The appeal of smokeless tobacco products among young Canadian smokers: the impact of pictorial health warnings and relative risk messages

Effects of Modified Risk Tobacco Product Claims on Consumer Responses

INTRODUCTION

US tobacco manufacturers can seek authorization from the US Food and Drug Administration (FDA) to market products using modified risk tobacco product (MRTP) claims. To inform regulatory decisions, we examined the impact of MRTP claim specificity and content, including whether the claims produced halo effects (ie, inferring health benefits beyond what is stated).

AIMS AND METHODS

Participants were 3161 US adult cigarette smokers. Using a two (general vs. specific) × 2 (risk vs. exposure) plus independent control design, we randomized participants to view one message from these conditions: general risk claim (eg, "smoking-related diseases"), general exposure claim (eg, "chemicals in smoke"), specific risk claim (eg, "lung cancer"), specific exposure claim (eg, "arsenic"), or control. Claims described the benefits of completely switching from cigarettes to the heated tobacco product IQOS.

RESULTS

MRTP claims of any sort elicited a higher willingness to try IQOS relative to control (d = 0.09, p = .043). Claims also elicited lower perceived risk of disease and exposure to harmful chemicals for completely switching from cigarettes to IQOS (d = -0.32 and -0.31) and partially switching (d = -0.25 and d = -0.26; all p < .05). Relative to specific MRTP claims, general MRTP claims led to lower perceived risk and exposure for complete switching (d = -0.13 and d = -0.16) and partial switching (d = -0.14 and d = -0.12; all p < .05). Risk and exposure MRTP claims had similar effects (all p > .05).

DISCUSSION

MRTP claims led to lower perceived risk and exposure, and higher willingness to try IQOS. General claims elicited larger effects than specific claims. MRTP claims also promoted unintended halo effects (eg, lower perceived risk of disease and chemical exposure for partial switching).

IMPLICATIONS

We found evidence that MRTP claims promoted health halo effects. In light of these findings, the FDA should require research on halo effects prior to authorization. Further, if an MRTP claim is authorized, FDA should require tobacco manufacturers to conduct post-market surveillance of how the claim affects consumer understanding, including partial switching perceived risk and exposure beliefs, as well as monitoring of dual-use behaviors.

The effect of cigarette modified risk claims and brand on perceived risk, product appeal, and use intentions

OBJECTIVES

No studies have examined the brand context in which modified risk claims appear on tobacco products. This study examines how marketing products with modified risk claims affects risk perceptions, appeal, and intentions among own-brand, other brand, and novel brand cigarettes.

METHODS

This experiment employed a 3 (claim: risk modification [RM], exposure modification [EM], control) x 3 (brand: own, other, novel) between-subjects design. A convenience sample (N = 1,557, Mage = 40.28, SDage = 19.01, 71.3% female, 80.3% White) of current or former Marlboro, Camel, or Newport users was collected. Participants were assigned to view their own brand, another brand, or a novel brand, with or without a claim, and rated perceived risk after switching to this product, product appeal, and use intentions.

RESULTS

Participants in the RM or EM conditions had lower risk perceptions (versus control). Claim did not affect appeal. Adult established cigarette users in the EM (but not RM) condition had higher intentions (versus control). Participants rated their own and another brand as more appealing than the novel brand. Interactions between brand and claim were not significant.

CONCLUSIONS

We found modified risk claims decreased risk perceptions but did not impact appeal. Whereas participants showed preference for their own brand in terms of appeal and intentions, brand did not moderate the impact of claims.

Country Participation in the WHO Framework Convention on Tobacco Control Health Warnings Database

Background

The World Health Organization’s (WHO) Framework Convention on Tobacco Control (FCTC) Health Warnings Database is an online, publicly available resource created for countries to upload and share pictorial health warnings for tobacco packaging. The purpose of this study was to evaluate the extent to which the database is used by countries for the sharing of pictorial warnings.

Methods

The study’s sample included parties to the FCTC who required graphic health warning labels on cigarette packaging from. Those countries were categorized as having a low, middle, and high Socio-Demographic Index (SDI). The Health Warnings Database was then analyzed for those countries’ unique pictorial images, as well as the number of pictorials that were shared between countries.

Results

Of the 110 countries that required pictorial warnings on cigarette packaging, only 53 (48%) voluntarily contributed pictorials to the database, with most of those (53%) being high SDI-level countries. There were 342 unique pictorials on the database, with 62 images posted by seven countries that were used by 13 other countries.

Conclusion

While sharing was evident from the database, there remains a need for more countries to upload the pictorials to the database. There is also a need to expand the database to include alternative tobacco products, such as waterpipe tobacco and e-cigarettes.

Exploring the implications of modified risk claim placement in tobacco advertising

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

Health warning labels describing snus as less harmful than smoking: effects on perceptions of risk

Background

Using snus (Swedish moist snuff) is less harmful than smoking, but health warning labels (HWLs) on snus products do not reflect this relation. There are few studies on the effects of comparative risk information in snus warning labels. The purpose of this experiment is to examine whether risk perceptions differ after exposure to non-comparative vs. comparative risk information in snus warning labels.

Methods

A total of 254 Norwegians aged 19–69 were exposed to pictures of snus packages in one of four HWL conditions: non-comparative EU-based (“Snus is damaging to your health”), control (the text “Snus” only), general comparative risk (“Snus is less damaging to your health than smoking”), or percentage comparative risk (“Snus is 90% less damaging to your health than smoking”). Perceptions of risk from snus use and smoking were measured before (pre) and during (post) exposure to the HWL. Changes from pre to post in (1) perceptions of risk from snus use and (2) perceptions of risk differences from snus use versus smoking were tested in repeated measures ANOVAs with current snus and cigarette use as covariates.

Results

Both the perceived risks from snus use and its perceived risk difference to smoking decreased more in the control and the percentage HWL conditions than in the EU-based HWL condition. When comparing the general comparative risk and the EU-based HWL, a similar difference was found for the perceived risk difference, but not for the separate measure of snus risk. Both the snus risk and risk difference perception decreased more for the percentage than for the general relative risk HWL.

Conclusions

The non-comparative EU-based HWL claiming that “Snus is health damaging” maintains a high level of perceived risk from snus use, while no HWL and the suggested comparative HWLs adjust perceptions of risk in the direction of lower harm from snus use. An HWL describing snus as 90% less harmful than smoking was more effective than a general claim.

Impact of tobacco-pack pictorial warnings on youth and young adults: A systematic review of experimental studies

INTRODUCTION

We conducted a systematic review of the experimental literature on the impact of tobacco-pack pictorial warning labels (PWLs) on youth and young adults.

METHODS

We systematically searched computerized databases and the reference lists of relevant articles. We included studies that used an experimental protocol to assess PWLs. Studies had to report findings for youth or young adult samples (aged <30 years). Thirty-one studies met the inclusion criteria, with a total sample size of 27506. Two coders independently coded all study characteristics and outcomes.

RESULTS

Twenty-eight studies experimentally evaluated PWLs for cigarette packs while three studies evaluated PWLs for smokeless tobacco packs. Generally, PWLs led to higher attention, stronger cognitive and affective reactions, more negative pack attitudes and smoking attitudes, and increased intentions not to use tobacco products compared to text warnings. PWLs were perceived to be more effective than text warnings for both cigarette packs and smokeless tobacco packs.

CONCLUSIONS

The systematic review showed that PWLs on tobacco products are effective across a wide range of tobacco-related outcomes among young people. Gaps in the literature include a lack of research on tobacco initiation and cessation and a dearth of literature on non-cigarette tobacco products.

Smokers' perceptions of risks and harm from snus relative to cigarettes: A latent profile analysis study

INTRODUCTION

Certain types of smokeless tobacco (SLT) products, particularly snus, carry fewer health risks than cigarette smoking and might be able to serve as harm-reduction products for smokers. However, studies frequently find that smokers misperceive SLT and snus to be as or more harmful than smoking. This perception is often measured with a single general harm question, and research on underlying risk perceptions is limited.

METHODS

Using a sample of 256 current smokers, we utilized Latent Profile Analysis to examine response profiles to items that assessed perceived risk of specific health outcomes (lung cancer, heart disease, oral cancer) from snus relative to cigarettes, along with the typical single item measure of overall harm from snus compared to cigarettes.

RESULTS

Three smoker response profiles emerged. Almost half (44.9%) of smokers perceived snus to be as or more risky than cigarettes for all three specific health outcomes (group 1), while over one third (38.3%) had an elevated perceived risk for oral cancer only (group 2). About 17% of smokers perceived snus to have lower risks for lung cancer only (group 3). Across each profile, perceived risk was highest for oral cancer.

CONCLUSIONS

If smokers are to consider snus for harm-reduction, efforts may be needed to better inform smokers about their lower relative risks, including for particular health outcomes of interest. This study also suggests that smokers may vary in their level of need for information to correct their relative risk misperceptions.

Systematic Review of Health Communication for Non-Cigarette Tobacco Products

The Food and Drug Administration, which now has regulatory authority over all tobacco products meeting the statutory definition, is tasked with communicating the risks of these products to the public through health warnings and public education. However, there have been no attempts to summarize what is known about non-cigarette tobacco product (NCTP) health messaging. We conducted a systematic review to examine the existing literature on health communication for NCTPs and identify key research gaps. A total of 45 unique studies were retrieved and coded, with the majority focused on messaging for smokeless tobacco (SLT, k = 32, 71.1%), followed by waterpipe tobacco (WT, k = 9, 20%), electronic nicotine delivery systems (ENDS, k = 2, 4.4%), cigars (k = 2, 4.4%), and a potentially reduced exposure product (k = 1, 2.2%). Studies most commonly examined tobacco product warnings (k = 26, 57.8%) and public education (k = 19, 42.2%), which included mass media campaigns. Most studies examined knowledge, attitudes, and beliefs as outcomes (k = 27, 60%), while behavior was an outcome in the minority of studies (k = 8, 17.8%). Pictorial warnings and public education about NCTPs demonstrated positive impact in some studies, although the literature is nascent. Given the increasing use of NCTPs such as ENDS, WT, and cigars, particularly among adolescents and young adults, more research is needed on effective ways to communicate product risk to those audiences most at risk.

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

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

The Impact of E-Cigarette Warnings, Warning Themes and Inclusion of Relative Harm Statements on Young Adults' E-Cigarette Perceptions and Use Intentions

Although e-cigarettes in the United States are required to carry one nicotine addiction warning, little is known about the impact of other potential e-cigarette warning themes, nor about pairing warnings with messages that communicate e-cigarettes' reduced-harm potential relative to cigarettes. We randomly assigned 876 young adults (ages 18⁻29) to view e-cigarette ads in a 3 × 2 plus control online experiment that varied by warning theme (i.e., nicotine addiction; nicotine's impact on adolescent brain development; presence of harmful chemicals) and warning type-i.e., the presence ("relative harm warning") or absence ("standard warning") of a relative harm (RH) statement in the warning label ("e-cigarettes may cause harm to health but are less harmful than cigarettes"). Warning believability, informativeness, understandability and support were high across conditions and there were no significant differences by warning theme on e-cigarette harm perceptions or use intentions nor on nicotine (mis)perceptions. Perceived warning effectiveness for discouraging youth initiation was higher for the "brain" and "chemicals" warnings compared to the addiction warning. Warnings with the included RH statement were perceived as less believable and credible and were less frequently correctly recalled. Research should continue to investigate the impact of different e-cigarette warning themes and formats with priority audiences.

Health Warning Labels for Smokeless Tobacco: The Impact of Graphic Images on Attention, Recall, and Craving

Introduction

Little research has examined the impacts of graphic health warnings on the users of smokeless tobacco products.

Methods

A convenience sample of past-month, male smokeless tobacco users (n = 142; 100% male) was randomly assigned to view a smokeless tobacco advertisement with a graphic health warning (GHW) or a text-only warning. Eye-tracking equipment measured viewing time, or dwell time, in milliseconds. Following the advertisement exposure, participants self-reported smokeless tobacco craving and recalled any content in the health warning message (unaided recall). Linear and logistic regression analyses evaluated the proportion of time viewing the GHW, craving, and GHW recall.

Results

Participants who viewed a GHW spent a significantly greater proportion of their ad viewing time on GHWs (2.87 seconds or 30%), compared to those viewing a text-only warning (2.05 seconds or 24%). Although there were no significant differences by condition in total advertisement viewing duration, those participants viewing a GHW had increased recall of health warning messages compared to the text-only warning (76% had any warning message recall compared to 53%; p < .05). Self-reported craving after advertisement exposure was lower in the GHW compared to text-only condition, but the difference was not statistically significant (a rating of 4.4 vs. 5.3 on a 10-point scale; p = .08).

Conclusions

GHWs attracted greater attention and greater recall of health warning messages compared to text-only warnings among rural male smokeless tobacco users.

Implications

Among a sample of rural smokeless tobacco users, GHWs attracted more attention and recall of health warning messages compared to text-only warnings when viewed within smokeless tobacco advertising. These findings provide additional empirical support that GHWs are an effective tobacco control tool for all tobacco products and advertisements.

The Effect of Tobacco Control Policies on US Smokeless Tobacco Use: A Structured Review

INTRODUCTION

Tobacco use has shifted increasingly from cigarettes to other products. While the focus has been mostly on cigarette-oriented policies, it is important to gauge the effects of policies targeting other products. We review and critique the literature on how policies affect smokeless tobacco (ST).

METHODS

We conducted a search of the literature on tobacco control policies as they relate to ST use, focusing on tobacco taxes, smoke-free air laws, media campaigns, advertising restrictions, health warnings, cessation treatment policies, and youth access policies. Findings from 78 total studies are summarized.

RESULTS

ST taxes, media campaigns, health warnings, and cessation treatment policies were found to be effective tools in reducing ST use. Evidence on the effects of current youth access policies is less strong. Studies have not yet been conducted on marketing or product content restrictions, but the literature indicates that product marketing, through advertising, packaging, flavorings, and extension of cigarette brands, plays an important role in ST use.

CONCLUSIONS

Although the evidence base is less established for ST policies than for cigarette policies, the existing literature indicates ST use responds to tobacco control policies. Policies should be structured in a way that aims to reduce all tobacco use while at the same time increasing the likelihood that continuing tobacco users use the least risky products.

IMPLICATIONS

Studies find that policies targeting smoking and policies targeting smokeless products affect smokeless use, but studies are needed to examine the effect of policies on the transitions between cigarette and smokeless use.

ST product characteristics and relationships with perceptions and behaviors among rural adolescent males: a qualitative study

Although smoking declines in the United States, the prevalence of male adolescent smokeless tobacco (ST; moist snuff and chewing tobacco) use remains unchanged. ST product characteristics, such as flavoring, packaging, and branding, could influence adolescents' ST initiation and continued use. This qualitative study examines the potential role of product characteristics in shaping ST-related perceptions and behaviors among rural adolescent males. Semi-structured individual interviews were conducted at three California rural high schools. ST users were asked about their experiences and perceptions related to product characteristics. Interviews were transcribed, coded, and analyzed using a general inductive approach. Participants associated flavored ST with appealing non-tobacco products, such as chewing gum and alcohol. Availability of different varieties and flavors stimulated interest and curiosity in sampling or switching between ST products. Time-limited promotional flavors and packaging also enhanced product appeal. Adolescent ST users preferred certain brands based on perceived brand features and perceived nicotine content, associating higher-strength brands as better suited for experienced ST users. Brand preferences frequently reflected perceived ST brand popularity within peer groups. Based on these observations, potential ST regulation and health education campaigns to address misconceptions about ST characteristics could influence adolescents' ST-related perceptions and reduce ST use among this vulnerable population.

The role of negative affect and message credibility in perceived effectiveness of smokeless tobacco health warning labels in Navi Mumbai, India and Dhaka, Bangladesh: A moderated-mediation analysis

OBJECTIVE

There is strong evidence showing that pictorial health warnings are more effective than text-only warnings. However, much of this evidence comes from high-income countries and is limited to cigarette packaging. Moreover, few studies have identified mechanisms that might explain the impact of warnings.

METHODS

The current study examined the potential mediating role of negative affect and the moderating influence of message credibility in perceived effectiveness of smokeless tobacco warnings in two low- and middle-income countries (LMICs). Field interviews were conducted in India and Bangladesh, with adult (19+ years) smokeless tobacco users (n=1053), and youth (16-18years) users (n=304) and non-users (n=687). Respondents were randomly assigned to view warnings in one of four conditions: (1) Text-only, (2) pictorial with symbolic imagery, (3) pictorial with graphic images of health effects, or (4) pictorial with personalized graphic images plus a personal testimonial.

RESULTS

The findings provide support for the mediating influence of negative affect in perceived effectiveness, for adult and youth smokeless tobacco users who viewed pictorial warnings (vs. text-only), and graphic health warnings (vs. personal testimonials). Among adults, message credibility moderated the indirect effect; the association was stronger when credibility was high and weaker when it was low. Among youth users and non-users, message credibility did not moderate the indirect effect.

CONCLUSIONS

Consistent with research from high-income countries, these findings highlight the importance of selecting imagery that will elicit negative emotional reactions and be perceived as credible. Differential effects among adults and youth highlight the importance of pre-testing images.

Measuring youth beliefs about the harms of e-cigarettes and smokeless tobacco compared to cigarettes

This study examined validity of direct and indirect measures of perceived harm of e-cigarettes and smokeless tobacco (SLT) compared to cigarettes. On direct measures, people compare one product to another, whereas on indirect measures, people rate each product separately and the researcher compares these ratings. Data from youth in Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study (2013-2014) were analyzed (N=13,651 youth aged 12-17years). The study included direct measures of perceived harm of e-cigarettes and SLT compared to cigarettes, and indirect measures were created by comparing ratings of the products. Weighted multinomial logistic regressions tested criterion validity by assessing whether direct and indirect measures were associated with criterion variables, including use of e-cigarettes and SLT. Youth were more likely to rate e-cigarettes as less harmful than cigarettes on the indirect measure (67.3%) than the direct measure (50.2%). The same pattern held for ratings of SLT as less harmful than cigarettes (indirect: 29.7%; direct: 11.7%). Direct measures explained unique variance in product use criterion variables even after adjusting for indirect measures, as did indirect measures after adjusting for direct measures. However, the criterion variables were more often associated with the direct measures than the indirect measures. Results offer preliminary support for using both direct and indirect measures when assessing youth's perceived relative harm of various types of products. However, if researchers cannot include both direct and indirect measures in a study, associations with product use criterion variables support prioritizing direct measures.

Mass media interventions for preventing smoking in young people

BACKGROUND

Mass media interventions can be used as a way of delivering preventive health messages. They have the potential to reach and modify the knowledge, attitudes and behaviour of a large proportion of the community.

OBJECTIVES

To assess the effects of mass media interventions on preventing smoking in young people, and whether it can reduce smoking uptake among youth (under 25 years), improve smoking attitudes, intentions and knowledge, improve self-efficacy/self-esteem, and improve perceptions about smoking, including the choice to follow positive role models.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE and Embase in June 2016. This is an update of a review first published in 1998.

SELECTION CRITERIA

Randomized trials, controlled trials without randomization and interrupted time-series studies that assessed the effect of mass media campaigns (defined as channels of communication such as television, radio, newspapers, social media, billboards, posters, leaflets or booklets intended to reach large numbers of people and which are not dependent on person-to-person contact) in influencing the smoking behaviour (either objective or self-reported) of young people under the age of 25 years. We define smoking behaviour as the presence or absence of tobacco smoking or other tobacco use, or both, and the frequency of tobacco use. Eligible comparators included education or no intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted information relating to the characteristics and the content of media interventions, participants, outcomes, methods of the study and risks of bias. We combined studies using qualitative narrative synthesis. We assessed the risks of bias for each study using the Cochrane 'Risk of bias' tool, alongside additional domains to account for the nature of the intervention. We assessed the quality of evidence contributing to outcomes using GRADE.

MAIN RESULTS

We identified eight eligible studies reporting information about mass media smoking campaigns, one of which is new for this update. Seven of the studies used a controlled trial design and one an interrupted time-series analysis. Risks of bias were high across all included studies and there was considerable heterogeneity in study design, intervention and population being assessed.Three studies (n = 17,385), one of which compared a mass media intervention to no intervention and two of which evaluated mass media interventions as adjuncts to school-based interventions, found that the mass media interventions reduced the smoking behaviour of young people. The remaining five studies (n = 72,740) did not detect a significant effect on smoking behaviour. These included three studies comparing a mass media intervention to no intervention, one study evaluating a mass media intervention as an adjunct to a school-based intervention, and one interrupted time-series study of a social media intervention. The three campaigns which found a significant effect described their theoretical basis, used formative research in designing the campaign messages, and used message broadcast of reasonable intensity over extensive periods of time. However, some of the campaigns which did not detect an effect also exhibited these characteristics. Effective campaigns tended to last longer (minimum 3 years) and were more intense (more contact time) for both school-based lessons (minimum eight lessons per grade) and media spots (minimum four weeks' duration across multiple media channels with between 167 and 350 TV and radio spots). Implementation of combined school-based components (e.g. school posters) and the use of repetitive media messages delivered by multiple channels (e.g. newspapers, radio, television) appeared to contribute to successful campaigns.

AUTHORS' CONCLUSIONS

Certainty about the effects of mass media campaigns on smoking behaviour in youth is very low, due to inconsistency between studies in both design and results, and due to methodological issues amongst the included studies. It would therefore be unwise to offer firm conclusions based on the evidence in this review. Methodologically rigorous studies investigating the effect of social media and novel forms of technology as part of tobacco prevention campaigns for youth are needed.

Evaluating Point of Sale Tobacco Marketing Using Behavioral Laboratory Methods

With passage of the 2009 Family Smoking Prevention and Tobacco Control Act, the FDA has authority to regulate tobacco advertising. As bans on traditional advertising venues and promotion of tobacco products have grown, a greater emphasis has been placed on brand exposure and price promotion in displays of products at the point-of-sale (POS). POS marketing seeks to influence attitudes and behavior towards tobacco products using a variety of explicit and implicit messaging approaches. Behavioral laboratory methods have the potential to provide the FDA with a strong scientific base for regulatory actions and a model for testing future manipulations of POS advertisements. We review aspects of POS marketing that potentially influence smoking behavior, including branding, price promotions, health claims, the marketing of emerging tobacco products, and tobacco counter-advertising. We conceptualize how POS marketing potentially influence individual attention, memory, implicit attitudes, and smoking behavior. Finally, we describe specific behavioral laboratory methods that can be adapted to measure the impact of POS marketing on these domains.

The Effect of Comparatively-Framed versus Similarity-Framed E-Cigarette and Snus Print Ads on Young Adults' Ad and Product Perceptions

OBJECTIVES

This study examined the effects of comparative-framing [C-F; ads highlighting differences between the advertised product and conventional cigarettes and/or smokeless tobacco products] versus similarity-framing (S-F; ads highlighting congruence with conventional cigarettes and/or smokeless tobacco products) in e-cigarette and snus ads on young adult smokers' and non-smokers' ad- and product-related perceptions.

METHODS

One thousand fifty one (1,051) young adults (18-24 years; 76% women; 50% smokers) from existing consumer panels were recruited in a within-subjects quasi-experiment. Each participant viewed 4 online advertisements, varied by tobacco product type (e-cigarette or snus) and ad framing (C-F or S-F). The dependent measures for this study were ad-related (ad perceptions, ad credibility) and product-related perceptions (absolute and comparative risk perceptions, product appeal, and product use intentions).

RESULTS

Former and current smokers rated C-F ads as more persuasive than S-F ads, as evidenced by favorable ad perceptions and high product use intentions. Former and current smokers also rated e-cigarette ads with more favorable ad perceptions, low absolute and comparative risk perceptions, high product appeal, and high product use intentions as compared to snus ads. However, the effect sizes of the significant differences are less than.2, indicating small magnitude of difference between the study variables.

CONCLUSIONS

Unless FDA regulates e-cig and snus advertising, there is a potential of decreasing risk perceptions and increasing use of e-cigs among young adults. Further research on implicit/explicit comparative claims in e-cigarettes and snus advertisements that encourage risk misperceptions is recommended.

The Impact of Health Warning Labels for Swedish Snus Advertisements on Young Adults' Snus Perceptions and Behavioral Intentions

INTRODUCTION

This study examined the impact of warning labels conveying the potential harms and addictiveness of Swedish snus and the potential-reduced harms of Swedish snus among young adult nonsmokers and smokers.

METHODS

A convenience sample of young adults aged 18-30 residing in the United States (n = 517, 56% male, 33% smokers) participated in an online experiment. Participants completed baseline measures and were randomized to 1 of 5 experimental conditions where they viewed a Swedish snus ad with warning labels that varied by condition: (1) Control-no warning; (2) Addiction-warning conveying the addictiveness of snus; (3) Harm-warning communicating the potential harms of snus; (4) Harm Reduction-warning conveying the potential-reduced harms of snus compared with cigarettes; (5) Harm Reduction Switch-warning communicating the potential-reduced harms of snus when switching completely from cigarettes to snus. Outcomes measured included perceived harms and addictiveness of snus, thoughts about not using snus, and intentions to use snus.

RESULTS

Participants in the Harm Reduction and Harm Reduction Switch conditions perceived snus to be less harmful than cigarettes compared with the Control, Addiction, and Harm conditions. Nonsmokers in the Harm Reduction condition reported fewer thoughts about not using snus than nonsmokers in the Harm condition.

CONCLUSIONS

Warnings conveying the potential-reduced harms of Swedish snus compared with cigarettes generate perceptions that snus is less harmful than cigarettes and produce fewer thoughts about not using snus among nonsmokers. Such perceptions have been associated with snus use in prior studies.

The Case for Requiring Graphic Warning Labels on Smokeless Tobacco Product Packages

On November 10, 2015, the U.S. Food and Drug Administration approved, for the first time, the sale of smokeless tobacco products authorized under the new premarket tobacco application pathway. This Food and Drug Administration regulatory decision draws attention to the growing worldwide use of smokeless tobacco products in general. Use of these tobacco products is particularly popular in low- and middle-income countries of Asia. Due to aggressive and strategic marketing to children, young adults, and current smokers, rates of smokeless tobacco use in men of all ages are on the rise in United States and elsewhere. The tobacco industry also continues to market these products to current cigarette smokers for use in the growing number of "smoke-free environments." Smokeless tobacco products are associated with cancers of the upper aerodigestive tract, particularly the oral cavity, esophagus, and pancreas; cardiovascular diseases; small-for-gestational-age infants; premature births; increased risk of apnea; and stillbirth. There is no convincing evidence regarding the efficacy of smokeless tobacco, including snus, to promote smoking cessation. Rather, studies from Europe and the United States demonstrate that smokeless tobacco use may facilitate regular cigarette smoking by acting as a gateway drug, especially for children. Caution is warranted before proposing smokeless tobacco as a harm-reduction strategy, in part because of the potential for further promoting smokeless tobacco in low- and middle-income countries where use is already widespread. Continued vigilance through comprehensive surveillance is warranted. We strongly recommend the use of graphic warning labels as a "no regrets" strategy for all smokeless tobacco products marketed globally.

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

BACKGROUND

Smokeless tobacco (SLT) products and their communication have been topics of discussion in harm reduction debates, but little is known about smokers' perceptions of existing SLT risk messages. This study aimed to explore smokers' perceptions of SLT and snus products and news stories with different risk messages about them.

METHODS

We conducted interviews with 30 smokers assigned to read 1 of 3 constructed news stories about SLT and snus with different messages about their risks relative to cigarettes: (1) a 'favourable' version (describing SLT/snus as a 'safer' smoking alternative); (2) a 'cautious' version (describing SLT/snus as having various risks); and (3) a 'mixed' version (both stating SLT risks and potential reduced-risk benefits).

RESULTS

Smokers felt somewhat more informed about snus after article reading and largely found quoted sources to be credible. Though some exposed to favourable SLT/snus messages appeared to modify their beliefs about the products' acceptability and risks, many were left unchanged given pre-existing SLT risk perceptions influenced by prior SLT warnings, observed effects in known users, and concerns about SLT's mode of use. Willingness to use/not use snus in the future was also influenced by non-risk-related factors (eg, preference for smoking rituals). Many referenced e-cigarettes as being safer and more attractive smoking alternatives.

CONCLUSIONS

Exposure to reduced-risk SLT information may have some impact on smokers' SLT perceptions and interest, but this might be limited by a variety of negative SLT beliefs and growth of other smoking alternatives. Future research should explore SLT risk message effects with larger samples and different study designs.

Assessing Constituent Levels in Smokeless Tobacco Products: A New Approach to Engaging and Educating the Public

INTRODUCTION

Providing accurate information about the constituents in nicotine-containing products may help tobacco users make informed decisions about product choices. An experimental study examined a novel approach for presenting accurate constituent information about brands and types of smokeless tobacco (SLT) that could be understood by the general public.

METHODS

Participants were recruited through Amazon's Mechanical Turk and presented information online about 2 constituent dimensions of SLT products-nicotine and/or toxicity (for simplicity, "toxicity" in this study refers to carcinogenic constituents) Participants completed measures of knowledge and tobacco health risks at 2 time points: before and after exposure to constituent information.

RESULTS

Participants were found to increase their knowledge that toxicity contributes to disease risk and nicotine contributes to addiction, that SLT products vary in their levels of nicotine and toxicity, and that both SLT and cigarette products have higher toxicity than medicinal nicotine replacement therapies (e.g., nicotine lozenges). Study results showed no differences when presenting toxicity information alone versus presenting it in conjunction with nicotine information, and found no misperceptions or confusions about the relative harmfulness of cigarettes, SLT, or nicotine replacement therapy.

CONCLUSIONS

Providing tobacco constituent information to smokers and nonsmokers will improve their knowledge about the relative toxicity across products and variations within a class of tobacco products without compromising the health risks associated with tobacco use.

Prevalence of tobacco use among women: a cross sectional survey from a squatter settlement of Karachi, Pakistan

Background

While the prevalence of tobacco use has been slowly declining in the developed countries, rates have been steadily rising in the developing countries. This has led to a rapid rise in tobacco related lung diseases among women.

Objective

Determine the prevalence of tobacco use (both smoking and smokeless) among women in an urban squatter settlement (Orangi Town) in Karachi, Pakistan.

Methods

A cross-sectional survey was conducted on 19,325 females aged between 15 and 80 years in Orangi Town, an urban squatter settlement in Karachi, Pakistan. Modified questionnaire, developed by World Health Organization WHO and Global Adult Tobacco survey (GATS), was used in Urdu. A total of 16,987 women agreed to participate.

Results

The mean age was 37.3 ± 9.8 years amongst whom 15,255 (89.80 %) were married, 9143 (53.82 %) admitted that at least one person uses tobacco in some form in their homes. The prevalence of smokeless tobacco was 42.25 % (7178). The prevalence of smoking tobacco was low as compared to smokeless tobacco i.e. 18.0 % (3058). Among smokers, 85.47 % (1789) admitted that they had tried to quit smoking during last 12 months but failed.

Conclusion

Tobacco use among women in an urban squatter settlement is very high and alarming. Preventive and control measures against tobacco use are required in these communities.

Associations of Proposed Relative-Risk Warning Labels for Snus With Perceptions and Behavioral Intentions Among Tobacco Users and Nonusers

INTRODUCTION

The US Food and Drug Administration can require changes in warning statements for modified risk tobacco products. We report an independent analysis of a consumer perception survey sponsored by Swedish Match as part of a Modified Risk Tobacco Product application to change warning labels for Swedish snus products.

METHODS

The survey exposed each of 4324 daily exclusive cigarette smokers, 1033 daily smokeless tobacco users, 1205 daily other tobacco users, 726 former users, and 5915 triers/never users to one of four current warnings and two proposed relative-risk labels (No tobacco product is safe, but this product presents lower risks to health than cigarettes, or No tobacco product is safe, but this product presents substantially lower risks to health than cigarettes) for snus. Descriptive and logistic regression analyses examined four outcomes: believability, harmfulness, motivation to use, and intention to buy snus.

RESULTS

Compared with the current not-safe-alternative warning, adult tobacco users who viewed the proposed labels perceived them as less believable, perceived snus as less harmful and were more likely to use and buy snus. The proposed labels had no impact on former smokers' likelihood to use and buy snus; triers/never users viewing the substantially lower risk label were more likely to buy snus.

CONCLUSIONS

Tobacco users viewing the proposed labels perceived snus as less harmful than cigarettes and may be more likely to use and buy snus. If labeling changes lead to increased snus use and cigarette reduction or abstinence, public health may benefit. If the opposite occurs, public health could suffer.

Nonsmokers' responses to new warning labels on smokeless tobacco and electronic cigarettes: an experimental study

BACKGROUND

Graphic warning labels are a tobacco control best practice that is mandated in the US for cigarettes under the 2009 Family Smoking Prevention and Tobacco Control Act. However, smokeless tobacco products are not required to carry graphic warning labels, and as of September 2014, electronic cigarettes in the US carry no warning labels and are aggressively marketed, including with "reduced harm" or "FDA Approved" messages.

METHODS

In this online experiment, 483 US adult non-users of tobacco were randomized to view print advertisements for moist snuff, snus, and e-cigarettes with either warning labels (current warning label, graphic warning label) or "endorsements" (a "lower risk" label proposed by a tobacco company, an "FDA Approved" label) or control (tobacco advertisement with no label, advertisement for a non-tobacco consumer products). Main outcome measures included changes in perceived harm, positive attitudes towards, openness to using, and interest in a free sample of moist snuff, snus, and e-cigarettes.

RESULTS

The graphic warning label increased perceived harm of moist snuff and e-cigarettes. "Lower risk" and "FDA Approved" labels decreased perceived harm of moist snuff and snus respectively. Current warning label and graphic warning label significantly lowered positive attitudes towards e-cigarettes. In this sample of non-users of tobacco, 15% were interested in a free sample of alternative tobacco products (predominantly e-cigarettes). Proportion of participants interested in a free sample did not differ significantly across the conditions, but those interested in a free sample had significantly lower perceptions of harm of corresponding tobacco products.

CONCLUSIONS

Regulatory agencies should not allow "lower risk" warning labels, which have similar effects to the "FDA Approved" label, which is prohibited, and should consider implementing graphic warning labels for smokeless tobacco products and e-cigarettes.

Self-reported exposure to tobacco warning labels among U.S. middle and high school students

BACKGROUND

Warning labels on tobacco products are a means to communicate information about the negative health effects of tobacco use to current and potential users. Most tobacco use begins in early adolescence, making it particularly important to understand the degree to which warning labels reach adolescents.

PURPOSE

To examine the extent to which youth report (1) seeing the current warnings on cigarettes and smokeless tobacco (SLT) products in the U.S. and (2) that seeing warnings makes them think about the health risks associated with tobacco use.

METHODS

Exposure to warning labels on cigarettes and SLT, as well as the degree to which adolescents report thinking about health risks in response to warnings, was examined among U.S. middle and high school students using data from the 2012 National Youth Tobacco Survey (NYTS) and analyzed in 2013.

RESULTS

Current data suggest that less than half of adolescents who saw a cigarette pack (46.9%) or SLT product (40.3%) reported seeing the warning label "most of the time" or "always." Among adolescents who reported seeing a warning, less than one third reported that cigarette (30.4%) or SLT (25.2%) warning labels made them think about health risks "a lot." These rates were even lower among current tobacco users (<14%).

CONCLUSIONS

Current warning labels for cigarettes and SLT could be improved by implementing warnings that incorporate features that make them salient and more likely to evoke thoughts about health risks.

Impact of smokeless tobacco packaging on perceptions and beliefs among youth, young adults, and adults in the U.S: findings from an internet-based cross-sectional survey

Background

Research demonstrates that tobacco packaging elements (including health warning labels, descriptive characteristics, and corporate branding) are associated with knowledge of health risks and product appeal with cigarettes. Yet, little research has assessed this with smokeless tobacco (SLT) packaging. This study evaluates the association between three SLT packaging elements with knowledge of health risks and perceptions of novelty and appeal. Additionally, we assess how effects of these messages may differ across age groups, including youth (14-17 years), young adults (18-25 years), and older adults (26-65 years).

Methods

1000 participants were administered a web-based survey in 2010 and shown three sets of SLT packs in random order, varied by descriptor (flavor descriptor vs. none), warning label format (graphic vs. text), and corporate branding (branded vs. plain packaging). Participants rated the packs compared with “no difference” on appeal, novelty, and risk perceptions associated with product use. Chi-square tests were used to test for significant differences in pack selections. Multinomial regression was employed to evaluate the association between effects of packaging elements and participant age.

Results

More respondents selected the pack with the graphic warning label as the pack to make them consider the health risks associated with SLT use, attract their attention, and be least attractive to a smoker. The product with the text warning label was the product someone their age would want to be seen using and would appeal to peers. The SLT pack with the flavor descriptor was not associated with health risks associated with product use. The pack with corporate branding was selected as more appealing, to attract attention, and one they would want to be seen using; the plain pack was less attractive to smokers. Youth and young adults were more likely to indicate that pack elements affected their perceptions of appeal and risk associated with SLT products.

Conclusion

These results suggest that SLT pack characteristics have a measurable effect on perceptions of health risk and product appeal. Future research should assess these findings in the context of harm reduction. Specifically, research is needed to determine whether pack elements on SLT products can effectively convey risk and harm.

A scoping review of unintended harm associated with public health interventions: towards a typology and an understanding of underlying factors

OBJECTIVES

Unintended harm theory as related to public health interventions (PHI) is under developed, with harm evaluation and reporting often absent or incomplete. This review presents a typology for, and underlying factors linked to, PHI-associated unintended harm.

METHODS

This scoping review was conducted electronically and includes articles from 1992 to June of 2013. Out of 2,490 originally identified titles, 26 full-text articles were included that discussed unintended harm associated with PHI. An iterative data analysis process was utilized to identify both a typology and underlying factors associated with unintended harm.

RESULTS

A typology of PHI-associated unintended harm was identified: (1) physical; (2) psychosocial; (3) economic; (4) cultural and (5) environmental. Five underlying factors associated with PHI unintended harm emerged: (1) limited and/or poor quality evidence; (2) prevention of one extreme leads to another (boomerang effects); (3) lack of community engagement; (4) ignoring root causes; and (5) higher-income country PHI implementation in a lower- or middle-income country.

CONCLUSIONS

PHI planning and evaluation frameworks may benefit from the consideration and potential incorporation of the unintended harm typology and underlying factors.

Appalachian residents' perspectives on new U.S. cigarette warning labels

The U.S. Food and Drug Administration revealed new pictorial warning labels in June 2011 for cigarette packages, yet little is known about how these labels are perceived by U.S. residents. We examined the reactions to and attitudes about the new labels among residents of Appalachian Ohio, a region with a high smoking prevalence. We conducted focus groups with Appalachian Ohio residents between July and October 2011. Participants included healthcare providers (n = 30), community leaders (n = 26), parents (n = 28), and young adult men ages 18-26 (n = 18). Most participants supported the addition of the new labels to U.S. cigarette packages, though many were unaware of the labels prior to the focus groups. Participants did not think the labels would be effective in promoting smoking cessation among smokers in their communities, but they were more positive about the potential of the labels to reduce smoking initiation. Participants reported positive feedback about the more graphic labels, particularly those showing a man with a tracheal stoma or a person with severe oral disease. The labels that include a cartoon image of an ill infant and a man who quit smoking received the most negative feedback. Participants generally supported adding pictorial warning labels to U.S. cigarette packages, but only a few of labels received mostly positive feedback. Results offer early insight into how the new labels may be received if they are put into practice.

Tobacco packaging and mass media campaigns: research needs for Articles 11 and 12 of the WHO Framework Convention on Tobacco Control

INTRODUCTION

Communicating the health risks of smoking remains a primary objective of tobacco-control policy. Articles 11 and 12 of the World Health Organization's Framework Convention on Tobacco Control establish standards for two important forms of communication: packaging regulations (Article 11), and mass media campaigns (Article 12).

METHODS

A narrative review approach was used to identify existing evidence in the areas of package labeling regulations (including health warnings, constituent and emission messages, and prohibitions on misleading information) and communication activities (including mass media campaigns and news media coverage). When available, recent reviews of the literature were used, updated with more recent high-quality studies from published literature.

RESULTS

Implementation of Articles 11 and 12 share several important research priorities: (a) identify existing consumer information needs and gaps, (b) research on the message source to identify effective types of content for health warnings and media campaigns, (c) research on how messages are processed and the extent to which the content and form of messages need to be tailored to different cultural and geographic groups, as well as subgroups within countries, and (d) research to identify the most cost-effective mix and best practices for sustaining health communications over time.

CONCLUSION

A unifying theme of effective health communication through tobacco packaging and mass media campaigns is the need to provide salient, timely, and engaging reminders of the consequences of tobacco use in ways that motivate and support tobacco users trying to quit and make tobacco use less appealing for those at risk of taking it up.

Non-cigarette tobacco products: what have we learnt and where are we headed?

A wide variety of non-cigarette forms of tobacco and nicotine exist, and their use varies regionally and globally. Smoked forms of tobacco such as cigars, bidis, kreteks and waterpipes have high popularity and are often perceived erroneously as less hazardous than cigarettes, when in fact their health burden is similar. Smokeless tobacco products vary widely around the world in form and the health hazards they present, with some clearly toxic forms (eg, in South Asia) and some forms with far fewer hazards (eg, in Sweden). Nicotine delivery systems not directly reliant on tobacco are also emerging (eg, electronic nicotine delivery systems). The presence of such products presents challenges and opportunities for public health. Future regulatory actions such as expansion of smoke-free environments, product health warnings and taxation may serve to increase or decrease the use of non-cigarette forms of tobacco. These regulations may also bring about changes in non-cigarette tobacco products themselves that could impact public health by affecting attractiveness and/or toxicity.

Impact of the removal of misleading terms on cigarette pack on smokers' beliefs about 'light/mild' cigarettes: cross-country comparisons

AIM

This paper examines how smokers' beliefs about 'light/mild' cigarettes in Australia, Canada and the United Kingdom were affected by the removal of misleading 'light/mild' terms from packs.

DESIGN, SETTING AND PARTICIPANTS

  The data come from the first seven waves (2002-09) of the International Tobacco Control Policy Evaluation (ITC) Four-Country Survey, an annual cohort telephone survey of adult smokers in Canada, the United States, the United Kingdom and Australia (21 613 individual cases). 'Light' and 'mild' descriptors were removed in 2003 in the United Kingdom, in 2006 in Australia and in 2007 in Canada. We compare beliefs about 'light' cigarettes both before and after the bans, with those of smokers in the United States serving as the control condition.

MEASURES

  Smokers' beliefs about 'light' cigarettes were assessed using a set of statements rated on a five-point 'agree'-'disagree' scale.

FINDINGS

  The proportions of respondents reporting misperceptions about light cigarettes declined between 2002 and 2009 in all four countries. There were marked temporary reductions in reported misperceptions in the United Kingdom and Australia, but not in Canada, following the removal of 'light/mild' descriptors.

CONCLUSIONS

  Removal of 'light/mild' descriptors and tar, nicotine and carbon monoxide yield information from cigarette packs is insufficient to effectively eliminate false beliefs. The combination of alternative descriptors and design features that produce differences in taste strength and harshness, independent of actual intakes, are sufficient to produce or sustain the same misbeliefs.

The scientific foundation for tobacco harm reduction, 2006-2011

Over the past five years there has been exponential expansion of interest in tobacco harm reduction (THR), with a concomitant increase in the number of published studies. The purpose of this manuscript is to review and analyze influential contributions to the scientific and medical literature relating to THR, and to discuss issues that continue to stimulate debate. Numerous epidemiologic studies and subsequent meta-analyses confirm that smokeless tobacco (ST) use is associated with minimal risks for cancer and for myocardial infarction; a small increased risk for stroke cannot be excluded. Studies from Sweden document that ST use is not associated with benign gastrointestinal disorders and chronic inflammatory diseases. Although any form of nicotine should be avoided during pregnancy, the highest risks for the developing baby are associated with smoking. It is documented that ST use has been a key factor in the declining rates of smoking and of smoking-related diseases in Sweden and Norway. For other countries, the potential population health benefits of ST are far greater than the potential risks. In follow-up studies, dual users of cigarettes and ST are less likely than exclusive smokers to achieve complete tobacco abstinence, but they are also less likely to be smoking. The health risks from dual use are probably lower than those from exclusive smoking. E-cigarette users are not exposed to the many toxicants, carcinogens and abundant free radicals formed when tobacco is burned. Although laboratory studies have detected trace concentrations of some contaminants, it is a small problem amenable to improvements in quality control and manufacturing that are likely with FDA regulation as tobacco products. There is limited evidence from clinical trials that e-cigarettes deliver only small doses of nicotine compared with conventional cigarettes. However, e-cigarette use emulates successfully the cigarette handling rituals and cues of cigarette smoking, which produces suppression of craving and withdrawal that is not entirely attributable to nicotine delivery. THR has been described as having "the potential to lead to one of the greatest public health breakthroughs in human history by fundamentally changing the forecast of a billion cigarette-caused deaths this century."