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Dewhirst T. 'Proudly Canadian' and 'no Big Tobacco affiliation': STLTH e-cigarette advertising and positioning in Canada. Tob Control 2024; 33:833-836. [PMID: 37208170 DOI: 10.1136/tc-2023-057960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Affiliation(s)
- Timothy Dewhirst
- Department of Marketing and Consumer Studies, Gordon S. Lang School of Business and Economics, University of Guelph, Guelph, Ontario, Canada
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Weiger C, Gratale SK, Ganz O, Wackowski OA. From "Additive-Free" to "Tobacco & Water": Assessing the Impact of Marketing Claim Changes on Natural American Spirit and L&M Cigarettes. Nicotine Tob Res 2024; 26:1097-1102. [PMID: 38417417 DOI: 10.1093/ntr/ntae040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/20/2023] [Accepted: 02/13/2024] [Indexed: 03/01/2024]
Abstract
INTRODUCTION The 2017 agreement between the U.S. Food and Drug Administration and the makers of Natural America Spirit (NAS) cigarettes restricted the use of "additive-free" (AF) in brand marketing, which the company replaced with "tobacco ingredients: tobacco & water" (TW), a phrase subsequently adopted by L&M. We tested how participants' perceptions differed when exposed to AF versus TW claims on NAS and L&M packs. AIMS AND METHODS A between-subjects experiment was embedded within an online survey in August 2022 (n = 2526). Participants were randomized to view one of three packs (NAS AF pack, NAS TW pack, L&M TW pack). Logistic regressions assessed differences (by pack exposure) in perceived pack attractiveness and relative chemical and harm perceptions compared to other cigarettes. Interactions by smoking status were explored. RESULTS No significant differences were observed between the NAS AF and NAS TW packs on perceived attractiveness or relative harm, although never smokers had higher odds of having lower relative chemicals perceptions in response to the NAS AF versus NAS TW pack (OR = 1.81). Compared to participants who saw the NAS TW pack, those who saw the L&M TW pack tended to have lower odds of perceiving the pack as attractive, believing that the product had fewer chemicals than other products, or believing the product was less harmful than other products compared to the NAS TW pack. CONCLUSION Results suggest the more implicit "tobacco ingredients: tobacco & water" claim functions similarly to "additive-free" and as an unauthorized modified risk claim. NAS brand image also appears to contribute to higher perceived pack attractiveness and lower perceptions of chemicals and harm. Additional marketing regulations and corrective campaigns may be needed to reduce risk-related misperceptions about NAS cigarettes. IMPLICATIONS Our findings show that replacing "additive-free" claims with "tobacco ingredients: tobacco & water" did not sufficiently address the illegal use of unauthorized modified risk claims by the makers of NAS cigarettes. Further regulatory action restricting the TW claim could potentially reduce inaccurate lower harm perceptions about NAS cigarettes. Educational campaigns may also be needed to mitigate NAS's history of marketing that implies reduced harm, given that the effects of implicit reduced risk claims like TW have a greater effect on pack perceptions for NAS than L&M.
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Affiliation(s)
- Caitlin Weiger
- Rutgers Institute for Nicotine & Tobacco Studies, Rutgers University, New Brunswick, NJ, USA
| | - Stefanie K Gratale
- Rutgers Institute for Nicotine & Tobacco Studies, Rutgers University, New Brunswick, NJ, USA
| | - Ollie Ganz
- Rutgers Institute for Nicotine & Tobacco Studies, Rutgers University, New Brunswick, NJ, USA
| | - Olivia A Wackowski
- Rutgers Institute for Nicotine & Tobacco Studies, Rutgers University, New Brunswick, NJ, USA
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Erinoso O, Liber AC, Hogan A, Martínez B, Miller F, Kue D, Sangoleye D, Pearson J. Cigarette unit sales volume for brands using 'natural', 'organic' and 'tobacco and water' pack terms in the USA, 2018-2022. Tob Control 2024:tc-2024-058593. [PMID: 38897726 DOI: 10.1136/tc-2024-058593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 06/05/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Terms such as 'natural', 'organic' and 'tobacco and water' on cigarette packs may communicate misleading reduced harm messages to consumers. This study describes sales volume and price for brands that used these misleading descriptors in the USA by year, brand and state. METHODS The data come from Information Resources Incorporated sales data collected in 44 US states from January 2018 to January 2023. Trained coders used Universal Product Codes, purchased packs and internet searches to identify cigarettes sold with 'natural', 'organic' and 'tobacco and water' on packs. We report cigarette pack unit sales counts (sales volume) and average price per pack by year, as well as per cent year-over-year change in sales volume and price and annual market share by descriptor terms. RESULTS Overall, pack sales volume decreased year-over-year from 2019 to 2022. Sales volume for packs with 'natural', 'tobacco and water' and 'organic' decreased less than overall; in some cases, they increased. In 2022, packs with 'natural' accounted for the greatest share of cigarette unit sales (5.42% or 33 605 036 packs), followed by 'tobacco and water' (2.25% or 12 959 905 packs) and 'organic' (0.53% or 4 614 592 packs). Natural American Spirit (NAS) and Winston accounted for most sales with 'natural' and 'tobacco and water'; NAS accounted for nearly all sales with 'organic'. Packs with 'natural', 'tobacco and water' or 'organic' made up the largest portion of sales in western (Oregon, Idaho, California, Colorado and Washington) and northeastern (Vermont, Massachusetts and New Hampshire) US states. CONCLUSION Brands using 'natural', 'tobacco and water' and 'organic' on packs increased their market share between 2019 and 2022; in some states, market share was over 10% in 2022. Our findings emphasise the importance of regulating these terms and continually monitoring their population impact.
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Affiliation(s)
- Olufemi Erinoso
- School of Public Health, University of Nevada Reno, Reno, Nevada, USA
| | - Alex C Liber
- Policy and Regulatory Science Program, RTI International Social Statistical and Environmental Sciences Unit, Research Triangle Park, North Carolina, USA
| | - Alexis Hogan
- School of Public Health, University of Nevada Reno, Reno, Nevada, USA
| | | | - Felicia Miller
- School of Public Health, University of Nevada Reno, Reno, Nevada, USA
| | - Donald Kue
- School of Public Health, University of Nevada Reno, Reno, Nevada, USA
| | - Dotun Sangoleye
- School of Public Health, University of Nevada Reno, Reno, Nevada, USA
| | - Jennifer Pearson
- School of Public Health, University of Nevada Reno, Reno, Nevada, USA
- Department of Health, Behavior, and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Dewhirst T. Lucky Strike advertising: the use of 'anaphora' as a rhetorical device to highlight 'smooth' as a cigarette product descriptor. Tob Control 2024; 33:275-277. [PMID: 35953285 DOI: 10.1136/tc-2022-057517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Timothy Dewhirst
- Department of Marketing and Consumer Studies, Gordon S Lang School of Business and Economics, University of Guelph, Guelph, Ontario, Canada
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Gratale SK, Pearson JL, Mercincavage M, Wackowski OA. Organic, Earth-Friendly Tobacco With a Charcoal Filter and Smooth Taste: A Randomized Experiment Testing Effects of Natural American Spirit's "Sky" Cigarette Advertising on Consumer Perceptions. Nicotine Tob Res 2024; 26:161-168. [PMID: 37349148 PMCID: PMC10803116 DOI: 10.1093/ntr/ntad099] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 06/17/2023] [Accepted: 06/20/2023] [Indexed: 06/24/2023]
Abstract
INTRODUCTION The Natural American Spirit (NAS) brand has a history of marketing tactics that may convey reduced harm. While no longer allowed to use "additive-free" or natural descriptors (except in the brand name), it continues promoting potentially misleading attributes. This study examined perceptions of NAS's newer "Sky" style, promoted as organic tobacco with a charcoal filter. AIMS AND METHODS In an online experiment, we randomized 1927 adult past 30-day tobacco or nicotine product users to one of six conditions showing Sky ads with different descriptors: (1) charcoal filter, (2) charcoal + organic, (3) charcoal + earth-friendly, (4) charcoal + smooth taste, (5) charcoal + all other descriptors, and (6) no-descriptor control (Sky ads without target descriptors). Product perceptions were compared by condition. Participants also reported perceived benefits of charcoal filters. RESULTS Overall, 28% of participants indicated Sky is less harmful and 38% believed it exposes users to fewer chemicals. Participants in the "charcoal + organic," "charcoal + earth-friendly," and the all-descriptor conditions had higher odds of believing Sky reduces chemical exposure (respectively, 43%, 40%, and 42%), relative to the no-descriptor control. Fewer control participants endorsed beliefs that Sky has a "better filter" and is "more environmentally friendly". Many believed cigarettes with charcoal filters could confer benefits relative to other cigarettes, such as reducing chemical exposure, or being cleaner, purer or safer (though research on relative safety of charcoal filters in cigarettes is inconclusive). CONCLUSIONS Sky marketing may promote misperceptions about product safety and composition, and ads using both charcoal and organic text may particularly reinforce them. IMPLICATIONS This study examined the impact of new cigarette advertising promoting the use of charcoal filters and organic tobacco along with other suggestive claims ("environmentally friendly," "smooth taste") on tobacco users' perceptions of the advertised product-NAS Sky cigarettes. Our study provides new data about positive consumer perceptions of charcoal-filtered cigarettes, and results suggest that combinations of these marketing terms evoke perceptions about reduced harm and reduced exposure to harmful chemicals that may be misleading to the public. Our findings underscore a need for additional regulatory action regarding tobacco marketing that makes use of natural-themed marketing.
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Affiliation(s)
- Stefanie K Gratale
- Rutgers Institute for Nicotine & Tobacco Studies, Rutgers Biomedical and Health Sciences, Rutgers University, New Brunswick, NJ, USA
| | - Jennifer L Pearson
- Department of Health Behavior, Policy, and Administration Sciences, School of Public Health, University of Nevada, Reno, NV, USA
| | - Melissa Mercincavage
- Rutgers Institute for Nicotine & Tobacco Studies, Rutgers Biomedical and Health Sciences, Rutgers University, New Brunswick, NJ, USA
| | - Olivia A Wackowski
- Rutgers Institute for Nicotine & Tobacco Studies, Rutgers Biomedical and Health Sciences, Rutgers University, New Brunswick, NJ, USA
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, NJ, USA
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Gratale SK, Ganz O, Wackowski OA, Lewis MJ. Naturally leading: a content analysis of terms, themes and word associations in Natural American Spirit advertising, 2000-2020. Tob Control 2023; 32:583-588. [PMID: 35022329 PMCID: PMC9273802 DOI: 10.1136/tobaccocontrol-2021-056938] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 12/22/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Natural American Spirit (NAS) is a cigarette brand distinguished by supposed 'natural', 'additive-free' characteristics, marketing of which is tied to misperceptions of reduced harm. In 2017, NAS's manufacturer agreed (with the Food and Drug Administration) to remove 'natural'/'additive-free' from US marketing. Prior research has explored NAS marketing immediately post-agreement. This study sought to identify prominent post-agreement terms and themes and analyse how they had been used in pre-agreement ads. METHODS We conducted a content analysis of NAS ads from 2000 to 2020 (N=176), documenting prominent pre-agreement and post-agreement terms/themes and examining how they are used in NAS ads. We coded for descriptors, themes, imagery and promotions, and extended prior research by analysing how leading post-agreement terms were used in conjunction and thematically associated with 'additive-free' and 'natural' before the agreement. RESULTS Results indicated 'tobacco and water' and 'Real. Simple. Different.' increased post-agreement, as did environmental imagery. 'Organic' was prominent pre-agreement and post-agreement. The descriptors used most often in post-agreement ads almost always appeared in conjunction with (and were thematically linked to) 'natural' and 'additive-free' in pre-agreement ads. CONCLUSIONS In the years since the agreement, NAS ads have heavily relied on still-allowable descriptors that may invite reduced risk misperceptions. Notably, these descriptors were consistently used alongside the banned terminology before the agreement and presented as if affiliated conceptually, possibly prompting similar connotations. Findings indicate a continuing need for research into NAS advertising effects and a potential role for additional regulatory action.
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Affiliation(s)
- Stefanie K Gratale
- Center for Tobacco Studies, Rutgers University, New Brunswick, New Jersey, USA
| | - Ollie Ganz
- Center for Tobacco Studies, Rutgers University, New Brunswick, New Jersey, USA
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, New Jersey, USA
| | - Olivia A Wackowski
- Center for Tobacco Studies, Rutgers University, New Brunswick, New Jersey, USA
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, New Jersey, USA
| | - M Jane Lewis
- Center for Tobacco Studies, Rutgers University, New Brunswick, New Jersey, USA
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, New Jersey, USA
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Xie Z, Lee S, Xu E, Li D. Public Perceptions and Discussions of Premium Cigars on Reddit. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.06.22.23291751. [PMID: 37425876 PMCID: PMC10327260 DOI: 10.1101/2023.06.22.23291751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Introduction While premium cigars have similar addictive, toxic, and carcinogenic constituents as other cigars and cigarettes, about 1% of the US adults reported premium cigar use from 2010 to 2019. This study aimed to understand public perceptions and discussions of premium cigars on Reddit, one of the most popular social media platforms. Methods Using keywords such as "premium cigar", we extracted 2,238 Reddit posts from Reddit Archive between July 2019 and June 2021. Among them, 1,626 posts were related to premium cigars. By employing the inductive approach, we manually coded each Reddit post on premium cigars to understand public perceptions and discussions of premium cigars by summarizing them into different topics and subtopics. Results Longitudinal analysis showed that the number of Reddit posts on premium cigars increased since June 2020. Content analysis showed that among Reddit posts related to premium cigars, the most popular topic is "Information sharing" (75.72%), in which Reddit users shared their perceptions about premium cigars, asked for advice, and provided some recommendations about premium cigars. Over one-quarter of posts (27.17%) are sharing user experiences of premium cigars (such as taste). Nearly one-fifth (18.99%) of posts are discussing the affordability of premium cigars. In addition, 7.87% of posts are discussing legal/policy issues related to premium cigars, and 6.82% of posts are related to the health risks of premium cigars compared to cigarettes. Conclusions Public perceptions including misperceptions, user experiences, and affordability related to premium cigars have been actively discussed on Reddit.
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Affiliation(s)
- Zidian Xie
- Department of Clinical & Translational Research, University of Rochester Medical Center, Rochester, NY, USA
| | - Sarah Lee
- Goergen Institute for Data Science, University of Rochester, Rochester, New York, USA
| | - Emily Xu
- Goergen Institute for Data Science, University of Rochester, Rochester, New York, USA
| | - Dongmei Li
- Department of Clinical & Translational Research, University of Rochester Medical Center, Rochester, NY, USA
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Pearson J, Giovenco DP, Lewis MJ, Moran M, Ganz O. Natural American Spirit launches 'Sky', the brand's first commercial organic cigarette with a charcoal filter. Tob Control 2023; 32:397-399. [PMID: 34593613 PMCID: PMC8964832 DOI: 10.1136/tobaccocontrol-2021-056731] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Jennifer Pearson
- Division of Social and Behavioral Health/Health Administration and Policy, University of Nevada Reno, Reno, Nevada, USA
| | - Daniel P Giovenco
- Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
| | - M Jane Lewis
- Rutgers Center for Tobacco Studies, Rutgers School of Public Health, Piscataway, New Jersey, USA
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, New Jersey, USA
| | - Meghan Moran
- Health, Behavior & Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ollie Ganz
- Rutgers Center for Tobacco Studies, Rutgers School of Public Health, Piscataway, New Jersey, USA
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, New Jersey, USA
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9
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Dewhirst T. Interplay of food and tobacco product descriptors and health claims. Tob Control 2023; 32:e130-e131. [PMID: 34511406 DOI: 10.1136/tobaccocontrol-2021-056831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Timothy Dewhirst
- Department of Marketing and Consumer Studies, Gordon S. Lang School of Business and Economics, University of Guelph, Guelph, Ontario, Canada
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10
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Striley CW, Nutley SK, Hoeflich CC. E-cigarettes and non-suicidal self-injury: Prevalence of risk behavior and variation by substance inhaled. Front Psychiatry 2022; 13:911136. [PMID: 36147965 PMCID: PMC9485578 DOI: 10.3389/fpsyt.2022.911136] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 07/29/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Nicotine and cannabis inhalation through vaping or electronic delivery systems has surged among young adults in the United States, particularly during the coronavirus disease pandemic. Tobacco and marijuana use are associated with select adverse mental health outcomes, including symptoms of major depressive disorder and suicidal behaviors. Given the need for addiction specialists to treat problematic substance use with an integrated approach, the association between non-suicidal self-injury (NSSI) and use of e-cigarettes, tobacco, marijuana, and alcohol was examined among a diverse sample of college students. METHODS Healthy Minds Study data from 47,016 weighted observations, collected from college students in the 2018-2019 academic year, was used to explore associations between NSSI-related behaviors and past 30-day use of a vaping product (nicotine or marijuana). These relationships were assessed among those using vaping products only, and then among individuals using vaping products and alcohol, conventional cigarettes, and/or marijuana. Hierarchical logistic regression models estimating the relationship between vaping and NSSI were computed to adjust for the effects of demographic factors, symptomatology of psychiatric disorders, and concurrent use of other substances. RESULTS A fifth (22.9%) of respondents disclosed past 12-month NSSI; they were significantly more likely to screen positive for depression or anxiety compared to young adults without NSSI. Rates of using vaping products, conventional cigarettes, marijuana, or other substances were higher among students with NSSI even after controlling for potential cofounders. Additionally, students who used a THC-based liquid in their e-cigarettes were more likely to endorse NSSI in comparison to those who used "just flavoring." However, young adults who vaped were less likely to disclose frequent NSSI-related behaviors than their peers who did not vape. CONCLUSIONS These findings revealed an association between past 12-month NSSI and past 30-day vaping in a sample of young adults. Further surveillance among college populations and examination of potential sociodemographic confounders is necessary to confirm these findings and advance the substance use and addiction field.
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Affiliation(s)
- Catherine W Striley
- Department of Epidemiology, College of Public Health & Health Professions and College of Medicine, University of Florida, Gainesville, FL, United States
| | - Sara K Nutley
- Department of Epidemiology, College of Public Health & Health Professions and College of Medicine, University of Florida, Gainesville, FL, United States
| | - Carolin C Hoeflich
- Department of Epidemiology, College of Public Health & Health Professions and College of Medicine, University of Florida, Gainesville, FL, United States
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Hoeper S, Crosbie E, Holmes LM, Godoy L, DeFrank V, Hoang C, Ling PM. "The Perfect Formula:" Evaluating Health Claims, Products and Pricing on Cannabis Dispensary Websites in Two Recently Legalized States. Subst Use Misuse 2022; 57:1207-1214. [PMID: 35532143 DOI: 10.1080/10826084.2022.2069267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Introduction: Many cannabis dispensaries market and sell their products online through websites designed to attract and maintain customers; often, these websites incorporate a variety of product claims and other marketing tactics. This study evaluated website content, product pricing and discounts on dispensary websites in California and Nevada, states that legalized recreational cannabis in 2016. Methods: We content coded product availability, marketing claims and discounts on cannabis dispensary websites in the San Francisco Bay Area (N = 34) and Reno (N = 15) from March to June 2020 using a web crawler to scrape pricing information for four product types. We conducted bivariate analyses comparing both locations. Results: Prices were significantly lower for flower, edibles, and concentrates in Reno compared to the Bay Area, but not cartridges. In both areas, a range of marketing claims were made regarding the health effects of certain products. The most common were that cannabis products treated pain, nausea/vomiting, spasms, anxiety, insomnia, and depression. Products were also said to promote creativity and euphoria. Other marketing claims related to potency, pleasure enhancement, and improved social interactions. Discounts targeted to senior citizens and veterans were found on over half of all websites. Conclusions: Dispensary websites in the Bay Area and Reno frequently make health-related claims which should not be allowed in absence of scientific evidence. Non-health related claims are similar to those used for selling e-cigarettes and other tobacco products. Monitoring cannabis dispensary websites provides insight into local sales tactics and may help identify subpopulations for research on behavioral impacts of cannabis marketing activities.
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Affiliation(s)
- Samantha Hoeper
- School of Public Health, University of Nevada, Reno, Reno, Nevada, USA
| | - Eric Crosbie
- School of Public Health, University of Nevada, Reno, Reno, Nevada, USA.,Ozmen Institute for Global Studies, University of Nevada, Reno, Reno, Nevada, USA
| | - Louisa M Holmes
- Departments of Geography and Demography, Penn State University, University Park, Pennsylvania, USA
| | - Lindsey Godoy
- School of Public Health, University of Nevada, Reno, Reno, Nevada, USA
| | - Vincent DeFrank
- School of Public Health, University of Nevada, Reno, Reno, Nevada, USA
| | - Christine Hoang
- Center for Tobacco Control Research and Education, University of California, San Francisco, San Francisco, California, USA
| | - Pamela M Ling
- Center for Tobacco Control Research and Education, University of California, San Francisco, San Francisco, California, USA.,Division of General Internal Medicine, Dept of Medicine, University of California, San Francisco, San Francisco, California, USA
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