Tobacco industry consumer research on socially acceptable cigarettes

Awareness and Attitude Towards Tobacco Products and Tobacco Industry and Perception about Government's Role in Tobacco Control among the Adult Rural Population: A Cross-sectional Study in the Indian State of Bihar

Background

Attitudes and impressions toward the tobacco industry and tobacco products among the general public are important determinants for curbing the menace of the tobacco epidemic. Accordingly, this study aimed to assess the knowledge and perceptions about the tobacco industry and tobacco products and analyze attitudes towards social denormalization (SD) of tobacco use and tobacco industry denormalization (TID) among the rural population of Bihar, India.

Methods

This community-based cross-sectional survey was conducted on 421 adults aged 18 to 65 years who were selected using multistage systematic random sampling in a rural area of Bihar State in India from January to March 2022. Results were presented as proportions and the factors associated with support for TID and SD were identified using the chi-square test and binary logistic regression.

Findings

Out of 421 participants, 342 (81.2%) did not consider smokeless tobacco to be very dangerous. Nearly half (192, 45.6%) of the individuals believed that tobacco companies never tell the truth about the ill effects of tobacco use on health. Maximum, 345 (89.5%) also believed that the tobacco industry is responsible for adverse health effects of tobacco use and that the government should sue them. The prevalence of favorable attitudes toward TID and SD was found to be 55.1% [95% CI: 50.3% - 59.8%] and 38.2% [95% CI: 33.7% - 42.9%], respectively.

Conclusion

One out of every two and one out of every three individuals showed favorable attitudes toward TID and SD, respectively. There is a need to inform and educate the public on the ill effects of tobacco and the deceptive strategies used by the tobacco industry to help them choose health over tobacco.

Chemosensory Contributions of E-Cigarette Additives on Nicotine Use

While rates of smoking combustible cigarettes in the United States have trended down in recent years, use of electronic cigarettes (e-cigarettes) has dramatically increased, especially among adolescents. The vast majority of e-cigarette users consume "flavored" products that contain a variety of chemosensory-rich additives, and recent literature suggests that these additives have led to the current "teen vaping epidemic." This review, covering research from both human and rodent models, provides a comprehensive overview of the sensory implications of e-cigarette additives and what is currently known about their impact on nicotine use. In doing so, we specifically address the oronasal sensory contributions of e-cigarette additives. Finally, we summarize the existing gaps in the field and highlight future directions needed to better understand the powerful influence of these additives on nicotine use.

Marketing claims on websites of brick-and-mortar vape shops in the Greater Los Angeles area

INTRODUCTION

Brick-and-mortar vape shops have increased in recent years, but there is limited research on the types of marketing claims consumers are exposed to on their websites - a dominant channel for marketing electronic nicotine delivery systems (ENDS). We investigated the websites of vape shop retailers in the Greater Los Angeles Area to describe their ENDS marketing claims.

METHODS

Data collection occurred between 25 March and 20 June 2020. Of the 104 brick-and-mortar vape shops identified, 37 were found to have active websites. Rules were established to analyze website content. ENDS Marketing Claims were coded as the presence or absence of: 1) a direct claim of ENDS as a quitting aid; 2) a disclaimer that ENDS are not approved as smoking cessation devices (i.e. ENDS products are not FDA-approved for smoking cessation); 3) a direct claim of ENDS as healthier/safer than combustible cigarettes; and 4) direct claims regarding social benefits, including that ENDS are less expensive, can be used in more places, are cleaner or less messy/smelly, and are more socially accepted than combustible cigarettes.

RESULTS

Smoking cessation-related benefits were claimed most frequently (43%), followed by health-related claims (30%), and disclaimers that ENDS are not approved as smoking cessation devices (24%). More than half (56.4%) of websites had an age restriction, requiring the user to click on a box to state that they were aged ≥21 years to view the site. None required proof or outside verification of age.

CONCLUSIONS

Brick-and-mortar vape shops in the Greater Los Angeles Area are marketing ENDS on their websites as a healthier alternative to smoking cigarettes. Although half of the websites had an age gate popup that consumers see when they enter the website, action is needed to better enforce age restriction on access to vape shop websites. Utility for smoking cessation was claimed most frequently, followed by the claims of healthier alternatives to smoking cigarettes, and disclaimers that ENDS are not approved as smoking cessation devices. We discuss implications for tobacco regulatory policy.

Moving targets: how the rapidly changing tobacco and nicotine landscape creates advertising and promotion policy challenges

Tobacco, nicotine and related products have and continue to change rapidly, creating new challenges for policies regulating their advertising, promotion, sponsorship and sales. This paper reviews recent commercial product offerings and the regulatory challenges associated with them. This includes electronic nicotine delivery systems, electronic non-nicotine delivery systems, personal vaporisers, heated tobacco products, nicotine salts, tobacco-free nicotine products, other nicotine products resembling nicotine replacement therapies, and various vitamin and cannabis products that share delivery devices or marketing channels with tobacco products. There is substantial variation in the availability of these tobacco, nicotine, vaporised, and related products globally, and policies regulating these products also vary substantially between countries. Many of these products avoid regulation by exploiting loopholes in the definition of tobacco or nicotine products, or by occupying a regulatory grey area where authority is unclear. These challenges will increase as the tobacco industry continues to diversify its product portfolio, and weaponises 'tobacco harm reduction' rhetoric to undermine policies limiting marketing, promotion and taxation of tobacco, nicotine and related products. Tobacco control policy often lags behind the evolution of the industry, which may continue to sell these products for years while regulations are established, refined or enforced. Policies that anticipate commercial tobacco, nicotine and related product and marketing changes and that are broad enough to cover these product developments are needed.

Claims of Reduced Odor on Tobacco Packs in Low- and Middle-Income Countries

INTRODUCTION

Cigarettes designed to have less smoke smell were developed by the tobacco industry to supposedly reduce negative qualities. Cigarettes with marketing claims communicating these designs have been sold in high-income countries and marketing of "less smoke smell" terms on cigarette packaging can promote cigarette use. It is unclear to what extent they have been marketed in low- and middle-income countries (LMICs).

AIMS AND METHODS

The Tobacco Pack Surveillance System (TPackSS) systemically collected tobacco packs available in 14 LMICs with high tobacco use between 2013 and 2017. We coded 4354 packs for marketing appeals, including claims related to smoke smell. We describe "less smoke smell" and similar claims found on these packs and compare across country and tobacco manufacturers.

RESULTS

Phrases communicating less smoke smell were present on packs purchased in nine of 14 LMICs, including Bangladesh, Brazil, China, India, Mexico, Philippines, Russia, Ukraine, and Vietnam. The most commonly (74.1%) used terminology was "less smoke smell," "LSS," or a combination of the two. Packs from Russia had the most prevalent use (11.8%) of such claims. Companies using these terms across 21 brands included Japan Tobacco International (JTI), British American Tobacco (BAT), Philip Morris International (PMI), and other smaller companies. JTI accounted for 70.9% of packs with such terms.

CONCLUSIONS

Some of the world's largest tobacco companies are communicating less smoke smell on packs in LMICs. Less smoke smell and similar phrases on packaging should be prohibited because they can enhance the appeal of cigarettes.

IMPLICATIONS

Tobacco companies are using "less smoke smell" and similar phrases on cigarette packs in LMICs. These claims have the potential to increase the appeal of smoking and promote cigarette use. Countries should consider policies to restrict attractive labeling claims, in accordance with the WHO Framework Convention on Tobacco Control (FCTC) Article 13 guidelines, which recommends restrictions on attractive design elements on tobacco packaging.

Associations between smoking trajectories, smoke-free laws and cigarette taxes in a longitudinal sample of youth and young adults

Cigarette smoking patterns vary within the population, with some individuals remaining never smokers, some remaining occasional users, and others progressing to daily use or quitting. There is little research on how population-level tobacco control policy interventions affect individuals within different smoking trajectories. We identified associations between tobacco control policy interventions and changes across different smoking trajectories among adolescents and young adults. Using 15 annual waves of data drawn from the National Longitudinal Survey of Youth 1997 (NLSY97), we applied a group-based trajectory model to identify associations between days smoked per month, comprehensive smoke-free laws, cigarette tax rates, and known socio-demographic risk factors for membership in different smoking trajectories. Comprehensive smoke-free laws were associated with reduced risk of initiation and reductions in days smoked per month for all trajectories other than occasional users. Higher tax rates were associated with reduced risk of initiation and days smoked for all trajectories other than established users. Overall, population-based tobacco control policies, particularly comprehensive smoke-free laws, were associated with reduced smoking. Tobacco taxes primarily reduced risk of initiation and use among never smokers, experimenters, and quitters, consistent with previous research suggesting that tobacco manufacturers lower prices after tax increases to reduce the cost of continued smoking for established users. These results provide support for expanding smoke-free laws and establishing a minimum tobacco floor price, which could improve public health by reducing the risk of initiation as well as use among occasional and established smokers.

Well-being and harm reduction, the consolidated reality of electronic cigarettes ten years later from this emerging phenomenon: A narrative review

Tobacco use is the greatest threat to public health worldwide, killing more than seven million people annually. This paper, about 10 years after the first review on electronic cigarettes, analyses the evolution that this tool has had in these years. It concludes with comments on the significance of the research and why it constitutes an original contribution. We searched PubMed (National Library of Medicine), and PsycINFO (Ovid) (2006-2020) for studies on e-cigarettes (harms and benefits, e-cigarette use, craving and smoking cessation) and smoking cessation treatment (smoking cessation treatment or varenicline or tobacco cessation or reduction or bupropion or NRT or behavioral treatment or ecigarette) and evidence suggests that they may effective as smoking cessation tool and may be less harmful alternatives to combustible cigarette smoking. Consequently, e-cigarettes could be considered as an applicable instrument for Tobacco Harm Reduction (THR) and smoking cessation.

Tobacco smoking, related harm and motivation to quit smoking in people with schizophrenia spectrum disorders

This narrative review focuses on the topic of tobacco smoking amongst people with schizophrenia spectrum disorders. We searched PubMed, PsycInfo and Scopus databases for schizophrenia spectrum disorders and smoking and included articles about the epidemiology of tobacco smoking in people with schizophrenia spectrum disorders, examining the relationship between smoking and mental health. This narrative review describes that a higher prevalence, frequency and impact of both high nicotine dependence and its harmful effects in patients with schizophrenia spectrum disorders compared with those in the general population. Despite several existent theories, the reasons for high smoking rates, the high dependence on nicotine and severity of nicotine withdrawal symptoms are not fully understood. The main aim of this paper is to inform mental health personnel and particularly clinical and health psychologists about the impact and role of tobacco smoking for smokers with schizophrenia spectrum disorders.

Is vaping better than smoking for cardiorespiratory and muscle function?

Cigarette smoking is a risk factor for respiratory disorders, cardiovascular diseases and even decrements in muscle function. Electronic cigarette use (vaping) is considered a healthier alternative to cigarette smoking and may help in smoking cessation. However, the effects of vaping are not clear yet and particularly the long-term effects of vaping are largely unknown. Some reports suggest that vaping maybe as harmful for e.g. respiratory function, as cigarette smoking. In this narrative review the effects of vaping and cigarette smoking on respiratory, cardiovascular and muscle function are compared. Overall, vaping has been found to cause similar effects as smoking on lung function and cardiovascular function. Future studies are needed to clarify the severity of smoking- and vaping-induced decrements on muscle function.

Revolution or redux? Assessing IQOS through a precursor product

Background

Philip Morris International (PMI) currently claims that its heated tobacco product, IQOS, reduces health risk by reducing users’ exposure to harmful and potentially harmful constituents present in tobacco smoke. Given the tobacco industry’s long history of misrepresenting and obfuscating research, independent assessment of PMI’s claims is important. Analysis of Accord, a failed but strikingly similar precursor to IQOS, may help contextualise PMI’s claims in its Modified Risk Tobacco Product (MRTP) application.

Methods

We analysed previously secret internal Philip Morris (PM) and PMI documents, public communications and MRTP application.

Results

PM marketed Accord as a ‘cleaner’ tobacco product in an attempt to address smokers’ growing health concerns without making explicit health claims. While PM communications asserted that Accord reduced users’ exposure to harmful constituents, company scientists and executives consistently stressed to both regulators and the public that such reductions did not render Accord safer. IQOS’s design and marketing are similar to Accord’s. On the basis of aerosol chemistry data, IQOS reduces user exposure to some compounds compared with Accord but raises them for others.

Discussion

IQOS appears to be a variant of Accord without consistent improvements in exposure to aerosol toxic compounds. In contrast to PM’s past claims for Accord, PMI now claims in its MRTP application that IQOS reduces health risk. This shift in stance is likely not the result of any toxicological difference between Accord and IQOS, but rather a change in the social and regulatory landscape permitting these claims.

"Essentially, All Models are Wrong, but Some Are Useful": A Preliminary Conceptual Model Of Co-Occurring E-Cig and Alcohol Use

PURPOSE OF REVIEW

As prevalence rates of electronic cigarette (e-cig) use increase, researchers and clinicians should not only be paying careful attention to the direct health effects of e-cigs, but also the potential impact e-cigs may have on alcohol use behaviors. We review the current state of the literature and propose a conceptual model for the relationship between e-cig and alcohol use, including important consequences, mechanisms, and moderators of this relationship.

RECENT FINDINGS

The model is based in emerging literature examining the direct relationship between e-cig and alcohol use, as well as indirect evidence concerning potential mechanisms from research on cigarette and alcohol use. Overall, research indicates a robust relationship between e-cig and alcohol use.

SUMMARY

We suggest that a relationship between e-cig use and alcohol use could be particularly problematic, especially for adolescents and for those with or at risk for alcohol use disorders. We hope the presented conceptual model can stimulate research in this area. We make research recommendations, including the need for more methodological rigor, including improved measurement of e-cig use, and expanding research to longitudinal and experimental designs.

Philip Morris research on precursors to the modern e-cigarette since 1990

BACKGROUND

Use of electronic cigarettes (e-cigarettes) is increasing rapidly. Chinese pharmacist Hon Lik is frequently cited as inventing the modern e-cigarette in 2003. However, tobacco companies have developed electronic nicotine delivery systems since at least 1963.

METHODS

We searched the University of California San Francisco Truth (formerly Legacy) Tobacco Industry Documents beginning with the terms 'electric cigarette' and 'electronic cigarettes', 'e-cigarette', 'smokeless cigarettes', 'nicotine aerosol', 'tobacco aerosol', and 'vaping' and then expanded the search using snowball sampling. We focused our analysis on Philip Morris (PM) documents discussing technology that aerosolised a nicotine solution because these devices resembled modern e-cigarettes. Over 1000 documents were reviewed; 40 were included in the final analysis.

RESULTS

PM started developing a nicotine aerosol device in 1990 to address the health concerns and decreased social acceptability of smoking that were leading smokers to switch to nicotine replacement therapy. PM had developed a capillary aerosol generator that embodied basic e-cigarette technology in 1994, but in the mid-to-late 1990s focused on applying its aerosol technology to pharmaceutical applications because of uncertainty of how such products might affect potential Food and Drug Administration regulation of tobacco products. In 2001, PM resumed its work on a nicotine aerosol device, and in 2013, NuMark (a division of Altria, PM's parent company) released the MarkTen, a nicotine aerosol device.

CONCLUSIONS

Rather than a disruptive technology, PM developed e-cigarette technology to complement, not compete with, conventional cigarettes and evade tobacco control regulations.

Philip Morris research on precursors to the modern e-cigarette since 1990

BACKGROUND

Use of electronic cigarettes (e-cigarettes) is increasing rapidly. Chinese pharmacist Hon Lik is frequently cited as inventing the modern e-cigarette in 2003. However, tobacco companies have developed electronic nicotine delivery systems since at least 1963.

METHODS

We searched the University of California San Francisco Truth (formerly Legacy) Tobacco Industry Documents beginning with the terms 'electric cigarette' and 'electronic cigarettes', 'e-cigarette', 'smokeless cigarettes', 'nicotine aerosol', 'tobacco aerosol', and 'vaping' and then expanded the search using snowball sampling. We focused our analysis on Philip Morris (PM) documents discussing technology that aerosolised a nicotine solution because these devices resembled modern e-cigarettes. Over 1000 documents were reviewed; 40 were included in the final analysis.

RESULTS

PM started developing a nicotine aerosol device in 1990 to address the health concerns and decreased social acceptability of smoking that were leading smokers to switch to nicotine replacement therapy. PM had developed a capillary aerosol generator that embodied basic e-cigarette technology in 1994, but in the mid-to-late 1990s focused on applying its aerosol technology to pharmaceutical applications because of uncertainty of how such products might affect potential Food and Drug Administration regulation of tobacco products. In 2001, PM resumed its work on a nicotine aerosol device, and in 2013, NuMark (a division of Altria, PM's parent company) released the MarkTen, a nicotine aerosol device.

CONCLUSIONS

Rather than a disruptive technology, PM developed e-cigarette technology to complement, not compete with, conventional cigarettes and evade tobacco control regulations.

Protocol for a randomised pragmatic policy trial of nicotine products for quitting or long-term substitution in smokers

BACKGROUND

Smoking is Australia's leading preventable cause of premature mortality and a major contributor to the national disease burden. If quit rates do not dramatically improve, then smoking will continue to be a major public health issue for decades to come. Harm-reduction approaches using novel nicotine products like e-cigarettes as long term replacements for smoking have the potential to improve quit rates. However, little research has assessed such approaches.

METHODS/DESIGN

DESIGN

Three-arm parallel-group pragmatic randomised controlled trial.

PARTICIPANTS

People living in Australia who are at least 18 years old, smoke five or more cigarettes per day and are willing to try a sample of nicotine products.

INTERVENTION

Participants are randomised to receive standard quit advice and medicinal nicotine (Condition A); quit or substitute advice and medicinal nicotine (Condition B); or quit or substitute advice and medicinal nicotine and e-cigarettes (Condition C). Participants choose which (if any) nicotine products to receive to try in a free sample pack followed by a two to three week free supply of their favourite product(s) and the option to purchase more at a discounted price. Follow-up surveys will assess nicotine product use and smoking.

PRIMARY OUTCOME

Continuous abstinence for at least 6 months. Target sample size: 1600 people (Condition A: 340; Condition B: 630; Condition C: 630) provides at least 80 % power at p = 0.05 to detect a 5 % difference in abstinence rates between each condition.

DISCUSSION

This trial will provide data on tobacco harm-reduction approaches and in particular the use of e-cigarettes as a replacement for smoking.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry: ACTRN12612001210864. Date of registration: 15/11/2012.

Risk perceptions of smokeless tobacco among adolescent and adult users and nonusers

The recent growth in smokeless tobacco (ST) consumption has raised questions about consumer risk perceptions of ST products, especially in high-risk vulnerable populations. This qualitative study examined risk perceptions of ST among adolescent and adult users and nonusers in Ohio Appalachia. Focus groups and interviews were held with adolescents (n = 53; M age = 17 years) and adults (n = 63; M age = 34 years) from four Ohio Appalachian counties. Participants were asked about their perceptions of ST-related health risks, ST safety, and the relative safety of ST compared with cigarettes. Transcriptions were coded independently by two individuals. Overall, participants were knowledgeable about health problems from ST use (e.g., oral cancers, periodontal disease). Nearly all participants stated that ST use is not safe; however, there was disagreement about its relative safety. Some perceived all tobacco products as equally harmful; others believed that ST is safer than cigarettes for either the user or those around the user. Disagreements about ST relative safety may reflect mixed public health messages concerning the safety of ST. Comprehensive consumer messages about the relative safety of ST compared with cigarettes are needed. Messages should address the effect of ST on the health of the user as well as those exposed to the user.

Promotion of waterpipe tobacco use, its variants and accessories in young adult newspapers: a content analysis of message portrayal

The objective of our study was to identify waterpipe tobacco smoking advertisements and those that promoted a range of products and accessories used to smoke waterpipe tobacco. The content of these advertisements was analyzed to understand the messages portrayed about waterpipe tobacco smoking in young adult (aged 18-30) newspapers. The study methods include monitoring of six newspapers targeting young adults from four major cities in the Southeastern United States over a 6-month period. A total of 87 advertisements were found; 73.5% (64) were distinct and content analyzed. The study results showed that of the advertisements analyzed, 25% advertised waterpipe tobacco smoking, 54.7% featured waterpipe tobacco smoking and other tobacco use, 14.1% featured non-tobacco waterpipe variants (i.e. vaporizers), and 6.3% featured waterpipe apparatus accessories (e.g. charcoal, hoses). The sociability (34%) and sensuality (29.7%) of waterpipe smoking were promoted themes. Alternative to cigarette use messages (3.1%), and harm-reduction messages (17.1%) emphasized that smoking waterpipe tobacco using the featured accessory or waterpipe variant was a healthier experience than cigarette smoking. The study concluded that the messages that promoted waterpipe tobacco smoking to young adults are parallel to those used to promote cigarette use. Tobacco control professionals should continue to monitor young adult newspapers as a source of waterpipe-related advertising.

Cardiovascular responses induced by Catalase Inhibitior into the Fourth Cerebral Ventricle is changed in Wistar rats exposed to sidestream cigarette smoke

OBJECTIVES

This experimental study aimed to evaluate the effects of central catalase inhibition on cardiovascular responses in rats exposed to sidestream cigarette smoke (SSCS) for 3 weeks.

METHODOLOGY

A total of 20 males Wistar rats (320-370g) were implanted with a stainless steel guide cannula into the fourth cerebral ventricle (4(th)V). Femoral artery and vein were cannulated for mean arterial pressure (MAP) and heart rate (HR) measurement and drug infusion, respectively. Rats were exposed to SSCS for three weeks, 180 minutes per day, 5 days/week [carbon monoxide (CO): 100-300 ppm)]. Baroreflex was tested with one pressor dose of phenylephrine (PHE, 8 μg/kg, bolus) and one depressor dose of sodium nitroprusside (SNP, 50 μg/kg, bolus). Cardiovascular responses were evaluated before and 15 minutes after 3-amino-1, 2, 4-triazole (ATZ, catalase inhibitor, 0.001g/100μL) injection into the 4(th) V.

RESULTS

Vehicle treatment into the 4(th) V did not change cardiovascular responses. Central catalase inhibition increased tachycardic peak, attenuated bradycardic peak and reduced HR range at 15 minutes, increased MAP at 5, 15 and 30 min and increased HR at 5 and 15 min. In rats exposed to SSCS, central ATZ increased basal MAP after 5 min and increased HR at 5, 15 and 30 minutes, respectively, and attenuated bradycardic peak at 15 minutes.

CONCLUSION

This study suggests that brain oxidative stress caused by SSCS influences autonomic regulation of the cardiovascular system.

Effects of the administration of a catalase inhibitor into the fourth cerebral ventricle on cardiovascular responses in spontaneously hypertensive rats exposed to sidestream cigarette smoke

OBJECTIVE

Previous studies have demonstrated a relationship between brain oxidative stress and cardiovascular regulation. We evaluated the effects of central catalase inhibition on cardiovascular responses in spontaneously hypertensive rats exposed to sidestream cigarette smoke.

METHODS

Male Wistar Kyoto (WKY) rats and spontaneously hypertensive rats (SH) (16 weeks old) were implanted with a stainless steel guide cannula leading into the fourth cerebral ventricle (4th V). The femoral artery and vein were cannulated for arterial pressure and heart rate measurement and drug infusion, respectively. The rats were exposed to sidestream cigarette smoke for 180 minutes/day, 5 days/week for 3 weeks (CO: 100-300 ppm). The baroreflex was tested using a pressor dose of phenylephrine (8 μg/kg, bolus) and a depressor dose of sodium nitroprusside (50 μg/kg, bolus). Cardiovascular responses were evaluated before and 5, 15, 30 and 60 minutes after injection of a catalase inhibitor (3-amino-1,2,4-triazole, 0.001 g/100 μL) into the 4th V.

RESULTS

Vehicle administration into the 4th V did not affect the cardiovascular response, whereas administration of the central catalase inhibitor increased the basal HR and attenuated the bradycardic peak (p<0.05) to a greater extent in WKY rats exposed to sidestream cigarette smoke than in WKY rats exposed to fresh air. However, in spontaneously hypertensive rats, the effect of the catalase inhibitor treatment was stronger in the fresh air condition (p<0.05).

CONCLUSION

Administration of a catalase inhibitor into the 4th V combined with exposure to sidestream cigarette smoke has a stronger effect in WKY rats than in SH rats.

Strategies to reduce indoor tanning: current research gaps and future opportunities for prevention

Exposure to ultraviolet radiation from indoor tanning device use is associated with an increased risk of skin cancer, including risk of malignant melanoma, and is an urgent public health problem. By reducing indoor tanning, future cases of skin cancer could be prevented, along with the associated morbidity, mortality, and healthcare costs. On August 20, 2012, the CDC hosted a meeting to discuss the current body of evidence on strategies to reduce indoor tanning as well as research gaps. Using the Action Model to Achieve Healthy People 2020 Overarching Goals as a framework, the current paper provides highlights on the topics that were discussed, including (1) the state of the evidence on strategies to reduce indoor tanning; (2) the tools necessary to effectively assess, monitor, and evaluate the short- and long-term impact of interventions designed to reduce indoor tanning; and (3) strategies to align efforts at the national, state, and local levels through transdisciplinary collaboration and coordination across multiple sectors. Although many challenges and barriers exist, a coordinated, multilevel, transdisciplinary approach has the potential to reduce indoor tanning and prevent future cases of skin cancer.

Tobacco industry strategies to minimize or mask cigarette smoke: opportunities for tobacco product regulation

INTRODUCTION

The tobacco industry has developed technologies to reduce the aversive qualities of cigarette smoke, including secondhand smoke (SHS). While these product design changes may lessen concerns about SHS, they may not reduce health risks associated with SHS exposure. Tobacco industry patents were reviewed to understand recent industry strategies to mask or minimize cigarette smoke from traditional cigarettes.

METHODS

Patent records published between 1997 and 2008 that related to cigarette smoke were conducted using key word searches. The U.S. Patent and Trademark Office web site was used to obtain patent awards, and the World Intellectual Property Organization's Patentscope and Free Patents Online web sites were used to search international patents.

RESULTS

The search identified 106 relevant patents published by Japan Tobacco Incorporated, British America Tobacco, Philip Morris International, and other tobacco manufacturers or suppliers. The patents were classified by their intended purpose, including reduced smoke constituents or quantity of smoke emitted by cigarettes (58%, n = 62), improved smoke odor (25%, n = 26), and reduced visibility of smoke (16%, n = 18). Innovations used a variety of strategies including trapping or filtering smoke constituents, chemically converting gases, adding perfumes, or altering paper to improve combustion.

CONCLUSIONS

The tobacco industry continues to research and develop strategies to reduce perceptions of cigarette smoke, including the use of additives to improve smoke odor. Surveillance and regulatory response to industry strategies to reduce perceptions of SHS should be implemented to ensure that the public health is adequately protected.

Whose butt is it? tobacco industry research about smokers and cigarette butt waste

Background

Cigarette filters are made of non-biodegradable cellulose acetate. As much as 766 571 metric tons of butts wind up as litter worldwide per year. Numerous proposals have been made to prevent or mitigate cigarette butt pollution, but none has been effective; cigarette butts are consistently found to be the single most collected item in beach clean-ups and litter surveys.

Methods

We searched the Legacy Tobacco Documents Library (http://legacy.library.ucsf.edu) and http://tobaccodocuments.org using a snowball strategy beginning with keywords (eg, ‘filter’, ‘biodegradable’, ‘butts’). Data from approximately 680 documents, dated 1959–2006, were analysed using an interpretive approach.

Results

The tobacco industry has feared being held responsible for cigarette litter for more than 20 years. Their efforts to avoid this responsibility included developing biodegradable filters, creating anti-litter campaigns, and distributing portable and permanent ashtrays. They concluded that biodegradable filters would probably encourage littering and would not be marketable, and that smokers were defensive about discarding their tobacco butts and not amenable to anti-litter efforts.

Conclusions

Tobacco control and environmental advocates should develop partnerships to compel the industry to take financial and practical responsibility for cigarette butt waste.

Menthol: putting the pieces together

Objective

To integrate information on cigarette companies' understanding and use of menthol as summarised in published research based on previously internal tobacco industry documents with results from large population-based surveys of tobacco use and other independent sources.

Data sources

Papers published in this supplement of Tobacco Control, together with papers identified using PubMed searches.

Results

Tobacco companies shaped consumer perceptions of menthol cigarettes. Menthol is not just a flavouring agent. Cigarette companies use menthol's ability to mask irritation and provide sensory effects to make menthol cigarettes appeal to youth and health-concerned smokers, in part because menthol makes low-tar cigarettes more palatable. Consistent with targeted marketing, youths, women and African Americans disproportionately smoke menthols. There appear to be complex interactions with addictive effects of nicotine. The ubiquitous addition of menthol by tobacco companies to over 90% of all tobacco products, whether labelled ‘menthol’ or not, demonstrates that menthol is not simply a flavour or brand. Menthol imparts sensory characteristics to cigarettes and has a complex interaction with nicotine that affects smoking behaviour whether it is perceived or not, or whether cigarettes containing menthol are marketed as ‘menthol’ or not. Adding menthol increases fine particles in cigarette smoke, which have immediate adverse effects on the risk of heart attack.

Conclusion

Information from industry documents, confirmed by independent scientific literature, consistently demonstrates that menthol increases population harm from smoking by increasing initiation and reducing cessation in some groups. Menthol facilitates and increases smoking, which causes disease and death.

Local smoke-free policy development in Santa Fe, Argentina

OBJECTIVE

To describe the process of approval and implementation of a comprehensive smoke-free law in the province of Santa Fe, Argentina, between 2005 and 2009.

METHODS

Review of the Santa Fe smoke-free legislation, articles published in local newspapers and documentation on two lawsuits filed against the law, and interviews with key individuals in Santa Fe.

RESULTS

Efforts to implement smoke-free policies in Santa Fe began during the 1990s without success, and resumed in 2005 when the provincial Legislature approved the first 100% smoke-free subnational law in Argentina. There was no strong opposition during the discussions within the legislature. As in other parts of the world, pro-tobacco industry interests attempted to block the implementation of the law using well known strategies. These efforts included a controversy media campaign set up, the creation of a hospitality industry association and a virtual smokers' rights group, the introduction of a counterproposal seeking modification of the law, the challenge of the law in the Supreme Court, and the proposal of a weak national bill that would 'conflict' with the subnational law. Tobacco control advocates sought media attention as a strategy to protect the law.

CONCLUSIONS

Santa Fe is the first subnational jurisdiction in Latin America to have enacted a comprehensive smoke-free policy following the recommendations of the World Health Organization (WHO) Framework Convention on Tobacco Control. After 3 years of implementation, pro-tobacco industry forces failed to undermine the law. Other subnational jurisdictions in Argentina, as well as in Mexico and Brazil are following the Santa Fe example.

The utility of anger in promoting clean indoor air policies

This investigation examined antecedents associated with support for clean indoor air policies. Participants (N = 550) living in a Midwestern county (population = 62,223) were randomly sampled. Results suggest that beliefs in the health risks associated with secondhand smoke are positively associated with favorable attitudes toward clean indoor air policies, whereas trait reactance is negatively associated with these attitudes. Findings also indicate that risks and trait reactance are indirectly associated with support for clean indoor air policies, mediated through anger arousal toward exposure to secondhand smoke. In addition, regression analyses revealed that health risks, trait reactance, and smoking status explained a significant amount of variance regarding anger toward exposure to secondhand smoke, but only health risks and smoking status accounted for a significant amount of variance toward clean indoor air attitudes. Finally, the Smoking Status x Health Risks interaction was supported for anger toward exposure to secondhand smoke and favorable attitudes toward clean indoor air policies. Our findings suggest the incorporation of anger appeals when promoting clean indoor air policies.

Social smoking implications for public health, clinical practice, and intervention research

BACKGROUND

Social smoking is increasingly prevalent and poses a challenge to traditional cessation practices. Tobacco companies conducted extensive research on social smokers long before health authorities did and marketed products to promote this smoking behavior.

PURPOSE

Research is described and mechanisms identified that are used to promote social smoking to help improve cessation strategies in this growing group.

EVIDENCE ACQUISITION

Searches from 2006 to 2008 of previously secret tobacco industry documents using keywords social smoker, light smoker, casual smoker, youth smoker, and occasional smoker, followed by snowball searching. Data analysis was conducted in 2008.

EVIDENCE SYNTHESIS

Tobacco industry research identified characteristics of social smokers that include: (1) denial of personal nicotine addiction; (2) self-categorization as a nonsmoker; (3) propensity for decreased tobacco use in response to smoke-free laws; (4) variations in age, education, ethnicity, and socioeconomic backgrounds; and (5) a perceived immunity to personal health effects of tobacco but fear of consequences to others. Tobacco companies developed marketing strategies aimed at social smokers, including "non-habit forming" cigarettes.

CONCLUSIONS

Previously considered a transient behavior, social smoking is also a stable consumption pattern. Focused clinical questions to detect social smoking are needed and may include, "Have you smoked any cigarettes or used any tobacco products in the past month?" as opposed to "Are you a smoker?" Clinicians should recognize that social smokers might be motivated to quit after education on the dangers of secondhand smoke rather than on personal health risks or with pharmacotherapy.

Examining antecedents of clean indoor air policy support: implications for campaigns promoting clean indoor air

This investigation sought to examine the association between knowledge of the risks associated with environmental tobacco smoke and voter support for clean indoor air policies. In doing so, 2 antecedents were employed to enhance understanding of this relationship: attitudes and subjective norms. In addition, differences between nonsmokers and smokers were assessed across the aforementioned variables. The study sampled participants (N = 550) living in the Appalachian foothills as a means of conducting formative research prior to developing messages promoting clean indoor air policies. The study controlled for tobacco usage, age, biological sex, and income. Results revealed that awareness of risk is a good predictor of attitudes and social norms, and in return, attitudes and social norms are good predictors of support for clean indoor air policies. In addition, results reveal that nonsmokers maintain a significantly stronger belief in the dangers associated with environmental tobacco smoke, as well as more favorable attitudes, subjective norms, and support for clean indoor air policies when compared with smokers. These findings are discussed with a focus on message design strategies for practitioners and academics with interests in promoting clean indoor air policies.

Is smokeless tobacco use an appropriate public health strategy for reducing societal harm from cigarette smoking?

Four arguments have been used to support smokeless tobacco (ST) for harm reduction: (1) Switching from cigarettes to ST would reduce health risks; (2) ST is effective for smoking cessation; (3) ST is an effective nicotine maintenance product; and (4) ST is not a "gateway" for cigarette smoking. There is little evidence to support the first three arguments and most evidence suggests that ST is a gateway for cigarette smoking. There are ethical challenges to promoting ST use. Based on the precautionary principle, the burden of proof is on proponents to provide evidence to support their position; such evidence is lacking.

Effect of the California tobacco control program on personal health care expenditures

BACKGROUND

Large state tobacco control programs have been shown to reduce smoking and would be expected to affect health care costs. We investigate the effect of California's large-scale tobacco control program on aggregate personal health care expenditures in the state.

METHODS AND FINDINGS

Cointegrating regressions were used to predict (1) the difference in per capita cigarette consumption between California and 38 control states as a function of the difference in cumulative expenditures of the California and control state tobacco control programs, and (2) the relationship between the difference in cigarette consumption and the difference in per capita personal health expenditures between the control states and California between 1980 and 2004. Between 1989 (when it started) and 2004, the California program was associated with $86 billion (2004 US dollars) (95% confidence interval [CI] $28 billion to $151 billion) lower health care expenditures than would have been expected without the program. This reduction grew over time, reaching 7.3% (95% CI 2.7%-12.1%) of total health care expenditures in 2004.

CONCLUSIONS

A strong tobacco control program is not only associated with reduced smoking, but also with reductions in health care expenditures.

"And they told two friends...and so on": RJ Reynolds' viral marketing of Eclipse and its potential to mislead the public

OBJECTIVE

To explore viral marketing strategies for Eclipse cigarettes used by the RJ Reynolds Company (Winston-Salem, North Carolina, USA).

METHODS

Analysis of previously secret tobacco industry documents and multimedia materials.

RESULTS

The failure of RJ Reynolds' (RJR) 1988 "smokeless" cigarette, Premier, was in part due to widespread bad word of mouth about the product's flavour, quality and difficulty of use. In 1994 RJR introduced an updated version of Premier, the ostensibly "reduced risk" Eclipse cigarette. RJR developed viral marketing channels to promote Eclipse using (1) exploratory interviews to motivate consumers to spread the word about Eclipse prior to market release, (2) promotional videos featuring positive feedback from test group participants to portray majority consensus among triers, (3) "Tupperware"-like parties for Eclipse where participants received samples to pass around in their social circles and (4) the Eclipse website's bulletin board as a forum for potential users to discuss the brand in their own words. These strategies targeted the brand's likeliest adopters, recruited informal and credible representatives of the product unaffiliated with RJR, and controlled the information spread about the product.

CONCLUSIONS

Viral marketing techniques may be particularly useful to promote new tobacco products such as Eclipse that have limited appeal and need a highly motivated audience of early adopters and acceptors. Such techniques help evade the mass rejection that could follow mass promotion, circumvent marketing restrictions, and allow tobacco companies to benefit from health claims made by consumers. Cigarette manufacturers must be held accountable for perceived health benefits encouraged by all promotional activities including viral marketing.

Tobacco industry efforts undermining evidence linking secondhand smoke with cardiovascular disease

BACKGROUND

The scientific consensus that secondhand smoke (SHS) increases cardiovascular disease (CVD) risk by 30% is based on epidemiological and biological evidence. The tobacco industry has contested this evidence that SHS causes CVD, but how and why they have done it has not been described.

METHODS AND RESULTS

About 50 million pages of tobacco industry documents were searched using general keywords and names of industry consultants and scientists. Tobacco industry-funded epidemiological analyses of large data sets were used to argue against an epidemiological association between SHS and CVD and smoke-free regulations, but these analyses all suffered from exposure misclassification problems that biased the results toward the null. More recent industry-funded publications report an increased risk of CVD associated with SHS but claim a low magnitude of risk. When early tobacco industry-funded work demonstrated that SHS increased atherosclerosis, the industry criticized the findings and withdrew funding. RJ Reynolds focused on attacking the biological plausibility of the association between SHS and CVD by conducting indirect platelet aggregation studies, exposure chamber experiments, and literature reviews. Although these studies also suffered from exposure misclassification problems, several produced results that were consistent with a direct effect of SHS on blood and vascular function. Instead, RJ Reynolds attributed these results to an unproven epinephrine-related stress response from odor or large smoke exposure, which supported their regulatory and "reduced-harm" product development efforts. Philip Morris' recent "reduced-harm" efforts seem supportive of a similar corporate agenda.

CONCLUSIONS

The tobacco industry attempted to undermine the evidence that SHS causes CVD to fight smoke-free regulations while developing approaches to support new products that claim to reduce harm. The industry interest in preserving corporate viability has affected the design and interpretation of their cardiovascular studies, indicating the need for great caution in current debates about future tobacco industry regulation and development of reduced-harm tobacco products.

Concentrations of the carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone in sidestream cigarette smoke increase after release into indoor air: results from unpublished tobacco industry research

Research has shown that the toxicity of sidestream cigarette smoke, the primary constituent of secondhand smoke, increases over time. To find potential mechanisms that would explain the increase in sidestream smoke toxicity over time, we analyzed unpublished research reports from Philip Morris Co. using the internal tobacco industry documents now available at the University of California San Francisco Legacy Tobacco Documents Library and other Web sites. Unpublished research from Philip Morris Tobacco Company shows that 4-(methylnitrosamino)-I-(3-pyridyl)-1-butanone (NNK), a highly carcinogenic tobacco-specific nitrosamine, can form in sidestream cigarette smoke after it has been released into ambient air. In experiments done between 1983 and 1997, Philip Morris scientists measured the concentration of NNK in sidestream smoke in a sealed stainless steel test chamber at initial particle concentrations of 24 mg/m(3) over the course of 6 to 18 h. They repeatedly showed that airborne NNK concentrations in sidestream cigarette smoke can increase by 50% to 200% per hour during the first 6 h after cigarettes are extinguished. Two experiments done in a real office showed that NNK concentrations increase for the first 2 h after cigarettes are extinguished. If NNK formation also occurs in the lower smoke concentrations observed in real smoking environments, these results suggest that nitrosation of nicotine and/or nicotine breakdown products in aging secondhand smoke is a significant contributor to nitrosamine exposure in humans.

Philip Morris's Project Sunrise: weakening tobacco control by working with it

OBJECTIVE

To analyse the implications of Philip Morris USA's (PM's) overtures toward tobacco control and other public health organisations, 1995-2006.

DATA SOURCES

Internal PM documents made available through multi-state US attorneys general lawsuits and other cases, and newspaper sources.

METHODS

Documents were retrieved from several industry documents websites and analysed using a case study approach.

RESULTS

PM's Project Sunrise, initiated in 1995 and proposed to continue through 2006, was a long-term plan to address tobacco industry delegitimisation and ensure the social acceptability of smoking and of the company itself. Project Sunrise laid out an explicit divide-and-conquer strategy against the tobacco control movement, proposing the establishment of relationships with PM-identified "moderate" tobacco control individuals and organisations and the marginalisation of others. PM planned to use "carefully orchestrated efforts" to exploit existing differences of opinion within tobacco control, weakening its opponents by working with them. PM also planned to thwart tobacco industry delegitimisation by repositioning itself as "responsible". We present evidence that these plans were implemented.

CONCLUSION

Sunrise exposes differences within the tobacco control movement that should be further discussed. The goal should not be consensus, but a better understanding of tensions within the movement. As the successes of the last 25 years embolden advocates to think beyond passage of the next clean indoor air policy or funding of the next cessation programme, movement philosophical differences may become more important. If tobacco control advocates are not ready to address them, Project Sunrise suggests that Philip Morris is ready to exploit them.

'We will speak as the smoker': the tobacco industry's smokers' rights groups

INTRODUCTION

The tobacco industry usually keeps its commercial and political communications separate. However, the images of the smoker developed by the two types of communication may contradict one another. This study assesses industry attempts to organize 'smokers' rights groups,' (SRGs) and the image of the smoker that underlay these efforts.

METHODS

Searches of the Legacy Tobacco Documents Library, the British American Tobacco documents database, and Tobacco Documents Online.

RESULTS

1100 documents pertaining to SRGs were found, including groups from across Europe and in Australia, New Zealand, and Hong Kong. From the late 1970s through the late 1990s they were active in numerous policy arenas, particularly the defeat of smoke-free laws. Their strategies included asserting their right to smoke and positioning themselves as courteous victims of tobacco control advocates. However, most SRGs were short-lived and apparently failed to inspire smokers to join in any significant numbers.

CONCLUSION

SRGs conflated the legality of smoking with a right to smoke. SRGs succeeded by focusing debates about smoke-free policies on smokers rather than on smoke. However, SRGs' inability to attract members highlights the conflict between the image of the smoker in cigarette ads and that of the smokers' rights advocate. The changing social climate for smoking both compelled the industry's creation of SRGs, and created the contradictions that led to their failure. As tobacco control becomes stronger, the industry may revive this strategy in other countries. Advocates should be prepared to counter SRGs by exposing their origins and exploiting these contradictions.