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Abstract
Aims To explore the impact, if any, that using plain (non-branded) cigarette packs in real-life settings has on young adult smokers.
Methods Naturalistic-type research was employed, where smokers used brown ‘plain’ packs for 2 weeks and their regular packs for 2 weeks, in real-life settings. Participants were recruited in Glasgow, Scotland. Of the 140 smokers aged 18–35 years who participated in the naturalistic study, 48 correctly completed and returned all questionnaires. Over the 4-week study period, participants completed a questionnaire twice a week assessing pack perceptions and feelings, feelings about smoking, salience of health warnings and smoking-related behaviours. A subsample of 18 participated in a post-study interview, which employed a semistructured topic guide to assess perceptions and experiences of using plain packs.
Results Trends in the data show that in comparison with branded packaging, plain packaging increased negative perceptions and feelings about the pack and about smoking. Plain packaging also increased avoidant behaviour (hiding the pack, covering the pack), certain smoking cessation behaviours, such as smoking less around others and forgoing cigarettes, and thinking about quitting. Almost half (n=8) of those in the post-study interview, predominantly women (n=6), reported that the use of plain packs had either increased avoidant behaviour or reduced consumption.
Conclusions This pilot naturalistic study suggests that plain packaging could potentially help reduce tobacco consumption among some young adult smokers, and women in particular. Employing an innovative research methodology, the findings of this study are consistent with, and indeed support, past plain packaging research.
- Tobacco
- plain packaging
- young adults
- packaging and labelling
- public policy
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Introduction
It is a quarter of a century since the use of plain brown wrappers for tobacco products was first suggested by Canadian doctors, who pointed out the anomaly of permitting such a dangerous product to be ‘dressed up’.1 Since then, the debate on plain packaging has continued. This has centred around four main issues: (1) tobacco industry costs, (2) counterfeiting and pricing, (3) legality and (4) proportionality.
Costs
Tobacco companies argue that plain packaging would cause them significant additional costs for pack redesign and printing. However, this would be a one-off expense—once plain packs were introduced they would, by definition, remain much the same thereafter. This contrasts with the present situation, where the pack shape, livery and method of opening are continuously researched and redesigned—the costs of which are both considerable2 and ongoing. In this sense, then, plain packaging is a cheaper option for tobacco companies.
Counterfeiting and pricing
Tobacco companies argue that plain packaging would stimulate growth in counterfeit tobacco as it would be easier, and cheaper, to produce. This would combine with a tendency for them to compete more assiduously on price—one of their few remaining marketing tools—to drive down prices. This, in turn, would encourage consumption and outweigh the public health benefits of plain packaging.3 However, both assumptions are questionable. First, there is no evidence to suggest plain packaging would increase counterfeiting, and given that the costs of manufacturing cigarettes for the illicit market on a large scale are so low, the presence of branding on packaging is unlikely to have an impact on these costs in any meaningful way.4 And the predicted price war, should it materialise, would actually reduce the appeal of illicit sources. Second, the suggestion that plain packaging would stimulate more price competition is not an argument against its introduction, but for pricing regulation.
Legality
Tobacco companies argue that plain packaging would breach intellectual property rights and contravene international trade agreements. They accept that there are exemptions to these principles on the grounds of public health, but then argue that the evidence on the public health gain from plain packaging is weak and hence the measure is not proportionate.3 5–7 However, this position is undermined by industry documents which show that they consider the protection of both intellectual property and trade agreements to be insufficient to prevent plain packaging from being introduced.8 9 This would suggest that they are unlikely to have a successful legal challenge to the move towards plain packaging in Australia.10 11
Proportionality
Nonetheless, the issue of proportionality remains, and regulators must show a clear public health gain to justify introducing plain packaging. At the third Conference of Parties for the Framework Convention on Tobacco Control,12 13 plain packaging was recognised to have three such benefits: it would (1) reduce the promotional appeal of the pack,14 (2) make the health warnings more prominent and effective15 16 and (3) prevent the use of design elements, such as colours, which consumers often erroneously see as indicators of product safety.17 A review of existing plain packaging research found that all studies located had explored, and found support for, at least one of these three benefits.18
The tobacco industry, however, questions the strength of this evidence base and, in particular, argues that studies to date have been artificial measures of the perceived effects of plain packaging, rather than real-world measures of actual effects.3 5–7 Real-world effects are, of course, difficult to assess until the measure is actually introduced, so there is a danger of this objection becoming a barrier to progress.
We attempted to get around this impasse by conducting a real-world test of plain packaging. A group of smokers were given plain packs and asked to use them, instead of their normal branded ones, for 2 weeks. For 2 weeks, they transferred their cigarettes to the plain packs provided, but otherwise smoked and socialised as normal. For the other 2 weeks, the smokers used their own packs. This is the first attempt at a ‘naturalistic’-type study of plain packaging.
Methods
Sample selection
The study involved four separate but related stages conducted with young adult smokers aged 18–35 years recruited in Greater Glasgow by market recruiters. Young adult smokers were recruited for two reasons: (1) industry documents reveal 18–35-year-olds to be the key target group19 20 and (2) smoking prevalence is particularly high among this age group in the UK.21 22
Design and procedure
The first stage of the research involved eight focus groups with 54 smokers, in February 2010, to explore perceptions of cigarette packaging and plain packaging and to inform and guide the naturalistic study by exploring: an appropriate plain pack colour to use (dark grey, light grey, dark brown or light brown/beige), a suitable neutral fictitious brand name for the plain packs (either Kerrods, Standards or Netral) and perceived difficulties with using plain packs in real-life settings. Dark brown was perceived as the least appealing colour in all groups, and the fictitious brand name Kerrods elicited neither positive nor negative associations. As such, dark brown plain packs with the brand name Kerrods were used in the naturalistic study. A suggestion to increase compliance was to provide smokers with the cigarettes already contained within the plain packs. Although a viable option, we decided against this because smokers who may otherwise quit would be encouraged to continue and also because of the additional costs required for supplying prepackaged cigarettes.
A pre-pilot naturalistic study was then conducted with six smokers, in March 2010, who were provided with 14 plain packs (without cigarettes inside) and asked to transfer cigarettes from their packs into the plain packs each day for a 2-week period. They were also asked to complete identical questionnaires every second day for these 2 weeks. Questionnaires were developed by the research team, primarily from smokers' reactions to plain packs within the focus groups, and covered five areas: pack perceptions, pack feelings, feelings about smoking, health warnings (measured on five-point scales) and behavioural change/avoidant behaviour (measured via yes/no responses). The items on behaviour change and avoidant behaviour were adapted from the International Tobacco Control project. Two focus groups were subsequently employed to explore participants' experience of using the plain packs, completing and comprehension of the questionnaires, and any aspects of the study protocol that could be improved. Smokers did not question the authenticity of the Kerrods packs or highlight any problems transferring their cigarettes into these packs, which took only a minute or so. All smokers reported using the packs for the 2 weeks, although one smoker reported not using the pack on a night out after he ran out of cigarettes. The two focus groups thought that the questionnaire was comprehensible but completing it every second day was cumbersome.
The main naturalistic study was carried out from May to June 2010. Young adult smokers (n=140) were recruited from 14 randomly selected postcode sectors in Greater Glasgow, using random location quota sampling. The 14 postcode sectors were randomly selected, stratified by deprivation category score (a measure of multiple deprivation), to ensure coverage of a range of socio-economic backgrounds. Within each selected postcode sector, 10 participants were recruited, using the door knock method, according to quota controls on age, gender and social grade. All potential participants were informed that the study was concerned with smokers' experiences of, and opinions about, tobacco packaging. If individuals indicated that they were willing to participate, and available for the study duration, they were asked to complete a recruitment questionnaire that included questions on consumption and cessation behaviour (motivation to quit, attempts to quit). If they satisfied the criteria for study inclusion, participants were instructed on what they were required to do throughout the study period and given a ‘completion’ pack; this contained the 14 plain packs, the questionnaires (labelled by day and date), and a timetable explaining when to use the plain packs and when to use their own packs and also when to complete each of the questionnaires.
The study lasted for 4 weeks. For either the first or the last 2 weeks, participants were instructed to transfer cigarettes from their own packs into the packs supplied to them and then use these packs; ordering was randomised with half using the plain packs in the first 2 weeks and half in the last 2 weeks. The same text message (Smoking Kills) was used on the pack front and the same pictorial image of diseased and healthy lungs on the rear panel to minimise costs—in the UK, all cigarette packs carry one of two text warnings on the front panel of the pack and one of fourteen pictorial warnings on the rear panel. Participants were also instructed to complete questionnaires twice a week and return them via pre-addressed envelopes or email. This resulted in four questionnaires relating to their experience of the plain packs and four for their own packs. The questionnaires were identical to those used in the pre-pilot study but were only to be completed twice a week, rather than every second day, to reduce the burden on participants. In an attempt to manage sample maintenance, market recruiters were instructed to text respondents once a week reminding them to complete and return the questionnaires and to use the correct pack (their own pack or the plain pack), as specified by the timetable. A member of the research team also sent an email, once a week, to participants who had provided an email address, as an additional reminder to complete and return the questionnaires. Participants received £20 for using the packs and £2.50 per questionnaire returned.
From the 140 smokers recruited in the main study, 50 were phoned and invited to participate in a follow-up interview in the week following study completion; 20 could not be reached by telephone (after five attempts), seven declined to take part and five reported not participating in the study and were deemed ineligible. Reasons for non-participation were personal or familial health problems for three respondents, giving up smoking for one respondent and losing the packs for another respondent. Those who could not be contacted did not differ from those who completed, or refused to complete, the interview, in terms of age, gender, social grade or smoking behaviour. Participants comprised nine men and nine women, 12 aged 25–35 years and 6 aged 18–24 years, and 7 from social grade ABC1 and 11 from social grade C2DE. A semistructured topic guide was developed to explore the same themes covered in the questionnaire. Interviews lasted approximately 30 min. Each interviewee received £10 for participation.
Analysis
At the analysis stage, some items were recoded to ensure the same direction of coding and thus facilitate interpretation and creation of composite variables. Composite scores were derived for pack perceptions, pack feelings, feelings about smoking and response to warnings by summing the individual items within each and then rescaling to a five-point scale. Cronbach's α was acceptable for each, thus supporting the decision to create composite scores at each wave and for each pack type, although Cronbach's scores for pack perceptions of Kerrods at the first and third measures (0.66 and 0.69, respectively), and overall pack feelings of own pack at the second measure (0.63), were marginally lower.
Analysis focused on comparing ratings between branded and plain packs. To ensure packs were compared against equivalent time points, the ratings of the plain pack at the first, second, third and fourth measures were compared with the ratings of the participant's own pack at the first, second, third and fourth measures, respectively. For each time point, paired t tests were used to produce mean scores for the plain packs relative to mean scores for their own packs. Given the ordinal nature of the five-point scales, the Wilcoxon signed rank test, a non-parametric procedure suited to paired data, was used to test for significant differences between the ratings of plain packs versus the ratings of the participant's own packs at each measure. Data on occurrence of avoidant behaviours are binary (yes/no), and the McNemar test was used to test for differences in response between participants' first, second, third and fourth measure on the plain pack and the respective measure on their own pack.
Results
Naturalistic study
From the 140 participants recruited, 34 (25%) were non-completers, who failed to participate at all, 58 (41%) were partial completers (who participated but did not return all the questionnaires or report using the correct pack) and 48 (34%) were completers, who completed the full study as intended. Non-completers, with a mean age of 23 years (SD=4.7), were younger than both completers (mean age=27 years, SD=5.5) and partial completers (mean age=28 years, SD=5.5). There was no marked difference in participation, however, by amount smoked, motivation to quit or attempts to quit. The analysis focuses only on the 48 completers.
Pack perceptions
On average, participants rated Kerrods negatively on all pack perceptions (not stylish, unfashionable, cheap, uncool, unattractive, poor quality, unappealing), with mean scores ranging from 1.35 to 2.07, lower scores indicating more negative perceptions (see table 1A). For their own packs, mean scores ranged from 2.64 to 3.48, indicating more positive perceptions. For the overall pack perception score, participants rated the Kerrods pack more negatively than their own packs. Overall ratings did not vary across time for either pack.
Mean ratings on response to Kerrods pack versus own pack
Pack feelings
On average, participants reported more negative feelings (embarrassed, ashamed, unaccepted) about using the Kerrods pack, relative to their own packs (see table 1B). For the Kerrods pack, mean scores ranged from 2.24 to 2.70, whereas mean scores for their own packs ranged from 3.18 to 4.20. Overall ratings did not vary across time for either pack.
Feelings about smoking
Participants reported more negative feelings about smoking from the Kerrods pack (see table 1C). Participants, on average, rated the smoking experience with their own packs as more ‘enjoyable’ (mean scores 3.13–3.37) and ‘satisfying’ (mean scores 3.13–3.35) than for the Kerrods packs, rated as less ‘enjoyable’ (mean scores 2.53–2.78) and ‘satisfying’ (mean scores 2.58–2.70). Overall ratings for Kerrods did not vary across time. However, the average overall feelings about smoking from their usual pack were less positive at the third and fourth measures compared with the first.
Health warnings
For both packs, participants rated the warnings as being noticeable (mean scores 3.39–4.11), serious (3.85–4.28), believable (4.09–4.34) and highlighting the health risks of smoking (3.67–3.98; see table 1D). Only at the first and second measures, warnings on the Kerrods pack were rated as more noticeable relative to their own packs. Only at the fourth measure, warnings on the Kerrods pack were rated as more serious. However, overall ratings of the warnings did not differ between the packs and did not vary across time for either pack.
Behavioural change/avoidant behaviour
Across all four measures, participants indicated greater occurrence of the following actions when using the Kerrods pack: keeping the pack out of sight, covering the pack, smoking less around others and thinking about quitting. In addition, when using the Kerrods pack, participants were always more likely to forgo a cigarette (although only significantly so at the third and fourth measures), and always more likely to indicate that they wanted to quit (although only significantly so at the second and fourth measures; table 2).
Proportion of participants reporting behaviour change or avoidant behaviour as a result of pack
Post-study interviews
Pack perceptions
About half (n=10) of the 18 smokers who participated in the interviews perceived the Kerrods pack as less appealing (see table 3). Despite these negative perceptions, the durability of the Kerrods pack was viewed as similar to branded packs.
Smokers' perceptions and feelings of packaging and smoking in the post-study interview
Pack feelings
Five (female) smokers said they felt embarrassed or guilty when using the Kerrods pack, often because of the attention it drew from others (see table 3). Some liked this attention but, as was found in the pre-pilot focus groups (not previously reported), they acknowledged that it was due to a novelty factor that would not exist if all cigarette packs on the market were brown.
Feelings about smoking
Twelve smokers reported not feeling any differently when using the Kerrods pack. Six (five women) said that even though they knew it was their own brand inside the Kerrods pack, it felt like they were smoking cheap cigarettes or that the cigarettes did not taste as good (see table 3).
Health warnings
Twelve smokers thought the warnings on Kerrods packs were just as salient, believable and serious as on branded packs. Six considered the warnings on the Kerrods packs more salient, five more believable and four more serious (see table 4).
Smokers' perceptions of health warnings on plain packs and avoidant behaviour and behavioural change
Behavioural change/avoidant behaviour
About half (n=8) reported some change in their smoking behaviour when using the Kerrods pack, again mostly women (n=6). This included taking out cigarettes less often, handing out cigarettes less frequently and hiding the pack more. Three women also reported reducing their usual consumption levels. Reasons given for avoidant behaviour, or behaviour change, included the pack colour, the reactions from others and the more prominent warnings (see table 4). Three smokers suggested that if all cigarettes came in the dark brown packs, they would consider quitting.I would definitely try to quit (Female, 25–35 years, C2DE)
Of the 10 smokers who perceived no change in their smoking behaviour, when asked about the possible impact of plain packaging on youth, 6 thought it would deter them from starting.A person might think that maybe smoking is a disgusting habit. It's brown, the colour of crap and the crap I'm putting in my lungs and smoking, over time, might just get less and less appealing to them (Male, 18–24 years, C2DE)
For the four smokers who thought that plain packaging did not, and would not, have any effect on them, or others, they explained that smoking is an addiction and it is the cigarette, not the pack, which is important.At the end of the day it is not the packet you are smoking, it is the cigarettes in the packet. It is the cigarette you are addicted to and not the cardboard box (Male, 25–35 years, C2DE)
Discussion
Employing an innovative methodology, we explored young adult smokers' perceptions of using non-branded packaging on a daily basis. The study used, for the first time, a naturalistic design, but our findings are consistent with past research. First, warnings on dark brown ‘plain’ packs were rated as more salient than warnings on branded packs, at least at the first and second measures, and for a third of those in the post-study interview. Some smokers pointed out that the increased salience increased thoughts about the harms of tobacco.
Second, plain packs had less promotional appeal, being perceived negatively throughout the study. The pack colour, distinct from all other brands on the UK market, was viewed as unattractive by smokers and others. The use of a faecal brown pack colour appeared to both destroy the symbolism of tobacco branding and heighten the awareness of associated health risks. For instance, one smoker commented that ‘Even the colour of the pack just made me think, oh God, are my lungs this colour as well?’ These negative perceptions often resulted in embarrassment, shame or guilt. Although we did not explore gender differences in the quantitative analyses, the post-study interviews strongly suggests that these negative pack perceptions and feelings are most pronounced for women and considerably less so for lower income men. Interestingly, some smokers reported positive feelings when first using the plain packs but, in both the pre-pilot focus groups and post-study interviews, all smokers who reported a positive ‘novelty effect’ described it as transient and claimed that it would not exist if the dark brown packs were the norm, that is, if plain packaging was mandated.
Third, we found that plain packaging was associated with changes in the sensory perceptions of the product, known as ‘sensory transfer’, where pack colour affected taste perceptions.23 24 Approximately a third of smokers in the post-study interviews reported that their cigarettes did not taste as good from the brown pack—even though it was their normal brand of cigarettes. The removal of familiar, and often reassuring, branding altered perceptions of product taste, and for some it was associated with, or appeared to directly trigger, avoidant behaviour (eg, covering the pack), a reduction in consumption and increased thoughts of quitting. This was apparent in both the quantitative analyses and the post-study interviews. This effect on avoidant and smoking cessation behaviours requires verification, but it is a direct benefit of the naturalistic design employed, which makes it possible to uncover real-world effects.
The study has its limitations, most notably the small sample size—exacerbated by high attrition and some failure to correctly comply with study protocol. This was, however, a pilot study, with a high level of participant involvement, intended to explore the feasibility of such research and allow some insights into smokers' perceptions of plain packaging in real-world settings. Future research could deploy greater resources and recruit a larger and nationally representative sample. The study protocol could also be simplified, particularly by providing smokers with their own brand of cigarettes already in plain packs. This would help reduce attrition and eliminate the need for smokers to transfer the cigarettes into plain packs, especially as it is impractical to verify that all smokers did so. This option was suggested in the focus groups, but our limited pilot-study resources precluded adopting the idea. Another possibility to increase compliance is to provide larger incentives for participation and reduce the length of the study period.
The use of a generic brand name, even though neutral, may have affected participants' perceptions of plain packaging. Although providing each smoker with plain packs carrying the name of their brand was not possible in this study for legal reasons, given a possible breach of copyright, future research should consider the role and importance that brand name may have for smokers in the event of plain packaging. Another limitation is that the study is dependent on self-reports, in terms of reported behaviour change and the use of Kerrods packs. For the latter, reported use may also have been inflated by socially desirable responding. Aside from providing cigarettes within packs, it is difficult, however, to envisage an alternative approach when using naturalistic research. The study also provides no insight into the potential impact that plain packaging may have for older adult smokers.
Conclusion
Notwithstanding the small sample size, this is the first naturalistic study of plain packaging and it adds an important real-world dimension to the evidence base. As well as confirming the general lack of appeal of plain packs, some adult smokers reported decreased enjoyment and consumption as a direct result of using plain packs, and others claimed that they would attempt to quit if all cigarettes came in dark brown unbranded packs. This suggests that plain packaging may have a role to play in helping smokers, and based on the post-study interviews, particularly female smokers, on the road to becoming smoke free.
What this paper adds
Past research on plain (unbranded) tobacco packaging suggests that the removal of branding from packaging may help to increase the salience and seriousness of health warnings, reduce the appeal of both the package and smoking, and promote cessation behaviour.
Using a naturalistic design this study is the first to attempt to provide a real-world measure of the possible impact of plain packaging. The findings show that in comparison with branded packaging, the use of plain packs resulted in more negative perceptions and feelings about the pack, more negative feelings about smoking, and for some smokers it also increased avoidant behaviours such as covering the pack and cessation behaviours such as forgoing cigarettes and thinking about quitting.
Acknowledgments
We would like to thank the advisory group (Deborah Arnott, Karine Gallopel-Morvan, David Hammond, Heather Wardle) for providing advice on the study design and methodology and to Diane Dixon for helping to coordinate the study.
Footnotes
Funding Cancer Research UK.
Competing interests None.
Ethics approval This study was conducted with the approval of the University of Stirling.
Provenance and peer review Not commissioned; externally peer reviewed.