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Misleading cigarette descriptors (descriptive words) have for decades been a concern, as descriptors such as ‘light’ and ‘mild’ can cause smokers to incorrectly believe that these products, compared to other cigarettes, reduce their risk of negative health outcomes.1–4 Now, as countries move towards standardised packaging, tobacco companies appear to increasingly use descriptors to communicate a brand's attributes to the public5 ,6 and sell their products to target audiences.6–8 In 2009, the US banned companies from using ‘low’, ‘light’, ‘mild’ and ‘similar descriptors’, except on Food and Drug Administration-designated modified-risk tobacco products.9 Internationally, the WHO Framework Convention on Tobacco Control requires a ban on misleading descriptors such as ‘light’ and ‘mild’.10 Notably, neither US law nor the Convention explicitly ban ‘natural’, ‘organic’, or ‘additive-free’ descriptors, which the public also associate with reduced risk of harm relating to tobacco,11–15 positive connotations that may have carried over from ‘organic’ and ‘natural’ food.16 ,17 However, in 2014, the European Union banned any pack labelling suggesting “vitalising, energetic, healing, rejuvenating, natural, organic properties” or making reference to the absence of additives.18 Additionally, in August 2015, the US Food and Drug Administration issued warning letters to three tobacco manufacturers for their unauthorised use of the terms ‘additive-free’ and ‘natural’.
The legal status of ‘natural’, ‘organic’ and ‘additive-free’ descriptors is a timely concern. Natural American Spirit brand cigarettes, which are advertised using all three of these descriptors, are increasingly popular in the USA and are also sold internationally.19 As a result of legal settlements, American Spirit ads in the USA are accompanied by disclaimers stating that being additive-free or organic ‘does NOT mean a safer cigarette’. Use of the word ‘natural’ requires no disclaimers.
An important question remains: Do disclaimers sufficiently help consumers understand that cigarettes with ‘organic’ or ‘additive-free’ descriptors are just as harmful as other cigarettes?20 Research on disclaimers in general finds they have limited ability to reduce misperceptions about products.21–23 We were unable to find any studies in the peer-reviewed literature that examine how the public perceives the cigarette disclaimers. Thus, in the present study, our aim was to learn about perceptions of an American Spirit ad containing ‘natural’, ‘organic’ and ‘additive-free’ descriptors, and the required disclaimers.
We recruited participants for nine focus groups (FGs) stratified by age—adolescent (13–17 years), young adult (18–25 years) and adult (26–65 years)—and smoking status (smokers, non-smokers). We had separate groups for susceptible and non-susceptible non-smoker adolescents, using a measure predictive of future smoking behaviour.24 We defined smokers as those who smoke cigarettes every day or some days and, for the adult group, who have smoked at least 100 cigarettes in their lifetime.25 Eligibility criteria included being aged 13–65 years, and being able to read and understand English. We recruited participants via print, radio, television and internet advertisements.
FGs were facilitated by KEM and two other researchers with training and experience in qualitative data collection, following a guide that, among other topics (Moracco KE, Morgan JC, Mendel JR, et al ‘Looks like croutons:’ Knowledge and perceptions of cigarette smoke constituents among adult smokers and nonsmokers, under review), included questions about participants’ responses to an American Spirit magazine ad (figure 1). Questions included queries on what participants think about the descriptors in the ad and how participants think the safety of American Spirit cigarettes compares to other brands. An eligibility screener assessed participant demographics prior to their participation. FGs were digitally recorded and transcribed, and a subset was checked for accuracy. Participants received a $50 gift card for their time.
We followed a thematic content analysis strategy.26 Two coders (MJB and SAB) analysed the transcripts using ATLAS.ti 7.5 software (ATLAS.ti GmbH, Berlin, Germany). Each coder independently reviewed all transcripts using an initial codebook based on the research aims noting emergent themes. We next came to consensus on which sections of the transcripts to code and what inductive codes to include in our final codebook. Each coder then applied this final codebook to every transcript, and we reconciled discrepancies by consensus (see final Codebook and example quotes in online supplementary material). Finally, we exported code reports and created narrative summaries for each code along with illustrative quotes, and used these in preparing the results.
The nine FGs had 59 participants (30 male and 29 female) ranging in age from 13 to 64 years (table 1). About half (49%) were smokers. While some smokers had opinions about American Spirit cigarettes based on their experiences smoking them, we did not see clear differences in how different groups interpreted the ad.
Responses to the American Spirit ad
Scepticism and confusion about descriptors in ad
Many participants were sceptical of the additive-free and organic claims in the American Spirit ad. As one said, “There's probably less additives and less chemicals but I don't think it's just straight off tobacco and paper” (FG- 3). Participants saw the use of the words ‘organic’ and ‘natural’ as a ‘sales tactic’, or said that companies may have found a ‘loophole’ in the organic certification standards. Others did not know how to interpret organic cigarettes: “I don't know what organic means really” (FG-5) and “I can't even begin to understand what organic menthol is” (FG-5).
Varying perceptions about health risk
Many participants perceived American Spirit cigarettes as being no safer than other cigarettes. Some noted that the harm from smoking was due to the burning of tobacco, and thus differences in the tobacco did not make a difference in the harm from smoking. One participant said, “I guess organic is a silly word…like jumping off a skyscraper and jumping off a cliff. Both will kill you, but the cliff's organic” (FG-4).
In contrast, many other participants said cigarettes with these descriptors might carry less health risks. When asked about the relative safety of American Spirit cigarettes compared to other cigarettes, responses included, “it's probably safer” (FG-1); “…maybe if there's more chemicals it would be worse for you” (FG-2); and “…perhaps you're not smoking in all of those other chemicals so you might have a 90 per cent chance of lung cancer instead of 95” (FG-7). Some participants did not see how an additive-free cigarette could have the same health risk as a regular cigarette. As one young-adult smoker said, “If additives equal bad, then how can having no additives make it no better?” (FG-5).
Thus, some participants thought American Spirit cigarettes might be less harmful or at least that cigarettes with additives may be more harmful. Notably, some responses referred to emotional aspects of the ad, including one comment that the ad is “kind of trying to make you feel safe” (FG-1) and another that the ‘no-additives’ descriptor is there “to make you feel less guilty” (FG-9).
Responses to disclaimers
Table 2 contains categories of responses to the disclaimers. Some participants believed the disclaimer and used it to explain their position that, clearly, American Spirit cigarettes are no safer than other cigarettes. However, some did not initially notice the disclaimer. Some said that other parts of the ad drew their attention away from the small text. Others questioned the efficacy of the disclaimer since consumers have become ‘immune’ to warnings and ignore them. Some participants were not sure if the disclaimers were truthful. A few indicated that these messages may not be trustworthy since they likely originate from the government. A few misunderstood the meaning of the disclaimers, for example, believing they referred to addictiveness rather than health risks. In most of the FGs, after the disclaimers had been brought up, there were participants who continued to express opinions that American Spirit cigarettes may be less harmful than other cigarettes.
Switching to reduce health risks
A few smokers shared stories of people who had switched to American Spirit cigarettes from another brand, as a less harmful alternative. One said, “I had a co-worker who became pregnant and was a smoker, so she turned to American Spirits to try to make it safer for the baby” (FG-5). Another shared how a friend had switched to American Spirit cigarettes, with the belief that “they're not as bad for you”, as a compromise with his wife who had wanted him to quit (FG-9). One young-adult smoker said that she “tried to get into American Spirit” (FG-5) because she heard they are additive-free, but she did not enjoy them.
American Spirit was the main brand smoked or one of the main brands for some FG participants. One said that he switched from Camel cigarettes to American Spirit because American Spirits are all natural and he believes they are a bit safer, even, as he noted, if it is ‘naive’ to say so (FG-8). A participant explained how smoking these cigarettes made her feel better about her smoking:
I mean they're my brand. [Safety] is the reason that I'm smoking them and make myself feel better about it, but really, I know they're not a safe cigarette. (FG-5)
One participant explained that “I have friends that don't smoke, but if I have a pack of American Spirits, they'll bum a cigarette or something because it's like, well, it's not really a real cigarette” (FG-5).
To the best of our knowledge, our study is the first to explore public perceptions about disclaimers in ‘additive-free’ and ‘organic’ cigarette ads. We found that some people attribute a health benefit to cigarettes labelled as ‘natural’, ‘organic’, or ‘additive-free’, a finding also noted in previous studies.11–15 Additionally, the scepticism and confusion we encountered about cigarettes with these descriptors were similar to findings from documents of tobacco industry FGs.15 This study adds numerous possible reasons disclaimers do not fully negate the impact of cigarette descriptors. Some people, when glancing at an ad, do not notice the small print, especially when ad designs give unequal weight to descriptors and disclaimers. Others seem to consciously ignore disclaimers, some out of distrust for government-mandated messages. Importantly, in most groups, even after the moderator brought the disclaimers to everyone's attention, some individuals expressed opinions that these cigarettes may carry less health risk. We also found that some smokers, even after countless exposures to disclaimers on the packs, smoke American Spirits with the belief that they are safer. Our study suggests that the mere presence of the disclaimers does not sufficiently counter misperceptions. For the disclaimers to be effective, they need to be noticed, read, cognitively processed and remembered.27 ,28 Also, as noted, there are no current disclaimers when using the word ‘natural’.
Additionally, advertisements often focus on emotion, associating a feeling with a product.29 In this way, American Spirit and other ‘natural’ cigarettes may benefit from positive health associations with organic, natural and additive-free food.16 ,17 Furthermore, as risk perceptions have strong origins in feelings and emotion,30 people's positive affective responses to naturalness may reduce the risk that they attribute to these cigarettes. Even if people logically accept that these cigarettes are as harmful as others, they may feel safer smoking them. These misperceptions may facilitate casual use of these cigarettes among youth and cause experienced smokers to switch to American Spirits rather than quit.
Strengths of this study include the purposive sampling and stratified approach, the inclusion of susceptible adolescent non-smokers, and the fact that we asked smokers about their real-world experiences. While qualitative research can identify themes among people's beliefs, a limitation of such research is that it does not quantify the prevalence or distribution of those beliefs. Population-based surveys should examine whether our findings on the limitations of disclaimers are widely prevalent.
Governments should be concerned that the present study, as well as previous work, indicates some people viewing ‘natural’, ‘organic’ and ‘additive-free’ cigarette ads and packages perceive these products as lower risk. It is particularly concerning that many of the individuals at greatest risk for smoking initiation (adolescent and young adult non-smokers) hold this inaccurate belief. Our study indicates that disclaimers have not solved the problem. If additional research replicates these findings, it may be appropriate for regulatory agencies to ban ‘natural’, ‘organic’ and ‘additive-free’ descriptors, categorising them as similar to ‘light’ and ‘mild’. In accordance with the obligations of the Framework Convention on Tobacco Control, signatory countries may need to ban these descriptors. Countries considering standardised packaging should consider descriptor restrictions as a component of their legislation. A ban could prevent misconceptions among current smokers and reduce the appeal of these products among potential smokers.
What this paper adds
Previous studies showed that cigarettes with the descriptors ‘natural’, ‘organic’, or ‘additive-free’ are perceived to be less harmful than other cigarettes.
To address these misperceptions, the US government and tobacco companies reached settlements that require disclaimers on advertisements and cigarette packs containing ‘organic’ or ‘additive-free’ descriptors, stating that these cigarettes are not safer.
The effectiveness of this solution in correcting the public's misperceptions is unknown.
Among a diverse sample of 59 people in Southern USA, we found that the disclaimers have not sufficiently corrected misperceptions because they are ignored, distrusted, doubted, or simply not seen.
The authors would like to thank Marissa Hall, Jennifer Mendel, Kathryn Peebles, Deborah Tate, Randall Teal and Maihan Vu for their help with instrument development, focus group recruitment and data collection. They also thank the focus group participants for their valuable input.
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
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