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Sunday, June 2, 2013

The Global Adult Tobacco Survey: Saving Lives From Tobacco Related Diseases

Antismoking mass media campaigns can help reduce the prevalence of smoking by discouraging young persons from initiating smoking and by encouraging current smokers to quit (1,2). Smoking cessation is a multistage process; intention to quit smoking precedes quit attempts (3). 
To assess whether awareness of anti-cigarette smoking information in four mass media channels (television, radio, billboards, and newspapers or magazines) was significantly associated with a current cigarette smoker's intention to quit, CDC analyzed data from 17 countries that participated in the Global Adult Tobacco Survey (GATS). Logistic regression was used to analyze the relationship between awareness of antismoking messages and intent to quit smoking; odds ratios were adjusted to control for demographic factors, awareness of warning labels on cigarette packages, and awareness of tobacco advertisements. 

In nine of 17 countries, intent to quit was significantly associated with awareness of antismoking messages in a single media channel versus no awareness, with adjusted odds ratios ranging from 1.3 to 1.9. In 14 countries, intent to quit was significantly associated with awareness of messages in multiple channels versus no awareness, with adjusted odds ratios ranging from 1.5 to 3.2. Antismoking information in mass media channels can help reduce tobacco consumption by encouraging smokers to contemplate quitting and might be more effective when presented in multiple channels.

GATS is an ongoing, nationally representative household survey of noninstitutionalized adults aged ≥15 years (4). This report used data from current cigarette smokers in 17 countries that participated in GATS during 2008–2011. Current smokers who were categorized as intending to quit included 1) persons who indicated they planned to quit smoking in the next month and 2) persons who indicated they were thinking about quitting smoking in the next 12 months. Survey questions asking whether current smokers noticed anti-cigarette smoking information during the last 30 days in any of four media channels (television, radio, billboards, and newspapers or magazines) were used to measure awareness of the messages.
Logistic regression was used to analyze the relationship between awareness of antismoking messages and intention to quit smoking. Awareness of antismoking messages was classified into three categories: 1) did not notice antismoking information in any media channels; 2) noticed antismoking information in one of the four channels; and 3) noticed antismoking information in more than one of the channels. Because intention to quit and exposure to antismoking information might both be associated with demographic characteristics, variables for sex, age, residence, education, and socioeconomic status (5) were entered into the model. Additionally, to control for media influence, two indicators were entered into the model: whether the respondent noticed warning labels on cigarette packages in the last 30 days and whether the respondent was aware of protobacco marketing in the last 30 days. Awareness of protobacco marketing was measured by affirmative responses to a series of questions asking whether the respondent had noticed protobacco advertisements, promotions, or sponsorships in the last 30 days in various marketing channels (6).
A total of 265,564 persons participated in the 17 country surveys. Response rates for the surveys ranged from 65.1% in Poland to 97.7% in Russia, with a median response rate of 93.6%.*
Of the participants, 50,209 reported they were current smokers. In all 17 countries, these respondents noticed antismoking information during the last 30 days in all four of the media channels (television, radio, billboards, and newspapers or magazines). More than half of respondents noticed antismoking information in at least one of the four media channels in all countries, and more noticed antismoking information on television compared with the other three media channels. Awareness of antismoking information on television was reported by >80% of smokers in four countries: Turkey (87.8%), Malaysia (86.7%), Vietnam (85.6%), and Mexico (82.8%). Awareness for radio was highest in Mexico (47.9%), followed by Malaysia (47.0%) and Uruguay (43.0%). Awareness for billboards ranged from 17.6% in Brazil to 73.9% in Malaysia, while awareness for newspapers or magazines ranged from 9.4% in Indonesia to 74.3% in Malaysia (Table 1).
Among the respondents, 10,439 said they intended to quit. In five of the 17 countries, the number of respondents intending to quit was >30% (43.8% in Bangladesh, 34.6% in Mexico, 33.7% in Uruguay, 31.7% in Poland, and 30.2% in Vietnam). Intention to quit smoking was <20% in five countries (18.7% in Brazil, 16.0% in China, 14.5% in Russia, 14.2% in Malaysia, and 10.5% in Indonesia). The proportion of respondents who noticed a warning label in the last 30 days was high in all countries, ranging from 70.7% in India to 97.9% in Romania. Wide variation was observed in the percentage of respondents who noticed any type of protobacco marketing in the last 30 days, ranging from 0.0% in three countries (Egypt, Thailand, and Vietnam) where all forms of tobacco advertising, promotions, and sponsorship are banned to 87.3% in Indonesia, where only the distribution of free samples of cigarettes is banned (6,7) (Table 1).
In nine of the 17 countries, the association between intent to quit and awareness of antismoking messages in a single channel versus no awareness was significant, with adjusted odds ratios ranging from 1.3 to 1.9. The association between intent to quit and awareness of messages in multiple channels versus no awareness was significant in 14 of the 17 countries, with adjusted odds ratios ranging from 1.5 to 3.2. The strongest association (adjusted odds ratio: 3.2) was in Bangladesh (Table 2).

Reported by

Roberta B. Caixeta, Pan American Health Organization; Dhirendra N. Sinha, South-East Asia Regional Office; Rula N. Khoury, European Regional Office; James Rarick, Western Pacific Office; Heba Fouad, Eastern Mediterranean Regional Office; Edouard Tursan d'Espaignet, Doug Bettcher, World Health Organization. Linda J. Andes, Krishna Palipudi, Samira Asma, Office of Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.Corresponding contributor: Linda J. Andes,, 770-488-5784.

Editorial Note

The World Health Organization Framework Convention on Tobacco Control requires countries to provide widely accessible, comprehensive information about the addictiveness, risks, and harms of exposure to tobacco smoke. Antismoking messages in the mass media are one means to accomplish this goal. Whereas awareness of antismoking messages demonstrates that the information has reached the public, smokers' intentions to quit are an indicator of the effectiveness of those messages. Campaign reach, intensity, duration, and the content of messages might influence effectiveness (8).
Research has shown that mass media campaigns might be ineffective if they do not meet a threshold for sufficient population exposure. Among the GATS countries included in this study, such a threshold might be difficult to overcome without the use of television, the primary media channel associated with the greatest exposure. The content of the messages also matters; messages that convey the adverse health effects of tobacco use and secondhand smoke exposure have been found to be more effective than other message types (8).
The findings in this report are subject to at least six limitations. First, awareness of mass media antismoking messages does not directly measure the frequency or duration of exposure to specific messages. The extent of the mass media campaigns in the countries studied was not reported. Second, differences in content can be found in antismoking media messages as well as in protobacco marketing and warning labels on cigarette packages; these differences might account for differences in their association with intention to quit. Third, additional factors (e.g., increases in tobacco prices or smokefree laws) not controlled for in this analysis might influence whether smokers intend to quit (8). Fourth, different types of smoked tobacco products other than cigarettes are common in several countries (e.g., bidis in Bangladesh and India and shisha in Egypt, Turkey, and Ukraine). This report is limited to anti-cigarette smoking messages specifically and does not consider media messages aimed at the use of other types of smoked tobacco. Fifth, although intention to quit has been correlated with actual quit behavior (3,8), it is not a direct measure of quit behavior. Finally, the survey design is cross-sectional, and causality cannot be inferred from the associations described in this report.
This report adds to the body of evidence showing that awareness of mass media antismoking messages can be associated with intent to quit smoking. Mass media campaigns also can help reduce smoking prevalence by stimulating discussion and changing social norms regarding tobacco use and secondhand smoke exposure and are a crucial element of comprehensive tobacco control programs (8,9). These global findings provide additional support for CDC's Tips from Former Smokers mass media campaign (10).


  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.
  2. 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.
  3. DiClemente CC, Prochaska JO, Fairhurst SK, Velicer WF, Velasquez MM, Rossi JS. The process of smoking cessation: an analysis of precontemplation, contemplation and preparation stages of change. J Consult Clin Psychol 1991;59:295–304.
  4. Kalsbeek WD, Bowling JM, Hsia J, Mirza S, Palipudi KM, Asma S. The global adult tobacco survey (GATS): sample design and related methods. Vancouver, Canada: Joint Statistical Meetings, July 31–August 5, 2010. Available at Adobe PDF fileExternal Web Site Icon
  5. Palipudi KM, Gupta PC, Sinha DN, Andes LJ, Asma S, McAfee T. Social determinants of health and tobacco use in thirteen low and middle income countries: evidence from Global Adult Tobacco Survey. PLoS One 2012;7:e33466.
  6. CDC. Adult awareness of tobacco advertising, promotion, and sponsorships—14 countries. MMWR 2012;61:365–9.
  7. World Health Organization. WHO report on the global tobacco epidemic, 2011: warning about the dangers of tobacco. Geneva, Switzerland: World Health Organization; 2011. Available at Web Site Icon.
  8. Durkin S, Brennan E, Wakefield M. Mass media campaigns to promote smoking cessation among adults: an integrative review. Tob Control 2012;21:127–38.
  9. CDC. Best practices for comprehensive tobacco control programs—2007. Atlanta, GA: US Department of Health and Human Services, CDC; 2007. Available at
  10. Rigotti NA, Wakefield M. Real people, real stories: a new mass media campaign that could help smokers quit. Ann Intern Med 2012; 157:907–9.

* Response rates for the 17 country surveys were as follows: Bangladesh 93.6%, Brazil 94.0%, China 96.0%, Egypt 97.2%, India 91.8%, Indonesia 94.3%, Malaysia 85.3%, Mexico 82.5%, Philippines 94.7%, Poland 65.1%, Romania 89.1%, Russia 97.7%, Thailand 94.2%, Turkey 90.9%, Ukraine 76.1%, Uruguay 95.2%, Vietnam 92.7%.
Current cigarette smokers included those who smoked manufactured cigarettes, hand-rolled cigarettes, or kreteks, daily or less frequently than daily.