Nicotine beliefs and perceptions of low nicotine labels and mitigating statements among people who do and do not smoke: a cross-sectional study from Aotearoa New Zealand.

BACKGROUND: Aotearoa New Zealand proposed a new maximum nicotine content of 0.8 mg/g for smoked tobacco products, although the new government plans to repeal this legislation. Requiring 'Very low nicotine' (VLN) messages on cigarettes meeting this standard may reinforce misperceptions that they are less harmful than cigarettes currently sold. METHODS: To explore knowledge of nicotine and very low nicotine cigarettes (VLNCs), and perceptions of cigarette packs featuring different low nicotine messages (eg, 'Very low nicotine') and mitigating statements (eg, 'No cigarettes are safe'), we surveyed 354 people who smoked, 142 who formerly smoked, and 214 people who had never smoked regularly. RESULTS: Around half of all respondents believed VLNCs were less harmful than regular cigarettes and around two-thirds incorrectly thought nicotine causes most of the related health problems resulting from smoking. Nearly a third thought VLNCs would be less harmful than regular cigarettes; 34% believed they would be just as harmful. Mitigating statements did not affect perceptions of people who smoked, although people who formerly, or who had never smoked regularly, perceived mitigating statements referring to poisons and cancer as significantly more likely than the VLN message to discourage smoking. CONCLUSIONS: Misunderstanding of VLNCs as less harmful than regular cigarettes is widespread; VLN messages may reinforce this misperception, which mitigating statements did not correct among people who smoke. As an alternative to VLN messages, policy makers could consider introducing VLNCs on a specified date and developing public information campaigns; these measures would avoid phase-in confusion and obviate the need for VLN messaging.

"I'm Bored and I'm Stressed": A Qualitative Study of Exclusive Smokers, ENDS Users, and Transitioning Smokers or ENDS Users in the Time of COVID-19.

BACKGROUND: To better understand the various influences of COVID-19 on tobacco use, we examined three different tobacco user groups using qualitative methods. METHODS: Ten online focus groups with 61 adults from the Atlanta, GA area were held in October-November 2020: four with exclusive smokers (n = 16), three with Electronic Nicotine Delivery System (ENDS) users (dual and exclusive, n = 22), and three with transitioning (recently quit or currently quitting) smokers and/or ENDS users (n = 23). RESULTS: Exclusive smokers reported smoking more frequently, driven by COVID-19-related stress, time at home, and boredom. They were not motivated to quit during the pandemic, and some considered smoking to be protective against COVID-19. ENDS users reported vaping less, with dual users often increasing their smoking; many were concerned about health effects of smoking and ENDS use during the pandemic. Transitioning smokers/ENDS users worried about their health and wanted to quit, but many found the stress of COVID-19 unbearable without tobacco use. CONCLUSIONS: There were some similarities among the groups, but also pronounced differences. Educational campaigns should capitalize on the teachable moment of COVID-19 to increase perceived risk of smoking. Smokers need access to more adaptive ways to deal with stress (such as mindfulness training) in lieu of smoking and systems-level approaches should address structural determinants of health that cause high levels of stress. The proposed policy to lower nicotine in combusted tobacco products might help smokers choose other means of coping instead of cigarettes by reducing the stress-relieving properties of smoking particularly salient during the pandemic. IMPLICATIONS: Smokers believe that cigarettes help them deal with the stresses and challenges of the COVID-19 pandemic. This needs to be counteracted by educational campaigns to increase perceived harm of smoking, alternative stress-relief strategies, and mandated changes to the combusted tobacco products to make them less appealing.

Brief report on IQOS point-of-sale marketing, promotion and pricing in IQOS retail partner stores in Atlanta, Georgia, USA.

OBJECTIVES: Philip Morris has a history of aggressive marketing tactics in its global pursuit of IQOS sales, which extant literature suggests may appeal to non-smokers and young adults. This study was the first to examine point-of-sale (POS) marketing and pricing of IQOS after it entered the US market in October 2019. METHODS: Trained field staff assessed 75 retail partner stores selling IQOS/HeatSticks in the Atlanta area in February-November 2020 using an IQOS-tailored, standardised assessment tool. The tool assessed store characteristics, product availability and accessibility, marketing and promotions and pricing for each store. RESULTS: All stores assessed sold HeatSticks in at least one of the three flavours (tobacco, smooth menthol, fresh menthol), but did not sell the IQOS device. IQOS/HeatSticks marketing was present inside 98.5% and outside 17.3% of stores assessed. Marketing for other tobacco products was present inside 98.5% and outside 32% of stores. The average price per HeatSticks pack was US$6.40 compared with US$6.08 for Marlboro Red cigarettes. CONCLUSION: Our study revealed a considerable amount of POS marketing and promotion for IQOS/HeatSticks at retail partner locations, visible to all retail consumers, including youth and non-smokers. This study was the first to examine IQOS POS marketing and promotion in the US context and findings add to the extant literature on IQOS global marketing strategies. As additional novel tobacco/nicotine products continue to enter the market, targeted monitoring of the POS marketing and promotion for these new products is warranted.

Effects of modified risk tobacco product claims on consumer comprehension and risk perceptions of IQOS.

INTRODUCTION: Tobacco industry studies on consumers' perceptions of modified risk claims (MRCs) often had important omissions (eg, no control group, not investigating whether consumers understand what 'switching completely' means). This study examined the effects of IQOS MRCs on risk perceptions and behavioural intentions. METHOD: Based on tobacco companies' MRCs, we manipulated three MRC language features: explanation about 'switching completely' (absent vs present), number of diseases (single vs multiple) and language certainty (hypothetical vs certain). In an online experiment, we randomised 1523 US adult current smokers and 1391 young adult non-smokers to 1 of 9 conditions following a 2×2×2+1 control design. People reported their comprehension of 'switching completely', IQOS risk perceptions and behavioural intentions after message exposure. RESULTS: More smokers exposed to MRCs that included an explanation about 'switching completely' (22.2%) (vs explanation absent (11.2%) and control (10.7%)) mentioned that 'switching completely' meant smoking 0 cigarettes. Compared with the control, several MRCs (eg, certain language) produced lower perceived risk of IQOS, including for diseases not mentioned in the MRCs. MRCs using certain and hypothetical language did not differ on any outcomes. MRCs highlighting reduced risk for a single disease and multiple diseases did not differ on any outcomes. MRCs did not influence behavioural intentions. CONCLUSION: The Food and Drug Administration should ensure that consumers understand what 'switching completely' means in an MRC and recognize that some language features may mislead consumers into believing that a product reduces the risk of diseases not mentioned in an MRC.

Communicating risk differences between electronic and combusted cigarettes: the role of the FDA-mandated addiction warning and a nicotine fact sheet.

INTRODUCTION: The US Food and Drug Administration requires e-cigarettes to carry a nicotine addiction warning. This research compared the effects of messages communicating comparative risk of electronic and combusted cigarettes (CR messages) with and without the mandated warning and tested the effects of showing a nicotine fact sheet (NFS) before exposure to CR messages with warning. METHOD: In an online experiment, 1528 US adult smokers were randomised to one of four conditions: (1) three CR messages, (2) three CR messages in condition one with an addiction warning, (3) an NFS followed by the three messages in condition 2 and (4) control messages. Outcomes included message reactions and perceived effectiveness, e-cigarette-related and cigarette-related beliefs and behavioural intentions and nicotine-related beliefs. RESULTS: CR messages with and without an addiction warning did not differ. The NFS condition produced higher odds of correctly understanding the risk of nicotine and stronger beliefs that switching to e-cigarettes could reduce health risks (response efficacy) than other treatments. Compared with control, all messages made it more likely for people to report e-cigarettes are less harmful than cigarettes and increased response efficacy and switch intentions to e-cigarettes. Only NFS condition increased correct beliefs about the risk of nicotine and self-efficacy about switching to e-cigarettes. CONCLUSION: Including an addiction warning on CR messages did not reduce intentions to switch to e-cigarettes. Communicating accurate risk of nicotine together with CR messages and addiction warning increased smokers' self-efficacy beliefs about switching completely to e-cigarettes, making it a potentially promising antitobacco communication strategy.

Inferences beyond a claim: a typology of potential halo effects related to modified risk tobacco product claims.

When tobacco products are marketed with modified risk tobacco product (MRTP) claims, consumers may infer additional health benefits not directly stated in the claims. We propose a typology of seven potential 'halo effects' (ie, an unintended generalisation) that may occur with MRTP marketing. Evidence currently exists that some of these types of halo effects occur after exposure to MRTP claims. These generalisations are likely unavoidable in certain situations and may sometimes produce accurate inferences. However, some halo effects may be problematic if they mislead consumers into false inferences and result in unintended consequences that have a negative public health impact (eg, reinitiation, dual tobacco product use). To help mitigate unintended consequences and guide regulatory decisions about MRTP claims, we encourage researchers studying MRTP claims to test for halo effects. Regulatory agencies should include potential unintended consequences associated with halo effects when assessing individual-level and population-level health impacts of MRTP claims. Moreover, tobacco manufacturers should be required to report both premarket and postmarket surveillance of halo effects to relevant regulatory agencies. If MRTP claims are to play a role in tobacco harm reduction, it is imperative that they be communicated and interpreted in ways that minimise harms and maximise public health benefits.

Trends in Trust in the Sources of Health Information on E-Cigarettes Among US Adults, 2015-2017.

Objectives. To evaluate recent levels and trends in trust in sources of health information on e-cigarettes in the United States.Methods. We obtained data from nationally representative samples of adults in 2015 (n = 5389), 2016 (n = 5273), and 2017 (n = 5389) that reported trust in 13 sources of health information on e-cigarettes in the United States. We used weighted linear regression models to examine temporal trends in trust levels.Results. Doctors, health organizations, the Centers for Disease Control and Prevention (CDC), health experts and scientists, the National Institutes of Health (NIH), the Food and Drug Administration (FDA), and family and friends were trusted, whereas news media, e-cigarette users, social media, vape shop employees, and e-cigarette and cigarette companies were distrusted. From 2015 to 2017, trust significantly increased for CDC, FDA, health experts and scientists, and news media (Ps < .01). Trust also increased for NIH between 2016 and 2017 (P < .01).Conclusions. US adults trust public health sources and distrust entities with commercial interest in e-cigarettes. This suggests that evidence-based messaging and information on health effects of e-cigarettes from public health professionals can effectively counter e-cigarette promotion and improve public understanding about e-cigarettes.

Testing messages about comparative risk of electronic cigarettes and combusted cigarettes.

INTRODUCTION: Health agencies are grappling with communicating risks of electronic cigarettes (e-cigarettes) compared with combusted cigarettes. This study examined smokers' responses to two types of comparative risk messages with one type incorporating more negative antismoking elements in the design. METHODS: In an online experiment, 1400 US adult (18+ years) current smokers and recent quitters were randomised to view one of three comparative risk messages about e-cigarettes (CR messages), one of three comparative risk messages that included more negative antismoking elements in the design (CR- messages) or a control message. Selection of outcomes was guided by the antismoking message impact framework. Multivariate analyses of covariance and logistic regression models analysed effects of messages on message evaluations, e-cigarette-related and cigarette-related beliefs and behavioural intentions. RESULTS: Both CR and CR- messages decreased smokers' intentions to smoke cigarettes, increased intentions to switch to e-cigarettes completely and increased perceptions that e-cigarettes are less harmful than combusted cigarettes. Neither message type increased dual use intentions relative to exclusive e-cigarettes use or smoking cessation. CR messages decreased perceived absolute risks of e-cigarettes and self-exempting beliefs about smoking, whereas CR- versus CR messages produced higher self-efficacy to quit smoking. CONCLUSION: Comparative risk communication might encourage smokers to switch to lower-harm tobacco products. Comparative risk messages with more negative antismoking elements in the design might be particularly effective, because they led to higher self-efficacy to quit smoking. Regulatory agencies may consider using comparative risk messages with more negative antismoking elements to educate the public about lower risk of e-cigarettes.

Light and mild redux: heated tobacco products' reduced exposure claims are likely to be misunderstood as reduced risk claims.

INTRODUCTION: Heated tobacco products (HTPs) are being marketed in several countries around the world with claims that they are less harmful than combusted cigarettes, based on assertions that they expose users to lower levels of toxicants. In the USA, Philip Morris International (PMI) has submitted an application to the Food and Drug Administration (FDA) in 2016 seeking authorisation to market its HTPs, IQOS, with reduced risk and reduced exposure claims. METHODS: We examined the PMI's Perception and Behavior Assessment Studies evaluating perceptions of reduced risk claims that were submitted to the FDA and made publicly available. RESULTS: Qualitative and quantitative studies conducted by PMI demonstrate that adult consumers in the USA perceive reduced exposure claims as reduced risk claims. CONCLUSION: The data in the PMI modified risk tobacco product IQOS application do not support reduced risk claims and the reduced exposure claims are perceived as reduced risk claims, which is explicitly prohibited by the FDA. Allowing PMI to promote IQOS as reduced exposure would amount to a legally sanctioned repeat of the 'light' and 'mild' fraud which, for conventional cigarettes, is prohibited by the US law and the WHO Framework Convention on Tobacco Control.

IQOS labelling will mislead consumers.

BACKGROUND: Philip Morris International (PMI) continually expands and diversifies their nicotine product portfolio, which includes IQOS, a heated tobacco product. In December 2016, PMI filed a modified risk tobacco product (MRTP) application with the US Food and Drug Administration (FDA), seeking authorisation to market IQOS in USA with three claims of reduced harm: 'switching completely from conventional cigarettes to the IQOS system…' (1) 'can reduce the risks of tobacco-related diseases;' (2) 'significantly reduce[s] your body's exposure to harmful or potentially harmful chemicals;' and (3) 'presents less risk of harm than continuing to smoke cigarettes.' Consumers may misunderstand what is meant by 'switching completely'. METHODS: We critically reviewed study reports submitted to FDA by PMI in support of proposed marketing claims in its MRTP application for IQOS and focused on the statement that switching completely to IQOS reduces risk. RESULTS: We found deficiencies with evidence provided by PMI supporting their assertions that: current smokers will understand what is meant by the phrase 'switching completely'; the proposed claims will not decrease smokers' intentions to quit; and IQOS users will in fact 'switch completely' from smoking cigarettes to using IQOS. The studies and measurement instruments employed by PMI suffer from design flaws and their reporting of associated findings is misleading. CONCLUSION: Consumers will not understand the condition of the claims-that they must quit using cigarettes completely to achieve the inferred health benefits of IQOS. Rather, they are likely to misunderstand the unsupported claims of reduced risks to mean IQOS are harm-free.

Testing messages to reduce smokers' openness to using novel smokeless tobacco products.

INTRODUCTION: Tobacco manufacturers' aggressive promotion of new smokeless tobacco products such as snus warrants a timely and effective public health response. This study tested potential countermarketing messages to discourage current and former smokers from becoming dual users of smokeless tobacco and cigarettes. METHODS: In a pretest-post-test experiment, 1836 adult current and recently former smokers from a national sample were randomised to view one of six antismokeless tobacco ads followed by a snus ad, to view a control ad followed by a snus ad; or to view two control ads. Perceived effectiveness of ads and actual changes in attitudes and openness to snus were compared across groups using analyses of variance. RESULTS: Some ads that were perceived as most effective did not change attitudes or openness to trying snus, and conversely, some ads not perceived as effective changed attitudes and openness to snus. Ads portraying the negative health effects of smokeless tobacco were perceived as most effective, but ads with antitobacco industry themes significantly decreased favourable attitudes toward snus. Responses to ads were different for smokers who had ever used smokeless tobacco: for this group health effects and humorous/testimonial ads were effective. CONCLUSIONS: Measures of perceived effectiveness of antitobacco ads need to be augmented with measures of actual effectiveness to assess countermarketing messages. Some of the developed ads, such as ads with anti-industry themes, were effective for the overall population of smokers whereas humorous/testimonial and health effects ads were particularly effective in changing attitudes of past users of smokeless tobacco.

Prevalence and associated factors of shisha smoking among students in Senegal: Global Youth Tobacco Survey 2020.

INTRODUCTION: Although shisha smoking is banned in Senegal, it has become increasingly popular, especially among youth. Despite the health risks associated with shisha smoking, there are few studies on shisha smoking in West Africa and none in Senegal. Our study assessed the prevalence and factors associated with shisha smoking among students aged 13-15 years in Senegal. METHODS: We used the 2020 Global Youth Tobacco Survey (GYTS) Senegal data from 2524 students aged 13-15 years. We calculated the weighted prevalence of ever and current (past 30 days) shisha smoking. Multivariable logistic regression analyses identified factors associated with ever and current shisha smoking among students. RESULTS: The prevalences of ever and current shisha smoking were 9.8% (95% CI: 7.7-12.3) and 2.2% (95% CI: 1.5-3.1), respectively. Ever shisha smoking was significantly associated with being male (AOR=1.97; 95% CI: 1.33-2.92), current cigarette smoking (AOR=7.54; 95% CI: 2.95-19.29), higher class grade (AOR=2.27; 95% CI:1.10-4.67), more weekly pocket money (AOR=3.29; 95% CI:1.36-7.95), current use of smokeless tobacco (AOR=11.53; 95% CI: 4.98- 26.72), and exposure to secondhand cigarette smoke in public (AOR=1.55; 95% CI: 1.00-2.41). Current shisha smoking was significantly associated with current cigarette smoking (AOR=21.75; 95% CI: 6.08-77.78), more weekly pocket money (AOR=8.91; 95% CI: 1.75-45.40), current use of smokeless tobacco (AOR=8.26; 95% CI: 2.07-33.04), and fathers' smoking (AOR=3.34; 95% CI: 1.24-8.96). CONCLUSIONS: One in 10 students aged 13-15 years have ever smoked shisha and 2.2% were currently smoking it, suggesting that shisha smoking is a public health concern in Senegal. Senegal might consider offering students more education on the harms of shisha, both in schools and through comprehensive media campaigns that address all tobacco products.

Reply to Foxon, F.; Shiffman, S. Comment on "Wang et al. Consumption of JUUL vs. Other E-Cigarette Brands among U.S. E-Cigarette Users: Evidence from Wave 5 of the PATH Study. Int. J. Environ. Res. Public Health 2022, 19, 10837".

In this reply, we respond to the comments by Foxon and Shiffman [...].

Examining reactions to smoking and COVID-19 risk messages: An experimental study with people who smoke.

BACKGROUND: Smoking cigarettes worsens COVID-19 outcomes, and news media and health agencies have been communicating about that. However, few studies have examined how these messages affect attitudes, beliefs, and behavioral intentions of people who smoke. These are critical variables that can inform public health campaigns to motivate quitting smoking during the COVID-19 crisis. METHODS: In August 2020, we conducted an online experiment in the U.S. with 1,004 adults who smoke. Participants were randomized to one of four message conditions: COVID-19 risk, smoking risk, combined risk of smoking for COVID-19 severity, or a non-risk control. Outcomes were message reactions (emotions and reactance), attitudes and beliefs (severity, susceptibility, self-efficacy, response efficacy for smoking and COVID-19, and conspiracy beliefs), and behavioral intentions (smoking intentions, COVID-protective intentions, and information-seeking). RESULTS: Multivariate analysis of covariance (MANCOVA) showed that combined risk messages elicited higher perceived severity of smoking-related disease than control messages. Similarly, the combined risk condition resulted in greater intentions to quit smoking in the next month (vs. COVID-19 risk condition) and intentions to reduce smoking in the next 6 months (vs. smoking risk and control; ps < .05). Multivariate logistic regression found that exposure to the combined risk messages (vs. control as referent) was associated with higher odds of mask-wearing intentions in the next 2 weeks (AOR = 1.97). CONCLUSIONS: Health agencies can possibly use messages that communicate about the combined risk of smoking and COVID-19 as a novel strategy to motivate people who smoke to quit and take protective action for COVID-19.

"You have to vape to make it through": E-cigarette Outcome Expectancies among Youth and Parents.

Objectives: Outcome expectancies are central to explaining health behavior and have been shown to predict tobacco use. Research on outcome expectancies for e-cigarette use among youth is scarce but increasingly important given the growing rates of use, particularly of high-nicotine pod devices and the recent outbreak of e-cigarette related lung disease. Methods: In 2019, we conducted 3 focus groups with middle school youth (N=25), 5 with high school youth (N=38), and 4 with parents (N=27). Youth and parents were not related and groups included both users and non-users. Participants discussed reasons for e-cigarette use and bad and good things that might happen to a person who vapes. Results: Participants described positive and negative psychoactive/sensory, social, and health-related outcome expectancies. Both youth and parents mentioned stress relief and appearing older as positive outcome expectancies, and e-cigarette flavors, acting rebellious, and structural opportunities as other reasons for initiating e-cigarette use. Social consequences and health outcomes were negative outcome expectancies deterring use. Conclusions: Regulations and public communication campaigns can counteract the positive outcome expectancies (flavor regulation, providing stress reduction tips) and capitalize on negative ones (communicating negative health outcomes) to decrease youth e-cigarette use.

An experimental study of messages communicating potential harms of electronic cigarettes.

There has been an upsurge of e-cigarette use in the United States in recent years. While e-cigarettes may contain lower levels of toxic chemicals than combusted cigarettes, they still pose serious health hazards, including increased risk for heart and respiratory disease. Despite these risks, public awareness of the health harms of e-cigarettes remains low. Thus, it is important to educate the public about the potential harms of e-cigarettes. This study took themes commonly found in antismoking messages and used them to develop messages about harms of e-cigarettes. A national sample of 2801 current smokers and nonsmokers (aged 18+ years) were randomized to view one of four e-cigarette messages (harmful effect of chemicals, uncertainty about ingredients, distrust of big tobacco, or cost of vaping) or a control message (bottled water ad). Participants' reactions to the messages and behavioral intentions were assessed immediately following the exposure. MANOVA examined effects of the messages on blocks of the outcome variables and univariate analyses estimated adjusted means for each experimental condition for each outcome. The message about harmful chemicals was perceived as the most informative and effective and elicited the highest levels of negative emotions (Ps<0.05). However, on measures of actual effectiveness, the other messages performed equally well. Specifically, messages with different themes (harmful chemicals, uncertainty about ingredients, anti-industry, or financial cost) increased perceived risk of e-cigarettes, support for e-cigarette control, and lowered self-exempting beliefs and intentions to use e-cigarettes (Ps<0.05). Themes commonly used in anti-smoking messages may be effective in educating the public about the potential harm of e-cigarettes. The observed differential effects of the messages suggest the need to use multiple themes in a public education campaign about e-cigarettes.

Warning Labels on Sugar-sweetened Beverages: An Eye Tracking Approach.

Objectives: In this study, we examined visual attention of a warning label on a sugar-sweetened beverage (SSB) and its effects on visual attention to SSB product descriptors and perceptions of SSB using eye tracking technology. Methods: We had 180 young adults view an image of a generic soda can with or without a text warning on a computer monitor. Results: Participants spent less time looking at marketing elements on the can in the "Warning" condition compared to the "No warning" (control) condition. Compared to the control, participants in the "Warning" condition viewed the sugar-sweetened beverage as less healthy (1.78 warning vs 2.21 control, p < .01) and believed that drinking SSBs contributed to diabetes (5.70 warning vs 5.27 control, p < .01). Visual attention to warning label was associated with correct recall of the warning and opting out of purchasing the can. Conclusions: Textual warning on SSB reduced visual attention to marketing elements on the can. Although there were few statistically significant differences between the conditions on most measures of product appeal or risk perception, warnings increased some perceived risks of SSBs indicating that warning labels on SSBs might be a promising strategy in informing consumers, particularly young adults, about risks of added sugars.

A Profile of Individuals with Anti-tobacco Message Fatigue.

OBJECTIVES: Message fatigue, a phenomenon of being tired of repeated exposure to messages promoting the same health behavior, may reduce the effectiveness of anti-tobacco messages, such as warning labels. As an initial step towards understanding the phenomenon, we examined predictors of anti-tobacco message fatigue. METHODS: An online study (N = 1838) involving a non-probability sample of nonsmokers and smokers in the United States assessed anti-tobacco message fatigue and individual-level factors including demographic variables and smoking status. General linear models were used to analyze the data. RESULTS: The multivariable results show that individuals who were younger, male, and had higher income and education reported higher levels of anti-tobacco message fatigue. African Americans reported significantly lower levels of message fatigue than other racial groups. Current smokers reported greater message fatigue than transitioning smokers and nonsmokers. Among current smokers, those with greater nicotine dependence reported higher levels of anti-tobacco message fatigue. CONCLUSIONS: These findings underscore the importance of segmenting the audience based on their levels of message fatigue and using more novel message strategies and delivery methods to influence populations with relatively higher levels of anti-tobacco message fatigue.