Abstract
Introduction
The 2017 agreement between the U.S. Food and Drug Administration and the makers of Natural America Spirit (NAS) cigarettes restricted the use of “additive-free” (AF) in brand marketing, which the company replaced with “tobacco ingredients: tobacco & water” (TW), a phrase subsequently adopted by L&M. We tested how participants’ perceptions differed when exposed to AF versus TW claims on NAS and L&M packs.
Aims and Methods
A between-subjects experiment was embedded within an online survey in August 2022 (n = 2526). Participants were randomized to view one of three packs (NAS AF pack, NAS TW pack, L&M TW pack). Logistic regressions assessed differences (by pack exposure) in perceived pack attractiveness and relative chemical and harm perceptions compared to other cigarettes. Interactions by smoking status were explored.
Results
No significant differences were observed between the NAS AF and NAS TW packs on perceived attractiveness or relative harm, although never smokers had higher odds of having lower relative chemicals perceptions in response to the NAS AF versus NAS TW pack (OR = 1.81). Compared to participants who saw the NAS TW pack, those who saw the L&M TW pack tended to have lower odds of perceiving the pack as attractive, believing that the product had fewer chemicals than other products, or believing the product was less harmful than other products compared to the NAS TW pack.
Conclusion
Results suggest the more implicit “tobacco ingredients: tobacco & water” claim functions similarly to “additive-free” and as an unauthorized modified risk claim. NAS brand image also appears to contribute to higher perceived pack attractiveness and lower perceptions of chemicals and harm. Additional marketing regulations and corrective campaigns may be needed to reduce risk-related misperceptions about NAS cigarettes.
Implications
Our findings show that replacing “additive-free” claims with “tobacco ingredients: tobacco & water” did not sufficiently address the illegal use of unauthorized modified risk claims by the makers of NAS cigarettes. Further regulatory action restricting the TW claim could potentially reduce inaccurate lower harm perceptions about NAS cigarettes. Educational campaigns may also be needed to mitigate NAS’s history of marketing that implies reduced harm, given that the effects of implicit reduced risk claims like TW have a greater effect on pack perceptions for NAS than L&M.
Introduction
The 2009 Tobacco Control Act (TCA) in the United States formally prohibited tobacco companies from making marketing claims stating or implying reduced harms or substance exposure without prior review and authorization by the Food and Drug Administration (FDA). In 2015, the FDA sent a warning letter to Santa Fe Natural Tobacco Company (SFNTC), manufacturer of the cigarette brand Natural American Spirit (NAS), about the use of the marketing claims “additive-free” (AF) and “natural.” The warning stated that using these terms inappropriately represented NAS cigarettes as free of a substance (ie, additives) or as being less harmful than other tobacco products without a modified risk authorization.1 SFNTC came to an agreement with the FDA in January 2017 to stop using “additive-free,” and “natural” in NAS marketing, but was explicitly allowed to continue using “natural” in their brand name and the phrase “tobacco ingredients: tobacco & water” (TW).2
Although the TW claim had been used in some NAS marketing (16%) prior to the 2017 agreement (often occurring in the same sentence as AF and “natural”), it was present in over 90% of ads in the first few years after the agreement went into effect.3 Some studies have investigated the potential impact of changes in NAS marketing. Pre- and post-agreement marketing terms in NAS advertisements yielded statistically indistinguishable harm perceptions in one study.4 Another experiment comparing the presence versus absence of the TW claim in NAS advertisements found increased perceptions of healthfulness and decreased perceived potential to cause disease when the claim was present.5 These findings suggest that the TW claim may still problematically communicate reduced harm. However, the effects of these claims on cigarette packs have not yet been investigated. The potential effect of the TW claim is additionally concerning because it has spread to other brands,6,7 including budget brand L&M (owned and manufactured by Altria).8 This new marketing angle, combined with the continued highlighting of L&M as an affordable brand, positions L&M to uniquely appeal to both health- and price-conscious adults who smoke.8
The expanded use of TW claims, which are arguably more implicit versions of the restricted AF claims, necessitates a better understanding of the effects of pre- versus post-agreement marketing claims. We conducted an online experiment to compare the effects of NAS packs with pre- versus post-agreement claims “additive-free” versus “tobacco & water,” further comparing the effect of “tobacco & water” between NAS and L&M, on product attractiveness and harm perceptions.
Methods
Procedure and Measures
Data were collected from 2526 participants in August 2022 from Wave 3 of the Rutgers Institute for Nicotine and Tobacco Studies Omnibus study, a repeated cross-sectional online survey of 18–45-year-olds living in the United States, conducted quarterly for surveillance purposes on Amazon Mechanical Turk (utilizing CloudResearch to maintain data integrity).9
An experiment was embedded within the survey where participants were randomized to see one of three cigarette pack images: (1) The front of a light blue NAS pack with a pre-agreement claim (“100% ADDITIVE-FREE NATURAL TOBACCO”) in all caps on the bottom left of the pack. This pack also contained the NAS brand name and logo (ie, an American Indian with a traditional headdress and “peace pipe” and a thunderbird); (2) An identical NAS pack with the pre-agreement claim replaced by the postagreement claim (“TOBACCO INGREDIENTS: TOBACCO & WATER”)10; (3) The front and back of a new L&M pack8,11 with the same “TOBACCO INGREDIENTS: TOBACCO & WATER” claim on the back of the pack. The L&M pack also featured similar light blue coloring (blue leaf and accents) against a light backdrop and had the following additional claims: “SIMPLE TOBACCO”; “FULL-BODIED TASTE”; “Enjoy premium tobaccos packed tightly for slow long-lasting flavor”; “It only tastes expensive.” Pack images were taken from actual cigarette packs. Textual claims were approximately the same size on all three packs.
During stimulus exposure, participants were asked: (1) “How attractive, if at all, is this packaging to you?” 1 = “not at all” to 5 = “extremely attractive”; (2) “Compared to other brands (eg, Marlboro, Camel, Newport), how much do you think this product would expose users to chemicals?”; (1 = “a lot more” to 5 = “a lot less exposure to chemicals”); and (3) “Compared to other brands (eg, Marlboro, Camel, Newport), how harmful do you think this product is to a person’s health?” (1 = “a lot more harmful” to 5 = “a lot less harmful”).
Participants were also asked questions about their demographics (sex assigned at birth, age, race/ethnicity) and cigarette use status.
Analysis
Outcome measures were dichotomized as follows: not at all/not very attractive versus somewhat/very/extremely attractive; a lot more/somewhat more/about the same [exposure/harmful] versus somewhat less/a lot less [exposure/harmful]. Logistic regressions modeling the effect of the condition on each outcome were run using the NAS TW condition as the reference. This allowed us to make comparisons between pre- versus post-agreement marketing claims (ie, between the two NAS packs) and between the TW claim on two brands (NAS vs. L&M). Regressions using other conditions as the reference are available in Table S1. We also examined interactions between smoking status and experimental conditions. When significant, we present outcomes stratified by smoking status. The main effects are discussed when interactions are not significant.
Results
Survey participants were 38.8% male and primarily 30–45 years of age (69.3%) (Table 1). Most identified as non-Hispanic White (68.2%) and had at least some college education (77.6%). Just over half (51.1%) were defined as never smokers, 18.9% as former smokers, and 30.1% as current smokers. There were no significant associations between these characteristics and condition.
Table 1.
Sample Characteristics from Online MTurk Convenience Sample, August 2022 (n = 2526)
| Total | L&M TW | NAS TW | NAS AF | p-Valuea | |||||
|---|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | ||
| Sex assigned at birth | |||||||||
| Male | 979 | 38.8 | 323 | 38.5 | 322 | 38.3 | 334 | 39.5 | .8694 |
| Female | 1546 | 61.2 | 515 | 61.5 | 519 | 61.7 | 512 | 60.5 | |
| Age | |||||||||
| 18–29 | 775 | 30.7 | 249 | 29.7 | 274 | 32.5 | 252 | 29.8 | .3575 |
| 30–45 | 1751 | 69.3 | 589 | 70.3 | 568 | 67.5 | 594 | 70.2 | |
| Race/Ethnicity | |||||||||
| White, non-Hispanic | 1722 | 68.2 | 565 | 67.4 | 595 | 70.8 | 562 | 66.5 | .4268 |
| Black, non-Hispanic | 259 | 10.3 | 92 | 11.0 | 77 | 9.2 | 90 | 10.7 | |
| Other, non-Hispanic | 265 | 10.5 | 92 | 11.0 | 86 | 10.2 | 87 | 10.3 | |
| Hispanic | 278 | 11.0 | 89 | 10.6 | 83 | 9.9 | 106 | 12.5 | |
| Education | |||||||||
| Some high school or less | 40 | 1.6 | 13 | 1.6 | 15 | 1.8 | 12 | 1.4 | .8785 |
| High school graduate | 276 | 10.9 | 87 | 10.4 | 90 | 10.7 | 99 | 11.7 | |
| Associate’s degree or some college | 916 | 36.3 | 294 | 35.1 | 302 | 35.9 | 320 | 37.8 | |
| Bachelor’s degree | 918 | 26.4 | 314 | 37.5 | 313 | 37.2 | 291 | 34.4 | |
| Master’s degree or higher | 375 | 14.9 | 130 | 15.5 | 121 | 14.4 | 124 | 14.7 | |
| Cigarette smoking statusb | |||||||||
| Never established smoker | 1290 | 51.1 | 426 | 50.9 | 415 | 49.3 | 449 | 53.1 | .6434 |
| Former established smoker | 476 | 18.9 | 158 | 18.9 | 163 | 19.4 | 155 | 18.3 | |
| Current established smoker | 759 | 30.1 | 253 | 30.2 | 264 | 31.4 | 242 | 28.6 | |
aChi-square test p-value.
bCigarette smoking status comprised three mutually exclusive categories: adults with never established smoking behavior (ie, never smoked more than 100 cigarettes), adults with former established smoking behavior (smoked at least 100 lifetime cigarettes but currently smoke not at all or rarely, with no smoking in the past 30 days), and adults with current established smoking behavior (smoked at least 100 cigarettes and report currently smoking some days, every day or rarely, but must have smoked in the past 30 days if indicating rarely smoking).
Regression results and stratified analyses for outcomes with significant interactions are described in Table 2. Perceived pack attractiveness ranged from 57.8% for the L&M pack to 66.7% for the NAS TW pack. There was a significant interaction between condition and smoking status for perceived pack attractiveness (p = .01). The L&M TW pack was significantly less likely to be considered attractive than the NAS TW pack among adults who reported former smoking only (OR: 0.34). There were no significant differences between the two NAS packs for any smoking subgroup.
Table 2.
Effect of Experimental Condition on Perceived Pack Attractiveness, Relative Chemical and Harm Perceptions with Interaction by Established Smoking Status (n = 2522)
| % | OR | (95% CI) | |
|---|---|---|---|
| Perceived pack attractiveness1 | |||
| L&M TW | 57.8 | 0.68 | 0.56–0.84 |
| NAS TW | 66.7 | ref | |
| NAS AF | 64.4 | 0.90 | 0.74–1.10 |
| Current established smokers | |||
| L&M TW | 66.7 | 0.69 | 0.47–1.02 |
| NAS TW | 74.2 | ref | |
| NAS AF | 75.2 | 1.05 | 0.70–1.57 |
| Former established smokers | |||
| L&M TW | 54.4 | 0.34 | 0.21–0.55 |
| NAS TW | 77.9 | ref | |
| NAS AF | 71.6 | 0.72 | 0.43–1.19 |
| Never established smokers | |||
| L&M TW | 54.0 | 0.87 | 0.66–1.14 |
| NAS TW | 57.5 | ref | |
| NAS AF | 56.0 | 0.94 | 0.72–1.23 |
| Condition × Smoking Status Interaction p-value: .0126 | |||
| Lower relative chemical perceptions2 | |||
| L&M TW | 21.6 | 0.62 | 0.50–0.78 |
| NAS TW | 30.6 | ref | |
| NAS AF | 36.2 | 1.28 | 1.05–1.57 |
| Current established smokers | |||
| L&M TW | 23.8 | 0.45 | 0.31–0.66 |
| NAS TW | 41.1 | ref | |
| NAS AF | 44.1 | 1.13 | 0.80–1.62 |
| Former established smokers | |||
| L&M TW | 24.1 | 0.40 | 0.25–0.64 |
| NAS TW | 44.4 | ref | |
| NAS AF | 43.9 | 0.98 | 0.63–1.52 |
| Never established smokers | |||
| L&M TW | 19.4 | 1.06 | 0.75–1.49 |
| NAS TW | 18.6 | ref | |
| NAS AF | 29.3 | 1.81 | 1.32–2.50 |
| Condition × smoking status interaction p-value: .0035 | |||
| Lower relative harm perceptions3: | |||
| L&M TW | 12.7 | 0.68 | 0.52–0.88 |
| NAS TW | 17.7 | ref | |
| NAS AF | 18.0 | 1.02 | 0.79–1.31 |
| Current established smokers | |||
| L&M TW | 16.6 | ||
| NAS TW | 21.6 | ||
| NAS AF | 21.9 | ||
| Former established smokers | |||
| L&M TW | 10.8 | ||
| NAS TW | 25.8 | ||
| NAS AF | 23.2 | ||
| Never established smokers | |||
| L&M TW | 11.0 | ||
| NAS TW | 12.1 | ||
| NAS AF | 14.0 | ||
| Condition × smoking status interaction p-value: .1705 | |||
Between 21.6% (L&M TW pack) and 36.2% (NAS AF pack) of participants perceived the product they saw to expose users to fewer chemicals than other brands. The effect of condition on relative chemical perceptions also differed by smoking status (p = .004). Adults who reported never established smoking behavior who were exposed to the NAS AF pack (compared to the NAS TW pack) had higher odds of thinking the product they saw exposed people to fewer chemicals than other brands (OR: 1.81). Adults with current (OR: 0.45) and former (OR: 0.40) smoking behavior exposed to the L&M TW pack compared to the NAS TW pack had lower odds of thinking the product they saw exposed people to fewer chemicals than other brands.
Between 12.7% (L&M pack) and 18.0% (NAS AF pack) of participants perceived the product viewed to be less harmful than other brands. Only the main effect of the condition was significant. Those exposed to the L&M TW pack had significantly lower odds of thinking that the product was less harmful than other brands compared to those exposed to the NAS TW pack. Differences between the two NAS packs were not significant (Table 2).
Discussion
This experiment tested the effect of pre- versus post-FDA agreement claims used on cigarette packs by the brand NAS (“100% additive-free natural tobacco” vs. “tobacco ingredients: tobacco & water”) and the post-agreement claim (“tobacco ingredients: tobacco & water”) by another brand—L&M. Importantly, there were no differences in pack harm perceptions or perceived attractiveness between the two NAS packs. Further, NAS packs were more likely to be perceived as attractive, having fewer chemicals, and being less harmful than other cigarettes compared to the L&M pack.
Consistent with previous experimental research,4 harm perceptions of those exposed to the NAS AF vs. the TW claims were statistically indistinguishable. There were also no differences between the two NAS packs on relative chemical perceptions among adults with current or former smoking behaviors—those who may be most likely to use these products (vs. adults who never established cigarette smoking). These findings signal that replacing AF with TW claims did not reduce inappropriate representations of NAS cigarettes as less harmful than other tobacco products, suggesting that TW may be similarly functioning as an unauthorized modified risk claim.12
Interestingly, the pre-agreement NAS AF pack was more likely to elicit lower chemical perceptions than the NAS TW pack only among adults who never established smoking behaviors. Given that the public widely believes that harmful chemicals largely originate from additives added to cigarettes by manufacturers,13 presence of the word “additive” may more specifically cue lower chemical perceptions than the more implied TW claim, particularly for those who may be less familiar with the brand. It is still notable that about one-fifth to one-third of participants reported believing packs with the TW claim exposed users to fewer chemicals than other brands, an indication that this claim is communicating unauthorized reduced exposure.
Given that the NAS TW pack more frequently elicited lower relative harm and chemical perceptions and higher perceived attractiveness compared to the L&M TW pack, there appears to be an additional effect of the NAS brand on perceptions. This effect could be due to an enduring brand image that promotes lower harm perceptions,14 including branding elements unique to NAS (eg, use of “natural” in the brand name, associations with American Indian tobacco use, imagery of plants and nature),15–17 its previous use of AF claims, or its image as a premium brand with perceived better quality tobacco.18 Regulators could consider more wide-ranging regulatory action, such as restricting the use of “natural” in all instances, including brand names, restricting a more sweeping range of descriptors or claims about ingredient constituency that may communicate reduced harm or exposure (eg, simple),19 and/or implementing plain packaging. Regulators could further consider enforcement actions for brands making unauthorized modified risk or exposure claims, such as warning letters, fines, and increasing penalties. While plain packaging may be ideal to address branding issues (although potentially unrealistic in the US context), strengthening health warning labels on existing packs by increasing their size, using pictorials, and moving them from the side of packs to the front and back of packs could work to increase their visibility and highlight negative health implications as a contrast to misleading marketing.
This study has some limitations. Generalizability may be limited due to the online convenience sample used, although patterns of results from experiments using MTurk are comparable to those from probability samples.20 No specific manipulation check was conducted, although the relative simplicity of the images likely promoted attention to the experimentally manipulated claims. The question about relative chemical perceptions did not specify “harmful” chemicals, which may have impacted responses. The L&M pack was not identical to the NAS packs, as all images came from actual packaging which had real-world variations, including different claims. However, even with additional marketing claims that could potentially also imply reduced exposure or harm (eg, “Simple tobacco”),19 the L&M pack was rated as less attractive and was less likely to induce lower relative harm and chemical perceptions than the NAS packs, suggesting that these differences in stimulus presentation did not give the L&M pack an advantage. Lastly, because participants did not view the side of stimuli packs, they did not see the mandated textual health warning on packs as part of their exposure, which could have influenced results.
Conclusions
Exposure to NAS packs with a “tobacco ingredients: tobacco & water” claim elicited virtually identical lower harm perceptions as exposure to the NAS “additive-free” pack, providing evidence that the brand continues to make inappropriate implicit representations that NAS cigarettes are less harmful than other cigarettes. Two brands using the TW claim (NAS and L&M) both elicited perceptions that the products pose lower chemical exposure than other brands in a sizeable percentage of participants. With emerging evidence about this unrestricted TW claim, the FDA may consider additional interventions to address and restrict its use. Educational campaigns to correct existing misperceptions about “fewer ingredient” cigarettes and NAS cigarettes specifically may be needed.
Supplementary material
Supplementary material is available at Nicotine and Tobacco Research online.
Acknowledgments
We would like to acknowledge the contributions of Nishi Gonsalves at the Office of Survey Methods and Data Analysis (at the Rutgers Institute for Nicotine & Tobacco Studies) for her work on data analysis.
Contributor Information
Caitlin Weiger, Rutgers Institute for Nicotine & Tobacco Studies, Rutgers University, New Brunswick, NJ, USA.
Stefanie K Gratale, Rutgers Institute for Nicotine & Tobacco Studies, Rutgers University, New Brunswick, NJ, USA.
Ollie Ganz, Rutgers Institute for Nicotine & Tobacco Studies, Rutgers University, New Brunswick, NJ, USA.
Olivia A Wackowski, Rutgers Institute for Nicotine & Tobacco Studies, Rutgers University, New Brunswick, NJ, USA.
Funding
Contributions by authors were supported by Award Number U54CA229973 from the Food and Drug Administration Center for Tobacco Products (CTP) and the National Cancer Institute (NCI). The content is solely the responsibility of the authors and does not necessarily represent the views of the NIH or FDA.
Declaration of Interests
The authors have no competing interests to declare. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.
Author contributions
Caitlin Weiger (Writing—original draft [lead]), Stefanie K Gratale (Conceptualization [supporting], Methodology [supporting], Writing—review & editing [equal]), Ollie Ganz (Conceptualization [supporting], Methodology [supporting], Writing—review & editing [equal]), and Olivia Wackowski (Conceptualization [lead], Funding acquisition [lead], Methodology [lead], Writing—review & editing [equal]).
Data availability
Study measures and stimuli images are available upon request to the authors. Data from the Rutgers Omnibus Survey are not available in a repository. Since we did not specify in the online consent that the data could be used for secondary data analyses, we are not able to make the data public. A restricted dataset may be requested from the PI of the Rutgers Omnibus Survey, Michelle Bover Manderski (bovermi@ints.rutgers.edu), and should include a plan for its use. Data may be made available to qualified researchers after the main findings are published in a peer-reviewed journal. All data sharing will comply with local, state, and federal laws and regulations and may be subject to appropriate human subjects institutional review board approvals.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Study measures and stimuli images are available upon request to the authors. Data from the Rutgers Omnibus Survey are not available in a repository. Since we did not specify in the online consent that the data could be used for secondary data analyses, we are not able to make the data public. A restricted dataset may be requested from the PI of the Rutgers Omnibus Survey, Michelle Bover Manderski (bovermi@ints.rutgers.edu), and should include a plan for its use. Data may be made available to qualified researchers after the main findings are published in a peer-reviewed journal. All data sharing will comply with local, state, and federal laws and regulations and may be subject to appropriate human subjects institutional review board approvals.