Preventive Medicine 126 (2019) 105782 Contents lists available at ScienceDirect Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed Natural American Spirit's pro-environment packaging and perceptions of T reduced-harm cigarettes Anna E. Eppersona, Eric F. Lambinb,c, Lisa Henriksena, Michael Baiocchia, June A. Florad, ⁎ Judith J. Prochaskaa, a Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA b School of Earth, Energy & Environmental Sciences, Woods Institute for the Environment, Stanford University, Stanford, CA, USA c Georges Lemaître Earth and Climate Research Centre, Earth and Life Institute, Université catholique de Louvain, Louvain-la-Neuve, Belgium d Solutions Science Lab, Department of Pediatrics, Stanford University, Stanford, CA, USA ARTICLE INFO ABSTRACT Keywords: Natural American Spirit (NAS) cigarettes feature a pro-environment marketing campaign on the packs. The NAS Tobacco product “Respect for the Earth” campaign is the first example of on-the-pack corporate social responsibility advertising. Environment In a randomized survey design, we tested perceptions of NAS relative to other cigarette brands on harms to self, Perceptions others, and the environment. Never (n = 421), former (n = 135), and current (n = 358) US adult smokers were recruited for an online survey from January through March 2018. All participants viewed packs of both NAS and Pall Mall. Participants were randomized to view NAS vs. Pall Mall and to pack color (blue, green, or yellow/ orange), which was matched between brands. Survey items assessed perceptions of health risk of the cigarette brand to self, others, and the environment and corporate perceptions. Consistently on all measures, NAS ci- garettes were rated as less harmful for oneself, others, and the environment relative to Pall Mall (p's < .001). Though Reynolds American owns both brands, participants rated the company behind NAS as more socially responsible than the company behind Pall Mall, F[1, 909] = 110.25, p < .001. The NAS advantage was sig- nificant irrespective of smoking status, pack color, and brand order, with findings stronger for current thannever smokers. Pro-environmental marketing on NAS cigarette packs contributes to misperceptions that the product is safer for people and the environment than other cigarettes and made by a company that is more socially re- sponsible. Stricter government regulations on the use of pro-environment terms in marketing that imply mod- ified risk are needed. Tobacco is the leading preventable cause of death (USDHHS, 2014) tobacco companies of the American public, leading many smokers to and the leading form of litter globally (Rath et al., 2012), releasing toxic switch rather than to quit smoking. Passed in 2009, the Family Smoking chemicals into the soil and water supply (Slaughter et al., 2011; Prevention and Tobacco Control Act banned the use of “light,” “low,” or Novotny et al., 2011). Further, mass production of tobacco involves “mild” labels on tobacco products without a modified risk tobacco significant environmental costs (Otanez and Glantz, 2011). Given the product order from the US Food & Drug Administration (FDA), yet the serious harms of smoking and the growing public concern about these tobacco industry still continues color coding cigarette packs to perpe- harms, an emphasis by the tobacco industry has been promotion of a tuate the idea that some cigarettes are healthier (Bansal-Travers et al., safer, less harmful way to smoke (Epperson et al., 2017). In the mid- 2011). 1950s, the tobacco companies created the illusion of filtration and mass More recent concern about cigarette marketing has been the focus marketed low tar cigarettes (Johnston, 1966), followed in the 1970s by on natural and organic tobacco, featured prominently in the branding the heavy promotion of light and ultra-light cigarettes (USDHHS, of Natural American Spirit (NAS) cigarettes. Similar to what occurred 2001). In 2006, United States vs. Philip Morris (D.O.J. Lawsuit) de- decades earlier with filters and lights, studies have shown that both termined that selling and advertising of low tar and light cigarettes as smokers and nonsmokers perceive the NAS brand as less harmful to less harmful than regular cigarettes was deliberate deception by the US health than other cigarettes (Moran et al., 2017; Gratale et al., 2019; ⁎ Corresponding author at: Stanford Prevention Research Center, Department of Medicine, Stanford University, Medical School Office Building, X316, 1265 Welch Road, Stanford, CA 94305-5411, USA. E-mail address: [email protected] (J.J. Prochaska). https://doi.org/10.1016/j.ypmed.2019.105782 Received 28 February 2019; Received in revised form 4 June 2019; Accepted 17 July 2019 Available online 17 July 2019 0091-7435/ © 2019 Elsevier Inc. All rights reserved. A.E. Epperson, et al. Preventive Medicine 126 (2019) 105782 Fig. 1. Pack images viewed. Participants viewed both brands but were randomized as to which pack they viewed first (Natural American Spirit or Pall Mall). Participants also were randomized to one of three pack colors (blue, green or orange/gold), with color matched for both packs viewed. There were 6 total randomized conditions, crossing pack brand order (2) by color (3). Pearson et al., 2016; Leas et al., 2018; Leas et al., 2017). The Population investigated in two studies to date. Participants shown advertisements Assessment of Tobacco and Health (PATH) Study estimated that over (e.g., print, online) highlighting environment/sustainability practices of half of US smokers who prefer NAS mistakenly believe the brand is less NAS production rated the brand more favorably than a control group harmful than other cigarette brands (Leas et al., 2017). An ultra-pre- not exposed to advertisements (Gratale et al., 2017). Similarly, parti- mium brand, NAS's market share has increased over 400% since 2002 cipants randomized to view NAS advertisements with the text “tobacco (Sharma et al., 2016). Due to concerns about reduced harm claims, the and water” or with references to “eco-friendly” practices were more FDA required NAS to cease use of “100% additive free” and “natural” in likely to report misperceptions of reduced harm to health compared to its product marketing and advertising, effective October 2018, those who viewed the NAS advertisements without these terms (Moran yet allowed continued use of “natural” in the trademarked brand name et al., 2018). Unexamined is the impact of pro-environment tobacco (Campaign for Tobacco-Free Kids, 2017). In place of “additive-free,” the marketing on cigarette packaging. The cigarette pack is a central mes- NAS packs substituted “tobacco ingredients: tobacco and water,” simi- sage vector viewed 7300 times a year by pack-a-day smokers. larly creating misperceptions of reduced harm (Gratale et al., 2019). In a within-subject and randomized survey design, the current study The NAS packs also now feature a pro-environment marketing examined the effect of NAS's pro-environment product labeling onto- campaign. While tobacco companies have a history of creating pro- bacco-related perceptions of health and environment among never, environment marketing campaigns (Otanez and Glantz, 2011; Gonzalez former, and current adult smokers. We tested the 2018 NAS packs, et al., 2012), the NAS “Respect for the Earth” campaign is the first which replaced the previous messages of “100% additive-free” with example of corporate social responsibility (CSR) advertising on cigar- “tobacco ingredients: tobacco and water.” Pall Mall was selected as the ette packs themselves (Epperson et al., 2018). Pro-environment mar- comparison brand pack because they are equally harmful, and both keting with a focus on biospheric values can inspire the public to pay a brands are owned by Reynolds American. Thus, all comparisons be- premium for products such as energy efficient appliances and organic tween NAS and Pall Mall have no actual differences (i.e., in health foods (Nguyen et al., 2016). In reality, biospheric values are entirely outcomes or corporate responsibility) and any perceived differences are incompatible with the manufacturing and smoking of cigarettes. Yet, misperceptions. the NAS “Respect for the Earth” CSR campaign advertises a facility that is “zero-waste-to-landfill” and includes a wreath of three tobacco leaves that mimics the symbol for recycling. The side of the pack features the 1. Method logo for the Programme for the Endorsement of Forest Certification (PEFC), a forest certification organization promoting sustainable forest 1.1. Recruitment management (Programme for the Endorsement of Forest Certification, 2018). Participants were recruited through the online platform Prolific Pro-environmental advertising campaigns for NAS have been (https://prolific.ac/) for a study on “different marketing approaches with consideration of health and the environment.” Based on Prolific 2 A.E. Epperson, et al. Preventive Medicine 126 (2019) 105782 screening data, we stratified by smoking status and restricted thein- Corporate social responsibility perceptions of the tobacco com- vitation to members over the age of 18, residing in the US, and fluent in pany behind each brand were assessed with 11 true/false statements English. The survey was limited to US residents because NAS marketing (Kuder-Richardson-20 = 0.70 for NAS/0.65 for Pall Mall); e.g., “The differs in non-US countries (e.g., NAS packs in Japan still include “light” company donates profits