Is snus the same as dip? Smokers' perceptions of new smokeless tobacco advertising

Perceptions and Discussions of Snus on Twitter: Observational Study

BACKGROUND

With the increasing popularity of snus, it is essential to understand the public perception of this oral tobacco product. Twitter-a popular social media platform that is being used to share personal experiences and opinions-provides an ideal data source for studying the public perception of snus.

OBJECTIVE

This study aims to examine public perceptions and discussions of snus on Twitter.

METHODS

Twitter posts (tweets) about snus were collected through the Twitter streaming application programming interface from March 11, 2021, to February 26, 2022. A temporal analysis was conducted to examine the change in number of snus-related tweets over time. A sentiment analysis was conducted to examine the sentiments of snus-related tweets. Topic modeling was applied to tweets to determine popular topics. Finally, a keyword search and hand-coding were used to understand the health symptoms mentioned in snus-related tweets.

RESULTS

The sentiment analysis showed that the proportion of snus-related tweets with a positive sentiment was significantly higher than the proportion of negative sentiment tweets (4341/11,631, 37.32% vs 3094/11,631, 26.60%; P<.001). The topic modeling analysis revealed that positive tweets focused on snus's harm reduction and snus use being an alternative to smoking, while negative tweets focused on health concerns related to snus. Mouth and respiratory symptoms were the most mentioned health symptoms in snus-related tweets.

CONCLUSIONS

This study examined the public perception of snus and popular snus-related topics discussed on Twitter, thus providing a guide for policy makers with regard to the future formulation and adjustment of tobacco regulation policies.

Mobile Text Messaging for Tobacco Risk Communication Among Young Adult Community College Students: Randomized Trial of Project Debunk

BACKGROUND

The use of new and emerging tobacco products (NETPs) and conventional tobacco products (CTPs) has been linked to several alarming medical conditions among young adults (YAs). Considering that 96% of YAs own mobile phones, SMS text messaging may be an effective strategy for tobacco risk communication.

OBJECTIVE

Project Debunk is a community-based randomized trial aiming to identify specific types of messages that effectively improve perceived NETP and CTP risk among YAs in community colleges.

METHODS

With YAs recruited offline from 3 campuses at the Houston Community College (September 2016 to July 2017), we conducted a 6-month randomized trial with 8 arms based on the combination of 3 message categories: framing (gain-framed vs loss-framed), depth (simple vs complex), and appeal (emotional vs rational). Participants received fully automated web-based SMS text messages in two 30-day campaigns (2 messages per day). We conducted repeated-measures mixed-effect models stratified by message type received, predicting perceived CTP and NETP risks. Owing to multiple testing with 7 models, an association was deemed significant for P<.007 (.05 divided by 7).

RESULTS

A total of 636 participants completed the baseline survey, were randomized to 1 of 8 conditions (between 73 and 86 participants per condition), and received messages from both campaigns. By the 2-month post campaign 2 assessment point, 70.1% (446/636) completed all outcome measures. By the end of both campaigns, participants had a significant increase in perceived NETP risk over time (P<.001); however, participants had a marginal increase in perceived CTP risk (P=.008). Separately for each group, there was a significant increase in perceived NETP risk among participants who received rational messages (P=.005), those who received emotional messages (P=.006), those who received simple messages (P=.003), and those who received gain-framed messages (P=.003).

CONCLUSIONS

In this trial, YAs had an increase in perceived NETP risk. However, with stratification, we observed a significant increase in perceived NETP risk upon exposure to rational, emotional, simple, and gain-framed messages. In addition, YAs generally had an increase in perceived CTP risk and presented nonsignificant but observable improvement upon exposure to emotional, complex, and loss-framed messages. With the results of this study, researchers and practitioners implementing mobile health programs may take advantage of our tailored messages through larger technology-based programs such as smartphone apps and social media campaigns.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03457480; https://clinicaltrials.gov/ct2/show/NCT03457480.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/10977.

Representations of Psychoactive Drugs' Use in Mass Culture and Their Impact on Audiences

Drug use has been increasing worldwide over recent decades. Apart from the determinants of drug initiation established in numerous studies, the authors wish to draw attention to other equally important factors, which may contribute to augmenting this phenomenon. The article aims to draw attention to the content of mass culture, especially representations of drug use in mass media, which may influence the liberalization of attitudes towards drugs and their use. The role of mass culture and its impact on the audience is discussed. It presents an overview of drug representations in the content of mass culture, e.g., in film, music, literature, and the occurrence of drug references in everyday products, e.g., food, clothes, and cosmetics. Attention was drawn to liberal attitudes of celebrities and their admissions to drug use, particularly to the impact of the presented positions on the attitudes of the audience, especially young people for whom musicians, actors, and celebrities are regarded as authorities. Indications for further preventive actions were also presented. Attention was drawn to the need to take appropriate action due to the time of the COVID-19 pandemic when many people staying at home (due to lockdown or quarantine) have the possibility of much more frequent contact with mass culture content, which may distort the image of drugs.

Going Smokeless: Promotional Features and Reach of US Smokeless Tobacco Direct-Mail Advertising (July 2017–August 2018)

Introduction

Although cigarette use in the United States has declined over time, smokeless tobacco (SLT) use has remained steady. Direct-mail advertising and coupon redemption have been linked to increased tobacco use, and efforts to promote SLT through direct-mail advertising may contribute to sustained SLT use. We examined reach of SLT direct-mail advertisements by recipient demographics and promotional features, including coupons.

Methods

Direct-mail data (n = 418) were acquired from Comperemedia (Mintel) and coded for product type (traditional [eg, chewing tobacco], pouched [eg, moist snuff, snus], or both [traditional SLT and any pouched SLT products]); promotions (eg, coupons); flavors; and themes (eg, masculinity). Using Mintel’s volume estimates for number of pieces sent, we calculated the proportion of mail volume sent by recipient demographics (age, income, region) and advertising features across product type.

Results

Between July 2017 and August 2018, tobacco companies sent an estimated 249 million pieces of SLT direct-mail to US households; approximately half (49.6%) featured pouched SLT products. Across product types, over 75% of mail volume was sent to 31- to 60-year-old adults and 30–40% was sent to low-income households. The majority (&gt;70%) of pouched SLT product mail contained coupons and flavor promotions. Outdoor and blue-collar-lifestyle themes were prominent in advertisements for all product types, along with less common adventure- and fun-related appeals.

Conclusions

Coupons, flavors, and a combination of blue-collar and fun/adventure message themes were used to promote traditional and pouched SLT products through direct-mail, particularly to low-income households. Results support limits on direct-mail coupon distribution and continued surveillance of marketing appeals.

Implications

There is a long history of research into tobacco advertising practices, largely focusing on cigarettes. This study highlights specific direct-mail marketing tactics used by the tobacco industry, including coupons to promote SLT products across the United States. Given the limited success in reducing SLT use and the association between direct-mail promotions and tobacco use, these study results provide support for policies to restrict use of coupons in direct-to-consumer tobacco marketing and indicate the need for continued surveillance of direct-mail advertisements as the SLT market continues to evolve.

Experiences of tobacco cessation including a prescription approach among patients in Swedish primary health care with a focus on socioeconomically disadvantaged areas

Background

Tobacco Cessation on Prescription (TCP) is a new intervention that is being evaluated in socioeconomically disadvantaged areas in Swedish primary health care (PHC). Patients’ perceptions of TCP are important to understand as this may have implications for the acceptability and adherence to treatment and explain cessation outcomes. Patients’ general experiences of tobacco cessation are also important to explore to improve cessation support in this setting.

Aim

To explore experiences of tobacco cessation and TCP among patients in Swedish PHC focusing on socioeconomically disadvantaged areas.

Methods

Inductive content analysis of transcripts from eight semi-structured interviews with patients recruited from the intervention group in a randomized controlled trial evaluating the effectiveness of TCP in socioeconomically disadvantaged areas in PHC in Stockholm.

Results

Two themes were identified: needing individualized support to quit, taking differences in patients’ experiences of tobacco use and cessation into account, acknowledging individual factors such as impact of health and wellbeing on tobacco use and differing attitudes towards tobacco and cessation and needing a supportive environment to facilitate tobacco cessation, taking contextual factors like professional support from the health care system, the importance of the social environment and supportive societal structures into account. Regarding TCP, the prescription form was perceived as useful for providers but did not appear to have a direct impact on tobacco cessation from the informants’ perspective. However, individualized counseling from a tobacco cessation specialist, an empathetic approach in the treatment and long-term follow-up was considered important.

Conclusion

A holistic approach may be needed in cessation treatment, combined with interventions outside the health care system, to facilitate tobacco cessation among patients in socioeconomically disadvantaged areas in Swedish PHC. The TCP prescription form may be helpful for PHC providers but counseling and follow-up appear to be the most important components of TCP for patients in this setting.

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.

Mobile Phone Text Messaging for Tobacco Risk Communication Among Young Adult Community College Students: Protocol and Baseline Overview for a Randomized Controlled Trial

Background

Community-college students are at high risk for tobacco use. Because the use of mobile phone text messaging is nearly ubiquitous today, short message service (SMS) may be an effective strategy for tobacco risk communication in this population. Little is known, however, concerning the message structure significantly influencing perceived tobacco risk.

Objective

We aim to outline the rationale and design of Project Debunk, a randomized trial comparing the effects of different SMS text message structures.

Methods

We conducted a 6-month randomized trial comparing 8 arms, based on the combination of the 3 message structures delivered to young adults in a 2×2×2 study design: framing (gain-framed or loss-framed), depth (simple or complex), and appeal (emotional or rational). Participants were invited to participate from 3 community colleges in Houston from September 2016 to July 2017. Participants were randomized to 1 arm and received text messages in 2 separate campaigns. Each campaign consisted of 2 text messages per day for 30 days. Perceived tobacco risk was assessed at baseline, 2 months after the first campaign, and 2 months after the second campaign. We assessed the perceived risk of using conventional products (eg, combustible cigarettes) and new and emerging products (eg, electronic cigarettes). The validity of message structures was assessed weekly for each campaign. A 1-week follow-up assessment was also conducted to understand immediate reactions from participants.

Results

We completed data collection for the baseline survey on a rolling basis during this time and assessed the validity of the message structure after 1 week of SMS text messages. For the entire sample (N=636), the average age was 20.92 years (SD 2.52), about two-thirds were male (430/636, 67.6%), and most were black or African American (259/636, 40.7%) or white (236/636, 37.1%). After 1 week of receiving text messages, the following was noted: (a) loss-framed messages were more likely to be perceived as presenting a loss than gain-framed messages (F_7,522=13.13, P<.001), (b) complex messages were perceived to be more complex than simple messages (F_7,520=2.04, P=.05), and (c) emotional messages were perceived to be more emotionally involving than rational messages (F_7,520=6.46, P<.001).

Conclusions

This study confirms that the recruitment, randomization, and message composition have been successfully implemented. Further analyses will identify specific types of messages that are more effective than others in increasing the perceived risk of tobacco use. If our results suggest that any of the 8 specific message structures are more effective for helping young adults understand tobacco risk, this would provide evidence to include such messages as part of a larger technology-based campaign such as mobile phone apps, entertainment-based campaigns, and social media.

Trial Registration

ClinicalTrials.gov NCT03457480; https://clinicaltrials.gov/ct2/show/NCT03457480 (Archived by WebCite at http://www.webcitation.org/6ykd4IIap)

Registered Report Identifier

RR1-10.2196/10977

Factors contributing to nass consumption among Iranian Turkmen: A qualitative study

INTRODUCTION

Nass is a smokeless tobacco product. Iranian Turkmen have a long history of nass consumption. However, the factors contributing to nass consumption among Iranian Turkmen are not known. The purpose of the present study is to examine the factors contributing to nass consumption among Iranian Turkmen.

METHODS

This qualitative study was conducted between January and March 2016 in four Turkmen cities of Golestan province in Iran. Participants included 34 male Turkmen nass consumers. Data were collected through individual and group interviews and were analyzed by content analysis. Data management was done by qualitative data analysis software MAXQDA, Version 10.

RESULTS

The results of data analysis revealed the following as the main reasons for nass consumption by the study population: 1) cultural, social, and environmental facilitators, 2) nass was considered as an alternative to cigarette smoking, 3) nass was believed to intensify the effects of opium and other drugs, 4) specific occupations and circumstances, and 5) beliefs related to nass.

CONCLUSIONS

Cultural and historical backgrounds, convenient access to nass at a very low price, curiosity, emulation, and peer pressure were the main factors driving nass consumption among Iranian Turkmen. Various beliefs, such as the idea that nass intensifies the effects of opium and alcohol, calms the nerves, and helps individuals quit smoking were also found to contribute to this phenomenon. Finally, individuals in certain lines of work, such as fishing, driving combines, and military service, were more likely to consume nass.

Beyond the brotherhood: Skoal Bandits' role in the evolution of marketing moist smokeless tobacco pouches

Background

Since 2006, "snus" smokeless tobacco has been sold in the U.S.. However, U.S. Smokeless Tobacco (USST) and Swedish Match developed and marketed pouched moist snuff tobacco (MST) since 1973.

Methods

Analysis of previously secret tobacco documents, advertisements and trade press.

Results

USST partnered with Swedish Match, forming United Scandia International to develop pouch products as part of the "Lotus Project." Pouched MST was not commonly used, either in Sweden or the U.S. prior to the Lotus Project's innovation in 1973. The project aimed to transform smokeless tobacco from being perceived as an "unsightly habit of old men" into a relevant, socially acceptable urban activity, targeting 15-35 year-old men. While USST's initial pouched product "Good Luck," never gained mainstream traction, Skoal Bandits captured significant market share after its 1983 introduction. Internal market research found that smokers generally used Skoal Bandits in smokefree environments, yet continued to smoke cigarettes in other contexts. Over time, pouch products increasingly featured increased flavor, size, nicotine strength and user imagery variation.

Conclusions

Marlboro and Camel Snus advertising mirrors historical advertising for Skoal Bandits, designed to recruit new users and smokers subjected to smokefree places. Despite serious efforts, pouched MST marketing has been unable to dispel its association with traditional smokeless tobacco stereotypes as macho and rural. Public education efforts to discourage new users and dual use of MST and cigarettes should emphasize that "new" pouch products are simply repackaging "old" smokeless tobacco.

Prevalence and Factors Associated with Smokeless Tobacco Use, 2014-2016

OBJECTIVES

We aimed to determine whether the prevalence of current use of smokeless tobacco products (STPs) changed during 2014-2016 and examine factors associated with use among adults in the United States (US).

METHODS

Data were obtained from Tobacco Products and Risk Perceptions Surveys of probability samples representative of US adults in 2014, 2015, and 2016. Change over time in current (past 30 day) STP use was examined using pairwise comparisons of proportions and multivariable logistic regression. Associated factors were examined using Rao-Scott χ2 and multivariable logistic regression.

RESULTS

The prevalence of current STP use was higher in 2015 (3.6%) than in 2014 (2.3%, p < .001) and 2016 (2.7%, p = .018) among US adults. In 2016, current STP use was associated with being male, under age 60, currently using hookah or e-cigarettes, and having less than a college degree. Rates of use did not vary by cigarette smoking status, race/ethnicity, income, or metropolitan statistical area (MSA).

CONCLUSIONS

The prevalence of current STP use peaked in 2015. In 2016, current STP use was more prevalent among males and adults with lower education. Continuous monitoring of STP use is needed, particularly non-cigarette tobacco product users.

Perceptions of harm and addiction of snus: An exploratory study

Tobacco companies in the United States are prohibited from making reduced harm claims without filing a modified risk tobacco product application with the Food and Drug Administration and obtaining an order to market as such. However, it is possible that product marketing may suggest reduced risk to individuals. This study examines perceptions, in particular those related to harm and addiction, of snus print advertisements using a combination of eye-tracking, survey, and semistructured interviews. Participants were 22 male smokers ages 19-29 (M = 26.64, SD = 2.92). Five snus advertisements were each displayed for 20 s and eye movements were tracked. Participants responded to questions about harm and addiction after each advertisement and interviews were conducted after seeing all advertisements. For each advertisement, descriptive statistics were calculated and regression analyses predicted harm and addiction perceptions from eye tracking areas of interest (e.g., warning label). Qualitative data were analyzed using inductive/deductive thematic analysis. For certain advertisements, areas of interest were significantly associated with harm and/or addiction perceptions. For example, higher total fixation duration on the graphic in the Smokeless for Smokers advertisement was associated with decreased perceptions of addiction (B = -.360, p = .048). Qualitative themes emerged and in many instances corroborated quantitative results. This study indicates that for some advertisements, attention on certain areas (measured through eye tracking) is associated with perceptions among young male smokers. Understanding how smokers perceive and understand products after viewing advertisements may inform regulations regarding claims about product harm and addiction and may guide public health efforts to educate smokers on the risks of emerging products. (PsycINFO Database Record

Do Emotions Spark Interest in Alternative Tobacco Products?

BACKGROUND

Exposure to advertisements for tobacco products and tobacco warning labels evokes emotions. This study evaluated the association of discrete positive and negative emotions with interest in alternative tobacco products.

METHOD

In 2013, 1,226 U.S. adult nonsmokers and current smokers viewed advertisements for moist snuff, snus, and electronic cigarettes (e-cigarettes) with various warning labels and then indicated their emotional responses in terms of anger, anxiety, sadness, guilt, disgust, discouragement, hope, and contentment. Outcomes were openness to using moist snuff, snus, and e-cigarettes in the future and interest in a free sample of each product. Data were analyzed in 2016.

RESULTS

Hope was positively associated with openness and interest across all alternative tobacco products as was contentment for moist snuff and snus. Anger was negatively associated with openness to moist snuff and e-cigarettes, disgust negatively to moist snuff and snus, and anxiety negatively to e-cigarettes. Being a current smoker, ever trying a corresponding product, being male, and younger age were associated with greater openness to and interest in moist snuff and snus. For e-cigarettes, being a current smoker, ever trying e-cigarettes, and being female were associated with greater openness, and being a current smoker was associated with greater odds of selecting a free sample.

CONCLUSIONS

Positive emotions, particularly hope, were consistently positively associated with interest in alternative tobacco products. Hope is widely used by tobacco and e-cigarette companies to advertise their products. Antitobacco messages should aim to lower hope associated with tobacco products but increase hope for cessation or life without tobacco.

A longitudinal, naturalistic study of U.S. smokers' trial and adoption of snus

To refine public health policy amidst a changing landscape of tobacco products in the United States, it is first necessary to describe fully the nature of smokers' alternative product use. Little research addresses smokers' snus use, and most studies are limited by small samples, cross-sectional designs, and crude outcome measurement. This study sample includes 626 adult US smokers who denied intention to quit in the next month and were randomized to receive free snus during a 6-week sampling period, after which no snus was provided. Participants were then followed for one year. Outcome data were collected via phone. Participants (mean age: 48.7years) were predominately female, White non-Hispanic. Eighty-four percent reported trial of snus. Eleven percent reported purchase (i.e., adoption). Current use declined from 47.1% at the end of the sampling period to 6.5% at the end of follow-up. Frequency and quantity of snus use among current users was low. Among snus users, 79.3% said it functioned as an alternative to smoking and 58.4% said it provided a means of coping with smoking restrictions; options not mutually exclusive. In logistic regressions, men were more likely to report trial (odds ratio [OR]=2.33, p<0.01) and adoption (OR=1.84, p<0.05) than women. Baseline expectations about the nature of snus use also predicted snus outcomes (OR=1.28-1.78, p<0.05). Smokers showed willingness to try snus, but product interest waned over time. Snus as currently marketed is unlikely to play a prominent role in US tobacco control efforts.

Application of the Smokeless Tobacco Expectancies Questionnaire to Snus

OBJECTIVE

Measures of consumer perceptions of emerging tobacco products are needed for understanding the potential for product adoption and use. The purpose of this research was to evaluate the applicability of the Smokeless Tobacco Expectancies Questionnaire to snus, and examine its association with interest in using snus.

METHODS

We recruited 116 adolescents (14-17 years of age), 463 young adults (18-34 years of age), and 596 older adults (35-65 years of age) from a Web-based opt-in panel. Participants completed a 10-item Snus Expectancies Questionnaire and questions about their interest in trying snus in the next month.

RESULTS

Confirmatory factor analysis supported a latent factor structure representing Positive Reinforcement (PR) and Negative Health Consequences (NHC) within each age group. The scales differentiate smokers and smokeless tobacco users and nonusers. Each scale was associated with interest in purchasing snus for younger (PR: OR 1.90; NHC: OR 0.66) and older (PR: OR 1.36; NHC: OR 0.69) adults controlling for tobacco use status.

CONCLUSIONS

The modified Smokeless Tobacco Expectancies Questionnaire is a valid measure of snus-related outcome expectancies, which are in turn, associated with self-reported tobacco use, and may help to identify groups who are susceptible to snus initiation and use.

Toxicity of Smokeless Tobacco Extract after 184-Day Repeated Oral Administration in Rats

The use of smokeless tobacco (ST) is growing rapidly and globally. The consumption of ST is associated with an increased risk for developing chronic diseases, such as diabetes, hypercholesterolemia, and myocardial infarction, and has led to many public health problems. It is very important to access the toxicity of ST. This experiment presents data from 184-day toxicology studies in Sprague-Dawley (SD) rats designed to characterize the chronic effects of a smokeless tobacco extract (STE). The control group and treatment groups were matched for a range of nicotine levels. Animals were given STE by oral gavage with doses of 3.75 (low-dose), 7.50 (mid-dose) and 15.00 (high-dose) mg·nicotine/kg body weight/day for 184 days, followed by 30 days for recovery. Variables evaluated included body weights, feed consumption, clinical observations, clinical and anatomic pathology (including organ weights), and histopathology. Decreased body weights and organ weights (heart, liver and kidney) were found in animals in the mid-dose and high-dose groups. STE also showed moderate and reversible toxicity in esophagus, stomach, liver, kidney and lung.

Use of electronic nicotine delivery systems and other tobacco products among USA adults, 2014: results from a national survey

OBJECTIVES

This study assessed the awareness and use of traditional and novel tobacco products and dual use of cigarettes with electronic nicotine delivery systems (ENDS) among USA adults.

METHODS

Data were obtained from the 2014 Tobacco Products and Risk Perceptions Survey of a probability sample of 5717 USA adults conducted June-November, 2014.

RESULTS

Use of ENDS varied by demography and by cigarette and other tobacco use. Adults aged 25-34, non-heterosexual adults, and those reporting poorer health reported higher rates of current ENDS use. Current cigarette smokers had much greater odds of ENDS ever use than never smokers, with one-half of all cigarette smokers having used ENDS and 20.7 % currently using them. However, 22.0 % of current ENDS users were former cigarette smokers, and 10.0 % were never cigarette smokers.

CONCLUSIONS

Patterns of ENDS use are evolving rapidly and merit continued surveillance. Nearly 10 % of adult ENDS usage is among never smokers. The public health challenge is how to enhance the potential that ENDS can replace combusted tobacco products without expanding nicotine use among youth, long-term ex-smokers, and other vulnerable populations.

Past Year Quit Attempts and Use of Cessation Resources Among Cigarette-Only Smokers and Cigarette Smokers Who Use Other Tobacco Products

INTRODUCTION

It is unclear how use of other tobacco products impacts cigarette-smoking cessation. We assessed differences in past year cigarette smoking quit attempts and use of counseling and medication among current cigarette-only users, cigarette and cigar users, and cigarette and smokeless tobacco (SLT) users.

METHODS

Data came from 24 448 current cigarette-only, 1064 cigarette and cigar only, and 508 cigarette and SLT only users who responded to the 2010-2011 Tobacco Use Supplement to the Current Population Survey. Demographic, smoking, and cessation characteristics were computed by group. Bivariate and multivariable logistic regression models assessed the relationship of tobacco use group to making a past year quit attempt, and use of counseling or medication during the last quit attempt.

RESULTS

Dual users of cigarettes and cigars or SLT had similar interest in quitting and prevalence of reported past year quit attempts compared to cigarette-only users. In unadjusted analyses, cigarette and SLT users had higher odds of trying to quit in the past year compared to cigarette-only users (odds ratio [OR] = 1.31, 95% confidence interval [CI] = 1.05, 1.64); no differences were found for cigarette and cigar users. However, adjusting for demographic and cigarette smoking variables, both groups of dual users had similar odds as cigarette-only users for having made a past year cigarette smoking quit attempt, and to have used counseling or medication during the last quit attempt.

CONCLUSION

Dual tobacco use was not associated with decreased attempts to quit smoking cigarettes; however, use of evidence-based treatment was sub-optimal among cigarette-only and dual users, and should be increased.

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.

Validation of a Measure of Normative Beliefs About Smokeless Tobacco Use

INTRODUCTION

Validated methods to evaluate consumer responses to modified risk tobacco products (MRTPs) are needed. Guided by existing literature that demonstrates a relationship between normative beliefs and future intentions to use tobacco the current research sought to (1) develop a measure of normative beliefs about smokeless tobacco (ST) and establish the underlying factor structure, (2) evaluate the structure with confirmatory factor analysis utilizing an independent sample of youth, and (3) establish the measure's concurrent validity.

METHODS

Respondents (smokers and nonsmokers aged 15-65; N = 2991) completed a web-based survey that included demographic characteristics, tobacco use history and dependence, and a measure of attitudes about ST adapted from the Normative Beliefs about Smoking scale. A second sample of youth (aged 14-17; N = 305) completed a similar questionnaire.

RESULTS

Exploratory factor analysis produced the anticipated three-factor solution and accounted for nearly three-quarters of the variance in the data reflecting (1) perceived prevalence of ST use, (2) popularity of ST among successful/elite, and (3) approval of ST use by parents/peers. Confirmatory factor analysis with data from the youth sample demonstrated good model fit. Logistic regression demonstrated that the scales effectively discriminate between ST users and nonusers and are associated with interest in trying snus.

CONCLUSIONS

Assessment of MRTPs for regulatory purposes, which allows messages of reduced risk, should include measurement of social norms. Furthermore, surveillance efforts that track use of new MRTPs should include measures of social norms to determine how norms change with prevalence of use.

E-cigarette marketing and older smokers: road to renormalization

OBJECTIVES

To describe older smokers' perceptions of risks and use of e-cigarettes, and their responses to marketing and knowledge of, and opinions about, regulation of e-cigarettes.

METHODS

Eight 90-minute focus groups with 8 to 9 participants met in urban and suburban California to discuss topics related to cigarettes and alternative tobacco products.

RESULTS

Older adults are using e-cigarettes for cessation and as a way to circumvent no-smoking policies; they have false perceptions about the effectiveness and safety of e-cigarettes. They perceive e-cigarette marketing as a way to renormalize smoking.

CONCLUSIONS

To stem the current epidemic of nicotine addiction, the FDA must take immediate action because e-cigarette advertising promotes dual use and may contribute to the renormalization of smoking.

Frequency and characteristics associated with exposure to tobacco direct mail marketing and its prospective effect on smoking behaviors among young adults from the US Midwest

OBJECTIVES

We examined the exposure to tobacco direct mail marketing and its effect on subsequent smoking behaviors in a US Midwest regional cohort of young adults.

METHODS

Data were collected from 2622 young adults (mean age = 24 years) in 2010 to 2011 (baseline) and 2011 to 2012 (follow-up). We collected information on demographics, tobacco use, and exposure to tobacco direct mail materials in the previous 6 months at baseline. Smoking behaviors were reassessed at follow-up. We investigated the characteristics associated with receiving these materials at baseline, and the associations between receiving cigarette coupons in the mail at baseline and smoking behaviors at follow-up.

RESULTS

Thirteen percent of participants reported receiving tobacco direct mail materials in the previous 6 months. Receipt of these materials was associated with age, education, and tobacco use (P < .05). Among those who received these materials, 77% and 56% reported receiving coupons for cigarettes and other tobacco products, respectively. Among baseline nonsmokers and ex-smokers, receiving coupons was associated with becoming current smokers at follow-up (P < .05). Among baseline current smokers, receiving coupons was associated with lower likelihood of smoking cessation at follow-up (P < .05).

CONCLUSIONS

Tobacco direct mail marketing promoted and sustained smoking behaviors among US Midwest young adults. Regulating this marketing strategy might reduce the prevalence of smoking in this population.

Prevalence, harm perceptions, and reasons for using noncombustible tobacco products among current and former smokers

OBJECTIVES

We provided estimates of noncombustible tobacco product (electronic nicotine delivery systems [ENDS]; snus; chewing tobacco, dip, or snuff; and dissolvables) use among current and former smokers and examined harm perceptions of noncombustible tobacco products and reasons for their use.

METHODS

We assessed awareness of, prevalence of, purchase of, harm perceptions of, and reasons for using noncombustible tobacco products among 1487 current and former smokers from 8 US designated market areas. We used adjusted logistic regression to identify correlates of noncombustible tobacco product use.

RESULTS

Of the sample, 96% were aware of at least 1 noncombustible tobacco product, but only 33% had used and 21% had purchased one. Noncombustible tobacco product use was associated with being male, non-Hispanic White, younger, and more nicotine dependent. Respondents used noncombustible tobacco products to cut down or quit cigarettes, but only snus was associated with a higher likelihood of making a quit attempt. Users of noncombustible tobacco products, particularly ENDS, were most likely to endorse the product as less harmful than cigarettes.

CONCLUSIONS

Smokers may use noncombustible tobacco products to cut down or quit smoking. However, noncombustible tobacco product use was not associated with a reduction in cigarettes per day or cessation.

Testing messages to reduce smokers' openness to using novel smokeless tobacco products

INTRODUCTION

Tobacco manufacturers' aggressive promotion of new smokeless tobacco products such as snus warrants a timely and effective public health response. This study tested potential countermarketing messages to discourage current and former smokers from becoming dual users of smokeless tobacco and cigarettes.

METHODS

In a pretest-post-test experiment, 1836 adult current and recently former smokers from a national sample were randomised to view one of six antismokeless tobacco ads followed by a snus ad, to view a control ad followed by a snus ad; or to view two control ads. Perceived effectiveness of ads and actual changes in attitudes and openness to snus were compared across groups using analyses of variance.

RESULTS

Some ads that were perceived as most effective did not change attitudes or openness to trying snus, and conversely, some ads not perceived as effective changed attitudes and openness to snus. Ads portraying the negative health effects of smokeless tobacco were perceived as most effective, but ads with antitobacco industry themes significantly decreased favourable attitudes toward snus. Responses to ads were different for smokers who had ever used smokeless tobacco: for this group health effects and humorous/testimonial ads were effective.

CONCLUSIONS

Measures of perceived effectiveness of antitobacco ads need to be augmented with measures of actual effectiveness to assess countermarketing messages. Some of the developed ads, such as ads with anti-industry themes, were effective for the overall population of smokers whereas humorous/testimonial and health effects ads were particularly effective in changing attitudes of past users of smokeless tobacco.

A qualitative study of smokers' responses to messages discouraging dual tobacco product use

Cigarette companies increasingly promote novel smokeless tobacco products to smokers, encouraging them to use smokeless tobacco in smoke-free environments. New messages may counteract this promotion. We developed 12 initial anti-smokeless message ideas and tested them in eight online focus groups with 75 US smokers. Those smokers who never tried smokeless tobacco were unaware of health risks of novel smokeless tobacco products, perceived scary messages as effective and acknowledged the addictive nature of nicotine. Smokers who had tried smokeless tobacco shared their personal (mainly negative) experiences with smokeless tobacco, were aware of health risks of novel smokeless tobacco products, but denied personal addiction, and misinterpreted or disregarded more threatening messages. Portraying women as smokeless tobacco users was perceived as unbelievable, and emphasizing the lack of appeal of novel smokeless tobacco products was perceived as encouraging continued smoking. Future ads should educate smokers about risks of novel smokeless tobacco products, but past users and never users may require different message strategies.

Hazards of new media: youth's exposure to tobacco Ads/promotions

BACKGROUND

A gap in knowledge exists about the youth's exposure to protobacco campaigns via new electronic media outlets. In response, we use national data to delineate the associations between tobacco ads/promotions delivered through new media outlets (i.e., social network sites and text messages) and youth attitudes/beliefs about tobacco and intent to use (among youth who had not yet used tobacco).

METHODS

Data were derived from the 2011 National Youth Tobacco Survey, a nationally representative sample of U.S. youth enrolled in both public and private schools (N = 15,673). Logistic regression models were used to examine associations between demographic characteristics and reported exposure to tobacco ads/promotions via social networking sites and text messages. Logistic regression models were also used to investigate associations between exposure tobacco ads/promotions and attitudes toward tobacco.

RESULTS

We found that highly susceptible youth (i.e., minorities, very young youth, and youth who have not yet used tobacco) have observed tobacco ads/promotions on social networking sites and text messages. These youth are more likely to have favorable attitudes toward tobacco, including the intention to use tobacco among those who had not yet used tobacco.

CONCLUSIONS

Our findings underscore the need for policy strategies to more effectively monitor and regulate tobacco advertising via new media outlets.

Smoking and snus use onset: exploring the influence of snus debut age on the risk for smoking uptake with cross-sectional survey data

INTRODUCTION

Snus use has become increasingly prevalent among young people in Norway, while smoking has declined. Little is known about the transitions between snus and other tobacco products, particularly among younger users. A major concern involves the association between snus initiation and future smoking uptake.

METHODS

A total of 409 lifetime snus users who had started with snus before cigarettes or were never-smokers were selected from a national sample of participants in annually repeated cross-sectional surveys (2005-2011) of Norwegian men and women aged 15-74 years. About 30% of them were lifetime smokers, 84% were men, and the mean age was 29.4 years. Logistic regression was applied to investigate the association between age of snus uptake and the risk for becoming a smoker later on.

RESULTS

Respondents who started using snus before the age of 16 years had an odds ratio of 3.1 (confidence interval = 1.98-4.76) of being lifetime smokers compared with those who initiated snus later. The prevalence of current smoking among early snus initiators (22.9%) was comparable to that found among never-snus-users (29.6%). Among late snus initiators, current smoking prevalence was 5.9%.

CONCLUSION

In this study, snus debut age was an important factor for the association between snus use and smoking.

Toxicity of gutkha, a smokeless tobacco product gone global: is there more to the toxicity than nicotine?

The popularity of smokeless tobacco (ST) is growing rapidly and its prevalence of use is rising globally. Consumption of Gutkha, an addictive form of ST, is particularly common amongst South Asian communities throughout the World. This includes within the US, following large-scale immigration into the country. However, there exists a lack of knowledge concerning these alternative tobacco products. To this end, a study was carried out to determine the toxicity of gutkha, and what role, if any, nicotine contributes to the effects. Adult male mice were treated daily for 3-week (5 day/week, once/day), via the oral mucosa, with equal volumes (50 μL) of either sterile water (control), a solution of nicotine dissolved in water (0.24 mg of nicotine), or a solution of lyophilized guthka dissolved in water (21 mg lyophilized gutkha). Serum cotinine, measured weekly, was 36 and 48 ng/mL in gutkha- and nicotine-treated mice, respectively. Results demonstrated that exposure to nicotine and gutkha reduced heart weight, while exposure to gutkha, but not nicotine, decreased liver weight, body weight, and serum testosterone levels (compared to controls). These findings suggest that short-term guhtka use adversely impacts growth and circulating testosterone levels, and that gutkha toxicity may be driven by components other than nicotine. As use of guthka increases worldwide, future studies are needed to further delineate toxicological implications such that appropriate policy decisions can be made.

First-year college students' interest in trying dissolvable tobacco products

BACKGROUND

Dissolvable tobacco products (DTPs) have been introduced into test markets in the U.S. We sought to gauge the level of interest in trying these products and correlates of interest among potential consumers.

METHODS

A web-based survey of freshman at 11 universities in North Carolina and Virginia was conducted in fall 2010. Multivariable logistic regression analyses were used to identify correlates of students' likelihood to try DTPs if offered a free sample.

RESULTS

Weighted prevalence of likelihood to try DTPs was 3.7%. Significant correlates of likelihood to try included male gender, current cigarette smoking, current snus use, sensation seeking, lifetime illicit drug use, and perceived health risk of using DTPs. Among current smokers, current snus use, current use of chewing tobacco, and considering quitting smoking were associated with likelihood to try DTPs.

CONCLUSIONS

While overall interest in trying these products was low, current users of cigarettes and snus were much more likely than others in trying a free sample. Some current smokers may consider DTPs to be an aid to smoking cessation, although the population-level impact of introducing these products is unknown.

Scaring the snus out of smokers: testing effects of fear, threat, and efficacy on smokers' acceptance of novel smokeless tobacco products

Novel smokeless tobacco products (such as snus) are aggressively promoted to smokers by the tobacco companies. The Extended Parallel Process Model (EPPM; Witte, 1992) was used to evaluate the current perceptions of threat, efficacy, attitudes, and behavioral intentions regarding snus in a nationally representative sample of 1,836 smokers. Participants were then exposed to messages designed to discourage smokers from trying snus. On average, smokers perceived health threat of snus as somewhat serious, but believed they can effectively avert this threat. Support was found for the EPPM's proposition that when efficacy is high, greater perceived threat is associated with greater desired outcomes (less favorable attitudes toward snus and lower behavioral intentions to try snus in the future). No support was found for the proposition that when perceived efficacy is low, greater threat is associated with greater message rejection. Instead, message rejection was explained by fear felt while exposed to the anti-smokeless ads. This finding indicates the need to more clearly distinguish between cognitive (danger control) and affective (fear control) responses posited by the EPPM.

A fresh look at tobacco harm reduction: the case for the electronic cigarette

Smokers of any age can reap substantial health benefits by quitting. In fact, no other single public health effort is likely to achieve a benefit comparable to large-scale smoking cessation. Surveys document that most smokers would like to quit, and many have made repeated efforts to do so. However, conventional smoking cessation approaches require nicotine addicted smokers to abstain from tobacco and nicotine entirely. Many smokers are unable – or at least unwilling – to achieve this goal, and so they continue smoking in the face of impending adverse health consequences. In effect, the status quo in smoking cessation presents smokers with just two unpleasant alternatives: quit or suffer the harmful effects of continuing smoking. But, there is a third choice for smokers: tobacco harm reduction. It involves the use of alternative sources of nicotine, including modern smokeless tobacco products like snus and the electronic cigarette (E-cig), or even pharmaceutical nicotine products, as a replacement for smoking. E-cigs might be the most promising product for tobacco harm reduction to date, because, besides delivering nicotine vapour without the combustion products that are responsible for nearly all of smoking’s damaging effect, they also replace some of the rituals associated with smoking behaviour. Thus it is likely that smokers who switch to E-cigs will achieve large health gains. The focus of this article is on the health effects of using an E-cig, with consideration given to the acceptability, safety and effectiveness of this product as a long-term substitute for smoking.

Alternative tobacco product use and smoking cessation: a national study

OBJECTIVES

We investigated the frequency of alternative tobacco product use (loose leaf, moist snuff, snus, dissolvables, electronic cigarettes [e-cigarettes]) among smokers and the association with quit attempts and intentions.

METHODS

A nationally representative probability-based cross-sectional survey of 1836 current or recently former adult smokers was completed in November 2011. Multivariate logistic regressions evaluated associations between alternative tobacco product use and smoking cessation behaviors.

RESULTS

Of the smokers, 38% had tried an alternative tobacco product, most frequently e-cigarettes. Alternative tobacco product use was associated with having made a quit attempt, and those intending to quit were significantly more likely to have tried and to currently use the products than were smokers with no intentions to quit. Use was not associated with successful quit attempts. Interest in future use of alternative tobacco products was low, except for e-cigarettes.

CONCLUSIONS

Alternative tobacco products are attractive to smokers who want to quit smoking, but these data did not indicate that alternative tobacco products promote cessation. Unsubstantiated overt and implied claims that alternative tobacco products aid smoking cessation should be prohibited.

Transnational tobacco company interests in smokeless tobacco in Europe: analysis of internal industry documents and contemporary industry materials

BACKGROUND

European Union (EU) legislation bans the sale of snus, a smokeless tobacco (SLT) which is considerably less harmful than smoking, in all EU countries other than Sweden. To inform the current review of this legislation, this paper aims to explore transnational tobacco company (TTC) interests in SLT and pure nicotine in Europe from the 1970s to the present, comparing them with TTCs' public claims of support for harm reduction.

METHODS AND RESULTS

Internal tobacco industry documents (in total 416 documents dating from 1971 to 2009), obtained via searching the online Legacy Tobacco Documents Library, were analysed using a hermeneutic approach. This library comprises documents obtained via litigation in the US and does not include documents from Imperial Tobacco, Japan Tobacco International, or Swedish Match. To help overcome this limitation and provide more recent data, we triangulated our documentary findings with contemporary documentation including TTC investor presentations. The analysis demonstrates that British American Tobacco explored SLT opportunities in Europe from 1971 driven by regulatory threats and health concerns, both likely to impact cigarette sales negatively, and the potential to create a new form of tobacco use among those no longer interested in taking up smoking. Young people were a key target. TTCs did not, however, make SLT investments until 2002, a time when EU cigarette volumes started declining, smoke-free legislation was being introduced, and public health became interested in harm reduction. All TTCs have now invested in snus (and recently in pure nicotine), yet both early and recent snus test markets appear to have failed, and little evidence was found in TTCs' corporate materials that snus is central to their business strategy.

CONCLUSIONS

There is clear evidence that BAT's early interest in introducing SLT in Europe was based on the potential for creating an alternative form of tobacco use in light of declining cigarette sales and social restrictions on smoking, with young people a key target. We conclude that by investing in snus, and recently nicotine, TTCs have eliminated competition between cigarettes and lower-risk products, thus helping maintain the current market balance in favour of (highly profitable) cigarettes while ensuring TTCs' long-term future should cigarette sales decline further and profit margins be eroded. Please see later in the article for the Editors' Summary.

Awareness, perceptions and use of snus among young adults from the upper Midwest region of the USA

BACKGROUND

Since its introduction in 2006, snus has been aggressively marketed by tobacco companies. However, little is known about the awareness, perceptions and use of snus among young adults after Camel and Marlboro snus were sold nationwide in 2010.

METHODS

Data were collected from 2607 young adults (ages 20-28) who participated in the Minnesota Adolescent Community Cohort Study in 2010-2011. Data include awareness of snus, ever and past 30-day use, perceived potential of snus as a quit aid, and perceived harmfulness and addictiveness of snus relative to cigarettes. The authors assessed the associations between these outcome variables and socio-demographic characteristics.

RESULTS

Overall, 64.8% of participants were aware of snus, 14.5% ever used snus and 3.2% used snus in the past 30 days. Men and participants who smoked >100 cigarettes in their lifetime were associated with these three outcomes (p<0.05). Among those who were aware of snus, 16.3% agreed snus can help people quit smoking, 17.3% agreed snus is less harmful than cigarettes and 11.3% agreed snus is less addictive than cigarettes. These perceptions were associated with ever use and the past 30-day use of snus (p<0.05).

CONCLUSIONS

In this regional sample of US young adults, the majority of young adults were aware of snus, and over one in 10 had used snus. More young adults in the sample than the overall US adult population believed that snus is less harmful than cigarettes. Perceptions of snus are associated with snus use. Strategic health communication interventions targeting young adults to confront the positive perceptions associated with snus may be needed to curb the interest in snus.