Health Promotion International Advance Access originally published online on January 28, 2005
Health Promotion International 2005 20(1):41-49; doi:10.1093/heapro/dah506
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Targeting smokers via tobacco product labelling: opportunities and challenges for Pan European health promotion
Cancer Research UK Centre for Tobacco Control Research, University of Stirling, Department of Marketing, Stirling, FK9 4LA, UK
Address for correspondence: Elinor Devlin, Cancer Research UK Centre for Tobacco Control Research, University of Stirling, Department of Marketing, Stirling, FK9 4LA, UK E-mail: elinor.devlin{at}stir.ac.uk
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SUMMARY |
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 TOP SUMMARY INTRODUCTIONMETHODSRESULTSDISCUSSION AND CONCLUSIONSREFERENCES |
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Cigarette on-pack messages are one of the principal vehicles for informing smokers about the risks of smoking and research has highlighted their role as a valid health communication tool. Furthermore, they have the potential to disrupt the powerful cigarette brand imagery associated with tobacco packaging. Responding to concerns within Europe that the old style on-pack messages were ineffective and the introduction of new tobacco product legislation across Europe (EU Directive 2001/37/EC
), this study was conducted to explore European smokers' response to the changes. The research draws upon two main areas of health communication: the need to pre-test messages to ensure they are appropriate for their intended audience; and the increased effectiveness of targeting messages to specific segments of the population. Two main research areas were addressed. First, the extent to which the new messages were appropriate for smokers in Europe and second, the potential to provide targeted and personally relevant messages to smokers via tobacco packs. Fifty-six focus groups were conducted across seven European countries (Finland, France, Germany, Greece, Spain, Sweden and the UK) with 17–64-year-old smokers, half of whom were not thinking about quitting (pre-contemplators) and half of whom were thinking of quitting in the next 6 months (contemplators and preparers). Implications for future labelling practices within Europe are discussed. Key words: Europe; targeting; tobacco labelling
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSION AND CONCLUSIONSREFERENCES |
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Tobacco consumption is responsible for 1.2 million deaths in Europe [World Health Organisation (WHO), 1999
]. This figure is estimated to rise to 2 million and account for one in five of all deaths in the European region by the year 2020 (Haglund, 2000). A comprehensive tobacco control strategy including policy on taxation, tobacco promotion, nicotine replacement therapies, smoke-free public places and health promotion is vital to persuade current smokers to quit and encourage young people not to start (World Bank, 2003). The labelling of tobacco products is an integral element of this strategy (Kaiserman, 1993) with many countries such as Australia, Poland and Canada introducing tougher legislation in this area (Borland, 1997; Przewozniak and Zatonski, 2002; Health Canada, 2003).
On-pack messages are a valid health communication tool. Research in Australia (Borland, 1997) found that new, more prominent information on tobacco packs (covering at least the top 25% of the front and the top third of the back of the pack) resulted in: increased noticing of the warnings; more potent stimulation of negative thoughts about smoking; and the premature stubbing out of cigarettes already lit. Research also supports design enhancements. The effectiveness of on-pack information can be increased by: being made more prominent (Kaiserman, 1993); being printed in contrasting colours (Ross, 1981); varying the design and content (Bhalla and Lastovieka, 1984); and by being developed for a target audience and informed by creative input and market research (Jacoby et al., 1982; Fischer et al., 1993). Cigarette packaging is known to play an important role in honing and supporting the imagery associated with powerful cigarette brands (Carr-Gregg and Gray, 1993). Research has shown that on-pack messages have the ability to disrupt this brand imagery by disrupting the available space on packs to communicate brand values and by undermining the influence of commercial communication (MacFadyen et al., 2001). Furthermore, Mahood (1999) argues that an effective warning system will create a situation of informed consent regarding the nature of the risks, the magnitude of the dangers and the probability of occurrence among smokers regarding the risks of tobacco smoke.
Within Europe, until recently, the labelling of tobacco products was governed by the 1992 EU Labelling Directive (EU Directive 1992/41/EC), which required a general message to be present on the most visible surface covering at least 4% (6% for countries with two languages) and an alternating specific warning on the back of the pack covering around 5%. The messages were required to be clear and legible, printed in bold letters and printed on a contrasting background. Research in the UK and across Europe found that the information provided fell short of informed consent (Health Education Authority, 1998) and that the messages were barely visible and not noticed by smokers (ASH, 1998).
EU legislation has begun to address these shortcomings with the introduction of the EU Directive on Tobacco Product Regulation (EU Directive 2001/37/EC). The Directive standardizes the design and content of messages across Europe and requires messages to be printed in black on a white background covering at least 30% of the front and 40% of the back of the pack, with a 5-mm black border. The Directive also prescribes a list of 16 messages (two for the front and 14 for the back), which are to be randomly rotated by member states (see Table 1).
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As a communication device, on-pack messages should follow the principles of communication theory and practice. It is recognized that good communication involves the active participation of both the sender and the receiver (Lannon and Cooper, 1983
; Meadows, 1983; Buttle, 1991). Effective health communications must therefore be designed in consultation with the target group, taking account of their needs and wants (Eadie and Smith, 1995). Audience research is generally conducted to formulate, develop and evaluate health communications (Atkin and Freimuth, 1989; Nowak and Siska, 1995). It follows that messages on tobacco packs, designed under this process, will be more effective in achieving their desired objective (Ross, 1981; Kaiserman, 1993; Eadie and Kitchen, 1999). Furthermore, careful targeting of messages will increase their effectiveness (Ross, 1981; Kaiserman, 1993) and it is argued that on-pack health information should be specific and targeted to certain segments of the population (Krugman et al., 1994; Mahood, 1999). Research was therefore conducted to examine the extent to which the new measures meet the needs of smokers in Europe and to explore the potential for labels to provide targeted and personally relevant messages.
The ‘Stages of Change’ model (Prochaska and DiClemente, 1983) was used to segment the target market. Prochaska and DiClemente's ‘Stages of Change’ model posits that behaviour change involves the progression through five stages: pre-contemplation, contemplation, preparation, action and maintenance. The model forms the basis of effective segmentation and allows messages to be designed that are tailored to the specific needs of the individual (Werch and DiClemente, 1994). The EU has identified those who want to quit as a priority group (Commission Report, 1999). However, as the majority of smokers are in the pre-contemplation stage it is vital to consider their views and ensure that any strategy developed does not alienate them. This research therefore explores the needs of smokers in the pre-contemplation and contemplation/preparation stages.
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METHODS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSION AND CONCLUSIONSREFERENCES |
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The research was conducted to provide an understanding of smokers' response to the range of measures outlined in the Directive including labelling messages and design. Given that smokers' response to such stimuli is likely to result from subconscious and entrenched attitudes, a qualitative research approach was required. This approach allows the researcher to elicit and understand underlying attitudes that cannot be directly observed or measured (Kumar et al., 1999
). Focus groups were employed; a technique which is widely used in commercial market research and the social sciences, and is extremely useful for exploring attitudes and perceptions and when exploring taboo or difficult behaviours such as smoking.
Sample
Fifty-six groups were conducted across seven countries (Finland, France, Germany, Greece, Spain, Sweden and the UK) with 17–64-year-old smokers. Groups typically comprised six to eight respondents and lasted between 1 and 2 h. The groups were purposively sampled according to age (17–24, 25–34, 35–44, and 45–64-year-olds), gender and smoking status: ‘pre-contemplators’ (those who are not thinking of quitting) and ‘contemplators/preparers’ (those who are thinking of quitting in the next 6 months). Throughout this report, descriptions and analysis of ‘contemplators/preparers’ is simplified to ‘contemplators’. The sample profile for each country is summarized in Table 2.
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In order to ensure consistency across the project, all countries used a specially designed recruitment questionnaire and followed agreed sampling procedures, although provisions were made for cultural differences. For example, recruitment of smokers in the UK was conducted door-to-door in residential locations, whereas Sweden advertized for volunteers. Similarly, all respondents were offered an incentive, according to local practice, to encourage their participation and to thank them for their contribution.
The groups were held in informal venues such as the recruiters' homes or a hotel. All groups were audio taped with respondents' permission and transcribed for thematic analysis.
Procedure
A semi-structured discussion guide was developed and translated into the relevant languages. While maintaining consistency, flexibility was afforded to allow for cultural differences in questioning techniques, to enable the participants to introduce their own salient points and to allow the researcher to explore issues as they arose.
Each group began with a warm-up discussion of current smoking behaviour and attitudes before focussing on response to both the old and the new style messages. This was examined by showing respondents packs of the three most popular cigarette brands in their country plus a pack of Marlboro (see Table 3) incorporating the old style messages and also mock packs incorporating the new labelling design.
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Message content was then explored using showcards of eight messages as outlined in the Directive (see Table 4). These comprise three message types: fear appeals, addressing the health consequences of smoking; social appeals, addressing the effect of smoking on others; and cessation support appeals.
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Analysis
The analysis process consisted of two stages. First, the groups were analysed in each country and a country report was prepared. Second, analysis of cross-country comparisons was conducted and reported.
In line with marketing research techniques, each focus group was transcribed for analysis (Wilson, 2003). The transcripts were then analysed by coding segments of the text according to the discussion guide and themes and issues resulting from the research. Important relationships between and among the codes were subsequently explored. Each country was instructed to produce a report based on their research. As all countries had used the same discussion guide and visual prompts, and to make the analysis process manageable, a generic report structure was provided for each country to follow. A new document was subsequently created which consisted of ‘cut and paste’ text (Wilson, 2003) from the original reports into separate sections relating to each topic. The re-categorized data was then printed out and key patterns, relationship and emergent themes were systematically coded and explored.
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RESULTS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSION AND CONCLUSIONSREFERENCES |
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Three key themes emerged from the research: the ineffectiveness of old message design and content; the strength of the new EU message format; and the potential of EU content.
Old message design and content
When presented with the packs incorporating the old message style, very few respondents in any of the countries spontaneously mentioned the messages, even when looking at and describing the pack. While this may be due to avoidance it appeared mainly due to a lack of prominence. This lack of prominence was blamed on both design problems and ineffective message content. As a result, the intended message virtually disappears.
...those little letters you never notice.(Spain)1
That is just part of the package.
(France, male, 45–64, contemplator)
Many respondents, particularly those who exhibited a degree of ambivalence about their habit, appeared happy to conspire with these cues, and ignore or rationalize away the message. They also raised suspicions about the motives behind the messages, seeing them as cynical or the hypocritical fulfilment of a legal obligation.
The tobacco industry washes its hands. They make the texts so small that it doesn't bother anyone, but they can claim having warned people.
(Finland, male, 25–34, pre-contemplator)
The content of the messages compounded the problem. They were felt to say nothing new and had remained unchanged for many years. Consequently, respondents tended to either reject them as patronizing and worn out, or displace them, arguing that they are only of relevance to children or new smokers. Again, a degree of rationalization was evident with many smokers content to be ‘let off the hook’.
They treat us like children, we're adults by now, we understand it's not good for us.(Spain)
A small number of respondents, particularly those from Northern Europe and those considering quitting, expressed a desire for larger, more effective messages that addressed issues of relevance to them.
EU message format
Respondents were then shown the more prominent message format as outlined in the Directive. The new message format was generally the first aspect of the pack mentioned and clearly undermined its ability to communicate brand values.
... the bigger it is, the better we see the warnings. It is unusual so we pay attention to it.(France, male, 17–24, contemplator)
The majority of respondents were supportive of the new format, perceiving it to add credibility to the intended message. Perhaps most importantly, the new message format seemed to provoke an emotional response among smokers who appeared quite shocked when first presented with the mock packs. It appeared to evoke feelings of guilt and prompted both thoughts and discussion around the negative aspects of smoking.
I feel sinful now and that is good.(Finland, female, 25–34, contemplator)
Scary.
(UK, female, 45–64, pre-contemplator)
There were exceptions however. Finnish respondents in the pre-contemplation stage expressed some genuine irritation about the new format and felt that it would not have much effect. They did, however, accept that the labels would help young people and may deter others from starting. In this respect they were willing to accept the role of the labels. Some respondents in Southern Europe, and especially Greece, seemed indifferent to the new format, and a minority of male respondents from Greece expressed irritation and hostility towards them, seeing them as invasive and pointless.
It therefore appears that the new format is able to gain the attention of smokers, at least on initial presentation. Pre-contemplators are more cynical than contemplators about the new format and respondents from Greece and Spain were more likely to question the role of on-pack labelling.
EU content
Response to new message content was then explored using a series of showcards as detailed in Table 4.
Fear appeals
This appeal category appeared to have a number of strengths. First, the messages were generally clear, short and to the point and respondents liked their simple and direct nature.
I think that was quite effective because it is just simple.(UK, female, 25–34, contemplator)
It's blunt, no beating around the bush.
(Spain)
Second, the tone of the message was perceived as realistic and appropriate given the seriousness of the message.
Third, fear appeals evoked a number of emotions among respondents such as anxiety and guilt. This was particularly true for descriptive messages such as ‘Smoking can cause a slow and painful death’. Finally, in the groups at least, these appeals gained the attention of smokers and prompted thoughts and discussion around the ill-effects of smoking. This often resulted in negative thoughts and attitudes about smoking.
However, the fear appeal category ignited a defensive reaction among some respondents. Upon discussion some respondents viewed the messages as an over-simplification of the dangers and consequently they tended to rationalize the possible dangers. They compared smoking to other activities such as alcohol consumption or road accidents in attempts to play down the dangers while also expressing the opinion that smoking receives unfair focus. This was particularly true for respondents from Southern European countries and for those in the pre-contemplation stage.
Using that guideline, they should also go after the cars as well, they also kill.(Spain)
Furthermore, some respondents did not perceive the messages to be providing them with any meaningful information. Consequently, they tended to be rejected as patronizing and ‘worn out’. This was particularly true for respondents from Northern Europe.
Subgroup differences also emerged. The long-term health effects of smoking tended to be more salient among those respondents in the contemplation stage: they were more willing to elaborate on fear messages and make some attempt to personalize the effects. Respondents in the pre-contemplation stage, however, made no attempt to personalize the messages and adopted a very defensive, hostile reaction dismissing the dangers as being too distant or unlikely.
Furthermore, the long-term health effects of smoking were not a salient issue among young respondents who also found it difficult to personalize and relate to this type of appeal category. They held the view that they would give up smoking before they were at serious risk from disease.
Social appeals
When messages in this category addressed the issue of children, respondents in all countries found such messages relevant and important, believing they have a moral obligation to protect children. Respondents, particularly females, were able to easily personalize and relate messages such as ‘Protect children: don't let them breathe your smoke’ to their own children and grandchildren and consequently such messages seemed to evoke a highly emotional response.
Personally I get furious when adults smoke among kids because they are innocent and can't do anything about it.(Sweden, male, 25–34, pre-contemplator)
When social appeals did not relate specifically to children (e.g. ‘Smoking seriously harms you and others around you’) country differences emerged. The majority of respondents from Northern and Middle Europe found it reasonable to modify their behaviour around those who do not smoke. They were generally aware of the dangers of passive smoking and were uncomfortable when smoking around non-smokers. Respondents in the South, however, seemed less comfortable with messages addressing this issue and viewed passive smoking more as an inconvenience to others.
Even at their most powerful (when focussing on children) these messages only prompted respondents to adapt their behaviour (e.g. smoking in the garden or on the balcony). They did not suggest the need to quit.
Support appeals
Contemplators, and particularly contemplators from Middle and Northern Europe, welcomed the supportive tone of these messages and saw them as a relief from fear-orientated messages. They found them positive and encouraging, appreciating what they felt was a sympathetic and understanding approach, and indicated a likelihood to seek out such advice and support.
It is nice because if you want to quit, people can help you, even if you previously failed quitting.(France, male, 17–24, contemplator)
It's encouraging, you CAN, we believe in you.
(Sweden, female, 35–44, contemplator)
Among more committed smokers and particularly respondents from the South, this type of appeal category had little to recommend it. These respondents viewed quitting as an individual activity, driven by self-motivation and consequently did not see support as either useful or feasible. In some countries, especially in Southern Europe respondents viewed support from doctors and pharmacists with scepticism.
When I make the decision I will go by myself—doctors treat you like you're useless.(Spain)
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DISCUSSION AND CONCLUSIONS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSION AND CONCLUSIONSREFERENCES |
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This was a cross-sectional, qualitative study and responses were explored in an artificial setting where the new labels were completely novel. Long-term impact, therefore, could not be assessed, and generalizations have to be made with caution. Nonetheless a number of tentative conclusions can be drawn, and recommendations made about future labelling practice.
The research has confirmed that the EU labelling format for tobacco packs, introduced in the EU Directive 2001/37/EC, is more noticeable than the one it replaces and has the potential to help smokers who wish to quit. This supports the available literature (e.g. Kaiserman, 1993; Borland, 1997), which suggests that larger more prominent messages communicate more effectively. It was also clear that the novelty of the new format made an impact. Three mechanisms are at work here. First, their bigger more prominent format facilitates processing of the health messages and makes it difficult for the smoker who wants to ‘screen out’ or avoid them. The message was the first aspect of the pack noticed and mentioned by smokers. Second, the new format created ‘noise’ that undermined the brands ability to interact with the smoker; as a result, brand imagery was diluted and impaired. Third, the fact that the messages are present at the point of consumption means that they provide very timely reminders of the risks of smoking and the benefits of quitting.
However, the new labels do pose some difficulties in targeting messages across Europe. As the segmentation and targeting literature suggests (Krugman et al., 1994), the labels were received and interpreted differently between regions. In particular, respondents in Southern Europe were less receptive to all the messages, and especially those addressing less familiar concepts such as passive smoking. They also viewed support from doctors and pharmacists with skepticism. This does not necessarily mean different messages are needed for every member state, just that some cultural sensitivity is desirable.
Two other segmentation criteria emerged from the research: commitment to smoking and age. Key differences were apparent between pre-contemplators' and contemplators' response to the content of the new labels. In the UK for example, respondents who were thinking of quitting wanted support and cessation advice and hence paid attention to on-pack messages that provide this. In contrast, committed smokers are inclined to ignore any messages, and therefore need to have their attention grabbed. In terms of age, there were differences between younger and older smokers' information needs. Younger respondents find the short-term health and cosmetic effects more salient, while older smokers are more concerned with illness and premature ageing.
These variations in response in terms of region, smoking status and age fit with the health communication literature and confirm that, in common with other types of campaign, on-pack messages should be pre-tested in order to explore smokers' comprehension and acceptability. The variations also confirm the wisdom of segmenting audiences and targeting messages.
Targeting on-pack messages is possible if challenging. It would make sense, for example, to focus cessation oriented messages on Northern Europe and more straightforward health messages on the South. It would also be possible to target according to age by attaching specific types of message to youth brands. Even potential quitters could be targeted by selecting appropriate brands such as Silk Cut or other former ‘light’ cigarettes.
This may seem a difficult route to follow, but it is exactly what the tobacco industry does in all its marketing. Their internal documents show how potential quitters, new recruits and regions within the UK—let alone Europe—are targeted not just with customized messages but entire marketing strategies (e.g. Hastings and MacFadyen, 2000). One lesson from this research is that health promoters need to approach this issue with the assiduity and resources as tobacco executives. The resource would be immediately extended if policy makers decreed that the whole pack—and not just the health message area—should become a platform for health promotion rather than leaving it as a marketing tool for tobacco. This would also maximize the opportunity for innovation and change that helps keep messages prominent.
By the same token, on-pack messages should be seen as just one fragment of the ‘health marketing strategy’. The reticent response of the Southern European smokers seems to reflect a generally more pro-smoking culture there than in the North (Shafey et al., 2003). This suggests a need for a broadly based tobacco control push to challenge this norm and support the on-pack messages. At the moment they seem to be something of a voice in the wilderness. Similarly, in the North the cessation support messages will only work if good help lines and services are in place. In short it is clear that on-pack warnings have to form part of a comprehensive tobacco control strategy.
Furthermore, labelling design and content should be varied and refreshed on a regular basis. Research conducted in the Netherlands, which examined the effect of the new messages on smokers found that although they resulted in an increase in noticing the messages, made tobacco products less appealing and increased some smokers' motivations to quit or smoke less, the impact of the messages decreased over time (Willemsen, 2002). Every opportunity should therefore be taken to maintain the novelty of the new messages. The EU could pursue the Canadian and Brazilian example of introducing pictorial messages on packs, while other opportunities could include regularly introducing new statements and pictures to the current library.
With these measures in mind, tobacco packaging can become an even more effective tool for both pan-European health promotion and tobacco control policy.
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ACKNOWLEDGEMENTS |
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The research was conducted in collaboration with seven cancer societies throughout Europe and the authors acknowledge their contribution to the results presented in this paper: Dr Matti Rautalahti (Cancer Society of Finland), Ms Sylviane Ratte (Ligue Nationale Française Contre le Cancer), Dr Volker Beck (German Cancer Society), Dr Nicolas Kordiolis (Hellenic Cancer Society), Dr Dolors Marin-Tuya (Societat Catalana per a la Prevenció del Tabaquisme), Ms Britt Marie Lindblad and Ms Tanja Tomson (Swedish Cancer Society) and Ms Jean King (Cancer Research UK). The principle sponsor of the research was the European Commission with financial support from Cancer Research UK and all participating cancer societies. Thanks go to all the participants who took part in the focus group discussions across Europe.
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FOOTNOTES |
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1 demographics for Spanish quotes not provided by research agency.
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