Visual Attention to the Source Matters: Using Eye Tracking to Understand the FDA's 'Every Try Counts' Campaign Message Effectiveness.

INTRODUCTION: Visual attention is a crucial mechanism in health messaging and campaign persuasiveness. Little is known about how visual attention may translate into cessation-related outcomes in tobacco public education campaigns. METHODS: Using the eye-tracking technology, this study investigated the relationships among visual attention, cognitive and affective message responses, and cessation-related outcomes (readiness to quit, intentions to quit, and intentions to seek cessation information). Four different posters from the Every Try Counts (ETC) campaign were used as message stimuli. A total of 80 adult current smokers participated. The associations between their behavioral eye gaze patterns and self-reported message responses and cessation-related outcomes were examined. RESULTS: Half of the sample (49.4%) were male, and 46.8% were White-with ages ranging from 18 to 36 years old (M = 21.22, SD = 2.86). Roughly 41% were daily smokers, and 78% had attempted quitting in the previous year. When exposed to campaign ads, only fixation on the FDA logo showed consistent positive relationships with cognitive and affective message responses. Mediation analyses revealed significant indirect effects of fixation on the FDA logo on quitting and information-seeking intentions mainly through positive affective message responses. CONCLUSIONS: Visual attention to the FDA logo played an important role in the effects of ETC campaign messages. IMPLICATIONS: This study contributes new evidence on the relationship of visual attention, message responses, and ETC campaign outcomes. The current findings suggest that highlighting FDA as a campaign sponsor in the visual display may enhance the effectiveness of FDA tobacco education messages.

Fear and Humor Appeals in "The Real Cost" Campaign: Evidence of Potential Effectiveness in Message Pretesting.

INTRODUCTION: In tobacco prevention campaigns, fear-appeal messages are widely used and generally shown to be effective, whereas the utility of humor appeals is less clear. This study compares the potential effectiveness of fear and humor ads developed for "The Real Cost" campaign. METHODS: Adolescents (N=1,315) aged 13-17 years who were either experimenting with smoking or susceptible to smoking initiation were randomized to view either a single ad (of three fear and two humor ads in total) or nothing (control condition). Those in the ad viewing condition completed measures on fear, amusement, and perceived ad effectiveness. All participants completed measures on smoking attitudes and risk perceptions. Data were collected in 2014 and 2015. Analysis was performed in 2016. RESULTS: Compared with control, both fear and humor ads produced greater risk perceptions (p<0.001). Fear ads also produced more negative smoking attitudes (p=0.001); humor ads had a similar effect on attitudes that approached significance (p=0.07). Fear ads scored higher on perceived ad effectiveness and fear, and lower on amusement than humor ads (p<0.001). In regression models, fear was a stronger predictor of perceived ad effectiveness, smoking attitudes, and risk perceptions than amusement for fear ads, whereas amusement was a stronger predictor of these outcomes than fear for humor ads. CONCLUSIONS: Both fear and humor appeals have potential to be effective in "The Real Cost" campaign. Concurrent employment of these message strategies should help to diversify messaging and consistently recapture the target audience's attention. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Fifth Anniversary Retrospective of "The Real Cost," the Food and Drug Administration's Historic Youth Smoking Prevention Media Campaign, which is sponsored by the U.S. Food and Drug Administration.

Lessons on Addiction Messages From "The Real Cost" Campaign.

INTRODUCTION: A key strategy in reducing the public health burden of cigarette smoking is preventing youth from ever becoming addicted to cigarettes in the first place. However, there is limited research exploring youth responses to addiction messages. This study assesses youths' responses to the U.S. Food and Drug Administration's "The Real Cost" campaign messaging depicting addiction as a "loss of control." METHODS: Between 2013 and 2016, three focus group studies and four copy testing studies were conducted to assess reactions to advertising concepts and near-final videos. Participants were aged 12-17 years and ethnically and geographically diverse. Researchers conducted a thematic secondary analysis of focus group transcripts and open-ended survey questions from the copy testing studies. Data analysis for this study took place in 2017. RESULTS: Youth responded favorably to loss of control messages showing real, often short-term, consequences of addiction, such as choosing to spend money on cigarettes instead of going to a movie, and depictions of scenarios that were relatable to youth. Youth also responded favorably to messages describing how nicotine changes the brain. A portion of youth remained skeptical, stating they felt the consequences depicted were unrealistic. CONCLUSIONS: This study shows that by framing addiction as a loss of control and tying that loss of control to short-term health and social consequences, addiction becomes more concrete and understandable, and the consequences feel more relatable and relevant to youth. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Fifth Anniversary Retrospective of "The Real Cost," the Food and Drug Administration's Historic Youth Smoking Prevention Media Campaign, which is sponsored by the U.S. Food and Drug Administration.

Recruiting Hard-to-Reach Populations for Survey Research: Using Facebook and Instagram Advertisements and In-Person Intercept in LGBT Bars and Nightclubs to Recruit LGBT Young Adults.

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

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

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

Why Peer Crowds Matter: Incorporating Youth Subcultures and Values in Health Education Campaigns.

Grounded on research showing that peer crowds vary in risk behavior, several recent health behavior interventions, including the US Food and Drug Administration's Fresh Empire campaign, have targeted high-risk peer crowds. We establish the scientific foundations for using this approach. We introduce peer crowd targeting as a strategy for culturally targeting health behavior interventions to youths. We use social identity and social norms theory to explicate the theoretical underpinnings of this approach. We describe Fresh Empire to demonstrate how peer crowd targeting functions in a campaign and critically evaluate the benefits and limitations of this approach. By replacing unhealthy behavioral norms with desirable, healthy lifestyles, peer crowd-targeted interventions can create a lasting impact that resonates in the target audience's culture.

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.

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

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

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

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