The impact of cigarette package design on young women in Brazil: brand appeal and perceptions of health risk by Christine White A thesis presented to the University of Waterloo in fulfillment of the thesis requirement for the degree of Master of Science in Health Studies and Gerontology Waterloo, Ontario, Canada, 2011 ©Christine White 2011 AUTHOR'S DECLARATION I hereby declare that I am the sole author of this thesis. This is a true copy of the thesis, including any required final revisions, as accepted by my examiners. I understand that my thesis may be made electronically available to the public. ii Abstract Tobacco use is responsible for 5.4 million deaths every year worldwide and a leading cause of preventable death. The burden of these deaths is rapidly shifting to low and middle-income countries, such as Brazil. Brazil is widely regarded as an international leader in tobacco control. The country has prohibited most forms of advertising; however, the cigarette pack remains a primary source of tobacco marketing. The current study sought to examine how tobacco packaging influences brand appeal and perceptions of health risk among female youth in Brazil. A between-subjects experiment was conducted in which 640 Brazilian females between the ages of 16 to 26 years participated in an online survey. Each participant was asked to view and rate a series of cigarette packages that were digitally altered to correspond to one of three experimental conditions: (1) ―standard‖ branded cigarette packages, (2) the same packs with all brand imagery removed (―plain packaging‖), or (3) the same packs with all imagery and brand descriptors removed. Participants rated the packages on perceived appeal, taste, smoothness, health risk, ease of quitting, desirability to be seen smoking, preference to try, and smoker attributes through single pack ratings and two-pack comparisons. A pack offer was used as a behavioural measure of general appeal. Linear and logistic regression modeling was used to test for differences between and within experimental conditions. Branded packs were rated as significantly more appealing, better tasting, and smoother on the throat than plain packs. Branded packs were also associated with a greater number of positive smoker attributes including style and sophistication, and were perceived as more likely to be smoked by females than the plain packs. Removing descriptors from the plain packs further decreased the ratings of appeal, taste and smoothness, and also reduced associations with positive attributes. Results of the study also indicated that packages marketed as lighter, through use of lighter coloured pack imagery, and descriptors referring to lighter colours and flavours, were more likely to be rated favourably. Over 52% of iii participants accepted a pack offer at the end of the study, and of those who selected a pack, more than three-quarters chose a branded pack over a plain pack. Overall, the findings suggest that plain packaging and removing descriptors from cigarette packs, including those that refer to flavours, may help to reduce the appeal of smoking, and consequently reduce smoking susceptibility among young women in Brazil. iv Acknowledgements First of all, I would like to thank my supervisor, David Hammond, for his ongoing support and mentorship over the past two years. His encouragement and guidance has made my time as a graduate student not only enjoyable, but has also fostered my growth as a researcher. I would also like to thank my committee members, Geoffrey Fong and Jim Thrasher, for their expertise, advice, and encouragement. Thank you to Said Bichara, Renato Costa, Samantha Daniel, Matt Grey, and Jessica Reid for your invaluable assistance conducting this research. I would also like to thank my family and friends for their support throughout the process. Thank you Mom and Dad for all your encouragement, love, patience and proofreading. Special thanks to Karina and Erica, as well as my ‗phenomenal‘ officemates, Lana, Sam and Seema, for your endless support and assistance, and last, but certainly not least, friendship and laughs along the way. Finally, I would like to gratefully acknowledge the financial support I received for this project through a Canadian Institute for Health Research (CIHR) Banting and Best Canada Graduate Scholarship, Ontario Graduate Scholarship, CIHR Training Grant Program in Population Intervention for Chronic Disease Prevention, and Ontario Tobacco Research Unit (OTRU) Ashley Studentship for Research in Tobacco Control. v Table of Contents Author's Declaration ..................................................................................................................................... ii Abstract ........................................................................................................................................................ iii Acknowledgements ....................................................................................................................................... v Table of Contents ......................................................................................................................................... vi List of Figures ............................................................................................................................................... x List of Tables ............................................................................................................................................... xi 1.0 Introduction ....................................................................................................................................... 1 2.0 Literature Review .............................................................................................................................. 4 2.1 Tobacco as a Global Health Issue ....................................................................................................... 4 2.2 Tobacco Use in Brazil ......................................................................................................................... 4 2.3 Tobacco Control in Brazil ................................................................................................................... 6 2.3.1 Current Tobacco Control Regulations ......................................................................................... 6 2.3.2 Framework Convention on Tobacco Control ............................................................................... 6 2.3.3 Gaps in Tobacco Control Regulation ........................................................................................... 8 2.4 Package Design and Cigarette Marketing Principles .......................................................................... 9 2.4.1 Communication of Brand Image and Positioning ........................................................................ 9 2.4.2 Establishment of Unique Brand Identity in Competitive Markets ............................................. 10 2.5 Cigarette Package Design and Consumer Perceptions...................................................................... 11 2.5.1 Brand Descriptors and Consumer Perceptions ........................................................................... 11 2.5.2 Brand Imagery and Consumer Perceptions ................................................................................ 15 2.6 Tobacco Packaging and Youth ......................................................................................................... 16 2.6.1 Brand Imagery, Identity and Youth ........................................................................................... 17 2.6.2 Flavoured Cigarette Brands and Youth ...................................................................................... 17 2.7 Plain Packaging ................................................................................................................................. 18 vi 2.7.1 Potential Impact of Plain Packaging .......................................................................................... 18 2.7.2 Plain Packaging in Other Fields ................................................................................................. 20 2.7.3 Plain Packaging and Industry Opposition .................................................................................. 21 2.8 Summary and Implications ............................................................................................................... 22 3.0 Study Rationale ............................................................................................................................... 24 3.1 Rationale ........................................................................................................................................... 24 3.2 Research Objectives .......................................................................................................................... 26 4.0 Methods........................................................................................................................................... 27 4.1 Study Design ..................................................................................................................................... 27 4.1.1 Participants ................................................................................................................................. 27 4.1.2 Recruitment ...............................................................................................................................