Janine Delahanty

Youth's Awareness of and Reactions to The Real Cost National Tobacco Public Education Campaign:

In 2014, the Food and Drug Administration (FDA) launched its first tobacco-focused public education campaign, The Real Cost, aimed at reducing tobacco use among 12- to 17-year-olds in the United States. This study describes The Real Cost message strategy, implementation, and initial evaluation findings. The campaign was designed to encourage youth who had never smoked but are susceptible to trying cigarettes (susceptible nonsmokers) and youth who have previously experimented with smoking (experimenters) to reassess what they know about the “costs” of tobacco use to their body and mind. The Real Cost aired on national television, online, radio, and other media channels, resulting in high awareness levels. Overall, 89.0% of U.S. youth were aware of at least one advertisement 6 to 8 months after campaign launch, and high levels of awareness were attained within the campaign’s two targeted audiences: susceptible nonsmokers (90.5%) and experimenters (94.6%). Most youth consider The Real Cost advertising to be effective, based on assessments of ad perceived effectiveness (mean = 4.0 on a scale from 1.0 to 5.0). High levels of awareness and positive ad reactions are requisite proximal indicators of health behavioral change. Additional research is being conducted to assess whether potential shifts in population-level cognitions and/or behaviors are attributable to this campaign. Current findings demonstrate that The Real Cost has attained high levels of ad awareness which is a critical first step in achieving positive changes in tobacco-related attitudes and behaviors. These data can also be used to inform ongoing message and media strategies for The Real Cost and other U.S. youth tobacco prevention campaigns.

Youth Receptivity to FDA's The Real Cost Tobacco Prevention Campaign: Evidence From Message Pretesting.

In February 2014, the Food and Drug Administration launched The Real Cost, a national youth tobacco prevention campaign. This article examines youth receptivity to potential campaign ads using data from 3 message pretesting studies featuring the same design and consistent instrumentation. A total of 3,258 adolescents ages 13–17 were randomized to either an ad-viewing condition or a no-exposure control condition. Perceived ad effectiveness, smoking-related beliefs, and attitudes were measured as outcome variables. The sample consisted of both experimental smokers (58%) and current nonsmokers at risk for cigarette initiation (42%). A total of 14 ads were tested across the three studies. Participants who viewed the ads generally considered them to be effective (with a mean perceived ad effectiveness score of 3.66 on a scale from 1 to 5). Compared to those in the control condition, participants in the ad-viewing condition reported stronger beliefs about the health risks of smoking (p < .001), a greater likelihood that smoking would lead to loss of control in life (p < .001), and more negative attitudes toward smoking (p < .001). Responses to campaign ads were largely consistent between experimenters and at-risk nonsmokers. Implications of the findings for the campaign are discussed.

Sexual and gender minority cigarette smoking disparities: An analysis of 2016 Behavioral Risk Factor Surveillance System data

We examined the association between lesbian, gay, bisexual, and transgender (LGBT) identity, cigarette and e-cigarette use, and potential risk factors in the United States. Using data from 198,057 adults in 26 states in the 2016 Behavioral Risk Factor Surveillance System (BRFSS), we estimated the prevalence of cigarette use, e-cigarette use, and potential risk factors by gender identity and sexual identity. Overall and sex-stratified bivariate and multivariate logistic regressions examined whether the relationship between sexual and gender identity and cigarette and e-cigarette use persisted after adjusting for demographics, socio-economic status, and other unhealthy behaviors. After adjusting for covariates, gender minority identity was no longer associated with increased likelihood of currently smoking cigarettes and ever use of e-cigarettes. Sexual minority identity continued to be significant after adjusting for covariates, indicating that sexual identity disparities in cigarette and e-cigarette use are not fully explained by these factors. Findings varied by identity. Compared to their straight peers, likelihood of tobacco product use among LGB individuals varied between sexes, by product, and by sexual identity (gay/lesbian versus bisexual). More research is needed to understand the mechanisms that influence diverse patterns of cigarette and e-cigarette use among sexual and gender minority adults.

Recruiting hard-to-reach populations for survey research: Using Facebook and Instagram advertisements and in-person intercept in LGBT bars and nightclubs to recruit LGBT young adults

Background Tobacco public education campaigns focus increasingly on hard-to-reach populations at higher risk for smoking, prompting campaign creators and evaluators to develop strategies to reach hard-to-reach populations in virtual and physical spaces where they spend time. Objective The aim of this study was to describe two novel recruitment strategies (in-person intercept interviews in lesbian, gay, bisexual, and transgender [LGBT] social venues and targeted social media ads) and compares characteristics of participants recruited via these strategies for the US Food and Drug Administration’s This Free Life campaign evaluation targeting LGBT young adults who smoke cigarettes occasionally. Methods We recruited LGBT adults aged 18-24 years in the United States via Facebook and Instagram ads (N=1709, mean age 20.94, SD 1.94) or intercept in LGBT social venues (N=2348, mean age 21.98, SD 1.69) for the baseline evaluation survey. Covariates related to recruitment strategy were age; race or ethnicity; LGBT identity; education; pride event attendance; and alcohol, cigarette, and social media use. Results Lesbian or gay women (adjusted odds ratio, AOR 1.88, 95% CI 1.54-2.29, P<.001), bisexual men and women (AOR 1.46, 95% CI 1.17-1.82, P=.001), gender minorities (AOR 1.68, 95% CI 1.26-2.25, P<.001), and other sexual minorities (AOR 2.48, 95% CI 1.62-3.80, P<.001) were more likely than gay men to be recruited via social media (than intercept). Hispanic (AOR 0.73, 95% CI 0.61-0.89, P=.001) and other or multiracial, non-Hispanic participants (AOR 0.70, 95% CI 0.54-0.90, P=.006) were less likely than white, non-Hispanic participants to be recruited via social media. As age increased, odds of recruitment via social media decreased (AOR 0.76, 95% CI 0.72-0.80, P<.001). Participants with some college education (AOR 1.27, 95% CI 1.03-1.56, P=.03) were more likely than those with a college degree to be recruited via social media. Participants reporting past 30-day alcohol use were less likely to be recruited via social media (AOR 0.33, 95% CI 0.24-0.44, P<.001). Participants who reported past-year pride event attendance were more likely to be recruited via social media (AOR 1.31, 95% CI 1.06-1.64, P=.02), as well as those who used Facebook at least once daily (AOR 1.43, 95% CI 1.14-1.80, P=.002). Participants who reported using Instagram at least once daily were less likely to be recruited via social media (AOR 0.73, 95% CI 0.62-0.86, P<.001). Social media recruitment was faster (incidence rate ratio, IRR=3.31, 95% CI 3.11-3.52, P<.001) and less expensive (2.2% of combined social media and intercept recruitment cost) but had greater data quality issues—a larger percentage of social media respondents were lost because of duplicate and low-quality responses (374/4446, 8.41%) compared with intercept respondents lost to interviewer misrepresentation (15/4446, 0.34%; P<.001). Conclusions Social media combined with intercept provided access to important LGBT subpopulations (eg, gender and other sexual minorities) and a more diverse sample. Social media methods have more data quality issues but are faster and less expensive than intercept. Recruiting hard-to-reach populations via audience-tailored strategies enabled recruitment of one of the largest LGBT young adult samples, suggesting these methods’ promise for accessing hard-to-reach populations.

Effect of a National Tobacco Public Education Campaign on Youth’s Risk Perceptions and Beliefs About Smoking:

Purpose: To assess the relationship between youth’s exposure to the Food and Drug Administration’s national tobacco public education campaign, The Real Cost, and changes in campaign-targeted beliefs. Design: Longitudinal design with baseline survey and 2 postcampaign follow-up surveys. Sample: Youth from 75 US media markets (N = 1680) who completed all 3 surveys and had experimented with or were susceptible to future cigarette smoking. Measures: Exposure was measured by self-reported frequency of ad exposure and media market–level target rating points. Agreement with 30 self-reported tobacco-related beliefs was assessed in 3 categories: (1) beliefs specifically targeted by campaign messages (campaign-targeted belief), (2) beliefs not targeted by the campaign (nontargeted beliefs), and (3) beliefs corresponding to other media campaigns on air concurrent with The Real Cost (ambiguous beliefs). Analysis: Descriptive analyses of aggregate changes in beliefs and logistic regressions to examine the association between campaign exposure and beliefs. Intervention: The Real Cost. Results: Agreement with campaign-targeted beliefs increased from baseline to first and second follow-ups, with a mean relative increase of 10.4% and 11.5%, respectively. Nontargeted beliefs did not change substantially. Both measures of campaign exposure were positively associated with increased odds of agreeing with 5 of 8 campaign-targeted beliefs. Exposure was not significantly associated with 12 of 14 nontargeted tobacco-related beliefs. Discussion: A sustained national tobacco public education campaign can change population-level perceptions of tobacco-related harms among youth.

Online Information About Harmful Tobacco Constituents: A Content Analysis

Introduction Tobacco products and smoke contain more than 7000 chemicals (ie, constituents). Research shows that consumers have poor understanding of tobacco constituents and find communication about them to be confusing. The current content analysis describes how information is communicated about tobacco constituents online in terms of source, target audience, and message. Methods A search was conducted in September 2015 using tobacco constituent and tobacco terms and identified 226 relevant Web sites for coding. Web sites were coded for type, target audience, reading level, constituent information, type of tobacco product, health effects, and emotional valence by two coders who independently coded half of the sample. There was a 20% overlap to assess interrater reliability, which was high (κ = .83, p < .001). Results The mean reading grade level of information online was 8.2 (SD = 2.8) with 81.7% of Web sites above the sixth grade reading level. Nearly all Web sites presented information in a qualitative narrative format (93%) and almost half (48.2%) presented information in a quantitative format. Nicotine (59.3%) and nitrosamines (28.8%) were the mostly frequently mentioned tobacco constituents. Cancer was the most frequently mentioned health effect (51.3%). Nearly a quarter (23%) of the Web sites did not explicitly state that tobacco constituents or tobacco products are associated with health effects. Conclusion Large gaps exist in online information about tobacco constituents including incomplete information about tobacco constituent-related health effects and limited information about tobacco products other than cigarettes and smokeless tobacco. This study highlights opportunities to improve the content and presentation of information related to tobacco constituents. Implications The US Food and Drug Administration (FDA) is required to publicly display a list of tobacco constituents in tobacco products and tobacco smoke by brand. However, little is known about tobacco constituent information available to the public. This is the first systematic content analysis of online information about tobacco constituents. The analysis reveals that although information about tobacco constituents is available online, large information gaps exist, including incomplete information about tobacco constituent-related health effects. This study highlights opportunities to improve the content and presentation of public information related to tobacco constituents.

Nicotine and addiction beliefs and perceptions among the US-born and foreign-born populations.

Little is known about nicotine and addiction beliefs held by those who are foreign-born in the US and how these beliefs are associated with acculturation and race/ethnicity. This study attempts to address these research gaps. Data were analyzed from two cycles of the Health Information National Trends Survey, HINTS-FDA 2015 (n = 3738) and HINTS-FDA 2017 (n = 1736). HINTS-FDA is a tobacco-focused, cross-sectional, nationally representative survey of US non-institutionalized civilian adults aged 18 years or older. We first assessed associations between foreign-born status and beliefs about nicotine and addiction using weighted chi-square analyses. Then, using only the foreign-born sample, we examined the associations of nicotine and addiction beliefs with race/ethnicity and acculturation (i.e., English proficiency and U.S. tenure) using weighted multiple linear regression. Results showed that, compared to US-born respondents, foreign-born respondents were more likely to be concerned with being addicted to nicotine and to believe that low nicotine cigarettes would have much lower lung cancer risk than a typical cigarette. Among the foreign-born, NH-Black and Hispanic respondents were more likely to see low nicotine cigarettes as harmful and addictive compared to NH-White respondents. The relationship between acculturation and nicotine beliefs was complex with lower acculturation associated with elevated misperceived risk of nicotine and also ratings of addictiveness. Further research among key subpopulations may inform communication, education and dissemination strategies, especially among vulnerable populations.

The role of sexual identity in tobacco information–seeking behaviours and perceptions

Objective: To explore differences in tobacco information–seeking behaviours and perceptions between sexual minority and heterosexual (or ‘straight’) adults and to determine if these differences are mediated by tobacco use. Design: Cross-sectional national survey. Setting: Nationally representative probability-based surveys of adults 18 years of age or older in the US civilian non-institutionalised population. Methods: Data from respondents identifying as gay, lesbian, bisexual (LGB; n = 156) or straight (n = 4,964) in the US National Cancer Institute’s Health Information National Trends Survey Food and Drug Administration cycles 1 and 2 (HINTS-FDA 2015, 2017) were analysed. We compared the responses of sexual minority and straight respondents aged 18 years and older concerning tobacco information-seeking behaviours and perceptions. Results: Sexual minority respondents were more likely than their straight counterparts to seek out tobacco health information, to look for information about e-cigarettes and to use the Internet for health information searches. Some of these differences were mediated by tobacco use. Sexual minority respondents were similar to their straight counterparts regarding perceptions of trust and confidence in tobacco health information, as well as perceptions of the hazards of tobacco use. Conclusion: Because sexual minority adults have higher rates of tobacco use and higher rates of tobacco information seeking than others, tobacco health information campaigns should consider carefully tailoring the messages directed towards sexual minority populations.

Cost-Effectiveness Analysis of The Real Cost Campaign's Effect on Smoking Prevention

INTRODUCTION A previous study found that the Food and Drug Administrations The Real Cost national tobacco education campaign was associated with preventing approximately 350,000 U.S. youth from initiating smoking between 2014 and 2016. This study translates the reduction in smoking initiation into monetary terms by examining the cost effectiveness of the campaign. METHODS The cost effectiveness of The Real Cost was assessed by measuring efficiency in two ways: (1) estimating the cost per quality-adjusted life year saved and (2) estimating the total monetary return on investment by comparing the cost savings associated with the campaign to campaign expenditures. Analyses were conducted in 2017. RESULTS The Real Cost averted an estimated 175,941 youth from becoming established smokers between 2014 and 2016. Campaign expenditures totaled

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

246,915,233. The cost per quality-adjusted life year saved of the campaign was