Article Text

Early evidence of the associations between an anti-e-cigarette mass media campaign and e-cigarette knowledge and attitudes: results from a cross-sectional study of youth and young adults
  1. Elizabeth C Hair1,2,3,
  2. Jennifer M Kreslake1,2,
  3. Jessica Miller Rath1,2,
  4. Lindsay Pitzer1,
  5. Morgane Bennett1,
  6. Donna Vallone1,2,3
  1. 1 Truth Initiative Schroeder Institute, Washington, DC, USA
  2. 2 Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
  3. 3 School of Global Public Health, New York University, New York, NY, USA
  1. Correspondence to Dr Elizabeth C Hair, Schroeder Institute, Truth Initiative, Washington, DC 20001, USA; ehair{at}


Objective Antismoking mass media campaigns have contributed to significant declines in combustible tobacco use among young people. This study evaluates a national anti-e-cigarette campaign to determine its association with knowledge, attitudes and beliefs in the context of increasing e-cigarette use in the USA.

Methods A national sample of respondents aged 15–24 years (n=8421) was drawn from a repeated cross-sectional online panel survey (220 participants/week) (October 2018 to December 2019). Self-reported exposure to the truth anti-e-cigarette campaign was measured according to level of ad awareness. Outcomes were subjective knowledge of campaign-targeted facts about e-cigarettes and attitudinal constructs about perceived e-cigarette harm, social unacceptability and anti-industry sentiments. Covariates included respondent demographics, current e-cigarette use and cigarette use, parental smoking, sensation seeking, mental health and growth in e-cigarette sales.

Results Ad awareness was associated with knowledge that e-cigarette users are more likely to start smoking (low OR: 1.28, 95% CI 1.14 to 1.44; high OR: 1.88, 95% CI 1.66 to 2.13) and of the nicotine content of JUUL compared with cigarettes (low OR: 1.63, 95% CI 1.45 to 1.82; high OR: 2.50, 95% CI 2.21 to 2.84). High ad awareness was associated with knowledge that the long-term health effects of JUUL use are unknown (OR: 1.88, 95% CI 1.57 to 2.28). High ad awareness was associated with significantly higher perceived product harm (OR: 1.35, 95% CI 1.18 to 1.54), social unacceptability (OR: 1.32, 95% CI 1.15 to 1.53) and anti-industry attitudes (OR: 1.40, 95% CI 1.21 to 1.62), compared with respondents with no awareness.

Conclusions Young people with awareness of anti-e-cigarette ads demonstrate higher levels of campaign-targeted knowledge, attitudes and beliefs. Future campaign evaluation priorities include measuring the campaign effects on e-cigarette use behaviours.

  • electronic nicotine delivery devices
  • denormalisation
  • social marketing

Data availability statement

Data are available upon reasonable request. Study data are archived on a secure server maintained by Truth Initiative. A data sharing agreement is required for use of all data. Investigators seeking access to data used in the study should make a written request to Truth Initiative authors and submit a detailed research plan including the purpose of the proposed research, required variables, duration of the analysis phase, IRB approval with FWA information and investigator training in human subjects. Approved investigators may access data sets via an analytic portal owned and administered by Truth Initiative.

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Decades of research at the national, state and local levels have documented how tobacco prevention mass media campaigns have contributed to the significant declines in tobacco use among young people.1 2 These campaigns are thought to help change tobacco use behaviour by helping to change knowledge, attitudes, beliefs and norms around tobacco.3 4 Mass media campaigns are an established component of comprehensive tobacco control programmes, and work in concert with policies to prevent initiation and promote cessation of tobacco use in target populations.5

Included within this research is evidence of the effectiveness of the US national truth campaign (‘truth’), adapted from the Florida state truth campaign, which was launched in 2000 with the goal of preventing initiation of combustible tobacco use among young people across the nation. Research has demonstrated the effectiveness of this campaign in increasing antismoking attitudes, decreasing intentions to smoke and decreasing smoking initiation among youth and young adults.6–10 A 2005 evaluation of the national truth antismoking campaign used an exogenous measure of campaign exposure—cumulative gross rating points (GRPs)—to identify a dose–response relationship between level of total campaign GRPs and odds of smoking among school-age youth within each media market in the USA.7 Dose–response effects of the campaign have also been observed using a self-reported measure of truth ad awareness to estimate campaign exposure.11 A more recent study followed a longitudinal cohort of youth and young adults starting in 2014, and by 2016, found a dose–response relationship in the positive association between awareness of a new phase of the truth antismoking campaign and campaign-targeted attitudes and intentions not to smoke.9

Today, the significant declines in cigarette use among young people in the USA have been eclipsed by the rapid and dramatic rise in e-cigarette use.12 Data from the National Youth Tobacco Survey indicate that past 30-day e-cigarette use increased from 11% in 2017 to almost 28% in 2019 among US high school students, while past 30-day cigarette smoking declined from 7.6% in 2017 to 4.6% by 2019.13–16 Between 2017 and 2018, a 46.2% increase in e-cigarette use prevalence (5.2%–7.6%) was observed among young adults aged 18–24 (ie, self-reported use every day or most days); the highest young adult e-cigarette use is found among those aged 18–21.17 Early exposure to nicotine affects adolescent brain development and susceptibility to addiction, with emerging evidence demonstrating increased risk of progression to combustible tobacco use among young e-cigarette users.12

In response to the alarming growth in e-cigarette use, the truth campaign aired a series of anti-e-cigarette media messages targeting youth and young adults (aged 15–24) in the fall of 2018. The formative research process used to identify message themes for the campaign is described in detail in a recent paper by Rath et al (in press).18 During this time period, the Food and Drug Administration (FDA) was also expanding its antismoking campaign, The Real Cost, to include e-cigarette use prevention among its target audience (youth aged 12–17). Research on the development of the FDA’s anti-e-cigarette ads used a between-subjects experimental design to demonstrate that forced exposure to two 30-second ads from The Real Cost campaign was associated with significant changes in vaping-related attitudes and beliefs, as well as intentions to vape, compared with participants who viewed control ads.19 20 To date, no population-based outcome evaluation studies of anti-e-cigarette mass media campaigns are yet available in the literature.

At the time of the truth campaign’s launch in October 2018, JUUL held 74.5% of e-cigarette market share.21 The brand dominated the e-cigarette landscape to the point that it had become synonymous with the act of e-cigarette use (ie, ‘JUULing’).22 23 Therefore, the truth campaign emphasised JUUL in its messages. Potential messaging targets were developed using quantitative formative research with 3539 youth and young adults.18 24 This work employed the Hornik and Woolf method, whereby facts or attitudes that were not already universally understood or endorsed (<70% of respondents) and that were associated with the ultimate outcome of interest (intention not to use e-cigarettes) were chosen.25 Accordingly, campaign messages were designed to: (1) correct misperceptions about the nicotine content of e-cigarettes; (2) change the perceived relative safety of e-cigarettes; (3) decrease the social acceptability of e-cigarette use among young people; and (4) increase anti-e-cigarette industry sentiments. The final 15 items representing four constructs were added to all implementation and outcome surveys in order to evaluate the campaign’s success. To help educate audiences, basic facts about the harm of e-cigarette use to young people were integrated into truth messages (see details on the Puppets campaign in online supplemental table A). Messages were designed to empower young people with the facts about e-cigarette companies, such as the fact that the manufacturers of JUUL had no information about the long-term health effects of its products (see details on the Tested on Humans campaign in online supplemental table A).26–29

The objective of the current study is to evaluate whether truth anti-e-cigarette campaign awareness was associated with e-cigarette-related outcomes following its launch in October 2018 through December 2019 among a national sample of the campaign’s target audience of youth and young adults. This study period of approximately 15 months falls within the timeline of when interim attitudinal effects have been demonstrated in response to antismoking campaigns aired at sufficient exposure levels.30 Given the need to inform the tobacco control field about promising interventions, this analysis explores associations between awareness of the campaign and e-cigarette-related knowledge, attitudes and beliefs over time. As this campaign had not yet run for a sufficient duration to establish behaviour change (eg, 3 years as demonstrated in other antismoking campaigns),30 it was premature to examine associations between campaign awareness and e-cigarette behaviour.


truth Anti-e-cigarette campaign description

The conceptual framework that guides the development of truth campaign content and subsequent evaluation studies is based on health behaviour literature that identifies changes in knowledge, attitudes and behavioural intentions as precursors to behaviour change.31 32 Informed by this literature, truth campaign content is designed to increase tobacco-related knowledge and antitobacco attitudes among members of the target audience.

The campaign was aired almost exclusively over digital platforms, as these are the dominant communication channels among youth and young adults.33 Social media platforms including Snapchat, Instagram, YouTube and TikTok are used by the majority of youth and young adults,33 34 and thus messages were developed for delivery over these platforms. The truth campaign employed similar strategies used by JUUL in promoting its products to young people; in addition to leveraging the digital landscape using a similar approach as JUUL, the campaign incorporated youth cultural symbols and youth influencers to empower young people to reject tobacco products.35–37

Three major creative executions designed to address vaping-related knowledge and attitudes were aired in succession over the course of the study period and are summarised in online supplemental table A. Ads were delivered through digital channels, and a reliable exogenous measure of campaign reach (often measured using GRPs in television campaigns) was not available to approximate population-level exposure. Digital video views and social media engagement statistics—defined as clicks on links or other digital content (eg, banners), social media page likes, and shares, comments and reactions to posts—were tracked to provide indicators of relative audience engagement with each creative approach (online supplemental table A), but were not used to approximate individual-level or population-level campaign exposure in the current study.

Messages containing two e-cigarette-related facts (‘Vaping makes you 4x more likely to start smoking cigarettes’ and ‘One JUUL pod is equal to 20 cigarettes’ worth of nicotine’)27–29 were introduced in the first set of ads (Puppets), from October 2018 to June 2019. Messages containing a third fact (‘No one knows the long-term effects of JUULing’26) were introduced in a new creative approach (Tested on Humans) airing from August 2019 to January 2020.

In addition to improving e-cigarette-related knowledge, campaign-targeted facts conveyed by the ads above may also inform e-cigarette attitudes. Attitudes targeted by all creative executions included antivape industry sentiments, social ‘unacceptability’ of e-cigarette use and perceived product harm (see online supplemental table A). Perceived e-cigarette product appeal (or ‘unappeal’) was not targeted in the creative approaches evaluated in this study. Therefore, no association is expected between ad awareness and product ‘unappeal’, and thus this attitude was measured as a counterfactual.

Sample and procedures

Data for this study are based on a repeated cross-sectional weekly survey of participants (aged 15–24 years) drawn from a national online panel (Dynata; formerly Research Now; The total study sample includes 8421 respondents who were each surveyed once from October 2018 through December 2019 (n=222 per week), starting at the launch of the truth anti-e-cigarette campaign and throughout the time period that the campaign aired. During this time period, anti-e-cigarette ads aired on television and digital platforms. Data were weighted to be nationally representative based on US Census demographic benchmarks (ie, age, sex, race and ethnicity).


Awareness of the truth anti-e-cigarette campaign

An aided recall measure was used to assess awareness of truth anti-e-cigarette ads aired in the past 6 months. Previous research has found aided recall to be positively associated with exogenous measures of campaign exposure and predictive of campaign-targeted beliefs.38 Survey participants were shown a collage of screenshots from recent truth ads, which included both images and text conveying specific messages (ie, campaign-targeted facts) (online supplemental table A). Participants reviewed one collage each featuring a set of images from concurrently running ads from the truth anti-e-cigarette campaign. The collage was modified as new ads aired, and therefore survey respondents saw different combinations of screenshots depending on the ads corresponding to their survey date. For example, those surveyed from October 2018 to July 2019 when the ads that used the Puppets theme were shown, were only asked about awareness of those ads, whereas those surveyed from August 2019 to December 2019 when the series of ads using the Tested on Humans theme were shown, were only asked about awareness of those specific ads. Participants were asked, ‘These pictures are from multiple ads or videos. How often would you say you have seen any of these ads/videos on TV or online recently?’, with response options 0=never, 1=rarely, 2=sometimes, 3=often, 4=very often. This measure of ad awareness has been used for both antitobacco campaign evaluation as well as measurement of exposure to tobacco advertising.39–42 The use of the ad awareness measure allows comparability of this study to the antitobacco campaign evaluation literature as well as studies measuring ad recall of protobacco advertising. Based on the distribution of this variable, a three-level categorical variable was created to represent none, low and high awareness of ads. Those who responded ‘never’ were recoded as (0) no awareness, those who responded ‘rarely or sometimes’ were recoded as (1) low awareness and those who responded ‘often or very often’ were recoded as (2) high awareness.

E-cigarette knowledge

Certain truth campaign ads presented facts about the potential harm of e-cigarettes to increase knowledge among audiences. Agreement with facts is a measure of subjective knowledge (ie, what audiences think they know about a topic) and is frequently used in studies of consumer behaviour.43 Knowledge was measured by asking participants surveyed from October 2018 to August 2019 to report agreement with the facts conveyed by truth ads: ‘One JUUL pod is equal to 20 cigarettes’ worth of nicotine’27 and ‘Vaping makes you 4x more likely to start smoking cigarettes’.28 29 Those surveyed from August 2019 to December 2019—when the ads that used the Tested on Humans theme were shown—were asked to report their agreement with the fact presented in those ads: ‘No one knows the long-term health effects of JUULing’.26 Response options included a 5-item Likert scale: 1=strongly disagree, 2=disagree, 3=neither agree or disagree, 4=agree, 5=strongly agree. Responses were dichotomised as 0=strongly disagree/disagree/neither agree or disagree and 1=agree/strongly agree.

E-cigarette-related attitudes

Potential messaging targets were developed for truth’s national anti-e-cigarette mass media campaign using formative research methods.18 Participants were asked to endorse a series of e-cigarette-related attitudinal items. Following an exploratory factor analysis to identify the underlying relationships among the items, three message theme constructs each were measured with three to four individual items: perceived product harm, social unacceptability of e-cigarette use and anti-e-cigarette industry sentiments (online supplemental table B). The message constructs were calculated using the average of items within each (1) perceived product harm measured using four items (α=0.61) (eg, ‘vapes/e-cigarettes contain dangerous chemicals’); (2) social unacceptability of e-cigarette use measured using four items (α=0.67) (eg, ‘vaping/using e-cigarettes is not okay for people my age’); and (3) anti-e-cigarette industry sentiment measured using four items (α=0.80) (eg, ‘vape companies try to get young people to start vaping’). Messages were not designed to inform attitudes about the level of appeal of e-cigarettes (unappeal), but a measure for this construct was created as a counterfactual using three items (α=0.61) (eg, ‘vaping/using e-cigarettes looks silly or childish’). Response options for all items included 1=strongly disagree, 2=disagree, 3=neither agree/disagree, 4=agree, 5=strongly agree. Responses were dichotomised as 0=strongly disagree/disagree/neither agree or disagree and 1=agree/strongly agree to represent campaign-aligned knowledge and attitudes.

Control variables

The following demographic variables were included in the analyses to account for potential confounding: age in years (0=15–17, 1=18–21, 2=22–25), gender (0=female, 1=male), race/ethnicity (0=non-Hispanic white, 1=non-Hispanic Black, 2=Hispanic, 3=non-Hispanic other, a collapsed measure of all racial categories besides white and Black that were not of Hispanic ethnicity) and perceived financial situation (0=live comfortably, 1=meet needs with a little left over, 2=just meet basic expenses, 3=don’t meet basic expenses).44 To control for weekly variation in the proportion of respondents who use e-cigarettes, the models controlled for respondents’ current e-cigarette use, measured by asking respondents, ‘During the past 30 days, on how many days did you use … JUUL?’ or ‘…e-cigarettes/vape (not including JUUL)?’ Responses of 1 day or greater for either product type were coded as current (past 30-day) e-cigarette users.

Models also controlled for other known risk factors for nicotine use, including current combustible cigarette use (smoked a cigarette one or more days in the past 30 days), parent smoking (0=neither parent smokes, 1=one/both parents smoke, 2=one/both parents used to smoke), sensation seeking (analysed as a continuous variable; measured with the 8-item Brief Sensation Seeking Scale, with higher score indicating higher sensation seeking; α=0.80)45 and mental health (analysed as a continuous variable, with higher scores indicating poorer mental health; α=0.70).46

E-cigarette sales data from Nielsen were also included as a control variable to account for the significant growth in e-cigarette sales and serve an indicator of the extent of exposure to societal e-cigarette use during the same time period. (The conclusions drawn from the Nielsen data are those of the researcher(s) and do not reflect the views of Nielsen. Nielsen is not responsible for, had no role in and was not involved in analysing and preparing the results reported.) The variable was calculated to reflect the percentage increase or decrease from the 4-week average of the period ending 15 July 2017 when national sales dollars reached $1 million. This variable was linked by respondent’s residential geographic location and survey date to capture regional and time differences in e-cigarette growth. For survey participants in the continental United States who did not live in one of the 25 state line estimate files provided by Nielsen, a growth variable was calculated using the estimate from their Census division of residence.

Analytical strategy

Logistic regression analyses were conducted using MPlus V.8.2.47 Eight fixed effects models assessed the relationship between individual-level awareness of the truth campaign and each dichotomised attitudinal construct and knowledge of e-cigarette facts, using the survey week variable to control for time. Other covariates were past 30-day e-cigarette use, past 30-day combustible cigarette use, parent smoking status, sensation seeking, mental health status, age, gender, race/ethnicity, perceived financial situation and growth in e-cigarette sales.


The majority of the sample included young adults aged 18–25 (74%), white, non-Hispanic respondents (64%) and who reported sufficient financial means (89%) and non-smoking parents (both never and former smokers (64%) as shown in table 1). The sample was approximately evenly split between male and female respondents (52% vs 48%). About 43% of the sample had ever used an e-cigarette/vape product and about 30% of the sample were current e-cigarette users. Three-quarters (74%) of the sample reported awareness of truth ads that were recently run. On average, the sample was slightly above the midpoint on sensation seeking (possible range 1–5; mean=3.26) and poor mental health (possible range 1–4; mean=2.70).

Table 1

Sample characteristics

Table 2 presents the results of the fixed effects models. Findings demonstrate an association between campaign awareness and e-cigarette knowledge for those who had seen a truth ad frequently—and for those who reported seeing the campaign less frequently—as compared with those who do not report any ad awareness. For example, compared with those who did not report seeing the ads, higher agreement with statement ‘Vaping makes you 4x more likely to start smoking cigarettes’ was positively associated with those with low ad awareness (OR: 1.28, 95% CI 1.14 to 1.44) and high ad awareness (OR: 1.88, 95% CI 1.66 to 2.13). Similar relationships were found between reported ad awareness and agreement with the ‘One JUUL pod is equal to 20 cigarettes’ worth of nicotine’ fact. Those who reported low and high frequencies of seeing the ads had greater odds of reporting higher agreement with this knowledge statement (low awareness OR: 1.63, 95% CI 1.45 to 1.82; high awareness OR: 2.50, 95% CI 2.21 to 2.84), compared with those who did not report seeing a truth anti-e-cigarette ad. For the statement ‘No one knows the long-term health effects of JUULing’, those with high ad awareness had greater odds of reporting higher levels of agreement (OR: 1.88, 95% CI 1.57 to 2.28), but a significant association was not found among those who reported low levels of ad awareness.

Table 2

Logistic regression models with a fixed effect for time (by week): ad awareness of the truth e-cigarette use campaign predicting e-cigarette knowledge, attitudes and beliefs

A greater likelihood of reporting higher scores across three of the four attitudinal constructs was found for respondents with high truth ad awareness (table 2). Those with high ad awareness had greater likelihood of reporting higher levels of perceived product harm (OR: 1.35, 95% CI 1.18 to 1.54), social unacceptability (OR: 1.32, 95% CI 1.15 to 1.53) and anti-industry sentiment (OR: 1.40, 95% CI 1.21 to −1.62) compared with those who did not see the ads. No significant association was found between level of ad awareness and unappeal, the only attitudinal construct measured that was not targeted by the truth anti-e-cigarette campaign. Significant differences in these attitudinal constructs were not observed for those reporting low awareness of the ads compared with those with no awareness.


Findings demonstrate that youth and young adult self-reported frequent exposure to this series of truth anti-e-cigarette campaign ads was associated with campaign-targeted e-cigarette knowledge and attitudes. These findings are consistent with previous studies demonstrating antismoking campaign effects on knowledge and attitudes,1–3 6 7 and provide early evidence that anti-e-cigarette campaigns may be a promising approach to addressing the epidemic of e-cigarette use among youth people. In this study, findings indicate that self-reported frequent exposure to truth campaign ads was associated with significantly greater likelihood of correct e-cigarette knowledge and a higher likelihood of anti-e-cigarette-related attitudes and beliefs at the population level. Only one attitudinal construct (‘unappeal’) did not have a significant association with ad awareness. Most truth ads aired during the study period lacked messaging that targeted product appeal. The lack of difference in the only attitude that was not targeted by the truth campaign according to level of ad awareness provides confidence that the effects were due to the campaign, given the specificity of the campaign effects. One feature that distinguishes the truth campaign from the FDA’s The Real Cost campaign is its emphasis on anti-industry themes. The positive association between high levels of truth ad awareness and the anti-industry attitudinal measure provides further confidence that the observed effects can be attributed to truth campaign exposure as opposed to The Real Cost anti-e-cigarette campaign.

These findings are promising given campaign-targeted knowledge and attitudes have been found to be precursors to behaviour change in previous evaluations of truth’s antismoking campaign. Awareness of truth’s antismoking campaign was shown to be associated with antismoking attitudes, which, in turn, were associated with a slower rate of progression from trial to established cigarette smoking.8 Future research is required to determine if the truth anti-e-cigarette campaign may have long-term effects on slowing or preventing established e-cigarette use.

Campaign-targeted knowledge and attitudes were only consistently associated with high levels of self-reported awareness of truth ads. It is recommended that public health agencies and other tobacco control organisations are allocated resources to ensure that anti-e-cigarette mass media campaigns achieve high levels of exposure among high-risk populations such as youth and young adults.

Antismoking mass media campaigns can support and complement policy interventions.3 5 The truth and other anti-e-cigarette campaigns were run nationally in advance of and while limited federal restrictions on youth access to e-cigarettes began to take effect. The US FDA has regulated the manufacture and marketing of e-cigarettes since 2010, but the growth in youth e-cigarette use persisted despite agency oversight. Immediately following this study period (January 2020), the FDA issued restrictions on characterising flavours (with the exception of menthol and tobacco flavours) for certain types of e-cigarette devices, specifically cartridge-based designs such as JUUL.48 However, other e-cigarette designs, such as disposable devices, are currently exempt from federal regulation and remain available to youth in a variety of appealing flavours such as fruit and mint.49 E-cigarettes fall under the increased minimum legal sales age for tobacco purchases, from age 18 to 21, implemented at the federal level by the end of this study period (December 2019). Future research is needed to examine the combined effect of recent federal policy changes and exposure to truth and other anti-e-cigarette campaigns. Future policy directions include national, state and local policies to (1) restrict youth access to e-cigarettes (eg, through retail licensing to regulate tobacco outlet density), (2) regulate e-cigarette product designs with youth appeal (eg, all flavours including menthol and inexpensive disposable devices which are currently exempt from federal regulation), and (3) restrict price discounting and other promotions that increase affordability to price-sensitive populations such as youth.50


Although the study has many strengths, findings are subject to several limitations. First, respondents were drawn from an online convenience sample. The study used quotas and weighting procedures to approximate a nationally representative sample, but the results could be biased to an unknown extent if some demographic groups are not represented in the weighting process or if survey participation from these groups is too small for accurate weighting.

Second, the cross-sectional nature of the data prevents drawing any causal conclusions between ad awareness and changes in knowledge and attitudes; it is possible that those who share anti-e-cigarette sentiments are more likely to have attended to and/or remember truth ads. However, selective attention to ads typically occurs among those engaging in the targeted behaviour (ie, e-cigarette users are more likely to attend to e-cigarette ads rather than those who do not engage in e-cigarette use).51–53 Future research to determine whether ad awareness is associated with changes in e-cigarette-related outcomes before and after campaign exposure should employ longitudinal designs to identify individual changes over time according to level of ad awareness. Other cross-sectional studies have employed exogenous measures of population-level campaign exposure such as television GRPs, which was not feasible for this study because the campaign was disseminated heavily over digital channels for which no analogous exogenous measure is available.54 Alternately, after a campaign has been aired for a sufficient number of years, evaluations using cross-sectional tracking surveys may employ an aggregated measure to approximate campaign exposure at the weekly or monthly level.55 56

Third, while the analysis controlled for known risk factors for tobacco use among youth, such as parental smoking and sensation-seeking tendencies, there may be social and environmental contributors to e-cigarette-related knowledge and attitudes, such as peer use or exposure to tobacco industry advertising, that were not included in the models. Finally, the study did not collect information on awareness of FDA’s The Real Cost campaign or other national anti-e-cigarette campaigns. Like the truth campaign, the FDA’s The Real Cost tobacco prevention campaign expanded to include e-cigarettes in 2018. The Real Cost campaign targets youth (aged 12–17) who have either used e-cigarettes or are open to trying them, with messages focused on educating youth about e-cigarette addictiveness and potential health consequences.19 57 Of note, the target audience of The Real Cost was younger (aged 12–17) than truth’s target audience (aged 15–24) and this study sample. While it is possible that respondents were confusing recognition of truth ads with other national and state-level ads, awareness was measured via responses to screenshots from actual truth ads used to help prevent confusion between campaigns.


This study is likely one of the first to indicate that anti-e-cigarette campaigns may be effective in boosting youth and young adults’ e-cigarette knowledge and anti-e-cigarette attitudes. Those who reported frequent exposure to the truth’s anti-e-cigarette campaigns demonstrated higher levels of knowledge, attitudes and beliefs targeted by campaign messages. Future campaign evaluation priorities include measuring the longer term campaign effects on e-cigarette use. Future research is also needed to examine the impact of anti-e-cigarette campaigns like truth before and after the implementation of US federal policy changes to determine whether campaigns accompanied by policy interventions may maximise their effectiveness.

What this paper adds

  • Antismoking mass media campaigns have contributed to declines in combustible tobacco use among young people, but evidence of effective campaign approaches is needed to address the rapid rise in e-cigarette use among young people. This study is the first to demonstrate that awareness of the truth anti-e-cigarette campaign is associated with campaign-targeted knowledge, attitudes and beliefs among youth and young adults.

Data availability statement

Data are available upon reasonable request. Study data are archived on a secure server maintained by Truth Initiative. A data sharing agreement is required for use of all data. Investigators seeking access to data used in the study should make a written request to Truth Initiative authors and submit a detailed research plan including the purpose of the proposed research, required variables, duration of the analysis phase, IRB approval with FWA information and investigator training in human subjects. Approved investigators may access data sets via an analytic portal owned and administered by Truth Initiative.

Ethics statements

Patient consent for publication

Ethics approval

Advarra Institutional Review Board approved the study.


Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


  • Twitter @ehairphd

  • Contributors ECH and DV conceptualised and designed the study. JMR oversaw data collection. LP conducted the analyses under the guidance of ECH. JMK and MB composed the manuscript with significant written contributions by JMR, LP and DV. ECH provided final review of the manuscript.

  • 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.

  • Competing interests None declared.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.