Message Valence, Industry Influence, and Stakeholder Narratives in Global Conversations on Tobacco Harm Reduction: Content Analysis.

Abstract

Tobacco harm reduction (THR) has become increasingly prominent in global tobacco discourse, with industry actors and advocates actively shaping messaging on social media platforms. This study aimed to analyze how THR is discussed on X (formerly known as Twitter), examining message valence toward THR (pro, anti, mixed, or none), stakeholder participation, geographic and temporal variation, and the involvement of industry and THR advocates. We conducted a content analysis of 17,361 posts related to THR from 87 countries, published between July 2019 and December 2023. Thematic analysis was used to identify dominant narratives. Pro-THR posts comprised the majority (12,393/17,361, 71.4%), followed by anti-THR (3925/17,361, 22.6%) and neutral or mixed messages (63/17,361, 0.4%). Pro-THR messages were most prevalent in high-income countries (9193, 78.3%) and were primarily disseminated by THR advocates (7084/7426, 95.4%), tobacco users (3618/3692, 98%), and industry-affiliated accounts (973/1042, 93.3%). Anti-THR posts were more common among government entities (276/333, 82.9%), tobacco control advocates (256/364, 70.3%), and in lower-middle-income regions (149/244, 61.2%). Self-identified health care providers represented 9.4% (1629/17,361) of the dataset, with their posts nearly evenly split between pro-THR (716/1629, 44%) and anti-THR (826/1629, 50.7%) narratives. Pro-THR narratives emphasized the safety and smoking cessation potential of newer nicotine and tobacco products, consumer rights, and skepticism toward public health authorities. In contrast, anti-THR messages focused on youth protection, health risks of newer products, distrust of industry motives, and advocated for complete cessation of tobacco and nicotine use. Notably, 39.6% (6881/17,361) of THR-related posts mentioned newer products, and 15.7% (2724/17,361) included marketing efforts. There was a marked increase over time in overall THR-related post volume, posts by THR advocates, product mentions, and marketing attempts. Overall, high-income countries contributed the majority of posts (11,739/17,361, 67.6%) while nearly half originated from North America (8553/17,361, 49.3%). The online discourse surrounding THR is characterized by a predominance of pro-THR messaging, particularly in high-income countries and among industry-affiliated stakeholders. The growing volume of THR advocacy and marketing efforts on social media presents new challenges for tobacco regulation and public health policy.