Exposure to alcohol advertising is independently associated with initiating drinking, drinking dependence, and binge drinking among young adults .Middle and high school students that own alcohol branded merchandise are more likely to report ever alcohol use. Ownership of alcohol branded merchandise is positively associated with youth perceptions on peer use and peer acceptance of alcohol.Nicotine cravings are enhanced by alcohol use and alcohol cravings are enhanced by nicotine use.Indeed, cigarette companies use imagery of alcohol use in their cigarette advertisements in print media, which disproportionately impacts young adults, particularly college students. Likewise, exposure to television food commercials is an important predictor for unhealthy food choice, brand preference, and high caloric food consumption.Receptivity to television fast food marketing is associated with youth obesity, with a one point increase in marketing receptivity being associated with a 19% increased odds of being obese.Electronic commerce such as internet, mail order, text messaging, and social media sales are difficult to regulate, leading to increased youth sales, tax evasion, and illicit trade compared to traditional tobacco sales.Although tobacco companies advertise on the internet, a substantial amount of tobacco promotion occurs through social media and user-generated promotional media, and the content is predominantly positive. These messages reach both adults and adolescents.In addition, internet sales have provided new avenues for tobacco companies to market their products to youth.A 2002 study that examined cigarette advertising on the Internet in the USA found that nearly 20% of cigarette-selling websites did not include warnings that sales to minors are illegal or prohibited. Among those websites that required some form of age-verification,vertical rack more than half required that a buyer confirm legal purchase age , 15% required that buyers manually type in their date of birth, and 7% required buyers manually enter information from a driver’s license.

At least fifteen US attorneys general have conducted Internet stings and found that children as young as 9 years old were able to purchase cigarettes. For example, a New York sting operation found that 93% of websites observed had sold to children under 18 . A 2004 study found that more than 96% of minors aged 15-16 were able to find an Internet cigarette vendor and place an order in less than 25 minutes, with most completing the order in seven minutes.A study in California found that 101 websites selling tobacco failed to comply with California laws regarding age and ID verification to prevent youth sales. A detailed 22-page summary of the scientific evidence through 2011 on tobacco sales through the Internet submitted to the US Food and Drug Administration to conclude that youth access to tobacco cannot be prevented by existing rules and procedures in the US, including those by which sellers conduct age verification were ineffective at preventing youth access to tobacco products.A 2013 report by the World Health Organization shows that 96 countries banned internet tobacco advertising,141 but enforcing such bans has proven difficult. For example, while the sale of snus is illegal in all European Union countries except Sweden, online vendors in Sweden target online marketing activities toward EU citizens outside of Sweden, including sales promotions, price discounts, and gifts with purchase. A study that made test purchases in ten EU member states reported a 96% success rate . Age-verification relied on self-reports from buyer, and the majority of these sales applied Swedish taxes only, contrary to EU requirements.According to smokers in Western countries, aside from television, the most common source of health information regarding the risks of smoking comes from tobacco product packaging.Indeed, evidence from the Global Adult Tobacco Survey shows that among 12 countries surveyed between 2008 and 2010, more than 90% of men had reported seeing the health warning label on cigarette packages.Large graphic warnings and plain packaging reduce tobacco use, discourage nonsmokers from initiating, and encourage smokers to quit. Large warnings specified in the WHO Framework Convention on Tobacco Control have spread across the world as countries have implemented the FCTC, with slower adoption of effective warning labels in countries that had previously entered into voluntary agreements with the tobacco industry.

The extent to which health warning labels on tobacco packages impact risk perceptions and smoking behavior largely depends upon the size, prominence, position, and design of these messages.Warning labels that cover up to at least 50% or more of principal display areas, and not just limited to the sides of the tobacco package,are associated with increases in health knowledge and motivation to quit. Experimental studies in Canada demonstrate that increasing the warning label from 50% to 75%, 90%, or 100% increased its effectiveness among youth.Studies evaluating graphic, pictorial warning labels in Canada and Australia have shown high levels of cognitive processing and an association between cognitive processing, intentions to quit, and quit attempts.In Brazil and Thailand, countries with strong pictorial depictions on the health impacts of smoking, had the strongest impact on thinking about quitting among current smokers.Nationally representative data from Canada demonstrate that 80% of youth reported pictorial health warning messages decreased the attractiveness of smoking.Compared to small, text-only warning labels, large warning labels that include images in addition to text are more effective at communicating health risks associated with use, evoking an emotional response, provoking thoughts about quitting, increasing motivations and quit attempts among smokers.National data from Canada show that 95% of youth rated pictorial health warnings as more effective at communicating health risks than text-only versions.Large pictorial warnings have longer lasting effects on increasing risk perceptions, encouraging quitting and quit attempts among smokers,and are more likely to be seen by low-literacy adults and children.In contrast, small, text-only warning labels, such as those used for tobacco in the United States, have low impact on youth tobacco use.In addition, these warning labels do not effectively communicate health messages on the specific health risks of tobacco consumption to the public.Young people are less likely to recall seeing text-only warning labels.Among participants that report text-only warning label recall, only one-third were able to accurately recall message content.Additional requirements for effective warning labels include positioning health messages on front and back, and on the top of all principal display areas. Warning labels on tobacco packages are more effective when novel health warnings and messages are used, and the content, layout, and design of the warning label are rotated periodically to avoid “burn out” of stale messages.

While youth perceive health messages on US warning labels for tobacco products to be believable, 186 few reported that these messages were informative or relevant, and that these messages were “vague”, “stale”, and “worn-out”.Warning labels that include messaging with cessation information and a toll-free quitline number are associated with an increase in calls to the quitline,particularly among male smokers and those from low socioeconomic groups,and help to address tobacco-related health disparities. Implementation of comprehensive warning labels for tobacco packaging has been actively opposed by tobacco industry interference in the policy process.Between 1984 and 2003, countries without mandated HWL on tobacco packages transitioned to having either some form of HWL or a voluntary industry HWL passed by the tobacco companies. Countries with voluntary industry HWLs were less likely to adopt comprehensive HWLs, which were compliant with FCTC guidelines than countries with previously enacted mandated HWLs.These findings also point to the importance of implementing at the time of legalization a comprehensive set of demand reduction policies for marijuana before a large marijuana industry develops and works to weaken or defeat public health strategies to control use.Cigarette pack design is a key component to tobacco company marketing techniques.Package design establishes brand identity and promotes brand appeal,seedling grow rack particularly among youth. Tobacco companies design products that are attractive to children while being marketed toward young adult peers. A longitudinal study on youth attitudes toward cigarette brands found a ten-point increase in the proportion of teenage girls reporting a favorite cigarette brand between 2007 and 2008. The study coincided with the launch of RJ Reynold’s campaign for Camel No. 9, a brand that appears to be specifically designed to attract teenage girls, and which accounted for the majority of the increase in brand preference.116 Similar impacts on brand preference were found among young people in Mexico191 that had reported a greater exposure to tobacco marketing and advertising. Tobacco companies use package design techniques to mislead consumers into perceiving their products as less harmful or safer than other tobacco products. Tobacco product packaging with descriptors such as “natural”, “light”, “mild”, and “organic” are associated with false beliefs of the health risks of smoking,and are perceived as less harmful or healthier than tobacco products without these descriptors,likely because the tobacco companies target concerned195 and older smokers at risk of quitting. Indeed, the cigarette companies consider the color of the package as an “ingredient” of the cigarettes that can be used to manipulate users’ perception of the taste of the product in ways interchangeable with changes in the physical product itself.The effectiveness of health warnings may be enhanced through the use of standardized packaging ,a strategy used to reduce attractiveness and appeal of tobacco, to increase the prominence of health warnings,and to correct misperceptions on the health risks of smoking. Plain packaging enhances the effectiveness of health warnings by increasing their notice ability, and has been shown to make smoking less appealing and has the potential to reduce the level of false beliefs about the risks of different brands. Compared to branded packages, tobacco products in standardized packaging are associated with reduced brand awareness and identification,and reduced brand appeal,particularly among young women.

Consistent with previous research in high-income countries, plain packaging in low and middle-income countries have similar impacts on reducing tobacco product appeal.Consistent with adopting a comprehensive tobacco control approach, plain packaging may be useful even if nations have adequately funded mass media campaigns . Unlike media campaigns, packaging changes have almost universal reach and ongoing frequency of exposure. Packaging changes cost little to governments, unlike media campaigns that constantly have to justify their funding allocations against ongoing efforts by tobacco companies to defund media campaigns.As discussed in detail in the next section, plain packs with larger graphic health warning labels complement media campaign messages, amplifying their impact. There is broad scientific consensus that mass media campaigns aimed at the general population are an important element of a comprehensive program to prevent youth initiation of tobacco use and reduce its prevalence.US Surgeon General Report concludes that there is sufficient evidence to infer a causal relationship between the level of funding for anti-smoking media campaigns and reduced smoking prevalence among youth.The effectiveness of well-done anti-tobacco media campaigns is not an argument against other elements of a comprehensive tobacco control policy. Indeed, media campaigns can amplify the effects of other policies, such as plain packaging, advertising restrictions, graphic warning labels and smoke free laws, as well as the other way around, since marketing prohibitions reduce the salience of pro-smoking cues, and increase and reinforce anti-smoking norms. In particular, in Australia, introduction of pictorial health warnings on cigarette packets was supported by a televised media campaign highlighting illnesses featured in two of the warning labels .Between 2005 and 2006, the proportion of smokers aware that gangrene is caused by smoking increased by 11.2 percentage points , and awareness of the link between smoking and mouth cancer increased by 6.6 percentage points . In contrast, awareness of throat cancer decreased by 4.3 percentage points, and this illness was mentioned in the pack warnings but not the advertisements. Smokers who had prior exposure to the warnings were significantly more likely to report positive responses to the advertisements and stronger post-exposure quitting intentions. Thus, anti-smoking television advertisements and pictorial health warnings on cigarette packets reinforced each other to positively influence awareness of the health consequences of smoking and motivation to quit. Analysis of the impact of tobacco control policies and mass media campaigns on smoking prevalence in Australian adults found that stronger smoke free laws, tobacco price increases and greater exposure to mass media campaigns combined to independently explain 76% of the decrease in smoking prevalence from February 2002 to June 2011.For example, youth exposure to anti-tobacco media campaigns reduced the odds of current cigarette use by 15% and smokeless use by 30% compared to students with zero media exposure.