Harm reduction in U.S. tobacco control: Constructions in textual news media

International Journal of Drug Policy 26 (2015) 575–582

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Research paper

Harm reduction in U.S. tobacco control: Constructions in textual news media Michael H. Eversman ∗ Department of Social Work, Rutgers University – Newark, Newark, NJ 07102, United States

a r t i c l e

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Article history: Received 16 October 2014 Received in revised form 19 January 2015 Accepted 23 January 2015 Keywords: Discourse analysis News media Public health policy Smoking Tobacco harm reduction

a b s t r a c t Background: U.S. tobacco control has long emphasized abstinence, yet quitting smoking is hard and cessation rates low. Tobacco harm reduction alternatives espouse substituting cigarettes with safer nicotine and tobacco products. Policy shifts embracing tobacco harm reduction have increased media attention, yet it remains controversial. Discourse theory posits language as fluid, and socially constructed meaning as neither absolute nor neutral, elevating certain views over others while depicting “discursive struggle” between them. While an abstinence-based framework dominates tobacco policy, discourse theory suggests constructions of nicotine and tobacco use can change, for example by positioning tobacco harm reduction more favorably. Methods: Textual discourse analysis was used to explore constructions of tobacco harm reduction in 478 (308 original) U.S. textual news media articles spanning 1996–2014. Using keyword database sampling, retrieved articles were analyzed first as discrete recording units and then to identify emergent thematic content. Results: Constructions of tobacco harm reduction shifted over this time, revealing tension among industry and policy interests through competing definitions of tobacco harm reduction, depictions of its underlying science, and accounts of regulatory matters including tobacco industry support for harm reduction and desired marketing and taxation legislation. Conclusions: Heightened salience surrounding tobacco harm reduction and electronic cigarettes suggests their greater acceptance in U.S. tobacco control. Various media depictions construct harm reduction as a temporary means to cessation, and conflict with other constructions of it that place no subjective value on continued “safer” tobacco/nicotine use. Constructions of science largely obscure claims of the veracity of tobacco harm reduction, with conflict surrounding appropriate public health benchmarks for tobacco policy and health risks of nicotine use. Taxation policies and e-cigarette pricing relative to cigarettes are key for wider adoption, while concerns are raised for whether their availability will increase initiation. © 2015 Elsevier B.V. All rights reserved.

Introduction In the United States, tobacco smoking remains the leading preventable cause of disease and death (U.S. Department of Health & Human Services, 2014). Adult smoking rates peaked at roughly 42% in 1964 and have fallen steadily since (Bolden, 2010; Warner, 2006); currently about 20% of U.S. adults smoke, with the highest rates among non-whites, the poorer and less educated, and those with mental health and substance abuse disorders (Centers for Disease Control, 2014). U.S. tobacco control and public health

∗ Tel.: +1 973 353 1144. E-mail address: [email protected] http://dx.doi.org/10.1016/j.drugpo.2015.01.018 0955-3959/© 2015 Elsevier B.V. All rights reserved.

policies addressing smoking have long emphasized abstinence – primary prevention and cessation based interventions for current smokers; yet cessation rates are low and nicotine replacement therapies (NRT) (patches, gum, medication) are not appealing to all smokers, limiting options for those who are unable or unwilling to quit (Shiffman et al., 2002; Sweanor, Alcabes, & Drucker, 2007; Warner, 2006; Zeller & Hatsukami, 2009). Alternatives, known as tobacco harm reduction, are essentially defined as substitution nicotine and tobacco forms that reduce the health hazards of continued nicotine and/or tobacco use (detailed below) (Stratton, Shetty, Wallace, & Bondurant, 2001; Warner, 2002; Zeller & Hatsukami, 2009). Intended for so-called inveterate smokers, some define tobacco harm reduction to include nicotine replacement therapies (NRT) such as nicotine gum, transdermal

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patches, and medications;1 yet the emerging marketing and use of tobacco and other nicotine vaporization products as harm reduction provokes debate (Parascandola, 2011; Warner, 2006). These products include electronic nicotine delivery systems (ENDS) such as electronic cigarettes (e-cigarettes) and noncombustible chewing or smokeless tobacco (SLT) such as snuff or snus. Opposition to endorsing these products as harm reduction stems from public health concerns surrounding the addictive properties of nicotine, and concerns that continued tobacco and nicotine use discourages cessation efforts, while encouraging tobacco use initiation (especially among youth) and increasing dual use (i.e., using harm reduction products as well as cigarettes) (Hatsukami, Henningfield, & Kotlyar, 2004; Shiffman et al., 2002; Warner, 2002). The 2009 Family Smoking Prevention and Tobacco Control Act (FSPTCA) drew national attention to tobacco harm reduction (discussed below) (Gostin, 2009; Parascandola, 2011; Timberlake, Pechmann, Tran, & Au, 2011). While harm reduction has long informed public health policies and programs for illicit drug use, it has historically been regarded as controversial and politically divisive (Riley & O’Hare, 2000). Widely accepted NRT products are marketed as a cessation based treatment (despite that some smokers may use them long-term); yet uncertainty and concern surrounds whether and how tobacco products and e-cigarettes will be marketed as harm reduction and how harm reduction with these products will be constructed. News media provide a policy agenda framework through which social concerns are presented, influencing public opinion and desirable policy solutions (Clegg Smith et al., 2008). Discourse analysis is a social constructionist theory and method for understanding textual communications and societal power relations; the theory posits that language is fluid and that socially constructed meaning is neither absolute nor neutral (Jorgensen & Phillips, 2002; Lupton, 1992). Textual news media can thus be said to elevate certain views of truth over others, resulting in “discursive struggle”. Despite the centrality of abstinence in U.S. tobacco control and public health policy, discourse theory suggests that social constructions of, and sociopolitical positions toward, nicotine and tobacco use can change, for example by positioning tobacco harm reduction as equally, or more favorable, to abstinence-only. This study explores the discourse used to construct tobacco harm reduction in textual U.S. news media from 1996 to 2014. Harm reduction: background Clearly defining harm reduction and what constitutes its products, programs, and policies is complex; it is neither neutral nor objective, and can be defined in different ways (Riley & O’Hare, 2000). As a public health paradigm, harm reduction stresses a pragmatic, empirical approach toward substance abuse; rather than emphasizing morality (by stigmatizing) and criminal punishment, harm reduction instead prioritizes the health problems of substance use by minimizing its individual and societal consequences (Riley & O’Hare, 2000; Riley et al., 1999; Tammi, 2004). While abstinence is highly compatible with harm reduction (Marlatt & Tapert, 1993), the paradigm acknowledges it is not achievable (or desired) by all substance users, and instead provides nonabstinence alternatives for those seeking to lessen their exposure to risk and harm. The underlying politics of harm reduction are Libertarian, rooted in classic political liberalism, and often at odds with – and critical of – existing drug control policies (i.e., the war on

1 NRT products are typically marketed as cessation-based treatments, aligning them with an abstinence-based approach; yet some smokers may use NRT long-term as a form of nicotine maintenance, and as such NRT can also be considered harm reduction.

drugs); as a social movement, harm reduction encourages actions such as mutual aid networking, self-advocacy, and empowerment by drug users to promote change (Hathaway, 2002; Tammi, 2004). Methadone maintenance for opiate dependence has existed in the U.S. since the 1960s (Marsch, 1998), but the emergence of HIV/AIDS among intravenous drug users in the 1980s initiated contemporary harm reduction interventions (primarily needle exchange) focused on preventing disease transmission (Tammi, 2004). Additional harm reduction strategies include Buprenorphine (opiate maintenance and cessation) and Naloxone (to revive and prevent death from opiate overdose), and policy reform that treats drug use more as a public health than criminal problem – decriminalizing and/or legalizing possession and use – is also considered harm reduction (Riley & O’Hare, 2000). While harm reduction for tobacco parallels its applications for illicit drugs – notably by maintaining the underlying behavior (continued drug ingestion) – there are key differences. As licit substances, tobacco and nicotine procurement and use are not subject to legal sanctions and are not as stigmatized as illicit drugs. Further, accessing the harm reduction product or service is not per se stigmatizing for those seeking tobacco harm reduction, whereby community stigmatization is a central feature of many harm reduction services for illicit drugs users. Lastly, the centrality of government sponsorship and public funding for illicit drug harm reduction is absent with tobacco harm reduction, which instead involves private market mechanisms and minimal government oversight.

Tobacco harm reduction Tobacco harm reduction assumes that harm from smoking derives from exposure to cigarette smoke, and that nicotine use per se is relatively benign (Sweanor et al., 2007). Cigarette smoke is highly toxic, containing over 4000 chemicals, 40–60 of which are known carcinogens; long term smokers are exposed to these millions of times (Bolden, 2010; Warner, 2006). Constructed as such, tobacco harm reduction holds that using alternative tobacco or nicotine products to quit smoking or to maintain nicotine use is reduced harm relative to habitual combustible cigarette smoking. This is a sharp contrast to an abstinence-based framework, which holds tobacco and nicotine use unhealthy per se, and especially when compared to no use at all. A substantial body of research supports tobacco harm reduction; Rodu (2011) reviewed a vast literature that supports the health benefits of electronic-cigarette and smokeless tobacco use relative to combustible cigarette smoking, while the “Swedish Snus experience” of lower lung cancer rates among Swedish men has led many to endorse smokeless product switching as harm reduction (Sweanor et al., 2007; Warner, 2006). A recent review found that e-cigarette users consistently describe them as having helped them quit or reduce cigarette smoking and bring about improved respiratory functioning (Hajek, Etter, Benowitz, Eissenberg, & McRobbie, 2014). Etter and Bullen (2011) conducted a large survey (n = 3587) of current and former cigarette smokers and found that over 90% reported e-cigarettes helped them reduce and/or quit smoking. Yet tobacco harm reduction remains controversial, and as others note the supportive science remains incomplete, particularly regarding long-term e-cigarette use (Maziak, 2014). Furthermore the production of e-cigarette liquid and aerosol is not uniformly regulated, and recent reports note concerns for its toxicity (Richtel, 2014). While studies examining e-cigarette content have found them unlikely to pose risk, avoiding second hand exposure to vapor has been advised (Hajek et al., 2014). The 2009 FSPTCA empowered the U.S. Food and Drug Administration to regulate tobacco and establish a tobacco control arm, the Center for Tobacco Products, emphasizing prevention, cessation,

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and decreased harm from tobacco use (Kroll, 2014). While some expect major policy shifts from the FSPTCA (Bolden, 2010), others criticized it as too lax (Gostin, 2009). Notably, the FSPTCA prohibits marketing claims that tobacco products reduce harm without scientific proof and FDA approval (Gostin, 2009; Timberlake et al., 2011); this is particularly relevant to constructions of tobacco harm reduction, as it potentially allows harm from tobacco use to be depicted on a “less to more” continuum, and allows marketing claims (i.e., package labelling) of reduced harm on related products. Support for strong tobacco regulation stems from a legacy of deceptive marketing, research manipulation, and failure by tobacco companies to provide “true” harm reduction products, first with filtered cigarettes, and then light (low-tar/low-nicotine) cigarettes (Hatsukami et al., 2004; Parascandola, 2011; Shiffman et al., 2002; Warner, 2002). Widespread use of these so-called “safer cigarettes” caused more public health harm than good, ensuring skepticism toward industry claims (Parascandola, 2005; Stratton et al., 2001). Litigation in the 1990s forced “Big Tobacco” to acknowledge the addictive, hazardous qualities of cigarettes, and the industry has since morphed into highly consolidated transnationals (Bialous & Peeters, 2012). Clearly defining the tobacco industry today is difficult, with many companies having expanded into non-tobacco nicotine products and e-cigarettes, while seeking to rebrand themselves as socially responsible, and improve political alliances (Bialous & Peeters, 2012; Peeters & Gilmore, 2014).

Tobacco in U.S. newsprint Analyses of tobacco in U.S. textual news media (newspapers) in the late 1990s were spurred by public debate surrounding the health hazards of smoking, product marketing, and industry liability which resulted in the 1998 Master Settlement Agreement (MSA) between states and tobacco companies (Lima & Siegel, 1999). These studies typically examine the framing of tobacco news coverage, for example as supporting either weaker (pro-tobacco) or stronger (anti-tobacco) tobacco control policies (Clegg Smith & Wakefield, 2005; Clegg Smith, Wakefield, & Edsall, 2006; Long, Slater, & Lysengen, 2006; Menashe & Siegel, 1998); others examined associations between the volume of tobacco coverage and survey data of youth smoking (Clegg Smith et al., 2008; Dunlop & Romer, 2010). Menashe and Siegel (1998) examined the framing of front-page tobacco stories (n = 179) in the New York Times and Washington Post from 1985 to 1996 and found that the most frequent protobacco frames depicted strong tobacco control policies as a threat to personal liberty, opportunity, and equality, whereas anti-tobacco frames emphasized tobacco use as a health issue and the tobacco industry as deceptive and predatory (i.e., encouraging youth smoking). They also noted that media framing of tobacco changed over time, with the position of each side (pro/anti) informed by and designed to counteract the other. Clegg Smith & Wakefield (2005) analyzed 162 daily newspaper editorials published in 2001 and found tobacco was often framed as warranting strong regulation, especially concerning second-hand smoke. While no consensus emerged regarding policy recommendations, the opinions expressed tended to support strong tobacco control initiatives. Clegg Smith et al. (2006) analyzed tobacco focused news and opinion pieces (n = 9859) in major newspapers from 2001 to 2003 and found that most endorsed “positive” tobacco control strategies (i.e., tax increases, smoke-free zoning). They also found smoking was infrequently framed as a health issue, for example as an addiction. Long et al. (2006) examined 373 print and TV news stories from 2002 to 2003 and found tobacco was framed more frequently as a political debate than a public health matter, and noted concern that this underemphasizes the risks of tobacco use.

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Two studies linked tobacco media coverage to survey data of youth smoking (Clegg Smith et al., 2008; Dunlop & Romer, 2010). Clegg Smith et al. (2008) analyzed 8390 news and opinion pieces in daily newspapers appearing between 2001 and 2003 alongside survey data of youth smoking rates and perceptions of it. Noting that positive tobacco control content (“anti-tobacco”) appeared twice as often as negative (“pro-tobacco”) or neutral tobacco control content, these authors found a positive association between the frequency of tobacco news coverage and youth disapproving of, and refraining from, smoking. Similarly, Dunlop and Romer (2010) examined 108 news articles published between 2001 and 2004 and survey data from 1501 youth to assess the impact of exposure to newspaper coverage on attitudes toward light cigarettes, finding that youth who reported low newspaper readership were more likely to believe the purported health claims of light cigarettes. Despite the importance of smoking and tobacco use, there are just a few studies examining the depiction of tobacco harm reduction. Five were uncovered for this review; three examined tobacco harm reduction products–snus, e-cigarettes, and smokeless tobacco (Bell & Keane, 2012; Timberlake et al., 2011; Wackowski, Lewis, Delnevo, & Ling, 2013), and two examined the discursive use of harm reduction in tobacco industry and policy documents (Givel, 2011; Peeters & Gilmore, 2014). The first of these analyzed advertisements for Camel Snus (an SLT product) appearing in U.S. newspapers and magazines between 2007 and 2010 (Timberlake et al., 2011). The findings support claims that Camel Snus was marketed to smokers as a situational, “dual use” product (i.e., for use in the presence of smoking bans), and the authors note that used in this way, snus likely induces greater, not reduced health harms. Bell and Keane (2012) analyzed reactions to e-cigarettes from various media and public health organizations, concluding they are negatively perceived largely because they blur the distinction between recreational and medicinal nicotine use. Wackowski et al. (2013) examined the health content in 877 SLT articles between 2006 and 2010 and found that most opinion articles (63.6%) were anti-SLT, and that “news articles frequently portrayed SLT as a harmful or potentially harmful product” (p. 1293). Additionally, the authors found these articles did not differentiate the health risks posed by using different types of SLT (i.e., that SLT products vary in toxicity), falsely leading readers to conclude that all SLT products pose equal risk. Two additional studies examined harm reduction within tobacco industry documents, casting skepticism toward the sincerity of tobacco companies (Givel, 2011; Peeters & Gilmore, 2014). Peeters and Gilmore (2014) analyzed 455 litigation documents from four tobacco transnational companies spanning 1971–2009, and found that the phrase “harm reduction” entered the industry vernacular in 1999 and began to be used publically in 2002 following an influential report published by the Institute of Medicine. Givel (2011) analyzed 99 Federal tobacco policy documents spanning 2004–2008, during which Phillip Morris – at odds with other major tobacco companies – began supporting legislation (the eventual FSPTCA) embodying tobacco harm reduction. Both studies conclude the term harm reduction was used disingenuously by the tobacco industry to rehabilitate their public image, regain access to policymakers, and ensure profits (Givel, 2011; Peeters & Gilmore, 2014). Theoretical perspective This paper is informed by Jorgensen and Phillips (2002) summation of Ernesto Laclau and Chantal Mouffe’s discourse theory, a social constructionist perspective appropriate for examining societal power relations (Jorgensen & Phillips, 2002). While acknowledging first that discourse creates meaning, Laclau and Mouffe also claim that since language is inherently fluid, meaning

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Methods Textual discourse analysis is a theory and method for understanding textual communication (Lupton, 1992). By identifying inherent textual patterns, discourse analysis illuminates competing, socially constructed depictions of truth to understand why some are accepted as knowledge over others (Jorgensen & Phillips, 2002). Similar to traditional content analysis, discourse analysis differs by being more explicit and explanatory, and by identifying and challenging existing societal power relations (Lupton, 1992; van Dijk, 1983). A form of qualitative content analysis, discourse analysis is effectual because “the way in which an issue was represented. . .can be more important than the number of times the issue is mentioned (Lupton, 1992, p. 147). This analysis examines tobacco themed keywords (discussed below) and considers their content and usage regarding tobacco harm reduction, a particular application of textual data analysis (Hsieh & Shannon, 2005). Sampling The study analyzed relevant textual content identified in 478 U.S. textual news media articles published from 1996 through June, 2014. After eliminating redundancies – notably syndicated articles published in multiple sources – the final sample consisted of 308 original articles. Articles were retrieved from four newspaper databases – Access World News, Factiva Newspaper Source Plus, Westlaw Campus Research – and Google Web, which published textual articles from internet based U.S. news outlets such as magazines, broadcast news outlets, and web-based newspaper editions. Only articles appearing in mainstream media outlets were included, and “alternative” and “social media” sources were omitted. Database searches used relevant keywords, and all sampled articles contained the phrase “harm reduction” and one or more of the keywords “tobacco”, “nicotine”, and/or “cigarettes”. Sampling the term “harm reduction” in this manner ensured that all articles explicitly reference the ideas under study, yet it also omits articles that may cover tobacco harm reduction ideas using different terms. While all sampled articles referenced harm reduction and at least one keyword, not all articles presented harm reduction as the central focus. General and business news stories, columns, opinions (editorials, op-eds), and letters to the editor were included; letters were included only when the writer indicated an institutional or professional credential. Community announcements and obituaries were excluded, and blog content was included only when connected to a mainstream news outlet (typically online newspaper editions). All database retrieval was conducted by the author.

123 106 39

2013

2014 (June)

2011

19 2012

2009

2007

2008

2006

2004

2005

2003

2001

1

2002

7

23 2010

48 14 16 14 17 11 11 13 13 3 2000

140 120 100 80 60 40 20 0

1999

is never fixed and/or absolute. Further, they claim that discourse is never neutral, yet rather that it elevates a set of sociopolitical interests over others; thus textual communications can be said to depict a “discursive struggle” between competing constructions of knowledge and what is held as “true” (Jorgensen & Phillips, 2002, p. 6). This perspective highlights and informs understanding the discursive struggle and sociopolitical tension within social constructions of tobacco harm reduction. Whereby an abstinence-only framework is dominant in tobacco control and related health policy in the U.S., a vast body of research supports tobacco harm reduction (Rodu, 2011), and its heightened salience as an alternative framework can be considered to challenge this; discourse theory suggests that socially constructed and accepted meanings of tobacco and nicotine use, and related interventions – including harm reduction – can and do change. This study uses textual discourse analysis to explore and describe news media constructions of ‘harm reduction’ relevant to tobacco use, and tobacco control and public health policy in mainstream U.S. textual news media from 1996 to June, 2014.

1996

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Fig. 1. Yearly distribution of all 478 articles. Table 1 Definitions of Harm Reduction. Harm reduction defined as

(N = 308)

Electronic cigarette SLT product Not specified Safer cigarette/tobacco Cutting back More than one definition Other

131 83 41 22 12 12 7

Sample description Fig. 1 shows the distribution of all 478 articles spanning 1996 through June 2014 (none were retrieved for 1997–1998); of note is the marked increase occurring after 2012. While articles variously defined tobacco harm reduction, it was primarily defined as transitioning from combustible cigarette smoking to using reduced-risk tobacco and nicotine products, which over this period included “safer tobacco” cigarettes (1999–2003), smokeless/chew tobacco and dissolvable nicotine products (2002–2009), and electronic cigarettes (2009–2014). Table 1 displays the tobacco harm reduction definitions presented in the 308 original articles. Over one-third (35.3%) of the 308 original articles were hard news, which combined with business news (16.8%) accounted for over half the sample. Columns (25.6%) and opinion pieces (20.1%) comprised just under half the sample, and letters to the editor 1.9%. Regional distribution of originating news outlets for the full sample included Southern (29.1%), Northeastern (26.8%), Midwestern (20.1%), and Western U.S. states (5.2%), and National (4.4%) outlets. Outlets in tobacco producing states such as North Carolina (11.7%) and Virginia (4.4%) were well represented. Table 2 shows the modal distribution of sampled media outlets, including national newspaper, magazine, and internet-based outlets. Data analysis Articles were saved as word processing documents and entered as qualitative data analysis software files (Atlas TI, v. 7). Next, a Table 2 Modal distribution of news outlets. News outlet name

(N)

Winston-Salem Journal New York Times Wall Street Journal Richmond Times-Dispatch Washington Times Huffington Post ABC News Forbes USA Today Charleston Gazette

31 18 10 10 9 7 6 5 5 5

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Keyword-In-Context search for “harm reduction” was performed; for each occurrence, surrounding text was examined for meaning, and recording units identified. Recording units are discretely determined by “a definable boundary, or symbolic meaning” (Riffe, Lacy, & Fico, 1998, p. 58); here, units were initially coded (labelled) based on inherent meaning expressed; codes included “definitions” (references defining harm reduction, for example “HR defined, switching to SLT”), “business strategy” (references to harm reduction as a business plan, for example “business strategy, tobacco industry”), and “regulations” (proposed or enacted regulation governing tobacco harm reduction, for example “regulation, ecigarettes”). A total of 444 unique recording units were identified. To assess reliability, a random sampling of 25% (n = 111) of coded recording units was examined simultaneously with an undergraduate student oriented to the coding schema, and enabled confirmation or clarification (“agree” or “disagree”) of the coding; the student noted 13 instances of disagreement. Next, the kappa statistic was calculated; kappa indicates the strength of inter rater agreement by estimating the likelihood of agreement occurring by chance, with perfect agreement (not by chance) equaling 1, and agreement by chance alone equaling 0 (Viera & Garrett, 2005). The kappa was calculated at .883, indicating “almost perfect” agreement and suggesting the data coding and categorization are credible. Next, second-level analysis involved identifying and organizing conceptual themes within these coded data (Coleman & Unrau, 2005); using a modified template analysis approach, the recording unit code labels were listed and arranged in a conceptually cohesive manner that revealed patterns and yielded thematic understanding (King, 1998). In this way all recording units can be seen to depict one of the three themes (below) that emerged.

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cigarettes or “cigarette like devices”). Later definitions (2002–2009) focused on the use of smokeless tobacco (SLT) over combustible cigarette smoking, typically deemed “switching to smokeless”. Switching to SLT was seen by some as “a simple and practical harmreduction strategy” and “life-saving” when compared to smoking. Switching to SLT was also seen to offer flexibility for smokers who are unable to quit on their own, and it was pitted by some as an attractive alternative to NRT products: Some harm-reduction advocates say smokers can better manage their nicotine addiction by switching to smokeless tobacco, which delivers a concentrated hit of nicotine into the body more quickly and for far longer than nicotine patches and gum. (Column, Wall Street Journal, July 2, 2002) Harm reduction constructed as switching to SLT was also questioned; in particular its claims of efficacy were recast as “so-called” harm reduction, “harm creation”, or as an otherwise “pitiful” public health strategy. Underlying much of the tension posed by SLT as harm reduction were competing claims about nicotine, for example whether it is benign (“akin to caffeine”) or not, concern over its addictive nature (seen to rival heroin and cocaine), and the risk of relapse posed by its continued use. Emphasizing cessation as the only appropriate goal of tobacco control strategies, these views countered depictions of SLT use as harm reduction, calling instead for an “unambiguous public health message” embracing NRT: Tobacco use in any form must stop. With new, safe and effective smoking cessation aids on the market – and more being currently studied – it seems unethical to promote smokeless tobacco as a means to quit smoking. Even in the name of harm reduction. (Opinion, ABCNews.com, June 15, 2007)

Findings Sociopolitical tensions toward tobacco control and tobacco harm reduction are revealed in particular textual constructions of it. Three identified themes are discussed below: (1) definitions of tobacco harm reduction, which changed over time and reveal particular tension over depictions of various tobacco and nicotine products and nicotine use; (2) the depiction of science underlying tobacco harm reduction, which reveals tension in differing accounts of efficacy and credible research; (3) accounts of tobacco industry strategy and related regulatory matters, which reveal tension regarding industry support for harm reduction and differing views toward legislation for product marketing and taxation. Block quotations from sampled articles are shown to illustrate identified themes, and expressive or commonly used descriptive words or brief phrases are also quoted. The type of article the block quotation is from (hard news, business news, opinion, letter to editor), the name of the media outlet, and the publication date are parenthetically denoted. Definitions of tobacco harm reduction Over the period studied, definitions of tobacco harm reduction shifted to embody changing perceptions toward the believed health efficacy of smoking less, changes in tobacco industry research strategies and product development, the emergence of smokeless tobacco use as harm reduction, and the eventual development and growth of modern e-cigarettes. These definitions also involve differing claims regarding nicotine, and competition between NRT products and tobacco products for harm reduction. The earliest (circa 2001–2002) definitions of tobacco harm reduction focused on reduced cigarette smoking (“cutting back”) and/or the use of alternative “safer cigarettes” (low tar/nicotine

With the emergence of modern electronic cigarettes, tobacco harm reduction was most recently (2013–2014) defined almost synonymously with these products. Largely due to their mimicry of combustible cigarette smoking, some termed e-cigarettes the “most effective” tobacco harm reduction strategy ever, and by stressing their “flexibility” as an NRT alternative, they’ve also been positioned as more favorable: We all know how hard it is to quit smoking. We also know that nicotine replacement therapies, like the patch, haven’t worked especially well. The electronic cigarette is the first harmreduction product to gain serious traction among American smokers. Yet the public health community is not cheering. (Column, New York Times, December 7, 2013) Opposition to e-cigarettes as harm reduction stemmed largely from concerns about a lack of research on their long-term use, a lack of regulation on their public use (second hand exposure), and a lack of oversight for product manufacturing and quality assurance (ecigarette liquid content), while also linking them to the continued fortunes of the tobacco industry: Electronic cigarettes are just the next wave of products designed to undermine the motivation and ability of nicotine addicts to overcome that addiction. Remember, no company that sells an addictive chemical for profit is interested in having you quit. THR is about market share, not public health. [Opinion, GainesvilleSun.com (FL), October 12, 2013] Major tobacco companies have acquired or produced their own e-cigarette products. They’re promoting the products as “harm reduction” for smokers, which allows them to protect their

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cigarette market while promoting a new product. (Column, HuffingtonPost.com, May 14, 2014) Depictions of science While some constructions of tobacco harm reduction claimed it rests on “proven science”, others describe the science as incomplete and/or not to be trusted given the legacy of manipulated research by the tobacco industry. Tension is revealed by questions raised in these accounts, such as what constitutes “real science” and the “responsible use” of it, whether research findings are believed to apply to U.S. smokers, and whether research on e-cigarettes is sufficient enough to endorse them as harm reduction. Some accounts noted that tobacco harm reduction is supported by “peer-reviewed articles” and studies in “leading scientific journals”, and describe the science base as well vetted and backed by mainstream medicine: Harm reduction was the focus of a recent article in the prestigious medical journal Lancet, which made a compelling case that tobacco regulation based on scientific and medical principles: “. . . should promote complete cessation. . .but also encourage. . .(those) unable to stop smoking to adopt a less hazardous source of the drug (nicotine). . .” [Opinion, Buffalo News (NY), November 12, 2007] Depictions of SLT switching as harm reduction consistently invoked the “Swedish Snus experience”, whereby the incidence of low lung cancer rates among Swedish men was seen to support efficacy claims: Forty percent of Swedish men use tobacco products. Yet Sweden has the lowest rate of lung cancer by far. Why? Largely because of snus, which represents half of all the tobacco that Swedish men use. . .Smoking opponents should herald snus. But instead, the very notion of harm reduction inflames them. (Opinion, New York Times, April 6, 2004) Nicotine is addictive, but it is not itself harmful. That explains why tobacco harm reduction saves lives. Its goal is to reduce the devastating health risks of tobacco. The success of this policy in Sweden over the past four decades is widely accepted — but not among America’s tunnel-visioned health regulators. (Opinion, Forbes.com, February 16, 2012) Yet the applicability of these findings to the U.S. was also questioned, partly by noting key marketing and regulatory differences between there and Sweden: Sweden also has a rigorous system of controls over manufacturing and advertising of spit tobacco products. The United States has no regulatory control over spit tobacco and very few restrictions on advertising. The United States and Sweden are not similar when it comes to spit tobacco products and should not be compared for harm reduction purposes. [Opinion, Greensboro News & Record (NC), April 26, 2009] While it was accepted that existing research on e-cigarettes is lacking or otherwise incomplete, some accounts depicted their benefits relative to combustible cigarette smoking as “common sense”, and this was typically constructed with anecdotal accounts of how e-cigarettes help smokers quit or curtail smoking and improve their health. Particularly salient depictions of this sort came from e-cigarette advocacy groups and trade organizations, associations of e-cigarette “vapers”, and small e-cigarette business owners, employees, and customers:

Kevin Bowers (runs e-cigarette advocacy website) tried nicotine patches and gums. He tried to quit cold turkey. To him, e-cigarettes are simply life-savers. “I really hope our government at some point embraces harm reduction,” he said “They shouldn’t be trying to take something less harmful than cigarettes away from us. It makes no sense to me.” [Column, Republican-American (CT), August 27, 2013] “There’s been a lot of focus on the concept of tobacco harm reduction and e-cigarettes have a role to play,” Donahue (Ecigarette store owner) concluded. “It makes me happy to be able to help people who are trying to live healthier lives without smoking and for many vaping is a second chance.” [Column, North Jersey.Com (NJ), November 21, 2014] Other depictions emphasized that research has yet to show whether e-cigarettes are safe, claiming instead that they “warrant further study” before they can be endorsed as harm reduction, while also noting this will require “credible research” that is not sponsored by tobacco industry interests. Some accounts suggested that e-cigarette use may actually lead to worsened public health outcomes such as increased population harm (i.e., higher nicotine/tobacco use initiation, lower cessation) and increased dual use (of e-cigarettes and combustible smoking): Harm reduction advocates argue that for those currently addicted to traditional cigarettes e-cigarettes are a less harmful substitute. In a perfect world this may be true, but the research on how these products are actually used is scarce and some of it suggests that e-cigarettes aren’t being used as replacement products but instead are being used to simply supplement other tobacco use and to circumvent current no-smoking policies that have taken decades to achieve. (Opinion, HuffingtonPost.com, July 22, 2013) Tobacco industry and regulatory concerns Depictions of tobacco harm reduction related to the tobacco industry and regulatory concerns also shifted during this period. After initially referencing harm reduction as a tobacco industry business strategy, later depictions of it focused on concerns surrounding Federal legislation and product claim marketing, the lack of a regulatory framework in light of the growth of e-cigarettes, and tax policy affecting product pricing. Following the 1998 Master Settlement Agreement, references to harm reduction were prominent among tobacco industry news actors, usually appearing in business news articles. Harm reduction was typically reflected as a goal of product research (circa 1996–2003), while a harm reduction strategy was promoted as “a new era of (company) growth”, being a “primary corporate focus”, a “key strategic priority”, or a “commitment plank” for the company; having a “harm reduction portfolio” was consistently deemed “smart business”. Harm reduction was also seen to underlie later tobacco industry movements, such as acquiring smokeless tobacco and nicotine product lines, and referencing it to describe their business interests as aligned with public health: “Niconovum’s products (nicotine gum, pouches, and sprays) have great potential in meeting consumer demand and publichealth objectives,” Ivey said (Reynolds Chairwoman). “This acquisition extends the harm-reduction strategies Reynolds American and its operating companies have been developing over the past several years.” [Business News, Winston-Salem Journal (NC), December 3, 2009] Other depictions stressed concern for tobacco industry support of harm reduction, describing it as “another industry scheme” and advising skepticism toward efficacy claims; deeming harm

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reduction a “smokescreen”, these accounts claim harm reduction is misused in the service of “insidious marketing” designed to create and maintain nicotine addiction: The same tobacco companies pushing “harm reduction” have done everything they can to defeat efforts to reduce tobacco use. Their goal isn’t to reduce the harm caused by tobacco. It’s to sell more tobacco products by preventing current customers from quitting and addicting new ones. [Opinion, The Oklahoman (OK), October 10, 2012] References to harm reduction were central in the debate and design of the 2009 federal Family Smoking Prevention and Tobacco Control Act. Tension is revealed through what competing interested parties (tobacco industry and public health policymakers) desired in terms of standards for establishing harm reduction, while also seeking clarity on allowable claims and appropriate product marketing: Fundamentally, FDA regulation could and should move the tobacco industry toward competing in a market focused on harm reduction, and create clear rules on how to introduce potentially less-harmful products to the market. Without government oversight, there are no comprehensive regulatory standards to evaluate or to determine appropriate communications about potentially reduced-harm products to consumers. (Letter to the Editor, USA Today, May 24, 2005) Tobacco industry interests sought “common sense” and “objective” marketing regulations, while vocally opposing excessive rules that might “hinder” or “stifle” harm reduction efforts. Seeking to partner with policymakers, some within the industry positioned themselves as able to provide guidance on harm reduction regulations: Harm reduction, a phrase promoted by tobacco companies, would allow the government or industry to promote some products as safer than others. “We think we should work with the F.D.A. on that,” said Mr. Sylvia (spokesman) of Altria. (Business News, New York Times, January 5, 2009) After the FSPTCA was passed, depictions of harm reduction centered on questions of regulations and whether they should encourage smokers to switch to purported harm reduction products. For example, taxation policy that failed to differentiate the costs of e-cigarettes and combustible cigarettes was seen to pose barriers to product switching, thus diminishing the “significant harm-reduction potential” of e-cigarettes: The Tobacco Control Act of 2009 (FSPTCA) gave the Food and Drug Administration authority to regulate tobacco, ushering in an era in which regulation can and should reflect the tobacco harm continuum of risk. Regulatory actions, including tax policy, should encourage cigarette smokers to switch to e-cigarettes. A one-size-fits-all policy that treats e-cigarettes similarly to tobacco cigarettes could only result in e-cigarette consumers returning to traditional cigarettes – which simply doesn’t make sense from a public health perspective. (Opinion, USA Today, September 23, 2013) Discussion From 1996 through June, 2014, tobacco harm reduction became increasingly salient in U.S. textual news media, notably due to debate around the FSPTCA and the growth of e-cigarettes. As with illicit substances, harm reduction for tobacco is controversial and its

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narrative driven largely by competing societal values and interests. Constructions of tobacco harm reduction shifted over this period, reflecting changing views toward the benefits of “cutting back” and smoking “safe cigarettes”, to competition between products (NRT against SLT and most recently against e-cigarettes), and tobacco industry business strategies invoking harm reduction. While its construction is dynamic, the increased presence of tobacco harm reduction in news media suggests a growing acceptance (and perhaps inevitability) of it around tobacco and nicotine use in the U.S., with implications for tobacco control and public health policy, tobacco and nicotine product marketing, and current and future tobacco and nicotine users. As noted, defining harm reduction in absolute terms is difficult, and competing definitions of it have implications for how nicotine and tobacco products are marketed. A particular tension lies in whether or not tobacco harm reduction is defined as a temporary means (i.e., using a particular product for a fixed period) to achieve cessation. Making cessation an explicit goal is consistent with an abstinence-only framework, and this construction of harm reduction conflicts with other constructions of it, for example whereby no subjective value is placed on continued drug use so long as it is less harmful than prior use patterns (Marlatt, 1996). SLT and e-cigarette interests both emphasize the harm reduction tenet of “flexibility” in positioning their products relative to NRT, while e-cigarettes are particularly constructed as favorable, as their growth threatens to potentially replace combustible smoking. E-cigarette product holdings have increasingly moved from small businesses to tobacco multi-nationals, and the recent overlap of tobacco and pharmaceutical industry products renders moot the issue of “Big Pharma” versus “Big Tobacco”, as others also note (Bialous & Peeters, 2012; Peeters & Gilmore, 2014). To the extent the harm reduction paradigm seeks to provide alternatives, marketplace concentration as this may ironically diminish them. Despite agreeing on the hazards of combustible cigarette smoking, tension emerges through constructions of the science base of tobacco harm reduction, obscuring depictions of whether questions are resolved, what is to be believed, and who can be trusted. Much of this conflict lies with constructing an appropriate benchmark for tobacco harm reduction: should SLT and e-cigarette use be compared to combustible cigarette smoking or to no use of tobacco or nicotine at all? Constructed as such, this poses a false dichotomy between harm reduction and abstinence-based tobacco control strategies. For example, harm reduction posits that harm occurs on a continuum of “more to less”, and any behavior modification that inflicts less harm to an individual is desired; yet abstinence – when considered as an endpoint of a “more to less” continuum – is compatible with harm reduction, and the two are not mutually exclusive (Marlatt & Tapert, 1993). Taxation policies and pricing of e-cigarettes relative to combustible cigarettes are crucial to their wider availability, for example as high taxation on tobacco products is effective in encouraging quit attempts (Chapman & Mackenzie, 2010). It also remains to be seen whether the marketplace growth of e-cigarettes will result in increased initiation and how emerging research in this area is constructed (i.e., compared to smoking initiation rates or not). Study limitations include the sampling procedure, which used discrete keywords that may not reflect all news coverage of tobacco harm reduction issues, but rather only those making explicit references to it; implicit references to it or articles that discuss tobacco harm reduction by another name were not sampled. Further, sampled articles appeared only in mainstream textual news media and excluded non-journalistic (social media) and alternative information sources that also impact public opinion. Though textual news media coverage is a valid proxy for the overall news media (Clegg Smith et al., 2008), universal media sources (i.e., television, radio)

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were not included. Finally, the study made no attempt to discern whether and how some media outlets may construct tobacco harm reduction differently, for example whether favorable or unfavorable constructions of it can be explained by geographic region or ownership structure. Future studies should continue to critically examine media depictions of tobacco harm reduction, particularly given the growth of e-cigarettes. As smoking and tobacco use remains entrenched among particularly vulnerable groups within U.S. society, industry marketing practices (advertisements) should be scrutinized. Research of this sort should examine depictions of tobacco harm reduction in influential popular and non-journalistic media, particularly social media. Studies in this area should also examine depictions of emerging research on tobacco harm reduction (notably e-cigarettes) to gauge the presence of bias in their presentation, while media research should continue to follow U.S. media coverage of tobacco industry and tobacco harm reduction as related to specifications of the FTCSPA. Conflict of interest There are no conflicts of interest posed by the authorship and submission of this manuscript. References Bell, K., & Keane, H. (2012). Nicotine control: E-cigarettes, smoking, and addiction. International Journal of Drug Policy, 23(3), 242–247. Bialous, S. A., & Peeters, S. (2012). A brief overview of the tobacco industry in the last 20 years. Tobacco Control, 21(2), 92–94. Bolden, R. (2010). Tobacco use and nicotine dependence. In A. A. Abbott (Ed.), Alcohol, tobacco, and other drugs: Challenging myths, assessing theories, individualizing interventions. Washington, DC: NASW Press. Chapman, S., & Mackenzie, R. (2010). The global research neglect of unassisted smoking cessation: Causes and consequences. http://www.plosmedicine.org/ article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000216 Clegg Smith, K., Wakefield, M. A., Terry-McElrath, Y., Chaloupka, F. J., Flay, B., Johnston, L., et al. (2008). Relation between newspaper coverage of tobacco issues and smoking attitudes and behaviour among American teens. Tobacco Control, 17(1), 17–24. Clegg Smith, K., Wakefield, M., & Edsall, E. (2006). The good news about smoking: How do U.S. newspapers cover tobacco issues? Journal of Public Health Policy, 27(2), 166–181. Clegg Smith, K., & Wakefield, M. (2005). Textual analysis of tobacco editorials: How are key media gatekeepers framing the issues? American Journal of Health Promotion, 19(5), 361–368. Coleman, H., & Unrau, Y. A. (2005). Analyzing qualitative data. In R. M. Grinnell, & Y. A. Unrau (Eds.), Social work research and evaluation: Quantitative and qualitative approaches (7th ed., pp. 404–420). New York: Oxford University Press. Dunlop, S. A., & Romer, D. (2010). Relation between newspaper coverage of ‘light’ cigarette litigation and beliefs about ‘lights’ among American adolescents and young adults: The impact on risk perceptions and quitting intentions. Tobacco Control, 19(4), 267–273. Etter, J., & Bullen, C. (2011). Electronic cigarette: Users profile, utilization, satisfaction, and perceived efficacy. Addiction, 106(11), 2017–2028. Givel, M. (2011). Deconstructing social constructionist theory in tobacco policy: The case of the less hazardous cigarette. Journal of Policy Practice, 10(1), 19–34. Gostin, L. O. (2009). FDA regulation of tobacco: Politics, law, and the public’s health. Journal of the American Medical Association, 302(13), 1459–1460. Hajek, P., Etter, J., Benowitz, N., Eissenberg, T., & McRobbie, H. (2014). Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit. Addiction, 109(11), 1801–1810. Hathaway, A. (2002). From harm reduction to human rights: Bringing liberalism back into drug reform debates. Drug and Alcohol Review, 21(4), 397–404. Hatsukami, D. K., Henningfield, J. E., & Kotlyar, M. (2004). Harm reduction approaches to reducing tobacco-related mortality. Annual Review of Public Health, 25, 377–395. Hsieh, H. F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288. Jorgensen, M., & Phillips, L. (2002). Discourse analysis as theory and method. Thousand Oaks: Sage Publications. King, N. (1998). Template analysis. In C. Syman, & C. Cassell (Eds.), Qualitative methods and analysis in organizational research (pp. 118–134). London: Sage Publications.

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