Exposure to Court-Ordered Tobacco Industry Antismoking Advertisements Among US Adults

IMPORTANCE In 2006, US District Judge Gladys Kessler ordered tobacco companies to make corrective statements through paid advertisements informing the public of their deceptive practices. This landmark ruling and its subsequent execution represent the first time the tobacco industry sponsored a nationwide corrective advertising campaign against its own products. OBJECTIVE To assess the reach of the court-ordered antismoking advertisements within the US adult population, stratified by demographic characteristics and tobacco use. DESIGN, SETTING, AND PARTICIPANTS This nationally representative, population-based crosssectional survey of US adults included respondents to the 2018 Health Information National Trends Survey 5, Cycle 2. Respondents were representatives of households selected by equal-probability sampling of the Marketing Systems Group database of addresses that included all nonvacant US residential addresses. Data collection was conducted from January to May 2018, and analysis took place from December 2018 to April 2019. MAIN OUTCOMES AND MEASURES Self-reported exposure to court-ordered antismoking advertisements. RESULTS The overall sample of 3484 respondents included 2054 women (weighted percentage, 50.8%), 1976 non-Hispanic white respondents (weighted percentage, 59.9%), 2952 respondents who lived in urban US areas (weighted percentage, 84.9%), and 450 current smokers (weighted percentage, 15.6%). Estimated exposure to court-ordered antismoking advertisements was 40.6% (95% CI, 37.5%-43.7%) among the full sample and 50.5% (95% CI, 41.4%-59.6%) among current smokers. Exposure was lowest among those aged 18 to 34 years (37.4%; 95% CI, 28.0%-46.8%), those with a high school education or less (34.5%; 95% CI, 29.3%-39.8%), and those with household annual income less than $35 000 (37.5%; 95% CI, 32.0%-42.9%). Among current smokers, Hispanic respondents had lower exposure rates (42.2%; 95% CI, 18.5%-65.9%) than non-Hispanic white respondents (51.7%; 95% CI, 40.4%-63.1%). As the advertising campaign’s duration increased, exposure rates increased. Individuals with a high school education or less had lower odds of antismoking advertisement exposure than those with college or postgraduate degrees (adjusted odds ratio, 0.67; 95% CI, 0.48-0.94). Current smokers had higher odds of exposure than never smokers (adjusted odds ratio, 1.81; 95% CI, 1.17-2.80). Among those exposed to antismoking advertisements, 70.5% saw multiple antismoking messages. CONCLUSIONS AND RELEVANCE Approximately 1 of 2 smokers reported exposure to the federal court–ordered antismoking advertisements. However, exposure was relatively lower among several subgroups, including individuals aged 18 to 34 years, only one-third of whom reported exposure. (continued) Key Points Question What was the reach of federal court–ordered antismoking advertisements among the US adult population? Findings In a cross-sectional survey of US adults, estimated exposure to federal court–ordered antismoking advertisements was 40.6%. Exposure rates were lowest among those aged 18 to 34 years (37.4%), those with a high school education or less (34.5%), those earning less than $35 000 per year (37.5%), and Hispanic current smoker respondents (42.2%). Meaning Penetration of the tobacco industry–funded antismoking advertisements was suboptimal within the US population and in populations at greatest risk of tobacco use. Author affiliations and article information are listed at the end of this article. Open Access. This is an open access article distributed under the terms of the CC-BY License. JAMA Network Open. 2019;2(7):e196935. doi:10.1001/jamanetworkopen.2019.6935 (Reprinted) July 12, 2019 1/10 Downloaded From: https://jamanetwork.com/ by a Non-Human Traffic (NHT) User on 03/28/2021 Abstract (continued)continued) Increasing the duration of antismoking advertisements as well as expanding their coverage to youthoriented media may increase their potential public health impact. JAMA Network Open. 2019;2(7):e196935. doi:10.1001/jamanetworkopen.2019.6935


Introduction
In 1999, amid mounting evidence of deliberate and concerted efforts by the tobacco industry to antismoking advertisements, which appeared for the first time on prime time television and in major newspapers across the country in November 2017. 3,4 While the TV and newspaper advertising campaigns are now ended, court-ordered antismoking advertising via cigarette package onserts and tobacco company websites are ongoing, but point-of-sale displays remain subject to litigation. 5 Antismoking mass media campaigns are an effective public health intervention, [6][7][8] and Article 12 of the World Health Organization Framework Convention on Tobacco Control lists such campaigns as a measure that must be adopted by all countries to curb tobacco use. 9 When disseminated effectively, corrective advertising has been shown to be effective at reversing misconceptions. Prior to the finalization of the corrective statements, a 2011 study examined the effectiveness of different versions proposed by the Department of Justice, the tobacco industry, interveners, and research study investigators 10 and found that corrective statements were highly effective at reversing misconceptions about smoking. A 2010 study 11 examined the corrective statements and consumer beliefs about smoking and found a positive association of these statements with antismoking beliefs.
To our knowledge, since the dissemination of the corrective advertising campaign, no assessment has been conducted to evaluate the penetration of these advertisements within the US population. Given the tobacco industry's history of deceptiveness as well as the skepticism generated by an industry-sponsored public health campaign (albeit a federal court-ordered campaign), an assessment of the population-level penetration of this antismoking advertising campaign is crucial. Therefore, the purpose of this study was to assess the reach of these antismoking messages within the general population and at-risk groups, particularly current smokers. We examined rates and correlates of exposure to federal court-ordered antismoking advertisements using a nationally representative sample of US adults.

Study Population, Design, and Setting
States. In this sampling frame, addresses were grouped into low-and high-minority strata. The highminority strata was oversampled to enhance accuracy of estimates for this population. An equalprobability method was used to select addresses within each stratum, and then 1 adult per sampled household was selected to participate in the survey. The overall response rate for HINTS 5, Cycle 2 was 32.9% using the Response Rate 2 formula of the American Association of Public Opinion Research 12 and was comparable to previous cycles of HINTS. 13 Written informed consent was obtained from study participants. The Westat institutional review board approved HINTS 5, Cycle 2, and it was classified exempt from review by the US National Institutes of Health Office of Human Subjects Research Protections. This report follows the American Association of Public Opinion Research (AAPOR) reporting guideline. A detailed description of survey methodology has been published. 14 The US population that participated in the survey was exposed to the antismoking

Outcome Measure
The main outcome measure of this study was self-reported exposure to a court-ordered antismoking advertisement. It was defined as a yes response to the question, "In the past 6 months, have you seen messages in newspapers or on television that say that a federal court has ordered tobacco companies to make statements about the dangers of smoking cigarettes?"

Participant Characteristics
Several factors were considered in the evaluation of the reach of the court-ordered antismoking advertisements, including age, sex, race/ethnicity, level of education, rural-urban residence, household annual income, and smoking status. Age was grouped into 4 categories as follows: 18 to 34 years, 35 to 49 years, 50 to 64 years, and 65 years or older. Race/ethnicity was categorized as non-Hispanic white, non-Hispanic black, and Hispanic. Level of education was grouped into 3 categories: high school graduate or less, post-high school or some college (a combination of posthigh school training other than college and some college training), and college graduate or postgraduate. Residence was defined using the US Department of Agriculture's 2003 Rural-Urban Continuum Codes. Codes 1 to 3 were designated as urban, while codes 4 to 9 were categorized as rural. Household annual income was categorized as less than $35 000, $35 000 to $49 999, $50 000 to $74 999, and $75 000 or more. To derive respondents' smoking status, respondents were asked the question, "Have you smoked at least 100 cigarettes in your entire life?" Those who answered no were categorized never smokers. Among those who answered yes, a follow-up question was asked: "Do you now smoke cigarettes every day, some days, or not at all?" Those who answered not at all were categorized former smokers, while others were considered current smokers.

Type of Court-Ordered Antismoking Advertisement Seen
Respondents who reported exposure to court-ordered antismoking messages were asked a follow-up question: "Which of the following messages about the dangers of smoking cigarettes have you seen?" Possible responses were: (1) "federal court-ordered tobacco messages: health effects of smoking"; (2) "federal court-ordered tobacco messages: health effects of secondhand smoke"; (3) "federal court-ordered tobacco messages: addictiveness"; (4) "federal court-ordered tobacco messages: enhanced delivery"; (5) "federal court-ordered tobacco message: low-tar and light cigarettes"; and (6) "multiple federal court-ordered tobacco messages."

Statistical Analysis
Prevalence of exposure to the court-ordered antismoking messages were estimated for the overall sample as well as by age, sex, race/ethnicity, level of education, rural-urban residence, household annual income, and tobacco use characteristics. To evaluate the association of the duration of the advertising campaign with exposure prevalence, antismoking advertisement exposure was estimated by the month survey responses were returned by mail. To do this, respondents' exposure status was paired to the month when the survey questionnaire was returned. We considered the duration of exposure to begin in November 2017, when the antismoking advertisements commenced, and end the month the survey was returned.
Because smokers have a heightened tendency to be attuned to smoking-related advertisements, we examined exposure prevalence by sociodemographic characteristics among a subpopulation of current smokers. The type of antismoking message that participants reported exposure to was evaluated for the general population and for subgroups stratified by smoking status.
Factors associated with exposure were explored using multivariable survey logistic regression.
Statistical significance was defined as a P value less than .05, and all tests were 2-tailed. All data were weighted to be nationally representative and analyzed with SAS version 9.4 (SAS Institute).

Results
The Analysis of antismoking advertisement exposure by duration of advertising campaign revealed that as the advertising campaign's duration increased, so did rates of reported exposure (Table 1). Our multivariable logistic regression analysis revealed that, following adjustment, exposure odds were lower among those who had a level of education of high school or less compared with those who had a college or postgraduate degree (adjusted odds ratio, 0.67; 95% CI, 0.48-0.94) ( Table 3). The odds of exposure to antismoking advertisements were higher among current smokers than never smokers (adjusted odds ratio, 1.81; 95% CI, 1.17-2.80) ( Table 3).

Discussion
To our knowledge, this study is the first to examine the reach of the federal court-ordered antismoking advertising campaign sponsored by the tobacco industry within the US population. In a nationally representative sample of US adults, the estimated prevalence of antismoking advertisement exposure was 40.6% among the overall study population and 50.5% among current smokers.
Compared with the exposure rates of antismoking campaigns conducted by federal and state public health agencies, penetration of the tobacco industry-sponsored antismoking advertisements  6 Similarly, studies of state-level antitobacco advertising campaigns a Response to the following question: "In the past 6 months, have you seen messages in newspapers or on television that say that a federal court has ordered tobacco companies to make statements about the dangers of smoking cigarettes?" in Massachusetts 15 and California 16 recorded 88% and 69.5% exposure rates, respectively, within their overall study cohorts.
Of additional concern was our finding that the youngest members of the study sample, those in the lowest income bracket, and those with the lowest level of education registered the lowest rates of exposure to the court-ordered antismoking advertisements. In our subset analysis of current smokers, the lowest exposure rates were observed in the youngest members (consistent with the overall sample), while Hispanic respondents were found to have lower exposure rates than non-Hispanic respondents. Given the tobacco industry's history of aggressively targeting young people as well as racial minorities and socially disadvantaged (eg, poorly educated) populations, [17][18][19] it was critical that the corrective statements reach these populations.
Our study also found that, as the advertising campaign's duration lengthened, exposure rates improved significantly in the general population and in all demographic groups. This finding lends support to the recommendations of studies (conducted before and after finalization of the corrective statements) 10,20 that call for repeated exposure as a means to ensure a sustained effect.
While these federal court-ordered advertising campaigns represent a critical point in tobacco control from a historical and legal perspective, our findings suggest that their real-world association with preventing initiation and promoting cessation may be limited on account of their suboptimal population-level penetrance, especially among young adults, who are at greatest risk for smoking initiation. Careful consideration of medium and communication style for these advertisements is important to increase their effect; for example, placement in youth-oriented channels, including social media, may help increase awareness among young people. 21,22 Furthermore, increasing the dose of advertising has proven potential to boost population-level exposure during antismoking campaigns. 23 Findings from this study could potentially inform effective implementation and evaluation of ongoing court-ordered placement of corrective statements on cigarette package onserts and tobacco company websites as well as anticipated antismoking advertising at point-of-sale displays (the subject of ongoing litigation). 5 Epidemiologic studies would also be needed to evaluate the effect of these advertisements on smoking-related knowledge, intentions, and behaviors, including initiation, cessation, and tobacco consumption patterns overall.
The US federal court ruling on corrective statements raises questions on what constitutes deliberate deceptive practices that need correcting. It could be argued that such deceptive behavior is not limited to text or verbal statements made by representatives of the industry in the past but also includes current and ongoing deception in the form of glamorous or attractive tobacco product design and marketing that implies reduced harm or some healthful benefits. This implication of reduced harm is also a health equity issue given the marketing of several products has been targeted at minorities (eg, menthol cigarettes), which has resulted in disparities in tobacco use and tobaccorelated morbidity and mortality.

Limitations
Despite the strengths of this study, there are a number of limitations. First, HINTS data are crosssectional, and hence causal inferences cannot be made. Second, HINTS data are self-reported and prone to recall and social desirability bias. Further, we could not independently assess exposure by advertising medium (television or newspaper) because these data were pooled.

Conclusions
This study found that the unprecedented national-level antismoking advertising campaign sponsored by the tobacco industry had a suboptimal reach within the US population. Penetration rates were even lower in known at-risk groups, such as young adults. This study offers critical cues for oversight of ongoing and future tobacco industry-sponsored antismoking advertising campaigns.
This study also draws attention to the important role that the judiciary, along with regulatory agencies, public health agencies, and health interest groups, can play in comprehensive tobacco