Natural, Organic, Additive-Free and Pure on Cigarette Packs in 14 Countries
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Natural, Organic, Additive-free and Pure on Cigarette Packs in 14 Countries Kevin Welding, PhD Ryan David Kennedy, PhD Meghan Bridgid Moran, PhD Joanna E. Cohen, PhD Katherine Clegg Smith, PhD Objectives: The tobacco industry uses terms like “light” and “mild” to mislead consumers to be- lieve its product is less harmful. US tobacco brands have marketed products with terms (eg, nat- ural) that inaccurately convey reduced harm. Little is known about how these terms are being used elsewhere. This study aims to describe the frequency of “natural,” “organic,” “additive-free,” and “pure” descriptors on cigarette packs in 14 low- and middle-income countries (LMICs). Meth- ods: Cigarette packs were purchased as part of TPackSS (Tobacco Pack Surveillance System) be- tween 2013 and 2017 from 14 LMICs where the majority of tobacco users live. Packs were coded for “natural,” “organic,” “additive-free,” and “pure” descriptors. Results: Packs containing at least one of the 4 sets of descriptors were found in 12 of 14 countries. “Natural” terms were most com- monly identified, present on packs from 10 countries. “Organic” terms were least common, only found in 2 countries. Overall, 2.8% of the 5576 country-year-unique packs contained at least one of the studied descriptors. Conclusions: The tobacco industry is using potentially misleading terms on packs in LMICs. These problematic associations can be resolved by following labeling guidelines to prevent misleading or deceptive terms. Key words: tobacco; cigarette pack; policy; content analysis; LMICs Tob Regul Sci.™ 2019;5(4):352-359 DOI: https://doi.org/10.18001/TRS.5.4.5 he World Health Organization’s Framework and “fine” to circumvent bans on other terms,9-12 Convention on Tobacco Control (FCTC), as well as light-colored tobacco pack colors, which Article 11 (Packaging and labeling of tobac- are more likely to be perceived to have lower risk.13- Tco products) recognizes the importance of the pack- 16 Terms that convey a product is natural or free age as a promotional vehicle for tobacco companies from additives have also been used by the tobac- and requires the removal of potentially misleading co industry to describe their products. The use of packaging information, including the terms “light” term “natural” has been used by American tobacco and “mild.”1-8 companies to describe aspects of cigarettes for over However, even when these descriptors are banned, 100 years. One initial use of the term was to de- tobacco companies use a variety of other tactics to scribe the tobacco growing process or tobacco with convey inaccurate reduced risk of cigarette brands phrases in advertising such as “naturally ripened by or brand variants to consumers.2 For example, the the sun.”17 Later, the term natural was used to char- tobacco industry has used terms such as “smooth” acterize aspects of the physical cigarette such as the Kevin Welding, Senior Biostatistician, Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior & Society, Institute for Global Tobacco Control, Baltimore, MD. Ryan David Kennedy, Assistant Professor, Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior & Society, Institute for Global Tobacco Control, Baltimore, MD. Meghan Bridgid Moran, Assistant Professor, Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior & Society, Baltimore, MD. Joanna E. Cohen, Professor, Johns Hopkins Bloom- berg School of Public Health, Department of Health, Behavior & Society, Institute for Global Tobacco Control, Baltimore, MD. Katherine Clegg Smith, Professor, Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior & Society, Institute for Global Tobacco Control, Baltimore, MD. Correspondence Dr Welding; [email protected] 352 Welding et al filter, the menthol and the tobacco. 17 chase in a country by visiting a mix of vendor types More recently, the cigarette brand Natural Amer- located in high-, middle-, and low-income neigh- ican Spirit has been marketed using the labels borhoods in the most populous city and then 2 (3 “natural,” “organic,” and “additive-free.”18,19 Smok- in India and 4 in China) of the remaining cities in ers of Natural American Spirit cigarettes have 22 the top 10 most populous in each country. Data times greater odds than smokers of other brands to collectors visited 12 neighborhoods in each city (falsely) believe that their brand of cigarette is less and visited up to 4 vendors within a neighborhood harmful than other brands.20 US- and Canadian- to find additional unique packs. A walking proto- based research has found that consumers perceive col that included alternating vendor types was used these specific terms to convey reduced risk.17,21-24 to increase the chances of finding unique packs in Research has found that tobacco marketing that as- each locale. More information on sampling and sociates the product with environmentally friendly data collection methods are outlined extensively practices (sometimes described as greenwashing), elsewhere.30 Between 2015 and 2017, TPackSS re- or that conveys a product is additive-free through turned to 9 of the 14 countries (Bangladesh, Brazil, other terms, such as ‘tobacco and water’, conveys China, India, Indonesia, Philippines, Russia, Thai- inaccurate reduced risk to consumers.25,26 This effect land, and Vietnam), where tobacco control policies is known as a ‘health halo’ and occurs when con- related to packaging or labeling had changed, to sumers use one attribute about a product (ie, that it collect a new sample of packs employing the same is ‘natural’) to make inferences about the product’s sampling principles. healthfulness, even when it is unrelated.27,28 In the United States (US), the tobacco industry Coding Procedures has been using these problematic tactics to mislead Coding the packs included a thematic approach consumers about product risk. However, there is to coding all lexical content other than brand name little understanding about how prevalent the use or health warning label on the outside of the pack- of these types of descriptors are in non-US settings. aging. Where necessary, lexical content was trans- Such monitoring can alert policymakers to poten- lated to English. All packs were first double-coded tially problematic marketing tactics requiring regu- by a pair of trained coders for the presence of any lation. To address this need, in the current study, natural or organic related references. The percent we sought to identify the frequency of “natural,” agreement between coders was 99.5% and the “organic,” “additive-free,” and “pure” (and related prevalence and bias adjusted kappa was 0.991. This terms) on cigarette packs from 14 low- and mid- subset of packs was then further coded to separate dle-income countries. We reviewed cigarette packs the presence of terms categorized as (1) natural from collected through the Tobacco Pack Surveillance those of (2) organic. Lexical content categorized as Study (TPackSS), which systematically collects to- ‘natural’ included the specific term ‘natural’ and bacco packs in the low- and middle-income coun- versions of the term (eg, ‘naturalness’, ‘naturally’). tries with the greatest number of smokers.29 Similarly, the ‘organic’ category included the use of specific term ‘organic’ and variations. All packs METHODS were also double-coded for the presence of terms Sample “additive-free,” and/or “no added flavors,” and/or In 2013, cigarette packs were collected from 14 “pure.” The percent agreement between coders was countries (Bangladesh, Brazil, China, Egypt, India, 99.3% and the prevalence and bias adjusted kappa Indonesia, Mexico, Pakistan, Philippines, Russia, was 0.987. This subset of packs was then coded to Thailand, Turkey, Ukraine, and Vietnam) using a separate the presence of terms categorized as (3) ad- standardized protocol.30 These countries were se- ditive-free from those of (4) pure. Lexical content lected because, at the start of data collection, they categorized as ‘additive-free’ included the specific were among the low- and middle-income countries terms ‘no additives,’ ‘additive-free,’ or other state- with the greatest number of tobacco users. The ments claiming the product did not contain addi- primary goal in sample construction was to collect tives. Lexical content categorized as ‘pure’ included one of every unique cigarette pack available for pur- the specific term ‘pure’ and variations like ‘purity’. Tob Regul Sci.™ 2019;5(4):352-359 DOI: https://doi.org/10.18001/TRS.5.4.5 353 Natural, Organic, Additive-free and Pure on Cigarette Packs in 14 Countries Table 1 Presence of the Lexical Terms, “Natural,” “Organic,” “Additive-free,” or “Pure” on Cigarette Packs Collected in Low- and Middle-income Countries – Reported by Country Sample Size Any Category Natural Organic Additive-free Pure Country (N) % (n) % (n) % (n) % (n) % (n) Bangladesh 424 2.83% (12) 1.42% (6) 0.00% (0) 1.42% (6) 0.00% (0) Brazil 269 0.74% (2) 0.74% (2) 0.00% (0) 0.00% (0) 0.00% (0) China 1191 1.18% (14) 0.76% (9) 0.08% (1) 0.34% (4) 0.25% (3) Egypt 58 0.00% (0) 0.00% (0) 0.00% (0) 0.00% (0) 0.00% (0) India 230 1.74% (4) 0.43% (1) 0.00% (0) 0.43% (1) 0.87% (2) Indonesia 467 6.00% (28) 6.00% (28) 0.00% (0) 0.00% (0) 0.21% (1) Mexico 134 5.22% (7) 5.22% (7) 0.00% (0) 0.00% (0) 0.00% (0) Pakistan 382 3.14% (12) 0.52% (2) 0.00% (0) 2.36% (9) 0.26% (1) Philippines 251 0.00% (0) 0.00% (0) 0.00% (0) 0.00% (0) 0.00% (0) Russia 1004 5.98% (60) 2.99% (30) 0.40% (4) 1.89% (19) 2.09% (21) Thailand 237 0.42% (1) 0.00% (0) 0.00% (0) 0.42% (1) 0.00% (0) Turkey 308 0.65% (2) 0.00% (0) 0.00% (0) 0.65% (2) 0.00% (0) Ukraine 324 0.93% (3) 0.93% (3) 0.00% (0) 0.00% (0) 0.00% (0) Vietnam 297 4.38% (13) 3.03% (9) 0.00% (0) 0.67% (2) 0.67% (2) Total 5576 2.83% (158) 1.74% (97) 0.09% (5) 0.79% (44) 0.54%(30) (All Countries) Note.