Article Text
PDF
Abstract
Introduction Many countries removed misleading descriptors (eg, ‘light,’ ‘mild’) from cigarette packaging because they falsely conveyed messages of reduced risk. It is unclear if relabelled products currently promote misperceptions or differences in product use and toxicant exposure. We compared product perceptions, use and exposure between a US sample of Marlboro Gold (formerly ‘light’) and Red smokers.
Methods 240 non-treatment-seeking adult daily Marlboro smokers (70% male, 71% White, mean cigarettes/day=16.4 (SD=8.3)) completed two laboratory sessions over a 5-day period. During sessions, participants smoked two cigarettes through a topography device to capture their puffing behaviour, provided precigarette and postcigarette carbon monoxide (CO) assessments, and completed risk perception and subjective rating questionnaires. Self-reported cigarettes per day were verified via daily filter collection; urine collected at the end of the period was assayed for nicotine metabolites.
Results Gold (n=49) smokers were more likely than Red (n=191) to incorrectly believe their cigarettes had less nicotine and tar than regular cigarettes (ps<0.001), and rated them as weaker, less harsh, and mild tasting (ps<0.05). Differences between Red and Gold smokers in cigarettes per day and puffing behaviours trended towards significance (ps<0.1). Notably, there were no group differences on CO boost or total nicotine equivalents (ps>0.1).
Conclusions Misperceptions about nicotine and tar exist years after rebranding Marlboro Lights as Marlboro Gold. Biological results support that Gold smokers do not have lower toxicant exposure. The US should consider comprehensive packaging or product design regulations to properly inform smokers of product risks.
Trial registeration number
- packaging and labelling
- advertising and promotion
- nicotine
- public policy
- smoking topography
Data availability statement
Data are available on reasonable request. Deidentified data and a measures codebook will be made available on request.
Statistics from Altmetric.com
Introduction
Although its prevalence is declining,1 combustible cigarette smoking remains the leading cause of preventable death worldwide.2 To further reduce tobacco use and related disease, many countries have adopted legislation to enact stronger regulations on tobacco products, including the 2009 Family Smoking Prevention and Tobacco Control Act (FSPTCA) in the USA3 and the WHO’s Framework Convention on Tobacco Control (FCTC) in other countries.4 Provisions of both the FSPTCA and the FCTC allowed for the removal of misleading descriptors (eg, ‘light,’ ‘mild,’ ‘low (tar)’) from cigarette packaging and advertising,3 4 as these terms explicitly and/or implicitly convey inaccurate messages of lower risk.5 Brands affected by the descriptor ban, however, retained all other marketing and design features. When descriptors were banned in the UK, perceived benefits of light cigarettes decreased initially, but afterward rebounded slightly.6 Years after the USA enacted a similar ban, it is unknown whether these products mislead consumers about health risks or impact product use and toxicant exposure.
For decades, the tobacco industry used ‘light,’ ‘mild,’ “low (tar),’ and other misleading terms to exploit smokers’ health concerns about cigarettes.5 Cigarettes labelled with these descriptors were marketed as having lower nicotine and tar yield based on a flawed and now abandoned testing method that determined exposure to cigarette constituents using machine-generated puffing behaviour, not actual human smoking behaviour.5 In real-world use, design features on light and low-tar products (eg, ventilation) allow smokers to adjust their puffing behaviours and extract similar or greater levels of nicotine and toxicants compared with ‘full-flavour’ cigarettes, ultimately resulting in similar disease risk.5 7 As such, nicotine and tar yields stated on cigarette packages and advertisements were poor indicators of actual exposure, yet the industry continued to deceive consumers and maintain sales by marketing these products as healthier alternatives to full-flavoured varieties.8 9
When tobacco manufacturers were prevented from using misleading descriptors in cigarette labelling and advertising, they took several actions to preserve implicit messages about reduced risk. Many brands enacted colour-coding schemes, in which ‘light’ or ‘ultralight’ products were renamed with colours implicitly conveying the same level of health risk, such as blue, gold or silver (eg, Marlboro Lights became Marlboro Gold).10 11 Retailers were provided with flyers detailing these changes to easily redirect consumers to the previous product labelling system.12 Onserts affixed to packages also reassured smokers that nothing about their brand would change despite forthcoming federally required packaging changes (although in the USA, the Food and Drug Administration eventually required that brands discontinue the use of onserts).13 Thus, although the intent of removing misleading descriptors was to correct misperceptions, the industry recognised that other components of the cigarette package (eg, colour) could communicate health risk messages14 and minimise the policy’s effects.
Unsurprisingly, studies6 15 16 conducted soon after misleading terms were banned found little effect on improving smokers’ knowledge of product risks. Using four waves of data from the International Tobacco Control Policy Evaluation Four-Country Survey, Borland et al found that perceived benefits of light cigarettes in the UK decreased immediately following the country’s descriptor ban, but only to levels similar to those in the USA where no policy change occurred. Further, at a subsequent wave, those perceptions rebounded slightly.6 Similarly, after the USA banned misleading terms, Falcone et al found that fewer than half of light cigarette smokers recruited for an in-person study were aware that any changes had occurred to the packaging of their brand.15
Despite having several product lines affected by various countries’ descriptor bans over the past 15 years, Marlboro remains the most popular cigarette brand globally and in the USA.17 Given that Marlboro Gold (formerly Lights) packaging has changed little aside from removing the word ‘light,’ and that the cigarettes themselves have remained unchanged, it is plausible that smokers still choose this sub-brand for perceived health benefits. However, there have been no studies since those conducted immediately after the descriptor ban addressing whether Marlboro Gold cigarettes still mislead consumers about health risks in the absence of the ‘light’ label or previously stated nicotine and tar yields. Further, there is little data objectively characterising smoking behaviours and toxicant exposure among current Gold smokers. Research on this specific sub-brand is critical, as Marlboro Gold Kings were the top-selling cigarette pack in USA convenience stores in 2018.18 Additionally, marketing tactics employed by Marlboro to boost sales are likely to be replicated by other brands striving to match Marlboro’s popularity.
This study examined differences in product perceptions, smoking behaviours and exposure between Marlboro Gold and Red smokers participating in a 5-day baseline period of a randomised trial of cigarette packaging. Because Gold cigarettes have retained both their design (ie, filter ventilation) and packaging features other than the ‘light’ descriptor, we hypothesised that consistent with prior research,5–7 16 19 Gold smokers would be more likely to: endorse false perceptions of health risks about their cigarettes,20–22 subjectively rate their cigarettes as lighter/weaker23; engage in compensatory smoking behaviours (smoke more cigarettes per day and/or puff more intensively)24 25 and have toxicant exposure levels similar to Red smokers.26
Methods
Sample and design
Participants were 240 non-treatment-seeking daily adult smokers who completed a 5-day baseline period of a larger randomised trial of cigarette packaging. Smokers were recruited from the Philadelphia area from October 2014 to February 2019 using digital and print media advertisements and through contacting former participants. Smokers were excluded if they reported: drinking >25 alcohol-containing drinks/week; using other nicotine-containing products; current/planned cessation programme enrolment; a serious/unstable medical condition or substance abuse disorder in the past 12 months; pregnancy and/or lactation; or if they provided a breath alcohol concentration reading >0 or carbon monoxide (CO) sample <5 ppm during their initial visit. Those eligible were aged 21–65 and reported smoking ≥5 filtered non-menthol cigarettes/day (CPD), smoking regularly for ≥5 years and smoking either Marlboro Gold or Red cigarettes (irrespective of length) >80% of the time.
Sample rationale
We recruited Marlboro smokers because Marlboro is the leading cigarette brand worldwide and domestically, commanding 43% of both the USA27 and the greater Philadelphia area markets in 2018 (unpublished analysis of regional Nielsen Scan Track data28). Limiting recruitment to smokers of one brand helped ensure that observed differences are not attributed to other features that vary between brands, enabling us to conduct a more focused comparison of packaging and marketing effects. Analysing baseline data collected at the onset of our randomised trial allowed us to comprehensively characterise the perceptions, use behaviours and exposure of Marlboro Red and Gold smokers when using their own brand.
Procedures
Initial eligibility was determined via telephone interview. Those eligible attended an initial laboratory visit at the University of Pennsylvania to provide written informed consent and confirm eligibility. During this visit, participants were required to physically bring a pack of their own cigarettes to confirm that they were Marlboro Gold or Red smokers. They completed assessments of demographics, medical and smoking history, and product risk perceptions. They also smoked two cigarettes (separated by 45 min) through a topography device to capture their puffing behaviour, provided CO samples before and after, and provided subjective ratings after smoking each cigarette. Participants returned 5 days later, repeated all but consent and eligibility procedures, and provided a urine sample later analysed for biomarkers of nicotine exposure. Between visits, participants collected spent cigarette filters in date-labelled resealable plastic bags to assist in tracking self-reported daily smoking.29–32 Those who completed all requirements during the baseline period were compensated up to US$75 and continued onto the primary study protocol.
Measures
Demographics and smoking history
Demographics included participants’ age, gender, race, ethnicity and highest completed education level. Smoking history included preferred brand characteristics (eg, variety/strength (referred to hereafter as ‘brand’), length, mentholation), self-reported CPD assessed using the question ‘In the past 7 days, how many cigarettes did you smoke per day?,’ and nicotine dependence assessed using the Fagerström Test for Nicotine Dependence.33
Product perceptions
Perceived risks of using participants’ preferred brand relative to ‘regular’ cigarettes were assessed with an 8-item scale.34–37 Each item was rated on a 5-point response scale: 1 = ‘definitely not true’, 2 = ‘not true’, 3 = ‘unsure’, 4 = ‘true’, 5 = ‘definitely true.’ Because few smokers endorsed the ‘definitely true’ option, responses were collapsed into three categories: 1 = ‘not true’, 2 = ‘unsure’, 3 = ‘true.’ Based on extant research,5 we scored the ‘not true’ and ‘true’ responses, respectively, as ‘correct’ and ‘incorrect.’
Subjective ratings were assessed using a 14-item, 100 mm Visual Analogue cigarette characteristic rating scale.31 36 38 Scale anchors were item-specific (eg, for the ‘strength’ item: 0 = ‘very weaks, 100 = ‘Very strong’). Lower scores indicated more negative ratings, except for draw and smoke harshness items that were reverse scored.
Smoking behaviours
CPD was assessed via self-report, verified by spent filters collected for all cigarettes smoked throughout the 5-day baseline period.30–32 Puffing behaviour was captured using the handheld, portable Clinical Research Support System topography device (Borgwaldt, KC; Richmond, Virginia USA) to provide per cigarette estimates of total puff volume (total amount of smoke inhaled), mean puff volume (average amount of smoke inhaled per puff), puff count (number of puffs taken), duration (average length of each puff), interpuff interval (average length between puffs) and maximum velocity (greatest velocity captured during a puff).30–32 Consistent with our previous work,30–32 total puff volume was the primary measure of puffing behaviour, as it assesses total smoke intake from a single cigarette while accounting for other behavioural changes (ie, compensation; eg, increasing puff number or duration).
Nicotine and tobacco exposure
Biomarkers of nicotine exposure were urinary-derived measures that assessed nicotine; its primary metabolite, cotinine and 3-hydroxycotinine, the primary metabolite of cotinine. These measures were summed to provide an estimate total nicotine equivalents (TNE), as recent research indicates the molar sum of these three metabolites predicts nicotine intake as the molar sum of nicotine and its six metabolites.39
CO assessed at the onset of each session provided a measure of daily tobacco exposure, while the difference in assessments taken before and after each cigarette smoked in the laboratory, or CO boost, was used to measure smoke exposure from a single cigarette.30–32
Data analyses
Analyses were conducted using IBM SPSS Statistics V.26. Unpaired t-test and χ2 test, respectively, compared continuous and categorical variables by study completion status and Marlboro preferred brand group. We used the mean for outcomes assessed repeatedly over the baseline period (eg, CO, CPD), and included only full study days when computing mean daily cigarette consumption.30 31 Given unequal group sizes within our sample (ie, n=191 vs 49), we report corrected t values for analyses violating Levene’s test for equal variances; χ2 tests are robust against unequal groups.
Results
Sample characteristics
Participants, on average, were 42.8 years old (SD=10.9), reported smoking 16.4 CPD (SD=8.3) over the past 7 days, and were moderately to heavily nicotine dependent (M=5.4, SD=2.2). The majority were male (68.3%) and non-Hispanic (95.0%); 71.3% identified as white and 43.3% had completed some college or technical training as their highest level of education. The majority smoked Marlboro Red cigarettes (79.6%) and smoked king-sized/regular length (60.8%).
Compared with Gold smokers (n=49), Red smokers (n=191) were marginally more likely to be male, χ2 (1)=3.6, p=0.059, and significantly more likely to have a high school education/GED or less as their highest completed education level, χ 2 (1)=9.6, p=0.002. There were no differences by preferred brand on age (t (238)=−1.2, p=0.232), race (χ2 (1)=0.001, p=0.975), ethnicity (χ2 (1)=0.6, p=0.452), CPD (t (238)=0.1, p=0.937), years smoking (t (238)=1.2, p=0.227) or nicotine dependence (t (237)=0.9, p=0.348).
Primary outcomes
Product perceptions
As shown in table 1, Gold (vs Red) smokers were more likely to endorse incorrect or unsure responses to perceptions that their cigarettes contained less nicotine (χ2 (2)=72.0, p<0.001) and less tar (χ2 (2)=68.3, p<0.001) than regular cigarettes. No other items differed by preferred brand.
Participant responses for risk perception items by preferred brand groups
As illustrated in table 2, Gold (vs Red) smokers rated their cigarettes as weaker (t (86.5)=3.1, p=0.002), less harsh (t (238)=2.5, p=0.014), more mild (t (238)=2.1, p=0.033), having less harsh smoke (t (238)=−2.4, p=0.019) and having weaker smoke (t (238)=2.2, p=0.026). Mean ratings for all other items were not statistically different between groups (t (238)’s=−1.8 to 1.6, ps=0.079–0.999).
Mean (±SE) outcome measures by preferred brand groups
Smoking behaviours
Although not statistically significant, we observed that Gold smokers smoked marginally more CPD during the baseline period compared with Red smokers (t (238)=−1.7, p=0.091); see table 2. There were no differences by preferred brand on total puff volume, (t (238)=−0.6, p=0.496), the primary puffing behaviour measure. However, Gold (vs Red) smokers had shorter mean interpuff interval (t (238)=2.1, p=0.039) and marginally, but not significantly, shorter mean puff duration (t (238)=1.8, p=0.077). There were no group differences in mean puff volume (t (238)=0.7, p=0.488), puff number (t (238)=−1.5, p=0.152) or peak puff velocity (t (238)=−0.6, p=0.538). Thus, although there were some statistically significant differences between Gold and Red smokers on secondary puffing measures, these did not collectively result in differences in total volume, the primary measure.
Nicotine and tobacco exposure
Importantly, there were no statistically significant differences between Red and Gold smokers on either mean session onset CO (t (61.2)=−1.1, p=0.255) or CO boost (t (238)=1.6, p=0.102], as seen in table 2. There were also no differences on individual nicotine metabolites (ie, nicotine (t (238)=−0.2, p=0.879), cotinine (t (61.7)=−0.3, p=0.734) or 3-hydroxycotinine (t (65.1)=−1.4, p=0.186) or TNE (t (65.9)=−1.0, p=0.323.
Discussion
This study compared product perceptions, smoking behaviours and toxicant exposure among a sample of adult, daily Marlboro Gold and Red smokers to determine if cigarettes no longer labelled as ‘light’ still have the potential to mislead consumers. Our hypothesis that Marlboro Gold (vs Red) smokers would hold more false beliefs about their cigarettes was supported for two items regarding the amount of nicotine and tar in their preferred brand. Gold (vs Red) smokers were more likely to be incorrect or unsure that their cigarettes contained less nicotine and tar than regular cigarettes, but did not differ on other risk perception items. It is encouraging that Gold and Red smokers did not differ on beliefs that their cigarettes were healthier or less likely to cause cancer than regular cigarettes as was demonstrated before the descriptor ban.21 22 It is possible that rebranding Marlboro Lights as Gold successfully corrected some misperceptions about the product. However, the fact that misperceptions exist specifically about nicotine and tar, the two characteristics that were targeted directly by flawed testing methods and that can be evaluated objectively via biomarker assessment, remains concerning. Because Gold cigarettes are no longer labelled as ‘light’ and do not explicitly display either nicotine or tar yield, these findings suggest that these beliefs persist due to remaining marketing and/or product characteristics of the Gold cigarette (eg, ventilation, white-coloured (vs cork-) coloured filter). While our data do not support that Gold smokers are misled about explicit health risks of their cigarettes, they clearly show that Gold smokers are misled on nicotine and tar product attributes, which may be connected implicitly with health risk perceptions.
Contrary to our hypothesis that Gold smokers would engage in greater smoking behaviours compared with Red smokers, the greater CPD and secondary puffing measures observed among Gold smokers were not statistically different from Red smokers. It is important to note that our sample was comprised of brand verified, established Marlboro smokers using their own brand that they provided rather than free preferred brand or novel cigarettes supplied by the study (ie, not a ‘switching’ or first impression study). Thus, this study design has high external validity and these results represent actual smoking behaviour of specific sub-brands when used exclusively for years; differences between Red and Gold smokers may be more subtle than have been previously observed when full-flavoured smokers are switched to ‘light’ brands, or provided cigarettes free of charge.40
Our hypothesis that Gold and Red smokers would have equivalent toxicant exposure was confirmed, as we found no significant differences between groups on either nicotine exposure (assessed via urinary metabolites) or smoke exposure (assessed via CO). Together with the risk perception findings, we provide critical data showing that Marlboro Gold smokers believe their intake of nicotine and tar to be lower from their preferred brand than regular cigarettes, which is factually incorrect, as objective measurements of biological exposure demonstrate no differences between Gold and Red smokers. Further, because use behaviours were comparable between groups, it is not the case that Gold smokers engaged in compensatory behaviours that offset less exposure per cigarette (eg, smoking more CPD but with fewer puffs). This finding is important because it illustrates that beliefs about inhaling lower nicotine and tar from Gold (vs other) cigarettes are demonstrably false and emphasises a need for additional regulatory actions to correct these misperceptions.
Finally, as hypothesised, Gold smokers provided subjective ratings of their cigarettes consistent with smoking a ‘light’ or ‘mild’ product. Items related to satisfaction and taste did not differ between groups, but Gold (vs Red) smokers endorsed their cigarettes as being weaker/less harsh and having less harsh/weaker smoke. These results likely reflect responses to greater filter ventilation on the Gold cigarettes creating the sensory perception of ‘smoother’ or ‘weaker’ taste,41 although the present study is unable to disentangle these effects from other characteristics of Gold smokers and their cigarettes (eg, packaging differences). Given previous research20 23 42 demonstrating that subjective experiences of a ‘weak’ or ‘light’ tasting cigarette may reinforce false perceptions of product risks, these results may contribute to the differences in perceptions about nicotine and tar content we observed between brands.
Taken together, findings suggest that despite no longer being explicitly labelled as ‘light,’ Marlboro Golds are still associated with perceptions of less nicotine and tar, even though users of these products do not inhale lower levels of these constituents. While Gold smokers did not endorse false explicit perceptions that their cigarettes were healthier or less addictive than regular cigarettes, it is clear that the Gold brand conveys that it has ‘less’ of certain constituents (nicotine and tar), which consumers may implicitly associate with some health benefit, perhaps contributing to the enduring popularity of the Gold sub-brand. Years of exposure to deceptive marketing8 9 by the industry, in conjunction with product design characteristics that share prohealth connotations (eg, white filters, ventilation that creates a smoother/lighter taste), are likely responsible for the persistence of misperceptions among this sample of inveterate Gold smokers. More restrictive packaging (eg, plain packaging or warning labels) or design (eg, removing filter ventilation) regulations and education campaigns may be needed to inform smokers that their nicotine and tar exposure, and consequent disease risk, does not differ between products.
Findings from this study should be viewed with consideration of a few limitations. First, data were collected from a convenience sample of smokers of two sub-brand cigarette varieties from a single US city, although this sample is highly representative of the non-menthol smoking population in Philadelphia and greater USA (unpublished analysis of regional Nielsen Scan Track data28). Second, because we compared group differences during a single 5-day period rather than examine changes before and after the descriptor ban, we cannot determine causality between the descriptor ban and our outcomes. However, given that the descriptor ban went into effect in late 2010, and that our sample reported smoking daily for an average of 26 years (range: 3–48) with >85% reporting smoking daily for at least 10 years, a notable strength of this study is that the majority of our sample was smoking their brand pre-descriptor ban and thus essentially participated in a naturalistic experiment during implementation of the ban. Third, because participants were not randomised to a preferred brand condition, we cannot disentangle whether differences in outcomes may be due to specific marketing (eg, pack colour) or product design (eg, filter ventilation) features, as they share significant overlap and likely interact to influence outcomes. Future experimental studies are needed to manipulate these features and determine their unique effects on beliefs and behaviour. Fourth, it is possible that risk perception items may not have been specific or nuanced enough to detect differences between Red and Gold smokers. For example, asking whether participants’ cigarettes had fewer additives or toxicants instead of the broader term of ‘chemicals’ may have yielded different results. Finally, we assessed only urinary nicotine and exhaled breath CO as our measures of toxicant exposure. Future research may consider using a comprehensive panel of biomarkers43 44 to provide more rigorous product evaluation.
In summary, US Marlboro Gold smokers reported believing that their cigarettes contain less nicotine and tar than regular cigarettes, despite objectively having the same nicotine and toxicant exposure as smokers of ‘full-flavour’ Marlboro Red cigarettes. Actions taken to correct these misperceptions such as removing the ‘light’ descriptor from Gold cigarette packaging and abandoning previous methods of measuring nicotine and tar content are insufficient. Additional packaging (eg, plain packaging, graphical warning labels) and product regulations (eg, removing filter ventilation), as well as education campaigns, may be warranted to accurately convey to Gold smokers that their nicotine intake and ultimate disease risk is similar between cigarette sub-brands.
What this paper adds
Years after several countries implemented Article 11 of the Framework Convention on Tobacco Control, the USA also removed the term of ‘light’ from Marlboro Gold cigarette packaging to correct consumers’ misperceptions about these products.
This study provides recent experimental data demonstrating that despite removing the ‘light’ descriptor in the USA, Marlboro Gold smokers believe their cigarettes have less nicotine and tar than regular cigarettes, but in fact have carbon monoxide levels and nicotine exposure equivalent to Marlboro Red smokers.
Our data suggest that additional regulations to cigarette packaging or to the products themselves are needed beyond simply removing the ‘light’ descriptor to address product misperceptions about nicotine and tar in the USA.
Data availability statement
Data are available on reasonable request. Deidentified data and a measures codebook will be made available on request.
Ethics statements
Patient consent for publication
Ethics approval
The university institutional review board approved all procedures.
References
Footnotes
Twitter @melmercincavage, @dannygiovenco
Contributors AAS designed, received funding for and oversaw implementation of the larger randomisd trial. AAS and MM together conceptualised the present secondary analysis of baseline data from the larger trial. MM analysed the data and wrote the initial paper draft, with subsequent contributions from all authors. BA and VS monitored and collected data for the larger trial. All authors contributed to paper revisions and have approved of the final version of the manuscript.
Funding This research was supported by the National Institutes of Health and FDA Center for Tobacco Products (P50CA179546 to Lerman/Hornik; U54CA229973 to Strasser/Delnevo) and the National Institutes of Health (K07CA218366 to Mercincavage).
Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the FDA.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.