S. From 1950 to 1967, 1,009 such referendums were held with
fluoridation being adopted in 41% and rejected in 59%. From 1980 to
1988, 150 referendums were held with voters approving fluoridation 36%
of the time. During the subsequent period 1989 to 1994 the trend
reversed with fluoridation supporters winning 19 (59%) of the 32
referendums conducted. Historically, however, adoption of fluoridation
has occurred more often through administrative action by governing
bodies than through voters. While only one out of every three
referendums resulted in adoption of fluoridation from 1980 to 1988,
approximately three out of every four administrative actions resulted in
adoption of fluoridation during this same period (Neenan, 1996). The
greater success with governing bodies than among voters continued in the
2000 election cycle, with pro-fluoridation forces winning ten of eleven
votes conducted by city councils or boards, and losing 14 of 23 ballot
measures. However, fluoridation was approved by voters in the largest
cities or counties where it appeared on the ballot in San Antonio, Texas
and Clark County, Nevada, which includes Las Vegas.

The issue of how fluoridation is decided politically falls into a
broader debate over the merits of referendums and initiatives, and the
advantages and disadvantages of direct versus representative democracy
(Magleby, 1984; Cronin, 1989; Bowler and Donavan, 1998; Sabato, 2001;
Broder, 2000; Abrams, 2002; Gerber, 1999; Zimmerman, 2001; Waters;
Magleby and Patterson 1998; Dubois and Feeney, 1998; Haskell, 2001;
Bowler et al., 1998; Caves, 1992; Smith, 1998; Ellis, 2002; Witt and
McCorkle, 1997). Most of the framers of the Constitution were strong
advocates of representative democracy, and were skeptical of giving
voters direct authority over lawmaking. "Pure democracies," James
Madison wrote in Federalist 10, "have ever been spectacles of turbulence
and contention" (Madison, Hamilton, and Jay, \[1788\] 1987; quoted in
Sabato et al., 2001). The widespread use of referendums and initiatives
stems from the Populist movement of the late 19^th^ century and the
Progressive movement of the early 20^th^ century (Cain and Miller,
2001). The use of referendums and initiatives has increased
significantly since the late 1970s, igniting a debate among citizens,
academics, and political practitioners over direct democracy (Ernst,
2001). Sabato et al. nicely summarize both sides of the argument.

> Proponents of the initiative process argue that ballot initiatives
> serve as an important tool of "last resort" when legislatures fail to
> act in the public interest. They also maintain that initiatives allow
> the popular will to be expressed directly without the "distortion" of
> representative politics or "special" interests. What's more, argue
> proponents, ballot initiatives encourage change, reduce citizen
> alienation, heighten voter awareness, and eliminate corruption endemic
> to the legislative process.
>
> To counter these arguments, critics of the ballot initiative offer a
> litany of complaints about the conduct and propriety of the process.
> For example, many critics claim that political consultants and moneyed
> interests now exercise far too much influence in ballot campaigns,
> polluting a process originally intended to give citizens voice in
> policymaking. Other critics claim that voters possess neither the
> knowledge nor the expertise to understand and evaluate the measures on
> which they are voting. Still other critics have blasted the ballot
> initiative process for producing poorly written laws and facilitating
> the passage of legislation that disregards minority rights. Finally,
> many critics of the ballot initiatives lament the shrill,
> uncompromising, and manipulative discourse typically found in
> contemporary ballot initiative campaigns. Such discourse, they argue,
> is a poor substitute for the deliberation and compromise that
> accompany serious legislative debate (x-xi).

### Community Process for Making Fluoridation Decisions

Many of these same issues have arisen in communities considering
fluoridation, with citizens and groups debating not only the merits of
fluoridation itself, but the appropriate process for deciding the issue.
The heated nature of many referendum campaigns combined with the
tendency for governing authorities to call for voter decision through
special elections that do not include their election or re-election
status and often result in low voter turnout has led some in the oral
health community to believe that deciding the issue at the ballot box
should be "avoided at all costs" (Neenan, 1996). However, campaigns are
often unable to determine which method will be used and must be prepared
to gain the support of voters.

The literature suggests that ballot measure campaigns and campaigns
aimed at persuading a governing body share many similarities, including
successful coalition building, effective use of the media, and gaining
endorsements from influential community, state, and national
representatives (Faine et al., 1981; Isman, 1981; McGuire, 1981; Neenan,
1996). However, there are also important differences. For example, when
the issue is decided directly by voters, ballot wording, ballot timing,
and careful control of public debates have often been cited as important
factors influencing the likelihood of victory. A challenge for success
of administrative or legislative campaigns include proving to decision
makers that there is a need and a desire for fluoridation on behalf of
the community. Another important factor is controlling the level of
perceived controversy over the issue. As McGuire (1981) notes, keeping
the overall level of controversy low, may help advocates keep the
decision at the level of a governing body.

> Perceived controversy and public confusion about fluoridation also
> tend to shift responsibility from the city council to the voters. It,
> therefore, is imperative for local health professionals and proponents
> of fluoridation to acquire political acumen to achieve water
> fluoridation in their community (p. 686).

As McGuire indicates, to be successful, fluoridation advocates need a
degree of political sophistication to navigate the volatile political
context that surrounds this issue. Victorious fluoridation campaigns
adapt to this volatility by adopting diversified strategies that are
responsive to a dynamic campaign environment (Jones et al., 1989; Isman,
1981, Faine et al., 1981; Boriskin, 1979).

# 

# 

# III. Perspectives on Communication and Campaign Outcomes

This section examines a number of works that may provide useful
perspectives on the subject of fluoridation campaigns. Throughout the
section, works specifically on fluoridation as well as other potentially
relevant literature are explored.

-   Part A looks at what much of the sociological literature on
    fluoridation refers to as "structural" characteristics of
    communities, such as socioeconomic status, structural
    differentiation, social integration, centralization of authority,
    social capital, and demographic variables. In multi-case studies,
    many of these factors have been observed to influence the likelihood
    of fluoridation adoption. While these factors may not be elements
    that campaigns can influence or change, they are nonetheless
    important variables that should be examined in this study and
    understood by those who favor fluoridation.

-   Part B explores relevant literature on political behavior, drawing
    heavily from public opinion and voting studies. This subsection
    investigates many of the cues voters use in referendum elections,
    and includes topics such as voting in low information elections,
    cues provided by policy elites, the influence of self-interest, the
    impact of risk aversion, and the importance of alienation, political
    efficacy, and trust.

-   Part C examines how a risk perception approach may help us
    understand the issue of fluoridation, and includes an application of
    Sandman's "hazard versus outrage" framework to this issue.

-   In Part D we explore media and campaign effects, particularly the
    importance of framing.

-   Part E investigates how diffusion of innovations theory may help
    explain why some communities adopt fluoridation while others do not.

-   Finally, Part F looks at specific campaign variables such as
    organization and professionalism, coalition building, campaign
    research, campaign finance, ballot wording, and the timing of
    elections.

## A. Structural Community Factors

A variety of scholars have examined how certain structural
characteristics of communities can affect decision making and outcomes
related to fluoridation. In their frequently cited work, Crain and
Rosenthal (1967, 1968), looking both at areas where fluoridation is
considered via administrative action and where it is voted on in a
referendum, find a curvilinear relationship between community
socioeconomic status and fluoridation outcomes, with *low status* and
*very high status* communities more likely than *middle class*
communities to adopt fluoridation. This finding runs counter to what one
would predict based on individual level survey data, which shows a
direct positive correlation between education and support for
fluoridation. Crain and Rosenthal suggest that the reasons for this
apparent contradiction lie in the political decision making process of
middle class communities, where citizens are easier to mobilize, more
issue oriented, and likely to favor "reform" mechanisms for democratic
decision making, such as the referendum and non-partisan elections. Such
communities will likely have weak party loyalty, open decision making
processes, and cautious politicians. The result, according to Crain and
Rosenthal, is a context ripe for political controversies.

> Middle-class cities will have a less stable government, will be less
> willing to embark on controversial programs, and when they do attempt
> to innovate, there will be higher levels of community debate and hence
> higher levels of controversy and a greater possibility of stalemate.
> In contrast, in low-status cities, citizens are less readily able to
> mobilize to influence the decision-making process; this may result in
> either government by a traditional political machine, or in a
> government heavily influenced by the local economic elite; but in any
> case there should be less controversy, and few programs, once begun,
> will be sidetracked (p. 972).

Crain and Rosenthal's explanation of the relationship between
socioeconomic status, political involvement, and fluoridation outcomes
seems to contradict others who have argued that civic involvement and
voluntary associations encourage political stability and help avoid
controversy (Coleman, 1957). Crain and Rosenthal suggest that civic
participation can lead to stability, but only when participation is *"at
a high and stable level"* (italics original) (p. 976). Importantly, such
involvement is likely to occur only in high socioeconomic status
communities. In these communities, where civic involvement is consistent
and strong, there will be regularized contact between citizens and
government, stable leadership, and predictable public opinion. Also, the
number of people available for mobilization will be relatively low
because so many people are already involved and active in organizations.

Thus, the linkages between socioeconomic status and political engagement
may explain the curvilinear relationship between socioeconomic status
and fluoridation outcomes. In low-status communities, the lack of
engagement increases the likelihood of adoption. In middle class areas,
a higher level of engagement creates political instability and makes
passage difficult. Finally, in high status communities, very high levels
of consistent involvement lead to political stability, which facilitates
adoption.

Smith (1979) also has examined the impact of community structural
features on fluoridation outcomes, focusing on three characteristics:
structural differentiation, community integration, and the
centralization of authority. Smith suggests that *structural
differentiation* will occur when "communities grow and develop a more
extensive division of labor in a number of sectors," leading to greater
organizational complexity and more specialized interests (p. 149).
Highly differentiated communities will have specialized and professional
organizations focused on specific issues. High levels of *social
integration* exist when individuals are deeply attached to their
communities, and there is "a consensus of values and norms and an
extensive and interlocking communications network between community
members, organizations and leaders" (p. 149). The *centralization of
authority* examines how power is organized in government structures,
particularly "the degree of executive centralization and
participativeness of the system" (p. 150). Partisan elections,
mayoral-council systems, and low use of referendums are characteristics
of highly centralized political authority structures. Using a three-part
typology of communities that adopt fluoridation, those that reject it,
and "nonconsidering" communities that neither adopt nor reject, Smith
finds that adopters and rejecters have higher levels of differentiation
than do nonconsiderers, while nonconsiderers and adopters have higher
levels of integration and centralization than do rejecters. Thus,
communities that adopt fluoridation are likely to have relatively high
levels of differentiation, integration, and centralization.

Although it has not been applied to this issue, social capital theory
may have implications for the study of fluoridation. Popularized by
scholars such as Coleman (1990), Fukuyama (1995), and especially Putnam
(2000), the concept of social capital has been studied in a variety of
disciplines, including public health (see Kreuter and Lezin, 2002 for a
review of the public health literature on social capital). Putnam
describes social capital in the following manner:

> Whereas physical capital refers to physical objects and human capital
> refers to properties of individuals, social capital refers to
> connections among individuals--- social networks and the norms of
> reciprocity and trustworthiness that arise from them (p. 19).

Putnam's work has identified a serious decline in social capital in the
U.S. in recent years, particularly in terms of civic and political
participation. In public health, scholars have suggested that
communities with high levels of social capital may be more successful in
implementing community-based health promotion interventions (Kreuter and
Lezin, 2002). There are similarities between social capital and the
concept of "community capacity," which is frequently used in
community-based public health efforts. Norton et al. (2002) describe
community capacity as "the nature and extent of social relationships
that exist within communities and the presence of community factors that
may affect the ability of communities to mobilize to address systemic
problems" (p. 195). The work on social capital and community capacity
suggests that communities with higher levels of social capital or
community capacity may be better equipped to pass fluoridation measures.

Neenan (1996) cites several additional factors pertaining to community
structure that have been hypothesized to contribute to campaign
outcomes. Specifically, she looks at the possible effects of demographic
trends on voter mobilization. While Frazier (1980) cites studies that
find little or inconclusive evidence for the effects of demographic
trends, Neenan favors taking another look at the effects of
socioeconomic status, race, language, suburbanization, education, and
housing status in fluoridation studies. She argues that in areas where
socioeconomic differences exist between urban and suburban populations,
suburban voters are likely to turn out at the polls at a higher rate
and, as a result, have a disproportionate impact on local referendum
outcomes. Moreover, the more mobilized suburban populations are likely
to vote based on certain conservative values. Neenan writes,

> In 1990, 46 per cent of the population lived within the suburban
> frontier, where the action is politically concentrated in the US.
> Suburban enclaves tend to be wealthier, more educated, more Caucasian,
> more anti-tax, more anti-establishment, and more conservative than big
> city cores. Suburbanites believe that the government can no longer
> solve problems pertaining to health care; they just want Washington to
> keep the economy booming. While the suburbanites vote, inner city
> residents often do not. The implications of
> urbanization/suburbanization may impact efforts to fluoridate many of
> the non-fluoridated cities which are located in the Western states,
> especially California (p. 12).

## B. Political Behavior

This section reviews some of the relevant literature on public opinion
and voting behavior as it relates to referendum voting generally, and to
fluoridation campaigns specifically. The section focuses on fluoridation
as a ballot measure, although some of the same dynamics regarding public
opinion could also influence instances when fluoridation is considered
by an administrative body. First, we examine how voters make decisions
in contests, such as referendum campaigns, where there may be relatively
little information available. Second, we look at the relationship
between elite and mass opinion. The third part of this section discusses
how individuals may pursue their self-interest when making voting
decisions. Fourth, we explore how a general inclination toward risk
aversion may affect referendum campaigns. The final part of the section
examines how alienation, efficacy, and trust may affect public opinion
on fluoridation and similar issues.

### Voting in Low Information Campaigns

As discussed above, fluoridation is one of the few public health issues
regularly decided by a direct vote at the ballot box. Thus, fluoridation
campaigns may have some unique characteristics related to the particular
challenges of communicating about public health issues in a charged
campaign environment. Nonetheless, fluoridation ballot measures share
many characteristics with other issues decided directly by voters.
Perhaps most importantly, these campaigns are generally low information
elections in which voters lack voting cues and information shortcuts
available in other campaigns.

The early, classic works in the study of American public opinion and
voting behavior, such as Campbell et al.'s influential *The American
Voter* (1960), painted a somewhat bleak picture of the average voter,
who in all likelihood knew little about issues or candidates, showed
little ideological consistency in his or her opinions across issues, and
was even unlikely to maintain consistent opinions over time. Much of
this work suggested that one factor, political party identification, had
a far stronger impact than any other on how citizens vote. Partisanship
was a relatively stable attribute that voters acquired through
socialization at a young age---few voters ever changed their party
affiliation and few crossed party lines when voting.

However, as the influence of parties began to decline (Wattenberg,
1994), political scientists began to reexamine the nature of party
attachments and their role in voting behavior. At the same time, there
was increasing evidence that voters were able to make decisions based on
issues (Nie et al., 1976). As Neimi and Weisberg (1993) have pointed
out, there developed a "revisionist" school of voting behavior that
opened the door for new interpretations of voter decision making.

Building on this work, as well as advances in cognitive psychology, many
scholars have begun to paint a slightly more optimistic picture of
citizens as "reasoning voters," who, while still lacking in-depth
knowledge about many issues, are able to make informed political choices
by using cognitive shortcuts or "heuristics" (Popkin, 1991; Sniderman et
al. 1991). For instance, research has indicated that when evaluating
candidates, voters may rely on information shortcuts such as
incumbency/challenger status, a candidate's group affiliation, or a
candidate's gender (McDermott, 1997). And here again party
identification is considered a key to understanding how voters make
decisions. In this view, however, party identification is less a
socialized characteristic than a cognitive device used by voters to
reason about choices, and determine which candidate or position most
closely reflects their own beliefs. Faced with uncertainty and
incomplete information, voters use reasonable shortcuts to reach
political decisions.

In referendum elections, however, many of these cues and shortcuts are
not available. For example, no party is identified with the "yes" or
"no" choice presented to voters, and no candidates are on the ballot.
Moreover, referendum elections may receive less media attention than
races for high profile political offices, or may concern issues---such
as fluoridation---that are unfamiliar to many voters.[^3]

One result from this lack of information is that public opinion during
referendum campaigns is more volatile than during candidate races. In
his survey of ballot propositions, Magleby found that voters are
significantly more likely to change their minds over the course of a
referendum campaign than during a candidate election (Magleby, 1984).
Similarly, in a cross-national study of referendum campaigns, LeDuc
(2002) found that "the amount of volatility found in referendum
campaigns is, on average, about 50 percent higher" than in other
elections.

Thus, fluoridation referendum campaigns may be characterized by low
voter information, a lack of common voter cues, and high levels of
opinion volatility. In such situations, what type of heuristics *do*
voters use? Bowler and Donovan (1998) suggest three possible
shortcuts: 1) responding to elite cues; 2) voting in a manner consistent
with self-interest; and 3) responding to uncertainty by voting "no."

### Cues from Policy Elites

A great deal of research demonstrates that mass opinion is strongly
influenced by elite opinion, and that individual citizens respond to
cues provided by elites, such as elected officials, community leaders,
or the media (Zaller, 1992). In particular, when the costs of acquiring
information about an issue are high---for instance it may cost a
considerable amount of time to learn about a new issue---citizens may
look to elites in the policy making arena for cues about which position
is consistent for their own beliefs. Lupia's (1994) study of five
complex insurance initiatives on the 1988 California ballot shows that
relatively uninformed voters were able to use the insurance industry's
position on these issues as a cue for making decisions (1994). Lupia
concludes that "voters who lack encyclopedic information about the
content of electoral debates can nevertheless use information shortcuts
as though they were well informed" (p. 63).

Evidence from studies of fluoridation campaigns suggests that voters in
these settings may employ similar shortcuts and that elites may play a
pivotal role. Crain et al. (1969) suggest that support from mayors and
civic organizations increased the likelihood of passage for fluoridation
ballot and legislative measures in cities with populations of
10,000-100,000. Extending this work to smaller communities with
populations of 1,000-10,000, Wong (1978) found similar results. Wong
also suggests that voters may take cues from health professionals,
finding evidence of a correlation between dental and health professional
involvement and fluoridation campaign success.

Another way in which elite opinion may influence election outcomes is
through newspaper endorsements. Political practitioners often consider
them a crucial part of a successful campaign, and research has largely
shown that newspaper endorsements can influence outcomes, with a number
of studies uncovering relationships between endorsements and votes in
presidential, senatorial, and gubernatorial elections (Coombs, 1981). A
recent study of U.S. Senate campaigns by Kahn and Kenney (2002) found
that newspaper endorsements also affect campaign coverage. Despite the
journalistic norm of separation between a paper's news and editorial
pages, Kahn and Kenney find that "information on news pages is slanted
in favor of the candidate endorsed on the newspaper's editorial page"
(p. 381). The authors also uncover evidence that this slanted coverage
leads voters to have a more favorable view of the endorsed candidate.

In addition to campaigns for federal office, newspaper endorsements can
affect local elections. Krebs (1998) finds a significant positive
relationship between newspaper endorsements and candidate vote share in
city council elections. Moreover, newspaper endorsements have been found
to be particularly important in local elections with *lengthy ballots*,
a situation in which fluoridation decisions are often made (Hooper,
1969). Zisk also found that editorial endorsements were related to
ballot initiative outcomes, particularly when the newspaper endorsed the
"no" position (Zisk, 1987). Studies of fluoridation have linked
editorial endorsements to successful campaigns (Mueller, 1966; Crain et
al., 1969).

Campaigns also often seek endorsements from politicians, subject matter
experts, celebrities, and political or civic organizations, although
empirical support for the impact of these endorsements is mixed
(Magleby, 1984). Nonetheless, some studies suggest that endorsements can
increase the likelihood that a ballot measure will pass. For instance,
Baker (1960) argues that a League of Women Voters endorsement of an
Oregon reapportionment referendum added prestige to that campaign. In
his examination of a 1976 California nuclear power initiative, Magleby
found that voters were more influenced by endorsements by scientific
elites than by political elites.

This stems in part, Magleby suggests, from politicians' "untrustworthy
image" (p. 158). Isman (1981) suggests that a deeper level of
involvement by elites in a campaign may be useful. Citing the example of
a successful 1978 fluoridation referendum effort in Portland, Oregon,
Isman notes that the popular coach of the NBA's Portland Trailblazers,
Jack Ramsay, served as campaign champion, or "figurehead." Ramsey did
press conferences and radio spots for the campaign, and pictures of the
coach appeared in local publications, asking rather cleverly, "Why is
Jack Ramsay smiling?" Isman, echoing Magleby's findings, suggests that
having a celebrity such as Ramsay as a figurehead is more effective than
having a politician.

One influential view of how elites may affect referendum campaign
dynamics is the "community conflict" model, which has been used to
analyze fluoridation and other controversial political issues (Darcy and
Laver, 1990; Boles, 1979; Coleman, 1957; Mansbridge, 1986). This model
seeks to explain a particular pattern in public opinion, common to many
referendum elections, in which a significant initial majority in favor
of a proposition shifts to an eventual majority against the proposition.
Labeling this pattern a "referendum dynamic," Darcy and Laver describe
it as:

> a process which begins with apparent large-scale popular support for
> some proposal. The proposal is scheduled for a vote, triggering a
> referendum campaign which ends with a massive short-term opinion
> reversal and the defeat of the once popular proposal (1990, p. 2).

As Darcy and Laver note, in the 1960s scholars discovered that this
dynamic was characteristic of many fluoridation votes (Mueller 1965,
1966). One early attempt to explain this pattern was the "confusion
hypothesis," which suggested that during the course of fluoridation
campaigns antifluoridationists successfully raised enough doubts to
create confusion in voters' minds and shift opinion towards rejecting
fluoridation (Sapolsky, 1969; Magleby, 1984). However, as Darcy and
Laver note, the confusion hypothesis fails to account for why some
opposition campaigns successfully raise doubts while others fail. The
community conflict model, on the other hand, provides an explanation for
why the referendum dynamic only sometimes appears, by focusing on one
key element: the "withdrawal of established elites" from the political
arena (Dacry and Laver, 1990, p. 16).

This process leading from initial support to elite withdrawal to
proposition failure, according to the community conflict model, begins
when an established group or organization develop a concern about a
policy issue. Working with political elites, the group is able to push
the issue onto the community's political agenda; specifically in this
case, the group is able to get the issue on the ballot as a public
referendum. However, this new issue draws new groups into the debate,
"often ad hoc groups supported by organizations and networks based
outside the established political elite" (Darcy and Laver, 1990, p. 15).
These new groups, who tend to view the new issue as a threat to their
core values, widen the overall scope of conflict and unconstrained by
established political norms, bring an unusually divisive tone to the
campaign. Concerned about the growing divisiveness of the new issue,
established elites essentially withdraw from the debate. Voters take
this cue to mean the proposal has lost legitimacy, and it is defeated.

Here again, elites provide cues to the voting public, in this case by
essentially avoiding the issue, thereby sowing the seeds of doubt in
voters' minds. Additionally, the void caused by elite flight leads to a
more contentious tone of political debate, something that has
characterized numerous fluoridation battles. Many considered the
community conflict model a powerful explanation for the fluoridation
campaigns of the 1950s and 1960s (Coleman, 1957; Crain et al., 1969).
Although few have applied community conflict to fluoridation in recent
years, it remains one of the more developed models for explaining public
opinion and voting behavior on this issue.

A final way in which elites may influence a fluoridation race concerns
the nature of antifluoridationist movements. Like many groups active in
initiative politics, antifluoridationists are often characterized as
"grassroots" activists, working in the tradition of American populism.
However, in his study of anti-tax activists and the initiative process,
Smith (1988) notes that many contemporary, seemingly grassroots, direct
democracy movements are in fact "*faux* populist" movements that have a
"a populist-sounding message without the political mobilization of 'the
people" (p. 48). In this view, which contradicts most media coverage and
conventional wisdom, most anti-tax ballot initiative campaigns of recent
years, starting with California's Proposition 13 in 1978, have been
top-down, professionalized, and elite-driven efforts. In his critical
study of initiative politics, Ellis (2002) similarly concludes that,
contrary to naïve views about direct democracy, interest groups and
political elites frequently dominate the initiative process. Witt and
McCorkle (1997), in their volume on anti-gay rights initiatives, note
that the initiative process, championed by Progressives as a check on
narrow interests and corrupt legislatures, has in many ways empowered
special interest groups.

> The irony is that the modern initiative process---with its high priced
> consultants, paid signature gatherers, sophisticated media campaigns,
> and single-issue focus--- is now frequently a tool of the special
> interests the Progressives wanted to avoid (p. 3).

These and other scholars suggest that many movements involved in
initiative campaigns may be less "populist" than they appear. For this
study, the implication is that the nature of antifluoridationist efforts
should be explored to determine whether they are grassroots, bottom-up
political movements or top-down, elite-led campaigns.

### Self-interest

Numerous scholars have examined the impact of self-interest on voting
behavior. For example, political scientists have looked for evidence of
so-called "pocketbook" voting---supporting a candidate who favors
policies that are in your economic self-interest---with mixed results
(Markus, 1988). Given the lack of voting cues and low amount of
available information, one might expect that voters would be
particularly likely to turn to self-interest when casting ballots on
referendum issues such as fluoridation. Several studies of referendum
voting, however, have failed to support this hypothesis (Hahn and
Kamieniecki, 1987; Hall and Piele, 1976; Mueller, 1969; Wilson and
Banfield, 1963). An exception is Bowler and Donavan's (1998) study of
issues such as prohibition, school vouchers, and tax policy, in which
they find that many referendum voters act in a manner consistent with
self-interest.

One way in which self-interest may affect voting on fluoridation
measures is in the voting behavior of the elderly. Neenan describes how
elderly citizens may not find fluoridation in their self-interest.

> Over the last two decades, disenchantment with government and apathy
> have led to significant declines in voter participation in the United
> States. However, elderly people do vote and they also tend to view
> fluoridation as a benefit primarily directed at children and are
> therefore less likely to be supportive. Simply put, many elderly
> people do not see a need for fluoridation, nor do they want to pay for
> it. Framing fluoridation solely as a children's health issue is
> problematic for campaign organizers (p. 14).

As Neenan suggests, older Americans vote at higher rates than younger
citizens, and, as recent research on the politics of Social Security has
demonstrated, the elderly are particularly likely to become mobilized
when their economic self-interest is at stake (Campbell, 2002).
Conversely, those who are perceived to have the most to gain from
fluoridation either are unable to vote (children) or are less likely
than others to vote (the poor).

### Risk Aversion

A great deal of research suggests that voters are often risk averse,
exhibiting a "negativity bias" and seeking to avoid potential losses
(Ansolabehere and Iyengar, 1993; Brady and Ansolabehere, 1989; Kahneman
and Tversky, 1984). This is consistent with what Sunstein (2002) terms
"loss aversion:" "People tend to be loss averse, which means that a loss
from the status quo is seen as more undesirable than a gain is seen as
desirable" (p. 42). As Bowler and Donovan (1998) suggest, in a low
information environment, voters may behave in a risk averse manner and
simply vote "no," feeling that it is better to stick with the status
quo. A tendency among voters to support the status quo has been noted by
many observers of referendum elections, and political professionals
generally consider a "yes" vote campaign more challenging than a "no"
vote campaign.[^4]

### Alienation, Efficacy, and Trust

The community conflict model suggests that opinion on fluoridation
measures shifts in part because new players enter the political arena
once the issue is introduced. These new groups often come from outside
the political establishment and frequently do not play by the accepted
rules of the game. Another perspective that emphasizes the importance of
actors outside the political establishment is the "alienation
hypothesis," which, according to Martin's survey of the literature, has
been "the most widely used in analyzing the fluoridation controversy"
(1989, p. 63). The alienation hypothesis suggests that the issue of
fluoridation presents an opportunity for protest and resistance by the
angry and disaffected: "antifluoridationism, according to this
hypothesis, is essentially a revolt of the powerless who have latched
onto fluoridation as a symbol of the impositions which they oppose"
(Martin, 1989, p. 63).[^5]

Several researchers found support for this view by examining public
opinion data (Gamson, 1961; Simmel, 1961), interviewing
antifluoridationist leaders (Green, 1961), and by reviewing
antifluoridationist literature (Davis, 1959). However, scholars
ultimately turned from the alienation hypothesis because it was
difficult to see how a somewhat fixed trait like alienation could
account for the short-term swings in public opinion characteristic of
fluoridation campaigns, the previously mentioned "referendum dynamic"
(Sapolsky, 1968, 1969; Crain et al., 1969; Frazier, 1980).

Nonetheless, while perhaps not a comprehensive explanation of the
opinion dynamics surrounding fluoridation, the alienation hypothesis
does raise important questions about the types of voters who may be
attracted to and mobilized by antifluoridationism. In work subsequent to
most of his fluoridation research, one of the proponents of the
alienation hypothesis, William Gamson, has advanced the so-called
"Gamson hypothesis," which suggests that at least some citizens who are
disenchanted with and distrustful of the political system are ripe for
mobilization. Specifically, Gamson argues that individuals with high
levels of political self-efficacy and low levels of trust in government
are vulnerable to mobilization (1968).

Evidence for this view has been mixed over the years, with some studies
suggesting the Gamson hypothesis has little explanatory power (Watts,
1973; Sigelman and Feldman, 1983; Craig, 1979), and others finding at
least partial support for it (Paige, 1971; Marsh, 1977; Craig and
Maggiotto, 1981; Madsen, 1987). There is some evidence that the
hypothesis explains mobilization only on the political right. Zurcher
and Monts (1972), for example, found that the hypothesis successfully
accounted for the mobilization of ideological conservatives. Similarly,
Hollander (1997) found that it successfully predicted the mobilizing
effects of talk radio, but only among ideological conservatives. Talk
radio, an increasingly important arena for political discourse,
especially among conservatives, may often provide a venue for those
seeking to mobilize the high efficacy, low trust in government voter
that Gamson describes. Neenan has described the important role played by
local talk radio during a 1985 fluoridation campaign in San Antonio
(1996). As Neenan points out, talk radio listeners tend to be better
educated, have higher incomes, and vote more regularly than the average
citizen, making them an attractive target audience for those who oppose
fluoridation.

## C. Risk Perception

The concept of risk, and the discipline of risk communication, may offer
a useful lens for understanding public perceptions of fluoridation.
Freudenburg (1993) examines some of the theoretical foundations of risk
in modern, technologically advanced societies, noting that today we are
dependent on others with specialized technical knowledge, and vulnerable
to what he terms "recreancy" by these specialists, "the failure of
institutional actors to carry out their responsibilities with the degree
of vigor necessary to merit the societal trust they enjoy" (p. 916).
"Paradoxically," Freudenburg writes, "the very division of labor that
permits many of the achievements of advanced industrial societies may
also have the potential to become one of the most serious sources of
risk and vulnerability" (p. 914). Freudenburg examines public attitudes
toward nuclear waste disposal and finds that those with lower levels of
trust in the federal government or in science and technology tend to
have higher levels of concern about disposal. Interestingly, he finds
higher levels of distrust among moderate voters than among liberals.

> The "antinuclear activists" who are emerging in communities across the
> U.S. are proving to be almost the polar opposites of traditional
> stereotype. Many of them are middle-aged, conservative
> Republicans...many are "silent majority" members who have never before
> spoken up in public (p. 928).

One strategy for dealing with public perceptions of risk on scientific
issues is to provide the public with technical information---what
Sandman et al. (1996) have labeled the "knowledge breeds support"
perspective, often popular among scientific experts. However, as Sandman
et al. note, "the link between technical knowledge and support for
controversial technologies show mixed results" (p. 585) (Melber et al,
1977; Kuklinski et al 1982; Nealy et al, 1983; Bord and O'Connor, 1990;
Board and O'Connor, 1992; Baird, 1986; Johnson and Baltensperger, 1987;
Golding et al, 1992, Wyner and Mann, 1983; Johnson, 1993; Johnson and
Fisher, 1989; Weinstein and Sandman, 1992a; Weinstein and Sandman,
1992b). Mazur, on the other hand, has argued that the more information
citizens are exposed to, the more concerned about a risk they are likely
to become (Mazur, 1981; Mazur, 1990).

Sandman and his colleagues (Sandman, 1987; Sandman, 1991; Sandman, 1993;
Hance et al, 1988; Hance et al, 1990; Sandman et al, 1987), as well as
many other writers (Kasperson, 1986; Bord, 1987; Krimsky and Plough,
1988; Johnson, 1987; Covello et al, 1988; Covello and Allen, 1988;
Slovic, 1987), have suggested that in order to fully understand public
perceptions of risk, we must examine the nontechnical aspects of risk
communication. Sandman has developed a well-known framework of "hazard,"
which refers to technical issues, versus "outrage," which refers to
nontechnical issues.

> In Sandman's terminology, "hazard" is the product of risk magnitude
> and probability, while "outrage" is a function of whether people feel
> the authorities can be trusted, whether control over risk management
> is shared with affected communities, etc. Supporters of this
> distinction argue that hazard and outrage are both concepts of risk
> deserving attention, and that laypeople have had as little success
> communicating what they consider significant about risks to the
> experts as the experts have had communicating to the public. No matter
> how serious the risk is (in hazard terms), and no matter how much
> technical detail is used to explain it, this view maintains that the
> degree of *outrage* is likely to determine much of the public's
> response to the risk (Sandman et al., 1993, p. 585).

Sandman has identified 13 risk communication variables that should be
taken into account in order to minimize outrage when conveying
information to the public on risk controversies, and has applied these
to the issue of fluoridation (Park et al., 1990). The table below, which
is adapted from Park et al. (1990), looks at these variables, along with
how Sandman assesses the "status of public outrage" on the issue of
fluoridation by assigning positive and negative scores to each.[^6]

+------------------+--------------------------------------+-----------+
| #### Tab         |                                      |           |
| le 2: Sandman's  |                                      |           |
| 13 Risk Communic |                                      |           |
| ation Variables  |                                      |           |
|                  |                                      |           |
| and Their        |                                      |           |
| Application to   |                                      |           |
| Fluoride         |                                      |           |
| (adapted from    |                                      |           |
| Park et al.,     |                                      |           |
| 1990)            |                                      |           |
+------------------+--------------------------------------+-----------+
| Variable         | ######## Description                 | #####     |
|                  |                                      | ### Score |
+------------------+--------------------------------------+-----------+
| Voluntary vs     | When exposure to a hazard is         | \-        |
| Coerced          | voluntary, it is perceived by the    |           |
|                  | public as being less "risky." A      |           |
|                  | decision to fluoridate made through  |           |
|                  | referendum appears less coercive     |           |
|                  | than an administrative decision by   |           |
|                  | city council.                        |           |
+------------------+--------------------------------------+-----------+
| Natural vs       | A risk that is "natural" or          | \-        |
| Industrial or    | "naturally occurring" will not       |           |
| Man-made         | generate the same level of public    |           |
|                  | outrage as will man-made or          |           |
|                  | artificial risk (e.g., natural       |           |
|                  | carcinogens in food vs food          |           |
|                  | additives or water treatment)        |           |
+------------------+--------------------------------------+-----------+
| Familiar vs      | Unfamiliarity increases the level of | \+        |
| Exotic           | public outrage, leading to increased |           |
|                  | perception of risk. The public must  |           |
|                  | become familiar with the             |           |
|                  | "unfamiliar" to decrease the         |           |
|                  | perception of risk. Concerning the   |           |
|                  | issue of fluoridation, the public is |           |
|                  | familiar with the use of fluoride    |           |
|                  | and its dental health benefits, but  |           |
|                  | is unfamiliar with the relative      |           |
|                  | health risks that may be associated  |           |
|                  | with fluoride.                       |           |
+------------------+--------------------------------------+-----------+
| Nonmemorable vs  | This principle relates to personal   | \+        |
| Memorable        | experiences with a particular risk,  |           |
|                  | or the ease with which the public    |           |
|                  | can picture something going wrong.   |           |
|                  | An issue or event can become         |           |
|                  | memorable through increased media    |           |
|                  | coverage, raising the public's sense |           |
|                  | of outrage and increasing the        |           |
|                  | perception of risk.                  |           |
+------------------+--------------------------------------+-----------+
| Not Dreaded vs   | "Tooth decay" is a far less dreaded  | \-        |
| Dreaded          | disease than "cancer." Growing       |           |
|                  | concern can be expected (increased   |           |
|                  | sense of outrage) regarding the      |           |
|                  | association between fluoride and     |           |
|                  | cancer. The best way to deal with    |           |
|                  | the "fear of cancer" is to           |           |
|                  | acknowledge that a risk may exist,   |           |
|                  | that the public health community is  |           |
|                  | concerned, and that it is willing to |           |
|                  | examine new information regarding    |           |
|                  | the potential risks. The worst way   |           |
|                  | to address emerging fears is to      |           |
|                  | become overly defensive and to state |           |
|                  | that the public should not be        |           |
|                  | concerned.                           |           |
+------------------+--------------------------------------+-----------+
| Diffuse in Space | A risk that is perceived as diffuse  | \+        |
| and Time vs      | in terms of space and time is        |           |
| Static and       | generally more acceptable than a     |           |
| Focused          | risk that is concentrated within a   |           |
|                  | relatively short time frame (e.g.,   |           |
|                  | risk of dying of lung cancer from    |           |
|                  | smoking vs risk of dying of an       |           |
|                  | outbreak of infectious disease).     |           |
+------------------+--------------------------------------+-----------+
| Knowable vs      | This variable is more than the       | \-        |
| Unknowable or    | extent to which experts know or can  |           |
| Unknown          | define the risk. The level of public |           |
|                  | outrage increases if there is        |           |
|                  | scientific controversy surrounding   |           |
|                  | an identified risk. The general      |           |
|                  | public will seek information         |           |
|                  | concerning the "worst-case           |           |
|                  | scenario," then will tend to view    |           |
|                  | the risk as more serious. When       |           |
|                  | experts disagree, public perception  |           |
|                  | of "unknowability" increases and the |           |
|                  | level of outrage also increases.     |           |
+------------------+--------------------------------------+-----------+

+------------------+--------------------------------------+-----------+
| ######## Table 2 |                                      |           |
| : Sandman's 13 R |                                      |           |
| isk Communicatio |                                      |           |
| n Variables and  |                                      |           |
|                  |                                      |           |
| ########         |                                      |           |
| Their Applicatio |                                      |           |
| n to Fluoride *( |                                      |           |
| adapted from Par |                                      |           |
| k et al., 1990)* |                                      |           |
+------------------+--------------------------------------+-----------+
| Variable         | ######## Description                 | #####     |
|                  |                                      | ### Score |
+------------------+--------------------------------------+-----------+
| Controlled by    | If the public is excluded from the   | \--       |
| the Individual   | decision-making process, its sense   |           |
| vs Controlled by | of "control" over the hazard         | (very     |
| Society          | decreases; it becomes more difficult | negative) |
|                  | for the public to develop a sense of |           |
|                  | control over its own destiny. The    |           |
|                  | public health community must share   |           |
|                  | control with the public if we expect |           |
|                  | to lower the level of outrage and    |           |
|                  | perceived risk related to community  |           |
|                  | water fluoridation.                  |           |
+------------------+--------------------------------------+-----------+
| Fair vs Unfair   | The level of public outrage is lower | \+        |
|                  | if the risks and benefits are        |           |
|                  | perceived to be fair. If the         |           |
|                  | distribution of benefits and hazards |           |
|                  | is similar, then the potential risk  |           |
|                  | could be viewed as equitable or more |           |
|                  | acceptable, thus lowering the        |           |
|                  | public's perception of risk. With    |           |
|                  | respect to fluoridation, the         |           |
|                  | benefits and the risks appear to be  |           |
|                  | distributed evenly across the        |           |
|                  | community, and may be considered by  |           |
|                  | the public to be acceptable in terms |           |
|                  | of risks and benefits.[^7]           |           |
+------------------+--------------------------------------+-----------+
| Morally          | Issues that are perceived as being   | +-        |
| Irrelevant vs    | morally relevant will tend to        |           |
| Morally Relevant | increase the public's sense of       | (even)    |
|                  | outrage. The moral relevance of the  |           |
|                  | risk of cancer makes the             |           |
|                  | cost-benefit trade-off of water      |           |
|                  | fluoridation more difficult to       |           |
|                  | defend. It is important to           |           |
|                  | acknowledge both sides of the        |           |
|                  | morality factor, allowing the public |           |
|                  | health community to be perceived as  |           |
|                  | respecting the values of others.[^8] |           |
+------------------+--------------------------------------+-----------+
| Trustworthy vs   | If the public perceives the source   | \--       |
| Not Trustworthy  | of information as being              |           |
|                  | "trustworthy," then its level of     | (very     |
|                  | outrage toward an issue would be     | negative) |
|                  | lower. The extent to which the       |           |
|                  | public views government agencies and |           |
|                  | authority figures as trusted sources |           |
|                  | of information depends on whether    |           |
|                  | these sources are accountable. In    |           |
|                  | general: 1) people want to perceive  |           |
|                  | themselves as partners in the        |           |
|                  | decision-making process, 2) there is |           |
|                  | more trust on a person-to-person     |           |
|                  | level, and 3) the public perceives a |           |
|                  | warning message with a higher degree |           |
|                  | of trust than it would a reassuring  |           |
|                  | message. The public health community |           |
|                  | and the dental profession no longer  |           |
|                  | can maintain the inflexible position |           |
|                  | that "we are experts, trust us,"     |           |
|                  | without offending the public's sense |           |
|                  | of trust. We must invite the public  |           |
|                  | to establish systems of              |           |
|                  | accountability. The public will in   |           |
|                  | fact trust us more if we invite them |           |
|                  | to "trust us less."                  |           |
+------------------+--------------------------------------+-----------+

+------------------+--------------------------------------+-----------+
| ######## Table 2 |                                      |           |
| : Sandman's 13 R |                                      |           |
| isk Communicatio |                                      |           |
| n Variables and  |                                      |           |
|                  |                                      |           |
| ########         |                                      |           |
| Their Applicatio |                                      |           |
| n to Fluoride *( |                                      |           |
| adapted from Par |                                      |           |
| k et al., 1990)* |                                      |           |
+------------------+--------------------------------------+-----------+
| Variable         | ######## Description                 | #####     |
|                  |                                      | ### Score |
+------------------+--------------------------------------+-----------+
| Open Sources vs  | Society becomes angry when it        | \--       |
| Secret or Closed | perceives that information is        |           |
| Sources          | withheld. The price of releasing     | (very     |
|                  | information is less expensive than   | negative) |
|                  | not releasing it.                    |           |
+------------------+--------------------------------------+-----------+
| Courtesy and     | Contempt for the public's perception | \-        |
| Caring vs        | is inappropriate. Authority figures  |           |
| Arrogance and    | often are perceived by the public as |           |
| Defensiveness    | demonstrating an air of "technical   |           |
|                  | coldness," which is interpreted as   |           |
|                  | being arrogant and defensive. The    |           |
|                  | public health community must         |           |
|                  | acknowledge the public's outrage in  |           |
|                  | a courteous and caring manner.       |           |
|                  | Further, Sandman stated that it is   |           |
|                  | imperative that the scientific and   |           |
|                  | public health community not only     |           |
|                  | respect the opposite viewpoint, but  |           |
|                  | acknowledge that there may be        |           |
|                  | substance in new information. He     |           |
|                  | recommends that fluoridation         |           |
|                  | advocates should "not trash new      |           |
|                  | information" when it does not agree  |           |
|                  | with past experience. The best       |           |
|                  | approach is to acknowledge its       |           |
|                  | existences, recognize that it may    |           |
|                  | not be definitive, and comment       |           |
|                  | publicly that the information will   |           |
|                  | be investigated thoroughly.          |           |
+------------------+--------------------------------------+-----------+

Summing up the number of positive and negative ratings, the overall
score for fluoridation is a --7, which means it is an issue ripe for
public outrage. Sandman also offers nine recommendations for how to
reduce outrage on fluoridation matters (reprinted here from Park et al.,
1990, p. 287):

-   Make decisions on fluoridation and the use of fluorides more
    voluntary

-   Increase the public's familiarity with the risks

-   Acknowledge the dread

-   Temper expert disagreement

-   Share control with the public, increasing the likelihood of
    community referendums

-   Acknowledge the moral relevance

-   Invite the public to become our partners and to set up systems of
    accountability

-   Release important information

-   Demonstrate concern and caring

Thus, Sandman advocates an open decision making process and a campaign
that acknowledges public concerns and provides citizens with relevant
information. Some studies suggest that fluoridation campaigns have not
always followed this kind of approach in the past, as several authors
note that past campaigns have been plagued by a somewhat arrogant
posture on the part of pro-fluoridation experts who, relying on the
weight of scientific evidence, have been dismissive of public concerns
(Frazier, 1980; Sapolsky, 1969).

A final way in which perceptions of risk may affect public debate on
issues such as fluoridation concerns Sunstein's notion of "group
polarization." This dynamic suggests that public discussion of risk can
push individuals toward extreme points of view.

> When like-minded people are talking mostly to one another, especially
> interesting things are likely to happen. If members of a group tend to
> think that (an issue) poses a significant danger, their discussions
> will move them, not to the middle, but to a more extreme point in line
> with their original tendencies (p. 88).

Public debate therefore, can have a reinforcing effect, solidifying
opinions that may not accurately reflect objective risk assessments.
Over the course of a campaign, public opinion may grow increasingly
polarized and, in the case of fluoridation, it may become more and more
difficult to persuade voters who lean toward the antifluoridationist
position.

## D. Media and Campaign Communication

Having witnessed the German propaganda of the 1930s and 40s, many early
scholars of mass communication feared the persuasive power of political
propaganda. "Social scientists of the time," Kinder writes, "worried
whether ordinary citizens could maintain their democratic values and
economic autonomy in the new and scary world of mass communication"
(1998, p. 185). These fears, however, were often based on intuition or
observation, not on rigorous social scientific testing. Scholars who
began empirically investigating these claims came to very different
conclusions, perhaps captured most famously in Klapper's (1960) "minimal
effects" model, which suggested that propaganda rarely changes
individual attitudes; instead, it tends to reinforce existing attitudes.

But in recent years political communication specialists have questioned
the minimal effects model, judging it "not so much wrong as incomplete"
(Kinder, 1998, p. 189). While mass communication may rarely result in
high levels of persuasion and large swings in public opinion, other more
subtle effects have become apparent, including agenda setting, priming,
and framing. In one classic study, Iyengar and Kinder (1987), used
experimental methods to examine the agenda setting and priming effects
of television news coverage. Regarding agenda setting, Iyengar and
Kinder found that viewers exposed to news broadcasts edited to emphasize
a particular problem were more likely to consider that problem a
priority. In support of their priming hypothesis, the authors found that
viewers tended to evaluate politicians based on issues they had been
exposed to through the edited broadcasts. For instance, those who had
been exposed to broadcasts emphasizing national defense tended to
evaluate candidates based on their stance regarding defense.

Framing is another important way in which media may affect public
opinion. Numerous studies from public health and political communication
examine how the media, campaigns, and advocates frame issues to
influence attitudes and behavior (Iyengar, 1991; Wallack et al., 1993;
Bales et al., 1998). Iyengar describes framing as "subtle alterations in
the statement or presentation of judgment and choice problems, while the
term 'framing effects' refers to the changes in decision outcomes
resulting from these alterations" (1991, p. 11). Whereas studies of
agenda setting and priming tend to focus on the amount of media
coverage, analyses of framing tend to emphasize the content of
communication (Nelson et al., 1997; Gamson, 1992; Gamson and Lasch,
1983; Gamson and Modigliani, 1987, 1989; Iyengar, 1991; Nelson and
Kinder, 1996). In many ways, as Simon and Xenos note (2000), framing is
about constructing messages to link associated concepts, "To say a
message constructs an issue, we are really saying that it has built-in
particular associations between concepts." "Thus," they continue,
"framing analysis is a careful examination of the way concepts are
associated within discourse" (p. 367). In a situation, such as
referendum voting, where voters lack normal voting cues and have
relatively little information, framing may be particularly important as
voters may be particularly susceptible to new information and campaigns
may be able to create new associations in voters' minds (see also
section below on ballot wording).

A framing perspective has been used by many scholars to examine media
effects. In addition, several studies have looked at how political
campaigns use framing to achieve their electoral goals (Popkin, 1991;
Jamieson and Waldman, 2003). Rival campaigns, through rhetoric,
advertising, and other communication efforts, try to frame issues in
ways that will encourage citizens to agree with their positions. Frames,
in this sense, represent an effort to define an issue and characterize
the available political choices. They are the tools political elites use
to garner mass support (Nelson and Kinder, 1996; Manheim, 1991; Skocpol,
1994). "Elites," Nelson and Kinder write, "wage a war of frames because
they know that if their frame becomes the dominant way of thinking about
a particular problem, then the battle for public opinion has been won"
(p. 1058). Political campaigns may develop different frames for
different target audiences, frequently using polling or focus group
research to identify messages that are particularly effective with
targeted segments of the voting population. Similarly, in the field of
public health, behavior change and health education campaigns will
develop tailored message concepts for different demographic or cultural
groups (see for example Brugge et al., 2002).

The discipline of media advocacy, which Wallack and Dorfman (2001, p.
393) define as "the strategic use of mass media in combination with
community organizing to advance public health policies," has recently
focused a great deal of attention on the importance of framing for
public health campaigns. Opposing sides on issues such as tobacco
policy, nuclear energy, and abortion have used "contested frames" in
attempts to define these issues in the public mind (Wallack et al.
1993). For instance, the tobacco industry successfully undermined the
1978 California indoor air initiative---which would have created
non-smoking areas in certain public spaces---by framing it as a
referendum on government intrusion on individual rights, rather than as
a vote about non-smoker rights (Magleby, 1984).

Central the success of any political campaign is the ability to define
the campaign issues in a favorable light. The literature on fluoridation
suggests that frames can be extremely important. For example, Isman
(1980) has suggested that allowing a phrase like "mandatory"
fluoridation onto the ballot can shift a referendum from a public health
issue to an issue of government interference and individual rights.

One final note on the subject of campaign communication concerns the
issue of public campaign debates. Such debates have become a staple of
many political campaigns, the best known of course being the
presidential debates every four years between the major party
presidential candidates. Debates can serve a useful educational purpose,
informing voters about the major issues and choices they face in the
voting booth. However, many fluoridation advocates have determined that
public debates do not serve their side well because they appear to lend
credibility to the opposition, giving antifluoridationists an equal
platform and seemingly legitimizing views that have little scientific
support. Indeed, in their analysis of a successful fluoridation campaign
in La Crosse, Wisconsin, Jones et al. (1989) note that fluoridation
advocates explicitly avoided debates for this reason. Another problem
faced by fluoridation advocates is that opponents have clear and direct
messages, while scientific answers are usually highly qualified, giving
the impression that scientists cannot provide definitive answers to
highly charged claims.

## E. Diffusion of Innovations

Diffusion of innovations theory provides another perspective for
understanding the issue of fluoridation. Used widely in public health,
this theory explores why "innovations"---such as public health
strategies, policies, or tools---spread across communities. In a seminal
work, Rogers (1983) identified five categories of innovation adopters:
innovators, early adopters, early majority adopters, late majority
adopters, and laggards. As Oldenburg et al. (2002) note in their survey
of the diffusion of innovations literature, "The identification of such
categories is the basis for designing and implementing intervention
strategies targeted at particular groups of individuals" (p. 272). The
implication for the study of fluoridation is that the characteristics of
late majority adopters and laggards need to be identified, and
interventions need to be designed to encourage these groups to adopt the
innovation of community water fluoridation.

In addition to developing categories of adopters, scholars have
identified characteristics of innovations that affect the likelihood
they will be adopted. Hunt (1983) has applied diffusion of innovations
theory to fluoridation, and has analyzed how these characteristics apply
to this issue. Table 3 provides definitions for each characteristic
(from Glanz and Rimer, 1997) and summarizes Hunt's analysis of how each
applies to fluoridation.

+--------------+--------------------------+----------------------------+
| #### Tabl    |                          |                            |
| e 3: Innovat |                          |                            |
| ion Characte |                          |                            |
| ristics and  |                          |                            |
| Fluoridation |                          |                            |
+--------------+--------------------------+----------------------------+
| Ch           | ######## Definition      | ######## A                 |
| aracteristic |                          | pplication to Fluoridation |
+--------------+--------------------------+----------------------------+
| Relative     | The degree to which an   | It may not be readily      |
| Advantage    | innovation is seen as    | apparent to the public     |
|              | better than the idea,    | that the benefits of       |
|              | practice, program, or    | fluoridation outweigh the  |
|              | product it replaces.     | financial, social, and     |
|              |                          | political costs.           |
+--------------+--------------------------+----------------------------+
| C            | How consistent the       | Adopting fluoridation may  |
| ompatibility | innovation is with       | be more difficult in       |
|              | values, habits,          | certain individualistic    |
|              | experience and needs of  | political cultures.        |
|              | potential adopters.      |                            |
+--------------+--------------------------+----------------------------+
| Complexity   | How difficult the        | Although the impact of     |
|              | innovation is to         | fluoride on tooth decay    |
|              | understand and/or use.   | may not seem complex,      |
|              |                          | antifluoridationists are   |
|              |                          | often successful in        |
|              |                          | confusing the public and   |
|              |                          | making the issue appear    |
|              |                          | complex.                   |
+--------------+--------------------------+----------------------------+
| Triability   | Extent to which the      | Fluoridation cannot be     |
|              | innovation can be        | tried on a limited basis.  |
|              | experimented with before |                            |
|              | a commitment to adopt is |                            |
|              | required.                |                            |
+--------------+--------------------------+----------------------------+
| O            | Extent to which the      | The benefits of            |
| bservability | innovation provides      | fluoridation may be        |
|              | tangible or visible      | long-term in nature and    |
|              | results.                 | the reduction in caries    |
|              |                          | not easily seen by the     |
|              |                          | public.                    |
+--------------+--------------------------+----------------------------+

This analysis of fluoridation as an innovation leads Hunt to conclude
that it "clearly has a low adoptive potential, especially when decided
by referendum" (p. 154).

The communication channels used to disseminate information about an
innovation also may strongly affect the likelihood of adoption. For
public health innovations, both medical professionals and community
leaders may play an important communication role. In his study of
fluoridation in small Iowa communities, Hunt found that mayors play a
significant role in adoption. He also found that when "opinion leaders,"
including in some cases local dentists, spoke at local council meetings
where the issue was being debated, the council tended to support the
side with the most speakers supporting its position. Thus, the diffusion
of innovations literature further highlights the important role policy,
health, and community elites may play in the decision making process.

## F. Other Campaign Variables

In addition to effective communication strategies, there are many other
factors that may influence the success of a political campaign, whether
it is a referendum effort or a campaign to pass an initiative through a
governing body. This section explores a number of these factors:
campaign organization, coalition building, research, campaign finance,
ballot wording, and the timing of an election.

### Campaign Organization

Political practitioners usually view campaign organization and
professionalism as a key to electoral victory in both candidate
elections and ballot measures. In a practical, how-to guide for
fluoridation supporters, the American Dental Association (1997) suggests
a number of steps for organizing an effective campaign, including
establishing campaign committees and subcommittees (such as steering,
finance, and legal committees), developing campaign slogans and logos,
acquiring lists of registered absentee voters, conducting telephone
canvassing, and contacting local editors and other members of the media.

One important component of a successful campaign is having good
personnel, including "a well organized and vigorous staff" (Faine et
al., 1981), as well as potentially hiring various campaign consultants
for research, petition drives, get out the vote efforts, advertising,
media purchasing, message and materials development, voter targeting,
and other purposes. It is also important to solicit help from volunteers
and to enlist the support of a wide variety of community members.

### Coalition Building

As many observers of public health and political campaigns have noted,
building broad-based community support is often crucial to success.
Jones et al. (1989) provide an example from the successful 1988
fluoridation referendum campaign in La Crosse, Wisconsin. Here, the
campaign organized a 34-member coalition in support of the initiative,
the "Citizens for a Better Dental Health in La Crosse," which "met twice
a month for five months preceding the April referendum, planning and
implementing an educational and political campaign for fluoridation" (p.
1406). As Butterfoss and Kegler (2002) note in their survey of the
coalition literature, the field of interorganizational relations has
demonstrated that organizations are likely to join a coalition when they
perceive the benefits of participation as outweighing the costs of
participation (see also Gray, 1989; Prestby et al., 1990;
Roberts-DeGennaro, 1986; Whetten, 1981). Isman (1981), discusses how
fluoridation advocates may get organizations involved in a coalition by
emphasizing the particular benefits those organizations may realize if
fluoridation is adopted. For instance, he suggests that arguments
concerning the potential reduction of dental costs will be persuasive to
business groups, organized labor, and, especially, health insurance
organizations.

### Formative Research and Use of Data

Several studies of referendum politics note the importance of campaign
research, such as focus groups and survey research (Gerber, 1999;
Schultz, 1996; Donavan et al., 2001). Campaigns use scientific polling
of registered voters for a variety of purposes, including measuring the
current state of public opinion, targeting potential supporters, testing
the impact of potential endorsements, and testing the effectiveness of
campaign messages both for and against a proposal. Focus groups are also
used by campaigns to hone messages and identify persuasive and
motivating language. Of course, these research efforts can be too
expensive for campaigns with limited finances.

In their study of fluoridation efforts in Tennessee, Brumely et al.
(2001) discuss another way in which campaigns may use research, which
they label the "community diagnosis process." In 1995, oral health
advocates in Tennessee decided to collect and disseminate local oral
health data as a means of educating decision makers about the need for
fluoridation. They conducted oral health surveys on children in various
local communities and presented these data to county health councils
comprised of representatives from civic organizations, business, health
professions, government, and education, as well as general consumers.
The data showed a significant difference in levels of dental caries
among children in fluoridated and non-fluoridated areas. When presented
with the data, health councils in four non-fluoridated counties decided
unanimously to make fluoridation a top health policy priority and to
push for its adoption. The councils then presented their recommendations
to the local decision making body, in this case the utility district
board, and in end, fluoridation was adopted in all four counties. This
example illustrates how local data might be used in campaigns where a
governing body has jurisdiction over the decision to fluoridate. Brumley
et al. do not speculate about how this method might apply to a situation
in which voters make the decision, but the community diagnosis process
may have some utility in those cases as well.

### Campaign Finance

Another important factor for any campaign is the role of money.
Particularly if an issue is to be decided at the ballot box, a campaign
will need sufficient resources for advertising, and if possible, for
other expenses such as paid staff and research. A sizeable amount of
research has been conducted on the influence of money in referendum and
initiative campaigns (Shockley, 1980; Lydenburg, 1981; Lowenstein, 1982;
Zisk, 1987; Bowler et al., 1992; Cronin, 1989; Magleby, 1984). Several
of these studies have indicated that campaign finances are an extremely
important factor in such elections, frequently determining victory. Many
critics of direct democracy argue that a financial imbalance between
opposing sides of a referendum often leads to an unfair competition at
the polls (Gierzynski, 2000). Zisk's (1987) study of ballot measures in
California, Massachusetts, Michigan, and Oregon is generally consistent
with these reservations. Zisk found that the side with more campaign
funds won 78% of the time. Other authors have discovered a slightly more
nuanced relationship between spending and victory, finding that money is
most important when spent by the side that opposes the ballot measure
(Bowler and Donovan, 1998).

### Ballot Wording

Another campaign specific factor that must be considered when analyzing
referendums is the issue of ballot wording. Studies of fluoridation have
found that proposition wording can affect the likelihood of passage.
According to Boriskin (1979), in many cases, ballot wording is the only
piece of election literature that all voters ever see during a
fluoridation campaign. Thus, the wording becomes both education and
campaign material, and must be "clear in its intent, but also
informative, explaining fluoridation's purposes and benefits" (p. 58).

The case of the 1974 East Bay Municipal Utility District (EBMUD)
referendum in California is instructive. In two previous
elections---both unsuccessful---the proposition's wording read: "Shall
the East Bay Municipal District add fluorine and fluorine compounds to
the water supply of said district?" Besides being inaccurate (fluorine
is a gaseous element, versus fluoride, whose use as a preventative
dental health measure is more familiar to the public), the proposition's
wording contained virtually no information on either the purpose or
benefits of fluoridation. In the successful 1974 campaign, however,
although the proponents were not able to achieve all the wording changes
desired, the wording was updated to use the word "fluoride" instead of
"fluorine," and included the statement "subject to the regulations of
the California State Department of Health" (Boriskin, 1979, p. 58).

Isman (1981) provides another salient example of the importance of
ballot wording, raising issues of clarity and bias. In the 1978 campaign
for the fluoridation of Portland, Oregon's water supply, proponents of
fluoridation voted simply for the "fluoridation of municipal water
supply." In the subsequent 1980 campaign led by antifluoridationists to
repeal the previously successful effort, the proposition read:
"Eliminates mandatory fluoridation of city water" (p. 717). The 1980
proposition passed, eliminating fluoridation in Portland.

According to Isman, two key elements of the ballot wording influenced
the outcomes of the two elections. First, confusion was created in the
latter case because a "no" vote meant voting for fluoridation, and a
"yes" vote was against it. Other authors have argued that propositions
should always be worded so that a positive vote is in favor, and a
negative vote is against the measure (McGuire, 1981; Boriskin, 1979). In
the Portland case, a follow-up survey of three hundred voters revealed a
high level of confusion about how to vote for or against the
proposition. Secondly (as noted previously), the use of the word
"mandatory" in the proposition wording, according to Isman, created a
bias against the measure because of the word's negative connotations.
Promoting the idea that government or administrative measures are being
forced upon the general population is a popular tactic among
antifluoridationists. Obviously, the issue of ballot wording also falls
under the more general issue of message framing.

### Timing

Isman (1981) also mentions another important variable for referendum
campaigns, the timing of an election. Isman feels that fluoridation has
the best chance for success at the polls when turnout is high.
Situations when turnout is low, as with most special elections, "tend to
draw special interest voters who are more likely to vote against
fluoride than for it" (p. 719). Generally, turnout is higher for general
elections than for primaries, and is highest for presidential elections.

### 

# IV. Discussion

As this survey of the literature suggests, the number of potentially
relevant works and perspectives on fluoridation is quite large. The
challenge for the *exploratory research* project will be to identify the
most important factors that influence the success of fluoridation
campaigns and to develop a research design that examines those factors.
This review is the first step in that process.

The table below lists some of the major variables identified in the
literature, grouping them into five categories, structural, elite level,
voter level, campaign communication, and other campaign variables.

######### 

+------------------------+---------------------------------------------+
| #### Tab               |                                             |
| le 4: Potentially Impo |                                             |
| rtant Variables Identi |                                             |
| fied in the Literature |                                             |
+------------------------+---------------------------------------------+
| Structural variables   | Socioeconomic status                        |
+------------------------+---------------------------------------------+
|                        | Structural differentiation                  |
+------------------------+---------------------------------------------+
|                        | Social integration                          |
+------------------------+---------------------------------------------+
|                        | Centralization of authority                 |
+------------------------+---------------------------------------------+
|                        | Social capital                              |
+------------------------+---------------------------------------------+
|                        | Community capacity                          |
+------------------------+---------------------------------------------+
| Elite level variables  | Involvement of health professionals         |
+------------------------+---------------------------------------------+
|                        | Newspaper endorsements                      |
+------------------------+---------------------------------------------+
|                        | Elite endorsements/figurehead               |
+------------------------+---------------------------------------------+
|                        | The nature of policy elite participation    |
+------------------------+---------------------------------------------+
| Voter level variables  | Age/presence of children                    |
+------------------------+---------------------------------------------+
|                        | Alienation, efficacy                        |
+------------------------+---------------------------------------------+
|                        | Trust in government                         |
+------------------------+---------------------------------------------+
|                        | Trust in science in technology              |
+------------------------+---------------------------------------------+
| Campaign communication | Campaign's main communication themes/frames |
| variables              |                                             |
+------------------------+---------------------------------------------+
|                        | Public debates                              |
+------------------------+---------------------------------------------+
|                        | Sandman's risk communication variables      |
+------------------------+---------------------------------------------+
| Diffusion of           | Characteristics of innovation               |
| innovations variables  |                                             |
+------------------------+---------------------------------------------+
|                        | Communication channels                      |
+------------------------+---------------------------------------------+
| Other campaign         | Organization/professionalism                |
| variables              |                                             |
+------------------------+---------------------------------------------+
|                        | Coalition building                          |
+------------------------+---------------------------------------------+
|                        | Research                                    |
+------------------------+---------------------------------------------+
|                        | Campaign finances                           |
+------------------------+---------------------------------------------+
|                        | Ballot wording                              |
+------------------------+---------------------------------------------+
|                        | Election timing                             |
+------------------------+---------------------------------------------+

Campaigns, whether conducted to gain the approval of a governing body or
to win victory among voters, are dynamic, complex events and their
effects are extremely difficult to measure. Nevertheless, in order to
understand how fluoridation campaigns can develop better strategies for
success, it is necessary to understand more about the complex
relationships among the variables affecting success or failure, some of
which are highlighted in this review. Below, in an effort to begin the
process of exploring these relationships, we present a preliminary model
of the communication processes involved in fluoridation referendum
elections.

#### ![](media/image2.wmf){width="5.997916666666667in" height="4.467361111111111in"}Figure 1: Fluoridation Referendum Campaign

In this model, pro- and antifluoridation campaigns attempt to influence
both elites and voters through message framing. Both campaigns also try
to build coalitions among elites and attempt to either alleviate public
concerns about fluoridation or, in the case of antifluoridationists,
increase those concerns. Elites, after being lobbied by both sides,
provide valuable cues to voters, who weigh the information they have
been given and ultimately determine the outcome.

The model for a campaign in which a governing body will decide the
outcome is quite similar. The major difference in this model is that the
message framing, risk communication information, and cues are provided
both to voters and the governing body, under the assumption that
campaigns will want to influence voters because they believe voters will
in turn have influence over the governing body. This linkage between
voters and the governing authority is also represented in the model.[^9]

#### ![](media/image3.wmf){width="5.997916666666667in" height="4.467361111111111in"}Figure 2: Fluoridation Campaign for Governing Body

# V. References

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[^1]: Community water fluoridation is defined as the adjustment of
    fluoride concentration in drinking water to levels optimal for
    preventing caries (i.e. tooth decay).

[^2]: According to Cronin, an "initiative allows voters to propose a
    legislative measure ... or constitutional amendment ... by filing a
    petition bearing a required number of valid citizen signatures" (2).
    Meanwhile, a "referendum refers a proposed or existing law or
    statute to voters for their approval or rejection" (2). In this
    review, consistent with most of the literature on fluoridation, we
    will refer mostly to referendums, although as the project progresses
    we will want to note any significant differences between the
    dynamics of initiative and referendum campaigns.

[^3]: For more on public knowledge of fluoridation, see Gift et al.
    (1994).

[^4]: Also, see the section below on ballot wording.

[^5]: In addition to studies of fluoridation, several studies have
    suggested that alienation explains negative referendum voting in
    general (Horton and Thomson, 1962; Boskoff and Ziegler, 1964),
    although Magleby (1984) casts doubts on these findings.

[^6]: The text in Table 2 is taken verbatim from Park et al. (1990),
    although it does not appear in table format in that article.

[^7]: Note that this may contradict Neenan's statement about older
    citizens' perceptions of fluoridation benefits.

[^8]: A threat is "morally relevant" when it is perceived as so
    threatening that any risk of it occurring is essentially
    unacceptable.

[^9]: Ultimately, the important variables in referendum campaigns and
    campaigns directed at governing authorities may prove to be quite
    different, or may at least operate quite differently in the two
    contexts. This is an issue that will be explored in greater depth in
    the next phases of the research.