Awareness of "The Real Cost" Campaign Among US Middle and High School Students: National Youth Tobacco Survey, 2017.

OBJECTIVES: Monitoring awareness of a public education campaign can help to better understand the extent of sustained population-level exposure to the campaign. We examined unaided awareness (awareness that does not include a visual image to remind the respondent of the campaign or advertisement) and correlates of unaided awareness of "The Real Cost," a national youth tobacco education campaign developed by the US Food and Drug Administration and implemented in 2014. METHODS: This secondary analysis examined unaided campaign awareness by using data from the 2017 National Youth Tobacco Survey, a nationally representative school-based sample of young persons aged 9-19 years (n = 17 269) surveyed approximately 3 years after campaign launch. We compared unaided campaign awareness among various cigarette user groups (experimenters, susceptible nonsmokers, current or former smokers, and nonsusceptible nonsmokers). We examined associations between unaided campaign awareness and demographic and tobacco-related correlates, overall and by cigarette user group. RESULTS: Three years after "The Real Cost" campaign was launched, most middle and high school students (58.5%) still reported unaided campaign awareness. Of 17 269 middle and high school students in the sample, 62.0% of susceptible nonsmokers and 64.5% of experimenters reported unaided campaign awareness. Among susceptible nonsmokers, unaided campaign awareness differed by age and race/ethnicity and was higher among students with greater tobacco-related harm perceptions (vs lower harm perceptions) and exposure to pro-tobacco marketing (vs no exposure). CONCLUSIONS: Future surveillance and research could examine awareness of "The Real Cost" campaign and effects of the campaign on young persons' knowledge, attitudes, and beliefs to further assess the public health impact of tobacco prevention campaigns.

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.

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.

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.

Leveraging the private health sector to enhance HIV service delivery in lower-income countries.

Evidence that the private health sector is a key player in delivering health services and impacting health outcomes, including those related to HIV/AIDS, underscores the need to optimize the role of the private health sector to scale up national HIV responses in lower-income countries. This article reviews findings on the types of HIV/AIDS services provided by the private health sector in developing countries and elaborates on the role of private providers of HIV services in Ethiopia. Drawing on data from the nation's innovative Private Health Sector Project, a pilot project that has demonstrated the feasibility of public-private partnerships in this area, the article highlights the potential for national governments to scale up HIV/AIDS services by leveraging private health sector resources, innovations, and expertise while working to regulate quality and cost of services. Although concerns about uneven quality and affordability of private sector health services must be addressed through regulation, policy, or other innovative approaches, we argue that the benefits of leveraging the private sector outweigh these challenges, particularly in light of finite donor and public domestic resources.

Acculturation and conflict in Mexican immigrants' intimate partnerships: the role of women's labor force participation.

This study explores women's workforce participation as a potential agent for acculturation, and how it shapes conflict dynamics within intimate partnerships among Mexican immigrants. Analysis of in-depth interview data from 20 immigrant Mexican women and men believed to be in violent relationships indicated that women's employment following migration created several sources of intracouple conflict by challenging gender-based norms and behaviors surrounding the division of household labor, financial decision making, and how women and men interact within intimate relationships. Immigrant Latino women tended to embrace an assimilation strategy for acculturation, whereas immigrant Latino men embrace a separation strategy.

Oral health of children and adults in Latino migrant and seasonal farmworker families.

Oral health is one of the greatest unmet health needs of immigrant farmworkers. This paper describes use of dental services and current oral health problems of children and parents in farmworker families. Interviews were conducted with 108 women in Latino farmworker families in western North Carolina and southwestern Virginia. Dental care had been received in the past year by 73% of children, 47% of mothers, and 37% of spouses. Children were most likely to have received care on a regular basis, while adults usually received no care or emergency care. In general, children's teeth were in better condition than parents' teeth. Children's receipt of dental care and their teeth condition were predicted by being born in the US. No family member's care was related to acculturation or mother's education, typical predictors of health behavior. Differences among family members suggest that access to services, not lack of education, is the primary barrier facing farmworker families.

Pesticides in the homes of farmworkers: Latino mothers' perceptions of risk to their children's health.

Pesticide exposure has been linked with immediate and delayed health effects. Anyone who lives in a farmworker household may be exposed to pesticides. Studies with farmworkers have found generally low levels of awareness of pesticide exposure and prevention. Less is known about the perceptions of nonfarmworkers living with farmworkers. This article presents the results of 41 in-depth interviews conducted with Latino women in farmworker households regarding their knowledge of pesticides and perceptions of risk to their children's health. Their perceptions and behavior differ from scientific understanding and policy recommendations for exposure management, resulting in behaviors that may increase children's risk of exposure and subsequent health problems. Because the level at which exposure becomes harmful remains a subject of scientific debate, the wisest course of action is to minimize exposure (the precautionary principle). Families living in farmworker households would benefit from health education programs that target their specific needs.

Housing characteristics of farmworker families in North Carolina.

Adequate housing is a basic human right and an important determinant of environmental health. Little research has documented the housing quality of immigrant Latino farmworker families. This analysis uses data from four surveys of North Carolina farmworker communities conducted in 2001 and 2003 to document aspects of housing quality that could affect farmworker family health. Three housing domains are considered: dwelling characteristics, household characteristics, and household behaviors. Most farmworker families live in mobile homes, and few own their dwellings. Many are located near agricultural fields. Most houses are small, but household size is large, containing adults, in addition to the nuclear family. Crowding is common among farmworker families. Many farmworker households lack basic facilities, such as washing machines. Farmworkers attempt to reduce exposure by frequently cleaning their dwellings. These findings suggest that the health of farmworker families is at risk due to inadequate housing. Further research on housing-related health effects among farmworker families is needed.

Pesticide safety behaviors in Latino farmworker family households.

BACKGROUND: Studies to assess pesticide exposure of individuals living in agricultural settings suggest that farmworkers create a "take-home" pathway from the fields to the home that increases exposure risk for non-farmworker household members. METHODS: A survey was conducted with 142 Latino women in farmworker family households in North Carolina to identify predictors of adherence to pesticide safety behaviors that may affect take-home exposure risk. Behaviors included changing work clothes before entering the house, storing and washing contaminated work clothes separately from family clothing, and showering upon returning home. RESULTS: The number of farmworkers in the household was negatively associated with adherence to recommended changing, storing, and showering behaviors. Most workers followed recommended laundry procedures for work clothes. CONCLUSIONS: Results support existing evidence for a take-home pathway for pesticide residues in homes with several farmworkers. Pesticide safety education needs to reinforce behaviors that reduce take-home exposure in farmworker households.

Children's health and workers' productivity: an examination of family interference with work in rural America.

This article examines the association of children's health with their parents' performance in the workplace using data from a random survey sample of adults living in rural western North Carolina (N=206). Guided by the effort-recovery model, the authors hypothesized that parents whose children are more ill have poorer performance in the workplace because their parenting requires greater effort and they have less opportunity for physical and psychological recovery. Child health was unassociated with parents cutting back at work because of physical health. Poorer child health was associated with parents cutting back at work because of emotional health, and a portion of this association, as hypothesized, was explained by more limited opportunities for parental recovery. There was no evidence suggesting that associations differed by parental gender.

Organophosphate Pesticide Exposure in Farmworker Family Members in Western North Carolina and Virginia: Case Comparisons.

Farmworkers and their family members are exposed to pesticides in their homes as well as at work. Using a sample of nine farmworker households in western North Carolina and Virginia, this analysis describes the organophosphate (OP) pesticide urinary metabolite levels of adults and children in these households, and compares these farmworker household OP metabolite levels to the national reference data. Data from survey and in-depth interviews are analyzed to find dwelling, household, and work characteristics related to OP metabolite levels. All participants had measurable OP metabolites. Every household had a high level of OP metabolites when compared to national reference data. There were common factors among the households that could cause the high household OP exposure, including farm employment and living adjacent to agricultural fields. Factors associated with household variability in OP exposure included having a non-nuclear family structure, and, therefore, having more adult males who were employed doing farm work, living in rental housing, not owning a vacuum cleaner, residing in a dwelling that is difficult to clean, and the season (spring versus summer) in which urine samples were collected. These results indicate that regulatory changes that improve low income housing, improve industrial hygiene standards, and provide farmworkers information about their pesticide exposure are needed to protect farmworkers and their families.

Reporting pesticide assessment results to farmworker families: development, implementation, and evaluation of a risk communication strategy.

The collection of environmental samples presents a responsibility to return information to the affected participants. Explaining complex and often ambiguous scientific information to a lay audience is a challenge. As shown by environmental justice research, this audience frequently has limited formal education, increasing the challenge for researchers to explain the data collected, the risk indicated by the findings, and action the affected community should take. In this study we describe the development and implementation of a risk communication strategy for environmental pesticide samples collected in the homes of Latino/a migrant and seasonal farmworkers in a community-based participatory research project. The communication strategy was developed with community input and was based on face-to-face meetings with members of participating households. Using visual displays of data effectively conveyed information about individual household contamination and placed it in the context of community findings. The lack of national reference data and definitive standards for action necessitated a simplified risk message. We review the strengths and weaknesses of such an approach and suggest areas for future research in risk communication to communities affected by environmental health risks.

Agricultural and residential pesticides in wipe samples from farmworker family residences in North Carolina and Virginia.

Children of farmworkers can be exposed to pesticides through multiple pathways, including agricultural take-home and drift as well as residential applications. Because farmworker families often live in poor-quality housing, the exposure from residential pesticide use may be substantial. We measured eight locally reported agricultural pesticides and 13 pesticides commonly found in U.S. houses in residences of 41 farmworker families with at least one child < 7 years of age in western North Carolina and Virginia. Wipe samples were taken from floor surfaces, toys, and children's hands. We also collected interview data on possible predictors of pesticide presence, including characteristics of the household residents, cleaning practices, and characteristics of the home. All families were Spanish-speaking, primarily from Mexico. Results indicate that six agricultural and 11 residential pesticides were found in the homes, with agricultural, residential, or both present in 95% of homes sampled. In general, residential pesticides were more commonly found. Presence of both types of pesticides on the floor was positively associated with detection on toys or hands. Agricultural pesticide detection was associated with housing adjacent to agricultural fields. Residential pesticide detection was associated with houses judged difficult to clean. Although the likelihood of agricultural pesticide exposure has been considered high for farmworker families, these results indicate that residential pesticide use and exposure in this population merit further study.

Student Participation in Community-Based Participatory Research To Improve Migrant and Seasonal Farmworker Environmental Health: Issues for Success.

Involving students in community-based participatory research is a useful mechanism for engaging the community and helping it build future capacity. This article describes student involvement in a series of community-based environmental health research projects with migrant and seasonal farmworkers in North Carolina. High school, undergraduate, graduate, and professional school students have participated in various aspects of these projects, including planning, data collection, analysis, and reporting results. Students were required to invest time in learning about the farmworker population, as well as in learning to conduct community-based environmental health research. Drawing on these experiences, we offer observations regarding successful student integration in this type of research. Community-based projects benefit from student participation while encouraging the development of future community-oriented environmental health researchers.

North Carolina Growers' and Extension Agents' Perceptions of Latino Farmworker Pesticide Exposure.

Pesticide exposure poses a significant health hazard to everyone who works in agriculture. Growers have more control over their own exposure risk than do the farmworkers they employ. While growers are responsible for providing a safe work environment, their perceptions of the health risk of pesticides influence the amount and quality of safety training and protection they offer to workers. This paper analyzes growers' and cooperative extension agents' perceptions of farmworker pesticide exposure. Data are from in-depth interviews conducted with growers and extension agents who work in western North Carolina. Both groups indicated that the danger of pesticide exposure is exaggerated by the media and the public. They feel that workers are at little risk of exposure because they have received training and protective equipment as required by law and because they are not in direct contact with chemicals. Their perceptions are at odds with results of other research indicating many farmworkers have not received the required training and do not always utilize protective gear. Linguistic and cultural barriers contribute to this discrepancy in perceptions and must be addressed if measures to reduce farmworker pesticide exposure are to be effective.

Hispanic farmworker interpretations of green tobacco sickness.

This paper describes the explanatory model of green tobacco sickness (GTS) held by migrant and seasonal farmworkers in North Carolina and compares it with a research-based biobehavioral model. GTS is a form of acute nicotine poisoning that affects individuals who work in wet tobacco fields. It is characterized by nausea, vomiting, headache, and dizziness. There are no standard diagnostic criteria for GTS; clinicians must diagnose it based on a combination of symptoms and exposure risk. GTS resembles pesticide poisoning, but treatment is quite different. Many farmworkers in tobacco today are Spanish-speaking immigrants from Mexico with limited experience in tobacco work. In-depth interviews about GTS were conducted with 23 Hispanic farmworkers in central North Carolina to explore their understanding of the problem. Workers generally attributed the symptoms to other aspects of working in tobacco, such as pesticides or heat, rather than nicotine. They cited many of the same risk factors identified in the biobehavioral model, such as wet work conditions and inexperience with tobacco work. Prevention and treatment include a combination of exposure avoidance and common medications. The symptoms of most importance to farmworkers were insomnia and anorexia, both of which impaired the ability to work. This jeopardized their income, as well as their work security. If health care providers understand the explanatory model held by farmworkers, they will be more effective at diagnosing and treating GTS and be better prepared to teach patients how to prevent future episodes.

A clinic-based, case-control comparison of green tobacco sickness among minority farmworkers: clues for prevention.

BACKGROUND: Green tobacco sickness (GTS) is a highly prevalent occupational illness among tobacco workers. Working in wet tobacco is a major risk factor for GTS. Little is known about preventing GTS. This analysis examines possible GTS preventive measures. METHODS: Data were collected from 36 patients with GTS and 40 controls who presented at clinics in eastern North Carolina in 1999 and 2000. Each participant completed an interview that included questions about their personal characteristics, work characteristics, and GTS risk factors. RESULTS: Participants were Mexican men. Those with GTS were much less likely to have worn rain suits while working in wet tobacco and more likely to be in the United States on a work contract. CONCLUSIONS: Wearing a rain suit while working in wet tobacco can significantly reduce the risk of GTS among tobacco workers. Care must be taken that farmworkers do not have heat stress from wearing rain suits.