Eye movement data reveal increased attention to combined health warnings on cigarette packs

Managing Fear Responses: A Qualitative Analysis of Pictorial Warning Labels Five Years Post-Plain Packaging

INTRODUCTION

Although pictorial warning labels (PWLs) now dominate tobacco packages sold in many countries, few studies have probed how people who smoke respond to the threats presented several years post-plain packaging and larger PWLs. Understanding how people manage the fear and dissonance PWLs arouse, and the strategies they use to rationalize, diminish, and reject risk messages, could inform future PWL design.

AIMS AND METHODS

We undertook 27 in-depth interviews with people aged 18 and over (16 female, 8 Māori, and 13 aged ≤35) who smoked roll-your-own tobacco and lived in Aotearoa New Zealand. We probed participants' views on current PWLs and how they responded to these, then asked them to use alternative images and headlines to create new PWLs. We drew on the extended parallel processing model to interpret the data, which we analyzed using a reflexive thematic analysis approach.

RESULTS

People who smoke dislike PWLs, which they think reduce them to diseased body parts. While a minority thought existing PWLs were believable and effective, most reported avoiding PWLs by hiding or cognitively blocking them. Participants used diverse counterarguments to diminish PWLs' relevance and impact, and a minority displayed strong reactance. Several suggested developing PWLs that recognized them as whole people rather than patients in waiting, and recommended greater use of testimonials, particularly from people who had successfully become smoke free.

CONCLUSIONS

PWLs using more holistic and diverse messages could elicit greater engagement and responsiveness, and motivate cessation more effectively than existing health-oriented warnings.

IMPLICATIONS

Our findings suggest existing PWLs, which aim to arouse fear of ill health, could be complemented by warnings that emphasize the benefits of quitting. Continuing to use threat-based PWLs could stimulate greater rationalization and reactance. By contrast, PWLs that aim to illustrate how cessation could benefit people who smoke and their families, rather than instill a fear of disease, could avoid message rejection and counter-argument, and may prove a more powerful way of motivating cessation.

Exploring attention to the Canadian 24-Hour Movement Guidelines for Children and Youth using eye-tracking: A randomized control trial

BACKGROUND

The Canadian 24-Hour Movement Guidelines for Children and Youth ("Guidelines") not only pioneered the notion of an integrated movement continuum from sleep to vigorous-intensity physical activity but also introduced a new branded Guideline visual identity.

OBJECTIVES

This study evaluated youths' (N = 46) attention to and thoughts about the Guidelines and the brand.

DESIGN

A cross-sectional between-participants randomized intervention design was used.

SAMPLE

Canadian youth between 10 and 17 years of age comprised the study sample.

INTERVENTIONS

Participants were randomly assigned to view either branded Guidelines (n = 26) or unbranded Guidelines (n = 20). Youths' eye-movements (e.g., dwell time, fixation count) were recorded during Guideline viewing. Participants completed a follow-up survey assessing brand perceptions and Guideline cognitions.

RESULTS

The branded Guidelines neither drew greater overall attention nor led to more positive brand perceptions or Guideline cognitions compared to the unbranded Guidelines.

CONCLUSIONS

Exploratory analyses provide valuable, yet preliminary insight into how branding and Guideline content may shape how Guidelines are perceived and acted upon. These findings inform an agenda for future health education resources.

The Response of Smokers to Health Warnings on Packs in the United Kingdom and Norway Following the Introduction of Standardized Packaging

INTRODUCTION

Standardized packaging was phased in between May 2016 and May 2017 in the United Kingdom and July 2017 and July 2018 in Norway. In both countries, the health warnings on packs prior to standardized packaging being implemented were from the former Tobacco Products Directive library of warnings (text warnings covering 43% of the pack front and pictorial warnings covering 53% of the pack reverse). The warnings on packs, postimplementation, were from the current Tobacco Products Directive library of warnings (novel pictorial warnings covering 65% of the pack front and reverse) for the United Kingdom but unchanged in Norway.

AIMS AND METHODS

Longitudinal online surveys were conducted prior to standardized packaging (United Kingdom: April-May 2016; Norway: May-June 2017) and postimplementation (United Kingdom: September-November 2017 and May-July 2019; Norway: August-September 2018). We explored smokers' response to the on-pack warnings (salience, cognitive reactions, and behavioral reactions).

RESULTS

In the United Kingdom, noticing warnings on packs, reading or looking closely at them, thinking about them, thinking about the health risks, avoidant behaviors, forgoing cigarettes, and being more likely to quit due to the warnings significantly increased from waves 1 to 2, and then decreased from waves 2 to 3, but remained higher than at wave 1. In Norway, noticing warnings, reading or looking closely at them, thinking about them, thinking about the health risks, and being more likely to quit due to the warnings significantly decreased from waves 1 to 2; avoidant behaviors and forgoing cigarettes remained unchanged.

CONCLUSIONS

The inclusion of large novel pictorial warnings on standardized packs increases warning salience and effectiveness.

IMPLICATIONS

Two longitudinal online surveys in the United Kingdom and Norway explored the impact of standardized packaging on warning salience and effectiveness. That warning salience and effectiveness only increased in the UK postimplementation, where standardized packaging was implemented alongside new larger pictorial warnings on the pack front and reverse, and not in Norway, where standardized packaging was introduced but older smaller text warnings (pack front) and pictorial warnings (pack reverse) were retained, highlights the importance of removing full branding and introducing stronger warnings simultaneously.

Consumer Response to Standardized Tobacco Packaging in the United Kingdom: A Synthesis of Evidence from Two Systematic Reviews

Standardized packaging of tobacco products has now been fully implemented in 15 countries. However, there is limited evidence, apart from in Australia, on how consumers have responded to the policy. Two systematic reviews explored consumer, tobacco industry and retailer response to standardized packaging in the United Kingdom (UK), which became mandatory for cigarettes (factory-made and hand-rolled) from May 2017, following a twelve-month transition period. In the first review, electronic databases were searched for published primary research from January 2016 to February 2019. The second review used the same methods, with searches conducted between February 2019 and September 2020. The current study conducted a narrative synthesis of the findings exploring consumer response from these two systematic reviews. Eleven studies met the inclusion criteria. Studies examined consumer response to on-pack warnings (n=7 studies), appeal of packs and smoking (n=4), perceptions of harm (n=5), and behavioral responses (n=8). There was consistent evidence that standardized packaging was associated with increased warning salience and effectiveness, and reduced appeal. Findings were mixed with respect to whether standardized packs were associated with increased perceptions of harm. Standardized packaging was generally thought to deter never or occasional smokers. Standardized packaging was associated with increased thoughts of quitting during the transition period, but no study directly explored cessation or relapse prevention. Some smokers switched to cheaper cigarettes. Standardized packaging in the UK seems to be reducing the appeal of packaging and smoking and making warnings more salient, but the behavioral impact is unclear. More consumer research is needed to assess longer-term behavioral response.

Avoidance of tobacco health warnings? An eye-tracking approach

AIMS

Among three eye-tracking studies, we examined how cigarette pack features affected visual attention and self-reported avoidance of and reactance to warnings.

DESIGN

Study 1: smoking status × warning immediacy (short-term versus long-term health consequences) × warning location (top versus bottom of pack). Study 2: smoking status × warning framing (gain-framed versus loss-framed) × warning format (text-only versus pictorial). Study 3: smoking status × warning severity (highly severe versus moderately severe consequences of smoking).

SETTING

University of Bristol, UK, eye-tracking laboratory.

PARTICIPANTS

Study 1: non-smokers (n = 25), weekly smokers (n = 25) and daily smokers (n = 25). Study 2: non-smokers (n = 37), smokers contemplating quitting (n = 37) and smokers not contemplating quitting (n = 43). Study 3: non-smokers (n = 27), weekly smokers (n = 26) and daily smokers (n = 26).

MEASUREMENTS

For all studies: visual attention, measured as the ratio of the number of fixations to the warning versus the branding, self-reported predicted avoidance of and reactance to warnings and for study 3, effect of warning on quitting motivation.

FINDINGS

Study 1: greater self-reported avoidance [mean difference (MD) = 1.14; 95% confidence interval (CI) = 0.94, 1.35, P < 0.001, ηp2  = 0.64] and visual attention (MD = 0.89, 95% CI = 0.09, 1.68, P = 0.03, ηp2  = 0.06) to long-term warnings, but not for reactance (MD = 0.14, 95% CI = -0.04, 0.32, P = 0.12, ηp2  = 0.03). Increased visual attention to warnings on the upper versus lower half of the pack (MD = 1.8; 95% CI = 0.33, 3.26, P = 0.02, ηp2  = 0.08). Study 2: higher self-reported avoidance of (MD = 0.70; 95% CI = 0.59,0.80, P < 0.001, ηp2  = 0.61) and reactance to (MD = 0.37; 95% CI = 0.27, 0.47, P < 0.001, ηp2  = 0.34) loss-framed warnings but little evidence of a difference for visual attention (MD = 0.52; 95% CI = -0.54, 1.58, P = 0.30, ηp2  = 0.01). Greater visual attention, avoidance and reactance to pictorial versus text-only warnings (all Ps < 0.001, ηp2  > 0.25). Study 3: greater self-reported avoidance of (MD = 0.37; 95% CI = 0.25, 0.48, P < 0.001, ηp2  = 0.33) and reactance to (MD = 0.14; 95% CI = 0.05, 0.23, P = 0.003, ηp2  = 0.11) highly severe warnings but findings were inconclusive as to whether there was a difference in visual attention (MD = -0.55; 95% CI = -1.5, 0.41, P = 0.24, ηp2  = 0.02).

CONCLUSIONS

Subjective and objective (eye-tracking) measures of avoidance of health warnings on cigarette packs produce different results, suggesting these measure different constructs. Visual avoidance of warnings indicates low-level disengagement with warnings, while self-reported predicted avoidance reflects higher-level engagement with warnings.

Reactions to Standardized Cigarette Packs With Varying Structural Designs, and the Association With Smoking Susceptibility: A Postimplementation Cross-Sectional Survey With Never-Smoking Adolescents in Scotland

INTRODUCTION

From May 20, 2017, cigarettes in the United Kingdom must be sold in standardized (plain) packaging. We explore postimplementation reactions to standardized cigarette packaging among never-smokers in Scotland, whether reactions vary in relation to permitted variations in pack structure, and whether reactions are associated with susceptibility.

AIMS AND METHODS

A cross-sectional survey with 12-17-year-old never-smokers (n = 507) in Scotland, conducted November 2017-November 2018. Participants were shown one "regular" standardized cigarette pack (flip-top lid and straight-edged pack, similar to designs in Australia) and three standardized packs with varied pack structures (beveled-edges, slim pack, and shoulder box), which are permitted postimplementation in the United Kingdom. Participants rated each pack on eight five-point reaction measures (eg, attractiveness). Participants also indicated which pack, if any, they would choose. Smoking susceptibility was the outcome.

RESULTS

The mean reaction scores for all four packs were mostly negative, however the shoulder box was consistently rated less negatively than the regular, slim, or beveled-edge packs. Most participants (87%) said they would not select any of the four packs, although susceptible participants were more likely to select one than nonsusceptible participants (25% vs. 7%; χ 2 = 29.70; p < .001). For all four packs, not finding them off-putting was associated with susceptibility (Adjusted Odds Ratio range: 2.73-3.69), albeit only a minority of adolescents did not find each pack off-putting.

CONCLUSIONS

Adolescents have negative reactions to the standardized cigarette packs implemented in the United Kingdom, albeit permitted variations in structure can reduce the extent of negativity. Most reactions to standardized packaging had no association with susceptibility.

IMPLICATIONS

We provide the first empirical evidence that adolescents find the standardized cigarette packs implemented in the United Kingdom unappealing and that most pack reactions have no association with susceptibility among never-smokers, with the exception of the minority who did not think that they would put them off smoking. This suggests that the legislation is achieving one of its primary aims, to reduce the appeal of packaging. That permitted variations in pack structure (eg, shoulder boxes) somewhat reduce negative reactions suggests that the United Kingdom, and other countries introducing similar legislation, should ensure that all aspects of pack design are fully standardized.