Do Emotional Appeals in Public Service Advertisements Influence Adolescents' Intention to Reduce Consumption of Sugar-Sweetened Beverages?

Journal of Health Communication International Perspectives

ISSN: 1081-0730 (Print) 1087-0415 (Online) Journal homepage: http://www.tandfonline.com/loi/uhcm20

Do Emotional Appeals in Public Service Advertisements Influence Adolescents’ Intention to Reduce Consumption of Sugar-Sweetened Beverages? Amy Bleakley, Amy B. Jordan, Michael Hennessy, Karen Glanz, Andrew Strasser & Sarah Vaala To cite this article: Amy Bleakley, Amy B. Jordan, Michael Hennessy, Karen Glanz, Andrew Strasser & Sarah Vaala (2015) Do Emotional Appeals in Public Service Advertisements Influence Adolescents’ Intention to Reduce Consumption of Sugar-Sweetened Beverages?, Journal of Health Communication, 20:8, 938-948, DOI: 10.1080/10810730.2015.1018593 To link to this article: http://dx.doi.org/10.1080/10810730.2015.1018593

Published online: 09 Jun 2015.

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Date: 17 September 2015, At: 02:09

Journal of Health Communication, 20:938–948, 2015 Copyright # Taylor & Francis Group, LLC ISSN: 1081-0730 print/1087-0415 online DOI: 10.1080/10810730.2015.1018593

Do Emotional Appeals in Public Service Advertisements Influence Adolescents’ Intention to Reduce Consumption of Sugar-Sweetened Beverages? AMY BLEAKLEY1, AMY B. JORDAN1, MICHAEL HENNESSY1, KAREN GLANZ2, ANDREW STRASSER3, and SARAH VAALA1 1

Annenberg Public Policy Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA Department of Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA 3 Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA

Journal of Health Communication 2015.20:938-948.

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Mass media campaigns are a commonly used approach to reduce sugary drink consumption, which is linked to obesity in children and adolescents. The present study investigated the direct and mediated effects of emotional appeals in public service advertisements (PSAs) that aired between 2010 and 2012 on adolescents’ intention to reduce their sugar-sweetened beverage (SSB) consumption. An online randomized experiment was conducted with a national sample of adolescent respondents ages 13 to 17 years old (N ¼ 805). Participants were randomly assigned to 1 of 4 conditions. Three experimental conditions represented PSAs with different emotional appeals: humor, fear, and nurturance, plus a fourth control condition. The outcome was adolescents’ intention to cut back on SSBs. The direct effect of fear appeals on intention was mediated through adolescents’ perception of the PSAs’ argument strength; perceived argument strength was also the key mediator for the indirect effects of humor and nurturance on intention. Several hypothesized mediators influenced by the appeals were not associated with intention. This is the first study to test the effect of persuasive emotional appeals used in SSB-related PSAs. The perceived strength of the PSAs’ arguments is important to consider in the communication of messages designed to reduce SSB consumption.

Obesity among children and adolescents in the United States has tripled in the past three decades and nearly one in five 12–19 year-old adolescents in the United States is obese (Ogden, Carroll, Curtin, Lamb, & Flegal, 2010; Ogden, Carroll, Kit, & Flegal, 2012). Sugar-sweetened beverages (SSBs), defined as nondiet sodas, sports drinks, energy drinks, sweetened teas, and fruit drinks, play a significant role in overweight and obesity (Gibson, 2008; Malik, Schulze, & Hu, 2006; Vartanian, Schwartz, & Brownell, 2007) and SSB consumption by children and adolescents increased 48% between 1974 and 1998 (French, Lin, & Guthrie, 2003). Soda consumption has shown signs of decreasing in recent years; however, sports and energy drink consumption among adolescents has tripled since 2000 (Han & Powell, 2013). The use of mass media campaigns to change health-related beliefs, attitudes, and behavior is a common and often effective public health strategy (Wakefield, Loken, & Hornik, 2010). As previously done with antitobacco (Leshner, Vultee, Bolls, & Moore, 2010), drinking and driving prevention (Elder et al., 2004), and antidrug (Kang, Cappella, & Fishbein, 2009) Address correspondence to Amy Bleakley, Annenberg Public Policy Center, University of Pennsylvania, 202 South 36th Street, Philadelphia, PA 19147, USA. E-mail: ableakley@asc. upenn.edu

communication campaigns, it is important (a) to understand whether beverage-related public service advertisements (PSAs) have their intended effect to reduce SSB consumption and (b) to identify which type of message content is effective with which specific audiences. But unlike other products that youth are discouraged from consuming (e.g., smoking, drugs, alcohol), there are well-financed and extensive SSB marketing campaigns aimed directly at youth. Media communications can play an important role in raising public awareness of the relation between SSB consumption and weight, influencing young people and their parents to drink fewer SSBs, and persuading policymakers to alter the beverage marketing environment to promote healthy beverage alternatives. However, it is unknown how health messages about a widely accepted and advertised product will be perceived by teen audiences. The testing of specific messages with different target audiences is essential to the effectiveness of health communication campaigns and can be used to estimate the effect of message features on cognitive and behavioral outcomes (Lang & Yegiyan, 2008; Witte & Allen, 2000). The content and appeal of a message and the reaction it provokes from the audience can be evaluated to help health experts understand whether and how a message can be influential. For example, some campaigns use a fear-based approach, which may be effective

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Sugary Drink PSA Message Testing in certain circumstances (Witte & Allen, 2000), but there is conflicting evidence about the persuasive effects of campaigns that feature humor (Nabi, Moyer-Guse, & Byrne, 2007). The present study was an online randomized experiment using a national sample of adolescents to test the effect of three distinct emotional persuasive appeals—humor, fear, and nurturance—on emotional and cognitive outcomes that mediate intention to cut back on sugary drinks (Holbert & Stephenson, 2003). The study examines which of the persuasive appeals were associated with greater intention to cut back, and whether the effect of the persuasive appeals was mediated by such outcomes as emotional response to the PSAs and beliefs about SSBs.


Use of Emotional Appeals in Health Communication Campaigns Emotional appeals can be powerful persuasive tools in the context of public health messaging (Turner, 2011). Although many of the emotions used and studied in the persuasion literature are negative (e.g., anger, fear, guilt), positive emotions such as happiness are also used. However, the success of the message depends largely on whether the emotion is matched well with the target audience in that it produces the appropriate reaction without causing the viewer to feel manipulated or to reject the message (Turner, 2007). Some campaigns use fear (e.g., 1993 Massachusetts AntiSmoking Media Campaign [Biener, McCallum-Keeler, & Nyman, 2000]) and humor (e.g., Healthy Penis Campaign [Vega & Roland, 2005]) to convey the relevant health promotion disease prevention messages. In the universe of beverage-related PSAs analyzed for the current study, three discrete types of emotional appeals emerged: fear, humor, and nurturance. A fear-based message is one which arouses fear when ‘‘a situation is perceived as both threatening to one’s physical or psychological self and out of one’s control’’ (Nabi, 1999). Arousal from such messages ideally produces a desire to avoid the perceived threat, resulting in the behavior recommended in the particular message (e.g., threat: foot amputation from diabetes, behavior: avoid sugar sweetened beverages). Although fear-based campaigns are less prevalent in the public health community compared with the late eighties and early nineties (Green & Witte, 2006), theoretical models such as the Extended Parallel Process Model (Witte, 1992) explain the circumstances under which fear appeals are effective. The Extended Parallel Process Model posits that the perceived threat, which produces fear, motivates an individual to act, and their perceived efficacy informs the extent of their action (Green & Witte, 2006). Fear-based messages have mixed success among adolescent audiences (e.g., Lee & Ferguson, 2002; Wolburg, 2006), with one explanation being that adolescents’ unique developmental stage results in a vulnerability to psychological reactance (Brehm & Brehm, 1981), in which their freedom feels threatened and they are therefore less likely to change their behavior—and in some instances, initiate risky behavior as result (e.g., Hornik, Jacobsohn, Orwin, Piesse, & Kalton, 2008). Unlike fear-based persuasive messages, the use of humor to motivate attitude and behavior change is thought by some

to avoid threatening tones to ‘‘offset possible unintended responses’’ (Lee & Chen, 2013, p. 355). Humor appeals can produce a variety of emotions (e.g., joy, surprise, happiness), and thus are generally defined as those that ‘‘purposefully use positive affect, through the use of humor, to connect positive feelings with the issue being addressed in the message’’ (Turner, 2011, p. 66). The positive affect generated by a humorous appeal is thought to increase attention and possibly reduce defensive actions, but it is unclear whether they are effective in producing behavior change (Lee & Ferguson, 2002; Turner, 2011). Humorous messages have been shown to reduce counterarguments in that the perceived argument quality of a message will remain high, however discounting the message as a joke becomes more likely (Nabi et al., 2007). The use of nurturance as a type of emotional appeal has not been well studied. In this study a nurturance appeal was defined as one which evoked the idea of caretaking, such as parents caring for their child’s health and well-being (i.e., doing something for the sake of one’s child). These types of appeals may be particularly effective with parents as a target audience, as there is long tradition of appealing to parents in health communication campaigns that focus on child-related outcomes such as promoting safe sleep positions to avoid sudden infant death syndrome (Meadows-Oliver & Hendrie, 2013), reducing antibiotic overuse among children (Hemo et al., 2009), and raising awareness of the dangers of lead poisoning (McLaughlin, Humphries, Tung, Maljanian, & McCormack, 2004). However, it is unknown how such appeals will resonate with youth. How Do Emotional Appeals Affect Intention? Intention to perform a behavior is based on a reasoned action approach to behavior change and prediction (Fishbein & Ajzen, 2010). Several meta-analyses that examine the intention–behavior relation in behaviors such as condom use (Albarracıń, Johnson, Fishbein, & Muellerleile, 2001), physical activity (Hagger, Chatzisarantis, & Biddle, 2002), and smoking (Topa & Moriano, 2010), as well as across many different health behaviors (Webb & Sheeran, 2006) and populations (e.g., adolescents), indicate the range of its predictive and practical utility. In an experimental context, when measuring actual behavior may be challenging, intention to perform the behavior of interest is consistently and effectively used as a proxy for behavior. One of the ways through which the emotional persuasive strategies may influence intention is through provoking specific emotional reactions (e.g., fear appeals arousing feelings of fear that lead to action). In addition to emotional responses, there are several other potential pathways through which the appeals may change adolescents’ intention to reduce their SSB consumption. Given that this study is the first to assess the effectiveness of beverage-related PSAs designed to address SSB consumption, we examined a wide range of mediators that may be applicable and that are based on results from other campaigns and message-testing experiments. The potential mediators measured in this study are shown in Figure 1.

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Fig. 1. Generic mediational model. The control condition is the referent group; for clarity, the correlations of errors terms of the mediators are not shown.

For adolescents, threat to choice is especially relevant. Psychological reactance theory (Brehm & Brehm, 1981) suggests that when a person’s freedom is threatened by commands or persuasive claims seen as circumscribing free choice, he or she responds with a motivational state called reactance, which involves motivational arousal to restore or reestablish the threatened freedom (Grandpre, Alvaro, Burgoon, Miller, & Hall, 2003). For example, reactance is recognized as a predictor of adolescent smoking initiation (Miller, Burgoon, Grandpre, & Alvaro, 2006) and has been shown to increase intention to smoke after exposure to smoking messages that explicitly told the viewer what to do or not to do (Grandpre et al., 2003). It is also possible that emotional stimuli could affect cognitions that are more typically related to intention, such as behavioral beliefs about the consequences of drinking SSBs (Fishbein & Ajzen, 2010), self-efficacy with regards to performing the proposed behavior (Bandura, 2002; Fishbein & Ajzen, 2010) and the perceived quality of an argument that is presented in the message. Argument strength and quality predicts persuasion (Park et al., 2007; Petty & Cacioppo, 1986) in that strong arguments dispose an audience toward a message in part by eliciting favorable thoughts. Perceived argument strength, which is conceptualized as an audience’s belief about the strength of the claim made in the message and the number of favorable thoughts it produces, is commonly assessed in message testing research. Similarly, message appeal has been associated with persuasiveness in advertising and is considered ‘‘an important mediator of message effectiveness’’ (Flynn, Worden, Bunn, Connolly, & Dorwaldt, 2011, p. 979). We also evaluate stigma as a potential. Campaigns focused on the link between SSB consumption and obesity may be perceived by viewers as stigmatizing or discriminatory against overweight people, potentially leading to ineffectiveness or backlash effects of the messages (Puhl & Heuer, 2009; Puhl, Peterson, & Luedicke, 2013). In past research with adults, obesity-related campaign messages perceived to be stigmatizing were rated less favorably than more neutral

messages, regardless of participants’ weight status, and participants reported lower motivation to comply with stigmatizing messages regarding weight (Puhl, Peterson, & Luedicke, 2013). It is not yet clear the extent to which adolescents perceive stigmatizing content within SSB-reduction messages, or whether such stigma would also undermine message efficacy among this population.

Methods Context In 2010, the Centers for Disease Control and Prevention funded the Communities Putting Prevention to Work initiative to address obesity and tobacco use, the leading preventable causes of morbidity and mortality in the United States.1 More than 50 communities were funded to promote and implement community prevention efforts and many created PSAs about the harms of drinking SSBs. The PSAs funded by the Communities Putting Prevention to Work initiative represent the largest source of beverage-related PSAs to date. Sample A national sample of 805 adolescents ages 13–17 years were identified from their parents who were selected from an online probability panel (KnowledgePanel) recruited by the survey firm GfK. The panel is designed to be representative of adults (ages 18þ years) in the United States. GfK relies on random digit dialing and address probability-based sampling to recruit households to the panel. KnowledgePanel recruitment uses dual sampling frames that include both listed and unlisted telephone numbers, telephone and non-telephone households, and cell-phone-only households, as well as households with and without internet access. Adolescent 1

For details regarding the Communities Putting Prevention to Work initiative, see http://www.cdc.gov/CommunitiesPuttingPreventiontoWork/ index.htm.

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Sugary Drink PSA Message Testing respondents were recruited through parents in the KnowledgePanel known to have a child between the ages of 13–17 years. Of the parents contacted, 85% gave consent for their child to participate; we obtained parental consent before enrolling their adolescents. Approximately 40% of eligible adolescents completed the survey and saw the videos. The survey took approximately 16 min to complete and was approved by the institutional review board at the University of Pennsylvania. The sample of respondents was weighted to be representative of the U.S. population based on the demographic and geographic data from the Current Population Survey. A poststratification weight was computed to adjust for any survey nonresponse as well as any noncoverage or underand oversampling resulting from the study-specific sample design. The data were weighted based on the following variables from the Current Population Survey: gender, age, race=Hispanic ethnicity, census region, metropolitan area, and household income. Experimental PSA Exposures The PSAs used in the experiment were selected from a sample that were content-analyzed by the study team (Annenberg Public Policy Center, 2013). Eligible PSAs aired between 2010 and 2012 and included SSB-specific messages. In total, 26 PSAs from 14 U.S. states were identified and coded. A coding strategy to identify PSAs by theme, intended outcomes, character descriptions, and production techniques was developed and refined for high internal consistency using a separate set of PSAs. Themes of fear, humor, and nurturance were identified by the coders as being frequently used in the PSAs. Coders’ assessments of the ads containing these appeals were later validated by a class of undergraduate students (n ¼ 50),who indicated whether each PSA used fear, humor, or nurturance. Two PSAs for each type of appeal were chosen for the experiment. For the six selected PSAs, both the students and coders were in agreement on the type of appeal used in that both the coders and the students thought the selected PSAs only used one type of appeal. PSAs deemed by the students and=or coders to have used more than one type of emotional appeal were considered ineligible for inclusion. Description of Selected PSAs PSAs with fear, humor, or nurturance appeals were selected for testing. Each PSA used in experiment is described in detail in Table 1. Procedures Participating respondents were randomly assigned to one of four experimental conditions. Three of the conditions represented the different emotional appeals: humor (n ¼ 184), fear (n ¼ 216), and nurturance (n ¼ 201). The fourth condition (n ¼ 204) was a control group that featured a PSA encouraging exercise from the VERB campaign, which urged teens to be physically active on a daily basis (Huhman et al., 2010).

VERB campaign PSAs were chosen as the control condition because they represented health-related PSAs that were of similar quality and length but did not have to do with food or beverage or use the persuasive tactics used in the other conditions. Each respondent was asked about his or her SSB consumption and then was shown the first PSA, followed by a set of message evaluation measures and reactions to the PSAs. The same procedure was repeated for the second PSA. The two PSAs in each condition were randomly ordered. We included more than one PSA for each type of strategy to increase the construct validity of the experimental condition. Two videos with a common, shared appeal would make it less likely that any of the findings could be attributed to extraneous or irrelevant message features. Intention to cut back on SSB consumption was asked (once) after respondents had seen both PSAs. For the analysis, the respondents’ message evaluations for each PSA in a particular condition were averaged into one variable that represented their evaluation of the messages for a particular emotional appeal. Measures The outcome measure is the respondent’s behavioral intention to ‘‘cut back on sugary drinks’’ in the next month. Following the convention for measures of behavioral intention (Fishbein & Ajzen, 2010), the responses were reported on a 7-point scale ranging from 1 (extremely unlikely) to 7 (extremely likely). The hypothesized mediating variables represent various dimensions of respondents’ PSA evaluations. Details, including specific items for the scales, appear in the Appendix. For most dimensions, respondents were presented with randomly ordered multiple statements and asked the extent to which they agree or disagree on a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). These measures included one item (‘‘I liked the ad overall’’) for appeal (Nan & Zhao, 2010), eight items (e.g., ‘‘The video gave strong reasons for cutting back on sugary drinks,’’ ‘‘The video is believable’’; a ¼ .92) for argument strength (Johnson, Maio, & Smith-McLallen, 2005; Park et al., 2007; Zhao, Strasser, Cappella, Lerman, & Fishbein, 2011), three items (e.g., ‘‘The video I just watched tried to manipulate me’’; a ¼ .91) for threat to choice (Quick & Considine, 2008), three items (e.g., ‘‘The video promotes negative attitudes towards obese people’’; a ¼ .93) for stigma (Puhl, Luedicke, & Peterson, 2013), and one item (‘‘The video made me feel able to cut back on sugary drinks’’) for self-efficacy (Dillard & Nabi, 2006). For emotional response (Dillard & Peck, 2000), on a 7-point scale ranging from 1 (none of this feeling) to 7 (a great deal of this feeling), participants were asked, ‘‘How much do each of the following words describe how you felt while seeing the message?’’ (surprised, happy, fearful, sad, guilty, contented, angry, empowered, hopeful, amused, disgusted, nurturing, protective). A factor analysis on the emotional responses identified four factors, which were included in the analysis: positive emotions (happy, content, amused), negative

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Table 1. Description and source information for public service announcements used in online randomized experiment


Description of public service announcements

Source

Humor A burger, a piece of pepperoni pizza, French fries, a doughnut, and a soda are sitting together in a support group=group therapy setting. The soda introduces himself, saying that he adds more than 1,000 calories to kids’ diets and that he is addictive but made of mostly water. The French fries and burger chime in, describing how they too were once in denial about being unhealthy in any way. The PSA tagline is: ‘‘Rethink your drink.’’ Set to the beat of a metronome, adolescents are shown nodding off to sleep and crashing their heads in various school settings, including at their desks, on the basketball court, at lunch, and in chemistry lab. As one student wakes up, he reaches for his can of cola, only to find it empty. The PSA concludes with a teen saying ‘‘Soda might give you a temporary lift, but it can also make you crash.’’ Fear The ad shows various sugar sweetened beverages (soda, sweetened tea, frozen coffee drink) typically consumed at different times of day (mid-morning, lunch, afternoon, and dinner) and states that these can add up to 93 packets of sugar per day. It then reminds the viewer about negative health outcomes (obesity, diabetes, heart disease, cancer), suggests some healthy beverage alternatives, and ends with the tag line ‘‘Are you pouring on the pounds?’’ The ad opens with people enjoying sugar sweetened beverages. Then the viewer is told that sugary drinks causes obesity that can lead to diabetes heart disease, and amputations. Then the ad focuses on children who drink one bottle of soda a day, and this equates this to 50 pounds of sugar per year. After suggesting healthy beverage alternatives, the tag line is ‘‘Are you pouring on the pounds?’’ Nurturance A mother sends her child to school with the child’s lunch box dripping sugar. It continues to drip sugar in school. The viewer is reminded that ‘‘hidden sugar’’ such as in the fruit drink in the child’s lunch box can cause diabetes, obesity, and heart disease. Then the ad is run backwards in time and we see the mother replacing the fruit drink with water. The tag line is ‘‘Know where the sugar is hiding.’’ A mother is serving her two children lunch and gets a 2 liter bottle of soda out of the refrigerator. But when she pours it into their glasses, we see that it is all sugar and not liquid. The ad points out that a 2 liter bottle of soda has 55 packs of sugar and that sugar can lead to obesity, diabetes, and heart disease. The tagline says ‘‘Choose low fat milk or water instead.’’

emotions (fearful, sad, guilty, angry, disgust), empowerment and hope, and nurturing and protective. ‘‘Surprised’’ was not included in the analysis because it did not correlate with any latent variable. Positive and negative beliefs about the effects of consuming SSBs were also assessed as potential mediators. Beliefs relevant to the PSAs of interest were selected. We asked respondents to indicate that extent to which they thought (not at all, a little, some, a lot) that drinking sugary beverages ‘‘causes people to be overweight,’’ ‘‘leads to type 2 diabetes,’’ ‘‘increases the number of calories people consume,’’ ‘‘eventually makes people crash,’’ ‘‘leads to sugar addiction,’’ ‘‘leads to heart disease,’’ ‘‘leads to stroke,’’ ‘‘leads to cancer,’’ and ‘‘makes it harder to focus in school’’ [negative beliefs, a ¼ .89]; satisfies thirst, makes people feel energized,

Cook County Department of Public Health Cook County, Illinois http://www.rethinkyourdrinknow.com/ryd/ Home

Reach Healthy Communities Initiative Bartholomew County, Indiana http://www.whatsyourreach.org (video not available online)

New York City Department of Health and Mental Hygiene New York, New York http://www.nyc.gov/html/doh/html/living/ sugarydrink-media.shtml

New York City Department of Health and Mental Hygiene New York, New York http://www.nyc.gov/html/doh/html/living/ sugarydrink-media.shtml

Multnomah County Health Department Multnomah County, Oregon http://web.multco.us/health/media?page=3

Public Health Kings County, Seattle, Washington http://www.kingcounty.gov/healthservices/ health/nutrition/sugarydrinks.aspx

makes people feel good, and is good for a special occasion [positive beliefs, a ¼ .73]. Statistical Analysis Descriptive analyses were conducted using Stata 12. To identify differences between experimental conditions and the control group on demographic indicators, we used either logistic or ordinary least squares regression depending on whether the outcome was dichotomous (e.g., gender) or continuous (e.g., income level). These analyses were conducted using the unweighted data because randomization occurred before weighting. Regression analysis was also used to determine the direct effects of persuasive appeals on intention, and path analysis was conducted for the meditational

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Sugary Drink PSA Message Testing analysis (MacKinnon, Fairchild, & Fritz, 2007). See Figure 1 for the generic analysis model. Although not pictured in Figure 1, the error terms of the mediating variables were correlated. We used MPlus 5.0 to estimate the equations simultaneously and all analyses were weighted.

Results Sample Fifty-two percent of adolescents were female, and the mean sample age was 15.05 (CI [14.91, 15.18]). The racial=ethnic breakdown was 55.8% White, 13.9% African American, 5.5% other, 21.7% Hispanic, and 3.1% two or more races. Of the adolescents, 48% lived in households with less than a US$60,000=year annual income.


Differences in Intention, by Experimental Condition Adolescents’ intention to cut back on sugary drinks was highest in the fear condition (M ¼ 5.09, CI [4.75, 5.43]), followed by humor (M ¼ 4.55, CI [4.20, 4.91]), nurturance (M ¼ 4.54 CI [4.14, 4.95]) and the control group (M ¼ 4.40, CI [4.02, 4.78]). Regression analysis (see Table 2) showed that those exposed to the videos using the fear appeal were the only group with significantly different intentions from the control. Postestimation tests showed that the fear group also had significantly higher intention than the nurturance group. Results of Mediation Analysis Although the path analysis was conducted simultaneously, the results are presented in two separate tables. Table 3 shows the effect of experimental condition (compared with the control group) on the mediators. Compared with the control group, all of the experimental conditions were associated with increased perceived argument strength, self-efficacy, and perceived threat to choice. However, none of the persuasive strategies affected the appeal of the PSAs (i.e., whether they liked it or not) or adolescents’ positive or negative beliefs about SSBs. Only the fear condition was associated with increased stigma. The effects of the mediators on intention to cut back are in Table 4. Four mediators were associated with an adolescent’s intention: argument strength, empowerment and hope, positive beliefs about SSBs, and negative beliefs about SSBs. Positive beliefs about SSBs were negatively associated with intention and the other mediators were positively associated. A summary of results is presented in Table 5. The three types of emotional appeals influenced many of the Table 2. Direct effects analysis of experimental condition in intention to cut back (N ¼ 805) Experimental condition Humor Fear Nurturance

p < .05.

p < .01.

b (SE) 0.16 (.26) 0.69 (.26) 0.14 (.28)

p < .001.

mediators; however, most of the mediators affected by the persuasive appeals were not associated with intention to cut back on SSB consumption. Only humor influenced more than one mediator that was associated with intention (argument strength and empowerment and hope), but the paths had opposite signs and most likely washed each other out, which explains the absence of a direct effect of humor on intention. None of the experimental conditions influenced adolescents’ positive or negative beliefs about SSBs, which were both strongly related to intention.

Discussion This is the first study to test the effect of persuasive strategies used in SSB-related PSAs. Either directly or indirectly, humor, fear, and nurturance appeals were each associated with an increased intention to cut back on sugary drinks. The direct effect of fear appeals on intention was mediated through adolescents’ perception of the PSAs’ argument strength; perceived argument strength was also the key mediator for the indirect effects of humor and nurturance on intention. Each of the persuasive appeals also was associated with several hypothesized mediators, including selfefficacy and perceived threat to choice; however, these were not associated with intention to cut back. Positive and negative beliefs about SSBs, both important predictors of intention, were not affected by any of the emotional appeals. Only the fear appeal was related to increased stigma, but stigma was not related to intention. Evidence suggests that attitude and belief change are more likely to occur from the processing of strong arguments rather than weak ones (Zhao et al., 2011). Audiences typically respond to high quality arguments, although there is often disagreement about how a quality argument is defined (O’Keefe & Jackson, 1995). In general, messages which support a particular position link their claims to evidence, and through measures of perceived argument strength one may discern the extent to which the respondents believe the claims are adequately supported. Among our national sample of adolescents, perceived argument strength was a key predictor of intention and was influenced by all three types of PSAs, most strongly by fear and nurturance appeals. The implications of this finding are significant: adolescents respond to arguments they perceive as strong when it comes to their intention to reduce their SSB intake. Messages in public health campaigns aimed at youth should focus on building strong and relevant arguments for why they should change their beverage-related behaviors. That said, audience characteristics (e.g., demographic factors) may affect how argument strength is related to intention. Although subsequent analyses showed there was no difference in the perceived argument strength-intention relation between White and non-White youth in our sample, other characteristics may be important to consider. In contrast to perceived argument strength, beliefs about the effects of consuming SSBs were related to intention to cut back but were not changed by any of the emotional appeals. This finding may present an opportunity for public

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Table 3. Structural equation modeling results on the effect of experimental condition on mediators (N ¼ 805) Experimental condition (referent: control condition) Appeal Argument strength Negative emotions Empower and hope Nurture and protect Positive emotion Self-efficacy Stigma Threat to choice Positive beliefs about sugar-sweetened beverages Negative beliefs about sugar-sweetened beverages

Humor

Fear

0.05 (.10) 0.35 (.10) 0.15 (.13) 0.86 (.19) 0.34 (.19) 0.11 (.18) 0.42 (.13) 0.02 (.10) 0.58 (.20) 0.14 (.09) 0.02 (.09)

0.11 (.11) 0.81 (.11) 1.20 (.15) 0.39 (.20) 0.03 (.20) 0.88 (.18) 0.74 (.14) 0.63 (.13) 1.11 (.21) 0.04 (.10) 0.10 (.10)

Nurturance 0.12 0.72 0.56 0.02 0.55 0.21 0.80 0.16 0.45 0.03 0.05

(.10) (.10) (.14) (.22) (.22) (.19) (.12) (.10) (.18) (.09) (.09)

R2 .012 .18 .15 .05 .04 .075 .12 .096 .074 .011 .004


Note. Values are expressed as b (SE). p < .05. p < .01. p < .001.

health professionals to dispel some of the positive beliefs (such as SSBs will give you energy) held by adolescents and leverage the negative beliefs (such as SSBs will make you gain weight). The beliefs used in the analysis were selected because they tied to the content of the tested PSAs. However, the absence of an experimental effect suggests that stronger arguments which highlight the negative effects of SSB consumption and counter-argue the positive ones may be necessary. The failure of the PSAs to affect beliefs about SSB consumption is an important finding. First, theoretical models such as the Integrative Model of Behavior Change and Prediction (Fishbein & Ajzen, 2010) posit that changing the underlying beliefs associated with the determinants of intention (attitudes, normative pressure, efficacy=control) are necessary for change in intention and ultimately behavior. Evidence-based campaigns designed specifically based on beliefs salient to the target audience are in general more effective in producing the desired behaviors (Fishbein & Cappella, 2006; Fishbein & Yzer, 2003; Jordan, Bleakley, Hennessy, & Vaala, in press). Although the PSAs in this Table 4. Structural equation modeling results on the effect of the mediators on intention to cut back on sugary drinks (N ¼ 805) Mediator

b (SE)

Appeal Argument strength Negative emotions Empower and hope Nurture and protect Positive emotion Self-efficacy Stigma Threat to choice Positive beliefs about sugar-sweetened beverages Negative beliefs about sugar-sweetened beverages Note. Goodness-of-fit statistics: RMSEA ¼ 0.07. R2 ¼ .31. p < .05. p < .01. p < .001.

v2(7) ¼ 32.445,

0.02 (.13) 0.60 (.21) 0.02 (.08) 0.16 (.08) 0.04 (.09) 0.09 (.04) 0.29 (.17) 0.13 (.11) 0.02 (.06) 0.30 (.12) 0.68 (.14)

p ¼ .00.

CFI ¼ .99,

experiment were not persuasive enough to change the specific beliefs associated with intention, it is possible that they affected beliefs that were unmeasured. The findings here illustrate the challenge of crafting effective health messages for adolescents. The persuasive appeals in these beverage-related PSAs failed to consistently change correlates of intention, which highlights the need to identify the correlates of intention prior to message development. Effective PSAs must affect specific cognitive beliefs that are also positively related to intention. Messages can maximize their influence on behavioral outcomes by focusing on content that affects as many as possible relevant correlates. Formative research to identify the behaviors of interest and the underlying beliefs associated with the behavior is a critical step in campaign development (Fishbein & Cappella, 2006) Although more elaborate processes that may involve elicitation studies, focus groups, and=or theory-based surveys of the target audience will yield the most detailed and useful information (Jordan, Piotrowski, Bleakley, & Mallya, 2012), it is often the case that a lack of resources such as time and funding may prevent their implementation. Any accommodation that can be made for formative research, even of a limited variety, will increase the potential for a campaign to be successful. In the context of public health campaigns, one or two exposures to specific PSAs are rarely expected to change behavior. Rather, campaign designers anticipate that some interaction of exposure to multiple PSAs along with other strategies such as those related to beverage access (e.g., in school settings) or price will encourage behavior change. Compared with state and federal fiscal support of tobacco control programs, antiobesity initiatives are in their early stages, and relative to controversial policy initiatives such as taxes on SSBs (Barry, Niederdeppe, & Gollust, 2013) and portion size limits, mass media efforts are a feasible approach to reducing obesity and related conditions because they attempt to affect demand directly. Another consideration is how SSBs are portrayed in mass media. The findings here are particularly unique because unlike other health campaign topics (e.g., smoking and drugs) advertising for SSBs is pervasive. Also, PSAs focused on these well-known risky behaviors (e.g., smoking, drugs)

945

Sugary Drink PSA Message Testing Table 5. Summary of indirect effects from experimental conditions to intention to cut back on sugary drinks Experimental condition Humor

Fear


Nurturance

Mediator ! ! (–) ! ! ! ! ! (–) ! ! ! ! ! ! ! !

Outcome

Indirect effect paths (p)

Argument strength Empowerment and hope Self-efficacy Threat to choice Total indirect effects

! !

Argument strength Negative emotions Positive emotions Self-efficacy Stigma Threat to choice Total indirect effects

!

b ¼ 0.762, SE ¼ .204

.000

Argument strength Negative emotions Nurture and protect Self-efficacy Threat to choice Total indirect effects

!

.007

Positive beliefs about sugar-sweetened beverages (–) Negative beliefs about sugar-sweetened beverages

! !

Intention Intention

b ¼ 0.149, SE ¼ .166

.033 .040

.370

Intention

Intention

b ¼ 0.751, SE ¼ .164

.000

Intention Intention

Note. Arrow (!) represents a statistically significant path. All paths are positive unless otherwise indicated with a minus sign (–).

act more as reminders about their potential dangers than by offering the audience new information. SSB PSAs differ in this regard from other campaigns by attempting to discourage consumption of beverages that are widely consumed, are often acceptable in moderation, and are heavily and strategically advertised. The information on anti-SSB PSAs provide may be new and more thought provoking, and perhaps can rely more on the messages’ arguments rather than emphasizing high sensation messages that grab attention. Limitations There may have been some selection bias among the teens who agreed to participate in this study that was not corrected by random assignment to condition or sampling weights. However, because this was an experimental study the limitations of the sample are not as problematic as they would be in cross-sectional research. It is also possible that because the PSAs in the control condition encouraged physical activity, which in addition to SSB consumption can be a correlate of obesity and other poor health indicators, differences between the experimental and control conditions could be underestimated. Another limitation of this study is the use of existing PSAs, some of which targeted a general audience and some of which were more oriented to adolescents. Finally, while meta-analysis demonstrates an association between intention and behavior (Kim & Hunter, 1993; Sheppard, Hartwick, & Warshaw, 1988), we are unable to determine if the exposure to a particular appeal was associated with subsequent behavior change given the design of the study.

Conclusion Following in the tradition of antitobacco and antidrug public service advertising, PSAs about sugary drinks represent a new but potentially powerful way to produce behavior change and impact the obesity epidemic among children and adolescents. PSAs using humor, fear, or nurturance affected both emotional and cognitive correlates of adolescents’ intention to cut back on sugary beverage consumption. Messages to reduce SSB consumption should address beliefs about SSBs that are related to intention and future research should also investigate other PSA elements (e.g., a celebrity endorsement) that might also affect the PSA strategyintention association.

Acknowledgments The authors thank Giridhar Mallya and Gretchen Van Wye for their thoughtful feedback and consultation.

Funding This study was funded by Healthy Eating Research, a national program of the Robert Wood Johnson Foundation.

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Appendix Detailed items for all hypothesized mediator constructs


Hypothesized mediator

Items

Response categories

a

Appeal (1 item)

The video I just watched . . . . . . is one that I liked overall

1 (strongly disagree) to 5 (strongly agree)

—

Argument strength (8 items)

The video I just watched . . . . . . is believable . . . is convincing . . . gives a reason for cutting back on sugary drinks that is important to me . . . helped me feel confident about to best cut back on sugary drinks . . . put thoughts in my mind about wanting to cut back on sugary drinks . . . put thoughts in my mind about not wanting to cut back on sugary drinks . . . gives strong reason for cutting back on sugary drinks . . . would help my friend cut back on sugary drinks


.92

Emotional responses

Positive emotions: happy, content, amused Negative emotions: fearful, sad, guilty, angry, disgusted Empowerment and hope Nurturing and protective

1 (none of this feeling) to 7 (a great deal of this feeling)

.77 .91 r ¼ .88 r ¼ .84

Self-efficacy (1 item)

The video I just watched . . . . . . makes me feel able to cut back on sugary drinks


—

Stigma (3 items)

The video I just watched . . . . . . promotes negative attitudes about obese people . . . is one that increase blame towards people for being obese . . . stigmatizes people who are obese

Threat to choice (4 items)

The videos I just watched . . . . . . tried to make a decision for me . . . tried to manipulate me . . . tried to pressure me . . . threatened my freedom to choose

Positive beliefs about sugar-sweetened beverages (4 items)

There are different ideas about the effects of consuming sugary drinks. Indicate the extent to which you think that drinking sugary beverages . . . . . . satisfies thirst . . . makes people feel energized . . . makes people feel good . . . is good for a special occasion

.89

Negative beliefs about sugar-sweetened beverages (9 items)

There are different ideas about the effects of consuming sugary drinks. Indicate the extent to which you think that drinking sugary beverages . . . . . . causes people to be overweight . . . leads to type 2 diabetes . . . increases the number of calories people consume . . . eventually makes people crash . . . leads to sugar addiction . . . leads to heart disease . . . leads to stroke . . . leads to cancer . . . makes it harder to focus in school

.73

.93


.91

Self-regulation interventions to reduce consumption of sugar-sweetened beverages in adolescents.

Symptoms Attributed to Consumption of Caffeinated Beverages in Adolescents.

Public Acceptability in the UK and USA of Nudging to Reduce Obesity: The Example of Reducing Sugar-Sweetened Beverages Consumption.

Appeals used in advertisements for psychotropic drugs: an exploratory study.

Artificially sweetened beverages--do they influence cardiometabolic risk?

[Demographic and socioeconomic differences in consumption of sugar-sweetened beverages among Colombian children and adolescents].

Do drug advertisements provide therapeutic information?

Differential Impact of Message Appeals, Food Healthiness, and Poverty Status on Evaluative Responses to Nutrient-Content Claimed Food Advertisements.

Content Analysis of Food and Beverages Advertisements Targeting Children and Adults on Television in Sri Lanka.

Emotional expressions in antismoking television advertisements: consequences of anger and sadness framing on pathways to persuasion.

[Nutritional content of food, and nonalcoholic beverages advertisements broadcasted in children's slot of Colombian national television].

[Surveillance of antibiotic consumption in hospitals: tasks of the Public Health Service].

Parental versus peer influence on adolescents' alcohol consumption.

Appeals.

Public Perceptions of Service Dogs, Emotional Support Dogs, and Therapy Dogs.

Consumption of beverages and food during labour in diabetic women.

Effectiveness of advice to reduce alcohol consumption in hypertensive patients.

Estimating the benefits of public health policies that reduce harmful consumption.

Using the theory of planned behavior to understand caregivers' intention to serve sugar-sweetened beverages to non-Hispanic black preschoolers.

Consumption of methylxanthine-containing beverages and risk of pancreatic cancer.

Do managed alcohol programs change patterns of alcohol consumption and reduce related harm? A pilot study.

Visual attention to alcohol cues and responsible drinking statements within alcohol advertisements and public health campaigns: Relationships with drinking intentions and alcohol consumption in the laboratory.

MEDIACONNEX: a multicenter randomised trial based on short message service to reduce suicide attempt recurrence in adolescents.

Moderate amounts of fructose- or glucose-sweetened beverages do not differentially alter metabolic health in male and female adolescents.