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. Author manuscript; available in PMC: 2023 Jul 3.
Published in final edited form as: Health Commun. 2020 Jan 10;36(7):804–815. doi: 10.1080/10410236.2020.1712526

“Tobacco and Water”: Testing the health halo effect of Natural American Spirit cigarette ads and its relationship with perceived absolute harm and use intentions

Irina A Iles 1, Jennifer Pearson 2, Eric Lindblom 3, Meghan Moran 4
PMCID: PMC10317043  NIHMSID: NIHMS1909793  PMID: 31922429

Abstract

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.

Keywords: tobacco advertising, health halo effects, perceptions of absolute harm, smoking

The 2009 Family Smoking Prevention and Tobacco Control Act (TCA) gave the Food and Drug Administration (FDA) authority to regulate tobacco marketing and required that tobacco companies obtain a permissive order from FDA prior to making any explicit or implicit reduced-harm or reduced-exposure claims about their products (Family Smoking Prevention & Tobacco Control Act, 2009a, 2009b, 2009c). Nevertheless, tobacco companies continue to use misleading packaging, labeling, advertising, and other strategies to deceive smokers and non-smokers who are concerned about the health risks of smoking (Byron, Baig, Moracco, & Brewer, 2016; Connolly & Alpert, 2014; Czoli & Hammond, 2014). For example, the Santa Fe Natural Tobacco Company (a Reynolds American subsidiary) advertises its Natural American Spirit brand of cigarettes using plant imagery and phrases such as “tobacco and water” and eco-friendly language (among other tactics), which mislead consumers by communicating reduced relative harm and addictiveness (Moran et al., 2018; Moran & Pearson, 2019).

The present study provides a secondary analysis of the data presented by Moran and colleagues (2018) to make two important additions to available research. First, it explores the mechanisms through which tobacco ad tactics influence perceptions of absolute harm to provide insight into what types of tactics are likely to mislead consumers about harmfulness, thereby informing possible new protective policies. Specifically, this study advances the hypothesis that certain Natural American Spirit ad tactics create a misleading health “halo effect,” meaning that positive attributes mentioned in the ads foster perceptions of other unspecified positive attributes. The idea that Natural American Spirit cigarette ads may produce a health halo effect has been conceptually proposed in the work of Epperson and colleagues (2017) and has surfaced in focus groups with adult smokers (Epperson, Averett, Blanchflower, Gregory, & Lee, 2019). Furthermore, in an experimental study, Gratale and colleagues (2018) observed effects of Natural American Spirit cigarette ads representative of a health halo effect. Here, we build on this research and formally propose and test the health halo effect as an overarching framework for explaining the influence of these ads on consumer perceptions.

Second, this study focuses on changes to absolute perceptions of harm (i.e., “Natural American Spirit cigarettes are not harmful to my health”), as opposed to relative perceptions of harm which were the focus of most prior research (i.e., “Natural American Spirit cigarettes are less harmful to my health than Brand X cigarettes”). Decision science, marketing, and psychology research finds that comparing one product to another can make quantifying or evaluating perception changes difficult because of the different products being used as the referent (Kaufman, Suls, & Klein, 2016). Absolute perceptions of harm, as opposed to relative ones, directly capture an individual’s perception of the health risks of a product and are not influenced by the referent of the comparison (Owotomo, Maslowsly, & Loukas, 2018). Accordingly, changes in absolute perceptions of harm are a critical indicator of the effects of Natural American Spirit ad tactics on participants’ harm perceptions and their impact, in turn, on intentions to smoke Natural American Spirit cigarettes.

Finally, our study tests the effects of Natural American Spirit cigarette ads in a group of American young adults between ages of 18 to 24. Young adults are 50% more likely than adults over the age of 34 to use Natural American Spirit cigarettes (Pearson et al., 2017). Furthermore, they represent an important target market for tobacco companies that attempt to recruit new users (Ling & Glantz, 2002). Therefore, understanding how young adults process these ads, how harmful they perceive the product to be, and whether they intend to use it is important.

Misleading Tobacco Advertising and Natural American Spirit Cigarettes

When the health risks of smoking were publicized and became a primary motivation to quit for smokers, cigarette manufacturers positioned some cigarettes as less harmful relative to others through the introduction of the filter; the use of descriptors such as “light”, “mild”, “low”; and the use of different cigarette, filter, and packaging colors (Alpert, Carpenter, & Connolly, 2018; Bansal-Travers, O’Connor, Fix, & Cummings, 2011; Borland et al., 2008; Hammond & Parkinson, 2009). Although these were not actually less harmful than other brands, consumers perceived that cigarettes with the above listed characteristics were less harsh, delivered less tar and nicotine, and posed reduced health risk compared to regular cigarettes (Alpert et al., 2018; Ashley, Cohen, & Ferrence, 2001; National Cancer Institute, 2008; Shiffman et al., 2001). Additionally, consumers mistakenly perceived and used “light” and “ultra-light” cigarettes as a way to reduce harms and risks without quitting smoking or as a harm-reducing intermediate step toward quitting (Ashley et al., 2001; Gilpin, Emery, White, & Pierce, 2002).

Based on such findings, the 2009 Tobacco Control Act banned tobacco companies from using “low”, “light”, “mild” and “similar descriptors” unless they first obtained a permissive order from FDA finding that the use of the terms would not mislead consumers and would be “appropriate for the protection of the public health.” (Family Smoking Prevention & Tobacco Control Act [TCA], 2009a, 2009b, 2009c). However, the TCA did not explicitly identify whether “additive-free”, “natural”, “organic”, or any other specific terms were “similar descriptors” requiring a permissive FDA order. After the TCA went into effect, the Santa Fe Natural Tobacco Company continued to advertise its Natural American Spirit cigarettes and roll your own tobacco products with descriptors such as “Made with Organic Tobacco”, “100% Additive-Free”, and “100% US Grown Tobacco” without seeking any prior permissive order from FDA. Subsequent research found that these Natural American Spirit product descriptors were associated with inaccurate beliefs that Natural American Spirit cigarettes are less harmful than other brands (Byron et al., 2016; Leas et al., 2017; McDaniel & Malone, 2007; O’Connor et al., 2017; Pearson et al., 2016). For example, an analysis of 10,565 current adult smokers found that 63.9% of Natural American Spirit smokers (but only 8.4% of smokers of other brands) believed that their cigarettes “might be” less harmful than other brands (Pearson et al., 2017).

In August 2015, the FDA issued a warning letter to Santa Fe Natural Tobacco Company alerting them that their “natural” and “additive-free” claims for its Natural American Spirit brands violated section 911 of the Tobacco Control Act (FDA, 2015). Two years later, the FDA and Santa Fe Tobacco Company reached an agreement whereby the company would remove the “additive-free” descriptor from any promotional materials and product packaging. But the agreement specifically permitted Santa Fe Tobacco Company to use the word “natural” in the Natural American Spirit brand name and the phrase “tobacco and water” to describe its ingredients (FDA, 2017). The settlement agreement did not address the company’s earth friendly growing practices ad tactics.

In addition to using “natural” in the Natural American Spirit brand names and “tobacco and water” in its ads, Santa Fe Tobacco Company uses plant imagery and references to eco-friendly or sustainable business and growing practices (such as “Respect for the Earth”) to promote its Natural American Spirit cigarettes (Epperson, Lambin, Henriksen, Baiocchi, Flora, & Prochaska, 2019). In one post-settlement study, Moran and colleagues (2018) found that exposure to the Natural American Spirit cigarettes’ eco-friendly language or the phrase “tobacco and water” lowered relative perceptions of harm and addictiveness compared to control among a sample of 3,054 U.S. 18–24-year-olds. In a randomized experiment, Gratale and colleagues (2018) provided further causal evidence that ads exemplifying Natural American Spirit marketing themes (e.g., natural, organic, taste) produced significantly greater beliefs that the cigarettes were healthier and safer, relative to a no-message control. In another study, survey participants exposed to Pall Mall and to Natural American Spirit cigarette packs featuring the phrase “Respect for the Earth” on the back of the pack perceived Natural American Spirit cigarettes as less harmful to one’s and others’ health and as better for the environment (Epperson et al., 2019).

Health Halo Effects as a Mechanism for Reduced Perceptions of Harm

Rather than identify specific terms, phrases, or images that mislead consumers about relative risk, research that identifies any underlying mechanisms driving reduced harm perceptions after exposure to certain tobacco advertising techniques can provide more comprehensive guidance for related FDA policymaking and enforcement. Prior work proposed that Natural American Spirit brand marketing techniques activate a robust cognitive bias, the health halo effect (Epperson, Henricksen, & Prochaska, 2017).

The concept of a health halo effect is that the initial impression created by the label “natural”, “eco-friendly”, or “organic” extends to other positive attributes the product does not explicitly claim (e.g., healthfulness or reduced harm) (Chandon, 2013; Kahneman, 2013). Halo effects may be indicative of more general spreading activation models. These models explain that we store semantically similar concepts in the memory together (e.g., natural, organic, healthful) (Collins & Loftus, 1975). When product labeling activates one of these concepts, the other closely related concepts also become cognitively available. So, according to these models, a “natural” product is almost automatically perceived as also “healthful”, for example, because “natural” and “healthful” are likely stored in memory together.

Such associative evaluations have been observed in experimental studies with a variety of products other than tobacco products (snack foods: Iles, Nan, & Verrill, 2018; Verrill, Iles, & Nan, 2019; coffee: Sorqvist et al., 2013; wine: Wiedmann, Hennigs, Behrens, & Klarmann, 2014; fair trade chocolate: Schuldt, Muller, & Schwarz, 2012). In the tobacco realm, Epperson and colleagues (2019) conducted six focus groups with adult smokers and found that the American Indian in headdress imagery on the packaging appeared to create a health halo effect, such that participants perceived Natural American Spirit cigarettes as healthier and safer. Further evidence of such an effect (although not framed in terms of a health halo effect) was also experimentally observed by Gratale et al. (2018) in their study.

Here, we build on this work and experimentally test the relationship between Natural American Spirit cigarettes’ advertising techniques and the presence of a health halo effect in a sample of young adults, a key target population for the brand. Consistent with spreading activation theory (Collins & Loftus, 1975) and with prior experimental research on health halo effects in food marketing (e.g., Iles et al., 2018; Verrill et al., 2019), we expected Natural American Spirit cigarette ad tactics to produce increased perceptions of specific unmentioned favorable attributes that are semantically related to the attributes the ads highlight. Stated formally, we developed the following hypotheses:

  • H1. Participants who view a Natural American Spirit ad featuring (1) plant imagery, (2) a reference to eco-friendly practices, (3) the phrase “tobacco and water” or (4) all three tactics will report stronger perceptions of positive attributes (a health halo effect), compared to individuals who view a Natural American Spirit ad containing none of these tactics.

As a corollary to H1, in line with prior research (e.g., Iles et al., 2018), we also hypothesized that:

  • H2: Participants who view a Natural American Spirit ad featuring (1) plant imagery, (2) a reference to eco-friendly practices, (3) the phrase “tobacco and water” or (4) all three tactics will report weaker perceptions of negative attributes, compared to individuals who view a Natural American Spirit ad containing none of these tactics.

Research suggests that cognitive biases (such as the health halo effect) indirectly impact intentions through perceptions of risk (Simon, Houghton, & Aquino, 2000). For example, overconfidence, illusion of control, and optimism fallacy are associated with reduced riskiness perceptions of a business venture and increased behavioral intention to pursue that business venture (Kannadhasan, Aramvalarthan, & Kumar, 2014; Simon, Houghton, & Aquino, 2000). In the context of the health halo effect, Apaolaza and colleagues (2017) showed that wine labeled as organic (compared to wine not labeled as organic) led to higher evaluations of specific sensory attributes (e.g., aroma intensity, aroma fineness, taste, body; indicative of a halo effect) which were then associated with higher overall hedonic evaluations. Taken together, these findings suggest that the health halo effect (captured by perceptions of specific product attributes) may mediate the relationship between a stimulus and an overall perception of a product, such as perceptions of absolute harm; perceptions of absolute harm are then likely associated with behavioral intention (Brewer, Gretchen, Gibbons, Gerrard, McCaul, & Weinstein, 2007; Kannadhasan, Aramvalarthan, & Kumar, 2014; Simon, Houghton, & Aquino, 2000). Therefore, we further hypothesized that:

  • H3. Perceptions of positive and negative attributes will be associated with perceptions of absolute harm, such that a) stronger perceptions of positive attributes will be associated with lower perceptions of absolute harm; and b) stronger perceptions of negative attributes will be associated with higher perceptions of absolute harm.

  • H4. A Natural American Spirit ad featuring (1) plant imagery, (2) a reference to eco-friendly practices, (3) the phrase “tobacco and water” or (4) all three tactics, compared to a Natural American Spirit ad containing none of these tactics, will have an indirect effect on intention to smoke through perceptions of positive and negative attributes and perceptions of absolute harm (serial mediation).

Figure 1 depicts our conceptual model and the direct effects hypothesized.

Figure 1.

Figure 1.

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Conceptual model

Methods

Participants and Procedures

Data for this study were from a larger web-based experiment investigating risk perceptions in response to advertising tactics on Natural American Spirit and Marlboro ads (Moran et al., 2018). The current study focuses only on the Natural American Spirit ads. Our sample (N = 1,577) included American young adults, ages 18 to 24. Study participants were recruited using Amazon Mechanical Turk (MTurk), an online labor system run by Amazon.com. Recruitment was restricted to workers who had completed at least 100 prior tasks and had a 90% approval rate.

The study was introduced to participants as a marketing research study with questions about tobacco products. After informed consent, participants reported sociodemographic and tobacco use information and were randomized to view one of five stimuli, in a between-subjects design. After viewing the ad, participants reported perceptions of Natural American Spirit cigarettes’ attributes, perceptions of absolute harm, and intention to use the product.

Stimuli

The five Natural American Spirit ads featured one of the following tactics: (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. The eco-friendly language claim, plant imagery, and the “tobacco and water” text came from existing Natural American Spirit ads and were photoshopped onto an existing Natural American Spirit ad that did not contain these features, so that the only difference between experimental conditions was the presence/absence of the feature. The stimuli are available from the authors upon request.

Measures

Covariates.

Participants reported sociodemographic characteristics (age, gender, race/ethnicity, education level), smoking status (never smoker; non-current/former smoker; someday, and every day smoker), and whether they had ever heard of Natural American Spirit cigarettes (yes/no). These variables were controlled for in the analyses.

Perceptions of positive product attributes.

After viewing the ad, participants rated whether the following terms described the product in the ad on a scale from 0 to 10: healthy, natural, organic, calming, good for the environment, American, robust, smooth, fun, youthful, tastes good, authentic, cool, high-quality, eco-friendly, sustainable, smells good, spiritual, and mellow. According to a principal component analysis with varimax rotation performed in SPSS, the items loaded on three components: healthfulness (healthy, organic, natural, good for the environment, eco-friendly, sustainable, spiritual), attractiveness (calming, smooth, fun, youthful, tastes good, cool), and wholesomeness (masculine, American, robust, authentic, traditional). The item “high-quality” loaded on two components and was dropped from the analysis. The three components were also internally consistent (Cronbach’s αhealthfulness = .91; Cronbach’s αattractiveness = .90; Cronbach’s αwholesomeness =.85); thus, the items under each component were averaged together to form indices of perceived positive product attributes (perceived healthfulness: M = 3.26; SD = 2.37; perceived attractiveness: M = 3.28; SD = 2.29; perceived wholesomeness: M = 4.26; SD = 2.43).

Perceptions of negative product attributes.

Participants were asked to rate the extent to which the following terms described Natural American Spirit cigarettes on a scale from 0 to 10: addictive, causes cancer, gross, deadly. The items were internally consistent and were averaged to form an index of cigarettes’ perceived potential to cause disease (Cronbach’s α = .89; M = 6.31; SD = 3.08). We conceptualized the positive and negative attributes as distinct product characteristics because the presence of a positive attribute (e.g., high-quality) does not necessarily imply the absence of a negative attribute (e.g., addictive). In other words, it is plausible that an individual could simultaneously hold perceptions of a product’s positive and negative attributes.

Perceptions of absolute harm.

Participants rated how harmful they thought the product was to their health, on a scale from 1- not at all to 5 – extremely harmful (M = 4.32; SD = 0.86) (adapted from Pearson et al., 2016).

Behavioral intention.

Participants were asked: “If one of your friends or someone close offered you one of the cigarettes being advertised, would you smoke it?” and rated their answers on a scale from 1 (“definitely no”) to 5 (“definitely yes”) (M = 1.96; SD = 1.01).

Analyses

Data were analyzed with SPSS PROCESS, Model 6 (serial mediation), an Ordinary Least Squares and logistic regression-based path analysis modeling tool (Hayes, 2017). The 95% confidence intervals for all effects used 10,000 bootstrapped samples to compute standard errors (Hayes, 2017). Dummy variables were created so that models could be run for each condition versus the control condition.

Results

Sample Characteristics

Over half (51%) of participants were male (48.3% female; 0.5% another gender; 0.2% did not report; recoded as 0 – male; 1 – female and other responses were treated as missing). The majority of participants reported being non-Hispanic white (63.6%; 14.2% Hispanic; 8.4% non-Hispanic black; 8.2% Asian; 1% other; 4.6% did not report and were excluded from the analyses; race/ethnicity was dummy coded such that non-Hispanic white was the reference category). A total of 43.6% reported having a college degree or more; 43.1% had some college education or an associate degree; and 13.2% had a high school degree or less (0.1% did not report their education and were excluded from the analyses; education was dummy coded such that a high school degree or less was the reference category). Regarding current smoking status, 12.9% reported smoking every day; 22.9% smoking some days; and 38.6% currently not smoking at all; 25.6% of participants reported they had never smoked (recoded as: 0 – never smokers; 1 – non-current/former smokers; 2 – someday or every day smokers; then dummy coded such that never smokers represented the reference category). Finally, 60.1% of participants had heard of Natural American Spirit cigarettes (39.7% had not heard and 0.2% did not respond and were excluded from the analyses). Sample characteristics are summarized in Table 1.

Table 1.

Sample characteristics by experimental condition (N = 1,577)

Eco-friendly (n=312) Plant imagery (n=286) Tobacco and Water (n=322) All tactics (n=333) Control (n=324) Total (N=1,577)
Age (M, SD) 22.25 (1.63) 22.32 (1.60) 22.31 (1.68) 22.41 (1.62) 22.32 (1.60) 22.32 (1.62)
Gender (%)
Male 47.2 49.3 53.4 52.9 52.2 51.0
Female 51.9 49.7 46 46.5 47.5 48.3
Another gender 0.3 1.1 0.3 0.3 0.3 0.5
Not reported 0.6 0.0 0.3 0.3 0.0 0.2
Race/Ethnicity (%)
NH White 61.9 60.8 61.8 65.8 67.6 63.6
NH Black/AA 8.0 10.5 6.5 9.9 7.4 8.4
NH Asian 8.3 9.1 10.9 6.3 6.2 8.2
NH Other 0.6 0.7 0.9 1.5 1.2 1.0
Hispanic 15.4 13.3 14.6 13.8 13.9 14.2
Not reported 5.8 5.6 5.3 2.7 4.0 4.6
Education (%)
High school degree or less 10.6 14 16.5 13.2 11.7 13.2
Some college/associate degree 44.6 43.0 41.6 41.7 44.4 43.1
College degree or more 44.6 43.0 41.9 4.7 43.5 43.6
Not reported 0.3 0.0 0.0 0.3 0.3 0.1
Smoking status (%)
Every day 12.8 10.5 15.2 10.5 15.4 12.9
Somedays 25.0 23.8 23.3 21.9 20.7 22.9
Non-current/Former smokers 39.1 38.8 35.1 37.8 42.3 38.6
Never smokers 23.1 26.9 26.4 29.7 21.6 25.6
NAS familiarity (%)
Yes 65.4 55.6 58.1 57.4 63.9 60.1
No 34.3 44.4 41.9 42.3 35.8 39.7
Not reported 0.3 0.0 0.0 0.3 0.3 0.2
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Hypothesis Testing

We report standardized effects. Significant results are presented in Figures 2 through 5. All results are included in an online supplemental document (Tables S1 and S2).

Figure 2.

Figure 2.

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Mediated effects of exposure to eco-friendly language versus control on behavioral intention to smoke, adjusted for age, gender, education, race, smoking status, and whether participants ever heard of Natural American Spirit cigarettes

* p < .05, ** p < .01, ***p < .001, ns – not significant

^indirect effect through perceived healthfulness and perceived absolute harm (top) and perceived potential to cause disease and perceived absolute harm (bottom) on intention to smoke

Figure 5.

Figure 5.

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Mediated effects of exposure to all tactics together versus control on behavioral intention to smoke, adjusted for age, gender, education, race, smoking status, and whether participants ever heard of Natural American Spirit cigarettes

* p < .05, ** p < .01, ***p < .001, ns – not significant

^indirect effect through perceived healthfulness and perceived absolute harm (top) and perceived potential to cause disease and perceived absolute harm (bottom) on intention to smoke

Hypotheses 1 and 2.

We predicted a health halo effect, such that Natural American Spirit ads featuring any of the four strategies versus the control ad would produce stronger perceptions of positive product attributes and, conversely, weaker perceptions of negative product attributes. Results showed that the (separate) use of the phrase “eco-friendly” and plant imagery (versus control) were associated with reduced perceptions of healthfulness (βECO = −0.36, 95% CI = [−0.48; −0.25]; βPI = −0.35, 95% CI = [−0.46; −0.24]). The (separate) use of the phrase “tobacco and water” and use of all tactics together, on the other hand, were associated with increased perceptions of healthfulness (βTW = 0.24, 95% CI = [0.11; 0.36]; βALL = 0.69, 95% CI = [0.57; 0.80]). None of the ad tactics (versus control) was associated with perceptions of cigarette attractiveness or wholesomeness. The phrase “tobacco and water” and the use of all tactics together were associated with reduced perceived potential of the cigarettes to cause disease (βTW = −0.18, 95% CI = [−0.30; −0.05]; βALL = −0.38, 95% CI = [−0.51; −0.26]).

Hypothesis 3.

We then predicted that perceptions of positive and negative product attributes would be associated with perceptions of absolute harm. Given that only perceptions of healthfulness and potential to cause disease were predicted by the experimental condition and our interest in indirect effects, we only focus here on how those perceptions were associated with perceptions of absolute harm.

Perceptions of healthfulness were negatively associated with perceptions of absolute harm across ad tactics versus control (βECO = −0.35, 95% CI = [−0.41; −0.29]; βPI = −0.40, 95% CI = [−0.46; −0.33]; βTW = −0.27, 95% CI = [−0.32; −0.21]; βALL = −0.29, 95% CI = [−0.35; −0.23]).

Conversely, perceptions of potential to cause disease were positively associated with perceptions of absolute harm across ad tactics versus control (βECO = 0.27, 95% CI = [0.22; 0.33]; βPI = 0.27, 95% CI = [0.22; 0.33]; βTW = 0.27, 95% CI = [0.21; 0.33]; βALL = 0.34, 95% CI = [0.28; 0.40]).

Hypothesis 4.

The last hypothesis predicted an indirect effect of the experimental condition on behavioral intention through perceptions of positive/negative product attributes and perceptions of absolute harm. Results showed that the (separate) use of the phrase “eco-friendly” or plant imagery (versus control) had an indirect negative effect on intention to smoke through reduced perceptions of healthfulness and increased perceptions of absolute harm (βECO->healthfulness->harm->intention = −0.02, 95% CI = [−0.03; −0.01]; βPI->healthfulness->harm->intention = −0.02, 95% CI = [−0.03; −0.01]). However, the use of the phrase “tobacco and water” and the use of all three tactics together had a positive indirect effect on intentions to smoke through increased perceptions of product healthfulness and reduced perceptions of absolute harm (βTW->healthfulness->harm->intention = 0.01, 95% CI = [0.004; 0.02]); βALL->healthfulness->harm->intention = 0.02, 95% CI = [0.01;0.04]). Also, the use of the phrase “tobacco and water” and of all tactics together had a positive indirect effect on intentions to smoke through reduced perceived potential to cause disease and increased perceptions of absolute harm (βTW->disease->harm->intention = 0.01, 95% CI = [0.002; 0.01]); βALL->disease->harm->intention = 0.02, 95% CI = [0.01; 0.03]).

Supplemental analyses.

Although the primary objective of this study was to examine the effects of Natural American Spirit advertising tactics among an overall sample of young adults, it is possible that the effects could vary by participants’ smoking status. We conducted supplemental analyses to examine the extent to which smoking status moderated the effect of the advertising tactics. We ran a series of 5 (experimental condition: control, eco-friendly language, plant imagery, “tobacco and water” phrase, all tactics together) by 3 (smoking status: never smoker; non-current/former smoker; someday or every day smoker) ANCOVAs with each of the variables in our mediation model as the outcome. We controlled for race, gender, age, education, and whether participants ever heard of Natural American Spirit cigarettes. The experimental condition by smoking status interaction term was only significant with perceptions of absolute harm as the outcome (p = .05, η2 = .01).

Within smoking categories, no distinguishable patterns emerged: average perceptions of harm did not differ by experimental condition. When comparing between smoking categories, the pattern of means showed that someday/every day smokers tended to report lower perceived absolute harm compared to former/non-current smokers and never smokers. Full results of these additional analyses are presented in the online supplemental Table S3. We advise caution in interpreting these results, as these models do not include the mediating mechanism we were interested in testing (i.e., the health halo effect) and we still recommend that adequately powered studies re-test our model stratified by smoking status.

Discussion

In this study, we investigated the effects of several ad tactics used to promote Natural American Spirit cigarettes, a brand popular among U.S. young adults and that has historically positioned itself as natural and potentially healthful relative to other cigarette brands. By proposing the health halo effect as an overarching mechanism through which these ad tactics communicate reduced harm and exploring additional product and risk perceptions associated with the use of Natural American Spirit cigarette ad tactics, we add to prior work examining the impact on perceptions of healthfulness and safety, relative harm, addictiveness, and nicotine content from different Natural American Spirit ad tactics (Gratale et al., 2018; Moran et al., 2018; Pearson et al., 2016).

“Tobacco and Water” and All Ad Tactics Together

We find that the use of the phrase “tobacco and water” and the use of all of the studied ad tactics together (i.e., eco-friendly language, plant imagery, “tobacco and water”) increased perceptions of Natural American Spirit cigarettes’ healthfulness and reduced perceptions of Natural American Spirit cigarettes as having potential to cause disease, which, in turn, were associated with reduced perceptions of absolute harm and increased intention to use the product. These findings are consistent with prior work (Gratale et. al, 2018; Moran et al., 2018; Moran & Pearson, 2019) and show that Natural American Spirit cigarette ads continue to use misleading tactics despite FDA’s warning letter and the subsequent 2017 settlement with the agency.

Relatedly, a recent study by Gratale, Maloney, and Cappella (2019) found that Natural American Spirit ads that complied with the 2017 FDA settlement agreement which allowed using the phrases “tobacco and water” and “no chemicals” produced similar inaccurate perceptions of reduced relative harmfulness among smokers and nonsmokers as ads using the terms the settlement prohibited (i.e., “natural” and “additive-free”). But ads without any of the terms and phrases produced significantly lower levels of inaccurate reduced-risk perceptions. As Moran and colleagues (2018) suggested, it is possible that participants interpreted the expression “tobacco and water” to mean the cigarettes were “additive-free,” a descriptor Santa Fe Tobacco may no longer use (O’Gara et al., 2019). Consumers gravitate toward products described as natural or organic (e.g., Schleenbecker & Hamm, 2013; Walters & Long, 2012), due to a belief that unprocessed, wholesome products are better for one’s health and that pesticides and/or chemicals used in conventional products can be harmful (McDaniel & Malone, 2007; Rozin, 2005; Rozin et al., 2004).

Our findings further extend prior work by demonstrating an effect of these ads on absolute risk perceptions (in addition to their effect on relative risk perceptions observed by Moran et al. (2018)). We provide evidence that Natural American Spirit cigarettes are not seen as less harmful only in reference to other tobacco brands (i.e., Moran et al., 2018), but also as less harmful in absolute terms. When consumers believe that cigarette A poses less harm relative to cigarette B, they may still believe that both cigarettes A and B are overall harmful. More specifically, when individuals are asked to assess the harm of a tobacco product relative to another one, their assessment is influenced by the referent of the comparison (Kaufman, Suls, & Klein, 2016). For example, when comparing Natural American Spirit cigarettes to Marlboro cigarettes, a brand image effect may explain the result of that comparison. Whereas Natural American Spirit cigarettes have been historically framed as natural, organic, and additive-free, Marlboro cigarettes have not, facilitating one’s perception of Natural American Spirit products as less harmful compared to Marlboro. However, an absolute perception that cigarette A is less harmful to one’s health directly captures an individual’s perception of the health risks of that product.

Nevertheless, both perceptions of relative and absolute harm are important to study as they may have different implications for smoking behavior. Specifically, when comparing two cigarettes brands in terms of harm, consumers may believe that the health risks of smoking may be reduced by simply switching from the more harmful brand to the less harmful brand (Kaufman et al., 2016). This behavior has been observed with “light” cigarettes (Gilpin et al., 2002). It is possible that absolute perceptions of reduced harm not only encourage switching, but also smoking initiation due to the false hope of low health risks. Whereas our supplemental analyses did not show a significantly different effect of the ad tactics versus control on perceptions of absolute harm among non-smokers, this analysis should be replicated in future studies before any strong conclusion can be drawn.

Eco-Friendly Language and Plant Imagery

Unexpectedly, plant imagery and eco-friendly language reduced perceptions of healthfulness, increased perceptions of absolute harm, and indirectly decreased smoking intentions. Plants are symbolic of “nature” and “natural” and, in food marketing, research finds that the color green increases perceptions of healthfulness (Schuldt, 2013). Perhaps the presence of a plant in the ad without additional verbal claims may have been too abstract and participants had trouble interpreting it. It is also possible that participants in our study did not associate “eco-friendly” with healthfulness and, thus, a health halo effect may not have been initiated in that case. However, this does not explain the negative effect observed.

These results seem to be inconsistent with those of Moran et al. (2018) who found that eco-friendly language led to reduced relative perceptions of harm. Similarly, Epperson and colleagues (2019) found that Natural American Spirit cigarettes featuring the phrase “Respect for the Earth” on the back of the pack were perceived as healthier for the self, others, and the environment relative to Pall Mall cigarettes; and participants in Gratale et al.’s study (2018) perceived Natural American Spirit cigarettes as healthier and safer than other cigarettes after exposure to sustainability-themed ads. In reference to the Moran et al. (2018) study, we speculate that that the phrase “eco-friendly” or plant imagery may decrease perceptions of harm when Natural American Spirit cigarettes are compared to other cigarettes, but increase perceptions of harm when not compared to other cigarette brands. This finding also suggests that absolute and relative perceptions of harm may not be exchangeable as indices of an ad’s relative persuasiveness in this context (see O’Keefe (2015) for a discussion on equivalent indices of relative persuasiveness).

Relative to the Gratale et al. (2018) study, the inconsistency in results may also be partly explained by the stimulus design. Research finds that design elements such as type of font (Doyle & Bottomley, 2004), size of pictorial and text elements (Pieters, Wedel, & Zhang, 2007), or design complexity (Pieters, Wedel, & Batra, 2010) impact consumer responses to an ad. For example, our eco-friendly condition included the phrase “we work with farmers dedicated to responsibly using the earth’s resources” + “eco-friendly” in a green circle on top of a standard Natural American Spirit cigarette pack, and the Surgeon General’s warning. The simplicity of the design may have allowed participants to more easily focus on and process the eco-friendly element of the ad which then dominated their perceptions. Perhaps this element was not credible in our sample, resulting in reduced perceptions of healthfulness and increased perceptions of harm observed. However, when used in combination with other tactics (“tobacco and water” and plant imagery), the attention to this one element may have faded in favor of the other ad elements, affecting overall perceptions of the ad. These disparate findings across the two studies, then, suggest that how ad elements are combined or expressed can have a powerful effect on consumer perceptions and that such design variations and interactions should be considered when testing effects (O’Keefe, 2015).

Another way to look at our findings is through the lens of single versus multiple-message study designs (Kim & Cappella, 2019; O’Keefe, 2015). In our study, participants in each group saw only one instance of a plant imagery and eco-friendly language stimulus. Using multiple representations of those stimuli (similar to Gratale et al. (2018)) could have helped mitigate variations in message features and provided a more robust measure of effects. In other words, whereas our chosen eco-friendly and plant imagery stimuli reduced perceptions of healthfulness, increased perceptions of absolute harm, and indirectly decreased smoking intentions, other thematically-related stimuli may lead to different results. Analyzing such ad variations in one study would enable more confident generalizations than those that can be made in this study.

It is also important to mention the type of control group used in these different studies. Both Moran et al. (2018) and the current analyses compared the Natural American Spirit cigarette ads featuring tactics against a no-tactic Natural American Spirit ad (featuring the cigarette pack + the surgeon general’s warning), whereas Gratale et al. (2018) used a no-message control condition. As such, any differences in results should be interpreted with the appropriate comparison group in mind and future studies may consider including multiple control conditions, depending on their research questions. We argue that comparing Natural American Spirit cigarette ads with misleading tactics against ads that do not employ such tactics presents ecological validity and carries regulatory importance in the context of our study. Realistically, target publics will be exposed to the product under consideration (unless the product is completely banned from being sold to consumers). What can be changed is how the product is marketed to consumers (by using or not using certain terms and phrases) and such comparisons show how consumer perceptions and intentions to use the product differ under two critical scenarios: when a marketing tactic of the product is regulated versus when it is not.

The inconsistent findings may also be due, in part, to sample characteristics. In our study, we recruited young adults who may have had a different interpretation of the eco-friendly language and plant imagery relative to older adults. Different audiences may have different reactions to the same stimuli (Cappella & Kim, 2017), underscoring the importance of testing ads in relevant population groups to fully understand the range of effects.

Finally, the finding that “eco-friendly” alone increased absolute harm perceptions, while “tobacco and water” alone and all the ad tactics together reduced absolute harm perceptions, may also indicate that “tobacco and water has a more powerful effect on reducing harm perceptions and may overpower the contrary “eco-friendly” impact when used together. “Tobacco and water” was specifically approved by the FDA in its settlement agreement with Santa Fe Tobacco, and the company frequently uses it to promote Natural American Spirit cigarettes (O’Gara et al., 2019). We concur with Gratale et al. (2019), then, that more comprehensive language restrictions are necessary and that banning individual terms, while allowing tobacco companies to continue using synonyms and parallels until new research shows them to be misleading, is ineffective and fails to protect the public health.

Limitations

Our findings should be interpreted with several limitations in mind. First, participants in this study were recruited via Amazon Mechanical Turk (AMT), a platform in which individuals self-select. Prior research has found that AMT workers are more likely to be non-Hispanic white, tobacco users, more educated, and have lower incomes compared to the general U.S. population (Paolacci & Chandler, 2014). Also, participants opted into our study based on unknown preferences, beyond recruitment criteria we specifically imposed; these unknown factors may bias the results. Yet, studies also suggest that AMT research study findings are comparable to those obtained via nationally representative probability samples (Jeong et al., 2019; Kraemer, Strasser, Lindblom, Niaura, & May, 2017; Paolacci & Chandler, 2014).

Second, the stimuli were created for the purposes of this study, although they used imagery and language from existing Natural American Spirit ads. It is possible that the way the features were combined in the experimental stimuli was not completely representative of how the features were used in real Natural American Spirit ads.

Third, although prior research supports the hypothesis that the health halo effect, captured through perceptions of positive and negative product attributes, informs risk perceptions and such product attributes were measured prior to measuring absolute perceptions of harm in our study, we cannot confidently ascertain the temporal order of these variables (i.e., that attribute perceptions caused risk perceptions). Additionally, the product attribute items that were assessed contained more positive than negative attributes. It is possible that there are unmeasured perceived product attributes that were not assessed by the current study.

Finally, due to sample size limitations, we did not stratify our main mediation analyses by smoking status, although we controlled for the effects of this attribute. Future work can fill this gap and also explore whether perceptions of relative and absolute harm differentially impact smoking intentions among smokers and non-smokers.

Conclusion

This study adds to the already extensive research showing that Santa Fe Natural Tobacco Company continues to advertise Natural American Spirit cigarettes using tactics that mislead consumers by inaccurately communicating that the cigarettes are not harmful or less harmful than other brands, despite federal laws prohibiting such practices. In particular, our study shows that the singular use of “tobacco and water” and a combination of tactics in Natural American Spirit ads cause inaccurate absolute harmfulness perceptions among young adults, who disproportionately favor Natural American Spirit cigarettes (Pearson et al., 2017) and are regularly targeted by tobacco marketing because of their critical importance for the industry’s long-term viability (Ling & Glantz, 2002). Such misperceptions can both increase initiation and prevent or delay smoking cessation by prompting switching to brands inaccurately perceived to be less harmful. Continued misperceptions of Natural American Spirit cigarettes indicate that the company’s existing settlement agreement with FDA does not adequately protect public health.

This research also supports additional enforcement efforts against other companies using similar descriptors or tactics in their labeling or ads or otherwise clearly making explicit or implicit reduced-risk or reduced-exposure claims, unless the manufacturer has secured a permissive modified risk tobacco product order from FDA prior to using the terms or tactics, as required by the Tobacco Control Act. However, because the Act only specifically identifies a few descriptors as making such implicit relative-risk claims (e.g., “light”), manufacturers seem to be operating on the assumption that they are allowed to use descriptors and imagery that are likely to mislead consumers by making implicit reduced-risk claims until substantial enough independent research evidence accumulates to show they are misleading and otherwise violating the law and finally prompt FDA to initiate enforcement action (as occurred with the misleading “additive-free” and “organic” descriptors). But the Tobacco Control Act was designed to prevent such misleading reduced risk claims from being made in the first place, not just to stop them once serious damage has already been done. This state of affairs strongly encourages prohibiting a significantly more extensive set of cigarette descriptors that have been shown to communicate reduced harm or that are similar to these descriptors, a recommendation supported by the halo effect phenomenon we observed. Such action would better severe the public health of Americans who are ultimately severely affected by the tobacco industry’s practices.

Supplementary Material

Supplemental

Figure 3.

Figure 3.

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Mediated effects of exposure to plant imagery versus control on behavioral intention to smoke, adjusted for age, gender, education, race, smoking status, and whether participants ever heard of Natural American Spirit cigarettes

* p < .05, ** p < .01, ***p < .001, ns – not significant

^indirect effect through perceived healthfulness and perceived absolute harm (top) and perceived potential to cause disease and perceived absolute harm (bottom) on intention to smoke

Figure 4.

Figure 4.

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Mediated effects of exposure to “tobacco and water” versus control on behavioral intention to smoke, adjusted for age, gender, education, race, smoking status, and whether participants ever heard of Natural American Spirit cigarettes

* p < .05, ** p < .01, ***p < .001, ns – not significant

^indirect effect through perceived healthfulness and perceived absolute harm (top) and perceived potential to cause disease and perceived absolute harm (bottom) on intention to smoke

Table 2.

Means and standard deviations by experimental condition

Control (n = 324) Eco-friendly language (n = 312) Plant imagery (n = 286) “Tobacco and Water” (n = 322) All tactics (n = 333)
Healthfulness 2.58 (2.11) 3.84 (2.30) 2.82 (2.29) 2.86 (2.19) 4.13 (2.54)
Attractiveness 3.20 (2.30) 3.37 (2.19) 3.26 (2.29) 3.30 (2.39) 3.29 (2.31)
Wholesomeness 4.19 (2.53) 4.48 (2.34) 4.04 (2.32) 4.23 (2.45) 4.34 (2.48)
Potential to cause disease 6.97 (2.86) 6.11 (3.09) 6.36 (2.96) 6.19 (3.05) 5.92 (3.30)
Absolute harm 4.36 (0.85) 4.33 (0.84) 4.31 (0.91) 4.28 (0.89) 4.33 (0.83)
Intention to smoke 1.97 (1.03) 1.99 (1.01) 1.94 (1.00) 1.98 (1.01) 1.90 (1.02)
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Note: Means are unadjusted for age, gender, education, race, smoking status, and whether participants ever heard of Natural American Spirit cigarettes

Contributor Information

Irina A. Iles, Cancer Prevention Fellowship Program, Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Johns Hopkins Bloomberg School of Public Health.

Jennifer Pearson, School of Community Health Sciences, University of Nevada at Reno.

Eric Lindblom, O’Neill Institute for National & Global Health Law, Georgetown University Law Center.

Meghan Moran, Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health.

References

  1. Alpert H, Carpenter D, & Connolly G (2018). Tobacco industry response to a ban on lights descriptors on cigarette packaging and population outcomes. Tobacco Control, 27, 390–390. doi: 10.1136/tobaccocontrol-2017-053683 [DOI] [PubMed] [Google Scholar]
  2. Apaolaza V, Hartmann P, Echebarria C, & Barrutia J (2017). Organic label’s halo effect on sensory and hedonic experience of wine: A pilot study. Journal of Sensory Studies, 32. doi: 10.1111/joss.12243 [DOI] [Google Scholar]
  3. Ashley M, Cohen I, & Ferrence R (2001). ‘Light’ and ‘mild’ cigarettes: Who smokes them? Are they being misled? Canadian Journal of Public Health, 92, 407–411. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Baig S, Byron M, Lazard A, & Brewer N (2019). “Organic,” “natural,” and “additive-free” cigarettes: Comparing the effects of advertising claims and disclaimers on perceptions of harm. Nicotine & Tobacco Research, 21, 933–939. doi: 10.1093/ntr/nty036 [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Bansal-Travers M, O’Connor R, Fix BV, & Cummings M (2011). What do cigarette pack colors communicate to smokers in the U.S.? American Journal of Preventive Medicine, 40, 683–689. doi: 10.1016/j.amepre.2011.01.019 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Borland R, Fong G, Yong H, Cummings K, Hammond D, King B, … Zanna M (2008). What happened to smokers’ beliefs about light cigarettes when “light/mild” brand descriptors were banned in the UK? Findings from the International Tobacco Control (ITC) four country survey. Tobacco Control, 17, 256–256. doi: 10.1136/tc.2007.023812 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Brewer N, Chapman G, Gibbons F, Gerrard M, McCaul K, & Weinstein N (2007). Meta-analysis of the relationship between risk perception and health behavior: The example of vaccination. Health Psychology, 26, 136–45. doi: 10.1037/0278-6133.26.2.136 [DOI] [PubMed] [Google Scholar]
  8. Byron M, Baig S, Moracco K, & Brewer N (2016). Adolescents’ and adults’ perceptions of ‘natural’, ‘organic’ and ‘additive-free’ cigarettes, and the required disclaimers. Tobacco Control, 25, 517–517. doi: 10.1136/tobaccocontrol-2015-052560 [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Cappella JN & Kim M (2017). Media evaluation. In Rӧssler P, Hoffner CA, & van Zoonen L (Eds.), The International Encyclopedia of Media Effects (pp. 1–9). doi: 10.1002/9781118783764.wbieme0020 [DOI] [Google Scholar]
  10. Chandon P (2013). How package design and packaged-based marketing claims lead to overeating. Applied Economic Perspectives and Policy, 35, 7–13. doi: 10.1093/aepp/pps028 [DOI] [Google Scholar]
  11. Collins AM, & Loftus EF (1975). A spreading-activation theory of semantic processing. Psychological Review, 82, 407–428. doi: 10.1037/0033-295X.82.6.407 [DOI] [Google Scholar]
  12. Connolly G, & Alpert H (2014). Has the tobacco industry evaded the FDA’s ban on ‘light’ cigarette descriptors? Tobacco Control, 23, 140–140. doi: 10.1136/tobaccocontrol-2012-050746 [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Czoli C, & Hammond D (2014). Cigarette packaging: Youth perceptions of “natural” cigarettes, filter references, and contraband tobacco. Journal of Adolescent Health, 54, 33–39. doi: 10.1016/j.jadohealth.2013.07.016 [DOI] [PubMed] [Google Scholar]
  14. Doyle J, & Bottomley P (2004). Font appropriateness and brand choice. Journal of Business Research, 57, 873–880. doi: 10.1016/S0148-2963(02)00487-3 [DOI] [Google Scholar]
  15. Epperson A, Henriksen L, & Prochaska J (2017). Natural American Spirit brand marketing casts health halo around smoking. American Journal of Public Health, 107, 668–670. doi: 10.2105/AJPH.2017.303719 [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Epperson A, Averett P, Blanchflower T, Gregory K, & Lee J (2019). “The packaging is very inviting and makes smokers feel like they’re more safe”: The meanings of Natural American Spirit cigarette pack design to adult smokers. Health Education & Behavior, 46, 260–266. doi: 10.1177/1090198118820099 [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Epperson A, Lambin E, Henriksen L, Baiocchi M, Flora J, & Prochaska J (2019). Natural American Spirit’s pro-environment packaging and perceptions of reduced-harm cigarettes. Preventive Medicine, 126. doi: 10.1016/j.ypmed.2019.105782 [DOI] [PubMed] [Google Scholar]
  18. Family Smoking Prevention & Tobacco Control Act (2009a). Public Law 111–31. Retrieved from https://www.gpo.gov/fdsys/pkg/PLAW-111publ31/pdf/PLAW-111publ31.pdf
  19. Family Smoking Prevention & Tobacco Control Act (2009b). Public Law 111–31 Sec. 903(a), 21 USC 387c(a). Retrieved from https://www.gpo.gov/fdsys/pkg/PLAW-111publ31/pdf/PLAW-111publ31.pdf
  20. Family Smoking Prevention & Tobacco Control Act (2009c). Public Law 111–31 Sec 911, 21 USC 387k. Retrieved from https://www.gpo.gov/fdsys/pkg/PLAW-111publ31/pdf/PLAW-111publ31.pdf
  21. Food and Drug Administration (2015, August). Warning letter. Santa Fe Natural Tobacco Company, Inc. Retrieved from https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/warning-letters/santa-fe-natural-tobacco-company-inc-08272015 [Google Scholar]
  22. Food and Drug Administration (2017, January). Memorandum of Agreement between The United States Food and Drug Administration’s (FA) Center for Tobacco Products (CTP) and RAI Services Company (RAIS)/Santa Fe Natural Tobacco Company, Inc. (Santa Fe). Retrieved from http://www.tobaccofreekids.org/content/press_office/2017/NASagreement.pdf
  23. Gilpin E, Emery S, White M, & Pierce J (2002). Does tobacco industry marketing of ‘light’ cigarettes give smokers a rationale for postponing quitting? Nicotine & Tobacco Research, 4, 147–155. [DOI] [PubMed] [Google Scholar]
  24. Gratale S, Maloney E, Sangalang A, & Cappella J (2018). Influence of Natural American Spirit advertising on current and former smokers’ perceptions and intentions. Tobacco Control, 27, 498–504. doi: 10.1136/tobaccocontrol-2017-053881 [DOI] [PubMed] [Google Scholar]
  25. Gratale S, Maloney E, & Cappella J (2019). Regulating language, not inference: An examination of the potential effectiveness of Natural American Spirit advertising restrictions. Tobacco Control. Advance online publication. doi: 10.1136/tobaccocontrol-2018-054707 [DOI] [PubMed] [Google Scholar]
  26. Hammond D, & Parkinson C (2009). The impact of cigarette package design on perceptions of risk. Journal of Public Health, 31, 345–53. doi: 10.1093/pubmed/fdp066 [DOI] [PubMed] [Google Scholar]
  27. Hayes A (2017). Introduction to mediation, moderation, and conditional Process analysis (2nd edition). Guilford Press: New York, NY. [Google Scholar]
  28. Iles I, Nan X, & Verrill L (2018). Nutrient content claims: How they impact perceived healthfulness of snack foods and the mitigating effects of nutrition facts labels. Health Communication, 33, 1308–1316. doi: 10.1080/10410236.2017.1351277 [DOI] [PubMed] [Google Scholar]
  29. Jeong M, Zhang D, Morgan J, Ross J, Osman A, Boynton M, Mendel JR, & Brewer N (2019). Similarities and differences in tobacco control research findings from convenience and probability samples. Annals of Behavioral Medicine, 53, 476–485. doi: 10.1093/abm/kay059 [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Kahneman D (2013). Thinking, fast and slow (1st ed.). New York: Farrar, Straus, and Giroux. ISBN 978-0-374-53355-7 [Google Scholar]
  31. Kannadhasan M, Aramvalarthan S, & Pavan Kumar B (2014). Relationship among cognitive biases, risk perceptions and individual’s decision to start a venture. Decision, 41, 87–98. doi: 10.1007/s40622-014-0029-1 [DOI] [Google Scholar]
  32. Kaufman A, Suls J, & Klein W (2016). Communicating tobacco product harm: Compared to what? Addictive Behaviors, 52, 123–125. doi: 10.1016/j.addbeh.2015.06.039 [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Kim M & Cappella J (2019). Reliable, valid and efficient evaluation of media messages: Developing a message testing protocol. Journal of Communication Management, 23, 179–197. doi: 10.1108/JCOM-12-2018-0132 [DOI] [Google Scholar]
  34. Kraemer J, Strasser A, Lindblom E, Niaura R, & Mays D (2017). Crowdsourced data collection for public health: A comparison with nationally representative, population tobacco use data. Preventive Medicine, 102, 93–99. doi: 10.1016/j.ypmed.2017.07.006 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Leas E, Ayers J, Strong D, & Pierce J (2017). Which cigarettes do Americans think are safer? A population-based analysis with wave 1 of the PATH study. Tobacco Control, 26, 60. doi: 10.1136/tobaccocontrol-2016-053334 [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Ling P, & Glantz S (2002). Why and how the tobacco industry sells cigarettes to young adults: Evidence from industry documents. American Journal of Public Health, 92, 908–16. doi: 10.2105/ajph.92.6.908 [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. McDaniel P, & Malone R (2007). “I always thought they were all pure tobacco”: American smokers’ perceptions of “natural” cigarettes and tobacco industry advertising strategies. Tobacco Control, 16, 7. doi: 10.1136/tc.2006.019638 [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Moran MB, Brown J, Lindblom E, Kennedy R, Cohn A, Lagasse L, & Pearson JL (2018). Beyond ‘natural’: Cigarette ad tactics that mislead about relative risk. Tobacco Regulatory Science, 4, 3–19. doi: 10.18001/TRS.4.5.1 [DOI] [Google Scholar]
  39. Moran MB & Pearson JL (2019). Real. Simple. Deadly. A pilot test of consumer harm perceptions in response to Natural American Spirit advertising. Tobacco Regulatory Science, 5, 360–368(9). doi: 10.18001/TRS.5.4.6 [DOI] [Google Scholar]
  40. National Cancer Institute. Smoking & Tobacco Control Monograph No. 19.: The Role of the Media in Promoting and Reducing Tobacco Use. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health, National Cancer Institute; 2008. [Google Scholar]
  41. O’Connor R, Lewis M, Adkison S, Bansal-Travers M, & Cummings K (2017). Perceptions of “natural” and “additive-free” cigarettes and intentions to purchase. Health Education & Behavior, 44, 222–226. doi: 10.1177/1090198116653935 [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. O’Gara E, D’Silva J, Weiger C, Villaluz NT, Piedra W, & Moran MB (2019). Restricting “natural” and “additive-free”: Did FDA’s agreement with Santa Fe Natural Tobacco Company change advertising for Natural American Spirit? Tobacco Regulatory Science, 5, 332–338. doi: 10.18001/TRS.5.4.3 [DOI] [Google Scholar]
  43. O’Keefe D (2015). Message generalizations that support evidence-based persuasive message design: Specifying the evidentiary requirements. Health Communication, 30, 106–13. doi: 10.1080/10410236.2014.974123 [DOI] [PubMed] [Google Scholar]
  44. Paolacci G, & Chandler J (2014). Inside the Turk: Understanding Mechanical Turk as a participant pool. Current Directions in Psychological Science, 23, 184–188. doi: 10.1177/0963721414531598 [DOI] [Google Scholar]
  45. Pearson JL, Richardson A, Feirman S, Villanti A, Cantrell J, Cohn A, Tacelosky M, & Kirchner T (2016). American Spirit pack descriptors and perceptions of harm: A crowdsourced comparison of modified packs. Nicotine & Tobacco Research, 18, 1749–56. doi: 10.1093/ntr/ntw097 [DOI] [PubMed] [Google Scholar]
  46. Pearson JL, Johnson A, Villanti A, Glasser AM, Collins L, Cohn A, Rose SW, Niaura R, & Stanton CA (2016). Misperceptions of harm among Natural American Spirit smokers: Results from wave 1 of the Population Assessment of Tobacco and Health (PATH) study (2013–2014). Tobacco Control, 26, e61–e67. doi: 10.1136/tobaccocontrol-2016-053265 [DOI] [PubMed] [Google Scholar]
  47. Pieters R, Wedel M, & Zhang J (2007). Optimal feature advertising design under competitive clutter. Management Science, 53, 1815–1828. doi: 10.1287/mnsc.1070.0732 [DOI] [Google Scholar]
  48. Pieters R, Wedel M, & Batra R (2010). The stopping power of advertising: Measures and effects of visual complexity. Journal of Marketing, 74, 48–60. [Google Scholar]
  49. Rozin P (2005). The meaning of “natural”: Process more important than content. Psychological Science, 16, 652–658. doi: 10.1111/j.1467-9280.2005.01589.x [DOI] [PubMed] [Google Scholar]
  50. Rozin P, Spranca M, Krieger Z, Neuhaus R, Surillo D, Swerdlin A, & Wood K (2004). Preference for natural: Instrumental and ideational/moral motivations, and the contrast between foods and medicines. Appetite, 43, 147–154. doi: 10.1016/j.appet.2004.03.005 [DOI] [PubMed] [Google Scholar]
  51. Schleenbecker R, & Hamm U (2013). Consumers’ perception of organic product characteristics. A review. Appetite, 71, 420–429. doi: 10.1016/j.appet.2013.08.020 [DOI] [PubMed] [Google Scholar]
  52. Schuldt J (2013). Does green mean healthy? Nutrition label color affects perceptions of healthfulness. Health Communication, 28, 814–21. doi: 10.1080/10410236.2012.725270 [DOI] [PubMed] [Google Scholar]
  53. Schuldt JP, Muller D, & Schwarz N (2012). The “fair trade” effect: Health halos from social ethics claims. Social Psychological and Personality Science, 3, 581–589. doi: 10.1177/1948550611431643 [DOI] [Google Scholar]
  54. Shiffman S, Pillitteri J, Burton S, Rohay J, & Gitchell J (2001). Smokers’ beliefs about “light” and “ultra light” cigarettes. Tobacco Control, 10, 17–23. doi: 10.1136/tc.10.suppl_1.i17 [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Simon M, Houghton S, & Aquino K (2000). Cognitive biases, risk perception, and venture formation: How individuals decide to start companies. Journal of Business Venturing, 15, 113–134. doi: 10.1016/S0883-9026(98)00003-2 [DOI] [Google Scholar]
  56. Verrill L, Iles I, & Nan X (2019). Soda or VitaSoda: How naming influences perceptions of snack food healthfulness and the moderating role of nutrition facts labels. Health Communication. Advance online publication. doi: 10.1080/10410236.2019.1598745 [DOI] [PubMed] [Google Scholar]
  57. Walters A, & Long M (2012). The effect of food label cues on perceptions of quality and purchase intentions among high-involvement consumers with varying levels of nutrition knowledge. Journal of Nutrition Education and Behavior, 44, 350–354. doi: 10.1016/j.jneb.2011.08.008 [DOI] [PubMed] [Google Scholar]
  58. Wiedmann KP, Hennigs N, Behrens SH, & Klarmann C (2014). Tasting green: An experimental design for investigating consumer perception of organic wine. British Food Journal, 116, 197–211. [Google Scholar]

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