"The Real Cost" in Context: Comparative Surveillance of E-Cigarette Prevention Campaigns on Twitter (2018-2023)

E-cigarette prevention campaigns face visibility and sustainability challenges on social media, where provaping content dominates, and coordinated opposition is common. National initiatives such as the Food and Drug Administration's "The Real Cost" campaign operate alongside regional efforts, yet their comparative resilience and reach in digital spaces remain understudied.

To evaluate and compare national and state/local campaigns (2018-2023) on Twitter/X, machine-learning classifiers (F1>0.90 for opposition detection) and geotagged data from Twitter's Historical PowerTrack and Academic application programming interfaces were used to analyze campaign-related content across 4 domains: volume, valence (opposition versus prevention/neutral), engagement (retweets, potential reach), and user behavior (cross-campaign participation). Tweets were algorithmically assigned to campaigns using regular expressions and filtered for relevance. Data were collected from 2018 to 2023 and analyzed in 2025.

From April 2018 to April 2023, campaign-related posts declined by 61.8%, with opposition content consistently comprising >70% of posts and exceeding 90% in some months. Opposition was concentrated among a small subset of users (top 10% generated 57.9% of opposition retweets). About one fifth (20.5%) of "The Real Cost" campaign-related messages were classified as opposition, whereas regional campaigns, particularly Chicago's Vaping Truth, faced overwhelming opposition (99.6% of posts), with 96.2% originating outside intended campaign jurisdictions.

The relative resilience of "The Real Cost" reflects the advantages of sustained investment, national scope, and constant branding. Regional campaigns were particularly vulnerable to cross-jurisdictional narrative hijacking. Future prevention efforts must proactively identify and counter coordinated opposition strategies to improve digital reach and effectiveness.