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Published in final edited form as: Tob Control. 2022 Jan 12;32(5):583–588. doi: 10.1136/tobaccocontrol-2021-056938

Naturally Leading: A Content Analysis of Terms, Themes and Word Associations in Natural American Spirit Advertising, 2000–2020

Stefanie K Gratale 1, Ollie Ganz 1,2, Olivia A Wackowski 1,2, M Jane Lewis 1,2
PMCID: PMC9273802  NIHMSID: NIHMS1768511  PMID: 35022329

Abstract

Background:

Natural American Spirit (NAS) is a cigarette brand distinguished by supposed “natural”, “additive-free” characteristics, marketing of which is tied to misperceptions of reduced harm. In 2017, NAS’s manufacturer agreed (with the Food and Drug Administration) to remove “natural”/“additive-free” from US marketing. Prior research has explored NAS marketing immediately post-agreement. This study sought to identify prominent post-agreement terms and themes and analyse how they had been utilised in pre-agreement ads.

Methods:

We conducted a content analysis of NAS ads from 2000 to 2020 (N=176), documenting prominent pre- and post-agreement terms/themes and examining how they are used in NAS ads. We coded for descriptors, themes, imagery and promotions, and extended prior research by analyzing how leading post-agreement terms were used in conjunction and thematically associated with “additive-free” and “natural” before the agreement.

Results:

Results indicated “tobacco and water” and “Real. Simple. Different.” increased significantly post-agreement, as did environmental imagery. “Organic” was prominent pre- and post-agreement. The descriptors used most often in post-agreement ads almost always appeared in conjunction with (and were thematically linked to) “natural” and “additive-free” in pre-agreement ads.

Conclusions:

In the years since the agreement, NAS ads have heavily relied on still-allowable descriptors that may invite reduced risk misperceptions. Notably, these descriptors were consistently used alongside the banned terminology before the agreement and presented as if affiliated conceptually, possibly prompting similar connotations. Findings indicate a continuing need for research into NAS advertising effects and a potential role for additional regulatory action.

Keywords: Natural American Spirit, tobacco, advertising, misperceptions, natural, additives

INTRODUCTION

The 2009 Tobacco Control Act (TCA) gave the United States Food and Drug Administration’s (US FDA) Center for Tobacco Products authority to regulate cigarettes and their advertising in the US, including authority to ban terms that could mislead the public to believe such products pose reduced harm. The TCA also explicitly banned “light”, “low,” and “mild” in cigarette marketing, acting on research showing cigarettes marketed as light were commonly and incorrectly perceived by consumers as less addictive or less harmful, which in turn lowered intentions to quit.[1–6] These widely documented misperceptions helped to inspire FDA action and elucidate dangerous implications of misleading descriptors in cigarette marketing.

Yet the TCA could not explicitly preclude all misleading descriptors. In particular, it did not prohibit “natural,” “additive-free” or “organic”, terms that have been used in cigarette advertising, perhaps most notably by the premium brand Natural American Spirit (NAS). NAS is a leading brand in the US[7], manufactured by Santa Fe Natural Tobacco Company (SFNTC, which is owned by Reynolds American, a subsidiary of British American Tobacco); outside the United States, Japan Tobacco Group owns the rights to NAS, with a history of prominent markets in countries such as Japan and Switzerland.[8] NAS marketing has prominently employed the aforementioned descriptors,[9] historically distinguishing itself by promoting a “natural” composition utilizing tobacco without additives.[10] Generally speaking, marketing cigarettes with “natural”, “organic” or “additive-free” claims promotes misperceptions of reduced harm and increases product appeal and use intentions,[11, 12] including among adolescents/young adults.[13–15] Misleading descriptors on NAS ads in particular associate with misperceptions about it being a safer cigarette[16, 17] and with the brand’s “healthy” image.[18] Prior studies have also identified visual elements of NAS marketing that may implicitly communicate reduced harm (e.g., images of plants/water, bright colors, American Indians).[9, 19, 20] Misperceptions about NAS safety/healthfulness directly associate with intentions to use or switch to the brand,[21, 22] and alarmingly, a majority of NAS smokers characterize their cigarettes as less harmful than other brands.[23]

Cognizant of mounting evidence of potentially harmful implications of NAS ads/descriptors, the FDA issued a warning letter to SFNTC in 2015 regarding the use of “natural” and “additive-free” terminology in US-based NAS marketing.[24] The letter was followed in January 2017 by an agreement between SFNTC and FDA, stipulating SFNTC would cease use of “additive-free” and “natural” in NAS packaging and advertising (effective August 2017).[25] The agreement, however, allowed continued use of “natural” in the brand’s name, as well as the implied additive-free claim, “Tobacco Ingredients: Tobacco and Water”. Despite pressure from tobacco control advocates to ban the word “organic”, the agreement did not do so, adding to concerns that still-allowable terms in NAS ads may continue to invite reduced harm misperceptions,[26,27], which some research has already indicated.[10, 28–30] To our knowledge, only one study has examined NAS marketing content since the 2017 FDA agreement, finding that in the period immediately following its enactment, brand marketing complied with restrictions overall but continued to utilize other potentially misleading descriptors that may signal reduced harm (e.g., “organic”, “whole leaf”) and imagery that supports a natural brand image (e.g., wildlife, farms).[31] However, that content analysis covered a limited time period (approximately 2.5 years before and 10 months after the agreement took effect in August 2017). It remains important to track ongoing agreement compliance and emerging patterns in post-agreement ad content, to inform regulatory considerations related to misperceptions arising from NAS marketing.

Thus, we aimed to assess longer-term agreement implications by identifying prominent post-agreement terms/themes and analyzing how they had been used in pre-agreement ads. Here, we conducted a content analysis of terms/themes, imagery, and patterns in word usage in NAS ads from 2000 to 2020. This study extends prior work in two ways. First, in terms of timeframe, it covers a 20-year period, establishing a wider baseline of ads before the agreement and over three years afterwards; this allowed us to document associations between prominent ad features that may have been established before prior research (and continued up to the agreement), as well as more lasting thematic patterns beyond the months immediately following agreement enactment. Furthermore, it provides an analysis of the manner in which prevalent terms have been used together in NAS ads – which has not previously been done. Specifically, we examined how terms and phrases commonly used after the agreement (such as “tobacco and water”) were used in conjunction with and contextually linked to the terms “natural” and “additive-free” in ads before the agreement.

METHODS

Sample

The sample consisted of 176 unique NAS magazine ads in the US from 2000–2020. Ads were retrieved from Trinkets and Trash (T&T; www.trinketsandtrash.org), a surveillance system that monitors, collects and documents tobacco industry marketing materials across a variety of channels including direct mailings, emails, brand websites, and magazine ads (the focus for our sample).

T&T collects tobacco magazine ads identified through subscriptions to and review of a purposive sample of popular national magazines in the US, including those related to Men’s Interests, Women’s Interests, Sports, Pop Culture/Music, Fashion/Luxury, LGBTQ Interests, and Black & Latino Special Interests. Subscriptions are selected (and sometimes discontinued) based on representation of audience interests/demographics, popularity/reach/circulation, and presence of tobacco advertising at least occasionally in the magazine (cancelling subscriptions for magazines observed to no longer carry tobacco ads). Over the full study period, T&T had subscriptions to over 30 magazines, with 16 unique titles remaining at the end of the study period.

Codes

The codes and coding guide for the content analysis were informed by a review of prior literature on NAS advertising and our own review of select ads in our sample that we conducted prior to coding.[17, 19, 28, 32, 33] We first completed the literature review to ascertain terms and themes previously determined to be significant in NAS advertising; then, we (OG, MJL) reviewed a selection of pre- and post-agreement NAS ads in our sample to identify additional emerging themes and descriptors. For instance, the literature review established “tobacco and water” as a leading NAS descriptor, but in our review of select ads, we identified additional trends including descriptors such as “different” and themes of quality (e.g., descriptions of “crafted” blends) and the environment (e.g., representations of nature). We coded for 1) descriptors; 2) themes; 3) imagery; and 4) product promotions.

Descriptors

Ads were coded for prominent words and phrases frequently used before and/or after the 2017 agreement’s passage. We coded for “natural”, “organic”, “additive-free” and “tobacco and water”, either in ad text or on cigarette packs featured in ads. Coding for “natural” only included occurrences outside of the brand name. For “organic”, coders distinguished between use on pictured packs versus in ad text. Ads were also coded for the term “crafted” and the post-agreement tagline “Real. Simple. Different.” and for occurrences of “real”, “simple”/“simply” and “different”/“differently” outside of the phrase “Real. Simple. Different.” (e.g., “we do things differently”).

Themes

Ads were coded for additional recurring themes in NAS marketing, including quality, taste, and brand history/characteristics; our ad review showed these themes were often presented in conjunction with the concepts of “natural” and/or “additive-free”. The quality theme included language such as “premium” and implicit or explicit comparisons to other brands, as well as the words “craft”/“crafted”, also potentially used to signify quality. The taste theme pertained to language directly referencing product taste. Finally, the theme of brand history and characteristics included language addressing company heritage and the brand’s eco-friendly nature, which have been identified as suggestive features in prior research.[9] See Supplemental Table S1 for examples of themes.

Imagery

Ads were coded for the use of environmental imagery (e.g., leaves, plants, farms, trees/wood) and bright colors (e.g., colors seeming “bright”, often primary colors or ones with high contrast), as these have previously been indicated as distinct elements of NAS ads that may attract attention and associate with perceptions of “natural” and reduced risk.[9, 19, 34]

Product promotions

Ads were coded for the presence of product promotions, specifically price promotions or offers for gift certificates or coupons. Some research indicates that tobacco coupons (historically a prominent feature in NAS advertising) associate with product use,[35–37] including among youth/young adults (a key NAS user demographic).

Coding procedures

Coding was a two-step process. First, to refine the coding guide, two separate coders (project staff members) who were trained in coding procedures coded a small sample of approximately 10 ads. This was an iterative process where areas of disagreement were discussed by the two coders and two other members of the study team (OG, MJL) until they were addressed and sufficient reliability was obtained.[see 38] Specifically, the team members discussed all discrepancies until there was 100% agreement, and then refined the coding guide as needed to make it clearer. After the coding guide was finalized, all ads were coded in Qualtrics by two project staff members, and discrepancies were settled via discussion including the coders and another member of the study team. Average percentage agreement between coders and average results of interrater reliability for the full sample were both high (93.5%; Kappa = .78). This includes one code that was found to initially have low agreement (“environmental imagery”, 55.1%; Kappa = .18), so the coding guidelines for this variable were revisited and clarified. Subsequent re-coding for this variable reflected the clarified coding guidelines, at which point 100% agreement was reached.

Analysis

Data from Qualtrics were imported into Stata/MP 16.1 for analysis.[39] Upon coding of ads, an FDA agreement variable was created to indicate whether an ad came out prior to the FDA/SFNTC agreement or after. Ads that ran prior to 2017 were coded as “pre-agreement”, and ads from 2018 or later were coded as “post-agreement”. Ads from 2017 were individually examined and coded as pre- or post-agreement based on use of the banned descriptors. For example, ads from early 2017 that included the term “additive-free” were coded as pre-agreement, whereas ads from later 2017 using the post-agreement tagline “Real. Simple. Different.” were coded as post-agreement.

We calculated the prevalence of each code for the entire sample and used chi-square tests to examine associations between the presence of these characteristics and FDA agreement period (pre/post). Additionally, we sought to identify whether the dominant post-agreement terminology (i.e., “tobacco and water”, “simple”/“simply”, “different”/“differently”, “organic”)1 was typically used in conjunction with the terms “natural” and “additive-free” in the pre-agreement period, to examine whether the terms may have been affiliated with the concepts of being “natural” and “additive-free” prior to the prohibition of the latter descriptors. In particular, we used cross tabs to determine the rate of pre-agreement co-occurrence of “natural” and “additive-free” with the other key descriptors. We then examined individual ads to assess how the terms were used with one another, reviewing specific examples of co-occurrences to identify whether the terms/phrases were presented in close proximity and as being conceptually linked.

RESULTS

Comparison of NAS ads pre- and post-agreement

Below are key findings for each coded category (see Table 1 for all results).

Table 1.

Natural American Spirit Ad Characteristics, Overall and Pre- and Post-FDA Agreement (N=176)

Total (N=176), n (%) Pre-agreement (n=151), n (%) Post-agreement (n=25), n (%) p-value
Descriptors
Natural (on pack or in text) 125 (71.0) 125 (82.8) 0 (0.0) <.001
Additive-free (on pack or in text) 128 (72.7) 128 (84.8) 0 (0.0) <.001
Organic (on pack or in text) 67 (38.1) 59 (39.1) 8 (32.0) .500
Organic (on pack) 31 (17.6) 24 (15.9) 7 (28.0) .141
Organic (in text) 55 (31.2) 50 (33.1) 5 (20.0) .190
Tobacco and water 47 (26.7) 24 (15.9) 23 (92) <.001
Real. Simple. Different. 11 (6.2) 0 (0.0) 11 (44.0) <.001
Real* 6 (3.4) 0 (0.0) 6 (24.0) <.001
Simple/simply* 8 (4.5) 7 (4.6) 1 (4.0) .888
Different/differently* 17 (9.7) 8 (5.3) 9 (36.0) <.001
Craft/crafted 12 (6.8) 0 (0.0) 12 (48.0) <.001
Themes
Quality 87 (49.4) 71 (47.0) 16 (64.0) .116
Taste 56 (31.8) 45 (29.8) 11 (44.0) .158
Company heritage 27 (15.3) 19 (12.6) 8 (32.0) .013
Eco-friendly 40 (22.7) 28 (18.5) 12 (48.0) .001
Imagery
Bright colors 165 (93.7) 140 (92.7) 25 (100.0) .163
Environmental 107 (60.8) 82 (54.3) 25 (100.0) <.001
Promotions
Product Promotions 136 (77.3) 129 (85.4) 7 (28.0) <.001
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*

Use of these words not including the entire phrase “Real.Simple.Different.”

Descriptors

Whereas the majority of pre-agreement ads featured the descriptors “natural” and/or “additive-free” (83%+), these terms were absent in post-agreement ads, indicating agreement compliance. References to “organic” tobacco were common in both pre- and post-agreement ads, and there was no significant association between its use and the pre/post-agreement time periods. The most prominent changes occurred with regard to the terms/phrases most heavily utilized in post-agreement ads. Although “tobacco and water” appeared in a minority of pre-agreement ads (16%), it appeared in nearly all post-agreement ads (92%). The phrase “Real. Simple. Different.” emerged as a new tagline in post-agreement ads, featured in almost half of ads, compared to no use in pre-agreement ads. While some pre-agreement ads used the descriptors “different”/“differently” (5%), these terms appeared far more often in post-agreement ads (36%, exclusive of use in the tagline). Similarly, “real” was not used in pre-agreement ads but was in 24% of post-agreement ads (exclusive of tagline use).

Themes

Although there were not significant associations between time period and explicit references to the themes of “taste” and “quality”, use of the words “craft”/“crafted” emerged in post-agreement ads, appearing in 48%. References to SFNTC’s company heritage and eco-friendly themes were also more common in post- (32%; 48%, respectively) versus pre-agreement ads (13%; 19%, respectively).

Imagery

Bright colors and environmental imagery evocative of nature were already prevalent in pre-agreement ads (93%; 54%, respectively), but occurred in every post-agreement ad, with the presence of environmental imagery significantly associating with time period.

Product Promotions

Presence of product promotions also associated with time period, decreasing from pre- (85%) to post-agreement (28%).

Co-occurrence of key phrases in pre-agreement ads

In every pre-agreement ad mentioning “tobacco and water”, the descriptors “natural” and “additive-free” also occurred (100% co-occurrence, see Table 2), even though the now-banned terms themselves did not appear in every pre-agreement ad. “Organic” co-occurred with “natural” and “additive-free” in almost 90% of pre-agreement ads. Similarly, “natural” and “additive-free” co-occurred with “simple”/“simply” in all ads using the latter terms. Nearly 90% of pre-agreement ads mentioning “different”/“differently” included the descriptor “natural”, and all used the “additive-free” claim.

Table 2.

Association between Key NAS Ad Phrases among Pre-Agreement Ads (N=151)

Tobacco and water, n (%) Simple/Simply, n (%) Different/ differently, n (%) Organic, n (%)
Natural 24 (100.0) 7 (100.0) 7 (87.5) 52 (88.1)
Additive-free 24 (100.0) 7 (100.0) 8 (100.0) 53 (89.8)
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Before the agreement, the banned descriptors were not only overwhelmingly present in ads that utilized the now prominent post-agreement ad terms, but they also were commonly used in close conjunction and in a manner that linked the terms conceptually (e.g., in the same sentence/phrase or part of the same idea). For instance, several 2012 and 2013 ads using “tobacco and water” presented graphical images of nature (e.g., tobacco leaves, raindrops) with the phrase, “Tobacco And Water – 100% Additive-Free Natural Tobacco”, implying an association between the additive-free composition and the ingredients tobacco and water. Relatedly, “organic” was tied thematically to “natural” and “additive-free”, including a 2015 ad reading, “100% Additive-Free Natural Tobacco – Ingredients – Organic Tobacco & Organic Menthol” and a 2013 ad stating, “Made with Organic Tobacco | Grown on American Soil | 100% Additive-Free Natural Tobacco”. Additionally, a 2012 ad with the term “simple” explained, “Natural American Spirit began with a simple mission – do away with all of the extras. Use only tobacco without additives”. A 2012 ad featuring the term “different” specified, “100% additive-free, whole leaf natural tobacco in every cigarette. That alone would make Natural American Spirit different, but it doesn’t stop there”. The use of “simple” and “different” alongside “natural” and “additive-free”/“without additives” potentially implicitly linked the additive-free composition with what makes NAS simple and different. Supplemental Table S1 provides links to the aforementioned ads (see trinketsandtrash.org for additional examples).

DISCUSSION

Research about NAS has repeatedly demonstrated that descriptors and images in brand advertising have implicitly perpetuated misbeliefs about safety and healthfulness, which is particularly problematic because misperceptions are difficult to correct once formed.[40, 41] Our content analysis sought to explore trends in NAS marketing content before and in the years since the 2017 agreement that intended to prevent such misperceptions, and it found that NAS marketing has come to rely on other potentially misleading terms that brand advertising has implicitly associated with “natural” and “additive-free”. Our research extends prior work in its broad timeframe, detailed analysis of prominent themes and phrases (e.g., the individual and collective use of the elements of the new tagline “Real. Simple. Different.”), and by considering how the wordage that now dominates NAS marketing was previously employed along with the descriptors “natural” and “additive-free”. Notable changes from pre- to post-agreement ads are increases in the phrase “tobacco and water”, environmental imagery, and allusion to the company’s heritage and eco-friendly nature – which have previously been associated with misperceptions about NAS as less harmful than other brands[9, 18, 19, 30] – and a decrease in the use of price-related promotions, which should be studied further to assess longer-term patterns in promotion types/rates. The strategic emphasis on “tobacco and water”, “organic” and other associated wording in NAS ads (e.g., “simple”, “different”) is concerning, considering that prior research has linked terms including “tobacco and water” and “organic” with similar health-related misbeliefs to those that result from “natural” and “additive-free”[18, 29, 30]

Noteworthy among our results is the finding that the terms that currently feature prominently in NAS ads (i.e., “different”, “simple”, “organic”, “tobacco and water”) are ones that were used almost exclusively in close conjunction with the now-forbidden descriptors in ads prior to the FDA agreement, and frequently in a manner that could imply the concepts were associated with one another. As such, it is possible that the descriptors in the new, agreement-compliant ads could conjure similar connotations to the banned ones, though future research should probe this further. In fact, NAS brand marketing has historically differentiated the product by its “additive-free natural tobacco”, and now distinguishes NAS by highlighting its organic constituents[10] and “different” characteristics. The emphasis on being “different” from competitors underscores the implications of this evolution, as pre-agreement NAS marketing implied that what makes it different and simple is its additive-free, natural composition (e.g., a 2012 ad stating, “We use only 100% additive-free, whole leaf natural tobacco… So we enjoy hearing things like: „This doesn’t taste like my usual cigarette.’ That’s because it’s not supposed to”; a 2007 ad saying “Simply 100% whole-leaf natural tobacco”). While our analysis focused specifically on magazine ads, a quick review of NAS materials on T&T suggests these associations extend to other forms of NAS marketing, such as a 2013 direct mailer reading “Naturally different since ‘82”, a 2016 mailer saying “Experience the difference. 100% additive-free natural tobacco” and a 2017 mailer describing the idea the brand started with – “Use only simple ingredients: 100% Additive-Free Natural Tobacco”. The implications of current ad terms that could convey similar meaning to the banned descriptors, and of the brand’s differentiation tactics, remain concerning and problematic from a public health perspective.

Limitations of this research are that it relied on the comprehensiveness of the sample from T&T and did not include other types of marketing. While we cannot be certain T&T includes all NAS magazine ads from our timeframe, the database has an extensive repository of content likely to capture the vast majority, especially because a brand’s tobacco ads at a given point reflect their marketing strategy and thus are often redundant across multiple sources[38, 42]; further, T&T has been used as an exclusive or supporting source in numerous tobacco marketing studies [see 9, 31, 38, 42–45]. Our analyses in some cases were limited by small sample sizes in the post-agreement period, considering its shorter timeframe relative to the pre-agreement period. In addition, we coded ads in 2017 as pre- or post- agreement based on whether they had the older descriptors or newer tagline, as the agreement went into effect in mid-2017; it is possible that based on this methodology, some ads coded as pre-agreement could have actually been post-agreement. Further, our analysis focuses specifically on NAS advertising within the US; as such, we are unable to draw conclusions about NAS advertising features in other prominent markets or about international implications of brand marketing, which would be a valuable avenue for future research. Still, our study illustrates concerning patterns in US-based NAS advertising that may also present themselves in other markets.

The research conducted here, which found continued prominence of suggestive terms like “organic” and increased use of potentially misleading claims (e.g., “tobacco and water”), underscores a need for continued study of NAS marketing effects and a possible need to consider additional regulatory action pertaining to natural cigarette marketing. However, it may not be feasible to ban every individual descriptor or image that may contribute to misperceptions of cigarettes like NAS, though this may be justified for specific terms that are demonstrably misleading or seemingly synonymous with the already banned descriptors (e.g., “tobacco and water”). Broader tobacco regulatory strategies may also help to address the issues resulting from NAS marketing, and should be researched further.[46] Graphic warning labels, for instance, may visually disrupt the appealing, healthy image of NAS ads and packs. More prominent disclaimers about organic cigarettes may help dispel misbeliefs. Plain packaging, a more drastic marketing restriction than those applied to date, could be another avenue to combat persistent misbeliefs.[46] Future experimental research could help to assess these considerations by directly testing the implications of leading post-agreement descriptors, as well as potential effects of various types of regulatory changes.

Overall, by extending prior content analytic research pertaining to NAS, our research illustrated that in the years since the FDA agreement, NAS ads have relied on terms that were associated with “additive-free” and “natural” in pre-agreement ads; some of these terms have previously been shown to engender the same detrimental misperceptions that the FDA acted to prevent. Thus, this study evinces the ongoing evolution of NAS marketing that continues to convey the distinct and enduring brand image. In so doing, it also highlights a role for future research to help inform further regulatory action in support of public health.

Supplementary Material

Supp1

What this paper adds.

  • Natural American Spirit (NAS) advertising has been linked to misperceptions about reduced harm, leading to the 2017 FDA agreement banning “natural” and “additive-free” from their marketing.

  • Immediately following the agreement’s enactment, brand advertising avoided the banned terms but incorporated other suggestive descriptors (e.g., “organic”, “whole leaf”).

  • Current research has not tracked longer-term agreement compliance or established which NAS ad themes/terms have emerged as prominent in the years since the agreement and how they are used.

  • This study examines pre- to post-agreement changes in NAS advertising, finding literal agreement compliance but marked increases in the phrase “tobacco and water”, environmental imagery, and allusion to the company’s heritage and eco-friendly practices (which are tied to misperceptions).

  • This is the first analysis to assess how NAS marketing descriptors used after the agreement were associated with the banned descriptors beforehand, finding that prominent terms/themes in NAS ads now (e.g., “simple”, “different”) were frequently used in conjunction with and conceptually linked to “natural” and “additive-free” pre-agreement, in a manner potentially promoting similar connotations.

Acknowledgments:

The authors thank Eugene Talbot, Zeinab Safi, Mariam Rashid and Dmitriy Nikitin for their contributions to ad coding.

Funding: This work was supported by the National Cancer Institute at the National Institutes of Health and the US Food and Drug Administration (U54CA229973).

Research Reporting Checklist: This manuscript reports results of a content analysis and does not fall into any of the research categories requiring a reporting checklist.

Footnotes

Data Availability Statement: The coding materials for this article can be made available upon reasonable request.

Declaration of Interests: The authors declare no conflict of interest. The funders had no role in study design/execution, data analysis, manuscript preparation/editing, or the decision to publish, and the sponsors did not review the text of this manuscript.

Ethics Approval: This manuscript did not require Institutional Review Board approval, as it was a content analysis that did not involve human or animal subjects.

1

The term “real” is not in the co-occuurrence analysis because it was not used in pre-agreement ads.

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