Adult smokers' perceptions of cigarette pack inserts promoting cessation: a focus group study

The Role of e-Cigarette Packaging as a Health Communications Tool: A Focus Group Study With Adolescents and Adults in England and Scotland

INTRODUCTION

In the United Kingdom, e-cigarette and refill packaging must display a nicotine addiction warning. This study explored how this message is perceived, responses to alternative on-pack messages, and other options for using e-cigarette packaging to discourage youth and people who neither smoke nor use e-cigarettes while encouraging smokers to switch.

AIMS AND METHODS

Between August and September 2022, 16 focus groups (n = 70) were conducted to explore these topics with adolescents (n = 31, aged 11-17 years) and adults (n = 39, nonsmokers, smokers that use e-cigarettes, smokers that do not use e-cigarettes) in England and Scotland.

RESULTS

While several participants thought the current nicotine addiction warning could help increase awareness of nicotine addiction, most reported that it failed to capture attention and was not a deterrent. Alternative messages shown on packs (about harm, toxicity, wellness, litter, or relative risk) received mixed responses. Relative risk messages were perceived as most beneficial for smokers switching but also thought to potentially encourage uptake among nonsmokers. Some participants considered certain harm and toxicity messages to potentially dissuade uptake. Participants proposed several ideas to reduce the appeal of e-cigarette packaging and devices to deter youth uptake, including more prominent warnings, standardized packaging, and devices that are plain or include health messages.

CONCLUSIONS

Packaging can play a crucial role in communicating product and health messages to different consumer groups. Further consideration of how packaging and labeling can meet the needs of non-nicotine users while simultaneously reaching those who may benefit from using e-cigarettes to stop smoking is warranted.

IMPLICATIONS

While some viewed the nicotine addiction warning required on e-cigarettes and refill packaging in the United Kingdom as helpful in raising awareness of nicotine addiction, it did not resonate with most of our sample of adolescents and adults. The findings suggest that e-cigarette packaging could be better used to encourage smokers to switch to a less harmful alternative, with relative risk messages showing promise. Furthermore, strengthening on-pack messaging (eg increasing salience and rotating messages) and reducing the appeal of packaging (eg drab colors) and devices (eg including warnings) may help increase awareness of e-cigarette harms while deterring use among adolescents and nonsmokers.

Tobacco packaging littering behaviours among Australian adults who smoke: findings from cross-sectional and observational studies to inform the implementation of cigarette pack inserts

BACKGROUND

Cigarette pack inserts are small cards that highlight the benefits of quitting and promote use of smoking cessation support. With evidence from Canada that they increase self-efficacy to quit, quit attempts and sustained cessation, inserts are set to be introduced into tobacco packs sold in Australia. Some people have expressed concern that the introduction of inserts may create more litter if incorrectly disposed of on pack-opening.

METHODS

We used a cross-sectional survey to assess self-reported pack-opening location and waste disposal behaviours of people who smoke to determine the potential for littering to occur when tobacco packs are first opened. We also visited a sample of supermarkets, convenience stores and tobacconists located throughout Melbourne, Australia, to discreetly collect observational data regarding pack-opening and waste disposal behaviours at the point of purchase.

RESULTS

Among participants in the cross-sectional study (N=369), the majority reported that they opened their most recent tobacco pack at home (70.9%) where there is little potential for littering, and this proportion was higher among those who smoke daily (78.6%) and men (74.3%). Self-reported behaviours that could result in littering were rare; 1.0% reported that they left tobacco packaging where they believed it would be collected for disposal. Of the 128 individuals observed at the point of purchase across 46 stores, 96.9% did not open the tobacco product immediately after purchase. One incident of littering was observed (0.8%).

CONCLUSION

The introduction of cigarette pack inserts in Australia is unlikely to create a substantial amount of additional litter.

Combining Inserts With Warning Labels on Cigarette Packs to Promote Smoking Cessation: A 2-Week Randomized Trial

BACKGROUND

Cigarette pack inserts with messages on cessation benefits and advice are a promising labeling policy that may help promote smoking cessation.

PURPOSE

To assess insert effects, with and without accompanying pictorial health warning labels(HWLs), on hypothesized psychosocial and behavioral outcomes.

METHODS

We conducted a 2 × 2 between-subject randomized trial (inserts with efficacy messages vs. no inserts; large pictorial HWLs vs. small text HWLs), with 367 adults who smoked at least 10 cigarettes a day. Participants received a 14-day supply of their preferred cigarettes with packs modified to reflect their experimental condition. Over 2 weeks, we surveyed participants approximately 4-5 times a day during their smoking sessions, querying feelings about smoking, level of worry about harms from smoking, self-efficacy to cut down on cigarettes, self-efficacy to quit, hopefulness about quitting, and motivation to quit. Each evening, participants reported their perceived susceptibility to smoking harms and, for the last 24 hr, their frequency of thinking about smoking harms and cessation benefits, conversations about smoking cessation or harms, and foregoing or stubbing out cigarettes before they finished smoking. Mixed-effects ordinal and logistic models were estimated to evaluate differences between groups.

RESULTS

Participants whose packs included inserts were more likely than those whose packs did not include inserts to report foregoing or stubbing out of cigarettes (OR = 2.39, 95% CI = 1.36, 4.20). Otherwise, no statistically significant associations were found between labeling conditions and outcomes.

CONCLUSIONS

This study provides some evidence, albeit limited, that pack inserts with efficacy messages can promote behaviors that predict smoking cessation attempts.

A mixed-method study of perceptions of cigarette pack inserts among adult smokers from New York and South Carolina exposed as part of a randomized controlled trial

While many countries require prominent pictorial health warning labels (PHWLs) on the outside of cigarette packs to communicate the harms of smoking, there is evidence that cigarette pack inserts that contain efficacy messages may enhance the effectiveness of PHWLs. The US Food and Drug Administration (FDA) has regulatory authority to communicate with smokers through inserts. While current labeling regulations do not require inclusion of inserts, the FDA could implement them in the future. This study assesses US smokers' perceptions of cigarette package inserts at the conclusion of a two-week randomized trial on cigarette labeling where half of participants were exposed to insert messages (two response-efficacy messages and two self-efficacy messages) in their packs. Participants (n = 359) completed a 30- to 60-min interview with both quantitative and qualitative assessments, including measures of recall and perceived message effectiveness (PME) for specific inserts. Correlates of recall and PME were estimated using mixed-effects regression models. Qualitative responses to PME items were analyzed using thematic analysis. Response-efficacy messages had higher PME and recall than self-efficacy messages. People had diverse responses to the inserts, including that they were positive, thought-provoking, and helpful. Reactions to and perceptions of the inserts indicate potential benefits of integrating efficacy messages into labeling policies.

Reasons for Using Roll-Your-Own Tobacco and Perceptions of Health-Promoting Pack Inserts: A Focus Group Study with Roll-Your-Own Tobacco Smokers in Scotland

INTRODUCTION

Use of roll-your-own (RYO) tobacco is increasing in most regions, but few qualitative studies have explored why RYO smokers use this product, and no study has considered their views of health-promoting pack inserts.

METHODS

Eight focus groups were conducted with 18-35-year-old RYO smokers (n = 50) in Greater Glasgow (Scotland) in February-March 2020 to explore reasons for using RYO and perceptions of health-promoting inserts. Participants were shown four inserts adapted from those required in cigarette packs in Canada, with all encouraging quitting, and two RYO-specific inserts explaining that RYO is not less harmful than cigarettes.

RESULTS

Lower price, better taste, the pleasure of rolling and ability to customize roll-ups, and the belief that RYO was less harmful than cigarettes were drivers for use. There were mixed perceptions of the extent to which inserts would capture attention if included in RYO packs. The positive messaging used on the Canadian inserts was considered motivational and inspirational, and contrasted with the on-pack warnings. The messaging on the RYO inserts, in comparison, was viewed unfavorably and generally dismissed. Participants, most of whom were not interested in quitting, did not feel that inserts would lead them to change their smoking behavior. However, some felt that the Canadian inserts could be helpful for those thinking about quitting and young people contemplating smoking.

CONCLUSIONS

Inserts with positive messaging about quitting, rather than messaging explicating the harms of RYO, were preferred by RYO smokers. What, if any, RYO-specific messaging resonates with RYO smokers merits further attention.

IMPLICATIONS

Aside from price, taste, and the pleasure associated with rolling and ability to individualize roll-ups, the erroneous belief that RYO is less harmful than cigarettes was a key reason for use. While inserts with positive messaging about quitting, as used on the Canadian inserts, were viewed as potentially helpful, inserts that challenged the idea that RYO was not less harmful than cigarettes were generally dismissed. Research is needed to understand what types of RYO-specific messaging could most effectively be used on inserts, or indeed in other media, to challenge the misperceptions that many RYO smokers hold.

'It brings light to what you really put into your body': a focus group study of reactions to messages about nicotine reduction in cigarettes

OBJECTIVE

In 2017, the US Food and Drug Administration (FDA) announced a proposed regulation to lower nicotine in cigarettes to minimally addictive levels to help smokers quit. We sought to explore effective message strategies communicating about nicotine reduction in cigarettes across the different key audiences that the regulation is most likely to influence.

METHODS

We designed four types of messages: efficacy messages, risk messages, a message about alternative sources of nicotine and a compensation message. Sixteen virtual focus groups were conducted in Atlanta and San Francisco in April-May 2020. Data were analysed in NVivo 12.0 using a thematic analysis approach.

FINDINGS

Exclusive smokers were receptive to both efficacy messages and risk messages. Dual users were the only group that was open to resorting to alternative sources of nicotine. Former smokers were critical of these messages as promoting the new kinds of cigarettes and potentially encouraging initiation and relapse of smoking. Non-smokers felt that efficacy messages downplayed the risks of smoking and did not scare people away from smoking. Presenting information that very low nicotine cigarettes (VLNCs) still contain harmful chemicals made smokers question continued smoking in the absence of nicotine and view VLNCs as harmful.

CONCLUSIONS

Messages communicating about nicotine reduction in cigarettes might help to motivate smokers to quit and can correct the misperceptions that VLNCs are less harmful. The FDA should consider specific target audiences and use different messages that complement each other in communicating about this regulation.

Optimising tobacco control campaigns within a changing media landscape and among priority populations

Reviews published over the past decade confirm tobacco control campaigns can be effective for influencing adult and youth tobacco use behaviours, with strengthening evidence for high cost-effectiveness. Evidence is also accumulating for positive campaign effects on interpersonal discussions, social norms and policy support that can help motivate and sustain quitting and reduce uptake. Research needs over the next decade centre on the rapidly changing media environment and the equity of campaign effects among high smoking prevalence communities. The field needs specific evidence on: how to measure total campaign reach and frequency across the diverse range of media platforms and channels; the optimum mix of traditional, digital and social media to achieve behaviour change, especially among high smoking prevalence communities; the relative reach and impact of the wide variety of integrated, digital and social media message delivery methods; the relative effectiveness of messages that aim to build capacity to quit and optimum methods for combining motivational and capacity-building messages, especially for high prevalence groups who face additional barriers to staying quit; the ongoing effectiveness of traditional versus new versions of messages highlighting tobacco industry practices; the influence of e-cigarette use on tobacco control campaign effects; and the effectiveness of different types of campaigns aiming to prevent e-cigarette uptake and motivate e-cigarette cessation. Research is also needed to investigate the potential for campaigns to influence the public's understanding and support for endgame tobacco control policies and for campaign elements that may influence the social and environmental contexts surrounding smokers that support and maintain behaviour change.

Protocol for creating new warnings on cigarette packs and evaluating their efficacy in a randomised experimental setting

INTRODUCTION

Tobacco smoking is one of the leading causes of preventable death. This is not inevitable as tobacco control tools have become more powerful and more effective. Among these, warnings on cigarette packs have proven to be somewhat effective. Our objective is to increase the efficacy of antismoking warnings by using innovative psychological approaches and to create an experimental setting for the evaluation of these new warnings based on behavioural indicators.

METHODS AND ANALYSIS

First, we created new warnings based on three categories of motivational leverage and on harm reduction. New warnings with innovative texts and pictures were designed for each category and inserted on plain packs. We will then use standard indicators to compare their effect to that of control packs: plain pack without warning, plain pack with conventional warning and branded pack with conventional warning. Second, the novelty of our approach will consist in designing an experimental protocol that uses monetary incentives to evaluate the effect of warnings. Subjects will be able to 'sacrifice' part of their participation defrayal to purchase a good whose subjective value is related to one's attitude towards smoking. These monetarily incentivised measures are designed to assess smokers' immediate/mid-term intention to quit and non-smokers' aversion to smoking. In both cases, the monetary amounts individuals accept to sacrifice may be a more reliable measure than declarative responses, which may be distorted by several hypothetical biases. In the end, we should be able to robustly measure the impact of our new warnings between intervention and control groups by using both traditional indicators and our new monetarily incentivised measure.

ETHICS AND DISSEMINATION

The ethics committee of the Groupement des Hôpitaux de l'Institut Catholique de Lille approved the research protocol on 5 July 2019 (CIER 2019-22). Results will be presented at scientific meetings and published.

Smokers' Perceptions of Cigarette Packaging With Audio Warning Messages: A Focus Group Study in Scotland

AIMS

The use of audio pack cues or messages is a recent trend in packaging design. There is scope to use audio technology to communicate health and cessation messages via cigarette packaging. We explored how smokers responded to cigarette packs which played audio health messages.

METHODS

Twenty focus groups were conducted in Scotland in 2015 with smokers (n = 120) segmented by age (16-17, 18-24, 25-35, 36-50, >50), gender and social grade. Perceptions of cigarette packs which played audio warnings were explored, with four messages used: (1) a cessation message with a quitline number, (2) mortality message, (3) fertility message, and (4) message about ageing skin.

RESULTS

Audio warnings were thought to increase message impact, particularly among younger smokers, as they would be hard to ignore or avoid, and repetition may lead to the messages being memorized. The warnings were considered annoying or embarrassing, and participants suggested they may discard the packs and use alternative storage. Some participants suggested that the audio warnings were off-putting and may alter their smoking behavior, with the mortality message deemed most effective and was considered relatable and felt personal. Older smokers were least likely to believe that audio warnings would affect their smoking behavior, although some thought that they may enhance cessation attempts among smokers seeking to quit, and could deter new or potential smokers, for example, young people.

CONCLUSIONS

Cigarette packs with audio messaging may have a role to play, now or in the future, as a novel way of communicating health and cessation information.

IMPLICATIONS

There is a lack of research exploring smokers' perceptions of cigarette packs which play audio health messages. This focus group study provides an understanding of smokers' immediate responses to cigarette packs which played a short health message when opened. Smokers generally viewed them as annoying or embarrassing, and some suggested the use of alternative storage. Audio warnings were thought to increase message salience, memorability, and impact, for younger smokers in particular, and some suggested that they be off-putting for themselves or others.

Roll-your-own smokers' reactions to cessation-efficacy messaging integrated into tobacco packaging design: a sequential mixed-methods study

BACKGROUND

Although loss-framed pictorial warning labels (PWLs) have increased knowledge of the health harms caused by smoking, they may elicit maladaptive responses among some smokers who have tried repeatedly, yet unsuccessfully, to quit smoking. However, research suggests that maladaptive responses may diminish if warnings are complemented with efficacy enhancing messages. Therefore, we explored New Zealand (NZ) adult roll-your-own (RYO) loose tobacco smokers' reactions to self-efficacy and response efficacy messages integrated into the RYO packaging structure and designed to complement PWLs.

DESIGN

We used a sequential mixed-methods design. In-depth interviews gauged participants' (n=22) acceptance of the designs and informed stimuli development for an online survey. The survey (n=785) compared self-efficacy and response efficacy designs to standard Quitline information, and examined agreement with emotions, beliefs and projected behaviours associated with quit attempts.

RESULTS

Our findings suggest placing gain-framed response efficacy messages on the inside flap of RYO tobacco pouches may stimulate specific emotional reactions, beliefs and projected behaviours associated with future quit attempts more effectively than NZ's status quo Quitline information. Those potentially more likely to benefit include smokers who have high baseline response efficacy and who intend to make a quit attempt.

CONCLUSIONS

Integrating cessation-related messaging within tobacco packaging could be a high reach, just-in-time micro-intervention at the point of decision-making. Enhanced efficacy messages could complement and enhance PWLs, and support quitting among groups where smoking prevalence is especially high.

Plain packaging: legislative differences in Australia, France, the UK, New Zealand and Norway, and options for strengthening regulations

By July 2018, five countries (Australia, France, the UK, New Zealand and Norway) had fully implemented plain (standardised) packaging. Using government documents, we reviewed the key legislative differences between these five countries to identify best practice measures and potential lacuna. We then discuss how governments planning to introduce plain packaging could strengthen their legislation. Differences between countries include the terminology used (either 'plain', 'standardised' or 'plain and standardised'), products covered and transition times (ranging from 2 to 12 months). Myriad differences exist with respect to the packaging, including the dimensions (explicitly stated for height, width and depth vs minimum dimensions for the health warnings only), structure (straight-edged flip-top packs vs straight, rounded and bevelled-edged flip-top packs and shoulder boxes) and size (minimum number of cigarettes and weight of tobacco vs fixed amounts) and warning content (eg, inclusion of a stop-smoking web address and/or quitline displayed on warnings on one or both principal display areas). Future options that merit further analysis include banning colour descriptors in brand and variant names, allowing pack inserts promoting cessation and permitting cigarettes that are designed to be dissuasive. Plain packaging legislation and regulations are divergent. Countries moving towards plain packaging should consider incorporating the strengths of existing policies and review opportunities for extending these. While plain packaging represents a milestone in tobacco-control policy, future legislation need not simply reflect the past but could set new benchmarks to maximise the potential benefits of this policy.

Extending health messaging to the consumption experience: a focus group study exploring smokers' perceptions of health warnings on cigarettes

Introduction: While most countries require health warnings on cigarette packs, the Scottish and Canadian Governments are considering requiring health warnings on cigarette sticks. Methods: Twenty focus groups were conducted in Glasgow and Edinburgh (Scotland) with smokers (n = 120) segmented by age (16-17, 18-24, 25-35, 36-50, >50), gender and social grade, to explore perceptions of cigarettes displaying the warning 'Smoking kills' on the cigarette paper and any demographic differences in how smokers responded to these. Results: A warning on each cigarette was thought to prolong the health message, as it would be visible when a cigarette was taken from a pack, lit, left in an ashtray, and with each draw, and make avoidant behavior more difficult. That it would be visible to others was perceived as off-putting for some. It was felt that a warning on each cigarette would create a negative image and be embarrassing. Within several female groups they were viewed as depressing, worrying and frightening, with it suggested that people would not feel good smoking cigarettes displaying a warning. Within every group there was mention of warnings on cigarettes potentially having an impact on themselves, others or both. Some, mostly younger groups, mentioned stubbing cigarettes out early, reducing consumption or quitting. The consensus was that they would be off-putting for young people, nonsmokers and those starting to smoke. Conclusions: Including a warning on each cigarette stick is a viable policy option and one which would, for the first time, extend health messaging to the consumption experience.

Young adult smokers' perceptions of plain packs, numbered packs and pack inserts in Turkey: a focus group study

INTRODUCTION

The Turkish Government's 'National Tobacco Control Program 2015-2018' included plans to introduce plain packaging and also a ban on brand names on cigarette packs, allowing only assigned numbers on packs. We explored perceptions of these proposed measures, and also pack inserts with cessation messages, another novel way of using the packaging to communicate with consumers.

METHODS

Eight focus groups were conducted with 47 young adult smokers in Manisa and Kutahya (Turkey) in December 2016. Participants were shown three straight-edged plain cigarette packs, as required in Australia, and then three bevelled-edged plain packs, as permitted in the UK. They were then shown plain packs with numbers rather than brand names, and finally three pack inserts with messages encouraging quitting or offering tips on how to do so. Participants were asked about their perceptions of each.

RESULTS

Plain packs were considered unappealing and off-putting, although the bevelled-edged packs were viewed more favourably than the straight-edged packs. Numbered packs were thought by some to diminish the appeal created by the brand name and potentially decrease interest among never smokers and newer smokers. Pack inserts were thought to have less of an impact than the on-pack warnings, but could potentially help discourage initiation and encourage cessation.

CONCLUSIONS

That bevelled-edged plain packs were perceived more positively than straight-edged plain packs is relevant to countries planning to introduce plain packaging. The study provides a first insight into smokers' perceptions of a ban on brand names, which was perceived to reduce appeal among young people.

Perceptions of cigarette pack inserts promoting cessation and dissuasive cigarettes among young adult smokers in the UK: a cross-sectional online survey

OBJECTIVES

To explore young adult smokers' perceptions of cigarette pack inserts promoting cessation and cigarettes designed to be dissuasive.

DESIGN

Cross-sectional online survey.

SETTING

UK.

PARTICIPANTS

The final sample was 1766 young adult smokers, with 50.3% male and 71.6% white British. To meet the inclusion criteria, participants had to be 16-34 years old and smoke factory-made cigarettes.

PRIMARY AND SECONDARY OUTCOME MEASURES

Salience of inserts, perceptions of inserts as information provision, perceptions of inserts on quitting, support for inserts and perceived appeal, harm and trial of three cigarettes (a standard cigarette, a standard cigarette displaying the warning 'Smoking kills' and a green cigarette).

RESULTS

Half the sample indicated that they would read inserts with three-fifths indicating that they are a good way to provide information about quitting (61%). Just over half indicated that inserts would make them think more about quitting (53%), help if they decided to quit (52%), are an effective way of encouraging smokers to quit (53%) and supported having them in all packs (55%). Participants who smoked factory-made cigarettes and other tobacco products (compared with exclusive factory-made cigarette smokers), had made a quit attempt within the last 6 months (compared with those that had never made a quit attempt) or were likely to make a successful quit attempt in the next 6 months (compared with those unlikely to make a quit attempt in the next 6 months) were more likely to indicate that inserts could assist with cessation. Multivariable logistic regression modelling suggested that compared with the standard cigarette, the cigarette with warning (adjusted OR=17.71; 95% CI 13.75 to 22.80) and green cigarette (adjusted OR=30.88; 95% CI 23.98 to 39.76) were much less desirable (less appealing, more harmful and less likely to be tried).

CONCLUSIONS

Inserts and dissuasive cigarettes offer policy makers additional ways of using the pack to reduce smoking.

Assessing Smoking Cessation Messages with a Discrete Choice Experiment

Objectives

Our aim was to identify message characteristics for cigarette pack inserts that aim to help smokers quit.

Methods

US adult smokers from an online consumer panel (N = 665) participated in a discrete choice experiment with a 2x2x2x2x4 within-subjects balanced incomplete block design, manipulating: image (vs no image), text type (testimonial vs informational), cessation resource information (vs none), call to action (vs none), and message topic (well-being, financial benefit, cravings, social support). Participants evaluated 9 choice sets, each with 4 inserts, selecting: (1) the most and least helpful for quitting; and (2) the most and least motivating to quit. Linear models regressed choices on insert characteristics, controlling for sociodemographics and smoking-related variables. We assessed interactions between insert characteristics and smoker attributes (ie, education, quit intention, self-efficacy).

Results

Inserts were most helpful and motivating when they included an image, provided cessation resource information, or referenced well-being and financial benefits. Significant interactions indicated that inserts with cessation resource information were relatively more helpful and motivating among smokers with low self-efficacy, an intention to quit, or lower education.

Conclusion

Cigarette pack inserts with imagery and cessation resource information may be particularly effective in promoting smoking cessation.

Adolescent tobacco coupon receipt, vulnerability characteristics and subsequent tobacco use: analysis of PATH Study, Waves 1 and 2

OBJECTIVES

We examine adolescent receipt of tobacco coupons and subsequent tobacco use.

METHODS

Data were from the Population Assessment of Tobacco and Health (PATH) Study (2013-2015). We identified correlates of coupon receipt at Wave 1 (youth sample age 12-17 ; n = 13 651) including demographics, additional vulnerability factors that may place youth at risk of tobacco use and correlates of coupon receipt by channel. We examined associations of Wave 1 coupon receipt with Wave 2 tobacco use using weighted multivariable models.

RESULTS

Overall, 7.6% of US youth received tobacco coupons in the 6 months before Wave 1. Coupon recipients were more likely to be women, living outside urban areas, living with a tobacco user, current and former (vs never) tobacco users, having high internalising mental health symptoms and having a favourite tobacco advertisement. Coupons were received primarily through direct mail (56%), product packs (28%) and online (25%). Never tobacco users at Wave 1 who received coupons were more likely to be ever users at Wave 2 (adjusted OR (aOR)=1.42; 95% CI 1.06 to 1.91). Coupon recipients were more likely to use a new tobacco product between waves (aOR=1.67; 95% CI 1.18 to 2.36) and report past 30-day tobacco use at Wave 2 (aOR=1.81; 95% CI 1.31 to 2.49).

CONCLUSIONS

One in 13 US youth (7.6%) received coupons. Vulnerable youth had the greatest odds of coupon receipt. Coupon recipients had greater odds of tobacco use among never users, trying a new tobacco product and current use. Coupon bans, limits on youth coupon exposure, stronger age verification, pack inserts or restricting coupon redemption may help reduce tobacco use among adolescents, particularly for those at greatest risk.

A systematic review of smoker and non-smoker perceptions of visually unappealing cigarette sticks

INTRODUCTION

Cigarette stick appearance can significantly contribute to perceptions of cigarette taste, harm, and appeal, and may be modified to reduce positive perceptions of cigarettes and other tobacco products. A systematic review was conducted to investigate how smokers and non-smokers identify cigarettes as being attractive or unattractive, and the resulting perceptions of cigarette appeal, perceived harm, and impact on quit intentions.

METHODS

Eligible articles were identified using database searches conducted with a date range of January 1990 to May 2017 in PubMed, CINAHL, PsycINFO, Google Scholar and Web of Science. Articles were included if they evaluated participant (any smoking status) perceptions of visual cigarette stick attributes. We identified studies describing visual attributes of cigarette sticks and the resulting perceptions of participants. Changes or differences in quitting intentions, cigarette appeal, perceptions of taste, and cigarette harm, and the likelihood of smoking uptake were recorded. Data were grouped into two main categories: those of physical cigarette design, and those including health messages on cigarette sticks.

RESULTS

Of the 950 identified non-duplicated records, 9 matched the eligibility criteria. These studies were all conducted in developed countries, and largely enrolled adolescent and young adult smokers and non-smokers. Slim, lighter coloured and branded cigarettes were favoured over longer, broader, or darker coloured cigarettes, and those without any branding or embellishments. Health warnings including ‘Minutes of life lost’, ‘Smoking kills’, and the names of carcinogenic constituents in cigarettes, reduced cigarette attractiveness and increased participant quit intentions.

CONCLUSIONS

Cigarette appeal and resulting smoking behaviours can be influenced by several visual attributes of individual cigarettes. Unappealing visual attributes of cigarette sticks, including modifications to the size and colour of cigarettes, and the inclusion of health warnings on cigarette sticks may serve as an effective tobacco control method, potentially leading to a reduction in tobacco use.