1. “Give me happiness vs. Take away our pain:” Consumers’ motivation in responding to prescription drug advertising Nithima Sumpradit, PhD 1 Frank J. Ascione, PharmD. PhD 2 Richard P. Bagozzi, PhD 3 1 Thai Food and Drug Administration 2 University of Michigan, College of Pharmacy 3 Rice University, Jesse H. Jones Graduate School of Management

2. Abstract Motivation & DTC advertising -Slide 1- 04.01.04 Problem Statement: Although direct-to-consumer advertising (DTCA) of prescription drugs is banned in Thailand, it recently became a global phenomenon largely because of advances in information technology. Proponents suggest that DTCA educates consumers about diseases and treatment. Opponents argue that DTCA misleads consumers and causes irrational drug use. Understanding the effects of DTCA can assist policy makers in making informed, appropriate decisions on this issue. Objective: To determine how DTCA motivates consumers, based on self-regulatory focus and self-construal orientation. Self- regulatory focus posits that behavior is regulated by two systems: promotion (emphasizing achievements) and prevention (emphasizing safety/obligations). Self-construal orientation suggests that behavior is guided by two self-views: independent self (emphasizing self-fulfillment/uniqueness) and interdependent self (emphasizing family/social relationships). The independent self emphasizes self-fulfillment and therefore is compatible with a focus on promotion. The interdependent self emphasizes maintaining relationships and avoiding mistakes, and therefore is consistent with a focus on prevention. We hypothesized that goal-compatible ads will lead to more favorable attitudes toward the ad and the brand advertised, greater intention to act and greater likelihood of action, and more perceived benefits and fewer perceived risks of the product. We also hypothesized that prevention ads will elicit better recall of risk information, more negative emotions, and fewer positive emotions than promotion ads. Design: A 2 (independence vs. interdependence) × 2 (promotion vs. prevention) factorial design was used. Setting and Study Population: A random sample of 220 females aged 40 years or older, who work at a large university but are not faculty members or healthcare professionals/practitioners, were randomly assigned to view one of the four mock ads for an anti- hyperlipidemia drug and complete a questionnaire. Outcome Measures: Main outcome measures included attitude toward the ad and the brand advertised, intention to act, likelihood of action, perceived benefits and risks of the drug, emotional response, and recall of risk information. Data were analyzed with ANOVA and ANCOVA. Results: Results partially supported the hypotheses regarding goal-compatibility and emotional responses to the ad. Surprisingly, results for recall of risk information were opposite to those hypothesized. Subgroup analysis showed that individuals with a positive or neutral attitude toward DTCA reacted to ads consistently with our predictions, whereas those with a negative attitude toward DTCA reacted to the same message in the opposite way to what we predicted. Conclusions: The motivational themes in DTCA affect consumer behavior. The impact is a function of the interaction between the themes and the pre-existing attitudes of consumers. Submitted: February 15, 2004

3. Introduction Motivation & DTC advertising -Slide 2- 04.01.04 Positive effectsNegative effects Create informed consumersCreate consumers’ demand Educate or inform consumers Increase discussion and MD-Pt relationship Improve consumer health Misinform or mislead consumers Create tension on MD-Pt relationship Jeopardize consumer health Direct-to-Consumer Advertising of Prescription Drugs (DTCA) –First introduced in UK and USA in the early of 1980s –3 types: Product specific ads (brand name + indication +“risk information as fair- balance regulation”), Help-seeking ads (indication w/o brand name), Reminder ads (brand name w/o indication) –Recently, help-seeking ads of Rx drugs were found in Thai consumer magazines. Effects of DTCA Goal of study: To investigate the effects of the motivational themes in DTCA on consumers’ attitudes, perception of drug’ risks/benefits, ability to recall of risk information, intention-to-act, and likelihood-of-action.

4. TheoriesGoal Compatibility Self-regulatory focus theory Promotion focus Goal is to achieve positive outcomes Sensitive to presence/absence of positive outcome Focus on accomplishment Prevention focus Goal is to avoid negative outcomes Sensitive to presence/absence of negative outcome Focus on safety & obligation Self-construal orientation Independent self Goal is to achieve personal benefits (personal goals) Focus on separateness, self- reliance, self-fulfillment Interdependent self Goal is to achieve group benefits (collective goals) Focus on connectedness, comply to duties, maintain harmonious relationship, avoid conflicts Study framework Motivation & DTC advertising -Slide 3- 04.01.04 Goal compatibility occurs when:  Promotion focus is combined with the independent self  Prevention focus is combined with the interdependent self

5. Hypotheses H 1 – 6: Ads with goal compatibility will elicit 1) more favorable ad attitude, 2) more positive brand attitude, 3) greater intention-to-act, 4) greater likelihood-of-action, 5) higher perceived drug’s benefits, and 6) lower perceived drug’s risks. Motivation & DTC advertising -Slide 4- 04.01.04 H 7: Prevention focused ads will elicit better recall of risk information. H 8a: Promotion focused ads will elicit more positive emotional responses to the ad. H 8b: Prevention focused ads will elicit more negative emotional responses to the ad.

6. Design: A 2 (promotion vs. prevention) x 2 (independence vs. interdependence) factorial design Selection criteria: - Females- Age 40 years old or older - Work or used to work at U of M- Living in Ann Arbor or nearby areas - Not faculty members or health practitioners Recruitment: - An invitation letter with a follow-up postcard - Incentive - Accommodating sessions Data collection procedures: - A random sample of 234 subjects attended the session (17.7% response rate). - They were randomly assigned to view one of the four mock ads for cholesterol- lowering drug (Travacor) and completed a questionnaire. - Of a total of 234, a sample of 220 yield useable questionnaires. Methods Motivation & DTC advertising -Slide 5- 04.01.04

7. Results: Main analysis #HypothesesResultsNext step H1-6Ads with goal compatibility will increase the effects on ad/brand attitudes, intention-to-act, likelihood- of-action, perception of drug’s benefits, and lower perception of drug’s risks Partially supported Profile plots were in a proper direction Subgroup analysis H 7Prevention ad (vs. promotion ad) elicits better recall of risk information Not supported Opposite direction Exploratory analysis H 8aPromotion ad elicit more positive emotional responses to the ad Supported- H 8bPrevention ad elicit more negative emotional responses to the ad Not stat. sig. result but Proper direction - Motivation & DTC advertising -Slide 6- 04.01.04

8. Total sample N = 220 Positive/Neutral DTCA attitude N = 95 Negative DTCA attitude N = 102 Reduce within group error variance Remove bias cases Subgroup analyses ANCOVA Subgroup analysis (H1-6) Motivation & DTC advertising -Slide 7- 04.01.04 The purpose of the subgroup analysis is to reduce within group error variance

9. When the self-construal frame matches the self-regulatory focus, the ad will lead to… Subgroup AnalysisMain A. Pos/Neu. DTCA attitude, N=95 Neg. DTCA attitude, N=102 Total N=220 H1 Ad attitudeNS H2 Brand attitudeNS (p = 0.07)NS H3 Intention to talk drug with MDp = 0.002p = 0.002*p=0.001 Intention to talk high cholesterolp = 0.028NS Intention to seek info (non MDNS H4 Likelihood of seeking info from doctor/ pharmacist, nurse p <.05NSp=0.001/ NS Likelihood of seeking info from non-health professional sources NS Likelihood of requesting an Rxp = 0.028NS H5 Perceived drug’s benefitp = 0.023NS H6 Perceived drug’s riskNS Results: Effects of goal compatibility Motivation & DTC advertising -Slide 8- 04.01.04

10. Example of profile plot: Simple main effects Intention to talk about high cholesterol with doctor (Scale from 1 = definitely not to talk to 5 = definitely yes to talk with MD) Positive/Neutral DTCA attitudeNegative DTCA attitude Motivation & DTC advertising -Slide 9- 04.01.04 - Interaction effects are in the predicted direction-Interaction effects are in the opposite direction to what we hypothesized

11. Results: Risk information recall (H 7) Exploratory AnalysisMain A. Positive/neutral DTCA attitude N=95 Negative DTCA attitude N=102 Total N = 220 H7: Prevention focused ad (vs. promotion focused ad) will elicit better recall of risk info* 3.1 vs. 4.2, p = 0.002 3.9 vs. 4.6 p = 0.045 3.5 vs. 4.3, p = 0.001 * Opposite direction Motivation & DTC advertising -Slide 10- 04.01.04

12. Discussions H1 – 6: Opposite patterns between positive/neutral vs. negative attitude groups Advertising acceptance – rejection assumption Acceptance – external message conforms to pre-existing attitude Rejection – external message differ from pre-existing attitude H 7: Promotion focused ad is better in eliciting risk information recall than prevention focused ad. Differences in strategic means: Approach vs. Avoidance The role of positive emotions on cognitive function (H8) The role of attention Motivation & DTC advertising -Slide 11- 04.01.04

13. Conclusions, Limitations & Public policy implications Conclusions –The motivational power of the ads depend on ads’ and consumers’ characteristics. –Self-regulatory focus as well as self-construal orientation proved to be a useful framework in understanding the mechanism of how DTCA influence consumer behavior. Limitations –Results may not be generalized to male or general populations –Study design is based on “forced exposure.” –Choice of product is limited to only cholesterol-lowering drugs –Choice of media is limited to print media only Public policy implications –It is important for public policy makers to understand the role of pre-existing attitude toward DTCA in persuasion –They also need to take the role of motivational themes in risk information recall in to consideration for drug advertising regulations. Motivation & DTC advertising -Slide 12- 04.01.04