Association Between The Real Cost Media Campaign and Smoking Initiation Among Youths — United States, 2014–2016

Abstract

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 educa-tion 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 dis-courage further smoking among youths who have previously experimented with smoking (4) (RTI International and FDA, unpublished data, 2016).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 ciga-rette 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levels (4) and evaluate the impact of The Real Cost on changes in smoking-related beliefs (RTI International and FDA, unpublished data, 2016) and behaviors, FDA conducted a national representative cohort study of U.S. youths.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 collec-tions 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 expo-sure 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 expo-sure 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 advertise-ments 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.