Cost-effectiveness of a smokeless tobacco control mass media campaign in India.

BACKGROUND: Tobacco control mass media campaigns are cost-effective in reducing tobacco consumption in high-income countries, but similar evidence from low-income countries is limited. An evaluation of a 2009 smokeless tobacco control mass media campaign in India provided an opportunity to test its cost-effectiveness. METHODS: Campaign evaluation data from a nationally representative household survey of 2898 smokeless tobacco users were compared with campaign costs in a standard cost-effectiveness methodology. Costs and effects of the Surgeon campaign were compared with the status quo to calculate the cost per campaign-attributable benefit, including quit attempts, permanent quits and tobacco-related deaths averted. Sensitivity analyses at varied CIs and tobacco-related mortality risk were conducted. RESULTS: The Surgeon campaign was found to be highly cost-effective. It successfully generated 17 259 148 additional quit attempts, 431 479 permanent quits and 120 814 deaths averted. The cost per benefit was US$0.06 per quit attempt, US$2.6 per permanent quit and US$9.2 per death averted. The campaign continued to be cost-effective in sensitivity analyses. CONCLUSION: This study suggests that tobacco control mass media campaigns can be cost-effective and economically justified in low-income and middle-income countries. It holds significant policy implications, calling for sustained investment in evidence-based mass media campaigns as part of a comprehensive tobacco control strategy.

Raw and real: an innovative communication approach to smokeless tobacco control messaging in low and middle-income countries.

The evidence on the efficacy of tobacco control messages in low and middle-income country (LMIC) settings is limited but growing. Low message salience and disengagement, in the face of tobacco control messages, are possible barriers to self-efficacy and cessation-related behaviours of tobacco users. Although adaptations of existing pretested graphic and emotional appeals have been found to impact on behaviours, more personalised, culturally relevant and compelling appeals may more fully engage message receivers to elicit optimal behavioural responses. The objective of these case studies is to use lessons learnt from high-income country tobacco control communication programmes, and adapt practical approaches to provide cost-effective, culturally nuanced, graphic and personalised messages from tobacco victims to achieve the optimal behavioural impact for population-level communication campaigns in the resource-constrained settings of LMICs. The 'raw and real' messaging approach, which emanated from message pretesting in India, outlines creative and production processes for the production of tobacco victim testimonials, given the need to source patients, facing life-threatening conditions. This cost-efficient approach uses real tobacco victims, doctors and family members in a cinéma vérité style approach to achieve more personalised and culturally resonant messages. The methodological approach, used for the development of a number of patient testimonial messages initially in India, and later adapted for tobacco cessation, smoke-free and graphic health warning communication campaigns in other countries, is outlined. Findings from campaigns evaluated to date are encouraging as a result of the simple fact that true stories of local people's suffering are simply too difficult to ignore.

I 'like' MPOWER: using Facebook, online ads and new media to mobilise tobacco control communities in low-income and middle-income countries.

New media campaigns hold great potential to grow public awareness about the dangers of tobacco use and advance tobacco control policies, including in low-income and middle-income countries (LMICs), which have shared in a decade of explosive growth in mobile and internet penetration. With the majority of deaths from the tobacco epidemic occurring in LMICs, new media must be harnessed both as an advocacy tool to promote social mobilisation around tobacco issues and to build public support for MPOWER policies. This paper examines three consecutive new media advocacy campaigns that used communication channels such as mobile SMS, Facebook and online advertising to promote tobacco control policies. It includes some of the lessons learned, such as the pitfalls of relying on viral growth as a strategy for obtaining reach and campaign growth; the challenge of translating strategies from traditional media to new media; and the importance of incorporating marketing strategies such as paid advertising, community organising or public relations. It also identifies some of the many knowledge gaps and proposes future research directions.

Responses to antismoking radio and television advertisements among adult smokers and non-smokers across Africa: message-testing results from Senegal, Nigeria and Kenya.

BACKGROUND: This study examined whether adaptation of existing antitobacco television and radio advertisements (ads) from high-income countries is a viable tobacco control strategy for Africa. METHODS: 1078 male and female adult smokers and non-smokers, aged 18-40 years, from major and smaller urban locations in Kenya, Nigeria and Senegal, were recruited into groups using locally appropriate convenience sampling methods and stratified by smoking status, gender, age and socioeconomic status. Eligibility criteria included age, smoking status and literacy. Each participant rated five radio and five TV antismoking ads on five-point scales, which were later aggregated into measures of perceived effectiveness, potential behaviour change and antitobacco industry sentiment/support for government actions. RESULTS: For radio ads across all three countries, two health harms-focused ads-Coughing Child followed by Suffering-had the highest odds of a positive rating on the Perceived Effectiveness measure among smokers and non-smokers. For television ads, the strong graphic ad Baby Alive tended to be rated most positively across the majority of measures by all subgroups. CONCLUSIONS: This first systematic study of tobacco control advertisements in Africa is consistent with findings from other countries, suggesting that graphic health-harms ads developed and used in other countries could also be effective in African countries. This implies that adaptation would be a successful approach in Africa, where scarce resources for tobacco control communications can be focused on advertising dissemination, saving programmes from the cost, time and technical expertise required for development of new materials.

Male smoker and non-smoker responses to television advertisements on the harms of secondhand smoke in China, India and Russia.

Mass media campaigns can play an important role in strengthening support for smoke-free policies and reducing exposure to secondhand smoke (SHS). Identifying anti-SHS advertisements that are effective in diverse cultural contexts may allow for resource sharing in low- and middle-income countries. A convenience sample of 481 male cigarette smokers and non-smokers in three high tobacco burden and culturally dissimilar countries (India, China and Russia) viewed and rated five anti-SHS ads. Multivariate logistic regression analyses were conducted for 'Message Acceptance', 'Negative Emotion', 'Perceived Effectiveness' and 'Behavioral Intentions'. Smokers and non-smokers in all countries consistently rated the strong graphic, health harm ads as the most effective, and the 'informational' ad as the least effective overall: the graphic ad 'Baby Alive' was at least 1.8 times more likely than the informational ad 'Smoke-free works' to receive positive ratings on all four outcomes (all P < 0.001). Graphic, health harm messages about SHS exposure have the greatest universal appeal and are the most effective in motivating changes in behavioral intentions. Similarity in reactions between smokers and non-smokers, and across countries, suggests that resource sharing and the use of a single graphic ad targeted at smokers and non-smokers would be cost-efficient strategies.

Smokers' responses to television advertisements about the serious harms of tobacco use: pre-testing results from 10 low- to middle-income countries.

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.

An Observational Study of the Implementation of the Tobacco-Free Film and Television Policy in India.

Background: Positive portrayals of tobacco use in entertainment media can normalize and perpetuate use. In 2012, the Government of India implemented the Tobacco-Free Film and Television Rules, a first-of-its-kind comprehensive regulation to restrict tobacco depiction in films and television programs. Two complementary studies were undertaken to assess the implementation of the film rules on television and in movie theaters. Methods: In the first part, movie theater observations and exit surveys were conducted from Feb. 3 to March 24, 2015. In total, 308 movie theaters were selected for the observation of films. A total of 3080 exit surveys were conducted to assess moviegoers' reactions toward the film rule. The second part comprised the systematic observation of 424 prerecorded television programs that aired from Nov. 20 to Dec. 30, 2015. Results: Compliance with the Tobacco-Free Film and Television Rules policy was lower on television than in movie theaters. While 66% of television programs with tobacco scenes implemented at least 1 of the 3 elements of the film rule, not a single program executed all required elements correctly. In movie theaters, 99% of films that contained tobacco scenes implemented at least one element of the film rule. However, all elements of the film rules were implemented correctly during 27% of the films observed. Exit surveys showed that among moviegoers who recalled viewing at least one element of the film rule, there was increased concern about tobacco's harms and intentions to quit. Conclusion: Implementation of the film rules was higher in movie theaters than on television, though there were gaps in implementation for both. Despite inconsistent application, audience reactions to the anti-tobacco messages were favorable, with increased concern about tobacco's harms and intention to quit. Overall, the film rules offer a strong tool for countering tobacco promotion, reaching hundreds of millions with anti-tobacco messaging.

Using a smokeless tobacco control mass media campaign and other synergistic elements to address social inequalities in India.

The burden of tobacco-related morbidity and mortality in India is substantial, with smokeless tobacco being the predominant form of tobacco use. Use of smokeless tobacco (for example gutkha, paan, khaini, and pan masala) is linked to a host of socioeconomic and cultural factors including gender, regional differences, educational level, and income disparities. Given the scale of the problem, a national social marketing campaign was developed and implemented. The creative approach used testimonials from a surgeon and patients at Tata Memorial Hospital in Mumbai. The communication message approach was designed to reflect the realities of disfiguring, disabling, and fatal cancers caused by smokeless tobacco. Evaluation of the campaign identified significant differences across a range of campaign behavioral predictors by audience segments aware of the campaign versus those who were "campaign unaware". Significant findings were also identified regarding vulnerable groups by gender (female/male) and rural/urban disparities. Findings are discussed in relation to the powerful impact of using graphic, emotive, and testimonial imagery for tobacco control with socially disadvantaged groups.

Results of a national mass media campaign in India to warn against the dangers of smokeless tobacco consumption.

OBJECTIVE: Smokeless tobacco consumption in India is a significant source of morbidity and mortality. In order to educate smokeless tobacco users about the health harms of smokeless tobacco and to denormalise tobacco usage and encourage quitting, a national television and radio mass media campaign targeted at smokeless tobacco users was aired for 6 weeks during November and December 2009. METHODS: The campaign was evaluated with a nationally representative household survey of smokeless tobacco users (n = 2898). The effect of campaign awareness was assessed with logistic regression analysis. RESULTS: The campaign affected smokeless tobacco users as intended: 63% of smokeless-only users and 72% of dual users (ie, those who consumed both smoking and smokeless forms) recalled the campaign advertisement, primarily through television delivery. The vast majority (over 70%) of those aware of the campaign said that it made them stop and think, was relevant to their lives and provided new information. 75% of smokeless-only users and 77% of dual users said that it made them feel concerned about their habit. Campaign awareness was associated with better knowledge, more negative attitudes towards smokeless tobacco and greater cessation-oriented intentions and behaviours among smokeless tobacco users. CONCLUSIONS: Social marketing campaigns that utilise mass media are feasible and efficacious interventions for tobacco control in India. Implications for future mass media tobacco control programming in India are discussed.

Testing Communication Concepts on COVID-19 Contact Tracing Among Black and Latinx/Hispanic People in the United States.

OBJECTIVE: Black and Latinx/Hispanic people were more than twice as likely to die from COVID-19 than White people, but because of legacies of discrimination and maltreatment in health care, were less likely to participate in some public health responses to COVID-19, including contact tracing. This study aimed to test three communication campaign concepts to engage Black and Latinx/Hispanic people in contact tracing efforts. METHODS: Twelve focus group discussions with 5 to 10 participants each were conducted online among participants from Black and Latinx/Hispanic urban populations in Philadelphia and New York state. Participants provided sociodemographic information and were presented with potential campaign concepts and prompted to rate the concepts and engage in open-ended discussion. For rating and sociodemographic data, chi-square tests were performed. For open-ended discussion data, a thematic analysis approach was used. RESULTS: Across groups, the campaign concept that was rated most likely to encourage cooperation with contact tracing efforts was "Be the One," with 45% of total first-place votes. Participants expressed that the campaign caught their attention (79%), motivated them to engage with contact tracers (71%) and to talk to others about contact tracing (77%). Discussions also elucidated: the importance of community engagement; the need for clearer explanations of contact tracing; the preference for already trusted, community-based contact tracers; the need to reassure people about confidentiality; and for contact tracing to be culturally competent and empathetic. CONCLUSIONS: This study highlights how strategic, culturally sensitive communication can buttress current and future contact tracing efforts, especially among Black and Latinx/Hispanic people.

How the "Are We Drinking Ourselves Sick?" Communication Campaign Built Support for Policy Action on Sugary Drinks in Jamaica.

Background: This study assesses the effectiveness of a campaign "Are We Drinking Ourselves Sick?" that ran nationally in Jamaica in four phases from 2017 to 2019 to increase knowledge about the harms of sugary drinks, shift attitudes, and build support for policy actions to address sugary drink consumption, including a tax and a ban in schools. Methods: Campaign impact was measured in representative cross-sectional household surveys of adults ages 18 to 55. A baseline survey was conducted before the launch of the campaign (n = 1430). Evaluation surveys were conducted mid-campaign (n = 1571) and post-campaign (n = 1500). Campaign impact was assessed by comparing changes across survey periods on key knowledge, attitudinal and policy support outcome indicators. The independent association between campaign awareness and outcomes was analyzed using logistic regression analyses. Results: The campaign was recalled by more than 80% of respondents and was well-received with 90% or more respondents describing it as believable and relevant. There was a decline in knowledge on the harms of sugary drinks from the baseline to post-campaign period, notably on risks of diabetes (adjusted odds ratio or AOR = 0.62, p < 0.001), overweight and obesity (AOR = 0.58, p < 0.001), and heart disease (AOR = 0.79, p < 0.003). However, post-campaign awareness was independently associated in logistic regression analysis with improved knowledge of the harms of sugary drinks, including risks of diabetes (AOR = 1.45, p = 0.019), overweight or obesity (AOR = 1.65, p = 0.001), and heart disease (AOR = 1.44, p = 0.011). Support for government action remained high across survey waves (≥90%), and campaign awareness was independently associated with increased policy support for sugary drinks taxes (Mid-campaign: AOR = 1.43, p = 0.019; post-campaign: AOR = 1.46, p = 0.01) and restrictions on sugary drinks in schools (AOR = 1.55, p = 0.01). Conclusion: This study demonstrates the role that media campaigns can play in maintaining knowledge and concern about the health harms of sugary drinks and increasing support for policy passage.

'Love with Less Salt': evaluation of a sodium reduction mass media campaign in China.

OBJECTIVE: This study examines the impact of a salt reduction campaign on knowledge, attitudes, intentions, behaviours and barriers to behaviour change relating to salt consumption in two provinces of China. METHODS: In 2019, the 'Love with Less Salt' campaign ran on China Central Television and on local television channels in Shandong and Anhui provinces. Data for this study come from two representative household surveys conducted among a sample of adults aged 25-65 years in Shandong and Anhui provinces: precampaign (n=2000) and postcampaign (n=2015). Logistic regression was performed to estimate the effects of the campaign on knowledge, attitudes, intentions, behaviours and barriers to behaviour change. RESULTS: Overall, 13% of postcampaign respondents recalled seeing the campaign, and reactions towards the campaign were positive. Postcampaign respondents were more likely to plan to reduce their purchase of foods high in salt than precampaign respondents (OR=1.45, p=<0.05). Campaign-aware respondents were significantly more likely than campaign-unaware respondents to report higher levels of knowledge, attitudes and behaviours regarding salt reduction. CONCLUSIONS: Findings reveal that salt reduction mass media campaigns can be an effective public health tool to support efforts to reduce salt consumption in China. Continued and sustained mass media investments are likely to be effective in addressing high salt consumption nationwide.

Increasing evidence for the efficacy of tobacco control mass media communication programming in low- and middle-income countries.

Antitobacco mass media campaigns have had good success at changing knowledge, attitudes, and behaviors with respect to smoking in high-income countries provided they are sustained. Mass media campaigns should be a critical component of tobacco control programs in low- and lower-middle-income countries. Mounting evidence shows that graphic campaigns and those that evoke negative emotions run over long periods of time have achieved the most influence. These types of campaigns are now being implemented in low- and middle-income countries. The authors provide 3 case studies of first-ever graphic warning mass media campaigns in China, India, and Russia, 3 priority high-burden countries in the global Bloomberg Initiative to Reduce Tobacco Use. In each of these countries, message testing of core messages provided confidence in messages, and evaluations demonstrated message uptake. The authors argue that given the initial success of these campaigns, governments in low- and middle-income countries should consider resourcing and sustaining these interventions as key components of their tobacco control strategies and programs.

Public health and environmental response to the first case of naturally acquired inhalational anthrax in the United States in 30 years: infection of a new york city resident who worked with dried animal hides.

In Pennsylvania on February 16, 2006, a New York City resident collapsed with rigors and was hospitalized. On February 21, the Centers for Disease Control and Prevention and the New York City Department of Health and Mental Hygiene were notified that Bacillus anthracis had been identified in the patient's blood. Although the patient's history of working with dried animal hides to make African drums indicated the likelihood of a natural exposure to aerosolized anthrax spores, bioterrorism had to be ruled out first. Ultimately, this case proved to be the first case of naturally occurring inhalational anthrax in 30 years. This article describes the epidemiologic and environmental investigation to identify other cases and persons at risk and to determine the source of exposure and scope of contamination. Because stricter regulation of the importation of animal hides from areas where anthrax is enzootic is difficult, public healthcare officials should consider the possibility of future naturally occurring anthrax cases caused by contaminated hides. Federal protocols are needed to assist in the local response, which should be tempered by our growing understanding of the epidemiology of naturally acquired anthrax. These protocols should include recommended methods for reliable and efficient environmental sample collection and laboratory testing, and environmental risk assessments and remediation.

Trends in tobacco, alcohol and branded fast-food imagery in Bollywood films, 1994-2013.

BACKGROUND AND AIMS: Exposure to tobacco, alcohol and fast-food use in films is associated with initiation of these behaviours. India is the world's largest film producer, but the extent of such imagery in Bollywood (Hindi cinema) films is unclear. We therefore aimed to describe the extent of and trends in tobacco, alcohol and fast-food imagery in Bollywood films, between 1994-2013. METHODS: For the 15 top-grossing films each year between 1994-2013, the number of five-minute intervals containing product images were determined separately for tobacco, alcohol and fast-food. Both the proportion of films containing at least one image occurrence, and occurrences per film, were described overall and by year. Negative binomial regression described associations between film rating and occurrences/film, and estimated time-trends in occurrences/film, adjusted for rating. RESULTS: We analysed 93 U-rated (unrestricted), 150 U/A-rated (parental guidance for children aged <12 years) and 55 A-rated (restricted to adult audience) films, containing 9,226 five-minute intervals (mean intervals/film 30.8, SD 4.0). 70% (n = 210), 93% (n = 278) and 21% (n = 62) of films contained at least one tobacco, alcohol and fast-food occurrence, respectively. Corresponding total mean occurrences/film were 4.0 (SD 4.9), 7.0 (4.7) and 0.4 (0.9). Tobacco occurrences were more common in U/A films (incidence rate ratio 1.49, 95% confidence interval 1.06-2.09) and A films (2.95; 1.95-4.48) than U-rated films. Alcohol occurrences were also more common in A-rated films than U-rated films (1.48; 1.15-1.85). Tobacco occurrences/film became less common over the observed period (adjusted trend -4% per annum; -2 to -7%; p <0.001), while alcohol (+2%; 0-3%; p = 0.02), and fast food (+8%; 2-14%; p = 0.01) occurrences/film became more common. CONCLUSIONS: Although the extent of tobacco imagery in Bollywood films fell over 1994-2013, it is still frequently observed. Alcohol imagery is widespread, even in U-rated films, and trends in both alcohol and fast-food imagery are upwards.

Results of a Mass Media Campaign in South Africa to Promote a Sugary Drinks Tax.

BACKGROUND: In South Africa, the increased consumption of sugary drinks has been associated with increased obesity rates. Mass media campaigns can play a crucial role in improving knowledge, shifting attitudes, and building support for government action on reducing sugary drink consumption. No study to date has evaluated the effectiveness of mass media campaigns on the health harms of sugary drinks in South Africa. OBJECTIVE: The purpose of this study was to evaluate the impact of a mass media campaign on knowledge and attitudes around sugary drinks and on public support for a proposed tax on sugary drinks in South Africa. METHODS: The "Are You Drinking Yourself Sick?" campaign aired in South Africa from October 2016 to June 2017 to shift attitudes toward sugary drinks, build personal risk perceptions of the health harms of consuming sugary drinks, and build public support for a proposed tax on sugary drinks. Campaign impact was measured in representative cross-sectional household surveys of adults ages 18 to 56. The surveys were conducted just prior to the launch of the campaign (N = 1000), from October 7 to 10, 2016, and immediately following its conclusion (N = 1000), from July 12 to 21, 2017. Campaign impact was assessed by comparing changes from the pre-campaign to the post-campaign period on key outcome indicators. In addition, the effect of campaign awareness was analyzed in logistic regression analysis of the post-campaign data. RESULTS: The campaign was recalled by 55% of survey respondents, and 78% of campaign-aware respondents said that the campaign's main message was "drinking sugary drinks can make you sick." There were significant changes from the pre- to the post-campaign period in knowledge that sugary drink consumption can lead to obesity and related health problems and that sugary drinks contribute toward the obesity problem in South Africa. Campaign awareness was also significantly associated with increases in knowledge about the harms of sugary drinks, and in particular, on government action, including the proposed tax on sugary drinks. DISCUSSION: Media campaigns are an effective intervention for obesity prevention. In addition to improving knowledge and shifting attitudes, media campaigns can effectively build public support for strong government action and therefore must be a component of a comprehensive obesity prevention approach.

Online media coverage of air pollution risks and current policies in India: A content analysis.

Background Air pollution is of particular concern in India, which contains 11 of the 20 most polluted cities in the world. Media coverage of air pollution issues plays an important role in influencing public opinion and increasing citizen demand for action on clean air policy. Hence, this study was designed to assess news coverage of air pollution in India and its implications for policy advancement. Methods Articles published online between 1 January 2014 and 31 October 2015 that discussed air pollution in India were systematically content analysed. From 6435 articles in the national media and 271 articles in the international media, a random selection of 500 articles (400 from national and 100 from international media) were analysed and coded by two independent coders, after high inter-rater reliability (kappa statistic above 0.8) was established. Results There was an increase in the number of news stories on air pollution in India in the national media over the study period; 317 (63%) stories described the risk to health from air pollution as moderately to extremely severe, and 393 (79%) stories described the situation as needing urgent action. Limited information was provided on the kinds of illnesses that can result from exposure. Less than 30% of stories in either media specifically mentioned the common illnesses resulting from air pollution. Very few articles in either media mentioned the population groups most at risk from air pollution, such as children or older people. Vehicles were presented most often as the cause of air pollution in India (in over 50% of articles in both national and international media). Some of the most important sources of air pollution were mentioned less often: 6% of national and 18% of international media articles mentioned unclean sources of household energy; 3% of national and 9% of international media articles mentioned agricultural field burning. Finally, the majority of articles (405; 81%) did not mention any specific institution or organization - such as the government or industry groups - as the primary responsible stakeholder, thus leaving ambiguous the organizations whose leadership was necessary to mitigate air pollution. Conclusion Gaps exist in the current media discourse on air pollution, suggesting the need for strengthening engagement with the media as a means of creating citizen engagement and enabling policy action. Through greater elaboration of the health burdens and evidence-based policy actions, the media can play a critical role in galvanizing India's action on air quality. These data may suggest opportunities for media advocacy and greater public and policy engagement to address issues around air quality in India.

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

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.