Literature review and summary of perceptions, attitudes, beliefs, and marketing of potentially reduced exposure products: communication implications.

Potentially reduced exposure products (PREPs) have continued to enter the market during the 1990s and first part of the 21st century. Attempts by the tobacco industry to develop and market products with implied reductions in adverse health effects (i.e., harm reduction) are not new. Over the last half of the 20th century, the tobacco industry developed and marketed several products that purported to reduce the health risks associated with smoking cigarettes. Among these were filtered cigarettes in the 1950s and light and ultra-light cigarettes in the 1970s and 1980s. This review summarizes published and unpublished research that is directly relevant to the marketing, advertising, and communication about PREPs. The marketing strategies for these new products do not appear to differ from those used by the tobacco industry for light and ultra-light cigarettes. Although smokers report not using the new products in large numbers because of dissatisfaction with taste, they are interested in using products with reduced risk. Despite the absence of explicit health claims by the industry for PREPs, many smokers believe that these products are safer based on the advertising claims of reduced exposure and a belief that claims are approved by the government. No data are available to indicate that PREPs are useful for prevention or cessation of smoking, nor does specific research exist to suggest what health communication messages will provide smokers with accurate information about these products.     

Effects of market liberalisation on smoking in Japan

OBJECTIVE: To document the effect of the liberalisation of the Japanese tobacco market on Japanese smoking rates and on Japanese tobacco industry practices. DATA SOURCE: Asahi Shimbun (major daily newspaper) from 1980 to 1996. STUDY SELECTION: Review of media coverage on the effects of market liberalisation following the imposition of the USA's section 301 trade sanction. DATA SYNTHESIS: The opening of Japan's tobacco market to foreign cigarette companies stalled a decline in smoking prevalence. Smoking rates among young women increased significantly, and also appear to be on the rise among adolescents. Aggressive marketing and promotional activities by US and Japanese tobacco companies in response to trade liberalisation appear responsible for these adverse trends. Steep increases in sales through vending machines were also possible contributors to the rising smoking prevalence among adolescents. On the positive side, market liberalisation indirectly promoted smoking control efforts in Japan, by causing an anti-smoking movement to coalesce. CONCLUSION: Market liberalisation in Japan played a significant role in increasing smoking prevalence among young women and adolescents while helping to transform the issue of smoking in Japan from a matter of individual choice to a public health problem.     

Tobacco industry consumer research on socially acceptable cigarettes

Objective: To describe tobacco industry consumer research to inform the development of more "socially acceptable" cigarette products since the 1970s. Methods: Analysis of previously secret tobacco industry documents. Results: 28 projects to develop more socially acceptable cigarettes were identified from Philip Morris, RJ Reynolds, British American Tobacco, and Lorillard tobacco companies. Consumer research and concept testing consistently demonstrated that many smokers feel strong social pressure not to smoke, and this pressure increased with exposure to smoking restrictions. Tobacco companies attempted to develop more socially acceptable cigarettes with less visible sidestream smoke or less odour. When presented in theory, these product concepts were very attractive to important segments of the smoking population. However, almost every product developed was unacceptable in actual product tests or test markets. Smokers reported the complete elimination of secondhand smoke was necessary to satisfy non-smokers. Smokers have also been generally unwilling to sacrifice their own smoking satisfaction for the benefit of others. Many smokers prefer smoke-free environments to cigarettes that produce less secondhand smoke. Conclusions: Concerns about secondhand smoke and clean indoor air policies have a powerful effect on the social acceptability of smoking. Historically, the tobacco industry has been unable to counter these effects by developing more socially acceptable cigarettes. These data suggest that educating smokers about the health dangers of secondhand smoke and promoting clean indoor air policies has been difficult for the tobacco industry to counter with new products, and that every effort should be made to pursue these strategies.     

The menthol smoker: tobacco industry research on consumer sensory perception of menthol cigarettes and its role in smoking behavior.

The use of menthol in cigarettes is actively promoted by the tobacco industry for its perceived sensory benefits, and smokers of menthol cigarettes commonly differ from nonmenthol smokers in markers of smoking behavior and addiction. In this study, we analyzed internal tobacco industry documents to describe the relationships between sensory perception and the attitudes, preferences, and patterns of cigarette use among menthol smokers. Two unique types of menthol smoker emerged from this analysis: those who cannot tolerate the harshness and irritation associated with smoking nonmenthol cigarettes, and those who seek out the specific menthol flavor and associated physical sensation. Among the first segment of menthol smokers, menthol reduces negative sensory characteristics associated with smoking. This segment of smokers may include a large proportion of occasional smokers or young people, as well as smokers who have "traded down" to a less strong cigarette because of perceived harshness or negative health effects. Some established menthol smokers, on the other hand, appear to be tolerant of and even actively seek stronger sensory attributes, including higher menthol levels. Smokers of these "stronger" menthols have traditionally been disproportionately Black and male. Some beginning or occasional smokers may adopt menthols for their mild properties and to cover up the taste of tobacco, but then develop a stronger desire for the menthol taste over time. Future research measuring smoking behavior and evaluating cessation outcomes of menthol smokers should consider the duration of menthol use and differentiate smokers according to their reasons for using menthols.     

Implications of the federal court order banning the terms “light” and “mild”: what difference could it make?

Federal District Judge Gladys Kessler found that the major American tobacco companies violated the Racketeer Influenced and Corrupt Organizations Act, defrauding the public by deceptively marketing "light" cigarettes. Judge Kessler's ruling prohibits the defendant tobacco companies from implying health benefits through using misleading terms such as "light", "mild" or "low-tar", or through other indirect means. This ruling could be interpreted narrowly as simply prohibiting certain words, or could be interpreted broadly as prohibiting implying health benefits by any other means, including colour, numbers or images. It is important to include indirect communications, as tobacco companies easily circumvent narrow advertising bans. A narrow interpretation would be inconsistent with the court's comprehensive factual findings of fraudulent intent by the industry. A broad interpretation of the Order, including existing brands, line extensions and new tobacco products such as potential reduced exposure products that are marketed as "cigarettes", Judge Kessler's order could make a substantial contribution to protecting health.     

Release of carbon granules from cigarettes with charcoal filters

OBJECTIVE: To inspect cigarettes with a triple granular filter for charcoal granules on the cut filter surface and, if present, to determine whether the charcoal granules on the filter are released during smoking. DESIGN: 400 Lark cigarettes in 20 packs were examined individually by each of three investigators for the presence of charcoal granules on the cut surface of the cellulose acetate filter. Without removing the cigarettes from the pack, the filters were examined with a stereo zoom microscope for charcoal granules. The percentage of cigarettes that had charcoal granules was defined, and charcoal granules on each filter were counted. Randomly selected cigarettes were then smoked by consenting adult smokers to assess whether the charcoal granules were released during smoking. Lark cigarettes were smoked with a conventional cigarette holder that had been configured to contain an in-line membrane. After smoking, the membrane was analysed microscopically for charcoal granules and other components of the filter that had been released during smoking. RESULTS: Charcoal granules were observed in 79.8% (319/400) of the cigarettes examined. The number of granules per cigarette was 3.3 (SD 3.7). Gaps between the tipping papers--the wrapping papers that surround the filter--were often seen (70%; 242 (71); n = 400 cigarettes). Further, the charcoal cavity was about 60% empty. For all smokers (n = 8/8), charcoal granules were released during smoking. The number of charcoal granules captured on the membranes was 22.5 (16.2) per cigarette. CONCLUSIONS: Charcoal granules are incorporated into cigarette filters to aid in removing toxins in cigarette smoke. In studies of Lark, a popular American cigarette with a charcoal filter, charcoal granules were observed on the filter surface, and were released from the filter when the cigarettes were smoked. During smoking, the toxin-containing charcoal granules are inhaled or ingested. The specific adverse health effects of inhaling or ingesting carbon granules have not been addressed; nevertheless, the smoker, as an educated consumer, should be informed of the possible health risks.


     

Marketing to the marginalised: tobacco industry targeting of the homeless and mentally ill

Objectives: To describe the tobacco industry''s relationships with and influence on homeless and mentally ill smokers and organisations providing services to them. Methods: Analysis of internal tobacco industry documents and journal articles. Results: The tobacco industry has marketed cigarettes to the homeless and seriously mentally ill, part of its "downscale" market, and has developed relationships with homeless shelters and advocacy groups, gaining positive media coverage and political support. Discussion: Tobacco control advocates and public health organisations should consider how to target programmes to homeless and seriously mentally ill individuals. Education of service providers about tobacco industry efforts to cultivate this market may help in reducing smoking in these populations.     

Smoking,social class,and gender: what can public health learn from the tobacco industry about disparities in smoking?

Objective: To discover how the tobacco industry considers social class and gender in its efforts to market cigarettes in the USA, particularly to socially disadvantaged young women. Methods: A systematic on-line search of tobacco industry documents using selected keywords was conducted, and epidemiological data on smoking rates reviewed. Results: The two largest cigarette manufacturers in the USA consider "working class" young adults to be a critical market segment to promote growth of key brands. Through their own market research, these companies discovered that socially disadvantaged young women do not necessarily desire a "feminine" cigarette brand. Conclusions: Considering the tobacco industry''s efforts, alongside the persistent and growing disparities in cigarette smoking by social class, and the narrowing of differences in smoking by gender, it is concluded that additional tobacco control resources ought to be directed toward working class women.     

Asian herbal‐tobacco cigarettes: “not medicine but less harmful”?

Objective

To describe the development and health claims of Asian herbal‐tobacco cigarettes.

Methods

Analysis of international news sources, company websites, and the transnational tobacco companies'' (TTC) documents. PubMed searches of herbs and brands.

Results

Twenty‐three brands were identified, mainly from China. Many products claimed to relieve respiratory symptoms and reduce toxins, with four herb‐only products advertised for smoking cessation. No literature was found to verify the health claims, except one Korean trial of an herb‐only product. Asian herbal‐tobacco cigarettes were initially produced by China by the 1970s and introduced to Japan in the 1980s. Despite initial news about research demonstrating a safer cigarette, the TTC analyses of these cigarettes suggest that these early products were not palatable and had potentially toxic cardiovascular effects. By the late 1990s, China began producing more herbal‐tobacco cigarettes in a renewed effort to reduce harmful constituents in cigarettes. After 2000, tobacco companies from Korea, Taiwan, and Thailand began producing similar products. Tobacco control groups in Japan, Taiwan, and Thailand voiced concern over the health claims of herbal‐tobacco products. In 2005, China designated two herbal‐tobacco brands as key for development.

Conclusion

Asian herbal‐tobacco cigarettes claim to reduce harm, but no published literature is available to verify these claims or investigate unidentified toxicities. The increase in Asian herbal‐tobacco cigarette production by 2000 coincides with the Asian tobacco companies'' regular scientific meetings with TTCs and their interest in harm reduction. Asia faces additional challenges in tobacco control with these culturally concordant products that may discourage smokers from quitting.     

Cigarette nicotine yields and nicotine intake among Japanese male workers

OBJECTIVES: To analyse brand nicotine yield including "ultra low" brands (that is, cigarettes yielding less-than-or-equal 0.1 mg of nicotine by Federal Trade Commission (FTC) methods) in relation to nicotine intake (urinary nicotine, cotinine and trans-3'-hydroxycotinine) among 246 Japanese male smokers. DESIGN: Cross sectional study. SETTING: Two companies in Osaka, Japan. SUBJECTS: 130 Japanese male workers selected randomly during their annual regular health check up and 116 Japanese male volunteers taking part in a smoking cessation programme. MAIN OUTCOME MEASUREMENTS: Subjects answered a questionnaire about smoking habits. Following the interview, each participant was asked to smoke his own cigarette and, after extinguishing it, to blow expired air into an apparatus for measuring carbon monoxide concentration. Urine was also collected for the assays of nicotine metabolites. RESULTS: We found wide variation in urinary nicotine metabolite concentrations at any given nicotine yield. Based on one way analysis of variance (ANOVA), the urinary nicotine metabolite concentrations of ultra low yield cigarette smokers were significantly lower compared to smokers of high (p = 0.002) and medium yield cigarettes (p = 0.017). On the other hand, the estimated nicotine intake per ultra low yield cigarette smoked (0.59 mg) was much higher than the 0.1 mg indicated by machine. CONCLUSIONS: In this study of Japanese male smokers, actual levels of nicotine intake bore little relation to advertised nicotine yield levels. Our study reinforces the need to warn consumers of inappropriate advertisements of nicotine yields, especially low yield brands.     

How Philip Morris unlocked the Japanese cigarette market: lessons for global tobacco control

Background: The Framework Convention on Tobacco Control includes tobacco advertising restrictions that are strongly opposed by the tobacco industry. Marketing strategies used by transnational tobacco companies to open the Japanese market in the absence of such restrictions are described.

Methods: Analysis of internal company documents.

Findings: Between 1982 and 1987 transnational tobacco companies influenced the Japanese government through the US Trade Representative to open distribution networks and eliminate advertising restrictions. US cigarette exports to Japan increased 10-fold between 1985 and 1996. Television advertising was central to opening the market by projecting a popular image (despite a small actual market share) to attract existing smokers, combined with hero-centred advertisements to attract new smokers. Philip Morris's campaigns featured Hollywood movie personalities popular with young men, including James Coburn, Pierce Brosnan, Roger Moore, and Charlie Sheen. Event sponsorships allowed television access despite restrictions. When reinstatement of television restrictions was threatened in the late 1980s, Philip Morris more than doubled its television advertising budget and increased sponsorship of televised events. By adopting voluntary advertising standards, transnational companies delayed a television advertising ban for over a decade.

Conclusions: Television image advertising was important to establish a market, and it has been enhanced using Hollywood personalities. Television advertising bans are essential measures to prevent industry penetration of new markets, and are less effective without concurrent limits on sponsorship and promotion. Comprehensive advertising restrictions, as included in the Framework Convention for Tobacco Control, are vital for countries where transnational tobacco companies have yet to penetrate the market.

     

Reducing the addictiveness of cigarettes

OBJECTIVE—To assess the feasibility of reducing tobacco-caused disease by gradually removing nicotine from cigarettes until they would not be effective causes of nicotine addiction.
DATA SOURCES—Issues posed by such an approach, and potential solutions, were identified from analysis of literature published by the US Food and Drug Administration (FDA) in its 1996 Tobacco Rule, comments of the tobacco industry and other institutions and individuals on the rule, review of the reference lists of relevant journal articles, other government publications, and presentations made at scientific conferences.
DATA SYNTHESIS—The role of nicotine in causing and sustaining tobacco use was evaluated to project the impact of a nicotine reduction strategy on initiation and maintenance of, and relapse to, tobacco use. A range of potential concerns and barriers was addressed, including the technical feasibility of reducing cigarette nicotine content to non-addictive levels, the possibility that compensatory smoking would reduce potential health benefits, and whether such an approach would foster illicit ("black market") tobacco sales. Education, treatment, and research needs to enable a nicotine reduction strategy were also addressed. The Council on Scientific Affairs came to the following conclusions: (a) gradually eliminating nicotine from cigarettes is technically feasible; (b) a nicotine reduction strategy holds great promise in preventing adolescent tobacco addiction and assisting the millions of current cigarette smokers in their efforts to quit using tobacco products; (c) potential problems such as compensatory over-smoking of denicotinised cigarettes and black market sales could be minimised by providing alternate forms of nicotine delivery with less or little risk to health, as part of expanded access to treatment; and (d) such a strategy would need to be accompanied by relevant research and increased efforts to educate consumers and health professionals about tobacco and health.
CONCLUSIONS—The council recommends the following: (a) that cessation of tobacco use should be the goal for all tobacco users; (b) that the American Medical Association continue to support FDA authority over tobacco products, and FDA classification of nicotine as a drug and tobacco products as drug-delivery devices; (c) that research be encouraged on cigarette modifications that may result in less addicting cigarettes; (d) that the FDA require that the addictiveness of cigarettes be reduced within 5-10 years; (e) expanded surveillance to monitor trends in the use of tobacco products and other nicotine-containing products; (f) expanded access to smoking cessation treatment, and strengthening of the treatment infrastructure; and (g) more accurate labelling of tobacco products, including a more meaningful and understandable indication of nicotine content.


     

Courtesy and the challenges of implementing smoke-free policies in Japan.

For decades, the tobacco companies have developed a worldwide campaign to oppose the creation of smoke-free environments. Public health efforts to promote clean indoor air have been uneven throughout the world, and in few places have such efforts faced as many challenges as in Japan. The Japanese market is dominated by Japan Tobacco, which is partly owned by the government, and Philip Morris International is also present in Japan. Japan Tobacco and Philip Morris International have developed campaigns promoting courtesy and tolerance that, until recently, seem to have resonated well with the public. The companies also have supported research promoting ventilation and have funded consultants to act as experts in the area of second-hand smoke exposure. Japan is a critical country to study, partly because of the strength of Japan Tobacco in the country and the growth of Japan Tobacco International in Southeast Asia and the rest of the world, and partly because of Japan's ratification of the World Health Organization Framework Convention on Tobacco Control. This paper uses tobacco industry documents to provide an overview of the tobacco industry's scientific and political efforts to stifle the development of clean indoor measures in Japan. Learning past industry strategies may assist policymakers and advocates in the development of future public health activities.     

Ensuring smokers are adequately informed: reflections on consumer rights, manufacturer responsibilities, and policy implications

The right to information is a fundamental consumer value. Following the advent of health warnings, the tobacco industry has repeatedly asserted that smokers are fully informed of the risks they take, while evidence demonstrates widespread superficial levels of awareness and understanding. There remains much that tobacco companies could do to fulfil their responsibilities to inform smokers. We explore issues involved in the meaning of "adequately informed" smoking and discuss some of the key policy and regulatory implications. We use the idea of a smoker licensing scheme-under which it would be illegal to sell to smokers who had not demonstrated an adequate level of awareness-as a device to explore some of these issues. We also explore some of the difficulties that addiction poses for the notion that smokers might ever voluntarily assume the risks of smoking.     

Urinary tobacco-specific nitrosamines and 4-aminobiphenyl hemoglobin adducts measured in smokers of either regular or light cigarettes.

Cigarette brands may differ in their reported yields of "tar" as determined by the Federal Trade Commission smoking-machine method. Brands with relatively lower tar and nicotine yields often are described as light cigarettes. Smokers of light cigarettes generally maintain a nicotine intake comparable to that of smokers of regular cigarettes through compensatory smoking behaviors, but similar data have not been reported for carcinogen biomarkers. In the present study we measured serum cotinine concentrations (a marker of nicotine exposure), urinary levels of 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL, a tobacco-specific nitrosamine [TSNA]), and hemoglobin adducts of 4-aminobiphenyl (4-ABP) in 150 smokers of either regular or light cigarettes. The TSNA and aromatic amines are known carcinogens in tobacco smoke. Multiple regression models were developed for each of the analytes and used to calculate adjusted geometric means. We found no significant differences in the levels of these biomarkers between customary users of light and regular cigarettes. Thus the concentrations of the carcinogen biomarkers NNAL and 4-ABP in the smokers who regularly smoked light cigarettes were essentially the same as those in the smokers who chose regular cigarettes.     

What the public thinks about the tobacco industry and its products

Objectives: To assess public attitudes toward the tobacco industry and its products, and to identify predictors of attitudes supportive of tobacco industry denormalisation.

Design: Population based, cross sectional survey.

Setting: Ontario, Canada.

Subjects: Adult population (n = 1607).

Main outcome measures: Eight different facets of tobacco industry denormalisation were assessed. A denormalisation scale was developed to examine predictors of attitudes supportive of tobacco industry denormalisation, using bivariate and multivariate analyses.

Results: Attitudes to the eight facets of tobacco industry denormalisation varied widely. More than half of the respondents supported regulating tobacco as a hazardous product, fining the tobacco industry for earnings from underage smoking, and suing tobacco companies for health care costs caused by tobacco. Majorities also thought that the tobacco industry is dishonest and that cigarettes are too dangerous to be sold at all. Fewer than half of the respondents thought that the tobacco industry is mostly or completely responsible for the health problems smokers have because of smoking and that tobacco companies should be sued for taxes lost from smuggling. In particular, less than a quarter thought that the tobacco industry is most responsible for young people starting to smoke. Non-smoking, knowledge about health effects caused by tobacco, and support for the role of government in health promotion were independent predictors of support for tobacco industry denormalisation.

Conclusions: Although Ontarians are ambivalent toward tobacco industry denormalisation, they are supportive of some measures. Mass media programmes aimed at increasing support for tobacco industry denormalisation and continued monitoring of public attitudes toward this strategy are needed.