Cultural variation in antismoking video ads between the United States, Taiwan, and China

Abstract

Antitobacco advertisement components, including types of messages and advertising appeals, have not been evaluated among multinational groups. This study identified and compared the content of antismoking video ads across three countries. We reviewed 86 antismoking video advertisements for the following information: severity of the consequences of smoking, types of risks, appeals to audiences’ self-efficacy, benefits of not smoking, targeted social–ecological level and types of message appeal used. Two researchers independently coded each advertisement with an average inter-coder reliability of 0.79.

Analyses showed a variety of focuses: smoking-related health risks (86%), severe consequences of smoking (54.7%), self-efficacy beliefs (40.7%) and benefits of not smoking (84.9%). Compared to the United States and Taiwanese ads, Chinese ads were more likely to target at the community level (10% versus 23.3% versus 47.2%). Additionally, 55% of the United States ads used the fear approach, whereas 61.1% of Chinese ads used the social approach. Taiwanese ads were evenly distributed among both approaches. In conclusion, the countries used different targeting strategies and approaches during message delivery. Although China’s neighboring country, Taiwan, has many similar cultural aspects, including the same language, they are greatly influenced by US antitobacco campaigns. As a result, Taiwan’s tobacco campaigns appear to have similar components to both China and the United States. Further research is warranted to understand the reasons for each method and to examine the effectiveness of the ads in reducing smoking rates.

Introduction

Smoking is widely recognized as harmful to people’s health. However, smoking rates remain high worldwide [ 1 ]. Smoking increases the risk of lung cancer, respiratory health problems, stroke, and coronary heart disease [ 2 ]. Additionally, smokers also affect others’ health via exposure to secondhand smoke (SHS) [ 3 ]. Particularly hazardous to children, SHS may increase the risk of lung cancer, stroke, and coronary heart, asthma and pneumonia and sudden infant death syndrome [ 4–9 ]. To decrease smoking rates and secondhand smoke exposure rates, the United States, Chinese, and Taiwanese governments have followed the WHO Framework Convention on Tobacco Control (FCTC) to develop new regulations. Furthermore, each country has produced numerous antismoking advertisements. Previous studies indicate that antismoking campaigns have a positive impact on people’s health knowledge and smoking behaviors [ 10 , 11 ]. The number and types of campaigns vary across multiple countries, For example, the United States has developed antitobacco campaigns for a relatively longer time compared to other countries. However, China accounts for the largest tobacco industry and smoking population (one-third of the smokers in the world) [ 12 ]. As a result, China has recently started to promote antismoking campaigns. Based on the unique yet similar regulations and cultural aspects, these countries were selected for this study that examined the tobacco control advertising regulations and the content of antismoking advertisements across the United States, Taiwan, and China.

Prevalence

In some high-income nations, such as the United States and Taiwan, there have been major efforts to develop tobacco control policies and enhance public awareness about the adverse effects of smoking and SHS [ 13 ]. As a result, smoking rates and SHS exposure rates have decreased from approximately 30 to 20% in the past decade within these nations [ 14 , 15 ]. For example, the smoking rate decreased from 42.4 to 16.8% from 1965 to 2014 in the United States and from 31.3 to 17.1% from 1971 to 2015 in Taiwan [ 14 , 15 ]. Additionally, youth smoking rates have decreased to 18.1% in 2011 in the United States and 10.4% for high school students and 3.5% for junior high school students in Taiwan in 2015 [14, 15]. The SHS exposure rate also decreased in countries implementing new regulations. For instance, the rate for SHS exposure declined from 87.9 to 40.1% in the United States and from approximately 31 to 16.5% from 2005 to 2011 in Taiwan [ 16 , 17 ]. In contrast, China accounts for 38% of tobacco consumption and 33% of smokers in the world, meaning it has the largest tobacco industry and smoking population [ 12 , 18 ]. In 2010, a director of the Chinese Centers for Disease Control and Prevention (CDC) mentioned that tobacco control was not regarded as a priority issue [ 19 ]. Therefore, the smoking rate (33.4% in 1996 versus 28.1% in 2010) and SHS exposure rate (72.4% in 2010) remain high [ 12 , 20 , 21 ].

Country selection and tobacco regulations

In 1967, the US government began implementing regulations on tobacco sales, marketing, and use [ 22 ]. Since then, the 1970 Public Health Cigarette Smoking Act banned any kind of cigarette advertising on television and radio, and the 1997 Tobacco Master Settlement Agreement prohibited tobacco companies from displaying outdoor advertisements on billboards and public transportation [ 22 , 23 ]. The 2009 Family Smoking Prevention and Tobacco Control Act (FSPTC Act) led to stricter advertising regulations among tobacco companies, including sponsorship of athletic, social or cultural events [ 24 ].

In Taiwan, it was not until the 1980s that the government and private organizations started to promote antismoking activities and regulations [ 25 ]. The 1997 Tobacco Hazards Prevention Act banned all types of cigarette advertising, such as radio, television, film, video materials, electronic signals, and computer networks [ 26 ].

In contrast to the United States and Taiwan, there have been few strong tobacco control policies in China, despite high smoking rates [ 27 ]. In 1995, the Chinese government prohibited tobacco advertising in movies, radio, television, print media, and public areas, yet the government failed to strictly implement the regulation [ 28 , 29 ]. In 2005, China became parties to the WHO FCTC. WHO FCTC aims at reducing smoking and SHS exposure rates, develop tobacco regulations, and increase public awareness about adverse effects of tobacco in the world [ 30 ]. Although Taiwan does not meet the qualifications to become a member of WHO FCTC due to China’s claim of ownership of Taiwan, Taiwan follows the regulations promoted by the FCTC.

In 2008, WHO introduced MPOWER, a framework for effective measurements for tobacco control. The United States and Taiwan have followed the framework and implemented new regulations regarding prohibited tobacco advertising, promotion, and sponsorship. Furthermore, to meet the requirements of the FCTC, China has developed antitobacco mass media campaigns that were aired on TV and/or radio to improve public awareness about the hazards of tobacco [ 12 ].

Similar to policy, mass media play an important role in promoting and reducing tobacco use. Mass media antismoking campaigns have increased public awareness of the adverse effects of smoking and SHS exposure [ 31–34 ]. Studies in the United States indicated that viewing antismoking advertisements may increase a smoker’s consideration of quitting smoking and may prevent youth from starting smoking [ 34–36 ]. Media campaigns have also successfully improved residents’ health knowledge and increased awareness of smoke-free ordinance implementation in Taiwan, which has led to reduced smoking and SHS exposure rates [ 10 , 37 ]. Antismoking campaigns in China have shown mixed results [ 38–40 ], but researchers predict that 12.8 million lives can be saved by 2050 if the government fully implements the WHO FCTC recommended policies [ 41 ].

Antismoking advertisements in this study

This study analysed advertisements from 2008 to 2013—the year just before both the United States and Taiwan announced new regulations. The authors analysed video advertisements collected from the CDC Media Campaign Resource Center (MCRC) since 2008 in the United States, and free video advertisements released by the governments in Taiwan after 2008 and in China after 2012 (when the first antismoking ad made by the government was produced).

The purpose of this cross-cultural study was to compare the content of freely accessible antismoking video advertisements produced by the United States, Taiwan, and China governments. Each advertisement was examined to determine the message type and target population, using two public health theories as frameworks. The health belief model (HBM) is the most commonly used theory in understanding individuals' health motivations and has been used to understand other media messaging [ 42 ]. Furthermore, the social–ecological model (SEM) is a widely used public health model that highlights the influences on the individual at multiple levels (interpersonal, community, and societal) [ 43 ]. In combination, these provide a broad understanding (SEM) and more specific messaging understanding (HBM) regarding the components of each advertisements [ 42 , 43 ]. Hence, the HBM and SEM were used as frameworks in conducting a content analysis in this study to understand the common themes, appeals, designs, and theoretical grounding of the antismoking advertisements produced by each government.

Method

Using readily accessible government-produced television advertisements from the United States, Taiwan, and China, this study examined whether the antismoking ads produced by each country provided the following information: (i) emphasis on the severity of the consequences of smoking; (ii) types of risks or threats caused by smoking; (iii) encouragement for audiences’ self-efficacy; (iv) benefits of not smoking. We also assessed which social–ecological level the advertisement targeted (v) and the type of message appeal used (vi).

Sample

A list of the United States video ads was obtained from the CDC MCRC database, which included 62 freely available antismoking ads produced since 2008. However, this study was not able to evaluate all of the video antismoking ads because CDC did not grant us permission to access the database. Videos were accessed by searching for advertisements on YouTube according to the description presented on the MCRC website. Seven of the ads have two kinds of versions: 15 and 30 seconds. Only one version of the ads was included in this study if both versions were selected. Using a random number generator, 20 free television advertisements were selected because some of the ads could not be found or access through the Internet.

Advertisements released by the Taiwanese government were obtained from the Taiwan Bureau of Health Promotion website, which included 58 antismoking advertisements produced since 2008, all of which were included in this study. All of the advertisements are available from YouTube. Advertisements using different languages or having different lengths, such as 15 versus 30 seconds, but displaying similar scenes and slogans were coded as one advertisement. Therefore, after accounting for repetitive advertisements, 30 advertisements were included in this study.

For China, the authors accessed the China Tobacco Control Resource Center and reviewed 36 advertisements released since 2012. All of the advertisements were included in this study and can be downloaded from China Tobacco Control Resource Center. Of those 36 advertisements, 13 advertisements were made by Hong Kong (HK) Department of Health. In 1997, the United Kingdom returned the sovereignty of HK to China, meaning it is considered part of China and deeply influenced and controlled by China, so the advertisements produced by HK were included in the current study.

Measures

General advertisement characteristics

Before analysing the messages of the antismoking television advertisements, we collected the general characteristics of each advertisement, including the length of the advertisement, the filming location and the target population. Advertisement length was categorized into four groups: (i) <31 seconds, (ii) 31–60 seconds, (iii) 61–90 seconds, and (iv) >90 seconds. The settings were categorized into (i) home, (ii) workplace, (iii) public areas, or (iv) other. For example, advertisements that were filmed in the living rooms was regarded as “home” and those that used an office as settings were categorized as “workplace.” There were two target populations in the study: (i) whose behavior the advertisement is meant to change and (ii) which population the advertisement is trying to protect. For example, an advertisement may be targeting parents (target population) about dangers of smoking around children (population to protect). Populations were each categorized into six groups: (i) people <25 years old, (ii) female, (iii) male, (iv) adult, (v) general population, and (vi) other. These categories were selected as they represented the most common target groups.

Messages

According to the HBM, realizing the benefits of not smoking and understanding the health consequences of smoking may influence one’s behavior. Antismoking advertisements (cues to action) might enhance one’s self-efficacy to modify their behavior. For this study, we examined the following variables from the HBM: perceived severity, perceived benefits, perceived threat, and self-efficacy ( Fig. 1 ).

Fig. 1.

Health belief model.

The severity of the consequences of smoking was categorized into (i) none, (ii) moderate or (iii) severe. Moderate consequences were defined as references to tobacco being bad for your health or breath; severe consequences were defined as references to chronic or severe illness, or damaging other’s health severely. For instance, advertisements that mentioned severe consequences of smoking included information such as smoking increases risk of lung cancer and showed pictures of lung cancer. Those that showed that smoking damages people's teeth were regarded as indicated moderate consequences of smoking.

Perceived threat of disease was determined based on whether the advertisement indicated what kinds of threats or risks smokers might face and whether the ad illustrated the severity of the consequences of smoking. The threats or risks identified were (i) social, (ii) health, (iii) financial, and (iv) other. “Social” threats refer to ads suggesting that peers, friends or strangers disapprove smoking, i.e. ads showed that people surrounded by the smokers were disgusted by smoke. Ads that mentioned how smoking may cause death or disease such as cancers were coded as “health” risks. Ads were coded as “financial” threat when they included a message referring to costs associated with smoking, including fines for smoking in certain public areas. If the ad presented any threats or risks other than those discussed above, threat was categorized as “other.”

Finally, advertisements were categorized by whether they included messages that encouraged audiences’ self-efficacy. If the ads indicated the audience could take some appropriate action, self-efficacy was coded as moderate; ads that included specific statements, such as “you can quit” were coded as strongly encouraging audiences’ self-efficacy beliefs. Perceived benefits was treated as a dichotomous variable with advertisements either addressing (yes) or not addressing (no) the benefits of not smoking or quitting smoking.

Based on the premise that public health strategies that focus on multiple levels are more likely to be effective, the ads were analysed in comparison the CDC’s socioecological framework. The ads were categorized into four types, corresponding to which social–ecological level the ad targeted: (i) individual, (ii) relationship, (iii) community or (iv) societal level. Advertisements that targeted the individual level concentrated on delivering messages, emphasizing the importance of not smoking or showing the consequences of smoking for an individual. For the relationship level, advertisements mentioned adverse health consequences that smokers bring to their family. The community level targeted ads focused on showing the importance of protecting communities’ environments, such as indicating that it is inappropriate to smoke in the workplace and different waiting rooms. Finally, some advertisements were aimed at announcing or promoting new tobacco control regulations, which were coded as targeting the societal level.

Previous studies have shown that different advertising appeals have distinctive impact on specific population. For instance, ads using fear approach were more effective for adults, while humor and social approach were more likely to influence adolescent [ 44–46 ]. Antismoking messages were categorized into one of four types of advertising appeals: (i) fear, (ii) humor, (iii) social, and (iv) personal responsibilities appeals [ 47 ]. Advertisements that presented fear-invoking themes, such as death, serious disease, were coded as using a “fear” approach, whereas advertisements that could make people smile or feel relaxed were coded as using “humor” appeals. “Social” appeal was coded when the advertisement referred to smoking as disgusting or not acceptable in society, and “personal responsibilities” appeal was coded for ads that delivered messages including smokers’ failure to accompany their family members. For example, an advertisement using a “personal responsibilities” appeal might show a girl who hoped her dad could attend her wedding, but her father died of smoking-related diseases at an early age.

Training and reliability

During the training process, coders discussed each coding instrument thoroughly and practiced coding five advertisements that were included in the database, but were excluded from the study sample. After a 1-week training period, coders modified the codebook and clarified terms or categories to increase the reliability. Two coders both coded 20% of the advertisements independently to determine inter-coder reliability. The average for the inter-coder reliability was 0.79, ranging from 0.61 to 1 ( Table I ). Coders discussed the context together after independently coding the ads if there was a disagreement among coders. We explained the reasons why we chose the answers and examined which explanation was more reasonable.

Table I.

Inter-coder reliability

Variables	Value
What is the length of the ads?	1.00
Whose behavior is the ad meant to change?	0.71
Which population does the ad try to protect?	0.74
Where is the setting?	0.81
What kind of threats or risks do the ad present toward smokers?	0.73
Does the ad indicate the severity of consequences of smoking?	0.61
How much does the ad encourage self-efficacy beliefs?	0.78
Does the ad indicate the benefits of not smoking or quitting smoking?	0.90
Which level of social–ecological model does the ad target?	0.74
Which types of advertising appeals does the advertisement use?	0.83

Data analysis

All data were coded into excel and then exported into SPSS (version 22) for analysis. Data were first analysed using χ ² without distinguishing between countries and then compared by countries to gain a better understanding of national/cultural differences.

Results

General advertisement characteristics

Descriptive statistics ( Table II ) indicated that among all of the antismoking advertisements, 53.5% were ≤30 seconds, 38.4% were between 31 and 60 seconds and 8.1% were more than a minute. A high percentage (62.8%) of advertisements were trying to change the general population’s behaviors. The target populations for rest of the advertisements varied: 15.1% were for adults, 10.5% for males, 7% for females, and 4.7% targeted people under 25 years old. Compared to the United States and Taiwan, China had a higher percentage of ads that targeted adults (22.2%) and males (13.9%). Most of the advertisements (68.6%) were trying to protect the general population, but several of them were targeting a more specific population. Among the remaining advertisements, 16.3% were trying to protect people <25 years old, 5.8% were trying to protect females, 3.5% were trying to protect males and 1.2% were trying to protect adults. The ads retrieved from the United States were more likely to target people <25 years old (15%). The filming locations for the advertisements were mostly in public areas (43%), and home (17.4%). The United States had a relatively higher percentage (50%) of the ads that were filmed at someone’s home, yet 32.6% of ads across the three nations did not have a clear filming location because they were made by animations, or a singular color background, such as black, brown or white. There were significant between country differences for setting and target behavior change, as noted within Table II .

Table II.

Descriptive statistics for general ad characteristics

Country	US ( n = 20)	Taiwan ( n = 30)	China ( n = 36	Overall ( n = 86)
Length (seconds), n (%)
0–30	13 (65)	14 (46.7)	19 (52.8)	46 (53.5)
31–60	6 (30)	12 (40)	15 (41.7)	33 (38.4)
61–90	1 (5)	4 (13.3)	0	5 (5.8)
>90	0	0	2 (5.6)	2 (2.3)
Setting, an (%)
Home	10 (50)	1 (3.3)	4 (11.1)	15 (17.4)
Workplace	0	1 (3.3)	4 (11.1)	5 (5.8)
Public areas	2 (10)	15 (50)	20 (55.6)	37 (43)
Other	8 (40)	13 (43.3)	8 (22.2)	29 (33.8)
Whose behavior the advertisement is meant to change, bn (%)
People <25 years old	0	4 (13.3)	0	4 (4.7)
Female	4 (20)	1 (3.3)	1 (2.8)	6 (7.0)
Male	3 (15)	1 (3.3)	5 (13.9)	9 (10.5)
Adult	1 (5)	4 (13.3)	8 (22.2)	13 (15.1)
General population	12 (60)	20 (66.7)	22 (61.1)	54 (62.8)
Protect, n (%)
People <25 years old	3 (15)	5 (16.7)	6 (16.7)	14 (16.3)
Female	2 (10)	1 (3.3)	2 (5.6)	5 (5.8)
Male	2 (10)	0	1 (2.8)	3 (3.5)
Adult	0	0	1 (2.8)	1 (1.2)
General population	13 (65)	24 (80)	22 (61.1)	59 (68.6)
Other	0	0	4 (11.1)	4 (4.7)

^a Significant difference between countries ( P < 0.05).

^b Significant difference between countries ( P < 0.001).

Messages

The study examined in-depth information about types of messages and appeals presented in antismoking ads ( Table III ). We found 58.1% of ads clearly mentioned the health risks that the smokers might have in the future, and 27.9% revealed both social and health risks in the ads. More than 50% of ads indicated smoking would have severe consequences, such as death, developing cancers or social stigma. Yet, 23.3% of the ads did not provide any information about the severity of consequences of smoking. About 41% of ads strongly encouraged self-efficacy beliefs, and 43% moderately encouraged self-efficacy beliefs. A high percentage of ads (84.9%) emphasized the benefits of not smoking.

Table III.

Descriptive statistics for messages

Country	US ( n = 20)	Taiwan ( n = 30)	China ( n = 36)	Overall ( n = 86)
Threat, an (%)
Social	0	4 (13.3)	1 (2.8)	5 (5.8)
Health	18 (90)	18 (60)	14 (38.9)	50 (58.1)
Financial	0	1 (3.3)	0	1 (1.2)
Social and health	2 (10)	3 (10)	19 (52.8)	24 (27.9)
Health and financial	0	2 (6.7)	2 (5.6)	4 (4.7)
Other	0	2 (6.7)	0	2 (2.3)
Severity of consequences of smoking, an (%)
No	0	4 (13.3)	16 (44.4)	20 (23.3)
Moderate	2 (10)	10 (33.3)	7 (19.4)	19 (22.1)
Severe	18 (90)	16 (53.3)	13 (36.1)	47 (54.7)
Self-efficacy beliefs, n (%)
No	2 (10)	4 (13.3)	8 (22.2)	14 (16.3)
Moderate	5 (25)	15 (50)	17 (47.2)	37 (43)
Strong	13 (65)	11 (36.7)	11 (30.6)	35 (40.7)
Benefits of not smoking, bn (%)
Yes	20 (100)	27 (90)	26 (72.2)	73 (84.9)
No	0	3 (10)	10 (27.8)	13 (15.1)
Social–ecological level, an (%)
Individual	13 (65)	15 (50)	3 (8.3)	31 (36)
Relationship	5 (25)	7 (23.3)	14 (38.9)	26 (30.2)
Community	2 (10)	7 (23.3)	17 (47.2)	26 (30.2)
Societal	0	1 (3.3)	2 (5.6)	3 (2.6)
Message appeal, an (%)
Fear	11 (55)	6 (20)	6 (16.7)	23 (26.7)
Humorous	0	9 (30)	2 (5.6)	11 (12.8)
Social	2 (10)	9 (30)	22 (61.1)	33 (38.4)
Personal responsibility	7 (35)	6 (20)	6 (16.7)	19 (22.1)

^a Significant difference between countries ( P < 0.001).

^b Significant difference between countries ( P < 0.05).

The results showed that 36% of ads were targeting individual level, 30.2% were targeting relationship level, 30.2% were targeting community, and 2.6% were targeting societal level. The percentage of each message appeal type used by antismoking ads are as follows: 26.7% of fear, 12.8% of humorous, 38.4% of social, and 22.1% personal responsibility appeals. There were significant between-country differences for all message aspects except self-efficacy beliefs, as noted in Table III .

Between-country differences

This study also compared the statistics cross-nationally to better understand the difference between countries. All of the ads in the United States mentioned the severity of consequences of smoking, with 90% emphasizing the consequences as severe. However, 13.3% of ads in Taiwan and 44.4% of ads in China failed to present the consequences of smoking. All of the ads in the United States focused on presenting the health and social threats toward smokers. Although there were a high percentage of ads in Taiwan and China that also presented the health and social threats, 10% of ads in Taiwan and 5.6% of ads in China mentioned the financial threats caused by smoking. Most (83.7%) of the ads across the three countries encouraged audiences’ self-efficacy of not smoking. Compared to Taiwan and China, the United States had a relatively higher percent of ads strongly encouraging audience’s self-efficacy (Taiwan: 36.7%, China: 30.6%, and United States: 65%). About one-fifth of ads in China did not encourage audiences’ self-efficacy of not smoking. All of the ads in the United States and 90% of ads in Taiwan mentioned the benefits of not smoking, yet there were 27.8% of ads in China that provided lack of information regarding the benefits of not smoking.

Both Taiwan and China’s governments produced antismoking ads that specifically targeted different social–ecological levels, yet none of the US ads targeted the societal level. The approaches of delivering antismoking messages varied between countries. Fear and personal responsibility appeals were more likely to be used in the United States, whereas over half of the ads in China used social appeals. In Taiwan, the percentages of using four types of message appeals were almost evenly distributed.

Discussion

The aim of this study was to review the content of antismoking ads in the United States, Taiwan, and China within the framework of the HBM and SEM. Results indicated that ads produced by the US CDC MCRC were more likely to mention the severe consequences of smoking, promote the self-efficacy of quitting, and illustrate the benefits of not smoking. Compared to the United States and Taiwan, China was least likely to provide the information that we regarded as important factors to increase people’s willingness of changing their behaviors.

A high percentage of the ads in the United States targeted the individual level, whereas most of the ads in China were aimed at the relationship or community levels. Also, none of the ads in the United States targeted the societal level. Further research is needed to understand why the CDC MCRC database does not include any ads for targeting the societal level, and why most of the ads in China were not targeting at the individual level. We suggest that it might because China is a communist country, where people concerns about their communities’ values. However, further study to address reasons why Chinese government chose to use these types of approaches is warranted. As for Taiwan, different ads were produced to target each social–ecological level and deliver messages using different approaches. We suggest that the antismoking ads include diverse components could have an impact to a larger group of people, which lead to low smoking and SHS exposure rates in Taiwan. Studies should examine whether it is necessary for each country to develop ads that include diverse components in the future. For example, to create culturally sensitive antismoking ads, health professionals in the United States should consider creating ads that indicate financial threats in the ads in the future.

The findings of this study were consistent with previous studies that indicated a fear approach is the most frequently used for delivering antismoking messages in the United States [ 47 ]. Research has also indicated this fear appeals could effectively motivate smokers change their behaviors [ 48 ]. The reasons the Chinese government uses social appeal when producing antismoking ads remain unknown. Future research could include examining the effectiveness of using social approach for delivering antismoking messages in China. Some approaches have been found more effective than others, depending on which population they target [ 44 ]. For example, one study showed that fear appeals are not effective for youth populations because death and diseases do not pose a threat to them in the short term [ 44 , 45 ]. Also, Beaudoin [ 44 ] found that the fear appeal is the most common type of approach overall in antitobacco advertisements, whereas advertisements targeting youth are more likely to use humor and social appeals. Understanding whether the impact of China ads is equivalent to those within United States or Taiwan that include additional content such as severity of smoking and benefits of not smoking may be beneficial.

Antismoking media campaigns can also be ineffective. McVey and Stapleton [ 49 ] found that smoking prevalence dropped in the first few months after delivering antismoking messages, but the effect of antismoking advertisements decreased over time due to reductions in advertising intensity. Therefore, in addition to promoting powerful antismoking messages, government agencies and antismoking campaigns should also improve the campaigns’ reach, intensity, and duration [ 50 ].

This study is not without limitations. First, we do not know the use/exposure of the ads for each country. Ads that we examined in this study were all accessible via the Internet, yet we do not know whether these ads have been aired or still aired. Second, there are some limitations regarding the samples. The researchers were unable to access the CDC MCRC database, and therefore accessed the advertisements via another source (YouTube). Therefore, the analysed advertisements might be over representative. It is possible that the selected advertisements have a higher quality or clicking rate, which led people or the campaigns to share the advertisements through YouTube.

For the data recruited in Taiwan, 50% of ads were determined from the uploaded year rather than the actual produced year of the ads because the Taiwan government did not provide the detailed information on the website. This might create some bias, as the objective was to analyse the ads after 2008. The other 50% of ads were made by citizens, who participated in a competition held by the Taiwanese government. Further study is needed to examine the quality of ads that were produced by residents, who were participants in a government-sponsored competition.

In China, among 36 ads, one-third were made by the HK Department of Health. HK was a colony of United Kingdom (UK) before 1997; thus, their cultural, lifestyle, and economics are deeply influenced by UK, a country which has produced a high number of antismoking ads [ 51 ]. We expect the ads produced by HK are more likely to provide the information that motivates people to remain healthy behaviors.

Conclusion

The present study is, to our knowledge, the first content analysis examining the antismoking ads retrieved from the Taiwan Bureau of Health Promotion website and the China Tobacco Control Resource Center. The present study provided important information about what kind of messages the ads provided in the United States, Taiwan, and China, and which type of message appeals each country used. McAfee et al. [ 52 ] found that the first national antismoking TV ads produced by the United States helped smokers to quit and increased the willingness of quitting. Since such powerful ads are all freely accessible online, Taiwanese and Chinese governments could analyse the content of the ads to understand how they can compose more powerful ads. Further research is warranted to compare the effectiveness of the ads that were examined in this study. This will allow the researchers and antitobacco campaigns to develop ads that have greater impact on people’s behaviors and beliefs in the future.

Acknowledgements

The authors would like to thank Jing Jin who assisted with coding 20% of the advertisements to improve the reliability of this study. Tzu-Jung Wong planned the study, searched the articles and reviewed all included articles in this study, as well as completed the manuscript and submission. Jamie Pomeranz provided support and comments during the stage of developing the study. Jessica King provided support to complete introduction section, conducted analyses, and edited the manuscript.

Conflict of interest statement

None declared.