Fairchild and Bayer Respond

Jing Jing Li contends that we made an argument for fear that was not based on evidence. Our article focused on five decades of debate over fear. We traced the ways in which tobacco control advocates increasingly embraced fear in the years after World War II. Remarkably, in the 1970s, bioethics accepted the use of fear in some circumstances.

In the context of the AIDS epidemic, however, human rights advocates in particular questioned the use of fear. Their argument was that because fear always stigmatized, fear never worked. But, as we noted, the evidence was more complicated. In fact, those involved in launching fear-based campaigns concluded, on the basis of careful, systematic reviews of evidence and ongoing evaluations, that fear could work.

Evaluations of the anti-tobacco counteradvertising initiatives of the 1970s and 1980s were glowing. Along with muscular policies effectively removing smoking (and smokers) from public spaces, they changed social norms. The counteradvertising campaign evaluations were very different from the experimental, empirical work on fear-based social marketing efforts, which generally involved randomized trials seeking to test prevailing theories of health behavior change. Different theories proposed complicated relationships between fear and behavior change that varied according to level of fear; perceived susceptibility, severity, and self-efficacy to make a change; and the perceived efficacy of interventions that individuals could adopt. The question was never so simple as does fear work? Rather, the issue was do the data support different theoretical models about how fear might or might not work?

Given this, it was possible to find in the body of literature both support for the argument that fear worked and support for the counterargument that scare tactics never worked to change behavior. Under such circumstances, the decision of whether to embrace fear would be driven—sometimes subtly, sometimes explicitly—by broader normative considerations.

By 2010 public health professionals, bolstered by mounting evidence, proved increasingly receptive to the use of fear, extending it to obesity and, after a decades-long grace period, to HIV. A 2015 meta-analysis by Tannenbaum et al. published in the premier journal of the American Psychological Association provided an unambiguous empirical foundation for such efforts: fear appeals were effective in positively influencing attitudes, intentions, and behavior; there were very few circumstances under which they were not effective; and there were no identifiable circumstances under which they backfired and led to undesirable outcomes.¹ Although efficacy-enhancing elements of campaigns could improve the likelihood of success, fear appeals did not backfire in their absence. To be sure, fear’s effects were minor, but they were not inconsequential.

We agree with Li that outcomes matter. Of course, if a strategy cannot or does not work, that is the end of the story. But if fear does work in a particular set of circumstances, that can open a conversation. How the story then plays out is a matter of not only outcomes but values and politics.