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  <front>
    <journal-meta>
      <journal-id journal-id-type="publisher-id">JPH</journal-id>
      <journal-id journal-id-type="nlm-ta">JMIR Public Health Surveill</journal-id>
      <journal-title>JMIR Public Health and Surveillance</journal-title>
      <issn pub-type="epub">2369-2960</issn>
      <publisher>
        <publisher-name>JMIR Publications</publisher-name>
        <publisher-loc>Toronto, Canada</publisher-loc>
      </publisher>
    </journal-meta>
    <article-meta>
      <article-id pub-id-type="publisher-id">v7i2e22946</article-id>
      <article-id pub-id-type="pmid">33560242</article-id>
      <article-id pub-id-type="doi">10.2196/22946</article-id>
      <article-categories>
        <subj-group subj-group-type="heading">
          <subject>Short Paper</subject>
        </subj-group>
        <subj-group subj-group-type="article-type">
          <subject>Short Paper</subject>
        </subj-group>
      </article-categories>
      <title-group>
        <article-title>Instagram Posts Related to Backwoods Cigarillo Blunts: Content Analysis</article-title>
      </title-group>
      <contrib-group>
        <contrib contrib-type="editor">
          <name>
            <surname>Sanchez</surname>
            <given-names>Travis</given-names>
          </name>
        </contrib>
      </contrib-group>
      <contrib-group>
        <contrib contrib-type="reviewer">
          <name>
            <surname>Montgomery</surname>
            <given-names>LaTrice</given-names>
          </name>
        </contrib>
        <contrib contrib-type="reviewer">
          <name>
            <surname>Sun</surname>
            <given-names>Ruoyan</given-names>
          </name>
        </contrib>
        <contrib contrib-type="reviewer">
          <name>
            <surname>Nguyen</surname>
            <given-names>Nhung</given-names>
          </name>
        </contrib>
        <contrib contrib-type="reviewer">
          <name>
            <surname>Park</surname>
            <given-names>Sejung</given-names>
          </name>
        </contrib>
      </contrib-group>
      <contrib-group>
        <contrib id="contrib1" contrib-type="author" equal-contrib="yes">
          <name name-style="western">
            <surname>Kim</surname>
            <given-names>Stephanie</given-names>
          </name>
          <degrees>MPH</degrees>
          <xref rid="aff1" ref-type="aff">1</xref>
          <ext-link ext-link-type="orcid">https://orcid.org/0000-0002-3894-8214</ext-link>
        </contrib>
        <contrib id="contrib2" contrib-type="author" equal-contrib="yes">
          <name name-style="western">
            <surname>Mourali</surname>
            <given-names>Alia</given-names>
          </name>
          <degrees>BS</degrees>
          <xref rid="aff1" ref-type="aff">1</xref>
          <ext-link ext-link-type="orcid">https://orcid.org/0000-0001-6942-5005</ext-link>
        </contrib>
        <contrib id="contrib3" contrib-type="author" equal-contrib="yes">
          <name name-style="western">
            <surname>Allem</surname>
            <given-names>Jon-Patrick</given-names>
          </name>
          <degrees>PhD, MA</degrees>
          <xref rid="aff1" ref-type="aff">1</xref>
          <ext-link ext-link-type="orcid">https://orcid.org/0000-0001-9135-8689</ext-link>
        </contrib>
        <contrib id="contrib4" contrib-type="author" equal-contrib="yes">
          <name name-style="western">
            <surname>Unger</surname>
            <given-names>Jennifer B</given-names>
          </name>
          <degrees>PhD</degrees>
          <xref rid="aff1" ref-type="aff">1</xref>
          <ext-link ext-link-type="orcid">https://orcid.org/0000-0001-9064-6603</ext-link>
        </contrib>
        <contrib id="contrib5" contrib-type="author" equal-contrib="yes">
          <name name-style="western">
            <surname>Boley Cruz</surname>
            <given-names>Tess</given-names>
          </name>
          <degrees>PhD, MPH, CHES</degrees>
          <xref rid="aff1" ref-type="aff">1</xref>
          <ext-link ext-link-type="orcid">https://orcid.org/0000-0002-5894-1802</ext-link>
        </contrib>
        <contrib id="contrib6" contrib-type="author" corresp="yes" equal-contrib="yes">
          <name name-style="western">
            <surname>Smiley</surname>
            <given-names>Sabrina L</given-names>
          </name>
          <degrees>PhD, MPH, MCHES</degrees>
          <xref rid="aff1" ref-type="aff">1</xref>
          <address>
            <institution>Department of Preventive Medicine</institution>
            <institution>Keck School of Medicine</institution>
            <institution>University of Southern California</institution>
            <addr-line>2001 North Soto Street</addr-line>
            <addr-line>Los Angeles, CA, 90032</addr-line>
            <country>United States</country>
            <phone>1 3234427367</phone>
            <fax>1 3234428201</fax>
            <email>slsmiley@usc.edu</email>
          </address>
          <ext-link ext-link-type="orcid">https://orcid.org/0000-0003-3202-7534</ext-link>
        </contrib>
      </contrib-group>
      <aff id="aff1">
        <label>1</label>
        <institution>Department of Preventive Medicine</institution>
        <institution>Keck School of Medicine</institution>
        <institution>University of Southern California</institution>
        <addr-line>Los Angeles, CA</addr-line>
        <country>United States</country>
      </aff>
      <author-notes>
        <corresp>Corresponding Author: Sabrina L Smiley <email>slsmiley@usc.edu</email></corresp>
      </author-notes>
      <pub-date pub-type="collection">
        <month>2</month>
        <year>2021</year>
      </pub-date>
      <pub-date pub-type="epub">
        <day>9</day>
        <month>2</month>
        <year>2021</year>
      </pub-date>
      <volume>7</volume>
      <issue>2</issue>
      <elocation-id>e22946</elocation-id>
      <history>
        <date date-type="received">
          <day>10</day>
          <month>8</month>
          <year>2020</year>
        </date>
        <date date-type="rev-request">
          <day>24</day>
          <month>9</month>
          <year>2020</year>
        </date>
        <date date-type="rev-recd">
          <day>27</day>
          <month>11</month>
          <year>2020</year>
        </date>
        <date date-type="accepted">
          <day>4</day>
          <month>1</month>
          <year>2021</year>
        </date>
      </history>
      <copyright-statement>©Stephanie Kim, Alia Mourali, Jon-Patrick Allem, Jennifer B Unger, Tess Boley Cruz, Sabrina L Smiley. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 09.02.2021.</copyright-statement>
      <copyright-year>2021</copyright-year>
      <license license-type="open-access" xlink:href="https://creativecommons.org/licenses/by/4.0/">
        <p>This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Public Health and Surveillance, is properly cited. The complete bibliographic information, a link to the original publication on http://publichealth.jmir.org, as well as this copyright and license information must be included.</p>
      </license>
      <self-uri xlink:href="http://publichealth.jmir.org/2021/2/e22946/" xlink:type="simple"/>
      <abstract>
        <sec sec-type="background">
          <title>Background</title>
          <p>Instagram, one of the most popular social media platforms among youth, offers a unique opportunity to examine blunts—partially or fully hollowed-out large cigars, little cigars, and cigarillos that are filled with marijuana. Cigarillo brands like Backwoods (Imperial Tobacco Group Brands LLC) have product features that facilitate blunt making, including a variety of brand-specific flavors that enhance the smoking experience (eg, honey, dark stout). Backwoods has an active online presence with a user-friendly website.</p>
        </sec>
        <sec sec-type="objective">
          <title>Objective</title>
          <p>This study examined the extent to which Backwoods cigarillo–related posts on Instagram showed blunt making. Instagram offers a unique opportunity to examine blunt making as Instagram accounts will contain images reflective of behavior occurring without the prime of a researcher.</p>
        </sec>
        <sec sec-type="methods">
          <title>Methods</title>
          <p>Data consisted of publicly available Instagram posts with the hashtag #backwoods collected from August 30 to September 12, 2018. Inclusion criteria for this study included an Instagram post with the hashtag “#backwoods”. Rules were established to content analyze posts. Categories included <italic>Type of post</italic> (ie, photo, video, or both); <italic>Blunt-related hashtags</italic> (ie, the corresponding post caption contained one or more hashtags like #blunts, #cannabis, and #weed that were identified in previous social media research); <italic>Rolling blunts</italic> (ie, the post contained an image of one or more individuals rolling a Backwoods cigarillo visibly containing marijuana); and <italic>Smoking blunts</italic> (ie, the post contained an image of one or more individuals blowing smoke or holding a lit blunt). We coded images for <italic>Product flavor</italic> reference, where a code of 1 showed a Backwoods cigarillo pack with a brand-specific flavor (eg, honey, dark stout, Russian crème) visible in the blunt-related image, and a code of 0 indicated that it was not visible anywhere in the image.</p>
        </sec>
        <sec sec-type="results">
          <title>Results</title>
          <p>Among all posts (N=1206), 871 (72.2%) were coded as <italic>Blunt-related hashtags</italic>. A total of 125 (10.4%) images were coded as <italic>Smoking blunts</italic>, and 25 (2.1%) were coded as <italic>Rolling blunts</italic> (ie, Backwoods cigarillo explicitly used to roll blunts). Among blunt images, 434 of 836 (51.9%) were coded as <italic>Product flavor</italic> (ie, a Backwoods pack with a brand-specific flavor was visible).</p>
        </sec>
        <sec sec-type="conclusions">
          <title>Conclusions</title>
          <p>Most Backwoods cigarillo–related Instagram images were blunt-related, and these blunt-related images showed Backwoods packages indicating flavor preference. Continued monitoring and surveillance of blunt-related posts on Instagram is needed to inform policies and interventions that reduce the risk that youth may experiment with blunts. Specific policies could include restrictions on product features (eg, flavors, perforated lines, attractive resealable foil pouches, sale as singles) that facilitate blunt making.</p>
        </sec>
      </abstract>
      <kwd-group>
        <kwd>Instagram</kwd>
        <kwd>blunts</kwd>
        <kwd>Backwoods cigarillos</kwd>
        <kwd>smoking</kwd>
      </kwd-group>
    </article-meta>
  </front>
  <body>
    <sec sec-type="introduction">
      <title>Introduction</title>
      <p>Blunts are partially or fully hollowed-out cigars, including little cigars or cigarillos, that are refilled with marijuana. Blunts are an increasingly popular way to smoke marijuana [<xref ref-type="bibr" rid="ref1">1</xref>,<xref ref-type="bibr" rid="ref2">2</xref>] and are associated with escalation in use of nicotine and marijuana among adolescents and adults [<xref ref-type="bibr" rid="ref3">3</xref>-<xref ref-type="bibr" rid="ref5">5</xref>]. Among US adolescents who have ever used a cigarillo or little cigar, 40% used them to make blunts [<xref ref-type="bibr" rid="ref6">6</xref>]. Blunt users are exposed to nicotine through the tobacco wrap [<xref ref-type="bibr" rid="ref7">7</xref>,<xref ref-type="bibr" rid="ref8">8</xref>], and they are exposed to greater carbon monoxide compared to non–blunt users who smoke marijuana wrapped in a cigarette rolling paper that does not contain nicotine [<xref ref-type="bibr" rid="ref9">9</xref>,<xref ref-type="bibr" rid="ref10">10</xref>].</p>
      <p>Cigarillos contain just as much nicotine and carcinogens as cigarette smoke, if not more [<xref ref-type="bibr" rid="ref11">11</xref>,<xref ref-type="bibr" rid="ref12">12</xref>], leading to increased health risks [<xref ref-type="bibr" rid="ref13">13</xref>]. Youth and young adults in the United States have among the highest prevalence of cigarillo use [<xref ref-type="bibr" rid="ref14">14</xref>]. Cigarillos also face fewer federal restrictions (eg, allowed in flavors, sold as singles and in packs of two) than cigarettes [<xref ref-type="bibr" rid="ref14">14</xref>], but are similar to cigarettes in size, shape, and combustible use [<xref ref-type="bibr" rid="ref12">12</xref>,<xref ref-type="bibr" rid="ref14">14</xref>]. Cigarillos are widely available [<xref ref-type="bibr" rid="ref15">15</xref>-<xref ref-type="bibr" rid="ref18">18</xref>], and popular brands like Swisher Sweets (Swisher International, Inc) and Backwoods (Imperial Tobacco Group Brands LLC) have features that facilitate blunt making, including perforated lines or tobacco wrappers that are easy to unroll and fill with marijuana, smell-proof resealable foil pouches to conceal marijuana, and availability in a variety of flavors that enhance the smoking experience (eg, honey bourbon, sweet aromatic). Backwoods, in particular, uses advertisement claims that are misleading, like “always true” [<xref ref-type="bibr" rid="ref19">19</xref>].</p>
      <p>Prior research has investigated Backwoods-related posts on Instagram and found marijuana was a common theme [<xref ref-type="bibr" rid="ref20">20</xref>]. However, it was not determined whether Backwoods cigarillos were being used to complement marijuana use (ie, dual use) or explicitly used to roll blunts. As such, this study is an initial step to examine the extent to which Backwoods cigarillo–related posts on Instagram showed blunt making. Instagram is an image-based platform that has been used to study health-related attitudes and behaviors as well as promotional material from companies [<xref ref-type="bibr" rid="ref20">20</xref>,<xref ref-type="bibr" rid="ref21">21</xref>]. Instagram offers a unique opportunity to examine blunt making, as Instagram accounts will contain images reflective of behavior occurring without the prime of a researcher [<xref ref-type="bibr" rid="ref20">20</xref>,<xref ref-type="bibr" rid="ref21">21</xref>]. Instagram also offers multicontextual content (images and text) that has provided useful insights about user experiences with tobacco products [<xref ref-type="bibr" rid="ref20">20</xref>,<xref ref-type="bibr" rid="ref21">21</xref>]. This is important because blunt use has adverse health effects, and these product features might be expanding the population of tobacco users from marijuana users who otherwise would not use any tobacco.</p>
    </sec>
    <sec sec-type="methods">
      <title>Methods</title>
      <p>Data consisted of publicly available Instagram posts with the hashtag #backwoods collected from August 30 to September 12, 2018. Netlytic, an Instagram-approved vendor that accessed the public application programming interface of Instagram, was used to collect data. A total of 12,306 posts included the hashtag #backwoods during the study period. Similar to prior Instagram studies [<xref ref-type="bibr" rid="ref20">20</xref>,<xref ref-type="bibr" rid="ref21">21</xref>], we numbered each observation and then randomly drew observations using a random number generator until 10% of the sample was culled from the initial corpus. Multiple posts from the same users in either the overall sample frame or in the randomly selected posts were not treated as independent observations. Backwoods (Imperial Tobacco Group Brands LLC) was not the source of any of the posts. Rules were established to content analyze 1206 posts.</p>
      <p>The first and second authors generated a codebook based on prior research [<xref ref-type="bibr" rid="ref20">20</xref>-<xref ref-type="bibr" rid="ref22">22</xref>] and reviewed a subsample (N=200) of the posts to identify prominent themes. The unit of analysis was the individual Instagram post (ie, the image and corresponding caption), and the coding strategy assessed themes found in the posts. The coding strategy included (1) <italic>Type of post</italic> (ie, photo, video, or both); (2) <italic>Blunt-related hashtags</italic> (ie, the corresponding post caption contained one or more hashtags like #blunts, #cannabis, and #weed that were identified in previous social media research [<xref ref-type="bibr" rid="ref23">23</xref>,<xref ref-type="bibr" rid="ref24">24</xref>]); (3) <italic>Rolling blunts</italic> (ie, the post contained an image of one or more individuals rolling a Backwoods cigar visibly containing marijuana); and (4) <italic>Smoking blunts</italic> (ie, the post contained an image of one or more individuals blowing smoke or holding a lit blunt). Similar to previous research using Instagram data [<xref ref-type="bibr" rid="ref21">21</xref>], we coded images for (5) <italic>Product flavor</italic> reference, where a code of 1 showed a Backwoods package with a brand-specific flavor (eg, honey, dark stout, Russian crème) visible in the image (eg, next to a Backwoods cigarillo that contained marijuana), and a code of 0 indicated that a Backwoods pack with a brand-specific flavor was not visible anywhere in the image. Two investigators (SK and AM) independently coded all posts, and percentage agreement was substantial at 97.0% (<italic>Type of post</italic>; 1170/1206), 90.0% (<italic>Blunt-related hashtags</italic>; 784/871), 100% (<italic>Rolling blunts</italic>; 25/25), 99.2% (<italic>Smoking blunts</italic>; 124/125), and 100% (<italic>Product flavor</italic>; 434/434). Discrepancies were resolved via in-person discussion. We report the percentages of posts for each theme.</p>
    </sec>
    <sec sec-type="results">
      <title>Results</title>
      <p>Among all posts (N=1206), 913 (75.7%) were photos, 268 (22.2%) were videos, and 25 (2.1%) included both photos and videos. A total of 774 (64.2%) were posts from individual Instagram users, and 432 (35.8%) were posts from online tobacco retailers. A total of 871 (72.2%) were coded as <italic>Blunt-related hashtags</italic> (<xref rid="figure1" ref-type="fig">Figure 1</xref>A). A total of 125 (10.4%) images were coded as <italic>Smoking blunts</italic> (<xref rid="figure1" ref-type="fig">Figure 1</xref>C), and 25 (2.1%) were coded as <italic>Rolling blunts</italic> (ie, Backwoods cigarillo explicitly used to roll blunts; <xref rid="figure1" ref-type="fig">Figure 1</xref>B). Among blunt images, 434 of 836 (51.9%) were coded as <italic>Product flavor</italic> (ie, a Backwoods pack with a brand-specific flavor, such as honey, dark stout, or Russian crème, was visible; <xref rid="figure1" ref-type="fig">Figure 1</xref>D).</p>
      <fig id="figure1" position="float">
        <label>Figure 1</label>
        <caption>
          <p>Images representative of select themes: (A) Blunt-related hashtags; (B) Rolling blunts; (C) Smoking blunts; (D) Product flavor.</p>
        </caption>
        <graphic xlink:href="publichealth_v7i2e22946_fig1.png" alt-version="no" mimetype="image" position="float" xlink:type="simple"/>
      </fig>
    </sec>
    <sec sec-type="discussion">
      <title>Discussion</title>
      <p>Findings from this study suggest that blunt users perceive Backwoods cigarillos as vehicles for marijuana consumption and that they are comfortable sharing images of this behavior on Instagram. This may be the start of a growing trend as Imperial Brands, the parent company of Imperial Tobacco Group Brands LLC (America’s third-largest tobacco company [<xref ref-type="bibr" rid="ref25">25</xref>]), recently signed a US $123 million investment deal with Auxly Cannabis Group Inc of Vancouver, Canada [<xref ref-type="bibr" rid="ref26">26</xref>]. It appears that marijuana may play a substantial role in the tobacco market of the future, especially given that Imperial’s most popular machine-made cigar brand is Backwoods [<xref ref-type="bibr" rid="ref27">27</xref>].</p>
      <p>When considering Backwoods online presence, it should be noted that the age verification on the brand’s website currently reads, “To roll with us, you’ve got to be 21 or over” [<xref ref-type="bibr" rid="ref19">19</xref>]. This is concerning because Backwoods is clearly aligning itself with blunt making with a website greeting that suggests consumers should consider their tobacco products as good choices for rolling blunts. Findings complement previous research [<xref ref-type="bibr" rid="ref5">5</xref>,<xref ref-type="bibr" rid="ref18">18</xref>,<xref ref-type="bibr" rid="ref19">19</xref>] that cigarillo product features (eg, Backwoods brand name, “natural” leaf wrappers, flavors) facilitate blunt making, including on Instagram. </p>
      <p>Findings suggest that images on Instagram capture the social context in which individuals increasingly display blunt making. Instagram is one of the most popular social media platforms among youth; thus, they could view these public blunt-making posts. Research is needed to examine how youth might be turning to Instagram to learn about blunt making. This includes assessing whether posts were somehow more targeted to youth. Research is also needed to compare the reactions and responses of followers to the posts from individual Instagram users and online tobacco retailers across categories (ie, <italic>Rolling blunts</italic>, <italic>Smoking blunts</italic>). Additionally, blunt making facilitation and use on Instagram should be considered when designing smoking prevention programs for youth.</p>
      <p>Findings from this study should be considered with several limitations in mind, including the sole focus on the cigarillo brand Backwoods and related images on Instagram. Findings may not generalize to other companies or social media platforms (eg, Twitter, Facebook, Tumblr). The images analyzed in this study were collected from a 2-week time period and may not generalize to other time periods. Future research should examine longer timeframes, different social media platforms, and additional brands to fully characterize the blunt making and use experience.</p>
      <p>This study demonstrated that more than half of Backwoods cigarillo–related Instagram images were blunt-related, and over half of these blunt-related images showed Backwoods packages indicating flavor preference. This study also found that consumers of Backwoods cigarillos were using Instagram to promote smoking blunts and the blunt-making process (eg, rolling). Findings inform the Food and Drug Administration’s regulation of cigar products that are covered under the 2016 Final Deeming Rule [<xref ref-type="bibr" rid="ref28">28</xref>]. Specific regulations could include restrictions on product features (eg, flavors, perforated lines, attractive resealable foil pouches, sale as singles) that facilitate blunt making.</p>
      <p>The University of Southern California Institutional Review Board approved all study procedures.</p>
    </sec>
  </body>
  <back>
    <app-group/>
    <ack>
      <p>The authors would like to thank Christopher Rogers for his support to data management.</p>
      <p>Research reported in this publication was supported by grant number U54CA180905 from the National Cancer Institute (NIH-NCI) and the Food and Drug Administration Center for Tobacco Products (FDA-CTP). At the time of the study, SLS was supported through an award from the National Cancer Institute Research Supplement to Promote Diversity in Health-Related Research. The NIH-NCI or FDA-CTP had no role in study design, data collection, data analysis, interpretation of data, writing the report, or the decision to submit the report for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH-NCI or FDA-CTP.</p>
    </ack>
    <fn-group>
      <fn fn-type="con">
        <p>SK and SLS conceived of the study. JBU and TBC received funding for the study. SK and AM coded the images and analyzed the data. J-PA collected the data. SK and SLS drafted the initial manuscript. J-PA, JBU, and TBC revised the manuscript for important intellectual content. All authors approved the final manuscript.</p>
      </fn>
      <fn fn-type="conflict">
        <p>None declared.</p>
      </fn>
    </fn-group>
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