As seen on TV, marketing for good and evil.
Shills, pills and five essentials for fighting the good fight.
I’ve always thought advertising was cool. I guess it was the overabundance of TV I consumed as a kid. The list of shows that presented it as a fun aspirational career is a long one: Bewitched, Thirtysomething and Melrose Place are but a few. Ferris Bueller’s dad, a young Tom Hanks in Bosom Buddies and even Ward Cleaver made it all look fantastic, a perfect blend of creativity and entrepreneurialism that seemed more fun than work.
I’ve been in the advertising business most of my life, selling everything from internet access to oil changes. And while nothing compares to the gloss and glint of a situation comedy, the industry hasn’t disappointed. It’s been more fun than I imagine other jobs would be. I’ve toured power plants and paper mills, shot commercials in LA and Toronto, and interviewed an astronaut.
Highlighting consumer benefits and differentiating products and services has never felt like manipulation to me. I’ve seen myself as an informer, a clarifier and a truth teller. The slogan of the venerable McCann Erickson agency, “truth well told,” was part of my gospel.
Sure, there used to be cigarette ads with doctors in them, and I’ve seen Super Size Me. Not every product has good intentions, and yes, Americans tend to overdo it with the credit cards. But I was a bit taken aback at a conference in the early 2000s when one of the speakers reprimanded a room full of ad agency folks about Mad Men. “You think that it’s cool and makes your job seem interesting. It’s not. It’s not flattering.” Flattering or not, I still thought my job was an enviable one. But it wasn’t long before events made me question that stance.
“Don’t call it marketing,” my client said.
What? “Nurses don’t like marketing. They think you’re trying to trick people,” she elaborated. This was minutes before presenting what she referred to as a “consumer education campaign” to a hotel ballroom full of healthcare professionals. The campaign was supporting the largest statewide contraceptive access initiative in the country. I believed it to be the most significant work of my career. I was using my decades of expertise for the good of public health, supporting work that had the potential to change lives. And the people providing the care I was promoting were primed not to trust me.
Trustworthy or not, I’d decided to devote my career to behavioral change for good, to understanding the science behind the decisions people make. This means a lot of my work is focused on public health issues. And my client was right all those years ago — nurses can be skeptics.
“It’s big pharma,” was the explanation I got. I’m sure that’s part of it, along with the fact that marketing is hardly an exact science, and science is what nurses have been trained to respect.
In contrast, I’m an optimist. Seeing possibilities is a job requirement. And the assurance that things can be better was never more necessary than when my focus turned from capitalism to causes. Championing causes requires more grit than a syndicated procedural. You can’t change things without believing that people are fundamentally good, that they’ll do what’s better for themselves or for their families if given the best chance. My refusing to capitulate to cynicism is another job requirement.
Sometimes that’s easier said than done.
I just finished Painkiller, Netflix’s number one new series starring Matthew Broderick and Uzo Aduba. The show covers the spread of the opioid epidemic, the over-prescription of OxyContin by doctors and the corruption of Purdue Pharma CEO, Richard Sackler.
The opening episode depicts Richard’s father, Raymond Sackler’s role in starting the company. A physician, he bought a drug company and the largest medical advertising agency in the country after realizing that “the big money in medicine was in sales and marketing and lies.” He realized that addiction meant a customer for life, and Valium was his first blockbuster drug.
He got rich, and he wanted everyone to know it. He gave money to every museum, college and hospital that would take it. (Spoiler alert: they all took it.) The Guggenheim and The American Museum of Natural History in New York and The British Museum and Victoria and Albert Museum in London have galleries that still bear the Sackler name. Status through philanthropy is by no means a new strategy for the newly rich. But Raymond’s philanthropic endeavors were so aggressive and ego-driven that they felt desperate. And he passed his unquenchable ego onto his son, Richard, whose greed surpassed his father’s. Painkiller is Richard’s tale. It details a maniacal obsession with money and a demonic disregard for human suffering.
It feels wrong to say I enjoyed it. The tale was captivating and the acting ovation-worthy. Even though the events were dramatized, the toll of the crisis and Purdue’s complicity is undeniable. And the controversy surrounding the Sackler family continues. Only a few weeks ago, The Supreme Court halted a nearly $6 billion dollar settlement that would provide victim abatement for communities across the country and overdose rescue medication.
No wonder nurses are cynical.
When it comes to the business of healthcare, I’m starting to appreciate their perspective. Purdue used every arrow in its marketing quiver to change behavior, spreading substance use disorder across our country. None of us can change what’s been done, but we can better understand Purdue’s tactics, and put that knowledge towards helping people.
“All of human behavior is essentially comprised of two things. Run from pain. Run toward pleasure. It’s a cycle. If we place ourselves right there, between pain and pleasure, we will never have to worry about money again.”
– Richard Sackler in Painkiller
Running away from pain and toward pleasure — talk about primary drivers for behavioral change. But let’s look at some of the aspects of persuasion at play and see what we can learn from them.
1. Allocation
Complex algorithms determine what ads I see when I watch streaming services. Evidently my profile matches that of people with plaque psoriasis, psoriatic arthritis and Crohn’s disease because three drugs that treat these conditions, Skyrizi, Tremfya and Taltz, are in heavy rotation while I enjoy my favorite shows. Fortunately, I don’t have any of these conditions, but Johnson and Johnson, Abbvie and Lilly have spent plenty for me to be familiar with their respective drugs’ names.
The names Skyrizi, Tremfya and Taltz all contain the letters “X,” “Y” or “Z.” The National Library of Medicine’s article, “The Art and Science of Naming Drugs,” explains that this is a common practice used to give drugs hi-tech, scientific sounding names. Pharmaceutical companies spend hundreds of thousands of dollars to invent brand names with subtle messaging that still complies with the US Food and Drug Administration’s guidelines.
In OxyContin’s case (note the use of both “X” and “Y”), focus groups were held to test associations with codeine and morphine. The groups showed that OxyContin had no association with either drug. Perception was that codeine and morphine were used in acute cases. That meant that Purdue could position OxyContin as an alternative for less severe and therefore more common cases. Sackler knew abuse would be a problem, and naming was part of the plan.
While the drug companies scrutinize and strategize naming, state agencies and nonprofits’ consumer brands stand in contrast. They seem to fall victim to expected thinking and nomenclature by committee. The results are often meaningless acronyms, trite slogans or worse yet, directives. I’ve written before how the latter can be judgmental or shaming, both areas to avoid when a change in behavior is your goal. While there are a few well-funded programs that I’m sure have benefitted from focus groups and other forms of market research, most seem to lack the kinds of strategic insights that would lead to effective brand development.
The havoc created by Purdue was driven by money. The scale of it is part of what makes it so despicable. In 2001 alone, Purdue Pharma’s marketing budget exceeded $200 million. I know of no cause with that kind of money. But that doesn’t mean you can’t allocate your budget differently. I’ve heard executive directors explain that their funds need to support clinical interventions, not marketing. It’s understandable to want every dollar to be allocated to the service you are providing. But let’s not let laudable goals stand in the way of demand generation. Even the most perfect program can’t succeed without participants.
2. Representation
A subplot of Painkiller was the rise of a salesperson Shannon Schaeffer, played by West Duchovny. The character steps out of her parent’s trailer and into a Porsche dealership during the span of the six-part series. Recruited for her appearance and coached by a more seasoned salesperson, she flirts with middle-aged male doctors while bringing the standard gifts of lunch, branded merchandise and coupons. Depicted in tall heels and short skirts, one doctor refers to her as a “drug dealer with a ponytail.”
She’s trained to explain that OxyContin is less addictive than other opioids, with an addiction rate of one percent, provided the patient took it no more than twice a day. She was told that the pills’ time-release coating provided 12 hours of pain relief, making two doses per day safe. But the pills’ effects wore off more quickly, increasing cravings, doses and ultimately, addiction. You can read more about this in Slate’s article: “What’s Fact and What’s Fiction in Painkiller.” Overall, a pretty salacious and disturbing path to profits, but let’s mine Purdue’s approach for behavioral science that we might be put to work for the greater good.
Have you ever noticed how few charities and state agencies use spokespeople? I wonder how many simply rely on volunteered talent, or even avoid the use of models altogether.
Fashion brands don’t ask for volunteers to appear in their print advertisements and television commercials; they rely on the most expensive models in the world, investing in stylists and photography to make their products look as desirable as possible.
Are these brands just trying to make the rest of us feel bad about our own looks? While that may be the outcome for some consumers, the intent is for each of us to feel that we can project a bit of runway moxie if we wear the cologne or buy the shoes. But there’s more to it than that. It’s grounded in the System 1/System 2 aspect of behavioral science. System 1 is responsible for the brain’s instinctive and intuitive conclusions — the things we do without thinking, like tying your shoes. System 2 is responsible for more careful and considered reasoning, like weighing the pros and cons of an important decision.
Humans evolved by using System 1 to perform continuous assessments to inform survival. Does the saber-toothed tiger approaching me pose a threat? Should I trust this person I’ve just met? Daniel Kahneman refers to this calculation as a basic assessment in his book, Thinking Fast and Slow. And over millennia, we’ve become very good at it.
So good, that without even realizing it, we draw instant conclusions that impact what we believe, who we trust and how we behave. There’s a cool test here where you can experience how much facial recognition can occur in 50 to 100 milliseconds. While at Princeton University, Professor Alex Todorov conducted an experiment testing the likeability and competence of politicians. Todorov’s students were asked to rate pairs of candidates’ campaign portraits after just one-tenth of a second’s exposure. The students had no political context or familiarity with the candidates. Seventy percent of the candidates who were ranked highest won their elections. This experiment has been confirmed in subsequent studies in Finland, England, Australia and Germany. Kahneman calls this a judgement heuristic.
The attractive sales reps in Painkiller leverage the judgment heuristic. We are biologically programed to find those with favorable physical attributes more likeable and trustworthy. In Purdue’s case, if you’re telling lies, it’s best to be good looking.
Some public education campaigns use celebrities to encourage behavioral change. While well-intentioned, this doesn’t always work because celebrities aren’t relatable and empathic. You can read more on this in my previous post.
Most agencies and nonprofits don’t consider the science of what compels consumers to act. I’m not saying you should be exploitative or contribute to stereotypes you may be working to change. I am just encouraging you to consider your messenger more carefully. Messages about help for unhoused people don’t need to depict them pushing old grocery carts. While such an image may instantly telegraph “homeless,” it’s not an accurate representation of the unhoused. Further, it’s less relatable to supporters and donors. The same logic can be applied to a person dealing with substance misuse disorder. They’re just as likely to be in the corner office as on the street corner. So don’t fall back on tropes. Associate your cause with relatable and trustworthy messengers.
3. Pricing
I mentioned that OxyContin falsely claimed its time-release coating offered patients 12-hour dosing. What’s worse is that Purdue used the false 12-hour release coating to justify a higher price point than other opioids that required more frequent doses. The scientific maneuver at work here is called the anchoring effect.
The average price for a new car in 2023 is $48,008. In relaying that to you, I’ve just established an anchor for the price of a car. If I told you I found a new car for $25,000, you’d probably think that I bought an economy car. If I paid $55,000 for a sedan, you might think that I bought a premium brand. Anchors are in play all the time. When we’re frustrated by the grocery bill going up, the higher cost is exceeding our anchor.
The anchoring effect can be used to establish value. Dan Ariely’s book Predictably Irrational explains how Starbucks broke Americans’ anchor attached to the price of a cup of coffee. When a product exceeds our anchor price, the perception is that it is not only different, but also better.
Ariely led an experiment at MIT that showed the influence price had on the perceived effectiveness of a fictitious painkiller called Veladone. One set of subjects was told the cost for a single pill was $2.50, while a second set was told the price of the pill had been reduced to 10 cents. A technician asked both groups a series of questions about their medical history, took their blood pressure and listened to their heartbeat with a stethoscope. The tech administered a series of electric shocks before and after participants took a dose of Veladone. Almost everyone in the $2.50 group reported pain relief after taking the pill. Meanwhile, only half of the group that received the dose priced at 10 cents reported less pain from the shocks after taking Veladone. And for both groups, Veladone was actually a tablet of vitamin C.
OxyContin introduced a new anchor for opioids by charging a premium. That combination made the medical community believe that OxyContin was better than competing drugs and contributed to a false dialogue with doctors and insurers. But the anchoring effect doesn’t have to be used seditiously. You can use it to provide context to the cost of your intervention, or better yet, the cost of not intervening. For those of you leading nonprofits that need to raise money, anchors can be used to increase donations.
Kahneman asked a group of environmentalists about their willingness to save 50,000 offshore Pacific Coast seabirds from small oil spills. When asked an anchoring question: “Would you be willing to contribute $5?” the average donation was $64. When given an anchor of $400, their average contribution rose to $143. I’ve seen this first-hand. One of our clients achieved a significant uptick when they anchored their lowest annual giving tier to the cost of a single intervention. Something to consider when you think about your next fundraising campaign.
4. Community
Scenes in Painkiller show conferences with rapt crowds of providers chanting “Oxy…Contin.” While the fervor of the crowd in the series is theater, the American Journal of Public Health reports that “from 1996 to 2001, Purdue conducted more than 40 national pain-management and speaker-training conferences at resorts in Florida, Arizona and California. More than 5,000 physicians, pharmacists and nurses attended these all-expenses-paid symposia, where they were recruited and trained for Purdue's national speakers bureau.”
There’s clearly power in gathering, and Purdue used this to create a new social norm. We conform to the expectations and behaviors of those around us. Medical education produces conformity by design. In a profession trained for compliance and guided by best practices, practitioners have been shown to follow social norms even to the detriment of patients.
For those of us working to help others, there’s no shortage of conferences to attend. And there’s a certain sacredness around attending them. No one really has time, but go we must. The work will simply have to wait a few days. I believe this predilection is because the work we do is so damned difficult. Conferences give us the fuel we need to keep up the fight. We’ve all felt the energy and momentum that follows a convention. That we’re not in the boat alone is the social norm.
I’m not suggesting you start your own conference, though if some of you have, I applaud your effort. My point is, we all need to consider the power of implied social norms. Mainstream your cause and make addressing it a social norm. Avoid communicating the harm and abide the solution. For example, communicating that HPV vaccines for teenagers is a social norm can be far more effective than communicating the dangers of avoiding the vaccine.
5. Villains
When it was clear to the public that OxyContin was debilitating to patient’s wellbeing, Sackler blamed the victims. He refused to capitulate to public pressure, insisting that those addicted to the drug were the problem. Blame the addict, not the drug. Villainize the victim. For me this was the most sinister play of them all.
While the PR folks at Purdue were running afoul of morality, there is something worth noting — the villain. The best stories, be they books, films or advertisements all have them. Humans find conflict interesting and memorable, and you don’t have to be evil to use this. Think about Allstate’s “Mayhem” commercials. Want to sell Listerine? Create chronic halitosis. Even the ubiquitous “Just Do It” is there to slay excuses not to exercise.
We love to root for protagonists and root against antagonists. In behavioral science terms, it’s called ingroup bias. It’s an instinctive desire to belong, for there to be an “us” and a “them.” At one point in our evolution, ingroup bias was for protection, but it continues to inform how we learn and relate to others. Ever wonder why so many American films have British villains? In the business of behavior change, we’re all fighting something. So go figure out your enemy and put them to work for good.
This post is heavy. It’s taken a few days to write. During that time, I’ve doubted the premise of studying a company that created a death toll. Ultimately, I decided that was the point. To learn from it, spot it in the future and be wiser for it. And those nurses in that long-ago ballroom? They weren’t just cynical. They were also some of the most loyal ambassadors I’ve ever had once their trust was earned. That’s probably why my stance remains optimistic. It’s still a job requirement and the only way we’ll make a difference in the end.
Keep believing in good,
Kevin
