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. Author manuscript; available in PMC: 2026 Feb 21.
Published before final editing as: Am J Prev Med. 2026 Jan 30:108204. doi: 10.1016/j.amepre.2025.108204

Attentional, Affective, and Cognitive Responses to FDA’s "The Real Cost" Youth Cigarette and E-cigarette Prevention Campaigns among Young Adults

Caitlin Weiger 1, Dana Tfayli 2, Maryam Ibrahim 2, Jennifer A McKneely 3, Megan Vigorita 4, Emily B Peterson 4, Meghan B Moran 2
PMCID: PMC12922668  NIHMSID: NIHMS2139267  PMID: 41615351

Abstract

Introduction:

Research using self-reported measures demonstrates that “The Real Cost” Youth Cigarette and E-Cigarette Prevention Campaigns affect tobacco-related beliefs, attitudes, behavioral intentions, and behaviors. This study provides insights by assessing attentional, affective, and cognitive responses to ads from “The Real Cost” campaigns among US young adults (YA) using non-self-report measures.

Methods:

Attentional, affective, and cognitive responses (eye tracking, facial electromyography, electrodermal activity, functional near-infrared spectroscopy, and heart rate, collected from 2023-24 and analyzed 2024-25) were measured during exposure to campaign ads in a Baltimore-area convenience sample of N=25 YA who were susceptible to or experimenting with e-cigarettes and N=25 YA who were susceptible to or experimenting with cigarettes.

Results:

Faces generally attracted the most visual attention. All ads evoked increased cognitive activity associated with self-referential processing of the messages, and two e-cigarette campaign ads evoked cognitive activity associated with defensive processing. Heart rate decreased while watching most ads, indicating participants devoted cognitive resources to message processing. Affective responses varied across ads.

Conclusions:

Attentional, affective, and cognitive responses indicated a favorable response to campaign ads. Decreases in heart rate and increases in cognitive activity in the medial prefrontal cortex are associated with message processing and message-consistent behavior change. Some of the e-cigarette ads, but none of the cigarette ads, elicited cognitive activity associated with defensive processing; potentially due to YA’s perceptions of e-cigarettes as less harmful than cigarettes. More work will advance understanding of the rationale for increases in activity associated with defensive processing in response to the e-cigarette ads.

INTRODUCTION

“The Real Cost” Youth Cigarette and E-cigarette Prevention campaigns, educational campaigns aimed at preventing tobacco use initiation among youth ages 12-17, were launched by the U.S. Food and Drug Administration (FDA) in 2014 and 2018, respectively.1 The campaigns, which have appeared on platforms such as TV, radio, print, web and social media, depict the personal and social ‘costs’ of cigarette and e-cigarette use. Evidence from population-level surveys indicate the campaigns have been highly effective.2-4 “The Real Cost” Youth Cigarette Prevention Campaign (i.e., the cigarette campaign) is credited with preventing up to 587,000 youth aged 11-19 from initiating smoking between Feb. 2014 and Nov. 2016, half of whom may have gone on to become people who smoke regularly. “The Real Cost” Youth E-Cigarette Prevention Campaign has significantly reduced e-cigarette and cigarette susceptibility among adolescents and prevented an estimated 444,525 youth ages 11-18 from initiating e-cigarettes between 2023 and 2024.5-7 Most studies evaluating the effectiveness of “The Real Cost” campaigns rely heavily on self-reported measures to assess campaign awareness and differences in attitudes, intentions, or behaviors regarding tobacco use.3,7,8 While these methods provide valuable information about population-level effects, neuroimaging, eye-tracking, and psychophysiological measures can provide insights on mechanisms through which the campaign has elicited effects without the bias sometimes encountered with self-reported measures.

Research that elucidates the mechanisms underlying effective communication can advance health communication theory by providing insights into the biology of message processing and enable more successful or efficient replication of campaigns across diverse topics. Models focusing on information processing and the role of dual motivational systems are theoretically relevant to this study’s interest in physiological measurements of message effects, including the Dynamic Human-Centered Communication Systems Theory9 which grew from the Limited Capacity Model of Motivated Mediated Message Processing (LC4MP)10-12 and the Evaluative Space Model (ESM)13,14 as a theoretical orientation. This theoretic orientation assumes that humans have limited cognitive resources to attend to communication messages. In other words, there are bounds to an individual’s ability to devote cognitive resources (i.e., processes such as attention and encoding of messages) to a message. Allocation of available cognitive resources is motivated by appetitive/approach and aversive/avoidance systems influenced by both message properties (e.g., a message’s content and format) and individual characteristics (e.g., an individual’s pre-existing cognitive abilities). The ESM complements this perspective by emphasizing that appetitive and aversive systems operate as partly independent processes rather than opposite ends of a single continuum.13,15 Importantly for this study, these models assume that cognitive resource allocation and motivated processing can be observed by measuring neural and physiological changes in the brain and body.16 Attentional, affective, and cognitive measures can provide data about how people respond to messaging that goes beyond self-report. For instance, researchers have been able to explain more variance in actual behavior change by adding neurocognitive indicators of persuasion (e.g., hemodynamic response in specific areas of the brain) to self-reported measures than by using self-reported measures alone.17-20Additionally, these measures are not subject to self-report bias, can be captured in real-time as participants are exposed to stimulus, and do not rely on the subject to introspect about the nature of their own reactions.21-24 Thus, these measures are able to provide real-time information as to how audiences respond to media stimuli, allowing for insights regarding response to message content and features as they occur, which can supplement self-report data.

The current study expands upon the rigorous survey research that has assessed population-level effects of the campaigns by evaluating the attentional (via eye tracking), affective (via Electromyography and Electrodermal Activity), and cognitive (via Functional Near-Infrared Spectroscopy and heart rate) responses elicited by “The Real Cost” Cigarette and E-cigarette Prevention Campaigns’ video advertisements among 50 young adults (YA) who are either experimenting with or susceptible to tobacco use. Details of what each cognitive and psychophysiological indicator measures are described in the methods section below. Findings from this study can offer an understanding of how these advertisements influence YA at a deeper level. These findings can also extend understanding of mechanisms for effective prevention messaging and inform best practices for message design.

METHODS

Study population

The study population consisted of two groups (Cigarette group and E-cigarette group) of 25 YAs ages 18-24, recruited from the Baltimore area. Additionally, participants in the Cigarette group were either susceptible to smoking (assessed using the Susceptibility to Smoking Index)25 or had tried smoking, but smoked fewer than 100 lifetime cigarettes. Participants in the E-cigarette group were either susceptible to e-cigarette use or had ever tried e-cigarettes. Data was collected from 2023-24 and analyzed 2024-25.

Protocol

Participants completed an in-person study visit lasting approximately 90 minutes. After providing informed consent, participants were fitted with the measurement devices. Following equipment setup, participants were instructed to sit quietly for 2 minutes for environmental habituation. Participants then viewed four digital video advertisements (hereafter “ads”), presented in a random order, from either “The Real Cost" Youth Cigarette Prevention campaign (Cigarette group) or E-cigarette Prevention campaign (E-cigarette group). Each ad was preceded by a 60-second washout period to allow participant responses to return to baseline (a static screen directing them to wait for the researcher to proceed). Sixty seconds was used as the washout period because the hemodynamic response function (the slowest signal data were collected on) takes about 60 seconds to return to baseline.26 For 34 participants (13 from the Cigarette group and 21 from the E-cigarette group), eye-tracking data was captured after the Functional Near-Infrared Spectroscopy (fNIRS) and physiological data, by having participants view each ad a second time to acquire eye-tracking data. This was done to increase the comfort of participants by allowing them to not wear eye-tracking glasses. For remaining participants, eye-tracking, fNIRS and physiological data were captured simultaneously. This study was approved by the investigators' Institutional Review Board (IRB00011404).

Regarding the stimulus messages, there were two sets of four 15-30 second stimulus messages, one set from the cigarette campaign and one from the e-cigarette campaign. Cigarette campaign ads included were (1) ‘Auctioneer’ - an auction depicting harms from cigarettes, (2) ‘Delivery’ - a boy trading his teeth for cigarettes, (3) ‘Little Lungs Celebrity: Terry Crews’ – a humorous animated depiction of stunted lungs from smoking (hereafter ‘Little Lungs’), (4) ‘Said Every Smoker Ever’ - adult smokers reflecting on how, as teens, they did not think they would become addicted (hereafter ‘SESE’). E-cigarette ads included (1) ‘Addiction Isn’t Pretty: Toilet’ - a girl dropping her vape in a toilet and proceeding to use it anyway (hereafter ‘Toilet’), (2) ‘Scary Enough’ a monster depicting metals one could inhale from e-cigarettes, (3) ‘My Vaping Mistake: Chloe’ - a girl sharing her e-cigarette addiction experience (hereafter ‘Chloe’), (4) ‘No Vape in Team: Football’ - football players opposing vaping (hereafter ‘Football’). Expanded message descriptions are available in AppendixTable 1. These ads were selected from the broader suite of campaign ads to reflect the diversity of message content (e.g., focusing on different tobacco harms), formats (e.g., testimonial, fictional narrative, documentary style) and stylistic elements (e.g., Claymation, use of music, action shots).

Measures

Equipment specifications are detailed in Appendix Table 2.

Regarding attentional measures, the amount of time a participant spent looking at different areas of interest within each ad was assessed by measuring fixation time using eye-tracking software. Midway through the study, eye-tracking equipment was changed from the Tobii Pro Glasses 2 to the screen-based Tobii Pro Spark. This was to increase participant comfort. However, due to unforeseen interference between the infrared light emitted by the Tobii Pro Spark and the fNIRS device, participants using the Pro Spark viewed ads a second time for collection of eye-tracking data.

For the affective measures, facial electromyography (EMG) was used to measure muscle movement in the face associated with positive and negative emotional valence, which may capture activation of appetitive and defensive/aversive systems from the LC4MP model.27-30 Reusable EMG electrodes filled with saline gel were attached to the corrugator supercilii (activity associated with frowning) and zygomaticus major (activity associated with smiling27) regions using a bipolar configuration on the nondominant side of the participant's face after the skin was wiped with alcohol and gently abraded to reduce impedance.31

Electrodermal activity (EDA) quantifies the amount of sweat secreted on the fingers and is used as a measure of physiological or emotional arousal.30 After cleaning the fingers with water and drying with a clean paper towel, the transducers were placed on the medial digit of the fore and middle finger of the participant's nondominant hand (to enable typing/mouse clicking, which most people prefer to do with their dominant hand).

Regarding cognitive measures, functional near infrared spectroscopy (fNIRS) was used to indirectly measure brain activity via Blood-Oxygen-Level-Dependent Response. fNIRS uses near infrared light and properties of how that light diffuses through different types of tissues, in conjunction with the Modified Beer-Lambert Law, to measure changes in oxygenated hemoglobin in the first few centimeters of cortex. The medial prefrontal cortex (mPFC) is hypothesized to be involved in self-referential processing,32,33 or relating information to the self,34 and activity in the mPFC during persuasive message exposure has been associated with smoking reduction18,35,36 and smoking cessation.37,38 On the other hand, activity in the right dorsolateral prefrontal cortex (rdlPFC), hypothesized to be associated with internal defensive processing (e.g., counterarguing, source derogation etc.), negatively predicts message-consistent behavior change (e.g., continued smoking after exposure to cessation messaging).39-41 The fNIRS headband was centered over the nasion and secured across the participant’s forehead. The baseline measurement for the relative change in oxygenation was modified to be during seconds 30-45 from the 60 second washout period prior to each ad.

Heart rate (HR) can be an indicator of cognitive resource allocation. Evidence suggests that increased heart rate may be associated with allocation of cognitive resources to internal message processing such as counterarguing,42,43 while decreased heart rate may be associated with allocation of cognitive resources to external processing of information.44-46 HR was measured using a photoelectric pulse plethysmogram transducer on the ring finger of the participant's nondominant hand.

Statistical analysis

Sample descriptives are reported separately for the two groups. All analyses were conducted in Stata Version 15.47 Preprocessing, including reasons for missing data, is described in Appendix Table 2. Missing data were not replaced, but participant’s non-missing data was still used (i.e., participant was not removed entirely from the analyses if data were missing for only one indicator, but not others).

Areas of interest in each ad were identified a priori and then calculated the median fixation time spent on each area of interest as a percentage of the total time the area of interest was on the screen. This data was used to identify which areas of interest garnered the highest levels of fixation time for each ad.

EMG, EDA, and HR data were all analyzed similarly. Measures were normalized by subtracting the last second of the washout period (baseline) from each second of the ad, then computing average change scores for each ad. Mixed effects models, adjusted for race/ethnicity, and highest level of education, were run to explore the impact of each ad on change in each outcome (relative to baseline) with a random intercept for participant. Marginal estimates were used to assess if cognitive activity differed from 0 for any of the ads and pairwise comparisons were used to assess if activity occurring during ad exposure differed between the ads. Bonferroni corrections were applied to pairwise comparisons to account for inflated family-wide alpha.

For the neuroimaging data (fNIRS), aggregated measures were created by averaging changes in oxygenated hemodynamic activity over the medial prefrontal cortex (channels 7-10) and over the right dorsal lateral prefrontal cortex (channels 11, 13 and 15) by ad for each participant. The same mixed effects models used in EMG, EDA, and HR analysis were also used for fNIRS analysis. One additional control variable was included in the fNRIS analysis. Activity from short channels were included to account for changes in hemodynamic response from respiration, heart rate, and other physiological processes not related to the cognitive processes of interest.

Additionally, the mixed effects models described above were run including time x video interaction to assess whether change in each indicator over time varied by video. Change from baseline for each indicator were plotted over time for each video, which allows for better visualization of change in indicator over each video’s progression.

RESULTS

Sample characteristics

Table 1 presents sample characteristics. For the Cigarette group, most (76%) were between 22-24. Just under half (44%) identified as non-Hispanic Asian, and 24% non-Hispanic White. About two-thirds (68%) of participants had ever tried a cigarette, while the rest had never tried but were susceptible (32%). Among participants in the E-cigarette group, 84% were 21-24 years old. 40% of participants identified as non-Hispanic white. Just over half (56%) of participants had ever tried an e-cigarette, while 44% were susceptible.

Table 1.

Participant characteristics

Cigarette
(Group 1)		 E-cigarette
(Group 2)
Demographics n % n %
Age, years
  18 1 4.0 0 0
  19 4 16.0 3 12.0
  20 1 4.0 1 4.0
  21 0 0.0 3 12.0
  22 7 28.0 6 24.0
  23 7 28.0 8 32.0
  24 5 20.0 4 16.0
Race/Ethnicity
  NH Asian 11 44.0 6 24.0
  NH Black or AA 1 4.0 4 16.0
  Hispanic or Latino 2 8.0 1 4.0
  NH White 6 24.0 10 40.0
  More than 1 race or ethnicity 5 20.0 4 16.0
Education level
  High school degree or less 0 0.0 1 4.0
  Some college 11 44.0 7 28.0
  College degree or more 14 56.0 17 68.0
Employment status
  Full-time 4 16.0 11 44.0
  Part-time 9 36.0 10 40.0
  Don't currently work 12 48.0 4 16.0
Income level
  Not enough to get by 1 4.0 2 8.0
  Just enough to get by 11 44.0 10 40.0
  Only have to worry about money for fun 10 40.0 11 44.0
  Never have to worry about money 3 12.0 2 8.0
Cigarette use(b)
  Ever smoked a cigarette 17 68.0 (a) (a)
  Susceptible to cigarette use 8 32.0 (a) (a)
E-cigarette use(b)
  Ever used an e-cigarette 17 68.0 14 56
  Susceptible to e-cigarette use 8 32.0 11 44.0
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a.

Due to a programming error, cigarette use variables were not asked to the e-cigarette group

b.

Percentages reflect data reported in participant screening. When completing the survey during their study visit, one participant in the cigarette group's indicated they were not susceptible to cigarette use, and three participants in the e-cigarette group indicated they were not susceptible to e-cigarette use.

Attentional response

Among cigarette ads, fixation time was highest for the teenager’s face (58.0%) and the jar containing the cigarette (29.8%) in Auctioneer; the box containing the unknown to viewers ‘gift’ (85.9%) and the teeth (76.9%) in Delivery; the imagery of the Little Lungs after being hit by a train (63.9%) and the spokescharacter (lungs voiced by Terry Crews) (59.7%) in Little Lungs, and the face of the first person who smokes (84.0%) and third person who smokes (67.3%) in SESE. Among e-cigarette ads, fixation time was highest for the spokesperson (74.7% of total time on screen) and "The Real Cost" Logo (31.4% of total time on screen) in Chloe, the first spokesperson’s face (90.2%) and the players playing football (68.0%) in Football, the ‘vape monster’ (64.7%) and spokesperson (61.2%) in Scary Enough, and the text reading “What drug is so addictive you’d do anything to get a hit?” (62.7%) and “Most vapes contain seriously addictive levels of nicotine” (63.3%) in Toilet. Appendix Tables 3 and 4 present all eye-tracking data.

Affective response

Table 2 presents results on affective response. Among cigarette ads, Delivery and Little Lungs exhibited an increase of electrodermal activity compared to baseline, indicating greater arousal of the sympathetic nervous system. Little Lungs was associated with a greater overall increase in electrodermal activity compared to the other ads as well as greater increase over time compared to the other ads (vs. SESE: b=.0521, p<.001; vs. Delivery: b=.0496, p<.001; vs. Auctioneer: b=.0495, p<.001). No ads were associated with an increase of activity of the corrugator supercilii (i.e., frowning), though Little Lungs was associated with a decrease of activity, indicating less negative affect. The difference in activity of the corrugator supercilii between Little Lungs and the other ads was statistically significant. Little Lungs and Auctioneer were associated with increased activity of the zygomaticus major. The difference in activity of the zygomaticus major between these two ads, compared to Delivery and SESE, was statistically significant. Change in corrugator supercilia activity over time did not vary across ads. Change in zygomaticus major activity varied significantly over time between videos, such that Auctioneer demonstrated increased activity over time compared to the other videos (vs. SESE: b=.0003, p<.001; vs. Little Lungs: b=.0005, p=.009; vs. Delivery: b=.0002, p=.023). Appendix Figure 1 presents change in these indicators over time for each video.

Table 2.

Affective response and heart rate change (marginal means)

EDA (μS) EMGa (μV) EMGb (μV) Heart rate (BPM)
Video Title Mean
change		 95% CI Sig. Mean
change		 95% CI Sig. Mean
change		 95% CI Sig. Mean
change		 95% CI Sig.
Cigarette videos (Group 1)
 Auctioneer 0.08a ( −0.02 - 0.18) 0.126 2.02a (−1.17 - 5.22) 0.215 3.1ac (0.75 - 5.45) 0.010 −2.58ab (−3.72 - −1.46) <.0001
 Delivery 0.20b (0.1 - 0.29) <.0001 2.99a (−0.2 - 6.17) 0.066 0.99ab (−1.36 - 3.33) 0.408 −3.11a (−4.25 - −1.99) <.0001
 Little Lungs 0.34c (0.23 - 0.45) <.0001 −9.39b (−12.84 - −5.93) <.0001 5.14c (2.59 - 7.69) <.0001 −1.58b (−2.78 - −0.37) 0.010
 Said Every Smoker Ever −0.14d (−0.24 - −0.04) 0.005 0.77a (−2.4 - 3.94) 0.634 −0.80b (−3.13 - 1.53) 0.500 −4.20c (−5.32 - −3.08) <.0001
E-cigarette videos (Group 2)
 Chloe 0.17a (0.06 - 0.27) 0.002 0.22a (−0.83 - 1.27) 0.677 −6.68a (−8.88 - −4.48) <.0001 0.06a (−0.78 - 0.9) 0.885
 Football −0.02b (−0.13 - 0.09) 0.744 1.33b (0.21 - 2.45) 0.020 0.81b (−1.66 - 3.28) 0.52 −1.35b (−2.32 - −0.39) 0.006
 Scary Enough −0.19c (−0.3 - −0.08) <.0001 1.16b (0.12 - 2.21) 0.029 0.97b (−1.22 - 3.16) 0.387 −1.93b (−2.76 - −1.09) <.0001
 Toilet −0.17c (−0.28 - −0.07) 0.002 1.90b (0.85 - 2.95) <.0001 0.99b (−1.21 - 3.19) 0.378 −3.52c (−4.36 - −2.68) <.0001
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Note: Mean values with different subscripts are significantly different at p<.008 (adjusted p-value of .05 using Bonferonni correction)

Among e-cigarette ads, Chloe was associated with increased electrodermal activity, while Toilet and Scary Enough were associated with decreased electrodermal activity. This difference in electrodermal activity between Chloe and the other ads was statistically significant. Change in electrodermal activity over time varied significantly across videos, such that Chloe demonstrated increased activity compared to Scary Enough (b=.012, p<.001) and Toilet (b=.016, p<.001). Football, Scary Enough, and Toilet were associated with an increase of activity in the corrugator supercilii, significantly more so than Chloe. Change in corrugator supercilii activity over time varied between videos, such that Toilet demonstrated increased activity over time compared to Chloe (b=.0001, p<.001) and Scary Enough (b=.00009, p=.006). No ads were associated with increased activity of the zygomaticus major, though Chloe was associated with a decrease of activity in this area, significantly more so than the other ads. Change in zygomaticus major activity did not vary significantly over time across ads. Appendix Figure 2 presents change in these indicators over time for each video.

Cognitive response

Among cigarette ads, all ads showed a significant decrease in heart rate compared to baseline, indicating greater allocation of cognitive resources to message processing. SESE was associated with the greatest decrease in heart rate compared to the other ads. Change in heart rate over time did not significantly vary across videos. Among e-cigarette ads, Football, Scary Enough and Toilet were associated with decreased heart rate. Chloe was associated with overall less decrease in heart rate compared to the other ads, while Toilet produced the greatest overall decrease in heart rate. Change in heart rate over time was significantly increased for Chloe compared to Football (b=.181, p=.025), Scary Enough (b=.128, p=.001) and Toilet (b=.176, p<.001). Heart rate data are presented in Table 2.

Figure 1 presents fNIRS results. Compared to the washout period (baseline), each cigarette ad elicited significant increases in mPFC activity (i.e., activity associated with self-referential processing). None of the tested cigarette ads increased activity in the rdlPFC (i.e. activity associated with defensive processing) compared to baseline. SESE elicited significantly less mPFC activity overall compared to Auctioneer (p<.001), Delivery (p=.001), and Little lungs (p<.001). SESE also elicited less mPFC change over time compared to the other videos (Auctioneer: b=−.038, p<.0001; Delivery: b=−.040, p<.0001; Little Lungs: b=−.049, p=.002). Little Lungs elicited significantly more mPFC activity overall compared to Delivery (p=.001).

Figure 1.

Figure 1.

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Marginal estimates for relative change in oxygenated hemoglobin in the mPFC and rdlPFC during exposure to "The Real Cost" Youth E-cigarette and Cigarette Prevention Campaign videos

Overall, Little Lungs elicited significantly more rdlPFC activity compared to Delivery (p<.001) and SESE elicited increased overall rdlPFC activity compared to Auctioneer (p<.001) and Delivery (p<.001). Delivery elicited less rdlPFC change over time compared to SESE (b=−.039, p<.001) and Auctioneer (b=.024, p=.014).

Significantly increased activity was noted during all e-cigarette ads in the mPFC. Significantly increased activity was also observed in the rdlPFC during Chloe and Scary enough. Toilet elicited significantly less mPFC activity overall compared to Chloe (p<.001) and Scary enough (p<.001) and over time compared to Chloe (b=−.019, p=.004), Football (b=−.033, p=.013) and Scary enough (b=−.021, p=.001). Football elicited less rdlPFC activity overall than Chloe (p<.001) and Scary enough (p<.001..Compared to Chloe (b=−.034, p=.010) and Scary Enough (−.027, p=.041), Football also elicited less rdlPFC activity over time. Compared to Chloe (b=.015, p=.021), Football (b=.050, p<.0001) and Scary Enough (b=.022, p=.001), Toilet elicited more rdlPFC activity over time.

Table 3 summarizes findings.

Table 3.

Summary of main findings

Video Title Electrodermal
activity
(Arousal)		 Corrugator
Supercillii
activity
(Negative
affect)		 Zygomaticus
major activity
(Positive
affect)		 Heart rate
(Allocation
of
cognitive
resources)		 mPFC
activity
(Self-
referential
processing)		 rdlPFC
(Defensive
processing)		 Top 2 areas of attention
Cigarette videos (Group 1)
  Auctioneer n.s. n.s. + − + n.s. Character's face; Cigarettes in jar
  Delivery + n.s. n.s. − + n.s. Delivery box; Diseased teeth
  Little Lungs + − + − + n.s. Lungs after being hit by train; Spokescharacter (lungs voiced by Terry Crews)
  Said Every Smoker Ever − n.s. n.s. − + n.s. Face of1st person who smokes; Face of 2nd person who smokes
E-cigarette videos (Group 2)
  Toilet − + n.s. − + n.s. Text statement (vapes contain nicotine); Text statement (What drug is so addictive…?)
  Scary Enough − + n.s. − + + Metal vape monster; Spokesperson's face
  Chloe + n.s. − n.s. + + Main character's face; "The Real Cost" logo text
  Football n.s. + n.s. − + n.s Main character's face; Action of football playing
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DISCUSSION

This study used attentional, affective, and cognitive measures to assess response to “The Real Cost” Cigarette and E-cigarette Youth Prevention campaigns to better understand the mechanisms underlying the campaigns’ persuasive effects. Starting with attentional measures, faces (including those of animated characters) were among the top two areas viewed for all videos except for Toilet, where text was the dominant area viewed. This is not surprising, given the well-known human face attraction effect, where humans as young as newborns exhibit a preference for orienting towards human faces.48,49 Eye-tracking research has also shown that human faces often attract attention in advertising.50 These findings could further indicate participants are attending to the key information in each ad. In several ads, people delivered educational messages aloud (SESE, Chloe, Football, Scary Enough), while in Toilet, in which text received considerable focus, there was a standstill in the ad’s action to display educational text.51 The attention paid to the text in Toilet, illustrated by both this eye-tracking data as well as changes in heart rate over time, demonstrates one way that factual information (the statements “What drug is so addictive you’d do anything to get a hit?” and “Most vapes contain seriously addictive levels of nicotine”) can be integrated into a fictional narrative, and how choices made in video editing (a stop in the visual action) can be used to direct attention to this information. This approach could potentially be used for short-form content (as is prevalent in social media platforms) that may have limited time to integrate factual information within a narrative structure.

Less consistent results were seen in affective responses. Among cigarette campaign ads, Little Lungs, an animated ad, intentionally took a more lighthearted approach and elicited a positive affective response (increased zygomaticus activity and decreased corrugator activity) as a result. There was additional evidence of emotional arousal via increased sympathetic nervous system activity (EDA) in Little Lungs, which could be from the "shocking" moment where the stunted lungs are hit by a train, or by the fast-moving, animated action in the ad. Delivery also elicited increased sympathetic nervous system activity, which again could have been due to the "reveal" moment of the "delivery," diseased gums and teeth from cigarette smoking. Counterintuitively, increased zygomaticus activity (e.g., positive affect) was seen in response to Auctioneer, a serious message about trading your health and well-being for cigarettes. This could have been due to grimacing, which can also activate the zygomaticus major during exposure to disgust-eliciting stimuli.52,53

Among e-cigarette campaign ads, Toilet, Scary Enough, and Football elicited increased negative affect (i.e., corrugator activity). Negative affect could be due to activation of the aversive or defensive systems.16,43 This could indicate that the message evoked aversive reactions towards the product (e-cigarettes) among the participants, rather than the message or ad. However, it cannot be ruled out that this finding indicated a defensive response against the message itself.16,43

Heart rate data largely indicated that participants allocated cognitive resources to processing the ads. All cigarette ads showed a significant decrease in heart rate compared to baseline indicating greater allocation of cognitive resources to message processing. Chloe, which featured one person speaking to the camera in a nondescript room and used several quick camera cuts and flashy editing (which would be expected to increase message sensation value), elicited a less decrease in HR, both overall and across time, relative to the other e-cigarette ads. Toilet, which featured a compelling story where a teenager uses a vape she pulls from a toilet, but fairly standard editing and camera work, was associated with a greater decrease in HR. Chloe also exhibited increased EDA over time compared to Toilet. It's possible that these differences in video style might contribute to differences in HR data.

Neuroimaging data showed increased activity in the mPFC across all tested ads, indicating the potential for self-referential processing among participants. mPFC activity is one of the most consistently documented cognitive indicators of message-consistent behavior change.17-19,35,51,54 Some differences were found between ads. SESE elicited less mPFC activity relative to other cigarette ads. This is interesting, as SESE had a young woman speaking directly to the camera. Although it still elicited increased mPFC activity in an absolute sense, other videos that used more graphic visualizations of the health harms of smoking (Auctioneer and Delivery) or used animation (Little Lungs) elicited more cognitive activity associated with self-referential processing. Among e-cigarette ads, Chloe and Scary enough elicited more mPFC activity (associated with self-referential processing) than Toilet, although Toilet elicited less rdlPFC activity (associated with defensive processing) compared to those ads. It is possible that the narrative structure and potential perceived realism of Toilet served to suppress defensive processing by facilitating transportation into the narrative world and identification with characters.55 Among cigarette ads, none elicited increased activity in the rdlPFC, indicating that the ads may not have provoked defensive processing, although it should be noted that the animated video, Little Lungs and SESE elicited more rdlPFC activity than Auctioneer and Delivery, which used more traditional depictions of health harms. Among e-cigarette ads, rdlPFC activity increased in response to Scary Enough and Chloe, which could indicate increased defensive processing against the content of the ads. It is possible that these e-cigarette ads – but not cigarette ads - were associated with activity indicative of defensive processing because YA have lower prevalence of believing e-cigarettes are very or extremely harmful, compared to cigarettes (38% vs 72%).56 The messages about cigarette harms may have been more aligned with participants’ pre-existing beliefs, and thus more readily accepted. Among e-cigarette ads, Chloe and Scary enough elicited the greatest increases in rdlPFC activity compared to other e-cigarette ads, and additional research is warranted to further investigate what specific ad features contributed to this.

Implications

Collectively, attentional, affective, and cognitive responses indicate favorable response to “The Real Cost” Youth Cigarette and E-cigarette Prevention campaign ads. Decreases in heart rate, indicating devotion of cognitive resources to processing the messages, and activity in the mPFC which has been associated with message-consistent behavior change were among the strongest indicators of favorable response. These findings align with research documenting positive population-level effects of “The Real Cost” Cigarette and E-cigarette campaign messages and provide additional insight by demonstrating that the messages elicit cognitive responses associated with self-referential processing and capture participants attention. Eye-tracking data from this study indicate that attention tended to be most captured by the faces of characters in the ad, so future use of characters delivering messages may be fruitful. The text in the ad Toilet that was highly attended to was accompanied by a pause in the action of the video. Future ads featuring important text-based content should consider pausing or otherwise limiting visual action accompanying the text.

Limitations

This study is subject to several limitations. As in all communication neuroscience and psychophysiology research, it is difficult to match the exact cognitive, affective, or attentional process to the measurements taken, although triangulation between multiple measures may mitigate this concern.30,46 While ads were intentionally selected to represent a diversity of message types, this study was not designed for causal inference regarding the presence of any specific message feature for any specific participant response. Qualitative work including interviews or think-aloud protocols could help to better align attentional, physiological, and cognitive data with specific aspects of each ad. The sample was a Baltimore-based convenience sample, which may not be representative of the larger audiences for “The Real Cost” campaigns. Due to equipment limitations, procedures for eye tracking were changed during data collection; eye tracking data for some participants were measured during a second exposure, which may have changed viewing patterns. While, in general, patterns of elements most focused upon were relatively consistent between devices (i.e., the elements most focused on in an ad were the same regardless of device), it cannot be determined whether differences in the specific amount of time spent fixating on an element was due to differences in the devices themselves or due to the second exposure of the message. Several participants had missing data (e.g., due to a missed synchronization trigger or inability to fit equipment properly). Impedance was not checked during EMG data collection, which could have further ensured data quality. Due to resource constraints, the sample size was limited (n=25 young adults in each exposure group). The analyses may therefore be underpowered to identify all small psychophysiological effects, although several were large enough to be detected. Finally, the ads were designed for and formatively tested on youth. To address this, additional data are being collected to determine whether similar responses are exhibited among youth.

CONCLUSIONS

This study is, to the authors’ knowledge, the first to use attentional, affective, and cognitive measures to assess responses to “The Real Cost” Cigarette and E-cigarette Youth Prevention campaigns to better understand the mechanisms underlying the campaigns’ demonstrated population-level effects. Ultimately, findings from this study indicate that “The Real Cost” Cigarette and E-Cigarette Youth Prevention campaign ads tested elicited responses associated with persuasion. Those developing tobacco education campaigns can use the messages studied in this paper and the elicited attentional, affective, and cognitive response patterns as exemplars on which to base future messaging.

Supplementary Material

Appendix

ACKNOWLEDGMENTS

Funding

This manuscript was supported by the Food and Drug Administration (FDA) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award (2U01FD005942-08) totaling $232,581 with 100 percent funded by FDA/HHS. This information is not a formal dissemination of information from FDA and does not represent Agency position or policy.

Footnotes

Declaration of Interest

MBM served as a paid expert witness in litigation sponsored by the Public Health Advocacy Institute against RJ Reynolds. This arrangement has been reviewed and approved by the Johns Hopkins University in accordance with its conflict of interest policies. The other authors have nothing to disclose.

Data Availability Statement:

A summary of the data is available within the manuscript. The full dataset is unable to be shared publicly due to the potential risk of disclosing personally identifiable information.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Appendix
NIHMS2139267-supplement-Appendix.pdf (518.8KB, pdf)

Data Availability Statement

A summary of the data is available within the manuscript. The full dataset is unable to be shared publicly due to the potential risk of disclosing personally identifiable information.

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