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Scaring Up Attention: A Preliminary Overview
of Fear Appeals in DTC Print Advertising and
Suggestions for Enhancing Differentiation

Amy Handlin
Monmouth University

Fear-based appeals are far from dominant in direct-to-consumer advertising for
prescription drugs, but their incidence is not insignificant and appears to be on the
upswing. The author discusses some current uses of this approach and identifies five
opportunities for fear-based brand differentiation: self efficacy, source credibility, copy-
visual congruence, targeting, and message framing.
Marketers have long understood that people can be scared into taking action. More
specifically, fear-based message strategies have been found effective in helping to induce
behavior changes as diverse as quitting smoking; buckling seat belts; not driving when
intoxicated; and using products like smoke alarms and car seats. Thus it is hardly
surprising that fear appeals have begun to show up in direct-to-consumer ads for
prescription drugs. What has greater potential to motivate consumers than fear of dying
or getting seriously ill?
However, research has shown that fear in advertising can be ineffective, even
counterproductive. This paper reviews relevant fear-appeal research, provides an
overview of current fear appeals in DTC print ads, and posits some potential
opportunities for brand differentiation using this type of approach.
Marketers generally agree that fear appeals, or threat messages, are useful in calling
consumers' attention to a message and eliciting emotional arousal. However, it is unclear
exactly what relationship exists between fear arousal and message effectiveness.
Protection Motivation Theory [Rogers 1983; Rippetoe and Rogers 1987] attempts to
explain what happens when fear is aroused. Upon feeling threatened, this theory suggests,
a person will first assess the severity of the danger. Assuming it is judged to be
significant, he will then assess his own ability to respond to it (self-efficacy) and the
likely effectiveness of his response (coping response efficacy). Some studies [Lazarus
and Folkman 1984] have found that fear may enhance an individual's learning of
appropriate and constructive responses to danger.
However, as pointed out by Beck and Frankel [1981], there is a difference between fear control and danger control. A person's response to a threat message can be maladaptive -- in other words, he may act or think in such a way as to feel less afraid without reducing or constructively addressing the danger. Examples of these Maladaptive Coping Responses or MCRs [Rogers 1983; Janis 1986; Rippetoe and Rogers 1987] include defensive rationalization ("I've always smoked and I'm healthy, so why stop now?") or avoidance ("If I wait a few years to have a colonoscopy, there will be a new test and I won't need one.") The challenge for DTC marketers who use fear appeals is to convince consumers of two propositions: first, that the advertised drug is efficacious in responding to a given health threat; and second, that asking their doctor for this drug is the most appropriate and productive way they can address the threat. At the same time, marketers must work against MCRs, which are more likely to develop in the presence of misinformation or feelings of weak self-efficacy [Eppwright 2002] -- for example, if the danger is portrayed in such a way as to make the consumer feel powerless to take effective action, or to suggest that the situation is hopeless no matter what anyone does. MCRs are also more common when consumers are disproportionately influenced by experiential or anecdotal "knowledge" -- unsubstantiated folk wisdom or old wives' tales -- that seems to rebut the premise of the ad [Eppright, Tanner and Hunt 1994]. This would be the case, for instance, among cardiac patients who believe that practicing yoga is the only way to avert a second heart attack; or among cancer patients convinced that their only hope for recovery is a macrobiotic diet. Many scholars believe that the relationship between fear arousal and message persuasiveness has an inverted U shape. In other words, a relatively low degree of fear appears in most cases to enhance persuasion; but a high degree of fear may have the opposite effect [Ray and Wilkie 1970; Janis 1967]. It is suggested that the factors of self-efficacy and coping response efficacy operate by mediating between fear arousal and message effect. Additionally, research suggests that the persuasiveness of fear appeals is influenced by source credibility. While source characteristics can be important determinants of effectiveness of many types of advertising, this factor appears to be especially salient when the message is based on a threat. In the presence of low source credibility, there is an enhanced likelihood that the receiver will discount or ignore the threat [Chapman 1992]. THE USE OF FEAR IN DTC ADS: GENERAL OBSERVATIONS The author reviewed a convenience sample of 60 DTC print ads randomly drawn from four of the highest circulation national women's magazines during a two year period (2005-2007, with 30 ads selected from each year). The magazines included Family Circle, Woman's Day, Good Housekeeping and Ladies Home Journal. This review suggested the following observations: 1. Fear appeals/threat messages did not dominate DTC print ads during the two year period. They were identified in 20% (12 out of 60) of the sample ads. However, this is a large enough minority to warrant attention. 2. The number of fear appeals rose over time, from a total of nine during 2005-2006 to a total of 12 during 2006-2007 (the original nine were repeated, while three more fear appeals were new in the second year). This suggests that their use may be on the upswing. 3. Fear appeals were not limited to drugs for one disease category or type of health condition. Among the products touted in the sample ads were some to reduce cholesterol; treat acid reflux disease; reduce the incidence of breast cancer; lessen the symptoms of Alzheimer's; and prevent bacterial meningitis. 4. Fear appeals vary. In the ads reviewed, the most common threat (in 5 out of 12 ads) was heightened vulnerability to disease or to complications from that disease. Other threats included failure to heal/recover; more debilitating symptoms; and not doing enough to help a loved one prevent or recover from illness. 5. Both positive and negative framing are used in fear appeal ads. In other words, some emphasize the positive benefits of using an advertised product (e.g. "Help prevent another heart attack") while others emphasize the adverse consequences of failing to use it ("In just 24 hours, meningococcal meningitis can claim the life of a child.") 6. The degree of fear is consistently high across DTC ads based on fear. This is unsurprising, given the serious nature of the health conditions addressed in these ads. 7. As a function of FDA requirements, all DTC ads -- including those based on threat messages -- are straightforward, in both form and substance, in stating what the products do and what possible side effects they may have. FIVE OPPORTUNITIES FOR DIFFERENTIATION Because of the FDA-enforced uniformity of DTC ads in terms of information disclosure and support for product claims, there is little opportunity for differentiation among fear appeals based primarily on response efficacy. However, there are at least five opportunities to enhance the impact of the messages in these ads. Self Efficacy Given the link between self efficacy and MCRs, it is notable that self efficacy is addressed to differing degrees across DTC ads. Some already use language that can help strengthen and reinforce self efficacy. These ads emphasize how and why the consumer can, by taking the called-for action -- asking one's doctor for a prescription -- reduce a relevant danger. There are explicit warnings that failure to act can have serious adverse consequences. Here are three examples: 1. An ad for Menactra, a meningitis vaccine, suggests that a parent can save a child's life by asking their doctor for this product. 2. An ad for the cholesterol-lowering medication Crestor tells consumers that if they control their diet and take the advertised product, they can slow the progression of atherosclerosis (buildup of plaque in the arteries) and head off life-threatening disease. 3. The fear appeal for Evista, a treatment for osteoporosis, is that women at risk for that condition may also be at risk for invasive breast cancer. The ad states that by taking Evista, "You can address two major health concerns with one medicine." Other threat-based DTC ads can do more to specifically address self efficacy. For example, some point out simply that the advertised brand is "FDA approved" and/or "clinically proven." These may be important product attributes, but they will not necessarily convince a consumer that asking for a prescription is the strongest action she can take. Other ads seem to take self efficacy for granted, with no explicit recognition that patients might choose to try a non-pharmaceutical product -- or to do nothing. Source Credibility Threat messages emanate from the same types of sources as most other messages in DTC ads. Either anonymous patients or unidentified, white-coated health care providers are pictured as delivering the news, good or bad. Thus there may be opportunities to boost message salience by utilizing higher-credibility sources. A health threat may be both more attention-getting and more believable if delivered by an authority or personality whom the target consumer knows and trusts. Such sources could include noted disease researchers; authors of relevant health books; public health officials; or even celebrities who have benefited from the brand. Copy-Visual Congruence Intentionally or otherwise, some fear appeal ads convey mixed messages. While the body copy in these ads effectively describes a significant, even imminent danger, the visuals then mitigate its impact with upbeat, attractive, non-threatening imagery. Where such incongruence exists, it may encourage MCRs -- specifically, an avoidance response ("It sounds scary, but it doesn't look so bad."). DTC advertisers may be better served by visuals that serve to clarify and reinforce a threat message, even at the risk of making some readers anxious or uncomfortable. As concluded by Chapman [1992]: "If a high level of fear is suggested, then the threat stimuli (language and/or pictures) should be graphic and explicit." Another way to reinforce a threat message is to directly acknowledge and refute misinformation likely to lead to MCRs. For example, an introductory ad for Merck's chicken pox vaccine explicitly addressed the common misperception that chicken pox is a relatively harmless nuisance; in reality, it is a potentially serious disease. Targeting As indicated above, the fear appeal ads reviewed by the author appeared in national women's magazines, with circulations well over a million. Thus it can be assumed that these ads were designed for a general audience segmented only by gender and, to a lesser extent, age. This segmentation strategy makes sense in light of considerable evidence that middle aged and older women are the primary health care decision-makers and consumers for themselves and their families [Handlin 2007]. However, some research suggests that high levels of fear in an advertising message are most compelling when the message is targeted to subpopulations most susceptible to the particular fear -- and that it is possible to identify such subpopulations. For example, in an early study of direct mail promotions used by a health maintenance organization, Burnett and Oliver [1979] found that a fear-based promotion was 90% more effective when sent to specially identified segments than when mailed to the entire universe of prospects. Similarly, DTC advertisers who choose a threat message may enhance the sales impact by targeting an audience that is limited in size but more receptive to such messages than a general drug audience. Comprehension researchers have demonstrated that people interpret new information by attempting to fit it into a rational framework of preexisting attitudes and knowledge, called a schema. Among the total population of prospects for a particular drug, there are likely to be some with a schematic predisposition to respond appropriately to threat messages -- and conversely, some who are likely to react with MCRs. For example, a threat message about high cholesterol would probably elicit a different response from a woman with a family history of heart disease than from the average reader of Family Circle or Good Housekeeping. Before deciding to invest in a fear appeal ad for a mass market, DTC marketers should obtain attitudinal profiles of the target audience which may lead them in another, more differentiated direction. Message Framing Recent research has tested the effects of positive vs. negative framing on the persuasiveness and comprehension of DTC advertising [Handlin 2002]. While this research did not separate fear appeals from others, it found that DTC ads in general were more persuasive when positively framed -- specifically, when the drug's benefits were characterized as a gain rather than as aversion of a loss. There is also some evidence that the influence of framing is strongest when the message presents consumers with a choice among alternatives, each of which carries a degree of risk [Arora 2000]. Earlier studies of framing in the general area of health-related products and services
have been inconclusive [for examples of conflicting results, see Meyerowitz and Chaiken
1987, Trieber 1986]. Also, from a practical perspective, there may not always be an
obvious way to change the frame of a message. For instance, obtaining a vaccine is, by its
very nature, a means of averting disease (negative framing). However, communications
research could help identify effective new approaches, such as presenting the same
vaccine as a means of strengthening the body's natural defenses.
The purpose of this paper is to draw attention to and stimulate research questions
about fear appeals in DTC advertising. While far from ubiquitous, these appeals are
likely to multiply in the increasingly competitive drug marketplace. There are several
promising opportunities to improve fear-based brand differentiation, and to deepen DTC
marketers' understanding of how consumers react to threat messages.
More broadly, it is clear that this topic is ripe for further study. It offers compelling
new applications of existing fear appeal models, as well as potential to help extend the
models. At least two future studies could advance both application and theory: a
comparative test of positive vs. negative framing as used to deliver threat messages, and a
market segmentation study of attitude profiles associated with receptivity to fear appeals
in drug ads.

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Health Marketing Quarterly 18 (1/2), 29-43.
2. Beck, K. and A. Frankel (1981), "A Conceptualization of Threat Communications and
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3. Burnett, J. and R. Oliver (1979), "Fear Appeal Effects in the Field: A Segmentation
Approach," Journal of Marketing Research 16 (May), 181-190.
4. Chapman, K. (1992), "Fear Appeal Research: Perspective and Application,"
Proceedings of the AMA Summer Educators' Conference, 1-9.
5. Eppright, D. J. Tanner and J. Hunt (1994), "Knowledge and the Ordered Protection
Motivation Model: Tools for Preventing AIDS," Journal of Business Research 30 (1), 13-
6. Eppright, D., J. Hunt, J. Tanner and G. Franke (2002), "Fear, Coping and Information:
A Pilot Study on Motivating a Healthy Response," Health Marketing Quarterly 20 (1),
7. Handlin, A. (2007), "Gendered Opportunities to Enhance Direct-to-Consumer
Advertising of Gender-Neutral Pharmaceutical Brands," The Business Review,
7(1), 33-37.
8. Handlin, A. (2002), "The Effect of Message Framing on Persuasion and Comprehension of Direct-to-Consumer Advertising: An Exploratory Test," Proceedings of the 2002 Atlantic Marketing Association Annual Conference. 9. Janis, I. (1986), "Coping Patterns Among Patients with Life-Threatening Diseases," in C.D. Spielberger and I.G. Sarason, eds., Stress and Anxiety Vol. 10, Hemisphere: Washington DC, 461-476. 10. Janis, I. (1967), "Effects of Fear Arousal on Attitude Change: Recent Developments in Theory and Experimental Research," in L. Berkowitz (ed.), Advances in Experimental Social Psychology, Academic Press: New York, 166-224. 11. Lazarus, R. and S. Folkman (1984), Stress, Appraisal and Coping, Springer: NY. 12. Meyerowitz, B. and S. Chaiken (1987), "The Effect of Message Framing on Breast Self Examination Attitudes, Intentions and Behavior," Journal of Personality and Social Psychology 52, 500-510. 13. Ray, M. and W. Wilkie (1970), "Fear: The Potential of an Appeal Neglected by Marketing," Journal of Marketing 34, 54-62. 14. Rippetoe, P. and R. Rogers (1987), "Effects of Components of Protection Motivation Theory on Adaptive and Maladaptive Coping With a Health Threat," Journal of Personality and Social Psychology 52, 596-604. 15. Rogers, R. (1983), "Cognitive and Physiological Processes in Fear Appeals and Attitude Change: A Revised Theory of Protection Motivation," in J. Cacioppo and R. Petty (eds.), Social Psychophysiology, Guilford: NY 153-176. 16. Trieber, F. (1986), "A Comparison of Positive and Negative Consequences: Approaches to Car Restraint Usage," Journal of Pediatric Psychology 11, 15-24.


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