Network hubs cease to be influential in the presence of low levels of advertising.

Attempts to find central "influencers," "opinion leaders," "hubs," "optimal seeds," or other important people who can hasten or slow diffusion or social contagion has long been a major research question in network science. We demonstrate that opinion leadership occurs only under conventional but implausible scope conditions. We demonstrate that a highly central node is a more effective seed for diffusion than a random node if nodes can only learn via the network. However, actors are also subject to external influences such as mass media and advertising. We find that diffusion is noticeably faster when it begins with a high centrality node, but that this advantage only occurs in the region of parameter space where external influence is constrained to zero and collapses catastrophically even at minimal levels of external influence. Importantly, nearly all prior agent-based research on choosing a seed or seeds implicitly occurs in the network influence only region of parameter space. We demonstrate this effect using preferential attachment, small world, and several empirical networks. These networks vary in how large the baseline opinion leadership effect is, but in all of them it collapses with the introduction of external influence. This implies that, in marketing and public health, advertising broadly may be underrated as a strategy for promoting network-based diffusion.

US toddler milk sales and associations with marketing practices.

OBJECTIVE: Extensive marketing of 'toddler milks' (sugar-sweetened milk-based drinks for toddlers) promotes unsubstantiated product benefits and raises concerns about consumption by young children. The present study documents trends in US toddler milk sales and assesses relationships with brand and category marketing. DESIGN: We report annual US toddler milk and infant formula sales and marketing from 2006 to 2015. Sales response models estimate associations between marketing (television advertising spending, product price, number of retail displays) and volume sales of toddler milks by brand and category. SETTING: US Nielsen retail scanner sales and advertising spending data from 2006 to 2015. PARTICIPANTS: Researchers analysed all Universal Product Codes (n 117·4 million) sold by seven infant formula and eight toddler milk brands from 2006 to 2015. RESULTS: Advertising spending on toddler milks increased fourfold during this 10-year period and volume sales increased 2·6 times. In contrast, advertising spending and volume sales of infant formulas declined. Toddler milk volume sales were positively associated with television advertising and retail displays, and negatively associated with price, at both the brand and category levels. CONCLUSIONS: Aggressive marketing of toddler milks has likely contributed to rapid sales increases in the USA. However, these sugar-sweetened drinks are not recommended for toddler consumption. Health-care providers, professional organizations and public health campaigns should provide clear guidance and educate parents to reduce toddler milk consumption and address misperceptions about their benefits. These findings also support the need to regulate marketing of toddler milks in countries that prohibit infant formula marketing to consumers.

Parent and child perceptions of gambling promotions in Australian sport.

Gambling is recognized as a significant public health problem. However, there is little research exploring community attitudes towards gambling and the development of advocacy initiatives. Engaging adults and young people in advocacy efforts is recognized as being beneficial to the successful implementation of harm prevention and reduction strategies. This study explored the attitudes of young people and their parents towards the alignment of gambling with sport, and the strategies they perceive could be used to prevent and reduce gambling related harm. Using a Constructivist Grounded Theory approach, 30 family groups from Melbourne, Australia participated in semi-structured interviews. Parents and young people were asked about gambling and its promotion, alignment with sporting codes, the potential impact on young people and strategies that may prevent or reduce gambling harm. Thematic analysis was undertaken to interpret the data. The sample comprised 29 parents, one grandparent and 48 young people. Themes emerging from the data related to the use of imagery and appeal strategies in advertisements, the normalization of betting in advertisements and the alignment of betting with sport. Parents and young people also identified a number of potential gambling harm prevention and reduction initiatives. Parents and young people were able to describe a range of strategies used by gambling companies to promote their products, understand the potential impact of these strategies, and recommend strategies to reduce harm. Given this level of understanding there is clearly an opportunity to engage young people and stakeholders in advocacy initiatives aimed at reducing and preventing gambling harm.

Ten Years of Messaging about the Affordable Care Act in Advertising and News Media: Lessons for Policy and Politics.

Messaging about the Affordable Care Act (ACA) has seemingly produced a variety of outcomes: millions of Americans gained access to health insurance, yet much of the US public remains confused about major components of the law, and there remain stark and persistent political divides in support of the law. Our analysis of the volume and content of ACA-related media (including both ads and news) helps explain these phenomena, with three conclusions. First, the information environment around the ACA has been complex and competitive, with messaging originating from diverse sponsors with multiple objectives. Second, partisan cues in news and political ads are abundant, likely contributing to the crystallized politically polarized opinion about the law. Third, partisan discussions of the ACA in political ads have shifted in volume, direction, and tone over the decade, presenting divergent views regarding which party is accountable for the law's successes (or failures). We offer evidence for each of these conclusions from longitudinal analyses of the volume and content of ACA messaging, also referencing studies that have linked these messages to attitudes and behavior. We conclude with implications for health communication, political science, and the future outlook for health reform.

Adults' favorability toward prohibiting flavors in all tobacco products in the United States.

In November 2018, US Food and Drug Administration announced its intent to prohibit menthol in combustible tobacco products, prohibit flavored cigars, and prohibit flavored e-cigarettes unless they are sold in age-restricted, in-person locations. This study assessed adult attitudes toward prohibiting flavors in all tobacco products, including e-cigarettes. Data were from the 2016 Summer Styles survey of 4203 US adults aged ≥18 years. Respondents were asked whether they favored or opposed prohibiting flavors (e.g., menthol, spicy, sweet, or fruity flavor) in all tobacco products. Prevalence and correlates of favorability were assessed using weighted percentages and adjusted prevalence ratios (aPR) respectively. Assessed correlates were: sex, age, race/ethnicity, income, US Census region, marital status, children <18 years living in the home, perceptions toward e-cigarette advertising, and current (past 30-day) tobacco product use. Overall, 47.3% of adults reported favorable attitudes toward prohibiting flavors in all tobacco products. By tobacco product use status, prevalence was 52.0%, 48.4%, and 34.8% among never, former, and current users, respectively (p < .05). Among current tobacco product users, favorability was more likely among adults who believed e-cigarette ads exposure makes youth think about smoking (aPR = 1.82; 95% CI = 1.20-2.78) and those with any children aged <18 years in their household (aPR = 1.38; 95% CI = 1.05-1.82). To conclude, nearly half of adults favored prohibiting flavors in all tobacco products, including e-cigarettes. Prohibiting flavors in tobacco products could benefit public health by reducing both individual-level and population-level harms, including tobacco use initiation especially among youth.

Neighborhood Differences in Alternative Tobacco Product Availability and Advertising in New York City: Implications for Health Disparities.

INTRODUCTION: Alternative tobacco products (ATPs), such as cigars, smokeless tobacco, and electronic nicotine delivery systems (ENDS), have a strong presence in the US retail environment amid declining cigarette consumption. This study documented the promotion of ATPs in tobacco retailers in New York City and examined associations with neighborhood demographics. METHODS: Data on product availability and advertising were collected from a stratified, random sample of tobacco retailers in 2017 (n = 796). Multilevel models estimated adjusted prevalence ratios (aPRs) for each outcome by neighborhood racial/ethnic composition and median household income. RESULTS: Nearly half (49.8%) of retailers carried 99-cent cigarillos, but availability was significantly greater in neighborhoods in the highest (vs. lowest) quartile for the percentage of Black residents [68.2%, aPR: 1.59 (1.19, 2.11)] and in the lowest (vs. highest) income quartile [67.3%, aPR: 1.56 (1.04, 2.35)]. Conversely, retailers in neighborhoods with the highest percentage of White residents were significantly more likely to carry ENDS [66.4%, aPR: 1.71 (1.11, 2.62)]. Advertisements for ENDS were less common in neighborhoods in the highest (vs. lowest) quartiles for the percentage of Black and Hispanic residents [20.3%, aPR: 0.64 (0.41, 0.99); 22.9%, aPR: 0.62 (0.40, 0.98)]. CONCLUSIONS: The marketing of inexpensive, combusted tobacco products disproportionately saturates low-income, minority communities, while potentially lower risk, noncombusted products are more accessible in largely White and higher income neighborhoods. This pattern may exacerbate tobacco-related inequities. Public health policies should prioritize reducing the appeal and affordability of the most harmful tobacco products to help reduce health disparities. IMPLICATIONS: Although cigarette promotion at the point-of-sale is well documented in the literature, questions remain about the ways in which alternative tobacco products (ATPs) are marketed in communities. Importantly, these products fall on a continuum of harm, with combusted tobacco overwhelmingly responsible for tobacco-related death and disease. We found that retailers in minority and low-income communities were more likely to carry and advertise inexpensive ATPs such as cigarillos, while potentially less risky, noncombusted products such as smokeless tobacco and e-cigarettes were more accessible in higher income and predominantly White neighborhoods. Policies aligned with product risk may help reduce health disparities.

Exposure to Point-of-Sale Marketing of Cigarettes and E-Cigarettes as Predictors of Smoking Cessation Behaviors.

Introduction: Cue-reactivity theory suggests that smoking-related visual cues such as point-of-sale (POS) marketing (eg, advertising, product displays) may undermine cessation attempts by causing an increase in nicotine cravings among users. This study examined the relationship between recall of exposure to POS marketing and subsequent cessation behaviors among young adult cigarette smokers. Methods: Participants included 813, 18-29 year old (m = 21.1, SD = 2.70), current cigarette smokers attending 24 Texas colleges. Multivariable logistic regression models examined the impact of baseline self-reported exposure to cigarette and e-cigarette advertising and product displays, on using e-cigarettes for cessation and successful cigarette cessation at 6-month follow-up. Two-way interactions between product-specific advertising and between product-specific displays were examined to determine if the marketing of one product strengthened the cue reactivity of the other. Baseline covariates included sociodemographic factors, past quit attempts, intentions to quit smoking, and nicotine dependence. Results: Exposure to e-cigarette displays was associated with lower odds of cigarette smoking cessation, controlling for covariates and conventional cigarette display exposure. E-cigarette advertising was positively associated with the use of e-cigarettes for cigarette cessation among participants exposed to low (ie, at least 1 SD below the mean) levels of cigarette advertising. Cigarette advertising was associated with the use of e-cigarettes for cigarette cessation only among those exposed to low levels of e-cigarette advertising. Exposure to cigarette displays was not associated with either outcome. Conclusion: Smoking-related cues at POS may undermine successful cigarette cessation. Exposure to product displays decrease odds of cessation. Advertising exposure increased odds for using e-cigarettes for cessation attempts, but may have guided smokers towards an unproven cessation aid. Implications: By examining the interaction of conventional cigarette and e-cigarette marketing exposure, this study adds a unique insight into the impact of retail tobacco marketing on cigarette smoking cessation behavior among young adults. These findings suggest that policies that balance encouraging cigarette smoking cessation while limiting marketing strategies should be considered, such as POS product displays, that may undermine successful cessation attempts.

Prevalence and Determinants of Susceptibility to Tobacco Smoking Among Students in The Gambia.

INTRODUCTION: Smoking is the biggest preventable cause of death and kills about seven million people annually. As smoking prevalence is falling in developed countries, tobacco businesses are turning to low- and middle-income countries (LMICs) to generate new tobacco markets. To prevent young people from initiating smoking and becoming regular smokers, it is important to understand the causes of susceptibility to smoking. In this study, we report a nationwide survey of the prevalence and risk factors of smoking susceptibility among students aged 12-20 years in The Gambia. METHODS: We used two-stage cluster random sampling to select students in secondary schools throughout The Gambia and questionnaire to collect data on demographic characteristics and indicators on susceptibility to initiating smoking. RESULTS: Among the total sample of 10289 students, 9831 (96%; 55.6% girls and 44.4% boys, aged 12-20 years) nonsmokers were included in the analysis. Of these, 3333 (33.9%) were found to be susceptible to smoking. Smoking susceptibility was more common among students attending grant-aided schools, non-Muslims, who had smoking allowed at home, had family members or friends who smoke, were sent to purchase cigarettes, had poor knowledge of the harmful effects of smoking, noticed point-of-sale tobacco advertisements, and who had positive attitudes towards smoking. CONCLUSIONS: This study shows that susceptibility to smoking is common among students and associated with preventable exposures. Although based on cross-sectional data, these findings suggest that raising students' awareness of the harmful effects of smoking and reducing the prevalence of adult smoking, extending tobacco advertising restrictions to include point-of-sale, are all important to preventing the uptake of smoking among students. IMPLICATIONS: This is the first study to provide detailed data on smoking susceptibility and risk factors in a nationally representative sample of young people in The Gambia. Our findings show that susceptibility to smoking is relatively high and associated with preventable measures. Our results also identify an urgent need to broaden the ban on tobacco advertising to explicitly include point-of-sale advertisements. These findings provide valuable information for tobacco control policies and evidence to enable targeted intervention for young people most at risk of initiating smoking.

Share of Advertising Voice at the Point-of-Sale and Its Influence on At-Risk Students' Use of Alternative Tobacco Products.

INTRODUCTION: As adolescent tobacco use shifts from traditional cigarettes to alternative products, it is important to understand the influence of point-of-sale (POS) advertising on product use. This research investigated whether the percentage of POS advertising for a particular product, known as the share of advertising voice (SAV), moderated the relationship between exposure to POS tobacco advertisements and tobacco use among at-risk youth. METHODS: Longitudinal self-report data from 746 students attending 20 alternative high schools in southern California was merged with observational data cataloging 2101 advertisements for cigarettes, e-cigarettes, cigars, and smokeless tobacco from 87 tobacco retail outlets within a half mile of the schools. Four multilevel Poisson regression models examined whether SAV interacted with POS tobacco advertising exposure to influence the use of tobacco products 1 year later. RESULTS: Adolescent exposure to POS tobacco advertisements was significantly associated with increased use of all four tobacco products (p < .02). When SAV was added to the model as a moderator, the results showed a significant interaction, such that increasing the SAV for e-cigarettes was associated with greater use of that product (ß = 0.27, SE = 0.07, p < .001). The same moderating effect was found for smokeless tobacco (ß = 0.56, SE = 0.19, p = .004) but no moderating effect was observed for cigarettes or cigars. CONCLUSION: POS SAV has the potential to influence at-risk students' use of alternative tobacco products and may be a contributing factor to recent nationwide shifts in youth tobacco use. IMPLICATIONS: Future studies should monitor changes in SAV to gain insight into POS marketing trends that may be impacting youth tobacco use. In addition, state and local governments should consider implementing policies that limit the volume and proportion of POS tobacco advertising for all nicotine and tobacco products available in retail environments near schools. Restrictions placed on a single product may cause unintended shifts in product selection rather than a reduction in youth tobacco use.

Lesbian, Gay, Bisexual, and Transgender (LGBT) View it Differently Than Non-LGBT: Exposure to Tobacco-related Couponing, E-cigarette Advertisements, and Anti-tobacco Messages on Social and Traditional Media.

BACKGROUND: LGBT populations use tobacco at disparately higher rates nationwide, compared to national averages. The tobacco industry has a history targeting LGBT with marketing efforts, likely contributing to this disparity. This study explores whether exposure to tobacco content on traditional and social media is associated with tobacco use among LGBT and non-LGBT. METHODS: This study reports results from LGBT (N = 1092) and non-LGBT (N = 16430) respondents to a 2013 nationally representative cross-sectional online survey of US adults (N = 17522). Frequency and weighted prevalence were estimated and adjusted logistic regression analyses were conducted. RESULTS: LGBT reported significantly higher rates of past 30-day tobacco media exposure compared to non-LGBT, this effect was strongest among LGBT who were smokers (p < .05). LGBT more frequently reported exposure to, searching for, or sharing messages related to tobacco couponing, e-cigarettes, and anti-tobacco on new or social media (eg, Twitter, Facebook, etc.) than did non-LGBT (p < .05). Non-LGBT reported more exposure from traditional media sources such as television, most notably anti-tobacco messages (p = .0088). LGBT had higher odds of past 30-day use of cigarettes, e-cigarettes, and cigars compared to non-LGBT, adjusting for past 30-day media exposure and covariates (p ≤ .0001). CONCLUSIONS: LGBT (particularly LGBT smokers) are more likely to be exposed to and interact with tobacco-related messages on new and social media than their non-LGBT counterparts. Higher levels of tobacco media exposure were significantly associated with higher likelihood of tobacco use. This suggests tobacco control must work toward reaching LGBT across a variety of media platforms, particularly new and social media outlets. IMPLICATIONS: This study provides important information about LGBT communities tobacco-related disparities in increased exposure to pro-tobacco messages via social media, where the tobacco industry has moved since the MSA. Further, LGBT when assessed as a single population appear to identify having decreased exposure to anti-tobacco messages via traditional media, where we know a large portion of tobacco control and prevention messages are placed. The study points to the need for targeted and tailored approaches by tobacco control to market to LGBT using on-line resources and tools in order to help reduce LGBT tobacco-related health disparities. Although there have been localized campaigns, only just recently have such LGBT-tailored national campaigns been developed by the CDC, FDA, and Legacy, assessment of the content, effectiveness, and reach of both local and national campaigns will be important next steps.

Placing Antismoking Graphic Warning Posters at Retail Point-of-Sale Locations Increases Some Adolescents' Susceptibility to Future Smoking.

Objectives: This experiment tested whether introducing graphic antitobacco posters at point-of-sale (POS) had any effect on adolescents' susceptibility to future cigarette smoking and whether these effects were moderated by adolescents' baseline risk of cigarette smoking. Methods: The study was conducted in the RAND StoreLab, a life-sized replica of a convenience store that was developed to experimentally evaluate how changing aspects of tobacco advertising displays in retail POS environments influence tobacco use risk and behavior during simulated shopping experiences. In this study, 441 adolescents were randomized to one of the four conditions in a 2 (graphic antismoking poster placed near the tobacco power wall: no, yes) × 2 (graphic antismoking poster placed near the cash register: no, yes) experimental design. The outcome of interest was susceptibility to future cigarette smoking. Results: The addition of antismoking posters at POS led to a significant increase in future smoking susceptibility among those adolescents who already were at high risk for smoking in the future (p < .045). The introduction of graphic antismoking posters had no impact on committed never smokers, regardless of poster location; never smokers' susceptibility to future smoking was uniformly low across experimental conditions. Conclusions: Introducing graphic antismoking posters at POS may have the unintended effect of further increasing cigarette smoking susceptibility among adolescents already at risk.

Marketing with tobacco pack onserts: a qualitative analysis of tobacco industry documents.

BACKGROUND: Cigarette packs are a form of advertising that distributes brand information wherever smokers go. In the 21st century, tobacco companies began using onserts on cigarette packs to communicate new advertising messages to smokers. METHODS: We reviewed tobacco industry documents dated 1926 to 2017 to identify how the tobacco industry developed and used onserts in marketing and to serve the industry's political and legal objectives. RESULTS: Onserts added to cigarette packs became a more cost-effective way for brands to market in the year 2000. Manufacturers then began studying them, finding that new messages were appealing, while repeated messages were ignored. By 2005, tobacco companies were using onserts to effectively communicate about new tobacco products and packaging changes. They also used repeated 'corporate responsibility' messages that were, according to the industry's own research, likely to be ignored. CONCLUSIONS: Tobacco companies have expanded on cigarette pack-based advertising. Twenty-first century onserts simultaneously seek to increase sales using materials that are novel, attractive and provide independent value, while undercutting public health messages about the risks of tobacco use using materials that repeat over time and are comparatively unattractive. Health authorities can use this industry research to mandate onserts to communicate effective health messages.

Taking the pressure off the spring: the case of rebounding smoking rates when antitobacco campaigns ceased.

OBJECTIVE: Smoking rates have been compared with a spring, requiring continuous downward pressure against protobacco forces, rather than a screw, which once driven down stays down. Quality antitobacco mass media campaigns put downward pressure on smoking rates. The suspension of a major Australian state campaign provided a natural experiment to assess effects on smoking. Furthermore, we document the positive influence of robust monitoring and mature advocacy on the political decision to reinstate funding. We also document the misuse by industry of South Australian smoking data from the period between Australia's implementation and subsequent evaluation of plain packaging. METHODS: A time series analysis was used to examine monthly smoking prevalence trends at each of four intervention points: (A) commencement of high-intensity mass media campaign (August 2010); (B) introduction of plain packaging (December 2012), (C) defunding of campaign (July 2013); and (D) reinstatement of moderate-intensity campaign (July 2014). FINDINGS: The suspension of the antitobacco campaign was disruptive to achieving smoking prevalence targets. There was an absence of a downward monthly smoking prevalence trajectory during the non-campaign period. Moreover, there was a significant decline in smoking prevalence during the period of high-intensity advertising, which continued after the introduction of plain packaging laws, and at the recommencement of campaign activity. CONCLUSIONS: While the observed declines in smoking prevalence are likely due to a combination of interventions and cannot be attributed exclusively to antitobacco advertising, the results reinforce the political decision to reinstate the campaign and demonstrate the need for maintained investment to keep downward pressure on smoking rates.

Difference between recommended retail price and sales price for tobacco products in independent and convenience (small) retailers before and after the introduction of standardised tobacco packaging in the UK.

AIM: Recommended retail price (RRP) is a marketing strategy used by tobacco companies to maintain competitiveness, communicate product positioning and drive sales. We explored small retailer adherence to RRP before and after the introduction of the Standardised Packaging of Tobacco Products Regulations in the UK (fully implemented on 20 May 2017) which mandated standardised packaging of cigarettes and rolling tobacco, set minimum pack/pouch sizes and prohibited price-marking. METHOD: Monthly electronic point of sale data from 500 small retailers in England, Scotland and Wales were analysed. From May 2016 to October 2017, we monitored 20 of the best-selling fully branded tobacco products (15 factory-made cigarettes, 5 rolling tobacco) and their standardised equivalents. Adherence to RRP was measured as the average difference (%) between monthly RRPs and sales prices by pack type (fully branded vs standardised), price-marking on packaging and price segment. RESULTS: The average difference between RRP and sales price increased from +0.36% above RRP (SD=0.72) in May 2016, when only fully branded packs were sold, to +1.37% in October 2017 (SD=0.30), when standardised packs were mandatory. Increases above RRP for fully branded packs increased as they were phased out, with deviation greater for non-price-marked packs and premium products. DISCUSSION: Despite tobacco companies emphasising the importance of RRP, small retailers implemented small increases above RRP as standardised packaging was introduced. Consequently, any intended price changes by tobacco companies in response to the legislation (ie, to increase affordability or brand positioning) may be confounded by retailer behaviour, and such deviation may increase consumer price sensitivity.

Google AdWords and Facebook Ads for Recruitment of Pregnant Women into a Prospective Cohort Study With Long-Term Follow-Up.

Objectives Several types of epidemiologic studies suffer from decreasing participation rates, resulting in potential selection bias and delay or termination of studies. We aimed to determine the feasibility of online methods for recruitment of pregnant women into a prospective cohort study. Methods In addition to traditional recruitment through prenatal care providers, we advertized participation in the PRegnancy and Infant DEvelopment (PRIDE) Study, an ongoing prospective cohort study with long-term follow-up in The Netherlands enrolling women in early pregnancy, through Google AdWords (30 days) and Facebook Ads (31 and 27 days) campaigns between September 2016 and January 2017. We calculated costs per eligible participant and compared demographics, health-related characteristics, and follow-up rates between participants recruited through online methods and prenatal care providers. Results During the study period, we recruited six women through AdWords (€54.28 per participant), 59 through Facebook (€10.17 per participant), and 327 through prenatal care providers (no valid cost estimate available). Facebook participants seemed to be younger (29.0 vs. 30.7 years), to have a higher body mass-index and/or low/intermediate education (27.0 vs. 24.0 kg/m2 and 41 vs. 25%, respectively), and to start prenatal care in secondary care more often (12 vs. 5%) than participants recruited through prenatal care providers. Item non-response and loss to follow-up rates were higher among women recruited online than among those recruited through prenatal care providers. Conclusion Google AdWords did not contribute substantially, but Facebook Ads may complement traditional recruitment methods of pregnant women into prospective cohort studies, despite challenges that may threaten internal validity.

Medical Marketing in the United States, 1997-2016.

IMPORTANCE: Manufacturers, companies, and health care professionals and organizations use an array of promotional activities to sell and increase market share of their products and services. These activities seek to shape public and clinician beliefs about laboratory testing, the benefits and harms of prescription drugs, and some disease definitions. OBJECTIVE: To review the marketing of prescription drugs, disease awareness campaigns, health services, and laboratory tests and the related consequences and regulation in the United States over a 20-year period (1997-2016). EVIDENCE: Analysis (1997-2016) of consumer advertising (Kantar Media data for spending and number of ads); professional marketing (IQVIA Institute for Human Data Science, Open Payments Data [Centers for Medicare & Medicaid Services]); regulations and legal actions of the US Food and Drug Administration (FDA), Federal Trade Commission (FTC), state attorneys general, and US Department of Justice; and searches (1975-2018) of peer-reviewed medical literature (PubMed), business journals (Business Source Ultimate), and news media (Lexis Nexis) for articles about expenditures, content, and consequences and regulation of consumer and professional medical marketing. Spending is reported in 2016 dollars. FINDINGS: From 1997 through 2016, spending on medical marketing of drugs, disease awareness campaigns, health services, and laboratory testing increased from $17.7 to $29.9 billion. The most rapid increase was in direct-to-consumer (DTC) advertising, which increased from $2.1 billion (11.9%) of total spending in 1997 to $9.6 billion (32.0%) of total spending in 2016. DTC prescription drug advertising increased from $1.3 billion (79 000 ads) to $6 billion (4.6 million ads [including 663 000 TV commercials]), with a shift toward advertising high-cost biologics and cancer immunotherapies. Pharmaceutical companies increased DTC marketing about diseases treated by their drugs with increases in disease awareness campaigns from 44 to 401 and in spending from $177 million to $430 million. DTC advertising for health services increased from $542 million to $2.9 billion, with the largest spending increases by hospitals, dental centers, cancer centers, mental health and addiction clinics, and medical services (eg, home health). DTC spending on advertising for laboratory tests (such as genetic testing) increased from $75.4 million to $82.6 million, although the number of ads increased more substantially (from 14 100 to 255 300), reflecting an increase in less expensive electronic media advertising. Marketing to health care professionals by pharmaceutical companies accounted for most promotional spending and increased from $15.6 billion to $20.3 billion, including $5.6 billion for prescriber detailing, $13.5 billion for free samples, $979 million for direct physician payments (eg, speaking fees, meals) related to specific drugs, and $59 million for disease education. Manufacturers of FDA-approved laboratory tests paid $12.9 million to professionals in 2016. From 1997 through 2016, the number of consumer and professional drug promotional materials that companies submitted for FDA review increased from 34 182 to 97 252, while FDA violation letters for misleading drug marketing decreased from 156 to 11. Since 1997, 103 financial settlements between drug companies and federal and state governments resulted in more than $11 billion in fines for off-label or deceptive marketing practices. The FTC has acted against misleading marketing by a single for-profit cancer center. CONCLUSIONS AND RELEVANCE: Medical marketing increased substantially from 1997 through 2016, especially DTC advertising for prescription drugs and health services. Pharmaceutical marketing to health professionals accounted for most spending and remains high even with new policies to limit industry influence. Despite the increase in marketing over 20 years, regulatory oversight remains limited.

Google Trends as a Tool for Evaluating Public Interest in Facial Cosmetic Procedures.

BACKGROUND: The utility of Google Trends (GT) in analyzing worldwide and regional patient interest for plastic surgery procedures is becoming invaluable to plastic surgery practices. GT data may offer practical information to plastic surgeons pertaining to seasonal and geographic trends in interest in facial cosmetic procedures. OBJECTIVES: The authors sought to analyze geographic and temporal trends between GT search volumes and US surgery volumes using univariate analysis. METHODS: The "related queries" feature of GT generated potential search terms. GT data were compiled for cheek implants, mentoplasty, otoplasty, blepharoplasty, rhytidectomy, forehead lift, hair transplantation, lip augmentation, lip reduction, platysmaplasty, and rhinoplasty from January 2004 to December 2017. Annual volumes for respective procedures were obtained from annual statistics reports of the American Society of Plastic Surgeons (ASPS) from 2006 to 2017 and American Society of Aesthetic Plastic Surgery (ASAPS) from 2004 to 2017. RESULTS: Geographical and temporal variations in search volume were detected during the study. Search volume trends that correlated significantly with both ASPS and ASAPS surgery volume trends were: "eyelid plastic surgery" (ASPS R2 = 0.336, P = 0.048; ASAPS R2 = 0.661, P = 0.001); "facelift" (ASPS R2 = 0.767, P ≤ 0.001; ASAPS R2 = 0.767, P = 0.001); "lip injections" (ASPS R2 = 0.539, P = 0.007; ASAPS R2 = 0.461, P = 0.044); and "rhinoplasty surgery" (ASPS R2 = 0.797, P ≤ 0.001; ASAPS R2 = 0.441, P = 0.01). Several search terms demonstrated no significant relationships or were significant with only one database. CONCLUSIONS: GT may provide a high utility for informing plastic surgeons about the interest expressed by our patient population regarding certain cosmetic search terms and procedures. GT may represent a convenient tool for optimizing marketing and advertising decisions.

Marketing medicines: charting the rise of modern therapeutics through a systematic review of adverts in UK medical journals (1950-1980).

AIMS: To examine how pharmaceutical products that were first marketed between 1950 and 1980 were promoted to physicians through advertisements and briefly review advertising regulations and accuracy of the advertisements in the light of modern knowledge. METHODS: We systematically reviewed advertisements promoting drugs for specific therapeutic areas, namely central nervous system disorders (anxiety and sleep disorders, depression, psychoses, and Parkinson's disease), respiratory disorders, cardiovascular disorders, and gastrointestinal disorders. We examined about 800 issues of the British Medical Journal (1950-1980) and about 150 issues of World Medicine (1965-1984). RESULTS: Advertising material was minimally regulated until the mid-1970s. Many drugs were marketed with little preclinical or clinical knowledge and some with the expectation that prescribers would obtain further data. The peak of advertising occurred in parallel with the surge in the release of novel drugs during the 1960s, but declined markedly after the mid-1970s. Advertisements generally contained little useful prescribing information. The period we investigated saw the release of many novel pharmaceuticals in the therapeutic areas we examined, and many (or their class successors) still play important therapeutic roles, including benzodiazepines, tricyclic antidepressants, phenothiazines, levodopa, selective and non-selective ß-adrenoceptor antagonists, thiazide diuretics, ß-adrenoceptor agonists, and histamine H2 receptor antagonists. CONCLUSIONS: Advertising pharmaceuticals in the BMJ and World Medicine in 1950-1980 was poorly regulated and often lacked rigour. However, advertisements were gradually modified in the light of increasing clinical pharmacological knowledge, and they reflect an exciting period for the introduction of many drugs that continue to be of benefit today.

Alcohol Content in the 'Hyper-Reality' MTV Show 'Geordie Shore'.

AIM: To quantify the occurrence of alcohol content, including alcohol branding, in the popular primetime television UK Reality TV show 'Geordie Shore' Series 11. METHODS: A 1-min interval coding content analysis of alcohol content in the entire DVD Series 11 of 'Geordie Shore' (10 episodes). Occurrence of alcohol use, implied use, other alcohol reference/paraphernalia or branding was recorded. RESULTS: All categories of alcohol were present in all episodes. 'Any alcohol' content occurred in 78%, 'actual alcohol use' in 30%, 'inferred alcohol use' in 72%, and all 'other' alcohol references occurred in 59% of all coding intervals (ACIs), respectively. Brand appearances occurred in 23% of ACIs. The most frequently observed alcohol brand was Smirnoff which appeared in 43% of all brand appearances. Episodes categorized as suitable for viewing by adolescents below the legal drinking age of 18 years comprised of 61% of all brand appearances. CONCLUSIONS: Alcohol content, including branding, is highly prevalent in the UK Reality TV show 'Geordie Shore' Series 11. Two-thirds of all alcohol branding occurred in episodes age-rated by the British Board of Film Classification (BBFC) as suitable for viewers aged 15 years. The organizations OfCom, Advertising Standards Authority (ASA) and the Portman Group should implement more effective policies to reduce adolescent exposure to on-screen drinking. The drinks industry should consider demanding the withdrawal of their brands from the show. SHORT SUMMARY: Alcohol content, including branding, is highly prevalent in the MTV reality TV show 'Geordie Shore' Series 11. Current alcohol regulation is failing to protect young viewers from exposure to such content.

Assessing Youth-Appealing Content in Alcohol Advertisements: Application of a Content Appealing to Youth (CAY) Index.

Underage drinking is a serious public health problem in the United States, and youth exposure to alcohol advertising has been indicated as a possible contributing factor. Although a number of studies have identified advertising content features that youth find appealing, a key limitation of this research is the absence of a broader tool to examine those features, especially those used by alcohol brands that are popular with underage drinkers. We created an index of content elements found in the research literature to be appealing to youth, and then used this index in a content analysis to identify the degree to which youth-appealing content appeared in a sample of alcohol ads that aired on television shows popular among youth. Finally, using bivariate analysis, we tested the relationship between alcohol brands' use of this content and the popularity of those brands among youth. We found that many of the ads featured youth-appealing content, and that the ads for the alcohol brands most popular among youth had more youth-appealing content than the less popular brands.