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Population prevalence and predictors of self-reported exposure to court-ordered, tobacco-related corrective statements
  1. Kelly D Blake1,
  2. Gordon Willis2,
  3. Annette Kaufman2
  1. 1 Health Communication and Informatics Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland, USA
  2. 2 Tobacco Control Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland, USA
  1. Correspondence to Dr Kelly D Blake, Health Communication and Informatics Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD 20892-9671, USA; kelly.blake{at}nih.gov

Abstract

Objective To describe the population prevalence and predictors of self-reported exposure to court-ordered tobacco-related corrective statements in 2017–2018, when they were first implemented in newspapers and on television.

Methods Nationally representative data from the 2018 Health Information National Trends Survey were used (n=3504). Frequencies and weighted proportions were calculated for seeing any corrective statement and for each of the five court-ordered corrective statements. Weighted, multivariable logistic regression was used to examine sociodemographic and smoking status predictors of reported exposure to any corrective statement.

Results In 2018, an estimated 40.6% of US adults had seen messages in newspapers or on television in the past 6 months stating that a federal court has ordered tobacco companies to make statements about the dangers of smoking cigarettes. Reported exposure to topic-specific statements ranged from 11.4% (manipulation of cigarette design) to 34.7% (health effects). Those with a high school education were significantly less likely than those with a college degree to report seeing the statements (OR=0.69, CI 0.50 to 0.95) and current smokers were significantly more likely than never smokers to report seeing them (OR=1.68, CI 1.12 to 2.53).

Conclusions In the first 6 months of corrective statement implementation, an estimated 40.6% of US adults reported at least one exposure to any corrective statement, and current smokers were more likely than never smokers to report exposure. Traditional media channels can be effective for tobacco-related message dissemination; however, they may fail to reach more than half of the adult population without additional targeted communication efforts.

  • Tobacco industry
  • Media
  • Litigation

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Introduction

In 2017, the three major US tobacco companies (Altria and its subsidiary Philip Morris, USA; R.J. Reynolds Tobacco and ITG Brands) were ordered by the US District Court for the District of Columbia to publish ‘corrective statements’ about smoking and health as one of four legal remedies originally included in a 2006 judgement to ‘prevent and restrain’ tobacco companies and their predecessors from continuing to engage in fraud about the harms of cigarettes. The corrective statements were initially ordered in 2006, after the US Department of Justice won a landmark victory in a federal racketeering lawsuit brought against the tobacco companies in 1999 under the Racketeering Influenced and Corrupt Organizations (RICO) Act.1 After protracted legal battles, the companies were mandated in October 2017 to begin publishing the corrective statements in two initial media channels—newspapers and television—by the next month.2 Statements were ordered as full-page ads in the first section of a Sunday edition of at least 50 newspapers across the country, in five issues appearing from late November 2017 to early March 2018, and as prime-time spots on three major television networks five times a week for 1 year beginning in November 2017. In May 2018, the court ordered two additional implementation channels: tobacco company web sites (as of June 2018) and cigarette pack onserts (to appear in six installments for a total of 12 weeks over 2 years, beginning 21 November 2018). Potential implementation in a fifth channel, retail point-of-sale, is still being litigated.3

The corrective statements covered five specific topics for which Judge Kessler’s 2006 ruling indicated there was a ‘preponderance of evidence’ to support that the defendants had devised and executed a scheme to defraud consumers and potential consumers of cigarettes1 (online supplementary appendix). In newspapers, each ad contained one of the five court-ordered corrective statements according to the following schedule: 26 November 2017, adverse health effects of smoking; 10 December 2017, addictiveness of smoking and nicotine; 7 January 2018, lack of significant health benefit from smoking ‘light,’ ‘low tar,’ ‘ultra light,’ ‘mild,’ and ‘natural’ cigarettes; 4 February 2018, manipulation of cigarette design and composition to enhance optimum nicotine delivery and 4 March 2018, adverse health effects of exposure to secondhand smoke. On television, each ad was required to have text and voice-over containing one of the five corrective statements according to the following schedule: beginning 26 November 2017, television ads ran five times per week for 1 year (for a total of 260 spots) Monday through Thursday between 19:00 and 22:00 hours (7 p.m. and 10 p.m. ET) on CBS, ABC and NBC. On television, the topics were not staggered by date; each of the five corrective statements appeared in television ads within the first 2 weeks of implementation and continued to run simultaneously thereafter throughout the 1 year implementation period. To build on the court-ordered newspaper and television ads required of the tobacco companies, antitobacco groups such as the Campaign for Tobacco Free Kids, ClearWay Minnesota, and many others extended the reach and amplified the messaging around the corrective statements with both paid and earned print, social and digital media.

Some work has been done to describe the current or earlier, proposed versions of the corrective statements4–6 or to evaluate7–9 them in forced-exposure/aided recall studies where participants were shown the messages as stimuli in controlled research settings. No study, to date, has sought to estimate the population prevalence of self-reported exposure to the corrective statements in the broad public information environment since their real-world implementation in newspapers and on television began in 2017. Furthermore, no studies have examined the sociodemographic and smoking status predictors of self-reported exposure to the corrective statements. This is important, as the Structural Influence Model of Communication Inequality10 suggests that differences in access and ability to take advantage of information at the individual level can create knowledge gaps11 among those that do and do not receive adequate exposure to information. The purpose of this study was to examine population-level self-reported exposure to the corrective statements in the first two court-ordered media channels (newspapers and television) implemented in 2017 and 2018. While the court-ordered corrective statements are unique to the US context, lessons from their implementation may be valuable both domestically and internationally.

Methods

Sample population and data collection

This study used the US National Cancer Institute’s Health Information National Trends Survey (HINTS) 5, Cycle 2, which was fielded January to May 2018, coinciding with the time period during which the court-ordered statements were first implemented in newspapers and on television in the US. HINTS (https://hints.cancer.gov) is a nationally representative, cross-sectional, self-administered survey of civilian, non-institutionalised US adults age 18 and older. The survey assesses health-related and cancer-related knowledge, attitudes and behaviours as well as media and technology use, among other constructs. Data were collected using a probability-based sample of US postal addresses with an oversample of addresses in geographic areas with high concentrations of minority populations. Within each household, one adult was selected to complete the print questionnaire based on the next birthday method.12 Measures included on HINTS are often taken or adapted from other large national surveys such as the Tobacco Use Supplement to the Current Population Survey (TUS-CPS), Behavioral Risk Factor Surveillance System and National Health Interview Survey (NHIS). Items unique to HINTS are cognitively tested.13

The overall weighted response rate for HINTS 5, Cycle 2 (2018) was 32.85% (N=3504). Additional details about the HINTS data collection programme have been published elsewhere14–17 and specific details about the 2018 administration are available in the methodology report for HINTS 5, Cycle 2 (2018).18

Measures

HINTS 5, Cycle 2 (2018) contained six unique items related to the court-ordered, tobacco-related corrective statements, devised by the authors of the current study. The first, asked of all respondents, was ‘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? Yes/No’. The subsequent set of items, asked only of those who reported ‘yes’ to the first question, asked about each of the five court-ordered corrective statements: ‘Which of the following messages have you seen? Mark all that apply. (1) That a Federal Court has ordered tobacco companies to make statements about the health effects of smoking. (2) That a Federal Court has ordered tobacco companies to make statements about the health effects of secondhand smoke. (3) That a Federal Court has ordered tobacco companies to make statements about the addictiveness of smoking and nicotine. (4) That a Federal Court has ordered tobacco companies to make statements about how cigarettes are designed to enhance the delivery of nicotine. (5) That a Federal Court has ordered tobacco companies to make statements about low tar and light cigarettes being just as harmful as regular cigarettes . Frequency of self-reported exposure was not assessed.

To assess respondent smoking status, two standard items modeled from NHIS and TUS-CPS were presented: ‘Have you smoked at least 100 cigarettes in your entire life? Yes/No’ and ‘How often do you now smoke cigarettes? Every day/Some days/Not at all’. Smoking status was categorised as Never if respondents answered ‘no’ to the first question; as Current if respondents answered ‘yes’ to the first question and ‘every day’ or ‘some days’ to the second question; and as Former if respondents answered ‘yes’ to the first question and ‘not at all’ to the second question.

Sociodemographics such as age, sex, marital status, education, race, ethnicity and income were assessed in HINTS using measures selected or adapted from the US NHIS and the American Community Survey. Sexual orientation was assessed with the question ‘Do you think of yourself as… Heterosexual or straight; Homosexual or gay or lesbian; Bisexual; Something else—Specify’. Rural and urban residence was determined using the United States Department of Agriculture’s Rural-Urban Continuum Codes (RUCC) for metropolitan and non-metropolitan areas.19 Urban categorisation included RUCC 1–3 (metro area counties with greater than 20 000 residents) and rural categorisation included RUCC 4–9 (non-metro counties with populations ranging from 2500 to 20 000). For analyses, race/ethnicity was categorised as Hispanic, non-Hispanic white, non-Hispanic black or African American and non-Hispanic other race, which combined the low base-rate responses from the remaining race categories assessed.

Statistical analysis

Complete case analysis with listwise deletion was employed. Analyses were conducted using SAS 9.4 survey procedures to account for the complex sampling design of HINTS. All analyses used sample weights to produce population-level point estimates, and a set of jackknife replicate weights were used to compute variance estimates. Frequencies and weighted proportions were calculated for having seen any corrective statement and for each of the five corrective statements. These analyses were conducted for the full sample and by sociodemographic characteristics and smoking status, in weighted, unadjusted bivariate models using Wald χ2. Weighted, adjusted multivariable logistic regression was used to examine sociodemographic variables and smoking status as predictors of responding ‘yes’ to the first survey item that assessed self-reported exposure to any corrective statement. Tests of significance were conducted at the p<0.05 level.

Results

Sample characteristics (smoking status and sociodemographics) for the full sample are described in table 1. Descriptive statistics (unadjusted frequencies and weighted proportions) of self-reported exposure to any court-ordered, tobacco-related corrective statement and to each of five topic-specific statements are described in table 2. In 2018, 41.1% of HINTS respondents, which translates to a weighted population estimate of 40.6% of US adults, reported that in the past 6 months, they had seen messages in newspapers or on television stating that a Federal Court has ordered tobacco companies to make statements about the dangers of smoking cigarettes. Self-reported exposure to the five, topic-specific corrective statements was as follows: an estimated 34.7% of adults reported seeing messages about health effects of smoking; 26.5% about the health effects of secondhand smoke; 22.5% about the addictiveness of smoking and nicotine; 14.5% about there being no health benefit from light and low tar and 11.4% about manipulation of cigarette design to enhance nicotine delivery. Because frequency of exposure was not measured, self-reported exposure could have occurred even once.

Table 1

Sample characteristics: HINTS 5, Cycle 2 (2018) (n=3504)

Table 2

Weighted, unadjusted prevalence of self-reported exposure to court-ordered, tobacco-related corrective statements (overall and by topic), by sociodemographic characteristics and smoking status (n=3223)

In the multivariable model, education and smoking status were independent predictors of self-reported exposure to any corrective statement, when controlling for all other variables under study (table 3). Those with a high school education were significantly less likely than those with a college degree to report seeing a corrective statement (OR=0.69, CI 0.50 to 0.95) and current smokers were significantly more likely than never smokers to report seeing a corrective statement (OR=1.68, CI 1.12 to 2.53). There was no observed effect modification when interaction terms for smoking status and education levels were included in the model. Across the other sociodemographic variables under study, respondents were no more or less likely to report exposure to a corrective statement, suggesting otherwise consistent reach of the messages across those population groups.

Table 3

Weighted, multivariable logistic regression modeling odds of reporting ‘Yes’ to being exposed to court-ordered, tobacco-related corrective statements in newspapers or on television, by sociodemographic characteristics and smoking status (n=3223)

Discussion

This study is the first to estimate the population prevalence of self-reported exposure to the court-ordered, tobacco-related corrective statements during the time they were first implemented in newspapers and on television in the USA. Less than half of the adult population (an estimated 40.6%) reported seeing a message that a Federal Court had ordered tobacco companies to make statements about the dangers of smoking cigarettes. This translates to a weighted population estimate of more than 100 million adults reporting exposure. More current smokers (49.6%) than never (38.9%) or former (38.9%) smokers reported seeing any of the corrective statements.

In the multivariable logistic regression model, education and smoking status were independent predictors of self-reported exposure to corrective statements. We found that current smokers were 68% more likely than never smokers to report having seen a corrective statement. This could be because current smokers attend to and recall tobacco-related health messages more than people who have never smoked, as personal relevance of a topic may lead to selective exposure.20–22 There is little evidence to suggest that media consumption may be differential by smoking status (though at least one study has shown that smokers are more frequent television viewers than nonsmokers23), therefore differential viewership and readership likely do not explain the variability in reported exposure observed by smoking status.

In contrast, we know that newspaper readership is patterned by socioeconomic status,24 so our finding that those with a high school degree were 31% less likely than those with a college degree or more to have seen a corrective statement could be due, in part, to lower newspaper readership in that group. That interpretation, however, could be offset by the fact that those with lower levels of education tend to watch more television than those with higher levels of education.25 Regardless, the Structural Influence Model of Communication Inequality10 suggests that there are differences among social classes in the generation, manipulation and distribution of information at the societal level and differences in access and ability to take advantage of information at the individual level. Differences in the way health information is created, distributed and received among and across groups can create knowledge gaps11 among those that do and do not receive adequate exposure to information. At the individual level, communication inequality includes personal access to and use of media; attention to health information that is available in the communication environment; recall, knowledge and comprehension of health information and personal capacity to act on information.10 11 26 These are all reasonable explanations for our finding that those with lower levels of education were significantly less likely than those with a college degree or more to report seeing a corrective statement. The observed differential effects by education level are important to note and to monitor as corrective statement implementation extends to company web sites and cigarette pack onserts, and potentially to point-of-sale.

Limitations

HINTS is a nationally representative cross-sectional survey of US adults from which causality cannot be inferred. While the response rate to HINTS 5 Cycle 2 (32.85%) is lower than in-person, interviewer-administered surveys, it is comparable to other national surveys based on probability sampling, for which response rates have declined over time.27 Methodological research suggests that the negative impact of declining response rates on data quality may not be as significant as previously assumed.27–29

With respect to the potential for measurement error, HINTS did not include mechanisms to assess false-positive responses to exposure (such as false or ‘confederate’ statements), so our base prevalence estimates may be inflated, and our multivariable models potentially mis-specified. Indeed, measuring exposure has been the most central issue in communication research, and there is no gold standard for measuring campaign exposure. A well-established method in the communication campaign evaluation literature has been to use survey measures of self-reported exposure with unaided recall, aided recall and hybrid approaches.30 While our study was not designed to evaluate the effects of the corrective statements remedy on behavioural outcomes, some lessons from the campaign evaluation literature are nonetheless quite relevant. For example, the HINTS items used in this study were a hybrid approach that used a form of aided recall, where the items described some important, unique details about the statements (eg, using ‘Federal Court’ and other language specific to and unique to the corrective statements) and the five topics, but did not fully aid respondents by showing them the statements in their entirety. These types of items, which assess recognition, tend to produce higher estimates of campaign exposure than confirmed recall or unaided recall items;30 however, they do have broad utility for providing evidence of widespread levels of exposure in the aggregate.31 No exogenous measures of exposure were assessed other than the time-frame of corrective statement dissemination in newspapers and on television in 2017 and 2018; measures of self-reported exposure may not validly approximate actual exposure.30 32 That said, we were encouraged by the nature of the variation in self-reported exposure to the five individual statements—with more people reporting exposure to the general health effects statements versus the more specific statements. This helped to demonstrate that straight-lining, acquiescence or confirmation bias were unlikely, though there may have been issues with respondents’ ability to discriminate among other, general tobacco control messaging that exists in the cluttered public information environment.

The HINTS measures specifically asked about exposure from newspapers and television, but it was beyond the scope of the survey to disentangle the extent to which self-reported exposure occurred from ads placed by the tobacco industry in these court-ordered, ‘traditional’ media channels or from the efforts of antitobacco and public health organisations to extend the reach of the corrective statements by communicating about them through other channels such as social media.

Future research may examine the effects of exposure to the court-ordered corrective statements on tobacco-related knowledge, attitudes and smoking behaviours, which were not within the scope of the current study to examine. Likewise, this study did not evaluate the statements’ efficacy in ‘preventing and restraining’ future tobacco company fraud and deception.

Despite the study’s limitations, this paper is the first to estimate the population prevalence and predictors of self-reported exposure to the court-ordered corrective statements resultant of U.S. v Philip Morris USA, Inc. using a nationally-representative survey of US adults. It estimates that 4 in 10 US adults were exposed to any corrective statement and provides evidence that traditional media channels can be effective at reaching a limited segment of the general population, including current smokers, with tobacco-related messages.

What this paper adds

What is already known about this subject

  • Some work has been done to describe or evaluate the current or earlier, proposed versions of the corrective statements in forced-exposure/aided recall studies.

What important gaps in knowledge exist on this topic

  • No study, to date, has sought to estimate the population prevalence of self-reported exposure to the corrective statements in the broad public information environment since their real-world implementation in newspapers and television began in 2017.

What this paper adds

  • This is the first study to examine the population prevalence of self-reported exposure to court-ordered, tobacco-related corrective statements resultant of U.S. v Philip Morris USA, Inc. using a nationally representative sample.

  • The paper offers an estimate of the proportion of US adults who reported being exposed, even once, to any corrective statement (40.6%) and to the five topic-specific corrective statements (range=11.4%–34.7%).

  • The study examines correlates of self-reported exposure to the corrective statements and reveals that education and smoking status are independently predictive.

References

Footnotes

  • Contributors KDB: conceived of study, developed survey items, developed analytic plan, interpreted data, drafted manuscript and revisions. GW and AK: developed survey items, interpreted data, contributed to manuscript and revisions.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. The work was done as part of their duties as Federal employees of the U.S. National Cancer Institute (NCI). HINTS V was funded by NCI via contract to Westat (HHSN2612012000028I).

  • Disclaimer The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does the mention of trade names, commercial products, or organizations imply endorsement by the U.S. government. The findings and conclusions in this report are those of the authors and may not necessarily represent NIH positions or policies.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval HINTS V was reviewed by the NIH Office of Human Subjects Research and given a non-human subjects determination via exemption #13204 on April 25, 2016. HINTS V received an expedited approval from the Westat IRB on March 28, 2016.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository.