Abstract
Introduction:
This study examined visual attention to and recognition of The Real Cost Youth E-cigarette Prevention Campaign ads in simulated, naturalistic digital media environments.
Methods:
In 2024, a convenience sample of 2,040 individuals aged 18–24 years in the U.S. was exposed to a campaign ad in 1 of 4 simulated digital media environments (YouTube skippable and nonskippable, Instagram Reels and Stories). Participants’ cameras captured facial coding measurements (e.g., attention), and a survey captured brand and ad recognition. Analyses included descriptive statistics and statistical testing (z-scores for categorical outcomes, independent t-tests for continuous outcomes) to compare outcomes for ad placements.
Results:
Nonskippable YouTube ads captured the most attention, with participants focusing for 8.6–9.7 seconds, and 46%–54% paying attention to at least half the ad and the last 2 seconds. Instagram Stories held attention for 5–7 seconds; 25%–32% of viewers watched half the ad and the last 2 seconds. Instagram Reels and YouTube skippable ads received the least attention. Brand recognition was similar across YouTube nonskippable ads (37%–49%), Instagram Stories (45%–46%), and Instagram Reels (39%–41%), whereas fewer YouTube skippable viewers (23%–32%) recognized the brand. Ad recognition was highest for YouTube nonskippable ads (52%–73%), followed by Instagram Reels (36%–61%), Instagram Stories (32%–41%), and YouTube skippable ads (22%–48%).
Conclusions:
Results show that some media platforms and placements can capture more of a viewer’s attention than others. Results show that attention, brand awareness, and ad awareness can increase on several digital media platforms and ad placements.
INTRODUCTION
Historically, public health mass media campaigns relied on broadcast and cable TV to reach audiences.1,2 Given the rise of digital media and corresponding changes in media-use behaviors, campaigns have shifted to online and streaming video services that offer myriad options for sharing messages and content.3 This is particularly true for campaigns focused on youth and young adults—YouTube is one of the most popular platforms among teens and young adults; 9 in 10 teens and young adults reported use in 2024.4,5 Social media platforms (e.g., Instagram) are also popular among these groups,4,5 who use the platforms to interact with friends and experience culture. Characteristics that further drive the appeal of digital media include prominent audiovisual content and interactivity, such as platform notifications and engagement features (e.g., likes, comments). Although evidence on using digital media to drive behavior change is emerging, existing literature suggests promise for campaigns relying on digital media to reach youth and young adults. Recent studies found that public health campaigns targeting youth and young adults with digital media led to higher ad awareness6 and changes in campaign-specific beliefs.7
The U.S. Food and Drug Administration’s The Real Cost Youth E-cigarette Prevention Campaign, designed to reach youth aged 12–17 years who are at risk for E-cigarette use, adapted its media strategy to focus on social and digital media. Launched in 2014, the campaign initially relied on traditional media (e.g., cable TV, radio, print advertising) to communicate harms of cigarettes to U.S. youth. A longitudinal study found that campaign exposure between 2014 and 2016 prevented up to 587,000 U.S. youth aged 11–19 years from initiating smoking.8 In 2018, the campaign expanded from cigarettes to address harms of youth E-cigarette use and started relying more on digital media, expanding its presence on over-the-top streaming platforms (e.g., Hulu) and social media platforms (e.g., YouTube, Instagram, Snapchat). Building on previous campaign results, researchers found that higher exposure to The Real Cost Youth E-cigarette Prevention Campaign prevented an estimated 444,252 youth from initiating E-cigarettes use between 2023 and 2024.9 These results show that The Real Cost campaigns continue to reach audiences to prevent tobacco initiation.
The media landscape continues to evolve, requiring continual campaign adaptation to ensure success, particularly given that individuals use multiple platforms to consume media. Recent research found that teens use, on average, 5 different platforms, highlighting substantial exposure to digital content.10,11 As media consumption evolves, and ad buy options for campaigns expand, selecting the right media strategy is increasingly challenging. Platform selection is a key first step in media buying; however, a successful campaign requires careful consideration of how ad placements (i.e., specific location an ad is displayed such as in-feed Instagram ads) on specific platforms (e.g., Instagram, YouTube) deliver messages.
Campaigns must assess many factors on the basis of their goals, audience, and budget, while balancing cost with desired impact. For instance, viewers can skip a YouTube skippable placement after 5 seconds, which may have implications for brand recall and ad attitudes.12,13 Although viewers who skip the ad may be less likely to remember the ad and/or brand, skippable placements offer more control, which may improve the viewing experience by making the ad feel less intrusive.14 This could result in higher-quality views for those who watch ads beyond the skipping point. YouTube skippable ad placements can also be more cost effective because charges apply only when viewers watch at least 30 seconds of the ad (or the full ad if shorter) or interact with the video. Alternatively, nonskippable ads require the entire ad to play before the selected content appears, increasing the likelihood of exposure to the full message. Although some research has found that nonskippable ads appear more intrusive than skippable ads,14,15 Frade et al.13 (2023) found that nonskippable preroll ads were perceived as less intrusive than skippable ads.
In addition, Romberg and colleagues16 found that ad recall is influenced by completed ad views, with likelihood of ad recall doubling with each additional completed exposure. Because nonskippable ads typically ensure a full view, these findings emphasize the effectiveness and appeal of nonskippable ads.12,16 Campaigns often opt for nonskippable ads to guarantee exposure, even at a higher cost. Understanding how different placements capture attention and their subsequent effects can provide valuable insights for strategic placement decisions and seamless integration of ads for optimal impact.
Research to assess effectiveness of different placement types in capturing attention is ongoing.13 Understanding attention across ad placements is important because attention increases the likelihood that a message has been received and remembered.13,17 Attention is also critical to information processing because it is the gateway through which individuals engage with and absorb content.18,19 Attention is especially important for brand recall20; research shows that when the audience pays more attention to an ad, they are more likely to remember the associated brand.21–23 Although attention is not limited to visual attention, visual attention is commonly used in assessing attention in audiovisual digital media environments.
Few studies have examined how different ad placements impact attention and other key outcomes (e.g., brand and ad recall) on digital media platforms. One study found that YouTube nonskippable ads received higher visual attention and brand recall and more positive ad and brand attitudes, whereas skippable ads often led viewers to focus on the skip button, diminishing attention to ad content.13 Non-ad elements (e.g., timers, countdowns to skip) can divert attention from an ad.24 In addition, Gong (2024) found that video ads capture more attention than static ads on Instagram Stories.25 Although these studies offer valuable insights into how skippable and nonskippable placements on YouTube and video and static placements on Instagram affect attention, they were conducted in controlled environments, which do not reflect distractions and competing content on digital platforms. Understanding how ad placements affect attention in naturalistic digital environments is needed.
To address gaps in the literature and optimize The Real Cost Youth E-cigarette Prevention Campaign, this study explored the level of attention participants paid to 4 The Real Cost Youth E-cigarette Prevention Campaign ad placements in simulated, naturalistic digital media environments (YouTube, Instagram). A survey captured campaign ad and brand recognition after ad exposure. This study addresses the following research questions (RQs):
RQ1: How much visual attention do the campaign ads receive across different ad placements?
RQ2: Does the level of visual attention differ significantly across the different ad placements?
RQ3: What level of brand and ad recognition do the campaign ads achieve across the different ad placements?
RQ4: Does the level of brand and ad recognition differ significantly across the different ad placements?
METHODS
Study Sample
This study used a U.S. convenience sample of 2,040 individuals aged 18–24 years living in the U.S. to examine visual attention and brand and ad recognition for four 15-second ads from The Real Cost Youth E-cigarette Prevention Campaign (ad descriptions are in the Appendix, available online). The experimental design followed a 1 × 12 structure, with each ad tested across 3 placements within 2 digital media environments used by the campaign. Ads 1 and 2 were tested in Instagram Reels and YouTube skippable and nonskippable formats. Ads 3 and 4 were tested in Instagram Stories and YouTube skippable and nonskippable formats. Owing to sample size constraints, it was not feasible to test all ads in all 4 placements. Participants were randomly assigned to 1 of 12 experimental conditions (placement descriptions are in the Appendix, available online). Realeyes, an attention and facial coding measurement company, recruited participants through partnerships with existing online data collection panel providers. Recruitment methods (e.g., e-mail invitation, router sampling) were specific to each provider. Data collection occurred in August 12–24, 2024. Between 151 and 211 participants completed each condition (Table 1) and received up to $3.20 as a token of appreciation for completing the study.
Table 1.
Study Conditions: The Real Cost Youth E-cigarette Prevention Campaign Ad by Digital Media Environment and Placement
| Campaign ad name/digital media environment | Ad placement | Sample size |
|---|---|---|
| Ad 1: No Vape in Team: Track | ||
| Reels | 159 | |
| YouTube | Skippable | 173 |
| YouTube | Nonskippable | 211 |
| Ad 2: Toxic Taxidermy | ||
| Reels | 158 | |
| YouTube | Skippable | 148 |
| YouTube | Nonskippable | 197 |
| Ad 3: True Teen Stories: Anxiety | ||
| Stories | 158 | |
| YouTube | Skippable | 151 |
| YouTube | Nonskippable | 172 |
| Ad 4: Don’t Pollute Yourself | ||
| Stories | 170 | |
| YouTube | Skippable | 157 |
| YouTube | Nonskippable | 186 |
Participants completed all procedures online (through their mobile devices), starting with informed consent. Each participant interacted with 1 digital environment (i.e., Instagram) and placement (e.g., Stories). Participants’ ability to scroll, skip, or swipe past the 15-second study video ad was consistent with platform and placement characteristics (e.g., could not skip a YouTube nonskippable ad). Surrounding content in the simulated environment, excluding the target ad, was periodically refreshed to ensure that it used contemporary content and news.
After the exposure session, participants answered 2 standard Realeyes questions about brand and ad recognition. During the exposure session, Realeyes captured facial coding measurements (e.g., attention). RTI’s IRB approved this study (Approval Identification Number 22926).
Measures
Realeyes captured ad metrics, including (1) number of seconds the video was visible on participants’ screen (playback seconds) and (2) the percentage of participants who played the ad until the end (view through rate [VTR]). These metrics were captured through content tagging. Realeyes captured participant-specific attention metrics using facial coding technology, which uses the participant’s front-facing camera to capture nuances in facial reactions. Realeyes “quantifies focus, interest, and engagement by tracking head pose, face direction, palpebral aperture (eyelid openness), and gaze direction” to measure attention.26 Attention metrics include (1) the percentage of participants who paid attention to at least 50% of duration of the ad and the last 2 seconds of the ad (attentive VTR), (2) the number of seconds the ad received attention from the participant (attentive seconds), and (3) the percentage of total ad length the ad received attention (attention average). Brand recognition was assessed by asking, Have you seen an ad for any of the following brands during this test? Participants selected from 12 brands, including The Real Cost. Ad recognition was assessed by showing a static thumbnail from the midpoint (7.5-second mark) of a 15-second ad that they had been exposed to and asking (through yes/no responses), Do you remember viewing this ad? Because standard Realeyes measures were used, it was not possible to assess prior campaign exposure. No demographic or psychographic characteristics were collected from participants.
Statistical Analysis
All data were received in aggregate for each of the 12 conditions. Analyses included descriptive statistics and statistical testing to understand differences between placements. Descriptive statistics (i.e., frequencies, means) are presented by condition (i.e., ad, platform, placement) in Table 2.
Table 2.
Descriptive Statistics: Exposure Session Metrics
| Metrics | YouTube | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Reels | Stories | Nonskippable | Skippable | |||||||||
| Ad 1 | Ad 2 | Ad 3 | Ad 4 | Ad 1 | Ad 2 | Ad 3 | Ad 4 | Ad 1 | Ad 2 | Ad 3 | Ad 4 | |
| Playback seconds | 6.83s | 6.71s | 9.70s | 8.48s | 14.43s | 14.22s | 15.63s | 14.29s | 8.38s | 8.80s | 8.34s | 8.27s |
| VTR | 23.9% | 21.5% | 46.2% | 45.9% | 93.8% | 91.9% | 94.8% | 91.4% | 18.5% | 21.6% | 10.6% | 15.9% |
| Attentive VTR | 12.6% | 12.0% | 31.7% | 24.7% | 45.5% | 51.8% | 51.2% | 53.8% | 10.4% | 14.9% | 6.0% | 8.9% |
| Attentive seconds (i.e., attention) | 4.23s | 4.32s | 6.85s | 5.00s | 8.64s | 9.12s | 9.67s | 8.89s | 5.59s | 5.72s | 5.50s | 5.05s |
| Attention average | 28.2% | 28.8% | 42.8% | 33.4% | 57.6% | 60.8% | 60.5% | 59.2% | 37.3% | 38.1% | 34.4% | 33.7% |
| Brand recognition | 40.8% | 38.9% | 44.8% | 45.5% | 41.2% | 37.1% | 40.1% | 48.9% | 31.8 | 30.4% | 22.5% | 28.0% |
| Ad recognition | 60.5% | 35.7% | 40.9% | 317% | 72.5% | 52.8% | 57.0% | 52.2% | 48.0% | 34.5% | 23.2% | 22.3% |
VTR, video through rate.
Statistical testing was conducted to answer the RQs. The authors calculated z-scores to examine differences in proportions between placements for categorical outcomes (e.g., attentive VTR, brand recognition). For continuous outcomes (e.g., attentive seconds, playback seconds), authors used the ttesti command to conduct 2-sample independent t-tests to examine differences in means between placements. Authors conducted 3 comparisons of YouTube skippable with each of the other placements (YouTube nonskippable, Instagram Reels, and Instagram Stories). Authors compared YouTube skippable with Instagram Stories and Reels because of the similar viewer experience. Specifically, viewers were not forced to watch Reels or Stories ads and could swipe up to skip—similar to YouTube skippable ads. The significance threshold was adjusted on the basis of the number of comparisons conducted (e.g., 0.025 for 2 pairwise comparisons per ad). All analyses were conducted using Stata (Version 18). Participant demographic and psychographic characteristics data were unavailable. The data will be deposited into OpenFDA and will be available at https://open.fda.gov/.
RESULTS
Table 1 presents the descriptive statistics for study outcomes by placement. Exploring attention, participants had YouTube nonskippable ads visible onscreen the longest (14.2–15.6 playback seconds); playback duration for nonskippable ads was shorter than the total ad duration because viewers could exit the screen before the ad completed. Instagram Reels were visible on screen for the shortest time (6.7–6.8 seconds). Participants had YouTube skippable placements visible onscreen for ~8 seconds and Instagram Stories for ~9 seconds. Between 91% and 95% of participants viewing YouTube nonskippable viewed the ad until the end (i.e., highest VTR), followed by roughly 46% who viewed Instagram Stories, 22%–24% who viewed Instagram Reels, and 11%–22% who viewed YouTube skippable.
Between 46% and 54% of participants viewing YouTube nonskippable paid attention to at least 50% of the ad and the last 2 seconds (i.e., attentive VTR), followed by 25%–32% of participants viewing Instagram Stories, 12%–13% of participants viewing Instagram Reels, and 6%–15% of participants viewing YouTube skippable. YouTube nonskippable received the highest attention (8.6–9.7 attentive seconds), whereas Instagram Reels received the lowest attention (4.2–4.3 seconds). YouTube skippable received 5.1–5.7 attentive seconds, and Instagram Stories received 5.0–6.9 attentive seconds. Participants paid attention to YouTube nonskippable the longest (58%–61% of total ad length), followed by YouTube skippable (34%–38% of total ad length) and Instagram Stories (33%–43% of total ad length). Participants paid the least attention to Instagram Reels (28%–29% of total ad length).
Moving to brand and ad recognition, The Real Cost brand recognition was similar across YouTube nonskippable (37%–49%) and Instagram Stories (45%–46%). In addition, 39%–41% of participants who saw Instagram Reels and 23%–32% of participants who viewed YouTube skippable recognized the brand. Between 52% and 73% of participants who viewed YouTube nonskippable recognized the ads, followed by Instagram Reels (36%–61%), Instagram Stories (32%–41%), and YouTube skippable (22%–48%).
Next, YouTube nonskippable ads were compared with YouTube skippable ads. YouTube nonskippable outperformed YouTube skippable on all study outcomes (Table 3). Specifically, YouTube nonskippable were visible onscreen (i.e., playback seconds) longer than YouTube skippable across all ads (ps<0.001). Similarly, across all ads, a higher percentage of participants viewing YouTube nonskippable viewed the ad until the end (i.e., VTR) (ps<0.001) and paid attention to at least 50% of the ad and the last 2 seconds of the ad (i.e., attentive VTR) (ps<0.001) than those who viewed YouTube skippable. Participants who viewed YouTube nonskippable paid more attention to the ad (i.e., attentive seconds) (ps<0.001) and paid attention to a higher proportion of the total ad length (ps<0.001) than those viewing YouTube skippable.
Table 3.
Comparisons Between YouTube Nonskippable and Skippable Placements: Exposure Session Metrics
| Metrics | YouTube nonskippable versus YouTube skippble comparisons | |||||||
|---|---|---|---|---|---|---|---|---|
| Ad 1 | Ad 2 | Ad 3 | Ad 4 | |||||
| Nonskippable | Skippable | Nonskippable | Skippable | Nonskippable | Skippable | Nonskippable | Skippable | |
| Playback seconds, seconds | 14.43 | 8.38 | 14.22 | 8.80 | 15.63 | 8.34 | 14.29 | 8.27 |
| Z=18.28; p<0.001 | Z=14.99; p<0.001 | Z=23.75; p<0.001 | Z=18.17; p<0.001 | |||||
| VTR | 93.8% | 18.5% | 91.9% | 21.6% | 94.8% | 10.6% | 91.4% | 15.9% |
| Z=14.99; p<0.001 | Z=13.29; p<0.001 | Z=15.18; p<0.001 | Z=14.06; p<0.001 | |||||
| Attentive VTR | 45.5% | 10.4% | 51.8% | 14.9% | 51.2% | 6.0% | 53.8% | 8.9% |
| Z=7.49; p<0.001 | Z=7.07; p<0.001 | Z=8.84; p<0.001 | Z=8.78; p<0.001 | |||||
| Attentive seconds (i.e., attention), seconds | 8.64 | 5.59 | 9.12 | 5.72 | 9.67 | 5.50 | 8.89 | 5.05 |
| Z=6.26; p<0.001 | Z=6.37; p<0.001 | Z=7.41; p<0.001 | Z=7.32; p<0.001 | |||||
| Attention average | 57.6% | 3.73% | 60.8% | 38.1% | 60.5% | 34.4% | 59.2% | 33.7% |
| Z=3.97; p<0.001 | Z=4.18; p<0.001 | Z=4.68; p<0.001 | Z=4.72; p<0.001 | |||||
| Brand recognition | 41.2% | 31.8% | 37.1% | 30.4% | 40.1% | 22.5% | 48.9% | 28.0% |
| Z=1.91; p=0.057 | Z=1.29; p=0.198 | Z=3.39; p=0.001 | Z=3.95; p<0.001 | |||||
| Ad recognition | 72.5% | 48.0% | 52.8% | 34.5% | 57.0% | 23.2% | 52.2% | 22.3% |
| Z=4.91; p<0.001 | Z=3.39; p=0.001 | Z=6.16; p<0.001 | Z=5.66; p<0.001 | |||||
Note: Boldface indicates significant difference.
VTR, view through rate.
A higher percentage of participants viewing YouTube nonskippable reported brand recognition than those who viewed YouTube skippable for 2 of the 4 ads (Ad 3: p=0.001, Ad 4: p<0.001). A higher percentage of participants viewing YouTube nonskippable reported campaign ad recognition than those who viewed YouTube skippable across all ads (ps<0.001).
Instagram Reels were visible on the screen (i.e., playback seconds) for less time than YouTube skippable (Ad 1: p=0.003, Ad 2: p<0.001) (Table 4). Participants who viewed Instagram Reels paid less attention (i.e., attentive sections) to the ad than those who viewed YouTube skippable (Ad 1: p=0.004, Ad 2: p=0.006). There were no differences between Instagram Reels and YouTube skippable for VTR, attentive VTR, and attention average.
Table 4.
Comparisons Between YouTube Skippable and Instagram Reels Placements and Between YouTube Skippable Ads and Instagram Stories Placements: Exposure Session Metrics
| Metrics | Ad 1 | Ad 2 | Ad 3 | Ad 4 | ||||
|---|---|---|---|---|---|---|---|---|
| Instagram Reels | YouTube Skippable | Instagram Reels | YouTube Skippable | Instagram Stories | YouTube Skippable | Instagram Stories | YouTube Skippable | |
| Playback seconds | 6.83 | 8.38 | 6.71 | 8.80 | 9.70 | 8.34 | 8.48 | 8.27 |
| Z=−2.99; p=0.003 | Z=−4.02; p<0.001 | Z=2.32; p=0.021 | Z=0.37; p=0.709 | |||||
| VTR | 23.9% | 18.5% | 21.5% | 21.6% | 46.2% | 10.6% | 45.9% | 15.9% |
| Z=1.20; p=0.228 | Z=−0.02; p=0.983 | Z=6.91; p<0.001 | Z=5.83; p<0.001 | |||||
| Attentive VTR | 12.6% | 10.4% | 12.0% | 14.9% | 31.7% | 6.0% | 24.7% | 8.9% |
| Z=0.62; p=0.533 | Z=−0.73; p=0.468 | Z=5.74; p<0.001 | Z=3.79; p<0.001 | |||||
| Attentive seconds (i.e., attention) | 4.23 | 5.59 | 4.32 | 5.72 | 6.85 | 5.50 | 5.00 | 5.05 |
| Z=−2.89; p=0.004 | Z=−2.75; p=0.006 | Z=2.37; p=0.018 | Z=−0.10; p=0.924 | |||||
| Attention average | 28.2% | 37.3% | 28.8% | 38.1% | 42.8% | 34.4% | 33.4% | 33.7% |
| Z=−1.76; p=0.079 | Z=−1.73; p=0.083 | Z=1.52; p=0.127 | Z=−0.06; p=0.953 | |||||
| Brand recognition | 40.8% | 31.8% | 38.9% | 30.4% | 44.8% | 22.5% | 45.5% | 28.0% |
| Z=1.70; p=0.089 | Z=1.55; p=0.121 | Z=4.14; p<0.001 | Z=3.27; p=0.001 | |||||
| Ad recognition | 60.5% | 48.0% | 35.7% | 34.5% | 40.9% | 23.2% | 31.7% | 22.3% |
| Z=2.29; p=0.022 | Z=0.22; p=0.825 | Z=3.33; p=0.001 | Z=1.92; p=0.055 | |||||
Note: Boldface indicates significant difference.
VTR, view through rate.
There were no differences in The Real Cost brand recognition between Instagram Reels and YouTube skippable for the 2 ads examined. Participants who viewed Instagram Reels reported higher campaign ad recognition than those viewing YouTube skippable for 1 of 2 ads (Ad 1: p=0.022).
Instagram Stories were visible onscreen (i.e., playback seconds) for longer than YouTube skippable for 1 of 2 ads examined (Ad 3: p=0.021) (Table 4). Across both ads, a higher percentage of participants viewing Instagram Stories viewed the ad until the end (i.e., VTR) (Ad 3: p<0.001, Ad 4: p<0.001) and paid attention to at least 50% of the ad and the last 2 seconds of the ad (i.e., attentive VTR) (Ad 3: p<0.001, Ad 4: p<0.001) than those who viewed YouTube skippable. Participants who viewed Instagram Stories paid more attention to the ad (i.e., attentive seconds) than those who viewed YouTube skippable for 1 of 2 ads examined (Ad 3: p=0.018). There were no differences in the proportion of the ad length (i.e., attention average) participants paid attention to between the 2 placements.
A higher percentage of participants who viewed Instagram Stories reported The Real Cost brand recognition than those who viewed YouTube skippable for both ads (Ad 3: p<0 .001, Ad 4: p=0.001). A higher percentage of participants who viewed Instagram Stories reported ad recognition than those who viewed the YouTube skippable for 1 of 2 ads examined (Ad 3: p=0.001).
DISCUSSION
Ad placements for a campaign impact attention. This study found that nonskippable YouTube ads remained visible onscreen for the longest and drew the most attention, corroborating previous findings regarding nonskippable ads.27 Nonskippable ads create a captive, forced-view experience, making them harder to ignore if viewers want to resume watching intended content. Frade et al.13 (2023) found that intrusiveness was lower for pre-roll nonskippable ads (than for skippable) ads. It is possible that viewers may expect to watch a nonskippable ad in full. Together, these factors may contribute to a smoother viewing experience, resulting in higher attention.
Higher attention can increase the likelihood of a message being received and remembered.17,19 Results showed that YouTube nonskippable ads had the highest brand and ad recognition of all placements. This is consistent with research showing that YouTube nonskippable placements are effective at capturing attention, increasing brand recall, and generating positive attitudes.13 The effectiveness of the YouTube nonskippable ads in capturing attention13 and building brand and ad awareness demonstrates the strategic value of including nonskippable placements in media buys, making them a powerful tool to strengthen campaign reach and impact. It may not be possible for campaigns to exclusively purchase nonskippable placements; some of the most popular platforms do not offer this or offer limited nonskippable ad inventory. As such, other placements should be considered. It is also possible that overexposing viewers to nonskippable placements could result in ad reactance and negative attitudes.15,28
YouTube skippable placements were less effective at capturing attention (5.1–5.7 seconds of attention) than their nonskippable counterparts. Research shows that for YouTube skippable placements, the Skip button and time counter can negatively impact attention to ads.24 The expectation of being able to skip an ad may lower initial attention because viewers focus on the option to skip over the ad content and many bypass the ad as soon as they are able to do so. Research has yet to examine the role of attention quality in skippable versus nonskippable placements. YouTube skippable ad placements also resulted in the lowest brand and ad recognition. Nonetheless, about a third of participants exposed to YouTube skippable placements reported brand recognition, and between a quarter and a half reported ad recognition, which is still a sizable portion. Findings suggest that this placement can contribute to increased brand awareness and ad recall, especially when used in a broader, multitouchpoint campaign. In addition, viewers who choose to watch a full skippable ad may pay more attention because they may expect to derive value from the content and thus have a more meaningful viewing experience.29
Instagram Stories represent another promising placement for capturing attention—they held participant attention for about 5–7 seconds, and about half played the ad until the end. There are several explanations for why Stories ads may capture more attention: they blend seamlessly with organic content, feeling more like a natural part of the feed. Less obtrusive ad placements can be more persuasive and interesting to viewers, which can increase the potential of them paying attention to ads.30 Stories ads may also generate higher attention because they are primarily viewed by followers who requested to view that creator’s posts. Stories often feature more exclusive or raw content, which may make ads feel more personal and authentic. Finally, given their temporary nature, there may be a sense of urgency to view Stories ads before they disappear. For these reasons, viewers may be more accepting of Stories ads, which could explain the slightly higher levels of attention for this placement than for other placements. In contrast, Reels did not capture as much attention (4 seconds on average). Designed for quick, engaging consumption, Reels ads may capture a different or unique type of attention from other placements. However, it remains unclear whether and how this attention influences cognitive processing or whether viewers who watch full Reels ads pay higher-quality attention.
Stories and Reels showed similar brand and ad recognition. Despite not generating high levels of attention, Reels ads may lead to higher recall because they automatically loop and facilitate repeated views, whereas Stories can only be viewed again if the user purposefully swipes right to rewatch the content. After exposure to Reels and Stories placements, 39%–46% of participants reported brand awareness, and 32%–61% reported ad awareness. These findings highlight the potential effectiveness of Reels and Stories in increasing brand and ad awareness, making them a valuable complement to other placements. They provide an opportunity to engage audiences in a different context and platform, reinforcing messages and broadening reach and frequency.
Although higher attention paid to any single ad exposure is valuable for message processing, partial views or lower attention exposures may have cumulative value for a campaign. Brief, repeated exposures can increase familiarity with a brand or message, potentially increasing receptivity or believability, just as mere exposure can lead to a stronger preference.31 This may mean that many brief exposures can be meaningful for increasing ad or brand awareness even in the absence of higher-quality attention to a single ad.
Lower recall among YouTube skippable, Instagram Reels, and Stories placements (than among YouTube nonskippable) may be due in part to the survey measure that used a thumbnail from the ad’s midpoint (7.5 of 15 seconds) to assess ad recognition. Participants who skipped the ad before the midpoint—which some did, as indicated by the average seconds of attention for skippable placements ranging from 4.2 to 6.9 seconds—were less likely to recognize the thumbnail because they never saw it. This would not be true for nonskippable placements where participants viewed the whole ad.
Findings from this study suggest that testing placements in a naturalistic environment offers public health education campaigns additional information for evaluating campaign content and making media buy decisions. Campaigns, including The Real Cost, use formative testing to develop and refine ad concepts.32 Although formative testing is considered a best practice, this approach typically does not provide insights on campaign channel selection1 or how an ad may perform in the cluttered media environment. Integrating results on platform and placements would complement findings from forced exposures and strengthen and expand insights that formative studies provide to evaluators and campaign planners. Measuring attention also offers evaluators and campaign planners additional metrics, outside of self-report data, which are typically collected from respondents in the formative phase of campaign evaluation. These data would allow evaluators to establish benchmarks for ads over time or compare ad performance with that of other ads within the same industry. This type of testing can also be implemented with new platforms and placements to understand ad performance with new media. Campaign planners should pursue platforms and ad placements that maximize their media buy’s impact given the budget available.
These findings have implications for campaign strategies, including prioritization of nonskippable ad formats where possible; shorter ads to deliver messages more quickly and counter low attention, particularly in ad placements that can be bypassed; and ad formats and creative strategies that are less disruptive to the viewer. They also emphasize a need for a diverse media strategy to reach the audience and provide repeated exposures, even if they are of varying levels of attention.
Limitations
This study has several limitations. First, reliance on aggregate data limited the authors’ ability to conduct more detailed analyses (e.g., exploring the relationships between attention and recall). No demographic or media use data were available to control for these characteristics. Aside from the campaign target ad, content in the simulated media environment changed daily. If the surrounding content on certain days was more distracting, it could have influenced attention to study ads (reducing internal validity while improving external validity). Because ads had previously been in market, participants may have recognized them from prior exposure. In addition, the ad-recognition measure used a thumbnail from the ad midpoint, which could have impacted ad recall for YouTube skippable placements and Instagram ads of participants who did not watch the ad to that point. Finally, this sample only included young adults aged ≥18 years. Given the focus of The Real Cost Youth E-cigarette Prevention Campaign on youth aged 12–17 years who are at risk for E-cigarette use, future studies would benefit from including youth in future research.
Future studies should further investigate the role of attention. Research could explore whether the relationship between attention levels or quality and campaign recall remains consistent across platforms and ad placements, particularly as platforms change, new platforms emerge, and ad placement offerings evolve. Future work could study the mechanisms driving attention on various platforms and placements and whether certain platform and placement features influence how attention translates into recall. In addition, it would be valuable to examine how participant characteristics—such as demographics, media use habits, or cognitive factors—influence the relationship between attention and recall. Finally, future studies could explore whether different attention metrics (e.g., facial coding, eye tracking, self-report) differentially impact recall, which may provide a more nuanced understanding of attention metrics and their effect on campaign performance.
CONCLUSIONS
Testing ads across digital media in naturalistic settings offers a rapid approach to understanding whether ads can break through media clutter to capture attention and generate recall. This type of testing can be used to evaluate campaign content and help inform media implementation. Results show that some media platforms and placements (e.g., YouTube nonskippable) can capture more attention than others. The study examined media effects on brand and ad recognition and showed that YouTube nonskippable ads had the highest brand and ad recognition; however, results show that attention, brand awareness, and ad awareness can be earned across several digital media platforms and ad placements.
Supplementary Material
Supplemental materials associated with this article can be found in the online version at https://doi.org/10.1016/j.amepre.2025.108215.
ACKNOWLEDGMENTS
The authors would like to acknowledge Chloe Coletta and Vaughn Armbrister for their invaluable contributions to ensuring the quality and integrity of the study implementation and data. Their meticulous attention to detail and commitment to quality control were essential in maintaining the accuracy and reliability of this study.
Funding:
This study was funded by the U.S. Food and Drug Administration Center for Tobacco Products. This research was funded by the U.S. Food and Drug Administration under Contract Number HHSF223201610032I.
Declaration of interest:
MJ, JG, KH, SHC, and MS are employees of the company receiving the funding (RTI International). ELPS and MG are U.S. Food and Drug Administration employees who contributed to the study and the manuscript. No other financial disclosures were reported.
Footnotes
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Food and Drug Administration.
Publication of this supplement is sponsored by the Food and Drug Administration’s Center for Tobacco Products.
CREDIT AUTHOR STATEMENT
Elizabeth L. Petrun Sayers: Conceptualization, Methodology, Project administration, Formal analysis, Writing – original draft, Writing – review & editing. Mihaela Johnson: Conceptualization, Methodology, Investigation, Formal analysis, Writing – original draft, Writing – review & editing. Merrybelle Guo: Conceptualization, Resources, Formal analysis, Writing – original draft, Writing – review & editing. Jamie Guillory: Conceptualization, Formal analysis, Supervision, Writing – original draft, Writing – review & editing. Kim Hayes: Project administration, Formal analysis, Writing – original draft, Writing – review & editing. Sarah Helen Cooper: Formal analysis, Writing – original draft, Writing – review & editing. McKinley Saunders: Formal analysis, Writing – original draft, Writing – review & editing.
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