Adult Awareness of Tobacco Advertising, Promotion, and Sponsorship — 14 Countries

According to the 2012 Report of the U.S. Surgeon General, exposure to tobacco advertising, promotion, and sponsorship (TAPS) is associated with the initiation and continuation of smoking among young persons (1). The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) requires countries to prohibit all forms of TAPS (2); the United States signed the agreement in 2004, but the action has not yet been ratified. Many countries have adopted partial bans covering direct advertising in traditional media channels; however, few countries have adopted comprehensive bans on all types of direct and indirect marketing. To assess progress toward elimination of TAPS and the level of awareness of TAPS among persons aged ≥15 years, CDC used data from the Global Adult Tobacco Survey (GATS) collected in 14 countries during 2008–2010. Awareness of any TAPS ranged from 12.4% in Turkey to 70.4% in the Philippines. In the four countries where awareness of TAPs was ≤15%, three of the countries had comprehensive bans covering all nine channels assessed by GATS, and the fourth country banned seven of the nine channels. In 12 countries, more persons were aware of advertising in stores than advertising via any other channel. Reducing exposure to TAPS is important to prevent initiation of tobacco use by youths and young adults and to help smokers quit (1).

GATS is an ongoing, nationally representative, in-person household survey of noninstitutionalized adults aged ≥15 years.* Fourteen countries completed GATS during 2008–2010. Countries conducting GATS used a standardized core questionnaire, sample design, data collection method, and analysis protocol to enhance comparability across countries. A multistage cluster sample design was used in each country, and data were weighted in analysis to account for the complex sample design (3). Survey questions regarding direct tobacco marketing asked whether participants noticed cigarette advertising in five marketing channels during the previous 30 days: 1) television or radio, 2) newspapers or magazines, 3) billboards or public walls, 4) Internet, and 5) point-of-sale in stores. Questions were asked regarding four channels of indirect tobacco marketing: 1) sponsorship of sports or sporting events, 2) free samples of cigarettes, 3) sales or coupons for cigarettes, and 4) clothing or other items featuring a brand name or logo.

During 2008–2010, all 14 countries banned at least one form of tobacco marketing. Three countries (Egypt, Thailand, and Vietnam) banned all nine channels of tobacco marketing that were assessed. Eight other countries (Bangladesh, Brazil, India, Mexico, Philippines, Poland, Turkey, and Uruguay) banned five to eight channels. Three countries (China, Russia, and Ukraine) banned four or fewer channels. All 14 countries banned advertising on television or radio, and all but Russia and Mexico banned advertising in newspapers or magazines. Russia and China were the only countries that did not ban advertising on billboards or public walls; China had no bans on any types of indirect marketing (Table 1).

Participants were aware of tobacco marketing in all countries, including the three countries that banned all nine TAPS channels: Egypt (13.0%), Thailand (15.0%), and Vietnam (14.7%) (Table 2). In general, awareness of TAPS was higher in those countries with the fewest bans. An exception was the Philippines, where participants had the highest awareness of TAPS (70.4%) despite bans on five TAPS channels. The next highest levels of awareness were in Russia (65.3%), which banned one channel, and Mexico (52.8%), which banned five. In China, which banned two channels, the government owns and operates the tobacco company. TAPS awareness in this country (16.9%) was lower than in other countries with partial bans (Table 2).

In seven countries, awareness of point-of-sale advertising in stores was >20% and, with the exception of China and Turkey, awareness of point-of-sale advertising in stores was higher than awareness of any other TAPS channel (Table 2). Awareness of tobacco advertising in newspapers or magazines was highest in Mexico (17.4%) and Russia (33.3%), the only two countries that do not ban tobacco advertising in print publications. Among the indirect marketing channels, awareness was <10% in most countries, with the exception of free samples (13.0% in Russia) and clothing or items with brand names or logos (11.0% in Mexico, 18.3% in the Philippines, and 20.9% in Russia) (Table 2).

Reported by

Roberta B. Caixeta, Pan American Health Organization; Dhirendra N. Sinha, Southeast Asian Regional Office, Rula N. Khoury, European Regional Office, James Rarick, Western Pacific Office, Heba Fouad, Eastern Mediterranean Regional Office, World Health Organization. Johanna Birckmayer, Ellen Feighery, Campaign for Tobacco-Free Kids. Linda J. Andes, Terry Pechacek, Samira Asma, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Corresponding contributor: Linda J. Andes, landes@cdc.gov, 770-488-5784.

Editorial Note

The WHO FCTC calls for the prohibition of all forms of tobacco advertising in digital media, broadcast media, and print. The FCTC also requires restrictions on tobacco industry sponsorship, direct and indirect incentives, and other promotions to purchase tobacco products. Countries also are encouraged to pursue more aggressive measures than those required by their obligations under the FCTC (2).

Awareness of tobacco marketing is one indicator of the success of advertising bans; other indicators include reduced tobacco consumption and exposure (e.g., measured directly by tobacco broadcast time or characteristics of store displays). In this report, awareness of TAPS was lower in the GATS countries with the most advertising and marketing channels banned. The importance of including bans on point-of-sale advertising and promotion is reflected in the finding that in 12 of the 14 GATS countries, adults were more aware of advertising in stores than via any other channel. As one of the few remaining channels for TAPS in most countries, point-of-sale advertising is a crucial arena for the development of tobacco control policies (1,4).

The findings in this report are subject to at least three limitations. First, certain countries did not assess all channels, limiting comparability. Second, data from GATS cannot be used to assess whether bans caused lower awareness of TAPS because the surveys are cross-sectional and omitted factors that might influence awareness. For example, comprehensive bans can only lower awareness of TAPS to the extent the bans are adequately enforced; compliance with TAPS bans might vary across countries as well as across marketing channels within countries. High levels of awareness of TAPS in the Philippines, even for channels banned by law, might indicate challenges with enforcement (5). Finally, although awareness of tobacco advertising has been found to be similar among adults and youths (6), the findings in this report were restricted to persons aged ≥15 years.

Since the 2008–2010 GATS was conducted, Brazil has implemented a ban on point-of-sale advertising in stores. Bans on direct advertising in stores and indirect marketing by providing free samples, sales or coupons, and clothing or other items will take effect in Ukraine later this year. A repeat survey of GATS countries will enable tracking of changes in awareness of TAPS within the historical context of changes in TAPS bans.

Tobacco use is the leading cause of preventable death worldwide; projections estimate that 1 billion tobacco-related deaths will occur during this century unless actions are taken to reduce tobacco use (7). Tobacco marketing encourages young persons to start smoking and current users to smoke more and decreases the motivation of smokers to quit (1,8). Comprehensive bans prohibiting TAPS reduce tobacco use among persons at all income and education levels; partial bans are less effective (9). Progress toward eliminating tobacco use will require the strengthening of existing bans to cover all TAPS channels, including point-of-sale advertising. Comprehensive TAPS bans are included in WHO's list of 10 practical and affordable "best buy" interventions to save lives, prevent disease, and reduce health-care costs (10).

References

1. US Department of Health and Human Services. Preventing tobacco use among youth and young adults: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 2012. Available at http://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/index.html. Accessed May 21, 2012.
2. World Health Organization. WHO Framework Convention on Tobacco Control. Geneva: Switzerland: World Health Organization; 2005.
3. CDC. Differences by sex in tobacco use and awareness of tobacco marketing—Bangladesh, Thailand, and Uruguay, 2009. MMWR 2010;59:613–8.
4. Feighery EC, Ribisl KM, Schleicher NC, Clark PI. Retailer participation in cigarette company incentive programs is related to increased levels of cigarette advertising and cheaper cigarette prices in stores. Prev Med 2004;38:876–84.
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7. Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years' observations on male British doctors. BMJ 2004;328:1519–28.
8. World Health Organization. WHO report on the global tobacco epidemic, 2008—the MPOWER package. Geneva, Switzerland: World Health Organization; 2008. Available at http://www.who.int/tobacco/mpower/2008/en/index.html. Accessed May 21, 2012.
9. National Cancer Institute. The role of the media in promoting and reducing tobacco use. Tobacco control monograph no. 19. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health, National Cancer Institute; 2008.
10. World Health Organization. Global status report on noncommunicable diseases, 2010. Geneva, Switzerland: World Health Organization; 2011. Available at http://www.who.int/nmh/publications/ncd_report2010/en/index.html. Accessed May 21, 2012.