"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.

Impact of The Real Cost Media Campaign on Youth Smoking Initiation.

INTRODUCTION: The purpose of this study was to assess the relationship between youth exposure to the U.S. Food and Drug Administration's national tobacco public education campaign, The Real Cost, and changes in smoking initiation. METHODS: From November 2013 to November 2016, a longitudinal study of youth was conducted with a baseline and 4 post-campaign follow-up surveys. The sample consisted of nonsmoking youths from 75 U.S. media markets (n=5,103) who completed a baseline and at least 1 follow-up survey. Exposure was measured by media market-level target rating points and self-reported ad exposure frequency. Smoking initiation was examined among youths who had never smoked at baseline and defined as first trial of a cigarette. Discrete-time survival models using logistic regression and controlling for confounding influences were estimated. Analyses were conducted in 2018. RESULTS: The odds of reporting smoking initiation at follow-up was lower among youths in media markets with higher levels of campaign advertisements than among those with less. Both between-wave and cumulative target rating points were associated with decreased risk of smoking initiation (AOR=0.69 [p<0.01] and AOR=0.89 [p<0.05], respectively); for every 3,500 between-wave target rating points on air, there was an associated 30% reduction in the hazard of smoking initiation among youths. Results from self-reported recall of the campaign advertisements found similar dose-response effects. The campaign is associated with an estimated 380,000-587,000 youths aged 11-19 years being prevented from initiating smoking nationwide. CONCLUSIONS: Sustained national tobacco public education campaigns like The Real Cost can change population-level smoking initiation among youths, preventing future generations from tobacco-related harms.

Little filtered cigars: US sales, flavours, package sizes and prices.

OBJECTIVE: At least four varieties of little filtered cigars (LFCs) violate the US prohibition on flavoured cigarettes other than menthol. This study characterises the sales of prohibited products and other LFCs by flavour category and pack size, as well as the price of LFCs relative to cigarettes. METHODS: Using retail sales data for 2016, we computed the sales volume in dollars and equivalent units and the percentage of total sales by flavour and pack size for the USA by region and state. Paired t-tests compared the prices for LFCs and cigarettes sold in same-sized packs and cartons. RESULTS: LFC sales totalled 24 033 equivalent units per 100 000 persons in 2016. Flavoured LFC varieties accounted for almost half (47.5%) of the total sales. LFCs were sold in 12 different pack sizes, but 79.7% of sales were packs of 20. The price of 20-packs averaged $2.41 (SD=$1.49), which was significantly less than cigarettes (M=$5.90, SD=$0.85). Regional differences suggest a greater proportion of menthol/mint LFCs and lower prices in the South than in other regions. CONCLUSION: Classifying all LFCs as cigarettes would require that they be offered in a minimum package of 20, eliminate flavoured varieties other than menthol and increase prices through applicable state and local cigarette taxes.

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.

The effect of exposure to media campaign messages on adult cessation.

INTRODUCTION: Numerous studies have examined the relationship between antitobacco mass-media campaigns and quit attempts. However, less is known about the effect of these campaigns on relapse. This paper evaluates the effect of media exposure on smokers' quit attempts and relapse. METHODS: We used data from the Florida Adult Cohort Survey, a telephone follow-up survey of adult smokers and recent quitters, who completed the Florida Adult Tobacco Survey. For this study, 1823 unique smokers and recent quitters from baseline first observed between July 2008 and October 2012 were surveyed through up to seven follow-up interviews between October 2009 and October 2013. Media exposure during this period primarily represents exposure to Florida's Tobacco Free Florida (TFF) campaign, although it also includes exposure to the Centers for Disease Control and Prevention's Tips From Former Smokers media campaign in 2012-2013. A multiple-spell discrete-time survival model was estimated using logistic regression. Each spell represents a quit attempt or relapse event. RESULTS: The odds of the first observed quit attempt are higher at higher levels of target rating points (TRPs) (aOR=1.02, p=0.023). The odds ratio for relapse and second quit and second relapse was not statistically significant. CONCLUSIONS: The results suggest that exposure to media campaign messages in Florida has led to increases in quit attempts. Although the estimates were not statistically significant for relapse or the second spell of quit attempts or relapse, the results suggest that media messages might also influence subsequent quit attempts or relapses after an initial quit attempt.

A cost-effectiveness analysis of the first federally funded antismoking campaign.

BACKGROUND: In 2012, CDC launched the first federally funded national mass media antismoking campaign. The Tips From Former Smokers (Tips) campaign resulted in a 12% relative increase in population-level quit attempts. PURPOSE: Cost-effectiveness analysis was conducted in 2013 to evaluate Tips from a funding agency's perspective. METHODS: Estimates of sustained cessations; premature deaths averted; undiscounted life years (LYs) saved; and quality-adjusted life years (QALYs) gained by Tips were estimated. RESULTS: Tips saved about 179,099 QALYs and prevented 17,109 premature deaths in the U.S. With the campaign cost of roughly $48 million, Tips spent approximately $480 per quitter, $2,819 per premature death averted, $393 per LY saved, and $268 per QALY gained. CONCLUSIONS: Tips was not only successful at reducing smoking-attributable morbidity and mortality but also was a highly cost-effective mass media intervention.

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.

The influence of antismoking television advertisements on cessation by race/ethnicity, socioeconomic status, and mental health status.

Disparities in tobacco use and smoking cessation by race/ethnicity, education, income, and mental health status remain despite recent successes in reducing tobacco use. It is unclear to what extent media campaigns promote cessation within these population groups. This study aims to (1) assess whether exposure to antitobacco advertising is associated with making a quit attempt within a number of population subgroups, and (2) determine whether advertisement type differentialy affects cessation behavior across subgroups. We used data from the New York Adult Tobacco Survey (NY-ATS), a cross-sectional, random-digit-dial telephone survey of adults aged 18 or older in New York State conducted quarterly from 2003 through 2011 (N = 53,706). The sample for this study consists of 9,408 current smokers from the total NY-ATS sample. Regression methods were used to examine the effect of New York State's antismoking advertising, overall and by advertisement type (graphic and/or emotional), on making a quit attempt in the past 12 months. Exposure to antismoking advertising was measured in two ways: gross rating points (a measure of potential exposure) and self-reported confirmed recall of advertisements. This study yields three important findings. First, antismoking advertising promotes quit attempts among racial/ethnic minority smokers and smokers of lower education and income. Second, advertising effectiveness is attributable in part to advertisements with strong graphic imagery or negative emotion. Third, smokers with poor mental health do not appear to benefit from exposure to antismoking advertising of any type. This study contributes to the evidence about how cessation media campaigns can be used most effectively to increase quit attempts within vulnerable subgroups. In particular, it suggests that a general campaign can promote cessation among a range of sociodemographic groups. More research is needed to understand what message strategies might work for those with poor mental health.

Multiple tobacco product use among adults in the United States: cigarettes, cigars, electronic cigarettes, hookah, smokeless tobacco, and snus.

OBJECTIVE: Noncigarette tobacco products are increasingly popular. Researchers need to understand multiple tobacco product use to assess the effects of these products on population health. We estimate national prevalence and examine risk factors for multiple product use. METHOD: We calculated prevalence estimates of current use patterns involving cigarettes, cigars, electronic cigarettes, hookah, smokeless tobacco, and snus using data from the 2012 RTI National Adult Tobacco Survey (N=3627), a random-digit-dial telephone survey of adults aged 18 and over. Associations between use patterns (exclusive single product and multiple products) and demographic characteristics were examined using Pearson chi-square tests and logistic regression. RESULTS: 32.1% of adults currently use 1 or more tobacco products; 14.9% use cigarettes exclusively, and 6.6% use one noncigarette product exclusively, 6.9% use cigarettes with another product (dual use), 1.3% use two noncigarette products, and 2.4% use three or more products (polytobacco use). Smokers who are young adult, male, never married, reside in the West, and made prior quit attempts were at risk for multiple product use. CONCLUSIONS: Over 10% of U.S. adults use multiple tobacco products. A better understanding of multiple product use involving combustible products, like cigars and hookah, is needed. Multiple product use may be associated with past quit attempts.

The impact of cessation media messages on cessation-related outcomes: results from a national experiment of smokers.

PURPOSE: Examine effects of exposure to two types of cessation advertisements on changes in cessation-related outcomes. DESIGN: Experimental data from a nationally representative, longitudinal sample of smokers, collected in three waves over 4 weeks. SETTING: National. Subjects. Three thousand and two adult U.S. smokers aged 18+ completed baseline and follow-up interviews at 2 and 4 weeks, from December 2010 to February 2011. INTERVENTION: Six randomly assigned conditions consisting of repeated exposure to cessation advertisements: why-to-quit advertisements featuring emotional, personal testimonies (1: WTQ-T) or graphic images (2: WTQ-G); how-to-quit advertisements (3: HTQ), a combination of both (4: WTQ-T + HTQ; 5: WTQ-G + HTQ), and no-ad condition (6: control). MEASURES: Cessation-related beliefs, attitudes, intentions, and quitting behavior. ANALYSIS: Multivariable ordinary least squares and logistic regressions testing whether exposure to antitobacco television advertisements were associated with changes in tobacco-related outcomes. RESULTS: Exposure to WTQ-T or WTQ-G advertisements, both alone and combined with HTQ advertisements, elicited positive change in beliefs, attitudes, and intentions as compared to controls. Smokers in three of four WTQ conditions were substantially more likely to have quit smoking at 4 weeks than controls (odds ratios range from 5.9 to 10.1, p < .05 or better). No effects were found for the HTQ-only condition. CONCLUSION: Exposure to WTQ advertisements markedly increases the odds that a smoker will quit in the study period, suggesting positive movement toward successful, long-term cessation. HTQ advertisements did not enhance advertising effectiveness and may not be suitable as a primary message strategy.

New York tobacco control program cessation assistance: costs, benefits, and effectiveness.

Tobacco use and cigarette smoking have long been causally linked to a wide variety of poor health outcomes, resulting in a number of public health policy initiatives to reduce prevalence and consumption. Benefits of these initiatives, however, have not been well-established quantitatively. Using 2005-2008 New York Adult Tobacco Survey data, we developed a simulation model to estimate the effectiveness and net benefits of the New York Tobacco Control Program's (NY TCP's) adult smoking cessation assistance initiatives, specifically media campaigns, telephone quitline counseling, and nicotine replacement therapy. In 2008, we estimate that NY TCP generated an estimated 49,195 additional, non-relapsing adult quits (95% CI: 19,878; 87,561) for a net benefit of over $800 million (95% CI: $211 million; $1,575 million). Although the simulation results varied considerably, reflecting uncertainty in the estimates and data, and data sufficient to establish definite causality are lacking, the cessation initiatives examined appear to yield substantial societal benefits. These benefits are of sufficient magnitude to fully offset expenditures not only on these initiatives, but on NY TCP as a whole.

Promotion of smoking cessation with emotional and/or graphic antismoking advertising.

BACKGROUND: Antismoking campaigns can be effective in promoting cessation, but less is known about the dose of advertising related to behavioral change among adult smokers, which types of messages are most effective, and effects on populations disproportionately affected by tobacco use. PURPOSE: To assess the impact of emotional and/or graphic antismoking TV advertisements on quit attempts in the past 12 months among adult smokers in New York State. METHODS: Individual-level data come from the 2003 through 2010 New York Adult Tobacco Surveys. The influence of exposure to antismoking advertisements overall, emotional and/or graphic advertisements, and other types of advertisements on reported attempts to stop smoking was examined. Exposure was measured by self-reported confirmed recall and market-level gross rating points. Analyses conducted in Spring 2012 included 8780 smokers and were stratified by desire to quit, income, and education. RESULTS: Both measures of exposure to antismoking advertisements are positively associated with an increased odds of making a quit attempt among all smokers, among smokers who want to quit, and among smokers in different household income brackets (<$30,000 and ≥$30,000) and education levels (high-school degree or less education and at least some college education). Exposure to emotional and/or graphic advertisements is positively associated with making quit attempts among smokers overall and by desire to quit, income, and education. Exposure to advertisements without strong negative emotions or graphic images had no effect. CONCLUSIONS: Strongly emotional and graphic antismoking advertisements are effective in increasing population-level quit attempts among adult smokers.

The consequences of high cigarette excise taxes for low-income smokers.

BACKGROUND: To illustrate the burden of high cigarette excise taxes on low-income smokers. METHODOLOGY/PRINCIPAL FINDINGS: Using data from the New York and national Adult Tobacco Surveys from 2010-2011, we estimated how smoking prevalence, daily cigarette consumption, and share of annual income spent on cigarettes vary by annual income (less than $30,000; $30,000-$59,999; and more than $60,000). The 2010-2011 sample includes 7,536 adults and 1,294 smokers from New York and 3,777 adults and 748 smokers nationally. Overall, smoking prevalence is lower in New York (16.1%) than nationally (22.2%) and is strongly associated with income in New York and nationally (P<.001). Smoking prevalence ranges from 12.2% to 33.7% nationally and from 10.1% to 24.3% from the highest to lowest income group. In 2010-2011, the lowest income group spent 23.6% of annual household income on cigarettes in New York (up from 11.6% in 2003-2004) and 14.2% nationally. Daily cigarette consumption is not related to income. CONCLUSIONS/SIGNIFICANCE: Although high cigarette taxes are an effective method for reducing cigarette smoking, they can impose a significant financial burden on low-income smokers.

Smoking initiation among youth: the role of cigarette excise taxes and prices by race/ethnicity and gender.

Existing evidence for the role of cigarette excise taxes and prices as significant determinants of youth smoking initiation is mixed. A few studies have considered the possibility that the impact of cigarette taxes and prices might differ by gender or race/ethnicity. In this paper, we address the role of cigarette taxes and prices on youth smoking initiation using the National Longitudinal Survey of Youth 1997 cohort and discrete-time survival methods. We present results overall and by gender, race/ethnicity, and gender by race/ethnicity. We examine initiation over the age range during which youth are most at risk of initiation and over a period in which substantial changes have occurred in tax and price. The result for cigarette excise taxes is small and mixed across alternative specifications, with the effect strongest for black youth. Cigarette prices are more consistently a significant determinant of youth smoking initiation, especially for black youth.

Promoting calls to a quitline: quantifying the influence of message theme, strong negative emotions and graphic images in television advertisements.

OBJECTIVE: To understand the relative effectiveness of television advertisements that differ in their thematic focus and portrayals of negative emotions and/or graphic images in promoting calls to a smokers' quitline. METHODS: Regression analysis is used to explain variation in quarterly media market-level per smoker calls to the New York State Smokers' Quitline from 2001 to 2009. The primary independent variable is quarterly market-level delivery of television advertisements measured by target audience rating points (TARPs). Advertisements were characterised by their overall objective--promoting cessation, highlighting the dangers of secondhand smoke (SHS) or other--and by their portrayals of strong negative emotions and graphic images. RESULTS: Per smoker call volume is positively correlated with total TARPs (p<0.001), and cessation advertisements are more effective than SHS advertisements in promoting quitline call volume. Advertisements with graphic images only or neither strong negative emotions nor graphic images are associated with higher call volume with similar effect sizes. Call volume was not significantly associated with the number of TARPs for advertisements with strong negative emotions only (p=0.71) or with both graphic images and strong emotions (p=0.09). CONCLUSIONS: Exposure to television advertisements is strongly associated with quitline call volume, and both cessation and SHS advertisements can be effective. The use of strong negative emotions in advertisements may be effective in promoting smoking cessation in the population but does not appear to influence quitline call volume. Further research is needed to understand the role of negative emotions in promoting calls to quitlines and cessation more broadly among the majority of smokers who do not call quitlines.

Racial/ethnic differences in perceived smoking prevalence: evidence from a national survey of teens.

Prior studies show that perceived smoking prevalence is a significant predictor of smoking initiation. In this study, we examine racial/ethnic differences in perceived smoking prevalence and racial/ethnic differences in exposure to contextual factors associated with perceived smoking prevalence. We used cross-sectional time series data from the Legacy Media Tracking Surveys (LMTS), a national sample of 35,000 12- to 17-year-olds in the United States. Perceived smoking prevalence was the primary outcome variable, measured using an LMTS question: "Out of every 10 people your age, how many do you think smoke?" Multivariable models were estimated to assess the association between perceived smoking prevalence; race/ethnicity; and exposure to social contextual factors. Findings indicate that African American, Hispanic, and American Indian youth exhibit the highest rates of perceived smoking prevalence, while white and Asian youth exhibit the lowest. Minority youth are also disproportionately exposed to social contextual factors that are correlated with high perceived smoking prevalence. These findings suggest that disproportionate exposure to social contextual factors may partially explain why minority youth exhibit such high levels of perceived smoking prevalence.

Income inequality, race, and child well-being: an aggregate analysis in the 50 United States.

Interest in income inequality as a predictor of health has exploded since the mid-1990s. Recent analyses suggest, however, that the effect of income inequality on population health is not robust to a control for the racial composition of the population. That observation raises two interpretational questions. First, does income inequality have an independent effect on population health? Second, what does the effect of racial composition on population health mean? We use data from the Urban Institute's Assessing the New Federalism project and the Kids Count Databook to evaluate the aggregate effects of income inequality on diverse measures of child well-being (e.g., infant mortality, high school drop-out rates) in the 50 U.S. states. We replicate the finding that, net of the racial/ethnic composition of the population, the effects of income inequality are not significant. Moreover, the effects of racial composition on child well-being appear to be compositional (i.e., they reflect the less positive outcomes observed among racial/ethnic minorities) rather than contextual (i.e., representing the independent influence of social context). Whereas cross-level effects are still possible, our results cast doubt on the health relevance of these aggregate characteristics of the population.

Promoting school connectedness: evidence from the National Longitudinal Study of Adolescent Health.

Increasing evidence shows that when adolescents feel cared for by people at their school and feel like a part of their school, they are less likely to use substances, engage in violence, or initiate sexual activity at an early age. However, specific strategies to increase students' connectedness to school have not been studied. This study examined the association between school connectedness and the school environment to identify ways to increase students' connectedness to school. Data from the in-school and school administrator surveys of the National Longitudinal Study of Adolescent Health (75,515 students in 127 schools) and hierarchical linear models were used to estimate the association between school characteristics and the average level of school connectedness in each school. Positive classroom management climates, participation in extracurricular activities, tolerant disciplinary policies, and small school size were associated positively with higher school connectedness.