Acute effects of charcoal filters and package color on cigarette perceptions and use behaviors: Results from a randomized pilot study examining Natural American Spirit "Sky".

INTRODUCTION: Charcoal-filtered cigarettes have been available for decades but have never held a major share of the U.S. cigarette market. This pilot study gathered initial behavioral data characterizing how "Sky"-a recently introduced charcoal-filtered cigarette variety that uses potentially misleading marketing features-is used and what impact its packaging color has on consumer perceptions. METHODS: Forty adult daily non-menthol cigarettes users (52.5% male, 75.0% White, mean age = 46.1, 14.3 mean cigarettes/day) completed a single-session deception study utilizing a 2 ×2 mixed factorial design to manipulate cigarette filter condition (charcoal vs. non-charcoal) and pack color (light vs. dark). Participants smoked two cigarettes identical in appearance and packaging but differing in filter type (blinded and order counterbalanced) and completed pre- and post-cigarette CO samples and post-cigarette questionnaires. RESULTS: Participants endorsed more favorable subjective ratings, puffed less of, held more correct beliefs about risks, and expressed greater intentions to use the charcoal (vs. non-charcoal)-filtered cigarette (p's <0.05). Pack color had few effects on outcomes; however, cigarettes in light vs. dark colored packs were rated as cleaner tasting (p <0.01). Neither filter condition nor pack color affected CO boost. There were no interaction effects on any outcomes. CONCLUSIONS: Under blinded conditions, Sky charcoal-filtered cigarettes are initially appealing independent of their packaging color. Findings warrant further study of these effects on perceptions, behavior, and harm exposure after longer, open-label use periods. Findings may inform regulatory decisions regarding cigarette packaging and filter composition.

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.

Effect of nicotine expectancy and nicotine dose reduction on cigarette demand, withdrawal alleviation, and puff topography.

BACKGROUND: Current FDA plans include proposed nicotine reduction mandates by the end of 2023. Most research on reduced nicotine cigarettes has been dose-blinded, while a mandate would be known to the public. Few laboratory studies have examined specifically how low nicotine content labeling impacts behavioral response. The purpose of this within-subject, balanced-placebo, human laboratory study was to evaluate the main and interactive effects of nicotine dose expectancy and dose reduction on cigarette reinforcement, withdrawal alleviation, and puff topography. METHODS: Participants who smoke daily (N=21; 9 female) completed one practice and four experimental sessions in which expectancy (labeled "average" versus "very low" nicotine) and nicotine dose (0.80mg versus 0.03mg yield) were manipulated. Participants in acute withdrawal sampled experimental cigarettes followed by withdrawal alleviation and puff topography measures. Cigarette demand was measured using an incentivized purchase task. Analyses evaluated main and interactive effects of expectancy and nicotine dose. RESULTS: Nicotine dose manipulation produced expected physiological effects (e.g., heart rate increases) and both reduced nicotine dose and expectation manipulations reduced perceived nicotine content. Expectation of reduced nicotine alone or in combination with reduced nicotine dose did not alter demand, withdrawal alleviation, or topography. Effective withdrawal alleviation was observed in all conditions. CONCLUSIONS: These data inform nicotine regulation policy by suggesting limited compensatory harms caused by reduced nicotine expectations. The minimal acute effects of reduced nicotine expectancy or exposure on demand suggests that reduced nicotine standards are likely to generate their greatest public health benefit through the slowing of newly initiating cigarette smoking.

Causal effects of point-of-sale cigarette promotions and subjective social status on cigarette craving: a randomised within-person experiment.

BACKGROUND: Cigarette smoking continues to be a leading cause of preventable deaths in the USA, in part because the USA has not adopted the WHO Framework Convention on Tobacco Control. One way the tobacco industry counteracts tobacco control policies is by heavily advertising cigarettes at the point of sale in retailers (eg, at the cash register) and by offering discounts on cigarettes. DESIGN: A within-subject experimental design with adults who smoke cigarettes daily (n=281) investigated whether: (1) exposure to images of cigarette promotions in an online experiment is associated with greater cigarette craving relative to viewing images of non-smoking cues, and (2) if exposure to images of point-of-sale cigarette promotions with a discount (vs without) increases cigarette craving. The study also examined how participants' subjective social status (compared with others in the USA) relates to cigarette craving after exposure to images of cigarette promotions with and without a discount. RESULTS: In an online experiment, exposure to images of smoking cues, including point-of-sale cigarette promotions, elicited greater craving relative to non-smoking cues (all p<0.001). In addition, images of promotions with a discount elicited higher levels of craving compared with those without a discount (b=0.09, p=0.001). Although participants with a higher (vs lower) subjective social status craved cigarettes less overall (b=-0.12, p=0.012), there was no difference in their craving between images of promotions with and without a discount, while craving was higher for images of promotions with a discount than without for participants with higher subjective social status (b=0.06, p=0.021). CONCLUSION: Viewing images of point-of-sale cigarette promotions can causally increase cravings to smoke, which may also apply to real-world retail settings that display cigarette promotions. Restricting point-of-sale promotions generally, and discounts specifically, could help reduce cigarette smoking and address tobacco use disparities in the USA.

Effect of nicotine corrective messaging on nicotine-related beliefs in US adults: a randomised controlled trial.

INTRODUCTION: Widespread misperceptions of the health risks of nicotine could undermine the public health benefits of the Food and Drug Administration's actions, including modified risk tobacco product authorisations and a reduced nicotine product standard for cigarettes. METHODS: 794 US adults (aged 18+) in NORC's AmeriSpeak panel participated in a randomised controlled trial in Spring 2021 to test the effect of three exposures to eight nicotine corrective messages (NCM) on beliefs about nicotine, nicotine replacement therapy (NRT), e-cigarettes and reduced nicotine content (RNC) cigarettes at 3-month follow-up. Analyses conducted in 2022 examined the effect of study condition (NCM (n=393) vs no message control (n=401)) on nicotine beliefs, use intentions and use of nicotine and tobacco products. RESULTS: Exposure to three NCM doses reduced nicotine (b=-0.33; 95% CI -0.60, -0.07), NRT (b=-0.49; 95% CI -0.85, -0.14), e-cigarette (b=-0.32; 95% CI -0.59, -0.05) and RNC cigarette false beliefs (b=-0.64; 95% CI -1.26, -0.02) compared with the control, controlling for baseline beliefs. Baseline tobacco use and concern about nicotine addiction attenuated intervention effects on false beliefs about RNC cigarettes. There were few intervention effects on intention or use of nicotine and tobacco products. CONCLUSIONS: Repeated exposure to NCM was necessary to reduce false beliefs about nicotine and tobacco products. Future studies will improve understanding of the dose and duration of nicotine education needed to shift intentions and behaviour, as well as tailored content for tobacco product users to achieve similar reductions in false beliefs as non-users. TRIAL REGISTRATION NUMBER: NCT04805515.

Effects of cigarette package colors and warning labels on marlboro smokers' risk beliefs, product appraisals, and smoking behavior: a randomized trial.

OBJECTIVE: Plain packaging and graphic warning labels are two regulatory strategies that may impact cigarette risk beliefs and reduce consumption, but data are needed to better understand how smokers respond to such regulations. METHODS: Adult, daily, Marlboro non-menthol smokers (Red [n = 141] or Gold [n = 43]) completed a mixed factorial randomized trial. Participants smoked their usual cigarettes during baseline (5-days) and were randomized to receive cigarette packs with a warning label manipulation (graphic vs. text-only). Within each warning label condition, participants completed three within-subjects pack color manipulations (red, gold, plain), each lasting 15 days. Participants were blinded to the fact that all packs contained their usual cigarettes. Mixed-effects models examined between- and within-subject differences on risk beliefs, product perceptions, and smoking behavior. RESULTS: Warning type and package color did not impact cigarette consumption or subjective ratings. However, use increased in all conditions (2.59-3.59 cigarettes per day) relative to baseline. While smokers largely held correct risk beliefs at baseline (Mean = 6.02, SE = 0.17, Range:0-8), the cumulative number of incorrect or uncertain cigarette risk beliefs increased from baseline in all pack color manipulations in the text (IRR range = 1.70-2.16) and graphic (IRR range = 1.31-1.70) warning conditions. Across all pack color periods, those in the graphic (vs. text) warning condition had reduced odds of reporting their study cigarettes as 'safer' than regular cigarettes (OR range = 0.22-0.32). CONCLUSIONS: Pack color modification may increase uncertainty about several key cigarette risk beliefs, though graphic warnings may attenuate these effects. Regulatory agencies could consider supporting policy changes with information campaigns to maximize public knowledge. TRIAL REGISTRATION: November 25, 2014; Registration number: NCT02301351.

Effects of pictorial warning labels depicting lesser-known and well-known risks of smoking on viewing patterns, recall, and knowledge of smoking harms.

BACKGROUND: In 2019, the Food and Drug Administration introduced 11 pictorial warning labels (PWLs) for inclusion on cigarette packages, created in compliance with court recommendations and tailored to increase knowledge of smoking harms. Several highlighted lesser-known risks of smoking. No behavioral studies have yet evaluated how risk content in PWLs impacts viewing patterns, recall, and knowledge of smoking harms. METHODS: Seventy adults who reported smoking cigarettes daily (62.9% male, 57.1% African American, mean age = 50.3, mean cigarettes per day = 14.4) completed a single-session laboratory study. They were randomized to view a set of four PWLs depicting either lesser-known or well-known risks of smoking while having eye movements recorded, then completed post-exposure recall and knowledge measures. RESULTS: Participants exposed to PWLs depicting lesser-known smoking risks viewed the text of the warning sooner and for longer than the image (p's <0.05); those exposed to PWLs depicting well-known risks viewed the image longer than text (p <0.001). PWL condition did not affect recall of text or image (p's >0.1). Those viewing lesser-known (vs. well-known) risks had greater knowledge of smoking causing lesser-known risks of bladder cancer, blindness, bloody urine, cataracts, diabetes, and head and neck cancer (p's <0.001). CONCLUSIONS: Individuals viewing PWLs depicting lesser-known (vs. well-known) smoking risks visually engaged with the PWL text more than image, had similarly high recall of PWL content, and had greater knowledge of lesser-known risks of smoking. Findings suggest including lesser-known risk information on PWLs improves overall knowledge of smoking health risks.

Effects of reduced nicotine content cigarette advertising with warning labels and social media features on product perceptions among young adults.

This study sought to understand reactions to very low nicotine (VLN) cigarette advertising compared with conventional cigarette advertising with consideration of warning labels and social media context. The online experimental study recruited young adult cigarette smokers and nonsmokers (N = 1,608). Participants completed a discrete choice task with a 2 × 2 × 3 mixed design: brand, (VLN, Marlboro), context (Ad only, Ad on social media), and warning (Text-only, Well-known risk pictorial, or Lesser-known risk pictorial). Participants made choices about attention, appeal, harm, buying, and quitting intentions. Social media context increased attention and appeal. A well-known risk pictorial warning outperformed a text-only warning. Smokers had increased odds of quit intentions for VLN ads, yet nonsmokers had increased intentions to buy cigarettes on social media with a text-only warning. Results indicate differences in how young adults react to cigarette ads on social media, especially with the warnings they portray.

Effects of Modified Tobacco Risk Products with Claims and Nicotine Features on Perceptions among Racial and Ethnic Groups.

Research suggests consumers may misunderstand modified risk tobacco product (MRTP) claims. We examined the effects of nicotine content across four tobacco products with and without MRTP claims among a racially and ethnically diverse sample of adults who do and do not smoke. Adults (n = 1484) aged 21-65 completed an online experiment using a 2 × 2 × 4 mixed factorial design to examine the effects of tobacco product (Classic White Snus, IQOS, JUUL e-cigarette, and VLN cigarette) and nicotine content (high vs. low) stratified by MRTP claim (present vs. absent) across four outcomes: (1) likely to try (2) serious disease if used regularly, (3) least addictive, and (4) ease of quitting smoking. Not including an MRTP claim resulted in an increased likelihood of trying a product, decreased concern of serious disease, lower perceived addictiveness, and increased ease of quitting smoking. Participants selected low nicotine IQOS without a claim as the least likely to cause serious disease. Low nicotine JUUL, without a claim, was selected as least addictive and most likely to facilitate quitting. Intentions to try were highest for low nicotine JUUL. Participants selected low-nicotine products as less addictive than high nicotine products. Regulatory efforts should consider how MRTP claims interact with different product characteristics. Subtle differences exist across outcomes between racial and ethnic groups, which indicates that further research is warranted.

Differences in biobehavioral measures of cigarette smoking by depression symptomology.

INTRODUCTION: Research that explores the clinical relevance of subclinical depressive symptoms and smoking is primarily focused on smoking cessation. We examine whether depression symptoms vary across an array of biological (carbon monoxide boost), behavioral (FagerströmTest of Nicotine Dependence, cigarettes per day, smoking topography), and psychological smoking-related outcomes (Questionnaire on Smoking Urges, Withdrawal Symptoms Checklist) in non-treatment-seeking smokers. METHODS: Baseline data were pooled from three research trials with identical procedures designed to assess individual smoking behavior using smokers preferred cigarette brands. Depression symptom level (asymptomatic, subsyndromal, syndromal) was defined using established Center for Epidemiological Depression Scale (CES-D) cutpoint criteria. Smokers were instructed to smoke as usual for one-week. At the beginning and end of the baseline period, nicotine dependence, smoking topography, CO boost, desire to smoke, anticipation of positive reinforcement, negative affect, and withdrawal were measured. RESULTS: Ordinary least squares linear regression models were used to test the association between depression symptom level and outcome measures adjusting for sex and education (N = 355). The results revealed no differences in topography measures, cigarettes per day and FTND. Smoking withdrawal and smoking urges were higher among both individuals with subsyndromal symptoms and syndromal depression symptoms compared to those who were asymptomatic. Individuals with subsyndromal depressive symptoms experienced higher smoke exposure and higher relief from negative affect. CONCLUSION: Increased smoke exposure, greater withdrawal symptoms and urges to smoke, and anticipation of negative affect relief among smokers with subsyndromal depression symptoms suggest that depression symptoms need not reach syndromal levels to alter smoking-related outcomes.

Changes in Pack Features Among Top-Selling Cigarettes in the U.S., 2018 and 2021.

INTRODUCTION: Cigarette packaging is designed to increase consumer appeal and remains a primary promotional tool in many countries, including the U.S. This study documented changes in the prevalence of pack characteristics among the top-selling cigarette products in the U.S. in 2018 and 2021. METHODS: The 50 cigarette packs with the highest national unit sales in U.S. convenience stores in 2018 and 2021 were identified using Nielsen's Scantrack data and subsequently purchased. Packs were coded for features such as dominant color(s), descriptive text, and promotional language. Descriptive analyses conducted in 2022 weighted by total annual unit sales compared the prevalence of pack characteristics between years. RESULTS: Three brands-Marlboro, Newport, and Camel-constituted over 80% of pack sales among the top-selling products. Packs with red as a dominant color grew less popular between years (33.3% vs 29.5%), whereas those with green became more prevalent (25.2% vs 28.9%), consistent with a rise in the proportion of menthol sales. The prevalence of descriptors such as flavor and fresh decreased from 46.0% to 39.4% and 9.7% to 5.2%, respectively. Meanwhile, the prevalence of promotional language (e.g., rewards programs) increased from 60.9% to 69.0%. CONCLUSIONS: The use of visual and named colors remains common, which can implicitly communicate sensory or health-related attributes. Moreover, promotions may help recruit and retain consumers in the context of more restrictive tobacco control policies and price increases. Given the strong influence that cigarette packaging exerts on consumers, packaging-focused policies, such as plain packaging laws, may reduce appeal and accelerate declines in cigarette use.

Assessing Attention to Tobacco Warnings With a Heatmapping Task.

INTRODUCTION: Attention is a critical outcome to understanding the impacts of tobacco warning labels and is commonly measured using eye tracking. Self-report, online methods may be efficient, scalable alternatives to capture attention. This study assesses warning label attention on cigarette marketing using a heatmapping task. METHODS: Young adults (n=1,608) aged 18-30 years and registered on Mechanical Turk with a WorkerID verified in the U.S. were included. Data were collected in 2021-2022 and analyzed in 2022. Tobacco advertisement exposure included a 2 × 3 between-subjects factorial design for varying contexts and warnings. Attention was operationalized with self-reported frequency and timing of warning selection. Outcomes include credibility, willingness to use the advertised cigarettes, and intentions to use cigarettes and low-nicotine cigarettes. RESULTS: Early and more frequent attention to the warning was associated with higher credibility (frequent: ß=0.28, 95% CI=0.11, 0.44; early: ß=0.14, 95% CI=0.02, 0.25), lower willingness to use the advertised cigarettes (frequent: ß= -1.78, 95% CI= -2.24, -1.32; early: ß= -1.16, 95% CI= -1.49, -0.84), lower cigarette use intentions in the next week (frequent: ß= -0.44, 95% CI= -0.64, -0.25; early: ß= -0.21, 95% CI= -0.35, -0.08), and lower low-nicotine cigarette use intentions in the next week (frequent: ß= -0.47, 95% CI= -0.66, -0.28; early: ß= -0.25, 95% CI= -0.38, -0.12) than no attention at all. CONCLUSIONS: Greater attention as measured by a heatmapping task was observed for pictorial warnings and associated with lower intentions to use tobacco. Heatmapping selection patterns were a suitable proxy for attention in this online sample.

Examining Visual Attention to Tobacco Marketing Materials Among Young Adult Smokers: Protocol for a Remote Webcam-Based Eye-Tracking Experiment.

BACKGROUND: Eye tracking provides an objective way to measure attention, which can advance researchers' and policy makers' understanding of tobacco marketing influences. The development of remote webcam-based eye-tracking technology, integrated with web-based crowdsourcing studies, may be a cost-effective and time-efficient alternative to laboratory-based eye-tracking methods. However, research is needed to evaluate the utility of remote eye-tracking methods. OBJECTIVE: This study aimed to detail the process of designing a remote webcam-based eye-tracking experiment and provide data on associations between participant characteristics and the outcomes of experiment completion. METHODS: A total of 2023 young adult (aged 18-34 years) cigarette smokers in the United States were recruited to complete a web-based survey that included a 90-second remote eye-tracking experiment that examined attention to e-cigarette marketing materials. Primary outcome measures assessed the completion of the remote eye-tracking experiment-specifically, experiment initiated versus not initiated, experiment completed versus not completed, and usable versus nonusable eye-tracking data generated. Multivariable logistic regressions examined the associations between outcome measures and participants' sociodemographic backgrounds, tobacco use history, and electronic devices (mobile vs desktop) used during the experiment. RESULTS: Study recruitment began on April 14, 2022, and ended on May 3, 2022. Of the 2023 survey participants, 1887 (93.28%) initiated the experiment, and 777 (38.41%) completed the experiment. Of the 777 participants who completed the experiment, 381 (49%) generated usable data. Results from the full regression models show that non-Hispanic Black participants (adjusted odds ratio [AOR] 0.64, 95% CI 0.45-0.91) were less likely to complete the eye-tracking experiment than non-Hispanic White participants. In addition, female (vs male) participants (AOR 1.46, 95% CI 1.01-2.11), those currently using (vs not using) e-cigarettes (AOR 2.08, 95% CI 1.13-3.82), and those who used mobile (vs desktop) devices (AOR 5.10, 95% CI 3.05-8.52) were more likely to generate usable eye-tracking data. CONCLUSIONS: Young adult participants were willing to try remote eye-tracking technology, and nearly half of those who completed the experiment generated usable eye-tracking data (381/777, 49%). Thus, we believe that the use of remote eye-tracking tools, integrated with crowdsourcing recruitment, can be a useful approach for the tobacco regulatory science research community to collect high-quality, large-scale eye-tracking data in a timely fashion and thereby address research questions related to the ever-evolving tobacco marketing landscape. It would be useful to investigate techniques to enhance completion rates and data usability. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/43512.

IQOS print magazine advertising characteristics and reach before and after FDA authorisation as a modified risk tobacco product.

INTRODUCTION: IQOS is a heated tobacco product that was authorised as a modified risk tobacco product (MRTP) in July 2020. While it was removed from the US market in 2021 for legal reasons, as the first tobacco product to receive an 'exposure modification' MRTP order, surveillance of IQOS marketing is needed to inform regulation and policy for future MRTPs. The purpose of this study is to expand the current research on IQOS advertising in the USA by examining content and readership characteristics of IQOS ads in print magazines before and after US Food and Drug Administration MRTP authorisation. METHODS: We merged content analysis data with Kantar Media data on magazine placement and expenditures. Magazine readership data were obtained from MRI-Simmons. We compared data from pre-MRTP authorisation with data post-MRTP authorisation. This study was conducted in 2021. RESULTS: There was one unique ad and there were 13 observations pre-MRTP, and eight unique ads and 132 observations post-MRTP. Compared with pre-MRTP ads, more post-MRTP ads featured Marlboro HeatSticks, including Amber HeatSticks, and featured people. All ads contained a warning label-most warning labels were cigarette specific. IQOS ads were featured in magazines that are especially popular among women. CONCLUSIONS: After receiving MRTP authorisation, IQOS increased ad expenditures in print magazines with a readership comprised of primarily women. If IQOS returns to the US market, it will be important for tobacco control to monitor their advertisement content, placement, and expenditures.

Effects of Sugary Beverage Text and Pictorial Warnings: A Randomized Trial.

INTRODUCTION: Multiple U.S. localities have introduced legislation requiring sugar-sweetened beverage (SSB) warnings. This study effects of different warning designs on beverage selections and perceptions. STUDY DESIGN: The study was an RCT. SETTING/PARTICIPANTS: An online virtual convenience store and survey were used with a nationally representative sample of primary caregivers of 6-11-year-olds (n=961). Data were collected in January 2020 and analyzed in May-July 2020. INTERVENTION: Participants were randomized to view SSBs with 1 of 4 front-of-package label designs: (1) no-warning control, (2) health-related text warning, (3) sugar pictorial warning (image of beverage sugar content in cubes/teaspoons/packets with health-related warning text), or (4) health pictorial warning (image of possible health consequences of overconsuming SSBs with health-related warning text). MAIN OUTCOME MEASURES: Outcomes included participants' beverage choice for their child and perceptions of beverages, their assigned labels, and warning policies. RESULTS: Proportionally fewer participants chose a SSB in the sugar pictorial warning condition (-13.4 percentage points; 95% CI= -21.6 to -0.1 percentage points; p=0.007) and in the health pictorial warning condition (-14.7 percentage points; 95% CI= -22.8 to -0.1 percentage points; p=0.004) compared to the control. Sugar pictorial warnings led to more accurate added-sugar content estimates than all conditions and greater label trust and support for sugar-sweetened beverage warning policies than health pictorial warnings. CONCLUSIONS: SSB warning policies may be most effective if they mandate images of beverages' added sugar content accompanied by warning text. TRIAL REGISTRATION: This study is registered at www. CLINICALTRIALS: gov NCT03648138.

Influence of cigarillo packaging characteristics on young adults' perceptions and intentions: findings from three online experiments.

OBJECTIVES: Packaging is an important component of tobacco marketing that influences product perceptions and use intentions. However, little research exists on cigar packaging. We leveraged variability in existing Swisher Sweets cigarillo packaging to extend the evidence base. METHODS: Between 2017 and 2019, we conducted three online experiments with 774 young adult past-year cigar smokers recruited via Amazon Mechanical Turk. After viewing Swisher package images that differed by flavour descriptor and/or colour, participants rated them on perceptions and purchase intentions. In study 1, participants viewed one of four cigarillos ('Wild Rush Encore', 'Wild Rush Limited', 'Twisted Berry' and 'Strawberry'). In study 2, participants viewed two different watermelon rum-flavoured cigarillos ('Boozy Watermelon' and 'Island Madness'). In study 3, participants viewed two of three 'Wild Rush' cigarillo versions ('Encore' with or without an explicit flavour descriptor or 'Limited'). RESULTS: In study 1, more participants perceived 'Twisted Berry' and 'Wild Rush Limited' as tasting good and less harsh tasting compared with 'Wild Rush Encore'. In study 2, compared with 'Island Madness', more participants perceived 'Boozy Watermelon' as tasting good, less harsh tasting and used by younger users but less by masculine users; female participants were more likely to purchase 'Boozy Watermelon'. In study 3, participants perceived 'Wild Rush Encore' with the explicit flavour descriptor as tasting better than packages without and being used by younger users but less by masculine users. CONCLUSIONS: Variations in cigarillo packaging, even among cigarillos with the same flavour, may have differential consumer appeal, suggesting packaging features should be considered in cigar product regulation.

Effects of IQOS health warnings and modified risk claims among young adult cigarette smokers and non-smokers.

INTRODUCTION: Heated tobacco products, including Marlboro IQOS, are available globally. In the USA, IQOS was authorised to be advertised with claims about reduced toxicant exposure relative to cigarettes. The effects of such modified risk claims and health warnings have not been studied among young adult cigarette smokers and non-smokers. METHODS: In 2020, US young adult (18-30 years, n=1328) cigarette smokers and non-smokers viewed an IQOS ad in a 4 (modified risk claim variations or none) by 3 (warning variations or none) between-subjects experiment. Outcome measures assessed perceived credibility and effectiveness of the health or risk message for discouraging IQOS use, perceived harms, efficacy beliefs, and IQOS use intentions. RESULTS: Smokers reported significantly higher (p<0.05) perceived credibility, lower perceived effectiveness, higher efficacy beliefs about switching to IQOS and higher intentions to use IQOS than non-smokers. Among smokers, health warnings increased perceived credibility (p<0.001) and effectiveness (p<0.05), but claims did not affect outcomes examined. Among non-smokers, warnings and claims increased perceived credibility, and warnings increased perceived effectiveness (p<0.003). The reduced exposure claim increased non-smokers' intentions to use IQOS (b=0.40, 95% CI 0.07 to 0.73). CONCLUSIONS: Among young adult smokers, health warnings increased perceived effectiveness at discouraging IQOS use and perceived credibility. Among non-smokers, warnings and claims increased perceived credibility and warnings increased perceived effectiveness, but the Food and Drug Administration-authorised reduced exposure claim increased intentions to use IQOS. Research is warranted to understand how the content of modified risk claims and health warnings for IQOS affects IQOS use in this population.

Effects of advertising features on smokers' and non-smokers' perceptions of a reduced nicotine cigarette modified risk tobacco product.

INTRODUCTION: Research is needed to determine the impact of marketing on perceptions and use of reduced nicotine content (RNC) cigarettes, particularly as US regulators have permitted the sale of an RNC cigarette modified risk tobacco product (MRTP) that seeks further authorisation to advertise using modified risk claims. This study examined the effects of two advertising elements (product name and disclaimer content) on perceptions of an RNC cigarette MRTP. METHODS: Adult participants (n=807, 28.7% smokers, 58.2% male, 74.2% non-Latinx white) completed an online MTurk survey. Participants were randomised to view one of six RNC cigarette advertisements, using a 2×3 between-subject factorial design to manipulate product name ('Moonlight' vs 'Moonrise') and disclaimer content (industry-proposed: 'Nicotine is addictive. Less nicotine does NOT mean a safer cigarette' vs focused: 'Less nicotine does NOT mean a safer cigarette' vs no content), then completed recall and product perception questionnaires. RESULTS: All participants who viewed the industry-proposed disclaimer (vs no content) perceived greater addiction risk (p's<0.05). Non-smokers who viewed this disclaimer also perceived greater health risks and held fewer false beliefs (p's<0.05). Smokers who viewed Moonlight (vs Moonrise) ads perceived lower health risks (p<0.05). CONCLUSIONS: Disclaimer content may effectively inform consumers about addiction risk of a new RNC cigarette MRTP, and further inform non-smokers about health risks. This element, however, had little effect on perceived health risks among smokers, among whom the Moonlight product name was associated with health risk misperceptions similar to the banned 'light' descriptor.

Effect of progesterone administration in male and female smokers on nicotine withdrawal and neural response to smoking cues: role of progesterone conversion to allopregnanolone.

BACKGROUND: Progesterone administration has therapeutic effects in tobacco use disorder (TUD), with females benefiting more than males. Conversion of progesterone to the neurosteroid allopregnanolone is hypothesized to partly underlie the therapeutic effects of progesterone; however, this has not been investigated clinically. METHODS: Smokers (n = 18 males, n = 21 females) participated in a randomized, double-blind, placebo-controlled crossover study of 200 mg progesterone daily across 4 days of abstinence. The ratio of allopregnanolone:progesterone was analyzed in relationship to nicotine withdrawal, smoking urges, mood states, subjective nicotine effects, and neural response to smoking cues. RESULTS: Allopregnanolone:progesterone ratio interacted with sex to predict withdrawal symptoms (p = 0.047), such that females with higher allopregnanolone:progesterone ratios reported lower withdrawal severity (b = - 0.98 [- 1.95, - 0.01]; p = 0.048). In addition, allopregnanolone:progesterone ratio interacted with sex to predict confusion (p = 0.014) and fatigue (p = 0.034), such that females with higher allopregnanolone:progesterone ratios reported less confusion (b = - 0.45 [- 0.78, - 0.12]; p = 0.008) and marginally lower fatigue (b = - 0.50 [- 1.03, 0.02]; p = 0.062. Irrespective of sex, higher ratios of allopregnanolone:progesterone were associated with stronger "good effects" of nicotine (b = 8.39 [2.58, 14.20]); p = 0.005) and weaker "bad effects" of nicotine (b = - 7.13 [- 13.53, - 0.73]; p = 0.029). CONCLUSIONS: Conversion of progesterone to allopregnanolone correlated with smoking-related outcomes in both sex-dependent and sex-independent ways. Sex-dependent effects suggest that conversion of progesterone to allopregnanolone may contribute to greater therapeutic benefits in females but not males with TUD. Trial registration Clinicaltrials.gov registration, retrospectively registered: NCT01954966; https://clinicaltrials.gov/ct2/show/NCT01954966 \.