Abstract
Introduction:
E-cigarette use is rising among youth. Advertising and anti-tobacco campaigns may be associated with use of e-cigarettes and other tobacco products. This study examines associations between tobacco use and exposure to The Real Cost’s first campaign focusing on e-cigarettes.
Methods:
Using the 2019 National Youth Tobacco Survey, a national survey of middle and high school students, associations between exposure to The Real Cost anti-tobacco campaign, exposure to pro-tobacco advertising, and use of tobacco products in the past 30 days (exclusive e-cigarettes, exclusive other tobacco use, and dual/poly use of e-cigarettes and other tobacco products) was examined. Other tobacco included anything but e-cigarettes.
Results:
Participants (N=13,165) were aged 11–17 years. Exposure to The Real Cost was associated with decreased odds of using other tobacco products (AOR=0.60, 95% CI=0.43, 0.84) and dual/poly use (AOR=0.77, 95% CI=0.63, 0.94) but not e-cigarettes. Greater e-cigarette advertising exposure was associated with increased odds of being an exclusive e-cigarette user (AOR=1.90, 95% CI=1.52, 2.30) or dual/poly user (AOR=1.69, 95% CI=1.31, 2.18). Greater exposure to other tobacco advertising was associated with increased odds of being a dual/poly user (AOR=1.32, 95% CI=1.01, 1.71) but lower odds of exclusive e-cigarette use (AOR=0.76, 95% CI=0.60, 0.97).
Conclusions:
Exposure to The Real Cost campaign was associated with decreased odds of using other tobacco products and dual/poly use. Exposure to pro-tobacco advertising was also associated with use. Future studies should assess the long-term effectiveness of anti-tobacco messaging.
INTRODUCTION
E-cigarette use is rising among young people,1 with 27.5% of high school students and 10.5% of middle school students reporting current use.2 Marketing is likely associated with the increase in e-cigarette use among youth,1,3–5 as exposure to e-cigarette advertising can increase use in this group.1,3–5
One way to combat the effects of advertising on e-cigarette use is through public health message campaigns. In 2018, The Real Cost (RC) unveiled a new campaign aimed at decreasing tobacco and e-cigarette use among young people.6 Campaigns from RC aimed at reducing cigarette smoking have been evaluated and found to be succesful7–11; however, the novel 2018 campaign, aimed at reducing e-cigarette use, has not been evaluated.
The current study examines whether self-reported exposure to RC campaign was associated with current use of e-cigarettes and other tobacco products in a nationally representative sample of youth, hypothesizing that exposure would be associated with decreased use. It also estimates associations between self-reported exposure to pro-tobacco advertisements (both for e-cigarettes and other tobacco products) and current use of e-cigarettes and other tobacco products among youth to understand how each uniquely contributed to use of tobacco products. It is hypothesized that greater exposure to e-cigarette advertisements and other tobacco advertisements is directly associated with use of e-cigarettes and other tobacco products, respectively.
METHODS
Study Sample
The data were collected through the 2019 National Youth Tobacco Survey.12 The University of Oklahoma Health Sciences Center’s IRB waived the review.
Measures
The full survey can be found on the Centers for Disease Control and Prevention’s website.12
The authors constructed a 4-level dependent variable representing past 30–day tobacco use: (1) no past 30–day use of e-cigarettes or other tobacco products; (2) past 30–day use of e-cigarettes, but not other tobacco products; (3) no past 30–day use of e-cigarettes, but past 30–day use of other tobacco products; and (4) past 30–day dual/poly use of e-cigarettes and ≥1 other tobacco product. Other tobacco products included cigarettes, cigars, hookah, smokeless tobacco, snus, pipes, roll-your-own cigarettes, dissolvable tobacco, and bidis.
Participants were asked 4 questions concerning how often they see ads for e-cigarettes and other tobacco products (e.g., other products listed above) on the Internet, in magazines, at retailers, and on TV. Responses for I don’t use [medium], never, and rarely; sometimes; most of the time; and always were recoded on a scale from 0 to 3, with 0 being assigned to the first 3 responses, and then summed across the 4 questions (range from 0 to 12) for e-cigarettes and for other tobacco products, separately. Owing to violations of linearity in regression models, these variables were categorized into low (0–1), medium (2–3), and ≥high (4) exposure groups based on tertiles of the distributions.
Exposure to the campaign was assessed with 1 question13: In the past 12 months, have you seen or heard The Real Cost, on television, the internet, social media, or radio as part of ads about tobacco? Response options included: yes, no, and not sure. The RC e-cigarette campaign launched in September 2018, and National Youth Tobacco Survey data were collected February to May 2019. The main focus of the campaign was e-cigarettes but did mention cigarettes and other products.
Participants reported how much harm was associated with using e-cigarettes some days, but not every day. Responses ranged from no harm to a lot of harm. Participants also reported perceived addictiveness of e-cigarettes relative to cigarettes. Responses included less addictive, equally addictive, more addictive, I have never heard of e-cigarettes, and I don’t know enough about these products.
Covariates includedage, sex, and race/ethnicity (Table 1).
Table 1.
Distributions of Demographics and Advertising Exposures Overall and According to Recalled Exposure to The Real Cost Campaign, National Youth Tobacco Survey, U.S., 2019a
| Variable | Recalled exposure to The Real Cost | |||
|---|---|---|---|---|
| Total (N=13,165) | Yes (N=10,136) | No (N=3,029) | p-valueb | |
|
| ||||
| Age, years, % | 0.12 | |||
| 11‒13 | 35.3 | 34.7 | 37.3 | |
| 14‒15 | 32.9 | 33.4 | 31.1 | |
| 16‒17 | 31.8 | 31.9 | 31.7 | |
| Sex, % | 0.12 | |||
| Male | 51.8 | 52.4 | 49.8 | |
| Female | 48.2 | 47.6 | 50.2 | |
| Race, % | <0.001 | |||
| Non-Hispanic White | 53.6 | 55.8 | 46.3 | |
| Non-Hispanic Black | 11.9 | 11.1 | 14.9 | |
| Hispanic | 23.7 | 22.7 | 27.1 | |
| Other/Multiple races | 10.8 | 10.5 | 11.7 | |
| Past 30-day tobacco use, % | 0.004 | |||
| No past 30-day use | 79.4 | 79.7 | 78.1 | |
| E-cigarettes only | 12.1 | 12.3 | 11.7 | |
| Other tobacco only | 2.4 | 2.1 | 3.5 | |
| E-cigarettes and other tobacco | 6.1 | 6.0 | 6.7 | |
| Exposure to e-cigarette advertising, % | <0.001 | |||
| Low | 45.5 | 42.7 | 55.1 | |
| Medium | 28.6 | 30.0 | 23.8 | |
| High | 25.9 | 27.3 | 21.1 | |
| Exposure to other tobacco advertising, % | <0.001 | |||
| Low | 33.5 | 29.8 | 46.3 | |
| Medium | 36.0 | 37.6 | 30.5 | |
| High | 30.5 | 32.6 | 23.2 | |
| Perceived harm of using e-cigarettes some days but not every day, % | <0.001 | |||
| No harm | 5.3 | 4.8 | 7.1 | |
| Little harm | 22.4 | 23.0 | 20.5 | |
| Some harm | 39.9 | 40.5 | 37.9 | |
| A lot of harm | 32.3 | 31.7 | 34.5 | |
| Perceived addictiveness of e-cigarettes compared to cigarettes, % | <0.001 | |||
| Less addictive | 18.1 | 18.7 | 16.1 | |
| Equally addictive | 37.1 | 38.4 | 32.6 | |
| More addictive | 27.5 | 28.5 | 24.3 | |
| Never heard of e-cigarettes | 2.2 | 1.5 | 4.5 | |
| I don’t know enough | 15.0 | 12.9 | 22.6 | |
Notes: Percentages might not sum to 100% due to rounding. Boldface indicates statistical significance (p<0.05).
Estimated proportions were weighted to account for the complex sampling design; unweighted participant counts are reported. Estimates were derived from the analytic subpopulation of youth who were: ages 11- to 17-years-old; answered yes or no to the item assessing exposure to The Real Cost campaign; and had complete data for all independent variables, dependent variables, and covariates used in the multivariable model. Compared to youth included in the analytic subpopulation, those excluded from analyses (for reasons unrelated to being outside the ages of interest) were younger and more likely to use non-e-cigarette tobacco products, be non-Hispanic Black or Hispanic, and to have low exposures to e-cigarette and tobacco advertising.
P-values were calculated using Rao-Scott chi-square tests.
Statistical Analysis
Sampling weights and strata were used to account for the complex sampling design in all analyses. The analytic subpopulation included participants who were aged 11–17 years, responded yes or no to the item assessing exposure to RC campaign (i.e., those answering not sure were excluded), and had complete data for all variables used in modeling.
Distributions of all variables were evaluated overall and according to self-reported exposure to RC campaign; Rao–Scott chi-square tests were used to evaluate whether distributions differed according to exposure to RC campaign. Multinomial logistic regression was used to model associations between self-reported exposure to RC campaign, advertisement exposure, and past 30–day tobacco use, while controlling for demographics and ad exposure. Stata/SE, version 16.1 was used for all analyses, and α=0.05 was used to assess statistical significance.
RESULTS
A total of 19,018 youth participated in the 2019 National Youth Tobacco Survey, and 13,165 were included in the analytic subpopulation (Table 1).
In adjusted models, self-reported exposure to the RC campaign was associated with lower odds of past 30–day use of other tobacco products (AOR=0.60, 95% CI=0.43, 0.84) and dual/poly use of e-cigarettes and other tobacco products (AOR=0.77, 95% CI=0.63, 0.94), but it was not associated with odds of exclusive e-cigarette use (Table 2). A high level of exposure to e-cigarette advertising was associated with higher odds of exclusive e-cigarette use (AOR=1.90, 95% CI=1.52, 2.30) and dual/poly use of e-cigarettes and other tobacco (AOR=1.69, 95% CI=1.31, 2.18), but not with exclusive use of other tobacco. A high level of exposure to other tobacco advertising was associated with lower odds of exclusive e-cigarette use (AOR=0.76, 95% CI=0.60, 0.97) and higher odds of dual/poly use of e-cigarettes and other tobacco (AOR=1.32, 95% CI=1.01, 1.71), but it was not associated with odds of exclusive other tobacco use. Several covariates were associated with tobacco use outcomes (Table 2).
Table 2.
Adjusted Associations Between Recalled Exposure to The Real Cost Campaign and Past 30-day Tobacco Use Among Youth, National Youth Tobacco Survey, U.S., 2019a
| Variable | E-cigarettes only AOR (95% CI) | Other tobacco only AOR (95% CI) | E-cigarettes and other tobacco AOR (95% CI) |
|---|---|---|---|
|
| |||
| Recall of exposure to The Real Cost campaign (ref: no) | |||
| Yes | 0.93 (0.78, 1.10) | 0.60 (0.43, 0.84) | 0.77 (0.63, 0.94) |
| Age (ref: 11‒13 years) | |||
| 14‒15 years | 3.07 (2.37, 3.98) | 2.02 (1.33, 3.08) | 2.57 (1.84, 3.58) |
| 16‒17 years | 4.65 (3.67, 5.89) | 3.42 (2.28, 5.12) | 3.98 (2.90, 5.46) |
| Sex (ref: male) | |||
| Female | 1.34 (1.16, 1.56) | 0.85 (0.61, 1.19) | 0.69 (0.56, 0.85) |
| Race (ref: non-Hispanic White) | |||
| Non-Hispanic Black | 0.42 (0.32, 0.56) | 2.63 (1.68, 4.14) | 0.68 (0.49, 0.94) |
| Hispanic | 0.91 (0.75, 1.11) | 1.49 (0.93, 2.38) | 0.74 (0.56, 0.97) |
| Other/Multiple races | 0.70 (0.52, 0.94) | 1.32 (0.68, 2.57) | 0.58 (0.42, 0.81) |
| Exposure to e-cigarette advertising (ref: low) | |||
| Medium | 1.53 (1.28, 1.82) | 1.08 (0.74, 1.58) | 1.14 (0.88, 1.46) |
| High | 1.90 (1.57, 2.30) | 1.27 (0.80, 2.03) | 1.69 (1.31, 2.18) |
| Exposure to other tobacco advertising (ref: low) | |||
| Medium | 0.88 (0.76, 1.03) | 0.67 (0.45, 1.00) | 1.02 (0.80, 1.30) |
| High | 0.76 (0.60, 0.97) | 1.12 (0.78, 1.60) | 1.32 (1.01, 1.71) |
Notes: Boldface indicates statistical significance (p<0.05).
Survey-weighted multinomial logistic regression was used; the reference group included youth who had not e-cigarettes or other tobacco products in the past 30-days. Estimates were derived from the analytic subpopulation of youth who were: ages 11- to 17-years-old; answered yes or no to the item assessing exposure to The Real Cost campaign; and had complete data for all independent variables, dependent variables, and covariates used in this analysis.
DISCUSSION
The current study provides preliminary information about youth exposure to pro-tobacco advertising and RC at a time when e-cigarette use was high in this population.1 Even though RC’s 2018 campaign focused on e-cigarettes, the authors did not see an association between exposure to it and reduced odds of exclusive use of the product. However, there was an association between exposure to RC and reduced odds of other tobacco use and dual/poly use. It may be that youth were recalling older campaigns focused on other tobacco use, and with time and repeated exposure, exposure to the campaign focused on e-cigarettes may have an association with decreased odds of exclusive use of e-cigarettes. Past research has found that increased exposure to the RC, when focused on other tobacco use, was associated with decreased risk of smoking initiation.14 Consistent with past research,3–5 this study found that each level of e-cigarette advertising exposure was associated with e-cigarette use. However, other tobacco advertising exposure was not associated with exclusive other tobacco use, possibly because of the fact that youth know the harms of cigarettes, and use is on the decline.15
Limitations
Advertising and RC exposure were based on participant recall and may be subject to recall bias.16 As this study is only cross-sectional, future studies may benefit from the use of ecological momentary assessment, which would allow evaluation in real time.17 The authors cannot make causal conclusions owing to the cross-sectional design. Nonetheless, this study is the first to examine these associations.
CONCLUSIONS
This study examined the association between exposure to RC, pro-tobacco advertising, and use of tobacco products. Campaign exposure was associated with decreased odds of using other tobacco products (not e-cigarettes) and dual/poly use. High e-cigarette advertising exposure was associated with increased odds of being an exclusive e-cigarette user or dual/poly user. High other tobacco advertising exposure was associated with increased odds of being a dual/poly user. Results highlight the importance of continued youth anti-tobacco communication.
ACKNOWLEDGMENTS
This research was supported with intramural funds from the Oklahoma Tobacco Settlement Endowment Trust (092-016-0002l), the National Institute on Drug Abuse (K99DA046563: Stevens Principal Investigator [PI], K99DA046564: Hébert PI, U01DA04553, Wagener PI), National Cancer Institute (R01CA20489: Wagener PI), National Heart, Lung, and Blood Institute (K01HL148907: Tackett PI), and the Stephenson Cancer Center’s Cancer Center Support Grant (P30CA225520).
No financial disclosures were reported by the authors of this paper.
Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
REFERENCES
- 1.E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General. Rockville, MD: HHS, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2016. https://e-cigarettes.surgeongeneral.gov/documents/2016_sgr_full_report_non-508.pdf. Accessed August 7, 2017. [Google Scholar]
- 2.Cullen KA, Gentzke AS, Sawdey MD, et al. E-cigarette use among youth in the United States, 2019. JAMA. 2019;322(21):2095–2103. 10.1001/jama.2019.18387. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Mantey DS, Cooper MR, Clendennen SL, Pasch KE, Perry CL. E-cigarette marketing exposure is associated with e-cigarette use among US youth. J Adolesc Health. 2016;58(6):686–690. 10.1016/j.jadohealth.2016.03.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Padon AA, Lochbuehler K, Maloney EK, Cappella JN. A randomized trial of the effect of youth appealing e-cigarette advertising on susceptibility to use e-cigarettes among youth. Nicotine Tob Res. 2017;91(1):16–32. 10.1093/ntr/ntx155. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Villanti AC, Rath JM, Williams VF, et al. Impact of exposure to electronic cigarette advertising on susceptibility and trial of electronic cigarettes and cigarettes in US young adults: a randomized controlled trial. Nicotine Tob Res. 2016;18(5):1331–1339. 10.1093/ntr/ntv235. [DOI] [PubMed] [Google Scholar]
- 6.Evolving Zeller M. “The Real Cost” campaign to address the rising epidemic of youth e-cigarette use. Am J Prev Med. 2019;56(2 suppl 1):S76–S78. 10.1016/j.amepre.2018.09.005. [DOI] [PubMed] [Google Scholar]
- 7.Farrelly MC, Duke JC, Nonnemaker J, et al. Association between The Real Cost media campaign and smoking initiation among youths — United States, 2014–2016. MMWR Morb Mortal Wkly Rep. 2017;66(02):47–50. 10.15585/mmwr.mm6602a2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Duke JC, Farrelly MC, Alexander TN, et al. Effect of a national tobacco public education campaign on youth’s risk perceptions and beliefs about smoking. Am J Health Promot. 2018;32(5):1248–1256. 10.1177/0890117117720745. [DOI] [PubMed] [Google Scholar]
- 9.Huang L-L, Lazard A, Pepper J, Noar S, Ranney L, Goldstein A. Impact of The RealCost campaign on adolescents’ recall, attitudes, and risk perceptions about tobacco use: a national study. Int J Environ Res Public Health. 2017;14(1):42. 10.3390/ijerph14010042. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Grucza RA, Agrawal A, Krauss MJ, Cavazos-Rehg PA, Bierut LJ. Recent trends in the prevalence of marijuana use and associated disorders in the United States. JAMA Psychiatry. 2016;73(3):300–301. 10.1001/jamapsychiatry.2015.3111. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Kranzler EC, Gibson LA, Hornik RC. Recall of “The Real Cost” anti-smoking campaign is specifically associated with endorsement of campaign-targeted beliefs. J Health Commun. 2017;22(10):818–828. 10.1080/10810730.2017.1364311. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Centers for Disease Control. Historical NYTS Data and Documentation | CDC. National Youth Tobacco Survey. https://www.cdc.gov/tobacco/data_statistics/surveys/nyts/data/index.html. Published 2019. Accessed September 2, 2020. [Google Scholar]
- 13.Delahanty J, Ganz O, Bernat JK, et al. Awareness of “The Real Cost” campaign among US middle and high school students: National Youth Tobacco Survey, 2017. Public Health Rep. 2020;135(1):82–89. 10.1177/0033354919889992. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Duke JC, MacMonegle AJ, Nonnemaker JM, et al. Impact of The Real Cost media campaign on youth smoking initiation. Am J Prev Med. 2019;57(5):645–651. 10.1016/j.amepre.2019.06.011. [DOI] [PubMed] [Google Scholar]
- 15.Jamal A, Gentzke A, Hu SS, et al. Tobacco use among middle and high school students — United States, 2011–2016. MMWR Morb Mortal Wkly Rep. 2017;66(23):597–603. 10.15585/mmwr.mm6623a1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Conceptual Niederdeppe J., empirical, and practical issues in developing valid measures of public communication campaign exposure. Commun Methods Meas. 2014;8(2):138–161. 10.1080/19312458.2014.903391. [DOI] [Google Scholar]
- 17.Hébert ET, Vandewater EA, Businelle MS, Harrell MB, Kelder SH, Perry CL. Feasibility and reliability of a mobile tool to evaluate exposure to tobacco product marketing and messages using ecological momentary assessment. Addict Behav. 2017;73:105–110. 10.1016/j.addbeh.2017.05.004. [DOI] [PMC free article] [PubMed] [Google Scholar]