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

Background: Tobacco harm reduction (THR) has become increasingly prominent in global tobacco discourse, with industry actors and advocates actively shaping messaging on social media platforms. Objective: 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. Methods: 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. Results: 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%). Conclusions: 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.