Regulatory Landscape of Cannabis Warning Labels in US States with Legal Retail Nonmedical Cannabis, 2024.

Objectives. To characterize regulatory practices related to nonmedical cannabis warning labels in states across the United States that have legalized retail nonmedical cannabis. Methods. In March 2024, we conducted a content analysis of regulations for nonmedical cannabis warning labels required on product packages in 20 states where, as of March 2024, adults could legally purchase nonmedical cannabis in retail environments. For each state, we examined requirements related to warning label content and characteristics. Results. Required warning label content and characteristics varied widely across states. Only 2 states required a warning about mental health risks (10%) and 2 states required a warning for high potency products on risk of psychosis (10%). No states required front-of-package warning placement, only 2 states required rotating warnings (10%), and 4 states required contrasting colors (20%). Warnings were often verbose (mean = 57 words), vague, and had small or no minimum font size. Conclusions. Opportunities exist for states to improve the alignment of their nonmedical cannabis warning label regulations with evidence that has been generated so far in cannabis effects, cannabis warning efficacy, and warning label design. (Am J Public Health. 2024;114(S8):S681-S684. https://doi.org/10.2105/AJPH.2024.307722).

Analysis of Candy Tobacco Imitation Products Available Online in the United States.

INTRODUCTION: Youth tobacco use remains a critical public health concern, and childhood use of candy tobacco imitation products (CTIP) is associated with cigarette use among youth. However, no research has examined the full extent of CTIP available for purchase in the United States. AIMS AND METHODS: We conducted a content analysis of CTIP available on English-language, US-based websites. We identified sites that marketed CTIP utilizing Google and candy retail websites, examining each product for product names, the tobacco product being replicated (eg, cigar and cigarette), manufacturer, candy flavor, images, product rating, pack color, and if the product had packaging that may appeal to youth. RESULTS: We found 66 CTIP available. The most popular CTIP were cigars, with 39 separate products (59%), followed by candy cigarettes-14 products (21%), candy pipes-8 products (12%), and chewing tobacco-5 products (8%). In the 52 products where packaging design was available, 39 (75%) had packaging that may appeal to youth. CONCLUSIONS: CTIP, many of which contain packaging appealing to youth, are widely available for purchase online across the United States. These findings could stimulate policy actions, such as removal of CTIP from popular retail websites, labeling of CTIP as potentially dangerous to youth, or age verification requirements for purchasing CTIP. IMPLICATIONS: CTIP continues to be sold on the internet despite research indicating candy cigarette product use by youth increases their likelihood of smoking. We conducted research to understand the extent to which CTIP are sold on the internet and whether these products are being marketed to youth. The results provide evidence that some of the largest retail companies in the world continue to sell CTIP, and the majority are sold in packaging that likely appeals to youth. The results suggest that further research into the market for these products is needed, and regulatory measures should be considered to prevent CTIP from leading to youth tobacco use.

Perceived Effectiveness of Cigar Warnings in Discouraging Blunt Use.

INTRODUCTION: Many people remove the tobacco leaf from cigars and replace it with cannabis (ie, blunts), but few studies have examined whether messages about the risks of cigars, like warnings on cigar packages, can affect blunt use. METHODS: Participants were 438 U.S. adults who reported past 30-day cigar use and ever blunt use, recruited from a probability-based national panel to take an online survey. In a 2 × 2 experiment with a between-subjects design, we manipulated two cigar warning characteristics: (1) warning type: text-only versus pictorial (ie, text + image) and (2) warning size: 30% (smaller) versus 50% (larger) of the product package. Participants then viewed six different warnings on a fictious cigarillo package, within their randomly assigned condition. After evaluating all stimuli, participants were asked the extent to which the warnings discouraged them from wanting to use cigars to smoke cannabis (ie, blunt perceived warning effectiveness). Response options ranged from "not at all" (1) to "a great deal" (5). RESULTS: We observed no main effects of warning type or size on blunt perceived warning effectiveness. However, a significant interaction existed between the two experimental manipulations (p = .009). Whereas adding images made no difference to blunt perceived warning effectiveness when warnings were smaller (simple effect: -0.22, p = .28), images mattered for larger warnings. Specifically, adding images increased blunt perceived warning effectiveness when warnings were 50% of the product package (simple effect: 0.52, p = .008). CONCLUSIONS: This experiment provides preliminary evidence that larger pictorial cigar warnings may discourage blunt use relative to larger but text-only warnings. IMPLICATIONS: Blunts, which are hollowed out cigars with tobacco leaf wrappers that are filled with cannabis leaf, are one of the most common ways in which tobacco and cannabis are used simultaneously, yet few studies have examined whether messages about the risks of cigars can affect blunt use. We conducted an online experiment concerning the perceived effectiveness of cigar warnings among people who use blunts recruited from a probability-based panel. Results provide novel, preliminary evidence that larger pictorial cigar warnings may discourage blunt use, relative to larger but text-only warnings. More research evaluating cigar warnings on blunt use is needed.

Wanting to be "accepted and heard": Perspectives about cessation messages from LGBTQ+ individuals who dual use cigarettes and e-cigarettes.

INTRODUCTION: Dual use of cigarettes and e-cigarettes is especially prevalent among lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ+) adults in the US. This is concerning as health risks of dual use may be as high or higher than exclusive smoking. We sought to learn about people who dual use and identify as LGBTQ+'s perspectives about dual use, quitting, and cessation ads. METHODS: Nineteen LGBTQ+ adults who dual use participated in virtual semi-structured interviews in North Carolina in 2022. We asked about perceptions of smoking and vaping in LGBTQ+ communities, their thoughts about quitting, and their opinions on four cessation ads. The ads advocated quitting one or both products. Transcripts were coded using ATLAS.ti and reviewed using a thematic content analysis approach. RESULTS: Participants described how within LGBTQ+ communities, smoking and vaping are common and accepted and are used to cope or to socialize. Most participants made past quit attempts. Many said they were not ready to quit both products, but some were open to quitting smoking. Some thought e-cigarettes may be as harmful as cigarettes, reducing their motivation to quit smoking cigarettes due to the lack of perceived health benefits. Participants sought cessation ads that explicitly address dual use and are representative and supportive. They disliked ads that felt stereotypical or patronizing. CONCLUSIONS: Dual use in LGBTQ+ communities appears driven by both internal and external pressures. Participants were generally open to quitting cigarettes, and LGBTQ+ smoking cessation may be best encouraged with authentic ads that explicitly address both products. IMPLICATIONS: These qualitative findings about smoking and vaping among LGBTQ+ individuals provide guidance for communication ad campaign design to help reduce the high dual use rates among LGBTQ+ young adults.

The Role of Harm Visibility for Pictorial Health Warning Labels on Cigars.

INTRODUCTION: Pictorial health warning labels (HWLs) can communicate the harms of tobacco product use, yet little research exists for cigars. We sought to identify the most effective types of images to pair with newly developed cigar HWLs. AIMS AND METHODS: In September 2021, we conducted an online survey experiment with US adults who reported using little cigars, cigarillos, or large cigars in the past 30 days (n = 753). After developing nine statements about health effects of cigar use, we randomized participants to view one of three levels of harm visibility paired with each statement, either: (1) an image depicting internal harm not visible outside the body, (2) an image depicting external harm visible outside of the body, or (3) two images depicting both internal and external harm. After viewing each image, participants answered questions on perceived message effectiveness (PME), negative affect, and visual-verbal redundancy (VVR). We used linear mixed models to examine the effect of harm visibility on each outcome, controlling for warning statement. RESULTS: Warnings with both and external harm depictions performed significantly better than the internal harm depictions across all outcomes, including PME (B = 0.21 and B = 0.17), negative affect (B = 0.26 and B = 0.25), and VVR (B = 0.24 and B = 0.17), respectively (all p < .001). Compared to both, the external depiction of harm did not significantly change PME or negative affect but did significantly lower VVR (B = -0.07, p = .01). CONCLUSIONS: Future cigar pictorial HWLs may benefit from including images depicting both or external harm depictions. Future research should examine harm visibility's effect for other tobacco pictorial HWLs. IMPLICATIONS: The cigar health warning labels (HWLs) proposed by the US Food and Drug Administration are text-only. We conducted an online survey experiment among people who use cigars to examine the effectiveness of warnings with images depicting different levels of harm visibility. We found HWLs with images depicting both an internal and external depiction of cigar harm, or an external depiction of harm alone, performed better overall than images portraying internal depictions of harm. These findings provide important regulatory evidence regarding what type of images may increase warning effectiveness and offer a promising route for future cigar HWL development.

Qualitative perspective on nicotine pouches from adults who smoke cigarettes in North Carolina.

BACKGROUND: Little is known about how nicotine pouch products are perceived by people who smoke, including if they are perceived as a cessation aid or a substitute for when they cannot smoke. We qualitatively investigated the reactions and perceptions about On!, a leading brand of nicotine pouches. METHODS: We conducted online semistructured interviews with 30 adults who smoke cigarettes. Participants viewed an On! brochure and an image of an opened nicotine pouch and were asked about their initial impression, who the intended user is, and how they thought of the product's safety compared with other tobacco and cessation products. Transcripts were independently coded and the data were analysed using thematic content analysis. RESULTS: Among the participants, half identified as female and slightly more than half were white (n=16). The mean age was 43 years old. The following are the central themes that emerged: (1) participants perceived the concealability, flavours and packaging of On! as appealing to youth and young adults; (2) participants perceived nicotine pouches as a product that would supplement rather than replace tobacco use; and (3) the product raised health concerns, which decreased interest in trying nicotine pouches. CONCLUSIONS: Participants believed that the On! nicotine pouch promotional material may promote youth and young adult nicotine product initiation and dual product use for people who smoke. Most viewed On! as a product to use with cigarettes, rather than a way to quit cigarettes. Increased surveillance of nicotine pouches is warranted to monitor the trajectory of this emerging tobacco product and prevent youth initiation.

Improving Point-of-Sale Warnings for Single Cigars: Implications for Premium Cigars.

INTRODUCTION: For cigars sold individually without packaging, including many premium cigars, the US Food and Drug Administration (FDA) proposed that retailers display six warning statements on a sign at the point-of-sale (POS). AIMS AND METHODS: To examine the potential effectiveness of cigar warning signs, we conducted a between-subjects online experiment. Participants were 809 U.S. adults who reported using cigars (78% ever large cigar use, 49% past 30-day large cigar use) recruited from a probability-based panel. Participants viewed an image of a cigar store countertop with randomization to one of four conditions: (1) no warning sign, (2) a sign with six FDA proposed text-only warnings, (3) a sign with six novel text-only warnings, or (4) a sign with six novel text + image warnings. We used analysis of variance (ANOVA) models and post hoc Tukey tests to examine the results. RESULTS: The FDA-proposed text-only warning sign was perceived as less effective in discouraging participants from smoking cigars (M: 3.26, SD: 1.39; scale range: 1-5, where five indicates higher discouragement) compared with the novel text-only warning sign (M = 3.38, SD = 1.40) and the novel text + image warning sign (M = 3.65, SD = 1.34). The novel text + image warning sign increased discouragement from smoking cigars versus the FDA-proposed text-only warning sign (p = .02) and decreased the perceived satisfaction of smoking cigars versus no warning sign (p = .04). In a sensitivity analysis, the novel text + image warning sign decreased the perceived satisfaction of smoking cigars (p = .01), decreased cigar purchase intentions (p = .03), decreased the urge to smoke (p = .03), and increased discouragement from smoking cigars (p = .006) compared with all other study conditions. CONCLUSIONS: Results provide new evidence that policymakers, such as the FDA, could use when proposing POS warning signs for cigars. IMPLICATIONS: The US FDA proposed that retailers display a warning sign at the POS for cigars sold individually without packaging. We conducted an online experiment concerning the potential effectiveness of this regulatory policy with people who use cigars recruited from a probability-based panel. Results provide the first evidence that the FDA-proposed text-only warning sign was perceived as less effective than other types of warning signs and that adding images could potentially increase the effectiveness of warning signs. These findings are particularly relevant for premium cigars, which are often sold individually in brick-and-mortar retail settings.

Reducing Misperceptions About Very Low Nicotine Content Cigarettes: Insights From Adults Who Smoke.

INTRODUCTION: Many people incorrectly think that very low nicotine content (VLNC) cigarettes are less carcinogenic than current cigarettes. This risk misperception by people who smoke could reduce motivation to quit under a nicotine reduction policy. We qualitatively examined perspectives on campaign messages designed to reduce misperceptions. AIMS AND METHODS: Adults who smoke from North Carolina participated in online interviews. After being introduced to the idea of a VLNC policy, participants were shown VLNC messages and asked about their perceptions on the clarity, understandability, persuasiveness, and meaning of the messages. We conducted a thematic content analysis of the transcripts. RESULTS: Thirty adults who smoke cigarettes participated (15 females, 13 males, 2 nonbinary) with a mean age of 43 years. Central themes that emerged were: (1) Confusion about the proposed VLNC cigarette policy affected how messages were interpreted; (2) Messages that promote self-efficacy for quitting rather than guilt or fear were better received; and (3) Direct and succinct messages were seen as more able to grab attention and inform people who smoke. Some participant concerns focused on whether VLNC cigarettes would relieve their nicotine cravings and whether they would need to smoke more VLNC cigarettes to feel satisfied. CONCLUSION: Campaign messages to educate the public about the harmful effects of smoking VLNC cigarettes may be more effective if people who smoke are informed about the policy's rationale to understand why nicotine is removed rather than the other harmful chemicals. Messages should also acknowledge the difficulty of quitting and be short and direct to capture attention. IMPLICATIONS: Adults who smoke have some confusion about nicotine reduction in cigarettes and this affects how they perceive potential communication campaign messages about the risk of smoking VLNC cigarettes. In our qualitative research, we found that adults who smoke prefer messages about VLNC cigarettes that acknowledge the challenge of quitting and that are direct and succinct. With further development, campaign messages may be able to reduce misperceptions about VLNC cigarettes and maximize the public health benefit of a nicotine reduction policy.

Knowledge and beliefs about blunts among youth in the United States.

Background: Blunts (i.e., cannabis rolled in cigar paper with or without tobacco) are a popular way of consuming cannabis. Little survey research has examined knowledge and beliefs about blunts, especially among youth who use cigars or are susceptible to cigar use. Methods: Participants were a convenience sample of N = 506 youth (ages 15-20) from the United States (US) recruited April-June 2023 who reported ever using little cigars or cigarillos (LCCs), past 30-day use of LCCs, or susceptibility to using LCCs. We used adjusted logistic and ordinal regression models to examine correlates of knowledge that blunts contain nicotine and, separately, relative addiction/harm perceptions for blunts vs. unmodified cigars containing only tobacco. Results: One-third of youth (32.1 %) thought that blunts do not contain nicotine. Around half of youth thought that blunts were "much less" or "slightly less" addictive (45.0 %) and "much less" or "slightly less" harmful (51.5 %) than unmodified cigars. Youth who identified as Black/African American (vs. white) had lower odds of knowledge that blunts contain nicotine (aOR = 0.51, 95 % CI: 0.30, 0.87). Youth who frequently used blunts were less likely to report that blunts were more addictive (aOR = 0.39; 95 % CI: 0.24, 0.63) and harmful (aOR = 0.31; 95 % CI: 0.19, 0.50 (vs. unmodified cigars) compared with youth who never used blunts. Conclusions: Our study with a sample of US youth-who have used or are susceptible to using LCCs-found that about 1 in 3 participants thought that blunts do not contain nicotine, and many believed blunts were less harmful and addictive than unmodified cigars.

Examining the influence of cigar and cannabis co-marketing on packaging perceptions: An experiment with a sample of US youth.

SIGNIFICANCE: Cigars are sometimes marketed with cannabis references because they are often used for smoking blunts (i.e., cannabis rolled in cigar paper with or without tobacco). However, little research exists on the impact of cannabis co-marketing on cigar perceptions. METHODS: Participants included 506 US youth (ages 15-20) recruited April-June 2023 through Qualtrics who reported ever using little cigars or cigarillos (LCCs), past 30-day use of LCCs, or susceptibility to using LCCs. We then conducted a between-subjects experiment, randomizing youth to view one of two cigarillo packages: 1) a package with cannabis co-marketing (i.e., the package included a cannabis-related flavor descriptor and the word "blunt" appeared in the brand name and product label) or 2) a package with no cannabis co-marketing. We assessed the effects of the packaging on perceptions of product ingredients, addictiveness and harm perceptions, product appeal, susceptibility to using the product shown, and purchase intentions. RESULTS: Packages with cannabis co-marketing were perceived as more likely to contain cannabis (OR: 5.56, 95 % CI: 3.73, 8.27) and less likely to contain tobacco (OR: 0.42, 95 % CI: 0.25, 0.70) or nicotine (OR: 0.57, 95 % CI: 0.40, 0.82). Cannabis co-marketing also led to higher susceptibility to using the product shown (B: 0.21, p = 0.02). We did not find evidence that cannabis co-marketing changed harm perceptions or purchase intentions. CONCLUSIONS: Among a sample of US youth, cannabis co-marketing on cigar packages may change perceptions of product ingredients and increase susceptibility to using such products, which could lead to the initiation of cigars and cannabis.

How do current tobacco warnings compare to the WHO FCTC guidelines: a content analysis of combustible tobacco warnings worldwide.

OBJECTIVE: Many countries have adopted warning labels for combustible tobacco products, yet little research exists describing tobacco warning characteristics globally and to what extent they meet the WHO Framework Convention for Tobacco Control (FCTC) Guidelines. This study evaluates characteristics of combustible tobacco warnings. DESIGN: We conducted a content analysis to describe the overall landscape of warnings using descriptive statistics and compared to the WHO FCTC Guidelines. SETTING: We searched existing warning databases for combustible tobacco warnings from English-speaking countries. We compiled warnings meeting inclusion criteria and coded for message and image characteristics using a pre-defined codebook. PRIMARY AND SECONDARY OUTCOMES MEASURES: Characteristics of combustible tobacco warning text statements and warning images were the primary study outcomes. There were no secondary study outcomes. RESULTS: We identified a total of 316 warnings from 26 countries or jurisdictions worldwide. Of these warnings, 94% included warning text and an image. Warning text statements most often described health effects to the respiratory (26%), circulatory (19%) and reproductive systems (19%). Cancer was the most frequently mentioned health topic (28%). Fewer than half of warnings included a Quitline resource (41%). Few warnings included messages about secondhand smoke (11%), addiction (6%) or cost (1%). Of warnings with images, most were in colour and showed people (88%), mostly adults (40%). More than 1 in 5 warnings with images included a smoking cue (ie, cigarette). CONCLUSIONS: While most tobacco warnings followed WHO FCTC guidance on effective tobacco warnings, such as communicating health risks and inclusion of images, many did not include local Quitline or cessation resources. A sizeable minority include smoking cues that could inhibit effectiveness. Full alignment with WHO FCTC guidelines will improve warnings and better achieve the WHO FCTC objectives.