Smokers’ perceptions of smokeless tobacco and harm reduction
Existing survey data indicate that most smokers are not receptive to harm reduction incentives of switching to smokeless tobacco (SLT). Little is known about the underlying reasons for these views. To explore smokers’ perceptions of SLT, we conducted a focus group (eight in total) study of daily smokers between 2009 and 2010 at the University of California, Irvine. We transcribed each 2-hour focus group verbatim and analyzed it using domain analysis. The discussions revealed several reasons why smokers are not receptive to SLT. First, smokers associated new spit-less SLT (that is, Snus) with historic images of chewing tobacco. Second, smokers viewed smoking as an incentive to take a break from their daily routine. Third, smokers expressed lack of control over nicotine delivery when using SLT, relative to cigarettes. These findings challenge tobacco manufacturers’ strategies to market a smokeless alternative as a growing number of smoke-free policies are introduced.
Keywordssmokeless tobacco harm reduction tobacco control qualitative domain analysis
Harm reduction, an alternative to abstinence of risky behavior, represents a growing strategy in public health. However, the concept has been viewed cautiously by tobacco-control advocates, due largely to deceptive claims that smokers’ face fewer health risks from use of ‘low tar’ or ‘light’ cigarettes.1 The debate over tobacco substitutes has been rekindled by studies of male Swedish smokers who have given up their cigarettes for the smokeless product Snus, a trend correlated with a decline in lung cancer incidence.2 Sweden may be undergoing a natural experiment in tobacco harm reduction,3 the results of which appear to favor the European Union's removal of its ban on Snus.4 Some have argued that Sweden's success may result from more traditional tobacco control measures.5 The debate over harm reduction is growing in other countries, such as the United States, where the proliferation of smoke-free policies pressured the tobacco industry to consider smokeless alternatives.6
Tobacco-control advocates have expressed concern that the US industry may be marketing Snus to adolescents or current smokers interested in a complementary tobacco product, rather than a tobacco replacement.7 Several countries may follow developments in the United States, particularly since World Health Organization's adoption of the Framework Convention on Tobacco Control (FCTC).8 Article 8 of the FCTC emphasizes the necessity of creating smoke-free environments in workplaces and public places. As more countries implement the FCTC principles, tobacco manufacturers may consider smokeless alternatives to counter smoke-free policies.
The question of whether the popularity of Snus in Swedish males is attributed to Sweden's ‘cultural uniqueness’9 remains unanswered. For comparative purposes, smokeless tobacco (SLT) in the United States became popular among youths in the 1980s probably as a result of aggressive marketing.10 Most smokers in the state of California, for example, are not receptive to using smokeless tobacco as an alternative,11 perhaps because of the perception that it is equally or more harmful than cigarettes.12
Smokers’ perceptions of new SLT products and harm reduction messages have not been thoroughly assessed. Qualitative methods are more likely than surveys to capture the complexity of reasons why smokers may or may not be receptive to SLT, including perceived cancer risk, product appeal, marketing, economics, convenience, and/or social acceptability.13,14,15 Using focus groups, we examined smokers’ perceptions about new SLT products considering the motivations and reinforcements for smoking, incentives for quitting smoking, and use of health information in making choices about harm reduction.
Recruitment of participants
We recruited participants for this study through flyers, advertisements in the Orange County Register, and online postings on Craigslist.org. Most participants (71 per cent) responded to the last. Our objective was to obtain a diverse sample of smokers in Orange County, California. After responding, we directed individuals to a brief online survey of smoking behavior (SurveyMonkey.com). Those who characterized themselves as daily smokers were subsequently contacted to participate in the study, conducted from November 2009 to June 2010. An initial focus group, designed to test questions and audio-recording equipment, had five participants over 18 years (three men, two women). We conducted the remaining seven focus groups separately by age group to account for age/generational differences in smoking attitudes: two groups of 18–24-year-olds; two groups of 25–35-year-olds; two groups of 36–49-year-olds; and one group of participants over 50 years of age. We initially targeted ten persons per focus group with the goal of having eight persons per group, over-recruiting by a minimum of 20 per cent.16 Mojgan Sami, MA, moderated each group. Her extensive experience as a facilitator helped manage group dynamics and group participation. The Institutional Review Board at the University of California, Irvine, approved our protocol for human subjects research on 8 May 2009.
Administration and analysis of focus groups
Each participant completed a self-administered questionnaire with 35 items covering their smoking behavior and perceptions of risk and health. Each focus group lasted 2 hours, and included a 10–15 minute break. We gave all participants who completed the entire focus group and questionnaire US$40 for their participation, in addition to food and beverage. The facilitator used an open-ended, semi-structured guide consisting of questions aimed at fostering discussion about perceptions of new SLT and other alternatives to cigarettes. We recorded each focus group (18 hours in total), transcribed it verbatim (500 total pages), and observed verbal and non-verbal communication.
Summary of domain analysis of eight focus groups of participants from Orange County, California, conducted from November 2009 to June 2010
X is a reason for →
Boredom/‘killing time’/something to do/taking a break/going outside
Enjoying ‘hand-to-mouth’ motion/‘watching smoke come out of your mouth’/oral fixation/cigarette is a source of comfort
Seeing other people smoke
Drinking/being drunk/using marijuana
‘My identity’/‘fitting in’/‘being cool’/‘common bond’/‘to impress a girl’. ‘Everyone has a vice, my vice is smoking’
‘Doing something forbidden’/‘rejecting rules’/‘do not give a damn’
‘Being stressed out’/‘situational triggers‘/feeling irritable
‘Smoking is inevitable’/‘addictive personality’/‘being able to smoke’
Getting in the car/driving
Not able to replace smoking with anything else (for example, music, reading)
It's hard/wanting a cigarette/avoiding pain/too much effort/not ready
(2) Not quitting
Side effects from Nicotine Patches
Not willing to ‘switch’ addictions
‘Smoking is part of my life’/‘smoking is just a phase’/‘no regrets’
Having motivation/will power
Future child/be a good example to kids/pregnancy/baby being born
Awareness/cancer/shortness of breath/coughing/being sick
Family member dying/parents smoking
Fiancé nagging/parents’ opinions
Testing yourself/testing your level of addiction/if you smoke all day
Being ‘labeled’ a smoker/smelling like smoke
Medical school/working in the medical field
New Year's resolutions/friends who quit and nag you to quit
Do not have to spit (that is, SNUS versus traditional chewing tobacco)
(4) Using SLTs
Convenience (for example, movies/airplane/nightclub) when not able to smoke
Framing SLTs as NRTs when contemplating quitting cigarettes
Free tins of SNUS/free samples
Stigma (when framed in context of traditional tobacco)/disgust/girls
(5) Not using SLT
Still addictive/‘would rather quit than switch’/distrust of product/dizzy
Inadequate replacement for cigarettes/lack of satisfaction
Perceived as more ‘unhealthy’ than cigarettes/gum disease
Does not help to quit cigarettes/bad prior experience/bad taste
Trusting information on package regarding health risks
(6) Accessing health information
Humor of messages/making fun of information
Everyone already knows the risks of smoking and tobacco/familiarity of information/already know warnings/lack of interest
(7) Not accessing health information
Biased/irrelevant info from tobacco companies, Truth Campaign
The eight focus groups, including the pilot, included 37 adults, 24 men, and 13 women, and ranged from two to eight participants per group. The racial/ethnic makeup of the 37 participants was 75.7 per cent Caucasian (n=28), 13.5 per cent Asian (n=5), 5.4 per cent Latino (n=2), and 5.4 per cent Other (n=2). By design, individuals differed by age according to their assigned focus group. All resided in Orange County, California, with the largest group (24 per cent) living in the city of Irvine. Sixty-five adults (37 men, 28 women) were originally confirmed to participate, 28 of whom did not show up despite repeated phone calls and e-mail reminders. Those who did and did not attend a focus group varied little by race/ethnicity (for example, 75.7 per cent versus 71.4 per cent Caucasian, respectively), but did vary by gender (35.1 per cent male versus 53.6 per cent female).
Smokers’ perceptions of smoking
As summarized in Table 1, smokers in our study voiced many of the common reasons cited for smoking – boredom, drinking, socialization, stress, irritability, and the satisfaction derived from the cigarette. As expected, our study also demonstrated differences in smokers’ perceptions by age group. Younger smokers tended to perceive their smoking behavior as a temporary phase (that is, they could ‘stop at any time’), whereas older smokers viewed their cigarette behavior as an addiction that would require external assistance to quit.
The most interesting finding in the analysis was smokers’ perceptions of indoor smoking bans. Far from being a deterrent to cigarette smoking, the smokers in our study overwhelmingly supported smoke-free policies as justification for them to ‘go outside and take a break’ from their daily routine and schedule. Ironically, smokers thought of going outside to smoke as a health benefit because it allowed them time to de-stress. In fact, smokers expressed pity for non-smokers who did not have an incentive to take a break and go outside. In this light, smokers viewed SLT products as barriers to taking a break. This finding suggests that health policy researchers should carefully examine whether smoke-free policies are having the intended consequence of reducing overall smoking, or the unintended consequence of perpetuating smoking.
Smokers’ perceptions of health information and quitting
Contrary to our hypothesis that additional health information would be useful for encouraging smokers to try quitting, smokers in our study did not perceive such information as being motivational. Furthermore, smokers did not consider additional health information on the comparative risks of alternative tobacco products when making decisions about switching to SLT. Smokers said that ‘everyone already knows that cigarettes are bad for you’. They felt that the resources being used in anti-smoking campaigns (that is, Truth Campaign) could be better used elsewhere. As anticipated, these perceptions did not translate into either searches for health information on the Internet, or use of the information in making health decisions. Rather, health information was sought mainly as a proxy for medical advice, to assess medication interactions or diagnose symptoms possibly related to smoking. In contrast to health information, encouragement from a loved one (for example, parent or child) provided motivation and incentive to consider a quit attempt. Pregnancy was by far the most important motivator for young smokers wanting to ensure the health and safety of their future child. Although health and cancer risks weighed more heavily on the minds of older smokers, such information was not seen as an incentive to quit smoking. One of the participants confessed that he relapsed 1 year after open-heart surgery because ‘one cigarette a day isn’t going to kill you’.
Smokers’ perceptions of SLT
New SLT products had little appeal to current smokers. The smokers in our study were acutely aware that switching to SLT meant replacing one health risk with another, while continuing to be addicted to a nicotine product. They overwhelmingly preferred to stop smoking ‘cold turkey’ over switching to a SLT product, such as Snus. They noted many sacrificed pleasures when switching from cigarettes to SLT, such as the ability to take a break from work, the ‘hand-to-mouth’ action, and the feeling of smoke going into the lungs and seeing the ‘puffy cloud of smoke’. Our analysis also highlighted a great sense of distrust of new tobacco products. The smokers in our study were familiar with the nicotine delivery of certain tobacco products and brands, and discussed dosage and impact with one another. Although the participants recognized the hazards of cigarette smoking, they felt they could vary the strength of their smoke inhalation to provide a sense of control over the amount of nicotine delivered by each cigarette. This was not the case for SLT, which represented an ‘unknown’, because a smoker's hands or lungs could not control the level of nicotine delivery. Putting tobacco ‘inside’ the body (for example, keeping a Snus packet tucked away in your mouth for hours at a time), rather than cigarette smoke, elicited uneasiness. Several smokers mentioned that SLT either made them dizzy or failed to provide appropriate nicotine delivery.
The smokers’ sense of control over the cigarette appeared to translate to their perception of SLT as a more harmful product than cigarettes. They anticipated less control over SLT because of its constant and direct contact with tissue in the mouth. They believed that the ‘hand-to-mouth’ action of smoking provides more control over how much toxin they ingest. Seeing exhaled smoke inclined smokers to believe that they were blowing out the cigarettes’ toxins. The smokers’ perception of SLT as more harmful did not appear to be based on scientific evidence or health information. When the moderator attempted to clarify studies demonstrating decreased cancer risk associated with SLT, participants displayed skepticism and disbelief, stating that they would not be willing to trade one addiction for another.
These reasons why smokers expressed minimal receptiveness to SLT were considered in the context of their own smoking behavior. Historic images of chewing tobacco heavily influenced participants’ perceptions of the new spit-less products, such as Snus. When researchers explained that the new tobacco products do not require spitting, smokers responded viscerally in describing SLT as ‘gross’, ‘disgusting’, and ‘nasty’. Smokers were acutely aware of the public perception of SLT. One participant said ‘If you spit on the floor, people will lose their mind’. To assist smokers understand the distinction between new and traditional SLT products, we used pictures to assess smokers’ reactions. Despite our efforts, smokers in our study could not overcome their historic perception of SLT. In describing the users of new SLT, participants still characterized them as ‘lower class’, ‘cowboys’, and ‘rednecks’. A desire not to be identified with a stigmatized social group associated with chewing tobacco may constitute an additional barrier preventing wider adoption by smokers of new SLT.
The small minority of participants who felt positively about new SLT products also perceived SLT in the context of their own smoking behavior. When comparing novel SLT with cigarettes, they mentioned the convenience of a smokeless/spit-less product when there was no opportunity to smoke. Only a few participants discussed taste, experiences with SLT (for example, Snus), or the perception that SLT felt ‘cleaner’ than smoking.
The most appealing product for the smokers in our focus groups was the electronic cigarette, or e-cigarette. One male participant brought his e-cigarette and used it for the entire duration of the focus group. Although the smokers were genuinely intrigued by the idea of the e-cigarette, no one expressed a desire to switch to this product. In fact, the participant who used the e-cigarette asked for a ‘real’ cigarette during a break. Generally, smokers who framed SLT in a positive light did so not because they enjoyed these new tobacco products, but because of convenience when they could not smoke. Given a choice, none of the smokers in our study chose novelty SLT over a cigarette.
The most revealing finding from this study was the participants’ association of new SLT with historic images of chewing tobacco. Secondly, smoking was viewed as an incentive to take a break from daily routines; and thirdly, smokers expressed lack of control over nicotine delivery when using SLT, relative to cigarettes. Another key finding was the disregard for health information concerning risks of tobacco use. In fact, increased knowledge of health risks associated with cigarettes was not viewed as motivation for harm reduction (that is, switching to SLT) or as an effective incentive to quit. Finally, participants’ consideration of SLT was mitigated in the context of their own smoking behavior, evident for issues ranging from product appeal to risk perception of tobacco use. This framing could be a function of discussions on the motivators and deterrents of smoking.
Important lessons can be drawn from our study, particularly on the current marketing of Snus. This form of SLT is being marketed to smokers who encounter smoking restrictions (for example, indoor bars), and have a reason for using a smokeless alternative. Evidence for this was found in point-of-purchase marketing in gas stations and convenience stores,19 Internet websites,7 and advertisements of Camel Snus in print media.20 A content analysis found that 100 per cent of the original print advertisements for Camel Snus (excluding the more recent Break Free advertisements) were intended for smokers.
Most participants expressed displeasure at having to give up their incentive for an outdoor smoking break, a message contrary to the themes of some Camel Snus advertisements. Participants in our study suggested that smoking breaks represent an opportunity to ‘be alone’ and decompress from daily routines. Rather than encourage switching to the use of SLT, smokers in our study did not object to indoor smoking bans because they compelled them to go outdoors for a cigarette. Consequently, the marketing of Snus may not have a substantial impact because either the message (that is, use anywhere/anytime) does not resonate with smokers, or the product itself is an aversion to smokers because of the social stigma, often about spitting tobacco ‘juices’. The appeal of not having to spit, a message conveyed in 52.5 per cent of the Camel Snus advertisements,20 plus recent advertising in female-oriented magazines (for example, Vogue), was part of a larger effort to attract a broader base for SLT.6 Despite the industry's efforts and smokers’ awareness of spit-less tobacco's modernity, smokers in our focus groups still reacted with disdain upon hearing the term SLT.
The participants’ perception of SLT use as a more harmful behavior than cigarette smoking is consistent with surveys of smokers21 and college students,22 perhaps a misperception because Swedish data suggest reduced cancer risk when replacing cigarettes with SLT.2 The US Food and Drug Administration's view that no safe tobacco product exists does not acknowledge comparative tobacco risks. It denies smokers their rights to information on harm reduction options.23,24 Although the debate over comparative tobacco risks has occurred mostly in industrialized countries, it may gain momentum elsewhere as developing countries adopt smoke-free policies (for example, Mexico City). Article 11.1(a) of the FCTC states that the packaging and labeling of tobacco products should not include any information on health effects that is unwarranted or misleading.8 Nevertheless, based on responses from participants in our focus groups, it is unlikely that information on tobacco risks would have an impact on smokers’ decisions regarding health. This could be traced to smokers' concerns over biased information, a sense of knowing all of the risks, or simple apathy. The last may be particularly evident for young smokers; as reported in another focus group study,25 18 to 22-year-old smokers indicated continued use of non-traditional tobacco products (for example, bidis) because of product appeal, cost, and convenience, but not health.
This study was strengthened by the rigorous application of an inductive analysis technique that is new to the debate over tobacco harm reduction. Through the use of this approach, we identified novel perspectives on harm reduction that have implications for tobacco marketing, risk perception, and health information. No study, to our knowledge, has reported the perception of having more control over nicotine and toxin delivery in cigarettes versus SLT as the reason for smokers’ beliefs about comparative tobacco risks.
A limitation of our study was the use of a convenience sample in Orange County, California. This potentially challenges one of our principle findings – the incentive to smoke, namely ‘going outside to take a break’. Weather in Southern California is amenable to this behavior; thus, this finding may be conditional in environments that are conducive to year-round outdoor breaks. Although our study was limited by use of a convenience sample and variability in focus groups (that is, 2–8 persons per group), we relied on theoretical sampling to address the potential bias. This approach is a method of sampling based on concepts/themes emerging from the analysis, not on probabilistic sampling of individual participants.17 After each focus group, we transcribed and analyzed data immediately to inform the following focus groups. Each emerging concept/theme was explored until it reached a point of ‘saturation’.17
In addition to using theoretical sampling, we made extensive efforts, including repeated phone calls and e-mail reminders, to obtain a larger number of participants. Despite the study limitations, the perceptions of smokers in Orange County, CA, were quite similar to those interviewed in a much larger and more representative sample of California smokers.11 That study was the impetus for this one; both indicated smokers’ nominal receptiveness to the use of SLT for harm reduction. Using focus groups in the current study, we uncovered complexities of smoking behavior that can help frame discussions on harm reduction, an important consideration for tobacco control efforts. At the moment, harm reduction is a secondary issue in tobacco control policy in the developing world. However, increased prevalence of smoke-free policies may pressure tobacco manufacturers toward smokeless alternatives. In other words, initiatives such as the World Health Organization's FCTC may inadvertently encourage the proliferation of SLT use in the developing world.
Irrespective of policy or industry initiatives, our focus group study suggests that SLT is not likely to be adopted by most smokers, either for harm reduction or convenience. This has many implications for tobacco harm reduction. If product appeal is the primary barrier to the adoption of novelty SLT, then concerns about cancer risk,26 for example, are likely to play a less important role. Efforts to market the novel products to a more sophisticated audience7 may prove to be ineffective. Despite the fact that our focus group participants were informed of the ‘spit-less’ attribute of the new products, they still associated the novel SLT with historic images of chewing tobacco. Finally, if there is only nominal receptiveness to health information, efforts to promote novelty SLT as a safer tobacco substitute may yield few results. In order to determine if our participants' attitudes and perceptions are expressed by smokers outside of Orange County, California, additional qualitative studies should be conducted across different cultures and countries.
We thank the American Cancer Society for funding this project through the IRG Seed Grant (IRG–98-279-07), administered via the University of California, Irvine; Martha Feldman for mentorship in qualitative data analysis; and Robin Marion for help coding and categorizing transcript data. Finally, we thank Chelsea Semrau and Ann Ngyuen for their support and assistance in recruitment and transcription.
- U.S. Department of Health and Human Services. (2001) Risks Associated with Smoking Cigarettes with Low Machine-Measured Yields of Tar and Nicotine. Bethesda, MD: National Institutes of Health, National Cancer Institute.Google Scholar
- World Health Organization. (2011) The WHO Framework Convention on Tobacco Control. Guidelines for Implementation. Geneva, Switzerland: World Health Organization.Google Scholar
- Kreuger, R.A. (1988) Focus Groups as Qualitative Research. London: SAGE.Google Scholar
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- Kozlowski, L.T. and Edwards, B.Q. (2005) ‘Not safe’ is not enough: Smokers have a right to know more than there is no safe tobacco product. Tobacco Control 14 (2): ii3–ii7.Google Scholar
- Richter, P., Caraballo, R., Gupta, N. and Pederson, L.L. (2008) Exploring use of nontraditional tobacco products through focus groups with young adult smokers, 2002. Preventing Chronic Disease 5 (3): 1–8.Google Scholar