The impact of exposure to FDA e-cigarette authorization messages on product perceptions and interest - an experiment with adults who smoke and youth.

INTRODUCTION: In the United States, e-cigarettes have entered a new regulatory era, needing authorizations from FDA to remain on or enter the marketplace. This study explored the impact of e-cigarette authorization messages on product perceptions and interest. METHODS: We conducted an online experiment in June 2022 with nationally-representative samples of adults (21+) who smoke cigarettes (n=866) and youth ages 15-20 (n=859). They were randomized to one of five conditions: viewing an ad for a fictional e-cigarette brand with no reference to FDA (control), an ad with an "authorized for sale by FDA" claim in varying presentation styles (plain text, FDA "approved" stamp, FDA logo), or reading a fictional news excerpt about the product's authorization plus control ad. We compared group differences on product interest, susceptibility, harm perceptions and message perceptions. RESULTS: Among adults who smoke, there were no effects on product interest nor susceptibility, but ratings of the product's harmfulness compared to cigarettes were lower among those in the news versus control condition (ß=-0.25, p=.04). Among youth, odds of susceptibility were higher among ever e-cigarette users who viewed the ad with the FDA logo authorization message relative to the control ad (OR=6.3, 95% CI:1.67-23.9, p<0.01). About 40% of all participants agreed the authorization claim makes them think the product is safe to use, but fewer (14-19%) agreed it makes them more interested in trying it. CONCLUSIONS: FDA e-cigarette authorization messages may impact some beliefs about product harm. More research is needed to track potential impacts on product use. IMPLICATIONS: This study provides new data about the potential impact of messages about FDA authorization of e-cigarette products (presented as ad claims or a news story) on authorized product perceptions, interest and susceptibility among adults who smoke cigarettes and youth. Our results suggest that FDA e-cigarette authorization messages may impact harm-related beliefs among adults who smoke and product susceptibility among youth who have ever used e-cigarettes before, though real-world effects are likely to be impacted by message type and format, and perceived message source and credibility. Authorization messages are likely to be misinterpreted as "FDA approval" by some; therefore, providing clarifications about authorization meaning and standards are relevant where possible.

From "Additive-Free" to "Tobacco & Water": Assessing the Impact of Marketing Claim Changes on Natural American Spirit and L&M Cigarettes.

INTRODUCTION: The 2017 agreement between the U.S. Food and Drug Administration and the makers of Natural America Spirit (NAS) cigarettes restricted use of "additive-free" (AF) in brand marketing, which the company replaced with "tobacco ingredients: tobacco & water" (TW), a phrase subsequently adopted by L&M. We tested how participants' perceptions differed when exposed to AF versus TW claims on NAS and L&M packs. METHODS: A between-subjects experiment was embedded within an online survey in August 2022 (n= 2,526). Participants were randomized to view one of three packs (NAS AF pack, NAS TW pack, L&M TW pack). Logistic regressions assessed differences (by pack exposure) in perceived pack attractiveness and relative chemical and harm perceptions compared to other cigarettes. Interactions by smoking status were explored. RESULTS: No significant differences were observed between the NAS AF and NAS TW packs on perceived attractiveness or relative harm, although never smokers had higher odds of having lower relative chemicals perceptions in response to the NAS AF versus NAS TW pack (OR=1.81). Compared to participants who saw the NAS TW pack, those who saw the L&M TW pack tended to have lower odds of perceiving the pack as attractive, believing that product had fewer chemicals than other products, or believing the product was less harmful than other products compared to the NAS TW pack. CONCLUSION: Results suggest the more implicit "tobacco ingredients: tobacco & water" claim functions similarly to "additive-free" and as an unauthorized modified risk claim. NAS brand image also appears to contribute to higher perceived pack attractiveness and lower perceptions of chemicals and harm. Additional marketing regulations and corrective campaigns may be needed to reduce risk-related misperceptions about NAS cigarettes. IMPLICATIONS: Our findings show that replacing "additive-free" claims with "tobacco ingredients: tobacco & water" did not sufficiently address the illegal use of unauthorized modified risk claims by the makers of NAS cigarettes. Further regulatory action restricting the TW claim could potentially reduce inaccurate lower harm perceptions about NAS cigarettes. Educational campaigns may also be needed to mitigate NAS's history of marketing that implies reduced harm, given that effects of implicit reduced risk claims like TW have a greater effect on pack perceptions for NAS than L&M.

Does noticing cigar warnings associate with cigar harm perceptions and smoking behaviors? Analysis from Wave 5 of the population assessment of tobacco and health study.

BACKGROUND: In the US, cigar warning label standards are less stringent than cigarette warning requirements and are not uniformly required; research is needed about warning efficacy in promoting cigar risk beliefs, discouraging use and supporting public health. METHODS: Using data from the PATH Study (Wave 5), we analyzed associations between noticing cigar warnings and perceived harm from cigar use, frequency of thinking about harms, and effects of warnings labels. RESULTS: Among adults who smoke cigars, respondents noticing warnings at least sometimes (vs. never/rarely) had higher odds of thinking about harms of their tobacco use often/very often (cigarillos 30% vs. 19%, p <.001, aOR 1.80 [1.27, 2.56]); filtered cigars: 43% vs. 16%, p <.001, aOR 3.81 [2.50, 5.82]) and of reporting that smoking cigars is very/extremely harmful (cigarillos: 59% vs. 46%, p =.001, aOR 1.45 [1.05, 1.99]). A substantial majority found cigar warnings to be very/extremely believable (cigarillos: 63%, filtered cigars: 59%, traditional cigars: 65%), with 16%, 24% and 12% respectively reporting past-30-day warning avoidance. Those noticing warnings at least sometimes (vs. rarely) had higher rates of reporting that warnings sometimes/often/very often stopped them from having a cigar in the past 30 days (cigarillos: 36% vs. 10%; filtered cigars: 50% versus 6%; traditional cigars: 30% versus 9%; p's < 0.001) and that warnings made them somewhat/a lot more likely to quit smoking (cigarillos: 55% versus 37%, p <.01; filtered cigars: 55% versus 26%, p <.001; traditional cigars: 39% vs. 24%, p <.05). CONCLUSIONS: Results support potential public health benefits of mandating the presence and increasing salience of cigar warning labels.

Organic, Earth-Friendly Tobacco With a Charcoal Filter and Smooth Taste: A Randomized Experiment Testing Effects of Natural American Spirit's "Sky" Cigarette Advertising on Consumer Perceptions.

INTRODUCTION: The Natural American Spirit (NAS) brand has a history of marketing tactics that may convey reduced harm. While no longer allowed to use "additive-free" or natural descriptors (except in the brand name), it continues promoting potentially misleading attributes. This study examined perceptions of NAS's newer "Sky" style, promoted as organic tobacco with a charcoal filter. AIMS AND METHODS: In an online experiment, we randomized 1927 adult past 30-day tobacco or nicotine product users to one of six conditions showing Sky ads with different descriptors: (1) charcoal filter, (2) charcoal + organic, (3) charcoal + earth-friendly, (4) charcoal + smooth taste, (5) charcoal + all other descriptors, and (6) no-descriptor control (Sky ads without target descriptors). Product perceptions were compared by condition. Participants also reported perceived benefits of charcoal filters. RESULTS: Overall, 28% of participants indicated Sky is less harmful and 38% believed it exposes users to fewer chemicals. Participants in the "charcoal + organic," "charcoal + earth-friendly," and the all-descriptor conditions had higher odds of believing Sky reduces chemical exposure (respectively, 43%, 40%, and 42%), relative to the no-descriptor control. Fewer control participants endorsed beliefs that Sky has a "better filter" and is "more environmentally friendly". Many believed cigarettes with charcoal filters could confer benefits relative to other cigarettes, such as reducing chemical exposure, or being cleaner, purer or safer (though research on relative safety of charcoal filters in cigarettes is inconclusive). CONCLUSIONS: Sky marketing may promote misperceptions about product safety and composition, and ads using both charcoal and organic text may particularly reinforce them. IMPLICATIONS: This study examined the impact of new cigarette advertising promoting the use of charcoal filters and organic tobacco along with other suggestive claims ("environmentally friendly," "smooth taste") on tobacco users' perceptions of the advertised product-NAS Sky cigarettes. Our study provides new data about positive consumer perceptions of charcoal-filtered cigarettes, and results suggest that combinations of these marketing terms evoke perceptions about reduced harm and reduced exposure to harmful chemicals that may be misleading to the public. Our findings underscore a need for additional regulatory action regarding tobacco marketing that makes use of natural-themed marketing.

Perceptions about levels of harmful chemicals in e-cigarettes relative to cigarettes, and associations with relative e-cigarette harm perceptions, e-cigarette use and interest.

BACKGROUND AND AIMS: Exposure to chemicals contributes to harm from nicotine products, and e-cigarette communications often refer to chemicals. However, while e-cigarette studies commonly measure perceived harmfulness of e-cigarettes relative to cigarettes, few have assessed comparative perceptions about chemicals. This study measured perceived levels of harmful chemicals in e-cigarettes compared with cigarettes and associations with e-cigarette/cigarette relative harm perceptions, e-cigarette use and interest. DESIGN, SETTING AND PARTICIPANTS: This was an on-line cross-sectional survey of adults/young adults from a nationally representative research panel in the United States conducted in January 2021. Participants were independent samples of 1018 adults who smoked cigarettes and 1051 young adult non-smokers (aged 18-29 years). MEASUREMENTS: Participants were asked their perceptions of the level of harmful chemicals in e-cigarettes versus cigarettes (fewer/about the same/more/do not know), perceived harmfulness of using e-cigarette versus cigarettes (less/about the same/more/do not know) and their current e-cigarette use and use interest. FINDINGS: Approximately 20% of all participants (18.1% of adult smokers, and 21.0% of young adult non-smokers) believed e-cigarettes contain fewer harmful chemicals than cigarettes, while 35.6% of adult smokers and 24.9% of young adult non-smokers responded 'do not know'. Participants more frequently reported 'do not know' to the chemicals item than the harm item. Approximately half (51.0-55.7%) of those who believed e-cigarettes contain fewer harmful chemicals also believed e-cigarettes are less harmful than cigarettes. Both beliefs were associated with higher odds of interest in using e-cigarettes [less harmful belief, odds ratio (OR) = 5.53, 95% confidence interval (CI = 2.93-10.43); fewer chemicals belief, OR = 2.45, 95% CI = 1.40-4.29] and past 30-day e-cigarette use (less harmful belief, OR = 2.53, 95% CI = 1.17-5.44; fewer chemicals belief, OR = 5.09, 95% CI = 2.31-11.19) for adults who smoke, but not young adult non-smokers. CONCLUSIONS: In the United States, most adults who smoke cigarettes and young adult non-smokers do not appear to think that e-cigarettes have fewer harmful chemicals than cigarettes, and many are uncertain about how these levels compare.

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.

Young adults' cigarillo risk perceptions, attention to warning labels and perceptions of proposed pictorial warnings: a focus group study.

OBJECTIVE: Although cigars pose similar health risks to cigarettes, they are not uniformly required to carry a warning label on their packaging in the USA. The US Food and Drug Administration's 2016 deeming rule established a cigar warning requirement, but it was challenged in federal court for failing to document warning effects on prevention/cessation, thus necessitating an evidentiary base for such requirements. We sought to explore young adult users' understanding of cigarillo risks and addictiveness, as well as their perceptions of current (voluntary) and proposed cigar warning labels. DESIGN: In December 2020-January 2021, we conducted eight focus groups with young adult cigarillo smokers. We asked participants their first associations of cigarillos and beliefs about product harms/addictiveness, and then discussed existing warning labels and examples of potential pictorial warnings. SETTING: Focus groups were conducted remotely via the Adobe Connect platform, with participants from 20 US states. PARTICIPANTS: Participants included 42 young adults (ages 18-29; 50% male), who were recent cigarillo users (ie, past 30 days) or less frequent users (ie, past 12 months). RESULTS: Participants frequently used cigarillos as blunts and often conveyed uncertainty about cigarillo risks and addictiveness, in general and relative to cigarettes. Participants typically paid little attention to current text warnings, but many expressed that pictorial warnings would more effectively promote knowledge of product risks and discourage use among prospective users. CONCLUSIONS: US young adult cigarillo users may lack knowledge about product risks and addictiveness. Standardised warning requirements, particularly pictorial labels, may help address this knowledge gap and deter use.

Cigar Warning Noticing and Demographic and Usage Correlates: Analysis from the United States Population Assessment of Tobacco and Health Study, Wave 5.

Although cigars pose health risks similar to cigarettes, their packaging/marketing is not subject to commensurate regulation in the US. In a 2000 agreement with the Federal Trade Commission, seven major manufacturers agreed to use some form of cigar warning. In 2016, the Food and Drug Administration passed a rule requiring larger standardized warnings, but the requirement was successfully challenged in court. Here, we examined U.S. population-level trends in noticing existing cigarillo, traditional and filtered cigar warnings. We analyzed Wave 5 Population Assessment of Tobacco and Health adult data to assess prevalence of past-30 day warning noticing and associations with socio-demographic and tobacco use variables. Noticing was higher among current users of cigarillos (27%), filtered (34%) and traditional cigars (21%), than non-users (8% for each product, p < 0.0001), and among every-day vs. some-day users, established vs. experimental users, and past-30 day users vs. those without past-30 day use. Results varied by product, but generally indicated lower noticing among non-Hispanic Whites and dual cigarette users, but higher noticing among those purchasing cigars by the box/pack (vs. not purchasing for themselves). Low overall noticing but higher prevalence among frequent users underscores a need for a stronger, uniform cigar warning label policy in the US.

Exploring the implications of modified risk claim placement in tobacco advertising.

The United States Food and Drug Administration (FDA) has developed a regulatory process by which tobacco companies can apply to make "modified risk tobacco product" (MRTP) marketing claims that their product poses a lower risk of disease or exposure to harmful constituents. The impact of MRTP claims to promote harm reduction may be limited by perceptions that claims come from the tobacco industry, lack of attention, and the simultaneous presence of health warnings on ads, which may be perceived as conflicting information. Some studies have examined the potential of alternative "modified risk warnings". We aimed to contribute to this literature by exploring issues of claim attention, perceived source and credibility when viewing MRTP claims within or outside of a warning label. We conducted 11 focus groups with adult smokers and young adult (ages 18-25) non-smokers (n = 54) who viewed three e-cigarette or snus advertisements which varied in where an MRTP message was placed: outside the warning label, inside the warning label, or in a modified label style. Results suggest that MRTP claims presented within or in the style of a warning label (compared to claims outside the label), may be perceived as coming from a government or health-related source rather than a tobacco industry, and thus seem more credible. Yet these formats may receive insufficient message attention, as they are smaller and appear as part of labels consumers are accustomed to ignoring. Future research should further probe effects of MRTP statements and how they vary by message source, channel and format.

Attitudinal Spillover from Misleading Natural Cigarette Marketing: An Experiment Examining Current and Former Smokers' Support for Tobacco Industry Regulation.

This research examined the influence of natural cigarette advertising on tobacco control policy support, and the potential for misbeliefs arising from exposure to cigarette marketing to affect such support. Ample research indicates that natural cigarettes such as Natural American Spirit (NAS) are widely and erroneously perceived as safer than their traditional counterparts because of their marketed "natural" composition. Yet regulatory action regarding natural cigarette marketing has been limited in scope, and little research has examined whether misleading product advertising affects support for related policy, an important component of the policy process. Here, we administered a large-scale randomized experiment (n = 1128), assigning current and former smokers in the United States to an NAS advertising condition or a control group and assessing their support for tobacco industry regulation. Results show that exposure to NAS advertising reduces support for policies to ban potentially misleading terminology from cigarette advertising, and these effects are stronger for daily smokers. Further, misinformed beliefs about the healthy composition of NAS partially mediate effects on policy support. Yet interestingly, exposure to NAS marketing does not reduce support for policies to establish standards for when certain terms are permissible in cigarette advertising. The results of this analysis indicate potential spillover effects from exposure to NAS advertising in the realm of support for regulatory action pertaining to tobacco industry marketing.

Regulating language, not inference: an examination of the potential effectiveness of Natural American Spirit advertising restrictions.

OBJECTIVE: In 2017, the United States Food and Drug Administration (FDA) reached an agreement with Santa Fe Natural Tobacco Company (SFNTC) stipulating that SFNTC will remove 'natural' and 'additive-free' from Natural American Spirit (NAS) marketing to combat misperceptions that NAS is a healthier cigarette. The purpose of this study was to assess experimentally the potential effectiveness of the agreement in addressing NAS misperceptions. METHODS: In an online experiment, 820 current and former smokers were assigned randomly to advertising conditions with existing claims from NAS advertisements, modified claims or a no-exposure control. Advertising conditions included (1) 'original' NAS advertising text before the agreement; (2) '2017 agreement' language permissible under the FDA-SFNTC agreement (removing 'natural', 'additive-free'); (3) more restrictive ('stricter') language representing additional regulation (removing 'natural' from the brand name and the phrases 'tobacco+water', 'no chemicals'). Participants completed outcome measures assessing misinformed beliefs and intentions towards NAS. RESULTS: One-way ANOVA showed that relative to the 'original' language, the '2017 agreement' language reduced misconceptions about NAS addictiveness, but not about health or constituent composition. Yet 'stricter' language significantly reduced all categories of misinformed beliefs, which in turn mediated effects on (lower) intentions to use NAS. CONCLUSION: The 2017 agreement helps dispel some misconceptions about NAS addictiveness, but does not sufficiently rectify misinformation about health or composition. Since 'stricter' language more effectively corrects misinformed beliefs, our results suggest the need for further regulations in addressing misinformation that drives intentions towards NAS.

Influence of Natural American Spirit advertising on current and former smokers' perceptions and intentions.

OBJECTIVE: This study sought to demonstrate causal effects of exposure to Natural American Spirit (NAS) advertising content on misinformed beliefs of current and former smokers, and to empirically establish these beliefs as a mechanism driving intentions to use NAS. METHODS: Our study employed a randomised experimental design with 1128 adult daily, intermittent and former smokers. We compared participants who were exposed to NAS advertisements or claims made in the advertisements with those in a no-message control group to test the effects of NAS advertising content on inaccurate beliefs about NAS and attitudes and intentions towards the product. RESULTS: One-way analysis of variance revealed that exposure to NAS advertisements produced inaccurate beliefs about the composition of NAS cigarettes among current and former smokers (p<0.05). Planned contrasts indicated a compilation of arguments taken directly from NAS advertisements resulted in significantly greater beliefs that NAS cigarettes are healthier/safer than other cigarettes (for former smokers, t(472)=3.63, p<0.001; for current smokers, t(644)=2.86, p=0.004), demonstrating that suggestive claims used in the brand's marketing have effects on beliefs not directly addressed in the advertisements. Regression and mediation analyses showed that health-related beliefs predict attitudes towards NAS for current and former smokers, and mediate intentions to use NAS. CONCLUSIONS: The findings of this study provide causal support for the need for further regulatory action to address the potentially harmful ramifications of claims used in NAS advertising.