Journal of Behavioral Medicine, Vol. 27, No. 4, August 2004 ( C© 2004)

Preliminary Investigation of the Advertisingand Availability of PREPs, the New “Safe”Tobacco Products

Norval Hickman,1 Elizabeth A. Klonoff,1,2 Hope Landrine,1

Kennon Kashima,1 Bina Parekh,1 Senaida Fernandez,1

KaMala Thomas,1 Catherine Brouillard,1 Michele Zolezzi,1

Jennifer Jensen,1 and Zorahna Weslowski1

Accepted for publication: May 20, 2004

The tobacco industry recently introduced a new set of “safe” cigarettes andnicotine delivery devices that purportedly entail reduced tobacco-related dis-ease risk due to their lower level of some carcinogens and toxins. Little isknow about the biological impact of these potential reduced exposure prod-ucts (PREPs) and nothing is known about their advertising and availability.Hence, two pilot studies were conducted to examine the latter issues for thefirst time. In Study 1, we examined tobacco ads in 10 popular magazines1998–2002 and found that only 1% of ads were for PREPs. In Study 2, weattempted to purchase PREPs in a random sample of 113 small stores andfound that only 4.4% sold any PREP. These preliminary findings tentativelysuggest that the industry might not yet be heavily invested in products thathave the potential to increase tobacco use by decreasing its perceived harm.Studies with larger samples are recommended.

KEY WORDS: PREPs; safe cigarettes; new tobacco products; advertising; availability.

The tobacco industry recently introduced a new generation of to-bacco products and nicotine delivery devices that purportedly entail re-duced tobacco-related disease risk due to their lower level or absence ofsome carcinogens and toxins (Institute of Medicine [IOM], 2001; Shield,

1SDSU/UCSD Joint Doctoral Program in Clinical Psychology, San Diego State University,San Diego, California.

2To whom correspondence should be addressed at SDSU/UCSD Joint Doctoral Program inClinical Psychology, San Diego State University, 6363 Alvarado Court, Suite 103, San Diego,California 92120; e-mail: eklonoff@sunstroke.sdsu.edu.

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2002). The ostensible purpose of these potential reduced exposure products(PREPs; shown in Table I) is to render tobacco use safer (i.e., less health-damaging), as well as to provide smokers with a nonsmoking means for self-administering nicotine in settings where smoking is banned. Health scien-tists from a variety of disciplines, along with the National Cancer Institute(2002), are gravely concerned about PREPs. Hence, in a 2001 report onPREPs, the Institute of Medicine concluded that the three major questionsabout PREPs that must be answered by research are as follows: (1) Doesuse of these products decrease exposure to the harmful substances in to-bacco as claimed by the tobacco industry? (2) Is this potential decreasedexposure associated with decreased tobacco-related morbidity and mortal-ity? and (3) What are the public health implications of these products?

The first two questions highlight the need for research on the short-and long-term biological impact of the use of PREPs. Although such stud-ies recently have begun (Breland et al., 2002; Fagerstrom et al., 2000; Sladeet al., 2002), PREPs clearly “have not been evaluated comprehensivelyenough or for a sufficient amount of time to conclude that they are asso-ciated with a reduced risk of disease compared to conventional tobaccouse” (IOM, 2001, p. 5); hence, more research on the biological impact ofPREPs is badly needed. The third question above also is important becauseit “addresses the population impact of these products. That is, althougha product might be risk-reducing for an individual’s health compared toconventional tobacco products, its use may not be harm-reducing for thepopulation as a whole” (IOM, 2001, p. 4). This is because the changes totobacco products entailed in PREPs—like other ostensibly harm-reducingchanges that the tobacco industry has made to its products—might increaserather than decrease tobacco use. For example, one well-known, ostensiblyharm-reducing change that the industry made was the introduction of the“low tar,” “light,” and “ultra light”cigarette (Pollay and Dewhirst, 2002;Shiffman et al., 2001a,b; Thun and Burns, 2001). Although these productsdo indeed emit lower tar, nicotine, and carbon monoxide than conven-tional products (as measured by smoking machines), they do not appearto pose a lower health risk (e.g., lower lung cancer rates) than conven-tional cigarettes if only because of compensatory smoking (i.e., inhalinglights more deeply; Thun and Burns, 2001). Yet, people “believed, andstill do, that these products pose less risk to health than other cigarettes”because ads imply this (IOM, 2001, p. 26; Pollay and Dewhirst, 2002;Shiffman et al., 2001a,b). Hence, rather than cease tobacco use, muchof the public switched to light cigarettes: The market share of lights in-creased from 4% in 1970 to 50% in 1980 (after advertising campaigns ofthe mid-1970s) and to 80% in 1998 (IOM, 2001). The same may be thecase for PREPs: Whether PREPs entail less harm for the individual user

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Table I. The 10 New Prepsa

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Table I. Continued

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Table I. Continued

(as the industry claims) or not, the population impact of PREPs may bethat

tobacco users who might otherwise have quit do not . . . former tobacco users [might]resume use, [and] some people who would not have otherwise initiated tobacco use[might] do so because of perceptions that the risk with the “new” products is min-imal and therefore acceptable . . . the desire to quit may also be reduced if the useof nicotine products is encouraged in areas that restrict tobacco use so that the in-dividual no longer needs to contend with withdrawal symptoms in these situations.(IOM, 2001, pp. 32, 112)

Such concerns stem not only from knowledge of the effects of the industry’sprevious harm-reduction product modifications, but also from data on theindustry’s general advertising strategy (IOM, 2001; Pollay and Dewhirst,2002) and specific strategy for PREPs (IOM, 2001): The general advertis-ing strategy of the industry (since the 1970s introduction of light cigarettes)has been to provide consumer reassurance about cigarettes and the smokinghabit by claimed low deliveries [of toxins]; thus, ads are constructed in ways

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so as not to provoke anxiety about health but to alleviate it (Tobacco Indus-try document, cited in IOM, 2001). Hence, a typical (2000) ad for PREPsreads: “The best choice for smokers who are worried about their health isto quit. Here’s the next best choice: Eclipse” (IOM, 2001). Consequently,in addition to the need for research on the chemical constituents and healthimpact of PREPs, IOM stressed the

urgent need for information on a broad range of elements necessary to understandthe population impact of . . . PREPs, including attitudes, beliefs, product character-istics, product distribution and usage patterns, marketing messages such as harmreduction claims, and advertising. (p. 197)

To date, there are no studies of the population impact of these prod-ucts (IOM, 2001). Thus, the purpose of these pilot studies was to begin toexplore the availability and advertising of PREPs for the first time, with at-tention paid to the possible differential targeting of populations. The latteris of concern because the tobacco industry has a long history of marketingits products to specific communities, and to women, minorities, and youth inparticular (Cotton, 1990). For example, numerous studies have found thatthere are significantly more cigarette ads in Black than in White magazines(Cummings et al., 1987; Hoffman-Goetz et al., 1997; King et al., 2000), andsignificantly more tobacco billboards in Black and in Latino neighborhoodsthan in White ones (Hackbarth et al., 2001; Stoddard et al., 1997). Likewise,data indicate that Asian Americans also have been targeted with tailoredtobacco advertising (Muggli et al., 2002), and that the Gay/Lesbian com-munity has been targeted as well—e.g., with tailored ads for Marlboro andVirginia Slims in the gay/lesbian publications Out and Advocate (Butching,2002; Goebel, 1994). In addition, women continue to be targeted withtailored tobacco ads (linking smoking to emancipation and empowerment)in women’s magazines (Amos, 1990; Amos and Haglund, 2000; O’Keefeand Pollay, 1996). Similarly, menthol cigarettes are marketed primarily toAfrican Americans, with tailored ads that link smoking Kool to being cool(Gittelsohn et al., 1999; Huang et al., 1992; King et al., 2000)—much as adsfor smokeless tobacco primarily target men and male teens with tailoredmessages that link its use to being a rugged outdoors man (Ernster, 1989).Moreover, it is clear in these and other studies that this targeted, tailoredmarketing is planned and purposeful, and has been successful insofar as itplays a significant role in smoking initiation and patterns of brand prefer-ences (Cummings et al., 1987, 2002; Huang et al., 1992; King et al., 1998,2000; Pierce et al., 1991, 1998, 1999; Wayne and Connolly, 2002).

Given this history of targeted tobacco advertising, this additional ques-tion about PREPs must be raised: Does the advertising and distribution ofPREPs also target specific populations? To provide preliminary answers to

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this question, we conducted two, small pilot studies; in the first, we exam-ined ads for PREPs in magazines for different populations, and in the sec-ond, examined the availability of PREPs in various ethnic neighborhoods.

STUDY 1

Method

Ten (10) popular magazines were selected: Ebony and Jet (Blackmagazines), Us and People (General/White magazines), People in Spanish(Latino magazine), Glamour and Cosmopolitan (women’s magazines),Playboy (men’s magazine), and Glamour and Cosmopolitan in Spanish(Latina women’s magazines). Every issue of the monthly magazines wasexamined, along with the first weekly issue of each month of the weeklymagazines (Us, People, Jet), for the 4.5-year period of January 1998 throughAugust 2002. Each magazine issue was searched for ads for these fourPREPs: Omni, Advance Lights, Accord, and Eclipse. These PREPs repre-sent four of the six that are designed to replace conventional cigarettes; thetwo remaining such products (Quest and Scor; see Table I) were excludedfrom this study because they were not yet on the market in August 2002.PREPs designed to replace smokeless tobacco were not examined in thispreliminary study. Digital photographs were taken of all ads for the fourPREPs.

Results

A total of N = 289 issues of magazines were examined: 1218 tobaccoads (approximately 4 per issue) were found (see Table II). Only 12 of these

Table II. Tobacco Ads in 10 Popular Magazines for Various Groups

Ads for tobacco

Magazines audience No. of issues PREPS Cigarettes Row totals

Blacks/African Americans 56 4 (2.3%) 171 175Whites/general audience 54 4 (1.2%) 335 339aHispanics/Latinos (in Spanish) 32 0 51 51

Women 56 0 323 323Men 53 4 (1.4%) 279 283

Latina Woman (in Spanish) 38 0 47 47Column totals 289 12 (1.0%) 1206 (99%) 1218

aThese magazines began in 1999; the lack of issues for 1998 and the small number of issues in1999 reduced the total N for both relative to magazines in English.

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ads (1%) were for PREPS—i.e., there were significantly more ads for con-ventional cigarettes than for PREPs in all magazines (Likelihood Ratio χ2

(df, 5) = 11.140, p = 0.05). Ads for PREPs began to appear in February2002; there were no ads for any of the four PREPs prior to that date. The 12ads for PREPs were found between February and August 2002 distributedas follows: 4 ads were in Black magazines (Ebony), 4 were in men’s maga-zines (Playboy), and 4 were in General/White magazines (People). Therewere no ads for PREPs in the women’s magazines, the Latina women’smagazines, or in the magazines in Spanish that were examined. Differencesin the content of the ads and the number of pages devoted to them alsowere observed: The four ads in Playboy were each 2-page ads, the four adsin People were each 1-page ads, and of the four ads in Ebony, two were1 page and two were 2 pages. In addition, although all 12 ads containedharm-reduction messages (“Reduced carcinogens”), those in Ebony weremore likely to depict people: 3 of the 4 ads in Ebony (75% of PREP ads)depicted a Black woman, whereas only 1 of the 4 ads in both Playboy andPeople (25% of PREP ads) depicted a person (a White woman).

STUDY 2

Method

A random sample of 113 small grocery and convenience stores in SanDiego was selected, distributed as follows: 29 stores in White neighbor-hoods, 29 in Black neighborhoods, 30 in Latino neighborhoods, and 25 inAsian American neighborhoods. The ethnicity of a neighborhood was de-fined as ≥60% of the residents are members of the ethnic group in question,according to 2001 census data. Because of funding limitations, 4 (of the ex-isting 10) PREPs were randomly selected. Research assistants attemptedto purchase those four PREPs (Omni, Accord, Eclipse, and Ariva) once inevery store in each neighborhood.

Results

As shown in Table III, only 4.4% of the stores sold any of the PREPs,and all of these stores were in minority neighborhoods. Each PREP costapproximately $5.00 irrespective of the ethnicity of the neighborhood, andhence was comparable to the price of a pack of cigarettes in California.However, PREPs (i.e., a pack of Omni) purchased in the Black neighbor-hood had two free packs attached, but no free packs were attached to anyPREP purchased in any other neighborhood.

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Table III. San Diego Stores Selling PREPs

White stores Black stores Latino stores Asian stores Row storesProduct (N = 29) (N = 29) (N = 30) (N = 25) (N = 113)

Omni 0 1 1 1 3Accord 0 0 0 0 0Eclipse 0 0 0 0 0Ariva 0 1 0 1 2Column totals 0 (0%) 2 (6.9%) 1 (3.3%) 2 (8%) 5 (4.4%)

DISCUSSION

The tobacco industry may not yet be heavily invested in PREPs in-sofar as there are few ads for PREPs in popular, national magazines. Of1218 tobacco ads in 10 such magazines, only 12 (1.0%) were for PREPs.All 12 of these ads were for OmniTM and all 12 appeared in 2002—albeitsome PREPs have been on the market for several years (e.g., Eclipse since1994). In addition, four ads for PREPs were found in magazines for men,for Blacks, and for Whites (respectively), but none were found in women’smagazines, magazines in Spanish, or in Latina women’s magazines. Thesmall sample size (total number of PREP ads) rendered these differencesstatistically nonsignificant, and hence the question of the targeted adver-tising of PREPs remains unanswered by the pilot study. Moreover, unlikeother magazines, all ads in Playboy were 2-page ads; while the sample sizewas too limited for this difference to be significant, this preliminary findinghighlights the need to examine tobacco ads directed at men. Indeed, giventhat studies of ads for tobacco in magazines rarely have included men’smagazines, research investigating the possible targeting of men with ads forconventional and for PREPs tobacco products are needed. Likewise, thecontent of the ads also appeared to differ across magazines and this mightsuggest possible tailoring of PREP ads: Ads in Playboy stressed reducedcarcinogens and contained no photos of people, whereas ads in Ebony andPeople emphasized reduced carcinogens and “premium taste”—and bothdepicted a woman.

It must be emphasized, however, that these findings are highly pre-liminary for two reasons in addition to their lack of statistical significance:(1) the number of magazines examined was limited (N = 10), and hence(2) the number of magazines for each group was a mere 1 or 2. More adsfor PREPs may have been found had more magazines been examined foreach population. Thus, these magazine-ad pilot data suggest the need fora more extensive study of magazine advertising of PREPs, with particu-lar attention to possible targeting and tailoring of ads for diverse genderand ethnic groups, and for the gay/lesbian community as well. Moreover,

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studies of store-window ads for PREPs also must be conducted becausethese may be more prevalent than magazine ads. This is particularly possi-ble in some states (e.g., California, Massachusetts) insofar as data indicatethat there is significantly greater point-of-purchase advertising in states withcomprehensive tobacco-control programs than in states without such pro-grams (Slater et al., 2001).

Similarly, the purchase-attempt findings may suggest that PREPsmight not yet be widely available in small grocery and convenience stores:Only 4.4% of a random sample of such stores sold any PREP. Nonetheless,to the limited extent that PREPs were available in such stores, they weresold only in minority neighborhoods. Here too, however, the small samplesize (total N of stores selling PREPs) rendered the White vs. Minority storedifference statistically nonsignificant. These results are further limited bythe small number (N = 113) and limited types of stores examined, as wellas the small number (4 of 10 or 40%) of PREPs we attempted to purchase.More PREPs may have been found had we attempted to purchase all 10and had large grocery and liquor stores been included. Furthermore, it ispossible that PREPs are not widely available in San Diego but are readilyfound in stores in larger, more diverse California cities (e.g., Los Angeles),in other U.S. states, and in other countries. Hence, studies that assess theavailability of PREPs in a large, random sample of a variety of types ofstores in rural, urban, gay, minority, poor and wealthy communities areneeded. Likewise, studies of the magazine advertising of PREPs in popularmagazines in other countries, along with studies of the availability of thesenew products in a variety of countries, also are needed.

In summary, these pilot studies represent the first exploration of theadvertising and availability of the new ostensibly reduced-exposure tobaccoproducts. Although these highly preliminary findings are limited by thedearth of magazine ads for PREPs and by the low availability of them insmall stores, that result itself might mean that the tobacco industry is not—thus far—pushing products that have the potential to increase tobacco useby decreasing its perceived risk. We encourage studies of the availabilityand price of PREPs in the United States and elsewhere, along with studiesof the magazine, store window, and point-of-purchase advertising of theseproducts. Studies of perceptions of the reduced harm of these products andof the extent to which they increase or decrease smoking and quit rateslikewise are critical to assessing their population impact.

ACKNOWLEDGMENTS

Supported by funds provided by the National Cancer Institute GrantNo. 1-U56- CA92079 -01A1; the University of California Tobacco-Related

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Disease Research Program Grant No. 9RT-0043; and by the California De-partment of Health Services Tobacco Control Section Grant Nos. 90-11528,94-20962, and 96-26617.

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