Fear and persuasion in public health discourse: The case of CDC anti-smoking campaigns

Abstract

Fear has long been recognised as a potent tool for persuasive communication. A plethora of research has examined the role of fear appeals in influencing the target audience. However, scant attention has been given to the choice of persuasive strategies used to craft fear messages, particularly in the public health domain. This study aims to bridge the gap in the literature by examining the prevalence of fear strategies and the interplay between persuasion and fear in an anti-smoking campaign, drawing on Aristotle’s persuasion theory and Fear Appeals by Witte and Allen (2000). Methodologically, the study employs a qualitative, descriptive content analysis to examine how fear-based persuasive strategies are constructed in the CDC’s press releases. A qualitative analysis was conducted on a corpus of 27 press releases issued between 2012 and 2024 as part of the Centers for Disease Control and Prevention’s (CDC) Tips From Former Smokers campaign. The analysis reveals five predominant fear strategies utilised by the CDC in their press releases: fear-induced narratives, health-hazard emphasis, statistics, expert endorsement, and urgency. These strategies enhance the CDC's message by amplifying fear appeals, thereby altering smokers' current behaviours and attitudes. This study contributes to the literature by providing insights into the strategies adopted in crafting fear appeals in anti-smoking campaigns and how fear patterns shape individuals’ behavioural change against smoking tobacco.

Keywords

Fear appeals / Persuasion / Public health communication / CDC / Anti-smoking campaign / Behavioural change

CRediT authorship contribution statement

Rabab'ah Ghaleb: Writing - review & editing, Writing - original draft, Supervision, Methodology, Formal analysis, Conceptualization. Fakir Al Gharaibeh: Writing - original draft, Resources, Methodology, Data curation. Sharif Alghazo: Writing - review & editing, Writing - original draft, Validation, Methodology, Formal analysis, Conceptualization. Rima Malkawi: Writing - original draft, Validation, Formal analysis, Data curation.

Ethical approval

This article does not contain any studies with human participants performed by any of the authors.

Informed consent

Our study does not include human subjects.

Funding

We declare that we have not received any funding for this research.

Declaration of Competing Interest

We have nothing to declare.

Data availability

Data will be made available on request.

References

[1] Al Thani M., Leventakou V., Sofroniou A., Butt H. I., Hakim I. A., Thomson C., & Nair U. S. (2022). Factors associated with baseline smoking self-efficacy among male Qatari residents enrolled in a quit smoking study. Plos One, 17(1), Article e0263306. https://doi.org/10.1371/journal.pone.0263306

[2] Al-Dmour H., Masa’deh R. E., Salman A., Al-Dmour R., & Abuhashesh M. (2022). The role of mass media interventions on promoting public health knowledge and behavioral social change against COVID-19 Pandemic in Jordan. Sage Open, 12(1), Article 21582440221082125. https://doi.org/10.1177/21582440221082125

[3] Amos C., Zhang L., King S., & Allred A. (2021). Aristotle’s modes of persuasion and valence effects on online review trustworthiness and usefulness. Journal of Marketing Communications, 1-32. https://doi.org/10.1080/13527266.2021.1881806

[4] Armstrong K., Richards A. S., & Boyd K. J. (2021). Red-hot reactance: Color cues moderate the freedom threatening characteristics of health PSAs. Health Communication, 36(6), 663-670. https://doi.org/10.1080/10410236.2019.1700885

[5] Babb S., Malarcher A., Asman K., Johns M., Caraballo R., VanFrank B., & Garrett B. (2020). Disparities in cessation behaviors between hispanic and non-hispanic white adult cigarette smokers in the United States, 2000-2015. E 10 Preventing Chronic Disease, 2020(17), Article 190279. https://doi.org/10.5888/pcd17.190279.

[6] Bafunno D., Catino A., Lamorgese V., Del Bene G., Longo V., Montrone M., & Galetta D. (2020). Impact of tobacco control interventions on smoking initiation, cessation, and prevalence: A systematic review. Journal of Thoracic Disease, 12(7), 3844. https://doi.org/10.21037/jtd.2020.02.23

[7] Burris J. L., Riley E., Puleo G. E., & Smith G. T. (2017). A longitudinal study of the reciprocal relationship between ever smoking and urgency in early adolescence. Drug and Alcohol Dependence, 178, 519-526. https://doi.org/10.1016/j.drugalcdep.2017.06.007

[8] Chen L., & Yang X. (2018). Using EPPM to evaluate the effectiveness of fear appeal messages across different media outlets to increase the intention of breast self- examination among Chinese women. Health Communication, 34(11), 1369-1376. https://doi.org/10.1080/10410236.2018.1493416

[9] Chu H., & Liu S. (2024). Risk-efficacy framework-a new perspective on threat and efficacy appraisal and the role of disparity. Current Psychology, 43, 5999-6012. https://doi.org/10.1007/s12144-023-04813-9

[10] Clark J. (2019). Reducing the risk: psychological and technological approaches for improving handwashing practices in the foodservice industry. Unpublished PhD dissertation, University of Arkansas.

[11] Colin C., & Droulers O. (2022). Effect of combining fear and anger in anti-smoking messages to discourage young smokers. Public Health, 211, 47-52. https://doi.org/10.1016/j.puhe.2022.06.031

[12] Cruz T. B., Rose S. W., Lienemann B. A., Byron M. J., Meissner H. I., Baezconde- Garbanati L., … Unger J. B. (2019). Pro-tobacco marketing and anti-tobacco campaigns aimed at vulnerable populations: A review of the literature. Tobacco Induced Diseases, 17. https://doi.org/10.18332/tid/111397

[13] Davis K. C., Murphy-Hoefer R., Levine B., King B. A., Hu S., & Rodes R. (2019). Evidence of the impact of the tips from former smokers campaign: Results from the behavioral risk factor surveillance system. Preventing Chronic Disease, 16, Article 190110. https://doi.org/10.5888/pcd16.190110

[14] Durham A. L., & Adcock I. M. (2015). The relationship between COPD and lung cancer. Lung Cancer, 90(2), 121-127. https://doi.org/10.1016/j.lungcan.2015.08.017

[15] Ettinger J., Walton P., Painter J., & DiBlasi T. (2021). Climate of hope or doom and gloom? Testing the climate change hope vs. fear communications debate through online videos. Climatic Change, 164(1), 19. https://doi.org/10.1007/s10584-021-02975-8

[16] Githaiga J. N., & Swartz L. (2017). Socio-cultural contexts of end-of-life conversations and decisions: Bereaved family cancer caregivers’ retrospective co-constructions. BMC Palliat Care, 16, 40. https://doi.org/10.1186/s12904-017-0222-z

[17] Giuntella O., Hyde K., Saccardo S., & Sadoff S. (2021). Lifestyle and mental health disruptions during COVID-19. Proceedings of the National Academy of Sciences, 118 (9), Article e2016632118.

[18] Glascoff D. W. (2000). Articles of interest: Fear appeals, quality perceptions, and "e- health" marketing. Marketing Health Services, 20(4), 35-36.

[19] Greene K., & Brinn L. S. (2003). Messages influencing college women’s tanning bed use: Statistical versus narrative evidence format and a self-assessment to increase perceived susceptibility. Journal of Health Communication, 8(5), 443-461. https:// doi.org/10.1080/10810730390233271

[20] Hampsher-Monk S. C., Prieger J. E., & Patwardhan S. (2024). E-cigarette regulations and why they fail. Tobacco regulation, economics, and public health, Volume III: Clearing the air on e-cigarettes and harm reduction (pp. 1-130). Switzerland: Springer Nature. https://doi.org/10.1007/978-3-031-47096-7_1

[21] Huang X., Gan Y. C., & Syed A. (2024). Narratives of anxiety and depression on YouTube: A corpus-based thematic analysis. Language and Health, 2(2), Article 100029. https://doi.org/10.1016/j.laheal.2024.09.001

[22] Janis I. L., & Feshback S. (1953). Effects of fear-arousing communications. Journal of Abnormal and Social Psychology, 48(1), 78-92. https://doi.org/10.1037/h0060732

[23] Jeong J. S., Choi J., & Noh G. Y. (2022). Fear appeal effectiveness in antismoking campaigns: Do anger and smoking matter? Psychology, Health Medicine, 27(10), 2105-2112. https://doi.org/10.1080/13548506.2021.2006251

[24] Joseph D. A., & DeGroff A. (2019). The CDC colorectal cancer control program, 2009-2015. Preventing Chronic Disease, 16. https://doi.org/10.5888/pcd16.190336

[25] Kessar S., Rabab’ah G., Al-Khadra W., & Hamdan H. J. (2021). The representation of the Algerian Hirak protest movement in the international media: France 24 and Al- Jazeera. Cogent Social Sciences, 7(1), Article 1930646. https://doi.org/10.1080/23311886.2021.1930646

[26] Kopfman J. E., Smith S. K., Ah Yun J., & Hodges A. (1998). Affective and cognitive reactions to narrative versus statistical organ donation messages. Journal of Applied Communication International Journal of Communication, 26(3), 279-300. https://doi.org/10.1080/00909889809365508

[27] Leventhal H. (1970). Findings and theory in the study of fear communications. In L. Berkowitz (Ed.), Advances in experimental social psychology, 5 pp. 119-186). New York: Academic Press. https://doi.org/10.1016/S0065-2601(08)60091-X.

[28] Lueck J. A. (2019). Should we activate risk perceptions in the context of suicide prevention? Examining fear appeals, help-seeking determinants, and help-seeking sources among university employees who suffer from depression. Prevention Science, 20(6), 884-893. https://doi.org/10.1007/s11121-019-0979-9

[29] Martini C., Ronzani P., Panizza F., Savadori L., & Motterlini M. (2022). Countering vaccine hesitancy through medical expert endorsement. Vaccine, 40(32), 4635-4643. https://doi.org/10.1016/j.vaccine.2022.06.031

[30] Massey Z. B., Duong H. T., Churchill V., & Popova L. (2022). Examining reactions to smoking and COVID-19 risk messages: An experimental study with people who smoke. International Journal of Drug Policy, 102, Article 103607. https://doi.org/10.1016/j.drugpo.2022.103607

[31] Mattingly D. T., Hirschtick J. L., Meza R., & Fleischer N. L. (2020). Trends in prevalence and sociodemographic and geographic patterns of current menthol cigarette use among US adults, 2005- 2015. Preventive Medicine Reports, 20, Article 101227. https://doi.org/10.1016/j.pmedr.2020.101227

[32] McKinley C., Limbu Y., & Jayachandran C. (2017). Message-framing effects on Indian females’ mammography-screening intentions: Examining moderating and mediating relationships. International Journal of Communication, 11, 3541-3565. Available at 〈http://ijoc.org〉.

[33] Mullens A. B., McCaul K. D., Erickson S. C., & Sandgren A. K. (2004). Coping after cancer: Risk perceptions, worry, and health behaviors among colorectal cancer survivors. Psycho-Oncology: Journal of the Psychological, Social and Behavioral Dimensions of Cancer, 13( 6), 367-376. https://doi.org/10.1002/pon.751

[34] Ngondo P. S., & Klyueva A. (2019). Fear appeals in road safety advertising: An analysis of a controversial social marketing campaign in Russia. Russian Journal of Communication, 11(2), 167-183. https://doi.org/10.1080/19409419.2018.1555772

[35] Noar S. M., Bell T., Kelley D., Barker J., & Yzer M. (2018). Perceived message effectiveness measures in tobacco education campaigns: A systematic review. Communication Methods and Measures, 12(4), 295-313. https://doi.org/10.1080/19312458.2018.1483017

[36] Ooms J. A., Jansen C. J., & Hoeks J. C. (2020). The story against smoking: An exploratory study into the processing and perceived effectiveness of narrative visual smoking warnings. Health Education Journal, 79(2), 166-179. https://doi.org/10.1177/0017896919867436

[37] Orwenjo D. O. (2025). Waiting to die: Language, discourse and meaning in palliative care contexts in Kenya. Language and Health, 3(2), Article 100069. https://doi.org/10.1016/j.laheal.2025.100069

[38] Rabab’ah G., & Khawaldeh M. (2016). Persuasive Appeals in English and Arabic TV Advertisements: Implications for EFL Learners and Teachers. DIRASAT: Human Social Sciences, 16(5), 2259-2271. 〈 https://archives.ju.edu.jo/index.php/hum/article/view/9739〉.

[39] Rabab’ah G., & Al-Qudah S. (2022). Linking cognition with pathos in American restaurants’ menus: Jordan as a case. Heliyon, 8(2), Article e09000. https://doi.org/10.1016/j.heliyon.2022.e09000

[40] Rabab’ah G., Idir L., & Alghazo S. (2020). Persuasive appeals in Jordanian and Algerian telecommunication television commercials. Open Linguistics, 6, 307-321. https://doi.org/10.1515/opli-2020-0021

[41] Rabab’ah G., Yagi S., Alghazo S., & Malkawi R. (2024). Persuasive strategies in email marketing: An analysis of appeal and influence in business communication. Journal of Intercultural Communication, 24(2), 12-25. https://doi.org/10.36923/jicc.v24i2.839

[42] Rogers R. (1975). A protection motivation theory of fear appeals and attitude change1. Journal of Psychology, 91(1), 93-114. https://doi.org/10.1080/00223980.1975.9915803

[43] Schneider S., Gadinger M., & Fischer A. (2012). Does the effect go up in smoke? A randomized controlled trial of pictorial warnings on cigarette packaging. Patient Education and Counseling, 86(1), 77-83. https://doi.org/10.1016/j.pec.2011.03.005

[44] Sell T. K., Hosangadi D., & Trotochaud M. (2020). Misinformation and the US Ebola communication crisis: Analyzing the veracity and content of social media messages related to a fear-inducing infectious disease outbreak. BMC Public Health, 20(1), 1-10. https://doi.org/10.1186/s12889-020-08697-3

[45] Siegenthaler P., Ort A., & Fahr A. (2021). The influence of valence shifts in fear appeals on message processing and behavioral intentions: A moderated mediation model. Plos One, 16(9), Article e0255113. https://doi.org/10.1371/journal.pone.0255113

[46] Smith G. T., & Cyders M. A. (2016). Integrating affect and impulsivity: The role of positive and negative urgency in substance use risk. Drug and Alcohol dependence, 163, S3-S12. https://doi.org/10.1016/j.drugalcdep.2015.08.038

[47] Staunton T. V., Alvaro E. M., & Rosenberg B. D. (2020). A case for directives: Strategies for enhancing clarity while mitigating reactance. Current Psychology, 1-11. https:// doi.org/10.1007/s12144-019-00588-0

[48] Suess C., Maddock J. E., Palma M., Youssef O., & Kyle G. (2024). An application of protection motivation theory to understand the influence of fear-appeal media on stated donations for coral reef restoration. Tourism Management, 100, Article 104797. https://doi.org/10.1016/j.tourman.2023.104797

[49] Teeny J. D., Siev J. J., Bri˜nol P., & Petty R. E. (2021). A review and conceptual framework for understanding personalized matching effects in persuasion. Journal of Consumer Psychology, 31(2), 382-414. https://doi.org/10.1002/jcpy.1198

[50] Van Bavel R., Rodríguez-Priego N., Vila J., & Briggs P. (2019). Using protection motivation theory in the design of nudges to improve online security behavior. International Journal of Human-Computer Studies, 123, 29-39. https://doi.org/10.1016/j.ijhcs.2018.11.003

[51] Witte K. (1992). Putting the fear back into fear appeals: The extended parallel process model. Communication Monographs, 59, 329-349. https://doi.org/10.1080/03637759209376276

[52] Witte K., & Allen M. (2000). A meta-analysis of fear appeals: Implications for effective public health campaigns. Health Education Behavior, 27(5), 591-615. https://doi.org/10.1177/109019810002700506

[53] Witte K., Cameron K. A., McKeon J. K., & Berkowitz J. M. (1996). Predicting risk behaviors: Development and validation of a diagnostic scale. Journal of Health Communication, 1(4), 317-341. https://doi.org/10.1080/108107396127988

[54] Yahya N. H., & Abdul Rahim H. (2023). Linguistic markers of depression: Insights from English-language tweets before and during the COVID-19 pandemic. Language and Health, 1(2), 36-50. https://doi.org/10.1016/j.laheal.2023.10.001

[55] Yoo C. W., Lee J., Yoo C., & Xiao N. (2021). Coping behaviors in short message service (SMS)-based disaster alert systems: From the lens of protection motivation theory as elaboration likelihood. Information Management, 58(4), Article 103454. https://doi.org/10.1016/j.im.2021.103454

[56] Hong W., Yu Z., Wu L., & Pu X. (2020). Influencing factors of the persuasiveness of online reviews considering persuasion methods. Electronic Commerce Research and Applications, 39, 100912. https://doi.org/10.1016/j.elerap.2019.100912

[57] Facchinetti R. (2021). News discourse and the dissemination of knowledge and perspective: From print and monomodal to digital and multisemiotic. Journal of Pragmatics, 175, 195-206. https://doi.org/10.1016/j.pragma.2021.01.015