Article Critique

Article Critique
BRIEF REPORT Perceptions of Harm and Addiction of Snus: An Exploratory Study Annette R. Kaufman National Institutes of Health, Rockville, Maryland Emily Grenen ICF International, Rockville, Maryland Meredith Grady National Institutes of Health, Rockville, Maryland Bryan Leyva Warren Alpert Medical School of Brown University Rebecca A. Ferrer National Institutes of Health, Rockville, Maryland Tobacco companies in the United States are prohibited from making reduced harm claims without filing a modified risk tobacco product application with the Food and Drug Administration and obtaining an order to market as such. However, it is possible that product marketing may suggest reduced risk to individuals. This study examines perceptions, in particular those related to harm and addiction, of snus print advertisements using a combination of eye-tracking, survey, and semistructured interviews. Par- ticipants were 22 male smokers ages 19 –29 (M 26.64,SD 2.92). Five snus advertisements were each displayed for 20 s and eye movements were tracked. Participants responded to questions about harm and addiction after each advertisement and interviews were conducted after seeing all advertisements. For each advertisement, descriptive statistics were calculated and regression analyses predicted harm and addiction perceptions from eye tracking areas of interest (e.g., warning label). Qualitative data were analyzed using inductive/deductive thematic analysis. For certain advertisements, areas of interest were significantly associated with harm and/or addiction perceptions. For example, higher total fixation duration on the graphic in theSmokeless for Smokersadvertisement was associated with decreased perceptions of addiction (B .360,p .048). Qualitative themes emerged and in many instances corroborated quantitative results. This study indicates that for some advertisements, attention on certain areas (measured through eye tracking) is associated with perceptions among young male smokers. Understanding how smokers perceive and understand products after viewing advertisements may inform regulations regarding claims about product harm and addiction and may guide public health efforts to educate smokers on the risks of emerging products. Keywords:snus, harm, addiction, eye-tracking, qualitative Supplemental materials:http://dx.doi.org/10.1037/adb0000230.supp Attitudes toward cigarette smoking have shifted over the years and have contributed, in part, to a decline in cigarette consumption in the U.S. (Chassin et al., 2003;Robert Wood Johnson Founda- tion, 2011). Tobacco companies have diversified their productsand expanded smokeless options, including snus, a pouch of moist tobacco that is typically placed under the lip and is generally not accompanied by spitting. Snus originated in Sweden and was introduced to the U.S. market in 2006 (Rogers et al., 2010). Annette R. Kaufman, Tobacco Control Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Rockville, Mary- land; Emily Grenen; Technology and Management Solutions, ICF Inter- national, Rockville, Maryland; Meredith Grady, Tobacco Control Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health; Bryan Leyva, Warren Alpert Medical School, Warren Alpert Medical School of Brown University; Rebecca A. Ferrer, Basic Biobehav- ioral and Psychological Sciences Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health.The results from this study were presented as part of a symposium, “Social Psychological Perspectives on the Prevention of Substance Use Behaviors,” at the Society for Prevention Research 23rd Annual Meeting (2015) in Washington, DC. A poster of these results was presented at the World Conference on Tobacco or Health (2015) in Abu Dhabi, United Arab Emirates. Correspondence concerning this article should be addressed to An- nette R. Kaufman, Tobacco Control Research Branch, Behavioral Re- search Program, Division of Cancer Control and Population Sciences, National Cancer Institute National Institutes of Health, 9609 Medical Center Drive, 3-E-546, Rockville, MD 20850. E-mail:[email protected] .nih.gov Psychology of Addictive BehaviorsIn the public domain 2016, Vol. 30, No. 8, 895–903http://dx.doi.org/10.1037/adb0000230 895 Smokeless tobacco products pose many risks, including cancer (International Agency for Research on Cancer, 2012;National Cancer Institute [NCI], 2001;U.S. Department of Health & Hu- man Services, 2014). Despite these risks, sales and consumption of smokeless tobacco products, including snus, have increased in the U.S. (Maher et al., 2012;Mitka, 2014;Popova & Ling, 2013). Increased use of snus is likely due in part to heightened mar- keting. The Family Smoking Prevention and Tobacco Control Act of 2009 states “A tobacco product shall be deemed to be mis- branded…ifitsadvertising is false or misleading in any particular manner” (FDA, 2009, Section 903). Tobacco companies have a history of making risk reduction claims regardless of accuracy (NCI, 2001). These unsubstantiated advertising claims influence public perceptions about tobacco products (NCI, 2008). In light of this history, it is important to assess whether snus advertisements may implicitly make risk reduction claims and to monitor how the public perceives and engages with advertisements. While research exploring perceptions about snus is increasing (Bahreinifar et al., 2013;Choi et al., 2012;Choi & Forster, 2013; Lund & Scheffels, 2014;Sami et al., 2012;Wackowski et al., 2015; Wray et al., 2012;Zhu et al., 2013), no studies to date have explicitly examined the influence of snus advertisements on perceptions of snus. Eye-tracking is an unobtrusive way to gather objective measurement of attention and information processing (Rayner, 1998;Wedel & Pieters, 1999). The current study utilizes a combination of eye- tracking methodology to examine advertisement viewing patterns, survey, and semistructured interviews to measure perceptions (i.e., harm and addiction), related to snus print advertisements among a sample of young-adult male smokers. Method Participants A community convenience sample (N 22) of young adult male daily cigarette smokers ages 18 –29 was recruited by newspaper advertisements, online postings, local flyers, and social media in the Washington, DC area between August, 2013 and September, 2013. Eighty-two potential participants were screened (participants were excluded based on preset criteria such as being female, outside the age range specified, some day smoking) to achieve a mix of ages, edu- cation statuses, and race/ethnicities, and to screen out participants who could not be calibrated for the Tobii Eye Tracker (e.g., those with trifocal contact lenses) or did not speak fluent English. Procedure Participants completed a consent form and baseline question- naire. Tobii Studio TX300 was used to display five snus print advertisements and track eye movements. The snus print adver- tisements were selected to represent a variety of brands, al- though brand names and symbols were removed, with diverse messaging and imagery. The warning label was standardized across all advertisements and the advertisements were random- ized to account for order effects. The eye-tracker had a sam- pling rate of 300 Hz, and was equipped with infrared iris reading sensory optics and a remote camera that tracked eye movement while participants were seated naturally.Participants were seated with their faces approximately 65 cm away from the23-inch monitor. Participants’ eye movements were calibrated and gaze was tracked and time-locked as they viewed each advertisement for 20 s. Fixations were defined as 60 ms or more. After each advertisement, participants responded to questions. Participants then engaged in a one-on-one semistructured inter- view. The interview protocol underwent pilot testing (n 9) to ensure that questions were clear and understandable. The moderator guide can be found in the supplemental material. The protocol consisted of open-ended questions designed to elicit participants’ awareness of snus, general perceptions of snus, health consequences of using snus, intentions to use snus, advertisement features, and warning labels. A trained research assistant conducted the interviews according to stan- dardized qualitative methodology (Denzin & Lincoln, 2005). Inter- views were conducted in English in a private room and were audio- recorded and transcribed verbatim by a professional transcription company. At the end of the session, participants were debriefed about the study purpose and provided information about the risks of tobacco and cessation resources. Participants received $50 for participa- tion. This study was considered exempt from Institutional Review Board review by the Office of Human Subjects Research Protec- tions at the National Institutes of Health. Measures Supplemental material shows baseline measures for this study. Self-reported sociodemographic variables assessed included age, education, race/ethnicity, marital status, and employment status. Age of first cigarette, age first started daily smoking, number of cigarettes per day, past quit attempts, having heard of snus and prior snus use, and intentions to use snus were also assessed. Prior to advertisement exposure, harm and addiction perceptions of snus were assessed. After viewing each advertisement, participants were asked “Do you believe that the snus product in THIS advertisement is less or more {harmful to one’s health/addictive} than ordinary cigarettes? Would you say the snus product in this advertisement is…”Forboth items, participants evaluated relative harm using a 5-point scale (much less harmful/addictive, less harmful/addictive, about the same, more harmful/addictive, much more harmful/addictive). To operationalize these constructs, participants were categorized as endorsing each snus product as less harmful/addictive (much less/less) and harmful/addic- tive (about the same/more/and much more;Kaufman et al., 2014). A priori “areas of interest” (AOI) on each advertisement were designated as graphics, warning, text, headers, and packs (seeFigure 1;Strasser, 2012.). Time to first fixation (TTFF) measured time in seconds before a participant fixates on an AOI for the first time. The time measurement started when the image was displayed and stopped when the participant fixated on the AOI. If a participant did not fixate on a particular AOI, the TTFF was recorded as missing. Total fixation duration (TFD) measured, in seconds, the sum of the duration for all fixations within an AOI. If a participant returned to the same AOI then the new fixations on the AOI were included in the metric. If a participant did not fixate on a particular AOI, the TFD was 0. Data Analyses Quantitative analysis.Statistical analyses were performed using SPSS 21. To test whether AOI TTFF and TFD predicted 896 KAUFMAN, GRENEN, GRADY, LEYVA, AND FERRER harm and addiction perceptions, two multiple linear regression analyses were conducted for each advertisement. The predictors of harm for each advertisement included all areas of interest and baseline harm perception. The predictors of addiction perception for each advertisement included all areas of interest and baseline addiction perception. Participants were excluded from an analysis if they had missing data (e.g., they never fixated on a specific area) on key measures in the analysis. Qualitative analysis.Interview transcripts and field notes were systematically analyzed using a hybrid process of inductive/ deductive thematic analysis (Fereday & Muir-Cochrane, 2006; Glaser & Strauss, 2009). Line-by-line coding was conducted using QSR International NVivo10 Software, 2011. Thematic analysis focused on identifying, examining, and recording patterns within the data, as well as the general agreement among participants (Shontz, 1985). Results Table 1shows sample descriptive statistics. More than half (54.5%) had heard of snus prior to the study: Only one participant reported using snus more than once, three reported using once, and18 reported never using snus (data not shown). At baseline, the majority believed that snus posed about the same harm and addic- tion as ordinary cigarettes; four participants reported believing that snus was less harmful whereas six participants reported that snus was much less (n 3) or less (n 3) addictive than ordinary cigarettes (data not shown). Eye Tracking Figure 1shows the five advertisements, highlighted AOI, and heat maps from eye tracking results.Table 2shows eye tracking descriptive statistics by advertisement. As depicted in the heat maps and by the mean TFD, generally participants spent the most time looking at the text portion of each advertisement. On average, participants’ TFD on the warning labels across all five advertise- ments was 1.60 s (SD 0.86) and TTFF was 6.14 s (SD 2.56; data not shown). Harm Perceptions The top ofTable 3shows the results of the multiple linear regression. For TTFF, there was a marginally significant associa- Figure 1.Advertisement, advertisement’s areas of interest, and heat maps. The top row are the advertisements as they appeared for participants. The second row shows a priori areas of interest (AOI) designated as graphic, headers, packs, text, and warning label. The bottom row shows heat maps, which show where participants spend time looking. Red indicates the longest time and green the least, with varying levels in between. No color indicates participants did not look in the area. See the online article for the color version of this figure. 897 PERCEPTIONS OF HARM AND ADDICTION tion for the smokeless for smokers advertisement such that the faster someone looked at header 1, the less harmful they perceived this product (B .205,p .052); however, the overall model did not reach significance. The overall model predicting harm perception from TFD was significant in the “smokeless for smok- ers” advertisement,R 2 .64,F(6, 18) 3.50,p .03. Longer fixation on the warning label was associated with greater perceived harm of the product (B .139,p .009). Finally, longer fixation on the graphic in the “emissions” advertisement was significantly associated with increased harm perceptions; however, the overall model did not reach significance. Addiction Perceptions The bottom ofTable 3shows the results of the multiple linear regression. TFD on AOI’s for the “smokeless for smokers” adver- tisement were significantly associated with perceived addiction of the product,R 2 .682,F(6, 19) 4.643,p .010. Longer fixation on the graphic (B .360,p .048) and Header 2 (B .277,p .003) were associated with lower perceived addiction of the product, whereas longer fixation on Header 1 (B .107,p .046), text (B .079,p 018), and the warning label (B .090,p .041) were associated with greater perceived addiction of the product. TTFF on the AOI’s for the “Swedish” advertisement indicated that the faster people looked at the header, the less addictive they perceived the product (B 1.012,p Table 1 Sample Descriptive Characteristics (N 22) N% Age (M 24.63,SD 2.92) 19–24 10 45.5 25–29 12 54.6 Education High school diploma 8 36.4 Post high school training (not college) 3 13.6 Some college 9 40.9 College degree or more 2 9.1 Race/ethnicity Non-Hispanic White 5 22.7 Non-Hispanic Black 14 63.6 Latino/Hispanic 3 13.6 Marital status Married 1 4.6 Single 20 90.9 Divorced 1 4.6 Employment status Employed 12 54.6 Unemployed 5 22.7 Student 3 13.6 Disabled 1 4.6 Missing/don’t know 1 4.6 Age at first cigarette (M 15.77,SD 2.35) Range 9–21 Age when starting smoking daily (M 18.18,SD 2.59) Range 12–25 Number of cigarettes smoked per day (M 9.82,SD 5.58) Range 3–22 Ever prior quit attempt Yes 19 86.36 If yes: In the past 12 months? 13 59.09 No 3 13.64 Table 2 Descriptive Eye Tracking Statistics for Each Advertisement Emissions Resolution Without matches Smokeless for smokers Swedish NTTFF M(SD)TFD M(SD)NTTFF M(SD)TFD M(SD) NTTFF M(SD)TFD M(SD) NTTFF M(SD)TFD M(SD) NTTFF M(SD)TFD M(SD) Graphic 21 2.45 (4.92) 2.55 (1.74) 21 .50 (.37) 3.29 (2.14) 22 .91 (2.10) 4.24 (2.33) 12 9.71 (6.65) .86 (.72) 20 .63 (.79) 3.95 (2.68) Header1 20 2.78 (5.21) 1.25 (.91) 22 1.29 (2.26) 3.09 (2.86) 21 2.52 (4.38) 1.83 (2.77) 21 1.51 (3.55) 4.43 (2.21) 19 .79 (.59) 1.42 (.67) Header2 — n/a n/a — n/a n/a — n/a n/a 18 3.18 (3.14) 1.22 (1.10) — n/a n/a Packs 16 8.81 (5.70) .70 (.74) 18 10.91 (5.08) .76 (.68) — n/a n/a n/a n/a 16 9.22 (5.98) .51 (.41) Text 21 1.78 (1.48) 9.01 (4.11) 22 3.64 (3.31) 7.16 (3.81) 21 2.71 (4.28) 3.62 (2.50) 21 3.43 (1.49) 5.06 (3.02) 20 3.89 (2.62) 7.23 (3.44) Warning label 19 6.78 (6.13) 1.97 (2.11) 21 7.89 (6.0) .95 (.76) 20 3.35 (3.48) 2.22 (2.42) 20 7.05 (3.85) 2.48 (2.03) 20 5.75 (6.65) 1.13 (1.67) Note.M mean;SD standard deviation; TTFF time to first fixation: The time from the start of the ad display until the participant fixates on an AOI for the first time (seconds); TFD total fixation duration: Duration of all fixations within an AOI (seconds). Participants were excluded from an analysis if they had missing data (e.g. theynever fixated on a specific area) on key measures in the analysis. Header2 and Packs were not present in all advertisements and in such cases is shown as n/a. 898 KAUFMAN, GRENEN, GRADY, LEYVA, AND FERRER .015), but the more quickly people looked at the packs (B .054, p .034), and text (B .170,p .013), the greater perceived addiction,R 2 .773,F(6, 13) 3.984,p .047. The overall regression models for both TTFF,R 2 .786,F(5, 14) 6.624, p .007; and TFD,R 2 .650,F(5, 18) 4.837,p .010, on AOI’s for the “without matches” advertisement were significant; however, baseline addiction perceptions were the only significant associations. Finally, for the “resolution” advertisement, longer fixation on the packs was associated with greater perceived addic- tion of the product (B .404,p .007); however, the overall model did not reach significance. Qualitative Themes Table 4shows themes and examples of associated quotes that emerged in the semistructured interviews. Themes associated with perceived harm and addiction were mentioned frequently, and sometimes together; suggesting that participants were not differ- entiating these concepts. Participants noted that convenience may increase addiction to tobacco products and this increase in fre- quency could lead to harmful consequences in the future. How- ever, many participants perceived the snus products in the adver- tisements to be less harmful than cigarettes. The absence of smoke Table 3 Multiple Linear Regression Results of Eye Tracking Areas of Interest Predicting Harm and Addiction for Each Advertisement Emissions Resolution Without matchesSmokeless for smokers Swedish Harm B (p-value) Time to first fixation (TTFF) ❶Graphic .017 (p .676) .266 (p .602) .156 (p .372) .014 (p .626) .150 (p .503) ❷Header 1 .042 (p .496) .292 (p .195) .026 (p .355) .205 (p .052) .362 (p .419) ❸Header 2 n/a n/a n/a .184 (p .153) n/a ❹Packs .071 (p .327) .002 (p .960) n/a n/a .065 (p .085) ❺Text .134 (p .356) .045 (p .617) .105 (p .235) .068 (p .668) .137 (p .128) ❻Warning label .013 (p .783) .001 (p .974) .052 ( p .169) .001 (p .990) .018 (p .511) Baseline harm .152 (p .837) .115 (p .779) .193 (p .549) .449 (p .366) .330 (p .432) Total fixation duration (TFD) ❶Graphic.193 (p .018) .043 (p .397) .059 (p .207) .234 (p .329) .023 (p .631) ❷Header 1 .170 (p .195) .039 (p .332) .006 (p .866) .120 (p .084) .058 (p .758) ❸Header 2 n/a n/a n/a .142 (p .100) n/a ❹Packs .073 (p .649) .005 (p .981) n/a n/a .222 (p .451) ❺Text .036 (p .212) .011 (p .729) .011 (p .769) .039 (p .272) .071 (p .108) ❻Warning label .086 (p .158) .258 (p .134) .093 (p .113).139 (p .009).028 (p .745) Baseline harm .120 (p .693) .132 (p .673) .505 (p .168) .259 (p-.346) .089 (p .746) Addiction B (p-value) Time to first fixation (TTFF) ❶Graphic .027 (p .502) .060 (p .916) .086 (p .463) .011 (p .786) .207 (p .210) ❷Header 1 .035 (p .544) .254 (p .301) .011 (p .557) .015 ( p .898) 1.012 (p .015) ❸Header 2 n/a n/a n/a .062 (p .702) n/a ❹Packs .056 (p .396) .009 (p .827) n/a n/a.054 (p .034) ❺Text .026 (p .872) .045 (p .645) .029 (p .615) .039 (p .855).170 (p .013) ❻Warning label .026 (p .486) .008 (p .774) .017 (p .486) .009 (p .873) .025 (p .170) Baseline addiction .602 (p .196) .268 (p .517).802 (p .002).972 (p .111).898 (p .010) Total fixation duration (TFD) ❶Graphic .043 (p .642) .048 (p .286) .039 (p .373) .360 (p .048) .003 (p .937) ❷Header 1 .095 (p .557) .011 (p .763) .002 (p .942).107 (p .046).102 (p .544) ❸Header 2 n/a n/a n/a .277 (p .003)n/a ❹Packs .076 (p .702).505 (p .007) n/a n/a .206 (p .427) ❺Text .002 (p .967) .006 (p .829) .022 (p .526).079 (p .018) .053 (p .183) ❻Warning label .058 (p .467) .109 ( p .464) .021 (p .589).090 (p .041).007 (p .930) Baseline addiction .145 (p .641) .461 (p .079).796 (p .002).224 (p .251) .481 (p .089) Note. Bold values indicate statistical significancep .05. TTFF time to first fixation: The time from the start of the ad display until the participant fixates on an AOI for the first time (seconds); TFD total fixation duration: Duration of all fixations within an AOI (seconds) Participants were excluded from an analysis if they had missing data (e.g. they never fixated on a specific area) on key measures in the analysis. Header2 and Packs were not present in all advertisements and in such cases is shown as n/a. 899 PERCEPTIONS OF HARM AND ADDICTION Table 4 Qualitative Themes on Harm and Addictiveness From Semistructured Interviews Themes Examples Harm and addictionThey were trying to say that it was better and less addictive, but I mean it’s got nicotine and stuff in it, so of course it’s addictive and of course it’s harmful to your health. It seems like in some ways it’s more harmful, and in other ways it’s less harmful. It seems less harmful because it is not a cigarette, and it seems as though any alternative to cigarettes is probably less harmful in some form. It also seems more harmful in a sense, because we all start smoking cigarettes because there is something about it that we enjoy—we either enjoy the experience of it, the way it feels, long before we are actually addicted to the nicotine and getting anything chemically from it….Butwith this stuff, I mean, what is there to enjoy in this other than getting a dose of nicotine? So in that sense, it seems more harmful because it’s just kind of reinforcing this addictive behavior. Harm A “safer” alternative…ifyoucanmake a product like Nicorette gum, I would think you could make a relatively healthy like product like snus relatively safe. It makes it sound like it’s something not as harmful as like inhaling smoke in your lungs. Well, after I saw the number zero I read the emissions, and I am thinking okay, smoke-free. It’s kind of like thinking of a soda product that says zero calories or whatever, and so I was, like, okay, zero calorie cigarette, or a zero calorie product, tobacco product. I’m like, okay, that could be a safer alternative towards smoking. Frequency of useFirst off, because I don’t really know that it causes mouth cancer, and I don’t think I would do it enough to make it cause mouth cancer. If you use it frequently, like they smoke cigarettes, you might go through a pack of cigarettes a day, maybe two packs a day. If they use snus on the regular—I feel like it causes mouth cancer. Smoke exposureBut at least we’re not harming the people who don’t smoke, or at least we’re caring about the people who don’t smoke by trying to make a product that won’t harm them with the secondhand smoke kind of stuff. Before I looked at the warning and I saw “smokeless for smokers,” I was, like, well, maybe this might be something that you could try that won’t really have an effect on your lungs—you know, an effect on your health. Flavors. . . it’s saying…wehave a variety of different flavors for you. So it was, like, that was the catch…first catch was it’s smokeless, that people that normally smoke so people are, like…maybethis might be a little bit healthier than a regular cigarette. And then they’re kind of like pulling you in, saying they got several tastes. WorryThis is mouth cancer. Mouth cancer is kind of more scary to me just because it’s more visible. You can’t really see what a person’s lungs look like until after you are already performed the autopsy. I would be less worried with the snus because there’s no direct, you know, danger…butthesnus, I just sit it there and it does everything by itself. It just practically disappears. So, I would feel less concerned with the snus as opposed to a cigarette. Believability of warning labelThe negative things it just says it causes. The product can cause mouth cancer. It’s saying “can.” They don’t know. It’s not saying that you will catch it. It’s just saying it may cause that. Okay, if I believe that this will cause mouth cancer, then that’s what will happen in my life. If I see this and I’m, like, “I control my life and my reality,” then I wouldn’t believe that this would cause mouth cancer for me—no matter how much I may use the product or not. I do believe that it causes mouth cancer. I don’t believe it will cause mouth cancer for myself. I believe I have the power to make my reality what it is. Yes, I actually do believe it, because tobacco is not going to stop being tobacco. Juxtaposition of warning and advertisementIt’s an alternative to smoking cigarettes. The way they have it, it’s a lot better than smoking cigarettes. The way they have it is snus is a good product and everything, but the warning sign is bigger than day right there. So you know it’s not really good for you, but the way they have the advertisement, it looks like a good product to take. It doesn’t really show that it’s going to harm you, it shows you—if the warning wasn’t at the bottom, you wouldn’t really be, like, “This is something that could potentially kill you.” Addiction Greater addictionBut with this stuff, there’s no way you can deny that you’re an addict. I mean, so that is one negative thing that would affect one’s self-image…ifyouarenowexperimenting with different ways of getting a chemical into your body, it probably would make you more willing to try other ways as well. You know, it’s just another tobacco product to get people or to keep people addicted while they’re working or something. I’ve heard that it has more nicotine, which is the stuff that actually gets you addicted. I think it’s more addictive[than regular cigarettes].I feel like if I tried it and enjoyed it then I would start wanting to buy it. It would be so readily available that I could get addicted to it really quick. Increased use opportunitiesBecause[with]cigarettes you have to step outside. My job doesn’t always allow me to go outside, but with this you can use it while you’re inside, so you can use it all the time. I think it’s more dangerous. It’s more available and more convenient. CessationMaybe sometime in the future, yeah I would switch[to snus]because lately I’ve been worrying about my health from smoking. If I get to that point where I know that I’m going to stop smoking or I want to try something different it would bethis…anelectronic cigarette or snus. Well, they say Nicorette gum can help you quit smoking so why couldn’t this? 900 KAUFMAN, GRENEN, GRADY, LEYVA, AND FERRER and comparisons made with cigarettes gave some participants the impression that using snus was not worse than using cigarettes and might be less harmful. All reported awareness of cigarette smoking health consequences and many mentioned the harms of inhaling cigarette smoke and/or chemicals into their lungs. Unlike with cigarettes, many participants thought that snus might not have widespread physical effects on health beyond the mouth. Other themes that emerged related to harm perceptions included fre- quency of use, flavors, worry about health outcomes, and increased opportunities for use. Many perceived that snus use may lead to greater addiction. Unprompted, half of the participants reported that snus could be used as a means to help with smoking cessation. While there was some variation in responses by advertisement, in general participants found the ads appealing. They said snus looked like “little pillows” making it seem less harmful or “scary.” About half of the participants thought that the advertising text and imagery made a smoke-free product like snus appear healthier or mentioned that the advertisement made the product look less harmful or addictive. Several participants thought the advertise- ments were being directed to young people. The colorfulness of the packs (implying flavors) and overall feel of the ads were cited as being enticing to younger audiences. Most participants said that the warning label was believable. However, some were skeptical about the warning label and pointed out the incongruence with the advertisement design with appealing product messaging. Behavioral Intentions At baseline, 64% of participants stated that it was extremely unlikely that they would switch to snus completely and give up cigarettes. However, about 23% of participants reported that they would belikely/extremely likelyto try a free package of snus, while about 36% reported they would be eitherlikely/extremely likelyto use snus instead of cigarettes in situations where they could not smoke. At the end of the interview sessions, about half of partic- ipants maintained their curiosity about trying snus (“I like to try new things so I would just see what the fuss is about”) although they were not interested in long-term use or use in combination with cigarettes. Participants described the enjoyment of smoking and did not believe snus would be as pleasurable. They expressed concern that using snus in combination with cigarettes or in places they otherwise do not use tobacco would increase their tobacco exposure and nicotine addiction. Discussion This study revealed that attention to particular areas of snus product advertisements, as measured by eye tracking, was associ- ated with perceptions about the product. This is the first study to use a combination of eye tracking, survey, and interview methods to understand how current cigarette smokers perceive a novel alternative tobacco product and how advertisements may contrib- ute to their beliefs about these products. Tobacco companies are prohibited from making reduced harm claims without review and approval (FDA, 2009, Section 911). However, our findings sug- gest that marketing for snus may implicitly contribute to young male smokers’ perceptions about snus. The quantitative findings from our study show that addiction perceptions were driven strongly by components of the advertisements, whereas harm perceptions were not. Our qualitative findings suggest that half of the participants, unprompted, viewed snus as a smoking cessation aid. Prior research has shown that snus marketing reflects an attempt to prevent smokers from quitting (Richardson et al., 2014). There is no evidence that snus is associated with cessation among U.S. smokers and manufacturers have not submitted snus to the FDA for consideration as a cessation aid. Our findings also suggest that individuals may not look at warning labels on some advertisements in real life viewing situa- tions. Individuals typically spend about4sonagiven magazine page (Kanakubo et al., n.d.;Süssenbach, Niemeier, & Glock, 2013), and in the current study, participants did not look at the warning label until about 6 s after exposure. The amount of time it takes a viewer to see a warning label may depend on features of the advertisement. For example, the advertisement (“without matches”), where participants fixated faster on the warning label, had less text and more color contrast than the other advertisements. The Family Smoking Prevention and Tobacco Control Act of 2009 has provisions around contrasting colors for smokeless tobacco warnings on tobacco products’ packages and advertisements: “The text of the label statement shall be black on a white background or white on a black background…”(FDA, 2009, Section 3). Warnings on packages must be “…inamanner that contrasts, by typography, layout, or color, with all other printed material on the package…”andonadvertisements must be “conspicuous and legible.” Future research should explore in what context (e.g., predominant color on advertisements, other advertisement fea- Table 4 (continued) Themes Examples I just wouldn’t use it because if I somehow found a way to quit cigarettes then I’m just going to stay away from tobacco products altogether. I wouldn’t want to risk getting addicted to anything else. Other Appeal to youthAnd what it seems like is that generally ads like these, when tobacco’s advertised, it’s being targeted at young people because those are the people who are thinking about starting to smoke. I don’t think anybody starts smoking when they’re 45, you know. They start targeting young people, and they make it sound sexy, they make it sound appealing, they make it sound like it’s not that dangerous….Andthen people get addicted . . . they can’t quit, and then they either end up spending tons of money on it, it has social consequences, health consequences. I mean, you know, ultimately it’s a really, really horrible thing… A little kid would probably look at it—they see the can, and they assume it’s candy. They see you’re not blowing smoke or anything, now you say you just keep it in there. So you know, it pretty much gives them an idea of, like, hey, let me try that. 901 PERCEPTIONS OF HARM AND ADDICTION tures) these warning label contrasts are most effective on adver- tisements. There are several limitations to consider. This is a small, ex- ploratory study aimed at examining how snus advertisements are perceived by young male smokers. Multiple comparisons were made (increasing likelihood of Type I error). Due to the small convenience sample and laboratory setting, the findings have lim- ited generalizability. Future studies should explore potential dif- ferences in eye tracking and perceptions by sociodemographics. There may be differences in how consumers view and interpret advertisements in real life. Participants were aware that they were engaging in a research study and as a result may have changed their behavior or responses. Survey measures of harm and addic- tion perceptions of snus compared it with cigarettes (Kaufman et al., 2016) and future studies may change the comparator or use absolute perceptions. Unfortunately, we did not assess if partici- pants had seen these particular advertisements prior to the study and were unable to determine if this influenced their responses. These limitations are offset by strengths. Studies examining snus have focused mainly on non-Hispanic White samples (e.g., Bahreinifar et al., 2013;Wray et al., 2012) and our study utilized a more diverse sample of predominately African American male smokers. The role of race and socioeconomic status (SES) in the advent of emerging tobacco products is important and future research may consider studying more diverse samples. To our knowledge, this is the first study to directly link eye-tracking data with self-reported perceptions. 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