Health Beliefs of American Indian Imagery on Natural American Spirit Packs

369 Natural American SpiritTM (NAS), a superpremium cigarette brand, has increased in popularity in the United States (US), rising over 400% in market share from 2002 to 2013,1 and at 3.4% in 2018.2 According to prior research, marketing claims of natural, additive-free and organic are associated with misperceptions that NAS offers a safer and less harmful product relative to other commercial cigarettes.3-10 These health misperceptions were associated with an increased intention to purchase NAS in the future.9 In response to the US Food and Drug Administration’s (FDA) warnings more than 2 years prior, NAS ceased use of the text descriptors natural and additive-free in 2017.11 However, natural was retained in the trademarked brand name,11 and the product ingredients are listed as “tobacco plus water,” still implying that the product is additive-free.12 Natural American SpiritTM packaging also retains the iconic image of a fictional American Indian in ceremonial headdress smoking a peace pipe with a thunderbird above in a distinctive American Indian (Native) design. In many Native cultures, the thunderbird is a sacred spirit-being and a symbol of protection.13 Since its inception, the packaging has emphasized the brand’s ties to the southwest-