What is the truth an application of the

This art icle was downloaded by: [ Universit y of I llinois at Urbana- Cham paign] On: 02 Sept em ber 2013, At : 19: 19 Publisher: Rout ledge I nform a Lt d Regist ered in England and Wales Regist ered Num ber: 1072954 Regist ered office: Mort im er House, 37- 41 Mort im er St reet , London W1T 3JH, UK Health Communication Publicat ion det ails, including inst ruct ions f or aut hors and subscript ion inf ormat ion: ht t p: / / www t andf online com/ loi/ hht h20 What Is the Truth? An Application of the Extended Parallel Process Model to Televised Truth® Ads Nicole R LaVoie a & Brian L Quick a a Depart ment of Communicat ion, Universit y of Illinois at Urbana–Champaign Published online: 18 Jan 2013 To cite this article: Nicole R LaVoie & Brian L Quick (2013) What Is t he Trut h? An Applicat ion of t he Ext ended Parallel Process Model t o Televised Trut h® Ads, Healt h Communicat ion, 28: 1, 53-62, DOI: 10 1080/ 10410236 2012 728467 To link to this article: ht t p: / / dx doi org/ 10 1080/ 10410236 2012 728467 PLEASE SCROLL DOWN FOR ARTI CLE Taylor & Francis m akes every effort t o ensure t he accuracy of all t he inform at ion ( t he “ Cont ent ” ) cont ained in t he publicat ions on our plat form However, Taylor & Francis, our agent s, and our licensors m ake no represent at ions or warrant ies what soever as t o t he accuracy, com plet eness, or suit abilit y for any purpose of t he Cont ent Any opinions and views expressed in t his publicat ion are t he opinions and views of t he aut hors, and are not t he views of or endorsed by Taylor & Francis The accuracy of t he Cont ent should not be relied upon and should be independent ly verified wit h prim ary sources of inform at ion Taylor and Francis shall not be liable for any losses, act ions, claim s, proceedings, dem ands, cost s, expenses, dam ages, and ot her liabilit ies what soever or howsoever caused arising direct ly or indirect ly in connect ion wit h, in relat ion t o or arising out of t he use of t he Cont ent This art icle m ay be used for research, t eaching, and privat e st udy purposes Any subst ant ial or syst em at ic reproduct ion, redist ribut ion, reselling, loan, sub- licensing, syst em at ic supply, or dist ribut ion in any form t o anyone is expressly forbidden Term s & Condit ions of access and use can be found at ht t p: / / www.t andfonline.com / page/ t erm s- and- condit ions Health Communication, 28: 53–62, 2013 Copyright © Taylor & Francis Group, LLC ISSN: 1041-0236 print / 1532-7027 online DOI: 10.1080/10410236.2012.728467 What Is the Truth? An Application of the Extended Parallel Process Model to Televised Truth® Ads Downloaded by [University of Illinois at Urbana-Champaign] at 19:19 02 September 2013 Nicole R LaVoie and Brian L Quick Department of Communication University of Illinois at Urbana–Champaign The purpose of this study was to analyze television ads in the truth® campaign using the Extended Parallel Process Model (EPPM) as a framework Among the ads (n = 86) analyzed, results revealed a heavy reliance on severity messages, modest attention to susceptibility messages, and no inclusion of recommended response messages in the form of self-efficacy and response efficacy The reliance on emphasizing the health threat, without incorporating recommended response messages, is discussed with respect to the likelihood of galvanizing maladaptive responses such as psychological reactance, denial, and defensive avoidance resulting from exposure to these ads Additionally, the unintended outcomes for secondary audiences including but not limited to stigma are considered Implications and suggestions for practitioners and theorists are explored Tobacco smoking is a costly health behavior, both for individuals who smoke and for the broader community who pays for tobacco-related disease According to the World Health Organization (WHO, 2011a), smoking is the number one contributor to preventable death in the world Further, for the United States alone, the financial cost associated with these preventable diseases is estimated at $193 billion per year (Centers for Disease Control and Prevention [CDC], 2011) Despite these rising health costs, however, 26.4% of U.S adults above the age of 15 years currently smoke, and 15.7% of adults report daily cigarette smoking (WHO, 2011b) On a positive note, smoking prevalence has decreased over the last decade or so Among ninth to 12th graders, for example, smoking decreased from 35% in 1999 to 20% in 2009 (CDC, 2011; National Center for Health Statistics [NCHS], 2011) The percentage of adult smokers declined, as well, from 1999 to 2004, although smoking prevalence among this age group has since begun to increase again (CDC, 2011; NCHS, 2011) Many factors could be, and often have been, cited as contributing to the overall decline in smoking in the United States, including education, better understanding of Correspondence should be addressed to Brian L Quick, Department of Communication, University of Illinois at Urbana–Champaign, 244 Lincoln Hall, MC-456, 702 S Wright Street, Urbana, IL 61801 E-mail: bquick@uiuc.edu addiction, antismoking policies, and tax increases Additionally, the contributions of antismoking campaigns and media efforts are certainly important and are our primary interest here Numerous studies have been conducted on the effectiveness of a variety of smoking prevention and cessation campaigns and advertisements (e.g., Davis, Farrelly, Messeri, & Duke, 2009; Davis, Nonnemaker, & Farrelly, 2007; Flay, 1987; Mudde & De Vries, 1999; Niederdeppe, Fiore, Baker, & Smith, 2008; Siegel & Biener, 2000; Wakefield et al., 2006) However, as far as antismoking campaigns are concerned, one in particular has received the lion’s share of attention The truth® campaign, launched in 2000, is a national tobacco prevention effort that educates the public with facts about smoking consequences and “Big Tobacco.” The campaign has received much praise, and numerous studies have been conducted to analyze its effectiveness (e.g., Cowell, Farrelly, Chou, & Vallone, 2009; Farrelly, Davis, Duke, & Messeri, 2008; Farrelly, Nonnemaker, Davis, & Hussin, 2009; Richardson, Green, Xiao, Sokol, & Vallone, 2010) However, surprisingly few studies have systematically examined the content embedded within these specific ads Previous analysis of smoking prevention and cessation message features and theories has included numerous theoretical frameworks, such as the stages of change model (DiClemente & Prochaska, 1985), prospect theory Downloaded by [University of Illinois at Urbana-Champaign] at 19:19 02 September 2013 54 LAVOIE AND QUICK (e.g., Toll et al., 2007), the activation model of information exposure and sensation seeking (e.g., Helme, Donohew, Baier, Zittleman, 2007; Niederdeppe, Davis, Farrelly, & Yarsevich, 2007), message tailoring (e.g., Rimer & Kreuter, 2006), and the limited capacity model of motivated media message processing (Leshner, Vultee, Bolls, & Moore, 2010) Given that the truth® ads present the uncensored truth of the health costs associated with smoking using unparalleled vivid language and images, however, we elected to employ the Extended Parallel Process Model (EPPM) (Witte, 1992) to better understand the content within these televisions ads In understanding what makes a fear appeal effective, we turn to the EPPM (Witte, 1992) EXTENDED PARALLEL PROCESS MODEL With respect to the various discrete emotions to arouse when creating health ads, few appear as often as fear appeals In examining the effectiveness of fear appeal messages, Witte’s (1992) model represents the most sophisticated framework as it draws from Leventhal’s (1970) parallel process model and Rogers’s (1975) protection motivation theory Together, Witte (1992) asserts that viewers will strive to control their fear or the danger presented in a fear-appeal message depending on which messages are communicated (Witte, 1994) In the following, we briefly review Witte’s model by identifying the key message features included in fear appeals, the central hypotheses to the EPPM, and the literature using Witte’s model as a framework A successful fear-appeal message will communicate both the health threat and the recommended response (Roberto, Murray-Johnson, & Witte, 2011) The health threat conveys the danger to which the message seeks to admonish Fear appeals failing to communicate the threat will be dismissed by most viewers as nonsignificant The threat component of the EPPM can be bifurcated into two message features: severity and susceptibility Severity refers to the threat’s magnitude, whereas the latter communicates the likelihood of experiencing the health costs associated with the admonished behavior (Witte, 1992) Susceptibility, on the other hand, emphasizes that the health threat could happen to a person who engages in the behavior Together, the combination of severity and susceptibility creates an overall assessment of the magnitude of the threat, thereby arousing fear Once message recipients appraise the threat, they proceed to consider the recommended response (Witte, 1992) The second step of message appraisal is of extreme importance in the mediation of an audience’s ultimate reaction (Witte, 1992) Thus, the EPPM cautions health campaigners against communicating the threat without highlighting the recommended response (Witte, 1992) Like the health threat, the recommended response features two specific message features—self-efficacy and response efficacy Selfefficacy refers to the message recipient’s perception that the recommendation is something that he or she is capable of carrying out (Stephenson & Witte, 2001; Witte, 1992) Response efficacy, then, is the recipient’s perception that the recommended response will effectively reduce or eliminate the threat (Witte, 1992) For example, messages modeling the advocated behavior communicate self-efficacy, whereas attention to the positive health outcomes of not smoking would communicate response efficacy Following exposure to a fear-appeal message, three distinct types of message processing can occur (Roberto et al., 2011) First, if the message is evaluated as being of little or no personal threat, message processing ceases, and results in no motivation to change a behavior However, if the message is appraised as communicating a health threat, a recipient is likely to experience fear, which results in fear-control processing (Stephenson & Witte, 2001; Witte, 1992) Fear-control processing results in a number of maladaptive responses such as defensive avoidance, denial, perceived manipulation, and psychological reactance Third, messages communicating both the health threat and the recommended response will result in danger-control processing (Stephenson & Witte, 2001; Witte, 1992) Danger-control processing leads to a protection motivation and results in beliefs, attitudes, intentions, and behaviors consistent with the advocated message Danger-control processing is considerably more likely to occur when perceived efficacy exceeds the perceived health threat (Witte & Roberto, 2009) Research spanning more than two decades supports EPPM predictions (for a systematic review of this literature, see Roberto et al., 2011; Witte & Allen 2000); therefore, practitioners should be cognizant of the importance of communicating both the health threat and recommended response to ensure that perceived efficacy outweighs the perceived threat in order to elicit danger-control processing (Witte & Roberto, 2009) The EPPM has been examined in a variety of health contexts, such as messages regarding HIV/AIDS (e.g., Witte, 1994, 1998; Witte & Morrison, 2000), meningitis (Gore & Bracken, 2005), cardiovascular disease (Rimal, 2001), sexually transmitted diseases (STDs) and pregnancy (e.g., Roberto, Zimmerman, Carlyle, & Abner, 2007), hearing loss for coal miners (Murray-Johnson et al., 2004), and various cancers (Hubbell, 2006; Kline & Mattson, 2000; Morman, 2000; Stephenson & Witte, 1998) Additionally, the EPPM has been used as a framework for other preventative behaviors including gun safety (Roberto, Meyer, Johnson, & Atkin, 2000) and self-defense (Morrison, 2005) The EPPM, as a design strategy for fear appeals, seems to be widely applicable to a number of dangerous behaviors but, interestingly, its utility for the theoretical analysis of message features and mechanisms has been rarely applied to antitobacco campaigns Downloaded by [University of Illinois at Urbana-Champaign] at 19:19 02 September 2013 APPLICATION OF THE EPPM TO TELEVISED TRUTH® ADS There has been a long history of criticism and resistance to using fear appeals to persuade health behavior change, especially within the context of smoking (Hill, Chapman, & Donovan, 1998) Despite this, however, many smoking prevention and cessation ads arouse fear, with the intention of increasing smokers’ sense of urgency to quit (Hill et al., 1998) Scare tactics, thus, have made their way into the norm of mainstream health messages, especially with respect to tobacco use Although fear appeals seem to abound within the antismoking movement, few studies examine these ads within the framework of the EPPM Smith and Stuts (2003) examined the effectiveness of emphasizing long- and short-term costs of smoking among adolescents and found smoking behavior declined following message exposure, regardless of message type More recently, Wong and Cappella (2009) used the EPPM to predict smokers’ intentions to seek help In addition to discovering a threat by efficacy interaction consistent with the EPPM predictions, they discovered a three-way threat by efficacy by readiness to quit interaction, such that efficacy was the most important dimension for those high in readiness, but that both threat and efficacy were equally important for those low in readiness (Wong & Cappella, 2009) Although these few studies are informative from a message design standpoint, little has been done by way of analyzing the message features unique to the EPPM within existing televised antismoking ads Other scholars have examined antismoking message features such as emotional content (Davis, Nonnemaker, Farrelly, & Niederdeppe, 2011; Leshner et al., 2010), stylistic features such as cuts and vividness (Niederdeppe et al., 2007), and perceived vulnerability (Shadel et al., 2006) However, the message components of the EPPM have not been systematically analyzed Moreover, considering the threatening consequences of smoking, it is interesting that the EPPM has not enjoyed greater popularity as a theoretical lens through which to assess antitobacco messages One such movement that offers a plethora of televised messages communicating the dangers of smoking is the truth® campaign THE TRUTH® CAMPAIGN The truth® campaign is the first and only national antismoking campaign which is not sponsored by the tobacco industry Introduced more than a decade ago, the truth® campaign has become increasingly recognizable, not only as a campaign, but as a brand Designed by the American Legacy Foundation as a countermarketing effort, truth® is a prevention campaign aimed at American adolescents between the ages of 12 and 17 years (American Legacy Foundation [ALF], 2012) According to the American Legacy Foundation, truth® “exposes the tactics of the tobacco industry, the truth about addiction, and the health effects and social consequences of smoking it 55 works by allowing teens to make their own informed choices about tobacco use” (ALF, 2012) The campaign has included television ads, print ads, interactive websites, and apps for social networking sites Further, it has had variously themed “subcampaigns” over the years, such as “Infect truth,” “The Sunny Side of truth,” and “Crazyland” (truth® , 2012) Researchers and public health organizations, alike, have lauded the success of the truth® campaign According to several studies, truth® has been successful in lowering teen intentions to smoke, increasing positive antitobacco attitudes and beliefs, and even reducing peer smoking prevalence perceptions (Cowell et al., 2009; Davis et al., 2009; Davis et al., 2007; Farrelly et al., 2008) Furthermore, some research cites this nationwide campaign as contributing to reductions in teen smoking For example, Farrelly et al (2005) found that a 2-year exposure to truth® resulted in a 22% decrease in teen smoking from 1999 to 2002 A more recent study by Farrelly, Nonnemaker, Davis, and Hussin (2009) supports earlier findings, citing that exposure to the truth® campaign had an independent effect on the reduction of smoking initiation among teens, beyond many other individual-, family-, and community-level influences Other supporting health agencies including the Institute of Medicine (2007) have also proffered their support of the truth® campaign, while other research has found truth® to be cost-effective and to have dramatic economic impacts when campaign cost is weighed against savings in health care expenditures (Holtgrave, Wunderink, Vallone, & Healton, 2009) However, it is important to note that although the truth® campaign, or others like it, may promote decreases in smoking among adolescents, it is not the only contributing factor The truth® campaign undeniably takes a unique approach to promoting smoking prevention, especially in contrast to tobacco sponsored prevention messages such as the Phillip Morris campaign “Think Don’t Smoke,” which has been shown to potentially lead to boomerang effects among youth (Davis et al., 2009; Farrelly et al., 2008) The ALF claims that the aim of truth® is not to judge anyone or to be “antismoker” or “antismoking,” but to provide facts about smoking and the tobacco industry (ALF, 2012; truth® , 2012) Its various subcampaigns each have a different “feel” and strategy for delivering the facts about smoking However, by nature of the potentially severe consequences of tobacco use, audiences may feel fearful when exposed to these messages, regardless of the subcampaign or the intention of the campaign designers Further, although the campaign is intended to promote prevention among youths, its audience is broad, by nature of its nationally televised ads, and often includes older viewers and smokers (Richardson et al., 2010) Following the guidance of the EPPM, this study is designed to analyze the specific message features presented in truth® ads for television That is, are truth® ads consistent with EPPM maxims in communicating both the health threat and recommended response? 56 LAVOIE AND QUICK METHOD Downloaded by [University of Illinois at Urbana-Champaign] at 19:19 02 September 2013 Sampling and Procedures The current investigation examined truth® ads for television These ads were obtained via extensive Internet searches Specifically, because the desired ads were television commercials, YouTube and Google Video were the two primary search engines used In both of the search engines, the following phrases and combinations of phrases were entered: “truth campaign,” “American Legacy Foundation,” “truth,” “smoking,” “antismoking,” “antitobacco,” “big tobacco,” “commercials,” “television,” “advertisements,” and “videos.” Because videos are often posted and reposted online, each video was reviewed by one of the authors to confirm its originating organization, truth® or the ALF Advertisements were included for analysis if (a) they were produced by the ALF or truth® , (b) were complete (e.g., were not cut off), and (c) were of adequate visual and audio quality to code All truth® commercials meeting these criteria were coded, regardless of the subcampaign or production year As ads were located and verified, they were compiled into a document and each video’s working title, length, and URL were recorded This process was repeated until each subsequent search in Google or YouTube failed to produce any new advertisements, regardless of the combination of search terms.1 As with any content analysis project, an important question pertains to the unit of analysis Neuendorf (2002) refers to a unit of analysis as “an identifiable message or message component, (a) which serves as the basis for identifying the population and drawing a sample, (b) on which variables are measured, or (c) which serves as the basis for reporting analysis” (p 71) Each ad represented a unit of analysis for this investigation The final sample consisted of 86 different truth® television advertisements ranging in length from 30 seconds to minutes Two coders were extensively trained by the authors on the four primary message components of the EPPM including both the health threat (severity and susceptibility) and recommended response (self-efficacy and response efficacy) After adequate training of these four message components was achieved, the coders independently coded approximately 25% of the messages (Lombard, Snyder-Dutch, & Bracken, 2002) The intercoder reliabilities were calculated prior to resolving disagreements among the coders Reliability between coders was calculated using simple agreement as well as Brennan and Prediger’s (1981) kappa Brennan and Prediger’s kappa was selected over Cohen’s kappa because Cohen’s kappa penalizes coders for maintaining higher level of simple agreement, whereas Brennan and Prediger’s kappa corrects for this by assuming chance The authors will provide a complete list of the final sample of commercials upon request agreement is determined by the number of categories in the coding scheme For each variable coded, both simple agreement (SA) among the coders and Brennan and Prediger’s kappa (KB & P ) are provided Categories Health threat Following the EPPM, the health threat contains the severity of the threat and the susceptibility of experiencing the consequences of the threat (Witte, 1992) Each message was coded to determine the presence of threat severity and susceptibility overall as well as bifurcating each message by audio and video components to more precisely capture the magnitude of threat severity and susceptibility All primary categories were examined and coded dichotomously, since the scope of the current study was to determine what features of the EPPM were being employed in this campaign Additionally, message features such as vivid language and demographic similarity were also useful to examine (Witte, Meyer, & Martell, 2001) Therefore, these two categories were also considered as subthemes within severity and susceptibility, respectively Severity Message severity refers to the health costs associated with performing a specific behavior (Witte, 1992) For the present study, severity was captured in communicating the negative consequences of tobacco use (e.g., smoking causes cancer, debilitating diseases) or by showcasing the chemical components of cigarettes (e.g., cigarettes contain rat poison) Overall, the coders achieved acceptable intercoder reliability for threat severity (SA = 95, KB & P = 90) With respect to audio (SA = 1.0, KB & P = 1.0) and visual (SA = 85, KB & P = 70) components of the messages, severity received respectable intercoder reliability among the trained coders, as well Within the severity message feature, we also coded for the magnitude of perceived message vividness overall as well as with respect to audio and visual components (Witte et al., 2001) In doing so, the coders indicated the degree of vividness on a = low vividness to = high vividness scale With respect to message vividness for the audio (α = 93) and visual (α = 84) components, the coders achieved acceptable intercoder reliability Susceptibility Message susceptibility is the likelihood that an individual will experience the health costs of performing a specific behavior (Witte, 1992) Susceptibility was presented in the form of the probability that there would be negative consequences due to smoking (e.g., tobacco kills out of of its users, tobacco kills 1,200 people a day) Intercoder reliability was established for susceptibility among the coders overall (SA = 95, KB & P = 90), as well as for the audio (SA = 1.0, KB & P = 1.0) and visual (SA = 90, KB & P = 80) components of the messages For susceptibility, we also coded for the magnitude of perceived demographic similarity overall, as well as with respect to audio and visual components (Witte et al., 2001) In doing APPLICATION OF THE EPPM TO TELEVISED TRUTH® ADS so, the coders indicated the degree of similarity on a = low similarity to = high similarity scale For demographic similarity, the coders achieved adequate intercoder reliability for the audio (α = 1.0) and visual (α = 71) components Downloaded by [University of Illinois at Urbana-Champaign] at 19:19 02 September 2013 Recommended response The recommended response refers to self-efficacy and response efficacy (Witte, 1992) Similar to the health threat, each ad was coded for the presence of self-efficacy and response efficacy overall, as well as by examining the audio and video content of each message to more precisely capture the magnitude of self-efficacy and response efficacy Self-efficacy Self-efficacy captures images and texts reinforcing how to perform an advocated behavior in the hopes of increasing confidence to follow through and perform the recommended act (Witte, 1992) In the current study, phrases such as “You not need tobacco” capture self-efficacy Overall, the coders achieved excellent intercoder reliability for self-efficacy (SA = 1.0, KB & P = 1.0) Identical intercoder reliabilities were observed across both audio (SA = 1.0, KB & P = 1.0) and visual (SA = 1.0, KB & P = 1.0) components of the messages Response efficacy Response efficacy suggests that by performing the recommended behavior, an individual will avert the health costs from occurring (Witte, 1992) Phrases such as “By not smoking I can live longer” exemplify the response-efficacy construct in the current investigation Like self-efficacy, overall, the coders achieved perfect intercoder reliability for response efficacy overall (SA = 1.0, KB & P = 1.0) and across both audio (SA = 1.0, KB & P = 1.0) and visual (SA = 1.0, KB & P = 1.0) components of the messages Data Analysis Strategy With an individual ad as the unit of analysis, it was reasonable for an ad to contain more than one of the coded message components After all, each category represented a nonindependent dichotomous nominal variable For this reason, our data analysis strategy took this non-independence into account when selecting an approach to analyze the data Specifically, Cochran’s Q tests were performed to ascertain if certain message features emerged more frequently than others Following a significant Cochran’s Q test, McNemar tests were conducted to determine where significant differences were present To minimize Type I error from occurring when interpreting the McNemar tests, the decision was made to adjust the alpha level by making a Bonferroni-type correction by dividing the conventional alpha level (α = 05) by the number of pairwise comparisons (6), resulting in an alpha level of 008 In addition to presenting the statistical analyses that follow, exemplars of each message feature were extracted from the television ad to illustrate how each was presented 57 RESULTS The overarching objective of the current project was to determine the frequency with which truth® ads communicate the health threat and the recommended response A Cochran’s Q test showed that the ads differed in how often they communicated health severity, susceptibility, self-efficacy, and response efficacy across the ads, Q(3, N = 86) = 169.69, p < 001 Among the four message features, severity was presented most often (n = 72), followed by susceptibility (n = 31), self-efficacy (n = 0), and response efficacy (n = 0) McNemar tests revealed that severity was communicated more often than susceptibility (p < 001), self-efficacy (p < 001), and response efficacy (p < 001) With respect to the audio components of the ads, a Cochran’s Q test determined that the ads differed in communicating severity (n = 54), susceptibility (n = 17), self-efficacy (n = 0), and response efficacy (n = 0), Q(3, N = 86)= 128.93, p < 001 Specifically, McNemar tests revealed severity was communicated more often than susceptibility, self-efficacy, and response efficacy at p < 001 For the video components of the ads, a Cochran’s Q test found differences between severity (n = 48), susceptibility (n = 12), self-efficacy (n = 0), and response efficacy (n = 0), Q(3, N = 86) = 119.08, p < 001 McNemar tests again revealed that severity was communicated more than susceptibility, self-efficacy, and response efficacy at p < 001 Along with examining differences between severity, susceptibility, self-efficacy, and response efficacy, we tested for variation in ad vividness communicating the severity between audio and video components, t(86) = 2.378, p < 05 Results from the paired-sample t-test revealed that video (M = 1.90, SD = 1.02) content was perceived as being more vivid than audio content (M = 1.59, SD = 82) The majority of the ads communicated severity by emphasizing the health costs associated with smoking For example, in the ad entitled The Real Marlboro Man: You Don’t Always Die from Tobacco, viewers watch a man dressed as a cowboy riding through the streets of New York The cowboy sets up camp complete with a guitar-playing friend and campfire in the middle of the street He then takes off the bandana around his neck to reveal a quarter-sized hole where his larynx used to be, and proceeds to sing, with the aid of a mechanical larynx, about the consequences of living with smoking-initiated health costs In the ad entitled Rat Poison, viewers see a person holding a digital number counter that rolls and then stops at 101 The accompanying onscreen writing states, “Cigarette smoke contains 101 poisons That’s a hundred more than rat poison.” Although not appearing as often as threat severity, susceptibility was portrayed with some regularity throughout the truth® ads Overall, across the ads, McNemar tests revealed that susceptibility was communicated more often than selfefficacy and response efficacy at p < 001 Similarly, Downloaded by [University of Illinois at Urbana-Champaign] at 19:19 02 September 2013 58 LAVOIE AND QUICK susceptibility was communicated more than self-efficacy and response efficacy with respect to both audio and visual message features at p < 001 Differences in perceived similarity were examined across audio (M = 1.23, SD = 76) and video (M = 1.17, SD = 54) components of the ads with results suggesting no statistical difference between them, t(86) = 55, p = 58 Several ads were designed to make viewers feel susceptible to the health costs linked to smoking For example, in the ad entitled 1,200, 1,200 people wear t-shirts labeled with the numbers through 1,200 as they stand outside a major tobacco company Simultaneously, all 1,200 people “fall down dead” in the street A man remains standing with a sign stating, “Tobacco kills 1,200 people a day.” In another ad entitled Career Seminar, a lecture hall is filled with college students energized to learn about an exciting career opportunity The Big Tobacco executive asks the students, “Who here would want to work in a high-paying recession proof multi-billion-dollar industry once they graduate?” As most hands go up, the executive concludes with the question, “Who wants to work in an industry whose products could potentially be responsible for billion deaths in the 21st century?” Every hand in the audience goes down and the speaker says, “Nobody?” McNemar tests to determine differences between selfefficacy and response efficacy were not conducted because both variables contained the same values for the ads overall Similarly, no differences could be detected with respect to the audio and video components of the ads as these features were not present DISCUSSION According to the EPPM, a successful fear appeal must elicit both perceived efficacy and perceived threat (Roberto et al., 2011; Witte, 1992, 1994) Our findings reveal that the truth® campaign relies heavily on communicating the health threat, particularly with respect to video content, but offers no recommended response by way of self-efficacy and response efficacy to viewers This result is consistent throughout the ads and extends across visual and audio components as well In particular, our results demonstrated greater vividness among the video components of these ads than audio features Although many studies have claimed that the truth® campaign has been a factor in the reduction of adolescent smoking prevalence, there still lie several concerns regarding the potential reactions to these advertisements, according to Witte’s model In the following we discuss the theoretical and practical implications of these findings Theoretically speaking, if an audience is presented with a threat but no recommended response, the audience’s processing becomes one of fear control (Witte, 1992); that is, the audience focuses on alleviating the emotion of fear over eliminating the real danger Interestingly, one of the potential results of fear control is psychological reactance (Brehm, 1966), which is an outcome that the truth® campaign fervently attempts to avoid (truth® , 2012) According to Brehm (1966), reactance, operationalized as an amalgamation of anger and negative cognitions (Dillard & Shen, 2005), follows a threat to or an elimination of an established freedom and motivates an individual to reestablish the threatened or removed freedom (Quick & Stephenson, 2008) Designers of truth® ads undeniably understand the importance of minimizing reactance, especially for their adolescent audience, who maintain a proclivity to experience reactance following freedom-threatening tobacco messages (see Miller, Burgoon, Grandpre, & Alvaro, 2006) In fact, the campaign arguably uses psychological reactance theory by tapping into adolescents’ natural tendency toward rebellion to galvanize reactance against Big Tobacco (truth® , 2012) However, for all of these efforts, there is still one loose end: Reactance could become problematic for teens processing the truth® television ads provided the reliance on communicating the health threat without the recommended response (Roberto et al., 2011), especially for reactant prone teens (Miller et al., 2006) This is an empirical question deserving of future research Another potential fear-control process for adolescents is that teens may simply avoid the message (Witte, 1992) In this case, ads highlighting the severity or likelihood of smoking consequences without any recommended response for how to avoid the social pressure to smoke may result in teens agreeing with the danger, but initiating smoking anyway There is some concern, in fact, that the reduction of smoking prevalence among adolescents has flatlined (truth® , 2012) The authors acknowledge the myriad possible explanations for this leveling, including desensitization to the campaign However, another possibility to consider is the campaign’s lack of recommended response messages The truth® campaign provides the why to the argument against smoking, but it doesn’t provide the how with respect to strategies against temptation or social pressure As research has shown, the antidrug campaigns of the 1980s and 1990s showcased the severity of drug use while not adequately identifying the recommended response and as a result were not particularly effective (e.g., Fishbein, Hall-Jamieson, Zimmer, von Haeften, & Nabi, 2002) Reactance and defensive avoidance are not the only possible maladaptive outcomes of fear-control processing warranting empirical investigation in future studies, however Denial, message derogation, and perceived message manipulation may also be forms of fear-control processing (Roberto et al., 2011; Stephenson & Witte, 2001; Witte, 1994) Although these outcomes have not been examined within a smoking prevention campaign, they deserve future consideration in this context For example, if teens not know how to effectively avoid or resist the temptation to smoke, they may choose “not to think about it” as a defensively avoidant response to the real dangers of smoking Another Downloaded by [University of Illinois at Urbana-Champaign] at 19:19 02 September 2013 APPLICATION OF THE EPPM TO TELEVISED TRUTH® ADS outcome, denial, may also be problematic, especially among teens, who, by and large, tend to hold beliefs of invincibility (see Wickman, Anderson, & Smith-Greenberg, 2008) In sum, although the truth® campaign has had some success with smoking prevention among teenagers, the overrepresentation of severity and susceptibility messages coupled with the nonexistence of corresponding efficacy messages points to potentially problematic outcomes, according to the EPPM Scholars and practitioners alike would benefit from future research exploring the conditions under which each of these undesirable outcomes is employed as reactions to fear in antismoking campaigns In addition to potential maladaptive responses, there are broader unintended consequences of the campaign Because of the multimediated format of these ads, and especially because of their television ads, the truth® campaign is viewed by a much more diverse audience that nonsmoking adolescents According to Richardson et al (2010), the awareness of the truth® campaign is as high as 68% among viewers between the ages of 18 and 24 years Because this viewership reaches beyond adolescents, the primary strategy of the truth® campaign (rebellion) may not be appealing or understood by this unintended audience, whether 18–24 or older Indeed, the truth® website states, “[Truth] is hard for someone over the age of 30 to understand The adult word [truth] is very different from the teens’ The values are different The goals are different If adults don’t get what we’re saying and how we choose to say it, then it’s probably okay” (truth® , 2012) By creating an “us versus them” mentality (teens versus adults), the campaign earns ethos with adolescents and promotes healthy rebellion However, there are several potential drawbacks with this philosophy, as well First, the campaign mentions adults (defined as 30 years and older) and teens, but what about people between 18 and 29 who, as we already established, view the truth® ads (Richardson et al., 2010)? Second, it may be undesirable for adults (or anyone else) unable to relate to the campaign If a viewer doesn’t understand the primary strategy (rebellion) or doesn’t identify with that strategy, it leaves the viewer with an understanding of only the default message, which is a fear appeal communicating the health threat without any reference to a recommended response One could argue that this may not be a bad thing; after all, the audience is getting the message about the consequences of tobacco However, the lack of identification, coupled with the lack of efficacy messages, could be problematic for older audiences, resulting in consequences such as low message attendance or maladaptive fear-control processes In addition, this campaign may act as a double-edged sword, producing both positive and negative unintended outcomes Awareness of truth® was actually higher among smokers than nonsmokers (Richardson et al., 2010), and significant correlations emerged between truth® antitobacco ads and smoking cessation intentions (Richardson et al., 2010) In other words, although the truth® campaign’s primary goal 59 is prevention, it may affect cessation efforts as a by-product Despite its prevention mission, it is possible that ads regarding the dangers of tobacco are more salient to those who already smoke, explaining the greater awareness of these ads among smokers On its face, intentions to quit smoking may seem like an inadvertent positive outcome of a campaign that is supposed to be aimed at prevention However, if this is the case, this unintended benefit does not come without a corresponding cost The imbalance of threat and recommended response may be of even greater concern for the smoking audience than for those who not smoke Answers to questions such as the ones raised here would be welcomed additions to the literature Some of the unintended consequences for smokers are undeniably undesirable Ideally, a fear appeal guided by the EPPM should result in danger-control processes (not smoking for nonsmokers, and smoking cessation for smokers) if an adequate recommended response is included in the ad However, for smokers who view the truth® ads, following EPPM predictions, it is theoretically more likely that they would resort to fear-control processes given the heavy reliance on threat and lack of attention to the recommended response The EPPM may showcase the health threat of smoking, but without any perceived self-efficacy or response efficacy communicated, smokers may not feel like they can quit For example, smokers may engage in denial to reduce their fear Many people with a friend or family member who smokes have likely heard a version of the following argument: “Most people who die of lung cancer were smokers, but most smokers don’t die of lung cancer.” These types of counterarguments, while they may be completely illogical, may also act as self-soothing or reassuring responses to fear-arousing messages lacking efficacy, and aid in creating denial of susceptibility The potential feeling of “helplessness” (e.g., “Smoking is scary but I just don’t think I can quit or know how”) is likely more exacerbated by particular messages, such as several truth® ads that feature people living (or dying) with smoking-related diseases who share that they got these diseases long after they quit smoking Unfortunately, this may encourage smokers to adopt a “what’s the point?” attitude and further engage in fear control such as denial, since the perception may be that there is nothing they can to help themselves (no response efficacy even if they possessed self-efficacy) Finally, although not the intended audience of the truth® ads, smokers may feel stigmatized by fear appeals that don’t contain recommended response messages The graphic imagery and hard-hitting statistics used in truth® ads highlight the dangers of smoking but not acknowledge how difficult it is to quit Although the campaign website states that it is not “antismoker,” it may be difficult for nonsmokers to grasp the true struggle with addiction, which could enhance negative perceptions of those who smoke The discrimination experienced by those with addiction can lead to social isolation and segregation from society (Smith, 2007; Downloaded by [University of Illinois at Urbana-Champaign] at 19:19 02 September 2013 60 LAVOIE AND QUICK Strauser, Ciftci, & O’Sullivan, 2009) This marginalization can lead to self-stigmatizing beliefs (internalization), and has been correlated with lower self-esteem, increased substance use, poor physical and mental health, and less satisfaction with life (Corrigan, Markowitz, Watson, Rowan, & Kubiak, 2003; Smith, 2007) In essence, a cycle is created and negative perceptions are continually reinforced by both public attitude and the reception of that attitude by those living with addiction In all, the truth® campaign at best may help some who already smoke But at worst, it may contribute to myriad maladaptive and unintended responses that add to the existing problem It stands to reason that a campaign can have a primary goal, such as prevention, but should also find ways to promote secondary goals such as cessation Future research should determine exactly how smokers and “adults” (as defined by the truth® organization) perceive the campaign, as well as how they react to it Additionally, studies should investigate how antismoking ads contribute to unintended effects by examining potential mediating factors such as similarity and identification The goal of our study was to determine whether the components from the EPPM were present in televised truth® ads However, this was only a first step in examining this campaign Because we chose to initially look for the presence or absence of each message feature of the EPPM framework, our conclusions are constrained by a dichotomous coding scheme, which is often the case in content analysis projects (see Quick et al., 2011; Silk et al., 2003) Future researchers may choose to utilize a more nuanced coding scheme to further investigate message feature strategies Although we have established the heavy reliance on threat throughout these ads, understanding how threat is generated and what message features might make a threat maximally effective would be a worthy undertaking Determining how consistently specific message strategies (e.g., color, cuts, graphic imagery) are employed and to what degree they are replicated may shed additional light on what conditions may exacerbate the possible unintended consequences or enhance the intended persuasiveness of this campaign Our study found that vividness was more pronounced in the visual elements than in the audio elements in these ads Further, to achieve a sufficiently large sample, the authors grouped all subcampaigns together for analysis Admittedly, the truth® campaign employs multiple subcampaigns, which offer a variety of distinct approaches in their thematic presentations However, most truth® ads relay the same ultimate messages regarding the scariness of tobacco-use consequences, even when the threat is embedded in a larger dominant strategy Future research should consider each subcampaign separately to tease out the various strategies used in conjunction with threat, as well as determining whether audiences perceive these subcampaigns differently Additionally, establishing whether viewers perceive some ads as more persuasive than others, along with the reasons behind such perceptions, would be a welcomed addition to the literature Although several studies have been conducted on the effectiveness or use of Witte’s EPPM, yet to be answered is the question of proportions within the model In other words, what is the ideal proportion of each of the components within the EPPM? Although the EPPM’s effectiveness is necessitated by ideal balance of threat and efficacy components, scholars have yet to thoroughly examine what the ideal balance might be and whether this balance is audience or context specific Further research should explore these inquiries, and scholars should look to advance the EPPM by refining and specifying the balance needed between components The goal of this investigation was to apply the EPPM to the truth® campaign Our results suggest that these television ads rely on fear appeals The commercials use severity messages frequently and susceptibility to a moderate degree However, no self- or response-efficacy messages were found in the ads According to the EPPM, the campaign message will not be successful under these conditions Although there is support for the effectiveness of truth® , it is difficult to claim that these results are strongly causally related to the campaign because of many other potential contributing factors such as policy 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