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Surveillance indicators for potential reduced exposure products (PREPs): developing survey items to measure awareness

Karen Bogen1*, Lois Biener2, Catherine A Garrett2, Jane Allen3, K Michael Cummings4, Anne Hartman5, Stephen Marcus5, Ann McNeill6, Richard J O'Connor4, Mark Parascandola5 and Linda Pederson7

Author Affiliations

1 Mathematica Policy Research, Cambridge, MA, USA

2 Center for Survey Research, University of Massachusetts Boston, Boston, MA, USA

3 American Legacy Foundation, Washington, DC, USA

4 Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, NY, USA

5 National Cancer Institute, National Institutes of Health, Washington, DC, USA

6 Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK

7 Beth-El College of Nursing & Health Sciences, Univ of Colorado, Colorado Springs, CO, USA

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Harm Reduction Journal 2009, 6:27  doi:10.1186/1477-7517-6-27

Published: 19 October 2009



Over the past decade, tobacco companies have introduced cigarettes and smokeless tobacco products (known as Potential Reduced Exposure Products, PREPs) with purportedly lower levels of some toxins than conventional cigarettes and smokeless products. It is essential that public health agencies monitor awareness, interest, use, and perceptions of these products so that their impact on population health can be detected at the earliest stages.


This paper reviews and critiques existing strategies for measuring awareness of PREPs from 16 published and unpublished studies. From these measures, we developed new surveillance items and subjected them to two rounds of cognitive testing, a common and accepted method for evaluating questionnaire wording.


Our review suggests that high levels of awareness of PREPs reported in some studies are likely to be inaccurate. Two likely sources of inaccuracy in awareness measures were identified: 1) the tendency of respondents to misclassify "no additive" and "natural" cigarettes as PREPs and 2) the tendency of respondents to mistakenly report awareness as a result of confusion between PREPs brands and similarly named familiar products, for example, Eclipse chewing gum and Accord automobiles.


After evaluating new measures with cognitive interviews, we conclude that as of winter 2006, awareness of reduced exposure products among U.S. smokers was likely to be between 1% and 8%, with the higher estimates for some products occurring in test markets. Recommended measurement strategies for future surveys are presented.