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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URL: http:/mc.manuscriptcentral.com/cdep Email: Torsten Kolind, tk.crf@psy.au.dk
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