Estimating the return on investment of the New York Tobacco Control Programme: a synthetic control study.

OBJECTIVE: To assess the return on investment (ROI) of the New York Tobacco Control Programme (NY TCP). SETTING: New York and other states of the USA. INTERVENTIONS: NY TCP. OUTCOMES: Smoking prevalence, smoking-attributable healthcare expenditures (SAEs), smoking-attributable mortality, years of life lost (YLL), the dollar value of YLL and the ROI for healthcare expenditures and mortality. DESIGN AND METHODS: We used a synthetic control method to estimate the effectiveness of NY TCP funding on smoking prevalence. The synthetic control method created a comparison group that best matched the adult smoking prevalence trend in New York state in the period prior to implementation of the NY TCP and compared smoking prevalence in the state to smoking prevalence in the synthetic control in the period after treatment (2001-2019). The synthetic control group represents what the trend in smoking prevalence in New York would have been had there been no tobacco control expenditures. The ROI was calculated as net savings for each outcome divided by net programme expenditures. RESULTS: Cumulative savings in SAE in New York from 2001 to 2019 amounted to US$13.2 billion. An estimated 41 771 smoking-attributable deaths (SADs) were averted in New York from 2001 to 2019, and an estimated 672 141 YLL averted as a result of NY TCP funding in the same period. From 2001 to 2019, the ROI for SAE in New York was approximately 14, the economic value ROI of the YLL due to SAD was nearly 145 and the combined ROI was almost 160. CONCLUSIONS: In this study, we found relatively large ROIs for the NY TCP, which suggests that the programme-which lowers SAE and saves lives-is an efficient use of public funds.

Effects of a National Campaign on Youth Beliefs and Perceptions About Electronic Cigarettes and Smoking.

INTRODUCTION: Our study assesses the relationship between the exposure of youth to the US Food and Drug Administration's national tobacco public education campaign, The Real Cost, and changes in campaign-focused risk perceptions and beliefs. METHODS: A nationally representative cohort study of youth was conducted from June 2018 to July 2019, consisting of a baseline and one follow-up survey. We performed logistic regressions to examine the association between campaign exposure and beliefs. Exposure was measured by self-report as the frequency of exposure to individual campaign advertisements about the health consequences of e-cigarette use and of smoking cigarettes. RESULTS: We found that increased levels of exposure to campaign advertising was associated with a significant increase in the odds of reporting agreement with campaign-specific beliefs. Positive patterns of findings were found across multiple items selected by specific advertisements, whereas unrelated beliefs were not associated with advertisement exposure. CONCLUSION: A sustained national tobacco public education campaign can change beliefs about the harms of e-cigarette use and cigarette smoking among youth. Combined with other findings from The Real Cost evaluation, results indicate that prevention mass media campaigns continue to be an effective and cost-efficient approach to reduce the health and financial cost of tobacco use in the US.

Perceived Message Effectiveness and Campaign-Targeted Beliefs: Evidence of Reciprocal Effects in Youth Tobacco Prevention.

Perceived message effectiveness (PE) has been widely used in campaign formative research and evaluation. The relationship between PE and actual message effectiveness (AE) is often assumed to be causal and unidirectional, but careful conceptualization and empirical testing of this and other causal possibilities are generally lacking. In this study, we investigated the potential reciprocity in the relationship between PE and AE in the context of a national youth tobacco education campaign. In so doing, we also sought to generate much needed evidence on PE's utility to predict campaign-targeted outcomes in youth tobacco prevention. Using five waves of campaign evaluation data (N = 1,128), we found significant lagged associations between PE and campaign-targeted beliefs, and vice versa. These results suggest a dynamic, mutually influencing relationship between PE and AE and call for greater attention to such dynamics in campaign research.

Estimating the return on investment of the Bureau of Tobacco Free Florida tobacco control programme from 1999 to 2015.

OBJECTIVE: To assess the return on investment (ROI) of the Florida tobacco control programme, the Bureau of Tobacco Free Florida (BTFF), in terms of healthcare expenditure savings and mortality cost saved as a result of reduced mortality due to the programme from 1999 to 2015. METHODS: We use a synthetic control method to estimate the impact of the BTFF on smoking-attributable mortality, years of life lost (YLL), healthcare expenditures, and the economic value of premature mortality due to smoking in Florida from 1999 through 2015. We calculated an ROI for healthcare expenditures and for the value of life years saved. RESULTS: From 1999 to 2015, adult smoking prevalence in Florida averaged 0.98 percentage points lower than prevalence in the synthetic control states (19.6% vs 20.6%). The ROI over the period from 1999 to 2015 was 9.61 for healthcare expenditures and 112.44 for premature mortality. These ROIs suggest that for every US$1 of expenditure by BTFF, smoking-attributable healthcare expenditures decreased by almost US$11 and reductions in the economic costs associated with YLL due to smoking-attributable mortality totaled approximately US$113. CONCLUSIONS: Our results suggest the BTFF resulted in fewer YLL, substantial healthcare cost savings and substantial savings in terms of mortality costs. The positive ROIs for healthcare expenditures and premature mortality suggest that the BTFF is a good investment of public funds.

Effect of a Statewide Media Campaign on Smoking Cessation Among Florida Adults.

INTRODUCTION: Since December 2010, Florida's Bureau of Tobacco Free Florida has aired a statewide tobacco education campaign to encourage smoking cessation. The Tobacco Free Florida campaign consists of evidence-based advertisements primarily characterized by strong emotional content and graphic imagery designed to increase awareness of the health risks of tobacco use. We evaluated the effect of the media campaign on population-level quit attempts by using a statewide representative sample of Florida adults aged 18 or older. METHODS: We examined data from 5,418 Florida adult cigarette smokers and recent quitters aged 18 or older from the Florida Adult Tobacco Survey, an annual, cross-sectional survey conducted from 2011 through 2018. The primary outcome was incidence of quit attempts in the previous 12 months. We used multivariable logistic regression models to estimate the odds of making a quit attempt as a function of advertising levels across state media markets. Rates of quit attempts in Florida were also estimated. RESULTS: Approximately 66% of smokers in the study made at least 1 quit attempt. Exposure to the campaign was associated with increased odds of a quit attempt in the previous 12 months (odds ratio = 1.25; P = .02) among smokers and recent quitters. The Tobacco Free Florida campaign was associated with an estimated 332,604 additional smokers making quit attempts per year during the study period. CONCLUSION: The Tobacco Free Florida campaign affected cessation-related behaviors in Florida over an 8-year period. Evidence-based state tobacco education campaigns can accelerate progress toward the goal of reducing adult smoking.

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.

Adolescents' Use of Basic, Intermediate, and Advanced Device Types for Vaping.

Introduction: Advanced vaping devices likely pose a greater risk to adolescent health than basic or intermediate devices because advanced devices deliver nicotine more effectively and heat e-liquid to higher temperatures, producing more harmful chemical emissions. However, little is known about adolescents' risk factors for using different device types. Methods: We used social media to recruit an online sample of 1508 US adolescents aged 15-17 who reported past 30-day use of electronic vaping products (EVPs) in September 2016. We assessed tobacco use, beliefs, and knowledge about EVPs and EVP use behavior, including the device type participants use most frequently. We used multinomial logistic regression to examine differences between adolescents who usually use intermediate versus basic and advanced versus basic devices. Results: Most respondents usually used modifiable advanced devices (56.8%) rather than basic "cigalike" (14.5%) or pen-style intermediate (28.7%) devices. Use of multiple device types was common, particularly among those who primarily used basic devices. Younger age and less frequent vaping were associated with mainly using basic devices. Adolescents who were older, male, personally bought their main device, and had ever mixed e-liquids were at elevated risk for usually using advanced devices. Conclusions: Adolescents who primarily use basic devices may be newer users who are experimenting with multiple devices. Future research should examine which adolescents are most likely to transition to advanced devices in order to develop targeted interventions. Regulators should consider strategies to reduce access to all types of EVPs, such as better enforcement of the current ban on sales to minors. Implications: This research addresses two gaps in research on adolescent electronic vaping product use: (1) characterizing use of advanced devices as distinct from intermediate devices rather than grouping them together and (2) examining factors associated with use of specific device types. This study suggests that there are distinct profiles of adolescents who use primarily basic, intermediate, or advanced devices. Adolescents who most often use basic devices may be new users experimenting with vaping, whereas adolescents who most often use advanced devices appear to be buying devices for themselves and engaging in risky behaviors such as mixing their own e-liquid.

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

INTRODUCTION: A previous study found that the Food and Drug Administration's The Real Cost national tobacco education campaign was associated with preventing approximately 350,000 U.S. youth from initiating smoking between 2014 and 2016. This study translates the reduction in smoking initiation into monetary terms by examining the cost effectiveness of the campaign. METHODS: The cost effectiveness of The Real Cost was assessed by measuring efficiency in two ways: (1) estimating the cost per quality-adjusted life year saved and (2) estimating the total monetary return on investment by comparing the cost savings associated with the campaign to campaign expenditures. Analyses were conducted in 2017. RESULTS: The Real Cost averted an estimated 175,941 youth from becoming established smokers between 2014 and 2016. Campaign expenditures totaled $246,915,233. The cost per quality-adjusted life year saved of the campaign was $1,337. When considering the costs of smoking, the averted established smokers represent >$31 billion in cost savings ($1.3 billion when only external costs considered). The overall return on investment of the campaign was $128 in cost savings for every $1 spent ($4 for every $1 spent when only external costs considered). These conclusions were robust to sensitivity analyses surrounding the parameters. CONCLUSIONS: Campaign expenditures were cost efficient. The cost savings resulting from The Real Cost represent a large reduction in the financial burden to individuals, their families, and society as a result of tobacco. Public health campaigns, like The Real Cost, that reduce tobacco-related morbidity and mortality for a generation of U.S. youth also provide substantial cost savings.

Examining Youth Dual and Polytobacco Use with E-Cigarettes.

E-cigarettes and other non-cigarette tobacco products are increasingly popular among youth. Little is known to inform public health efforts to reduce youth use. We examined psychosocial correlates of single and multiple tobacco product use among youth e-cigarette users. Data were from the 2014 Florida Youth Tobacco Survey (N = 69,923), a representative sample of Florida middle and high school students. Associations between combinations of e-cigarette, cigarette and other tobacco product (OTP) use and psychosocial variables were examined using multinomial logistic regression with an analytic sample of N = 2756. Most e-cigarette-using youth used at least one other product (81%). Perceiving cigarettes as easy to quit was significantly associated with greater likelihood of combined e-cigarette/OTP use (relative risk ratio (RRR) = 2.51, p < 0.001) and combined e-cigarette/cigarette/OTP use (RRR = 3.20, p < 0.0001). Thinking you will be smoking cigarettes in 5 years was associated with product combinations that include cigarettes. Tobacco company marketing receptivity was associated with multiple product user types. Given that specific psychosocial factors put youth at risk for concurrent use of e-cigarettes with tobacco products, public health efforts should address polytobacco use specifically, instead of individual product use. Youth perceptions about the ease of quitting cigarettes, intentions to continue smoking cigarettes and receptivity to tobacco company marketing are promising areas for messaging aimed at reducing e-cigarette polytobacco product use.

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.

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'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.

Impact of a U.S. antismoking national media campaign on beliefs, cognitions and quit intentions.

In 2012, the Centers for Disease Control and Prevention launched a national tobacco education campaign, Tips From Former Smokers, that consisted of graphic, emotionally evocative, testimonial-style advertisements. This longitudinal study examines changes in beliefs, tobacco-related cognitions and intentions to quit smoking among U.S. adult smokers after a 12-week airing of the campaign (n = 4040 adult smokers pre- and post-campaign). Exposure to the campaign was associated with greater odds of intending to quit within the next 30 days [odds ratio (OR) = 1.28, P < 0.01] and within the next 6 months (OR = 1.12, P < 0.05), and quit intentions were stronger among respondents with greater campaign exposure (OR = 1.12, P < 0.01). Campaign exposure was also associated with significant changes in beliefs about smoking-related risks (ORs = 1.15-2.40) and increased worries about health (b = 0.30, P < 0.001). Based on study change rates applied to U.S. census data, an estimated 566 000 additional U.S. smokers reported their intention to quit smoking within the next 6 months as a result of viewing campaign advertisements. Campaign effects were consistent with the theory of reasoned action and an expanding body of research demonstrating that graphic, emotional advertisements are highly effective for prompting positive cessation-related cognitions and behavioral intentions.

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.

The marketing of dissolvable tobacco: social science and public policy research needs.

The latest generation of smokeless tobacco products encompasses a wide range of offerings, including what is commonly referred to as dissolvable tobacco. Designed to deliver nicotine upon dissolving or disintegrating in a user's mouth, dissolvable tobacco products currently appear in various United States markets as strips, orbs, sticks, and lozenges. The emergence of these new products poses distinct opportunities and challenges for social and behavioral science and public health research and raises important public policy questions.