Original research Tob Control: first published as 10.1136/tobaccocontrol-2019-055463 on 14 July 2020. Downloaded from Assessing cigarette packaging and labelling policy effects on early adolescents: results from a discrete choice experiment Inti Barrientos- Gutierrez ,1 Farahnaz Islam,2 Yoo Jin Cho ,3 Ramzi George Salloum ,4 Jordan Louviere,5 Edna Arillo- Santillán,1 Luz Myriam Reynales- Shigematsu,1 Joaquin Barnoya,6 Belen Saenz de Miera Juarez ,7 James Hardin,2 James F. Thrasher1,3 ► Additional material is ABSTRact of increasing the size of pictorial HWLs, while also published online only. To view Introduction Cigarette packaging is a primary channel considering the effects of other cigarette packaging please visit the journal online characteristics that may make smoking appeal, or (http:// dx. doi. org/ 10. 1136/ for tobacco advertising, particularly in countries where tobaccocontrol- 2019- 055463). traditional channels are restricted. The current study not, to youth. The current study used a discrete evaluated the independent and interactive effects of choice experiment (DCE) to evaluate the effects of For numbered affiliations see cigarette packaging and health warning label (HWL) cigarette packaging and HWL characteristics on the end of article. characteristics on perceived appeal of cigarette brands appeal of smoking for early adolescents. DCEs are for early adolescents in Mexico. increasingly used in tobacco research,6 as they allow Correspondence to for assessment of the independent and potentially Dr James F. Thrasher, Health Methods A discrete choice experiment (DCE) was Promotion, Education, and conducted with early adolescents, aged 12–14 years interactive effects of policy configurations before Behavior, School of Public (n=4251). The DCE involved a 3×25 design with six their implementation. Health, University of South attributes: brand (Marlboro, Pall Mall, Camel), tobacco Carolina, Columbia SC 29208, flavour (regular, menthol), flavour capsule (none, 1 or South Carolina, USA; HWL characteristics 2 capsules), presence of descriptive terms, branding thrasher@ mailbox. sc. edu Pictorial HWLs are more effective than text- only (vs plain packaging), HWL size (30%, 75%) and HWL 7 8 HWLs ; however, the impact of increasing the size Received 15 October 2019 content (emphysema vs mouth cancer). Participants copyright. of pictorial HWLs is less well studied. Increasing Revised 15 May 2020 viewed eight sets of three cigarette packs and selected a Accepted 19 May 2020 HWL size is a potentially powerful policy that pack in each set that: (1) is most/least attractive, (2) they Published Online First may not only enhance the effectiveness of HWLs are most/least interested in trying or (3) is most/least 14 July 2020 by increasing their salience, but also minimise the harmful, with a no difference option. effectiveness of package branding elements due to Results Participants perceived packs as less attractive, the diminished space for pro- tobacco messages. Pre/ less interesting to try and more harmful if they had plain post observational studies to evaluate implementa- packaging or had larger HWLs, with the effect being http://tobaccocontrol.bmj.com/ tion of larger HWLs with novel content, including most pronounced when plain packaging is combined pictorial imagery, have found evidence of greater with larger HWLs. For attractiveness, plain packaging had 9–13 attention to HWLs, negative perceptions of the biggest influence on choice (43%), followed by HWL 14 cigarette packs, stronger beliefs about smoking- size (19%). Interest in trying was most influenced by 9 13 15–18 17 related harms and lower smoking rates. brand name (34%), followed by plain packaging (29%). The few experimental studies of youth that have Perceived harm was most influenced by brand name systematically manipulated pictorial HWL size have (30%), followed by HWL size (29%). found conflicting evidence of the effects of larger Conclusion Increasing the size of HWLs and 19–21 pictorial HWLs on risk perceptions, with posi- implementing plain packaging appear to reduce the 22 tive effect on attention, no effect found for atten- appeal of cigarettes to early adolescents. Countries 19–21 tion and willingness to try cigarettes. Other should adopt these policies to minimise the impact of on September 28, 2021 by guest. Protected studies have found that adult smokers perceive tobacco marketing. 23 larger HWLs as more effective and report less positive perceptions of packaging.24 Research is needed on the effects of increasing HWL size in populations that are sensitised already to pictorial INTRODUCTION HWLs. Indeed, FCTC implementation guidelines25 Cigarette packaging is a primary channel for recommend adopting HWLs that ‘cover more than tobacco advertising, especially when advertising 50% of the principal display areas and aim to cover has been restricted, banned or self-regulated by the © Author(s) (or their 1–3 as much of the principal display areas as possible.’ employer(s)) 2021. No industry. Following guidelines from the World commercial re-use . See rights Health Organization’s Framework Convention on and permissions. Published Tobacco Control (FCTC), more than 100 coun- Tobacco flavours by BMJ. tries have adopted prominent health warning labels Flavours in tobacco product design and marketing To cite: Barrientos- (HWLs) on cigarette packaging to communicate the promotes the appeal of cigarettes, with menthol as 4 5 26 27 Gutierrez I, Islam F, Cho YJ, harms of smoking using pictorial imagery. As these the leading flavour. The prevalence of flavoured et al. Tob Control countries aim to optimise their tobacco control cigarette use among youth is relatively higher 2021;30:505–514. policies, it is critical to estimate the potential effects than among adults.28–31 Many young smokers Barrientos- Gutierrez I, et al. Tob Control 2021;30:505–514. doi:10.1136/tobaccocontrol-2019-055463 505 Original research Tob Control: first published as 10.1136/tobaccocontrol-2019-055463 on 14 July 2020. Downloaded from initiate with menthol cigarettes,32 33 which may be particularly adolescent e- cigarette use is higher than in the USA (ie, 12% important in early stages of tobacco use because the menthol of urban middle schoolers in 201770; 3.3% of middle schoolers reduces the harshness of cigarette smoke.32 Perhaps because of in the USA in 201771), although use in the USA has increased this anaesthetic property, menthol also promotes misperceptions substantially in recent years (ie, 10.5% of middle schoolers in of reduced harm compared with non- flavoured, ‘regular’ ciga- the USA in 2019).72 E-cigarette flavours that appeal to youth are rettes,26 27 34–36 although these perceptions are not consistently similar to those found in cigarette capsules in Mexico (eg, berry, found, with more recent studies finding that smokers misper- mint, cucumber, mango).73 The current study aimed to evaluate ceive menthol cigarettes as more harmful.37–41 the potential effects of changes to cigarette packaging and label- A rapidly growing market segment, particularly in Latin ling policies among early adolescents in this context. America,42 43 involves cigarettes with flavour capsules in the filter that consumers can crush at any time to release a liquid that METHODS flavours the smoke. Introduced in 2008, by 2017 flavour capsule Study population varieties represented 36% of the cigarette market share in Chile, Data were collected from students in the final grade of middle 34% in Peru, 32% in Guatemala and 22% in Mexico. Preference school (approximately 12–14 years old) in the three largest for flavour capsule cigarette varieties is most prevalent among cities in Mexico (ie, Mexico City, Guadalajara and Monterrey) young adults (Australia, Mexico, USA, UK),34 44–46 adolescents between October and November 2016. Sixty schools were orig- (Mexico)47 and non- smoking young adults (New Zealand).47 48 inally selected for a longitudinal study using a stratified-random Flavour capsule varieties are sold in both regular and menthol sampling scheme that considered: (1) neighbourhood socioeco- cigarettes,49 with some varieties including two differently nomic status, based on schools’ location, and (2) city- specific flavoured capsules in the same filter.42 43 50 No research has tertiles of retail establishment density, which were estimated systematically assessed the independent and potentially interac- using an official database of commercial establishments likely to tive effects of flavoured tobacco and flavour capsules, which may sell tobacco within school census tracts. A detailed description of be particularly important for informing flavour ban policies. the original school selection process can be found elsewhere.74 Students provided active consent to participate in the study Packaging characteristics with parents providing passive consent. The paper and pencil Packaging size, shape, graphic design and use of descriptive terms questionnaire was self-administered in Spanish, using questions can all influence consumer perceptions of a particular cigarette based on prior, validated surveys and pretested using cognitive product,2 3 19 51–54 and they may increase the appeal of smoking interviews to ensure student comprehension. The DCE was for youth and vulnerable groups.55–59 To reduce the effectiveness included in the surveys for a random selection of 30 schools of packaging as a promotional vehicle, a number of countries (n=4325 students). Due to missing data on covariates, 74 (1.7%) copyright. have introduced