Effects of a National Campaign on Youth Beliefs and Perceptions About Electronic Cigarettes and Smoking

Anna J. MacMonegle, MA; Alexandria A. Smith, MSPH; Jennifer Duke, PhD; Morgane Bennett, DrPH; Leah R. Siegel-Reamer, MPH; Lindsay Pitzer, PhD; Jessica L. Speer, MS; Xiaoquan Zhao, PhD


Prev Chronic Dis. 2022;19(4):e16 

In This Article

Abstract and Introduction


Introduction: Our study assesses the relationship between the exposure of youth to the US Food and Drug Administration's national tobacco public education campaign, The Real Cost, and changes in campaign-focused risk perceptions and beliefs.

Methods: A nationally representative cohort study of youth was conducted from June 2018 to July 2019, consisting of a baseline and one follow-up survey. We performed logistic regressions to examine the association between campaign exposure and beliefs. Exposure was measured by self-report as the frequency of exposure to individual campaign advertisements about the health consequences of e-cigarette use and of smoking cigarettes.

Results: We found that increased levels of exposure to campaign advertising was associated with a significant increase in the odds of reporting agreement with campaign-specific beliefs. Positive patterns of findings were found across multiple items selected by specific advertisements, whereas unrelated beliefs were not associated with advertisement exposure.

Conclusion: A sustained national tobacco public education campaign can change beliefs about the harms of e-cigarette use and cigarette smoking among youth. Combined with other findings from The Real Cost evaluation, results indicate that prevention mass media campaigns continue to be an effective and cost-efficient approach to reduce the health and financial cost of tobacco use in the US.


Every year since 2011, cigarette use among youth in the US has decreased, with historic lows in recent years.[1–3] In 2019, only 2.3% of middle-school–age children and 5.8% of high-school–age youth reported smoking a cigarette in the past 30 days, compared with 2011 rates of 4.3% and 15.8%, respectively.[3] Although this low use rate is a culmination of years of tobacco control efforts, the rapid rise in e-cigarette use has introduced nicotine to a new generation of young people. Rates of current e-cigarette use increased rapidly from 2017 to 2019: whereas 11.7% of high-school–age youth reported in 2017 that they had used an e-cigarette in the past 30 days, 27.5% reported the same behavior in 2019.[1,3–5]

Effective national tobacco control strategies employ a combination of efforts — public education campaigns, smoke-free laws, taxes, and graphic warning labels among other measures — to reduce smoking prevalence in the population.[6,7] Policy changes, such as smoke-free laws, increased taxes, or age-of-purchase laws are typically one-time actions that have a sustained effect on the population.[6–8] Public education campaigns are ongoing endeavors that require substantial effort and resources but can adapt to an ever-changing media and tobacco product environment.[9] With the development of new tobacco products, such as e-cigarettes, and new media platforms, such as advertisement-free streaming services, it is imperative that educational campaigns be evaluated regularly to determine if the strategies are effective. The US Food and Drug Administration (FDA) Center for Tobacco Products produces a youth tobacco prevention campaign, The Real Cost, that aims to prevent youth use of cigarettes and e-cigarettes. Our study examines early evaluation results from the expanded campaign related to both cigarette and e-cigarette products.[10]

Increases in youth risk perceptions and agreement with beliefs about the harms of cigarettes and e-cigarettes indicate progress toward reductions in use and initiation. However, perceptions and beliefs can be affected by external influences, such as new stories about the risk of e-cigarettes, and other respondent characteristics, such as age. Thus, it is important to demonstrate a relationship between exposure and agreement with campaign-specific beliefs to serve as an early indicator of campaign effectiveness. We used data from the first 2 waves of a national longitudinal survey of US youth that took place during 2018 and 2019 to 1) examine changes in cigarette and e-cigarette beliefs and 2) examine association between self-reported exposure to The Real Cost advertisements (ads) and participant agreement with corresponding campaign-specific beliefs.