Testing the optimal design of health-promoting pack inserts and dissuasive cigarettes

Key points
- This study was commissioned by the Department of Health and Social Care, through the National Institute for Health and Care Research (NIHR) Public Health Policy Research Unit, to understand whether there may be potential public health benefits associated with two tobacco-related policies: 1) health-promoting pack inserts, i.e. pieces of card which are included inside packs of cigarettes or rolling tobacco with messages encouraging smokers to quit; and 2) dissuasive cigarettes, i.e. cigarettes which display warnings and/or are a colour intended to be unappealing.

- Focus groups and online surveys explored how adolescents (11-17 year-olds) and adult smokers responded to inserts with messaging aimed at promoting quitting, and cigarettes which displayed warnings and/or were an unappealing colour.

- Participants (N=138) in the focus groups were asked about 16 inserts, two within each of the eight themes (Physical health, Mental health, Financial benefits, Conception and pregnancy, Cravings, Perseverance, Quitting in older age, Stop smoking aids). They were also asked about cigarettes displaying warnings, which addressed different themes (Risk, Harm to others, Poison/Toxicity, Cosmetic), as well as coloured cigarettes (Black, Brown, Green, Grey) and coloured cigarettes with warnings.

- Participants in the adolescent survey (N=2,234) and adult smoker survey (N=3,053) were randomly shown and asked about four (of 16) inserts. They were also shown and asked about random cigarette triads (which included a standard white cigarette, one of the four coloured cigarettes, and a white or coloured cigarette with a warning).

- The findings, particularly from the adult smoker survey, suggest that health-promoting pack inserts may be beneficial in helping some adult smokers in the UK quit. For the best-performing inserts within each of the eight themes, over 30% of adult smokers agreed it would motivate them to quit, and encourage them to look for help to quit.

- We explored adolescent non-smoker’s views of health-promoting pack inserts. While not the target audience, or a population previously explored, our findings tentatively point to inserts as having the potential to discourage some adolescents from smoking.

- Within the focus groups, the four coloured cigarettes were viewed as off-putting by some, but appealing by others. In the adult smoker survey, each coloured cigarette was rated as significantly more dissuasive than a white cigarette. A similar pattern was observed for adolescents, although the findings did not always reach significance.

- Within the focus groups, cigarettes in each of the four warning themes were viewed as off-putting by some participants. Cigarettes displaying warnings, irrespective of warning theme and cigarette colour, were significantly more dissuasive than cigarettes without warnings in both the adult smoker and adolescent surveys. Cigarettes displaying warnings were more dissuasive than coloured cigarettes.

- The findings need to be considered in light of potential limitations, including the novelty of the stimuli, forced exposure, the possibility of socially desirable responding, and the failure to measure perceptions over time or provide insight into behavioural response.