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Abstract
Background Tobacco retail displays promote smoking experimentation among youth; however, little is known about their effect on smokers making a quit attempt. Calls to ban tobacco retail displays would be strengthened if this measure would deter initiation and support cessation.
Methods Semistructured in-depth interviews were conducted with 20 individuals, from two New Zealand provincial cities, who had attempted to quit smoking in the last 6 months.
Results Tobacco products had high visibility, and elicited emotional and physical reactions that created on-going temptation, complicated cessation attempts and stimulated impulse purchases. Participants strongly supported banning tobacco retail displays primarily because they thought this would reduce youth initiation, promote greater consistency with smoke-free promotions and assist those attempting to quit.
Conclusions The effects of tobacco retail displays on smokers making a cessation attempt are explored. The findings are consistent with experimental and survey research, and expand a growing evidence base that supports government-mandated bans on tobacco retail displays.
- Point of sale
- cessation
- qualitative
- advertising and promotion
- qualitative study
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The New Zealand Smoke-free Environments Act 1990 banned tobacco advertising and sponsorship, leading tobacco companies to rely more heavily on media that have fewer restrictions, such as retail store displays and product branding.1–4 Point-of-sale (POS) marketing maintains brand visibility and promotes sales, and provides tobacco companies with undiscriminating reach and potentially high exposure to children.5–9 Analyses of industry documents suggest that retail marketing is a pivotal medium in “dark markets”, where mainstream mass media are restricted.2 4 10–13 Displays position tobacco products as “a benign cultural commonplace … on a par with milk and bread”,14 and their ubiquity facilitates initiation by suggesting that smoking is more prevalent than is actually the case, enhances perceptions of smoking and weakens non-smoking intentions.15 Accumulating research findings suggest that tobacco retail displays may attract new users, particularly children, and have prompted calls to ban in-store tobacco marketing.16–22
Evidence that tobacco displays promote smoking initiation raises the question of whether they may also maintain the salience of smoking and induce nicotine craving, thus impeding cessation and promoting relapse among recent quitters.23 Given the tobacco industry's interest in retaining concerned smokers, uneven compliance with existing regulations, and the difficulty of quitting,14 24 identifying environmental factors that inhibit cessation could inform more effective policy development.
To date, few studies have explored whether or how retail displays affect smokers, particularly those making a quit attempt or who have recently become smoke-free. Carter et al's (2006) experimental study concluded that tobacco imagery affected adult smokers' cravings for cigarettes.25 Given that their test stimuli comprised only eight cigarette packets arranged as an isolated group, full POS displays may have even stronger effects, a suggestion supported by a survey of Australian smokers, which concluded that tobacco retail displays stimulate impulse purchases and tempt those trying to quit.26
Behaviour modification theory recognises that environmental variables, such as POS stimuli, cue and maintain behaviour; logically, this theory suggests that exposure to retail displays impedes smoking cessation.27–29 Yet, despite theoretical and empirical evidence that POS displays could maintain smoking among smokers, few studies have explored how former smokers and lapsed quitters understand, and are affected by, tobacco retail displays. As this knowledge would inform policy development and add a new dimension to existing findings, we investigated how lapsed quitters and former smokers perceived retail displays and regulatory proposals that would limit these.
Methods
Twenty in-depth interviews were undertaken with 11 Māori and 9 non-Māori participants. All had made a quit attempt in the last 6 months; 12 were still smoke-free while 8 had lapsed. The sample included a high proportion of Māori as smoking prevalence is disproportionately high among these people (45.7% cf 20.6% among non-Māori) and results in serious health inequalities.30 Participants were purposively recruited to promote diversity and were drawn from cessation providers, including the NZ Quitline (8) and an iwi (indigenous Māori) health provider (10) and personal networks (2). Participants were aged between 23 and 59 years, came from varied socioeconomic backgrounds, had differing smoking histories and included both genders. Interviewing continued until saturation of themes became apparent. Table 1 contains details of participants' demographics and smoking history.
Participants' quitting history
Three interviewers (two Māori and one non-Māori) made telephone contact (including up to 10 callbacks) with potential participants. In total, 61 people were contacted; 4 refused to participate, 9 had an inactive number, 23 had moved, 3 resided with other participants, 2 were unavailable during the fieldwork period and 20 were successfully interviewed. After deducting ineligible participants, the response rate was 83%.i
McCracken's “long interview” approach provided an overall protocol for the research, which began with a detailed literature review and considerable reflection by research team members.31 As recommended, the semistructured interviews opened with biographical and behavioural questions, questioning then encouraging participants to review their quit experiences, the factors influencing these attempts, and the outcome. Participants also commented on how they perceived retail environments and explained whether they would support a ban on point of sale tobacco displays.
Interviews took place in participants' homes or workplaces and lasted between 20 and 40 min. Each interview was recorded and transcribed verbatim, and two interviewers (one Māori and one non-Māori) used Braun and Clarke's (2006) approach to review transcripts and recordings, and identify themes.32
Quotations illustrate emergent themes and note whether participants were Māori (M) or non-Māori (NM), female (F) or male (M), their smoking status quit (Q) or lapsed (L), and their age. Ethical issues in the research protocol were reviewed and approved by the Department of Public Health, University of Otago.
Results
Factors motivating quit attempts
The interviews created a discussion context by exploring participants' smoking history. On average, participants had smoked for 28 years (range 12–40 years), made multiple quit attempts, and, at different stages in their lives, been smoke-free for periods ranging from 1 day to 4 years. Participants' desire to re-assert control over their lives provided the strongest motivation to quit. Many also wanted to avoid smoking-related harm, particularly when they had first-hand experience of illnesses attributable to smoking. Becoming smoke-free was also strongly linked to financial liberation, as it would release participants from choice dilemmas, such as their need for tobacco versus their responsibility to provide for their families.
Influences on quit attempts
Participants' environments and circumstances often complicated their quit attempts; stressful situations, lack of preparation, on-going access and exposure to tobacco imagery had affected their ability to become (or remain) smoke-free. The high salience of tobacco products was a recurring theme, particularly the size and position of tobacco displays: “Oh yeah, they are right smack bang in front of you, so you can't miss them” [MML,23]. The prominence and position of tobacco displays ensured high visual salience: “When I go up to the counter, the first thing that catches your eyes, at the back of them [staff] is the cigarette counter… [they] are in your face… they are right there in front of you … in full view… in a big huge cabinet.” [MFQ,43] as did the location of these: “It's staring straight at you when you walk up to the counter.” [MMQ,43].
While a small group felt unaffected by displays, others felt tempted. Awareness of the display, the difficulty of avoiding seeing tobacco brands and the ease with which they could access these brands stimulated desire: “…there was a temptation there… I knew what I was buying and my eyes would flash across to the display where the cigarettes were.” [MFQ,37] and “You are just thinking, “hmmm, I wish I could have some of those”, cause they are right there.” [MML,23].
Temptation created physical and emotional cravings: “Right behind the flaming counter, because when I gave up, that's all I'd look at when I'd go to a dairy or petrol station for smokes … Yeah, it did make me long for a smoke when I saw them… It made me think, gosh, look what I'm missing out on.” [NMFL,44]. Cravings prompted purchase: “Yeah, normally I see the smokes and then that'll trigger me to buy a packet.” [MFL,32].
Participants' cravings went beyond physiological responses and were anchored by deep affective feelings: “It was in your face… it would be like I could see a smoker and I would be… kind of drawn to it in a sense.” [NMMQ,45]. Tobacco brand imagery exerted a mesmerising influence as smokers accessed the persona they created via the brand: “There's a connection made, you know, between observing, seeing the packet, and then knowing what the packet feels like, and then you can start by getting warmed up about opening the packet and smelling the cigarettes and lighting one up and what that means for you and you know there's whole number of connections that are made… it's advertising.” [NMMQ,45]. Exposure to tobacco imagery reminded quitters of familiar behaviours and the benefits they derived, and created a powerful challenge to their cessation attempts.
Responses to policy proposals
Most participants supported proposals to ban tobacco retail displays because these increased the difficulty of quitting: “I would agree…that having them in your face, for those who are trying to give up, [that] … it is harder for them.” [MFQ,43]. Removing displays would thus remove a barrier quitters must overcome in their cessation journey: “I think it would be a hell of a lot easier if it wasn't there… because you know, the temptation's not there.” [NMML,59]. Exposure to brand imagery challenged their quest to become (and remain) smoke-free: “I'd be quite happy if they were all to go, under the counter, or in a back room, or something like that… I felt very tempted. And it brought back to me what I was missing out on again, just that emptiness.” [NMFL,44].
Participants also felt strongly that a ban on tobacco displays would protect children. Some thought it morally wrong to expose children to toxic products: “I don't think it's right that those cigarettes are where they are… I don't think… that children should be exposed to cigarettes.” [NMMQ,45]. Others believed removing displays would increase the chances that young people would not smoke: “I reckon it might be a good chance of them not smoking, 'cause it's not there when they walk into a shop.” [MFQ,28]. Some projected their own feelings of temptation and thought removing displays would reduce the risk that young people might smoke: “It's possibly encouraging for younger people who are more easily tempted.” [NMMQ,47].
In addition, several thought removing tobacco displays would help promote consistent smoke-free messages: “The message is conflicting in the sense that we've stopped smoking in a pub, we've stopped smoking on a bus, but we still let cigarettes be retailed in just about every shop in New Zealand. That… seems a paradox.” [NMMQ,45].
Banning tobacco displays would challenge the view of smoking as “normal”: “It's [allowing displays] doing, letting, telling them it's okay to smoke” [MFQ,43]. Participants thought making tobacco less visible would reduce perceived social approval of smoking, which would decrease the number who began smoking: “Maybe then [once retail displays were banned]… less people would take it up and it would be a thing that eventually… you don't see that many people doing anymore.” [NMMQ,45].
Discussion and conclusions
This study probed how lapsed quitters and former smokers view tobacco POS displays and feel affected by them, and explored their reaction to a proposed ban on tobacco retail displays. The findings explain how these displays function and confirm effects reported earlier.15 25 26
Participants explained how tobacco displays reminded them of the addiction they are relinquishing, and the ease with which they could resume it. Exposure to tobacco brand imagery also stimulated physical cravings and resurrected the emotional ties they had with “their” brand. The key themes are logically aligned with behaviour modification theory, and its recognition of the role brand imagery and learned associations play in fostering purchase.
On one level, participants' support for a government ban on tobacco retail displays, and the benefits they thought this would bring, reflects the difficulty of becoming and staying smoke-free. However, it also recognises the influence tobacco imagery exerts and their desire to protect future generations.
Our findings suggest that tobacco retail displays promote smoking and undermine cessation attempts. Given the difficulty of quitting and the multiple attempts often required, policy makers need to create supportive quitting environments by eliminating stimuli that promote lapsing. Article 13 of the Framework Convention on Tobacco Control calls for a “comprehensive ban of all tobacco advertising, promotion and sponsorship” and requests signatories to go beyond the provisions specified.33 Given that participants viewed POS displays as advertising, our findings imply that bans on these displays would be consistent with existing legalisation and Framework Convention on Tobacco Control obligations. More generally, the findings align with results from experimental studies and surveys and suggest that eliminating tobacco retail displays would deter initiation and support addicted smokers seeking to become smoke-free.
What this paper adds
Calls for tobacco display bans are supported by experimental and survey evidence, but little is known about how displays affect quitters or why many support bans on these.
This qualitative study found that tobacco retail displays elicited emotional and physical responses, and undermined quit attempts. Current and former smokers strongly supported banning tobacco displays, which they thought would assist smokers attempting to quit and remove an on-going invitation that encourages young people to experiment with tobacco.
Acknowledgments
We are grateful to the individuals who agreed to participate in this research and whose detailed responses provided the basis of this article.
References
Footnotes
Funding New Zealand Cancer Society (PO Box 12700, Wellington 6144, New Zealand) and Action on Smoking and Health (PO Box 99 126, Newmarket, New Zealand).
Competing interests All authors have undertaken work for the Cancer Society of New Zealand and Action on Smoking and Health New Zealand. Although we do not consider it a competing interest, for the sake of full disclosure we note that all authors have undertaken tobacco-related research for the New Zealand Ministry of Health. All authors have received funding for tobacco-related research from the Health Research Council of New Zealand.
Patient consent Obtained.
Ethics approval This study was conducted with the approval of the Department of Public Health, University of Otago.
Provenance and peer review Not commissioned; externally peer reviewed.
↵i RR=(20/61−(9+23+3+2))100=83%.