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Abstract
Background Since 2006, leading US cigarette companies have been promoting new snus products as line extensions of popular cigarette brands. These promotional efforts include direct mail marketing to consumers on cigarette company mailing lists. This study examines smokers' reactions to this advertising and perceptions of the new snus products.
Methods Eight focus groups (n=65 participants) were conducted in San Francisco and Los Angeles in 2010 with smokers who received tobacco direct mail advertising. The focus group discussions assessed smokers' perceptions of the new snus products. Focus group videos were transcribed and coded using Transana software to identify common themes.
Results Most participants were aware of snus advertising and many had tried free samples. Most were aware that snus was supposed to be ‘different’ from traditional chewing tobacco but consistently did not know why. Participants willing to try snus still identified strongly as smokers, and for some participants, trying snus reinforced their preference for smoking. Snus' major benefits were use in smoke-free environments and avoiding social stigma related to secondhand smoke. Participants were sceptical of the idea that snus was safer than cigarettes and did not see it as an acceptable substitute for cigarettes or as a cessation aid.
Conclusions Smokers repeated some messages featured in early snus advertising. Snus was not seen as an acceptable substitute for smoking or way to quit cigarettes. Current smoker responses to snus advertising are not consistent with harm reduction.
- Advertising and promotion
- harm reduction
- non-cigarette tobacco products
- tobacco industry
- prevention
- social marketing
Statistics from Altmetric.com
- Advertising and promotion
- harm reduction
- non-cigarette tobacco products
- tobacco industry
- prevention
- social marketing
Introduction
Prior to the 20th century, in the USA, tobacco was primarily consumed as leaves placed between the cheek and gums and occasionally chewed.1 While cigarettes are now the most popular tobacco product, since the 1980s, moist snuff use has increased.2–6 In 2009, approximately 3.5% of US adults used smokeless tobacco, and 75% of the smokeless tobacco market was moist snuff: cured tobacco ground into fine particles where a pinch or ‘dip’ is placed between the cheek and gum.7 ,8 Traditional chewing tobacco requires users to expectorate, and it has been associated primarily with outdoor male activities.
Since 2006, two leading US cigarette companies, RJ Reynolds (parent company Reynolds American Inc.) and Philip Morris (parent company Altria), acquired smokeless tobacco companies and began to market new snus products.9 Snus (rhymes with ‘loose’) is finely ground moist tobacco snuff packaged in small porous pouches that are placed between the cheek and gum and traditionally used in Scandinavia. The juices produced in the mouth when using snus are swallowed rather than spit out. In Sweden, snus processing typically involves heat treatment or pasteurisation, which is thought to reduce carcinogens, such as tobacco-specific nitrosamines, compared with traditional US chewing tobacco.10 US snus marketing has emphasised the Swedish origins of snus (figure 1). However, it is unknown whether products currently marketed with the name ‘snus’ in the USA are processed in the same way as Swedish snus, and limited studies of product composition suggest that the American and Swedish products are not equivalent.11
Example of early Camel snus advertising (2007) emphasising its Swedish origins and promoting its use in smoke-free environments (at a concert, in an airplane, at a bar or club). RJ Reynolds. Camel Snus. 2007. http://www.trinketsandtrash.org/tearsheet.asp?ItemNum=211916.
Furthermore, snus products in the USA have been promoted as line extensions of powerful cigarette brands: Marlboro and Camel. Following test marketing, both Camel and Marlboro snus products were launched nationally in 2009 and 2010 respectively,12 in cities that have smoke-free laws in workplaces, bars or restaurants.13 With increasing clean indoor air laws, snus has been marketed as a product that could be used discreetly in public, unlike chewing tobacco (which requires spitting)14 or cigarettes (figure 2).12 Snus products are suggested for use in bars, offices and airplanes ‘when smoking isn't an option’ (figure 3). In this way, snus has been marketed primarily as an adjunct to smoking, rather than a replacement.
Examples of Camel snus advertising (2009) emphasising (A) the discreet nature of snus and (B) the message that snus is not the same as traditional smokeless tobacco, also known as ‘dip’. The coupon (far right panel) offers one free tin of Camel snus. RJ Reynolds. Camel snus. http://www.trinketsandtrash.org/tearsheet.asp?ItemNum=212801 (A) and http://www.trinketsandtrash.org/tearsheet.asp?ItemNum=212564 (B).
Example of Marlboro snus direct mail advertising (2009) targeting smokers. The coupon offers a free pack of Marlboro snus with any Marlboro product purchase. Philip Morris. Marlboro Snus. 2009. http://www.trinketsandtrash.org/tearsheet.asp?ItemNum=212750.
Outside the USA, snus products have been promoted by British American Tobacco (BAT) in South Africa, Japan and Canada, bearing cigarette brand names such as Lucky Strike and Peter Stuyvesant.15–17 In 2009, Phillip Morris International also entered into an agreement with Swedish Match AB to commercialise smoke-free tobacco products such as Swedish style snus worldwide outside of Scandinavia and the USA.18
The use of snus as a harm-reduction product has been a topic of debate within the public health community.10 Some argue that in Sweden, the rates of tobacco-related mortality and morbidity were reduced as male users replaced cigarettes with snus.19 However, the use of snus may deter smokers from smoking cessation, it may attract new users who would have not otherwise used tobacco and it normalises tobacco use and the tobacco industry.20 ,22 Promoting smokeless tobacco products as line extensions of established cigarette brands may also encourage dual use of both products.21 ,9 Dual use of cigarettes and smokeless tobacco is of unclear benefit to public health and may actually increase the risk of tobacco-related morbidity and mortality.22 ,23 Dual use has been associated with increased risk of acute myocardial infarction compared with smoking and chewing tobacco alone.24 In addition, a longitudinal study demonstrated that dual users were less likely to quit using tobacco.23
The public health community and general public likely view smokeless tobacco products differently, in part because of different exposure to marketing messages and different access to information about smokeless tobacco. As traditional broadcast tobacco advertising (such as billboards) has been restricted, tobacco companies have increased the use of direct mail, email and other direct to consumer advertising. This approach aims to develop and maintain relationships with existing customers, often by offering steep discounts on purchases of multiple packs of cigarettes.25 Direct mail or email marketing largely remains outside the scrutiny of the public health community.25 Current adult smokers in New Jersey were 4.5 times more likely than never/former smokers to report receiving direct mail from tobacco companies.26
Tobacco companies used multiple strategies to build their direct mail databases: they purchased commercial marketing databases, directly recruited consumers through sweepstakes forms and other contests, collected contact information when distributing free tobacco samples or at entry to industry sponsored events (such as those held at bars or nightclubs) and collected names from signed coupons or brand-loyalty programme orders.26 Direct mailings have been used to promote Marlboro and Camel snus with coupons and free packages of snus, often linked with the purchase of cigarettes (figures 2 and 3). This research aimed to explore smokers' perceptions of direct mail advertising campaigns and smokeless tobacco products. The guiding research questions were (1) How do smokers perceive snus compared to chewing tobacco? (2) What has motivated any smokers to try snus? and (3) What do smokers perceive as the risks and benefits of using snus?
Methods
We conducted eight focus groups (four in San Francisco and four in Los Angeles, California) with 65 smokers in July 2010. Eligible participants were adult current or former smokers who had received direct mailing advertisements for tobacco products in the past year. We felt that smokers in California were a relevant study population due to aggressive snus advertising promoting dual use in smoke-free environments, the low smoking prevalence, longstanding clean indoor air laws and role as a test market for Camel snus since 2008.
We contracted with a commercial market research firm based in both San Francisco and Los Angeles to use existing commercial market research databases, telephone, internet and street recruitment to identify participants. A member of our research team moderated all focus groups. Participants' receipt of direct mail advertising from tobacco companies was validated both by description and by participants bringing examples of direct mail they received to the focus group. While the number of smokers on mailing lists is not known, Philip Morris' database contained 37.7 million names in 2005,27 and there were an estimated 45.1 million smokers in the USA in 2005, so a substantial proportion of smokers were likely exposed to direct mail marketing. We expected that around one-third of smokers would be on direct mail lists, as 35% of current adult smokers in New Jersey reported that they were on lists to receive direct mail tobacco advertising.26 This requirement limited the potential pool of participants, so we did not limit focus group participation further by gender, age, brand or other factors. All subjects completed written informed consent, and all study protocols were approved by the University of California San Francisco Committee on Human Research. The 90 min focus groups were video recorded to facilitate accurate transcription and analysis. Small digital video cameras mounted on tripods and visible on the side or corner of the room were used, and participants were all informed that they were being video recorded and observed by researchers in the other room. None of the participants objected, and we did not note any self-conscious behaviours among the participants.
Participants described the direct mailings they brought with them or a piece of direct mail advertising they selected from samples provided to the group. Participants described their routine of sorting through and opening direct mail advertisements and how they used the discounts and coupons offered therein. This was followed by a discussion of their likes and dislikes of such mailings and the perceived effect these mailings had on their use of tobacco products, including smokeless tobacco products. This analysis focuses on discussion of smokeless tobacco direct mail advertising, which was a subset of the direct mail advertisements discussed.
Data analysis
Video recordings of the focus groups were transcribed and then open-coded using Transana software, which synchronises the transcript with the video data allowing analysts to work with both simultaneously and to correct and annotate transcripts as video recordings are reviewed.28 Synchronised analysis of video and transcripts enables the researcher to better understand and identify individual voices during simultaneous and collaborative talk and to view non-verbal interaction, such as gaze and agreement or disagreement with the current speaker.29–32
The research team met frequently to discuss the open coding process, code word definitions, to explore discrepancies in coding and to identify emerging themes in the data. Several focus groups were double coded by two different team members to identify and discuss differences in the coding schemes. Collections of data related to different topics were created, based on our guiding research questions and summary memoranda including illustrative quotes were written. These memoranda were reviewed and discussed by multiple team members, who iteratively identified more specific research questions (eg, how do smokers differentiate between smokeless tobacco and cigarettes?) and emergent themes.
Results
The demographic characteristics and tobacco use history of participants are summarised in table 1.
Participant demographic characteristics and tobacco use (N=65)
Although not all smokers in the focus groups had tried smokeless tobacco products, most participants were familiar with smokeless tobacco and reported that they had seen or received advertising for new snus products (primarily Camel snus). Those participants who had tried smokeless tobacco products related their experiences with the product to other members of the group.
How do smokers differentiate between smoking and smokeless tobacco?
When participants were asked about smokeless tobacco products and their use, they began by making a clear distinction between ‘smokers’ and ‘chewers’:
I used to hang around with a lot of cowboys. They don't smoke cigarettes. They chew tobacco. And like baseball players. It's just like a tribal kind of habit for them. And I don't know, it doesn't seem so gross when it's in a big group of guys that are doing it, just through the work day or whatever. —LA, female, 53
Yeah, most smokers that I knew back in the day, that is one or the other—I mean either you were a, you know, you were a tobacco chew guy, or you were a cigarette guy, or you know, or cigars.—LA, male, 29
These comments also illustrate the widely held notion that smokeless tobacco use was regarded as a male activity. Smokers' experimentation with snus, however, did not cause them to reclassify themselves as ‘chewers’. Women seemed amenable to trying snus, but not with great enthusiasm:
… It's not the same as smoking. It wasn't anything I wanted, but I tried it just because it was something new and weird… it's not anything I would ever buy.—SF, female, 26
Overall, most participants who tried smokeless tobacco identified themselves as smokers and continued emphasising that they would remain a smoker. Ultimately, participants strongly preferred smoking:
It is. I tried it. I did it. … really wasn't for me, though. I tried one packet of it. I remember it wasn't really— I was always just a cigarette smoker. I never really got into the tobacco, you know.—LA, male, 29
Some remarked that using snus products reminded them how much they missed the experience of smoking a cigarette, including the use of the hands and feeling of the smoke itself:
It's not that I didn't like anything about it [snus]. It's what I miss from smoking. I like to inhale and to see smoke and that whole process behind it. Even though I was getting the nicotine in my body, I still felt like I didn't get what I wanted and I wanted to smoke.—SF, male, 33
I don't really understand like what smoke-free tobacco is, like, it just sounds weird to me. Like, the whole smoke is like what makes you want them. I don't know. They go together. Why would you smoke and not have any smoke come out.—SF, female, 20
No one in the focus groups identified themselves as being a ‘dual user’ of both cigarette and smokeless tobacco, and the concept of dual use was not brought up. Participants strictly retained their smoker identity, even if they had tried smokeless tobacco products.
Differentiating snus from chewing tobacco
Participants familiar with Camel and Marlboro snus advertisements perceived a difference between traditional smokeless and the snus products. Traditional smokeless was referred to as chewing tobacco, ‘chew’ or by brand names, such as Copenhagen or Skoal. Snus was recognised as something different:
It's a little pouch, that's not real Copenhagen. It's just tobacco. You can chew it.—LA, male, 37
It's a packet of tobacco, like basically chew that you don't chew. And it's just spittable.—SF, male, 26
While snus was perceived as different from traditional smokeless tobacco, participants varied in how they described these differences. Some named differences in how the product was used (need to spit out the juices):
You just put it in, and what I've heard, if you accidentally swallow some, it can cause hiccups, or like maybe throw up, so they are trying to make it safer to chew tobacco, and they made little packets and you just chew on a packet, or suck on a packet and spit it out.—SF, male, 23
Smokers also expressed some confusion about whether or not snus products actually required spitting or not. Some participants specified that the product did not require one to spit out juices, while others noted that the snus packet needed to be spit out:
It's in a little pouch that you just put under your lip and you basically get the nicotine into your gums that way. It's like—but you don't spit. You don't chew and you don't spit. It's supposed to take five to 15 minutes; I think it said, before you start feeling the nicotine.—SF, male, 27
Other participants described the difference from loose chewing tobacco primarily as packaging in a tea bag or a pouch. This was one of the distinct characteristics of snus that smokers were able to describe easily:
So, it's like a tea bag?—SF, male, 23 Yes, exactly. Very small.—SF, female, 51
Additionally, almost all smokers who had been exposed to snus advertisements associated it with being a Swedish product:
It's a Swedish—it's called “snus.” It's a Swedish spitless tobacco.—LA, male, 29
However, one smoker assumed that the Swedish origin was a creative marketing ploy:
Camel's come out with about everything under the sun to get everyone to smoke—now the snus, of course, because you can do it privately and no one sees you. Of course when I saw this, first thing I looked through it—I went and ran and saw my roommate because he's Swedish. I asked if it really started in Sweden. First thing I really look for is, is it free?—SF, female, 44
Some participants remarked that snus was intended to be safer or better than traditional chewing tobacco:
Yeah, you put them like in between your lip, and they're [referring to snus] supposed to be better than chew.—LA, female, 23
While smokers appeared to reflect the message that snus was different from traditional chewing tobacco, the fact that the product and its name were different made snus less attractive to some:
The name's kind of weird—snus.—SF, male, 33
It sounds like a Muppet.—SF, female, 26
Like a Smurf or something. People I know—we've had conversations—the name doesn't make you want to try it. It kind of sounds like a new drug or something. Like, [whispering] “got any snus on you?”—SF, male, 33
Smokers' motivations to try snus
Offers for free packages of snus appeared to be the primary motivator for participants to experiment with snus, particularly given the high cost of cigarettes. Despite widespread concerns expressed about the high cost of cigarettes, smokers in our groups did not remark upon the comparatively lower cost of snus even without the coupons:
I won't buy them… I won't. They're too much money [Referring to cigarettes]. I need a coupon. And so this coupon, actually this one seems to have coupons, and then it also has—they have new things now called some tobacco-less tobacco, or where you don't—you chew it, you don't smoke it, and they give free—they give you free samples with these. And that's what I like about it.—LA, female, 45
In some cases, the free samples made some participants feel the tobacco companies' aggressive promotions of free snus at bars and clubs were an attempt to unload an unpopular product:
You swiped [referring to swiping magnetic strip on an identification card] and got the two free packs of cigarettes. But they made you take a handful of snus. Like a double fisted handful.—SF, male, 26
What are the perceived risks of smokeless tobacco?
Only a minority of smokers expressed a perceived risk of both toxicity and addictiveness of smokeless products compared with cigarettes. Swallowing the juices of snus packets was perceived by participants as both disgusting and potentially toxic, as illustrated in this exchange between three participants in San Francisco:
With the chewing tobacco, you spit out the juice. With this snuff stuff, they say you don't have to.—SF, male, 31
You swallow it.—SF, male, 26
Yeah, exactly, which I think is disgusting. I mean, that—that pollutes your body just ten times.—SF, male, 33
Another participant in Los Angeles speculated:
…those [referring to snus] are more addicting—LA, male, 50
Although snus advertisements in the USA do not make overt claims that snus as less harmful than cigarettes, some participants were aware of this claim. One participant also compared snus with other chewing tobacco:
Yeah, it's supposed to be a health—it's supposedly healthier—I won't say the word healthier. It's kind of oxymoronic, but it's a better alternative than to regular [referring to chewing tobacco].—LA, male, 29
What are the perceived advantages of using snus?
Participants frequently discussed the benefits of using snus products indoors where smoking is restricted:
Well, all these restaurants being smoke-free and stuff… there's a market for that, it seems.—SF, male, 32
It's for when you can't smoke a cigarette, I think, because if you're in, like, an office working or anywhere I think, or if you're in a studio or anything just where you can't smoke.—LA, male, 27
Yeah. Well, I think because you can use either of them in a restaurant—smoking where you can't smoke. So it's being able to get your nicotine when you're being told you can't.—SF, male, 27
It's [referring to snus] called “work-friendly.”—LA, male, 29
The ability to consume snus discreetly was another advantage compared with cigarettes or spitting tobacco:
I have friends who sit in class and have them in their mouth.—LA, male, 18
People think you're chewing gum or something.—LA, female, 35
Another perceived advantage of snus over cigarettes was to avoid exposing others to secondhand smoke. However, rather than a way to avoid the health risks associated with secondhand smoke, snus was viewed as a way to avoid social stigma:
I think it has something to do with, you know, second hand smoke. I know I worry about second hand smoke. I hate smoking around people. I hate getting those disgusting looks from people, you know, I'm smoking, and they hate it.—LA, female, 23
Participants' experiences trying snus
Only a minority of participants had actually tried snus; those who tried snus almost universally described the product as ‘weird’ and ‘disgusting’ and not something they would try again:
It's not very enjoyable. It sort of burns the mouth. It's supposed to give you a –sort of—I bought the one that was mellow, which was supposed to keep you calmer, and it did not. It just made me uncomfortable.—LA, male, 18
Because it burned really bad. It didn't taste good. It was disgusting. It wasn't anything like a cigarette… it wasn't natural.—LA, male, 27
I didn't like the feeling in my mouth… I'd rather chew gum… it just wasn't for me.— LA, female, 37
In addition to the taste, participants who tried the product found it did not live up to its ‘spitless’ claim
It was really strong, it made me kind of sick. Like, it was just really, really strong. I had to spit it out. I got a headache.—SF, female, 32
Well, I mean maybe it, like, just to have it for a couple of minutes, but once it starts to get like grass, I would spit it out… well, you still kind of have to spit, if you don't want to swallow it. —LA, female, 23
Well, you—you don't have to spit, but you spit the thing out.—SF, male, 26
Discussion
Six main points emerged from these focus group discussions: (1) snus was seen as a temporary replacement for cigarettes for situations where one could not smoke; (2) snus was perceived as different from traditional chewing tobacco, but specific differences were less consistently noted; (3) promotions offering free samples either through coupons on cigarette packs, direct mail advertising or distribution at clubs and events successfully motivated smokers to try snus; (4) smokers did not perceive snus as less harmful than other tobacco products for users but recognised that snus eliminated some social problems of smoking; (5) the major benefit of using snus was that it could be used discreetly in smoke-free environments and (6) smokers' experiences with snus were unappealing.
Other studies have examined smokers' perceptions of cigarettes, potentially reduced-exposure tobacco products33 and non-traditional tobacco including snuff, but we identified only one study in the USA that has examined smokers' perceptions of Camel snus through a qualitative analysis of Camel snus's website message board.34 The message board participants frequently tried Camel snus free samples, similar to participants in our study. In contrast to our findings, perceptions of the board participants about Camel snus were overwhelmingly positive, although several participants disliked the spice-flavoured snus.34
Camel snus advertising between 2006 and 2009 attempted to differentiate snus from traditional smokeless tobacco and promoted its use in smoke-free environments (figures 1 and 2). Our findings suggest that the industry has communicated these messages successfully to smokers. The situational use of snus to deal with clean indoor air laws was perceived as a major benefit that was commonly discussed among our participants. This theme is also expressed in the message board study.34 Snus was also widely perceived as a temporary replacement and not a complete substitution for cigarettes. Our findings are consistent with a study examining US smokers' reactions to a brief trial of oral nicotine products that found that smokers viewed using smokeless tobacco products such as Camel snus and Marlboro snus as a temporary rather than a complete substitution for their smoking.35
An intriguing finding in our study was that for some smokers, using snus reinforced their preference for cigarettes and the feeling of smoking. Snus was not perceived as a cessation aid; one participant had tried snus while quitting but did not continue using it.
While almost all participants used coupons to initially try snus, this did not translate into continued purchases, despite the lower price of snus compared with cigarettes. Almost all participants who tried snus disliked it and stated that they would not purchase or try snus again. The message board participants commented that the price of snus was too high compared with other smokeless tobacco products, while others noted that the price seemed ‘acceptable’ when compared with smoking.34 The ‘acceptable’ cost of these products still did not promote a complete switch to snus.
There is growing attention to tobacco harm reduction and an increased interest in promoting the use of lower nitrosamine smokeless tobacco such as snus in lieu of smoking.10 ,19 Most smokers in our study appeared sceptical about whether or not snus was a safer alternative to cigarettes. The use of snus as a harm-reduction product was rarely mentioned, and participants expressed scepticism about the notion that snus was healthier. While harm reduction is hotly debated within the tobacco control community, the issue is largely absent from the discussion by the California smokers participating in our study, who generally echoed messages from snus advertising. Other studies that have looked at smokers' perceptions of smokeless tobacco products such as snus have been conducted in Sweden where the use of snus is more prevalent and perceived as attractive and trendy.36 In the USA, snus is a new product that has no established cultural context or established user base, so a campaign discouraging dual use of cigarettes and snus in the USA needs to deter adoption of a new product. This suggests that the Swedish experience with snus is highly unlikely to translate directly into patterns of use in the USA.
Tobacco companies are engaging in lobbying efforts to overturn the snus ban in European countries outside Scandinavia.37 This may lead to the global expansion of snus marketing. As a result, future studies should examine and monitor the international smokeless tobacco markets and marketing strategies, particularly products modelled after Swedish snus. With the implementation of the Framework Convention on Tobacco Control and increasing clean indoor air policies, the tobacco companies' response may be to market snus globally even more aggressively. International studies might aid in our understanding of the effects of these marketing efforts by including questions about the interest in or rates of adoption of snus products by smokers and others, the reasons for doing so and the effects on tobacco use patterns. Hypotheses resulting from this research that could be tested in future studies include: in countries where smokeless tobacco is used primarily by men, female smokers who perceive snus to be different from traditional smokeless tobacco are more likely to try it; current snus products marketed in the USA are poor substitutes for cigarettes and smokers who adopt US snus products are unlikely to quit or reduce their cigarette consumption.
Our sample of exclusively urban smokers from California limits the generalisability of our findings to smokers outside of California's metropolitan centres. The study is limited to a convenience sample of smokers on direct mail lists that were not further subdivided into groups based on demographic or tobacco use, so the data have limited application to specific subgroups. One would expect experienced smokeless tobacco users would have markedly different perceptions of snus, its attractiveness or trial experiences, and future research should assess participants living in rural areas and urban centres outside of California. It would also be interesting to explore perceptions of snus marketing among non-smokers, particularly youth and young adults. Continued surveillance of direct mail marketing of snus and assessment of its impact on snus purchases is needed.
It appears that snus advertising promotes dual use of cigarettes and snus. Our study suggests that counter-marketing messages are needed to discourage use of multiple tobacco products, particularly if such patterns of use discourage smoking cessation. Drawing attention to product deficiencies (participants almost universally found snus unappealing) may be a useful strategy to discourage the uptake of snus by smokers who may be otherwise motivated to quit. Pointing out similarities between snus and other smokeless tobacco products may decrease their attractiveness, particularly to women, who have low rates of traditional smokeless tobacco use. Implementation of clean indoor air policies should ideally be accompanied by incentives to quit smoking rather than to take up another type of tobacco product. Targeted financial incentives (such as offers for free or discounted smoking cessation aids) may be particularly relevant to smokers on tobacco direct mail lists, whose behaviour was frequently motivated by free sample offers and coupons. Finally, campaigns that de-normalise the tobacco industry may support scepticism about new tobacco product ‘innovations’ (including snus and dissolvable products), encouraging smokers to recognise that these products may promote continued tobacco use and are designed to increase tobacco industry profits.
What this paper adds
This paper contributes to the literature on new aggressive smokeless tobacco product advertising in the USA. This paper provides the first qualitative analysis of smokers' perceptions of Camel and Marlboro snus direct mail advertising and their experiences trying the new products. Our analysis reveals that smokers found these products were not an acceptable temporary or permanent substitute for smoking. In fact, for some, using these products reinforced their preference for smoking. Smokers were attracted to snus primarily as a way to deal with smoke-free environments and avoid social stigmas associated with secondhand smoke. Few smokers were willing to continue using snus after trying a free sample, and none found it to be an acceptable substitute for smoking or a viable smoking cessation aid.
References
Footnotes
Funding This research was funded by the National Cancer Institute Grant (R01-CA141661) and the Public Health Trust.
Competing interests None.
Ethics approval Ethics approval was provided by University of California San Francisco Committee on Human Research.
Provenance and peer review Not commissioned; externally peer reviewed.