Ferenczi, B, Lee, W, Frankel J et al: Anti-tobacco advertising–is bladder cancer adequately addressed? Urol Pract 2021; 10: 1097.

Bladder cancer is a relatively common tobacco-associated malignancy. The incidence in the United States is estimated to be 81,400 in 2020, accounting for approximately 4.5% of cancer deaths.¹ Approximately 50% of bladder cancer can be attributed to first-hand tobacco exposure, with an approximate twofold increase in relative risk of developing bladder cancer in current smokers.² Anti-tobacco advertising has been demonstrated to be efficacious in educating the public on the adverse health effects of tobacco.³ Despite this efficacy, there is a clear lack of awareness regarding the causative role that tobacco plays in development of bladder cancer with less than 50% of the general public aware of the association.⁴ The goal of this study was to quantify the inclusion of bladder cancer in online anti-tobacco advertising campaigns compared to other malignancies and assess whether bladder cancer is appropriately referenced in online anti-tobacco video advertisements.⁵

We identified smoking cessation videos using the Google Video search page. Google Video is a public internet search engine of video files available for online viewing.⁶ Search terms included “Quit smoking commercial,” “Smoking health risks advertisement,” “Anti-smoking campaign” and “Stop smoking ad.” The first 50 video results for each search term were included in our analysis. Smoking cessation videos were evaluated by 2 independent reviewers and coded by diseases or conditions impacted by smoking behavior that were mentioned in the advertisement. Videos were categorized as malignancy-related antitobacco advertisement (ATA-m) or all anti-tobacco advertisement (ATA-a). Relative weight for each type of cancer was defined as the rate of reference within ATA-m divided by the incidence of that cancer among all smoking-related malignancies for the year 2018.⁵

Our final analysis included 200 total videos, which had been viewed a total of 264,666,578 times. Overall, the most common conditions highlighted in advertisement campaigns were addiction (56, 27.0%) and death (26, 13.0%). Of all advertisements, 68 (34.0%) addressed tobacco-associated malignancy. The most common malignancies addressed in the videos were lung cancer (22, 11.0%), throat cancer (20, 10.0%) and oral cancer (9, 4.5%). Lung cancer and throat cancer alone accounted for 61.8% of ATA-m. Of the 200 videos reviewed, 1 (0.5%) mentioned smoking as a cause of bladder cancer. Regarding outreach, the total number of views for videos related to throat cancer, oral cancer and lung cancer were 46.2 million, 17.4 million and 3 million, respectively, while there were 21,500 total views for videos discussing bladder cancer. Accounting for incidence, the relative weights of each malignancy were lung cancer 1.09, oral cancer 18.26, throat cancer 1.94, bladder cancer 0.14 (see table).⁵

This study demonstrates that significant opportunity for public education regarding the relationship between tobacco use and bladder cancer exists. Lung cancer, which accounts for 29.6% of tobacco-related malignancy, is appropriately the most commonly referenced malignancy in ATA-m. The relative weight of lung cancer of 1.09 demonstrates a close relationship between disease incidence and prevalence in anti-tobacco advertisement. Throat cancer, however, is clearly disproportionately overrepresented in anti-tobacco advertisement. While it represents only 1.6% of tobacco-related malignancy, it accounts for nearly a third of ATA-m. In contrast, of 200 videos assessed only 1 noted the association between tobacco use and bladder cancer. This translates directly into decreased outreach. Although bladder cancer makes up a larger proportion of tobacco-associated malignancy than throat cancer, in our sample of advertisements there were over 46 million more views for advertisements discussing throat cancer.

Based on our review of ATA-m, it appears that the current approach heavily relies on a “shock value” approach to tobacco prevention. Throat cancer and oral cancer, with clearly visible comorbidities associated with both the disease and treatment, are heavily represented in ATA-m. However, studies suggest that fear-based approaches in marketing are often ineffective and can in fact lead to unintended adverse effects including complacency regarding risks.⁷ Using a more representative approach towards depicting tobacco-associated malignancy in anti-tobacco advertising may be a more effective way both to educate the public on harms of smoking and to deter tobacco use.