direct-to-consumer advertising may disrupt randomized controlled drug trials because some people may, particularly if they create strong perceptions of value ...
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: jschwa@tulane.edu
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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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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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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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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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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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
