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Yes—well-designed public-health campaigns can change how people interpret the risks of cigarettes, vaping and other harmful products. The clearest evidence is not that an advertisement automatically changes conduct, but that repeated, audience-specific messages can make particular health beliefs more salient. In a nationally representative U.S. youth cohort, greater self-reported exposure to the FDA’s The Real Cost advertisements was associated with stronger agreement with the harms those advertisements targeted. That is a meaningful perception effect, while still falling short of proof that advertising alone caused every later change in use.
The practical lesson is to treat perception as one stage in a chain: people must encounter a message, understand its intended claim, update a belief or intention, and only then might behavior change. Campaigns that skip those distinctions can claim success too early or accidentally mislead people about relative risks.
What “tobacco-style” countermarketing actually does
Tobacco-style public-health advertising is usually a form of countermarketing. Rather than selling a product, it challenges demand by explaining health consequences, exposing producer motives and revealing how marketing practices can manipulate audiences. Palmedo, Dorfman, Garza, Murphy and Freudenberg’s 2017 review in Annual Review of Public Health describes countermarketing as communication intended to reduce demand and undermine commercial promotion.
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The approach has several recurring components:
- Make consequences concrete: explain adverse health effects in language an intended audience can understand.
- Use emotion deliberately: negative emotions can make an otherwise abstract risk feel personally relevant.
- Expose manipulation: show how an industry’s advertising, product design or promotional tactics can influence choices.
- Involve the audience: engage intended users in campaign design or implementation so that the message reflects their concerns and vocabulary.
The review concludes that tobacco countermarketing has been demonstrated as an effective component of comprehensive tobacco control and may help denormalize tobacco, alcohol and unhealthy-food marketing. That is evidence for a communication approach, not a guarantee that a tobacco message can be copied unchanged onto every other product.
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What the strongest youth evidence shows
The Real Cost and ad-specific beliefs
MacMonegle and colleagues reported a 2022 analysis in the CDC journal Preventing Chronic Disease. The study followed a nationally representative cohort of U.S. youth surveyed at baseline and follow-up between June 2018 and July 2019. Participants reported whether they had encountered FDA The Real Cost advertisements and answered questions about beliefs that the advertisements were designed to address.
Young people who reported greater exposure had higher odds of agreeing with multiple campaign-specific harm beliefs. The association appeared for beliefs linked to the ads, whereas unrelated beliefs did not show the same pattern. That specificity matters: it is more consistent with messages influencing the ideas they directly addressed than with a general tendency for highly aware respondents to agree with every health statement.
The correct wording is “greater reported exposure was associated with stronger agreement with targeted beliefs.” The longitudinal cohort design did not prove that exposure alone caused all subsequent behavior change. Exposure was self-reported; other prevention campaigns may have worked alongside The Real Cost; and, as with other observational longitudinal analyses, unmeasured differences between participants could contribute to the result.
What FDA says the campaign measures
FDA describes The Real Cost as a youth campaign about the negative health effects and risks of smoking and vaping. Its evaluation framework separates several outcomes:
- Awareness: did the intended audience notice or recognize an advertisement?
- Knowledge and beliefs: did people understand and accept the specific risk the message presented?
- Attitudes and intentions: did the product become less attractive, or did intentions to start or continue change?
- Behavior: did initiation, use or cessation change?
FDA’s own description captures the purpose: “The e-cigarette and cigarette prevention campaigns focus on educating youth about the negative health effects and risks of vaping and smoking.” Awareness is therefore an entry condition, not the final outcome.
Why perception can change before behavior
Products are chosen in social and commercial environments. A campaign can alter the information people retrieve when they think about a product, the credibility they assign to its marketing and the social acceptability they attach to use. Those changes may affect intentions, but they compete with price, availability, dependence, peer influence, stress and existing habits.
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For that reason, an evaluation should report a sequence rather than a single “impact” number. A person may remember an advertisement without accepting its claim; accept the claim without intending to quit; intend to quit without succeeding; or change behavior for reasons unrelated to the campaign. Conversely, a campaign can contribute to a population trend while policy, enforcement, school programs and healthcare advice are also operating.
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Message design: four decisions that determine what people learn
1. Define the audience and product
A campaign should specify who is meant to receive it and what product decision is at issue. A message for adolescents who have never used nicotine is different from one for adult smokers considering a substitute. Age, current use, dependence, literacy, culture and media habits affect which explanation is understandable and which fear appeal is credible.
“Harmful products” is not one scientific category. Cigarettes, electronic cigarettes, alcohol and ultra-processed foods have different exposure patterns, health outcomes and consumer choices. Evidence for one category should be presented as a starting point for design, not as proof of equal effectiveness elsewhere.
2. Choose the claim: absolute harm, relative harm, addiction or conduct
Campaigns can emphasize the product’s absolute health risks, compare it with a more harmful or less harmful alternative, explain addiction, or expose industry conduct. These claims answer different questions. A statement about whether vaping is harmful is not the same as a statement about whether vaping is less harmful than smoking.
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3. Make manipulation visible without replacing evidence
Showing how marketing creates appeal can help audiences question commercial claims. The 2017 review identifies industry manipulation as a common countermarketing element, alongside health consequences and emotional appeals. Manipulation-focused content should still explain the underlying risk; anger at a producer is not a substitute for accurate health information.
4. Involve intended users
Audience participation can reveal which words, images and examples are credible and which are dismissed as exaggerated. It can also expose misunderstandings before launch. Participation does not remove the need for medical accuracy or independent evaluation; it improves the chance that the intended audience will understand the message as designed.
Relative-risk communication: the vaping warning
Evidence from England’s 2022 vaping update shows why a simple instruction to “make the product seem harmful” can backfire. A systematic review found that interventions communicating vaping’s absolute harms generally increased perceptions that vaping is harmful. Interventions communicating reduced harm compared with smoking generally increased the perception that vaping is less harmful than smoking.
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| Message emphasis | Perception that the evidence update found | Design implication |
|---|---|---|
| Vaping’s absolute health harms | Generally increased perceived harm from vaping | Explain the risk precisely and avoid implying equivalence with smoking unless that is the claim being supported |
| Vaping’s lower harm relative to smoking | Generally increased the belief that vaping is less harmful than smoking | Name both products and the comparison; distinguish “less harmful” from “safe” |
England’s 2021 survey of adult smokers illustrates the communication challenge. Only 34.1% accurately perceived vaping as less harmful than smoking; 32.1% thought the harms were about the same, 11.9% thought vaping was more harmful and 22% did not know. These figures describe England in 2021, not a current worldwide estimate.
What the early FDA figures mean—and what they do not
FDA’s campaign summary reports several results from the early U.S. evaluation of The Real Cost. They are campaign-specific estimates tied to the stated period and audience:
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| Reported result | Qualification |
|---|---|
| More than 90% of the target audience aware of the first ad wave less than a year after launch | FDA figure reported in 2015 for the U.S. youth campaign |
| 30% decrease in youth smoking initiation from 2014 to 2016 | FDA-reported evaluation result for that campaign period |
| $180 in cost savings for every dollar invested during the first two years | FDA-reported estimate for the early campaign evaluation |
These numbers should not be presented as a guaranteed return, a universal youth effect or evidence that advertising alone produced every decline in initiation. They show what FDA reported for a defined U.S. campaign, period and evaluation. A new campaign needs its own reach, outcome and cost analysis.
How to evaluate a campaign without confusing awareness for impact
A practical evaluation plan follows the audience through distinct checkpoints:
- Document delivery and reach. Record where and when messages ran, the intended audience and the frequency of exposure. Ask respondents whether they saw or heard the material, rather than assuming delivery equals exposure.
- Test message recognition and comprehension. Use unaided and aided recall, then ask what the advertisement was claiming. A remembered image with a misunderstood claim is not a successful communication.
- Measure targeted beliefs. Predefine the exact belief each ad is intended to change. Include unrelated beliefs as checks, as the youth cohort study did, to see whether movement is specific rather than a general response tendency.
- Track attitudes and intentions. Measure perceived risk, product appeal, intentions to start, continue, quit or switch, and confidence in taking the intended action.
- Measure behavior separately. Use initiation, current use, cessation, switching or purchase outcomes appropriate to the product. State the time window and whether the measure is self-reported.
- Assess alternative explanations. Account for other campaigns, policy changes, school or clinical programs and differences in who was exposed. Avoid assigning a broad population trend to one campaign without supporting causal evidence.
- Monitor unintended interpretations. Check whether people infer that a less harmful product is harmless, that two products have equal risk, or that a warning applies to a group for whom the comparison differs.
This sequence lets decision-makers locate the problem. High reach with little belief change suggests a message or credibility issue. Belief change without intention change points to competing incentives or dependence. Intention change without behavior change may indicate barriers that communication cannot solve on its own.
Independent reader supportYour contribution helps us test, update, and keep practical guides available for everyone.Applying the approach to alcohol, food and other products
Palmedo and colleagues discuss alcohol and unhealthy-food marketing as potential applications of countermarketing. The word potential is important. Tobacco’s evidence base does not prove that the same imagery, emotional tone or producer-focused argument will work for alcohol, food, gambling or another category.
Transfer requires product-specific evidence about exposure, dose, benefits and harms. For food, a message about marketing tactics may need to coexist with practical information about portions, availability and household constraints. For alcohol, risk varies with amount, frequency, age, pregnancy and other factors. For nicotine products, the relative-risk relationship between smoking and vaping must be stated accurately for the audience in question.
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Use the following comparison axes before adapting a campaign:
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- Audience and current product use.
- Absolute harm, relative harm, addiction or industry conduct as the central claim.
- Reach, frequency and duration of exposure.
- Intermediate outcomes—awareness and beliefs—versus behavioral outcomes.
- Potential misunderstandings created by the comparison or emotional framing.
Common failure modes and corrections
Claiming behavior change from attention alone
Failure: “Most teens saw the ad, so the campaign stopped use.”
Correction: Report awareness, targeted beliefs, intentions and behavior as separate outcomes, and identify the evaluation design behind each claim.
Using absolute warnings that erase relative differences
Failure: Saying a product is harmful without clarifying how its risk compares with the product being considered as an alternative.
Correction: Name the reference product, avoid “safe” language and test comprehension among both non-users and current users.
Assuming emotional intensity is sufficient
Failure: Relying on shock or anger without a clear, credible health explanation.
Correction: Pair emotion with a specific consequence, an understandable mechanism and an action or decision relevant to the audience.
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Failure: Treating a decline in use as proof that one advertising effort caused it.
Correction: Examine concurrent policies, prices, access restrictions, clinical advice and other communications before making a causal claim.
Copying tobacco creative into a new category
Failure: Reusing a tobacco message for alcohol, food or vaping without testing its interpretation.
Correction: Retain the countermarketing principles, but develop and evaluate product-specific claims and comparisons.
A decision framework for building a credible campaign
Before approving creative work, require clear answers to these questions:
- Which people, in which product situation, must change a belief or decision?
- What single claim should the audience remember, and is it about absolute or relative harm?
- What evidence supports that claim for this product and population?
- How could a reasonable viewer misunderstand the message?
- What exposure level is expected, and how will actual exposure be measured?
- Which targeted belief should move first?
- Which intention or behavior will be measured later, and over what period?
- What other campaigns or policies could explain the same outcome?
Answering these questions does not guarantee success. It does prevent a common category error: treating a memorable advertisement as if it were a complete public-health intervention. Countermarketing works as one component of a broader system that may include regulation, education, treatment and changes to the environments in which people make choices.
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