Background:
Cigarette marketing impacts brand awareness of very young children in low- and middle-income countries (LMICs). Exposure to tobacco marketing during childhood is associated with favorable attitudes towards smoking and early engagement in tobacco use. With more restrictions on tobacco marketing, the pack is becoming an increasingly important platform for branding. To what extent and how is branding on tobacco packs designed in such a way as to appeal to youth in LMICs?

Methods:
We purchased cigarette packs from 6 LMICs (Brazil, Indonesia, Philippines, Russia, Vietnam, and Thailand) in 2015-2016. Packs were purchased from 12 diverse neighborhoods in three diverse cities in each country and were coded by 2 independent coders; youth appeal was measured using 2 of more than 70 standardized codes applied to all packs.

Results:
From our sample of 1,351 packs, 21 (< 1%) were coded for explicit youth appeal—these packs tended to reference sports or depict popular music. A subsequent, more inductive review of all packs identified numerous other elements that are potentially relevant but more difficult to assess objectively as appealing primarily/exclusively to youth. These include the appeal of certain colors (e.g. purple), fonts, patterns and holograms. Depictions of animals (e.g. butterflies and cats) and animal prints may attract young people's attention, as might fruits or flowers. References to sustainability and natural products may appeal. Special edition packs may also tap into young people's tendency to collect things (e.g sports cards or stickers). Finally, we will discuss the need to consider the appeal of a specific pack to a specific audience (such as youth) in relation to other packs within the same brand or brand variant.

Conclusions:
There is value to a common coding approach to assessing pack appeals across numerous settings, but cultural specificity and artistic quality complicate accurate interpretation and application of more subtle or nuanced codes.