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Pharmaceutical advertising practitioners’ approach to trust and emotion

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Jennifer Ball University of Minnesota, Minneapolis, Minnesota, USA, and

Michael Mackert University of Texas, Austin, Texas, USA Abstract Purpose – Studies of direct-to-consumer pharmaceutical advertising (DTCA) have examined the views of consumers and healthcare providers but the perspective of pharmaceutical advertisers has been largely absent. This study sought to fill that gap by exploring the perspectives of advertising professionals working on pharmaceutical brands. Design/methodology/approach – Interviews were conducted among 22 advertising professionals regarding the use of emotion in DTCA and considerations about consumer distrust and ad credibility. Findings – Results suggest emotion is used to gain attention, increase involvement, and enhance information processing. Consumer trust of pharmaceutical companies was recognized as an issue, and various thoughts were provided on trust-building strategies. However, several respondents expressed doubt that negative opinions of the industry translated into negative evaluations of the specific ads or brands with which consumers were familiar. Research limitations/implications – Based on participants’ assertions, this paper poses a number of specific avenues for future research regarding the effects of emotion on response to DTCA and consumers’ conflicting sense of trust within the pharmaceutical category. Originality/value – While scholars examining the design and effects of DTCA have inferred the motivations of pharmaceutical advertisers, this study provides insight on practitioners’ actual intentions behind the messages created for DTCA. Keywords Advertising, Trust, Direct-to-consumer, Emotion, Interviews, Pharmaceutical products Paper type Research paper

International Journal of Pharmaceutical and Healthcare Marketing Vol. 7 No. 3, 2013 pp. 244-264 q Emerald Group Publishing Limited 1750-6123 DOI 10.1108/IJPHM-04-2013-0021

Introduction and background Direct-to-consumer pharmaceutical advertising (DTCA) has sparked controversy since its inception. Numerous stakeholders are involved in this debate including regulators, healthcare professionals, pharmaceutical manufacturers and marketers, and consumers. However, research has focused primarily on the perspectives of consumers and healthcare providers in addition to evaluating ad content. The point-of-view of advertising professionals designing drug advertisements is largely absent from the literature. To fill that gap, the purpose of our study was to gain a better understanding of the perspectives and message design considerations of advertising professionals working on pharmaceutical brands. In particular, the analysis reported here focused on perceptions regarding the role of emotion and issues of trust in DTCA. The omission of the advertising practitioner’s perspective in DTCA research is not a trivial matter. The importance of gaining this perspective can be traced to the long-standing principle of communication that the intended message crafted by the

sender (e.g. advertisers) may differ from the perceived message interpreted by the recipient (e.g. consumers and researchers) (Shannon and Weaver, 1949). Accordingly, scholars generally acknowledge the value of examining the views and practices of advertising professionals (Nyilasy and Reid, 2009). Furthermore, the argument has been made that advertising production – encompassing the considerations and process of designing and executing advertisements – should be an imperative part of the study of advertising to inform a valid interpretation of content analyses and consumer response studies (Soar, 2000). Certainly, it is reasonable to assume that incorporating practitioners’ input in the empirical literature increases the potential for scholarly work to impact advertising practice while providing insight for theoretical development and application. Despite the recognized significance of capturing advertising professionals’ beliefs and decision-making strategies, this topic of research is minimal in the advertising literature and virtually non-existent in DTCA research. Understanding advertisers’ views is particularly important with regard to DTCA since the current form of DTCA in the US is still relatively new (broadcast ads have only been legal since 1997) and evolving. In addition, this ad category is unique from that of most consumer products due to heightened regulation, greater complexity of information contained in the messages, and the potentially life-altering effects of “product” consumption. Altogether, this suggests two pertinent subjects for examination: the approaches pharmaceutical advertising professionals take in applying persuasive message strategies to this specialized category, and their consideration of social responsibility and regulation compliance in designing prescription drug ads (see Hoek (2008) and Mogull (2008) for historical summaries of DTCA regulations and the Code of Federal Regulations (2012) for a complete list of current DTCA regulations). The only other published study to date of interviews with pharmaceutical advertising professionals addressed these two issues in terms of language usage and the advertisers’ efforts to meet the informational needs of low health literate audiences (Mackert, 2011). This topic was relevant in light of research showing the prevalent use of complex medical terminology in drug ads which interfered with consumers’ information comprehension (Kaphingst et al., 2004, 2005) despite FDA policy stating the ads should use consumer-friendly language (Food and Drug Administration, 2009). The interviews revealed practitioners preferred using simpler language but were held to legal standards that often required more technical terminology to be medically accurate (Mackert, 2011). Thus, this finding refuted the previous presumption that drug ads were purposely designed to confuse consumers and suggested implications for policy. To build on the contribution of Mackert (2011), the current study aimed to extend exploration of pharmaceutical advertising professionals’ perspective on the application of persuasive message strategies within DTCA and their consideration of social responsibility and regulation compliance issues pertaining to the ads. Specifically, we examined advertisers’ stance toward emotional appeals and consumer trust in DTCA as relevant to the unique challenges of developing strategic and responsible pharmaceutical advertisements. Emotion is considered an effective means of achieving persuasive outcomes in advertising, but it is criticized as a manipulative tactic and distraction from information about side effects when applied to DTCA (Wolfe, 2002). Therefore, we deemed it important to explore the views of pharmaceutical advertising

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professionals toward the role and appropriate use of emotion in DTCA. At a broader level, doubts regarding the ethicality of pharmaceutical company practices have led to a climate of distrust surrounding the pharmaceutical industry and prescription drug messages (Harris Interactive, 2011; Kaiser Family Foundation, 2008). Prevailing distrust could not only be detrimental to pharmaceutical advertisers’ persuasive objectives but also interfere with the ability of these ads to fulfill a health education function. Therefore, we aimed to examine advertisers’ thoughts on the level and effects of consumer distrust and whether they incorporated tactics to build trust – pertaining to regulation compliance or otherwise – within their strategic design of the ads. The remainder of this paper provides an overview of relevant literature regarding emotion and trust in the context of pharmaceutical advertising. Subsequently, the study methods and results are described followed by a discussion of the implications of key findings for practitioners, researchers, and policy-makers. Literature review DTCA and emotion Emotion can be thought of as a form of affect that is short-lived, object-specific, and relatively intense (Hazlett and Hazlett, 1999). Emotion manifests in the executional design as affective cues such as “drama, mood, music, and other emotion-eliciting strategies” (Yoo and MacInnis, 2005, p. 1397) and within the main message as communication points entailing the emotional reward or experience of buying and/or using the advertised brand (Puto and Wells, 1984; Ruth, 2001). Such emotional appeals are often contrasted with cognitive-oriented informational appeals that primarily provide “factual (i.e. presumably verifiable), relevant brand data in a clear and logical manner” (Puto and Wells, 1984, p. 638). Both emotional and informational appeals have their value for varying marketing outcomes (see Bagozzi et al. (1999) and Erevelles (1998) for extensive reviews of the role of emotion in marketing) and are both utilized in DTCA to varying degrees (Pinto, 2000). However, the use of emotional appeals in DTCA is particularly controversial. The concern appears to stem from the view that emotional elements in the ads interfere with consumers’ comprehension and processing of information about the indicated health conditions and medications. In particular, some DTCA scholars have expressed concern that a predominant use of emotional benefits within the ads is a deceptive persuasion tactic of embellishment (Frosch et al., 2007) intended to manipulate consumers into requesting the advertised drug (Wolfe, 2002). Some have argued emotional ad content overshadows important information, especially regarding side effects (Royne and Myers, 2008) which can lead to consumer misperceptions. Therefore, the recommendation is typically a call to minimize emotional appeals and instead provide more and clearer information within fact-based informational appeals. The view of emotion as distraction is consistent with economic-oriented theories of decision-making and information processing developed from an expectancy-value framework. Such theories assume consumers are or should be carefully calculative decision-makers who utilize information from a message to evaluate the cost and utility of a purchase or other behavior (Vaughn, 1980). Consistent with this frame, emotion may be viewed as a disruption to “rational” consideration of a message (e.g. Chattopadhyay and Nedungadi, 1992) or as a basis for persuasion when a person lacks the motivation or ability to engage in a more cognitive, attribute-focused

approach (Shiv and Fedorikhin, 1999). The ability of emotion to influence information processing by biasing the content of cognitive responses (Petty et al., 2001) or, particularly in the case of positive emotions, reducing attention to the informational arguments in the message (Bless and Schwarz, 1999) is posed as leading to potentially faulty judgments (Wegener and Petty, 1995). However, another paradigm considers emotion as a source of relevant information in itself and hence a valid basis for decision-making via more or less systematic information processing (e.g. MacInnis and Jaworski, 1989; Forgas, 1994). This is especially the case when the nature or source of emotions is pertinent to one’s goals (Pham et al., 2001). Consistent with this view, emotion is beneficial in strengthening the formation of ad and brand attitudes (Stout and Leckenby, 1988; Batra and Ray, 1986) and improving decision-making (Damasio, 1994). Emotional responses are also seen as advantageous for enhancing learning and memory through increased relevance and involvement (Zajonc, 1980; Kamp and MacInnis, 1995). Thus, emotion would be viewed as facilitating rather than detracting from processing important information in a message. The limited research exploring consumer views and responses to emotion in drug ads suggests consumers do not share critics’ negative views of emotional appeals. Consumers have indicated they did not think pharmaceutical ads were “too emotional” and their views did not impact trust toward the category (Ball et al., 2009). Another study found pharmaceutical advertising using a persuasive ad format (described as non-factual and appealing to desirable lifestyle benefits similar to an emotional appeal) led to more positive ad and brand attitudes as well as greater intentions to ask a doctor about the advertised medication (Limbu and Torres, 2009). However, current research does not take into account the impact of emotional appeals on consumers’ processing and comprehension of ad information such as side effects, nor does it capture pharmaceutical advertisers’ objectives for incorporating emotion in their ads. To the latter point, developing a better understanding of pharmaceutical advertising professionals’ perceived role of emotion can guide a more nuanced assessment of how emotion is executed in DTCA. This is turn can inform the selection of theoretical frameworks for consumer research on this topic. Particularly, advertisers’ account of how they use emotion in ads may suggest additional factors regarding the execution and effects of DTCA messages that have yet to be investigated. Additionally, gauging advertisers’ beliefs about consumers’ processing of emotional message appeals in DTCA suggests their propensity to respond to criticisms from scholars presuming a detrimental impact of emotion on information processing. With the aim of pursuing a broad inquiry on this topic, our first set of research questions were as follows: RQ1. What do pharmaceutical advertising professionals see as the role of emotion in DTCA? RQ2. How have pharmaceutical advertisers implemented emotional strategies in ads they have been involved in? DTCA and trust Trust is considered a fundamental element to achieving desired outcomes in a wide array of contexts. While conceptualizations of trust vary, commonly used definitions have dealt with a “willingness to be vulnerable” (Mayer et al., 1995) or holding


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“confident expectations” regarding another’s actions in relation to oneself (Lewicki et al., 1998). These aspects are captured in the definition of trust in advertising posed by Soh et al. (2009) as “confidence that advertising is a reliable source of product/service information and willingness to act on the basis of information conveyed by advertising.” This definition is suitable for the current study as well with pharmaceutical advertising serving as the more specific object of trust. As in other fields, consumer-related research supports the significant contribution of trust to business and communication objectives. For example, brand trust has been linked to brand loyalty, commitment, and satisfaction (Delgado-Ballester et al., 2003; Chaudhuri and Holbrook, 2002). Findings also suggest trust toward advertising increases attention and processing of ads (Soh et al., 2009) as well as perceived advertising appeal, relevance, and attitudes (Austin et al., 2002; Okazaki et al., 2007). Furthermore, advertising trust has been found to be related to media credibility (Soh et al., 2007). Relatedly, believability of prescription drug ads was linked to behavioral intentions to talk to a doctor and ask for a prescription for an advertised medication (Beltramini, 2006). Pharmaceutical advertisers face the issue of faltering trust as consumers have grown increasingly wary of prescription drug messages. Surveys show a majority of consumers feel they cannot trust pharmaceutical advertising (Kaiser Family Foundation, 2005; Beltramini, 2006). This has been accompanied by a major decline in the reputation of the entire pharmaceutical industry (Harris Interactive, 2011). Given the importance of trust to the successful achievement of communication objectives, one would expect advertisers in this category are interested in restoring consumer trust. Reinstating trust once it has been lost is a difficult endeavor, but research on the related constructs of credibility and believability suggests various communication strategies that could improve trust in DTCA. One main tactic is to employ a source perceived as credible based on characteristics such as expertise, similarity, or lack of bias (Hovland and Weiss, 1951; Kelman, 1961). Offering greater transparency including the disclosure of negative information about a product can also enhance credibility (Eisend, 2006; Lang et al., 1999). This latter technique is consistent with research showing consumers’ desire for more and clearer information about drug risks to increase the believability of DTCA (Atkin and Beltramini, 2007). However, research has shown that providing more information about side effects led to lower evaluations of the ad and brand and heightened anxiety and fear (Polen et al., 2009; Morris et al., 1985). Given this potential trade-off, it is of interest to understand if pharmaceutical advertisers are willing to disclose more complete information about drug side effects to improve consumers’ trust toward prescription drug ads. This may depend on whether or not they are even concerned about increasing consumer trust and link trust to advertising effectiveness. The presence or absence of a concern for restoring trust has implications for pharmaceutical advertisers’ likelihood to respond to criticisms about the ads and adhere to regulations. Hence, our second set of guiding research questions were as follows: RQ3. To what extent are pharmaceutical advertising professionals concerned about the issue of consumer trust in pharmaceutical advertising? RQ4. What, if anything, are advertisers doing to instill greater consumer trust in pharmaceutical advertising?

Method Participants were recruited via snowball sampling to gather diverse perspectives on DTCA among advertising professionals. Participants included 22 individuals (n ¼ 22), fourteen females and eight males. All were industry professionals working on at least one pharmaceutical brand with an average of 7.1 years (SD ¼ 3.7) of experience in pharmaceutical advertising. Participants represented seven advertising agencies and three pharmaceutical companies. Account directors and executives were the majority (n ¼ 14) in addition to five creative directors and content creators and three professionals involved with consumer research and brand planning. Interviews were conducted via phone after participants provided oral consent. Participants were informed all identifiable data would be eliminated from study findings. With approval from the Institutional Review Board, the semi-structured interview guide was formulated to answer the primary research questions. The particular questions asked in the interviews were wide-ranging (e.g. “what do you see as the role of emotion – using emotional appeals, triggering an emotional response – in pharmaceutical ads?” and “are consumers more skeptical or distrustful of pharmaceutical advertising compared to ads for other types of products?”) and included potential probes (e.g. “how do you use emotion – what parts of the ad/what techniques?” and “what do you do or have you considered doing to build trust toward the ads and the brands you work on?”). Each interview took approximately 30 minutes, and a $10 gift card was given to individuals in exchange for participation. The interview guide was reassessed after every interview considering any modifications or new issues to be addressed in subsequent interviews as recommended by Morse et al. (2002). Two coders analyzed all interview transcriptions with the unit of analysis being each block of text. To denote shifts between the interviewer and participant, textual blocks were generated during transcription. After reading through the transcriptions of all interviews, each coder generated a list of themes that surfaced in the data, consistent with Bulmer (1979) and Creswell and Plano Clark (2007). These lists were then merged to produce a coding guide that could guide analysis of the data. The coding guide was refined through discussion and revisiting the data as outlined by Glaser (1965), after which both coders examined a sub-sample of textual blocks to evaluate reliability in identifying themes (see Table I for themes). Intercoder reliability was calculated as k ¼ 0.97 averaged across all themes, higher than the k ¼ 0.75 value that represents excellent agreement (Banerjee et al., 1999). The complete transcripts were analyzed after having proven reliability in the identification of themes. Results The use of emotion in DTCA The first part of the analysis was focused on emotion, which was depicted as serving a number of functions related to effective communication such as gaining attention and building a connection with consumers. Participants also portrayed conscientious consideration of how emotional appeals should be executed to meet consumer needs and regulatory obligations. With few exceptions, participants considered emotional content to be important for the successful execution of ads. While some noted certain factors like the type of health condition or advertised treatment could alter the relative importance of emotion in


Table I. Themes regarding emotion and trust in DTCA “Right now on almost all the projects I’m working on, emotion is a big factor, and what we’re trying to do is make that emotional connection with our audience [. . .] what we’re trying to do is have people see a communication and say, I can relate to that. I feel that way or I have felt that way or I know somebody who feels this way and I understand that” “So you need to look at what emotional factors are going to affect an individual. So is it doing something compelling for themselves? A lot of times what we found with genital herpes is that when you try to speak to somebody about telling them to do it for themselves, to make themselves feel better, it actually wasn’t there. It wasn’t until you tied it in that there’s a loved one that you’re affecting by not doing something for yourself that we could then push an individual in. So it’s finding the triggers to our target audience that are actually going to compel them to go in and talk to their doctor or go online and find more information to empower themselves and then go in and talk to their doctor”

Example

“But I think by and large, the feeling of trust right now is still a little bit [. . .] like well it’s a big company, they’re scientists, they have a lot of R&D behinds things, they’re investing a lot of money, it’s still generally like a feeling of possibilities that you are doing this for our benefit. Yes you’re going to make money off it, but they can help, because there’s a science backing to it, which I think gives it integrity and credibility and a force of reason. People still believe in science as a power, and I think they have the buffer of the great evil in terms of healthcare which is perceived as the health insurance companies and the HMO type of stuff, which everyone universally hates” “So for a company to try and build trust directly with the public is very challenging and Consumers are Statements indicating a perception that distrustful consumers do not trust the pharmaceutical very difficult because the public looks at the company as trying to capitalize and make money out of their misfortune – which might be their disease or what have you” industry, companies, and/or advertising “I think the way you approach it is establishing a positive association with the company Strategies for Statements referring to communication gaining trust strategies believed to instill greater trust in and a lot of materials we were doing and still doing now are speaking to the history of the company and speaking to the good things they’ve done to try to dispel some of the bad the pharmaceutical industry, companies, perceptions that people may have because if you don’t talk about the company they’re just and/or advertising going to continue to have that perception”

Trust and distrust Consumers are Statements indicating a perception that trusting consumers trust the pharmaceutical industry, companies, and/or advertising

Statements regarding intended and observed consumer outcomes (e.g. attention, involvement, comprehension, behavioral intentions) of emotional content in DTCA Statements related to designing DTCA with Appropriate use of emotion the appropriate type or degree of emotional content to meet consumer needs, marketing objectives, or regulation requirements

Description

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Emotion Functions of emotion

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DTCA, emotion was generally seen as a natural component of the messages given its relevance to health issues. Specifically, participants described the emotion patients often experience in coping with health issues, as illustrated in the following statement: [. . .] you get either the, oftentimes, the frightening position they’re in, and you can approach them in a style that communicates that, they will begin to listen to your story, and they will become, they will not be unnerved to try and think out the condition and the medication and how it works. I think emotion is just about all of it.

In light of this view, participants discussed a number of ways emotion was perceived to increase the effectiveness of ads. For instance, emotion was described as a vehicle for gaining attention in a crowded communication environment. Part of it is if you’re going to communicate it has to be interesting enough for people. You know, if it’s on TV, you’re competing with other things out there [. . .] so the more interesting and interactive we can make it and engaging, the more information they’re actually going to get and read. So I think as far as emotion goes and engagement goes, there’s definitely a role because it makes people want to stick with it and find out more.

This participant acknowledged that DTCA must compete with other advertisements for consumers’ attention. As stated, including emotion in an ad can help “break through” clutter by first attracting and then maintaining interest in the ad. A similar theme entailed the importance of emotion associated with portrayal of a relatable experience in building a connection with consumers to increase ad relevance. This connection with consumers was deemed critical to effective communication. Alternatively, a prescription drug ad employing an informational appeal devoid of emotion was thought to be inadequate in engaging and motivating consumers. Through capturing attention and heightening relevance, emotional appeal elements were also thought to encourage consumers to pay more attention to the informational portion of the ad. The quote referenced above articulates this point in the phrase “making people want to stick with it and find out more.” Other comments echoed the assertion emotion could facilitate information processing by encouraging elaboration on information about the health condition, enhancing understanding, and providing a narrative to cope with information overload. While emotion could be a valuable tool, some participants expressed criticism of the generic manner in which emotion has been executed in pharmaceutical advertisements: I think it’s really important, but it needs to be used the right way. And I think too often what you see is this attempt at emotion. You know the commercials with the same generic couple walking down the beach or the same sappy, not – great, take care of your health.

Such a blanketed use of emotion in the form of peripheral cues was seen as ineffective since it would fail to distinguish the brand and motivate consumers. Hence, participants emphasized the need to use emotion appropriately. Specifically, the degree and type of emotion needed to fit the ad medium, health condition, and nature of treatment. Many relied on consumer research to ensure the proper tone to reflect consumers’ emotionally-charged experiences with health issues. While the appropriate use of emotion was often discussed in regards to achieving persuasive outcomes, other comments related to ensuring that emotional execution strategies did not overshadow educational goals and complied with regulations generally pertaining to information accuracy. Hence, a common theme was the need to


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balance emotional elements of an ad with information about functional drug benefits and the health condition. Participants generally held the view that consumers would only tolerate emotional appeals if factual arguments were provided to support emotional benefit claims: And that’s emotional but once you get beyond that place where you’re connecting with people on an emotional level and you have to deliver the information to them, there’s definitely a balance in where you have to flip that switch and make sure they’re getting all the information in the category.

This comment complements the previous point that pharmaceutical advertisers expressed intent to use emotion to secure consumers’ attention and then direct that attention to important information in the ad. This example suggests that pharmaceutical advertisers may purposely limit the degree to which emotion is used in the ad so as not to distract consumers from receiving the information they need. Participants were also cognizant that overuse of emotion could trigger regulatory reprimands. It is so complicated and it’s a question we’re always dealing with because we’re always dealing with the tone and manner in which we’re communicating and because these have to go through regulations we’re always struggling to figure out what’s acceptable, what’s not acceptable, is it considered too entertaining versus educational? We’re always dealing with those different ends of the spectrum.

This statement portrays a desire to ensure message design complies with regulations with regards to the balance of emotional and informational content. However, it also suggests a degree of uncertainty as to what constitutes a message that meets regulatory approval. In addition to participant comments indicating balancing emotional and informational content within one ad, another strategy participants described involved balancing the use of emotion over the lifecycle of a brand or campaign. In these depictions, emotion was infused into the advertising more prominently only once the educational message was established. This view assumed consumers’ information needs evolve over time and a heavier emphasis on emotion was acceptable once consumers were familiar with the health condition and medication. In relation to using emotion appropriately, several participants brought up the link between emotion and trust. Because of the general aura of distrust surrounding the pharmaceutical category, participants discussed the need to apply emotional message strategies judiciously to avoid triggering consumer perceptions of pharmaceutical advertising as manipulative. Balancing emotion with education or choosing the right emotion to fit the health condition were ways to avoid negative perceptions. For example, one participant stated: I think if the approach is right I don’t think you happen to get a push back, but definitely there’s a fine line [. . .] but I think if [emotion is] done right people in general will not be offended and if you talk to enough people and you’re taking a consensus to what you think will fit with people the right way, you’re fine.

The idea expressed here is that presenting relevant emotional content in a pharmaceutical ad can increase trust or at least thwart skepticism. The theme of relevance overcoming distrust also manifested in comments regarding strategies to cope with consumer distrust.

The issue of trust in DTCA The second part of the analysis examined the perceived impact of trust. Participants offered a range of techniques to boost the consumer trust in DTCA or advance the reputation of pharmaceutical companies. However, these strategies were not necessarily being executed, and some doubted that distrust toward the industry filtered down to specific ads and brands. When asked about consumers’ trust toward pharmaceutical advertising, some participants discussed the prevailing sentiment toward manufacturers, expressing the belief that consumers maintained confidence in pharmaceutical companies. Specific statements asserted that consumers were reassured pharmaceutical products were grounded in rigorous scientific research, considered medications beneficial, and directed more animosity toward other institutions of the healthcare system such as insurance companies. However, a more common perception was that trust in the broader pharmaceutical industry was severely lacking, posing an obstacle for effective communication. Participants identified various reasons for faltering consumer trust: pharmaceutical companies reaping huge profits apparently fueled by high drug prices, drug safety controversies, and perceptions that the ads were confusing and biased. Others believed accessibility to various sources of health information created more savvy consumers and fostered cynicism toward marketing messages. Interestingly, some described an inconsistency between consumers’ distrust of the pharmaceutical industry and their views toward specific medication brands and ads as illustrated by the following quote: I don’t know that it matters whether people in general trust pharma. Because yeah, we’re big bad pharma, the axis of evil, one of the three industries people hate most, but that is sort of set aside for personal needs, when you know that you’re suffering from depression and back several years ago you didn’t know what was wrong with you. You just knew you couldn’t get out of bed. And then you see Zoloft advertising, and it speaks to you because it’s a problem you’re having. It makes you aware that maybe it’s not my fault, maybe there is something that can help me get out of the funk. You’re back to living. It’s sort of like people set aside their hatred of oil, so that they can put the gas in their car and keep going.

This comment conveys the observation that consumers’ negative views of the pharmaceutical industry may not always translate into negative attitudes toward particular prescription brands. The participant ascribed this separation to a willingness to put aside or trade-off disdain for pharmaceuticals as an institution in order to receive a needed benefit of medication (i.e., addressing a relevant need is powerful enough to counteract an overarching distrust). Others similarly noted consumers seemed more willing to trust pharmaceutical advertisements if they are seeking health solutions and consider the information in the ads to be useful. While the relevance of a drug or ad information was depicted as offsetting negative perceptions of the pharmaceutical industry and DTCA, participants were cognizant of how the plethora of DTCA contributed to distrust of the industry. For example, one participant stated: Cause on the one hand people need drugs and they need medicine and they need all this research to happen, but on the other side of it, they don’t like how excessive it is and DTC advertising is the most obvious outlet for spend that looks frivolous.


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This quote suggests consumers approve of the resulting product of pharmaceutical companies but believe the expense of marketing the drug so profusely does not benefit consumers. Others commented the magnitude of advertising consumers see leads them to question why that money is not being directed toward research. Within this may be the belief that higher spending on advertising ultimately raises healthcare costs as some participants noted. Participants thought the perception of pharmaceutical companies’ intentions to exploit consumers through a bombardment of advertising messages posed a major challenge to rebuilding consumers’ trust. While participants understood the reasons for such skepticism, some believed consumers would feel differently if they were more aware of the value offered by pharmaceutical companies. Along these lines, increasing efforts toward public relations promoting the corporations’ expertise and benevolent good deeds was mentioned as a way pharmaceutical companies could bolster their reputation. Others thought consumers would be less skeptical if they were more aware of the regulations in place to ensure the accuracy of information presented in ads. Of course, this last point assumes consumers have confidence in the ability of regulations to deter unethical advertising. While the aforementioned ideas for improving consumer trust addressed the broader context of DTCA, other suggested tactics pertained to the informational content or creative design of the ads themselves. For example, one participant considered full disclosure within ads to be the key to trust-building: Well, I mean, it is something that we talk about all the time. And I think that transparency and openness is the best way to build that kind of trust. And we’re hoping that at some point we’ll have a client who’s willing to take that leap and actually kind of have a two way conversation with their customers but we haven’t gotten there yet. Wherever possible what we try to do is encourage our client to tell both sides of the story. To not just come at it with their marketing angle and tell it from their perspective. But that’s often not a possibility so when we work on marketing strategies we try to think about the cynical mind of the consumer and how we can speak to them in a way that will sort of help them to feel a little bit more trusting of the brand.

The strategy mentioned here of “tell both sides of the story” is at the heart of discussions and critiques regarding the fair balance between communication of drug side effects and benefits. The above comment suggests those creating the ads may strive to impart a better balance of information, but pharmaceutical company clients may not be as willing to sacrifice marketing objectives for such openness. In other cases, participants described clients who were willing to provide more patient education in messages and disclose side effects information more prominently. However, client endorsement of these approaches was driven by a desire to create a caring image that would feed back to the bottom line or fear of regulatory repercussions. For example, one participant whose client agreed to place side effects information “upfront, center, and not hidden” stated the following reason for disclosure: I don’t know if it’s an aspect of saying we’re not hiding anything or they just don’t want to get the FDA to pull their stuff. And so they just err on the side of really being blatant about it [. . .] the hope is that people are so used to [the risk messages] that they don’t pay attention to them.

This comment illustrates how relatively transparent risk disclosure may not indicate true pharmaceutical company benevolence. Furthermore, the idea of being hopeful

consumers tune out negative information in the ad about the drug underscores a key criticism of DTCA. Overall, participants as creators of prescription drug messages appeared in favor of providing more complete and balanced information to enhance trust, but pharmaceutical companies were depicted as reluctant to support this strategy unless it facilitates sales. Participants also mentioned the value of using credible sources to deliver messages in a trustworthy manner. Some participants relied on expert endorsers, but others believed employing a typical consumer endorser to whom consumers can relate was equally or more effective. Connecting with consumers through a relevant message was also thought to cultivate trust. One participant illustrated an example in which presenting a meaningful, empathetic message was effective in changing perceptions of a pharmaceutical company: But if you do it successfully, you can make the pharmaceutical company look like a hero, and we do that a number of times when we went to focus groups where women came in and said, “Oh you know, they just want to make money and my co-pay.” They tell stories of the difficulty they’re having paying for their drug, and yet by the time they’ve finished reading the brochure, they were like, “Oh my God, I can’t believe a pharmaceutical company would go do such lengths to give me this kind of information.”

This comment suggests presenting the right kind of information which consumers value can express empathy on the part of pharmaceutical companies. As with the previous concept of providing more information to impart a benevolent image, enhancing the relevance of a message was thought to signify caring and understanding that can help build trust. While a variety of tactics to help build consumer trust in pharmaceutical ads were discussed, several participants acknowledged that not much was actually being done to address the climate of distrust. Some corporate clients may not consider trust-building to be a worthwhile investment. As one participant put it, “So it’s definitely something the companies are aware of, it’s just a matter of how many resources they want to put towards it and how big of a problem they feel it is.” Going back to an earlier point that consumers may not trust the pharmaceutical industry and yet have trust toward, or at least continue to use, particular medication brands, manufacturing companies may not see incentives in trying to increase consumer trust as long as drug sales are not affected. Discussion The objective of this study was to add the perspective of those involved in the creation of DTCA to supplement the existing studies of consumers (e.g. Davis, 2007; DeLorme et al., 2009), healthcare providers (e.g. Friedman and Gould, 2007; Mackert et al., 2010), and ad content (e.g. Avery et al., 2012; Macias et al., 2008). In particular, this paper focused on advertising professionals’ views toward the use of emotion in DTCA and their perceptions of and responses to the current level of consumer trust – a more useful and accurate approach than simply inferring what advertisers intended to communicate based on content analysis. Interpretation of findings Two overriding themes that bridged the discussion of emotion and trust were the concepts of relevance and balance. Participants relied on emotion to increase the


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relevance of prescription drug messages and tried to incorporate emotional content in an appropriate, relevant manner. The relevance of both emotional and informational components of ads were seen as a critical determinant of trust since, according to participants, consumers were less skeptical of messages considered pertinent and beneficial. Along with considerations for relevance, participants acknowledged the need to balance emotional and informational content and to balance information provided about the risks and benefits of a pharmaceutical. This was discussed in the context of meeting consumers’ needs and regulators’ requirements. Of course, scholars and regulators also continue to grapple with what constitutes a true “balance” between the different message components of DTCA (Avery et al., 2012; Food and Drug Administration, 2011). Participants were likewise vague about the precise manner with which such balance is executed, but their general mindfulness of presenting a balanced message signals a sense of social responsibility among pharmaceutical advertising professionals. As discussed previously, the application of emotion appeals in DTCA has been criticized as a tactic for manipulating consumers and diverting attention from important information (Royne and Myers, 2008; Wolfe, 2002). Conversely, participants discussed the intended role of emotion in DTCA as enhancing attention to and facilitating comprehension of complex information presented in ads. Additionally, although DTCA has been depicted as heavily emotional, content analyses have indicated an equivalent presence of emotional and rational/informational appeals (Macias et al., 2008; Frosch et al., 2007) reflecting the balance described by participants. Altogether, these results question the claim that DTCA overemphasizes emotion and incorporates emotion as a manipulative tactic. Mackert and Love (2011) argue that emotional appeals are common and admired in social marketing health campaigns, suggesting a double standard in evaluations of how pharmaceutical ads deliver health messages. However, participants did not distinguish between utilization of emotion to enhance communication of drug risks or benefits. Presumably, emotion is likely to be integrated into communication of benefits since that is the promotional portion of the message. This is not necessarily problematic unless portrayal of emotional benefits overwhelms the description of drug risks. This could occur due to greater vividness of an emotional benefits message in contrast to a risk message void of emotional cues. An announcer’s verbal statement of possible side effects could also be overshadowed by a simultaneous but inconsistent visual depiction of positive emotional benefits. Overly positive emotions associated with drug benefits can also appear contradictory to the bothersome if not dangerous side effects of a drug (DeLorme and Huh, 2009) which could negatively impact message trust. While participants did not directly address these issues, further research could investigate comprehension, recall of drug benefits compared to drug risks, and overall ad trust when emotional content is incorporated at different points of an ad (i.e. during benefits versus risk segments) at heavy to minimal levels. The disclosure of some participants that emotion is used as a means for enhancing the relevance of an ad could also evoke a common concern that prescription drug ads try to encourage otherwise healthy people to self-diagnose and seek unneeded treatments. However, the context of participants’ comments conveyed a desire to reach only the individuals for whom the treatment would be applicable since this group

would relate most to the emotional appeal within the ad. This point is consistent with advertising principles of segmentation and targeting and is supported by the efforts participants described in developing emotional appeals for prescription drug ads. The alignment of specific emotions with certain health conditions concurs with a recent content analysis (Macias et al., 2008). They observed a relationship between emotional appeal type and the health condition indicated in the ad and speculated there was “probably a connection.” This study suggests this relationship stems from a considered effort to create messages that resonate among targeted segments. Of course, this does not preclude the possibility that non-targeted individuals might also relate to the messages, but the intention of participants appeared to be a narrower appeal. Another intriguing insight extracted from this analysis is participants’ assertion that consumers were more willing to trust a prescription drug ad if the information and medication were deemed relevant. Survey research has similarly found the perceived usefulness of information was associated with greater trust in DTCA (Ball et al., 2009). As a result, there may be a disconnect between consumer sentiment toward the pharmaceutical industry and specific ads or brands. In some cases, consumers may view the overall pharmaceutical category unfavorably but make an exception for ads promoting medications addressing their health needs because of the benefit these medications provide. In other cases, consumers may completely dissociate specific ads and medication brands from the overall pharmaceutical industry, especially if they do not link a drug with its manufacturing company. In either case, industry level distrust would not translate into lower sales or negative views toward the particular medications consumers are using, and positive judgments of specific ads and brands would not funnel up to improve the reputation of the pharmaceutical industry. This point identifies several avenues for further investigation. An initial step is to conduct additional research to confirm the degree to which consumers hold conflicting views at the industry, corporation, and brand levels. The proposed disconnect between levels of trust also suggests that current DTCA research may not have sufficiently tapped into all the levels of consumer opinion toward this category. Survey studies have typically queried a broad group of consumers about their judgments of pharmaceutical advertising or the industry as a whole (e.g. DeLorme et al., 2009; Huh et al., 2004; Choi and Lee, 2007). However, unlike messages for most other consumer products, prescription drug ads are only relevant to a narrow segment of the population. Therefore, in addition to assessing perceptions of the category as a whole among a relatively general population, it is important to capture perceptions of and responses to ads for a particular class of medication among those involved with the corresponding health condition. Implications for emotion and trust This study conveys the implicit theories advertising practitioners may hold regarding emotion and trust in the context of DTCA. Such insight serves to highlight the potential relevance of theories for further study of DTCA. Participant’s discussion of emotion as a tool for connecting with consumers to increase relevance is in line with Kamp and MacInnis’ (1995) examination of emotional integration and flow in advertisements to boost empathy, brand relevance, ad involvement, and self-brand image congruity. Theories of narrative processing (Green and Brock, 2000; Escalas, 2004) as well as emotion’s contribution to memory and attention (e.g. Kroeber-Riel,


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1979; Bower, 1981; Scott et al., 1990) also apply. Interestingly, participants questioned the paradigm of trust as a gateway to gaining desired behavioral responses to advertising. Likewise, the assertion that consumers are less skeptical of pharmaceutical messages pertaining to their needs counters predictions by the Elaboration Likelihood Model that relevance increases critical evaluation of a persuasive message (Petty and Cacioppo, 1986). For DTCA, factors such as the necessary intervention of a health professional to authorize treatment may alter the typical role of trust in ad response. Participants’ ideas regarding ways to increase trust were in line with existing theory, though, that recommends transparency (Eiser et al., 2009), touting characteristics of expertise and benevolence (Li and Miniard, 2006; Mayer et al., 1995), and emphasizing contextual aspects (like regulations) that foster a safe environment for trust (McKnight and Chervany, 2001-2002). Managerial and policy implications In terms of practical implications, this analysis suggests more targeted media placement of pharmaceutical advertisements is needed in addition to targeting message content. According to participants, consumers considered the current practice of mass marketing prescription medications to be excessive and made pharmaceutical companies seem wasteful, manipulative, and profit-driven. Consumer research corroborates this view (DeLorme et al., 2007). Given pharmaceutical companies have spent around $4 billion on DTCA in the US in recent years (IMS, 2012), the barrage of prescription drug messages may be especially bothersome if the ads are seen as irrelevant. Hence, the applicability of prescription drug messages to only a select group of consumers may underlie the pervasive dissatisfaction with the abundance of pharmaceutical advertising. This study suggests employing a more precision-oriented media plan would be more efficient and reduce negative consumer views regarding the excessiveness of pharmaceutical marketing. It is notable there were some instances of uncertainty as to what regulators considered acceptable, suggesting clearer guidance from policymakers is needed. In addition, while there was recognition that balanced information is beneficial to consumers and can help build trust, some participants hoped consumers would not pay too much attention to the side effects information. To this point, only limited research has examined the degree to which consumers process ad information about side effects (Kaphingst et al., 2005). If further research demonstrates a lack of attention, comprehension, and application of side effects information to decision-making by consumers, questions arise as to whether the requirement to include this risk information for fair balance as it is currently formulated is serving its intended purpose. Limitations and additional future research There are, of course, limitations of this study to note. The observations and perceptions of pharmaceutical advertising professionals we captured do not necessarily reflect actual effects of DTCA. Additional research of consumer subjects is needed to assess the validity of participants’ comments concerning, for example, the effects of emotional appeals on information processing of DTCA and the assertion that perceived relevance of messages overcomes distrust toward DTCA. In addition, given the qualitative nature of this study, conclusions cannot be drawn regarding the extent to which the

views expressed by participants are shared with other pharmaceutical advertising professionals; this is particularly true given that some participants worked in advertising agencies and others worked in pharmaceutical marketing, which could lead to different perspectives on some of the issues addressed. Follow-up survey research is necessary to establish the generalizability of our results. Broader surveys could focus on establishing the industry-wide prevalence of the views expressed by participants in this project, for example, and provide a useful counterpoint to national data describing the perceptions of consumers and healthcare providers to the practice of DTCA. Such research could also investigate the specific drugs on which participants have worked and potential differences across categories as to what is deemed appropriate. Interviews with ad practitioners servicing over-the-counter medication accounts or working on social marketing health campaigns, particularly in relation to emotional message strategies, would also be enlightening. Such research would provide some insight into the degree to which the tactics discussed in this study are unique to prescription pharmaceutical executions or common to promotional health messages in general. Moreover, a valuable expansion of this study’s focus on emotion and trust would be to address broader questions related to overall creative design, the choice of employing an informational or emotional appeal, and the challenges and considerations of developing digital advertising in the pharmaceutical category. Conclusions The advertising professionals interviewed in this study generally expressed a desire to design messages responsibly to serve the end-benefit of improving individuals’ health. They discussed efforts to abide by regulations in terms of avoiding superfluous emotional content and balancing drug benefits and risks. However, participants were cognizant that persuasive tactics, such as using emotion, were necessary to ensure their pharmaceutical ads could compete for consumers’ attention with other ads. They additionally saw emotional appeals as an opportunity for overcoming distrust and adding creativity where much of the ad content is mandated. Some participants also admitted their clients were not always willing to permit more comprehensive disclosure of risks or sacrifice marketing goals to engage in basic patient education. Reflecting the tensions surrounding the DTCA debate, advertising professionals appear to be faced with the challenge of developing messages that satisfy clients’ promotional objectives and regulators’ informational requirements amid a backdrop of consumer distrust. References Atkin, J.L. and Beltramini, R.F. (2007), “Exploring the perceived believability of DTC advertising in the US”, Journal of Marketing Communications, Vol. 13 No. 3, pp. 169-180. Austin, E.W., Miller, A.C., Silva, J., Guerra, P., Geisler, N., Gamboa, L., Phakakayai, O. and Kuechle, B. (2002), “The effects of increased cognitive involvement on college students’ interpretations of magazine advertisements for alcohol”, Communication Research, Vol. 29 No. 2, pp. 155-179. Avery, R.J., Eisenberg, M. and Simon, K.I. (2012), “Fair balance in direct-to-consumer antidepressant print and television advertising”, Journal of Health Communication, Vol. 17 No. 3, pp. 250-277.


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