Yes—well-designed public-health countermarketing can change what people believe about a harmful product. The strongest evidence here comes from the U.S. Food and Drug Administration’s youth campaign The Real Cost: in a national youth cohort, people who reported greater exposure were more likely to agree with the specific harm beliefs targeted by the advertisements. That is evidence of an exposure–belief association, not proof that advertising alone changed everyone’s behavior.
The practical lesson is to treat perception as one step in a chain. A campaign must reach a defined audience, make a precise claim understandable, shift a relevant belief, and then be evaluated separately for intentions and actual use. Tobacco-style methods can inform work on vaping, alcohol, unhealthy food and other products, but the risk comparison and evidence must be tailored to each category.
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What “tobacco-style” public-health advertising means
Tobacco-style campaigns are a form of countermarketing. Instead of promoting a product, they reduce demand by showing its health consequences, exposing how producers market it, or both. A 2017 review by Palmedo, Dorfman, Garza, Murphy and Freudenberg describes countermarketing as communication intended to undermine marketing practices and reduce demand. The review concludes that tobacco countermarketing can be an effective part of comprehensive tobacco control and says similar approaches may help denormalize alcohol and unhealthy-food marketing.
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- Explain a credible, relevant adverse health consequence.
- Use emotions such as concern, disgust or empathy when they help the audience understand the consequence.
- Reveal industry tactics, incentives or manipulation that audiences may not have considered.
- Involve intended users in designing or implementing the campaign so the message fits their language and circumstances.
These elements work together. A frightening image without a clear explanation can be dismissed as exaggeration; a factual explanation that ignores a producer’s marketing strategy may fail to challenge the product’s appeal.
What the evidence shows about changing beliefs
The Real Cost and a national youth cohort
MacMonegle and colleagues analyzed a nationally representative cohort of U.S. youth surveyed at baseline and follow-up between June 2018 and July 2019. Greater self-reported exposure to FDA’s The Real Cost advertisements was associated with higher odds that participants agreed with beliefs specifically targeted by those ads. The pattern appeared across multiple ad-linked beliefs, while unrelated beliefs did not show the same association.
This is a meaningful result because it connects reported exposure with the intended cognitive outcome rather than with a vague measure of campaign awareness. The study was longitudinal, but it was not a randomized experiment. Self-reported exposure and beliefs can contain measurement error, and young people may also have encountered other prevention campaigns. The appropriate wording is therefore “exposure was associated with stronger agreement,” not “the ads proved they caused all later behavior change.”
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FDA describes The Real Cost as a youth education campaign about the negative health effects and risks of smoking and vaping. Its evaluation framework tracks awareness, knowledge, attitudes, beliefs and behaviors, including whether a teenager starts using e-cigarettes. FDA’s campaign summary reports three early U.S. estimates:
| Measure | Reported result | Qualification |
|---|---|---|
| Awareness of the first ad wave | More than 90 percent of the target audience | Reported by FDA less than a year after launch; FDA, 2015 |
| Youth smoking initiation | 30 percent decrease | Change reported for 2014–2016 in FDA’s evaluation summary |
| Estimated cost savings | $180 saved for every $1 invested | Estimate for the campaign’s first two years, reported by FDA |
Those figures describe one campaign, audience and evaluation period. They are not a guaranteed return or effect size for a campaign about alcohol, food, vaping or any other product. The initiation and cost estimates also sit within a wider tobacco-control environment that includes policy, price, availability, school programs and changing social norms.
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How a campaign can move perception
Make an invisible consequence concrete
Many harmful products produce delayed or probabilistic outcomes. A message can make the pathway easier to understand by connecting a product, a mechanism and a consequence: for example, showing how nicotine affects a developing adolescent brain or how a marketing tactic encourages repeated use. The claim must be medically accurate and proportionate; sensational wording that cannot be defended can reduce trust.
Expose the producer’s strategy
Countermarketing does more than list harms. It can show how flavors, packaging, influencers, placement or data-driven targeting are used to attract a particular audience. This reframes the audience from a passive consumer to someone being addressed by a commercial strategy. The 2017 review treats this exposure of producer motives and marketing practices as a defining feature of countermarketing.
Use emotion to support, not replace, information
Negative emotion can increase attention and make a consequence memorable, but emotion alone is not a guarantee of persuasion. The ad still needs a clear point, a credible source and an action or interpretation the audience can understand. Testing should check whether viewers can accurately explain the intended claim after the emotional response fades.
Repeat a coherent idea over time
One exposure may create recognition; sustained delivery gives people opportunities to notice, discuss and integrate a message. Reach and duration should be recorded rather than assumed. A campaign can have high awareness but little effect if the audience sees an ad once, cannot recall its claim or receives contradictory information elsewhere.
Perception is not the same as behavior
Public-health teams should keep four outcomes separate:
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- Exposure: Did the intended audience encounter the message, and how often?
- Belief: Did the specific claim change—for example, a belief about addiction, a health consequence or an industry tactic?
- Intention: Did willingness to start, continue, quit or substitute change?
- Behavior: Did initiation, frequency, cessation or product switching change over time?
FDA explicitly lists these kinds of measures for The Real Cost. The 2022 youth-cohort study supports the second step: exposure was associated with campaign-specific beliefs. It does not establish that every belief change produced a reduction in use. A rigorous evaluation reports each stage and tests whether changes persist, rather than treating awareness as proof of health impact.
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The central communication problem differs by category. For cigarettes, a campaign may need to counter normalization and explain long-term disease risk. For vaping, audiences may need both an explanation of absolute health risks and an accurate comparison with smoking. For alcohol or unhealthy food, the relevant harms, time horizon, social context and available alternatives differ again.
Absolute harm versus relative harm
England’s 2022 vaping evidence update illustrates the danger of a one-directional rule such as “make the product seem harmful.” Its systematic review found that interventions communicating vaping’s absolute harms generally increased perceptions that vaping is harmful. Interventions communicating reduced harm relative to smoking generally increased the perception that vaping is less harmful than smoking. The reviewed studies had a high risk of bias, and longer-term effects on vaping, smoking and substitution remained unclear.
The implication is not that one message is always correct. It is that a message must answer the audience’s actual decision. A teenager who has never smoked needs an understandable warning about vaping’s risks. An adult smoker considering a switch needs an accurate relative-risk comparison so that a warning about vaping does not falsely imply that it is equally harmful as combustible smoking.
A documented perception gap among smokers in England
In 2021 survey data cited by the same English update, adult smokers’ answers were divided as follows:
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| Answer about vaping compared with smoking | Share of adult smokers in England |
|---|---|
| Vaping is less harmful | 34.1% |
| About equally harmful | 32.1% |
| Vaping is more harmful | 11.9% |
| Do not know | 22% |
These are England-specific survey findings from 2021, not a current global estimate. They show why campaign planners should measure the exact misconception they want to correct instead of assuming that all audiences interpret “harm” in the same way.
Independent reader supportYour contribution helps us test, update, and keep practical guides available for everyone.A practical design process for a countermarketing campaign
1. Define the audience and decision
Specify age, product use, geography and the decision the campaign seeks to influence: preventing initiation, encouraging cessation, reducing relapse or correcting a relative-risk misunderstanding. A single ad rarely serves all of these purposes well.
2. Choose one primary belief
Write the belief in a testable sentence, such as “This product can cause dependence” or “This marketing tactic is aimed at people my age.” Distinguish absolute harm, relative harm, addiction, social acceptability and industry conduct. Secondary claims should not obscure the primary one.
3. Build the message from evidence
Connect the product, mechanism and consequence in plain language. If the claim compares two products, state the comparison and its limits. Avoid implying that a product is risk-free merely because it is less harmful than another, or that every user experiences the same outcome.
4. Involve the intended users
Use audience members in formative research and creative development. Ask what they believe now, which words they distrust, what they think the ad is saying and whether they can distinguish the intended claim from an unintended one. This follows the participatory element identified in the countermarketing review.
5. Test comprehension before buying reach
Measure unaided recall, aided recognition, comprehension, perceived credibility and possible reactance. Include questions about both the intended belief and plausible misinterpretations. A high recall score is not sufficient if viewers remember the image but draw the wrong conclusion.
6. Deliver enough reach and duration to be observed
Record where and when the audience can encounter the message, estimated frequency and the period of delivery. Compare exposure levels where the evaluation design allows it, while recognizing that people who notice health advertising may already differ from those who do not.
How to evaluate whether perceptions changed
A useful evaluation plan links each objective to a measure and a cautious interpretation:
| Stage | Example measure | What it can tell you |
|---|---|---|
| Exposure | Self-reported ad recognition or verified delivery data | Whether the audience likely encountered the campaign |
| Targeted belief | Agreement with the exact claim featured in the ad | Whether the intended perception moved |
| Unrelated belief | Agreement with a belief not addressed by the ad | Whether the association is specific rather than a general response tendency |
| Intention | Plans to start, stop, continue or switch products | Whether motivation may be changing before behavior |
| Behavior | Initiation, frequency, cessation or substitution at follow-up | Whether the campaign coincided with a real-world outcome |
The design should identify other influences—taxes, restrictions, school programs, product changes and competing campaigns—so that analysts do not credit an advertisement alone for a population trend. Longitudinal studies can strengthen timing, but they still require careful handling of self-reporting, attrition and unmeasured differences between exposed and unexposed people.
Common failure modes and corrections
- Claiming that awareness equals impact: report exposure, belief, intention and behavior as separate outcomes.
- Using an absolute-risk warning where a relative comparison is needed: state both the risk of the product and the comparison relevant to the audience.
- Copying tobacco creative into another category: retain the countermarketing principle but rebuild the claim, imagery and evidence for the new product.
- Relying on fear without explanation: show the mechanism and consequence, then test comprehension.
- Overstating causality: use “associated with” for observational exposure findings and identify other plausible influences.
- Ignoring unintended interpretation: test whether non-users, current users and people considering a switch understand the message differently.
What these campaigns can—and cannot—establish
Tobacco-style countermarketing can make health consequences and commercial tactics more salient, challenge the normality of use and shift targeted beliefs. The Real Cost evidence demonstrates that this pathway is measurable among U.S. youth, and FDA reports substantial early campaign reach alongside campaign-specific estimates for smoking initiation and cost savings.
Those findings do not establish a single best creative style, prove that advertising alone changes behavior or show that a belief shift reduces harm for every product. Campaigns work alongside regulation, prices, availability, clinical support, education and social norms. The strongest public-health communication therefore makes a precise claim, measures the belief it targets, checks for misunderstanding and follows the audience through intentions to behavior.
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