Those who smoke cigarettes with individual public health warnings could reduce smoking

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Health warnings printed on individual cigarettes could play a key role in reducing smoking, according to new research from the University of Stirling.

Experts from Stirling’s Institute of Social Marketing examined smokers’ perceptions of the warning ‘Smoking kills’ on individual cigarettes – as opposed to the message only appearing on packs.

The team, led by Dr. Crawford Moodie, found that smokers felt the innovative approach has the potential to discourage smoking among young people, those starting to smoke, and non-smokers.

Participants felt that a warning on each cigarette would prolong the health message, as it would be visible when taken from a pack, lit, left in an ashtray, and with each draw, thus making avoidant behavior more difficult.

The visibility of the warning to others was perceived as off-putting for some because it was associated with a negative image.

Within several female groups, the warnings were viewed as depressing, worrying and frightening; with it suggested that people would not feel good smoking cigarettes displaying a warning.

The possibility of warnings on cigarettes is included in the Scottish Government’s tobacco-control action plan, ‘Raising Scotland’s Tobacco-free Generation’.

It suggests changes to “color, composition and/or warning messages on each stick”.

The Canadian Government has also held a consultation on the proposals and published their findings earlier this month [August 2019].

The Stirling study canvassed the opinion of 120 smokers, aged 16 and over, in 20 focus groups held in Edinburgh and Glasgow in 2015.

Within every group, participants felt that warnings on individual cigarettes would potentially have an impact on themselves or others.

“The consensus was that individual cigarettes emblazoned with warnings would be off-putting for young people, those starting to smoke, and non-smokers,” Dr Moodie said.

“This study suggests that the introduction of such warnings could impact the decision-making of these groups.

It shows that this approach is a viable policy option and one which would – for the first time – extend health messaging to the consumption experience.”

This shows the cigarette with the warnings written on them

Image of warnings on cigarettes. The image is credited to University of Stirling.

The research – funded by Cancer Research UK – also involved: Dr Rachel O’Donnell, Joy Fleming, Dr Richard Purves and Jennifer McKell (all of the ISM at Stirling), and Fiona Dobbie, of the Usher Institute of Population Health at the University of Edinburgh.

Professor Linda Bauld, Cancer Research UK’s prevention expert, said: “Too many young people are still taking up smoking.

Government anti-smoking campaigns and tax rises on cigarettes remain the most effective methods to stop young people starting smoking, but we need to continue to explore innovative ways to deter them from using cigarettes to ensure that youth smoking rates continue to drop.

“This study shows that tactics like making the cigarettes themselves unappealing could be an effective way of doing this.”


Tobacco control measures such as educational campaigns and tobacco packaging health warnings have led to significant declines in tobacco use, and its attributable morbidity and mortality.1 Adolescents and young adults are a key target group for these interventions, as the majority of adult smokers start using tobacco products and developed nicotine addiction during these formative years.2 

High-school finishers who enroll in college are presented with a unique set of challenges, stressors, and experiences, including exposure to the use of alcohol, tobacco, and other drugs.3 

Nearly 4,000 adolescents smoke their first cigarette each day in America, and 14% of 18–24 year olds smoke at least weekly in Australia.

Therefore, ensuring that this vulnerable age group are dissuaded from tobacco products, and strengthening their health-promoting behaviors is essential in improving the health of future generations.46

Health-promoting behaviors are influenced by several factors, described within multiple theories, such as the Health Belief Model (HBM).7 

The HBM describes health-related behaviors as being influenced by six major elements, encompassing an individual’s perceptions of a behavior and its relationship to good or poor health, modifying factors (including personal and social), and triggers for taking action.8 

Within the context of smoking, the HBM describes that a person’s perceived susceptibility (element 1) and severity (element 2) of known smoking-related consequences contributes to their belief of how smoking can harm their own health.

This belief and their subsequent behaviors are also influenced by their perceived benefits (element 3) (both for smoking and not smoking) and perceived barriers (element 4) (both in quitting smoking and actively smoking).

These factors may lead to changes in health behavior through a combination of a person’s cue to action (element 5) and perceived self-efficacy (element 6) in performing these actions.7,911 

The HBM was selected as a theoretical framework for this research due to its multi-faceted construction (six major elements), all of which are addressed to some degree in current tobacco control interventions.

Health warnings therefore play an essential role in ensuring the accurate portrayal of comprehensible negative consequences of tobacco use, and actionable messages to support quitting.

In Australia, text and pictorial warnings cover the majority of the packaging surface and are rotated to prevent image wear-out, and are supplemented by plain (standardized) packaging.

These interventions have demonstrated effectiveness in reducing tobacco use, through minimizing the appeal of tobacco packaging, increasing viewer awareness of the dangers associated with tobacco use, and increasing smoker quit attempts.1215 However, recent research has identified these warnings are subject to diminished effectiveness over time, due to repetition of viewing and a loss of shock value.12,16 

There are also issues with the vulnerable population of younger smokers not identifying with the fatal and debilitating diseases portrayed on cigarette packs in the same manner as older adults.17 

This lack of a connection between smoking and smoking-attributable diseases amongst this age group results in perceived self-exemption from these consequences and allows rationalization for continued smoking.18,19

As a potential method for addressing these shortcomings, a novel method for communicating the risks of tobacco is the use of health warnings and messages on individual cigarette sticks.

The small number of exploratory studies published in 2015 and 2016 primarily gathered the perceptions of adolescents and young adults.2026

A systematic review of these studies identified that health warnings such as “Smoking Kills” and the “Minutes of Life Lost” on cigarettes reduced cigarette appeal, affected viewer perceptions of the harm caused by cigarettes, increased quit intentions, and reduced the likelihood of smoking uptake.27 

An additional study that interviewed packaging and marketing experts also found that the cigarette-stick warnings were considered a powerful deterrent.28 Two recent quantitative studies, one amongst school-aged students (aged 15–18 years) and one amongst university students, both found a trend of desensitization towards current packaging warnings, and a general acceptance towards cigarette-stick warnings, particularly those depicting novel and shorter-term warnings.29,30

However, these previous quantitative studies do not provide in-depth explanations as to why cigarette-stick warnings are perceived as they are. In the current study, we aimed to build upon recent findings, and identify which health warnings are perceived as the most effective by young adults, and why.

To achieve reductions in smoking prevalence amongst young adults, they must understand their personal susceptibility to a sufficient range of attributable consequences, whilst also being confident in their ability to avoid smoking (non-smokers), and overcome barriers that prevent them from quitting (smokers).

Therefore, developing new health promotion materials that address the elements of the HBM may increase awareness amongst this population, leading to behavioral changes and better health outcomes. We therefore aimed to answer the following research questions (RQ) using a qualitative approach, and relating the findings to the HBM and its six elements:

  1. How do university students perceive current cigarette packaging warnings, and their effectiveness as a tobacco control intervention?
  2. How do university students perceive the inclusion of health warnings and messages on cigarette sticks, and their potential strengths and weaknesses as a tobacco control intervention?
  3. What forms of tobacco control interventions do university students believe as being the most effective in promoting public health into the future?

Results

Sixteen students participated in three focus groups, and an additional eleven participated in the phone interviews.

Their characteristics and participation details are listed in Table 1. Twenty-one (78%) participants were female, with a mean age of 25.3 years (range 18–47 years), of whom 12 (44%) were non-smokers, 13 (48%) were smokers, and two (8%) were ex-smokers.

There was an overlap of participants’ views in the FGDs and phone interviews, with participants having similar views, and many of the issues raised at the FGDs resonated in the interview sessions. Overall, six major themes and three sub-themes were identified as described below and presented with verbatim illustrative quotes.

The themes identified and their relevance to the elements of the HBM and perceived outcomes on health-behaviours are depicted in Figure 2.

Data saturation was achieved by the ninth phone interview participant (participant #20), where no new data relating to perceptions of cigarette packaging warnings, cigarette stick warnings, or ideas for future tobacco control interventions were identified. Quotations which illustrate these themes are annotated with a numerical indicator to identify the participant, whose details are described in Table 1.

RQ1: How do university students perceive current cigarette packaging warnings, and their effectiveness as a tobacco control intervention?

Table 1

Participant characteristics for focus groups and phone interviews

ID no.Method of participationGenderAgeSmoking status
1Focus group #1Female18Non-smoker
2Focus group #1Female18Non-smoker
3Focus group #1Female18Non-smoker
4Focus group #1Male18Non-smoker
5Focus group #1Male31Non-smoker
6Focus group #1Female33Non-smoker
7Focus group #2Male21Smoker
8Focus group #2Female30Smoker
9Focus group #2Female22Smoker
10Focus group #3Female47Non-smoker
11Focus group #3Female31Ex-smoker
12Focus group #3Female18Non-smoker
13Focus group #3Female18Non-smoker
14Focus group #3Female18Non-smoker
15Focus group #3Female19Non-smoker
16Focus group #3Female41Non-smoker
17Phone interviewFemale45Smoker
18Phone interviewFemale19Smoker
19Phone interviewFemale30Ex-smoker
20Phone interviewMale19Smoker
21Phone interviewMale24Smoker
22Phone interviewFemale28Smoker
23Phone interviewFemale19Smoker
24Phone interviewFemale19Smoker
25Phone interviewFemale30Smoker
26Phone interviewMale18Smoker
27Phone interviewFemale31Smoker
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Object name is PRBM-12-361-g0002.jpg
Figure 2
Elements (e1–e6) of the Health Belief Model influenced by health warnings on current Australian cigarette packaging, and individual cigarette sticks in this study, and perceived outcomes.

Health warnings currently implemented on cigarette packaging in Australia were generally perceived as minimally effective by all participants (males and females, smokers and non-smokers). Two underlying themes emerged describing the basis for these perceptions: the disregard of packaging warnings and warning irrelevance to readers. These themes were primarily related to how packaging warnings influence readers’ perceived susceptibility and severity of tobacco-attributable consequences.

Disregard of packaging warnings

There was a general consensus amongst participants that health warnings on cigarette packaging were now not noticed or internalized by the majority of smokers.

“I think the packaging gets ignored actively, like put it in their pocket to make sure they don’t see it and no-one else does” (ID#4), “You see all the pictures on the packages and you sort of get used to it. I feel like they never really had an impact on me” (ID#24).

There was however belief that there may be some residual effect on non-smokers and young experimental smokers, due to their less frequent exposure to the warnings and retention of warning shock value. This also contributed to dissuading non-smokers from associating with smokers. “My dislike towards tobacco products was already there but these packaging warnings have contributed more” (ID#6), “The pictures gross me out…it is a deterrent for me, and reinforces what I already know” (ID#10).

Irrelevance of packaging warnings

There was also an underlying trend of disbelief, and perceptions that current packaging warnings are irrelevant, with younger participants in particular feeling disconnected from the threats of chronic diseases, which may develop after decades of tobacco use. “Since I have started buying my own [cigarettes], I have ignored the health warnings because I keep telling myself that it would never happen because I am young and am not going to smoke for long” (ID#26), “When talking to people about smoking and advertisements, they say they don’t really believe the smoke warnings” (ID#23).

As depicted in Figure 2, these findings highlight the shortcomings of current packaging warnings relative to the HBM, particularly in depicting an appropriate level of perceived susceptibility to tobacco-attributable consequences.

Both non-smoking and smoking participants were also dismissive of the packaging mentioning the benefits of quitting, and the inclusion of the “Quitline” number on packaging, with the primary reason being a lack of addressing the barriers experienced when quitting. This indicates their minimal effectiveness in acting as a cue to take health-improving actions. The perceived severity of the health consequences portrayed was high however, with participants describing their beliefs of the severity of lung cancer and oral diseases on cigarette packaging.

RQ2: How do university students perceive the inclusion of health warnings and messages on cigarette sticks, and their potential strengths and weaknesses as a tobacco control intervention?

Two major themes emerged describing participants’ perceptions of the cigarette warnings and messages: novelty of the cigarette stick warnings, and the proximity of tangible warnings. Proximity of tangible warnings had three sub-themes, namely financial consequences, personal appearance, and calculable loss of time. These themes encompassed most of the elements of the HBM, most notably the increased susceptibility and severity of a wider range of consequences of smoking, including non-health consequences.

As depicted in Figure 2, cigarette-stick warnings were also perceived as effective in better outlining the benefits of quitting, and acting as an additional cue for changes in smoking behavior. The notable exception was the lack of addressing the perceived barriers of quitting, with neither the cigarette packaging nor cigarette stick warnings managing to address this element.

Novelty of the cigarette stick

Most participants showed interest in the cigarette-stick warnings and messages, with non-smokers in particular finding them a novel and potentially effective medium for tobacco warnings and messages. Smokers also held this belief, though to a lesser extent, suggesting that these warnings would likely suffer the same shortcomings as current packaging warnings.

They did however support the introduction of cigarette stick warnings, perceived as being likely to lead to some reductions in tobacco use. Utilizing the individual cigarette stick as a novel medium for communicating the consequences of smoking received positive comments from non-smokers, though mixed comments from smoking participants. Most could see the benefit of its use as a warning medium due to its visibility when smoking, and opposing the sought-after “coolness factor”. “Having warnings on the cigarettes will make them less attractive. Maybe the cool factor will be affected [others agreeing]” (ID#15), “I remember in high school other people would sell [you individual] cigarettes, and you just got the cigarette and not any of the warnings or anything else” (ID#11).

However, some were also concerned that it might experience the same shortfalls as packaging warnings with repetitive exposure, and be less likely to have an influence on certain sub-groups, such as long-established smokers. “In the beginning [they might be effective], but it might be the same thing as the pictures, and would just get to be part of the cigarette and you wouldn’t really see it anymore” (ID#9), “I see this as probably a waste, the only time they might be effective is if they don’t see the packaging warnings, because if those warnings don’t get to you, then these won’t” (ID#16), “For a continuing smoker it might work for them…if they want to change their life it might work, but not for other people and the addiction is too strong” (ID#1).

Proximity of tangible warnings

Specific warnings and messages were also identified as particularly engaging over the others, with the warnings describing the more proximal (short-term) and tangible consequences of smoking perceived as the most likely to be influential on smoking behaviors, both amongst non-smokers and smokers. This included the cigarettes describing the financial cost of smoking, the impact of smoking on personal appearance, and the calculable loss of time, which were perceived as the most relevant and effective.

Financial consequences as the most effective dissuader

The cigarette depicting the financial burden of smoking was the most notably described message by participants as being both novel and universally relatable to the wider population of any age and smoking status. “If you are a new smoker, you don’t want to be spending that much per year. I could buy a car with that, or pay for this year’s university fees” (ID#4), “A lot of adults in Australia worry about their finances, so saying that smoking a pack a day costs so much is a good prompter for people to start worrying about their wallet” (ID#26), “I think the cost of smoking message would hit smokers hard, because cigarettes are really expensive now, and for me with a young family, spending that money is better spent elsewhere” (ID#19). This message addresses many of the elements within the HBM. It clearly depicts an accurate susceptibility and severity of smoking from a financial standpoint, clearly outlines the benefits of both not starting to smoke, and the benefits of quitting, and serves as a cue to action for current smokers, who value their real-time financial stability over future health stability.

Importance of personal appearance for young adults

Personal appearance was similarly highly regarded, and considered as a strong motivating factor for young adults to avoid smoking, though believed to be less so for older, long-established smokers. “A lot of people smoke to keep their weight down…so saying all of those consequences counters the idea that if you smoke, it can help you be beautiful” (ID#4). The proximal threat of yellow teeth, bad breath, and stained fingers in particular for young women was seen as a strong deterrent, and directly opposed the “coolness” often sought when smoking. “The fingers and bad breath one especially for teenage girls, it is very important about how they look” (ID#9). Conversely, the distal threats of chronic diseases were seen as disconnected from the act of smoking and unlikely to modify smoking behaviors in young smokers. “I think the stats and cancers are just too far off into the future for younger people, you have a different timeline in perspective in how life is going to be lived” (ID#21), “People will think ‘that won’t happen to me, I won’t get mouth cancer or emphysema’” (ID#13). Similar to the financial consequences of smoking, the novelty of this form of warning and its relevance to younger participants increased their perceived susceptibility and severity of smoking, and outlined further benefits of not smoking.

Calculable loss of time

Apart from the financial and appearance-related consequences, the proximal and calculable loss of time (minutes of life) per cigarette was also viewed as a shocking and thought-provoking message with a strong potential to incite behavioral change. “The minutes of life lost I found interesting, because it is serious but not overly dramatic, which some of the pictures can be…I thought it just jumped out at me” (ID#21). However, some participants believed that describing the loss of such short time-intervals to young people may have the opposite effect, as they feel like they expect to yet live for such a long time compared to older smokers. “Though teenagers might not care about their minutes of life lost, like ‘who cares I am young and I got years to worry about that’” (ID#8).

RQ3: What forms of tobacco control interventions do university students believe as being the most effective in promoting public health in the future?

Two major themes emerged describing participants’ perceptions of effective ways in promoting further reductions in tobacco use in Australia: an increased proportion of messages which are supportive in nature, to guide smokers in how to quit, and social media as a delivery medium for tobacco warning interventions. These suggestions by participants support the RQ2 findings, where the elements of the HBM relating to self-efficacy and cues to change behavior were minimally influenced by both the current cigarette packaging, and the cigarette stick warnings and messages utilized in this study.

Supportive messages for smokers

Smoking participants in particular also believed that using more positive and supportive messages which guide smokers on how to quit would be more beneficial than the current tobacco warning climate, which is dominated by negative-framed messages. This identified that smokers desire more cues to action for quitting, and need greater self-efficacy in doing so, which they perceive as not being significantly supported by current tobacco packaging interventions. Both smokers and non-smokers believed that the current dominance of negative messages were having minimal (and sometimes the opposite) effect, and smokers were becoming more defensive towards this method of tobacco control intervention. “You can’t always shame smokers for smoking, because it is addictive…so you have to balance ‘this is really bad’ but we also need to support them as well” (ID#3), “I think using positive messages might be effective, because then it is not being harped on again, rather strategies and options so you feel supported” (ID#17).

Social media as a delivery medium

Whilst most participants agreed that the cigarette stick as a medium for warnings may lead to reductions in tobacco use, they also believed that an increased presence of tobacco warnings in social media would reach a greater proportion of young adults. The importance of dissuading young adults from tobacco products combined with their propensity for regular social media use led to its suggestion as a tobacco control platform. “Social media is a big platform that everybody is using…the younger generation is being exposed to smoking and it is important to limit that and [influence] the choices they make” (ID#20). Some participants described the difficulty in making effective social media-based warnings and messages, and the likelihood for poorer message uptake amongst older persons. “A lot of middle aged and older people aren’t really interested in social media, they might check it once a week…but they don’t use it several times a day to see what is going on” (ID#11), “Social media messages might still come off as being negative, and will either be ignored or avoided” (ID#5). Whilst not directly linked to any specific element of the HBM, social media platforms as a delivery tool would increase exposure to health warnings and messages, particularly amongst the younger generations, who use this technology frequently. The warnings and messages for implementation within these platforms would then themselves be designed to address specific elements of the HBM according to the needs of the community.

From these findings it is apparent that within the HBM, that participants desire an increase in the range of tobacco control interventions which act as cues to action, and improve smoker self-efficacy to quit. These elements within the HBM were perceived as being poorly addressed by current packaging warnings, and also not sufficiently addressed by the proposed cigarette stick warnings and messages.


Source:
University of Stirling
Media Contacts: 
Greg Christison – University of Stirling
Image Source:
The image is credited to University of Stirling.

Original Research: Open access
“Extending health messaging to the consumption experience: A focus group study exploring smokers’ perceptions of health warnings on cigarettes”. Crawford Moodie, Rachel O’Donnell, Joy Fleming, Richard Purves, Jennifer McKell & Fiona Dobbie.
Addiction Research and Theory. doi:10.1080/16066359.2019.1653861

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