Naturally leading: a content analysis of terms, themes and word associations in Natural American Spirit advertising, 2000-2020.

BACKGROUND: Natural American Spirit (NAS) is a cigarette brand distinguished by supposed 'natural', 'additive-free' characteristics, marketing of which is tied to misperceptions of reduced harm. In 2017, NAS's manufacturer agreed (with the Food and Drug Administration) to remove 'natural'/'additive-free' from US marketing. Prior research has explored NAS marketing immediately post-agreement. This study sought to identify prominent post-agreement terms and themes and analyse how they had been used in pre-agreement ads. METHODS: We conducted a content analysis of NAS ads from 2000 to 2020 (N=176), documenting prominent pre-agreement and post-agreement terms/themes and examining how they are used in NAS ads. We coded for descriptors, themes, imagery and promotions, and extended prior research by analysing how leading post-agreement terms were used in conjunction and thematically associated with 'additive-free' and 'natural' before the agreement. RESULTS: Results indicated 'tobacco and water' and 'Real. Simple. Different.' increased post-agreement, as did environmental imagery. 'Organic' was prominent pre-agreement and post-agreement. The descriptors used most often in post-agreement ads almost always appeared in conjunction with (and were thematically linked to) 'natural' and 'additive-free' in pre-agreement ads. CONCLUSIONS: In the years since the agreement, NAS ads have heavily relied on still-allowable descriptors that may invite reduced risk misperceptions. Notably, these descriptors were consistently used alongside the banned terminology before the agreement and presented as if affiliated conceptually, possibly prompting similar connotations. Findings indicate a continuing need for research into NAS advertising effects and a potential role for additional regulatory action.

'95% less harmful'? Exploring reactions to quantitative modified risk claims for snus and e-cigarettes.

OBJECTIVES: Studies examining perceptions of 'modified risk tobacco product' (MRTP) messages for e-cigarettes and smokeless tobacco have indicated consumers want statistics and quantification of harm reduction. However, limited research exists on reactions to quantitative MRTP messages. DESIGN: We conducted 12 focus groups in the USA in 2019-6 focused on e-cigarette messages and 6 on snus messages. Eight groups were with current smokers (ages 21-66) and four with young adult (ages 18-25) non-smokers (n=57). Participants discussed messages stating that use of snus and vaping products have been estimated by scientists to be about 90% and 95% less harmful than smoking cigarettes, respectively. RESULTS: Several participants agreed the messages strongly communicated that the products are less harmful than cigarettes, were attention getting and could be 'convincing'. However, participants expressed scepticism about the source and accuracy of the stated figures, and some noted the claims could be misleading and attractive to young people. Comments also reflected some claim misunderstandings (eg, that e-cigarettes only pose a 5% chance of harm). Participants also agreed that stating e-cigarette risks 'are unlikely to exceed 5% of cigarette smoking harms' was confusing and less impactful than the '95% less harmful' wording. CONCLUSIONS: Quantitative claims suggesting high levels of reduced risk when comparing e-cigarettes or smokeless tobacco/snus relative to cigarettes may be successful in gaining attention and being persuasive for some audiences, particularly, if from more credible sources. However, message developers, users and evaluators should be mindful of message limitations and aim to mitigate unintended consequences.

From the Deeming Rule to JUUL-US News Coverage of Electronic Cigarettes, 2015-2018.

INTRODUCTION: News media may influence public perceptions and attitudes about electronic cigarettes (e-cigarettes), which may influence product use and attitudes about their regulation. The purpose of this study is to describe trends in US news coverage of e-cigarettes during a period of evolving regulation, science, and trends in the use of e-cigarettes. METHODS: We conducted a content analysis of e-cigarette topics and themes covered in US news articles from 2015 to 2018. Online news databases (Access World News, Factiva) were used to obtain US news articles from the top 34 circulating newspapers, four national wire services, and five leading online news sources. RESULTS: The number of articles increased by 75.4% between 2015 and 2018 (n = 1609). Most articles focused on policy/regulation (43.5%) as a main topic, followed by health effects (22.3%) and prevalence/trends (17.9%). Discussion about flavor bans quadrupled (6.1% to 24.6%) and discussion of youth e-cigarette use was most prevalent (58.4%) in 2018, coinciding with an increase in coverage about JUUL. JUUL was mentioned in 50.8% of 2018 articles. Across years, articles more frequently mentioned e-cigarette risks (70%) than potential benefits (37.3%). CONCLUSIONS: E-cigarettes continue to be a newsworthy topic, with coverage both reflecting numerous changes and events over time, and providing repeated opportunities for informing the public and policymakers about these novel products. Future research should continue to track how discourse changes over time and assess its potential influence on e-cigarette perceptions and policy changes. IMPLICATIONS: E-cigarette news coverage in the United States increased between 2015 and 2018 and predominantly focused on policy and regulation. Notable spikes in volume were associated with some but not all major e-cigarette events, including the FDA's deeming rule, Surgeon General's report, and release of the National Youth Tobacco Survey data in 2018. Coverage of the 2018 National Academy of Medicine, Engineering, and Sciences report on the Public Health Consequences of E-cigarettes received minimal news coverage. The high volume in 2018 was driven in large part by coverage of the e-cigarette brand JUUL; over half of news articles in 2018 referenced JUUL specifically.

'Being politically active does not have to be difficult.' A content analysis of tobacco industry-sponsored advocacy websites.

OBJECTIVE: To characterise the thematic content of tobacco industry-sponsored advocacy websites in the USA and to compare these sites to identify differences in products, target audience, policies or themes. METHODS: In 2017, US-based Google and purposive searches identified six US tobacco industry-sponsored advocacy websites. A coding guide based on existing literature, tobacco policy issues and iterative review of the websites was developed and, descriptive analyses of themes on individual websites and overall were conducted. RESULTS: We identified 18 themes; the most common of these were: tobacco taxes (13.9%), providing advocacy resources (10.6%) and pleas for action (10.3%). Related themes were aggregated into four broad categories: advocacy (36.7%), taxes (31.4%), legislation is excessive or unnecessary (21%), and support for weaker tobacco control policies (10.9%). Websites targeting consumers provided more resources to facilitate advocacy than websites targeting retailers. CONCLUSIONS: Websites promoting protobacco advocacy are an important and evolving strategy for the tobacco industry. Websites are particularly well suited to leverage marketing activities (eg, building relationships with retailers and consumers) to achieve policy objectives. Monitoring these tactics may allow advocates to counter and anticipate industry opposition to tobacco policy.

Widespread Belief That Organic and Additive-Free Tobacco Products are Less Harmful Than Regular Tobacco Products: Results From the 2017 US Health Information National Trends Survey.

SIGNIFICANCE: US smokers of Natural American Spirit, a brand marketed as "organic" and "additive-free," are more likely than other cigarette smokers to believe that their brand might be less harmful than other brands. This article (1) describes the prevalence of belief that "organic" and "additive-free" tobacco is less harmful than regular tobacco products in the US population and (2) describes the sociodemographic characteristics of adults who believe tobacco products with these descriptors are less harmful. METHODS: Data were drawn from the 2017 Health Information National Trends Survey (HINTS), a nationally representative survey of US adults. Logistic regression models were used to examine correlates of the belief that "organic" or "additive-free" tobacco products are less harmful than regular tobacco products. RESULTS: Overall, 26.7% of US adults and 45.3% of adult smokers believe that "organic" tobacco products are less harmful than regular tobacco products. Similarly, 35.2% of US adults and 47.1% of smokers believe that "additive-free" tobacco products are less harmful. When examining gender, age, education, race/ethnicity, sexual orientation, and smoking status, only age (adjusted odds ratio [aOR] ~0.98, 95% confidence interval [CI]: 0.97, 0.99 for both outcomes) and smoking status (current vs. never smokers, aOR ~1.78, 95% CI 1.03, 3.07 for both outcomes) were correlates of believing that "organic" or "additive-free" tobacco is less harmful than regular tobacco products. CONCLUSIONS: Belief that "organic" and "additive-free" tobacco products are less harmful than other products is widespread. Younger adults and current smokers are most likely to be misinformed by "organic" or "additive-free" tobacco product descriptors. IMPLICATIONS: Belief that "organic" and "additive-free" tobacco products are less harmful than other products is widespread among US adults and most prevalent among smokers. Removal of terms that incorrectly imply reduced harm may correct current and future consumers' misperceptions about the brand.

The Impact of Smokeless Tobacco Risk Information on Smokers' Risk Perceptions and Use Intentions: A News Media Experiment.

Little research exists on the impact of risk information comparing smokeless tobacco (SLT) use, particularly snus, to cigarette smoking. This study explored this topic using a communication channel where smokers may be exposed to such information-the news media. We randomly assigned 1008 current smokers to read one of three constructed news stories or to a control group (no article). The "favorable" story framed snus as a "safer" smoking alternative while the "cautious" story described snus risks. The "mixed" version described potential risks and harm-reduction benefits. Participants completed a post-article survey with snus risk and harm perception and use intention measures. Article condition was significantly associated with perceived harm of daily snus use relative to smoking (1 = a lot less harmful - 5 = a lot more harmful; p < .0001), and mean ratings of snus harm in the favorable (2.46) and mixed conditions (2.66) were significantly lower than those of the cautious (2.96) and control conditions (2.98). Mean interest in trying snus in the next 6 months was low, but significantly higher for those in the favorable (1.55) and mixed conditions (1.32) versus those in the cautious (1.17) and control conditions (1.16)(1 = not at all - 5 = extremely interested, p < .0001). There were no significant differences by group in terms of the story's perceived interestingness, importance, or relevance. Exposure to reduced-risk news messages about SLT and snus relative to cigarettes may impact smokers' SLT harm perceptions and use intentions. Tobacco control professionals and FDA officials should consider the potential impact of the news media when communicating about tobacco risks.

In Their Own Words: Young Adults' Menthol Cigarette Initiation, Perceptions, Experiences and Regulation Perspectives.

Background: Menthol cigarettes are disproportionately used by young people and have been called smoking starter products. However, limited qualitative research exists on young adults' perceptions of and experiences with these products, with much of it based on document reviews of the tobacco industry's research. Methods: We conducted six focus groups with young adult (ages 18-24) menthol smokers in New Jersey (half with black smokers) between December 2014 and March 2015. Participants were asked open-ended questions about their menthol smoking initiation, preference reasons, substitution behaviors, and perceptions of menthol cigarette risks and regulation. Results: Participants' menthol cigarette initiation and preference were influenced by their perceived popularity, brand recognition, taste, smoothness, satisfaction and access (including as "loosies," typically available for Newport). Some believed menthol cigarettes were less harmful than non-menthol cigarettes when initiating smoking. Many currently believed menthol cigarettes were more harmful because they contained extra "additives," were stronger (ie, requiring fewer cigarettes to feel satisfied), and/or based on hearsay. Many had tried new brand Camel Crush, which was perceived to be especially minty, fun, and attractive for newer smokers. While some used non-menthol cigarettes when menthols were unavailable, many said they would never or almost never substitute. Many acknowledged a menthol cigarettes ban would likely help them quit smoking, even though they did not support the idea. Conclusions: Menthol cigarette initiation is influenced by an interplay of multiple factors including their sensory properties, marketing, perceived popularity and availability. The FDA should continue to pursue closing this flavored cigarette loophole. Implications: In this first qualitative study of menthol cigarette use among young adults, we found further evidence that menthol cigarettes can act as starter products because they are perceived as easier to smoke and taste and smell better than non-menthol cigarettes. We also add to the literature in finding that menthol cigarettes are perceived by young people who smoke menthol cigarettes as delivering satisfaction with fewer cigarettes, being accessible as "loosies", and being popular among their peers. Many did not understand the reasons behind a potential menthol ban. Any future regulation of menthol cigarettes should include a public educational campaign to support buy-in.

Content Analysis of US News Stories About E-Cigarettes in 2015.

Background: Coverage of e-cigarettes in the news media may shape public perceptions about them but little is known about such news content. This content analysis characterized discussion of e-cigarettes in leading print and online US news sources in 2015. Methods: We searched Access World News and Factiva databases for e-cigarette-related news articles appearing in the top 30 circulating newspapers, 4 newswires, and 4 online news sources in the United States in 2015 (n = 295). Coders identified the presence of various e-cigarette topics (e.g. regulation), and benefit and risk statements. Results: Nearly half of articles (45.1%) focused primarily on e-cigarette policy/regulatory issues, although e-cigarette prevalence (21.0%) and health effects (21.7%) were common main topics. Concerns about youth were frequently mentioned, including the rise in youth e-cigarette use (45.4%), gateway to smoking potential (33.9%) and appeal of flavors (22.4%). Youth e-cigarette prevalence was more frequently mentioned than adult prevalence in articles discussing FDA regulation (61% vs. 13.5%, respectively). News articles more frequently discussed potential e-cigarette risks or concerns (80%) than benefits (45.4%), such as smoking harm-reduction. Quoted physicians, researchers, and government representatives were more likely to refer to e-cigarette risks than benefits. Conclusions: In 2015, rising rates of e-cigarette use among youth and policy strategies to address e-cigarettes dominated US e-cigarette news stories, leading up to their FDA regulation in 2016. Statements about e-cigarettes' potential risks were frequently attributed to trusted sources such as physicians, and outnumbered claims about their harm-reduction benefits. Such coverage may impact e-cigarette risk perceptions, use intentions and policy support. Implications: In the year leading up to the FDA's Deeming Rule, concerns about youth use or potential use were frequently discussed in e-cigarette news. News articles more frequently discussed potential e-cigarette risks/concerns compared to potential harm-reduction benefits relative to tobacco cigarettes. While such coverage may inform the public about potential e-cigarette risks, they may also contribute to increasing perceptions that e-cigarettes are as harmful as tobacco cigarettes. E-cigarette risk and benefit statements were most frequently made by or attributed to researchers and physicians in articles, which is significant given that they may be particularly trusted sources of e-cigarette risk information.

"They're Pretty Much Made for Blunts": Product Features That Facilitate Marijuana Use Among Young Adult Cigarillo Users in the United States.

INTRODUCTION: Cigarillo use is prevalent among young adults in the United States. Many young people use cigarillos as "blunts," a term for a cigar emptied of its tobacco and replaced with marijuana. Because cigars in the United States are not subject to the same regulations as cigarettes, they offer a diverse selection of flavors and packaging styles. It is unclear how these and other product attributes facilitate blunt use. METHODS: Semi-structured telephone interviews were conducted with a sample of 40 young adult cigar or cigarillo users in the United States to assess patterns of use and perceptions about product features. Quotations from interview transcripts were coded for major themes and summarized across participants. RESULTS: Regardless of their preferred brand, participants felt that the brand Black & Mild is primarily smoked for the tobacco. There was a strong perception, however, that other popular cigarillo brands are almost always used to make blunts. Participants believed that cigarillo companies design their products to simplify blunt-making, with features such as perforated lines or wrappings that unroll easily. Resealable foil pouches, a popular packaging style, are often used to hold unused marijuana and mask its smell. CONCLUSIONS: Blunt use is pervasive among young adult cigarillo users in the United States, and certain cigar companies have developed products that facilitate blunt-making. Future surveillance measures should capture the extent to which cigarillo users are using these products as blunts. Continued surveillance of cigarillo sales and popular product attributes are needed. IMPLICATIONS: Cigarillo use is prevalent among young adults in the United States, many of whom are using the products as blunts. This study found that product features such as brand, flavor, packaging, and price influence the selection of cigarillos used for this purpose. There is also a strong perception among young adult cigarillo users that cigarillo companies design their products and packaging to make the blunt-making process simple and enjoyable. Better surveillance measures are needed to capture the extent to which cigarillos are used as blunts and which product features are driving category growth.

"Gone are the days of mass-media marketing plans and short term customer relationships": tobacco industry direct mail and database marketing strategies.

BACKGROUND: As limitations on traditional marketing tactics and scrutiny by tobacco control have increased, the tobacco industry has benefited from direct mail marketing which transmits marketing messages directly to carefully targeted consumers utilising extensive custom consumer databases. However, research in these areas has been limited. This is the first study to examine the development, purposes and extent of direct mail and customer databases. METHODS: We examined direct mail and database marketing by RJ Reynolds and Philip Morris utilising internal tobacco industry documents from the Legacy Tobacco Document Library employing standard document research techniques. RESULTS: Direct mail marketing utilising industry databases began in the 1970s and grew from the need for a promotional strategy to deal with declining smoking rates, growing numbers of products and a cluttered media landscape. Both RJ Reynolds and Philip Morris started with existing commercial consumer mailing lists, but subsequently decided to build their own databases of smokers' names, addresses, brand preferences, purchase patterns, interests and activities. By the mid-1990s both RJ Reynolds and Philip Morris databases contained at least 30 million smokers' names each. These companies valued direct mail/database marketing's flexibility, efficiency and unique ability to deliver specific messages to particular groups as well as direct mail's limited visibility to tobacco control, public health and regulators. CONCLUSIONS: Database marketing is an important and increasingly sophisticated tobacco marketing strategy. Additional research is needed on the prevalence of receipt and exposure to direct mail items and their influence on receivers' perceptions and smoking behaviours.

Interviews with smokers about smokeless tobacco products, risk messages and news articles.

BACKGROUND: Smokeless tobacco (SLT) products and their communication have been topics of discussion in harm reduction debates, but little is known about smokers' perceptions of existing SLT risk messages. This study aimed to explore smokers' perceptions of SLT and snus products and news stories with different risk messages about them. METHODS: We conducted interviews with 30 smokers assigned to read 1 of 3 constructed news stories about SLT and snus with different messages about their risks relative to cigarettes: (1) a 'favourable' version (describing SLT/snus as a 'safer' smoking alternative); (2) a 'cautious' version (describing SLT/snus as having various risks); and (3) a 'mixed' version (both stating SLT risks and potential reduced-risk benefits). RESULTS: Smokers felt somewhat more informed about snus after article reading and largely found quoted sources to be credible. Though some exposed to favourable SLT/snus messages appeared to modify their beliefs about the products' acceptability and risks, many were left unchanged given pre-existing SLT risk perceptions influenced by prior SLT warnings, observed effects in known users, and concerns about SLT's mode of use. Willingness to use/not use snus in the future was also influenced by non-risk-related factors (eg, preference for smoking rituals). Many referenced e-cigarettes as being safer and more attractive smoking alternatives. CONCLUSIONS: Exposure to reduced-risk SLT information may have some impact on smokers' SLT perceptions and interest, but this might be limited by a variety of negative SLT beliefs and growth of other smoking alternatives. Future research should explore SLT risk message effects with larger samples and different study designs.

E-cigarette versus nicotine inhaler: comparing the perceptions and experiences of inhaled nicotine devices.

BACKGROUND: Novel nicotine delivery products, such as electronic cigarettes (e-cigarettes), have dramatically grown in popularity despite limited data on safety and benefit. In contrast, the similar U.S. Food and Drug Administration (FDA)-approved nicotine inhaler is rarely utilized by smokers. Understanding this paradox could be helpful to determine the potential for e-cigarettes as an alternative to tobacco smoking. OBJECTIVE: To compare the e-cigarette with the nicotine inhaler in terms of perceived benefits, harms, appeal, and role in assisting with smoking cessation. DESIGN: A cross-over trial was conducted from 2012 to 2013 PARTICIPANTS/INTERVENTIONS: Forty-one current smokers age 18 and older used the e-cigarette and nicotine inhaler each for 3 days, in random order, with a washout period in between. Thirty-eight participants provided data on product use, perceptions, and experiences. MAIN MEASURES: The Modified Cigarette Evaluation Questionnaire (mCEQ) measured satisfaction, reward, and aversion. Subjects were also asked about each product's helpfulness, similarity to cigarettes, acceptability, image, and effectiveness in quitting smoking. Cigarette use was also recorded during the product-use periods. KEY RESULTS: The e-cigarette had a higher total satisfaction score (13.9 vs. 6.8 [p < 0.001]; range for responses 3-21) and higher reward score (15.8 vs. 8.7 [p < 0.001]; range for responses 5-35) than the inhaler. The e-cigarette received higher ratings for helpfulness, acceptability, and "coolness." More subjects would use the e-cigarette to make a quit attempt (76 %) than the inhaler (24 %) (p < 0.001). Eighteen percent (7/38) of subjects abstained from smoking during the 3-day periods using the e-cigarette vs. 10 % (4/38) using the inhaler (p = 0.18). CONCLUSION: The e-cigarette was more acceptable, provided more satisfaction, and had higher perceived benefit than the inhaler during this trial. E-cigarettes have the potential to be important nicotine delivery products owing to their high acceptance and perceived benefit, but more data are needed to evaluate their actual efficacy and safety. Providers should be aware of these issues, as patients will increasingly inquire about them.

A content analysis of smokeless tobacco coverage in U.S. newspapers and news wires.

INTRODUCTION: Research attention on smokeless tobacco (SLT) has focused on SLT use, health risks, harm-reduction potential, and risk perceptions, but few studies have examined mediated communications about SLT. This study aims to contribute to the literature by providing the first description of SLT coverage in the news, an important communication channel given its ability to educate and shape public opinion about tobacco issues. METHODS: A content analysis was conducted on SLT-related news and opinion articles between 2006 and 2010 from top circulating national and state newspapers and select news wires. Articles were coded for the main SLT topic, SLT risk references, and slant of opinion articles. RESULTS: SLT was discussed in news/feature articles (n = 677) in terms of business (28%), new products, product regulation and harm reduction (19%), prevention/cessation (11.4%), taxation (10.2%), profiles/trends in use (9%), bans (8.1%), and tobacco industry promotional activities (4.9%). Health risk references (i.e., addictiveness, carcinogenicity, and specific health effects including oral cancer) were found in 40% of articles, though frequency differed by article topic. Although the majority of opinion articles (n = 176) conveyed an anti-SLT slant (64%), 25.6% were pro-SLT. CONCLUSIONS: SLT topics of both national and local importance are covered in the news. Public health professionals can participate in SLT coverage by sending in press releases about new study findings, events, or resources and by submitting opinion pieces to share views or respond to previous coverage. Research on SLT news should continue given its potential to shape the public's SLT knowledge and opinions.