14ALLIED MEDICAL WASTE TRANSPORT VETERINARIAN DIVISIONRob.docx

14
ALLIED MEDICAL WASTE TRANSPORT: VETERINARIAN
DIVISION
Robert E. Stevens
John Massey Professor of Business
John Massey School of Business
Department of Management and Marketing
1405 N. 4th Ave. PMB 4118
Southeastern Oklahoma State University
Durant, OK 74701
Phone: 580-745-3181
Fax: 580-745-7479
E-mail: [email protected]
Lawrence S. Silver
Associate Professor of Marketing
Department of Management and Marketing
1405 N. 4th Ave. PMB 4118
Durant, OK 74701-0609

(580) 745-3190 (Phone)
(580) 745-7479 (Fax)
E-mail: [email protected]
C. W. Von Bergen
John Massey Endowed Chair in Management
Durant, OK 74701-0609
Phone: 580-745-2430
Fax: 580-745-7479
E-mail:[email protected]
ALLIED MEDICAL WASTE TRANSPORT: VETERINARIAN
DIVISION
Kathy West, Vice President of Marketing at Allied Medical
Waste Transport of Oklahoma, sat at her desk reading her boss’s
request for a strategic marketing plan for the next three years
including pro forma income statements for the newly started
veterinary division of the company. She had thought about this
project off and on for the past couple of months and now faced
the daunting task of actually creating the overall strategy and
the mix of personal selling and advertising. The home office
expected substantial growth from the veterinary operation and
Ms. West searched for growth options to meet the desired
sales/profit levels.
Background
Medical waste first came to the attention of the general public
several years ago when it washed up on New Jersey beaches.

Because of the media exposure of this event and others
pertaining to undesirable disposal practices as well as fear of
AIDS, public hysteria resulted and pressure was put upon
regulatory officials to develop comprehensive regulations to
prohibit such occurrences. HR3515 (The Medical Waste
Tracking Act of 1988) was passed requiring the federal
Environmental Protection Agency (EPA) to begin an
investigation to determine whether federal legislation was
necessary. The EPA provided their findings in 1991 that led to
federal regulations on medical waste disposal.
Also, the Occupational Safety and Health Administration,
OSHA, has begun to fine waste generators for improper disposal
practices within their facilities and most states have adopted
some type of regulation pertaining to infectious waste disposal
requirements. The concern was not just for human medical
waste but also animal medical waste since farmers and ranchers
inoculated animals including beef, pork, and poultry.
The MWTA initially applied to facilities in Connecticut, New
Jersey, and New York. Illinois, Indiana, Michigan, Minnesota,
Ohio, Pennsylvania, and Wisconsin also were included within
the original scope of the MWTA but were permitted to, and each
elected to, opt out of coverage. The federal government
permitted other states to opt into coverage under the MWTA,
but only Rhode Island and Puerto Rico elected coverage. The
MWTA only covered medical waste generated in one of the
covered states. Conversely, the MWTA did not cover medical
waste transported from a non-covered state to a covered state
for treatment and/or disposal.
The EPA issued regulations (MWTA regulations) under the
MWTA listing applicable generators, identifying the wastes that
had to be tracked and outlining standards for separating,
packaging, and labeling medical waste. Facilities producing less
than fifty pounds of waste per month are exempt from the

tracking requirements of the MWTA. The MWTA Regulations
impose record-keeping requirements on all generators,
transporters, and destination facilities and require each to
maintain all tracking records for three years. The program
requires the use of a specified uniform tracking form.
Additional requirements and operating procedures are
applicable to transporters and treatment, storage and disposal
facilities. Generators exporting medical waste to a foreign
country for treatment, destruction, or disposal must receive
written confirmation of receipt within forty-five days,
otherwise, an Exception Report must be filed by the forty-sixth
day.
While the act was focused on human medical waste, there was
also concern for animal medical waste and some sections of the
law could be applied to animal waste. The following abstract
echoes the concern of the veterinary medical professionals
regarding medical waste and refers to a model plan developed
by the American Veterinary Medical Association:
Lawmakers have enacted a variety of laws and regulations to
ensure proper disposal of certain potentially infectious or
otherwise objectionable waste. The veterinary medical
profession supports scientifically based regulations that benefit
public health. In 1988, Congress passed the Medical Waste
Tracking Act, a federal program that mandates tracking certain
regulated waste. Several types of waste generated in the typical
clinical veterinary medical practice are considered regulated
veterinary medical waste. Discarded needles, syringes, and
other sharps; vaccines and vials that contained certain live or
attenuated vaccines; cultures and stocks of infectious agents and
culture plates; research animals that were exposed to agents that
are infectious to human beings and their associated waste; and
other animal waste that is known to be potentially harmful to
human beings should be handled as regulated veterinary medical
waste. Regulated veterinary medical waste should be handled
with care. It should be decontaminated prior to disposal. The

most popular, effective methods of decontamination are steam
sterilization (autoclaving) and incineration. Chemical
decontamination is appropriate for certain liquid waste. Waste
should be packaged so that it does not spill. Sharps require rigid
puncture- and leak-resistant containers that can be permanently
sealed. Regulated veterinary medical waste that has not been
decontaminated should be labeled with the universal biohazard
symbol. Generators retain liability for waste throughout the
entire disposal process. Therefore, it is essential to ensure that
waste transporters and disposal facilities comply with state and
federal requirements. Veterinary practices should maintain a
written waste management program and accurate records of
regulated veterinary medical waste disposal. Contingency
planning and staff training are other important elements of a
veterinary medical waste management program. The guide
includes a model veterinary medical waste management
program; however, it does not address all the variations in state
and local regulations. Veterinarians should obtain copies of
state and local laws and regulations and modify AVMA's model
plan to create an individualized practice plan that complies with
federal, state, and local laws and regulations. State and local
veterinary medical organizations should monitor state and local
regulation to influence decisions that affect veterinarians and to
keep their members informed of changing requirements.
Veterinarians and veterinary medical organizations must stay
involved so that regulations do not unfairly burden the
veterinary medical profession.(J Am Vet Med Assoc 1989 Oct
15;195(8):1130.)
Company History
Allied Medical Waste Transportation, Inc. (AMWT) emerged in
late 1988 in response to concerns expressed by federal, state
and local regulators regarding biomedical waste disposal
practices and the impact upon human health and the
environment if improperly managed. At that point in time, in
most market areas, only BFI and/or Waste Management offered

biomedical waste management services; and, as a result, those
companies enjoyed a near monopoly in the marketplace, which
reflected itself in the prices charged by those companies.
AMWT, since signing its very first account in March 1989, has
grown to be one the largest provider of biomedical waste
management services in the state of Oklahoma with over 400
clients in Oklahoma and currently manages 450,000 pounds of
biomedical waste per month generated within the state.
AMWT opened a subsidiary office in Denton, Texas in early
1990 and enjoyed significant success throughout the Dallas-Ft.
Worth market area. This branch presently contracts with 23
hospitals that generate a total of 150,000 pounds of biomedical
waste each month. The Dallas-Ft. Worth Hospital Council
recently endorsed AMWT as the preferred provider of
biomedical waste management services to its member hospitals.
This endorsement should lead to greater presence in the market.
In addition to serving Oklahoma and Northern Texas, AMWT
also presently services numerous medical facilities located in
Kansas, Missouri, Arkansas, Colorado and Wyoming. AMWT
received endorsement from Voluntary Hospitals of America
(VHA) for its biomedical waste disposal service to VHA
member facilities in the areas serviced by AMWT.
A major factor in the success of AMWT in addition to its
quality of service and competitive pricing is the exclusive use
of a newly constructed fully permitted incinerator with a
capacity of 100 tons per day. This incinerator was designed
specifically for biomedical waste (including
antineoplastic/chemotherapy wastes) and is located in
Oklahoma. AMWT routinely arranges for potential clients to
tour this facility. It is impressive and instills confidence
regarding the disposition of the biomedical wastes it processes.

All AMWT employees directly involved in the hands-on
management of biomedical wastes receive training in the proper
use of personal protective equipment and appropriate corrective
actions relating to spills, including decontamination techniques
and procedures. All AMWT employees, including drivers,
submit to AMWT's proactive substance abuse program, that
includes drug testing upon employment and randomly thereafter.
All AMWT drivers must also meet U. S. Department of
Transportation driver qualification standards, including physical
exams and an annual review of their driving records. In
addition, AMWT employs a team of emergency responders who
completed a forty (40) hour emergency response course
conducted by the Oklahoma State University.
AMWT's corporate management includes an environmental
attorney licensed by the State of California and whose other
credentials include a Masters level certification in hazardous
materials management from the National Institute of Hazardous
Materials Management. He also serves as an adjunct extension
program faculty member in environmental management at the
Oklahoma State University.
AMWT is permitted to manage biomedical materials that are to
be discarded and that are infectious wastes (those wastes
capable of producing an infectious disease) and chemical wastes
(such as pharmaceutical wastes) laboratory wastes,
antineoplastic drugs and other chemicals, and that are not
regulated as hazardous wastes, such as the following:
Infectious wastes include:
1. Cultures and stocks of infectious agents and associated
biologicals.
2. Human blood and blood products

3. Pathological wastes
4. Contaminated sharps
5. Contaminated animal carcasses, body parts and bedding
6. Wastes from surgery, autopsy and other medical procedures
7. Laboratory wastes
8. Dialysis unit wastes
9. Isolation wastes unless determined to be non-infectious by
the infection control committee at the health care facility
Any other material and contaminated equipment that, in the
determination of the
Facility's infection control staff, presents a significant danger of
infection because it is
contaminated with, or may reasonably be expected to be
contaminated with etiologic
agents. Etiologic agent means a type of microorganism,
helminth or virus that causes, or significantly contributes to the
cause of, increased morbidity or mortality of humans.
Chemical wastes include:
1. Pharmaceutical wastes
2. Laboratory reagents contaminated with infectious body
fluids
3. All the disposable materials that have come in contact with

cytotoxic/antineoplastic
agents during the preparation, handling and administration
of such agents. Such waste
includes, but is not limited to, masks, gloves, gowns, empty
IV tubing bags and vials,
and other contaminated materials.
4. Other chemicals that may be contaminated by infectious
agents as designated by experts at the point of generation of the
waste.
The Veterinary Division
AMWT realized that no major competitors had focused on
veterinary waste and saw this as an opportunity to be one of the
first providers of this service in the states they were already
operating in and possible expansion into other states as demand
increased. Rick Stewart and Joan Craig were to manage this
division. Rick was to be the division’s sales representative and
Joan was to be in charge of operations. Rick was an
experienced salesman who had worked for the company since its
inception in a sales capacity and his specialty was opening new
accounts. Joan was formerly employed by a large waste
management company, where she helped set up their medical
waste program and ranked first in sales and service throughout
that company in their biomedical waste operations. Her
background and training enabled her to assist medical facilities
in their efforts to properly manage biomedical wastes in a safe
and economical manner consistent with all regulations and Joint
Commission guidelines. Their first task was to provide input
into the strategic marketing plan being prepared by Kathy West.
In their initial meeting with West, Rick and Joan stated that the
initial operation of the division should be in Oklahoma. The
start up model was to “start small, learn the business, and then
expand”

Both Rick and Joan had made exploratory calls on veterinary
clinics in the Tulsa area to talk to vets and get a better idea of
the types and quantities of medical waste generated by a clinic.
This information would help determine the waste management
containers needed and how frequently waste should be picked
up. AMWT would offer its clients a comprehensive medical
waste management program and assists them in a consultative
role. This includes assessment of their current system and
recommendations for improvement or if a program does not
exist, to help to develop one. This process can take several
hours for a large clinic or a less than an hour for smaller clinics.
Once service begins, AMWT adds the clients onto a pick-up
route that allows AMWT to conform to a schedule and gives the
client assurance of timely service. AMWT provides all clients
with containers into which the waste will be deposited and also
documentation affirming pick-up of their waste and providing
the client with an actual date of incineration of waste. AMWT
currently uses a twenty (20) foot bob truck, that collects the
waste at the generator's site. A trained technician, at the end of
a route, transports the waste to AMWT's transfer facility and
there off-loads it into a fifty-three (53) foot trailer. When full,
AMWT transports the trailer to the incinerator in Oklahoma. It
is essential that long haul transportation costs stay at a
minimum to allow AMWT to be competitive. AMWT currently
uses a nationwide transportation company who provides all
trailers and transport to Oklahoma within a forty-eight (48) hour
period from pick-up. These drivers must complete a special
spill-response training course.
Oklahoma does not presently require animal waste generators to
have a comprehensive infectious waste management plan in
place and does not requires documentation of proper disposal,
written standard operating procedures and regular monitoring of
the disposal practice. However, a bill is currently before state
legislators to enact such a law.

There are 1839 licensed veterinarians in Oklahoma with about
90% being in private practice. Each would generate
approximately 3 pounds of infectious waste per day. That
would mean a total of about 150,000 lbs. a month (1839 X .9 X
3 X 30) or roughly 1.8 million pounds a year. A monthly fee of
$30 per location plus a disposal rate of $.50 per pound would
generate potential revenues of about $955,170 a year for
Oklahoma.
Competition in the marketplace favors AMWT because of
AMWT's strength in disposal capacity and capabilities,
technology, service and track record as well as expertise. The
major competitor in Oklahoma and well as others operating in
the area all acknowledge major weaknesses since most of them
have decided to autoclave rather than incinerate. Autoclaving
involves steam sterilization of waste and disposal in a landfill.
AMWT, on the other hand, uses state of the art incineration in
Oklahoma and has a staff of specialized industry experts.
Marketing Activities
Marketing activities in the new division were to mirror the
activities used in other locations. AMWT focused on personal
selling since an on-site inspection of a waste generator’s
facility was required to determine whether the facility met
current codes for handling waste and the volume of waste on a
monthly basis.
AMWT also used direct mail pieces to help introduce the
company to prospective clients and familiarize them with the
companies operations. Sales people, (Rick Stewart) provided
comprehensive waste stream assessments, comparative cost
analyses and intensive staff training in servicing as well as
ongoing consultation in regulatory compliance issues. Ms. West
thought that sales calls as well as telemarketing support and a
mail-out campaign might be best to reach the potential clients.
While the high level of interest encountered by Rick and Joan

among Tulsa area veterinarians was encouraging, she knew it
would take some time to reach full potential in Oklahoma.
However, when analyzing the size of the market, she was rather
disappointed with the overall low potential compared to the
main division of the company and was wondering if this new
division would be financially feasible. Potential Financial
Performance
The new division was expected to be financially independent by
the end of the second year of operation and produce a net profit
after taxes of 10% by the end of the third year. Kathy West had
developed three proforma income statements for the first three
years of operations based on three levels of market penetration-
30, 40, and 50%. However, since there were no laws
compelling veterinarians to develop waste disposal procedures,
participation would be strictly voluntary and she wondered if
the levels of penetration she used in the proformas were even
reasonable. The projections are show in the accompanying table.
The new division would have to be successful before the
company would be willing to expand into other states and Kathy
had no real assurances that they could achieve the success
needed to meet top management’s expectations. On the positive
side, the same trucks that picked up waste from other clients
could pick up waste from the vets’ clinics meaning no
additional investment in equipment was needed. Since the
waste from each client had to be labeled separately for tracking
purposes, the vets waste could be transported along with other
waste generators. Although no new investment in plant and
equipment was needed for the new division, at least $100,000 in
working capital would be needed for the start up operations.
Exhibit 1
ALLIED MEDICAL WASTE TRANSPORTATION:
VETERINARY DIVISION PRO FORMA BASED ON
DIFFERENT LEVELS OF MARKET PENETRATION

Year 1
Year 2
Year 3
Market penetration level
30%
40%
50%
Estimated Sales Revenue
$ 286,551.00
$382,068.00
$477,585.00
Variable Expenses:
13,200.00
13,200.00
14,000.00
Utilities/Communications
3,600.00
4,000.00
5,000.00
Office Expense
2,500.00
3,000.00
4,000.00
Auto Expense
1,200.00
1,500.00
2,000.00
Fuel
8,700.00
10,000.00
15,000.00
Repairs and Maintenance
2,000.00
2,000.00
5,000.00
Marketing/Advertising

6,000.00
6,000.00
6,000.00
Accounting/Legal
1,200.00
1,500.00
1,500.00
Miscellaneous
1,200.00
1,500.00
2,000.00
Total Variable Expenses
$39,600.00
42,700.00
54,500.00
Fixed Expenses:
Salaries
130,000.00
150,000.00
150,000.00
Rent
14,700.00
14,700.00
14,700.00
General Liability Insurance
11,616.00
13,000.00
15,000.00
Medical/Life Insurance
4,800.00
6,000.00
8,000.00
Unemployment, Federal/State

3,000.00
4,000.00
5,000.00
Total Fixed Expenses
$164,111.00
$187,700.00
$192,700.00
Estimated Net Income Before Taxes
$82,83500
$151,668.00
$230,385.00
Estimated Income Taxes
$24,850.50
$45,500.40
$69,115.50
Estimated Net Income After Taxes
$57,984.50
$106,167.60
$161,269.50
4
14
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
Bryan Leyva
Warren Alpert Medical School of Brown University
Rebecca A. Ferrer
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 the Smokeless for Smokers
advertisement 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 products
and 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

Solution
s, 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 Behaviors In the public domain
2016, Vol. 30, No. 8, 895–903
http://dx.doi.org/10.1037/adb0000230
895

http://dx.doi.org/10.1037/adb0000230.supp
mailto:[email protected]
mailto:[email protected]
http://dx.doi.org/10.1037/adb0000230
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 . . . if its advertising 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 the
23-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 . . .” For both
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 (see
Figure
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 1 shows 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,

and
18 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 1 shows the five advertisements, highlighted AOI, and
heat maps from eye tracking results. Table 2 shows 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 of Table 3 shows 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.
897PERCEPTIONS 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, R2 � .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 of Table 3 shows 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, R2 � .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
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.015), but the more quickly people looked at the packs (B �
.054,
p � .034), and text (B � .170, p � .013), the greater perceived
addiction, R2 � .773, F(6, 13) � 3.984, p � .047. The overall
regression models for both TTFF, R2 � .786, F(5, 14) � 6.624,
p � .007; and TFD, R2 � .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 4 shows 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 matches
Smokeless for
smokers Swedish
Harm B (p-value)
Time to first fixation (TTFF)
❶
Graphic �.017 (p � .676) .266 (p � .602) �.156 (p � .372)
.014 (p � .626) �.150 (p � .503)
❷
Header 1 .042 (p � .496) �.292 (p � .195) .026 (p � .355)
�.205 (p � .052) �.362 (p � .419)
❸
Header 2 n/a n/a n/a .184 (p � .153) n/a
❹
Packs �.071 (p � .327) .002 (p � .960) n/a n/a .065 (p �
.085)
❺
Text �.134 (p � .356) .045 (p � .617) .105 (p � .235) �.068
(p � .668) .137 (p � .128)
❻
Warning 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)

❶
Graphic .193 (p � .018) �.043 (p � .397) .059 (p � .207)
�.234 (p � .329) .023 (p � .631)
❷
Header 1 �.170 (p � .195) �.039 (p � .332) �.006 (p � .866)
.120 (p � .084) .058 (p � .758)
❸
Header 2 n/a n/a n/a �.142 (p � .100) n/a
❹
Packs �.073 (p � .649) .005 (p � .981) n/a n/a .222 (p �
.451)
❺
Text �.036 (p � .212) �.011 (p � .729) .011 (p � .769) .039
(p � .272) �.071 (p � .108)
❻
Warning 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)
❶
Graphic �.027 (p � .502) �.060 (p � .916) .086 (p � .463)
�.011 (p � .786) .207 (p � .210)
❷
Header 1 .035 (p � .544) �.254 (p � .301) .011 (p � .557)
�.015 (p � .898) �1.012 (p � .015)
❸
❹
Packs �.056 (p � .396) �.009 (p � .827) n/a n/a .054 (p �

.034)
❺
Text �.026 (p � .872) .045 (p � .645) �.029 (p � .615)
�.039 (p � .855) .170 (p � .013)
❻
Warning 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)
❶
Graphic .043 (p � .642) �.048 (p � .286) .039 (p � .373)
�.360 (p � .048) �.003 (p � .937)
❷
Header 1 �.095 (p � .557) �.011 (p � .763) .002 (p � .942)
.107 (p � .046) .102 (p � .544)
❸
❹
Packs �.076 (p � .702) .505 (p � .007) n/a n/a .206 (p �
.427)
❺
Text �.002 (p � .967) �.006 (p � .829) �.022 (p � .526)
.079 (p � .018) �.053 (p � .183)
❻
Warning 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 significance p � .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.
Table 4
Qualitative Themes on Harm and Addictiveness From
Semistructured Interviews
Themes Examples
Harm and addiction They 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. . . . But with 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 . . . if you can make 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 use First 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 exposure But 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 . . . we have 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 . . . may be this 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.
Worry This 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 . . . but the snus, 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
label

The 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 advertisement
It’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 addiction But 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 . . . if you are now experimenting
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
opportunities
Because [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.
Cessation Maybe 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
be this . . . an electronic cigarette or snus.
Well, they say Nicorette gum can help you quit smoking so why
couldn’t this?

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 be likely/extremely likely to try a free package of snus,
while
about 36% reported they would be either likely/extremely likely
to

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 about 4 s on a given 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 “. . . in a manner that contrasts,
by
typography, layout, or color, with all other printed material on
the
package . . .” and on advertisements 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 youth And 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. . . . And then 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.
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. Showing each advertisement for
20

s gave participants an opportunity to explore the entire
advertise-
ment; however, future studies may want to use a more
naturalistic
viewing period to better understand how dwell time on the
adver-
tisement influences attention.
Tobacco companies have a history of making risk reduction
claims, often implicitly, regardless of accuracy. This study is
the
first to explore consumer perceptions about an emerging market
of
tobacco products applying innovative methods including eye
tracking methodology to understand basic attentional processes
in
viewing snus advertisements. Understanding consumer percep-
tions of products is crucial to informing tobacco control efforts.
Regulation of tobacco product marketing is needed, particularly
the marketing of emerging products for which individuals are
forming beliefs and attitudes based on this messaging.
References
Bahreinifar, S., Sheon, N. M., & Ling, P. M. (2013). Is snus the

same as
dip? Smokers’ perceptions of new smokeless tobacco
advertising. To-
bacco Control, 22, 84 –90.
http://dx.doi.org/10.1136/tobaccocontrol-
2011-050022
Chassin, L., Presson, C. C., Sherman, S. J., & Kim, K. (2003).
Historical
changes in cigarette smoking and smoking-related beliefs after
2 decades
in a midwestern community. Health Psychology, 22, 347–353.
http://dx
.doi.org/10.1037/0278-6133.22.4.347
Choi, K., Fabian, L., Mottey, N., Corbett, A., & Forster, J.
(2012). Young
adults’ favorable perceptions of snus, dissolvable tobacco
products, and
electronic cigarettes: Findings from a focus group study.
American
Journal of Public Health, 102, 2088 –2093.
http://dx.doi.org/10.2105/
AJPH.2011.300525

Choi, K., & Forster, J. (2013). Awareness, perceptions and use
of snus
among young adults from the upper Midwest region of the USA.
Tobacco Control, 22, 412– 417.
http://dx.doi.org/10.1136/tobacco
control-2011-050383
Denzin, N. K., & Lincoln, Y. S. (2005). The SAGE handbook of
interview
research: The complexity of the craft. Thousand Oaks, CA:
SAGE
Publications, Inc.
Fereday, J., & Muir-Cochrane, E. (2006). Demonstrating rigor
using the-
matic analysis: A hybrid approach of inductive and deductive
coding and
theme development. International Journal of Qualitative
Methods, 5,
80 –92.
Food and Drug Administration. (2009). Family smoking
prevention to-
bacco control act. Washington, DC: Author.

Glaser, B. G., & Strauss, A. L. (2009). The discovery of
grounded theory:
Strategies for qualitative research. Piscataway Township, NJ:
Transac-
tion Publishers.
International Agency for Research on Cancer. (2012). A review
of human
carcinogens: Personal habits and indoor combustions. Lyon,
France:
World Health Organization, International Agency for Research
on Can-
cer.
Kanakubo, Y., Leung, N., & Yacoe, M. (n.d.). Magazine
advertising copy.
Retrieved from http://courses.washington.edu/webrhet/engl281/
handouts/genreguidech3.pdf
Kaufman, A. R., Mays, D., Koblitz, A. R., & Portnoy, D. B.
(2014).
Judgments, awareness, and the use of snus among adults in the
United
States. Nicotine & Tobacco Research, 16, 1404 –1408.
http://dx.doi.org/

10.1093/ntr/ntu116
Kaufman, A. R., Suls, J. M., & Klein, W. M. P. (2016).
Communicating
tobacco product harm: Compared to what? Addictive Behaviors,
52,
123–125. http://dx.doi.org/10.1016/j.addbeh.2015.06.039
Lund, I., & Scheffels, J. (2014). Perceptions of relative risk of
disease and
addiction from cigarettes and snus. Psychology of Addictive
Behaviors,
28, 367–375. http://dx.doi.org/10.1037/a0032657
Maher, J. E., Bushore, C. J., Rohde, K., Dent, C. W., &
Peterson, E. (2012).
Is smokeless tobacco use becoming more common among U.S.
male
smokers? Trends in Alaska. Addictive Behaviors, 37, 862– 865.
http://
dx.doi.org/10.1016/j.addbeh.2012.02.015
Mitka, M. (2014). CDC: Use of emerging tobacco products
increasing
among U.S. youths. Journal of the American Medical

Association, 311,
124. http://dx.doi.org/10.1001/jama.2013.285837
National Cancer Institute (NCI). (2001). Risks associated with
smoking
cigarettes with low tar machine-measured yields of tar and
nicotine.
Bethesda, MD: Department of Health and Human Services,
National
Institutes of Health, National Cancer Institute.
National Cancer Institute (NCI). (2008). The role of the media
in promot-
ing and reducing tobacco use. Tobacco Control Monograph No.
19.
Bethesda, MD: U.S. Department of Health and Human Services,
Na-
tional Institutes of Health, National Cancer Institute.
National Cancer Institute and Centers for Disease Control and
Prevention.
(2014). Smokeless tobacco and public health: A global
perspective.
Bethesda, MD: U.S. Department of Health and Human Services,
Centers

for Disease Control and Prevention, and National Institutes of
Health,
National Cancer Institute.
Popova, L., & Ling, P. M. (2013). Alternative tobacco product
use and
smoking cessation: A national study. American Journal of
Public
Health, 103, 923–930.
http://dx.doi.org/10.2105/AJPH.2012.301070
Rayner, K. (1998). Eye movements in reading and information
processing:
20 years of research. Psychological Bulletin, 124, 372– 422.
http://dx
.doi.org/10.1037/0033-2909.124.3.372
Richardson, A., Ganz, O., Stalgaitis, C., Abrams, D., &
Vallone, D. (2014).
Noncombustible tobacco product advertising: How companies
are sell-
ing the new face of tobacco. Nicotine & Tobacco Research, 16,
606 –
614. http://dx.doi.org/10.1093/ntr/ntt200

Robert Wood Johnson Foundation. (2011). Social norms and
attitudes
about smoking 1991–2010. Retrieved from
http://www.rwjf.org/content/
dam/web-assets/2011/04/social-norms-and-attitudes-about-
smoking
http://dx.doi.org/10.1136/tobaccocontrol-2011-050022
http://dx.doi.org/10.1037/0278-6133.22.4.347
http://dx.doi.org/10.1037/0278-6133.22.4.347
http://courses.washington.edu/webrhet/engl281/handouts/genreg
uidech3.pdf
http://courses.washington.edu/webrhet/engl281/handouts/genreg
uidech3.pdf
http://dx.doi.org/10.1093/ntr/ntu116
http://dx.doi.org/10.1093/ntr/ntu116
http://dx.doi.org/10.1016/j.addbeh.2015.06.039
http://dx.doi.org/10.1037/a0032657

http://dx.doi.org/10.1001/jama.2013.285837
http://dx.doi.org/10.1037/0033-2909.124.3.372
http://dx.doi.org/10.1037/0033-2909.124.3.372
http://dx.doi.org/10.1093/ntr/ntt200
http://www.rwjf.org/content/dam/web-assets/2011/04/social-
norms-and-attitudes-about-smoking
http://www.rwjf.org/content/dam/web-assets/2011/04/social-
norms-and-attitudes-about-smoking
Rogers, J. D., Biener, L., & Clark, P. I. (2010). Test marketing
of new
smokeless tobacco products in four U.S. cities. Nicotine &
Tobacco
Research, 12, 69 –72. http://dx.doi.org/10.1093/ntr/ntp166
Sami, M., Timberlake, D. S., Nelson, R., Goettsch, B., Ataian,
N., Libao,
P., & Vassile, E. (2012). Smokers’ perceptions of smokeless
tobacco and
harm reduction. Journal of Public Health Policy, 33, 188 –201.
http://

dx.doi.org/10.1057/jphp.2012.9
Shontz, F. C. (1985). A personologic approach for health
psychology
research. American Behavioral Scientist, 28, 510 –524.
http://dx.doi.org/
10.1177/000276485028004007
Strasser, A. A. (2012). The effect of graphic warning label
features on
extended duration recall. Presentation to the Food and Drug
Adminis-
tration. American Journal of Preventive Medicine, 43, 41– 47.
http://dx
.doi.org/10.1016/j.amepre.2012.02.026
Süssenbach, P., Niemeier, S., & Glock, S. (2013). Effects of and
attention
to graphic warning labels on cigarette packages. Psychology and
Health,
28, 1192–1206.
http://dx.doi.org/10.1080/08870446.2013.799161
U.S. Department of Health and Human Services. (2014). The
health

consequences of smoking—50 years of progress: A report of the
Surgeon
General. Atlanta, GA: U.S. Department of Health and Human
Services,
Centers for Disease Control and Prevention, National Center for
Chronic
Disease Prevention and Health Promotion, Office on Smoking
and
Health.
Wackowski, O. A., Lewis, M. J., & Delnevo, C. D. (2015).
Interviews with
smokers about smokeless tobacco products, risk messages and
news
articles. Tobacco Control, 25, 671– 678.
http://dx.doi.org/10.1136/
tobaccocontrol-2015-052412
Wedel, M., & Pieters, R. (1999). Eye fixations on
advertisements and
memory for brands: A model and findings. Marketing Science,
19,
297–312. http://dx.doi.org/10.1287/mksc.19.4.297.11794

Wray, R. J., Jupka, K., Berman, S., Zellin, S., & Vijaykumar, S.
(2012).
Young adults’ perceptions about established and emerging
tobacco
products: Results from eight focus groups. Nicotine & Tobacco
Re-
search, 14, 184 –190. http://dx.doi.org/10.1093/ntr/ntr168
Zhu, S. H., Gamst, A., Lee, M., Cummins, S., Yin, L., & Zoref,
L. (2013).
The use and perception of electronic cigarettes and snus among
the U.S.
population. PLoS ONE, 8, e79332.
http://dx.doi.org/10.1371/journal
.pone.0079332
Received January 27, 2016
Revision received October 4, 2016
Accepted October 5, 2016 �
http://dx.doi.org/10.1093/ntr/ntp166
http://dx.doi.org/10.1057/jphp.2012.9

http://dx.doi.org/10.1057/jphp.2012.9
http://dx.doi.org/10.1177/000276485028004007
http://dx.doi.org/10.1177/000276485028004007
http://dx.doi.org/10.1016/j.amepre.2012.02.026
http://dx.doi.org/10.1016/j.amepre.2012.02.026
http://dx.doi.org/10.1080/08870446.2013.799161
http://dx.doi.org/10.1287/mksc.19.4.297.11794
http://dx.doi.org/10.1093/ntr/ntr168
http://dx.doi.org/10.1371/journal.pone.0079332
http://dx.doi.org/10.1371/journal.pone.0079332Perceptions of
Harm and Addiction of Snus: An Exploratory
StudyMethodParticipantsProcedureMeasuresData
AnalysesQuantitative analysisQualitative analysisResultsEye
TrackingHarm PerceptionsAddiction PerceptionsQualitative
ThemesBehavioral IntentionsDiscussionReferences

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