The Relationship Between Advertising-Induced Anger and Self-efficacy on Persuasive Outcomes A Test of the Anger Activism Model Using the Truth Campaign Vinu Ilakkuvan, MSPH; Monique Mitchell Turner, PhD; Jennifer Cantrell, DrPH, MPA; Elizabeth Hair, PhD; Donna Vallone, PhD, MPH Turner’s Anger Activism Model (AAM) contends anger and efficacy interact in a unique way to determine message responses to campaign materials. This study tested the AAM using responses to 2 truth antismoking advertisements collected in August-October 2014 via an online, cross-sectional survey of 15- to 21-year-olds. Those aware of each of the truth advertisements (n = 319 for each) were organized into 4 anger/efficacy groups. Analysis of variance and regressions were conducted to understand group differences in message-related cognitions (persuasiveness, receptivity, conversation). Message cognitions were highest among the high anger/high efficacy group and lowest among the low anger/low efficacy group. Key words: Anger Activism Model, communication, emotion, theory, tobacco T is considered obvious, perhaps, that the ob- stronger attitudes among the overall target audi- I jective of a public health media campaign is to ence. Effects of this ilk can happen when public modify the at-risk audience’s behaviors. In the to- health professionals leverage these strong attitudes bacco control domain, preventing tobacco use is a to develop the aligned audience into vehicles of be- common goal of media campaigns, as it was with havior change among the broader target audience the original truth campaign in the early 2000s. through their social influence. In other words, the The original version of the truth campaign targeted aligned audience can become influencers. youth who were open to smoking and/or sensation This precise the aim of the current iteration of the seeking in an attempt to prevent them from initiat- truth campaign, entitled Finish It, launched in Au- ing smoking cigarettes.1 gust 2014.3 Teen smoking rates have declined sig- Yet, another audience vital to the success of pub- nificantly since the early 2000s, with only 7%of lic health campaigns is the aligned audience—those teenagers in grades 8, 10, and 12 saying that they individuals whose attitudes and behaviors already smoked a cigarette in the past 30 days in 2015.4 align with the public health or antitobacco mes- Despite this decline, tobacco use remains the lead- sage at hand (ie, “preaching to the choir”). Such ing cause of preventable death in the United States,5 audiences may require attitudinal or behavioral and nearly 90% of cigarette smokers began smok- maintenance,2 but, perhaps more importantly, cam- ing before the age of 18 years.6 Thus, addressing paigns targeting these audiences can help develop the issue of tobacco use among teenagers remains a critical public health issue. Given that the over- Author Affiliations: Evaluation Science and Research, Truth whelming majority of teens—91%—do not use to- Initiative, Washington, District of Columbia (Ms Ilakkuvan and Drs bacco products,7 the Finish It campaign seeks to Cantrell, Hair, and Vallone); Department of Prevention and Com- build on this momentum and rally the current gener- munity Health, The George Washington University Milken Insti- tute School of Public Health, Washington, District of Columbia ation of young people to be the generation that ends 3 (Ms Ilakkuvan and Dr Turner); Department of Health, Behavior, and youth smoking. However, there are few, if any, be- Society, Johns Hopkins Bloomberg School of Public Health, Balti- havioral or communication theories that specifically more, Maryland (Drs Cantrell and Hair); and Global Institute of Pub- deal with (a) aligned audiences or (b) how to com- lic Health, New York University, New York (Dr Vallone). pel them into becoming behavior change agents, or Data collection was funded internally by Truth Initiative. There are activists. One novel, and fairly new, theory articu- no other funding sources for this work. lating the process by which aligned audiences can The authors have no conflicts of interest to report. be leveraged to take action for a particular cause is 8 Correspondence: Vinu Ilakkuvan, MSPH, Department of Preven- the Anger Activism Model (AAM). tion and Community Health, The George Washington University Milken Institute School of Public Health, 950 New Hampshire Ave ANGER ACTIVISM MODEL NW, Washington, DC 20037 ([email protected]). It has long been understood that emotions have a Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. robust impact on attitudes, decisions, judgments, DOI: 10.1097/FCH.0000000000000126 and behaviors.9-11 Although most studies regarding 72 Family and Community Health January–March 2017 ■ Volume 40 ■ Number 1 Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. V. Ilakkuvan et al. Relationship Between Advertising-Induced Anger and Self-efficacy on Persuasive Outcomes 73 the role of emotion in health messaging have fo- ticipants had more negative thoughts about the mes- cused on the effects of fear, guilt, or humor, there sage (which had logical flaws embedded in it) and is reason to believe that anger can have beneficial were less supportive of message recommendations effects.8,11 To some degree, this is a surprising state- than the fear group. Notably, Nabi did not assess ment given that several studies reveal the deleteri- the effects of the intensity of the angry feelings expe- ous effects of anger, such as misjudging individuals rienced by participants. Yet, Frijda25 proposed that or events.8,12 In fact, Turner developed the AAM to action tendencies depend on an emotion’s intensity. predict when anger can lead to constructive versus The AAM posits that the intensity of the angry feel- deleterious effects on cognitions.8 Here, we focus on ings is a critical factor in determining cognitive and constructive outcomes. behavioral outcomes.8 Like health messaging studies broadly, research Whether feelings of anger lead to construc- on youth tobacco prevention campaigns has also tive outcomes (eg, systematic processing) or non- focused largely on the effects of fear, disgust, sad- constructive ones (eg, misjudging individuals or ness, and humor.13 While there is evidence that fear- events) is dependent upon the intensity of the inducing antismoking messages featuring health anger experienced.8 The AAM hypothesizes differ- consequences are effective among youth, much of ent cognitive and behavioral outcomes dependent the evidence for the effectiveness of fear appeals in upon how angry message recipients report being; antitobacco campaigns comes from campaigns fo- as Loewenstein and Lerner stated, “at sufficient cused on adult cessation, not youth prevention.14 levels of intensity, emotion can overwhelm cogni- There are many emotions beyond fear that can be tive processing and deliberative decision making evoked by health messages, and anger, in particular, altogether.”26(p627) is underexplored in the literature. The AAM pro- Turner argued that despite its potentially deleteri- vides a unique framework with which to understand ous outcomes, even intensely felt anger can lead to the impact of a tobacco prevention campaign such constructive results.8 Given that we are interested as truth. in persuasive situations, it would be a misstep to The AAM is an emerging theory that rests on sev- fail to recognize the role of self-efficacy, one’s be- eral key assumptions.8 First, anger is triggered when lief in his or her ability to accomplish a particu- one’s goals,15 particularly goals related to the preser- lar task, in affecting behavioral intentions.27 Peo- vation of ego, are threatened.16 Experiencing anger ple with a high degree of perceived self-efficacy are communicates that something in the environment able to translate knowledge into behavior.27 Hence, is wrong,17-19 motivating individuals to remove ob- the perceived ability to control a situation may be stacles blocking goal attainment.15 So, anger func- what distinguishes constructive from nonconstruc- tions to motivate people to regain or maintain con- tive anger. trol of a threatening situation.20 Second, anger can Turner argued that, taking an audience segmen- be caused by a campaign message or communica- tation perspective, we can use anger and efficacy to tion in general. Third, the effects of anger on indi- form 4 distinct audience segments that will uniquely viduals’ cognitions in response to a message depend respond to the anger-inducing campaign message.8 on 3 key moderating variables: (a) the intensity of The first group, activists, experience strong feelings the anger experienced (ie, communication can cause of anger and strong efficacy beliefs. The activist angry feelings ranging from mad to rage), (b) self- group will have the most positive attitudes regard- efficacy or perceptions of being able to control the ing the topic, will be most willing to engage in angering stimulus, and (c) whether the target au- higher commitment behaviors, and will engage in dience is aligned or not aligned with regard to the higher levels of systematic processing. The second angering stimulus (anger appeals are most effective group, empowered, experiences low levels of anger with aligned audiences).8 The model has thus far and strong perceptions of efficacy. Empowered been tested only with older adolescent populations.8 people feel that something can be done to “fix” the issue, but they do not perceive the issue to be anger- ANGER EFFECTS, ANGER INTENSITY, AND ing (ie, the topic is not of high importance). Thus, SELF-EFFICACY they will have positive attitudes but will only be Lazarus and Lazarus15 proposed that the coping re- willing to engage in midlevel behaviors. The third sponse of angry people is to remove barriers block- group, angry, is distinguished by strong feelings ing goal attainment, thereby motivating people to of anger and weak feelings of efficacy. Thus, these regain control of a threatening situation. Anger also people are angry about the current state of affairs, directs attention, memory, and judgments; in fact, it but they do not perceive that anything can be done.