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Research papers
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}cancervic.org.au

Abstract

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

https://doi.org/10.1136/tobaccocontrol-2011-050171

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    Introduction

    Comprehensive reviews of controlled field experiments and population studies demonstrate that mass media campaigns can promote smoking cessation in adults.1–3 Population studies have documented reductions in adult smoking prevalence when mass media campaigns are combined with other strategies in tobacco control programmes.1 ,2 ,4 ,5 Population-based5–11 and forced exposure studies1 ,12 that compare message styles point to (or attest to) the superiority of messages that give strong reasons to quit, through the use of emotional engagement to elicit disgust, fear or sadness through graphic imagery, simulation and/or personal testimonial executional styles. One previous forced exposure study demonstrated that youth in three countries rated the same 10 anti-smoking ads similarly, suggesting the potential for more sharing of ads across countries.13 Most evidence has been generated from high-income countries. A challenge is to ensure the application and resourcing of effective media campaigns in low- to middle-income countries, consistent with the objectives of Article 12 of the WHO Framework on Tobacco Control.14

    The cost, lead time and expertise involved in producing new media campaigns in countries with limited resources can present considerable barriers.15 One way to reduce these barriers is to translate and adapt advertising material produced elsewhere, thereby saving on production costs and time and concentrating resources for actual campaign broadcast.13 ,15 Ads with good potential may include those without people (eg, featuring only body parts or using a simulation) or those where people do not speak directly to the camera, so a voiceover can be recorded.15 Even ads featuring people, where licensing and talent fees might apply, may also be adapted by re-shooting the ad with local actors. Existing ads still need local pre-testing.

    Mindful of the evidence about ad characteristics that perform well,1 we selected five ads from a clearinghouse of anti-tobacco ads (http://www.worldlungfoundation.org/mmr), which had high potential to be efficiently adapted for use elsewhere and had evaluated positively in their countries of origin.16–20 The aim of this study is to assess the comprehension, acceptability and potential effectiveness of these five television ads in communicating an anti-smoking message and motivating cessation among adults in low- and middle-income countries. The study also presents a method for pre-testing multiple anti-smoking ads to assist decision making about specific ad selection within countries, as well as the more general features of ads that may perform well within countries.

    Method

    Design

    We employed a mixed quantitative and qualitative method whereby smokers in 10 countries individually rated and then discussed in a group, a set of 10 anti-smoking television ads. This paper focuses on the five specific ads that were shown and rated in all countries. The remaining five ads differed in each country and are excluded from analysis.

    Participants

    Participants were recruited from 10 low- to middle-income countries that have high smoking prevalence. In each country, approximately 240 adult smokers (24 groups of 8–12 smokers) were recruited using convenience sampling by a local market research agency through face-to-face or telephone interviewing. The recruitment strategies used were appropriate for each country. Groups were split by age, gender, location and order of ad presentation (table 1), with more male groups to reflect higher male smoking prevalence.

    View this table:
    Table 1

    Sampling structure used in each country

    Eligible participants were daily cigarette smokers (including female bidi smokers in India) aged 18–34 years, who could read and write in their own language and who did not work in health promotion, market research, advertising or the tobacco industry. Smokers of at least 5 cigarettes/day were targeted in recruitment. To minimise potential dominance by highly educated participants in group discussions, we set an upper limit of two university-educated participants per group. While adherence to these two latter criteria was generally strong, a higher proportion of university-educated participants were recruited in Bangladesh, Egypt, India and Mexico. Also, >20% of participants in Bangladesh, India, Mexico and Vietnam smoked 5 or fewer cigarettes per day. In Bangladesh, only male smokers were recruited, since it was impractical to recruit sufficient numbers of female smokers.

    Anti-smoking advertisements

    The ads were all 30 s in duration with original English text and speech. The ad scripts were translated by country-based research agencies into the local language (or languages in India) and then back translated into English and reviewed. We repeated this process until an accurate and appropriate translation was achieved. The original content of ad scripts was closely preserved, allowing for some variation to maximise cultural acceptability and comprehension. Ads were then dubbed into the local language and end-frames removed or replaced with a local equivalent. The five ads are described in table 2 and appendix 1 and can be viewed at http://www.worldlungfoundation.org/mmr.

    View this table:
    Table 2

    Descriptions of television ads shown to smokers in all countries

    Participant questionnaire

    The questionnaire first sought demographic information regarding gender, age, parental status, level of educational attainment, daily cigarette consumption, intention to quit in the next 12 months, previous quit attempts and residential location. The advertising rating component comprised 10 questions repeated for each ad, incorporating items from previous ad-rating studies.1 ,12 ,13 ,21–23 These questions measured the extent to which participants felt each ad was ‘easy to understand’, ‘believable’, ‘relevant’ and ‘effective’; whether the ad taught them ‘something new’, and made them ‘stop and think’, feel ‘uncomfortable’, ‘concerned about their smoking’ and ‘motivated to try to quit smoking’; and whether they would be ‘likely to talk to someone else’ about the ad. Each item was measured on a 5-point Likert scale, where 1 represented ‘strongly disagree’, 2 ‘slightly disagree’, 3 ‘neither agree nor disagree’, 4 ‘slightly agree’ and 5 ‘strongly agree’.

    An iterative process of translation and back translation of the ad rating materials was undertaken, ensuring the rating items were meaningfully translated into the local language(s), while accurately representing the original questionnaire to facilitate cross-country consistency.

    Procedure

    Data collection occurred between September 2008 and September 2010. Participants first completed the demographic items. They were then shown and rated a practice ad of an unrelated local product to ensure that they could see and hear the television. Next, participants were shown the first anti-smoking advertisement twice, after which they completed the ad rating questions. This process was repeated for the remaining nine ads. Participants were instructed not to talk to each other when watching and rating the ads. The five ads that were consistent across all countries were alternated with the five country-choice ads. To counterbalance any potential effects of ad viewing order, half the groups viewed the ads in the reverse order.

    After all ads were viewed and rated, the group moderator led a structured discussion, where each ad was replayed and discussed in turn. Discussion focused on message comprehension, acceptability (relevance, credibility) and cultural appropriateness (transgression of social mores). On average, each session lasted 2 h, after which, participants received an incentive of appropriate value for that country.

    Data analysis

    To reduce the 10 ad-rating items to a parsimonious set of outcomes, principal components analysis with oblique rotation was performed with SPSS 18.0 using data from all countries. To include the ad-rating data for all ads without repeating the principal components analysis for each different ad, individuals' scores on each ad-rating item were averaged across the 10 ads. The principal components analysis yielded two composite scales and two stand-alone items. This solution accounted for 82.3% of the variance in ad-rating responses, and no item loaded >0.40 on more than one component. The first scale, labelled Message Acceptance (Cronbach's α=0.80), comprised two items: Understand and Believable. The second scale labelled Personalised Perceived Effectiveness (PP-Effectiveness; Cronbach's α=0.94) comprised six items: Taught me something new; Stop and think; Relevant; Concerned about my smoking; Makes me more likely to try to quit and Effective. Two individual items were Uncomfortable and Likely to talk about (Discuss), which did not load on any component.

    Scores on the two scales and two individual items were binary coded to allow for logistic regression analyses using Stata/SE 11.1. For the two individual items, ratings of slightly/strongly agree were coded as positive responses towards the ad, while ratings of slightly/strongly disagree and neither agree nor disagree were coded as negative/neutral responses. The two multiple-item constructs were dichotomised by using the average of responses of the scale items, with averages >3.5 were classified as a positive response.

    Multivariate logistic regression analyses were performed for each of the four outcome measures, including all 10 countries and the five country-consistent ads. We used robust SEs to control for individuals each having rated multiple ads24 and adjusted for ad order (A or B), gender, age (18–24 years or 25–34 years), parental status (yes or no), education level (completed a university degree or lower than a university degree), average daily cigarette consumption (1–15 or 16 or more/day), thinking about quitting smoking in the next year (yes or no), having made a previous quit attempt (yes or no) and location (large urban city or regional city). Two-way interaction models were used to assess whether responses to each ad were consistent between countries. From these covariate-adjusted interaction models, average predicted probabilities of positive ad ratings on the four outcomes were calculated for each ad.

    The local research agency reviewed recordings of the group discussions and analysed the key themes. A summary report was then prepared in English, including translated verbatim quotes.

    Results

    Smoker characteristics

    Complete data were obtained from 2399 participants, ranging from 192 in Bangladesh to 280 in the Philippines (table 3). Half the sample in each country was aged 18–24 years and half was 25–34 years. Two-thirds were men in all countries except Bangladesh. In all countries, the majority smoked 1–15 cigarettes/day and were not parents. Across countries, most had made a previous quit attempt, while one- to two-thirds were thinking about quitting in the next 12 months. Highest education level varied, although in all countries a smaller proportion of participants had completed a university degree than not.

    View this table:
    Table 3

    Demographic characteristics of participants

    Ad ratings

    For all countries combined, Alive and Artery evidenced the highest odds of a positive rating across all four measures (table 4), with Alive the highest for Message Acceptance and Uncomfortable and Artery the highest for PP-Effectiveness and Discuss. Sponge showed the third highest odds across all measures, followed by Bubblewrap. Zita was least likely to achieve positive ratings across all measures.

    View this table:
    Table 4

    Multivariate logistic regression analyses of positive ad ratings by country and ad for Message Acceptance, Personalised Perceived Effectiveness, Uncomfortable and Discuss

    Across all ads and outcome measures, participants from India, Mexico and the Philippines had higher odds of positive ad ratings relative to the other countries (table 4). Conversely, those from Russia, Bangladesh and Indonesia tended to show lower odds of positive ad ratings than other countries. Participants from China, Egypt, Turkey and Vietnam showed more moderate ratings overall. All ads showed low ratings on Uncomfortable in Vietnam (figure 1C), relative to other Vietnamese ad ratings.

    Figure 1
    Figure 1

    (A–D) Predicted probabilities of positive ad ratings by country and ad for all outcomes.

    There were some systematic differences in outcomes by smoker subgroup. Men were significantly less likely than women to give positive ratings to the ads for all outcome measures. Those who had completed a university qualification were significantly less likely than those who had not to give positive ad ratings on PP-Effectiveness, Uncomfortable and Discuss. Participants from large urban cities were significantly more likely than those from smaller urban cities to give positive ad ratings for PP-Effectiveness, Uncomfortable and Discuss. Participants who were thinking about quitting in the next year were significantly more likely than those who were not to give positive ad ratings on all four measures, while those who had previously tried to quit were significantly more likely than those who had not to give positive ad ratings on PP-Effectiveness and Uncomfortable.

    Other smoker characteristics were less systematically related to outcomes. Heavier smokers were significantly less likely than lighter smokers to give positive ad ratings on Uncomfortable, while younger smokers were less likely than older smokers to report that they would Discuss an ad. There were no associations of parental status or ad order for any measure.

    Ad and country interactions

    Significant interactions between ad (five categories, Zita as the reference) and country (10 categories, Russia as the reference) were found for all four outcome measures (all p<0.001). Examination of plots of the average predicted probabilities of positive ad ratings for each country (figure 1A–D) indicated that Zita and Bubblewrap have differential ratings for each outcome across countries, while similar ratings across countries were apparent for the other three ads. Post hoc analyses were performed to examine this further. First, a new three-level ad variable was created with the values ‘Alive, Artery and Sponge (AAS) combined’, Zita and Bubblewrap. Two-way interaction models of this three-level ad variable (with AAS as the reference category) and country showed significant interactions for all four outcomes (all p<0.001). To explore the effect of ad within each country, logistic regressions with robust SEs were performed for each country on each outcome measure using the three-level ad variable, adjusting for previous covariates.

    Zita showed significantly lower ratings than AAS for all countries except India, Mexico, the Philippines and Turkey on Message Acceptance; significantly lower ratings than AAS for all countries except India, Mexico and the Philippines on PP-Effectiveness and Uncomfortable and significantly lower ratings than AAS for all countries except Mexico and the Philippines for Discuss. Bubblewrap showed significantly lower ratings than AAS for all countries except China, Egypt, India and Mexico on Message Acceptance; significantly lower ratings than AAS for all countries except China, India and the Philippines for PP-Effectiveness; significantly lower ratings than AAS for all countries except India and the Philippines for Uncomfortable and significantly lower ratings than AAS for all countries except Bangladesh, India and Vietnam on Discuss. Thus, for the ads Zita and Bubblewrap, there was variability in ad ratings both across and within countries, whereas ratings for AAS were more uniform across countries.

    Key qualitative findings

    Consistent themes from the structured qualitative discussion are summarised below, providing further depth and context to the overall quantitative ratings and indicating where more careful adaptation of an ad may be required in specific countries.

    Qualitative reactions to AAS were consistent with the quantitative ratings, with smokers in most but not every country considering these ads to communicate new and believable health information.

    “It tells the harm to lots of organs. These are all the most important ones in our body. I feel shocked.” (Alive, Male, 18–24 years, China)

    “I have smoked for years, but I have never thought that my lung could become as bad as described in the ad.” (Sponge, Female, 18–24 years, Turkey)

    The graphic imagery had a strong emotional impact on participants, with common reactions of disgust, fear and shock. The portrayals of external visible damage as a result of smoking, and serious damage to internal organs, were considered powerful and motivating.

    “Seeing this ad made me scared, made me think of quitting.” (Alive, Male, 18–24 years, Indonesia)

    “When they show real organs, it's more impressive. It's horrible.” (Artery, Female, 25–34 years, Russia)

    The qualitative discussions clarified why there was variability in ad ratings for Zita and Bubblewrap. In Vietnam, Egypt, Russia, China, Philippines and Mexico, many participants found Zita hard to comprehend, not always understanding the relationship between Zita's lung cancer and smoking, or that her altered physical appearance (ie, hair loss) was due to chemotherapy.

    “This ad is hard to understand because it does not clearly show the effect of the cigarette.” (Male, 18–24 years, Vietnam)

    “It is unclear how is her disease related to smoking. It's more like radiation.” (Male, 25–34 years, Russia)

    “Smoking could not cause all this.” (Female, 25–34 years, Egypt)

    In China, Indonesia, Mexico and Turkey, the testimonial style of Zita had a stronger impact, even though some still found this ad hard to comprehend. “Not bad, because this is a true story. But what caused the illness?” (Female, 18–24 years, Indonesia).

    Finally, some participants in Bangladesh, India, Indonesia, Russia, China, Mexico, Philippines and Turkey reported that Zita was targeted at women or those with children. “This is intended for women and mothers only.” (Male, 18–24 years, Indonesia). “This is really done for women.” (Female, 18–24 years, Russia). In Vietnam, it appeared that women responded particularly positively to the underlying message of this ad. However, some participants in Vietnam and Egypt also noted that the ad would have had more impact and relevance if a person of a similar background was used. “It is not so convincing because she is a woman. I hope they used a male character instead to make it more believable.” (Male, 25–34 years, Philippines). “We don't have children, so the thing is not relevant to me.” (Female, 18–24 years, China).

    For Bubblewrap, the use of the unfamiliar word ‘emphysema’ presented comprehension problems in most countries. “I knew that smoking caused cancer, but I hear emphysema for the first time.” (Male, 18–24 years, Turkey). “I couldn't understand what the harm of the emphysema is. It's too professional for the mass people.” (Female, 25–34 years, China). Furthermore, the visual metaphor in this ad—plastic bubblewrap used to represent human lungs—was complex and did not provide clarification of the verbal information. “The words should explain more about the holes.” (Female, 25–34 years, Indonesia).

    In the Philippines and Mexico, the visual metaphor did not present comprehension difficulties but was not widely accepted. “The plastic is an illustration…but it's not believable because it uses bubblewrap—that's just plastic.” (Male, 18–24 years, Philippines). There was also a tendency for participants in Russia and Indonesia to similarly reject this more complex visual metaphor. “My lungs are not of plastic.” (Female, 18–24 years, Russia).

    Discussion

    This study found consistently high ratings across countries of three television ads (AAS) featuring graphic images of the serious health harms of smoking, as assessed by measures of message acceptance and personalised perceived effectiveness. These three ads also elicited consistently high levels of discomfort among this sample of young adult smokers in different countries, suggesting that they produced a consistent negative emotional response, which was confirmed by the qualitative discussions. By comparison, response to an ad that employed visual simulation that was not disgust provoking to illustrate smoking-related emphysema (Bubblewrap) was more variable across countries due in part to lack of familiarity with this medical term and use of the complex metaphor of plastic bubblewrap to represent lung air sacs. Finally, an ad that used a personal testimonial from a female smoker with lung cancer (Zita) also had more variable response, scoring highly in Mexico, the Philippines and India but lower in Bangladesh, Russia and Indonesia. In some of these countries and those where Zita scored more moderately, qualitative feedback indicated that the lack of explicit references to smoking impeded comprehension and also that it was perceived as a message mainly for parents or women. Both the non-visceral simulation ad and the personal testimonial ad elicited less discomfort in countries where they had scored lower on Message Acceptance and PP-Effectiveness.

    This pattern of findings suggests that the use of graphic imagery in ads to communicate serious harms of smoking and provide reasons to quit may have universally high understanding and engagement. These ads often employ imagery that viewers can relate to no matter where they live, since internal body parts look the same in every country. Disgust is a universal response,25 ,26 and fear can be a strong motivator for behaviour change, if used correctly.27–30 Findings from recent anti-smoking mass media reviews also indicate that these types of ads perform well across a range of demographic and socioeconomic population groups.1 ,31 These ads are also readily able to be adapted for broadcast in different countries because most do not feature actors.15

    Our results indicate that the adaptation of ads highlighting more complex medical concepts requires adequate explanation of unfamiliar terminology and conditions and underlines the need for pre-testing. Personal testimonial executions, while performing well as a general class of ads in other studies,1 ,5 ,11 may be more subject to cultural mores because they rely exclusively on the specific individual featured in the ad. For example, it may be that in countries where messages from women or mothers are perceived as not applying to men, a testimonial featuring a man would have been more appropriate. Finally, it should be noted that Zita was one of a series of three ads that were originally designed to be broadcast as a set, so the viewing of this single ad may have limited the potential of this particular concept.

    There were few systematic differences in ratings by age group, parental status or amount smoked. Smokers who had previously tried to quit and those who were thinking about quitting were generally more likely to give higher ratings and this is to be expected. Overall, female smokers were more likely to respond positively to the ads than male smokers. Participants with lower educational attainment gave higher ratings than people with higher educational attainment. This is a positive finding since it indicates that messages did well even among those less educated, suggesting that these messages do not require high levels of health literacy to be effective. Finally, although there was little difference in message acceptance between smokers from larger and smaller cities, those from larger cities had significantly higher ratings on PP-Effectiveness and other outcomes. This may reflect greater readiness, ability or access to resources to convert important messages into actions and is worth more exploration.

    Our study was limited because we tested only five ads across all countries. Other examples of these types of ads may have produced different responses. Also, the ads were by no means complete adaptations. It is likely that ratings would have been higher on a finished ad, but we wanted to determine which ads had the greatest potential for adaptation, so that resources could later be allocated to adapting those that had rated well.

    We used a standard protocol, but in some instances, variations were necessary. For example, in some countries, female smokers were difficult to find. Due to concerns about tobacco marketing targeting women, it was important to include women and we nonetheless achieved around one-third of the sample as women. We used convenience sampling, so our groups may have not been representative of all smokers in each country.

    It is possible that the translation of some questionnaire measures was inexact. In Vietnam, the item ‘Uncomfortable’ may have been a particular example since ratings were extremely low across all ads compared with other ratings made by Vietnamese smokers. To minimise comprehension errors, we carefully translated and back translated the study protocol, ad scripts and questionnaires in every country. We also conducted a pilot study of two groups in each country to ensure participants could follow the procedure. We worked closely with local research agencies and communication advisors to adapt the protocol to ensure its application to each population. This resulted in slight variations in some countries in the gender split of participants and the composition of groups by educational attainment.

    While there may be more subtle differences in ad ratings by smoker subgroups within each country or within global regions, we found that the three graphic ads tested were highly acceptable, understandable and likely to be effective in the multiple countries tested. One other ad using a simulation had the potential for improvement by taking qualitative feedback into account. Overall, there was a high degree of resonance with the graphic visceral advertisements across the many cultures involved for men and women and different socioeconomic groups. This may reflect use of universally evocative images that demonstrate the health consequences of smoking in a direct way that is difficult to deny or discount. Our study suggests that low- and middle-income countries concerned with efficiently producing and broadcasting anti-tobacco media campaigns would benefit from selecting graphic ads showing the health harms for local pre-testing, translation and adaptation. Further population-based representative research is needed to determine the effects on smoking attitudes and behaviours of broadcasting of such media campaigns on smokers in these countries.

    What this paper adds

    • Few studies have assessed responses of smokers to anti-smoking mass television advertisements (ads) in low- and middle-income countries.

    • This study found that television ads made in high-income countries that graphically communicate the serious harms of tobacco use, with only minor adaptation, are likely to be effective with smokers in low- to middle-income countries.

    • 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.

    Acknowledgments

    We thank the government officials and other partners based in these countries who contributed to the data collection effort.

    Appendix 1 Ad descriptions

    All ads can be viewed at http://www.worldlungfoundation.org/mmr.

    Cigarettes Are Eating You Alive (Alive; New York City Department of Health; 30 s)

    The ad opens with an x-ray image of lungs shown over the silhouette of a man puffing on a cigarette, while a voiceover states, “Every time you smoke, cigarettes are eating you alive. Smoking eats away at nearly every vital organ and tissue of the body.” A close-up image of discoloured and damaged lung tissue is shown, followed by a rotating x-ray image of a torso. Graphic images of organs and disease are shown in rapid succession, while a voiceover names each of these: a palpitating heart, a healthy lung turning discoloured and diseased, a cancerous mouth, discoloured teeth, a throat tumour and images of a brain scan that has suffered a stroke. The images are repeated, and the voiceover states, “Cigarettes are eating you alive. Quit smoking today.”

    Artery (Australian National Tobacco Campaign; 30 s)

    Artery opens with a man lighting a cigarette on a gas stove. As he inhales, the camera follows the smoke through his trachea, and a voiceover says, “Every cigarette is doing you damage.” The scene then cuts to a surgeon's gloved hands squeezing fat from a section of aorta, while the voiceover continues: “This is a part of an aorta, the main artery to the heart. Smoking makes artery walls sticky and collect dangerous fatty deposits. This much was found stuck to the aorta of a smoker aged 32.” The camera then reverses out of the man's mouth and he coughs as the voiceover repeats, “Every cigarette is doing you damage.”

    Sponge (Cancer Institute of New South Wales; 30 s)

    Sponge shows an x-ray of lungs superimposed over the silhouette of a man's chest. As the voiceover states, “Lungs are like sponges, designed to suck up air,” two lung-shaped sponges are displayed over the x-ray, moving as if inhaling and exhaling. The voiceover continues, “Some people use their lungs to suck up cigarette smoke,” while the man inhales from a cigarette. The camera then zooms in on one of the sponges as cigarette smoke enters it, causing it to darken and deteriorate. Two hands are then shown holding a blackened sponge, and as a viscous black tar is wrung out of the sponge, the voiceover states, “If you could wring out the cancer-producing tar that goes into the lungs of a pack-a-day smoker every year, this is how much you would get.” The camera lowers to show a beaker almost full of the tar. The voiceover says, “It's enough to make you sick. Very sick.”

    Bubblewrap (Quit Victoria; 30 s)

    Bubblewrap shows a piece of bubblewrap in the shape of lungs and a trachea in front of an x-ray image of a torso. The camera zooms in on the bubblewrap as a hand brings the tip of a lit cigarette to one of the bubbles, causing it to burn and burst. The voiceover states, “Lungs are made up of millions of tiny air sacs. Toxic chemicals in tobacco smoke destroy them. It's called emphysema, and it's irreversible.” The cigarette continues to burn more of the bubbles as the voiceover continues, “Even if you only smoke low tar cigarettes, chances are you already have emphysema in its early stages. Just about every smoker does.” The camera pans out to reveal that almost half of the bubblewrap has burnt away.

    Zita—It Tears Apart a Family (Cancer Council Western Australia; 30 s)

    This ad is one of a three-part series in which a woman, Zita, gives a personal testimony of the impact of her lung cancer. In this ad, Zita describes how her disease affects her and her whole family. She details the moments she is going to miss with her children as a montage of images of her family is shown. Zita concludes, “I want them to know it's a real thing…it's not enough just to see what it does to your lungs, I want them to see how it tears apart a family.” The end frame contains text saying, “Zita Roberts passed away from lung cancer on 16 February 2007, aged 38.”

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    Footnotes

    • ↵* 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.