Adolescents’ reactions to, and perceptions of, dissuasive cigarettes: a focus group study in Scotland

TL;DR: The cigarette stick, as the primary form of packaging and the object of consumption, is an increasingly important marketing tool for tobacco companies as mentioned in this paper. But it could also be used to communicat...

Abstract: The cigarette stick, as the primary form of packaging and the object of consumption, is an increasingly important marketing tool for tobacco companies. It could, however, also be used to communicat...

Summary

Introduction

• The cigarette stick, as the primary form of packaging and the object of consumption, is an increasingly important marketing tool for tobacco companies.
• Participants were shown four dissuasive cigarettes; one displaying the warning ‘Smoking kills’; one featuring the word ‘TOXIC’ and a skull and crossbones image; and two unattractively colored cigarettes (darker and lighter green).
• First, adolescents have been an important target market for tobacco 47 companies for decades (Ford, Moodie, MacKintosh, & Hastings, 2013; Hastings & 48 MacFadyen, 2000; Kotnowski & Hammond 2013; MacFadyen, Hastings & MacKintosh, 49 2001), and this continues to be the case through innovations such as capsule cigarettes (Moodie Page 3 of 31 URL: http:/mc.manuscriptcentral.com/cdep.
• This population is important given Page 4 of 31 URL: http:/mc.manuscriptcentral.com/cdep.

79 Design and sample

• 80 Semi-structured focus groups were conducted with 16-17 year olds in secondary schools in 81 Scotland (Stirling, West Lothian and North Ayrshire), between November 2017 (six months 82 after standardized packaging became mandatory) and November 2018 (18 months after 83 standardized packaging became mandatory).
• All groups were conducted in assigned rooms at the school, and were facilitated by DM.
• These 420 existing discussions about the potential negative effects of smoking, health warning salience 421 and potential exposure to ‘regular’ cigarettes (imitation cork filter and white paper casing), 422 may have influenced how participants responded in the dissuasive cigarettes section.

Full text

For Peer Review Only
Adolescents’ reactions to, and perceptions of, dissuasive
cigarettes: A focus group study in Scotland
Journal:
Drugs: Education, Prevention & Policy
Manuscript ID
CDEP-2019-0139.R1
Manuscript Type:
Original papers
Keywords:
Dissuasive Cigarettes, Tobacco Control, Focus Groups, Adolescents
URL: http:/mc.manuscriptcentral.com/cdep Email: Torsten Kolind, tk.crf@psy.au.dk
Drugs: Education, Prevention & Policy

For Peer Review Only
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ABSTRACT
The cigarette stick, as the primary form of packaging and the object of consumption, is an
increasingly important marketing tool for tobacco companies. It could, however, also be used
to communicate health messaging. We therefore explore adolescents’ perceptions of cigarettes
designed to dissuade smoking. Eight focus groups were conducted with 16-17 year-olds in
Scotland (n=36) between November 2017 and November 2018. Groups were segmented by
gender and smoking status. Participants were shown four dissuasive cigarettes; one displaying
the warning ‘Smoking kills’; one featuring the word ‘TOXIC’ and a skull and crossbones
image; and two unattractively colored cigarettes (darker and lighter green). For comparison,
participants were also shown a standard cigarette (white cigarette paper and imitation cork
filter). All four dissuasive cigarettes were considered less attractive and more harmful than the
standard cigarette, particularly among never-smokers. Some participants considered the green
cigarettes to be ugly, and the on-cigarette warnings to be embarrassing and off-putting.
Although reactions were mostly negative for all four dissuasive cigarettes, participants
considered the on-cigarette warnings more off-putting than the green cigarettes. Participants
did not generally believe that the dissuasive cigarettes would encourage cessation among
established smokers, but that they may deter uptake among young people.
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1 INTRODUCTION
2 As countries worldwide are increasingly adopting standardized tobacco packaging (six
3 countries to date), or introducing large pictorial health warnings on packaging (over 100
4 countries to date), the cigarette stick has assumed greater importance as a marketing tool
5 (Moodie, Hoek, Scheffels, Gallopel-Morvan & Lindorff, 2018; Moodie et al., 2019b). This is
6 perhaps best demonstrated by the significant global growth of ‘capsule’ cigarettes, which
7 contain one or more capsules in the filter that can be burst to change the flavor (Moodie,
8 Thrasher, Cho, Barnoya & Chaloupka, 2019). Other cigarette designs, such as longer and
9 slimmer cigarettes, are often perceived as stylish, particularly among female smokers
10 (Anderson, Glantz & Ling, 2005; Carpenter Wayne & Connolly, 2005; Doxey & Hammond,
11 2011). Tobacco companies have a long history of exploiting any gaps in tobacco control
12 legislation (WHO, 2009), and recent studies suggest that they are also doing so in markets with
13 standardized packaging, particularly via filter innovation (Moodie et al., 2018). For example,
14 aside from the introduction of new capsule brand variants in the United Kingdom (UK), one
15 tobacco company has introduced cigarettes with star shaped filter tips, named Sterling Dual
16 Star Edition (Figure 1).
17 [Figure 1]
18 The UK’s standardized packaging legislation requires cigarettes to have a white or
19 imitation cork filter and white paper casing (Department of Health, 2016; Moodie et al., 2019a).
20 The legislation also permits the display of a brand variant name in a standardized font just
21 below the filter, unlike in Australia and New Zealand where only an alphanumeric code can be
22 displayed (WHO, 2018). Although a ban on flavors in cigarettes, including flavor-changing
23 capsules, will take effect in May 2020, there have been no other attempts to control the design
24 of cigarettes in the UK (UK Government, 2016). There is a growing body of evidence,
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25 however, which suggests that ‘dissuasive cigarettes’ provide a further opportunity to promote
26 cessation and reduce uptake, and can transfer some of the health messaging from the secondary
27 packaging (e.g. pictorial and written health warnings on the outer packaging) onto the actual
28 object of consumption. Suggested dissuasive designs include unattractively colored cigarettes
29 (e.g. green and yellow) and on-cigarette warnings (e.g. average minutes of life lost from
30 smoking each cigarette, smoking kills, short and long-term harms, and financial and social
31 costs) (Drovandi, Teague, Glass, & Malau-Aduli, 2019a, 2019b; Gendall, Eckert, & Louviere,
32 2016; Hassan & Shiu, 2013; Moodie, Hiscock, Thrasher & Reid, 2018).
33 Dissuasive cigarettes are considered a low cost opportunity to reach consumers at the
34 point of consumption (Moodie, 2018). They are supported by research with consumers,
35 marketing experts, and healthcare practitioners, with findings suggesting that they reduce the
36 appeal of smoking and intentions to try cigarettes, and increase perceptions of harm and
37 cessation (Drovandi, et al., 2019a, 2019b, 2019c; Hassan & Shiu, 2013; Hoek, Scheffels,
38 Gallopel-Morvan & Lindorff, 2019; Gendall, Eckert & Louviere, 2016; Lund & Scheffels,
39 2018; Moodie, 2016; Moodie, MacKintosh, Gallopel-Morvan, Hastings, & Ford, 2016; Moodie
40 et al., 2017b; Moodie, Hiscock, Thrasher & Reid, 2018; Moodie, Hoek; Moodie et al., 2019b;
41 Moodie, Purves, McKell & Andrade, 2015). Recent research has also suggested that the ability
42 of dissuasive cigarettes to deter young people from smoking may be enhanced through the
43 inclusion of images (e.g. skull and crossbones warning symbol), rather than just a colour or
44 text warning (Gallopel-Morvan, Droulers, & Pantin-Sohier, 2019).
45 There are at least five reasons why adolescents are an important target audience for
46 dissuasive cigarettes. First, adolescents have been an important target market for tobacco
47 companies for decades (Ford, Moodie, MacKintosh, & Hastings, 2013; Hastings &
48 MacFadyen, 2000; Kotnowski & Hammond 2013; MacFadyen, Hastings & MacKintosh,
49 2001), and this continues to be the case through innovations such as capsule cigarettes (Moodie
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50 et al., 2019). Second, adolescents often obtain single cigarettes, commonly from friends or
51 family members, or by purchasing single cigarettes from retail outlets, including in countries
52 where this is not permitted (Donaghy et al., 2013; Tjelta, Ritchie & Amos, 2016; Wackowski
53 et al., 2017). In doing so, adolescents may therefore avoid the on-pack pictorial health warnings
54 or dissuasive influence of standardized packaging. Third, with prices continuing to increase in
55 many markets, single cigarettes are an increasingly affordable option for price-sensitive young
56 people. In the UK, for instance, tobacco was 30% less affordable in 2017 than in 2007 (NHS
57 Digital, 2018), and prices have continued to rise after standardized packaging was implemented
58 (Critchlow et al., 2019). Fourth, as of May 2017, a minimum pack size of 20 factory-made
59 cigarettes and 30 grams of rolling tobacco became mandatory across the EU, which has
60 removed the option of the smaller and more affordable pack sizes favored by young people
61 (e.g. 10 cigarettes or 12.5 grams of rolling tobacco) (Centre for Tobacco Control Research,
62 2012). Finally, research has found that the cigarette itself may be considered cool or stylish
63 among adolescents, particularly slim cigarettes, those with decorative designs, and capsule
64 cigarettes (Ford, Moodie, MacKintosh & Hastings, 2014; Moodie, Ford, MacKintosh &
65 Purves, 2014). It is therefore possible that this communicative power could be used to promote
66 health behaviors, while simultaneously removing an opportunity to promote tobacco brands
67 and smoking.
68 While previous research consistently suggests that dissuasive cigarettes reduce the appeal
69 of smoking, there remain gaps in the evidence. There is limited qualitative research with
70 adolescents, despite their importance as a target audience. In addition, few studies have
71 examined the influence of dissuasive cigarettes in a market where standardized packaging is
72 mandatory (Drovandi et al., 2019a, 2019b, 2019c), or the effect of including warning images
73 on the cigarette. In this study, we therefore explore perceptions of, and responses to, four
74 dissuasive cigarette designs among adolescents in Scotland. This population is important given
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Frequently asked questions

Q1. How many focus groups were conducted in Scotland?

80 Semi-structured focus groups were conducted with 16-17 year olds in secondary schools in 81 Scotland (Stirling, West Lothian and North Ayrshire), between November 2017 (six months 82 after standardized packaging became mandatory) and November 2018 (18 months after 83 standardized packaging became mandatory). 

Q2. What could have influenced the participants’ responses?

The cigarettes used in the study had no 416 branding, filter innovation (e.g. flavor-changing capsules) or filter tip design (e.g. star shaped 417 filters), which may have influenced participants’ responses. 

Q3. What was the common opinion of the female ever-smoker?

Several female ever-smokers thought that the green cigarettes, 259 in particular the lighter green, were embarrassing, ugly and unattractive, compared to the 260 standard cigarette e.g. 

Q4. What is the way to reduce the effect of smoking cigarettes?

Concerning the impact 388 on others, it was consistently suggested that the cigarettes would have the strongest impact on 389 deterring newer smokers and susceptible never-smokers, and the effect would be reduced 390 among established smokers. 

Q5. What was the reason the authors chose to study only four dissuasive designs?

The groups were subject to time constraints to fit in with the school schedule, which 408 somewhat limited their ability to probe participants in more detail, and was the reason the authors 409 explored only four dissuasive cigarette designs. 

Q6. What is the common sign of hazardous substances?

The inclusion of a skull and cross bones image – a universal 365 sign of hazardous substances – elicited associations with harm from other dangerous chemicals 366 (e.g. bleach). 

Q7. What is the way to describe the cigarette warnings?

I think the green ones are the worst out of the bunch, because with the kind of light colors 319 you think [cigarettes with white paper], aw it’s kind of normal, then you see something 320 that’s like a dark green stick and your like, ew, never mind (Male never-smoker)321322 Concerning smoking attitudes and behavior among other people, most participants believed 323 that the explicit on-cigarette warnings would likely dissuade non-smokers and newer smokers.