1. Comparative performance of anti- smoking advertisements in seven low- and middle- income countries using a standard pre-testing protocol

2. Background Two-thirds of the world’s smokers live in 15 low- and middle- income countries The Bloomberg Initiative is supporting the scaling up of tobacco control efforts in these 15 priority countries Refine and optimise tobacco control programs Support advocates’ efforts to educate communities and to enhance tobacco control activities The World Lung Foundation has created a Global Tobacco Control Mass Media Resource for use in LMICs Current project aims to identify those ads from the Mass Media Resource that can be adapted and used in these target countries

3. Objectives Test existing anti-smoking ads in LMICs using a standard pre-testing protocol Assess the comprehension, acceptability and potential effectiveness of these ads Appropriateness and potential for transfer Ads that have tested well in high-income countries should also perform well in LMICs in terms of: Ad message acceptance Positive thoughts about quitting If so, LMICs can adapt existing ads for their own mass media campaigns at a lower cost than creating new ads

4. Sampling Within each country the sample consisted of: 24 groups of daily smokers, 8-12 smokers in each group 2/3 male, 1/3 female 50% in large urban city (usually capital city), 50% in smaller urban city Males, aged 18-24 years, large urban city (8 groups) Females, aged 18-24 years, large urban city (4 groups) Males, aged 18-24 years, smaller urban city (8 groups) Females, aged 18-24 years, smaller urban city (4 groups)

5. Participants Table 1: Participant demographic characteristics (%) ChinaIndiaIndonesiaMexicoPhilippinesRussiaVietnam N 240 226280231269240 Male 67 66 627067 Aged 18-24 years 50 48 Large urban area 50 5250 Smoked 6 or more cigarettes each day 100897285985769 Completed university degree or higher 556391265843

6. Ad Treatment Each ad was translated into the local language(s) Back-translations of ad content to ensure accuracy and appropriateness All voice-overs and speech were dubbed Quitline end-frames were removed or replaced with a local equivalent 10 ads were tested in each country 5 ads were tested in all countries Remaining 5 ads differed in each country

7. Method: Protocol Demographic Questionnaire Practice ad Part 1: Ad Rating First ad viewed twice Completed 10-item rating scale Process repeated for remaining 9 ads Part 2: Group Discussion All 10 ads played through Group discussion of ad acceptability, cultural appropriateness and message comprehension

8. Method: Scales 5-point scale: 1=Strong disagree, 5=Strongly agree 10 rating items were reduced to 5 scales: 1.Message Acceptance: Understand Believable Taught me something new 2.Positive Cognitions: Taught me something new Stop and think Relevant Concerned More likely to try to quit 3.Uncomfortable 4.Effective 5.Likely to talk about

9. Ad types Strong graphic Strong graphic ads used graphic visceral images to depict the negative health effects of smoking Medium health effects Medium health effects ads used visual simulation of negative health consequences without visceral imagery Interpersonal loss Interpersonal loss ads described an individual’s personal experience of loss or grief as a result of smoking Secondhand smoke Secondhand smoke provided an secondhand smoke message in a family or community setting Humorous Humorous ads used an entertaining, humorous approach to provide an anti-smoking message Anti tobacco industry Anti tobacco industry ads depicted an anti tobacco industry message, using images to describe harm and exploitation caused by the tobacco industry around the world

10. Ad types ChinaIndiaIndonesiaMexicoPhilippinesRussiaVietnam Strong graphic 4443556 Interpersonal loss 1424331 Medium health effects 1111121 Secondhand smoke 4-211-2 Humorous -1----- Anti tobacco industry --1---- Table 2: Number ads of each type shown in each country

11. Results 1 – Ad type

12. Smokers mostly rated ads of the same style in a similar way Compare the highest and lowest rated ad, relative to all other ads Ads are highlighted by ad type All results controlled for the following factors within each country: Demographic variables: Age; Gender; Education; Parental status Smoker characteristics: Number of cigarettes smoked daily; Thinking about quitting; Previous quit attempts Testing characteristics: Location with country, Ad order

13. Results 1: Message Acceptance ChinaIndiaIndonesiaMexicoPhilippinesRussiaVietnam HighestAlive Sponge Baby alive Sponge; Baby alive Baby alive AliveAliveBrainAlive LowestDisappearRonaldoParentsTorax Victim wife ParentsZita

14. Results 1 - Positive Cognitions ChinaIndiaIndonesiaMexicoPhilippinesRussiaVietnam HighestArterySpongeSponge Parents Zita Alive Parents; Zita; AliveAliveAliveAlive LowestDisappearRonaldoParentsTorax Victim wife ParentsZita

15. Results 1 – Uncomfortable ChinaIndiaIndonesiaMexicoPhilippinesRussiaVietnam HighestArterySponge Baby alive Alive Baby alive; Alive Ronaldo Alive Ronaldo; Alive ZitaAlive Zita; AliveArteryAlive Lowest Welcome Olympics RonaldoWorseTorax Victim wife Light/Mild Homes modelling

16. Results 1 – Effective ChinaIndiaIndonesiaMexicoPhilippinesRussiaVietnam HighestSpongeAliveAliveZitaAliveAliveAlive LowestZitaRonaldoParentsTorax Victim wife Light/MildZita

17. Results 1 – Likely to talk about ChinaIndiaIndonesiaMexicoPhilippinesRussiaVietnam HighestArtery Baby alive Sponge Alive Sponge; Alive Ronaldo Alive Ronaldo; AliveAliveArtery Baby alive LowestBMHB2RonaldoParentsTorax Victim wife Light/Mild Cancer/ Tumour

18. Results 1 - Summary Strong graphic ads Strong graphic ads showed the strongest performance overall Alive and Artery consistently highest Interpersonal loss ads Interpersonal loss ads were most commonly the lowest rated ads Interpersonal loss ads Medium health effects Mexico: Interpersonal loss ads also often among the highest rated, while Medium health effects (Torax) always lowest Medium health effectssecondhand smoke ads Medium health effects and secondhand smoke ads also frequently among the lowest Variability of responses: Some countries showed little variance (India, Philippines), where even the lowest rated ad showed relatively high ratings. Others showed large variance, where the lowest rated ad was substantially lower than all other ads

19. Results 2 – Ads shown in all countries

20. Ads: Artery From the Australian National Tobacco Campaign (NTC) Graphic visceral imagery Specific health message: smoking causes build up of fatty deposits in arteries Strong graphic

21. Ads: Sponge Cancer Institute of NSW Visual metaphor: sponges as human lungs Visceral imagery of black tar squeezed from lungs Specific health message: smokers inhale large quantities of cancer- causing tar Strong graphic

22. Ads: Bubblewrap Quit Victoria Visual metaphor: plastic bubblewrap as human lungs Depicts damage to lungs due to emphysema Specific health message: emphysema Medium health effects

23. Ads: Cigarettes are eating you alive New York City Graphic visceral imagery Describes diseases that affect many organs of the body Uses repetition of message and imagery Strong graphic

24. Ads: Zita ‘Tears apart a family’ Cancer Council WA Personal testimonial Zita Roberts describes her experience, and the impact of her disease on her family Montage of family photos and videos End-frame tells of Zita’s death from lung cancer, aged 38 Interpersonal loss

25. Analysis – Country consistent ads Comparative analysis of ad performance for those ads shown in all countries: Artery, Sponge, Bubblewrap, Zita and Alive Analysis is performed for groups within each country, not individuals: i.e. China, males, 18-24 years, Beijing, Order A Groups assigned a positive score if more than 80% of participants in that group gave a positive score on that item (i.e. answered strongly or somewhat agreed) Logistic regression analysis controlling for: Demographic characteristics Smoker characteristics Testing characteristics Overall group response tendency Results are presented in ranked order

26. Results 2 - Message Acceptance Table 3. Ranked probabilities for Message Acceptance, by country (1=Highest, 5=Lowest) ChinaIndiaIndonesiaMexicoPhilippinesRussiaVietnam Alive 1111111 Artery Artery 2222222 Sponge 3333333 Bubble- Bubble- wrap wrap 4444444 Zita 5555555

27. Results 2 – Positive Cognitions Table 4. Ranked probabilities for Positive cognitions, by country (1=Highest, 5=Lowest) ChinaIndiaIndonesiaMexicoPhilippinesRussiaVietnam Alive 1111111 Artery Artery 2222222 Sponge 3333333 Bubble- Bubble- wrap wrap 4444444 Zita 5555555

28. Results 2 – Uncomfortable Table 3. Ranked probabilities for Uncomfortable, by country (1=Highest, 5=Lowest) ChinaIndiaIndonesiaMexicoPhilippinesRussia Alive 111311 Artery Artery 222422 Sponge 333533 Zita Zita 444144 Bubble- wrap wrap 555255

29. Results 2 – Effective Table 3. Ranked probabilities for Effective, by country (1=Highest, 5=Lowest) ChinaIndiaIndonesiaMexicoPhilippinesRussiaVietnam Alive 1111111 Sponge 2222222 Artery Artery 3333333 Zita Zita 4444444 Bubble- wrap wrap 5555555

30. Results 2 – Likely to talk about Table 3. Ranked probabilities for Likely to talk about, by country (1=Highest, 5=Lowest) ChinaIndiaIndonesiaMexicoPhilippinesRussiaVietnam Artery 1111111 Alive Alive 2222222 Sponge 3333333 Bubble- Bubble- wrap wrap 4444444 Zita 5555555

31. Qualitative Results - Bubblewrap and Zita Bubble-wrap Bubble-wrap: ‘emphysema’ was unfamiliar “The key point is that I don’t know the emphysema.” (Male, China) “Is emphysema different from cancer?” (Female, Russia) “…it shocks me but I don’t know what kind of illness it is.” (Female, Vietnam) Zita Zita: More explicit detail about her illness “It did not show her smoking; how can we say that she got her sickness from there?” (Male, Philippines) “Maybe it’s not because of smoking, who knows?” (Female, Russia) Zita Zita: Testimonial style had varying impact “Not bad because this is a true story.” (Female, Indonesia) “I can hardly see much message about smoking, but her sad story.” (Female, China) “This ad is difficult to understand, too talkative, no main point.” (Male, Vietnam)

32. Conclusions Definite potential to recycle existing anti-smoking ads for mass media campaigns LMICs Strong visceral ads were successful across all countries Cigarettes are eating you alive and Artery Ads used simulation or visual metaphors were more moderately successful Sponge and Bubblewrap Personal testimonial ads are particularly susceptible to cultural factors Zita

33. Conclusions Current study was only a pre-test: Minimal adaptation of ad script No adaptation of visual content A more thorough adaptation would be required before any of these ads could be aired in these countries Qualitative feedback has provides the necessary information to do this Key improvements for any ad: Remove, or give a better explanation of, complex medical or anatomical terms Make explicit links between smoking and the diseases described in the ads Provide further supportive media for campaigns that introduce new and complex health information

34. Project Outcomes Results are presented to tobacco control and public health representatives in each country Ads that have been/will be, aired: China: Sponge India: Sponge Philippines: Passive smoking home Russia: Sponge; Cigarettes are eating you alive; Cigarettes are eating your baby alive Vietnam: SHS3; Cigarettes are eating you alive; Cigarettes are eating you baby alive

35. Thank You Sandra Mullin SVP, Communications World Lung Foundation smullin@worldlungfoundation.org