Attachment A_Campaign Evaluation Materials.pdf

RESEARCH ARTICLE

Youth's Awareness of and Reactions to The Real Cost National Tobacco Public Education Campaign Jennifer C. Duke1*, Tesfa N. Alexander2, Xiaoquan Zhao2,3, Janine C. Delahanty2, Jane A. Allen1, Anna J. MacMonegle1, Matthew C. Farrelly1

1 RTI International, Research Triangle Park, NC, United States of America, 2 Center for Tobacco Products, U.S. Food and Drug Administration, Silver Spring, MD, United States of America, 3 Department of Communication, George Mason University, Fairfax, VA, United States of America

* jduke@rti.org

Abstract 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 Costmessage strategy, implemen-tation, 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 lev-els. 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 demon-strate 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.

Introduction Every day in the United States, more than 2,600 youth younger than age 18 smoke their first cigarette, and nearly 600 become daily smokers [1]. Although cigarette smoking rates among middle and high school-age youth have decreased markedly in recent years [2], an estimated

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Citation: Duke JC, Alexander TN, Zhao X, Delahanty JC, Allen JA, MacMonegle AJ, et al. (2015) Youth's Awareness of and Reactions to The Real Cost National Tobacco Public Education Campaign. PLoS ONE 10(12): e0144827. doi:10.1371/journal.

pone.0144827

Editor: Raymond Niaura, Legacy, Schroeder Institute for Tobacco Research and Policy Studies, UNITED

STATES

Received: September 3, 2015

Accepted: November 24, 2015

Published: December 17, 2015

Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

Data Availability Statement: All relevant data are within the Supporting Information file.

Funding: The study was funded by the US Food and Drug Administration (FDA) contract HHSF223201310001B. JCD, JAA, AJM, and MCF are all employees of the company receiving the funding (RTI International).,Co-authors TNA and JCD

(2) are FDA employees and contributed to the writing and preparation of the manuscript.

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5.6 million Americans younger than age 18 at present are projected to die prematurely of smoking-related disease unless rates decline further [3]. Many more will live with a tobacco-related illness [3].

As a way to reduce the enormous public health burden of tobacco, the Family Smoking Pre-vention and Tobacco Control Act has given the Food and Drug Administration (FDA) the authority to take action to protect children, encourage smokers to quit, and reduce tobacco-related disease and death. The law also enables FDA to educate the public, especially young people, about the dangers of tobacco products. Research shows that public education mass media campaigns can be used to change attitudes and beliefs about tobacco use and reduce smoking prevalence [4–7]. In fact, the Centers for Disease Control and Prevention (CDC) con-siders mass media campaigns to be a “best practice” for tobacco control [8]. On February 11, 2014, FDA’s Center for Tobacco Products launched The Real Cost, the first of several comple-mentary national public education campaigns designed to reduce tobacco use among U.S.

youth aged 12 to 17. The initial phase of the campaign is designed to prevent smoking the initi-ation of cigarette smoking among youth who have never smoked but are susceptible to smok-ing (susceptible nonsmokers) and to discourage further smoking among youth who have experimented with smoking in the past (experimenters). The purpose of this paper is to (1) describe the rationale and implementation of The Real Cost; and (2) report results from the first follow-up evaluation of The Real Cost, with a focus on youth’s awareness of the campaign and their reactions to four advertisements that aired on television and the Internet prior to the first follow-up data collection.

The Real Cost Campaign Theoretical Basis for the Campaign Strategy. Systematic review of the literature suggests that campaigns with a solid theoretical basis are more likely to be effective [9]. Drawing from broad behavior change theories, such as the theory of reasoned action [10] and social cognitive theory [11], The Real Cost campaign seeks to influence tobacco use intentions and behavior among youth aged 12 to 17. The specific target population of the campaign includes nonsmok-ers who are susceptible to initiation as indicated by current intentions and cigarette experi-menters who have not yet transitioned into established smoking [12,13]. According to the theory of reasoned action and social cognitive theory, intentions to abstain from smoking may be formed and reinforced by youth’s attitudinal and social normative beliefs about smoking and by their perceived ability to reject smoking in the future. The overall campaign strategy of The Real Cost is to influence these underlying beliefs through creative messaging.

Factors Expected to Influence Campaign Effectiveness. Among factors that may influ-ence campaign effectiveness are audience exposure to and receptivity toward advertisements.

Research suggests that insufficient exposure is a prominent reason that behavior change cam-paigns do not produce effects [14]. According to guidelines for best practices in tobacco control [8], campaign messages should reach at least 75% of the target audience, each quarter of the year. However, exposure to a media campaign does not guarantee that youth will engage with its messages in any meaningful way. The elaboration likelihood model [15] indicates that in order for a message to produce strong, lasting effects, it should be fully attended to by the viewer and the message content must be adequately processed and understood. Changes in tobacco-related beliefs and attitudes are, in part, a function of the level of cognitive processing or “elaboration” that occurs in response to campaign messages, and a wide body of research in the health communication literature has established measures of advertising effectiveness from this perspective. Tobacco-related media messages have been evaluated with scales of per-ceived effectiveness (PE) that capture appraisals and ratings of ad quality (e.g., Davis et al.

Youth's Awareness of and Reactions to The Real Cost

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Competing Interests: The authors have declared that no competing interests exist.

Abbreviations: CDC, Centers for Disease Control and Prevention; FDA, Food and Drug Administration.

[16,17]; Niederdeppe et al. [18]; Wong and Cappella [19]). The PE scale used in this study, in particular, has been validated as predictive of tobacco-related beliefs, attitudes, behavioral intentions, and smoking-related behaviors (Davis et al., 2015, unpublished work) [17].

If a campaign generates sufficient exposure and the audience considers campaign advertise-ments to be effective, it is estimated to take approximately 3 to 6 months to detect population-level campaign awareness and 12 to 18 months to produce behavior change [8]. To assess the impact of The Real Cost, FDA is conducting a systematic evaluation using a longitudinal design to monitor the campaign’s implementation and impact. The current study focuses on ad awareness and perceived ad effectiveness, two outcomes that are suitable for examination given the 6- to 8-month time frame between campaign launch and data collection.

Campaign Message Strategy and Implementation. FDA launched The Real Cost in 75 media markets in February 2014. The Real Cost’s strategic message platform was informed by previous research [4,8] as well as findings showing that youth intention to smoke is correlated with beliefs about (1) the health consequences of tobacco use, (2) tobacco use leading to the loss of control and independence, and (3) the dangerous chemicals in each cigarette [20].

Based on these results, FDA worked with FCB Garfinkel advertising agency to conduct forma-tive research to inform the development of the campaign brand and campaign advertisements.

Formative research consisted of 12 focus groups with a total of more than 60 participants and quantitative online copy testing with over 1,600 respondents. Participants were aged 12 to 17 and either self-reported as nonsmokers who were susceptible to smoking in the future (i.e., sus-ceptible nonsmokers) or as having previously experimented with smoking (i.e., experimenters).

Informed from insights gained through formative research with the target audience, The Real Cost is designed to encourage teen susceptible nonsmokers and experimenters to reassess what they know about the “costs” of tobacco use to their body and their mind (Fig 1). The initial phase of campaign has focused on two primary message themes in television advertisements:

(1) novel, visceral, and age-relevant portrayals of the health consequences of smoking; and (2) the loss of control and independence as a result of smoking, which are presented to youth as “the real cost” of smoking.

The media purchase for The Real Cost included advertising on national television, online, radio, out-of-home, magazine, and cinema. Overall, the campaign delivered 1,975 mean total television target rating points (TRPs) on national broadcast and cable television from February through June 2014. An additional 1,197 digital TRPs also aired during the time period. Radio advertising aired during this period with an average of 465 planned radio TRPs per market.

The media purchase was complemented by additional campaign messages disseminated through social media, mobile gaming, and partnerships with people that are influential among the target audience. The goal of the media strategy for The Real Cost was to reach 75% of youth aged 12 to 17 with campaign messages.

Methods

Data Source and Sample Data are from a national longitudinal in-home and online survey of U.S. youth conducted in collaboration with RTI International as part of The Real Cost evaluation. The study sampling design produced a representative sample of youth aged 11 to 16 at baseline (who would age into The Real Cost target audience of 12- to 17-year-olds after campaign launch). An address-based sampling frame supplemented with marketing data was used to target households likely to have at least one youth in the target age range. Data collection occurred in 75 media markets.

In-person baseline data collection took place from November 11, 2013, through March 31, 2014 (Fig 2). Study data are from the first follow-up data collection, fielded from July 24

Youth's Awareness of and Reactions to The Real Cost

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Fig 1. The Real CostMessage Concepts.

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PLOSONE | DOI:10.1371/journal.pone.0144827 December 17, 2015 4 / 12 through October 27, 2014, which consisted of online or in-person interviews with youth. Inter-views were fielded only after parental permission and youth assent were verbally obtained and recorded by the field interviewer. The study and consent procedures were approved by the Institutional Review Boards at both the Food and Drug Administration (FDA) and RTI Inter-national as well as by the Office of Management and Budget (OMB). The final analytic sample size for the first follow-up survey was 5,773 youth, with 65% completing in person and 35% completing online.

At baseline, the unweighted household-level response rate was 47.8%, and the weighted household-level response rate was 43.7% (using the American Association of Public Opinion Research Response Rate #3 formula). At follow-up, the unweighted person-level response rate was 86.8%, and the weighted person-level response rate was 85.6%. To produce reliable esti-mates of target population parameters, baseline analysis weights that accounted for unequal probabilities of selection at each stage were adjusted for nonresponse at follow-up. Then, weights were calibrated to the Census 2010 population totals of the baseline target population with post-stratification for gender and race/ethnicity.

Measures Outcome Variables. Brand Awareness: The survey item used to measure brand awareness was, “In the past 3 months, have you seen or heard the following slogan or theme?” with a response option of “yes” or “no.”

Awareness of Individual Advertisements: To assess awareness of the four television adver-tisements for The Real Cost, which aired before the first follow-up interviews, respondents viewed each ad once via video streams during the survey. After viewing each ad, respondents immediately completed questions assessing their frequency of exposure to the ad in the past 3 months; response options were “never,” “rarely,” “sometimes,” “often,” or “very often.” Overall ad awareness was measured as a response of “rarely” or greater to any of the four ads. These procedures are a validated method of measuring individual ad exposure and have been shown to capture encoded exposure more precisely than tests that rely on memory recall alone [21].

Perceived Effectiveness (PE) Scale: Youth reactions and receptivity to each ad were assessed immediately after each ad was viewed (ads may be viewed at https://www.youtube.com/user/ USFoodandDrugAdmin/videos). PE was measured with a multi-item scale similar to those

Fig 2. The Real CostCampaign and Survey Timing.

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Youth's Awareness of and Reactions to The Real Cost

PLOSONE | DOI:10.1371/journal.pone.0144827 December 17, 2015 5 / 12 https://www.youtube.com/user/USFoodandDrugAdmin/videos https://www.youtube.com/user/USFoodandDrugAdmin/videos used in previous studies (e.g., Davis et al. [16,22]). After viewing each ad in the survey, respon-dents were asked whether they agreed or disagreed with the following statements: (1) this ad was worth remembering, (2) this ad grabbed my attention, (3) this ad was powerful, (4) this ad was informative, (5) this ad was meaningful, and (6) this ad was convincing. Each of these questions was answered on a 5-point Likert-type response scale from 1 (strongly disagree) to 5 (strongly agree).

A scale was created by summing the items and dividing by six to return the scale to its origi-nal item metric (i.e., 1 = strongly disagree to 5 = strongly agree). Consistent with prior published data [16,22], principal factor analysis suggests a strong one-factor solution for each scale. Fac-tor analysis for the PE scale yielded eigenvalues from 4.1 to 4.3 and factor loadings ranging from 0.73 to 0.90 across the six items in the scale and across all ads for which the scale was measured. All other factor eigenvalues were small and/or negative, and scale reliability was high across all ads (average Cronbach’s alpha = 0.93).

Demographic and Smoking-Related Variables. Demographic measures associated with tobacco use were examined, including age, gender, race/ethnicity, and preferred language (English or Spanish) among Hispanic respondents. Smoking-related variables include personal use, tobacco use in the household, and smoking susceptibility measures [12,13]. Among never smokers (not even one or two puffs), three items assessed future intentions to smoke: (1) “Do you think that you will try a cigarette soon?”; (2) “Do you think you will smoke a cigarette any-time during the next year?”; and (3) “If one of your best friends offered you a cigarette, would you smoke it?” with response options “definitely yes,” “probably yes,” “probably not,” or “defi-nitely not.” Youth who responded “definitely not” to all of these items were categorized as non-susceptible nonsmokers, whereas all others (those giving any response other than “definitely not” to any item) were defined as susceptible nonsmokers. Youth who reported smoking fewer than 100 cigarettes in their lifetime were defined as experimenters. Youth who reported smok-ing more than 100 cigarettes in their lifetime were defined as current or former smokers. Miss-ing responses for the demographic and smoking-related variables were less than 1.1%.

Analyses Descriptive statistics summarize data on The Real Cost campaign awareness and receptivity to advertisements. T-tests were used to examine demographic characteristics associated with sam-ple attrition and to examine differences in awareness and PE among demographic groups.

Demographic and smoking-related variables were used to stratify the data across population subgroups. At follow-up, current or former smokers were excluded from smoking status sub-group analyses due to small sample size (n = 76). All analyses were estimated using Stata statis-tical software 13.0.

Results

Sample Characteristics The first follow-up sample consisted of 5,761 youth. Respondents in the unweighted sample were evenly distributed across ages 12 to 16, with fewer youth aged 11 and 17 (Table 1). The sample was roughly equivalent by gender; it was 51.7% white, non-Hispanic; 29.0% Hispanic;

9.0% black, non-Hispanic; 3.3% Asian American or Pacific Islander; and 7.1% other or multira-cial. Among respondents who reported their ethnicity as Hispanic, Latino/a, or of Spanish ori-gin, a sizable proportion reported being English-only speakers (30.4%). Approximately 30% of the sample constituted the target audience for The Real Cost: susceptible nonsmokers (17.5%);

and experimenters (12.8%). Almost one-third of respondents (30.8%) reported living in the same household as a tobacco user. An analysis of sample attrition from baseline to follow-up

PLOSONE | DOI:10.1371/journal.pone.0144827 December 17, 2015 6 / 12 found that the samples were similar across age, gender, and household tobacco use categories.

The unweighted follow-up sample contained slightly more white respondents, fewer black respondents, fewer smokers, and more non-susceptible youth than the baseline sample; all dif-ferences were very small (e.g., mean difference across comparisons was 0.1%) and were accounted for in the first follow-up survey weighting procedures.

Awareness of The Real Cost Brand and Advertisements. Awareness of The Real Cost brand was 49.9% among youth. Awareness of one or more The Real Cost advertisements was 89.0% (Fig 3). Awareness of any ad was higher among youth aged 14 to 17 than among youth aged 11 to 13 (p< 0.01). Awareness did not differ significantly by gender or race/ethnicity. Ad awareness was higher among youth experimenters (94.6%) than among non-susceptible non-smokers (87.2%) (p< 0.001). Ad awareness was not statistically different between youth exper-imenters and susceptible nonsmokers (90.5%). Awareness was significantly higher among youth living with a smoker (94.1%) than youth living in smoke-free households (86.4%) (p< 0.001).

Of the four television advertisements, youth were most likely to recall “Skin” (79.6%), fol-lowed by “Bully” (76.2%), “Tooth” (76.1%), and “Alison” (67.2%). For “Alison,” “Skin,” and “Tooth,” awareness was higher among youth experimenters (range 74.7% to 84.8%) than

Table 1. Characteristics of First Follow-up Study Sample.

Characteristic N Unweighted % Weighted %

Age

11–13 2,199 38.2% 41.7%

14–15 1,989 34.5% 33.0%

16–17 1,573 27.3% 25.3%

Gender

Female 3,008 52.2% 49.3%

Male 2,753 47.8% 50.7%

Race/Ethnicity

White, non-Hispanic 2,981 51.7% 56.0%

Black, non-Hispanic 517 9.0% 12.4%

Hispanic 1,670 29.0% 22.6%

Asian or Pacific Islander 187 3.3% 4.6%

Other or multi-racial 406 7.1% 4.5%

Household Tobacco Use

Yes 1,759 30.8% 35.9%

No 3,951 69.2% 64.1%

Smoking Status

Non-susceptible nonsmoker 3,925 68.4% 67.5%

Susceptible nonsmoker 1,005 17.5% 15.7%

Experimenter 733 12.8% 13.7%

Former smoker 19 0.3% 0.6%

Smoker 57 1.0% 2.4%

Languagea

Spanish only 16 0.8% 1.2%

English and Spanish 1,391 68.8% 60.7%

English only 614 30.4% 38.1% a This question was asked of Hispanic or Latino participants or those responding with “Prefer not to answer” to the question “Are you Hispanic, Latino/a, or of Spanish origin?” (n = 2,033).

doi:10.1371/journal.pone.0144827.t001

PLOSONE | DOI:10.1371/journal.pone.0144827 December 17, 2015 7 / 12 among non-susceptible nonsmokers (64.1% to 77.5%, all p< 0.05). Youth aged 14 to 17 reported higher awareness than youth aged 11 to 13 for these same ads (70.4% to 83.2% com-pared with 62.5% to 74.4%, all p< 0.05). Awareness of “Skin” was significantly higher among Hispanic youth (85.6%) than among white youth (76.5%) (p< 0.01). Awareness of “Alison” and “Skin” was higher among black youth than among white youth (75.6% and 84.8% com-pared with 64.9% and 76.5%, respectively, both p< 0.05).

Perceived Effectiveness. The majority of youth perceived The Real Cost advertisements as effective, reporting high levels of agreement with items such as the ad “grabbed my attention” and was “powerful,” “worth remembering,” and “convincing.” Fig 4 displays the mean PE scores for The Real Cost ads overall and by key subgroups. Overall, youth reported a mean PE score of 3.99, with individual ad PE scores ranging from 3.91 to 4.07. Mean PE scores did not differ significantly by age, gender, race, or household tobacco use. PE scores were higher among non-susceptible nonsmokers (4.05) than among susceptible nonsmokers (3.87) (p< 0.05); experimenters did not differ significantly from the other two groups. PE scores were highest for The Real Cost ad “Tooth” (4.08), followed by “Skin” (4.07), “Bully” (3.99), and “Alison” (3.91) (data not shown).

Discussion Evidence from this study indicates that the initial phase of The Real Cost campaign has exceeded CDC recommendations for achieving population-level awareness levels that are

Fig 3. Percentage of Youth Reporting The Real CostAd Awareness, Overall and by Demographic and Smoking-related Variables. a 14–15 is significantly higher than 11–13 (p < 0.01). b 16–17 is significantly higher than 11–13 (p < 0.01). c Youth with household tobacco use is significantly higher than youth without (p < 0.001). d Experimenters are significantly higher than non-susceptible nonsmokers (p < 0.001).

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PLOSONE | DOI:10.1371/journal.pone.0144827 December 17, 2015 8 / 12 sufficient to potentially produce campaign effects in the future [8]. Half of all youth (49.9%) were aware of The Real Cost brand. The vast majority of youth aged 12 to 17 nationwide (89.0%) were aware of at least one television advertisement 6 to 8 months after campaign launch. High levels of awareness were attained for the campaign’s two targeted audiences: sus-ceptible nonsmokers (90.5%) and experimenters (94.6%). A larger proportion of youth experi-menters were aware of campaign advertising compared with youth non-susceptible nonsmokers (87.2%). Campaign awareness was also higher among older youth (aged 14 to 17) and youth who lived with a smoker than it was among youth aged 11 to 13 and those who lived in a nonsmoking household. These findings underscore the campaign’s reach among its pri-mary audience of youth at risk for smoking, as research shows that the odds of becoming an established smoker increase with age throughout adolescence, and that living with a smoker is a risk factor for smoking [12,23]. Campaign awareness did not differ significantly by gender or race/ethnicity, suggesting that the campaign reached a diverse population of youth at-risk for tobacco use nationwide. Overall, findings suggest that the campaign is currently generating suf-ficient exposure within the target audience to ultimately produce behavior change, if other campaign elements, such as messaging, function as expected.

Most youth consider The Real Cost advertising to be effective, based on assessments of PE (i.e., the degree to which youth agreed that ads were powerful, convincing, informative, mean-ingful, worth remembering, and attention grabbing). Because the PE scale ranges from 1

Fig 4. Perceived Effectiveness of The Real Cost Advertisements, Overall and by Demographic and Smoking-related Variables.Note: PE is an average score across the four advertisements on a scale from 1 (lowest) to 5 (highest). a Susceptible nonsmokers is significantly higher than non-susceptible nonsmokers (p < 0.05).

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(strongly disagree) to 5 (strongly agree), the overall mean PE ad score of 3.99 indicates general agreement of effectiveness among study youth. The Real Cost advertising was considered more effective among non-susceptible nonsmokers (4.05) than among susceptible nonsmokers (3.87). The ratings of experimenters fell in between (3.94) the other two groups and were not significantly different from either. The PE scores of all three groups are consistent with general agreement about the effectiveness of the advertisements. Consistent with previous studies of PE (Davis et al., 2015, unpublished work) [16], both groups reported positive ad appraisals, with black youth giving The Real Cost advertising a higher PE score (4.15) than white youth (3.98). PE scores did not differ significantly by age, gender, or household smoking status. These findings suggest that the campaign was well received overall and within the intended audience.

PE is an important proximal indicator of actual advertising effectiveness. Overall, youth’s positive reactions to The Real Cost advertisements are equal to or exceed reactions to previous campaign ads for youth prevention. Data from Florida youth indicate that PE scores across 12 youth tobacco prevention advertisements that had previously aired in the United States ranged from 3.40 to 4.20, with a mean of 3.78 (Duke, 2013, unpublished work). In comparison, the average PE score for four The Real Cost advertisements in the study is 3.99, while scores for all subpopulation groups ranged from 3.87 to 4.08. Although there are no youth-focused studies establishing a minimum PE score required for later campaign effectiveness two recent studies of adult cessation advertisements indicate PE is positively associated with subsequent behav-ioral change. A longitudinal study by Duke et al. [24] found that tobacco cessation advertise-ments with PE levels ranging from 3.67 to 4.03 subsequently increased adult smokers’ negative feelings about smoking, outcome expectations about the benefits of quitting, and quit inten-tions. A second study of PE was conducted on the national adult cessation public education campaign Tips From Former Smokers, which has been shown to produce cognitive and behav-ioral effects [25]. The study found that higher PE was predictive of increased quit attempts in a longitudinal sample of adult smokers, with average PE scores across the 15 ads ranging from

3.37 to 4.14 (Davis et al., 2015, unpublished work).

This study is subject to a number of limitations. First, this study relied on an aided recall method in which youth viewed each advertisement prior to reporting awareness, which may have resulted in some overreporting. However, this method is preferable to other measures, such as “confirmed awareness,” which require verbal descriptions of the ending of an ad after viewing the beginning; in the latter method, discrepancies in awareness may occur due to ad characteristics (e.g., narrative-style or non-sequential). For this reason, the aided awareness measure is now commonly used in media campaign evaluations [25]. Second, the PE measure has not been formally validated as predictive of tobacco-related cognitions or behaviors among youth in the published literature, and further evaluation using longitudinal studies is required to determine the influence of PE on youth cognitions and behavioral outcomes. Third, although follow-up data are weighted to account for its effects, sample attrition may limit these data.

Evaluations of previous campaigns have found that high levels of ad awareness and PE were associated with positive changes in campaign-targeted beliefs and attitudes as well as behavior change [4,26–29]). The current study has found similar high levels of ad awareness and PE, suggesting that this campaign has the potential to be effective in reducing smoking among at-risk youth. Initial findings are encouraging and continuing data collections will help determine whether achieving high campaign awareness and PE scores will be associated with future posi-tive youth outcomes for The Real Cost campaign.

In conclusion, The Real Cost has been widely viewed by youth and appraised as effective, both requisite proximal indicators that have been associated with subsequent changes in health-related beliefs, attitudes, and behavior. Ongoing research using longitudinal panel data

PLOSONE | DOI:10.1371/journal.pone.0144827 December 17, 2015 10 / 12 will allow for future assessment of the relationship between exposure to the campaign and potential subsequent shifts in youth population-level cognitions and/or behaviors. Currently, these data 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.

Supporting Information S1 File. The file includes variables that were used to conduct the analysis reported in this study.

(XLSX)

Acknowledgments We are grateful to April Brubach, Gem Benoza, Corinne Husten, Lucinda Miner, and Pamela Rao for helpful advice and thoughtful editorial suggestions. We would also like to thank James Nonnemaker and Jamie Ridenhour for their contributions to the study design, implementa-tion, and statistical guidance.

Author Contributions Conceived and designed the experiments: J. Duke JAAMCF. Performed the experiments: J.

Duke JAA MCF. Analyzed the data: J. Duke AJM. Wrote the paper: J. Duke TNA XZ J. Dela-hanty JAA AJMMCF.

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Youth's Awareness of and Reactions to The Real Cost

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Quantitative Research

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

Jennifer C. Duke, PhD1, Matthew C. Farrelly, PhD1, Tesfa N. Alexander, PhD2, Anna J. MacMonegle, MA1, Xiaoquan Zhao, PhD2,3, Jane A. Allen, MA1, Janine C. Delahanty, PhD2, Pamela Rao, PhD2, and James Nonnemaker, PhD1

Abstract

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 ¼ 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.

Keywords tobacco control, mass media campaign, adolescent, logistic regression

Purpose

In February 2014, the Food and Drug Administration’s (FDA)

Center for Tobacco Products launched The Real Cost, the first of several complementary national public education campaigns designed to prevent and reduce tobacco use among US youth aged 12 to 17. Initial campaign advertising under The Real Cost was designed to prevent the initiation of cigarette smoking among youth who have never smoked but are susceptible to smoking (susceptible nonsmokers) and to discourage further smoking among youth who have experimented with smoking in the past (experimenters).

A substantial body of research finds that media campaigns are effective at reducing youth smoking prevalence,1,2 prevent-ing initiation,3-5 and disrupting progression to established smoking.3,6 Moreover, campaigns that are designed for and delivered to a general population of at-risk youth can be effective across gender and racial/ethnic groups.7 Based on the strength of this research evidence, mass media campaigns are widely con-sidered to be a “best practice for tobacco control.”8-10

1 RTI International, Research Triangle Park, NC, UA 2 Center for Tobacco Products, US Food and Drug Administration, Silver

Spring, MD, USA 3 Department of Communication, George Mason University, Fairfax, VA, USA

Corresponding Author:

Jennifer C. Duke, RTI International, 3040 East Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709, USA.

Email: jduke@rti.org

American Journal of Health Promotion 1-9 ª The Author(s) 2017 Reprints and permission:

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DOI: 10.1177/0890117117720745

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The Real Cost is based on the Theory of Planned Behavior, which posits that behavior change is a result of changes in beliefs that, in turn, influence attitudes toward a behavior, per-ceptions of associated social norms, and/or self-efficacy to engage in or refrain from a behavior.11,12 The Centers for Dis-ease Control and Prevention’s (CDC) evidence-based guidance for implementing effective tobacco mass media campaigns is based on this theoretical framework, and numerous studies support its value for developing and evaluating public health and education campaigns.10,13,14

The Real Cost has aired continuously at high media levels since its launch, resulting in few unexposed youth aged 12 to

17 within the first year. More than 90% of the target audience

(ie, youth experimenters and susceptible nonsmokers) reported ad awareness 8 months after campaign launch, and most surveyed youth considered advertisements to be effec-tive based on assessments of perceived effectiveness.15 Stud-ies indicate that perceived effectiveness of ad is predictive of attitudes and behavioral outcomes across a range of health behaviors.16-19 Based on CDC guidance and evidence from prior youth tobacco education campaign evaluations, The

Real Cost should be influencing campaign-targeted beliefs2,10,20 after 14 to 16 months.

The current study examined the association between tem-poral and geographic variation in campaign exposure and indi-viduals’ beliefs with a focus on message content specific to The

Real Cost.21 We examined data from the first 3 waves of a national longitudinal survey of US youth to determine whether campaign exposure influenced campaign-targeted beliefs among the target audience.

Methods

Design and Sample

Data are from a nationally representative longitudinal survey of

US youth aged 11 to 16 at baseline who would age into The

Real Cost’s audience of 12- to 17-year-olds after campaign launch. The study was conducted as part of The Real Cost evaluation. We used an address-based sampling frame to ran-domly draw households clustered in US census block groups within 75 media markets and supplemented the frame with market research databases to identify households likely to have at least 1 eligible youth (approximately 5% of households). A lead letter describing the study was mailed to each of the selected addresses. Subsequently, a field interviewer visited each address to secure an immediate interview or schedule one for a later date. In-person baseline data collection took place from November 11, 2013, through March 31, 2014. First follow-up data collection (July 24, 2014, to October 27, 2014) and second follow-up data collection (April 6, 2015, to

July 4, 2015) consisted of online or in-person interviews with youth after obtaining parental permission and youth assent.

Youth participants received a $20 incentive for completion of the baseline survey and $20 or $25 for completion of each follow-up. The final total sample size for the second follow-up survey was 5240 youth. The study was approved by insti-tutional review boards at FDA and the researching institution.

The primary target audience consisted of youth experimen-ters and susceptible nonsmokers.22 Thus, we examined 1680 youth (32.1% of total sample) who were among the campaign’s target audience at baseline and completed the second follow-

up. Experimenters (n ¼ 399) were defined as youth who reported smoking fewer than 100 cigarettes in their lifetime at baseline. Susceptible nonsmokers (n ¼ 1281) were defined as never smokers (not even 1 or 2 puffs) who indicated an openness to trying cigarettes at baseline. Specifically, suscep-tible nonsmokers did not respond “definitely not” to at least 1 of 3 items assessing future intentions to smoke: (1) “Do you think that you will try a cigarette soon?,” (2) “Do you think you will smoke a cigarette anytime during the next year?,” and

(3) “If one of your best friends offered you a cigarette, would you smoke it?”23

At baseline, 7418 sampled households were eligible to par-ticipate (ie, contained youth aged 11 to 16 years). An additional

2083 households with unknown eligibility were estimated to be eligible. Participants in 4538 households completed a survey.

Thus, the unweighted household-level response rate was 47.8% and the weighted household-level response rate was 43.7% at baseline (American Association of Public Opinion Research

Response Rate #3 formula). At the first follow-up, the weighted person-level response rate was 85.6%. At the second follow-up, the weighted person-level response rate was 84.0% of the first follow-up. To produce reliable estimates of target population parameters, baseline analysis weights that accounted for unequal probabilities of selection at each of 3 stages (ie, media market, census block groups, and address) were adjusted for nonresponse. Then, weights were calibrated to the Census 2010 population totals of the baseline target population with post-stratification for gender and race/ethnicity. At each follow-up, weights were adjusted for nonresponse and calibrated to pop-ulation totals with poststratification.

Campaign Message and Implementation

The central theme of The Real Cost is “Every cigarette costs you something.” Advertising in the first year focused on short-term health effects (eg, cosmetic effects) and loss of control

(eg, nicotine addiction) associated with smoking. Advertising in the second year continued these themes and introduced new messages about the danger of the mix of toxic chemicals in cigarette smoke (Appendix A). The media purchase for The

Real Cost included advertising on national television, radio, the Internet, and out-of-home displays, as well as in magazines and at movie theatres directed at youth aged 12 to 17.