Background. Tobacco companies have actively promoted the substitution of cigarettes with purportedly safer tobacco products (e.g., smokeless tobacco, e-cigarettes) as tobacco harm reduction (THR). Given the tobacco, e-cigarette, and pharmaceutical industries’ substantial financial interests, we quantified industry influence on support for THR.Objectives. To analyze a comprehensive set of articles published in peer-reviewed journals assessing funding sources and support for or opposition to substitution of tobacco or nicotine products as harm reduction.Search Methods. We searched PubMed, Embase, Web of Science, and PsycINFO with a comprehensive search string including all articles, comments, and editorials published between January 1, 1992, and July 26, 2016.Selection Criteria. We included English-language publications published in peer-reviewed journals addressing THR in humans and excluded studies on modified cigarettes, on South Asian smokeless tobacco variants, on pregnant women, on animals, not mentioning a tobacco or nicotine product, on US Food and Drug Administration–approved nicotine replacement therapies, and on nicotine vaccines.Data Collection and Analysis. We double-coded all articles for article type; primary product type (e.g., snus, e-cigarettes); themes for and against THR; stance on THR; THR concepts; funding or affiliation with tobacco, e-cigarette, pharmaceutical industry, or multiple industries; and each author’s country. We fit exact logistic regression models with stance on THR as the outcome (pro- vs anti-THR) and source of funding or industry affiliation as the predictor taking into account sparse data. Additional models included article type as the outcome (nonempirical or empirical) and industry funding or affiliation as predictor, and stratified analyses for empirical and nonempirical studies with stance on THR as outcome and funding source as predictor.Main Results. Searches retrieved 826 articles, including nonempirical articles (21%), letters or commentaries (34%), editorials (5%), cross-sectional studies (15%), systematic reviews and meta-analyses (3%), and randomized controlled trials (2%). Overall, 23.9% disclosed support by industry; 49% of articles endorsed THR, 42% opposed it, and 9% took neutral or mixed positions. Support from the e-cigarette industry (odds ratio [OR] = 20.9; 95% confidence interval [CI] = 5.3, 180.7), tobacco industry (OR = 59.4; 95% CI = 10.1, +infinity), or pharmaceutical industry (OR = 2.18; 95% CI = 1.3, 3.7) was significantly associated with supportive stance on THR in analyses accounting for sparse data.Authors’ Conclusions. Non–industry-funded articles were evenly divided in stance, while industry-funded articles favored THR. Because of their quantity, letters and comments may influence perceptions of THR when empirical studies lack consensus.Public Health Implications. Public health practitioners and researchers need to account for industry funding when interpreting the evidence in THR debates.

Tobacco, nicotine and related products have and continue to change rapidly, creating new challenges for policies regulating their advertising, promotion, sponsorship and sales. This paper reviews recent commercial product offerings and the regulatory challenges associated with them. This includes electronic nicotine delivery systems, electronic non-nicotine delivery systems, personal vaporisers, heated tobacco products, nicotine salts, tobacco-free nicotine products, other nicotine products resembling nicotine replacement therapies, and various vitamin and cannabis products that share delivery devices or marketing channels with tobacco products. There is substantial variation in the availability of these tobacco, nicotine, vaporised, and related products globally, and policies regulating these products also vary substantially between countries. Many of these products avoid regulation by exploiting loopholes in the definition of tobacco or nicotine products, or by occupying a regulatory grey area where authority is unclear. These challenges will increase as the tobacco industry continues to diversify its product portfolio, and weaponises ‘tobacco harm reduction’ rhetoric to undermine policies limiting marketing, promotion and taxation of tobacco, nicotine and related products. Tobacco control policy often lags behind the evolution of the industry, which may continue to sell these products for years while regulations are established, refined or enforced. Policies that anticipate commercial tobacco, nicotine and related product and marketing changes and that are broad enough to cover these product developments are needed.

This study examined the effect of exposure to “cigalike” (products resembling cigarettes) e-cigarette advertisements on adolescents’ perceptions of cigarettes. A nationally representative sample of 802 adolescents (13–17 years old) was randomly assigned to watch three e-cigarette or three control advertisements. Never-smokers who saw the e-cigarette advertisements (n = 352) reported significantly lower perceived risks of smoking than those in the control condition (n = 320). Ever-smokers (n = 130) did not show significant differences across the conditions. In subgroup analyses, current smokers (reported smoking in the past 30 days, n = 31) in the e-cigarette condition reported significantly lower perceived benefits of smoking than those in the control condition. E-cigarette advertisements can affect adolescents’ perceptions of cigarettes. Many advertisements, especially the ones promoting “cigalikes,” depict e-cigarettes as being similar to cigarettes (e.g., look, flavor) but also as a solution for cigarettes’ shortcomings (e.g., bad smell). While the advertisements include messages about problems posed by cigarettes, proposing e-cigarettes as a solution may decrease the perceived risks of smoking among never-smokers. It may also not be clear to adolescents whether advertisements are for cigarettes or e-cigarettes. Regulating e-cigarette advertisements to minimize adolescents’ exposure may prevent potential harmful effects on never-smokers’ perception of smoking.

Background While fruit, candy and alcohol characterising flavours are not allowed in cigarettes in the USA, other flavoured tobacco products such as smokeless tobacco (ST) continue to be sold. We investigated tobacco manufacturers' use of flavoured additives in ST products, the target audience(s) for flavoured products, and marketing strategies promoting products by emphasising their flavour. Methods Qualitative analysis of internal tobacco industry documents triangulated with data from national newspaper articles, trade press and internet. Results Internally, flavoured products have been consistently associated with young and inexperienced tobacco users. Internal studies confirmed that candy-like sweeter milder flavours (eg, mint, fruit) could increase appeal to starters by evoking a perception of mildness, blinding the strong tobacco taste and unpleasant mouth feel; or by modifying nicotine delivery by affecting product pH. Discussion Similar to cigarettes, flavoured ST is likely to encourage novices to start using tobacco, and regulations limiting or eliminating flavours in cigarettes should be extended to include flavoured ST products.

Objective: Electronic cigarettes (e-cigarettes) which utilise prefilled ‘ pods ’ (pod devices) entered the US market in 2015. One brand, JUUL, captured more than half the e-cigarette market in early 2018, and the US Food and Drug Administration recently warned its manufacturer about adolescent uptake. This is the first qualitative study to describe distinct features of pod devices that appear to contribute to their popularity among young people. Design: Qualitative interview study of young adults who had used pod devices. Participants were recruited from Facebook, other social media, street recruitment and via snowball sampling. Setting: Participants were from California, with most from the San Francisco Bay Area. Participants: Young adults (aged 18–29 years) using multiple tobacco products (cigarettes, e-cigarettes and/or smokeless tobacco) were recruited. Of the sample of 60 participants, 24 were included in this analysis: 10 who reported experience with pod devices and 14 who used other non-pod e-cigarette devices. Results: Ten participants had used a pod device in the past year. Of the pod device users, seven still used a pod device at the time of the interview and five did so daily. Nearly all (n=9) pod device users smoked cigarettes in the past month; none were daily smokers. The 14 participants who used non-pod devices provided a point of comparison. Participants highlighted some distinct aspects of pod devices that facilitated use, including their aesthetic similarity to personal electronics, high levels of nicotine delivery with distinct psychoactive effects, more discreet and shorter duration use sessions, and greater social acceptability than more ostentatious non-pod e-cigarettes. Conclusions: Pod devices’ unique characteristics likely encourage pod device uptake among young people. Limitations on advertising in youth channels, flavours and distribution, and education about nicotine addiction may decrease initiation among young people and non-smokers.

Marketing plays a key role in increasing the popularity of e-cigarettes. We conducted a systematic review of the existing literature published between 2003 and 2019 in eight databases to describe e-cigarette marketing communication messages by communication channels and marketing communication strategies. Forty-one articles were included in the analysis after screening. Ten key messages were identified. Cessation and health-related benefits (each n = 31, 75.6%) were the most reported marketing communication messages, followed by sociability/lifestyle and use experience. The Internet (n = 32, 78.0%) was the most studied communication channel compared to print, TV/movie/radio, and point-of-sales (POS)/retail stores. The most studied marketing communication strategies were advertising (n = 28, 68.3%), followed by public relations and sales promotion. Published research studies reported consistent messages about e-cigarettes across communication channels and marketing communication strategies. Claims of smoking cessation and health-related benefits were widely identified in the existing literature. While therapeutic claims are prohibited, soft sell messages, such as social appeals, for which regulatory reach may be limited, may require educational campaigns. Internet marketing has attracted much attention, with limited studies on messages in print, TV/movie/radio, and POS/retail stores. The lack of studies of direct marketing messaging indicates a big gap between industry spending and academic research; more studies of messaging utilizing this strategy are needed.