Evaluating the impact of plain packaging among Canadian smokers: findings from the 2018 and 2020 ITC Smoking and Vaping Surveys

Managing Fear Responses: A Qualitative Analysis of Pictorial Warning Labels Five Years Post-Plain Packaging

INTRODUCTION

Although pictorial warning labels (PWLs) now dominate tobacco packages sold in many countries, few studies have probed how people who smoke respond to the threats presented several years post-plain packaging and larger PWLs. Understanding how people manage the fear and dissonance PWLs arouse, and the strategies they use to rationalize, diminish, and reject risk messages, could inform future PWL design.

AIMS AND METHODS

We undertook 27 in-depth interviews with people aged 18 and over (16 female, 8 Māori, and 13 aged ≤35) who smoked roll-your-own tobacco and lived in Aotearoa New Zealand. We probed participants' views on current PWLs and how they responded to these, then asked them to use alternative images and headlines to create new PWLs. We drew on the extended parallel processing model to interpret the data, which we analyzed using a reflexive thematic analysis approach.

RESULTS

People who smoke dislike PWLs, which they think reduce them to diseased body parts. While a minority thought existing PWLs were believable and effective, most reported avoiding PWLs by hiding or cognitively blocking them. Participants used diverse counterarguments to diminish PWLs' relevance and impact, and a minority displayed strong reactance. Several suggested developing PWLs that recognized them as whole people rather than patients in waiting, and recommended greater use of testimonials, particularly from people who had successfully become smoke free.

CONCLUSIONS

PWLs using more holistic and diverse messages could elicit greater engagement and responsiveness, and motivate cessation more effectively than existing health-oriented warnings.

IMPLICATIONS

Our findings suggest existing PWLs, which aim to arouse fear of ill health, could be complemented by warnings that emphasize the benefits of quitting. Continuing to use threat-based PWLs could stimulate greater rationalization and reactance. By contrast, PWLs that aim to illustrate how cessation could benefit people who smoke and their families, rather than instill a fear of disease, could avoid message rejection and counter-argument, and may prove a more powerful way of motivating cessation.

Estimating the Effectiveness of Health Warnings on Cigarette Packaging in Nigeria: A Modeling Study

INTRODUCTION

Tobacco consumption is associated with nearly 30 000 deaths annually in Nigeria alongside other adverse health and economic effects. Our objective was to estimate the health and economic implications of the current cigarette labeling policies (text-only HWs); new health warnings policies in the country (adding graphic health warnings with up to 60% coverage), and plain packaging policy as recommended by the World Health Organization.

AIMS AND METHODS

We used a probabilistic state-transition individual microsimulation model, considering natural history, healthcare costs, and quality-of-life losses associated with main tobacco-attributable diseases; and the potential effects of packaging and labeling policies. We used three scenarios: (1) text-only health warnings (HWs) covering 50% of the pack, (2) introduction of graphic HWs of 50% (and later increasing to 80%) of the pack, and (3) plain packaging with HWs covering 80% of the pack.

RESULTS

A total of 748 deaths are averted in the current situation; 7478 and 14 208 deaths can be averted with the new policy and with plain packaging, respectively. The number of cardiac, cerebrovascular, and cancer events that could be averted by adopting text and graphic HWs are 3093, 5093, and 1346, respectively; increasing to 5876, 9676, and 2557, respectively, with plain packaging. Up to 251 794 years were lost because of early deaths and disability, and ₦144.6 billion (USD 469 million) in health costs could be saved with HWs covering 50% to 80% of the pack over 10 years. With plain packaging and graphic HWs covering 80% of the package 478,408 years and ₦274.7 billion (USD 895 million) would be saved.

CONCLUSIONS

The new cigarette labeling policy in Nigeria may yield significant health and economic benefits over 10 years. Moving the current policy to plain packaging can significantly improve these benefits.

IMPLICATIONS

The new cigarette labeling policy that Nigeria is implementing should aim to achieve 100% compliance with its current regulation and the logical next step: Plain packaging with large warnings. The present study adds evidence of the potential health effects and cost savings of these levels of implementation, which is valuable for local policymakers.

Dissuasive cigarettes as a tobacco control measure: a scoping review

OBJECTIVE

The aim was to identify and review the research literature on dissuasive cigarettes, including key concepts, types, sources of evidence and research gaps.

DATA SOURCES

PubMed, Scopus and Web of Science databases were searched up to January 2023 with no language or date restrictions. All study designs were included. Reference lists of the identified studies were manually searched. Studies on tobacco products other than cigarettes or on external cigarette packaging alone were excluded.

STUDY SELECTION

Two reviewers screened titles and abstracts independently using eligibility criteria. The full text of the selected articles was subsequently screened independently by two reviewers to confirm eligibility.

DATA EXTRACTION

Two reviewers independently extracted data from all studies using data abstraction forms. Results were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist.

DATA SYNTHESIS

We identified 24 original studies, 3 review articles and 4 commentary articles. Research on dissuasive cigarettes was reported from Australia, New Zealand, Europe and North America. We presented results in four themes: the concept of dissuasive cigarettes; approaches and types; potential benefits, barriers and concerns; and current research gaps.

CONCLUSIONS

Dissuasive cigarettes represent a promising strategy that could be used in tobacco control. Parallel implementation with plain packaging would be feasible and synergistic.

Support for pictorial health warning labels on cigarette packages in the United States among adults who currently smoke or quit smoking: Findings from the ITC US Smoking and Vaping Surveys

INTRODUCTION

In March 2020, the US Food and Drug Administration (FDA) finalized new pictorial health warnings (PHWs), covering 50% of the front and back of the pack; however, legal challenges from cigarette manufacturers have prevented the new warnings from being implemented. About 70% of adults in the general US population support PHWs. This study assessed support for PHWs in 2016, 2018 and 2020 among US adults (aged ≥18 years) who currently smoke or formerly smoked cigarettes. We also assessed factors related to support.

METHODS

Respondents included adults who currently or formerly smoked cigarettes and participated in at least one wave of the US ITC Smoking and Vaping Surveys: Wave 1 (2016, n=2557); Wave 2 (2018, n=2685); and Wave 3 (2020, n=1112). We assessed changes in support for PHWs between 2016 and 2020, and assessed factors related to support (support vs oppose/don't know). Analyses were conducted on weighted data.

RESULTS

Overall, 38.0% of respondents supported PHWs in 2016, with a significant increase to 44.7% in 2018 (p<0.001), and leveling off to 45.0% in 2020 (2018 vs 2020, p=0.91). Support was highest among former smokers and lowest among daily smokers in all three survey years. Support for PHWs at all survey years was significantly higher among those who formerly smoked, were younger (aged 18-39 vs ≥40 years), those who identified as Black (vs White), and planned to quit smoking (vs not planning to quit). There were no differences by income level, education level, or sex.

CONCLUSIONS

Nearly half of US adults who smoke cigarettes or quit smoking supported PHWs in 2020, with support being higher among younger adults, ethnic minorities, and those who formerly smoked. Support increased between 2016 and 2018, but not between 2018 and 2020. Similar to other studies, fewer current and former smokers supported PHWs compared to the US adult general population.

Prevalence of depressive symptoms and cannabis use among adult cigarette smokers in Canada: cross-sectional findings from the 2020 International Tobacco Control Policy Evaluation Project Canada Smoking and Vaping Survey

BACKGROUND

Tobacco smoking and cannabis use are independently associated with depression, and evidence suggests that people who use both tobacco and cannabis (co-consumers) are more likely to report mental health problems, greater nicotine dependence and alcohol misuse than those who use either product exclusively. We examined prevalence of cannabis use and depressive symptoms among Canadian adults who smoke cigarettes and tested whether co-consumers of cannabis and tobacco were more likely to report depressive symptoms than cigarette-only smokers; we also tested whether cigarette-only smokers and co-consumers differed on cigarette dependence measures, motivation to quit smoking and risky alcohol use by the presence or absence of depressive symptoms.

METHODS

We analyzed cross-sectional data from adult (age ≥ 18 yr) current (≥ monthly) cigarette smokers from the Canadian arm of the 2020 International Tobacco Control Policy Evaluation Project Four Country Smoking and Vaping Survey. Canadian respondents were recruited from Leger's online probability panel across all 10 provinces. We estimated weighted percentages for depressive symptoms and cannabis use among all respondents and tested whether co-consumers (≥ monthly use of cannabis and cigarettes) were more likely to report depressive symptoms than cigarette-only smokers. Weighted multivariable regression models were used to identify differences between co-consumers and cigarette-only smokers with and without depressive symptoms.

RESULTS

A total of 2843 current smokers were included in the study. The prevalence of past-year, past-30-day and daily cannabis use was 44.0%, 33.2% and 16.1%, respectively (30.4% reported using cannabis at least monthly). Among all respondents, 30.0% screened positive for depressive symptoms, with co-consumers being more likely to report depressive symptoms (36.5%) than those who did not report current cannabis use (27.4%, p < 0.001). Depressive symptoms were associated with planning to quit smoking (p = 0.01), having made multiple attempts to quit smoking (p < 0.001), the perception of being very addicted to cigarettes (p < 0.001) and strong urges to smoke (p = 0.001), whereas cannabis use was not (all p ≥ 0.05). Cannabis use was associated with high-risk alcohol consumption (p < 0.001), whereas depressive symptoms were not (p = 0.1).

INTERPRETATION

Co-consumers were more likely to report depressive symptoms and high-risk alcohol consumption; however, only depression, and not cannabis use, was associated with greater motivation to quit smoking and greater perceived dependence on cigarettes. A deeper understanding of how cannabis, alcohol use and depression interact among people who smoke cigarettes is needed, as well as how these factors affect cessation activity over time.

How do current tobacco warnings compare to the WHO FCTC guidelines: a content analysis of combustible tobacco warnings worldwide

OBJECTIVE

Many countries have adopted warning labels for combustible tobacco products, yet little research exists describing tobacco warning characteristics globally and to what extent they meet the WHO Framework Convention for Tobacco Control (FCTC) Guidelines. This study evaluates characteristics of combustible tobacco warnings.

DESIGN

We conducted a content analysis to describe the overall landscape of warnings using descriptive statistics and compared to the WHO FCTC Guidelines.

SETTING

We searched existing warning databases for combustible tobacco warnings from English-speaking countries. We compiled warnings meeting inclusion criteria and coded for message and image characteristics using a pre-defined codebook.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Characteristics of combustible tobacco warning text statements and warning images were the primary study outcomes. There were no secondary study outcomes.

RESULTS

We identified a total of 316 warnings from 26 countries or jurisdictions worldwide. Of these warnings, 94% included warning text and an image. Warning text statements most often described health effects to the respiratory (26%), circulatory (19%) and reproductive systems (19%). Cancer was the most frequently mentioned health topic (28%). Fewer than half of warnings included a Quitline resource (41%). Few warnings included messages about secondhand smoke (11%), addiction (6%) or cost (1%). Of warnings with images, most were in colour and showed people (88%), mostly adults (40%). More than 1 in 5 warnings with images included a smoking cue (ie, cigarette).

CONCLUSIONS

While most tobacco warnings followed WHO FCTC guidance on effective tobacco warnings, such as communicating health risks and inclusion of images, many did not include local Quitline or cessation resources. A sizeable minority include smoking cues that could inhibit effectiveness. Full alignment with WHO FCTC guidelines will improve warnings and better achieve the WHO FCTC objectives.

Is perception reality? Associations among "light" cigarettes and number of cigarettes smoked per day

INTRODUCTION

Cigarette filter ventilation and light descriptors are associated with lowered perceptions of risk and smoking more cigarettes per day (CPD). This study examined the relationship between usual cigarette ventilation, perception, and CPD.

METHODS

A crowdsourced sample (N = 995) of individuals who smoke higher-ventilated (=>20% ventilation) or lower-ventilated (=<10% ventilation) cigarettes identified their usual cigarette as "light" or "full flavor", and reported their average CPD.

RESULTS

We found: 1) no association between ventilation status and perception of light versus full flavor (AUC=0.58), with the inaccurate perception being more prevalent in younger individuals (p = 0.041) and those who smoke L&M (73%, p < 0.001) and Camel (61%, p = 0.006) brands; and 2) perception, but not ventilation of usual cigarette, was significantly associated with CPD (p = 0.006), with individuals who perceived their cigarettes as light reporting an average of 13% more cigarettes per day (2.6 CPD), compared to those who perceived their cigarette as full flavor.

CONCLUSIONS

Perceptions of light versus full-flavor, but not ventilation status, predicted CPD. These findings may inform anti-smoking health communication strategies and smoking cessation interventions.

IMPLICATIONS

Tobacco control policies should eradicate the perception of cigarettes as light or full-flavored. Future research investigating the associations between cigarette filter ventilation and smoking behavior should consider the confounding effects that may lie in an individual's perceptions of their cigarettes.

Evaluating the Effects of Denmark's New Tobacco Control Act on Young People's Use of Nicotine Products: A Study Protocol of the §SMOKE Study

(1) Background: In December 2020, a broad majority of political parties in Denmark agreed on a new tobacco control act. In addition, price increases on tobacco in 2020 and 2022 became part of the Danish Finance Act. This study protocol describes the study "§SMOKE-A Study of Tobacco, Behavior, and Regulations" designed to monitor and evaluate the implementation and effect of the new strengthened tobacco control acts. The overall aim is to monitor tobacco use among young people before, during, and after implementation of the new tobacco control legislation, including an increased price on tobacco, a ban on point-of-sale tobacco displays, and plain packaging. Subgoals are to monitor overall use of nicotine products, attitudes, and norms. (2) Methods: This study is designed as a five-year impact evaluation with repeated cross-sectional survey data collections. The baseline survey was conducted before implementing an increased price on tobacco, the first step in the new legislation, initiated 1 April 2020. Study participants (n = 37,500) were a random sample of individuals living in Denmark aged 15 to 29 years. (3) Conclusions: This study examines the impact of the new strengthened tobacco control legislation in Denmark from 2020 to 2025. The findings of this study are relevant to other countries facing implementation of similar measures to explore intended and unintended consequences of the legislation and help to identify how the legislation could be further improved.

Plain packaging on tobacco products in France: Effectiveness on smokers’ attitudes one year after implementation

INTRODUCTION

New packaging of tobacco products, with plain packaging and new enlarged health warnings, was made compulsory in France in 2017. This study aims to measure the impact of new packaging on smokers’ embarrassment and their motivation to quit smoking.

METHODS

Data from Santé publique France 2016, 2017 and 2018 Health Barometer surveys were used. These randomized surveys were conducted by telephone with samples of 15216 (2016), 25319 (2017), and 9074 (2018) people aged 18–75 years. The association between smokers’ embarrassment and the influence of new packaging on motivation to quit smoking was studied using multivariate logistic regressions.

RESULTS

After the introduction of new plain packaging, the proportion of smokers who felt embarrassed taking out their pack of cigarettes in plain sight because of its appearance doubled in 2017 (11.9%, 95% CI: 10.2–13.9 vs 5.9%, 95% CI: 4.4–7.8 in 2016, p<0.001) and continued to increase in 2018 (15.5%, 95% CI: 13.7–17.5, p<0.01). In 2018, women were more embarrassed than men (OR=2.0; 95% CI: 1.5–2.6, p<0.001). In 2018, 26.8% (95% CI: 24.6–29.1) of smokers said the appearance of a pack of cigarettes motivated them to quit, and 22.5% (95% CI: 18.3–27.2) ex-smokers cited it as having motivated them to quit. Smokers who were embarrassed by displaying their pack were more likely to be motivated to quit because of the pack’s appearance. People with higher incomes were less likely to report motivation to quit due to the pack than people with the lowest income (OR=0.5; 95% CI: 0.3–0.7, p<0.001).

CONCLUSIONS

In the French context, the new plain packaging of tobacco products probably had an impact on smokers’ perception of tobacco by increasing the embarrassment they felt when they took out their pack of cigarettes in plain sight. It also influenced the motivation to quit smoking, and more generally, it could contribute to the denormalization of tobacco.

Moving targets: how the rapidly changing tobacco and nicotine landscape creates advertising and promotion policy challenges

Tobacco, nicotine and related products have and continue to change rapidly, creating new challenges for policies regulating their advertising, promotion, sponsorship and sales. This paper reviews recent commercial product offerings and the regulatory challenges associated with them. This includes electronic nicotine delivery systems, electronic non-nicotine delivery systems, personal vaporisers, heated tobacco products, nicotine salts, tobacco-free nicotine products, other nicotine products resembling nicotine replacement therapies, and various vitamin and cannabis products that share delivery devices or marketing channels with tobacco products. There is substantial variation in the availability of these tobacco, nicotine, vaporised, and related products globally, and policies regulating these products also vary substantially between countries. Many of these products avoid regulation by exploiting loopholes in the definition of tobacco or nicotine products, or by occupying a regulatory grey area where authority is unclear. These challenges will increase as the tobacco industry continues to diversify its product portfolio, and weaponises 'tobacco harm reduction' rhetoric to undermine policies limiting marketing, promotion and taxation of tobacco, nicotine and related products. Tobacco control policy often lags behind the evolution of the industry, which may continue to sell these products for years while regulations are established, refined or enforced. Policies that anticipate commercial tobacco, nicotine and related product and marketing changes and that are broad enough to cover these product developments are needed.