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How the Food and Drug Administration Convinced Teens to Rethink Their Relationship With Cigarettes

2019; Elsevier BV; Volume: 56; Issue: 2 Linguagem: Inglês

10.1016/j.amepre.2018.10.013

1873-2607

Kathleen Crosby,

Consumer Attitudes and Food Labeling

In a world of competing sorrows, when it is often hard to watch the news, it is a comfort to believe that some societal problems have been solved. It gives us a sense that things can change for the better, despite the craziness of the world around us. When it comes to the disease and death caused by tobacco use, some believe the problem has been solved. Decades of tobacco control policies have made amazing progress to improve our nation's health. Many federal, state, and local interventions have proven successful. Removing iconic cigarette advertising from TV and stopping the use of false and misleading claims have also reaped benefits for society.1HHSThe Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. HHS, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health;, Atlanta, GA2014Google Scholar As the laws changed over time, the social norm followed, to the point that smoking rates continue to decline to the lowest levels in 50 years for both adults and teens.2Wang TW Asman K Gentzke AS et al.Tobacco product use among adults—United States, 2017.MMWR Morb Mortal Wkly Rep. 2018; 67: 1225-1232https://doi.org/10.15585/mmwr.mm6744a2Crossref PubMed Scopus (462) Google Scholar, 3Wang TW Gentzke A Sharapova S et al.Tobacco product use among middle and high school students—United States, 2011–2017.MMWR Morb Mortal Wkly Rep. 2018; 67: 629-633https://doi.org/10.15585/mmwr.mm6722a3Crossref PubMed Scopus (253) Google Scholar, 4CDCYouth Risk Behavior Surveillance System Data 1991–2013. Trends in Current Cigarette Smoking Among High School Students And Adults, United States, 1965–2014. CDC;, Atlanta, GA2016Google Scholar This is all very promising but despite this good news, tobacco use remains the leading cause of preventable death today.1HHSThe Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. HHS, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health;, Atlanta, GA2014Google Scholar There are about 34 million current adult smokers in the U.S.2Wang TW Asman K Gentzke AS et al.Tobacco product use among adults—United States, 2017.MMWR Morb Mortal Wkly Rep. 2018; 67: 1225-1232https://doi.org/10.15585/mmwr.mm6744a2Crossref PubMed Scopus (462) Google Scholar Every year, almost half a million people lose their lives and more than 8 million live with a serious disease caused by smoking cigarettes.1HHSThe Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. HHS, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health;, Atlanta, GA2014Google Scholar, 5CDCCigarette smoking-attributable morbidity—United States, 2000.MMWR Morb Mortal Wkly Rep. 2003; 52: 842-844PubMed Google Scholar We lose more American lives to tobacco use than to alcohol, illegal drugs, homicide, suicide, car crashes, fires, and AIDS, combined.1HHSThe Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. HHS, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health;, Atlanta, GA2014Google Scholar, 6Murphy SL Xu JQ Kochanek KD Deaths: final data for 2010.Natl Vital Stat Rep. 2013; 61: 37-41Google Scholar This cannot be just a statistic to us. It is heartbreaking because it is largely preventable. Since the U.S. Food and Drug Administration (FDA) launched its first national youth smoking prevention media campaign, "The Real Cost," in 2014, the goal of the campaign has been to use dynamic advertising to convince teens to not use tobacco—it is as simple as that. Except that one of the hardest things to do in advertising is to get someone to think and act differently. For a prevention campaign to convince a teen to hit the pause-button and rethink his relationship with cigarettes, it must be highly creative, surprising, and evoke stopping power. There are approximately 25 million youth aged 12–17 years in the U.S.7Census Bureau U.S. Annual Estimates of the Resident Population by Single Year of Age and Sex for the United States: April 1, 2010 to July 1, 2015. U.S. Census Bureau, Washington, DC2016Google Scholar In 2014, nearly 10 million were identified to be at risk for cigarette smoking.8CDC, U.S. Food and Drug AdministrationTotal At-risk Experimenters and Susceptible Non-trier Estimates: 2015 NYTS Dataset and Codebook. CDC;, Atlanta, GA2015Google Scholar, 9Mowery PD Farrelly MC Haviland ML et al.Progression to established smoking among U.S. youths.Am J Public Health. 2004; 94: 331-337https://doi.org/10.2105/AJPH.94.2.331Crossref PubMed Scopus (80) Google Scholar Although smoking is not the norm anymore for most kids, it is for many of these teens because they are often surrounded by smokers. As described by Santiago and colleagues,10Santiago S, Talbert EC, Benoza G. Finding Pete and Nikki: defining the target audience for "The Real Cost" campaign. Am J Prev Med. 2019;56(2S1):S9–S15.Google Scholar many of the teens in "The Real Cost" target audience come from poorer homes in areas where schools are not always the best. They live chaotic, stressful lives, trying to handle problems at home and school. These are not the happy-go-lucky kids. They are the troubled ones who often turn to tobacco as a coping mechanism, along with other risky behaviors like drinking and drugs. However, long after the difficulties of youth are past, their relationship with tobacco may continue to haunt them. We know that smoking just a few cigarettes now and then can lead to cravings, a symptom of addiction, in some teens.11Ursprung WW DiFranza JR The loss of autonomy over smoking in relation to lifetime cigarette consumption.Addict Behav. 2010; 35: 14-18https://doi.org/10.1016/j.addbeh.2009.08.001Crossref PubMed Scopus (35) Google Scholar, 12Doubeni CA Reed G DiFranza JR Early course of nicotine dependence in adolescent smokers.Pediatrics. 2010; 125: 1127-1133https://doi.org/10.1542/peds.2009-0238Crossref PubMed Scopus (102) Google Scholar Nicotine changes the way a teen's brain works, causing him/her to crave more and more of it.13HHSHow Tobacco Smoke Causes Disease: A Report of the Surgeon General. HHS, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health;, Atlanta, GA2010Google Scholar And the younger a person starts smoking, the easier it is to become addicted and the harder it is to quit.14HHSPreventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. HHS, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health;, Atlanta, GA2012Google Scholar So when nearly 90% of adult daily smokers report they smoked their first cigarette by the time they were aged 18 years1HHSThe Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. HHS, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health;, Atlanta, GA2014Google Scholar—before they could vote, before they could drink, and before they graduated high school—it underscores what makes FDA's work both so important and so urgent. We are striving to influence attitudes and behaviors before addiction occurs, and this is a daunting task because every day in the U.S., more than 300 kids under age 18 years become daily cigarette smokers and that is 300 too many.15U.S. Substance Abuse and Mental Health Services Administration2017 National Survey on Drug Use and Health: Detailed Tables. SAMHSA, Rockville, MD2018https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHDetailedTabs2017/NSDUHDetailedTabs2017.pdfDate accessed: January 3, 2019Google Scholar At-risk teens too often underestimate the path they are walking when it comes to tobacco.10Santiago S, Talbert EC, Benoza G. Finding Pete and Nikki: defining the target audience for "The Real Cost" campaign. Am J Prev Med. 2019;56(2S1):S9–S15.Google Scholar, 14HHSPreventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. HHS, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health;, Atlanta, GA2012Google Scholar They do not believe they will ever get addicted.10Santiago S, Talbert EC, Benoza G. Finding Pete and Nikki: defining the target audience for "The Real Cost" campaign. Am J Prev Med. 2019;56(2S1):S9–S15.Google Scholar, 11Ursprung WW DiFranza JR The loss of autonomy over smoking in relation to lifetime cigarette consumption.Addict Behav. 2010; 35: 14-18https://doi.org/10.1016/j.addbeh.2009.08.001Crossref PubMed Scopus (35) Google Scholar, 12Doubeni CA Reed G DiFranza JR Early course of nicotine dependence in adolescent smokers.Pediatrics. 2010; 125: 1127-1133https://doi.org/10.1542/peds.2009-0238Crossref PubMed Scopus (102) Google Scholar,14HHSPreventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. HHS, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health;, Atlanta, GA2012Google Scholar And even if they do get addicted, many think they can quit at any time.14HHSPreventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. HHS, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health;, Atlanta, GA2012Google Scholar, 16Arnett JJ Optimistic bias in adolescent and adult smokers and nonsmokers.Addict Behav. 2000; 25: 625-632https://doi.org/10.1016/S0306-4603(99)00072-6Crossref PubMed Scopus (243) Google Scholar,17Popova L Halpern-Felsher BL A longitudinal study of adolescents' optimistic bias about risks and benefits of cigarette smoking.Am J Health Behav. 2016; 40: 341-351https://doi.org/10.5993/AJHB.40.3.6Crossref PubMed Scopus (26) Google Scholar But that is not always the case. Three of four teen smokers will become adult smokers—even if they had the best intentions to quit after a few years.14HHSPreventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. HHS, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health;, Atlanta, GA2012Google Scholar So the kids who are experimenting, or are one party away from taking their first puff of a cigarette, are really at a crossroads. They can decide to walk a healthier path, or they can walk a more costly one. To tackle this reality—to do our best to create a new reality—FDA has undertaken the largest, most comprehensive, sustainable advertising approach to youth tobacco prevention in the government's history. FDA is in it to win it, and we are taking a page right out of Madison Avenue's playbook and doing what the leading brands do. They are masters at understanding the marketplace, understanding their customers, and how to get new ones by designing provocative messaging to entice them. But the science and art of persuasion can be harnessed to become a powerful force for behavior change, too.18CDCBest Practices for Comprehensive Tobacco control Programs, 2014. HHS, CDC;, Atlanta, GA2014Google Scholar, 19NIH, National Cancer InstituteChanging Adolescent Smoking Prevalence. Tobacco control monograph No. 14. NCI, Bethesda, MD2001Google Scholar "The Real Cost" youth smoking prevention media campaign has now been in the market for 5 years. It seeks to make youth hyperconscious of the real cost of every cigarette using breakthrough and fresh portrayals of the health and addiction risks of smoking, as well as the toxic mix of 7,000 chemicals in every puff of cigarette smoke.20Hecht SS Research opportunities related to establishing standards for tobacco products under the Family Smoking Prevention and Tobacco Control Act.Nicotine Tob Res. 2012; 14: 18-28https://doi.org/10.1093/ntr/ntq216Crossref PubMed Scopus (97) Google Scholar, 21Hoffmann D Hoffmann I El Bayoumy K The less harmful cigarette: a controversial issue. A tribute to Ernst L. Wynder.Chem Res Toxicol. 2001; 14: 767-790https://doi.org/10.1021/tx000260uCrossref PubMed Scopus (607) Google Scholar, 22International Agency for Research on CancerTobacco smoke and involuntary smoking.IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. Volume 83. International Agency for Research on Cancer;, Lyon, France2004Google Scholar, 23International Agency for Research on CancerSome non-heterocyclic polycyclic aromatic hydrocarbons and some related exposures.IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. Volume 92. International Agency for Research on Cancer;, Lyon, France2010Google Scholar And we do it in ways that are truly unexpected.24Crosby K, Santiago S, Talbert EC, Roditis ML, Resch G. Bringing "The Real Cost" to life through breakthrough, evidenced-based advertising. Am J Prev Med. 2019;56(2S1):S16–S23.Google Scholar Since the campaign launched, we have reached up to 95% of teens with thousands of messages across the spectrum of laser-targeted TV, digital, social, outdoor, and radio platforms.25Duke JC Alexander TN Zhao X et al.Youth's awareness of and reactions to "The Real Cost" national tobacco public education campaign.PLoS One. 2015; 10e0144827https://doi.org/10.1371/journal.pone.0144827Crossref PubMed Scopus (76) Google Scholar More than 18.6 million teens spend time on TheRealCost.gov and 30.5 million youth are engaging with FDA on social media—questioning us, thanking us for getting their attention, and asking for help in quitting (U.S. Food and Drug Administration, unpublished data, 2018). Importantly, in just the first 2 years of the campaign, "The Real Cost" prevented nearly 350,000 youth aged 11–18 years from initiating smoking—half of whom might have gone on to become established smokers.26Farrelly 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: 47-50https://doi.org/10.15585/mmwr.mm6602a2Crossref PubMed Scopus (91) Google Scholar This has saved these teens, their families, and the country more than $31 billion by reducing smoking-related costs like early loss of life, costly medical care, lost wages, lower productivity, and increased disability.27MacMonegle AJ Nonnemaker J Duke JC et al.Cost-effectiveness analysis of "The Real Cost" campaign's effect on smoking prevention.Am J Prev Med. 2018; 55: 319-325https://doi.org/10.1016/j.amepre.2018.05.006Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar This is an incredible public health success story. FDA is not selling a product—we are selling an ideal—the promise of a healthier life gained by not doing something. And unlike many product marketers, we need to do more than increase market share or space on a retail shelf, we must find and utilize every opportunity to capture teens' attention so when they think about smoking, they will think again. There is a proven model for success when developing behavior change campaigns to ensure that bold, persuasive advertising is a powerful force for good.18CDCBest Practices for Comprehensive Tobacco control Programs, 2014. HHS, CDC;, Atlanta, GA2014Google Scholar, 26Farrelly 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: 47-50https://doi.org/10.15585/mmwr.mm6602a2Crossref PubMed Scopus (91) Google Scholar Although it is not rocket science, we must follow the best practices of communications, marketing, and social science when the goal is improving public health through advertising. The first step we undertook was to develop a behavior change logic model as the overarching playbook to closely follow. We established the campaign's development and implementation plan, which included formative research, strategy development, creative development, copy testing research, targeted media planning, and digital and social engagement strategies to be employed once the campaign was in market. Importantly, we designed the evaluation program to effectively measure shifts in knowledge, attitudes, beliefs, and behaviors over time, at the beginning of our journey, long before advertising was developed and launched. This supplement was designed to highlight several critical steps in the ongoing and cyclical development process of "The Real Cost," including how to•understand the problem as the first step in strategic planning;•identify the target audience and infuse research insights into the campaign strategy;•develop compelling, focused creative messaging directly from the formative research and the available science;•quantitatively test the campaign's perceived ad effectiveness;•understand the impact of the campaign on secondary audiences to realize a halo effect or identify unintended consequences;•execute a strategic media buy, laser-focused on the primary audience; and•be nimble and ready to pivot to meet emerging threats. As of early 2019, there is compelling evidence that "The Real Cost" has significantly advanced public health far into the future by convincing hundreds of thousands of teens to not smoke through a proven model for behavior change campaigns.26Farrelly 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: 47-50https://doi.org/10.15585/mmwr.mm6602a2Crossref PubMed Scopus (91) Google Scholar, 27MacMonegle AJ Nonnemaker J Duke JC et al.Cost-effectiveness analysis of "The Real Cost" campaign's effect on smoking prevention.Am J Prev Med. 2018; 55: 319-325https://doi.org/10.1016/j.amepre.2018.05.006Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar However, with the advent of e-cigarettes, the landscape of youth tobacco use is rapidly evolving, faster than the public health community can keep up with it.3Wang TW Gentzke A Sharapova S et al.Tobacco product use among middle and high school students—United States, 2011–2017.MMWR Morb Mortal Wkly Rep. 2018; 67: 629-633https://doi.org/10.15585/mmwr.mm6722a3Crossref PubMed Scopus (253) Google Scholar HHS and FDA are very concerned about the dramatic increases in youth usage of e-cigarettes since 2011.3Wang TW Gentzke A Sharapova S et al.Tobacco product use among middle and high school students—United States, 2011–2017.MMWR Morb Mortal Wkly Rep. 2018; 67: 629-633https://doi.org/10.15585/mmwr.mm6722a3Crossref PubMed Scopus (253) Google Scholar, 28Cullen KA, Ambrose BK, Gentzke AS, et al. Notes from the field: Use of electronic cigarettes and any tobacco product among middle and high school students—United States, 2011–2018. MMWR Morb Mortal Wkly Rep. 2018;67(45):1276–1277. https://doi.org/10.15585/mmwr.mm6745a5.Google Scholar E-cigarettes are now the most commonly used tobacco product among high school and middle school youth, and recent data are troubling.3Wang TW Gentzke A Sharapova S et al.Tobacco product use among middle and high school students—United States, 2011–2017.MMWR Morb Mortal Wkly Rep. 2018; 67: 629-633https://doi.org/10.15585/mmwr.mm6722a3Crossref PubMed Scopus (253) Google Scholar, 28Cullen KA, Ambrose BK, Gentzke AS, et al. Notes from the field: Use of electronic cigarettes and any tobacco product among middle and high school students—United States, 2011–2018. MMWR Morb Mortal Wkly Rep. 2018;67(45):1276–1277. https://doi.org/10.15585/mmwr.mm6745a5.Google Scholar According to data from the 2018 National Youth Tobacco Survey, e-cigarette use among U.S. high school students increased by 78% between 2017 and 2018, and the nation is now grappling with how to address the fact that more than 3.6 million high school and middle school students are currently using e-cigarettes.28Cullen KA, Ambrose BK, Gentzke AS, et al. Notes from the field: Use of electronic cigarettes and any tobacco product among middle and high school students—United States, 2011–2018. MMWR Morb Mortal Wkly Rep. 2018;67(45):1276–1277. https://doi.org/10.15585/mmwr.mm6745a5.Google Scholar Considering that many youth are unaware of the dangers of using e-cigarettes,29Johnston LD Miech RA O'Malley PM et al.Monitoring the Future National Survey Results on Drug Use: 1975–2017: Overview, Key Findings on Adolescent Drug Use. Institute for Social Research, The University of Michigan, Ann Arbor, MI2018www.monitoringthefuture.org/pubs/monographs/mtf-overview2017.pdfDate accessed: September 18, 2018Crossref Google Scholar "The Real Cost" launched a full-scale e-cigarette prevention effort in fall of 2018 utilizing the best practices of behavior change advertising to deliver a persuasive campaign to teens about the dangers of using e-cigarettes, or vaping. Our hope is to disrupt teens' cost-free mentality when it comes to vaping, so they have the facts they need to consider the costs associated with experimenting with e-cigarettes. As the science emerges, FDA will better understand the risks to teens, but as of now, we are focusing on the dangers of nicotine changing adolescents' developing brains and exposure to other dangerous chemicals like formaldehyde, acrolein, and others.13HHSHow Tobacco Smoke Causes Disease: A Report of the Surgeon General. HHS, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health;, Atlanta, GA2010Google Scholar,30National Academies of Sciences, Engineering, and MedicinePublic Health Consequences of E-cigarettes. National Academies Press, Washington, DC2018https://doi.org/10.17226/24952Google Scholar, 31Goniewicz ML Knysak J Gawron M et al.Levels of selected carcinogens and toxicants in vapour from electronic cigarettes.Tob Control. 2014; 23: 133-139https://doi.org/10.1136/tobaccocontrol-2012-050859Crossref PubMed Scopus (1177) Google Scholar, 32Cheng T Chemical evaluation of electronic cigarettes.Tob Control. 2014; 23: ii11-ii17https://doi.org/10.1136/tobaccocontrol-2013-051482Crossref PubMed Scopus (385) Google Scholar, 33Bein K Leikauf GD Acrolein–a pulmonary hazard.Mol Nutr Food Res. 2011; 55: 1342-1360https://doi.org/10.1002/mnfr.201100279Crossref PubMed Scopus (148) Google Scholar, 34Occupational Safety and Health Administration. Occupational Safety and Health Standards. Medical surveillance – Formaldehyde. Washington, DC: OSHA. www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10078. Accessed May 8, 2018.Google Scholar, 35Rubinstein M Delucchi K Benowitz N Ramo D Adolescent exposure to toxic volatile organic chemicals from e-cigarettes.Pediatrics. 2018; 141e20173557.https://doi.org/10.1542/peds.2017-3557Crossref PubMed Scopus (110) Google Scholar We are also informing teens that if they are vaping now, they may be more likely to try smoking a cigarette, too.30National Academies of Sciences, Engineering, and MedicinePublic Health Consequences of E-cigarettes. National Academies Press, Washington, DC2018https://doi.org/10.17226/24952Google Scholar Will this public education effort be enough to make teens pause and rethink their relationship with nicotine and tobacco? History will tell the end of this story, but FDA will not stop until the problem of youth tobacco use is solved—one of these tomorrows. Publication of this article was supported by the Center for Tobacco Products at the U.S. Food and Drug Administration (FDA). This publication represents the views of the author and does not represent FDA position or policy. The author would like to thank and gratefully acknowledge the many professionals at FDA and FCB New York who have contributed to the success of "The Real Cost" campaign over the past 5 years and are continuing to build on that success in support of our mission to prevent youth tobacco use in the U.S. No financial disclosures were reported by the author of this paper. This article is part of a supplement entitled Fifth Anniversary Retrospective of "The Real Cost," the Food and Drug Administration's Historic Youth Smoking Prevention Media Campaign, which is sponsored by the U.S. Food and Drug Administration.