Smokers Response to Alternative Tobacco Product Warning Labels: An Experimental Study

Theoretical Background and research questions/hypothesis:  Perceived risk of tobacco products is central to initiation, continued use, and cessation of tobacco. Warnings on cigarettes have been shown to promote cessation and effectively communicate risk. However, tobacco companies are fighting efforts to implement new graphic warning labels on cigarettes, and are exploiting the lack of regulations on electronic cigarettes (e-cigarettes). Research on warning labels on alternative tobacco products (smokeless tobacco, snus, and e-cigarettes) is nascent. E-cigarettes have been promoted widely, including being advertised as safer than tobacco and made in “FDA-approved” facilities. In addition, RJ Reynolds’ proposed a “warning” for smokeless tobacco that was essentially an endorsement: “Warning: No tobacco product is safe, but this product presents substantially lower risks to health than cigarettes.” We examined the effects of this warning label, an FDA endorsement, and other warning labels on smokers’ perceptions of risk of various tobacco products.

Methods:  Online experiment with a national sample of 988 adult smokers (509 exclusive smokers and 479 dual users who regularly used both smokeless tobacco and cigarettes) randomized to view print advertisements for snus, e-cigarettes, and moist snuff with one of six warning label conditions: 2 warning labels (current warning label, graphic warning label), 2 endorsements (“FDA-approved” or “safer alternative”), tobacco ad with no warning label, or a  control (non-tobacco) ad. Perceived harm, positive attitudes, and openness to use each product were measured at pretest and post-test.

Results: Current warning labels increased perceived harm of moist snuff and e-cigarettes for exclusive smokers, but had no effect on dual users’ perceptions of harm of any product. Graphic warning increased perceived harm of e-cigarettes and moist snuff for exclusive smokers and of e-cigarettes for dual users. Graphic warning decreased positive attitudes towards snus and e-cigarettes among exclusive smokers and towards all products for dual users. Graphic warning decreased openness to snus among dual users. Endorsements decreased perceived harm of snus among exclusive smokers; increased positive attitude towards moist snuff among dual users; decreased openness to snus among dual users, and increased openness to snus and e-cigarettes among exclusive smokers. 75% of exclusive smokers and 87% of dual users were interested in a free sample of at least one alternative tobacco product, but there were no significant differences between the experimental conditions on this outcome. Being interested in a free sample of an alternative tobacco product was associated with positive post-test attitudes and post-test openness to using the product, but not with post-test perceived harm.  Openness to all products among dual users decreased across all conditions, including control.

Conclusions: Current warning had no effect on perceptions among familiar products (e.g. smokeless tobacco perceptions among dual users), but current warning labels affected perceptions of unfamiliar products (smokeless tobacco perceptions among exclusive smokers, and for e-cigarettes among both groups).  Endorsements had counter-productive effects, and increased interest in alternative tobacco products.

Implications for research and/or practice:  Regulatory agencies should not allow endorsements on alternative tobacco products and should implement graphic warning labels for smokeless tobacco products and warning labels for e-cigarettes.