Perceived Relative Harm and Addictiveness Compared with Cigarettes and Intentions to Use Modified Risk Tobacco Products Utilizing FDA-Authorized Marketing Claims Among Adults in the United States

Abstract

Introduction.

We assessed adults’ perceived relative harm and addictiveness of products using FDA-authorized modified risk tobacco products (MRTP) claims and associations with intentions to use MRTPs.

Methods.

Data were from the May 2022 Rutgers Omnibus study among US 18–45-year-old adults (n=2964), collected by the Rutgers Institute for Nicotine and Tobacco Studies (INTS). Outcomes were perceived relative harm and addictiveness versus a typical cigarette and intentions to use a product stating a reduced harm claim (General Snus) or a reduced exposure claim (VLN King). We conducted regression analyses of associations between perceived relative harm and addictiveness and intentions to use each product, stratified by smoking status.

Results.

The minority of participants perceived products with a reduced harm claim as much less harmful vs. cigarettes (21%, 19%, 7%, and 8% among persons who smoked daily, smoked some days, formerly smoked, and never smoked respectively) and products with a reduced exposure claim as much less addictive vs. cigarettes (24%, 26%, 14%, 20% respectively). Perceived lower relative harm and addictiveness were significantly associated with higher intentions to use products stating reduced harm or reduced exposure claim across all smoking statuses with one exception (relative addictiveness was not associated with intention to use products stating the reduced harm claim among persons who formerly smoked).

Conclusions.

Two current FDA-authorized MRTP claims were not effective in conveying that MRTPs were less harmful or addictive than cigarettes to most participants. Perceiving products as less harmful or addictive were significantly associated with intentions to use MRTPs.

1. Introduction

Modified risk tobacco products (MRTPs) refer to legally designated tobacco products sold or distributed for use to reduce harm or the risk of tobacco-related disease associated with commercially marketed tobacco products in the United States (U.S. Department of Health and Human Services, 2012). Since 2019, the U.S. Food and Drug Administration has authorized thirteen tobacco products to be marketed as MRTPs, including 22^nd Century’s VLN King and VLN Menthol King cigarettes, Philip Morris’s IQOS 3 and IQOS tobacco heating system, eight products sold under the Swedish Match USA’s General Snus brand, and U.S. Smokeless Tobacco Company’s Copenhagen Classic Snuff (U.S. Food and Drug Administration Center for Tobacco Products, 2022). Presently, eleven FDA-authorized MRTPs (eight General Snus brand products, two VLN King cigarette products, and Copenhagen Classic Snuff) are available in the marketplace. One FDA-authorized MRTP (IQOS) has been taken off the U.S. market in November 2021 due a patent dispute and is not currently available. Another MRTP application from Camel Snus was withdrawn in 2022 (U.S. Food and Drug Administration Center for Tobacco Products, 2022).

MRTPs are permitted to use specific “reduced exposure” or “reduced harm” statements in their marketing. For instance, recently launched VLN King cigarettes are authorized to include these four claims: “Helps you smoke less.”, “95% Less Nicotine”, “Helps reduce your nicotine consumption.”, and “…greatly reduces your nicotine consumption”. The General Snus brand is authorized to state the claim: “Using General Snus instead of cigarettes puts you at a lower risk of mouth cancer, heart disease, lung cancer, stroke, emphysema, and chronic bronchitis.” The Copenhagen Classic Snuff brand is authorized to use the claim “IF YOU SMOKE, CONSIDER THIS: Switching completely to this product from cigarettes reduces risk of lung cancer” (U.S. Food and Drug Administration Center for Tobacco Products, 2022).

Assessing public perceptions of the relative harm and addictiveness and use intentions of currently authorized MRTPs is critical for several reasons. First, risk perception is an important construct in health behavioral change (e.g., Health Belief Model) (Mantler, 2013), risk communication (Schmälzle et al., 2017), and persuasion theories (e.g., Extended Parallel Process Model)(Witte, 1992). Risk perception plays a central role in tobacco use behavior research and in designing public education and policy interventions (e.g., package warning labels highlighting health risks) to reduce the prevalence of smoking (Slovic, 2001). A longitudinal study found that lower risk perceptions predicted e-cigarette initiation among college students in Texas (Cooper et al., 2018). A cross-sectional survey among Oklahoman undergraduate students who had tried a tobacco product reported that higher number of tobacco products used was associated with having lower perceptions of harm of tobacco and nicotine products (Leavens et al., 2019). During the COVID-19 pandemic, a survey among a nationally representative sample of U.S. adults reported that risk perceptions of the severity of smoking-related COVID-19 effects was associated with increased amount of cigarette smoking and greater readiness to quit smoking (Nyman et al., 2021).

Second, the FDA recognizes that tobacco products “exist on a continuum of risk, with combustible cigarettes being the deadliest” (Center for Tobacco Products, 2021). The FDA is pursuing research into communications that convey to adults who smoke cigarettes that nicotine, while highly addictive, is delivered via products with different risks compared with cigarettes (Center for Tobacco Products, 2023). However, all tobacco products are potentially harmful and addictive compared with not using any tobacco product at all. Importantly, understanding perceptions of authorized MRTP claims and susceptibility to use among youth, those who have never used tobacco products, and those who formerly used tobacco is essential as these groups should not initiate MRTP use. One study reported that youth who viewed either a Copenhagen snuff ad bearing a proposed reduced harm claim perceived smokeless tobacco as less harmful than those who viewed a control ad without the claim (Chaffee et al., 2023). In the same study, youth who were currently using tobacco (mostly e-cigarette users) and viewed the experimental ad were more willing to try smokeless tobacco than those who viewed control (Chaffee et al., 2023). Controlling for demographic variables and cigarette smoking status, adults who have not used non-cigarette tobacco products (e-cigarettes, cigarillos, and pipes) and perceived them as less harmful than smoking were more likely to report subsequent use of these products (Elton-Marshall et al., 2020).

Third, studying whether individuals who currently smoke accurately perceived the relative harm and addictiveness of MRTP claims as intended is critical to maximize the public health benefits of these products while minimizing potential negative impacts. If these individuals misperceive the MRTP claims as meaning that partially switching would provide health benefits, rather than completely switching to using MRTPs exclusively, this may lead to dual use of cigarettes and MRTPs and negate the risk/exposure reduction conferred by exclusive MRTP use. Conversely, if those who currently smoke misperceive reduced harm MRTPs as being equally harmful as cigarettes (or reduced exposure MRTPs as being equally addictive as cigarettes), they may not switch completely to these MRTPs to reduce their harm and exposure. The above scenarios would all negatively impact population health.

Research conducted prior to MRTP authorizations utilized hypothetical modified claims language. One study reported that viewing hypothetical reduced risk claims of potential MRTPs (heat-not-burn, e-cigarette, or snus) led adults who smoke and those who did not smoke to perceive lower chemical quantity, lower perceived risk, and higher susceptibility to use MRTPs (El-Toukhy et al., 2018). Another study among Californian young adults found that viewing hypothetical heated tobacco products’ claims of reduced exposure was associated with participants reporting lower harm of these products versus typical cigarettes, but there was no difference in intentions to use heated tobacco products (Chen-Sankey et al., 2021). An experimental study assessed the impact of manipulating various aspects of modified risk claims of a heated tobacco product (IQOS) among adults who smoke (Yang et al., 2021). IQOS was authorized as an MRTP but taken off the U.S. market in November 2021 due a patent dispute. The researchers manipulated the absence or presence of language to indicate that adults who smoke should switch completely from smoking to using IQOS, indicated either a single (lung cancer only) or multiple diseases (lung cancer, emphysema, heart disease, and stroke), and certainty of the harm reduction from using the product (may reduce risks vs. reduces risks of disease) (Yang et al., 2021). However, there was no observed difference in behavioral intentions to use the product across the message conditions (Yang et al., 2021).

This present study adds to the nascent literature by assessing perceptions of relative harm and addictiveness of MRTPs compared with typical cigarettes based on two FDA-authorized claims (General Snus and VLN King cigarettes) among a national opt-in online sample of adults. This evidence is needed to guide policies on product labeling and public health education efforts. We focused on the above two brands because at the time of this study (May 2022), IQOS was not available in the U.S. market and Copenhagen Classic Snuff was not yet authorized as a MRTP. The study’s objective is to evaluate people’s perceptions of reduced harm or reduced exposure claims rather than their overall brand perceptions of two specific products (e.g., ads and packaging design). We further compared whether perceived harm and addictiveness differed between adults who currently smoked, formerly smoked, and those who did not smoke and analyzed the associations between their perceptions and intentions to use MRTPs. Based on prior risk perception literature, we expect lower perceived relative harm and addictiveness of MRTPs compared with typical cigarettes (from reading the products’ reduced harm/reduced exposure claims) to be associated with higher intentions to use such products.

2. Materials and Methods

2.1. Study sample

Data were from the May 2022 Rutgers Omnibus study—a repeated, cross-sectional, web-based survey of 18–45-year-olds in the US fielded quarterly by the Rutgers Institute for Nicotine and Tobacco Studies (Ganz and Delnevo, 2023). Data were collected between May 3 and May 10, 2022. With ~2,500–3,000 individuals surveyed at each wave, roughly two-thirds of the sample at each wave are unique individuals while the remaining sample could have participated in prior waves. To ensure data quality, participants were drawn from CloudResearch’s opt-in panel of approved workers on Amazon MTurk, a micro-tasking platform (Amazon, n.d.), who had passed data quality tests using CloudResearch’s proprietary Sentry system to identify fraud, bots, and inattentive respondents on a weekly basis (Moss, 2023). Additionally, study team members manually reviewed responses for evidence of fraud/low quality (e.g., reviewing open-ended questions for any nonsensical responses). This survey was deemed by the Rutgers University Institutional Review Board as exempt due to minimal participant risk (protocol no. Pro2022000130). Questions specifically on perceptions of MRTP claims were asked for the first time in this wave of the Omnibus study.

2.2. Measures

Perceived relative harm, addictiveness, and intention to use a product using General Snus’s claim.

Participants were provided instructions to read a statement based on General Snus’s FDA-authorized claim: “Please read the following statement from a tobacco product brand. Using [Brand name] instead of cigarettes puts you at a lower risk of mouth cancer, heart disease, lung cancer, stroke, emphysema, and chronic bronchitis.” Immediately following this statement, they were asked two questions: “Compared to a typical cigarette, would you think that this product would be… (1 = Much more harmful to your health than a typical cigarette to 5 = Much less harmful to your health than a typical cigarette)?” and “Compared to a typical cigarette, would you think that this product would be…(1 = Much more addictive than a typical cigarette to 5 = Much less addictive than a typical cigarette)?” Higher scores indicated perceiving the product would be less harmful and addictive than a typical cigarette (i.e., more favorable beliefs about the product). Next, they were asked “How likely would you be to use this product (1=Very likely to 4=Very unlikely)?” We reverse-coded the intention measure such that a higher value indicated higher intention to use. These questions were adapted from the National Cancer Institute’s Health Information National Trends Survey (HINTS 5 Cycle 3). To be consistent with these questions, we did not include a “don’t know” response option (National Cancer Institute, 2019).

Perceived relative harm, addictiveness, and intention to use a product using VLN King’s claim.

Using a similar set of questions, we asked participants to read a statement of VLN King’s claims on one of their marketing materials: “Please read the following statement from a tobacco product brand. Helps you smoke less. 95% Less Nicotine. [Brand Name] smells, burns, and tastes like a conventional cigarette but greatly reduces your nicotine consumption.” We note that the VLN King’s marketing claims combined three of the four approved claims within the FDA’s Modified Risk Granted Order for this brand (U.S. Food and Drug Administration Center for Tobacco Products, 2022). Moreover, the brand included a phrase “VLN smells, burns, and tastes like a conventional cigarette” which was included in the MRTP application but not specifically approved within the Granted Order (U.S. Food and Drug Administration Center for Tobacco Products, 2022). We chose to use the actual language from VLN King’s marketing materials to assess participants’ perceptions to claims appearing in the marketplace. Immediately after reading the statement, participants were asked the same two questions on the perceived relative harm and addictiveness of this product compared to a typical cigarette and their intention to use this product as described above. Similarly, we reverse-coded the intention measure such that a higher value indicated higher intention to use.

We note that the MRTP claim used by General Snus is a reduced harm claim and did not include any reduced exposure information. Conversely, the claim from VLN King cigarettes is a reduced exposure claim and did not include any reduced harm information. We intentionally formatted the statements to omit specific brand names and product type (smokeless tobacco and cigarette) and presented these statements in plain text. The rationale was to elicit participants’ responses based on the authorized MRTP claims specifically and to avoid confounding by respondents’ perceptions of a brand (whether it is an established or a new brand), product type (whether it is a combustible cigarette or smokeless tobacco product), packaging, or advertising appeals. This approach to measure public perceptions and intentions based on MRTP claims of hypothetical tobacco products without specifying the type of tobacco product or brand has been utilized in prior research as well (Ahuja et al., 2021; O’Brien et al., 2018; Pearson et al., 2018). Although our approach may have reduced the realism of reading these claims among participants, our main focus was to isolate as much as possible their responses to perceived harm and addictiveness and their intentions to use based on reading the wording of the approved MRTP claim and reduce potential contamination from the above extraneous factors.

Smoking status.

We asked participants if they had smoked at least 100 cigarettes during their lifetime (yes/no). We also created variables capturing whether they endorsed currently smoking cigarettes “every day” or “some days” (yes/no), and whether they smoked cigarettes daily (yes/no). Based on their responses, they were categorized as either having smoked at least 100 cigarettes in their lifetime (established smoking) or never smoked. Among those with established smoking, they were categorized as formerly smoked (not currently smoking), currently smoked on some days, or currently smoked daily.

Prior product awareness and use.

We asked participants who used smokeless tobacco products if they had one brand of smokeless products they considered to be their regular brand (yes/no). Among those who reported they had a regular brand, we asked what their regular brand was and provided response options of common brands (Camel Snus, Copenhagen, Grizzly, Marlboro Snus, Skoal, General Snus, or some other brand). We also asked participants to report if they were aware of VLN cigarettes prior to the survey (yes/no). If they reported being aware of VLN cigarettes, they were asked if they had ever tried VLN cigarettes (yes/no). We did not include a question to assess whether participants had seen these statements prior to the survey.

Demographic variables.

We included questions on the participants’ age, sex, gender identity, sexual orientation, education, race and ethnicity to report the sample characteristics.

2.3. Analysis

We first conducted descriptive analyses of each outcome for the full sample and stratified by smoking status. We analyzed whether the outcomes differed across smoking statuses using the Pearson’s chi-squared test. To assess differences in these outcomes depending on the MRTP claim, we conducted paired t-tests to compare the means of parallel measures between General Snus versus VLN King claims for the full sample and stratified by smoking status (e.g., comparing means of the perceived relative harms of using a product that used the General Snus claim versus a product using the VLN King claim).

We conducted separate multiple regression analyses to assess associations between perceived relative harm and addictiveness measures predicting each of the two intentions measures, adjusting for age, sex, sexual orientation, education, race and ethnicity. Gender identity was not included in the model due to the small number of participants indicating they were transgender or nonbinary. Regression analyses were also conducted stratified by smoking status. We described the results separately for the analyses across the two sets of MRTP claims.

3. Results

3.1. Sample characteristics

Appendix 1 describes our sample. The May 2022 survey yielded 2964 participants from all 50 US states. The mean age of the sample was 33.1 years (SD=6.4), 55.3% were female assigned at birth, 97.4% were cisgender, 2.2% were transgender or nonbinary, 82.0% were heterosexual, 17.9% were LGBQ+, and 53.6% had a bachelor’s degree or higher. The race and ethnicity distribution of the sample was comparable to the US adult population ages 18 and older for three groups (68% non-Hispanic white in the sample vs. 64% nationally; 10% non-Hispanic Black/African American in the sample vs. 12% nationally; 7% non-Hispanic Asian in the sample vs. 6% nationally); however, Hispanic adults were underrepresented in this study (9% in the sample vs. 17% nationally).(US Census Bureau, 2021) Two cases missing smoking status were dropped from the regression models using complete case analysis. Half of the sample (50.4%) never smoked, 19.1% formerly smoked, 15.9% smoked some days, and 14.5% smoked daily, 2.7% reported having a regular brand of smokeless tobacco products, and 0.3% indicated General Snus as their regular brand, 2.9% were aware of VLN cigarettes, and 0.7% ever tried VLN cigarettes.

3.2. Descriptive analyses of perceived relative harm, addictiveness, and intentions to use

Appendix 2a and 2b summarize the distributions of perceived relative harm and addictiveness of a product using the General Snus reduced harm claim. Bivariate analyses of all the measures by smoking status were statistically significant (Pearson’s chi-squared test Ps<0.001). In this sample, 21% of people who smoked daily, 19% who smoked some days, 7% who formerly smoked, and 8% who never smoked perceived products with a reduced harm claim as much less harmful vs. cigarettes. In addition, 13.3% of people who smoked daily, 12.4% who smoked some days, 3.7% who smoked formerly, and 4.6% who never smoked perceived such a product to be much less addictive than a typical cigarette.

Appendix 2c and 2d summarize the distributions of relative harm and addictiveness of a product using the VLN King reduced exposure claim. Bivariate analyses of all the measures and smoking status were statistically significant (Pearson’s chi-squared test Ps<0.001). Among participants of this survey, 18.6% of those who smoked daily, 18.6% who smoked some days, 5.8% who formerly smoked, and 11.9% who never smoked perceived a product using the reduced exposure claim to be much less harmful than a typical cigarette. We observed that 23.7% of those who smoked daily, 26.0% who smoked some days, 13.7% who formerly smoked, and 19.5% who never smoked perceived the product as much less addictive than a typical cigarette.

Appendix 2e and 2f summarizes the distributions of intention to use a product using the General Snus reduced harm claim and a product using the VLN King reduced exposure claim, respectively. Bivariate analyses of intentions and smoking status were statistically significant (Pearson’s chi-squared test Ps<0.001). Of the sample, 14.0% of those who smoked daily, 10.2% who smoked some days, 1.8% who formerly smoked, and 1.5% who never smoked responded they were very likely to use the product using the reduced harm claim (General Snus). In addition, 17.0% of those who smoked daily, 14.0% who smoked some days, 2.7% who formerly smoked, and 2.1% who never smoked responded they were very likely to use the product using the reduced exposure claim (VLN King). Across the sample, 4.7% of participants were very likely to use the product with the General Snus claim and 6.3 % were very likely to use the product with the VLN King claim.

3.3. Comparisons of perceived relative harm, addictiveness, and intentions to use between products using General Snus reduced harm claim versus VLN King reduced exposure claim

Table 1 summarizes the comparisons of perceptions and intentions between product claims using paired t-tests. Those who formerly smoked, smoked some days, or smoked daily perceived significantly lower relative harm of using a product with the General Snus claim (compared to a typical cigarette) versus a product with the VLN King claim. In addition, participants across all smoking statuses perceived that using a product with the VLN King claim had significantly lower relative addictiveness (compared to a typical cigarette) versus a product with the General Snus claim. Among those who formerly smoked, intention to use a product with the General Snus claim was significantly higher than their intention to use a product with the VLN King claim.

Table 1.

Comparisons of mean perceived relative health harm, addictiveness, and intentions to use between General Snus and VLN King MRTP claims stratified by smoking status

	Never smoked	Formerly smoked	Smoked some days	Smoked daily	Total
	M (SE)	M (SE)	M (SE)	M (SE)	M (SE)
N	1489	566	469	429	2955
Perceived relative health harm (General Snus)a	3.688 (0.018)	3.693 (0.027)	3.883 (0.034)	3.853 (0.039)	3.743 (0.013)
Perceived relative health harm (VLN King)a	3.656 (0.019)	3.541 (0.026)	3.776 (0.036)	3.755 (0.04)	3.666 (0.014)
			**	**	***
N	1491	568	468	430	2959
Perceived relative addictiveness (General Snus)b	3.427 (0.017)	3.444 (0.025)	3.654 (0.034)	3.633 (0.037)	3.496 (0.013)
Perceived relative health harm (VLN King)b	3.81 (0.021)	3.792 (0.029)	3.964 (0.037)	3.891 (0.038)	3.842 (0.014)
	***	***	***	***	***
N	1493	567	470	429	2961
Intention to use product using (General Snus)c	1.423 (0.019)	1.695 (0.036)	2.685 (0.035)	2.657 (0.043)	1.855 (0.018)
Intention to use product using (VLN King)c	1.432 (0.02)	1.631 (0.036)	2.685 (0.039)	2.636 (0.046)	1.844 (0.018)
		**

Note: Means and standard deviations are reported.

^aValues range from 1 (Much more harmful to your health than a typical cigarette) to 5 (Much less harmful to your health than a typical cigarette).

^bValues range from 1 (Much more addictive than a typical cigarette) to 5 (Much less addictive than a typicalcigarette).

^cValues range from 1 (Very likely) to 4 (Very unlikely). A higher mean perceived relative harm and addictiveness indicated perceiving the product would be less harmful and less addictive than a typical cigarette (i.e., more favorable beliefs about the product than cigarettes). A higher mean intention indicated higher intention to use that product.

^*Paired t-test between each measure across products (General Snus versus VLN King) were conducted P<0.05,

^**P<0.01,

^***P<0.001. Analyzed sample sizes differ for the total sample and stratified by smoking status because two cases among the sample were missing on smoking status, 6 cases were missing on perceived relative harm for General Snus claim, 4 cases were missing on perceived relative harm for VLN King claim, 2 cases were missing on perceived relative addictiveness for General Snus claim, 3 cases were missing on perceived addictiveness for VLN King claim, 1 case was missing on intention to use product using General Snus claim, and 2 cases were missing on intention to use product using VLN King claim.

3.4. Associations between perceived relative harm, addictiveness, and intentions to use

Appendix 3 summarizes the regression models measuring associations of perceived harm and addictiveness of products utilizing the FDA-authorized claim of General Snus and marketing claims of VLN King cigarettes and intentions to use each product, stratified by smoking status and adjusted for age, sex, sexual orientation, education, race and ethnicity. Perceptions of higher relative harm were significantly associated with lower intentions to use products that utilized claims of both MRTPs across all smoking statuses. Higher relative addictiveness was significantly associated with lower intentions to use a product that utilized the FDA-authorized claim of General Snus among those who never smoked, smoked some days, and smoked daily. Higher relative addictiveness was significantly associated with lower intentions to use a product that utilized the claims of VLN King cigarettes among all smoking statuses.

4. Discussion

Consistent with behavioral change and persuasion theories (Mantler, 2013; Schmälzle et al., 2017; Witte, 1992), and the literature on the role of perceived risks in influencing tobacco use behaviors (Costello et al., 2012; Song et al., 2009), findings from this analysis supported the expectations that people who perceive lower relative harm and addictiveness of MRTPs tended to report higher intention to use an MRTP based on an FDA-authorized reduced harm or reduced exposure claims. We observed these patterns in the analyses among all smoking statuses with only one exception; the association between perceived relative addictiveness of a product stating the reduced harm claim and intention to use this product was not significant among those who formerly smoked.

Our study findings indicate a significant challenge to communicate relative harm and addictiveness of MRTPs on the continuum of harm (Zeller, 2013) to protect the health of people who use tobacco and non-users. Communicating the relative harms of tobacco products is complex and depends on whether combustible tobacco, or no tobacco use, is the default comparison (Kaufman et al., 2016) and who the intended audience is. Our study found that a higher proportion of those who smoke daily or some days perceived products with a reduced harm claim used by General Snus as much less harmful vs. cigarettes compared with those who smoked formerly or never smoked. This is potentially beneficial for population health as the goal of communicating reduced harm information is to promote the use of authorized reduced harm MRTPs among those who currently smoke cigarettes while not enticing non-users to use these products. However, our study also found a higher proportion of participants who smoke daily or some days perceived products with a reduced harm claim as much less addictive vs. cigarettes compared with those who smoked formerly or never smoked, even though the claim is not intended to convey less addictiveness. Seidenberg and colleagues described this as the “risk-to-exposure halo effect” (Seidenberg et al., 2020), whereby an MRTP claim describing reduced health risks could lead consumers to falsely infer that the using the product also has lower exposure to chemicals such as nicotine and is therefore less addictive.

Furthermore, this study found that a higher proportion of participants who smoke daily or some days perceived products with a reduced exposure claim used by VLN King as much less addictive vs. cigarettes compared with those who smoked formerly or never smoked. This finding supports how reduced exposure claims could be potentially beneficial for communicating to those who smoke regular cigarettes to use reduced nicotine products while not inadvertently influencing non-users to initiate the use of such products. However, we also learnt that a higher proportion of participants who smoke daily or some days perceived products with a reduced exposure claim as much less harmful vs. cigarettes compared with those who smoked formerly or never smoked. This unintended “exposure-to-risk halo effect” (Seidenberg et al., 2020) illustrates how an MRTP claim describing reduced exposure of nicotine could lead to consumers thinking inaccurately that using the product would lead to lower health harms than smoking typical cigarettes.

The above pattern of findings illustrates the complexity of conveying accurate information about either reduced harm or reduced exposure of MRTPs and the potential for unintended inferences or “halo effects” among consumers. These findings reinforce why careful formative message testing is needed to rigorously examine public understanding and perceptions of currently approved and future proposed MRTPs’ marketing and packaging claims as part of the FDA MRTP approval process. Understanding public understanding of MRTP marketing claims, in addition to measuring public perceptions of tobacco products, would also provide crucial information to support FDA’s initiatives on messaging for adults who smoke cigarettes on the continuum of risks of nicotine delivered in different forms, compared with cigarettes.

One strength of this study is the survey data was collected when two FDA-authorized MRTPs (General Snus and VLN King cigarettes) are available in the marketplace although under 1% of the sample have experience with using General Snus or VLN King cigarettes. We are therefore better able to assess perceptions of actual products using authorized MRTP claims compared with prior studies that report perceptions of hypothetical MRTP claims and products. This is a critical period for more research to assess consumers’ relative harm and addictiveness perceptions and how these perceptions are associated with intentions, purchasing, and use of MRTPs.

The survey was conducted among an opt-in panel of adults ages 18–45 and the findings may not be generalizable to the U.S. adult population. Participants were shown the statements of reduced risks or exposure claims within a survey and there was no comparison group that were not exposed to the claims. Perceptions of relative harms and addictiveness may differ when participants read claims that do not specify the brand name or product type within a survey compared with reading the claims on real General Snus or VLN King cigarette packaging and promotional materials. Some participants may find it difficult to answer the survey questions without being told what product they are evaluating. Future research should be conducted to address these limitations by obtaining nationally representative samples, asking participants about their perceptions of harms and addictiveness after reading real FDA authorized MRTP claims on product packaging and marketing, and including a comparison no-exposure group. Perceived harms and addictiveness questions did not include a “don’t know” option to be consistent with the HINTS questionnaire from which these questions were adapted. Although participants could skip questions if no responses were applicable to them, future research could consider providing this option for participants to explicitly indicate that they did not know. We did not randomize the order in which General Snus or VLN King claims appeared. Future experiments could consider randomizing the order of questions to assess order effects. We assessed intentions to use each of the two products using the MRTP claims and did not assess actual use. Longitudinal studies could examine product use and endorsement, as well as characterize polytobacco use behavior as a result of these MRTPs entering the marketplace.

5. Conclusions

We found that a minority of U.S. adults in an opt-in sample reported lower relative harm and addictiveness of products that used claims of General Snus and VLN King cigarettes compared with smoking typical cigarettes. The Tobacco Control Act emphasizes the importance of identifying sub-populations at risk; this study provides useful insights for future research to develop and evaluate the effects of marketing and product warnings to account for the differences in perceptions among those who smoke and those who do not smoke cigarettes. Efforts to systematically evaluate information conveyed by MRTP claims and their impacts on consumers’ understanding of the relative harm and addictiveness of MRTPs versus cigarette smoking among both groups will be needed to maximize the potential population health benefits of these products and minimize unintended impacts.

Figure 1. Perceived relative health harm and addictiveness among the sample and stratified by smoking status (%).

Figure 2. Intention to use MRTPs among the sample and stratified by smoking status (%).

Highlights.

• In 2022, 2964 US adults aged 18–45 were surveyed to assess their perceptions of harm and use intentions of hypothetical products using FDA-approved MRTP marketing claims.

• A minority of adults across all smoking statuses perceived products using MRTP claims were less harmful or addictive compared to cigarettes.

• Perceiving products using MRTP claims as less harmful and addictive compared to cigarettes was significantly associated with adults’ intentions to use these products.