Resistance Induction in the Context of Health Decision Making
Summary and Keywords
During the past few decades we have witnessed increased academic attention on resistance to persuasion. This comes as no surprise, as people are often persuaded by external forces when making important decisions that may affect their health. Public health professionals, scholars, and other concerned parties have developed numerous trainings, interventions, and regulations to teach or assist people to resist unwanted persuasion, deriving from media exposure (e.g., advertising) or social pressure. The extant literature on resistance induction encompasses strategies such as inoculation, media literacy interventions, trainings on specific persuasive techniques, warnings, and social influence interventions. Although the research findings of the discussed strategies vary in how straightforward they are, they do offer promising avenues for policymakers and health communication professionals. Furthermore, several avenues worthy of further study can be identified.
In current society, we are constantly confronted with temptations that are potentially harmful to our health. Everywhere we go there are environmental influences that may persuade us to engage in unhealthy behaviors, such as consuming unhealthy foods, drinking alcohol, or smoking cigarettes. These persuasive forces can be quite explicit, such as an advertisement for chocolate cake, but they can also be more implicit: for example, attractive food packaging, a teenager who encourages his or her friend to try a cigarette, or merely perceiving others enjoying alcohol on television or in real life.
Previous research has demonstrated that media exposure can have harmful effects on people’s health. Negative effects of media exposure have been found for violence (e.g., Anderson & Bushman, 2001), eating behavior (Harrison & Cantor, 1997; Grabe, Ward, & Hyde, 2008) and alcohol use (Anderson et al., 2009; Smith & Foxcroft, 2009); see also Strasburger, Jordan, and Donnerstein (2012) for a review on health effects of media on children and adolescents. Moreover, undesirable influences stem from one’s direct social environment. In line with this, research has, for example, established that a person’s chance to develop obesity is 57% higher when this person has a friend in his or her social network who is obese (Christakis & Fowler, 2007). The social environment in which one finds him or herself, and the norms that are being set by others, can therefore play an important role in health behavior (Robinson, Benwell, & Higgs, 2013; Stok, de Ridder, de Vet, & de Wit, 2012).
On a daily basis people are confronted with numerous influences in one’s (social) environment that may encourage unhealthy choices; however, there are several resistance-inducing strategies available that can assist people to engage in more deliberate and informed decision making. When desirable and appropriate this can subsequently result in resistance toward persuasion. In this article, we provide an overview on trainings, interventions, and regulations that are used to help people resist unwanted persuasion.
In the literature there can be found many definitions of persuasion. This chapter follows the broad definition of persuasion put forth by Gass and Seiter (2011): “Persuasion involves one or more persons who are engaged in the activity of creating, reinforcing, modifying, or extinguishing beliefs, attitudes, intentions, motivations, and/or behaviors within the constraints of a given communication context” (p.33). They further argue that persuasion is not necessarily intentional and that social modeling, socialization processes and social influence, can be perceived as persuasion. In this chapter we focus on the resistance of various influencers (e.g., advertising, media exposure, and social pressure) that may result in persuasion.
According to the Persuasion Knowledge Model (Friestad & Wright, 1994) people develop an understanding about persuasion throughout their lives. Knowledge about why, when, and how they are influenced, helps them to effectively cope with persuasive attempts. A distinction can be made between persuasion, topic, and agent knowledge. Persuasion knowledge concerns knowledge about the strategies that are adopted in a persuasive attempt (please note that the term persuasion knowledge is also used as an umbrella term for topic, agent, and persuasion knowledge). Topic knowledge is the knowledge that people have concerning the topic of the persuasive message, and knowledge about the sender of the message is referred to as “agent knowledge.” Although theoretically persuasion knowledge can result in both resistance and persuasion, empirical studies have often demonstrated that persuasion knowledge is positively related to resistance and negatively to persuasion (Van Reijmersdal et al., 2016). It is, therefore, not surprising that many trainings, intervention programs, and regulations focus on increasing one or more types of persuasion knowledge to decrease unwanted persuasion. The general rationale behind these trainings, interventions, and regulations is that informing the audience about (deceptive) persuasion tactics, the topic of consideration, the effects of the media, or the motivation of senders enhances their skills to ward off unwanted influence.
The next section will first provide a definition of resistance to persuasion and then present an overview of resistance inducing trainings, interventions, and regulations that focus on decreasing unwanted influence. The influence discussed in the current chapter can originate from media content, such as advertising, but also from product packaging or a person’s social environment (e.g., peer pressure). Note that this article does not claim to provide an exhaustive review of all possible resistance inducing strategies; the aim here is to provide an initial overview of available trainings and interventions examined in various domains, such as communication, psychology, and marketing. In doing so we hope to present a valuable starting point for future academic research and to provide insights for policymakers and health practitioners on this important topic.
Resistance to Persuasion
Resistance to persuasion is defined by McGuire (1964) as the ability to withstand a persuasive attack. Knowles and Linn (2004) make a distinction between resistance as an outcome and resistance as a motivational state. Resistance as an outcome refers to the lack of attitudinal or behavioral change after a persuasion attempt. Resistance as a motivational state refers to a state in which people purposely reduce attitudinal or behavioral change. In doing so they use several resistance strategies such as counter arguing, avoidance, and selective exposure (Zuwerink Jacks & Cameron, 2003). Different authors have proposed several categories to describe resistance strategies that are adopted when confronted with persuasive attempts. Fransen, Verlegh, Kirmani, and Smit (2015) proposed avoidance, contesting, and empowerment strategies in the context of resisting advertising, while Van ‘t Riet and Ruiter (2013) defined avoidance, denial, cognitive reappraisal, and suppression as strategies to resist persuasive health messages.
People hold different motivations to adopt different resistance strategies. These motivations may derive from, for example, a perceived threat to freedom (Reactance Theory; Brehm & Brehm, 1981), reluctance to change, concerns of deception (Fransen, Smit, & Verlegh, 2015), or an accuracy motivation (Kunda, 1990). Although people might have several motives to resist persuasion, they may not always be motivated—or they may lack the skills to effectively recognize or resist a persuasive attempt. Resistance induction strategies aim to inculcate these skills by informing people of a persuasive attempt or tactic, or by providing information such as pro and con arguments about the topic. In doing so, these resistance-inducing strategies often stimulate the use of different types of resistance strategies such as contesting (e.g., counter arguing) or empowering (e.g., attitude bolstering) strategies to decrease unwanted influence.
It is important to note that we do not argue that persuasion is always negative and that people should be assisted in resisting all forms of persuasion. Of course many persuasive attempts, particularly health messages, can be considered as positive and in the best interest of the recipient. In this context, resistance can be perceived as a problem (rather than a solution) for health communication professionals (Van‘t Riet & Ruiter, 2013). To encourage people to engage in healthy behavior, it is therefore also important and relevant to study ways to effectively deal with resistant audiences. However, in the present chapter we address the promotion of health behavior by focusing on the other side of resistance by discussing resistance-inducing strategies that aim to assist people in coping with persuasive situations that may seduce them in (unwanted) unhealthy decisions.
Resistance Inducing Strategies
As a result of media, environmental, and social influences people may, willingly or not, change prior healthy attitudes and behaviors (Compton, Jackson, & Dimmock, 2016). One of the first theories that focused on instilling resistance to unwanted persuasion is inoculation theory, developed by McGuire (1964). Inoculation theory draws parallels between protecting oneself against diseases and protecting oneself against persuasive attempts. It postulates that we can protect ourselves from persuasive attempts in the same way that we can inoculate ourselves against a virus. That is, by exposing ourselves to a weaker version of the virus, or in the case of persuasive attempts, a weaker version of the argument made against the position we hold. This inoculation will then help us to build up resistance against future persuasive attempts. More specifically, this weakened argument is thought to motivate a person to come up with counterarguments, which strengthens a person’s initial attitude. This then helps to resist subsequent persuasive attempts (Banas & Rains, 2010).
An inoculation message typically consists of two basic components that induce resistance to persuasion, that is threat and refutational preemption. Threat refers to the idea that people are made aware of the fact that their current position on a certain issue is vulnerable to persuasive attacks. This can for instance be accomplished by means of a forewarning. The threat should motivate people to guard themselves against a persuasive attack. Following this, a refutational preemption is introduced, usually consisting of introducing and refuting counterarguments against one’s position (Compton et al., 2016).
Inoculation theory has received a lot of attention from scholars over the past decades (for reviews see, Banas & Rains, 2010; Compton et al., 2016). Results from a meta-analysis indicate that inoculation is indeed an effective strategy to induce resistance to persuasion. Moreover, results indicate that resistance to persuasion generalizes beyond the arguments refuted during the inoculation treatment. That is, inoculation is effective both to guard against persuasive attempts that use arguments for which counterarguments were provided during inoculation, as well as new arguments (Banas & Rains, 2010).
Inoculation has been applied to enhance resistance against pressures to engage in harmful behaviors such as smoking (Banerjee & Greene, 2007; Pfau, Bockern, & Kang, 1992), alcohol use (Godbold & Pfau, 2000), and drinking and driving (Duryea, 1984). In a study by Pfau, Bockern, and Kang (1992) inoculation was applied to guard people against peer pressures that encourage smoking. In a large-scale study, adolescents were either assigned to an inoculation intervention or a control condition. The intervention was embedded in a video designed to inoculate adolescents against smoking initiation. The videos started with a threat component that warned adolescents that even though they might oppose smoking, during the next year many would start having doubts about smoking; some would even change their mind and try smoking as a result of peer pressure. After this warning several pro-smoking arguments were refuted, such as smoking is cool and smoking is not addictive. For those in the reinforcement conditions this message was repeated nine weeks later. Results indicated that the inoculation intervention was effective for adolescents with low self-esteem: that is, those more vulnerable to peer pressure. Both at first and second measurement (five and eight months after exposure), participants with low self-esteem who were exposed to the inoculation intervention reported more disapproving attitudes toward smoking, compared to the control condition.
While in Pfau et al. (1992) inoculation was used to counteract peer influences that encourage smoking, Mason and Miller (2013) investigated the effects of inoculation messages on inducing resistance to persuasion stemming from commercial food advertising (i.e., potentially deceptive health and nutrition claims). In this study, message frame and language concreteness were also used to examine how specific message characteristics affect inoculation message effectiveness. Participants in this study were assigned either to one of four inoculation message conditions or to a no-message control group. Inoculation messages either framed outcomes in terms of positive consequences of healthy eating or negative consequences of unhealthy eating. Moreover, messages contained more concrete or abstract language. It was expected that the threat that is part of an inoculation message would activate a more vigilant motivation, one more compatible with negative outcome frames than positive outcome frames. With regard to language use in inoculation messages it was expected that concrete language would result in more resistance to persuasion than abstract language and that frame and language would interact and produce fit effects. Fit was expected to be highest in the negative outcome—concrete language and positive outcome—abstract language conditions. Results indeed showed that participants in the negative outcome conditions perceived higher levels of threat, had more negative attitudes toward the source, and generated more counterarguments than those in the positive outcome conditions. When concrete language was used, this led to more negative attitudes toward the source and more counterarguments, compared to when abstract language was used. Regarding fit effects, it was found that participants in the high fit conditions generated more counterarguments than those in the low fit conditions. Upon inspection of the means, inoculation effects on counter arguing seem to be mainly driven by the inoculation message with negative outcome frames and concrete language.
Inoculation has proven to be an effective resistance inducing strategy (Banas & Rains, 2010). However, more research should be conducted into the underlying processes of inoculation and resistance, such as how inoculation against certain arguments creates inoculation against novel arguments (Banas & Rains, 2010), as well as the variables in the receiver (e.g., media skepticism) and message (e.g., modality) that determine the effectiveness of inoculation (Compton et al., 2016).
Media Literacy Interventions
Inspired by inoculation theory, media literacy interventions are designed to decrease potential negative effects of media exposure, which can result from both program content and advertising. Rather than trying to limit exposure to media or regulate the content, public health professionals have embraced health-promoting media literacy programs as an appropriate alternative to protect (young) people from the potentially negative impact of media. Media literacy refers to specific knowledge and critical-thinking skills that help audiences to develop independent judgments about media content (e.g., Aufderheide, 1993). Media literacy trainings typically aim to (1) enhance critical thinking by increasing knowledge of the media, (2) create awareness of the influence of the media, and (3) increase the ability to assess the level of realism of the media’s representation of reality (see Jeong, Cho, & Hwang, 2012). These aims can be assessed by focusing on (a) media-relevant outcomes such as understanding of persuasive intent (Austin & Johnson, 1997) and advertising knowledge (Nelson, 2016), (b) behavior-relevant outcomes such as attitudes, intentions, and behavior, (c) social norms perceptions, and (d) coping skills (Austin et al., 2005). Hence, these trainings aim to promote health behavior by teaching audiences to critically examine and resist media messages that persuade them to engage in risky behaviors.
Media literacy trainings are generally aimed at children and adolescents and often take place in a classroom setting. Most researched interventions focus on reducing alcohol, drugs, and tobacco use, as well as violence, body image and eating and advertising. Media literacy interventions that focus on advertising are also referred to as advertising literacy interventions (An, Jin, & Park, 2014; Nelson, 2016). A distinction can be made between general media literacy trainings and specific media literacy trainings. Austin and Johnson (1997), for example, examined the effects of these two types of trainings in the context of alcohol consumption. Both trainings started with a movie, designed by the Consumers Union of the United States (1990), aimed at teaching skepticism toward advertising. Participants in the general media literacy condition watched and critiqued advertisements on foods and beverages, not including alcohol advertisements. Participants in the specific media literacy condition watched and critiqued advertisements on food and drinks including alcohol advertisements. In both groups a guided discussion addressing what on television is real, what is right and wrong, and how it relates to real-life experiences followed. Participants in the control condition viewed an unrelated video in which advertisements for alcoholic and non-alcoholic drinks were included. In this condition, the discussion focused on the video rather than the advertisements. The results demonstrated, among other things, that both the general and specific media literacy interventions increased persuasion knowledge and decreased the likelihood to select an alcohol-related product. The alcohol-specific training was slightly more effective than the general training and was more effective for girls than for boys. In many media literacy programs it is clear that general as well as specific media-related elements are combined. Hence, they focus on teaching how media can influence behavior (i.e., persuasion knowledge) but also on why, for example, alcohol and drugs are bad for you (i.e., topic knowledge), and how you can cope with persuasive attempts (i.e., coping skills).
In recent years, several meta-analyses and reviews have been conducted to examine the effectiveness of media literacy programs (Hindmarsh, Jones, & Kervin, 2015; Jeong, Cho, & Hwang, 2012). Overall these overviews show positive but small, effects on several outcomes such as media knowledge, perceived realism, attitudes, and behavior. Jeong, Cho, and Hwang (2012) additionally found that interventions with more sessions are more effective, but interventions including different aspects of media literacy (e.g., enhancing knowledge and critical thinking in one intervention) were less effective. Therefore, for future research it seems important to examine which elements of media literacy interventions are most effective on the specified outcomes.
Parental mediation is another way to protect children and adolescents from the potential negative effects of media exposure on health. Although the setting is different than in most media literacy programs, the aims of parental mediation greatly overlap with the aims of media literacy programs. According to parental mediation theory, parents adopt different communication strategies to reduce the potential negative effects of different types of media (Clark, 2011). In the literature on parental mediation, a distinction between restrictive mediation (i.e., setting rules and regulation about children’s media use), active/instructive mediation (i.e., talking with children about consumed media content), and co-viewing (i.e., using media together) is often made. Particularly active parental mediation is comparable to media literacy interventions. Research has demonstrated that active mediation of television use can reduce negative outcomes, such as the cultivation of gender stereotypes (Nathanson, Wilson, McGee, Sebastian, 2002), unhealthy consumption behavior (Buijzen, 2009), materialism, purchase requests, parents-child conflicts (Buijzen & Valkenburg, 2005), aggression (Nathanson & Cantor, 2000), attitudes toward snack/fast-food advertisements (Yu, 2011) and increase positive effects such as skepticism regarding television content (Austin, 1993). Although restrictive mediation may also reduce negative effects of media, it can also result in a forbidden fruit effect, making the forbidden content more desirable. Sasson and Mesch (2014) demonstrated, for example, that restrictive parental supervision increased adolescents’ risky online behavior (e.g., frequency of posting personal details and meeting face-to-face with a stranger met online). Moreover, restrictive parental mediation may lead to negative attitudes toward the parents (Nathanson, 2002). For co-viewing the results are mixed. It has been found, for example, to enhance aggression (Nathanson, 1999) and children’s belief that television is real (Messaris & Kerr, 1984). However, co-viewing can also result in positive effects and greater enjoyment (Nathanson, 2001).
Trainings on Specific Persuasive Strategies
Besides more general media or advertising literacy interventions, several programs focusing on revealing specific (misleading or inappropriate) advertising strategies have been developed and tested. The general aim of these programs is to empower the audience to more critically evaluate persuasive attempts based on specific persuasion tactics.
Recognizing Specific Persuasive Strategies
A first example can be found in research focusing on helping message recipients recognize the legitimacy of adopted persuasive strategies. Sagarin, Cialdini, Rice, and Serna (2002) tested in a set of studies a short treatment with the goal to increase resistance toward persuasive attempts that use a deceptive persuasion strategy. More specifically, the aim of the treatment was to teach message recipients to recognize the legitimacy of authorities used in advertisements (e.g., a celebrity endorser). In doing so, participants in the treatment group were provided with a set of rules that decided whether the authority presented in an advertisement is used legitimately or not (e.g., the authority must be an expert on the product he or she is selling). Subsequently, they practiced with examples in which both legitimate and illegitimate authority figures were present. The results demonstrate that the treatment increased perceptions of undue persuasive intent for the illegitimate authority-based advertisements and that it decreased persuasion, partly mediated by negative cognitive responses. However, an unexpected side effect was found. Participants in the treatment condition were more strongly persuaded by a legitimate advertisement than participants in the no-treatment condition. Additionally, the treatment revealed much stronger effects when participants felt that they were vulnerable to these kinds of persuasive attempts.
In a similar vein, Coutinho and Sagarin (2006), in their study on the (il)legitimate use of scarcity as a persuasive technique (e.g., “limited edition”) examined whether people are able to accurately infer rules to decide whether an ad uses scarcity legitimately or not, after being told that in some ads this principle is used illegitimately. In addition, they tested whether such accurate rule induction increased perceived manipulative intent and resistance toward persuasion. The results demonstrate that people have great difficulty with inferring rules to decide whether scarcity is used legitimately or not, particularly when they feel invulnerable to advertising effects. Nevertheless, results show higher perceived persuasive intent and less persuasion for ads that illegitimately (versus legitimately) used scarcity appeals. Both studies reveal that in order to help people resist persuasion it is important that they feel vulnerable to advertising techniques and that they are taught clear decision rules on how to discern ads that make legitimate use of persuasive strategies versus those that do not.
Resisting Humorous Ads
Recent research on embodiment, emotion regulation, and resistance has also revealed an interesting strategy that might be adopted in increasing resistance to humor-based advertising (see Lewinski, Fransen, & Tan, 2016). By using automated facial expression coding software, these researchers found a positive relationship between the recorded expression of happiness (e.g., smiling) during exposure to a commercial (and the evaluation of a humorous commercial) and the advertised product (e.g., potato chips). Hence, the more people smile during exposure to funny commercials, the more they like the ad and the advertised product. In examining ways to decrease the persuasive effects of humor in advertising, several emotion regulation strategies were examined. For example, it was tested whether instructing participants to not express their emotions when watching a commercial would mitigate the positive relation between expressions of happiness on the one hand, and ad and brand liking on the other hand. The results demonstrated that when participants received the instruction not to express their emotions, they liked the commercial and the promoted brand less than participants in the control condition. This effect was mediated by observed expressions of happiness. In addition, they showed, in a related set of studies, that a “co-viewing” avatar demonstrating incompatible facial expressions during humorous ad exposure (i.e., disgust) decreased the viewer’s positive emotions and subsequently ad and brand liking. Hence, seeing others expressing negative emotions toward a humorous ad reduces recipients’ expressions of happiness and subsequent evaluations. Although research on the self-regulation of emotions in the context of resisting specific persuasion strategies is still in its infancy, teaching audiences to regulate their emotions while exposed to unsolicited advertising might provide a promising strategy in coping with emotion-based advertisements.
Forewarnings, Disclosures, and Warning Labels
Another way of helping people to resist persuasion is by means of warnings. Warnings have been examined in many different contexts and in many different forms such as disclosures and warning labels.
Forewarnings have received a great deal of attention in the literature on persuasive messages. Traditional forewarnings are intended to make the audience aware of either the persuasive intent or the content of an upcoming message. Studies have demonstrated that forewarnings of persuasive intent activate people’s cognitive and affective defense mechanisms, often resulting in reduced persuasion (Petty & Cacioppo, 1977; Lee, 2010). According to the literature review Cialdini and Petty (1981), forewarnings of persuasive intent indeed result in resistance, but forewarnings of message content can result in either resistance or in more agreement with the message. Chen, Reardon, Rea, and Moore (1992) revealed that the mixed effects of forewarnings of content depend on recipients’ involvement with the topic of the message. They demonstrated that when recipients are involved with the message, they resist the message after a warning of the content, but when they were uninvolved they were positively affected by the message, even when they received a warning. These effects disappeared when recipients were distracted from the message and had no cognitive capacity to elaborate on the message. A meta-analysis conducted by Wood and Quinn (2003) confirmed the important role of message involvement in forewarning effects. They revealed that a warning before receiving a message results in resistance when the message concerns a relevant topic and results in persuasion when the topic is less relevant. When recipients are warned after the message, it consistently results in resistance. Interestingly, no differences were found between forewarnings of persuasive intent and forewarnings of content.
Rozendaal, Buijs, and van Reijmersdal (2016) examined ways to strengthen children’s advertising defenses. They tested the effectiveness of two types of persuasive intent warnings, forewarning of commercial intent and forewarning of manipulative intent. Forewarnings of commercial intent inform people about the selling and persuasive intent of a message, whereas forewarnings of manipulative intent inform people of the fact that advertising can be deceptive. The authors expected that commercial intent warnings would activate a cognitive resistance process (i.e., increasing conceptual persuasion knowledge) whereas a warning of manipulative intent would activate an affective resistance process (i.e., attitudinal persuasion knowledge). The results demonstrated that only the forewarning of manipulative intent was successful in activating children’s advertising defenses. As expected, this forewarning had a positive effect on skepticism towards the advertisement (i.e., attitudinal persuasion knowledge), which resulted in a lower desire for the advertised product. No effects were found for the commercial intent warning. Based on these results, it can be suggested that for children, due to less strongly developed cognitive abilities, the activation of attitudinal persuasion knowledge by a forewarning of manipulative intent is an effective way to increase resistance.
Recent research has demonstrated that persuasive intent warnings in the context of advertising may also work on a more unconscious level. Fransen and Fennis (2014) conducted two studies in which they compared a traditional persuasive intent forewarning strategy to a persuasive intent priming strategy in which people were reminded of a situation in which someone intended to influence them. The results demonstrated that compared to a control condition, recipients who received a traditional persuasive intent warning or received the persuasive intent priming strategy showed more resistance to a heuristic-based advertisement (e.g., a dentist promoting toothpaste). Interestingly, the persuasive intent priming strategy required fewer cognitive resources, than the traditional persuasive intent warning. This is relevant since cognitive resources are scarce and audiences are often not motivated to use cognitive resources to resist advertisements.
A recent development in advertising is embedding persuasive commercial messages into traditional content. Examples are product placements, advergames, and advertorials. Sponsored content regularly portrays unhealthy behavior (e.g., James Bond drinking Heineken beer). Sponsored content can be defined as the purposeful integration of brands or branded persuasive messages into editorial media content, in exchange for compensation from a sponsor (Van Reijmersdal, Neijens, & Smit, 2009). Since it is difficult for audiences to recognize sponsored content as advertising, it has been argued that it violates the right of audiences to know when they are the subject of a persuasive attempt, which may result in unfair communication (e.g., Cain, 2011). To counter this concern, regulations that obligate senders to disclose sponsored content have been developed. Each country has different rules and regulations, but the most important function of disclosures is to reveal when media content contains advertising and to identify the sponsor of that message. This has resulted in various disclosures such as, “This program contains product placement” and “This program is sponsored by brand X.” In an extensive literature review of 21 studies, Boerman and van Reijmersdal (2016) present the effects of disclosing sponsored content to an adult audience on awareness, processing (e.g., activating persuasion knowledge), and effects on brand responses. The results demonstrate that awareness of disclosures is quite low and depends on the type and timing of the disclosure and involvement and familiarity with both the program and disclosures. When the audience is aware of the disclosure it has positive effects on the activation of persuasion knowledge; the audience is more likely to recognize the persuasive nature of sponsored content. The review of disclosures on brand responses demonstrated mixed results. Some studies showed negative effects of disclosures on brand memory and attitudes, and others showed no or positive effects. Disclosures, designed in such way that they attract attention and increase awareness, therefore seem an effective way to inform the audience about the presence of advertising in media content.
To examine whether recognizing the persuasive nature of such content also results in the adoption of resistance strategies, van Reijmersdal et al. (2016) conducted two experiments that tested the effects of disclosures in the context of sponsored blogs. The results demonstrated that participants who saw a disclosure (versus no disclosure) when reading a blog, recognized the persuasive nature of the blog to a greater extent and subsequently used cognitive (i.e., counter arguing) and affective (i.e., negative affect) resistance strategies. This resulted in decreased persuasion.
Nowadays more and more consumer products are provided with warning labels, as a result of government regulations and public safety concerns. Through these warning labels people are informed of the (potential) dangers associated with using a product (Argo & Main, 2004). While some warning labels mainly aim to inform, others aim to warn people of the dangers and health risks associated with the use of a product (Hadden, 1986, as cited in Wilkinson & Room, 2009), for instance by means of evoking emotional responses (e.g., graphic labels on tobacco products). In general, however, the aim of warning labels is to enable and encourage people to make informed (healthy) decisions. Examples of products that are provided with warning labels are alcohol, tobacco, household cleaners appliances, tools, and foods (Argo & Main, 2004; Miller, & Cassady, 2015). A large meta-analysis of 48 studies on the effects of warning labels on convenience and shopping goods (e.g., cigarettes, alcohol, electric generators), shows that warning labels in general have a moderate effect on attention. Attention can for instance be increased through the use of vividness enhancing message characteristics (e.g., colors and symbols). Also with regard to recall of information, moderate effects of warning labels are found. The relationship between warnings and the assessments of product hazards and risks, however, was weak. The relationship between warning labels and behavior was moderate but was found to be stronger when people are familiar with a product and when the costs of compliance are low (Argo & Main, 2004).
Tobacco. One product for which the costs of compliance are exceptionally high is tobacco. As advertising for tobacco products is generally prohibited, tobacco packages have become an important vehicle for marketing efforts (Moodie & Hastings, 2010; Wakefield, Morley, Horan, & Cummings, 2002). At the same time, health warning labels that communicate health risks are placed on cigarette packages to aid consumers in their ability to resist persuasion at point of purchase. Warning labels can therefore be viewed as a form of counter-advertising (Agostinelli & Grube, 2002). In many countries, warning labels were initially text based, but more and more, text is replaced with (or complemented by) pictures (e.g., European Commission, 2016). A recent meta-analysis by Noar, Hall, Francis, Ribisi, Pepper, and Brewer (2016) shows that pictures draw and sustain attention better than text. They result in higher levels of elaboration with regard to the labels’ content, more negative affective reactions such as fear and disgust, higher levels of credibility given to the warning, and lower cravings. Moreover, they lead to more negative attitudes toward the brand, package, and smoking behavior, and there were stronger intentions to not start or quit smoking. However, pictures also result in higher levels of averseness and reactance than text (Noar et al., 2016). Therefore, while this meta-analysis shows beneficial effects of pictorial warning labels on most outcome variables, people also find these warnings more difficult to look at and experience higher levels of reactance as a result of pictorial warning labels; this likely reduces the impact on behavior (Dillard & Shen, 2005).
Only two experiments so far have examined the impact of textual versus graphic warning labels on actual smoking behavior. In a study by Malouff et al. (2012) smokers were either e-mailed textual or pictorial warnings, once a week, during a period of four weeks. To examine the effects of these warnings on smoking behavior, participants reported their smoking rates before the intervention, immediately after the four exposures and one month later. However, no effects of these warning labels on actual smoking behavior were found. The second study by Dijkstra and Bos (2015) used a more realistic approach to examine the effects of textual versus pictorial warning labels on smoking behavior. In this study smokers had to place stickers, that either contained textual or pictorial warnings, on their cigarette packages, during a period of three weeks. Despite the more realistic approach this study also did not yield significant differences between textual and pictorial warning labels on quitting behavior. With regard to the reported reduction in smoking behavior they did find that smokers with low disengagement beliefs (e.g., “my grandfather was a smoker and he lived until he was 90 years old”) reported cutting down on their smoking more frequently when exposed to pictorial versus textual warning labels.
While the effects of pictorial warning labels on cognitive variables such as attention, recall and attitudes appear promising, more experimental research is needed that focuses on actual smoking behavior as an outcome. Moreover, theory on emotional appeals suggests that graphic warning labels that evoke negative affective reactions such as fear, should be supplemented by (messages that cause) a strong sense of efficacy (i.e., confidence that the performance of the recommended behavior will indeed prevent negative outcomes and confidence that one can actually perform the recommended behavior). This was confirmed in a meta-analysis that shows that threat inductions only result in health behavior when the receiver’s efficacy is high (Peters, Ruiter, & Kok, 2013). Studying how graphic warning labels interact with efficacy enhancing warning labels may therefore be a worthy avenue for further study.
Alcohol. Another product category that is provided with a warning label in many countries is alcohol (Stockwell, 2006). Warning labels can either contain information about the contents or composition of the beverage, or they contain information related to health risks. They can contain normative statements (e.g., “True Aussies drink responsibly,” p. 428) or relate to the adverse health effects of alcohol consumption (e.g., “According to the Surgeon General women should not drink alcoholic beverages during pregnancy because of the risk of birth defects,” Wilkinson & Room, 2009, p. 428). While some warning labels may focus on health implications for vulnerable groups, such as children and pregnant women, others focus on the general population (Stockwell, 2006). Research among Australians shows that a large majority (91%) supports the use of warning labels on alcoholic beverage containers (Thomson, Vandenberg, & Fitzgerald, 2012). Also in Europe, the support for alcohol warning labels that communicate risks of alcohol is high (79%; European Commission, 2010).
To evaluate the effects of alcohol warning labels, Greenfield, Graves and Kaskutas (1999) conducted several surveys over a five-year period after the introduction of warning labels in the US and compared this to responses from a control site where labels had not been implemented (i.e., Canada). Their study shows that over time awareness of warning labels increases (compared to the control site) and that awareness was generally higher among young people and heavy drinkers. They also found that reported exposure to warning labels was associated with interpersonal communication about drinking and driving and drinking when pregnant, but not the adverse health consequences of drinking. In another study the association between alcohol warning label introduction and drinking behavior among pregnant women was examined (Hankin et al., 1993). No general changes in alcohol consumption during pregnancy were found when comparing consumption before and after the introduction of the labels. When comparing light drinkers to risk drinkers they found a small decrease in alcohol consumption for light, but not risk drinkers. Additionally, when looking at another vulnerable group, adolescents, significant differences were found before and after the introduction of warnings on awareness, exposure and recall, but not risk perceptions, alcohol consumption or drinking and driving (MacKinnon, Nohre, Pentz, & Stacy, 2000). While people are generally supportive of alcohol warning labels, are increasingly aware of them after implementation and show a growing message recall, they do relatively little to increase resistance toward alcohol consumption (for a narrative review, see Wilkinson & Room, 2009).
Food. In addition to cigarettes and alcohol, food packaging is also provided with one or more labels to help consumers make informed decisions and resist the purchase of unhealthy foods (Hieke & Taylor, 2012). With regard to food labeling, a distinction can be made between ingredient lists and nutrition labels on the back of a package, and front-of-pack labels that provide nutrient information in a more concise way (e.g., smart choice logo, traffic light, health/nutrient claims; Miller & Cassady, 2015). As on-pack nutrition information can be quite complex, Miller and Cassady (2015) examined the use of different food labels and the role of consumers’ knowledge regarding nutrition and health in this. With regard to nutrition labels—which communicate calories, serving size and amounts and/or daily values of macronutrients, vitamins and minerals—they found positive associations between nutrition knowledge and nutrition label use in 28 out of 32 studies. Moreover, they found that nutrition knowledge rather consistently predicted understanding of nutrition labels. Only three studies were uncovered that investigated the relation between nutrition knowledge and ingredient list use. Ingredient lists include non-nutrition (e.g., additives) and nutrition information that can help consumers assess the healthfulness of foods. The three studies, however, consistently demonstrate a positive relation between knowledge and ingredient list use (Miller & Cassady, 2015).
As nutrition labels and ingredient lists are relatively complex and their use is partly dependent on how much a consumer already knows about nutrition and health, web-based interventions have been developed to enhance label reading skills among consumers to select healthier products. A recent example is the intervention by Miller et al. (2017). Participants in this intervention took part in a nutrition label training task, which for half of the participants was preceded by a brief education on nutrition information. The nutrition label task consisted of three introductory label tasks. The first task gave insight into the information that is present on a nutrition label, the second task required participants to extract specific information from the front or back of a package and for the third task participants were asked to indicate for four pairs which alternative was healthier, on which they then received feedback. Following that, participants completed three blocks of 24 nutrition label comparisons. Feedback was provided on each trial specifically and more generally per block. Results show that over the three blocks, accuracy indeed significantly increased. Moreover, for those who received a brief education on nutrition knowledge, the odds of providing a correct answer in the third block was 79% higher. The speed with which participants completed the trials also increased significantly across the blocks. This, however, was not dependent on the brief nutrition information education. This study provides initial evidence that the accuracy and speed with which nutrition information is used to make healthy choices can be trained by means of online interventions.
An alternative to communicating complex nutrition information is to provide consumers with more concise front-of-pack labels that are easier to comprehend (Hieke & Taylor, 2012). Andrews, Burton, and Kees (2011) investigated the effects of simple (i.e., smart choice logo) versus more detailed front-of-pack information (i.e., traffic light with the percentage of daily amounts of the specified nutrients) on the accuracy of nutrition information use and whether this depended on whether back-of-pack nutrition information was also present. When back-of-pack nutrition information was not present the more detailed traffic light label resulted in higher accuracy levels, compared to the simpler smart choice logo or no logo. The smart choice logo did improve accuracy levels compared to when no logo was present. When more detailed nutrition information was present on the back of a package, front-of-pack labels did not increase accuracy. In this study, the effects were not dependent on the nutrition consciousness of consumers.
When consumers do not check the more detailed nutrition label on the back of a package, which is likely often the case when shopping, the use of a traffic light logo with daily amounts of the specified nutrients seems preferable to the more concise smart choice logo. The traffic light logo likely reduces the chance that consumers overgeneralize and infer that the product is healthier than it really is (Andrews et al., 2011).
Social Pressure and Resistance Induction
In the foregoing, we mainly discussed resistance inducing strategies that focus on resisting influential forces in our environment such as the media and tempting products. However, it is also important to focus on the influence of other people in our environment because, in general, people like to do what others do. Following other people’s behavior might be beneficial, but when those in one’s social environment set a negative example this may result in unhealthy choices (Robinson et al., 2013). Apart from conformity to the unhealthy behavior of others in our social environment, people may also be influenced by what they think they should do according to others (Larimer, Turner, Mallett, & Geisner, 2004) or by more overt forms of peer pressure, such as encouragements to engage in risky behaviors (Gardner & Steinberg, 2005). Research among adolescents shows that about one quarter of adolescent smokers have offered cigarettes to friends and have tried to get friend to smoke (Brady, Morrell, Song, & Halpern-Felsher, 2013).
Social Influence Interventions
Social influence interventions are based on the idea that adolescents initiate substance use as a result of social or other external pressures, and that for this group it is difficult to resist these influences. Interventions that follow this approach therefore teach young people to resist substances by providing information, training resistance skills and educating about the prevalence and acceptability of use (Champion, Newton, Barrett, & Teesson, 2013). An example of a social influence intervention is the keepin’ it R.E.A.L. curriculum; a culturally grounded intervention, which aimed to foster anti-drug norms, attitudes, risk assessment, decision-making, and resistance skills. Resistance skills training received special emphasis in this curriculum. When it comes to resisting peer influences several resistance strategies have been identified, that is, refuse (refusal of the offer), explain (offering a more elaborate explanation for refusal), avoid (avoiding the environment in which substances are present) and leave (leaving the situation once substance use is encountered), together forming the acronym R.E.A.L. Among other things the keepin’ it R.E.A.L. curriculum consisted of four public service announcements about the different resistance strategies. Results of this intervention show that while the use of alcohol, cigarettes, and marijuana increased over time, this increase was significantly lower among students who had taken part in the keepin’ it R.E.A.L. intervention. The effects were most consistent for alcohol use (Hecht et al., 2003).
Social influence prevention programs have been proven effective and the use of this strategy is recommended (Cuijpers, 2002). However, the question remains what the effective elements in these interventions are. While a focus on knowledge regarding prevalence and acceptability of use were found to mediate effects of social influence interventions, this was not the case for resistance skills training (Cuijpers, 2002). Therefore, while social influence programs have been found to be effective, not all are effective and not all elements within the program affect behavior change (Midford, 2010).
Weaken Perceived Peer Pressure
Resisting explicit persuasive attempts by peers may not be the easiest thing to do, as going against that which is approved of by most people in a group may incur social sanctions (Lapinski & Rimal, 2005). A promising alternative to training young people to resist negative social pressures is to weaken perceived peer pressure. This approach is based on the idea that people tend to misperceive the extent to which others approve of substance use, as well as the level of consensus of this approval (Schroeder & Prentice, 1998). These misperceptions can be explained through pluralistic ignorance. Pluralistic ignorance describes the situation in which (almost) all members of a group privately reject certain beliefs, behaviors, or attitudes, such as heavy drinking or smoking but are at the same time convinced that others support these beliefs, behaviors, or attitudes (Prentice & Miller, 1996). This may for instance occur at a party where most people are drinking excessively and are seemingly having fun. This will then likely create the impression that all those present approve of heavy drinking. As a result a person may feel like he or she is the only one who disapproves of this behavior, while in fact all people privately disapprove of heavy drinking but do not act in a way that reflects this disapproval. To reduce substance use it is therefore necessary to remove such biases in perceptions, as this may “inoculate” people against pressures to conform (Blanton, Köblitz, & McCaul, 2008). To test whether interventions that remove pluralistic ignorance are effective in reducing alcohol consumption, Schroeder and Prentice (1998) conducted a study among first-year college students. Participants in this study took part in discussion groups about drinking on campus: the discussion either focused on the individual and how he or she could make sensible decisions about alcohol consumption, or the discussion focused on peers and pluralistic ignorance and the consequences thereof. The idea behind this was that if they realized that they overestimate how many people approve heavy drinking that this would weaken the perceived social pressure and thereby reduce drinking. They indeed found that those who took part in the discussion groups on pluralistic ignorance drank less than those who participated in the group discussions that focused on individual decision making, lending support to the idea that discussions on pluralistic ignorance indeed weaken peer influence and cause lower drinking rates.
People are often negatively influenced by media and social influences in their environment when forming attitudes and making health-related decisions. In this article, we aimed to provide an overview of trainings, interventions, and regulations that are currently used and may help people resist these undesirable persuasive attempts. The general aim of these strategies is to increase informed decision making, which may result in decreased persuasion and more resistance. Although the discussed strategies have different approaches and target different processes there are also similarities that can be identified. We can, for instance, make a distinction between strategies that focus on increasing knowledge about the persuasive attempt (i.e., persuasion knowledge) and strategies that focus on increasing factual knowledge about the topic at hand (i.e., topic knowledge).
Strategies that aim to increase persuasion knowledge are forewarnings, disclosures, and trainings on specific persuasive strategies (e.g., celebrity endorsement). What these strategies have in common is that they aim to inform people about the persuasive intent of a message and aim to enhance the ability to recognize persuasive (advertising) techniques that are used to persuade the audience to perform certain behavior. The idea behind these strategies is that when people are aware of the persuasive intent of the message, they engage in more deliberate decision making. The awareness and recognition of persuasive situations then often results in skepticism, which consequently decreases persuasion.
Inoculation, warning labels, and weakening perceived peer pressure (i.e., pluralistic ignorance intervention) can be categorized as strategies that focus on increasing (factual) knowledge to resist persuasion. These strategies aim to provide information about the topic at hand, which motivates people to resist unwanted persuasion. This can be achieved explicitly, as is often the case in interventions based on inoculation theory. In these interventions, counter-arguments are provided or people are explicitly asked to generate counter-arguments to inoculate themselves against future persuasive attempts. Knowledge can, however, also be provided more implicitly by focusing, for example, on pluralistic ignorance in the case of social pressure. The idea of such interventions is that when people have accurate knowledge about the variability in peers’ comfort with regard to certain behaviors (e.g., alcohol consumption), they infer that they overestimate how uniform other people’s thoughts are regarding this subject, which subsequently reduces the social pressure that people experience to conform.
Media literacy interventions and social influence interventions are often based on increasing both persuasion and topic knowledge. These types of interventions focus on increasing skills to resist influence, either from the media or other people, but they often also focus on providing information on the topic at hand (e.g., the negative effects of alcohol use). In general, positive effects have been observed for these types of interventions. However, in both streams of research it has been found that not all elements of the intervention are always effective (Cuijpers, 2002) and that offering more elements can be less effective than focusing on less elements (Jeong, Cho, & Hwang, 2012). It therefore seems important for future research to further disentangle what elements and what combination of elements of these types of interventions are most effective in instilling resistance toward unsolicited and potentially harmful influence.
As stated in the introduction, resistance is defined by McGuire (1964) as the ability to withstand a persuasive attack. Resisting a persuasive attempt can be achieved in multiple ways and, as can be witnessed in the reported studies, can also be operationalized in different ways. In many studies resistance is defined as the lack of attitudinal or behavioral change. In other words, when no change is observed it is assumed that people have resisted the persuasive attempt. The activation of persuasion knowledge, skepticism, perceived realism, and social norm perceptions are other variables that are often used as indicators of resistance and therefore a successful intervention. Interestingly, not many studies measure whether people actually use resistance strategies and if so, what type of resistance strategies they adopt in specific persuasive situations, as a result of trainings, interventions, and regulations. Some studies already demonstrated that, for example, disclosures and inoculation may result in counter arguing, but there are many more resistance strategies, such as attitude bolstering, source derogation, and avoidance (Fransen, Smit, & Verlegh, 2015) that might be adopted after interventions or trainings. Measuring these responses may explain in more detail which processes are involved in resistance and persuasion. Knowledge on how specific components of trainings, interventions, and regulations are related to the use of different types of resistance strategies might inform the design of more effective programs. In addition, the overall aim of most strategies, interventions, and regulations is to enhance critical thinking and encourage informed decision making, as not all media and advertisements necessarily pose a threat to one’s health and need to be resisted. It is therefore also important for future research to further define informed and critical decision making and to develop ways to assess these constructs more directly.
In this article, interventions, trainings, and regulations that aim to increase resistance toward different environmental cues that may affect people’s health-related behavior were discussed. We realize, however, that there may be substantial differences between the effects of different environmental influencers. For instance, when comparing the influence of media or advertising and the influence of one’s social environment, one could argue that the motivation to resist persuasive attempts varies in these situations. In trainings on specific persuasion tactics, for example, people learn what kind of (deceptive) persuasive strategies advertisers use to influence consumers’ behavior. For most people this will likely result in increased skepticism and negative emotions, because nobody wants to be fooled. As a result, these people are intrinsically motivated to resist the advertisement. This might, however, be different in a situation in which friends or peers try to influence a person’s behavior. Even after participating in a social influence intervention aimed at increasing resistance skills, people might not be motivated to resist social pressures, since other concerns are at stake. In a social situation it is often preferable to act in line with the behavior that is approved of by most others in a group. Therefore, when resisting such pressure this may result in social sanctions, such as exclusion (Lapinski & Rimal, 2005). For most people this is undesirable and these concerns may therefore negatively impact the effectiveness of these types of interventions.
Motivation to resist persuasion may also depend on the situation or the target. When presented with an advertisement of a product that you desire people are probably unmotivated to resist this ad even when they are, for example, warned of the persuasive intent of the message or have received an advertising literacy training. In these situations, the desire to buy the product most likely overrules skepticism regarding the advertisement activated by the training or warning. It might even be the case that these thoughts are actively suppressed. Motivation is thus an important factor to take into account when examining the effectiveness of resistance inducing trainings, interventions, and warnings. When people are unmotivated to resist persuasion, these types of efforts are likely ineffective.
An observation that can be made upon reviewing different resistance inducing strategies is that although the overall aims of the different trainings, interventions, and warnings greatly overlap, no research to date has compared the effectiveness of the different types of resistance-inducing strategies. Within each category we see that different types of, for example, media literacy trainings, and different types of forewarnings are compared; however, there is no research that, for example, compares the effectiveness of media literacy training with forewarnings. Although, it is a great challenge to compare these different methods, it is important: from an economic, social, and regulatory perspective it is beneficial to know which type of intervention, training, or regulation is most effective and also to know for what behavior and target group you can best use each of them.
From the discussed literature we can conclude that research on how people can be assisted to resist persuasion has received a lot of attention in academia. For many of the strategies discussed, review articles and meta-analysis are available (e.g., inoculation, media literacy, and disclosures). This means that the knowledge and working of these strategies is quite extensive and that the field has matured in the last decades. Moreover, these overviews also reveal the conditions under which specific strategies may or may not work. Interestingly, early-21st-century work on resistance toward persuasion seems to explore the possibility that people can also resist persuasion automatically without the need for cognitive capacity (Fransen & Fennis, 2014; Laran, Dalton, Andrade, 2011). This is relevant since it has become apparent that many persuasive attempts also work on an unconscious level. It could therefore be beneficial if we can find ways to automatically resist unwanted persuasion because in many situations people do not have the motivation or capacity to consciously resist a message.
When designing a resistance-inducing strategy, it might be fruitful to first examine the target’s motivations for resistance and the resistance strategies he or she is likely to use. This way, people’s natural motivation or strategy to resist can be triggered by an intervention. For example, from previous research it is known that young people are more likely to experience reactance (i.e., threat to freedom) when exposed to a persuasive attempt than older people. So, when assisting young people in resisting persuasion it might be beneficial to teach them how to recognize persuasive attempts so that they are more easily aware of the fact that someone is trying to influence their behavior. This can be achieved, for example, by a disclosure strategy. The awareness of the persuasive attempt is likely to result in reactance and subsequently in resistance. Another example of tailoring a resistance inducing intervention is to take into account people’s natural inclination to contest messages that are incongruent with their attitude or to bolster one’s original attitude when exposed to an incongruent message. This knowledge can help to select an appropriate strategy that either stimulates contesting a message (e.g., warning labels) or bolstering original attitudes (e.g., inoculation).
In conclusion, to enable people to resist persuasive attempts, stemming from one’s (social) environment, that may negatively affect health-behavior, many trainings, interventions, and regulations have been developed and tested for their effectiveness. In the present article we aimed to provide an overview of these methods and their results. Although the effectiveness of many programs is not straightforward and there are several aspects that require further study, so far it can be concluded that the observed findings are promising and can be of great assistance to health educators and policymakers in designing resistance inducing strategies.
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