In the United States, approximately 900,000 youths smoke their first cigarette each
year (
1
). Health communication interventions are evidence-based strategies for preventing
the initiation of tobacco use, promoting and facilitating cessation, and changing
beliefs and attitudes about tobacco use (
2
,
3
). This report describes the association between the Food and Drug Administration’s
(FDA’s) first national tobacco public education campaign, The Real Cost, and rates
of smoking initiation among youths in the United States from 2014 to 2016. A nationally
representative cohort study of youths (N = 5,185) was conducted during November 2013–March
2016. Results from a discrete-time survival model indicate that, among youths who
reported never having smoked a cigarette in the baseline survey, the odds of reporting
smoking initiation at follow-up were lower among youths with frequent exposure to
campaign advertisements than among those with little or no exposure (adjusted odds
ratio [aOR] = 0.70, 95% confidence interval [CI] = 0.55–0.91). Based on the results
of the model, The Real Cost is associated with an estimated 348,398 U.S. youths aged
11–18 years who did not initiate smoking during February 2014–March 2016. Sustained
youth-focused tobacco education campaigns, such as The Real Cost, can help speed progress
toward preventing tobacco use among youths in the United States.
FDA’s The Real Cost was based on behavior change theories and designed to prevent
the initiation of cigarette smoking among youths who have never smoked and discourage
further smoking among youths who have previously experimented with smoking (
4
) (RTI International and FDA, unpublished data, 2016). Since February 2014, the campaign
has aired tobacco education advertising designed for youths aged 12–17 years on national
television, radio, the Internet, and in out-of-home displays, as well as in magazines
and movie theaters (
4
). The central theme of the campaign is “Every cigarette costs you something.” In
the first 3 years of advertising, campaign themes focused on the cosmetic effects
of smoking, loss of control caused by addiction, and the dangerous mix of toxic chemicals
in cigarette smoke.* To monitor campaign awareness levels (
4
) and evaluate the impact of The Real Cost on changes in smoking-related beliefs (RTI
International and FDA, unpublished data, 2016) and behaviors, FDA conducted a national
representative cohort study of U.S. youths. Youths aged 11–16 years at baseline were
randomly selected from within 75 U.S. media markets and, after obtaining parental
permission and youth assent, were interviewed in person at baseline during November
2013–March 2014. Data collections for the three follow-up surveys were conducted during
July–October 2014, April–July 2015, and December 2015–March 2016 and consisted of
online or in-person interviews.
†
This report used data from the baseline survey and the first three follow-up surveys
to determine whether campaign exposure was associated with preventing smoking initiation
among youths who had never smoked at baseline (never smokers). The analytic sample
consisted of 5,185 eligible youths, and the model included 11,145 observations across
the surveys.
§
Self-reported campaign media exposure was assessed with a validated measure (
5
) at each follow-up survey via video stream embedded within the survey. After viewing
each advertisement, respondents reported their frequency of exposure to the advertisement
on a scale from 0 (never) to 4 (very often). Respondents viewed all advertisements
airing during the 3 months preceding each follow-up survey (a total of four advertisements
at first and second follow-ups, and six advertisements at third follow-up). The frequency
of exposure to all ads in each survey were summed, resulting in a score ranging from
0 to 16 at first and second follow-ups and from 0 to 24 at third follow-up. A dichotomous
exposure measure was then created, defined as either low campaign exposure (<4) or
high campaign exposure (≥4). Smoking initiation was defined as first trial of a cigarette
among youths who had never used cigarettes.
¶
A discrete-time survival model (
6
,
7
) was estimated using logistic regression and controlling for confounding influences,
similar to other longitudinal media studies (
8
).** Because the delivery of advertisements is not explicitly random, the model included
four types of potential confounders: demographic characteristics, individual risk
factors for smoking cigarettes, self-reported exposure to other national campaigns
(CDC’s Tips From Former Smokers and Truth Initiative’s truth campaign), and media
market and state-level variables. The estimated number of youths prevented from initiating
smoking was calculated using the difference between the predicted risk for initiation
by age with actual exposure to The Real Cost campaign and the predicted risk for initiation
by age in a hypothetical scenario where self-reported exposure to the campaign is
either absent or low nationwide. The difference in initiation rates was then applied
to the national population of nonsmoking youths at each age (2010 Census), and the
resulting estimated numbers of youths potentially prevented from initiating smoking
at each age were summed. Sensitivity analyses were conducted to examine the influence
of electronic cigarettes (e-cigarettes) and other tobacco products on smoking initiation.
An additional model examined the relationship between campaign exposure and using
marijuana, a risky behavior unrelated to campaign messaging. This additional analysis
was conducted to ascertain whether campaign effects were specific to smoking behaviors
and not a general association between campaign exposure and risky behaviors.
High campaign exposure was associated with a 30% decrease in the risk for smoking
initiation (aOR = 0.70, 95% CI = 0.55–0.91) (Table). The decrease in the risk for
smoking initiation is illustrated by the difference between the risk for initiation
with actual exposure to The Real Cost and the risk for initiation in a hypothetical
scenario where there is no or low self-reported exposure to The Real Cost nationwide
(Figure 1). Based on the results of the survival model, an estimated 348,498 youths
aged 11–18 years were potentially prevented from initiating smoking nationwide during
February 2014–March 2016 (95% CI = 331,825–365,168) (Figure 2).
TABLE
Results of a discrete-time survival model of the relationship between self-reported
exposure to The Real Cost media campaign and smoking initiation by youths aged 11–18
years — United States, 2014–2016
Explanatory variable*
OR (95% CI)
High exposure to The Real Cost (referent = no or low exposure)
0.70† (0.55–0.91)
Gender (referent = female)
Male
1.03 (0.86–1.24)
Race/Ethnicity (referent = white, non-Hispanic)
Black, non-Hispanic
1.35 (0.99–1.84)
Hispanic
1.39† (1.11–1.73)
Other, non-Hispanic
0.77 (0.54–1.09)
Youth income
§
1.03 (0.99–1.07)
Lives with tobacco user¶
2.44** (2.04–2.92)
Sensation seeking scale††
1.40** (1.25–1.56)
School environment§§
0.85† (0.77–0.94)
School performance¶¶
0.78** (0.70–0.87)
Educational plans***
0.92††† (0.84–1.00)
Parental communication§§§
0.84** (0.76–0.94)
Television use¶¶¶
1.03† (1.01–1.06)
Abbreviations: CI = confidence interval; OR = odds ratio.
*Additional control variables include average market-level family income, average
market-level high school completion rates, market population, 2013 Behavioral Risk
Factor Surveillance System state smoking prevalence, measures of self-reported exposure
to the Tips From Former Smokers and the Truth Initiative’s truth campaigns, an indicator
for whether the youth’s baseline interview was conducted after the launch of The Real
Cost, age indicators, and time trend indicators.
† p<0.01.
§ The amount of weekly discretionary income.
¶ Lives with a person who uses tobacco, including cigarettes, cigars, hookah, smokeless,
and other tobacco products.
** p<0.001.
†† The brief sensation seeking scale (BSSS-4) is a mean of four items: 1) “I would
like to explore strange places”; 2) “I like to do frightening things”; 3) “I like
new and exciting experiences, even if I have to break the rules”; and 4) “I prefer
friends who are exciting and unpredictable.” Responses ranged from 1 (disagree strongly)
to 5 (agree strongly).
§§ School environment was measured as the mean of three items: 1) “I feel close to
people at my school”; 2) “I am happy to be at my school”; and 3) “I feel like I am
a part of my school.” Responses ranged from 1 (disagree strongly) to 5 (agree strongly).
¶¶ School performance was assessed with the item “How well would you say you have
done in school?” with response options from 1 (much worse than average) to 5 (much
better than average).
*** School aspirations were assessed with the item “How far do you think you will
go in school?” with response options from 1 (I don’t plan to go to school anymore)
to 8 (graduate, medical, or law school).
††† p<0.05.
§§§ A youth’s relationship with parents was a mean of two items: 1) “Thinking about
the adult or adults you live with would you say you are satisfied with the way you
communicate with each other” (responses from 1 [very unsatisfied] to 5 [very satisfied]),
and 2) “How close do you feel to the adult or adults you live with?” (Responses ranged
from 1 [not close at all] to 5 [very close]).
¶¶¶ Continuous variable of daily hours spent watching television across all media
devices.
FIGURE 1
Estimated smoking initiation risk among youths aged 11–18 years with actual exposure
versus hypothetical scenario with low or no exposure to The Real Cost campaign, by
age — United States, 2014–2016
The figure above is a line chart showing estimated smoking initiation risk among youths
aged 11–18 years with actual exposure versus hypothetical scenario with low or no
exposure to The Real Cost campaign, by age, in the United States during 2014–2016.
FIGURE 2
Predicted number of youths* aged 11–18 years potentially prevented from initiating
smoking as a result of The Real Cost campaign, by age — United States, 2014–2016
* With 95% confidence intervals represented by error bars.
The figure above is a bar chart showing the predicted number of youths aged 11–18
years potentially prevented from initiating smoking as a result of The Real Cost campaign,
by age, in the United States during 2014–2016.
The association between campaign exposure and youth smoking initiation remained unchanged
in survival models that accounted for youths’ use of e-cigarettes and other tobacco
products during the study period. In a similar survival model, exposure to The Real
Cost was not associated with a change in the likelihood of marijuana initiation.
Discussion
The findings from this analysis indicate that exposure to The Real Cost campaign was
associated with preventing an estimated 348,398 U.S. youths aged 11–18 years from
initiating smoking during 2014–2016. Most tobacco dependence begins during adolescence
(
3
), and youth-focused campaigns to prevent smoking initiation, such as The Real Cost,
can have long-term effects on future rates of tobacco-related morbidity and mortality
(
9
).
Findings from this report support previous studies that indicate The Real Cost meets
or exceeds guidelines for effective health communication interventions (
2
). FDA conducted formative research to develop campaign advertisements for The Real
Cost, including qualitative and quantitative testing of campaign messages and draft
advertisements (RTI International and FDA, unpublished data, 2016). Since its launch,
campaign advertising has occurred with high frequency across multiple media channels
targeting youths. Research indicates that approximately 9 of 10 youths reported seeing
The Real Cost advertisements after 7 months, with more youths reporting awareness
of advertising in subsequent surveys (
4
). The Real Cost was also found to positively influence tobacco-related risk perceptions
and beliefs specific to campaign messages after 15 months (RTI International and FDA,
unpublished data, 2016). These results demonstrate the effectiveness of a national
campaign that focused on the harmful effects of smoking and delivered salient messages
that resonated with youths.
These findings align with previous research that found targeted mass media campaigns,
delivered with sufficient intensity and duration, can decrease smoking initiation
and prevalence (
2
,
9
). A comprehensive tobacco control approach that emphasizes proven strategies, such
as The Real Cost, can result in reductions in smoking among youths today, and such
reductions can lead to decreased future rates of smoking-attributable mortality, health
care costs, and lost workplace productivity (
3
,
9
).
The findings in this report are subject to at least four limitations. First, measurements
were self-reported and are subject to bias. Specifically, selective attention could
bias the results, such that nonsmoking youths at risk for future smoking might be
more likely to both pay attention to campaign messages and experiment with smoking.
However, such a positive association would be expected to lead to smaller observed
campaign effects on initiation. In addition, social desirability bias might have led
to underreporting of initiation and overreporting of campaign exposure. To address
the concerns of using self-reported exposure, future research that examines potential
campaign exposure based on measures of market-level media delivery (i.e., target rating
points
††
) is warranted. Second, although the model controls for youths’ exposure to other
tobacco-related media campaigns, this might not fully account for the independent
or synergistic effects of the other campaigns. Third, sample attrition might result
in bias. However, attrition analyses indicate the baseline and follow-up samples were
similar across demographics, susceptibility to smoking cigarettes, and household tobacco
use. Finally, because of sample size limitations, only initiation to smoking was examined,
not progression to established or daily smoking. Future analyses could examine the
campaign’s effect on youth smoking prevalence and further explore the campaign’s effect
among demographic subgroups.
The Real Cost is the first federally funded U.S. youth-focused tobacco education campaign,
and these findings indicate that youths’ self-reported exposure to the campaign was
associated with a reduction in smoking initiation during the evaluation’s 2014 to
2016 time frame. Sustained tobacco education campaigns such as The Real Cost can encourage
U.S. youths to abstain from tobacco use and accelerate progress toward future tobacco-free
generations.
Summary
What is already known about this topic?
Public education campaigns are evidence-based strategies for positive public health
outcomes such as preventing the initiation of tobacco use, promoting and facilitating
cessation, and shaping social norms related to tobacco use.
What is added by this report?
This study is the first to examine the association between the Food and Drug Administration’s
(FDA’s) youth-specific national media campaign, The Real Cost, and adolescent smoking
in the United States. Approximately 350,000 youths aged 11–18 years were prevented
from smoking nationwide during 2014–2016 as a result of FDA’s youth-specific public
education campaign.
What are the implications for public health practice?
The findings indicate that youths’ self-reported exposure to the campaign was associated
with a reduction in smoking initiation from 2014 to 2016. Sustained campaigns such
as The Real Cost can speed progress toward a tobacco-free future.