Updated July 29, Draskovic N. The cigarette pack as image: new evidence from tobacco industry documents. The impact of cigarette pack design, descriptors, and warning labels on risk perception in the U. Standardised cigarette packaging may reduce the implied safety of Natural American Spirit cigarettes. Comprehensive tobacco marketing restrictions: promotion, packaging, price and place. Campaign for Tobacco-Free Kids. Warning labels: showing the truth, saving lives.
Updated February 1, How did smokers respond to standardised cigarette packaging with new, larger health warnings in the United Kingdom during the transition period? Graphic warning labels elicit affective and thoughtful responses from smokers: results of a randomized clinical trial. Effect of pictorial cigarette pack warnings on changes in smoking behavior: a randomized clinical trial.
The effect of graphic cigarette warning labels on smoking behavior: evidence from the Canadian experience. Global evidence on the association between cigarette graphic warning labels and cigarette smoking prevalence and consumption. Real-world exposure to graphic warning labels on cigarette packages in US smokers: the CASA randomized trial protocol.
Tool to assess appeal-aversion response to graphic warning labels on cigarette packs among US smokers. Australian Government Department of Health. Tobacco plain packaging. Published January 30, Using graphic warning labels to counter effects of social cues and brand imagery in cigarette advertising. Properties of the urn randomization in clinical trials.
Salivabio passive drool method. Salivary cotinine. R Core Team. R: a language and environment for statistical computing. R Project for Statistical Computing. Imagery and smoking urges: the manipulation of affective content. Affective perseverance: the resistance of affect to cognitive invalidation. Addiction versus stages of change models in predicting smoking cessation. Efficacy of SMS text message interventions for smoking cessation: a meta-analysis.
Get the latest research based on your areas of interest. Weekly Email. Monthly Email. Save Preferences. Privacy Policy Terms of Use. Limit characters. Limit 25 characters. Conflicts of Interest Disclosure Identify all potential conflicts of interest that might be relevant to your comment.
Err on the side of full disclosure. Yes, I have potential conflicts of interest. No, I do not have potential conflicts of interest. Limit characters or approximately words. The following information is required and must be completed in order to submit a comment:. Thank You. Your comment submission was successful. Please allow up to 2 business days for review, approval, and posting.
This Issue. Views 7, Citations 0. View Metrics. Twitter Facebook More LinkedIn. Original Investigation. August 4, David R. Strong, PhD 1,2 ; John P. Dimofte, PhD 5 ; Eric C. Gentzke, et al. Hammond, D. Health warning messages on tobacco products: a review. Tobacco control, 20 5 , Wakefield, M. The cigarette pack as image: new evidence from tobacco industry documents.
Tobacco control, 11, II Department of Health and Human Services. A Report of the Surgeon General. Atlanta, GA: U. Actual Causes of Death in the United States. Murphy, S. Participants attached labels to each cigarette pack they finished, filled in the required information and posted them back to the research agency at the end of each week.
In the first week only, participants were also asked to return date-stamped receipts for cigarettes purchased that week. These were used to calculate the reimbursement for participants in the intervention condition in cases where purchasing smaller packs incurred a greater cost per cigarette than usual.
Text and telephone call reminders were sent to participants during the study to maximise adherence to the intervention. The true study aim was disclosed to participants during the final telephone debriefing. All analyses were conducted by a senior statistician MP and analyst KDL who were not involved in data collection and were blinded to allocation.
The sample size re-estimation procedure was conducted using R statistical software v3. Descriptive statistics were calculated for demographic and smoking characteristics of participants in each study arm. A full analysis of all outcome variables was conducted. All imputations for missing data, and assumptions concerning inconsistent responses on cigarette pack labels were made prior to analyses Additional File 2.
The primary analysis was a modified intention-to-treat analysis in which data from participants were included in the study arm to which they were allocated, excluding participants who did not provide complete data. The comparison of the primary outcome between study arms was made by estimating the difference in means using an independent samples t-test. A secondary analysis of the primary outcome was carried out using analyses of covariance ANCOVA adjusting for the pack sizes participants reported typically smoking from at recruitment.
A per-protocol analysis was also conducted for the primary outcome, which included only those participants who adhered to instructions by smoking from cigarettes in the instructed pack size. The per-protocol analysis was of interest, given our aim of assessing the actual effect of a policy to introduce a maximum size of cigarette packs rather than just asking people to smoke from smaller packs. Differences between study arms in the means of the secondary outcomes were estimated using ANCOVA where adjustment was made for the same measures taken at recruitment.
Of the smokers meeting the eligibility criteria, All demographic characteristics were comparable between participants who were excluded and those who completed the study Table 1. The mean age of included participants was The interim analysis took place in February when participants had been randomised.
Due to the need to communicate a decision rapidly to the research agency regarding recruitment, the interim analysis used a dataset without imputations for incomplete information.
Footnote 1 Of the 79 participants who finished the study, 61 had complete data available at this stage 28 in control arm, 33 in intervention arm. The pooled SD of the number of cigarettes smoked per day was 7. The mean difference in the number of cigarettes smoked between the intervention and control conditions was 1. The sample size re-estimation indicated that additional participants with complete data would be needed for sufficient power to detect a reduction of two cigarettes per day.
To account for attrition, participants would need to be randomised. This met the pre-specified criterion to terminate the trial due to futility i. These changes did not alter the conclusion of the interim analysis to stop the trial. Data from participants were included in the study arm to which they were allocated in an intention-to-treat analysis.
There was no clear evidence of a difference in the number of cigarettes smoked per day between the study arms Table 2. Participants in the intervention arm instructed to smoke from packs of 20 cigarettes smoked The mean number of cigarettes smoked by participants in the intervention arm was However, the confidence intervals around the mean difference include the possibility of an effect in either direction.
Similarly, no differences in heaviness of smoking, motivation to stop smoking or autonomy over smoking were detected. Larger cigarette packs are being introduced across the global market, prompting calls for the introduction of regulation to cap cigarette pack sizes [ 4 ]. The sample size re-estimation, afforded by the adaptive design, indicated that the number of additional participants required to detect the expected effect was not considered feasible within available resources, so the study was terminated at that stage.
The use of an adaptive design was a strength of the study; ensuring optimal use of resources given a lack of existing experimental evidence regarding an estimate of the effect and an uncertain estimate of the standard deviation of the primary outcome [ 18 ]. Terminating the study early prevented researcher time and participant effort from being spent completing a study that would have been underpowered to detect the hypothesised effect. Several limitations contributed to the early termination of the study.
The variability in the primary outcome — number of cigarettes smoked per day — was higher than expected based on our earlier pilot study, leading to a large sample size re-estimation in the interim analysis.
There are two possible factors contributing to this higher variability. First, it is possible that the measurement of the number of cigarettes smoked per day was unreliable.
We used a novel method of measurement that required participants to label and return their empty cigarette packs. This approach intended to address concern regarding the accuracy of traditional methods; smokers are known to under-report the number of cigarettes they smoke by up to one-third when using survey methods [ 26 ].
The labels used in our study required participants to fill in non-mutually exclusive fields. Unfortunately, this sometimes resulted in inconsistent responses that were difficult to interpret e. The full dataset is available URL to be added if accepted and includes details of the decisions made regarding interpretation of ambiguous responses see also Additional File 2.
Second, non-adherence to the intervention may have also increased the variability in the primary outcome. This non-adherence is likely to have undermined the effect of the intervention. If more participants had been able to adhere to the intervention, the per-protocol analysis would have carried greater precision in estimating the true impact of the pack size.
Smokers participating in the current study may not be representative of all smokers due to participants self-selecting and needing to be highly motivated to complete the study procedures and to pay closer attention than usual to their smoking which may, inadvertently, have increased their motivation to quit or cut down. Importantly, the current study was designed to detect a difference between randomised groups and so these factors should not cause a bias of the effect estimate as these factors will not affect the separate groups differentially.
The study sample are older than the average population of Australian daily smokers and older smokers generally smoke more and use larger pack sizes. However, the sample was also mostly female and more highly educated than the general population of Australian smokers and use of larger pack sizes is greater among males and the low-SES population [ 27 ], who also smoke more cigarettes per day on average [ 28 ].
Those with higher levels of consumption and who use larger pack sizes are expected to disproportionately benefit from a capping policy. Considerable uncertainty remains regarding the true effect of capping cigarette pack sizes at 20 in jurisdictions where this is currently the minimum pack size i.
Hoffman and colleagues [ 29 ] warn against complacency in tobacco control, highlighting the need for well-implemented, effective policies.
These lessons learned from the present study could inform a more efficient RCT. A study with a cross-over design, in which each participant takes part in both study arms, is likely to have greater power to detect an effect because within-person variation in cigarette consumption is generally smaller than between-person variation [ 30 ].
In this study we aimed to isolate the impact of pack size from the impact of price by compensating participants for the increase in cost-per-stick they would experience as a result of purchasing cigarettes in a smaller pack size. It is possible that a real-world cap on cigarette pack sizes would help to maintain a high cost per stick by reducing the opportunity for price-related promotions by tobacco companies [ 4 ] which may further contribute to the impact of the intervention.
It remains unclear whether capping cigarette pack sizes at 20 in jurisdictions where this is currently the minimum pack size reduces cigarette consumption. Importantly, the results of this study provides no evidence that capping cigarette pack sizes would be ineffective at reducing smoking.
An adaptive design allowed the early termination of a study that would have been underpowered to detect an effect. The limitations identified in this study can inform a more efficient RCT. Given the potential impact of increasing pack sizes on tobacco consumption, and the value of a policy to cap cigarette pack sizes to contribute to reducing global smoking prevalence, further research is urgently required to address the dearth of experimental evidence in this area.
In this dataset, dashes written by participants on their labels had been erroneously entered as missing data. Geneva: World Health Organisation, Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, a systematic analysis for the global burden of disease study Article Google Scholar.
ASH briefing: Health inequalities and smoking. ASH, Should cigarette pack sizes be capped? Article PubMed Google Scholar. Plain packaging: legislative differences in Australia, France, the UK, New Zealand and Norway, and options for strengthening regulations. Tob Control. All aspects of the package design are important.
Thus colors, graphic elements, proportioning, texture, materials and typography are tested and used in various combinations to create the desired brand image or personality [ 26 ]. The proper selection of color is crucial to appealing to the correct target market.
The selection of the color for the red Marlboro package was based on research conducted by the Color Research Institute of Chicago [ 18 ].
White means sanitary and safe. And if you put a low-tar cigarette in a red package, people say it tastes stronger than the same cigarette packaged in white" [ 13 ]. Gold connotes quality, but at a premium price [ 29 ]. Of course, some colors appeal more to one gender than the other. The challenge is to communicate a low tar message without communicating low flavor. Barely noticeable changes in the placement, orientation, number or thickness of stripes can all produce measurable changes in the impact of the design.
Those favorable noted that the pinstriped background is more appealing than a plain white background, suggesting a higher quality image" [ 29 ] Merit-PM. Changes in the texture of the packaging wrapper, paper, cardboard, foil, or plastic are important [ 26 , 31 ]. Embossing creates the impression of a higher quality product. Once recognized as embossed, this feature was seen as reinforcing quality cues for the cigarette via attention to detail in its packaging" [ 29 ] Merit-PM.
Manufacturers have experimented with a wide variety of novel shapes and sizes for cigarette packs, including cylinders, triangles, semi-circles and ovals [ 32 , 33 ].
Package configuration was mentioned in 19 documents and the functionality of the pack in One document includes drawings for more than 60 ideas for completely novel packaging configurations [ 33 ]. A variety of mechanisms for dispensing cigarettes one at a time have been investigated, including individually wrapped cigarettes on a roll that are torn off as needed.
Packs that break apart into two or more smaller packs have been evaluated. Packs fashioned from plastic and aluminum have been considered to better preserve freshness, but these nonbiodegradable materials were rejected due to environmental concerns [ 34 , 35 ].
From the uniformity of current cigarette pack configurations it is evident that none of these novel approaches have had lasting appeal in the USA. The physical functions of the pack are evaluated in the company research facilities. Tests are conducted to measure the crush resistance and moisture retention properties of alternative packaging materials [ 34 ]. Twelve documents concerned physical testing or manufacturing issues. The evaluation of the marketing performance is more involved and is commonly contracted to outside firms.
Candidate designs are subjected to a variety of qualitative and quantitative tests to determine which best meets the design criteria [ 36 , 37 ]. Consumer testing was mentioned in documents. Philip Morris, when seeking more women smokers for its Parliament brand, changed the package design to reduce its masculinity and raise its femininity and tested the prototypes on subjects [ 38 ].
The first evaluations are made with color drawings of the proposed designs [ 15 ]. Due to cost considerations, actual life size three dimensional, mock-ups of the packs are not generated until the field of contestants has been narrowed down to only a few [ 21 , 39 ].
Full scale mock-ups are required to evaluate the texture and feel of the pack, as well as its physical functions. The initial evaluations of the designs are conducted with either individual consumers or small homogeneous focus groups. The subjects in these studies are carefully chosen based upon demographic considerations and their current smoking preferences [ 40 ]. Subjects are asked to identify positives and negatives for each design to gain insight into which of many possible designs might be most appealing to targeted consumers [ 42 , 43 ].
The testing will often begin with open questions to evaluate consumers' spontaneous impressions of the packages and their contents. For example, subjects might be asked "what type of person would smoke this brand? For example, if the goal of the design change is to communicate a lower tar message, alternative designs will be compared on this performance criteria.
In practice, each design is simultaneously rated on its ability to communicate dozens of attributes concerning both the product image and the user image. Qualities used by Philip Morris and RJ Reynolds to rate cigarette packages according to appearance and functionality [ 19 , 45 - 47 ]. Selected attributes used to rate user imagery generated by Philip Morris Company package designs [ 48 , 49 ]. Attributes used by Philip Morris to rate package designs according to implied product imagery [ 47 , 49 ].
Tests may be conducted by stopping people in shopping malls, by telephone, or subjects may be invited to a central facility. Potential designs are tested in either a monadic or paired comparison design [ 23 , 50 ].
In monadic tests, subjects are shown one design at a time and asked to rate the pack on characteristics such as those listed in the tables. Subjects are given either opposite word pairs and asked to choose between the two, or are asked to rate each quality on a "thermometer" scale from 0 to [ 45 , 51 ].
In a paired comparison, subjects are shown designs side by side and asked to rate one against the other. This is done to compare a few final contestants, to compare a new design to the current design, or to compare a new design to a competitor's pack. Subjects' reactions to the pack designs are broken down statistically according to gender, income, region, and current brand preference [ 48 ].
Sophisticated statistical analyses may be performed. Through this process, it is determined which of the candidate designs best communicates the desired product and user imagery. The two package designs tied In terms of pack image, the new full flavor, lights and 's packs produced a more stylized smoker profile classy, elegant, distinctive, stylish, trendy than the current packs" [ 53 ] Virginia Slims-PM.
The white pack, on the other hand, would contribute an image of mildness, smoothness, appealing to older, conservative, down to earth women. The choice, then, becomes one of picking the package that is more consistent with the over-all marketing positioning the product is to be given" [ 55 ] Parliament-PM. The amount of product and user imagery that can be communicated without text or even pictures is impressive. Design details deliver these 'goods'. Three documents discussed how the package design communicates to consumers through subconscious processes.
The utility of objective testing is felt to be limited because the package design works through subliminal processes. That is, the fact that it does this is not readily apparent to the consumer" [ 28 ]. Actual text on cigarette packages is quite limited. Most of the imagery and communication of ideas to the consumer is achieved through the use of colors, shapes and textures.
Often the consumer is not aware that this process is occurring. For example, the color white is commonly used on low tar brands which were created to allay smokers of their health concerns. White is a color commonly associated with health care facilities. Nurses uniforms were traditionally white. Through the use of the color white on packages of low tar cigarettes, manufacturers can capture the consumer's stored associations of white with health.
Mock-ups of the narrowed field of designs are manufactured to allow for further testing. The ability of each design to quickly communicate the brand name is tested with a tachistoscope [ 46 , 49 , 56 - 58 ]. Ten documents mentioned the tachistoscope, a device which allows researchers to expose subjects to package designs under controlled conditions of lighting, size, distance and exposure times [ 58 ].
Exposures start at a few milliseconds. The subject is asked to describe any features of the pack that can be identified. The Marlboro pack was identified with only a four millisecond exposure [ 58 ].
Exposures are gradually lengthened until all features of the pack can be identified. The readability of the brand name can be affected by font size, font style, color, color contrast, text orientation, and design elements which compete for visual attention.
The "findability" of the pack may be quantified using a simulated shelf display in which the pack is positioned with several other brands and subjects are asked, after a 3 second exposure, to recall where it was located [ 46 , 49 ].
In-store tests of pack displays have been conducted with hidden cameras and one-way mirrors used to track shoppers' eye motions [ 18 , 59 ]. Carefully controlled experiments have been conducted in chains of convenience stores to determine the independent impact of displays and discount offers [ 60 ]. Manufacturers strive for "stand out," the package should stand out from the clutter of competing brands and be easily seen in a display rack.
Thirteen documents concerned the findability or readability of package designs. Perhaps the most intriguing tests are the widely used "sensation transfer" tests [ 19 , 61 - 63 ]. These were mentioned in 23 documents dating back to Subjects are given two packs with different designs containing identical cigarettes. They are asked to smoke one cigarette from each pack and to then rate the two cigarettes on a variety of criteria, such as taste, smoothness, after-taste, and quality. Surprisingly, the subjective evaluation of the cigarettes can be significantly impacted by the package design.
The influence of the package design on the subjective qualities of the cigarette are such that when an objective rating of the cigarette qualities is desired, the test cigarettes are all placed in standardized white packaging [ 64 ]. Manufacturers are always interested in increasing their market share by maintaining their "franchise", smokers who already smoke their brand, while attracting "trials" by smokers of the brands of their competitors [ 7 , 65 ].
Designing a pack to have maximum appeal to smokers who do not currently smoke the brand risks alienating current franchise smokers and particular care is given to avoid this scenario [ 7 , 66 ]. There is also concern that a change might result only in the cannibalization of market share of the company's other brands resulting in no overall benefit to the company [ 6 ].
The reactions of current franchise smokers are evaluated by asking them to compare and rate the proposed pack with their current pack and by asking if they would consider switching to another brand if the proposed changes were to be implemented. The "trial" potential of new designs are tested by studying the reactions of smokers who fit the target but who currently smoke the competition's brands in that market niche [ 46 , 68 , 69 ].
If the proposed pack performs as well as the current pack with franchise smokers, a regional test-marketing might be performed next [ 70 , 71 ]. Test marketing was mentioned in 48 documents. It is done primarily to detect any potential negative effects on brand sales. Test marketing requires a significant investment as actual packages containing cigarettes must be manufactured.
Shipments of the current package are stopped in carefully selected test markets, typically a major city, and replaced with shipments of the new design [ 42 , 70 ]. The introduction of the new package design typically coincides with a new advertising campaign in the test area, complete with in-store displays.
Displays are designed and tested to attractively present the packs. Contractual arrangements are set up with retailers whereby the company's brands are given prominent display for a set amount of time [ 72 ].
Test market shipments are monitored and compared to simultaneous changes in the brand's market share in other regions. Changes in state or local tobacco excise taxes can disrupt market tests [ 73 ]. If the test market results show no decline in sales, it is likely that a national roll-out will follow. There was ample evidence that the package design is used to convey an impression of lower tar and nicotine delivery. Only two documents actually used the word "health" in their evaluation of package designs.
However, perceptions of tar level were mentioned in Reductions in tar levels are typically associated with reductions in the strength of the taste of the smoke. A very common objective of package designers is to simultaneously communicate messages of low tar and full flavor. This is quite a challenge as design elements that communicate low tar bring out connotations of low flavor, while elements that communicate full flavor often imply high tar.
User imagery is tested to determine if the package design would be used by a smoker who is "concerned about health" [ 76 ]. While the following quote does not specifically address health, it raises concern that subconscious processes may be at work to undermine the conscious health arguments against smoking. It is my belief that stimulating the subconscious desires is much more effective than concentrating on the conscious ones.
If a person is aware of a stimulus, logical thinking may rationalize away the need. However, on a subconscious level this same human being may be strongly motivated to satisfy the need aroused" [ 77 ] RJR. We found no evidence in the documents that we were able to locate, to indicate that cigarette manufacturers target children with their package designs. This does not represent proof that such targeting does not occur. A different search strategy may have unearthed more documents.
It is possible that potentially embarrassing documents may have been destroyed, or withheld. The fact that we were able to locate more documents from the 's than from subsequent decades suggests that there has been a selective release of documents. The documents analyzed here certainly do not represent all of the manufacturers' activities concerning package design. Cigarette manufacturers carefully research their package designs to ensure that they project the desired product and user images and personalities.
Wide ranging restrictions on the advertisement and promotion of tobacco products have been implemented, but in every case the package design has been exempted [ 78 - 80 ]. If the goal of these restrictions is to curtail the promotion of tobacco products, tobacco companies must be prevented from using the package to conjure up enticing and reassuring imagery. Experimental evidence demonstrates that the cigarette package is capable of generating positive user imagery even without additional promotional communications.
In New Zealand, youths in 80 focus groups were shown packs of cigarettes [ 82 ]. Solely on the basis of the package design, without being exposed to advertising, the youths were able to construct a brand personality for the American packs [ 82 ]. By contrast, no brand imagery was associated with generic packs. As long as manufacturers have the package design to work with, they will be able to create brand images which appeal to consumers. The potential impact on adolescents of requirements for generic packaging has been evaluated [ 82 - 84 ].
Australian youths were asked to comment on a generic pack of cigarettes with much larger and effective health warnings. Their comments included, "the image is lost", "they take away the company look", "wouldn't be cool with these boxes", "I would be embarrassed to hold them", "people would feel like rejects if they carried these", "they look yucky", "are these real?
In another study, youths were shown generic packs that were beige with black lettering and displayed only the name of the brand, the UPC bar code, health warnings, and tar and nicotine levels [JR d'Avernas et al. Youths found the health warning on plain packs to look more serious and to be more noticeable, even though the warnings were the same on both types of packs.
The generic packages were rated as less Youths in New Zealand perceived generically packaged brands to be "dull and boring. In another study from New Zealand, youths demonstrated greater attention to, and recall of, health warnings when generic packaging was used [ 84 ].
0コメント