PT - JOURNAL ARTICLE AU - Stefanie K Gratale AU - Ollie Ganz AU - Olivia A Wackowski AU - M Jane Lewis TI - Naturally leading: a content analysis of terms, themes and word associations in Natural American Spirit advertising, 2000–2020 AID - 10.1136/tobaccocontrol-2021-056938 DP - 2022 Jan 11 TA - Tobacco Control PG - tobaccocontrol-2021-056938 4099 - http://tobaccocontrol.bmj.com/content/early/2022/01/11/tobaccocontrol-2021-056938.short 4100 - http://tobaccocontrol.bmj.com/content/early/2022/01/11/tobaccocontrol-2021-056938.full AB - 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 used in pre-agreement ads.Methods We conducted a content analysis of NAS ads from 2000 to 2020 (N=176), documenting prominent pre-agreement 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 analysing 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 post-agreement, as did environmental imagery. ‘Organic’ was prominent pre-agreement 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.Data are available upon reasonable request. The coding materials for this article can be made available upon reasonable request.