Changes in Sales of Vaping Products and Cigarettes Associated With the New York State Flavored Vaping Product Sales Restriction.

INTRODUCTION: New York (NY) implemented a statewide restriction on the retail sale of flavored vaping products to reduce availability of vaping products having youth-appealing flavors in 2020. We assessed the intended effects of the NY law on sales of flavored vaping products and explored whether policy implementation had unintended effects on consumer behavior by evaluating policy-associated changes in sales of combusted cigarettes, which could serve as more harmful substitute products for NY consumers of flavored vaping products. AIMS AND METHODS: We analyzed custom product-level weekly retail tobacco sales scanner data for NY and a comparison state (California [CA]) for convenience stores and other outlets from June 2018 through June 2021. We categorized flavor descriptors for vaping products as flavored or as tobacco or unflavored and categorized cigarettes as menthol or non-menthol. We used a difference-in-difference model to assess the effect of the sales restriction on unit sales of flavored and unflavored vaping products and menthol and non-menthol cigarettes in NY compared with CA. RESULTS: Following NY policy implementation, flavored and total vaping product sales decreased in NY relative to CA. Unflavored vaping product sales increased in NY, while menthol cigarette sales did not change significantly relative to CA sales. CONCLUSIONS: The NY flavored vaping product policy was associated with fewer sales of flavored and total vaping products. The increase in sales of unflavored vaping products did not suggest complete substitution, and sales data suggest that consumers did not turn to cigarettes after flavored vaping products became unavailable. IMPLICATIONS: This study provides evidence that NY's flavored vaping product policy is associated with reduced flavored vaping product access and sales. Our analyses of potential unintended consequences indicate that some consumers switched from flavored to unflavored vaping products, but that cigarette sales did not change concurrent with the policy which means that decreased availability of flavored vaping products did not result in vapers switching to cigarettes. NY's policy had its intended effect with limited unintended consequences.

Youth vaping beliefs and behaviors: evidence from New York.

Current use of vaping products has increased in recent years among youth in the United States. We conducted cross-sectional surveys of vaping product users aged 15-17 in New York in 2017 and 2019 to assess vaping freqency, reported nicotine content of vaping products used, risk perceptions of vaping and openness to vaping cannabis (2019 survey only). Between 2017 and 2019, the proportion of youth vapers who were frequent vaping product users increased from 16.8% to 26.2% (P < 0.05). The proportion of youth vapers who usually used high-nicotine vaping products also increased, from 12.6% to 40.0% (P < 0.05). In both years, the use of high-nicotine vaping products was positively associated with frequent use (P < 0.05). The perceived likelihood of harm from vaping increased (P < 0.05), but respondents' perception of harm from using tobacco-flavored vaping products remained higher than that from using menthol/mint or sweet flavors. In 2019, 60.6% of respondents reported having tried vaping cannabis. Results suggest shifts in youth vaping behavior toward more frequent use and use of higher nicotine vaping products, support previous findings about youth misperceptions about health risks of flavored vaping products and highlight openness to vaping cannabis among youth vaping product users.

LGBT young adults' awareness of and receptivity to the This Free Life tobacco public education campaign.

PURPOSE: This study measures awareness of and receptivity to the Food and Drug Administration's This Free Life campaign seeking to change tobacco-related attitudes and beliefs among lesbian, gay, bisexual and/or transgender (LGBT) young adults. METHODS: Participants were young adults who self-identify as LGBT. The evaluation uses a treatment-control design. This study includes data from four survey rounds with participants from each round invited to participate in subsequent rounds and new participants invited to account for attrition. Bivariate analyses assess treatment-control differences in campaign awareness by round. We used multivariable logistic regression models with a time×treatment interaction and covariates to assess whether increases in awareness were greater in treatment than control from follow-ups 1 to 4. Descriptive statistics describe perceived effectiveness and models explore covariates of perceived effectiveness. RESULTS: At each round, an increasing number of participants in treatment were brand aware (25%-67%) and reported high (16%-34%) and medium (16%-25%) video awareness compared with control (all p<0.001). Regressions revealed interactions in brand and video awareness, wherein the effect of treatment on awareness increased more over time, with significant treatment-control differences in change from follow-up 1 to 4 (all p<0.05). Reactions to all but one ad were positive (one neutral) with mean perceived effectiveness scores from 3.21 to 3.92 ('neither disagree nor agree' to 'agree' on 5-point scale). Perceived effectiveness differed by LGBT identity (all p<0.05). CONCLUSIONS: At follow-up 4, This Free Life reached most of the campaign audience in treatment markets and has achieved higher awareness in treatment than control markets, at individual survey rounds and over time.

"The Real Cost" Smokeless campaign: changes in beliefs about smokeless tobacco among rural boys, a longitudinal randomized controlled field trial.

BACKGROUND: The prevalence of current smokeless tobacco (SLT) use in 2019 among high school students was 4.8%, and the overall rate of SLT use was higher among high school boys (7.5%) than girls (1.8%). The U.S. Food and Drug Administration (FDA) launched "The Real Cost" Smokeless media campaign in April 2016 to educate rural youth about the dangers of SLT use. In this study, we evaluate the effectiveness of "The Real Cost" Smokeless campaign. METHODS: We use a 3-year (Jan 2016 - Dec 2018) randomized controlled longitudinal field trial that consists of a baseline survey of boys and a parent/guardian and four follow-up surveys of the boys. The cohort includes 2200 boys who were 11 to 16 years old at baseline and lived in the rural segments of 30 media markets (15 treatment markets and 15 control). "The Real Cost" Smokeless campaign targets boys who are 12 to 17 years old in 35 media markets. It focuses primarily on graphic depictions of cosmetic and long-term health consequences of SLT use. The key outcome measures include beliefs and attitudes toward SLT that are targeted (explicitly or implicitly) by campaign messages. RESULTS: Using multivariate difference-in-difference analysis (conducted in 2019 and 2020), we found that agreement with 4 of the 11 explicit campaign-targeted belief and attitude measures increased significantly from baseline to post-campaign launch among boys 14 to 16 years old in treatment vs. control markets. Agreement did not increase for boys 11-13 years old in treatment vs. control markets and only increased for one targeted message for the overall sample. CONCLUSIONS: These findings suggest that "The Real Cost" Smokeless campaign influenced beliefs and attitudes among older boys in campaign markets and that a campaign focused on health consequences of tobacco use can be targeted to rural boys, influence beliefs about SLT use, and potentially prevent SLT use.

Perceptions of the relative harmfulness of marijuana and alcohol among adults in Oregon.

This study documents perceptions of the relative harmfulness of marijuana and alcohol to a person's health among adults in Oregon just before the first legal sales of marijuana for recreational use. We surveyed 1941 adults in Oregon in September 2015. Respondents were recruited using an address-based sampling (ABS) frame (n = 1314) and social media advertising (n = 627). Respondents completed paper surveys (ABS-mail, n = 388) or online surveys (ABS-online, n = 926; social media, n = 627). We used descriptive statistics and logistic regression models to examine perceptions of the relative harmfulness of marijuana and alcohol by sample characteristics, including substance use. About half of adults in Oregon (52.5%) considered alcohol to be more harmful to a person's health than marijuana. A substantial proportion considered the substances equally harmful (40.0%). Few considered marijuana to be more harmful than alcohol (7.5%). In general, respondents who were younger, male, and not Republican were more likely than others to consider alcohol more harmful than marijuana. Respondents who were older, female, and Republican were more likely to consider marijuana and alcohol equally harmful. Most individuals who reported using both marijuana and alcohol (67.7%) and approximately half of those who used neither substance (48.2%) considered alcohol to be more harmful than marijuana. Perceptions about the relative harmfulness of marijuana and alcohol may have implications for public health. As state lawmakers develop policies to regulate marijuana, it may be helpful to consider the ways in which those policies may also affect use of alcohol and co-use of alcohol and marijuana.

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

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.

Exploring Differences in Youth Perceptions of the Effectiveness of Electronic Cigarette Television Advertisements.

INTRODUCTION: Studies suggest that exposure to televised electronic cigarette (e-cigarette) advertising contributes to the recent increase in e-cigarette use among youth. This study examines the relationship between perceptions of e-cigarette advertisements and attitudes toward and intentions to use e-cigarettes among youth who had never used e-cigarettes. METHODS: In May 2014, we conducted an online survey of 5020 youth aged 13 to 17. Participants were randomly assigned to answer questions about their attitudes toward and intentions to use e-cigarettes before or after viewing e-cigarette advertisements. Perceived effectiveness (PE) of advertisements was measured after ad exposure. Ordinary least squares models were used to assess the relationship between PE and study outcomes. RESULTS: Among never e-cigarette users, greater PE was associated with more positive attitudes toward e-cigarettes (b = 0.74, P < .001) and intentions to use e-cigarettes (b = 0.16, P < .001). Findings suggest that PE is predictive of outcomes controlling for study condition, youth demographics, and media use variables. CONCLUSIONS: After ad exposure, youth who have never used e-cigarettes previously perceive e-cigarettes as cooler, more fun, healthier, and more enjoyable. Youth who thought the ads were more effective were more likely to have a positive attitude toward e-cigarettes and greater intention to try e-cigarettes in the future. Restricting televised e-cigarette advertising may reduce e-cigarette initiation among youth. IMPLICATIONS: Previous studies demonstrate that, among adults, PE is antecedent to actual ad effectiveness across a range of behaviors. To our knowledge, this is the first study to document the relationship between PE and advertising effectiveness among youth. It provides evidence that PE may be a useful tool to quantify the potential influence of advertising on youth-advertising that, in this case, is designed to market a consumer good that may be harmful to youth but that may also be used to develop public health campaigns.

Comparing projected impacts of cigarette floor price and excise tax policies on socioeconomic disparities in smoking.

BACKGROUND: About half of all US states have cigarette minimum price laws (MPLs) that require a per cent mark-up on prices, but research suggests they may not be very effective in raising prices. An alternative type of MPL sets a floor price below which packs cannot be sold, and may be more promising. This new type of MPL policy has only been implemented in 1 city, therefore its benefits relative to excise taxes is difficult to assess. METHODS: We constructed a set of possible state floor price MPL options, and matched them to possible state excise tax hikes designed to produce similar average price increases. Using self-reported price and cigarette consumption data from 23 521 participants in the 2010-2011 Tobacco Use Supplement of the Current Population Survey, we projected changes in pack prices and cigarette consumption following implementation of each paired MPL and tax option, for lower and higher income groups. RESULTS: We project that state MPLs set at the average reported pack price would raise prices by $0.33 and reduce cigarette consumption by about 4%; a tax with a similar average price effect would reduce consumption by 2.3%. MPLs and taxes that raise average prices by more than $2.00 would reduce consumption by 15.9% and 13.5%, respectively. In all models, we project that MPLs will reduce income-based smoking disparities more than their comparable excise taxes. CONCLUSIONS: Floor price cigarette MPLs set at or above what consumers currently report paying could reduce both tobacco use and socioeconomic disparities in smoking.

Association between self-reports of being high and perceptions about the safety of drugged and drunk driving.

This study examines the relationship between self-reports of being high on marijuana and perceptions about driving high or drunk. Data were collected in 2014 from an online convenience sample of adult, past 30-day marijuana and hashish users in Colorado and Washington (n = 865). Respondents were asked, "Were you high or feeling the effects of marijuana or hashish when you took this survey?" Logistic regression was used to assess the relationship between being high and beliefs about driving high, controlling for demographics and marijuana use. Respondents who reported being high at the time of survey administration had higher odds of agreeing with the statements, "I can safely drive under the influence of marijuana" (OR = 3.13, P < 0.001) and "I can safely drive under the influence of alcohol" (OR = 3.71, P < 0.001) compared with respondents who did not report being high. Respondents who were high also had higher odds of being open to driving high under certain circumstances. Being high may influence perceptions about the safety of drugged and drunk driving. The effectiveness of public health messages to prevent drugged and drunk driving may depend in part on how persuasive they are among individuals who are high.

Reactions to graphic health warnings in the United States.

This study reports consumer reactions to the graphic health warnings selected by the Food and Drug Administration to be placed on cigarette packs in the United States. We recruited three sets of respondents for an experimental study from a national opt-in e-mail list sample: (i) current smokers aged 25 or older, (ii) young adult smokers aged 18-24 and (iii) youth aged 13-17 who are current smokers or who may be susceptible to initiation of smoking. Participants were randomly assigned to be exposed to a pack of cigarettes with one of nine graphic health warnings or with a text-only warning statement. All three age groups had overall strong negative emotional (ß = 4.7, P < 0.001 for adults; ß = 4.6, P < 0.001 for young adults and ß = 4.0, P < 0.001 for youth) and cognitive (ß = 2.4, P < 0.001 for adults; ß = 3.0, P < 0.001 for young adults and ß = 4.6, P < 0.001 for youth) reactions to the proposed labels. The strong negative emotional and cognitive reactions following a single exposure to the graphic health warnings suggest that, with repeated exposures over time, graphic health warnings may influence smokers' beliefs, intentions and behaviors.

Influence of point-of-sale tobacco displays and graphic health warning signs on adults: evidence from a virtual store experimental study.

OBJECTIVES: We tested the impact of banning tobacco displays and posting graphic health warning signs at the point of sale (POS). METHODS: We designed 3 variations of the tobacco product display (open, enclosed [not visible], enclosed with pro-tobacco ads) and 2 variations of the warning sign (present vs absent) with virtual store software. In December 2011 and January 2012, we randomized a national convenience sample of 1216 adult smokers and recent quitters to 1 of 6 store conditions and gave them a shopping task. We tested for the main effects of the enclosed display, the sign, and their interaction on urge to smoke and tobacco purchase attempts. RESULTS: The enclosed display significantly lowered current smokers' (B = -7.05; 95% confidence interval [CI] = -13.20, -0.91; P < .05) and recent quitters' (Β = -6.00, 95% CI = -11.00, -1.00; P < .01) urge to smoke and current smokers' purchase attempts (adjusted odds ratio = 0.06; 95% CI = 0.03, 0.11; P < .01). The warning sign had no significant main effect on study outcomes or interaction with enclosed display. CONCLUSIONS: These data show that POS tobacco displays influence purchase behavior. Banning them may reduce cues to smoke and unplanned tobacco purchases.

Research support for effective state and community tobacco control programme response to electronic nicotine delivery systems.

OBJECTIVE: To identify unmet research needs of state and community tobacco control practitioners pertaining to electronic nicotine delivery systems (ENDS or e-cigarettes) that would inform policy and practice efforts at the state and community levels, and to describe ENDS-related research and dissemination activities of the National Cancer Institute-funded State and Community Tobacco Control Research Initiative. METHODS: To determine specific research gaps relevant to state and community tobacco control practice, we analysed survey data collected from tobacco control programmes (TCPs) in all 50 U.S. states and the District of Columbia (N=51). Survey items covered a range of ENDS issues: direct harm to users, harm of secondhand vapour, cessation, flavours, constituents and youth access. RESULTS: There is no ENDS topic on which a majority of state TCP managers feel very informed. They feel least informed about harms of secondhand vapour while also reporting that this information is among the most important for their programme. A majority (N=31) of respondents indicated needs for research on the implications of ENDS products for existing policies. CONCLUSIONS: TCP managers report that ENDS research is highly important for practice and need research-based information to inform decision making around the inclusion of ENDS in existing tobacco control policies. For optimal relevance to state and community TCPs, research on ENDS should prioritise study of the health effects of ENDS use and secondhand exposure to ENDS vapour in the context of existing tobacco control policies.

Cigarette trafficking in five northeastern US cities.

BACKGROUND: Cigarette taxation is effective in reducing tobacco use in the USA. However, these benefits are reduced when taxes are unpaid. Cigarette trafficking (ie, the illegal importation of cigarettes into a high-tax jurisdiction from a lower-tax jurisdiction) is well documented in high-tax places like New York City (NYC), but the extent of trafficking in other northeastern cities is relatively unknown. OBJECTIVE: To estimate the extent of cigarette trafficking in Boston, NYC, Philadelphia, Providence and Washington, DC, and project the benefits of reducing cigarette trafficking for recouping lost taxes and reducing smoking in these cities. METHODS: Littered cigarette packs were collected from a random sample of Census tracts in five US cities. Data collection yielded 1439 total littered packs. The share of cigarette packs bearing proper local, known non-local, foreign or unknown, or no tax stamp was calculated for each city. These data were used to estimate tax revenue recovery if cigarette trafficking could be eliminated. We also estimated the extent to which eliminating cigarette trafficking would reduce cigarette consumption. RESULTS: Overall, 58.7% of packs did not have a proper local tax stamp, and 30.5-42.1% were attributed to trafficking. We estimate that eliminating cigarette trafficking would result in declines in youth smoking prevalence ranging from negligible in low-tax cities like Philadelphia to up to 9.3% in higher-tax NYC. We estimate that these five cities could recoup $680-729 million annually in cigarette tax revenue if cigarette trafficking was eliminated. CONCLUSIONS: Reducing cigarette trafficking would increase the effectiveness of tobacco taxes in reducing smoking and generate additional tax revenue, particularly in higher-taxed cities. Federal action to reduce cigarette trafficking, such as a track-and-trace system, is needed.

Quantifying the effect of changes in state-level adult smoking rates on youth smoking.

OBJECTIVE: Quantify the degree to which changes in state-level adult smoking prevalence subsequently influence youth smoking prevalence. DESIGN: Analysis of data from the Tobacco Use Supplement to the Current Population Survey (TUS-CPS) collected from 1995 to 2006 and the National Youth Tobacco Survey (NYTS) collected from 1999 to 2006. SETTING AND PARTICIPANTS: Adults 25 years or older who completed the TUS-CPS and youth in middle and high school who completed the NYTS. MAIN OUTCOME MEASURES: Current smoking among middle and high school students as a function of the change in state-level adult smoking, controlling for individual-level sociodemographic characteristics and state-level tobacco control policy variables. RESULTS: Among middle school students, declines in state-level adult smoking rates are associated with lower odds of current smoking (P < .05), and each doubling of the decline in adult smoking rates is associated with a 6.0% decrease in youth smoking. Among high school students, declines in state-level adult smoking rates are not associated with current smoking. Higher cigarette prices were associated with lower odds of smoking among middle and high school students. Greater population coverage by smoke-free air laws and greater funding for tobacco control programs were associated with lower odds of current smoking among high school students but not middle school students. Compliance with youth access laws was not associated with middle or high school smoking. CONCLUSION: By quantifying the effect of changes in state-level adult smoking rates on youth smoking, this study enhances the precision with which the tobacco control community can assess the return on investment for adult-focused tobacco control programs.

A comprehensive examination of the influence of state tobacco control programs and policies on youth smoking.

OBJECTIVES: We examined the influence of tobacco control policies (tobacco control program expenditures, smoke-free air laws, youth access law compliance, and cigarette prices) on youth smoking outcomes (smoking susceptibility, past-year initiation, current smoking, and established smoking). METHODS: We combined data from the 2002 to 2008 National Surveys on Drug Use and Health with state and municipality population data from the US Census Bureau to assess the associations between state tobacco control policy variables and youth smoking outcomes, focusing on youths aged 12 to 17 years. We also examined the influence of policy variables on youth access when these variables were held at 2002 levels. RESULTS: Per capita funding for state tobacco control programs was negatively associated with all 4 smoking outcomes. Smoke-free air laws were negatively associated with all outcomes except past-year initiation, and cigarette prices were associated only with current smoking. We found no association between these outcomes and retailer compliance with youth access laws. CONCLUSIONS: Smoke-free air laws and state tobacco control programs are effective strategies for curbing youth smoking.

Do different styles of antismoking ads influence the types of smokers who call quitlines?

This study examined the relationship between television antismoking advertisements and the proportion of smokers who call a smokers' quitline who are ready to quit or have high confidence in quitting. The primary data of interest came from completed intake interviews of smokers. Using a generalized linear model, we modeled the proportion of Quitline callers who are ready to quit and/or have high confidence in quitting. The primary explanatory variable was monthly target audience rating points (TARPs) for antismoking advertisements, a measure of broadcast media exposure, obtained from the state's media buyer. The proportions of callers ready to quit and with high confidence in quitting were negatively associated with total TARPs. This result, over all ad types, was driven by why to quit-graphic ads. These results suggest that why to quit-graphic ads influence smokers who are less ready to quit or have lower confidence they can quit, likely new quitters, to call the Quitline.

Perceived effectiveness of cessation advertisements: the importance of audience reactions and practical implications for media campaign planning.

Cessation television ads are often evaluated with measures of perceived effectiveness (PE) that gauge smokers' reactions to the ads. Although measures of PE have been validated for other genres of public service announcements, no studies to our knowledge have demonstrated the predictive validity of PE for cessation TV ads specifically. We analyzed data from a longitudinal Web survey of smokers in the United States to assess whether measures of PE for cessation TV ads are causally antecedent to cessation-related outcomes. These data consisted of baseline and 2-week follow-up surveys of 3,411 smokers who were shown a number of cessation TV ads and were asked to provide their appraisals of PE for those messages. We found that baseline PE for the ads was associated with increased negative feelings about smoking, increased outcome expectations about the benefits of quitting, increased consideration of the benefits of quitting, increased desire to quit, and increased intentions to quit smoking at follow-up. Results suggest that measures of PE for cessation TV ads can be powerful predictors of likely ad success. Hence, our findings support the use of PE in quantitative ad pretesting as part of a standard regimen of formative research for cessation television campaigns.

Influence of retail cigarette advertising, price promotions, and retailer compliance on youth smoking-related attitudes and behaviors.

CONTEXT: Exposure to retail tobacco marketing is associated with youth smoking, but most studies have relied on self-reported measures of exposure, which are prone to recall bias. OBJECTIVE: To examine whether exposure to retail cigarette advertising, promotions, and retailer compliance is associated with youth smoking-related outcomes using observational estimates of exposure. DESIGN: Data on retail cigarette advertising and promotions were collected from a representative sample of licensed tobacco retailers in New York annually since 2004. County-level estimates of retail cigarette advertising and promotions and retailer compliance with youth access laws were calculated and linked to the New York Youth Tobacco Survey, administered to 54,671 middle and high school students in 2004, 2006, and 2008. Regression models examined whether cigarette advertising, promotions, and retailer compliance were associated with youth's awareness of retail cigarette advertising, attitudes about smoking, susceptibility to smoking, cigarette purchasing behaviors, and smoking behaviors. RESULTS: Living in counties with more retail cigarette advertisements is associated with youth having positive attitudes about smoking (odds ratio [OR] = 1.10, 95% confidence interval [CI] = 1.03-1.19, P < .01). Living in counties with more retail cigarette promotions is associated with youth current smoking (OR = 1.57, 95% CI = 1.01-2.44, P < .05). Living in counties with higher retailer compliance with youth access laws is associated with higher odds of youth being refused cigarettes when attempting to buy in stores (OR = 1.12, 95% CI = 1.01-1.25, P < .05) and lower odds of retail stores being youth's usual source of cigarettes (OR = 0.88, 95% CI = 0.80-0.97, P < .01). CONCLUSIONS: Strong retailer compliance programs and policies that eliminate cigarette advertising and promotions may help reduce youth smoking.

Awareness of and receptivity to FDA's point-of-sale tobacco public education campaign.

The purpose of the study was to assess awareness of and receptivity to FDA's point-of-sale (POS) tobacco public education campaign for adult cigarette smokers called Every Try Counts; it was the first multi-county POS campaign in the U.S. The design was a county-level treatment-control three-wave longitudinal design. The setting was 15 treatment and 15 control counties. Subjects were smokers ages 25 to 54 (N = 3,628). 4,145 individuals screened in as eligible; 3,628 (87.5% response rate) completed the Wave 1 questionnaire (Wave 2: n = 2,812; Wave 3: n = 2,571; retention 70.9%). Measures were self-reported brand and ad awareness (saw any ad a few times or more) and receptivity (5-item perceived effectiveness scale). The analysis included descriptive analyses of receptivity; bivariate analyses of awareness by treatment group; and covariate- and time-adjusted logistic regression models to determine changes in awareness attributable to the campaign. Receptivity was moderate and differed significantly by race/ethnicity. As was the case for all waves, at wave 3, ad awareness was significantly higher in treatment (53.3%) than control counties (36.1%, p < .05). In regression models, brand (OR = 1.53, 95% CI: 1.26-1.86) and ad (OR = 1.74, 95% CI: 1.39-2.16) awareness were significantly higher in treatment than control counties. Every Try Counts generated a moderate level of receptivity and attention from cigarette smokers. Limitations include self-reports of campaign awareness and generalizability to a small number of U.S. counties.

The Impact of Social Media Use and Gaming on Initiation of Smokeless Tobacco Use Among Rural Male Youth.

PURPOSE: Smokeless tobacco (SLT) use is more common among White male youth in rural locations than among other youth. Previous literature documents risk factors for SLT use (e.g., perceived harm). However, no research has examined whether SLT initiation is associated with the use of social media and video games, despite the high prevalence of those behaviors among adolescent males. METHODS: As part of the evaluation of "The Real Cost" smokeless prevention campaign, we conducted a baseline survey of a cohort of US males aged 11-16 in 2016 and four follow-up surveys conducted approximately every 8 months. We used discrete-time survival analysis to examine factors associated with SLT initiation. Logistic regression estimated the odds of initiation as a function of lagged values of key predictors (social media use in tertiles and frequency of gaming) and other baseline and lagged correlates. The model controlled for campaign exposure. RESULTS: Relative to the lowest tertile of social media use, moderate (odds ratio [OR] = 1.80) or high use (OR = 2.77) was associated with increased risk of SLT initiation at the subsequent survey wave. Relative to playing every few weeks or less, playing video games once a day (OR = 0.50) or several times a day (OR = 0.33) was associated with decreased risk of SLT initiation. DISCUSSION: SLT initiation was positively associated with social media use and negatively associated with gaming. Future research should explore reasons for the protective nature of gaming (e.g., social support, improved mood) and whether parental supervision of social media use could mitigate its negative impact.