Tobacco industry response to a ban on lights descriptors on cigarette packaging and population outcomes

PMI's IQOS and cigarette ads in Israeli media: a content analysis across regulatory periods and target population subgroups

BACKGROUND

IQOS, manufactured by Philip Morris International (PMI), is the highest selling heated tobacco product globally. IQOS went through several regulatory changes in Israel: from no oversight to minimal tobacco legislation, to progressive legislation that included a partial advertisement ban (exempting print media) and plain packaging. We examined how PMI's advertising messages changed during these regulatory periods for both IQOS and cigarettes.

METHODS

Content analysis of PMI's IQOS and cigarette ads was performed using a predefined framework. Ad characteristics included regulatory period, target population, setting, product presentation, age and use restrictions, retail accessibility, additional detail cues (eg, QR code) and promotions. Ad themes included product features, legislation-related elements, social norms and comparative claims. Comparisons between IQOS and cigarette ads, and across regulatory periods, were examined using χ2 test or Fisher's exact test.

RESULTS

The dataset included 125 IQOS ads and 71 cigarette ads. IQOS ads featured more age restrictions, retail accessibility and additional detail cues, compared with cigarette ads (93.6% vs 16.9%; 56.0% vs 0.0%; and 95.2% vs 33.8%, p<0.001 for all). Cigarette ads featured mostly price promotions (52.1% vs 10.1% of IQOS ads, p<0.001). The main ad themes were technology for IQOS (85.6%) and quality for cigarettes (50.7%). In later (vs earlier) restrictive regulatory periods, IQOS ads featured more direct comparisons to cigarettes, QR codes and indoor settings, and did not feature product packaging.

CONCLUSIONS

IQOS advertisement content shifted as more restrictions went into effect, with several elements used to circumvent legislation. Findings from this study point to the necessity of a complete advertisement ban and ongoing marketing surveillance.

Legal and regulatory instruments for NCD prevention: a scoping review and descriptive analysis of evaluations in OECD countries

CONTEXT

Public health law is an important tool in non-communicable disease (NCD) prevention. There are different approaches available for achieving policy objectives, including government, co-, quasi- and self-regulation. However, it is often unclear what legal design features drive successes or failures in particular contexts. This scoping review undertakes a descriptive analysis, exploring the design characteristics of legal instruments that have been used for NCD prevention and implemented and evaluated in OECD countries.

METHODS

A scoping review was conducted across four health and legal databases (Scopus, EMBASE, MEDLINE, HeinOnline), identifying study characteristics, legal characteristics and regulatory approaches, and reported outcomes. Included studies focused on regulation of tobacco, alcohol, unhealthy foods and beverages, and environmental pollutants.

FINDINGS

We identified 111 relevant studies evaluating 126 legal instruments. Evaluation measures most commonly assessed implementation, compliance and changes to the built and lived environment. Few studies evaluated health or economic outcomes. When examining the design and governance mechanisms of the included legal instruments, government regulation was most commonly evaluated (n = 90) and most likely to be reported effective (64%). Self-regulation (n = 27) and quasi-regulation (n = 5) were almost always reported to be ineffective (93% and 100% respectively). There were few co-regulated instruments evaluated (n = 4) with mixed effectiveness. When examining public health risks, food and beverages including alcohol were more likely to be self- or quasi-regulated and reported as ineffective more often. In comparison, tobacco and environmental pollutants were more likely to have government mandated regulation. Many evaluations lacked critical information on regulatory design. Monitoring and enforcement of regulations was inconsistently reported, making it difficult to draw linkages to outcomes and reported effectiveness.

CONCLUSIONS

Food and alcohol regulation has tended to be less successful in part due to the strong reliance on self- and quasi-regulation. More work should be done in understanding how government regulation can be extended to these areas. Public health law evaluations are important for supporting government decision-making but must provide more detail of the design and implementation features of the instruments being evaluated - critical information for policy-makers.

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

INTRODUCTION

Cigarette packaging is designed to increase consumer appeal and remains a primary promotional tool in many countries, including the U.S. This study documented changes in the prevalence of pack characteristics among the top-selling cigarette products in the U.S. in 2018 and 2021.

METHODS

The 50 cigarette packs with the highest national unit sales in U.S. convenience stores in 2018 and 2021 were identified using Nielsen's Scantrack data and subsequently purchased. Packs were coded for features such as dominant color(s), descriptive text, and promotional language. Descriptive analyses conducted in 2022 weighted by total annual unit sales compared the prevalence of pack characteristics between years.

RESULTS

Three brands-Marlboro, Newport, and Camel-constituted over 80% of pack sales among the top-selling products. Packs with red as a dominant color grew less popular between years (33.3% vs 29.5%), whereas those with green became more prevalent (25.2% vs 28.9%), consistent with a rise in the proportion of menthol sales. The prevalence of descriptors such as flavor and fresh decreased from 46.0% to 39.4% and 9.7% to 5.2%, respectively. Meanwhile, the prevalence of promotional language (e.g., rewards programs) increased from 60.9% to 69.0%.

CONCLUSIONS

The use of visual and named colors remains common, which can implicitly communicate sensory or health-related attributes. Moreover, promotions may help recruit and retain consumers in the context of more restrictive tobacco control policies and price increases. Given the strong influence that cigarette packaging exerts on consumers, packaging-focused policies, such as plain packaging laws, may reduce appeal and accelerate declines in cigarette use.

Risk perceptions and continued smoking as a function of cigarette filter ventilation level among US youth and young adults who smoke

BACKGROUND

While evidence demonstrates that the industry's marketing of cigarettes with higher filter ventilation (FV) misleads adults about their health risks, there is no research on the relationships between FV, risk perceptions and smoking trajectories among youth (ages 12-17) and young adults (ages 18-24).

METHODS

Data on FV levels of major US cigarette brands/sub-brands were merged with the Population Assessment of Tobacco and Health Study to examine whether FV level in cigarettes used by wave 1 youth/young adults (n=1970) predicted continued smoking at waves 2-4, and whether those relationships were mediated by perceived risk of their cigarette brand. FV was modelled based on tertiles (0.2%-11.8%, low; 11.9%-23.2%, moderate; 23.3%-61.1%, high) to predict daily smoking, past 30-day smoking and change in number of days smoking at successive waves.

RESULTS

The odds of perceiving one's brand as less harmful than other cigarette brands was 2.21 times higher in the high versus low FV group (p=0.0146). Relationships between FV and smoking outcomes at successive waves were non-significant (all p>0.05).

CONCLUSION

Youth and young adults who use higher FV cigarettes perceived their brand as less harmful compared with other brands. However, level of FV was not associated with continued smoking.

Is perception reality? Associations among "light" cigarettes and number of cigarettes smoked per day

INTRODUCTION

Cigarette filter ventilation and light descriptors are associated with lowered perceptions of risk and smoking more cigarettes per day (CPD). This study examined the relationship between usual cigarette ventilation, perception, and CPD.

METHODS

A crowdsourced sample (N = 995) of individuals who smoke higher-ventilated (=>20% ventilation) or lower-ventilated (=<10% ventilation) cigarettes identified their usual cigarette as "light" or "full flavor", and reported their average CPD.

RESULTS

We found: 1) no association between ventilation status and perception of light versus full flavor (AUC=0.58), with the inaccurate perception being more prevalent in younger individuals (p = 0.041) and those who smoke L&M (73%, p < 0.001) and Camel (61%, p = 0.006) brands; and 2) perception, but not ventilation of usual cigarette, was significantly associated with CPD (p = 0.006), with individuals who perceived their cigarettes as light reporting an average of 13% more cigarettes per day (2.6 CPD), compared to those who perceived their cigarette as full flavor.

CONCLUSIONS

Perceptions of light versus full-flavor, but not ventilation status, predicted CPD. These findings may inform anti-smoking health communication strategies and smoking cessation interventions.

IMPLICATIONS

Tobacco control policies should eradicate the perception of cigarettes as light or full-flavored. Future research investigating the associations between cigarette filter ventilation and smoking behavior should consider the confounding effects that may lie in an individual's perceptions of their cigarettes.

Closing the loopholes on a flavored cigar ban: Anticipated challenges and solutions

For the first time since Congress authorized the U.S. Food and Drug Administration (FDA) to regulate tobacco in 2009, FDA proposed two tobacco product standards on May 4, 2022. After a period of public comment and agency review, if the product standards are finalized in their current form, they will ban menthol cigarettes (U.S. Food and Drug Administration, 2022b), which comprised 37% of the U.S. cigarette market in 2019 and 2020 (Federal Trade Commission, 2021), and flavored cigars (U.S. Food and Drug Administration, 2022a), which have exceeded 50% of cigar sales since 2012 (Delnevo et al., 2021b). This commentary examines potential challenges to banning flavored cigars and highlights issues FDA and Congress should consider.

"Tobacco and Water": Testing the Health Halo Effect of Natural American Spirit Cigarette Ads and Its Relationship with Perceived Absolute Harm and Use Intentions

In 2015, the FDA formally warned Santa Fe Natural Tobacco Company that their "natural" and "additive-free" claims for its Natural American Spirit cigarettes conveyed reduced harm to consumers. In a settlement, Santa Fe was allowed to continue using the word "natural" in the brand name and the phrase "tobacco and water". The company also uses eco-friendly language and plant imagery and these tactics have also been shown to communicate reduced product harm. In this study, we propose the health halo effect as an overarching framework for explaining how these ad tactics mislead consumers in an effort to provide more comprehensive guidance for regulatory action. In a between-subjects experiment, 1,577 US young adults, ages 18-24, were randomly assigned to view one of five Natural American Spirit cigarette ads featuring either: 1) eco-friendly language; 2) plant imagery; 3) the phrase "tobacco and water"; 4) all of these tactics; or 5) a control condition featuring none of these tactics. In line with past research, ads with the phrase "tobacco and water" or with all the tactics together (vs. control) created a health halo effect, increasing perceptions that Natural American Spirit cigarettes were healthier and had less potential to cause disease; these tactics also had an indirect positive effect on smoking intentions through reduced perceptions of the brand's potential to cause disease and perceived absolute harm. Inconsistent with prior work, the eco-friendly language and plant imagery (vs. control) reduced healthfulness perceptions, increased perceptions of absolute harm, and had an indirect negative effect on smoking intentions. We contribute to past research showing that Natural American Spirit cigarette ad tactics mislead consumers. Inconsistent findings are explained in terms of stimuli design and processing of message features, indices of relative message persuasiveness, and multiple versus single-message designs.

Smokers' perceptions of different classes of cigarette brand descriptors

INTRODUCTION

Cigarette brand descriptors such as 'light' are banned in several countries and often replaced by alternative descriptors that continue to mislead smokers about the relative risk from those brands. The objective of this study was to evaluate perceptions from current brand descriptors when presented independently of cigarette packaging.

METHODS

Eighty-eight daily cigarette smokers attended semi-structured interviews at three US research laboratories in 2018-2019 to assess smokers' perceptions of cigarette brand descriptors in four classes of brand features: prestige, connotation, taste, and color. Participants ranked descriptors within each brand feature on perceived harm, attractiveness, and appeal (willingness to try). Ranked perceptions were described using median rankings and percentages. Chi-squared was used to assess demographic effects on perceptions. Spearman's correlation was used to assess the association between harm, attractiveness, and appeal rankings.

RESULTS

Brand descriptors influenced perceptions of harm, attractiveness, and appeal within each brand feature. Smooth was perceived as the most attractive (42.5%) and appealing (33.0%) taste descriptor. Red was perceived as the most harmful (45.4%) and least appealing (22.7%) color descriptor. Perceptions of certain descriptors differed by demographic characteristics such as sex and age. Rankings of attractiveness and appeal were more strongly correlated (r=0.63) than rankings of harm and appeal (r=0.20, p<0.01).

CONCLUSIONS

Cigarette manufacturers replaced banned descriptors with alternative descriptors that continue to influence perceptions of cigarettes. Regulatory agencies should closely evaluate all brand descriptors and consider implications for alternative products with fewer regulations.

A quasi-experimental evaluation of partnerships for success's impact on community-level ethanol and prescription drug poisoning rates

The emerging dual threats of underaged drinking (UAD) and prescription drug misuse (PDM) require sustained prevention efforts across multiple levels of interventions. In response to the continuing proliferation of UAD and PDM among youth and young adults, the Substance Abuse and Mental Health Services Administration (SAMHSA) developed the Partnerships for Success (PFS) program. Across five cohorts funded from 2012 to 2016, PFS created linkages between health care providers, treatment and prevention services providers, government agencies, and nonprofit organizations for the delivery of multiple sets of services (e.g., prevention education, community activities, screening) targeted toward UAD and PDM. This paper reports on the impact of the PFS program on reductions in ethanol and prescription drug poisoning exposures as reported from data in the National Poisoning Data System (NPDS). Across 35 States, communities targeted by PFS interventions were compared to non-targeted communities using a non-equivalent comparison groups design and propensity score weighting. Using propensity-weighted, multilevel latent growth modeling, steeper reductions in ethanol and prescription drug poisoning exposure call rates were observed in States which had a higher proportion of communities participating in PFS. Grantee-level longitudinal analogs to Cohen's d effect sizes ranged from -0.24 to -0.97, whereas PFS' effects on individual communities (net of Statewide effects) were negligible. The study serves as a unique exemplar of using the NPDS to extract community-level intervention effects that might otherwise be "hidden" within epidemiological data while underscoring the cumulative effects of PFS' community-level efforts in stemming the tide on underaged drinking and prescription drug misuse.

Evolving IQOS packaging designs change perceptions of product appeal, uniqueness, quality and safety: a randomised experiment, 2018, USA

BACKGROUND

Globally, the tobacco industry is promoting heated tobacco products. These products may represent a strategy to promote dual use of tobacco products. One product, IQOS from Philip Morris International, is being proposed in the USA for marketing as a less harmful product. The visual design of tobacco products can influence consumers by implying product characteristics. Thus, we sought to test the impact of IQOS packaging designs on cognitive, affective and behavioural intention responses.

METHODS

From existing IQOS packages used globally, we developed three IQOS packages that decreasingly linked the product to the Marlboro brand. In September to October 2018, we assigned participants randomly to one package in an online experiment. All participants (n=954) were US adults reporting current smoking and no colour blindness. The experiment used quota sampling to ensure diversity by gender, sexual orientation, race, ethnicity and education. Measures were informed by the Context of Consumption Framework. To assess differences in ratings, we conducted non-parametric Kruskal-Wallis tests with post hoc comparisons using Dunn's test.

RESULTS

We found significant differences in cognitive indicators including appeal (H=6.87, p=0.03), uniqueness (H=15.68, p<0.01), brand equity-quality (H=122.35, p<0.01) and perceived safety compared with other tobacco products (H=14.27, p<0.01). Participants rated packages similarly on affective and behavioural intention measures. All were rated low for talking to others about the product and high for interest in trying with a coupon.

CONCLUSION

Linking or separating IQOS products with a well-established cigarette brand changes how adult smokers respond to the product. Regulators should consider the visual design of packaging.

Is the cigarette pack just a wrapper or a characteristic of the product itself? A qualitative study of adult smokers to inform U.S. regulations

Purpose

In the U.S., tobacco products are now regulated by the Food and Drug Administration (FDA). Litigation has quickly followed. One area of controversy is when a change to the design of the cigarette pack requires approval through FDA’s rigorous premarket review process. In this paper, we examine how adult U.S. smokers view the connection between the design of cigarette packs and the characteristics of the cigarettes within.

Methods

Data for this qualitative study came from six focus groups conducted in March 2017 with adult smokers. Two groups consisted of lesbian, gay, and bisexual (LGB) participants; two groups of participants with less than four years of college education; one group of LGB and straight identity; and, one group of the general population. All groups were selected for regional, gender, and racial/ethnic diversity. Participants (n = 33) represented all nine U.S. Census divisions. We conducted constant comparison qualitative analysis utilizing a grounded theory approach.

Results

Participants’ views reflected a belief that pack design is clearly a reflection of the cigarettes within and that a change in the pack signaled a change in the cigarettes. However, some participants felt price was the salient characteristic of cigarettes and design mattered more for enticing young people to smoke.

Conclusions

Changes in pack design signal changes to the product for smokers. Pack design and changes to pack design are seen as particularly relevant to new and young smokers. These findings provide support for regulations that require assessment of cigarette pack design changes for impacts on public health.

"Their Packaging Has Always Been Like a Power": A Qualitative Study of U.S. Smokers' Perceptions of Cigarette Pack Visual Design Features to Inform Product Regulation

Cigarette packaging matters to consumer behavior. However, it is less clear which changes to packaging design would be salient for adult smokers. Such information is critically important to regulators in the United States who are charged with reviewing new tobacco products for their impact on population health. In this qualitative study, U.S. adult smokers (n = 33) participated in six telephone-based focus groups in March 2017. Separate groups were comprised of lesbian, gay, and bisexual (LGB) participants; participants with less than four years of post-secondary education; a mix of LGB and straight participants; and, the general population. All groups were purposely selected for diversity. Open thematic coding identified salient design elements used on cigarette packaging. Smokers articulated design elements’ use, meaning, and links with consumer behaviors. Three themes were identified: (1) the power of color, (2) supporting color with other design elements (e.g., logos/images, typography, the pack itself), and (3) the combined product brand experience of multiple design elements. Participants linked design elements to product characteristics and to consumer behavior (e.g., purchase). As the Food and Drug Administration is charged with regulating tobacco products, these findings suggest the importance of considering the cigarette pack part of the characteristics of a product.