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Journal ArticleDOI

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

02 Mar 2020-Drugs-education Prevention and Policy (Taylor & Francis)-Vol. 27, Iss: 6, pp 462-469

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...
Topics: Tobacco control (56%), Focus group (54%)

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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

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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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Citations
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Journal ArticleDOI
TL;DR: Reactions to, and trial intentions for, three ‘dissuasive’ cigarette designs among adolescents in Scotland are explored, finding that negative reactions were more likely among younger adolescents, never-smokers (vs ever smokers) and non-susceptible never-Smoking susceptibility (vs susceptible never- Smokers).
Abstract: Objectives There has been growing academic and policy interest in opportunities to decrease the appeal of cigarette sticks, such as making them an unattractive colour or requiring them to display a health warning. We therefore explored reactions to, and trial intentions for, three ‘dissuasive’ cigarette designs among adolescents in Scotland. Methods A cross-sectional survey with 12–17 year olds in Scotland (n=594) was conducted between November 2017 and November 2018. Participants were shown one ‘standard’ cigarette (imitation cork filter with white paper casing) and three dissuasive cigarettes: (1) a cigarette with the warning ‘smoking kills’; (2) a cigarette with the warning ‘toxic’ and a skull and cross-bones image and (3) a dark green cigarette. Participants rated each cigarette on nine five-point reaction measures (eg, appealing/unappealing or attractive/unattractive). A composite reaction score was computed for each cigarette, which was binary coded (overall negative reactions vs neutral/positive reactions). Participants also indicated whether they would try each cigarette (coded: Yes/No). Demographics, smoking status and smoking susceptibility were also measured. Results More participants had negative reactions to the dark green (93% of adolescents), ‘smoking kills’ (94%) and ‘toxic’ (96%) cigarettes, compared with the standard cigarette (85%). For all three dissuasive designs, Chi-square tests found that negative reactions were more likely among younger adolescents (vs older adolescents), never-smokers (vs ever smokers) and non-susceptible never-smokers (vs susceptible never-smokers). Most participants indicated that they would not try any of the cigarettes (range: 84%–91%). Conclusion Dissuasive cigarettes present an opportunity to further reduce the appeal of smoking among adolescents.

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TL;DR: The process of conducting a thematic analysis is illustrated through the presentation of an auditable decision trail, guiding interpreting and representing textual data and exploring issues of rigor and trustworthiness.
Abstract: As qualitative research becomes increasingly recognized and valued, it is imperative that it is conducted in a rigorous and methodical manner to yield meaningful and useful results. To be accepted ...

4,958 citations


Journal ArticleDOI
David Hammond1Institutions (1)
TL;DR: The evidence indicates that the impact of health warnings depends upon their size and design: whereas obscure text-only warnings appear to have little impact, prominent health warnings on the face of packages serve as a prominent source of health information for smokers and non-smokers, can increase health knowledge and perceptions of risk and can promote smoking cessation.
Abstract: Objective To review evidence on the impact of health warning messages on tobacco packages. Data sources Articles were identified through electronic databases of published articles, as well as relevant ‘grey’ literature using the following keywords: health warning, health message, health communication, label and labelling in conjunction with at least one of the following terms: smoking, tobacco, cigarette, product, package and pack. Study selection and data extraction: Relevant articles available prior to January 2011 were screened for six methodological criteria. A total of 94 original original articles met inclusion criteria, including 72 quantitative studies, 16 qualitative studies, 5 studies with both qualitative and qualitative components, and 1 review paper: Canada (n¼35), USA (n¼29) Australia (n¼16), UK (n¼13), The Netherlands (n¼3), France (n¼3), New Zealand (n¼3), Mexico (n¼3), Brazil (n¼2), Belgium (n¼1), other European countries (n¼10), Norway (n¼1), Malaysia (n¼1) and China (n¼1). Results The evidence indicates that the impact of health warnings depends upon their size and design: whereas obscure text-only warnings appear to have little impact, prominent health warnings on the face of packages serve as a prominent source of health information for smokers and non-smokers, can increase health knowledge and perceptions of risk and can promote smoking cessation. The evidence also indicates that comprehensive warnings are effective among youth and may help to prevent smoking initiation. Pictorial health warnings that elicit strongemotionalreactionsaresignificantlymoreeffective. Conclusions Health warnings on packages are among the most direct and prominent means of communicating with smokers. Larger warnings with pictures are significantly more effective than smaller, text-only messages.

819 citations


Journal ArticleDOI
TL;DR: Evidence is provided that the tobacco industry has conducted extensive research on female smoking patterns, needs and product preferences, and has intentionally modified product design for promotion of cigarette smoking among women.
Abstract: Aims To examine internal tobacco industry research on female smoking patterns and product preferences, and how this research has informed the design of female-targeted cigarettes and impacted smoking behavior among this target population. Design Research was conducted through a systematic web-based search of previously secret industry documents made publicly available through the 1998 Master Settlement Agreement. Findings This study provides evidence that the tobacco industry has conducted extensive research on female smoking patterns, needs and product preferences, and has intentionally modified product design for promotion of cigarette smoking among women. Cigarette manufacturers responded to changing female trends by focusing on social and health concerns as well as promoting dual-sex brands that also featured traditional female style characteristics. Conclusions Product features responsive to female-identified needs and preferences may contribute to differences in female smoking patterns. Assessment of female-targeted product differences should inform smoking cessation and prevention programs tailored to women. Overall, these findings underscore the need for further investigation of effects of targeting on smoking behavior, health outcomes and regulation of tobacco products by public health agencies.

130 citations


Journal ArticleDOI
03 Mar 2001-BMJ
TL;DR: Teenagers are aware of, and are participating in, many forms of tobacco marketing, and both awareness and participation are associated with current smoking status, suggesting that the current voluntary regulations designed to protect young people from smoking are not working, and that statutory regulations are required.
Abstract: Objectives: To examine young people's awareness of and involvement with tobacco marketing and to determine the association, if any, between this and their smoking behaviour. Design: Cross sectional, quantitative survey, part interview and part self completion, administered in respondents' homes. Setting: North east England. Participants: Stratified random sample of 629 young people aged 15 and 16 years who had “opted in” to research through a postal consent procedure. Results: There was a high level of awareness of and involvement in tobacco marketing among the 15–16 year olds sampled in the study: around 95% were aware of advertising and all were aware of some method of point of sale marketing. Awareness of and involvement with tobacco marketing were both significantly associated with being a smoker: for example, 30% (55/185) of smokers had received free gifts through coupons in cigarette packs, compared with 11% (21/199) of non-smokers (P<0.001). When other factors known to be linked with teenage smoking were held constant, awareness of coupon schemes, brand stretching, and tobacco marketing in general were all independently associated with current smoking status. Conclusions: Teenagers are aware of, and are participating in, many forms of tobacco marketing, and both awareness and participation are associated with current smoking status. This suggests that the current voluntary regulations designed to protect young people from smoking are not working, and that statutory regulations are required.

118 citations


Journal ArticleDOI
TL;DR: Psychosocial needs satisfaction can be communicated without reference to cigarettes or smoking, which may explain why partial advertising bans are ineffective and comprehensive bans on all forms of tobacco marketing are effective.
Abstract: Objective: To explore messages of psychosocial needs satisfaction in cigarette advertising targeting women and implications for tobacco control policy. Methods: Analysis of internal tobacco industry documents and public advertising collections. Results: Tobacco industry market research attempted to identify the psychosocial needs of different groups of women, and cigarette advertising campaigns for brands that women smoke explicitly aimed to position cigarettes as capable of satisfying these needs. Such positioning can be accomplished with advertising that downplays or excludes smoking imagery. As women's needs change with age and over time, advertisements were developed to reflect the needs encountered at different stages in women's lives. Cigarette brands for younger women stressed female camaraderie, self confidence, freedom, and independence; cigarette brands for older women addressed needs for pleasure, relaxation, social acceptability, and escape from daily stresses. Conclusions: Psychosocial needs satisfaction can be communicated without reference to cigarettes or smoking. This may explain why partial advertising bans are ineffective and comprehensive bans on all forms of tobacco marketing are effective. Counter-advertising should attempt to expose and undermine the needs satisfaction messages of cigarette advertising campaigns directed at women.

116 citations