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fda.gov

The Real Cost

FDA Center for Tobacco Products' first national youth tobacco prevention campaign, launched February 2014 for 12-17-year-olds who are open to smoking or already experimenting. Ads dramatize concrete 'costs' of tobacco (skin damage, tooth loss, addiction as a bully); later waves added smokeless tobacco for rural boys (2016) and youth e-cigarette prevention. Funded by tobacco industry user fees.

Years
2014–now
Country
United States
Budget
$115 million at launch (FDA), funded by tobacco user fees; $246.9 million spent 2014-2016 (MacMonegle 2018)
Topic
TobaccoVaping
Asks people to
Never startStop
Strategy
Fear appealMetaphor
Channel
OutdoorPrintRadioSocial (paid)TV
Audience
Youth
12-17-year-olds susceptible to or experimenting with cigarettes; rural white male youth for smokeless (2016); youth e-cigarette prevention later.

Evidence

ExperimentalPositive

Nationally representative youth cohort (n~5,100, Nov 2013-2016). Frequent exposure: aOR 0.70 (0.55-0.91) for smoking initiation; ~348,000 youths 11-18 kept from starting Feb 2014-Mar 2016 (Farrelly 2017). Market-level TRP dose-response: each 3,500 TRPs associated with ~30% lower initiation hazard; 380,000-587,000 youths prevented from initiating (Duke 2019). Cost per QALY saved $1,337; $128 saved per $1 spent (MacMonegle 2018). 89% of youth aware of at least one ad 6-8 months after launch (Duke 2015). Smokeless wave, randomized field trial in 30 rural media markets (15 campaign vs 15 control), about 2,200 boys over 3 years (Farrelly 2021): boys 14-16 in campaign markets agreed with 4 of 11 targeted beliefs more than controls; no effect in boys 11-13.

Sponsor (who paid)

Credits (who made it)

Related campaigns

Sources

  1. Farrelly MC et al. Association Between The Real Cost Media Campaign and Smoking Initiation Among Youths - United States, 2014-2016. MMWR 2017;66(2):47-50 evaluation · 2017 · DOI 10.15585/mmwr.mm6602a2 · PMID 28103214
  2. Duke JC et al. Impact of The Real Cost Media Campaign on Youth Smoking Initiation. Am J Prev Med 2019;57(5):645-651 evaluation · 2019 · DOI 10.1016/j.amepre.2019.06.011 · PMID 31443954
  3. MacMonegle AJ et al. Cost-Effectiveness Analysis of The Real Cost Campaign's Effect on Smoking Prevention. Am J Prev Med 2018;55(3):319-325 evaluation · 2018 · DOI 10.1016/j.amepre.2018.05.006 · PMID 30122214
  4. Duke JC et al. Youth's Awareness of and Reactions to The Real Cost National Tobacco Public Education Campaign. PLoS One 2015;10(12):e0144827 evaluation · 2015 · DOI 10.1371/journal.pone.0144827 · PMID 26679504
  5. The Real Cost: a cost-effective approach (FDA) sponsor
  6. How FCB showed teens the real cost of smoking (LBB) news
  7. FDA Reveals Details of Youth Tobacco Prevention Campaign (CSNews) news · 2014
  8. AlDukhail SK et al. Population-level impact of 'The Real Cost' campaign on youth smoking risk perceptions and curiosity, United States 2018-2020. Tob Induc Dis 2023 evaluation · 2023 · DOI 10.18332/tid/174900 · PMID 38090739
  9. MacMonegle A et al. The Impact of 'The Real Cost' on E-cigarette Initiation Among U.S. Youth. Am J Prev Med 2026 evaluation · 2026 · DOI 10.1016/j.amepre.2025.02.015 · PMID 40090426
  10. Farrelly MC et al. 'The Real Cost' Smokeless campaign: changes in beliefs about smokeless tobacco among rural boys, a longitudinal randomized controlled field trial. BMC Public Health 2021 evaluation · 2021 · DOI 10.1186/s12889-021-12356-6 · PMID 34906127
  11. Stevens EM et al. Associations Between Exposure to The Real Cost Campaign, Pro-Tobacco Advertisements, and Tobacco Use Among Youth in the U.S. Am J Prev Med 2021 evaluation · 2021 · DOI 10.1016/j.amepre.2020.11.006 · PMID 33583677
  12. MacMonegle A et al. Evaluating The Real Cost Digital and Social Media Campaign: Longitudinal Effects of Campaign Exposure on E-cigarette Beliefs. Nicotine Tob Res 2024 evaluation · 2024 · DOI 10.1093/ntr/ntad185 · PMID 38366338
  13. Kowitt SD et al. The Impact of The Real Cost Vaping and Smoking Ads across Tobacco Products. Nicotine Tob Res 2023 evaluation · 2023 · DOI 10.1093/ntr/ntac206 · PMID 36006858
  14. Duke JC et al. Effect of a National Tobacco Public Education Campaign on Youth's Risk Perceptions and Beliefs About Smoking. Am J Health Promot 2018 evaluation · 2018 · DOI 10.1177/0890117117720745 · PMID 28759999
  15. MacMonegle AJ et al. Effects of a National Campaign on Youth Beliefs and Perceptions About Electronic Cigarettes and Smoking. Prev Chronic Dis 2022 evaluation · 2022 · DOI 10.5888/pcd19.210332 · PMID 35389831
  16. Peterson EB et al. Message evaluation equivalence in pre versus postproduction tobacco education ads. Am J Prev Med 2025;69(6):108044 evaluation · 2025 · DOI 10.1016/j.amepre.2025.108044 · PMID 40934634

Research notes

Credits checked 2026-10-22 against fetched pages: FCB (Adweek AgencySpy, Feb 2014: 'Draftfcb NY' launching The Real Cost; LBB Online 23 Jan 2023, read via Wayback, still credits FCB on the campaign run since 2014); RTI (AJPM 2019 PubMed record: RTI author affiliations, longitudinal cohort Nov 2013-Nov 2016). The Real Cost has its own social accounts; Meta Ad Library / Google Ads Transparency Center: search advertiser 'U.S. Food and Drug Administration' and 'The Real Cost' (campaign page). Consider separate records for the smokeless (2016) and e-cigarette (2017-) waves, which have their own evaluations. Corrected 2026-10-22: RTI years widened from 2013-2016 to 2013- per USAspending FDA evaluation orders: HHSF22313003 'Evaluation of general market youth campaigns' (June 2013-Jan 2018), HHSF22301001T 'Campaign evaluation services - The Real Cost' (Sept 2016-Mar 2024) and 75F40121F19001 'Evaluation of FDA's The Real Cost campaign' (Sept 2021-Sept 2027). AlDukhail 2023 added 2026-10-22 (openalex-deep queue; DOI checked on Crossref and PMID via NCBI esummary 2026-10-22): 63% exposed; exposed youth more likely to see cigarettes as risky (AOR 1.60), but higher curiosity among exposed Hispanic never-smokers (AOR 1.26). Evidence unchanged. Evidence updated 2026-10-22: level quasi-experimental -> experimental on Farrelly 2021, a market-randomized field trial of The Real Cost smokeless campaign as it aired (belief outcomes, not use). Kowitt 2023 (online forced-exposure ad test) added as a source but not used for the level, since it tests ads, not the campaign as it ran. Outcome kept positive. Reuse terms checked 2026-10-23 by an AI research pass for #47; not yet reviewed by a person.

Record cases/fda-the-real-cost.json, updated 2026-10-23· Link to this campaign