Perceptions of Cigarette Pack Inserts Promoting Cessation and Dissuasive Cigarettes Among Young Adult Smokers in the United Kingdom
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Perceptions of cigarette pack inserts promoting cessation and dissuasive cigarettes among young adult smokers in the United Kingdom Crawford Moodie1 PhD Rosemary Hiscock2 PhD Garth Reid3 PhD 1 Centre for Tobacco Control Research, Institute for Social Marketing, University of Stirling 2 Department for Health, University of Bath 3 Policy Evaluation, NHS Health Scotland, Edinburgh Suggested Citation Moodie C, Hiscock R, and Reid G (2018). Perceptions of cigarette pack inserts promoting cessation and dissuasive cigarettes among young adult smokers in the United Kingdom. Stirling, Scotland: Centre for Tobacco Control Research, University of Stirling. September 2018 ISM Institute for Social Marketing 1 Summary Combustible cigarettes continue to dominate the global nicotine market (Eriksen et al., 2015), with 5.5 trillion cigarettes sold in 2016 (CTFK, 2017). Cigarettes, unsurprisingly, are responsible for most of the seven million tobacco related deaths per year. While smoking remains the leading cause of avoidable morbidity and mortality in Scotland and across the UK, prevalence and consumption is lower than it has been for a number of decades. This trend is expected to continue, with the Scottish Government ambitiously pledging to reduce smoking prevalence to five percent or less by 2034. If this target is to be achieved, however, it is likely that a raft of novel tobacco control measures will be required between now and then. Tobacco control is already strong in Scotland, and across the UK, with prices for tobacco products high, tobacco advertising, promotion and sponsorship banned (including the open display of tobacco products in retailers), the continued use of anti-smoking mass media campaigns, and smoking prohibited in public places and in cars with minors. In addition, as of May 2017, the Standardised Packaging of Tobacco Products Regulations and Tobacco Products Directive significantly altered the appearance of cigarette packaging. The legislation requires cigarettes and rolling tobacco to come in packs with a drab brown base colour, large pictorial health warnings on the front and back of packs and two additional text warnings on the secondary surfaces (see Figure 1). These changes drastically reduce the ability of the pack to create favourable perceptions of the brand and of smoking (Moodie, 2013). However, there is clearly more scope for using the packaging to dissuade consumers. Regulators and academics alike have tended to focus on the exterior of the cigarette pack, with very little consideration of how the pack interior, for instance pack inserts or indeed the cigarettes themselves, could potentially be used to encourage smokers to think about their smoking behaviour. Figure 1: Standardised cigarette packaging in the UK We conducted an online survey with 1766 young adult smokers (aged 16-34 years) to explore their perceptions of cigarette design (a standard and two dissuasive cigarettes, displaying either a warning or unattractively coloured) and pack inserts with messaging promoting cessation. The two dissuasive cigarettes were perceived as significantly less appealing, and more harmful, than the standard cigarette. Participants were also significantly less likely to indicate that they (or a never smoker) would try one of the dissuasive cigarettes, compared to the standard cigarette. Approximately half the sample indicated that the two dissuasive cigarettes would put people off starting to smoke and make smokers want to quit. Half the sample thought that they would read the pack inserts, with three-fifths considering them a 2 good way to provide information to smokers about quitting. Just over half thought that the inserts would make them think more about quitting, might help them if they decided to quit, and were an effective way of encouraging smokers to quit. Those who had made a quit attempt in the last six months or were intending to quit within the next six months were most likely to find the inserts helpful for cessation. Approximately half supported having inserts promoting cessation inside packs, with a slightly lower proportion supporting all cigarettes having a warning on them or being an unattractive colour. 3 1. Introduction: The rise of the cigarette While Southwest Indians, Aztecs and Mayans used hollow reeds, cane or maize to fashion cylindrical holders for smoking tobacco as far back as the 9th century, and Sevillians had smoked discarded cigar scraps wrapped in paper (papeletas) since the 17th century, the cigarette as we know it did not emerge until the 19th century (Elliot, 2009). Cigarettes gained traction in Europe soon after, although being hand-rolled limited how many could be manufactured. This changed with the introduction of mechanised cigarette-rolling, and the mass-production of cheap cigarettes (Harvey, 2014). In the UK, by the early 20th century the cigarette was becoming more popular than snuff, plug, pipe tobacco and cigars, which had heretofore dominated the market (Leonard, 2015). The move to cigarettes was helped not only by advancements in cigarette making machinery but also changing social mores, lower taxation than for other tobacco products, a widespread distribution network and concentrated advertising campaigns (Proctor, 2011). The cigarette also represented a break from the past and symbolised a dynamism associated with modernity (Schechter, 2003). War too played an important role, with the cigarette a better fit with the cramped intimacy and frequent interruptions of front-line service for smokers than pipe or chewing tobacco (Proctor, 2011). By 1911 cigarettes accounted for 39% of the British tobacco market (Hannah, 2006), with market share steadily increasing thereafter. Globally, cigarette sales grew from 1.6 trillion in 1950 to 5.7 trillion by 2000 and, despite the 21st century being marked by significant advances in tobacco control in many countries, 5.5 trillion in 2016 (CFTK, 2017). Even with novel nicotine-containing products such as electronic cigarettes experiencing impressive growth, tobacco industry analysts predict that combustible cigarettes will remain the most popular form of consumption for some time yet (Hedley, 2015). 1.1 The cigarette as the primary package Packaging has a number of distinct levels (primary, secondary and tertiary) (Oostendrop et al., 2006), although there is debate about how best to define each of these (Hellström & Saghir, 2007). There is consensus that the primary packaging is in direct contact with the product (Ampuero & Vila, 2006), although there is some disagreement about whether the primary packaging is also the sales packaging (Prendergast & Pitt, 1996). For Simms and Trott (2010) the primary pack is in contact with the product and protects it (e.g. the plastic bag that contains cereal), while the secondary pack functions as the sales packaging, identifying it and communicating with the consumer (e.g. the cereal box) (Simms & Trott, 2010). If following the definition used by Simms and Trott (2010) then the primary pack would be the cigarette, as it is in direct contact with and protects the product (tobacco), with the cigarette pack being the secondary pack given that it identifies the brand, communicates product attributes and is on sale to consumers. This definition may not be accepted by those that maintain that the primary packaging must also be able to function as the sales packaging (Prendergast & Pitt, 1996), although single cigarettes have been on direct sale to consumers, at one time or another, the world over. Indeed, even though the Framework Convention on Tobacco Control (WHO, 2005) recommends a ban on the sale of single cigarettes, with the practice prohibited in the UK since 1992, it is still widespread in some parts of the world. For instance, single cigarettes are available for sale in vending machines in China, and in markets such as India and the Philippines more cigarettes are sold by the stick rather than by the pack (Lal et al., 2015). Single cigarettes are also available for sale across much of Africa, including in countries where their sale is banned (Wherry et al., 2014; African Tobacco Control Alliance, 2018). As such, defining the cigarette as the primary package would appear appropriate. 4 Irrespective of how the cigarette is best defined, tobacco industry documents support the notion of the cigarette being another level of packaging. A Philip Morris report, for instance, argues that “The cigarette should be conceived not as a product but as a package. The product is nicotine. The cigarette is but one of many package layers” (Dunn, 1972). 1.2 Dissuasive cigarettes While there are a number of tried and tested tobacco control measures, it is argued that novel interventions are needed to stop children taking up smoking and help smokers to quit (Beaglehole et al., 2015). Myriad ideas have been proposed, focusing on the user (e.g. restricting sales by year born, requiring a smoker’s licence or prescription-only sales), the market (e.g. minimum pricing, advantaging cleaner nicotine products such as e-cigarettes over combustibles, quotas on tobacco manufacture and imports that are regularly reduced under a ‘sinking lid’) and institutional structures (e.g. a regulated market model or state takeover of tobacco companies to be managed with a health mandate) (McDaniel et al., 2016). There have also been a number of product-focused proposals, including banning flavours, reducing nicotine levels, and increasing the pH level of cigarettes to make inhalation more unpleasant (McDaniel et al., 2016). Another