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Introduction: The purpose of this study was to assess the relationship between youth exposure to the U.S. Food and Drug Administration's national tobacco public education campaign, The Real Cost, and changes in smoking initiation., Methods: From November 2013 to November 2016, a longitudinal study of youth was conducted with a baseline and 4 post-campaign follow-up surveys. The sample consisted of nonsmoking youths from 75 U.S. media markets (n=5,103) who completed a baseline and at least 1 follow-up survey. Exposure was measured by media market-level target rating points and self-reported ad exposure frequency. Smoking initiation was examined among youths who had never smoked at baseline and defined as first trial of a cigarette. Discrete-time survival models using logistic regression and controlling for confounding influences were estimated. Analyses were conducted in 2018., Results: The odds of reporting smoking initiation at follow-up was lower among youths in media markets with higher levels of campaign advertisements than among those with less. Both between-wave and cumulative target rating points were associated with decreased risk of smoking initiation (AOR=0.69 [p<0.01] and AOR=0.89 [p<0.05], respectively); for every 3,500 between-wave target rating points on air, there was an associated 30% reduction in the hazard of smoking initiation among youths. Results from self-reported recall of the campaign advertisements found similar dose-response effects. The campaign is associated with an estimated 380,000-587,000 youths aged 11-19 years being prevented from initiating smoking nationwide., Conclusions: Sustained national tobacco public education campaigns like The Real Cost can change population-level smoking initiation among youths, preventing future generations from tobacco-related harms., (Copyright © 2019 American Journal of Preventive Medicine. All rights reserved.)

Introduction: A previous study found that the Food and Drug Administration's The Real Cost national tobacco education campaign was associated with preventing approximately 350,000 U.S. youth from initiating smoking between 2014 and 2016. This study translates the reduction in smoking initiation into monetary terms by examining the cost effectiveness of the campaign., Methods: The cost effectiveness of The Real Cost was assessed by measuring efficiency in two ways: (1) estimating the cost per quality-adjusted life year saved and (2) estimating the total monetary return on investment by comparing the cost savings associated with the campaign to campaign expenditures. Analyses were conducted in 2017., Results: The Real Cost averted an estimated 175,941 youth from becoming established smokers between 2014 and 2016. Campaign expenditures totaled $246,915,233. The cost per quality-adjusted life year saved of the campaign was $1,337. When considering the costs of smoking, the averted established smokers represent >$31 billion in cost savings ($1.3 billion when only external costs considered). The overall return on investment of the campaign was $128 in cost savings for every $1 spent ($4 for every $1 spent when only external costs considered). These conclusions were robust to sensitivity analyses surrounding the parameters., Conclusions: Campaign expenditures were cost efficient. The cost savings resulting from The Real Cost represent a large reduction in the financial burden to individuals, their families, and society as a result of tobacco. Public health campaigns, like The Real Cost, that reduce tobacco-related morbidity and mortality for a generation of U.S. youth also provide substantial cost savings., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Purpose: To assess the relationship between youth's exposure to the Food and Drug Administration's national tobacco public education campaign, The Real Cost, and changes in campaign-targeted beliefs., Design: Longitudinal design with baseline survey and 2 postcampaign follow-up surveys., Sample: Youth from 75 US media markets (N = 1680) who completed all 3 surveys and had experimented with or were susceptible to future cigarette smoking., Measures: Exposure was measured by self-reported frequency of ad exposure and media market-level target rating points. Agreement with 30 self-reported tobacco-related beliefs was assessed in 3 categories: (1) beliefs specifically targeted by campaign messages (campaign-targeted belief), (2) beliefs not targeted by the campaign (nontargeted beliefs), and (3) beliefs corresponding to other media campaigns on air concurrent with The Real Cost (ambiguous beliefs)., Analysis: Descriptive analyses of aggregate changes in beliefs and logistic regressions to examine the association between campaign exposure and beliefs., Intervention: The Real Cost., Results: Agreement with campaign-targeted beliefs increased from baseline to first and second follow-ups, with a mean relative increase of 10.4% and 11.5%, respectively. Nontargeted beliefs did not change substantially. Both measures of campaign exposure were positively associated with increased odds of agreeing with 5 of 8 campaign-targeted beliefs. Exposure was not significantly associated with 12 of 14 nontargeted tobacco-related beliefs., Discussion: A sustained national tobacco public education campaign can change population-level perceptions of tobacco-related harms among youth.

In the United States, approximately 900,000 youths smoke their first cigarette each year (1). Health communication interventions are evidence-based strategies for preventing the initiation of tobacco use, promoting and facilitating cessation, and changing beliefs and attitudes about tobacco use (2,3). This report describes the association between the Food and Drug Administration's (FDA's) first national tobacco public education campaign, The Real Cost, and rates of smoking initiation among youths in the United States from 2014 to 2016. A nationally representative cohort study of youths (N = 5,185) was conducted during November 2013-March 2016. Results from a discrete-time survival model indicate that, among youths who reported never having smoked a cigarette in the baseline survey, the odds of reporting smoking initiation at follow-up were lower among youths with frequent exposure to campaign advertisements than among those with little or no exposure (adjusted odds ratio [aOR] = 0.70, 95% confidence interval [CI] = 0.55-0.91). Based on the results of the model, The Real Cost is associated with an estimated 348,398 U.S. youths aged 11-18 years who did not initiate smoking during February 2014-March 2016. Sustained youth-focused tobacco education campaigns, such as The Real Cost, can help speed progress toward preventing tobacco use among youths in the United States.