Health decision making - Wiley Online Library

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DOI: 10.1002/arcp.1008

RESEARCH REVIEW

Health decision making Janet Schwartz A.B. Freeman School of Business, Tulane University, New Orleans, LA, USA Correspondence Janet Schwartz, A.B. Freeman School of Business, Tulane University, New Orleans, LA, USA. Email: [email protected]

Abstract Health decision making has become a fundamental part of everyday consumer life. In the relatively simple course of making a meal choice, planning a trip to the gym, or forgetting to pick up a prescription, consumers’ routine choices will cumulatively define their health. In this article, we will explore the marketplace forces that shape health decisions by drawing on classic and contemporary research from marketing, psychology, and health. KEYWORDS

consumer health behavior, goal activation, self-control

1 |  INTRODUCTION

of these policies is to make individuals more accountable for their

1.1 | Everyday decisions are health decisions

consumption behaviors by making them more directly responsible for sharing the financial cost of their poor lifestyle choices. In accordance

Good health is something most people value, so making good health

with these cost-­containing objectives, complementary marketplace

decisions is important. Everyone, regardless of age, gender, socioeco-

rules and efficiencies emerge to ensure that consumers have the

nomic status, ethnicity and racial background, makes health decisions,

necessary resources and motivation to help them make better health

and thus understanding how and why people make these decisions

decisions. The goal of this paper is to review the classic and recent re-

is also a priority. While there can be stark demographic disparities in

search on how consumers make decisions at this intersection of com-

health, even within wealthy industrialized nations (Chetty et al., 2016),

merce and public policy.

broader access to convenient and inexpensive resources increasingly makes it easier for almost all consumers to make good health choices. At the same time, population-­level metrics tell us that overall peo-

1.2 | A more health-­focused marketplace

ple are not necessarily becoming healthier or living longer and that

Marketplace efforts to improve everyday health decision making

health care continues to consume a large percentage of all nations’

often begin by making health-­relevant information easier for consum-

GDP. Americans, quite notably, are living shorter and less healthy lives

ers to access, use, and understand. For example, mandatory calorie

despite having the world’s most expensive healthcare system (Squires

and nutrition labeling on grocery and restaurant menu items helps

& Anderson, 2015). In this paper, we explore health-­related decisions

consumers find healthy food and beverage options and avoid or mod-

in the context of everyday life, where moment-­to-­moment choices

erate their consumption of less healthy items. Similarly, ubiquitous

are shaped by a variety of forces that can ultimately have a profound

warning labels and graphic images on tobacco products immediately

impact on consumers’ health.

convey the harms of tobacco to anyone who buys them. Other efforts

The drivers of healthcare costs are complex, but we know that

take advantage of new technology to reduce friction in the consumer

everyday decisions contribute substantially to individual and societal

experience and minimize the number of actions or the amount of ef-

health-­related expenses (Finkelstein, Trogdon, Cohen, & Dietz, 2009).

fort required to make a healthy choice. For instance, automatic pre-

Sometimes without realizing it, benign consumer choices regarding

scription refills and SMS-­based medical appointment reminders help

diet, exercise, tobacco use, and medication adherence translate into

people seamlessly incorporate health choices into their daily routines.

billions of dollars annually in direct and indirect medical costs (Mokdad

Health-­conscious consumers can log or track their daily exercise, calo-

et al., 2004). In response, the government officials, health insurers,

rie consumption, and sleep quality through various web-­enabled de-

and employers who often subsidize citizens’ health-­related expenses

vices and smartphone apps. These devices provide real-­time feedback

create consumer-­focused initiatives to control costs. A collective goal

about health metrics and progress toward health goals. Finally, the

Consum Psychol Rev. 2018;1:107–122.

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marketplace offers financial incentives to encourage healthy behav-

to engage in such unhealthy behaviors, it must be because of a ra-

iors and discourage unhealthy behaviors through various discounts,

tional calculus that deemed the benefits outweigh the risks. In that

rewards, penalties, and taxes—all of which are intended to motivate

case, giving incentives that make risky behaviors more costly should

better decision making by increasing the immediate salience of health

be able to shift the calculus in favor of healthy behaviors.

or the financial cost of making poor health decisions.

Such assumptions of rationality in decision making are important to

Consumer-­driven health care also generates significant market-

understand because they dominate both the early literature, and sub-

place opportunities for commercial stakeholders, who see profits in

sequently, how marketplace regulations and efficiencies are designed

the increased demand for products and services that guide people

to facilitate good health decisions. Reliance on these assumptions

toward healthier choices. Recent research shows how, with the help

persists today, where the first-­line response to almost any emerging

of technology, consumers’ data-­rich engagement with these prod-

health concern is to increase awareness and give information. If that

ucts and services provides real-­world insight into their health-­related

tactic fails to change people’s behavior, we start to see incentives in

decisions. For example, data from health-­focused information web-

the form of subsidies and taxes that make healthy options more finan-

sites (Adjerid, Acquisti, Telang, Padman, & Adler-­Milstein, 2015; Tian

cially attractive and unhealthy options less attractive. And if that tactic

et al., 2014) and mobile apps (Huyghe, Verstraeten, Geuens, & Van

also fails, regulators may go so far as to restrict access or ban the sale

Kerckhove, 2017; Van Ittersum, Wansink, Pennings, & Sheehan, 2013)

of certain items or services. While these approaches can be both well

shed light not only on how and when people search for health-­related

intended and received, research from the behavioral sciences shows

information, but how they use it in real-­time consumer decisions. Data

that the underlying assumptions of rationality do not adequately cap-

that combine customers’ health activities and Facebook user insights

ture how people really make decisions in many important consumer

show that simply liking a healthcare company’s Facebook page can sig-

domains (e.g., Tversky & Kahneman, 1986). As a result, the policies put

nificantly increase engagement in off-­line health behaviors (Mochon,

in place to help people make better choices are not always optimally

Johnson, Schwartz, & Ariely, 2017). As technology gives us a more

designed (Thaler & Sunstein, 2008).

comprehensive view of daily life, researchers are gaining a better understanding of how and where health decisions are really made.

To be fair, rationality-­based efforts to drive healthier marketplace decisions with better information or incentives, like calorie labeling

Contemporary research is also increasingly able to look at consumer

and cigarette taxes, sometimes do help people consume fewer calo-

health decisions over time, which gives new insight into how people’s

ries (Bollinger, Leslie, & Sorensen, 2011; Policastro, Palm, Schwartz,

habits may develop and change. For example, data from commercial

& Chapman, 2017) and less tobacco (Jha & Peto, 2014). However, the

rewards programs show us how consumers navigate a marketplace

success of this general approach is limited. Recent sales and popula-

that, like many customer rewards programs, turns their healthy food

tion health metrics indicate that many people still to not make health-

purchases, exercise activity, and routine health screenings into valu-

ier choices with better information, more education, or greater access

able points and savings (Mochon, Schwartz, Maroba, Patel, & Ariely,

to healthy options. So while these efforts may improve the behavior

2016; Schwartz et al., 2014). Finally, longitudinal databases span gen-

of some people, they do not improve it enough to see a real change

erations of information to identify the early-­development factors that

in consumption behaviors and a reduction in their associated burden-

influence adult health decision making (Mittal & Griskevicius, 2016).

some costs (Go et al., 2014).

These are just a few examples of how user-­generated information informs a more modern perspective on health decision making. In what follows, we will discuss how these insights further our knowledge by challenging the assumptions of traditional theories and testing their boundaries in the wild.

2.1 | Identifying and closing intention → behavior gaps As consumers’ real health behaviors clashed with normative expectations about how they would behave if they were rational, research-

2 |  MODELS OF HEALTH DECISION MAKING

ers began focusing on understanding why people stop taking their medication, overeat, or fail to get enough exercise when it is clear that these behaviors are harmful to their health (Ajzen, 1985, 1991). Interestingly, early evidence suggested that while information alone

Like many models of decision making, assumptions of rational-

did not sufficiently change behavior, it improved a variety of other

ity shaped early perspectives on how people make health decisions

health-­related beliefs such as knowledge, awareness, attitudes, and

(e.g., Becker, 1974). In the rational theorist’s view, individual health

intentions (Leventhal, Singer, & Jones, 1965). Such findings began

decisions are made by calculating the risks and benefits of certain be-

to reveal something very important about the challenge of achieving

haviors. As long as people are well informed about these risks and

good health: People often know what is good for them, they want to

benefits, we can assume that their choices will maximize their self-­

make healthier choices, and they know exactly what they should be

interest. Thus, simply making individuals aware the health-­related

doing to achieve their health goals. Where they struggle, however, is

dangers of smoking, overeating, forgoing an annual flu shot, or skip-

translating their knowledge and good intentions into real behaviors,

ping medication refills should change their behavior in order to mini-

even when there is a lot of support (e.g., Webb & Sheeran, 2006).

mize those risks. Moreover, if well-­informed people start or continue

Thus, while normative expectations of rational consumers might not

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adequately capture how people behave, they remain prescriptively

donation), we begin to see how trivial choice features can routinely

consistent with consumers’ aspirations and ideals about how they

lead to unhealthy decisions and, over time, accumulate into undesir-

should behave.

able effects on health.

Identifying discrepancies between healthy intentions and actual

The framing and positioning of products and services in the mar-

behaviors is crucial to understanding health decision making. First,

ketplace is often under the control of various stakeholders. When their

it provides a framework for identifying the forces that create these

interests are not aligned with consumers’ health goals, it creates an

gaps. Second, it allows researchers to develop and test theories

external force that makes it difficult to close the gap between healthy

about how to close the gaps. For example, external forces can cre-

intentions and good behaviors. The reality of today’s marketplace is

ate both real and perceived barriers to following through on good

that while some stakeholders do indeed deliver products and services

intentions by disrupting information access or processing, impos-

that are designed to improve individual health decisions, others ensure

ing costs, or making healthy choices less convenient. Internal forces

that for every 100 steps the health-­conscious consumer logs on her

can create psychological obstacles to healthy actions when people

Fit Bit, there is at least one Dunkin’ Donuts, Starbucks, cigarette, or

are poorly motivated, struggle to satisfy competing goals, or have

Netflix binge along the way (Schwartz, 2015; Schwartz & Ariely, 2016).

inadequate self-­control. These external and internal forces can op-

The allure of these pit stops is very deceptive because an individu-

erate independently or combine to create barriers that are difficult

al’s health status is cumulatively defined by many preceding behav-

to overcome, even among those who really want to act healthfully.

iors, which occur over many preceding years. There is no single donut,

Once these barriers are identified, the efficacy of approaches to re-

Frappuccino, or cigarette that feels too dangerous or to single out as

moving them can be tested. In the next sections, we will discuss

the cause of a decades-­later diagnosis of heart disease, diabetes, or

research that focuses on identifying the external and internal forces

cancer. The disconnect between any one consumption experience and

responsible for creating intention–behavior gaps and developing

its negative impact on health widens the intention–behavior gap, and

strategies to close them.

makes it that much easier for today’s benign consumer choices to accumulate into tomorrow’s costly patient burdens (Vita, Terry, Hubert,

3 | EXTERNAL FORCES THAT INFLUENCE HEALTH DECISIONS

& Fries, 1998).

3.1 | External forces can operate unconsciously

Some of the biggest challenges to the assumption that people make

In a busy and dynamic marketplace, research shows that trivial prod-

rational decisions comes from research showing that subtle, and

uct features can impact health decisions without consumers’ con-

largely irrelevant, features of choice environments affect people’s

scious awareness (see Krishna, 2012 for a sensory marketing review).

choices (Tversky & Kahneman, 1986). As an example, consider the

As information floods in through all five senses, it shapes people’s

well-­known finding that the decision to register as an organ donor

expectations and experiences. This process is especially well docu-

can vary much more as a function of whether someone must opt-­in

mented in food decisions, where considerable research shows that the

or opt-­out of a program than as a function of their altruistic motiva-

tendency to overeat can be influenced by unconscious visual cues.

tions (Johnson & Goldstein, 2003). Similarly, research has shown that

Cues about how much food to order, serve, or consume are activated

framing a surgical treatment as having a 5% mortality rate versus a

by a variety of sources that include ambient lighting (Biswas, Szocs,

95% survival rate makes it seem subjectively riskier and consequently

Chacko, & Wansink, 2016), the appearance and description of portion

reduces the likelihood that surgery will be chosen, even when it is ob-

sizes (Wansink, 2004), serving containers (Van Ittersum & Wansink,

jectively the best treatment option for a particular patient (Edwards,

2011), and even the size of food labels (Aydinoğlu & Krishna, 2010).

Elwyn, Covey, Matthews, & Pill, 2001). In both cases, the choice is

Throughout the marketplace many visual cues can make it difficult for

the same—people either decide to become organ donors or to have

consumers to even appropriately judge how much food to order or

surgery or they do not, so the framing and positioning of the options

eat (Schwartz, Riis, Elbel, & Ariely, 2012). As a result, they are prone

should not matter. But these factors do matter, even in important de-

to mindlessly consuming hundreds of unnecessary and unwanted

cisions where people really care about what happens and take a lot of

calories at every single meal (Wansink, 2004). Over time, these deci-

time to reason through their choices.

sions contribute to the overweight and obesity that drive poor health

It stands to reason that if relatively high-­stakes decisions are so

(Zlatevska, Dubelaar, & Holden, 2014).

susceptible to context effects, then more routine choices will be also.

Documenting the power of sensory cues to influence how much

For instance, research shows that beverages placed at eye level or next

food people buy and consume challenges some intuitive assumptions

to the cash register are more likely to be purchased and consumed than

that individuals have full control over eating and drinking behavior,

beverages placed in less noticeable and convenient locations, regard-

and perhaps more importantly, that the best way to help them self-­

less of whether they are healthy or unhealthy (Thorndike, Sonnenberg,

regulate is to make nutrition information more transparent. Because

Riis, Barraclough, & Levy, 2012). Considering that consumers make

overeating is the primary cause of obesity (Cutler, Glaeser, & Shapiro,

dozens of decisions about what to eat and drink throughout the day

2003), consumer psychologists make it a priority to identify how vi-

(compared to very few lifetime decisions about surgery and organ

sual cues lead people to consume unnecessary calories—often without

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110      

ever feeling that they have consciously overeaten. For example, ambi-

that it is more effective at reducing bacteria than sweet minty mouth-

ent lighting induces overeating by making food look more attractive;

washes. Manufacturers of health-­related products routinely add in-

it not only appears tastier, but people also judge that it is higher in

gredients to balms and elixirs that create sensations of heat, cold,

calories than the same food under less attractive lighting. In turn, this

burning, or stinging to foster perceptions that a product is working.

visual cue increases patrons’ appetites and causes them to eat more

Olfactory cues also invoke perceptions of product efficacy and drive

(Biswas et al., 2016).

consumption because they smell medicinal (Krishna, 2012; Krishna

Research has shown that consumers unconsciously regulate food

et al., 2013). For example, a product like Vick’s Vapo Rub might not

intake through visual cues provided by packaging and plate sizes

feel so soothing without its knowing menthol smell. Insights about

(Chandon, 2012). For example, diners feel more satiated after consum-

consumers’ sensitivity to these sensory experiences are often lev-

ing five ounces of ice cream from a 6-­ounce cup than five ounces of ice

eraged in the competitive marketplace (Deng & Srinivasan, 2013),

cream from a 12-­ounce cup. This phenomenon suggests that people

where visual, oral, olfactory, and haptic sensations persuade people

judge the appropriateness of a portion size by its volume relative to

to buy products that can help them meet their health goals (Shen,

the container, not its absolute volume. When a 5-­ounce portion fills

Zhang, & Krishna, 2016).

the container, it looks complete and consumers feel satisfied enough to stop eating. If, however, a serving takes up less than half the container, it looks deprived. Consumers not only report feeling less sati-

3.2 | External forces create expectations

ated, but are also inclined to continue eating above and beyond what

Health decisions are often susceptible to external forces like context

is nutritionally appropriate (Wansink & Chandon, 2014).

effects and sensory cues because they foster expectations. When

Visual cues can also drive how people consume products depend-

portion sizes appear abundant, diners have a more satisfying expe-

ing on whether or not they are wrapped into individual servings. For

rience in part because their expectations about the appropriateness

example, someone who consumes five cookies from a box of 100

of serving sizes have been met (Chandon & Wansink, 2012). These

cookies feels less satisfied than someone who ate five cookies from

expectations go beyond mere perception when consumers’ cognitive

a box with 20 individually wrapped packages of five cookies (Ilyuk &

evaluations of products’ prices (Waber, Shiv, Carmon, & Ariely, 2008),

Block, 2015). In the unconstrained box, it is difficult for consumers to

warning labels (Andrews, Netemeyer, Kees, & Burton, 2013), and ef-

regulate their portions because the relative volume of the remaining

ficacy claims subsequently influence their judgments of risk (Samper

cookies drives satiety cues. A box of 100 cookies that is only missing

& Schwartz, 2013), real experiences, and even their outcomes (Irmak,

five still looks pretty full, so there is no visual or informational cue,

Vallen, & Robinson, 2011).

such as an empty packet, to signal the discrete stopping point that

The most classic demonstration of the power of expectations in

helps consumers feel satiated and stop eating. Moreover, taking an-

health is the placebo effect (Beecher, 1955), whereby telling people

other individually wrapped 5-­cookie pack from the box of 20 seems

that medication will relieve symptoms leads to experienced symptom

indulgent because opening a second package exceeds the recom-

relief, even when the medicine has no active ingredients (Price, Finniss,

mended serving size. Although recommended serving sizes can be

& Benedetti, 2008). More recently, our understanding of placebo ef-

quite arbitrary, research has shown that they operate as an important

fects has expanded to show that they can be quite reliably produced

external reference point in determining what is an appropriate amount

by a variety of product attributes. For example, price creates a type of

to eat. Thus, recommended serving sizes are one of many external cues

placebo effect where people report feeling less pain from an electric

that can help customers see that portions are nutritionally appropri-

shock after taking an expensive, but fake, medication than after taking

ate (Chandon & Wansink, 2012; Wansink & Chandon, 2014; Wansink,

a cheap, and also fake, medication (Shiv, Carmon, & Ariely, 2005).

Payne, & Chandon, 2007). In fact, some consumers are reluctant to

Research that explores the boundaries of placebo effects informs

exceed serving size recommendations because it makes them more

our understanding of contemporary health decision making issues. For

consciously aware of overeating, which can induce feelings of guilt

example, although consumers can substantially reduce their out-­of-­

(Mohr, Lichtenstein, & Janiszewski, 2012).

pocket expenditures by switching from branded medications to less

Visual cues are not the only sensory-­based inputs that uncon-

costly generics, they often do not. Their tendency to overspend on

sciously affect consumers’ food regulation in surprising ways (e.g.,

branded medications may be partially driven by expectations that their

Krishna, Morrin, & Sayin, 2013). For example, a food’s texture pro-

higher price tags make them more effective, and if this price placebo

vides sensory information about fat content (Biswas, Szocs, Krishna,

effect also influences their experienced symptom relief, then those

& Lehmann, 2014). Foods that taste smoother and creamier are per-

intuitions are reinforced. Recent research has shown that placebo

ceived to have relatively higher fat content, which leads to people

effects can even be produced by advertising, as people experience

to both adjust their portion sizes and become more quickly satiated.

greater symptom relief from medications that are directly advertised

Findings such as these suggest that even with increased transparency

to consumers relative to competitors that are not (Kamenica, Naclerio,

in the food marketplace, such as calorie and nutrition labels, visual

& Malani, 2013).

cues can unconsciously inform consumers’ nutritional judgments.

Placebo effects have mixed implications for consumer welfare.

Strong tastes similarly convey health information about other

On the one hand, creating expectations that cause the mind and

products. For example, Listerine’s medicinal taste gives the perception

body to heal itself is beneficial by reducing exposure to unnecessary

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medical procedures, medication risks and treatment side effects (Shiv

price affects health decisions, especially in the context of everyday

et al., 2005). However, there are instances where placebo effects

consumer life (Schwartz, 2015).

can be harmful. For example, placebo effects driven by increased

In today’s literature, there is greater emphasis on understanding

direct-to-consumer advertising may disrupt randomized controlled

how prices influence health decision making because consumers have

drug trials because some people may, particularly if they create strong

a much greater cost-­sharing responsibility. As part of managing their

perceptions of value among only certain consumer segments (Carter,

spending on healthcare goods and services, they must make choices

Jambulingam, & Chitturi, 2015). Moreover, erroneous perceptions that

that prevent illness and disease. However, in everyday decisions about

one drug is better than another simply because it is more expensive,

diet, exercise, taking medication, or limiting tobacco use, being healthy

or it is directly advertised, or it is manufactured by a familiar brand

is only one of many important goals (for a review of goal-­directed be-

can undermine critical efforts to help reduce consumers’ unnecessary

havior, see Touré-­Tillery & Fishbach, 2018). Although consumers may

healthcare costs.

aspire to make healthier choices, they also want to save time and

As another example of the mixed implications of placebo ef-

money and have fun. In today’s marketplace, individuals’ health, finan-

fects, consider recent evidence of “wear-­off bias.” Wear-off bias is a

cial, and hedonic goals are often pitted against one another, which

placebo-­related phenomenon whereby participants believe that the

means that closing the gap between healthy intentions and behaviors

effects of a memory-­enhancing medication wear-off faster during a

can come at the real or perceived expense of leaving other gaps open

subsequently challenging (vs. easy) recall task (Ilyuk, Block, & Faro,

(e.g., Haws, Reczek, & Sample, 2017; Haws & Winterich, 2013).

2014). Wear-off bias suggests that consumers perceive a correlation

How people balance their goals to be healthy with other everyday

between the strength of their symptoms and how long a particular

priorities is an important topic in the consumer health literature. Much

drug can effectively manage them. Of course, potency duration does

research is devoted to identifying the forces that govern health goal

vary, but it is unlikely to be diminished because a drug works harder

salience to understand why it is so challenging for consumers to close

to manage some symptoms than others. Such findings raise two po-

the gap between their healthy intentions and real behaviors, especially

tentially important implications for health decisions. First, it is dan-

as the availability of healthier options increases. Nutrition decisions

gerous for people to believe that medication is sensitive to symptom

are once again fertile ground for testing goal-­related theories because

severity if it leads them to exceed recommended dosage amounts or

even very simple eating and drinking choices create competition be-

frequency. At the same time, there is some benefit to knowing that

tween many important goals. For example, consider the ubiquitous

recommended dosage intervals can produce placebo effects because

food service practice of bundling several food items, such as an en-

it implies that the experienced pain relief from the same dose of med-

trée, side dish, and beverage, into “value” meals. On the one hand,

ication could vary simply by stating it should be taken every 6–8 hr

these meals save consumers time and money, which are important

instead of every 4–6 hr. As such, these findings illuminate a potential

goals to satisfy. However, the typical value meal at a fast-­food or chain

intervention path whereby the overuse of certain classes of medi-

restaurant often approaches or exceeds the average sized adult’s en-

cation might be curtailed by simply extending people’s expectations

tire daily caloric needs, which results in indulgence and contributes

about when the drug will wear off. These insights might be particularly

to excess weight. Although consumers are often aware that restau-

useful for drugs that carry a high risk of dependency and are relatively

rant portions are too big (e.g., Schwartz et al., 2012), the continuing

susceptible to placebo effects, such as pain medication (Webster &

popularity of these meals suggests that value and convenience goals

Webster, 2005).

can easily override health goals in routine food choices (Haws, Reczek et al., 2017; Haws & Winterich, 2013).

4 | INTERNAL FORCES THAT INFLUENCE HEALTH DECISIONS 4.1 | Being healthy is only one of several competing goals

Research suggests there are a number of reasons why value trumps health in everyday decisions. With respect to food choices, breaking a meal bundle by substituting healthier options or by forgoing a side dish, beverage, or dessert usually results in higher costs. This practice eliminates the hedonic boost people experience from getting a deal and makes the purchase seem less justified. Next, consumers

Traditional models of health decision making were either very patient-­

have also become accustomed to eating and drinking certain items

focused or treated health as somewhat independent of other routine

together, so their overall experience can depend on complementary

choices. As mentioned earlier, these models often capture how people

pairings. If consumers expect that a cheeseburger will not taste as

make risk–benefit trade-­offs when deciding between treatments or

good without French fries and a coke, they are also likely to have that

whether to engage in certain behaviors. For example, some patients

experience and, consequently, lower overall satisfaction with their

decide to take medications that are less effective than others because

meal. Moreover, while the financial and hedonic costs of unbundling a

they lower the risk of experiencing unpleasant side effects. Likewise,

meal may be immediate and clear, there is no obvious corresponding

some people exercise because they see that the benefit of being ac-

health boost to offset feelings of sacrifice. The health benefit of forgo-

tive reduces the risk of future cardiovascular disease. While many

ing a side dish or substituting water for a sugar-­sweetened beverage

early health belief models acknowledge that cost could be a factor

at any one meal is relatively small, which makes any one-time decision

in how people make these trade-offs, very few really captured how

difficult to connect to the overall goal of being healthy.

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112      

As consumers struggle to make healthier nutrition choices, food

healthy options ironically causes less healthy choices. For example,

and beverage marketers are increasingly scrutinized for practices that

some studies have shown that participants estimated a hamburger

facilitate poor decisions and directly contribute to rising obesity rates

with lettuce and tomato to contain fewer calories than did partici-

(Young & Nestle, 2002). Some argue that food marketing is harmful to

pants who rated a plain hamburger (Chernev, 2011; Jiang & Lei, 2014).

health because it so efficiently coordinates the internal and external

Such findings tell us once again that even in today’s nutritionally trans-

forces that create psychological bias and cause overeating (Chandon

parent marketplace, consumers are not particularly good at estimating

& Wansink, 2012). For example, value meals disadvantage consumers

the number of calories in individual meal components. Adding a few

by imposing an aversive financial penalty for switching to healthier

healthy ingredients or items provides an additional cue, albeit one that

choices and by encouraging unconscious overeating with oversized

distorts the perceived healthfulness of an item.

portions. In response to growing concerns and even consumer back-

Research has also shown that adding healthy options to fast-­food

lash, some popular restaurant chains have reduced portion sizes and

menus creates psychological complexity with respect to how consum-

increased the flexibility of their meal bundles to include healthier op-

ers manage competing goals. Some evidence suggests that adding a

tions. For example, McDonald’s no longer serves “supersized” meals

healthy option to a mostly unhealthy menu increases the sales of un-

and makes it easier for patrons to substitute healthy items like water

healthy options because it forces people to make a discrete choice

and fruit for high-­calorie items like sugar-­sweetened beverages and

between being healthy or unhealthy. As the healthy option is less

French fries. These substitutions are psychologically important be-

likely to be hedonically appealing and perhaps more expensive than

cause they restrict the number of calories patrons can “mindlessly”

the unhealthy alternatives, consumers are more likely to choose to be

consume and reduce the friction they experience when health goals

unhealthy. And once patrons explicitly choose tasty burgers over blah

compete with financial goals.

salads, they feel licensed to include fries and sugary beverages as part

As new regulations require greater nutritional transparency, candy

of their unhealthy choice (Wilcox, Vallen, Block, & Fitzsimons, 2009).

and beverage manufacturers are also reformulating their recipes

Additional research has shown that when fast-­food customers

and voluntarily reducing portion sizes (Affordable Care Act, 2010;

encounter salads and other healthy menu items, they can experience

Moorman, Ferraro, & Huber, 2012). Such self-­regulatory moves bring

negative affect from being reminded to make a healthy, but less satis-

more nutritionally appropriate choices to the marketplace and may

fying, choice. This leads patrons to order and consume more hedoni-

help prevent further regulation, such as imposing taxes on unhealthy

cally appealing options, as the pleasure of eating indulgent foods can

items or restricting advertising (Dhar & Baylis, 2011). These efforts are

quickly counteract the negative feelings associated with goal failure

also directed at improving manufacturers’ relationships with the pub-

(Gardner, Wansink, Kim, & Park, 2014). Overweight customers may

lic, who express moral outrage over mounting evidence that food and

be particularly prone to regulating their mood with indulgent meal

beverage marketing practices are harmful to public health, and espe-

choices when exposed to menus that mix healthy and unhealthy items.

cially to children (Young & Nestle, 2002). Consumers’ perceptions that

The contrast not only reminds them of health goals, but can also ac-

certain practices, including oversize portions, are exploitative are not

tivate negative stereotypes that further worsen mood and increase

trivial in the marketplace because they can negatively influence sales

the likelihood of compensatory eating (Campbell & Mohr, 2011). Some

and brand perceptions. Research shows that when business practices

evidence suggests that overeating as a response to activating over-

encroach on consumers’ moral standards they foster feelings of out-

weight stereotypes can start in childhood, which can lead to a lifetime

rage and even disgust, which alienates consumers and decreases their

of unhealthy food habits (Campbell, Manning, Leonard, & Manning,

desire to interact with particular brands (Chan, Van Boven, Andrade,

2016). Overindulgence is a maladaptive, and unexpected, response to

& Ariely, 2014).

activating health goals. However, it is important to understand varied reactions to increased health saliency in the marketplace so that we

4.1.1 | How real is the demand for healthier options?

test ways to consumers feel good about their options and satisfied with their choices.

While many indicators suggest that consumers are driving demand toward generally healthier food and beverage items, their purchase decisions suggest that they do not always welcome what the mar-

4.1.2 | Being healthy is less fun and more expensive

ketplace offers (Irmak et al., 2011; Talukdar & Lindsey, 2013). These

Recent research also shows that dining options that include healthy

trends reflect a frequent tension in health decision making, where

items can produce negative affect because consumers are skeptical

good intentions and actual behaviors are often poorly correlated

that these foods will be satisfying—another important goal in their

(Schwartz, 2015). While fast-­food companies and restaurant chains

daily lives. In some cases, these perceptions are real and may reflect

invest in developing the healthier options that consumers say they

the reality that manufacturers often make foods healthier by reducing

want, the sales of these items persistently lag (Jargon, 2013). This re-

tasty ingredients such as fat, sugar, and salt, or by replacing them with

ality prompts consumer researchers to explore why adding healthy

less appealing and artificial substitutes. Research shows that over the

menu items and allowing healthy substitutions in meal bundles does

years, these practices have alienated consumers by creating negative

not close the gap between healthy eating intentions and real con-

dining experiences and fostering low expectations of foods that are

sumption choices. Some results are surprising and show that including

described or labeled as “healthy.” Indeed, today’s consumers often

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perceive food items as less tasty (Raghunathan, Naylor, & Hoyer,

rates (Malik et al., 2006) because they add hundreds of unnecessary

2006), more expensive (Haws, Reczek et al., 2017), and harder to

calories to people’s diets. Although there are many efforts to increase

obtain or prepare when they are described as healthy compared to

the public’s awareness of the relationship between sugary beverage

when no health claims are made (Judd, Newton, Newton, & Ewing,

consumption and poor health outcomes, consumers can still be easily

2014). Importantly, these perceptions persist regardless of objectively

persuaded to buy them using health-­focused rhetoric. In one recent

measured taste evaluations, prices, or convenience, but nonetheless

study, merely highlighting a sugary sports drink’s hydration benefits

lead to both lower consumption and satisfaction. The desire to sat-

encouraged consumption because people associate hydration with

isfy hedonic goals further motivates people to believe that healthy

health (Huang, Khwaja, & Sudhir, 2015).

eating comes at too high a monetary or physical cost. As such, it is

Marketing-­driven health halo effects are persuasive precisely be-

relatively easy to persuade consumers that the expense (Talukdar &

cause people feel that consuming certain products is consistent, rather

Lindsey, 2013), hassle (Judd et al., 2014), and poor taste quality of

than inconsistent, with their health goals. Today’s marketers appeal to

healthy food is unjustified at a particular moment (Hagen, Krishna, &

health-minded consumers’ by emphasizing that product ingredients

McFerran, 2017).

are 100% natural or organic, attributes that are also associated with

To the end that meeting demand for satisfying healthy options

good health. For instance, consumers believe that products made with

may require more expensive ingredients or smaller portions, consum-

organic sugar are healthier than those made with processed sugar,

ers must be convinced that they are still receiving good value for their

even though the body’s response is the same to both substances

money (Malik, Schulze, & Hu, 2006). Some consumers feel alienated

(Sütterlin & Siegrist, 2015). Although these rhetorical claims may seem

by such health-­ focused menu changes (Belei, Geyskens, Goukens,

relatively benign, consumers are sensitive to the health halo effects

Ramanathan, & Lemmink, 2012), especially if they have real economic

produced by such claims even when they are making choices in the

constraints (Briers & Laporte, 2013; Judd et al., 2014). Consequently,

context of serious health problems. For example, a study of recently

researchers are exploring how to make people more satisfied with

diagnosed type 2 diabetics’ grocery purchases showed that patients

smaller portions, even when prices remain the same or slightly in-

shifted away from sugary items in response to their change in health

crease (e.g., Ordabayeva & Chandon, 2013).

status, but only to purchase similarly unhealthy items with high-­fat and

One way that higher food prices can help curb consumption by

sodium content (Ma, Ailawadi, & Grewal, 2013).

making people more consciously aware of every bite (Haws, McFerran, & Redden, 2017). That is, consumers are more likely to slow down and savor what they are eating when the cost per bite is relatively high. As

4.1.3 | The boundaries of goal activation

a result, they satiate more rapidly and are less likely to overeat. Recent

One reason that dietary choices present such a rich context for study-

research has also shown that highlighting the sensory pleasures of a

ing goal-­oriented behavior is that it is easy to objectively measure

meal, rather than its abundance, increases satisfaction with smaller

whether people’s decisions are consistent with current guidelines

portions (Cornil & Chandon, 2016). Such findings suggest that smaller

and individual health goals. The average consumer has a good idea

portions can be appealing to consumers when they satisfy hedonic

of how many calories she should consume in a day, whether she is

goals. By emphasizing high-­quality or indulgent ingredients, people

overweight, and whether her weight is affecting her self-­ esteem,

can be persuaded to focus less on abundance-­based value and more

health, or disease-­related risk. More subjectively, we know that peo-

on taste-­based value. As a result, they consume fewer calories with-

ple’s intuitions and lay theories about what is healthy and what is not

out sacrificing their overall dining experience. Focusing on consumers’

are in relatively high agreement with what nutritionists recommend

judgments on meal quality over meal quantity also has the rare added

(McFerran & Mukhopadhyay, 2013). In short, people know that ap-

benefit of satisfying the objectives of multiple stakeholders. If con-

ples are healthy and candy is not, so their choices are reasonably well

sumers are willing to pay higher prices for smaller portions, manufac-

informed. Moreover, there is plenty of evidence that they aspire to

turers and retailers can preserve profits by lowering costs. In addition,

make healthier dietary choices and experience disappointment if they

policymakers are also less likely to intervene or impose regulations if

fail to meet this seemingly simple, but rather elusive goal. The disap-

they feel that food and beverage manufacturers are being responsive

pointment consumers’ feel when they fall short of their own expecta-

to public health concerns.

tions underscores the importance of understanding the boundaries of

Emphasizing quality over quantity in nutrition decisions is only one

health goal activation in everyday decisions.

of many ways to influence health decisions by activating goals. Even

Although being healthy is a superordinate goal that increasingly

without changing ingredients or portion sizes, marketers effectively

more consumers have, it is a difficult goal to make progress toward in

use rhetoric in their packaging and labeling to bolster perceptions that

any one consumption decision (Fishbach, Dhar, & Zhang, 2006). As we

their products are healthy (Chandon, 2012). Of course, these claims

know, much evidence suggests that behaviors tend to pursue what-

may not always reflect objective nutritional values. For example, po-

ever goal is most salient at the time decisions are made. Goal salience

sitioning beverages as sports or energy drinks that contain vitamins

is malleable and subject to internal and external forces that can eas-

and electrolytes can produce health halo effects that deflect concerns

ily redirect people to satisfy competing goals or persuade them that

about their high sugar content. Sugar-­sweetened beverages, includ-

their behaviors are goal-consistent. In addition, the overarching goal to

ing sports drinks, are considered to play a key role in rising obesity

be healthy is imperceptibly compromised by everyday decisions that,

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114      

although they may be judged as poor in isolation, often have no immediate health impact. The many choices that define people’s habits

4.2 | Activating self-­control in the marketplace

with regard to diet, exercise, tobacco use, and medication adherence

Throughout the marketplace, we see coordinated efforts to help

merely contribute to the cumulative risk of developing future disease.

consumers make better and more cost-­ effective health decisions.

As such, individual decisions that people may even acknowledge as

However, many of these efforts fall short of closing the gap between

being objectively poor do not necessarily feel too much at odds with

good intentions and real behaviors. Despite decades of providing nu-

the overall goal of being healthy.

tritional labels on grocery items and, recently, mandatory calorie labels

Another important boundary of goal activation in the marketplace

on chain restaurant menu items, more than two-­thirds of Americans

is that consumers vary in their response to efforts that make health

are overweight or obese, a trend that is increasing worldwide (World

more salient in their decisions. For example, research shows that some

Health Organization, 2017). Despite more than half a century of

people rebound and revert to their superordinate goals when momen-

regulations and warnings about the hazards of tobacco use, one in

tary diversions lead them to satisfy competing goals (Carlson, Meloy,

every five American adults smokes cigarettes (Centers for Disease

& Miller, 2013). That is, someone whose intention to have a healthy

Control, 2017a). While many consumers see the value in prevention

day was derailed by a free donut with their morning coffee purchase

services like vaccines (Zainuddin, Previte, & Russell-­Bennett, 2011),

may be more likely to stop at the gym after work if she receives a

less than 50% of American adults receive an annual flu shot (Centers

health goal reminder than if she does not. However, other research

for Disease Control, 2017b). Many also struggle to follow guidelines

suggests that some people experience negative affect when being re-

for routine screenings that identify and control the spread of disease

minded of specific goals or failures to meet them (Townsend & Liu,

(Plambeck & Wang, 2013). As the list goes on, we search for a better

2012). Negative feelings can promote further indulgence, particularly

understanding of why people are not better at making these choices,

with food choices, because the pleasure of eating quickly counteracts

even with many available resources and real intentions to be healthier.

the negative affect and emotions produced by goal failure (Di Muro &

While some lifestyle behaviors have improved over time and with

Murray, 2012).

better education, more information, increased accessibility, taxation,

Negative reactance to health goal reminders is important to un-

and other regulatory efforts that prioritize health, progress remains

derstand because it can undermine marketplace efforts to improve

disappointing. Almost 40% of preventable deaths in the United States

the quality of health decisions. For example, consumers may avoid

are annually attributed to poor diet, smoking, and being too sedentary

shopping and dining at places with calorie-­labeled items because

(e.g., Mokdad et al., 2004). For many consumers, the problem is not a

seeing that the latte they want has close to 300 calories can pro-

lack of awareness or information about the dangers of these behav-

duce feelings of guilt. Instead of ordering a smaller latte or substi-

iors, or even that their health goals are not active and salient when

tuting skim for whole milk, they simply switch to a café that does not

they make decisions, but rather that they lack self-­control.

put calorie labels on their coffee drinks. Furthermore, retailers and

Self-­control is important in many aspects of health decision mak-

manufacturers are less likely to voluntarily implement changes that

ing. People need self-­control to overcome an aversion to important

promote healthier consumption if they perceive it may alienate cus-

prevention activities, like vaccines and blood tests, which can be mo-

tomers. Research shows that reactance to the activation of health

mentarily painful or unpleasant. They need self-­control to engage in

goals appears to start at a very young age: Encouraging children

health activities that can reveal negative information, like submitting

to try foods like broccoli because it serves an instrumental goal of

to medical screenings or disclosing troubling symptoms. People have

being healthy leads them to think it tastes worse and consume less

a strong tendency to avoid negative information, especially if it dam-

of it than encouraging them to eat broccoli because it tastes good

ages their pride, decreases the quality of their moods and emotions,

(Maimaran & Fishbach, 2014).

or introduces feelings of guilt and shame when poor health outcomes

Knowing that goal activation can have unintended consequences

result from their own behaviors (Askegaard et al., 2014; Duhachek,

on health behaviors has led some researchers to investigate methods

Agrawal, & Han, 2012; Moore & Konrath, 2015; Wilcox, Kramer, &

for attenuating reactance. For example, one recent study showed that

Sen, 2010; Winterich & Haws, 2011). Finally, people need ongoing and

mindfulness training helps consumers learn to derive a hedonic boost

persistent self-­control to make healthy lifestyle choices about diet, ex-

from locating healthy options in a sea of unhealthy choices (Kidwell,

ercise, tobacco use, and medication adherence.

Hasford, & Hardesty, 2015). Such training helps people feel good

A good deal of today’s literature focuses on how to help consum-

about seeing a salad on a fast-­food menu and may increase the like-

ers improve self-­control in everyday decisions, particularly those that

lihood that they will decide to be healthy, rather than be unhealthy.

require persistent self-­control, such as eating and exercise. Efforts to

These positive feelings not only increase the likelihood of choosing a

improve dietary self-­control can range from nonrestrictive to very re-

salad over a burger, but have the potential to save additional calories

strictive. For example, once recent study showed that calorie label-

by disrupting the tendency to further indulge an explicity choice deci-

ing can be effective in helping people make healthier choices when it

sion to be unhealthy with other high-­calorie items (e.g., Wilcox et al.,

specifically targets certain menu items (Policastro et al., 2017). Others

2009). Consumer research on mindfulness training in dietary choices is

have shown that taxes on unhealthy choices improve self-­ control

somewhat nascent, but there is growing evidence that it is a promising

by imposing an immediate and tangible cost on indulgence (Shah,

approach.

Bettman, Ubel, Keller, & Edell, 2014; Yamin & Gavious, 2013). Finally,

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some research investigates whether allowing people to pre-­ order

know that encouraging them to substitute salads can lead to goal bal-

meals can help improve self-­control by locking them in to healthier

ancing behaviors that ultimately result in overindulgence (e.g., Wilcox

downstream choices (e.g., VanEpps, Downs, & Loewenstein, 2016).

et al., 2009). Alternatively, encouraging patrons to pair cheeseburgers

These strategies can be effective because they improve consumers’

with smaller orders of fries and less sugary beverages does not force

ability to exercise self-­control in the moments they are prone to mak-

them to choose between being healthy and unhealthy. Consequently,

ing poor choices.

they may be more open to moderating their indulgences.

One strategy for improving self-­control is making health knowl-

Consumers’ readiness to moderate their food and beverage intake

edge easier to implement in real-­time choices. As an example, con-

is not limited taking smaller portions or substituting lower-­calorie bev-

sider scant evidence that calorie labeling on restaurant menus reduces

erages. For example, one recent study shows that consumers prefer

the number of calories patrons purchase and consume (e.g., Bollinger

individual meals that have an appropriate mix of healthy and unhealthy

et al., 2011; Parker & Lehmann, 2014). Calorie labeling is one of many

items to meals that have either all unhealthy or all healthy items (Liu,

well-­intended policy efforts that has the potential to help consumers

Haws, Lamberton, Campbell, & Fitzsimons, 2015). Other research sug-

make better choices, but proves to be difficult in practice. Although

gests that consumers may be adopting a wider view of their eating

calorie labeling on each menu item provides some good information,

and drinking habits by balancing their intake of healthy and unhealthy

it gives little context for evaluating how it should be used to make

items over the course of the day (Haws, Liu, Redden, & Silver, 2017).

choices. As a result, consumers must be motivated to calculate the

Strategies that promote moderation by downsizing overly abundant

dietary impact of the various options themselves. This motivation de-

portions, replacing sugar-­sweetened beverages with water or low-­

creases when they are hungry, pressed for time, or looking to save

calorie alternatives, balancing ingredients within meals, and managing

money, which further strains self-­control resources.

a daily budget of healthy and unhealthy items may improve nutrition

As an alternative to simply providing calorie counts for each menu

decisions because they allow people to satisfy multiple goals without

item, some research suggests that also targeting specific menu items

too much demand on self-control resources. While saving a few hun-

helps patrons make better real-­time use of nutrition information. For

dred calories here and there may not seem like much in isolation, the

example, one recent study shows that when calorie messaging targets

savings quickly add up over the course of a routine day.

sugar-­sweetened beverages in bundled meals, dining patrons save

Encouraging consumers to moderate their behavior by balancing

hundreds of calories by switching to water (Policastro et al., 2017).

and budgeting the mix of healthy and unhealthy items at each meal or

Another study shows that prompting fast-­food patrons to save more

within certain time frames may be a more effective way to encourage

than 250 calories by downsizing starchy side dishes significantly re-

ongoing self-­control than directing them to develop better appetites

duces caloric intake by making portions smaller (Schwartz et al.,

for healthy options. In both the literature and the marketplace, there

2012). In both studies, the calorie-­saving messages target nonfocal

is a tendency to categorize food and beverage items as either healthy

meal items like beverages and side dishes, rather than entrees, which

or unhealthy. People are good at making these distinctions, which

consumers often acknowledge can add hundreds of unnecessary meal

helps them quickly identify healthy and unhealthy, but being able to

calories. Many of these calories are mindlessly consumed, which cre-

identify or distinguish between these items does not necessarily lead

ates an opportunity to make small changes that save patrons hundreds

to healthier choices. In fact, this crude categorization may represent

of calories that they are unlikely to miss. As a result, targeting calo-

a potentially false dichotomy that can undermine self-­control. First,

rie messages to certain menu items reduces the need for self-­control

the “vice–virtue” distinction in food is relatively insensitive to portion

by freeing up cognitive resources and helping consumers identify

sizes, which means that consumers are prone to eating foods that are

where to trim calories, without having to exert too much willpower.

considered nutritionally healthy in unhealthy amounts. Second, en-

Messages that target consumers’ decisions at the point of sale can be

couraging people to avoid certain items can cause reactance and ex-

particularly effective (e.g., Nikolova & Inman, 2015), especially if they

acerbate self-­control struggles by suggesting that even an occasional

help people make choices that limit their ability to consume beyond

dessert, slice of pizza, or glass of wine is unhealthy. As we gain better

their nutritional needs.

insight into how people incorporate health-related information and

Knowing that some consumers are indeed looking to cut excess

knowledge into their dietary choices, there is an increasingly compel-

calories from meals by taking smaller portions or switching to lower-­

ling argument for identifying strategies that help them moderate their

calorie beverages has several important marketplace implications.

consumption through better in-the-moment self control.

First, consumers sometimes accept changes for little or no discount, which signals their willingness to pay a premium for healthier options. Food manufacturers and retailers benefit from this willingness because

4.2.1 | A more sophisticated consumer

it allows them to serve smaller portions and make certain menu substi-

As with goal activation, the effectiveness of strategies that activate

tutions without alienating customers or sacrificing profits. Finally, by

self-­control, whether in diet, exercise, prevention, or other health-­

imposing self-­restraint on nonfocal menu items like sugary beverages

related behaviors, is subject to individual differences (Baumeister,

and starchy side dishes, consumers illuminate a path to activating their

Vohs, & Tice, 2007). Self-­control is a trait linked to many measures

health goals without causing reactance. For example, if patrons’ pri-

of success in life, including health (Tangney, Baumeister, & Boone,

mary reason for going to a fast-­food restaurant is cheeseburgers, we

2004). Research has shown that individuals with high self-­control

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116      

satiate to unhealthy foods more quickly and satiate to healthy foods

consumers often know they lack self-­control needed to achieve their

more slowly than individuals with low self-­control, helping them con-

health goals. With regard to exercise goals, some consumers know

sume fewer calories and better control their weight (Redden & Haws,

that they can be overly optimistic about their future gym attendance

2012). Research has also shown that some people are more sophis-

and will impose restrictions on the temptation to skip workouts (e.g.,

ticated about their levels of self-­control than others (O’Donoghue &

Acland & Levy, 2015). For example, one recent study showed that gym

Rabin, 1999, 2001). This self-­awareness actually leads them to better

members were willing to restrict their access to hedonic media con-

self-­control by avoiding temptation rather than actively asserting will-

sumption (e.g., audiobooks and movies) to when they were working

power. Correlational evidence from consumers’ supermarket grocery

out. This temptation bundling strategy has the double advantage of

purchases suggests there are plenty of sophisticated shoppers. In one

giving people an incentive to get to the gym and makes their workout

study, consumers’ purchasing patterns revealed that consumers are

more enjoyable (Milkman, Minson, & Volpp, 2013).

willing to forgo bulk discounts on certain items like cigarettes and junk

When consumers go to such lengths in pursuit of their health goals,

food to limit their consumption (Wertenbroch, 1998). Likewise, evi-

there are important implications for marketing and public policy (e.g.,

dence from grocery shopping data also suggests that people are more

Wertenbroch, in press). The first is that when consumers volunteer to

likely to take advantage of promotions that allow them to stock up on

courses of action that increase their costs and impose restrictions on

healthy items than those that allow them to stock up on unhealthy

their future behavior, we learn something about the magnitude of the

goods (Mishra & Mishra, 2011).

perceived problem. They are likely taking such actions because they

Evidence that some consumers are sophisticated enough to limit

really want to behave better, but also struggle to avoid temptation

their exposure to temptation by forgoing bulk discounts on unhealthy

through sheer willpower. Next, by demonstrating a willingness to pre-

items like junk food and cigarettes has led researchers to explore

commit to better behaviors, consumers signal that certain marketplace

whether this insight can be more explicitly leveraged in the market-

changes, such as offering smaller portions or implementing mecha-

place. Specifically, recent studies have examined the extent to which

nisms that allow self-­imposed penalties, can be both well tolerated

consumers are willing to explicitly “precommit” to being healthier by

and cost-­effective (e.g., Mochon et al., 2016).

imposing physical and financial constraints on their ability to give in to future temptation (for a review of decision making over time, see Mogilner, Hershfield, & Aaker, 2018). For instance, the fast-­food restaurant patrons who were prompted to downsize their starchy

5 | MORAL BOUNDARIES IN HEALTH DECISION MAKING

side dishes had effectively precommitting to smaller portions. Over a series of field studies, 22%–33% of customers willingly downsized

Health and healthcare choices are a rich context for studying the pro-

their meals for little or no discount. This behavior not only reduced the

cesses that underlie challenging and complex decisions (e.g., Luce,

average number of calories served when the restaurant offered down-

Bettman, & Payne, 1997; Luce, Payne, & Bettman, 1999). In today’s

sizing, compared to control periods when it did not, but also reduced

consumer-­ focused marketplace, health-­ related decisions are sub-

the average number calorie patrons actually consumed. Importantly,

ject to traditional forces, like trade-­ offs between safety, efficacy,

there was no evidence that patrons were less satisfied with downsized

and risk (e.g., Menon, Raghubir, & Agrawal, 2008; Yan & Sengupta,

meals or that they compensated for smaller portions with more indul-

2012) and an increasing array of moral complexities. These dilemmas

gent entrees (Schwartz et al., 2012).

arise from pricing health goods and services, the increased availability

In another field experiment, researchers asked consumers to pre-

enhancement-­only pharmaceuticals, and the reduced privacy that ac-

commit to purchasing healthier groceries. Members of a health rewards

companies many of the new technologies that help consumers navi-

program who were receiving a 25% cash-­back bonus on healthy grocery

gate toward better health.

items (e.g., fruit, vegetables, whole grains, and lean meats) were invited to make a binding six-­month pledge. Their goal was to increase the percentage of healthy food item purchases by a mere five percentage points,

5.1 | Taboo trade-­offs

relative to their household’s historical average. For example, households

Perhaps one of the biggest challenges for today’s health consumer is

whose monthly grocery receipts contained an average of 10% healthy

having to budget money for health-related expenditures like medica-

items pledged to increase to 15% for each of the following 6 months.

tion, insurance, and other out-of-pocket costs. Social relational theory

Those who made their goal could keep their 25% cash-­back bonus, but

(Fiske, 1992; Fiske & Tetlock, 1997) suggests that price considerations

those who failed agreed to have their bonuses clawed back from their

in health decisions qualitatively differ from those made in other con-

credit card statement. Relative to a control group who could only make a

sumer domains because health is considered to be a sacred value. Most

hypothetical pledge to improve their healthy grocery percentage, the pre-

marketplace transactions involve secular–secular trade-­ offs where

commitment group significantly increased their healthy purchases during

people exchange money for goods and services according to the tra-

the six-­month intervention and for almost another full 6 months after the

ditional market forces of supply and demand. The efficiency of these

penalty threat was removed (Mochon et al., 2016; Schwartz et al., 2014).

transactions is improved by accompanying transparency and compe-

Additional research shows that exercise behaviors also improve

tition, which makes it easier for consumers to understand the value

with precommitment. As with nutrition decisions, sophisticated

of items, calculate the various trade-­offs, and shop around for better

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prices. Healthcare transactions, however, are not like this. First, paying

over patient needs. The marketing literature suggests that asymme-

for healthcare products and services requires sacred–secular trade-­

tries in information, expertise, and power make consumers vulnerable

offs between attributes that are difficult to value. For example, when

to marketing practices that target experts (Moorman, Deshpande, &

making health decisions, consumers have great difficulty establishing

Zaltman, 1993). In healthcare, relationships between consumers and

how much monetary value to place on medications that can save their

expert health providers are especially privileged. This trust makes it

lives or reduce their chances of having terrible side effects. In fact, they

even less likely that consumers will shop around for alternatives or

feel that assigning a specific price to the sacred values of health and

question the expertise of their providers, even when those options are

life represents a taboo trade-­off that is simply impossible to calculate.

available and can save them money (Schwartz, Luce, & Ariely, 2011).

Second, various regulations and third-­party insurance payments limit

The pharmaceutical industry often responds to consumer

price transparency, competition, and consumers’ ability to lower costs

backlash over marketing practices by using rhetoric to justify their

by shopping around.

positions. Although consumers do express outrage over the ever-in-

Although health has an increasingly larger presence in everyday

creasing cost of health care, they are also driving demand for the

consumer transactions, it is still considered a sacred value. And, as

latest and greatest in pharmaceutical innovation. As such, they are

is often the case with sacred values, consumers have morally guided

increasingly facing the reality that medical advancement comes at

expectations about the pricing of health-­related goods and services

a financial cost. To the end that people would rather avoid the rel-

(Samper & Schwartz, 2013). In particular, they believe that pricing

atively unpleasant affect brought on by making “taboo” trade-­offs

should not restrict anyone who is sick or hurt from receiving medicine

between money and health, they are motivated to believe that pric-

and treatment. When consumers confront the reality of taboo trade-­

ing and promotion practices do align with communal goals. For ex-

offs in the marketplace, they can experience moral outrage and other

ample, the industry often deflects outrage over medication prices by

negative emotions that influence their decisions (McGraw, Schwartz,

reminding the public that innovative drugs are expensive to research

& Tetlock, 2012).

develop, so they must share the risky burden of bringing new medi-

How consumers respond to trade-­offs between health and money

cation to the marketplace (McGraw et al., 2012).

is often investigated within the context of medication. Drug prices are

Similarly, when responding to outrage over detailing practices,

particularly prone to consumer outrage because they are relatively

the industry argues that their primary goal is to educate doctors in

transparent, compared to other health goods and services, and their

the better service of their patients, not to unduly persuade them to

well-publicized prices can clash with consumers’ moral expectations

prescribe unnecessary drugs or to promote newer expensive brands

of accessibility. That is, as drug prices increase, medication becomes

over equally safe and effective, but older, alternatives. However,

increasingly limited to those who can pay. Consumers may perceive

challenges to this claim (Larkin et al., 2017) have led researchers

this as a morally unjust form of healthcare rationing (Fiske & Tetlock,

to develop new methods for teasing apart detailing’s influence on

1997). Moral violations cause feelings of outrage particularly when

education and persuasion in prescribing habits (Ching & Ishihara,

firms’ profit-­maximization goals appear to come at the expense of

2012). In part, this research is made possible by new regulations

consumer well-­being. Such outrage can quickly get the attention of

that require greater transparency in detailing practices. Under the

policy makers, who call for greater transparency and price regulation

Physician Payment Sunshine Act (Affordable Care Act, 2010), drug

(Affordable Care Act, 2010).

and device manufacturers must disclose all payments made to indi-

Scrutiny over the moral acceptability of pharmaceutical market-

vidual doctors. These payments range from speaking and consulting

ing practices is not limited to drug prices. Other practices, such as

fees, to small meals, educational conferences and free medica-

direct-to-consumer advertising can also be controversial. Although

tion samples and can be tied to individual level prescribing data.

proponents of direct-­to-­consumer advertising argue that it benefits

Consumers also benefit from Sunshine Law because the disclosure

consumer decision making by both increasing awareness and decreas-

information is available in a publicly searchable database. The data-

ing social stigma, others argue that it increases health expenditures

base allows consumers to look up individual doctors’ relationships

by creating unnecessary demand and driving market share toward ex-

with industry and potentially avoid contact with physicians who

pensive branded medications and away from less expensive generic

they perceive may have conflicts of interest.

equivalents (Wilkes, Bell, & Kravitz, 2000). Finally, physician detailing is another controversial practice where the pharmaceutical industry spends billions of dollars annually pro-

5.2 | Pharmaceutical enhancements

moting their drugs directly to the doctors and health service providers

As the boundaries of medical science are pushed beyond the preven-

who prescribe them. Detailing practices include paying doctors speak-

tion and cure of disease or illness and into the realm of enhancement,

ing and consulting fees, hosting educational seminars, and giving free

they bump up against additional moral constraints. Pharmaceutical

medication samples. While the industry argues that advertising and

enhancements are controversial because they represent a class of

detailing have the communal benefit of increasing physician awareness

medication that has no health-­ related purpose. Enhancements do

and education, others argue that detailing not only creates unneces-

not cure or prevent illness, but rather artificially bolster appearance

sary demand, but also produces conflict of interests when even small

and performance for vanity purposes. Although people are open to

payments and gifts cause doctors to prioritize industry relationships

using (and paying) for drugs that improve appearance if disfigurement

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118      

is caused by a medical problem such as acne, they are less tolerant

which can be influential in connecting everyday behaviors to health

when that medication is used to treat wrinkles or other natural signs

goals. However, we simply do not have enough evidence yet to say

of aging. Interestingly, perceptions that using enhancements violates

whether wearable fitness gadgets really improve health behaviors

moral standards is not uniform across all consumers. Research sug-

and outcomes (e.g., Piwek, Ellis, Andrews, & Joinson, 2016). First,

gests there is substantial double-­standard in the perceived ethical-

the appeal of these devices may be limited to consumers who are

ity of pharmaceutical enhancements, whereby people judge others’

already healthy, rather than those who are less healthy and stand to

enhancement consumption more harshly than their own (Williams &

substantially benefit. Second, like many other trendy fitness-­related

Steffel, 2014).

products (think Nordic Tracks and Thigh Masters) wearable devices

The malleability of consumers’ beliefs about the moral accept-

may have a limited shelf life. Once the novelty of having these de-

ability of pharmaceutical enhancements to individuals’ performance,

vices wears off, or the reality that self-­control is still required to log

appearance, and other fundamental self-­attributes makes them sus-

5,000 steps per day sets in, consumers may not find them all that

ceptible to external forces such as messaging and rhetorical framing

helpful. Next, we also know that temptation lurks within many de-

(Riis, Simmons, & Goodwin, 2008; Williams & Steffel, 2014). For ex-

vices. For example, increasingly common advertising technology like

ample, memory-­or mood-­enhancing drugs are perceived to be more

geofencing uses GPS to alert consumers that they are within steps of

morally acceptable when they are marketed as restoring consumers to

tempting treats and further entices them with discounts and rewards

a baseline state of happiness or alertness rather than boosting them

for giving in. Likewise, video streaming can easily derail active plans

to extraordinary levels (Riis et al., 2008). Reframing enhancements as

with the release of all 13 episodes of an addictive television series.

restorative decreases the moral stigma and increases the likelihood

The increased availability of food delivery via apps like UberEats

that patients will ask their doctors about these medications. Because

makes it easier for people to have their sedentary Netflix binges ca-

physicians are the gatekeepers who control consumers’ access to con-

tered by unhealthy food. Finally, researchers have begun to ques-

troversial enhancement-­only prescription drugs, they must balance

tion the extent to which consumers really benefit from technology

the psychological needs of their patients with the additional costs

that reduces their daily lives to a mere calculation of points, calories,

of unnecessary treatment. Recent research suggests that while phy-

steps, REM sleep cycles, and resting heart rates (e.g., Etkin, 2016).

sicians do not spontaneously offer enhancements, they are willing

As technology enhances consumers’ ability to make better ev-

to prescribe them to patients who specially ask for them (Marinova,

eryday health decisions, there are also mounting concerns about the

Kozlenkova, Cuttler, & Silvers, 2016). These prescribing patterns sug-

amount of personal information people volunteer. Each time Internet

gest that physicians defer judgments about the additional cost and

users search for a medication or troubling symptom, login to a fitness

moral acceptability of enhancement-­only treatments to their patients.

app, receive a SMS text medication refill reminder, or tap Uber for a

As those judgments are subject to external forces that use rhetoric

ride to the doctor, they leave a digital trail of information about their

in direct-­to-­consumer advertising to assuage consumers’ moral con-

personal health and lifestyle habits. This information can be used by

cerns, demand for enhancements is likely to increase.

advertisers, employers, and insurers in ways that restrict consumers’ access to certain services, takes advantage of opaque pricing, or

5.3 | Technology

leads to discrimination on the basis of health status or pre-­existing conditions. In a relatively unregulated digital environment, consum-

Technology greatly facilitates health decision making in everyday

ers have little awareness that their private information can be used

consumer choices. Simply increasing the availability and usability of

against them. Because they often volunteer information about their

complex health information helps consumers quickly search for infor-

health in exchange for free and convenient access to technology,

mation, organize their health histories, and implement plans to incorpo-

they may be giving up the right to keep their information protected

rate healthy choices into their daily routines. Technology gives people

(Singer, 2014).

unprecedented access to health-­related products and services that are customized to their individual healthcare needs and goals. Increasingly more devices and apps can track behaviors and provide feedback that

6 | CONCLUSION

makes engaging in certain behaviors more top of mind and immediately rewarding. Thanks to technology, today’s health consumer is better in-

In the era of consumer-­driven health, people are increasingly re-

formed and better equipped to make good health choices.

sponsible for the consequences of their everyday decisions. Within

Although technology gives us many reasons to be optimistic

their daily routines, consumers’ moment-­to-­moment choices about

that consumers will make better health decisions, historical and

diet, exercise, and medication may have little impact in isolation, but

contemporary trends remind us to be cautious. Our current enthu-

will ultimately combine to have a profound impact on their health.

siasm over mobile apps and wearable devices that track consumers’

Decades of research on health decision making tells us that people

progress toward their fitness goals may be short-lived if they cannot

recognize the value of good health and want to be healthier; but

help consumers really close the gap between their intentions and

even with greater access to information and resources, they con-

more healthful behaviors. Our enthusiasm is partially is driven by the

tinue in their struggle to develop better health habits. In this review

ability of these devices to provide real-­time feedback and progress,

of the recent literature from marketing, psychology, and health, we

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gain a more comprehensive perspective on why being healthy is so challenging. While today’s marketplace is evolving to accommodate more health-­conscious consumers, it also continues to create a variety of internal and external forces that prevent people from closing the gap between their good intentions and real behaviors. As we gain a better understanding of these forces, we can develop marketplace solutions that help people make decisions that are both satisfying and healthy.

ACKNOWLE DG ME NT The author thanks Lillian Bacon for research assistance and L. J. Shrum for editorial guidance.

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How to cite this article: Schwartz J. Health decision making. Consum Psychol Rev. 2018;1:107–122. https://doi.org/10.1002/ arcp.1008