Potential effectiveness of anti-smoking advertisement types in ten low and middle income countries: Do demographics, smoking characteristics and cultural differences matter?

Highlights

• Advertisements graphically portraying the health effects of tobacco use were most accepted and perceived as effective.

• Graphic health effects ads performed best in all population subgroups and were least subject to cultural congruence effects.

• Graphic health effects ads may be most suitable for wide population broadcast in low and middle income countries.

Abstract

Unlike high income countries, there is limited research to guide selection of anti-tobacco mass media campaigns in low and middle income countries, although some work suggests that messages emphasizing serious health harms perform better than other message types. This study aimed to determine whether certain types of anti-smoking advertisements are more likely to be accepted and perceived as effective across smokers in 10 low to middle income countries. 2399 18–34 year old smokers were recruited in Bangladesh, China, Egypt, India, Indonesia, Mexico, Philippines, Russia, Turkey and Vietnam to view and rate 10 anti-tobacco ads. Five ads were shown in all countries and five ads were chosen by country representatives, providing a total of 37 anti-smoking ads across all countries (10 graphic health effects ads, 6 simulated health effects, 8 emotional stories of health effects, 7 other health effects and 6 non-health effects). Smokers rated ads on a series of 5-point scales containing aggregated measures of Message Acceptance and Perceived Effectiveness. All ads and materials were translated into the local language of the testing regions. In multivariate analysis, graphic health effects ads were most likely to be accepted and perceived as effective, followed by simulated health effects ads, health effects stories, other health effects ads, and then non-health effects ads. Interaction analyses indicated that graphic health effects ads were less likely to differ in acceptance or perceived effectiveness across countries, gender, age, education, parental status and amount smoked, and were less likely to be affected by cultural differences between characters and contexts in ads and those within each country. Ads that did not emphasize the health effects of smoking were most prone to inconsistent impact across countries and population subgroups. Graphic ads about the negative health effects of smoking may be most suitable for wide population broadcast in low and middle income countries.

Introduction

Over 80% of the world's adult male smokers now live in low and middle income countries (Eriksen, MacKay, & Ross, 2012). In order to reduce global smoking prevalence as rapidly as possible, it is imperative to fully implement comprehensive evidence-based tobacco control strategies, such as those articulated in the WHO Framework Convention on Tobacco Control (FCTC). Anti-tobacco mass media campaigns increase quitting and reduce smoking prevalence in high-income countries (Durkin et al., 2012, National Cancer Institute, 2008) and are supported by FCTC Article 12 on public education and training (World Health Organization, 2003). Mass media campaigns directly prompt quitting in adult smokers, as well as reduce the broader social acceptability of smoking and build public support for the implementation of other key tobacco control policies (Durkin et al., 2012, Wakefield et al., 2010).

Recent reviews highlight that the effectiveness of anti-tobacco mass media campaigns depends upon the types of messages used and the extent to which campaigns can be funded to consistently reach the majority of the population (Durkin et al., 2012, National Cancer Institute, 2008). Population-based and advertisement (ad) rating studies of different message themes in high income countries indicate that negative health effects messages, most of which feature graphic imagery (visceral pictures of external and internal body parts riddled with smoking related disease), testimonial stories and/or elicit negative emotions, tend to be more effective than other message themes (Durkin et al., 2012, U.SDepartment of Health and Human Services, 2012). There is a small but growing body of evidence of the effectiveness of anti-tobacco mass media campaigns in low and middle income countries (Alday et al., 2010, Murukutla et al., 2011, Perl et al., 2011, Thrasher et al., 2011, Wakefield et al., 2013), although only one study has directly compared the effectiveness of different message types among adult smokers in such countries (Wakefield et al., 2013). That study found two ads containing graphic imagery, and a third showing a disgust-provoking simulation of the serious health effects of smoking, were rated consistently more positively on message acceptance and perceived ad effectiveness than an emotional story about the health effects of smoking and a simulation of the effects of emphysema, across 10 low and middle income countries (Wakefield et al., 2013). A limitation of the study was that all ads featured the negative health effects of smoking and there were only one or two representations of the different ad types. The current study aims to more fully explore the effects of different types of anti-tobacco ads, using a total of 37 ads in the same 10 countries.

As smoking prevalence differs across different demographic groups – for example by age, gender or socio-economic status (Eriksen et al., 2012) – it is often assumed that particular campaigns should be specifically designed for the highest prevalence subgroups. However, developing and producing many different ads for different subgroups requires substantial resources and erodes the amount of funding available to widely broadcast ads and reach the majority of smokers (Durkin et al., 2012, U.SDepartment of Health and Human Services, 2012). Campaigns specifically targeted to subgroups risk stigmatizing the targeted group by implicitly communicating to the public that this group is in particular need of the message (Hornik & Ramirez, 2006). Creating targeted messages for many different groups may also inadvertently reduce the potential for campaigns to support broader societal norm and policy change, due to public perceptions that the messages are of relevance only to specific subgroups (Hornik & Ramirez, 2006). Also, targeted campaigns may not perform better for a particular demographic subgroup than ‘common denominator’ ads that are relevant to a broad range of smokers (Durkin et al., 2012, Hornik and Ramirez, 2006, National Cancer Institute, 2008, U.SDepartment of Health and Human Services, 2012). Therefore, it has been suggested that if ‘common denominator’ messages are found to be equally effective across different demographic groups, a segmented strategy is unnecessary and not worth the potential risks as well as extra costs (Hornik & Ramirez, 2006).

Previous research in high income countries has found few differences between the response of different demographic groups to anti-smoking mass media campaigns among adolescents (National Cancer Institute, 2008, U.SDepartment of Health and Human Services, 2012) and adults (Bala et al., 2008, Durkin et al., 2012). A review of campaign effects in adolescents (National Cancer Institute, 2008) concluded that ad characteristics are more important than demographic characteristics in determining ad effectiveness, and that ads that perform well do so among many population groups. Consistent with this, in adults, negative health effects ads that have been found to be most effective across a broad range of smokers have also been found to be equally effective across different age groups and genders (Durkin et al., 2012). There is also emerging evidence these health effects ads are at least equally, if not more effective among lower income and lower educated smokers (Durkin et al., 2009, Durkin et al., 2011, Niederdeppe et al., 2011). Decisions about segmentation of campaign messages are particularly important for the development of campaigns in low and middle income countries, where funding is limited. Therefore this study aimed to examine whether certain types of negative health effects and non-health effects anti-smoking ads are more likely to be accepted and perceived as effective across a broad cross-section of smokers from low and middle income countries, or whether there are no ‘common denominator’ messages and only specific types of ads are effective for specific demographic subgroups.

It has been suggested that an efficient way of using funds available for anti-smoking campaigns in low and middle income countries is to adapt and/or recycle messages already used successfully in other jurisdictions to reduce costs associated with new campaign development (Cotter et al., 2010). However, it is possible that the success of some of these ads may be reduced within different countries due certain ads being culturally different (Wakefield et al., 2013). Communication theories indicate personal relevance or self-referencing where viewers relate events in the message back to their own life and behaviour (Burnkrant and Unnava, 1989, Burnkrant and Unnava, 1995) are important in determining message persuasiveness (Dunlop et al., 2008, Dunlop et al., 2010, Epstein, 2003, Green, 2008, Petty et al., 2005). Messages may have lower personal relevance and elicit less self-referencing among viewers if they include people and actors from cultures obviously different from their own. If smokers see people like themselves in the ad or if the story is more recognizable, messages may be more likely to be accepted and perceived as effective. Our study also aimed to examine whether cultural differences between the characters and contexts in the ad and the country in which it was tested affected the perceived impact of different types of anti-tobacco ads, and whether this differed by demographic and smoker subgroups.

Interest in quitting, quitting history and addiction level have also been found in some studies to influence responses to anti-tobacco mass media campaign messages. Those who have greater motivation to quit smoking and have made previous attempts to quit are more likely to perceive anti-smoking ads to be relevant and effective (Davis et al., 2011, Durkin and Wakefield, 2008, Niederdeppe et al., 2011, Veer et al., 2008), while those who smoke more or are more addicted tend to be less likely to report positive responses to anti-smoking messages (Davis et al., 2011, Strasser et al., 2009). Other studies have found more behaviourally-based responses to health effects anti-tobacco campaigns (i.e. quit attempts) to be more equally generated by sustained media campaign exposure irrespective of baseline interest in quitting (Borland and Balmford, 2003, Wakefield et al., 2011). The current study also aimed to examine if smokers in low and middle income countries who are more motivated to quit or who have previously tried to quit respond more positively, and heavier smokers less positively, to anti-smoking messages, and whether this differs depending on the type of message.