Case Study 01: The Surgeon General's Advisory on Soc...

Background

On May 23, 2023, US Surgeon General Vivek Murthy issued an advisory titled "Social Media and Youth Mental Health," marking the first time the nation's top public health official had formally warned about the potential hazards of social media for young people. The advisory came two years after Murthy had issued an advisory on the youth mental health crisis broadly, which identified the COVID-19 pandemic as a major contributor. By 2023, the focus had sharpened: Murthy argued that social media represented a "profound risk of harm" to adolescent mental health that required immediate attention from parents, policymakers, technology companies, and society at large.

The advisory was not a formal regulatory action—Surgeon General advisories carry no legal force. Rather, they represent the highest form of public communication available to the office: a formal declaration, based on the Surgeon General's review of available evidence, that a public health risk warrants attention. The precedents were significant: Surgeon General advisories have preceded policy changes on tobacco, alcohol during pregnancy, and the dangers of HIV. The choice to issue an advisory on social media signaled that Murthy believed the evidence had crossed a threshold that warranted public health action, even if that evidence fell short of scientific certainty.

The advisory represented a notable choice given the contested nature of the evidence. Many researchers, as Chapter 30 documents, argued at the time that the causal evidence for social media's harms was still developing and that confident public statements about harm were premature. Murthy's decision to proceed anyway reflected a judgment about when precautionary public health action is appropriate even in conditions of uncertainty—a judgment that other researchers, notably Orben and Przybylski, disputed.

Timeline

2021 (October): The Wall Street Journal publishes the "Facebook Files" series, including reporting on internal Facebook research finding that Instagram was "toxic" for a significant minority of teenage girls. Congressional hearings follow. Public and political attention to social media and teen mental health intensifies sharply.

2021 (December): Surgeon General Murthy issues an advisory on youth mental health, identifying COVID-19 as a primary driver but noting that the youth mental health crisis predated the pandemic and that social media played a role. This advisory was broader and does not focus specifically on social media.

2023 (January): A group of state attorneys general (later expanding to 41 states) announces investigations into whether social media platforms have violated consumer protection laws by harming the mental health of young users. This represented a significant escalation of legal pressure on the industry.

2023 (May): Murthy issues the dedicated social media advisory. The document reviews the available evidence on social media and youth mental health, identifies areas of concern, and makes specific recommendations to parents, policymakers, and technology companies. Critically, the advisory acknowledges that existing evidence "does not yet allow us to conclude definitively that social media is sufficient to cause mental illness in youth," while still calling for precautionary action.

2023 (June): Congressional response accelerates. Multiple bills targeting social media and youth safety are introduced, including the Kids Online Safety Act (KOSA) and the COPPA 2.0 bill seeking to update children's online privacy laws. None pass in 2023 but they signal legislative direction.

2023 (September): Meta announces several teen safety features, including automatic application of stricter privacy settings for teen accounts and new tools to limit contact from unknown adults. Critics characterize these as responsive to regulatory pressure rather than a fundamental change in business model.

2024 (January): Murthy testifies before the Senate Judiciary Committee alongside CEOs of Meta, TikTok, Snap, Discord, and X. The hearing features confrontational exchanges between senators and executives, with Murthy's advisory serving as the primary public health evidence base.

2024 (January): Murthy calls for warning labels on social media platforms analogous to cigarette warning labels, arguing that such labels would "remind parents and adolescents that social media has not been proven safe."

Analysis: What the Advisory Said and Didn't Say

The 2023 advisory was notable for its careful calibration of evidentiary claims. Unlike media reporting that often asserted clear causal relationships, the advisory repeatedly acknowledged uncertainty while still recommending precautionary action. Key claims included:

What the advisory claimed with confidence: That adolescent mental health had deteriorated significantly since 2010; that social media use was associated with poorer mental health outcomes in numerous studies; that social media use was associated with sleep disruption, exposure to harmful content, and cyberbullying; that certain groups (particularly girls, LGBTQ+ youth, and those with pre-existing mental health vulnerabilities) appeared to be at elevated risk.

What the advisory carefully avoided claiming: That social media definitively caused mental health problems; that all social media use was harmful; that there were no benefits to social media for young people.

What the advisory recommended: That Congress pass legislation protecting children from online harms, including age-appropriate health and safety standards; that tech companies implement safety by design principles, including default privacy settings for minors and restrictions on features known to increase compulsive use; that parents work to delay social media introduction, maintain phone-free times and zones, and model healthy device use; that adolescents be educated about social media's risks and encouraged to seek support if feeling depressed.

The advisory's framing around the analogy to tobacco was rhetorically powerful and epidemiologically contested. Murthy argued that we should not wait for certainty before acting on a plausible public health risk—the same reasoning applied to tobacco regulation before randomized controlled trials were possible. Critics of this framing argued that tobacco presented a more straightforward risk-benefit calculation (no known benefits of smoking; clear dose-dependent relationship with lung cancer) while social media presents genuine benefits alongside potential harms, making the precautionary principle harder to apply.

Using Chapter Concepts: The Evidence Gap

The Surgeon General's advisory illustrates a fundamental tension described throughout Chapter 30: the gap between what the scientific evidence shows and what policymakers, parents, and the public want to know.

The evidence shows: correlations between social media use and mental health problems; experimental evidence of some effects in some populations; plausible mechanisms; a gender-differentiated pattern consistent with those mechanisms; and internal corporate evidence of harm. This evidence is real, suggestive, and concerning.

What the evidence does not show with certainty: that reducing social media use will improve adolescent mental health at the population level; that any specific platform feature is causally responsible for harm; that the benefits of social media access do not outweigh the risks for the majority of adolescents.

Murthy's advisory chose to prioritize the precautionary principle: act on plausible risks before certainty is established, particularly when the population at risk (children and adolescents) is a vulnerable one. This is a defensible public health posture but represents a value judgment, not purely a scientific one.

The advisory also illustrates the "asymmetry of power" theme in this textbook. When a Surgeon General issues a formal advisory, the implicit recommendation is action—delay social media, restrict use, implement protective measures. But the harms of action (reducing access to online communities for isolated adolescents, including LGBTQ+ youth) are less visible and less politically salient than the harms of inaction (teen girls with depression and eating disorders). Public health communications that do not give equal weight to both types of potential harm may inadvertently cause their own damage.

What This Means for Users

For young people and their parents, the Surgeon General's advisory has several practical implications that navigate the evidence gap honestly.

Takeaway 1: The advisory's practical recommendations are more defensible than its causal framing. Protecting sleep, maintaining screen-free times and spaces, and maintaining honest communication about social media experiences with teenagers are practices supported by evidence independent of whether social media causes depression.

Takeaway 2: Individual context matters. The advisory correctly identifies LGBTQ+ youth as a group for whom social media may provide crucial community. Blanket restrictions applied without attention to individual circumstances may harm this group. Parents and teens should consider whether social media serves as a primary or significant source of social support for a particular individual before implementing restrictions.

Takeaway 3: The advisory reflects a legitimate public health posture, not a finding of definitive harm. Understanding that the advisory is a precautionary recommendation rather than a scientific verdict helps users interpret it appropriately. It is a reason to pay attention to one's social media use and its effects, not proof that any particular platform has caused any particular harm.

Takeaway 4: Corporate responses to the advisory may be inadequate. Meta's announcement of teen safety features in response to regulatory pressure, without fundamental changes to engagement-maximizing algorithms, illustrates a pattern of symbolic rather than substantive response. Users and policymakers should evaluate corporate safety measures against the specific mechanisms of harm identified in research rather than accepting them at face value.

Discussion Questions

The Surgeon General chose to issue an advisory about social media despite acknowledging the evidence did not "definitively" establish causation. Under what conditions is it appropriate for public health officials to take precautionary positions on contested evidence? What risks are associated with being too cautious, and with being too bold?
The tobacco analogy features prominently in discussions of social media and youth mental health. In what ways is social media analogous to tobacco as a public health issue? In what ways is the analogy misleading or inappropriate?
The advisory identified specific vulnerable groups (girls, LGBTQ+ youth, those with pre-existing mental health conditions). Should public health guidance about social media be targeted to these groups, or should it apply universally? What are the implications of each approach?
The advisory recommended that tech companies implement "safety by design" principles. What specific design changes do you think are most evidence-supported? Which of Murthy's recommendations to tech companies could be implemented without fundamentally changing the platforms' business models?
If you were advising the Surgeon General on a follow-up advisory in 2025, what new evidence would you want to cite? What gaps in the current evidence base are most important to fill, and how would you fill them?

Case Study 01: The Surgeon General's Advisory on Social Media and Youth Mental Health (2023)