Would banning menthol cigarettes, flavored cigars, and flavored e-cigarettes prompt users to seek illicit channels for obtaining them in the United States?

BACKGROUND: Banning flavors in tobacco and nicotine products may reduce youth initiation and prompt quit attempts but such bans may lead to illicit markets. We examined how likely current users would be to seek flavored products from illicit channels under various ban scenarios. METHODS: Cross-sectional surveys of 2552 current users of menthol cigarettes or flavored cigars and 2347 users of flavored e-cigarettes were conducted between 2021 and 2022 in the United States. For each ban scenario, respondents reported if they would have intentions to seek the banned flavored products from any illicit channels and identified the specific illicit channel they would consider. Logistic regressions were used to estimate how the likelihood of having intentions to seek illicit channels was associated with demographics, ban scenarios, and status of tobacco use. RESULTS: Under various ban scenarios, 24-30% of people who smoked said they would seek illicit channels to obtain the banned products compared with 21-41% of dual users and 35-39% of users of flavored e-cigarettes. Online retailers were favored by people who smoked while users of flavored e-cigarettes favored local retailers. Heavy users were more likely to say they would try illicit channels. Under bans restricting more types of flavored tobacco products, users would be less likely to try illegal channels. CONCLUSIONS: A significant proportion of users of flavored tobacco and nicotine products would not reject using illicit banned products. Tailored programs are needed to apply to the groups with a higher risk of seeking illicit channels for banned products.

Greenwashed Cigarette Ad Text and Imagery Produce Inaccurate Harm, Addictiveness, and Nicotine Content Perceptions: Results from a Randomized Online Experiment.

INTRODUCTION: The tobacco industry has a long history of circumventing regulations to present their products, inaccurately, as less harmful. Greenwashing (portraying a product as natural/eco-friendly) is increasingly used by tobacco companies and may mislead consumers to believe that certain cigarettes are less harmful than others. This study assesses the effect of some common greenwashing tactics on consumer product perceptions. METHODS: We conducted an online experiment with 1,504 participants ages 18-29, randomized to view a cigarette ad manipulated for presence/absence of a combination of 4 different greenwashing techniques: greenwashed ad text, greenwashed ad imagery, recycled paper ad background, and image of greenwashed cigarette pack. Participants rated perceived absolute harm, relative harm to other cigarettes, absolute addictiveness, relative addictiveness, and relative nicotine content. RESULTS: Participants who viewed ads containing greenwashed text were more likely to have inaccurate perceptions about absolute harm (AOR=1.72), relative harm (AOR=3.92), relative addictiveness (AOR=2.93) and nicotine content (AOR=2.08). Participants who viewed ads containing greenwashed imagery were more likely to have inaccurate perceptions of relative harm (AOR=1.55), absolute addictiveness (AOR=1.72), relative addictiveness (AOR=1.60) and nicotine content (AOR=1.48). Forty-two percent of those who saw an ad with all greenwashed features believed the product was less harmful than other cigarettes vs. 2% of those who saw an ad without greenwashed features. CONCLUSIONS: We found greenwashed text and imagery produced inaccurate risk perceptions. More active U.S. Food & Drug Administration (FDA) enforcement against such greenwashing and new FDA rulemaking to prohibit unnecessary imagery in tobacco advertising and establish plain packaging requirements would help protect consumers and public health. IMPLICATIONS: These findings provide evidence that greenwashing tactics used by the tobacco industry increase inaccurate product risk perceptions. These tactics could be a way for the industry to make implicit modified risk claims, despite applicable U.S. Family Smoking Prevention and Tobacco Control Act prohibitions. Findings from this study support the need for prohibitions on these tactics, and the potential for such prohibitions to help protect public health.

Tax incidence of electronic nicotine delivery systems (ENDS) in the USA.

BACKGROUND: A growing number of states or jurisdictions in the USA have imposed excise taxes on electronic nicotine delivery systems (ENDS). However, there is no consensus on how best to tax ENDS. OBJECTIVES: We specifically compare the tax incidence or burden for ENDS and cigarettes and analyse how ENDS tax incidence is associated with the choices of tax bases and rates. METHODS: We calculate ENDS excise tax incidence as the percentage of retail prices for each state or jurisdiction. Next, we use ordinary least squares to evaluate how tax incidence is associated with the choices of tax bases (eg, a specific tax base vs a value or ad valorem tax base) and rates and how these associations are moderated by product types. RESULTS: ENDS and cigarette tax incidence is similar at the state level. Nonetheless, when federal cigarette taxes are considered, the cigarette tax incidence is higher than the tax incidence on closed-system ENDS. The proportion of states that impose value taxes is higher for open systems (65.4%) than for closed systems (46.2%). A value tax base is associated with a 7 percentage point lower tax incidence compared with a specific tax base. Product type further moderates the association between tax base and incidence. CONCLUSION: Tax incidence can be used to measure the strength of ENDS tax policies and how they are compared with cigarette taxes. Policymakers who aim to prevent youth from using ENDS may consider a value tax base to raise the tax incidence of closed systems-the product type preferred by young people.

Impact of flavours, device, nicotine levels and price on adult e-cigarette users' tobacco and nicotine product choices.

INTRODUCTION: To understand the impact of e-cigarette devices, flavours, nicotine levels and prices on adult e-cigarette users' choices among closed-system and open-system e-cigarettes, cigarettes and heated tobacco products (HTPs). METHODS: Online discrete choice experiments were conducted among adult (≥18 years) e-cigarette users (n=2642) in August 2020. Conditional logit regressions were used to assess the relative impact of product attributes and the interactions between product attributes and user characteristics, with stratified analyses to examine differences by smoking status and primarily used e-cigarette device and flavour. RESULTS: On average, participants preferred non-tobacco and non-menthol flavours most, preferred open-system over closed-system e-cigarettes and preferred regular nicotine level over low nicotine level. However, the preference varied by demographics, smoking status and the primarily used e-cigarette device and flavour. The differences in preference among products/devices were larger than the difference among flavours or nicotine levels. Participants who primarily used closed-system e-cigarettes exhibited similar preferences for closed-system and open-system e-cigarettes, but those who primarily used open-system e-cigarettes preferred much more open-system over closed-system e-cigarettes. HTP was the least preferred product, much lower than cigarettes in general, but participants living in states where IQOS is being sold had similar preferences to cigarettes and HTPs. CONCLUSIONS: People are unlikely to switch to another product/device because of the restriction of flavour or nicotine level. If non-tobacco and non-menthol flavours were banned from open-system e-cigarettes, users may switch to menthol flavour e-cigarettes. Intervention strategies should be tailored to specific groups.

How Smokers of Menthol Cigarettes and Flavored Cigars Might Respond to FDA's Proposed Bans.

INTRODUCTION: A ban on menthol cigarettes and flavored cigars may reduce smoking and tobacco-related disparities. AIMS AND METHODS: We aimed to examine the response of current smokers to a hypothetical ban on menthol cigarettes and flavored cigars. Current smokers were recruited online and reported the alternative products that they may switch to under a hypothetical ban, if they would try to obtain the banned products from illicit channels, and their support to the ban. RESULTS: 51% of current smokers would use nonflavored cigarettes and cigars as alternatives, 45% would switch to flavored heated tobacco products or e-cigarettes or quit smoking. 17% would try to obtain the banned flavored products from illicit markets. A majority of menthol only smokers opposed the ban. Daily smokers would be more likely to switch to nonflavored smoking, to try illicit market products, and were less supportive of the ban. Black smokers would be less likely to switch to nonflavored smoking and were more supportive of the ban. Smokers who used menthol cigarettes only would be more likely to switch to nonflavored smoking, less likely to try illicit market sellers, and were the least supportive of the ban. CONCLUSIONS: In response to a ban of all added flavors for cigarettes or cigars, nearly half of the current smokers would quit smoking, largely by switching to nonsmoking products. However, smokers with more chronic use and those who used only menthol cigarettes would be more likely to switch to nonflavored smoking, diminishing the harm reduction potential. The ban may decrease the relatively higher prevalence of menthol cigarette smoking among Blacks compared with other groups. IMPLICATIONS: A ban on the sale of menthol cigarettes and flavored cigars may decrease the prevalence of smoking because some current smokers may quit smoking and switch to nonsmoking products. However, smokers with more chronic use and those who used menthol cigarettes only were more likely to switch to nonflavored cigarettes or cigars, diminishing the harm reduction potential of the ban. Black smokers would be more likely to switch to products other than cigarettes and cigars thus decreasing their relatively higher prevalence of smoking compared with other groups.

Should menthol e-cigarettes be banned? Reaction of adult smokers and users of e-cigarettes to hypothetical bans.

INTRODUCTION: This study examines how current smokers using menthol cigarettes or flavoured cigars, and current users of flavoured e-cigarettes may respond to three hypothetical flavour-ban scenarios: (1) banning only menthol cigarettes and flavoured cigars; (2) also banning e-cigarettes with any non-tobacco flavours except menthol; and (3) also banning e-cigarettes with any non-tobacco flavours, including menthol. METHODS: Recruited from mTurk, respondents were asked if they would quit all tobacco-nicotine use or continue or start using products that were still legally available. The patterns of responding to each ban scenario, for both flavoured smokers and users of non-tobacco flavoured e-cigarettes, were summarised. Multinomial logistic regressions were used to estimate associations between demographics, smoking or e-cigarette use status and reactions to a ban. RESULTS: A ban on menthol cigarettes and flavoured cigars would lead to 12%-20% of flavoured smokers trying to quit all tobacco use and 32%-52% switching to non-flavoured smoking, with the remaining switching to e-cigarettes or other products. Compared with a ban on only menthol cigarettes and flavoured cigars, also banning flavoured e-cigarettes would increase the likelihood of quitting all tobacco-nicotine use (OR=2.58) but also increase the likelihood of switching to non-flavoured smoking (OR=1.74). CONCLUSIONS: Our results indicate that a ban on menthol cigarettes and flavoured cigars would decrease smoking. However, it is unclear if adding a ban of menthol e-cigarettes would lead to additional benefits because without menthol e-cigarettes as an alternative, some smokers and e-cigarette users may switch to non-flavoured tobacco smoking, rather than quit all tobacco use.

Risk and safety profile of electronic nicotine delivery systems (ENDS): an umbrella review to inform ENDS health communication strategies.

OBJECTIVES: This umbrella review aims to summarise the evidence about electronic nicotine delivery systems' (ENDS) risk and safety health profile to inform ENDS health communication strategies. DATA SOURCES AND STUDY SELECTION: Six databases were searched for systematic reviews presenting evidence on ENDS-related health effects. Ninety reviews divided into five categories were included: toxicity=20, health effects=40, role in smoking cessation=24, role in transition to combustible cigarettes (CCs)=13 and industry marketing claims=4. DATA EXTRACTION: Findings were synthesised in narrative summaries. Meta-analyses were conducted by study type when appropriate. Quality assessment was conducted using the Measurement Tool to Assess Systematic Reviews. The Institute of Medicine's Levels of Evidence Framework was used to classify the evidence into high-level, moderate, limited-suggestive and limited-not-conclusive. DATA SYNTHESIS: We found high-level evidence that ENDS exposes users to toxic substances; increases the risk of respiratory disease; leads to nicotine dependence; causes serious injuries due to explosion or poisoning; increases smoking cessation in clinical trials but not in observational studies; increases CC initiation; and exposure to ENDS marketing increases its use/intention to use. Evidence was moderate for ENDS association with mental health and substance use, limited-suggestive for cardiovascular, and limited-not-conclusive for cancer, ear, ocular and oral diseases, and pregnancy outcomes. CONCLUSIONS: As evidence is accumulating, ENDS communication can focus on high-level evidence on ENDS association with toxicity, nicotine addiction, respiratory disease, ENDS-specific harm (explosion, poisoning) and anti-ENDS industry sentiment. Direct comparison between the harm of CCs and ENDS should be avoided. PROSPERO REGISTRATION NUMBER: CRD42021241630.

"Tobacco and Water": Testing the Health Halo Effect of Natural American Spirit Cigarette Ads and Its Relationship with Perceived Absolute Harm and Use Intentions.

In 2015, the FDA formally warned Santa Fe Natural Tobacco Company that their "natural" and "additive-free" claims for its Natural American Spirit cigarettes conveyed reduced harm to consumers. In a settlement, Santa Fe was allowed to continue using the word "natural" in the brand name and the phrase "tobacco and water". The company also uses eco-friendly language and plant imagery and these tactics have also been shown to communicate reduced product harm. In this study, we propose the health halo effect as an overarching framework for explaining how these ad tactics mislead consumers in an effort to provide more comprehensive guidance for regulatory action. In a between-subjects experiment, 1,577 US young adults, ages 18-24, were randomly assigned to view one of five Natural American Spirit cigarette ads featuring either: 1) eco-friendly language; 2) plant imagery; 3) the phrase "tobacco and water"; 4) all of these tactics; or 5) a control condition featuring none of these tactics. In line with past research, ads with the phrase "tobacco and water" or with all the tactics together (vs. control) created a health halo effect, increasing perceptions that Natural American Spirit cigarettes were healthier and had less potential to cause disease; these tactics also had an indirect positive effect on smoking intentions through reduced perceptions of the brand's potential to cause disease and perceived absolute harm. Inconsistent with prior work, the eco-friendly language and plant imagery (vs. control) reduced healthfulness perceptions, increased perceptions of absolute harm, and had an indirect negative effect on smoking intentions. We contribute to past research showing that Natural American Spirit cigarette ad tactics mislead consumers. Inconsistent findings are explained in terms of stimuli design and processing of message features, indices of relative message persuasiveness, and multiple versus single-message designs.

The Association of E-cigarette Flavors With Satisfaction, Enjoyment, and Trying to Quit or Stay Abstinent From Smoking Among Regular Adult Vapers From Canada and the United States: Findings From the 2018 ITC Four Country Smoking and Vaping Survey.

AIMS: This study examined whether nontobacco flavors are more commonly used by vapers (e-cigarette users) compared with tobacco flavor, described which flavors are most popular, and tested whether flavors are associated with: vaping satisfaction relative to smoking, level of enjoyment with vaping, reasons for using e-cigarettes, and making an attempt to quit smoking by smokers. METHODS: This cross-sectional study included 1603 adults from Canada and the United States who vaped at least weekly, and were either current smokers (concurrent users) or former smokers (exclusive vapers). Respondents were categorized into one of seven flavors they used most in the last month: tobacco, tobacco-menthol, unflavored, or one of the nontobacco flavors: menthol/mint, fruit, candy, or "other" (eg, coffee). RESULTS: Vapers use a wide range of flavors, with 63.1% using a nontobacco flavor. The most common flavor categories were fruit (29.4%) and tobacco (28.7%), followed by mint/menthol (14.4%) and candy (13.5%). Vapers using candy (41.0%, p < .0001) or fruit flavors (26.0%, p = .01) found vaping more satisfying (compared with smoking) than vapers using tobacco flavor (15.5%) and rated vaping as very/extremely enjoyable (fruit: 50.9%; candy: 60.9%) than those using tobacco flavor (39.4%). Among concurrent users, those using fruit (74.6%, p = .04) or candy flavors (81.1%, p = .003) were more likely than tobacco flavor users (63.5%) to vape in order to quit smoking. Flavor category was not associated with the likelihood of a quit attempt (p = .46). Among exclusive vapers, tobacco and nontobacco flavors were popular; however, those using tobacco (99.0%) were more likely than those using candy (72.8%, p = .002) or unflavored (42.5%, p = .005) to vape in order to stay quit. CONCLUSIONS: A majority of regular vapers in Canada and the US use nontobacco flavors. Greater satisfaction and enjoyment with vaping are higher among fruit and candy flavor users. While it does not appear that certain flavors are associated with a greater propensity to attempt to quit smoking among concurrent users, nontobacco flavors are popular among former smokers who are exclusively vaping. Future research should determine the likely impact of flavor bans on those who are vaping to quit smoking or to stay quit. IMPLICATIONS: Recent concerns about the attractiveness of e-cigarette flavors among youth have resulted in flavor restrictions in some jurisdictions of the United States and Canada. However, little is known about the possible consequences for current and former smokers if they no longer have access to their preferred flavors. This study shows that a variety of nontobacco flavors, especially fruit, are popular among adult vapers, particularly among those who have quit smoking and are now exclusively vaping. Limiting access to flavors may therefore reduce the appeal of e-cigarettes among adults who are trying to quit smoking or stay quit.

Has FDA abandoned its efforts to make fake-cigar cigarettes comply with federal tobacco control laws that apply to cigarettes but not cigars?

In the USA, legal definitions of cigarettes and cigars are critical to tobacco control policy because federal, state and local laws typically tax and regulate cigarettes more strictly than cigars. In 2016, near the end of the Obama Administration, the US Food and Drug Administration (FDA) sent warning letters to four filtered 'little cigar' manufacturers stating that their so-called 'cigars' were cigarettes and, therefore, subject to more stringent public health restrictions. Documents produced in response to a Freedom of Information Act request show that without explanation or public notice FDA has abandoned its prior determination that the manufacturers' 'little cigars' were actually cigarettes and, consequently, were violating the ban on flavoured cigarettes in the Family Smoking Prevention and Tobacco Control Act (TCA). The documents also present the manufacturers' arguments against FDA's original position. However, those industry arguments are inconsistent with the research, other evidence and legal analysis indicating that filtered 'little cigars' meet the legal definition of cigarettes under the TCA and other similar federal, state and local definitions. To protect the public health, FDA must renew its efforts to ensure that these filtered 'little cigars' do not continue to evade compliance with the many important restrictions and requirements that apply to cigarettes but not cigars. Other government regulatory and tax-collection agencies with similar definitions need to follow suit.

Cross-country comparison of cigarette and vaping product marketing exposure and use: findings from 2016 ITC Four Country Smoking and Vaping Survey.

OBJECTIVE: To compare exposure to and use of certain cigarette and vaping product marketing among adult smokers and vapers in four countries with contrasting regulations-Australia (AU), Canada, England and the USA. DATA SOURCES: Adult smokers and vapers (n=12 294) from the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping Survey (4CV1). ANALYSIS: Self-reported exposure to cigarette and vaping product advertising through point-of-sale, websites/social media, emails/texts, as well as exposure to and use of price offers were assessed for country differences using logistic regression models adjusted for multiple covariates. RESULTS: Reported exposure to cigarette advertising exposure at point-of-sale was higher in the USA (52.1%) than in AU, Canada and England (10.5%-18.5%). Exposure to cigarette advertising on websites/social media and emails/texts was low overall (1.5%-10.4%). Reported exposure to vaping ads at point-of-sale was higher in England (49.3%) and USA (45.9%) than in Canada (32.5%), but vaping ad exposure on websites/social media in Canada (15.1%) was similar with England (18.4%) and the USA (12.1%). Exposure to vaping ads via emails/texts was low overall (3.1%-9.9%). Exposure to, and use of, cigarette price offers was highest in the USA (34.0 % and 17.8 %, respectively), but the use rate among those exposed was highest in AU (64.9%). Exposure to, and use of, price offers for vaping products was higher in the USA (42.3 % and 21.7 %) than in AU, Canada and England (25.9%-31.5 % and 7.4%-10.3 %). CONCLUSIONS: Patterns of cigarette and vaping product marketing exposure generally reflected country-specific policies, except for online vaping ads. Implications for research and policy are discussed.

Harm Perceptions of Menthol and Nonmenthol Cigarettes Differ by Brand, Race/Ethnicity, and Gender in US Adult Smokers: Results from PATH Wave 1.

INTRODUCTION: Harm perceptions of menthol cigarettes may contribute to their appeal and use. African-Americans, women, and younger smokers disproportionately use menthol cigarettes, and may misperceive harm of menthol cigarettes. METHODS: Data were from Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study. Weighted analyses of current adult smokers (18 and older) were used to estimate the correlates of menthol smoking among all cigarette brands and separately for the top three cigarette brands (Newport, Camel, and Marlboro). Adjusted models examined the main effect of menthol smoking on harm perceptions of one's own brand of cigarette and interactions with race/ethnicity, age, and gender. RESULTS: Menthol cigarettes were used by nearly 40% of current smokers, although the prevalence of menthol smoking differed across the top three brands (94% Newport, 46% Camel, and 18% Marlboro). Among menthol smokers, 80% perceived their cigarette as equally harmful, 14% perceived their brand as more harmful, and 7% perceived their brand as less harmful. In adjusted models, menthol smokers were more likely than nonmenthol smokers to misperceive their own brand as more harmful than other brands (compared to no difference in harm). Race and gender emerged as moderators of the association between menthol brand preference and harm perceptions. CONCLUSIONS: In adjusted analyses, menthol smokers were more likely than nonmenthol smokers to perceive their brand as more harmful than other brands, with differences by sub-groups who disproportionately use menthol. IMPLICATIONS: Menthol cigarettes have been historically marketed with messages conveying lower harm than other cigarettes. Little is known about how contemporary adult menthol smokers perceive the harm of their usual brand, and potential differences by race, gender, and young adult versus older adult age group. After adjusting for other factors, menthol smokers were more likely than nonmenthol smokers to perceive their cigarette brand as more harmful than other brands. Further, the association between menthol smoking and harm perceptions differed by race and gender, but not by age group (young adult vs. older adult). This type of large-scale study identifies critical links between menthol smoking and harm perceptions among vulnerable smokers that will inform regulatory actions designed to decrease smoking-related harm.

The Effects of Varying Electronic Cigarette Warning Label Design Features On Attention, Recall, and Product Perceptions Among Young Adults.

This study was a 3 (Brand: Blu, MarkTen, Vuse) by 3 (Warning Size: 20%, 30%, or 50% of advertisement surface) by 2 (Warning Background: White, Red) experimental investigation of the effects of electronic cigarette (e-cigarette) warning label design features. Young adults aged 18-30 years (n = 544) were recruited online, completed demographic and tobacco use history measures, and randomized to view e-cigarette advertisements with warning labels that varied by the experimental conditions. Participants completed a task assessing self-reported visual attention to advertisements with a-priori regions of interest defined around warning labels. Warning message recall and perceived addictiveness of e-cigarettes were assessed post-exposure. Approximately half of participants reported attending to warning labels and reported attention was greater for warnings on red versus white backgrounds. Recall of the warning message content was also greater among those reporting attention to the warning label. Overall, those who viewed warnings on red backgrounds reported lower perceived addictiveness than those who viewed warnings on white backgrounds, and e-cigarette users reported lower perceived addictiveness than non-users. Among e-cigarette users, viewing warnings on white backgrounds produced perceptions more similar to non-users. Greater recall was significantly correlated with greater perceived addictiveness. This study provides some of the first evidence that e-cigarette warning label design features including size and coloring affect self-reported attention and content recall.

Potential deaths averted in USA by replacing cigarettes with e-cigarettes.

INTRODUCTION: US tobacco control policies to reduce cigarette use have been effective, but their impact has been relatively slow. This study considers a strategy of switching cigarette smokers to e-cigarette use ('vaping') in the USA to accelerate tobacco control progress. METHODS: A Status Quo Scenario, developed to project smoking rates and health outcomes in the absence of vaping, is compared with Substitution models, whereby cigarette use is largely replaced by vaping over a 10-year period. We test an Optimistic and a Pessimistic Scenario, differing in terms of the relative harms of e-cigarettes compared with cigarettes and the impact on overall initiation, cessation and switching. Projected mortality outcomes by age and sex under the Status Quo and E-Cigarette Substitution Scenarios are compared from 2016 to 2100 to determine public health impacts. FINDINGS: Compared with the Status Quo, replacement of cigarette by e-cigarette use over a 10-year period yields 6.6 million fewer premature deaths with 86.7 million fewer life years lost in the Optimistic Scenario. Under the Pessimistic Scenario, 1.6 million premature deaths are averted with 20.8 million fewer life years lost. The largest gains are among younger cohorts, with a 0.5 gain in average life expectancy projected for the age 15 years cohort in 2016. CONCLUSIONS: The tobacco control community has been divided regarding the role of e-cigarettes in tobacco control. Our projections show that a strategy of replacing cigarette smoking with vaping would yield substantial life year gains, even under pessimistic assumptions regarding cessation, initiation and relative harm.

Crowdsourced data collection for public health: A comparison with nationally representative, population tobacco use data.

INTRODUCTION: Internet-based crowdsourcing is increasingly used for social and behavioral research in public health, however the potential generalizability of crowdsourced data remains unclear. This study assessed the population representativeness of Internet-based crowdsourced data. METHODS: A total of 3999 U.S. young adults ages 18 to 30years were recruited in 2016 through Internet-based crowdsourcing to complete measures taken from the 2012-2013 National Adult Tobacco Survey (NATS). Post-hoc sampling weights were created using procedures similar to the NATS. Weighted analyses were conducted in 2016 to compare crowdsourced and publicly-available 2012-2013 NATS data on demographics, tobacco use, and measures of tobacco perceptions and product warning label exposure. RESULTS: Those in the crowdsourced sample were less likely to report an annual household income of $50,000 or greater, and e-cigarette, waterpipe, and cigar use were more prevalent in the crowdsourced sample. High proportions of both samples indicated cigarette smoking is very harmful and very addictive. Comparable proportions of non-smokers and smokers reported cigarette warning label exposure, however the likelihood of reporting that smoking is very harmful by frequency of warning label exposure was lower among smokers in the crowdsourced sample. CONCLUSIONS: Our findings indicate that crowdsourced samples may differ demographically and may not produce generalizable estimates of tobacco use prevalence relative to population data after post-hoc sample weighting. However, correlational analyses in crowdsourced samples may reasonably approximate population data. Future studies can build from this work by testing additional methodological strategies to improve crowdsourced sampling strategies.

FDA-Required Tobacco Product Inserts & Onserts­and the First Amendment.

In 2012, a federal court of appeals struck down an FDA rule requiring graphic health warnings on cigarettes as violating First Amendment commercial speech protections. Tobacco product inserts and onserts can more readily avoid First Amendment constraints while delivering more extensive information to tobacco users, and can work effectively to support and encourage smoking cessation. This paper examines FDA's authority to require effective inserts and onserts and shows how FDA could design and support them to avoid First Amendment problems. Through this process, the paper offers helpful insights regarding how key Tobacco Control Act provisions can and should be interpreted and applied to follow and promote the statute's purposes and objectives. The paper's rigorous analysis of existing First Amendment case law relating to compelled commercial speech also provides useful guidance for any government efforts either to compel product disclosures or to require government messaging in or on commercial products or their advertising, whether done for remedial, purely informational, or behavior modification purposes.

Communicating Tobacco Product Information to the Public.

The 2009 Family Smoking Prevention and Tobacco Control Act (TCA) requires tobacco companies to disclose information about the harmful chemicals in their products to the U.S. Food and Drug Administration (FDA). The law requires the FDA, in turn, to communicate this information to the public "in a format that is understandable and not misleading to a lay person." But how should the FDA comply with this requirement? What does it mean for information about complex chemicals to be "understandable and not misleading to a lay person"? These questions are not easy ones to answer. Disclosures about the amount of harmful chemicals (constituents) in different tobacco products may help to inform consumers, but may also conversely prompt consumers to reach incorrect or unsupported conclusions about products' relative health risks. This paper first analyzes the FDA's legal obligation to publish tobacco constituent information so that it is "understandable and not misleading to a layperson." Second, it discusses how that legal analysis has guided scientific research examining how members of the public interpret messages regarding tobacco constituents. Lastly, this paper concludes with policy recommendations for the FDA as it considers how to comply with the law's constituent disclosure requirement while still furthering its overall objective of promoting public health.

US Smokers' Beliefs, Experiences and Perceptions of Different Cigarette Variants Before and After the FSPTCA Ban on Misleading Descriptors Such as "Light," "Mild," or "Low".

INTRODUCTION: In December 2008, the Federal Trade Commission (FTC) took action that prompted the removal of nicotine and tar listings from cigarette packs and ads. As of June 2010, the US Family Smoking Prevention and Tobacco Control Act prohibited the use of explicit or implicit descriptors on tobacco packaging or in advertising that convey messages of reduced risk or exposure, specifically including terms like "light," "mild," and "low" and similar descriptors. This study evaluates the effect of these two policy changes on smokers' beliefs, experiences and perceptions of different cigarettes. METHODS: Using generalized estimating equations models, this study analyzed survey data collected between 2002 and 2013 by the International Tobacco Control Policy Evaluation Study regarding US smokers' beliefs, experiences, and perceptions of different cigarettes. RESULTS: Between 2002 and 2013, smoker misperceptions about "light" cigarettes being less harmful did not change significantly and remained substantial, especially among those who reported using lower-strength cigarettes. After the two policy changes, reported reliance on pack colors, color terms, and other product descriptors like "smooth" to determine cigarette strength style trended upward. CONCLUSIONS: Policies implemented to reduce smoker misperceptions that some cigarettes are safer than others appear to have had little impact. Because of pack colors, color terms, descriptors such as "smooth," cigarette taste or feel, and possibly other characteristics, millions of smokers continue to believe, inaccurately, that they can reduce their harms and risks by smoking one cigarette brand or sub-brand instead of another, which may be delaying or reducing smoking cessation. IMPLICATIONS: What this study adds: This study confirms that US policies to reduce smoker misperceptions that some cigarettes are less harmful than others have not been successful. Following the removal of light/low descriptors and tar and nicotine numbers from cigarette packs and ads, pack colors, color words, other descriptors (eg, smooth), and sensory experiences of smoother or lighter taste have helped smokers to continue to identify their preferred cigarette brand styles and otherwise distinguish between which brands and styles they consider "lighter" or lower in tar and, mistakenly, less harmful than others. These findings provide additional evidence to support new enforcement or regulatory action to stop cigarettes and their packaging from misleading smokers about relative risk, which may be reducing or delaying quit attempts.