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Smokers' responses to television advertisements about the serious harms of tobacco use: pre-testing results from 10 low- to middle-income countries
  1. Melanie Wakefield1,
  2. Megan Bayly1,
  3. Sarah Durkin1,
  4. Trish Cotter2,
  5. Sandra Mullin3,
  6. Charles Warne1,
  7. for the International Anti-Tobacco Advertisement Rating Study Team*
  1. 1Centre for Behavioural Research in Cancer, Cancer Council, Victoria, Australia
  2. 2Cancer Institute New South Wales, Sydney, Australia
  3. 3World Lung Foundation, New York, New York, USA
  1. Correspondence to Professor Melanie Wakefield, Director, Centre for Behavioural Research in Cancer, Cancer Council Victoria, 1 Rathdowne Street, Carlton VIC 3053, Australia; melanie.wakefield{at}


Background While television advertisements (ads) that communicate the serious harms of smoking are effective in prompting quitting-related thoughts and actions, little research has been conducted among smokers in low- to middle-income countries to guide public education efforts.

Method 2399 smokers aged 18–34 years in 10 low- to middle-income countries (Bangladesh, China, Egypt, India, Indonesia, Mexico, Philippines, Russia, Turkey and Vietnam) viewed and individually rated the same five anti-smoking ads on a standard questionnaire and then engaged in a structured group discussion about each ad. Multivariate logistic regression analysis, with robust SEs to account for the same individual rating multiple ads, was performed to compare outcomes (message acceptance, perceived personalised effectiveness, feel uncomfortable, likelihood of discussing the ad) across ads and countries, adjusting for covariates. Ads by country interactions were examined to assess consistency of ratings across countries.

Results Three ads with graphic imagery performed consistently highly across all countries. Two of these ads showed diseased human tissue or body parts, and a third used a disgust-provoking metaphor to demonstrate tar accumulation in smokers' lungs. A personal testimonial ad performed more variably, as many smokers did not appreciate that the featured woman's lung cancer was due to smoking or that her altered physical appearance was due to chemotherapy. An ad using a visual metaphor for lung disease was also more variable, mostly due to lack of understanding of the term ‘emphysema’.

Conclusion Television ads that graphically communicate the serious harms of tobacco use are likely to be effective with smokers in low- to middle-income countries and can be readily translated and adapted for local use. Ads with complex medical terms or metaphors, or those that feature personal testimonials, are more variable and at least require more careful pre-testing and adaptation to maximise their potential.

  • Tobacco
  • health education
  • advertising
  • television
  • adults
  • advertising and promotion
  • environmental tobacco smoke
  • media
  • packaging and labelling
  • social marketing
  • prevalence
  • tobacco industry
  • qualitative study
  • marginalised populations
  • industry public relations/media
  • industry documents

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  • * The International Anti-Tobacco Advertisement Rating Study Team comprises: Cancer Council Victoria: Melanie Wakefield, Megan Bayly, Sarah Durkin, Charles Warne; Cancer Institute New South Wales: Trish Cotter; World Lung Foundation: Bangladesh: Sandra Mullin, Tahir Turk; China: Yvette Chang, Winnie Chen; Egypt: Mohamed Elghamrawy, Stephen Hamill; India: Shefali Gupta, Sandra Mullin, Tahir Turk; Indonesia: Yvette Chang; Mexico: Jorge Alday, Claudia Cedillo; Philippines: Jorge Alday; Russia: Irina Morozova, Rebecca Perl; Turkey: Stephen Hamill, Mego Lien; Vietnam: Tom Carroll, Mego Lien.

  • Funding This study was funded by the World Lung Foundation as part of the Bloomberg Global Tobacco Initiative.

  • Competing interests None.

  • Ethics approval Cancer Council Victoria Internal Research Review Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.