How cigarette packet warnings affect children

"Graphic images don’t deter young smokers," says BBC News, reporting that picture warnings depicting the dangers of smoking have little impact on underage smokers.

While the headline correctly reflects the latest findings, it presents a negative spin of research that found that the warnings appeared effective for those who’d never smoked and those who’d “experimented” with smoking.

Researchers surveyed children aged 11-16 in 2008 (when health warnings on cigarette packets were text only) and a separate repeat sample in 2011 (after graphic images had been introduced).

Between 2008 and 2011, the proportion of children who noticed health warnings, looked closely at them and understood them did not change much. However, in 2011 recall of the three health warnings associated with the pictures increased. The proportion of all children who thought about health warnings often, and the proportions who thought the images could put them off smoking or make them less likely to smoke also increased.

However, these positive effects seemed to be limited to never smokers or experimental smokers, with no difference in regular smokers as suggested by the headlines. An increased proportion of regular smokers reported hiding the pack to “escape” the health image.

This research suggests how changes in cigarette packaging may impact on the thoughts and perceptions of UK children. But while there are both positive and negative findings, the research can’t tell us whether the changes have made any difference to the numbers of children starting or quitting smoking.

Where did the story come from?

The study was carried out by researchers from the Centre for Tobacco Control Research at the University of Stirling and was funded by Cancer Research UK. The study was published in the peer-reviewed journal, Tobacco Control.

The news coverage of this study is generally representative, but has put a negative spin on the findings, ignoring the signs of some positive effects of the new images on cigarette packs.

What kind of research was this?

This was a repeat cross-sectional survey examining young people’s thoughts and understanding of the warnings on cigarette packets in 2008 and 2011.

Many countries now have pictorial warnings on the dangers of smoking on cigarette packs, and a few countries, including Canada and Australia, have these warnings covering three-quarters of the pack surface.

However, the European Union (EU) has set lower standards. EU law requires the written warnings that are required on cigarette packs to be one of two general warnings covering 30-35% of the pack front, and one of 14 specific warnings covering 40-50% of the reverse. In 2005, The European Commission also adopted 42 images that could be included on the back of packs. However, few member states have adopted them, and none have used warning images that cover at least half of the pack surface.

The current study has examined the impact of warnings upon children before and after the introduction of pictorial warnings to packs in the UK. In 2008, textual warnings appeared on 43% of the front and 53% of the back of the pack. In 2011, the warnings were the same, except that images supported the warning on the back of the pack.

What did the research involve?

Random sampling methods were used to identify samples of 11 to 16 year olds from UK households in 92 electoral wards. A total of 1,401 children were recruited in 2008 and 1,373 in 2011. They were classified as:

never smokers (people who had never smoked)
experimental smokers – who had tried smoking, used to smoke or smoked less than one cigarette a week
regular smokers – who smoked at least one cigarette a week

Information was also obtained on age, gender, social grade and smoking by family members or close friends.

The children were asked how often, in the last month, they had noticed warnings on cigarette packs, and read or looked closely at them. Response options were from 1 (never) to 5 (very often). They were then asked about their thoughts and feelings when they looked at these warnings:

“Depth of processing”. The children were asked three questions about how often in the past month they had thought about or talked with others about what warnings are telling them (assessed on a 5-point scale).
“Comprehension and credibility”. The children were asked questions assessing how much they believed the warnings and thought them truthful (assessed on a 5-point scale).
“Unaided recall”. The children were asked questions assessing how well they could recall, unaided, any information they could remember from warnings (responses coded according to how well they matched warning themes).
“Persuasiveness”. The children were asked questions assessing two items on whether the warning does (1) or does not (5) put the participant off smoking (5), and makes them less (1) or more likely (5) to smoke.
“Avoidant behaviour/behavioural compliance”. Regular smokers were asked whether and how they avoided looking at warnings. They were asked whether they avoided buying cigarette packets with particular warnings on them, covered the warnings up, put the packet away, or used a cigarette case. They were also asked, in the last month, if warnings had stopped them from having a cigarette when they were about to smoke with response options from 1 (never) to 4 (many times).

What were the basic results?

Half of all children in both 2008 and 2011 had noticed warnings on packs “often” or “very often”, and around 20% in both years had looked closely at these warnings “often” or “very often”. However, when looking specifically at the responses of regular smokers, around three-quarters noticed warnings in 2008, and by 2011 it was only two-thirds.

Depth of processing

Thinking about the warning “often” or “very often” increased from a quarter of all children in 2008 to around a third in 2011. However, by smoking status, the increase was only significant for never smokers.

Comprehension and credibility

Most children in both 2008 and 2011 (more than 85%) considered warnings easy to understand, believable and truthful about the health risks. However, in 2011 slightly fewer never smokers considered the warnings easy to understand.

Unaided recall

In both 2008 and 2009, the most commonly recalled message on the pack was “‘Smoking Kills”, although recall of this message decreased from 58% of children in 2008 to 47% in 2011. The second most commonly recalled message – “Smoking seriously harms you and others around you” – also decreased, from 41% in 2008 to 25% in 2011.

The good news was that in 2011 there was increased recall of the three health warnings associated with the pictures related to:

risks of lung cancer (diseased lung picture)
the chemicals in cigarettes (rotten teeth picture)
risk of slow and painful death (image of neck tumour)

Persuasiveness

In both 2008 and 2011, most children (more than 80%) thought that warnings could put them off smoking or make them less likely to smoke, with a slight increase in proportions from 2008 to 2011. However, again, when analysed by smoking status the increases were restricted to never and experimental smokers.

Avoidant behaviour/behavioural compliance

In 2011 there was an increase in the proportion of regular smokers who hid their pack to avoid the image (23%) then there had been in 2008 (12%), but no change in other avoidant behaviours.

How did the researchers interpret the results?

The researchers conclude that “Including pictorial images on the back of cigarette packaging improved warning persuasiveness for never and experimental smokers, but had a negligible
impact on regular smokers. The findings have implications for warning design.”

They said: “As warnings need to be salient to be effective, positioning warnings only on the less visible reverse panel limits their impact.”

Conclusion

Overall, this is informative research on the effects that changes in cigarette packaging have had on the thoughts and perceptions of a representative sample of UK children. Overall, there was no difference in the proportion of children who noticed health warnings or looked closely at them before and after the picture warnings were introduced. Their comprehension and understanding of these warnings was also largely unchanged, but there are some positive findings.

In 2011, recall of the three health warnings that accompany the pictures on the back of packs increased. An increased proportion of regular smokers reported hiding the pack to escape the health image, and this may be a good thing too as it suggests that the pack looks less desirable so could mean less advertising for the product. However, it could be seen as a negative finding, as the warnings are being avoided.

The proportion of all children who thought about health warnings often, and the proportion who thought the images could put them off smoking or make them less likely to smoke also increased. However, these positive effects seemed to be limited to never smokers or experimental smokers, with no difference in regular smokers. This could suggest that never or experimental smokers may be less likely to take up regular smoking. But this research cannot tell us whether the changes make a real difference to uptake or quit rates.

Overall, this is valuable research that may help inform further consideration in how best to highlight to people the dangers of smoking. As the authors say, endorsement by the European Parliament’s Committee on the Environment, Public Health and Food Safety in July 2013 to have large pictorial warnings that take up 75% of the space of packs in the EU, will likely increase the impact that warnings have for all children, irrespective of smoking status.