Terror Management Theory in Health Communication : the moderating effects of smoking derived self-esteem on the denial of vulnerability in susceptibility salient vs. non-salient fear appeal messages

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Terror Management Theory in Health Communication 1

Graduate School of Communication

Master’s programme Communication Science

Master Thesis

Terror Management Theory in Health Communication

The moderating effects of smoking derived self-esteem on the denial of

vulnerability in susceptibility salient vs. non-salient fear appeal messages.

Student: Philippe Isarin Student ID: 11604514

Supervisor: Bas van den Putte Date: 29.06.2018

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The dominant paradigm in fear-appeal research posits that different levels of perceived threat will lead to different levels in the message’s persuasiveness. However, existing empirical evidence in health communication exploring the effects of cigarette warning labels on smoker’s message acceptance and intention behavior have reported inconsistent findings on this paradigm. The aim of the current analysis was to use the terror management theory (TMT), to a)

demonstrate the moderating effect of self-esteem on threat appraisal of mortality salient cigarette warning labels, as well as b) explore if a more susceptibility salient warning label can mitigate this effect. Results found, suggest that smoking derived self-esteem is a significant predictor on the outcome of the individuals perceived vulnerability to smoking health risks, and that there is a significant interaction between self-esteem and susceptibility salience of cigarette warning labels on the individuals perceived vulnerability. The study sheds new light on possible shortcomings in current studies of health communication theories such as the extended parallel process model (EPPM), which uses susceptibility salience as a key determinant of threat appraisal.

Keywords: terror management theory, extended parallel process model, self-esteem, susceptibility, cognitive-experiential self-theory

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Introduction

A dominant paradigm in the studies of fear-arousing persuasive messages is that different levels of perceived threat by recipients lead to differences in the persuasiveness of the message (Witte, 1994). While many researchers support the idea that higher levels of perceived threat will lead to individuals taking more positive steps to avoid the suggested negative outcome of their behavior (Hammond et al., 2004; Witte & Allen, 2000), others suggest that higher levels of perceived threat can lead to no change of behavior or even facilitate the engagement of the negative behavior, if other message components are not present in the fear appeal (Kok et al. 2018). Two popular theories in the research of fear-arousing persuasive messages are the

extended parallel process model (EPPM; Witte, 1994) and the stage model of processing of arousing communications (de Hoog et al., 2007). Both these theories postulate that for a fear-appealing health message to be effective, there needs to be both a perceived health threat by the recipient of the message, as well as sufficient perceived efficacy by the individual to avert the threat. In other words, only when an individual perceives a threat to his health and the individual feels capable of avoiding the threat will they take measures to change their unhealthy behavior.

In the context of this paper, it is important to note that models such as the EPPM, put a large emphasize on the role of perceived threat (Carey et al., 2013). However as will later be discussed, perceived threat and the fear derived from it has more factors contributing to it than only severity and susceptibility of the fear-appeal as was suggested by Witte (1994). Despite substantial findings on further predictors of threat appraisal and its effects on individuals

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commonly used framework for fear-appeal message design and has seen little change in the past twenty years (Maloney et al., 2011).

The majority of research done on fear-appeal messages have used this theory to explore how these conditions of perceived threat and perceived efficacy strengthen the persuasiveness of the message. Unfortunately, at the expense of understanding why these messages fail to persuade some individuals (Pechmann et al., 2003). It is clear from recent research that there seems to be some inconsistencies between these theories and empirical evidence (Peters & Kok, 2013). Namely, greater perceived threat does not always lead to positive behavioral change, even in the presence of an efficacy recommendation.

However, a theory that can help explain this inconsistency is the terror management theory (TMT; Greenberg et al., 1993). The TMT is widely used in human behavioral studies. However, despite substantial evidence that suggests the TMT helps predict human behavior, it is still somewhat neglected in the fields of health communication, in particular fear-appeal studies (Burke et al., 2010). The theory postulates that as a defensive reactance to existential anxiety (i.e. thoughts of death), individuals engage more in the things that they perceive as giving meaning to their existence. Furthermore, individuals will be far more likely to deny their vulnerability to an unhealthy behavior if they identify with that behavior (Hansen et al., 2010). For example, a smoker may feel that a serious threat of smoking health risks is far smaller than a non-smoker would (Keller, 1999). This process will be further elaborated on in the theoretical framework. What is important to note for now, is that variables of TMT have shown to be better predictors of individual responses to mortality salient fear appeals than variables used in the EPPM and the

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stage model of processing of fear-arousing communications (Carey et al., 2013). In the cases mortality salient fear-appeal messages, the outcome of these conflicting theories contradict each other, as I will demonstrate in this paper. Yet despite the increasing evidence supporting the TMT hypothesis in predicting outcomes of mortality salient fear appeals, many policy makers still predominately rely on such messages.

Research in the field of fear-appeal messages should therefore look beyond theories such as the EPPM, to explain possible reasons why fear-appeal messages often either fail to persuade individuals to take positive behavior change, or even facilitate unhealthy behavior (Peters & Kok, 2013). In this research I will use the TMT to address why mortality salient fear-appeal messages in the form of cigarette warning labels may fail to persuade individuals to refrain from smoking. Furthermore, I will explore if such failures could possibly be avoided by introducing a warning label that more strongly emphasizes the smoker’s susceptibility of the health risks. Exploring ways to minimize failure to persuade smokers to quit smoking should always be strived for by health communication professionals and researchers, as it can prevent smokers from developing serious smoking related health problems. Putting the EPPM into focal attention at the cost of neglecting other theories of human behavior when designing health communication messages will simply lead to repeated inconsistencies in the effectiveness of such messages.

Cigarette warning labels are the perfect touch point with smokers as most countries have made them mandatory on cigarette packages, therefore exposing smokers regularly to them. Countries with health policies that made cigarette warning labels mandatory have seen a great increase in the populations knowledge about smoking derived health risks (Hammond et al.,

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2006). Hence the improvement of these warning labels directly helps improve the populations knowledge and acceptance of these health risks. However as will be explained further, there are still some major factors such as those suggested by the TMT, that will lead to defensive

reactance’s to mortality salient fear-appeals. It is crucial to better understand these factors therefore, especially as most cigarette warning labels as recommended by the WHO have severe health risks that can lead to death (Sambrook Research International, 2009). Therefore, in this study I will attempt to answer if mortality salient cigarette warning labels, that more strongly emphasize the smoker’s susceptibility of smoking health risks, minimize defensive reactance suggested by the terror management theory.

Theoretical Framework

Terror Management Theory

Research in health psychology has shed light on questions such as why individuals make certain decisions in regards to their health. In recent decades fear-appeal messages such as tobacco warning labels have become a norm in many countries (Hammond et al., 2006). Such messages often highlight the severe health risks involved in engaging in the healthy behavior, such as “Smoking causes lung cancer” or “Smoking kills”. However, as already pointed out, studies have shown controversial results on the outcome of such fear-appeals (Hunt & Shehryar, 2011). Obviously, death is a most severe consequence on health, however the majority of studies in health communication do not take into account the individual’s awareness of mortality and

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how they manage psychological concerns about it. The terror management theory (TMT), focuses on the impact of such concerns on human behavior (Greenberg et al., 1993).

Humans have evolved in their cognitive capabilities to become aware of their own

existence and the consequential ceasing of it. As a species that is provided with a biological need for self-preservation, the realization that death is inevitable can potentially lead to great anxiety (Becker, 1973). The TMT postulates that humans create defensive mechanisms against such anxiety, such that they usually do not feel this anxiety on a daily basis. This is done by embracing cultural worldviews, values and symbolic systems that give life enduring meaning and significance (Greenberg et al., 1986).

The function of these cultural worldviews is to derive a sense of worth within the shared values in one’s society. Living up to the values of these cultural worldviews not only gives a person a sense of self-worth and self-esteem but according to the TMT, even offers a symbolic immortality (Shehryar & Hunt, 2005). Being part of something greater than oneself, being a valued contributor to the people and world around us and leaving something behind all

contributes to such symbolic immortality (Pyszczynski, 2015). The most common examples of such cultural worldviews include religion, nationalism or posterity. It brings comfort to live by one’s cultural worldviews and in turn can create anxiety if one does not live up to one’s own set standards (Becker, 1973). However, these cultural worldviews by no means are the same for everyone nor are they necessarily big ideas as those just stated, some individuals may derive a sense of worth and self-esteem from being an athlete, a respected photographer or simply being revered amongst one’s peers. It is an individual's assessment of how they live up to these cultural

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worldviews that determine their self-esteem. As these values serve as a measure of protection against thoughts of inevitable ceasing of existence, a person will engage more so into them when confronted with thoughts of death, to reaffirm the meaning of their existence (Pyszczynski, 2015).

Risky behaviors such as smoking cigarettes, reckless driving or skydiving are seen by some as a form of defiance in the face of danger and may lead to social recognition or validation in one’s social circle. If individuals derive self-esteem from risky behavior a mortality salient message (i.e. message that highlights our inevitable death) will consequently lead them to engage more in that risky behavior to bolster their self-esteem (Arndt et al., 2004). There has been substantial research done that supports this effect of TMT (Burke et al., 2010). Hirschberger et al. (2002) for example found that after exposure to a mortality salient message, individuals that derive self-esteem from risky behaviors were far more likely to engage in substance abuse when offered.

Terror Management Theory in Health Communication

Goldenberg and Arndt (2008) created a terror management health model (TMHM), in which they propose that when individuals are consciously confronted with death, there are two immediate ways in which they cope with it. In line with the extended parallel process model (EPPM) by Witte (1994), one defense suggested is to reduce the conscious vulnerability to death by engaging in the recommended healthy behavior such as smoking cessation. While the other defense is suppressing the threatening death-related cognition through so called proximal

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defenses (Das et al., 2014). This theory is in line with the EPPM model which suggests that recipients of fear appeal messages either control the danger by engaging in healthier behavior or control their fear by cognitive defense mechanisms such as denial of vulnerability (e.g. “It’s unlikely to happen to me.” (Mollen et al., 2017).

The EPPM model suggests that such cognitive defense mechanisms like denial of

vulnerability are a product of severe threat appraisal but a lack of self-efficacy, commonly due to no recommendation action being present in the fear-appeal message (Witte, 2000). The TMT similarly suggests that when exposed to mortality salient messages, individuals may take action to remove it from conscious thought, while often this leads to proximal defenses, it can also lead to adopting recommended health behavior, in particularly when there are concerns about

vulnerability (Cooper et al., 2014). So how does the TMHM differ from existing health model such as the EPPM when it comes to mortality salient fear appeals?

The TMHM suggests that after the thought of death is removed from the conscious mind, it is still being processed in subconscious thought (Hunt & Shehryar, 2011). It is here where the problems lie with mortality salient fear appeals. Following a delay or distraction after being exposed to thoughts of death, the thought of mortality is still being processed experientially and unconscious (Jessop et al., 2008). Greenberg et al. (2000) and Shehryar & Hunt (2005), have both shown that after initial proximal defenses, individuals will engage more in their self-esteem deriving behaviors, as predicted by the TMT. In the example of smokers that partially base their self-esteem on smoking for social esteem or adventures lifestyle reasons, this means they will actually smoke more as a defensive mechanism.

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Studies applying the TMT in fear-appeal messages have also commonly found another major problem of mortality salient fear appeal. That is, individuals that identify themselves with a certain behavior such as being a coffee drinker (Greenberg et al., 1993) or being a smoker (Freeman et al. 2001) are far more likely to engage in proximal defenses such as the denial of vulnerability. This is due to the increased self-esteem such individuals derive from these behaviors; the TMT posits that when the very cultural worldviews are under attack that give meaning to life, individuals will attempt to remove it from conscious thought immediately (Wong & Dunn, 2013). This is very problematic when looking at cigarette warning labels. Smokers that identify themselves with the behavior and derive self-esteem from it will therefore much more likely instantly deny their vulnerability to serious smoking health risks and in turn due to the thought of death being processed experientially in our subconscious, have even greater intention to smoke.

It is important to note however, that despite all this, individuals that derive self-esteem from a risky behavior do not always use proximal defenses such as denial when their cultural worldviews are being challenged, but rather only those that are mortality salient (Shehryar & Hunt, 2005). A message that may suggest the negative consequences of smoking on social relationships would more likely be processed rationally and therefore a smoker adapt a healthier behavior (Jessop et al., 2008). Hence it is possible for individuals to think rationally about their behavior. Individuals that derive self-esteem from smoking also often enough realize and accept the risks in the general sense, in other words they acknowledge that the health risks are real for others in general (Hansen & Malotte, 1986). Thus, a smoker may believe that smoking can cause

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lung cancer however will deny personal vulnerability. All of this is important to take into consideration in this study as it demonstrates that individuals that derive self-esteem from smoking are not immune to persuasion, nor do they believe there are no health risks at all. Hence, the first problem that leads to increased intention to smoke in individuals that derive high self-esteem from smoking, is thus the immediate denial of vulnerability (proximal defense).

Cognitive-Experiential Self-Theory

Distal defenses are those that follow proximal defenses, they are the unconscious coping of lingering existential anxieties, which drive individuals to engage more in self-esteem boosting behaviors (Greenberg et al., 2000). The cognitive-experiential self-theory (CEST; Epstein, 1985) helps explain this process. The theory posits that a majority of our cognitive processing is done automatically and experienced passively instead of conscious and logical. The effect of the TMT that increases engagement in cultural beliefs operates mainly in this unconscious, experiential mode (Arndt et al., 1997). In this mode of processing, individuals rely more strongly on past experiences and affiliated emotions. Through past experiences, automatic associations are made between things (Epstein, 2016). For example, a smoker who bases their self-esteem on smoking does not contemplate each time he sees someone smoking whether this is cool or not, smoking has already been associated with social status. Similarly, the TMT suggests that individuals, when confronted with death, do not always rationally process their thoughts of death, as this can lead to great anxiety. Instead they process these thoughts in the experiential mode, by

associations they’ve made between existential anxieties and valued cultural worldviews that provide them with self-esteem. This is why Becker (1973), suggests that when confronted with

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existential anxiety, it automatically triggers unconscious engagement in activities that give meaning in life.

A study by Routledge et al. (2004) conducted with women deriving self-esteem from tanning has shown that intention to use sun screen following a delay after exposure to mortality salient messages about the risks of sun exposure there was decreased intention to use it.

Suggesting the experiential, unconscious processing of information was used, namely the need to boost self-esteem by engaging in risky tanning. However, when asked directly after the exposure to the mortality salient message, when thoughts of death were still in the conscious mind,

participants had significantly higher intention to use sun screen. This shows that when having to process the information of a fear appeal analytically and rationally, it can increase intention to abstain from the risky behavior. Hence the goal of a mortality salient message should be to stimulate a more rational and analytical processing of information in order to hinder the unwanted proximal and sequentially distal defenses.

Susceptibility salient messages with statistics such as “1 out of 4 smokers develop lung cancer” requires more cognitive processing than a non-statistical message such as “Smoking causes lung cancer” (Braverman, 2008). Therefore, recipients of such a susceptibility salient message ideally use the rational system of processing, namely the information should be

processed more logically, rationally and analytically than experiential processing which is done more heuristically. As much of the TMT operates in the experiential mode, rational processing may undermine the defense mechanisms of the TMT (Simon et al., 1997). It makes sense that when feeling great stress due to an event, analyzing the situation and rationally coping with it

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can reduce stress reactions. When confronted with a mortality salient fear-appeal message that triggers the rational mode of processing, such as “1 out of 4 smokers develop lung cancer” there is an increased likelihood that recipients will take more rational defensive steps to cope with the confrontation of death, such as health-oriented defenses like smoking cessation. Therefore, my first hypothesis is:

H1: For individuals that derive high self-esteem from smoking, susceptibility salient

fear-appeal messages will lead to a greater perceived vulnerability of smoking health risks than non-susceptibility salient messages.

Furthermore, as they will process the information more rationally, it should undermine the more automatic processes of TMT that suggests the smoker will bolster their cultural values as a defensive reactance and engage more in self-esteem deriving actions (Simon et al., 1997). While a non-susceptibility salient fear-appeal message leads to greater intention to smoke, in smokers that derive high self-esteem from smoking, a susceptibility salient message should lead to a comparably lower intention to smoke. Hence my second hypothesis is that:

H2: For individuals that derive high self-esteem from smoking, susceptibility salient

fear-appeal messages will lead to a lower intention to smoke than non-susceptibility salient messages.

Whereas when the fear appeal is not susceptibility salient, individuals that derive self-esteem from smoking will be far more likely to deny their vulnerability to the health risks for the reasons suggested above. Therefore, my third hypothesis is:

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H3: For individuals that derive high self-esteem from smoking, non-susceptibility salient

fear-appeal messages will lead to an overall lower perceived vulnerability.

And finally, as the TMT suggests, smokers that derive self-esteem from smoking should have a greater intention to smoke when confronted with thoughts of death. Hence my fourth and final hypothesis is:

H4: Fear-appeal messages that are not susceptibility salient will lead to an overall

increased intention to smoke, in individuals that derive high self-esteem from smoking.

Moderating Factors of Denial of Vulnerability

In sum, the effectiveness of fear appeal messages when taking the TMT into account, depend strongly on the degree to which individuals derive self-esteem from the behavior in question as well as the salience of mortality in the message (Goldenberg and Arndt, 2008). As Figure 1, displays, a mortality salient fear-appeal message (e.g. Smoking causes lung cancer), can lead to a denial of vulnerability due to proximal defenses which in turn should lead to increased intention to smoke due to distal defenses. The likelihood of this happening according to theories discussed above, depend on the individual’s self-esteem derived from smoking. In this study I will explore if susceptibility salient fear-appeals (e.g. 1 in 4 smokers develop lung cancer) can help minimize this effect. Furthermore, I will explore if such a message can also counteract the defensive reactance suggested by the TMT.

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Figure 1: Moderating factors on perceived vulnerability and intention to smoke in mortality salient fear-appeals.

Method

Participants

I recruited a total of 133 participants through means of social media and personal requests. Out of these 133 participants, 80 smokers (61.3% male, Mage = 25.13, SDage = 2.68), aged 19 to 32, completed the survey. Other participants either did not consent to the surveys terms (N = 12), did not consider themselves to be smokers (N = 31), or simply did not complete the entirety of the survey (N = 10). It is important to note that individuals that occasionally smoke a cigarette but do not consider themselves to be smokers were excluded as it would distort the results, considering that their intention to smoke is already very low and most likely so is their perceived vulnerability to smoking health risks. The participants were randomly assigned to

Message type (susceptibility salient vs. non-salient) Intention to smoke Perceived vulnerability Self-esteem derived from smoking

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one of two experimental conditions, either the susceptibility salient fear appeal message (N = 42, 59.5% male, Mage = 25.76, SDage = 2.35) or the non-susceptibility salient fear appeal message (N = 38, 63.2% male, Mage = 24.42, SDage = 2.88).

Research Design

Participants were told that this studies goal is to better understand the brand and

packaging preferences of different types of smokers. To do this I presented participants with four pairs (i.e. eight brands in total) of cigarette packages. After giving consent to participate in this study, participants were asked simple background questions such as age, gender, smoking habits and preferred brand of cigarettes. I did not ask further demographic questions as I want to ensure that participants feel that their answers will be anonymous. As some participants have social ties with me, any further demographic information may reveal who they are. Following these

background questions, participants answered nine items to assess their smoking-based self-esteem, which I adapted from Taubman Ben-Ari et al. (1999) study on the impact of mortality salience on reckless driving.

Under the pretext of testing their cigarette brand preferences, I presented pictures of eight different cigarette packages, in pairs of two, all of which have warning labels on them that fit into their respective condition of susceptibility salient or non-salient (See Appendix A for image samples). These warning labels will vary depending on which condition participants are in. Either the message says “1 in 4 smokers will develop lung cancer” if they are in the

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non-Terror Management Theory in Health Communication 18

susceptibility salient condition. Participants chose one of the two packages presented on each of the four pages.

Subsequently I added a page with random questions related to smoking such as “Do people in your social circle smoke?” and “How many years have you been smoking?” as well as some questions not related to smoking such as color and art style preferences. As Greenberg et al. (2000) pointed out, effects of the TMT emerge not before death thoughts are removed from conscious awareness. These questions serve to distract participants from the warning labels they’ve just read and pre-occupy their conscious and rational information processing mind with other questions.

After this distraction, the dependent variables, namely the perceived vulnerability as well as intention of smoking are assessed. I used five items to measure intention of smoking, as well as two more question to measure perceived vulnerability. To measure intention, I used the same items as Mollen et al. (2017). After answering these seven questions, participants were thanked and debriefed on the final page on the actual purpose of the study.

Observed Variables

Self-esteem. Self-esteem derived from smoking was measured with nine items. For each statement participants choose from a scale of 1 (strongly agree) to 5 (strongly disagree) to the following statements: “Smoking brings out negative aspects of myself.”, “While smoking, I feel uncomfortable being with others.”, “Smoking brings out unwanted aspects of my character.”,

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“Smoking hurts my social relationships”, “Smoking damages my positive self-image.”, as well as reverse-coded items like “Smoking allows me to be one of the gang.”, “Smoking allows me to make a good impression on others.”, “Smoking allows me to feel worthy.”, “Smoking makes me feel I’m able to do things.” (M = 3.04, SD = .62; α = .69).

Perceived vulnerability. Perceived vulnerability was measured with the question: “Do you think your chances of developing lung cancer from smoking are...” and accompanied scale from 1 (no risk at all) to 4 (great). (M = 2.96, SD = .62).

Intention. Intention to smoke was assessed with five items that are measured from 1 (strongly agree) to 5 (strongly disagree): “I plan to quit smoking eventually”, “I will try to quit smoking in the near future.”, “I intend to smoke less in the future”, and reverse-coded items such as “I intend to smoke more in the future.”, “I intend to smoke a cigarette directly after this study.” (M = 2.16, SD = .89; α = .78).

Nicotine dependence. As another control variable I measured the level of nicotine

dependency of the individual smokers with two items derived from Heatherton et al. (1991) Heaviness of Smoking Index: “How many cigarettes/day do you smoke?” (1 = 10 or less, 2 = 11-20, 3 = 21-30, 4 = 31 or more) as well as “How soon after you wake up do you smoke your first cigarette?” (1 = Within 5 minutes, 2 = 6-30 minutes, 3 = 31-60 minutes, 4 = After 60 minutes). The second item was reverse-coded. Both items were summed to estimate nicotine dependence (M = 1.66, SD = .71, α = .69)

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Results

Control variables

To check whether I have to control any of my additionally measured variables such as age, gender or nicotine dependence in my analysis, I assessed the correlation of these control variables with perceived vulnerability and intention to smoke. Age did not correlate significantly with perceived vulnerability (r = .00, p = .978) nor with intention to smoke (r = .09, p = .424). Gender too did not correlate significantly with perceived vulnerability (r = .17, p = .132) or with intention to smoke (r = -.17, p = .136). When looking at nicotine dependance I found no

significant correlation with perceived vulnerability (r = -.09, p = .409) and it was just short of significant on intention to smoke (r = .21, p = .065). As none of these variables had a significant correlation with my dependent variables, I did not control them during my main analysis.

Main analyses

Perceived vulnerability. In order to test my model, I used the OLS regression path analysis modeling tool PROCESS by Andrew Hayes (2017). Model 7 allows me to test the moderated mediation effect of perceived vulnerability between the type of fear appeal message (susceptibility salient vs non-salient) and smoking intention, with smoking derived self-esteem moderating the direction of the relationship between type of fear appeal message and perceived vulnerability. Figure 2 gives an overview of the path model used in Model 7 (See Appendix B for more detail). Showing the direct effect of message type to intention to smoke and the

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conditional indirect effect through perceived vulnerability which is determined by message type, self-esteem and their interaction term.

Figure 2: Path model summarizing relationships between variables analyzed.

Note: Path model showing the analysis of Model 7 in PROCESS. Values represent standardized regression coefficients. * P<.05; ** P<.01; *** P<.001

The moderated regression will first be tested for my H1 and H3 which posit that individuals that derive high self-esteem from smoking will respectively - perceive greater vulnerability to smoking health risks if the fear-appeal is susceptibility salient (H1) and

decreased perceived vulnerability if the message is not susceptibility salient (H3). I bootstrapped the model to improve its reliability (Nsamples = 1000, CI = 95%). PROCESS ran a multiple regression analysis to test the predictability of message type, smoking derived self esteem, and their interaction term on the dependent variable of perceived vulnerability. As I am estimating a interaction between a moderator and independent variable, the variables have been mean

Message type Intention to smoke

Perceived vulnerability Message type x Self-esteem -.34** .29** -.02 -.49*** -.09 Self-esteem

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centered using the PROCESS macro. The overall model significantly predicts perceived

vulnerability to smoking health risks F (3,76) = 10.10, p < .001, R2 = .29, as also summarized in Table 1.

Table 1. Summary of the multiple regression model of perceived vulnerability.

Model b 95% CI β t p Lower Upper (Constant) 3.10 2.91 3.29 33.07 <.001 Message type -.04 -.41 .34 -.02 -2.86 .849 Self-esteem -.70 -1.00 -.40 -.461 -5.25 <.001 Message type*Self-esteem .86 .27 1.48 .29 2.89 .005 Note. N = 80; R2 = .29, F (3,76) = 10.10, p < .001

The model explains up to 29% of the total variance of perceived vulnerability (R2 = .29) when accounting for message type, smoking derived self-esteem and their interaction term. In particular smoking derived esteem has had an effect on perceived vulnerability, as self-esteem increases, perceived vulnerability significantly drops (b = -.70, β = -.46, t (76) = -5.25,

95% CI [-1.00, -.40], p = <.001). The interaction term too has significantly predicted perceived

vulnerability (b = .86, β = -.46, t (76) = 2.89, 95% CI [.27, 1.48], p = .005), this effect can be

more clearly visualized in Figure 3. As the intention term illustrates, smokers that derive higher self-esteem from smoking and are exposed to a susceptibility salient message will perceive higher vulnerability than those exposed to a non-susceptibility salient message, therefore H1 is accepted. Furthermore, the higher the smoking derived self-esteem is the lower the perceived

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vulnerability will be if exposed to a non-susceptibility salient message, H3 can too be accepted therefore. However, as the interaction term also suggests, at lower smoking derived self-esteem, a non-susceptibility salient message actually leads to greater perceived vulnerability than a susceptibility salient message. This is also clearly illustrated in Figure 3.

Figure 3: Moderation effect of smoking derived self-esteem and message type on perceived vulnerability.

Note. Self-esteem categorized into low, medium and high by its 17th, 50th and 84th percentile.

Intention. H2 and H4, posit that individuals that derive high self-esteem from smoking will respectively have - lower intention to smoke if the fear-appeal is susceptibility salient (H2) and increased intention to smoke if the message is not susceptibility salient (H4). To test these hypotheses, I looked at the mediation effect of perceived vulnerability between message type and intention to smoke. This too was done in the bootstrapped Model 7 PROCESS Macro (Nsamples = 1000, CI = 95%). The overall model was significant in predicting intention to smoke F (3,77) = 5.82, p = .004, R2 = .13. As can be seen in Table 2 perceived vulnerability significantly

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predicts intention to smoke, higher perceived vulnerability will lead to a lower intention to smoke (b = -.32, β = -.34, t (77) = -3.21, 95% CI [-.52, -.12], p = .002).

Table 2. Summary of the mediation effect of vulnerability between message type and intention.

Model b 95% CI β t p Lower Upper (Constant) 3.13 2.50 3.77 9.87 .004 Message type -.16 -.54 .21 -.09 -.86 .394 Perceived vulnerability -.32 -.52 -.12 -.34 -3.21 .002 Note. N = 80; R2 = .13, F (3,77) = 5.81, p = .004

As demonstrated in the moderation effect earlier, individuals with higher smoking derived self-esteem will have greater perceived vulnerability if the message is susceptibility salient (See Figure 3), which in turn will lead to a lower intention to smoke thanks to the mediation effect of perceived vulnerability on intention to smoke (β = -.34, p = .002), therefore H2 is accepted. Similarly, if the message is not susceptibility salient the same individuals will have lower perceived vulnerability and therefore increased intention to smoke, also confirming H4. Figure 4 more clearly illustrates this once more with three different levels of self-esteem at its 18th, 50th and 84th percentile. As demonstrated in the earlier test for moderation, self-esteem and its interaction term with message type significantly predicts perceived vulnerability, which in turn significantly predicts intention to smoke. Making self-esteem and message type good predictors of the individuals intention to smoke.

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Figure 4: Effects of smoking derived self-esteem and message type on the intention to smoke.

Note. Self-esteem categorized into low, medium and high by its 17th, 50th and 84th percentile.

Conclusion

Discussion and Implications

This study led to several important findings that have relevant implications for health communication researchers and professionals. The results in line with previous research suggest that higher smoking derived self-esteem indeed does have negative effects on the message acceptance, mainly due to proximal defenses such as denial of vulnerability. Furthermore, this study was to my knowledge the first to explore the interaction between the effects of

self-esteems on perceived vulnerability and susceptibility salience of the fear appeal. The experiment revealed that this effect can be mitigated to some degree by making the mortality salient fear appeal more susceptibility salient with statistical information.

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In line with other studies in applying the TMT in fear-appeal research (Morris et al., 2018), individuals that derive greater self-esteem from smoking cigarettes will be far more likely to dismiss their vulnerability to smoking health risks. From a TMT perspective this makes sense, as when exposed to mortality salient messages, individuals would reaffirm the meaning and significance of their existence by holding on to the cultural worldviews that provide them with self-esteem (Pyszczynski et al., 2015). Even though this effect is significant, the majority of research done into the effectiveness of fear-appeal messages have neglected this variable. This could also account for some of the inconsistencies between the current health communication theories and empirical evidence (Peters & Kok, 2013). Depending on the sample of a fear-appeal study, the results could be completely different. Sources of self-esteem and levels of self-esteem vary across ages and cultures (Bleidorn et al., 2016). An example would be adolescence which derive far more self-esteem from smoking because their cultural worldview values might be more peer acceptance oriented (Glendinning & Inglis, 1999).

To mitigate the effects of smoking derived self-esteem, susceptibility salient messages containing definite statistics can be used. However, while a susceptibility salient fear-appeal message led to increased perceived vulnerability and decreased intention to smoke, in individuals deriving high esteem from smoking, it did the opposite for individuals deriving low self-esteem from smoking. This later effect is interesting as it on first glance contradicts the traditional understanding that a susceptibility component in a message should increase the individuals perceived vulnerability (Maloney et al., 2017). One possible explanation for this contradiction, is in line with the extended parallel process model by Witte (1996). It suggests that if an individual perceive great threat from a fear-appeal message, however have low perceived

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efficacy to control the threat, they will instead control their fear through denial. I speculate that individuals that scored low on smoking derived self-esteem most likely do not like being smokers, however they lack the self-efficacy to quit. Hence when confronted with a more threatening message without a response recommendation they are more likely to control their fear by denying their vulnerability. This explanation is purely speculative and would require further research which includes a response recommendation in the fear-appeal. What is important to take though from this finding is that, at least in the absence of other message component such as efficacy, a susceptibility salient fear-appeal is not always more effective. The implication of this is that health communication professionals should not use a susceptibility salient fear appeal in every scenario, its effectiveness seems to be determined by further factors that need to be explored.

However, individuals that derive high self-esteem from smoking, as hypothesized, perceived greater vulnerability to smoking health risks and lower intention to smoke when exposed to a susceptibility salient fear-appeal message. This finding suggests that when confronted with a fear-appeal message that requires more cognitive processing, such as a statistical value (Braverman, 2008), the heuristic processing of information in which the terror management theory operates is undermined to some extent (Simon et al., 1997). This finding has great implications on health communication professionals. When addressing a certain unhealthy behavior, they need to take into account what the likely level of that behaviors derived self-esteem is, in their target audience. This requires prior understanding of their target group’s cultural worldview values. When targeting adolescent smokers for example, the message is likely

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to be more effective if it is susceptibility salient, as most adolescents derive self-esteem through peer acknowledgement (Glendinning & Inglis, 1999).

Although there have been countless studies done on the TMT since its introduction thirty years ago (Pyszczynski et al., 2015), a minority of these studies have focused on the effects of the TMT on health communication and to my knowledge only a handful of these manipulated the mortality salient message to explore possible ways to mitigate this effect. General conclusions derived from TMT studies suggest to abstain from mortality salient fear-appeal messages due to the effect of possible self-esteem deriving risky behaviors. However, as the EPPM (Maloney et al., (2017) and the stage model of processing of fear-arousing communications (de Hoog et al., 2007) suggest, greater perceived threat does motivate individuals to more defensive actions against the threat, if accompanied by a response recommendation. Therefore, I believe that rather than trading in one deficit for another when designing fear-appeal messages, efforts should be made to explore the interaction of these models and find ways to marginalize possible

shortcomings in their persuasiveness.

Nevertheless, until further research can examine these interactions, it is advisable for policy makers such as the European Commission to adapt their health communication strategy when it comes to cigarette warning labels to more varied warning labels. Currently the majority of the messages displayed on cigarette warning labels will likely increase smoking intention for people deriving self-esteem from smoking as was evident in this experiment (Sambrook

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Limitations and Future Research

While this study has demonstrated that self-esteem is an important predictor of fear-appeal message outcomes, as well as provided a first insight into how this effect can be mitigated to some extent by susceptibility salience, there are still some noteworthy limitations that need to be addressed. For starters, this study only included the threat appraisal aspect of the EPPM, and within it only susceptibility was manipulated. The outcome for a manipulation of severity (i.e. mortality salient vs non-salient) would be predictable as it has been studied extensively in the field of TMT. However, adding the efficacy appraisal aspect into this study could have revealed a lot more, and possible have explained why there was a negative relationship between

susceptibility salient messages and individuals with low smoking derived self-esteem. As Jessop et al. (2008) has shown in his study of recommendation manipulation in mortality salient

messages, it too can mitigate the effects of self-esteem. Therefore, a more extensive study where each of these aspects is tested in conjunction with each other, could reveal far more on the interaction of the TMT and the EPPM.

Furthermore, in this study, all participants were asked for their self-reported perceived vulnerability to smoking health risks at the same delay. The TMT distinguishes between immediate conscious reactions to death reminders (e.g. denial of vulnerability; proximal defenses) and the delayed reactions that operate more unconsciously (e.g. engagement in self-esteem deriving activity; distal defenses) (Jonas et al., 2014). While there were a few minutes of delay between the exposure of the mortality salient message and the measurement of perceived vulnerability, as well as distracting questions such as art preferences, it was unclear whether this

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was enough to make any conclusive statements about the cognitive state in which mortality operated. This is a major limitation as I theorized that a susceptibility salient fear appeal message with a statistic would be processed more rationally and require more cognitive effort

(Braverman, 2008), therefore could undermine the distal defenses such as increased engagement in smoking (Simon et al., 1997). If repeated, this study should have two further conditions, in one of which the perceived vulnerability is measured immediately and in the other it would be measured only after more lengthy delay.

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Appendix A

Susceptibility salient condition: (1 out of 4 pairs displayed)

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Appendix B