Richard Purves

Is Consumer Response to Plain/Standardised Tobacco Packaging Consistent with Framework Convention on Tobacco Control Guidelines? A Systematic Review of Quantitative Studies

Background and Objectives Standardised or ‘plain’ tobacco packaging was introduced in Australia in December 2012 and is currently being considered in other countries. The primary objective of this systematic review was to locate, assess and synthesise published and grey literature relating to the potential impacts of standardised tobacco packaging as proposed by the guidelines for the international Framework Convention on Tobacco Control: reduced appeal, increased salience and effectiveness of health warnings, and more accurate perceptions of product strength and harm. Methods Electronic databases were searched and researchers in the field were contacted to identify studies. Eligible studies were published or unpublished primary research of any design, issued since 1980 and concerning tobacco packaging. Twenty-five quantitative studies reported relevant outcomes and met the inclusion criteria. A narrative synthesis was conducted. Results Studies that explored the impact of package design on appeal consistently found that standardised packaging reduced the appeal of cigarettes and smoking, and was associated with perceived lower quality, poorer taste and less desirable smoker identities. Although findings were mixed, standardised packs tended to increase the salience and effectiveness of health warnings in terms of recall, attention, believability and seriousness, with effects being mediated by the warning size, type and position on pack. Pack colour was found to influence perceptions of product harm and strength, with darker coloured standardised packs generally perceived as containing stronger tasting and more harmful cigarettes than fully branded packs; lighter coloured standardised packs suggested weaker and less harmful cigarettes. Findings were largely consistent, irrespective of location and sample. Conclusions The evidence strongly suggests that standardised packaging will reduce the appeal of packaging and of smoking in general; that it will go some way to reduce consumer misperceptions regarding product harm based upon package design; and will help make the legally required on-pack health warnings more salient.

Evaluating Long-term Outcomes of NHS Stop Smoking Services (ELONS): a prospective cohort study

BACKGROUND NHS Stop Smoking Services (SSSs) provide free at the point of use treatment for smokers who would like to stop. Since their inception in 1999 they have evolved to offer a variety of support options. Given the changes that have happened in the provision of services and the ongoing need for evidence on effectiveness, the Evaluating Long-term Outcomes for NHS Stop Smoking Services (ELONS) study was commissioned. OBJECTIVES The main aim of the study was to explore the factors that determine longer-term abstinence from smoking following intervention by SSSs. There were also a number of additional objectives. DESIGN The ELONS study was an observational study with two main stages: secondary analysis of routine data collected by SSSs and a prospective cohort study of service clients. The prospective study had additional elements on client satisfaction, well-being and longer-term nicotine replacement therapy (NRT) use. SETTING The setting for the study was SSSs in England. For the secondary analysis, routine data from 49 services were obtained. For the prospective study and its added elements, nine services were involved. The target population was clients of these services. PARTICIPANTS There were 202,804 cases included in secondary analysis and 3075 in the prospective study. INTERVENTIONS A combination of behavioural support and stop smoking medication delivered by SSS practitioners. MAIN OUTCOME MEASURES Abstinence from smoking at 4 and 52 weeks after setting a quit date, validated by a carbon monoxide (CO) breath test. RESULTS Just over 4 in 10 smokers (41%) recruited to the prospective study were biochemically validated as abstinent from smoking at 4 weeks (which was broadly comparable with findings from the secondary analysis of routine service data, where self-reported 4-week quit rates were 48%, falling to 34% when biochemical validation had occurred). At the 1-year follow-up, 8% of prospective study clients were CO validated as abstinent from smoking. Clients who received specialist one-to-one behavioural support were twice as likely to have remained abstinent than those who were seen by a general practitioner (GP) practice and pharmacy providers [odds ratio (OR) 2.3, 95% confidence interval (CI) 1.2 to 4.6]. Clients who received group behavioural support (either closed or rolling groups) were three times more likely to stop smoking than those who were seen by a GP practice or pharmacy providers (OR 3.4, 95% CI 1.7 to 6.7). Satisfaction with services was high and well-being at baseline was found to be a predictor of abstinence from smoking at longer-term follow-up. Continued use of NRT at 1 year was rare, but no evidence of harm from longer-term use was identified from the data collected. CONCLUSIONS Stop Smoking Services in England are effective in helping smokers to move away from tobacco use. Using the 52-week CO-validated quit rate of 8% found in this study, we estimate that in the year 2012-13 the services supported 36,249 clients to become non-smokers for the remainder of their lives. This is a substantial figure and provides one indicator of the ongoing value of the treatment that the services provide. The study raises a number of issues for future research including (1) examining the role of electronic cigarettes (e-cigarettes) in smoking cessation for service clients [this study did not look at e-cigarette use (except briefly in the longer-term NRT study) but this is a priority for future studies]; (2) more detailed comparisons of rolling groups with other forms of behavioural support; (3) further exploration of the role of practitioner knowledge, skills and use of effective behaviour change techniques in supporting service clients to stop smoking; (4) surveillance of the impact of structural and funding changes on the future development and sustainability of SSSs; and (5) more detailed analysis of well-being over time between those who successfully stop smoking and those who relapse. Further research on longer-term use of non-combustible nicotine products that measures a wider array of biomarkers of smoking-related harm such as lung function tests or carcinogen metabolites. FUNDING The National Institute for Health Research Health Technology Assessment programme. The UK Centre for Tobacco and Alcohol Studies provided funding for the longer-term NRT study.

Are all cigarettes just the same? Female’s perceptions of slim, coloured, aromatized and capsule cigarettes

Twelve focus groups in Glasgow (Scotland) were conducted with female non-smokers and occasional smokers aged 12-24 years (N = 75), with each group shown 11 cigarettes: two (standard) cigarettes with cork filters; two coloured cigarettes (pink or brown); four slim cigarettes; an aromatized black cigarette; a menthol cigarette and a cigarette with a flavour-changing rupturable capsule in the filter. Participants were asked to rank the cigarettes by appeal, taste and harm. The capsule cigarette was then discussed in depth. The pink coloured cigarette and slim cigarettes created significant interest and were generally perceived as most appealing and pleasant tasting, and least harmful. The black aromatized cigarette received a mixed response, with some disliking the dark colour and associating it with low appeal, strong taste and increased harm, whereas for others the smell helped to enhance appeal and taste perceptions and lower perceptions of harm. The novel capsule cigarette, when discussed in-depth, was viewed very positively. Just as research shows that cigarette packs can influence perceptions of appeal, harm and taste, this study suggests that the actual cigarettes can do likewise. The findings have implications for tobacco education and policy.

E-cigarette marketing in UK stores: an observational audit and retailers’ views

Objectives To explore how e-cigarettes are being promoted at point of sale in the UK and how retailers perceive market trends. Setting Fixed retail outlets subject to a ban on the display of tobacco products. Participants Observational audit of all stores selling tobacco products (n=96) in 4 Scottish communities, conducted over 2 waves 12 months apart (2013–2014), and qualitative interviews with small retailers (n=25) in 4 matched communities. Primary and secondary outcome measures The audit measured e-cigarette display characteristics, advertising materials and proximity to other products, and differences by area-level disadvantage. Interviews explored retailers’ perceptions of e-cigarette market opportunities and risks, and customer responses. Results The number of e-cigarette point-of-sale display units and number of brands displayed increased between waves. E-cigarettes were displayed close to products of interest to children in 36% of stores. Stores in more affluent areas were less likely to have external e-cigarette advertising than those in deprived areas. Although e-cigarettes delivered high profit margins, retailers were confused by the diversity of brands and products, and uncertain of the sectors viability. Some customers were perceived to purchase e-cigarettes as cessation aids, and others, particularly low-income smokers, as a cheaper adjunct to conventional tobacco. Conclusions E-cigarette point-of-sale displays and number of brands displayed increased over 12 months, a potential cause for concern given their lack of regulation. Further scrutiny is needed of the content and effects of such advertising, and the potentially normalising effects of placing e-cigarettes next to products of interest to children.

Combining school and family alcohol education: a systematic review of the evidence

Purpose – The purpose of this paper is to map and identify evidence for effective components of combined school and family alcohol education interventions. The paper describes current practice, evaluative evidence of its effects, and highlights specific elements of school and family linked education associated with effective prevention or reduction of alcohol misuse by young people aged 11-18 years. Design/methodology/approach – This paper takes the form of a systematic review. Findings – The review found evidence of small positive effects for interventions delivered over short and longer term duration and low and higher levels of direct contact with students and families. Family-based elements that correlated with positive effects were targeting information and skills development, family communications, and stricter parental attitudes to alcohol misuse. School-based components which involved life skills and social norms approaches were associated with reductions in risky behaviours. Weaker evidence indic...

Young Women Smokers’ Perceptions and Use of Counterfeit Cigarettes: Would Plain Packaging Make a Difference?

Opponents of plain tobacco packaging argue that it would make production of counterfeit tobacco products cheaper; lower costs for consumers; confuse consumers in respect to product authenticity; and increase appeal and purchase of counterfeit tobacco. We explored the last of these contentions with young women smokers (N = 49), aged 16–24 years, recruited in Glasgow (Scotland). Participants were firstly asked about their perceptions and purchase of counterfeit cigarettes. Each group was then shown a mock display of legitimate and counterfeit plain cigarette packs. All the packs shown were the same colour (brown) with the only difference being the price and brand name. Participants were asked what brand they would smoke if all cigarettes came in brown (plain) packaging. Purchase of counterfeit cigarettes was lower for 16–17 year olds than 18–24 year olds. Perceptions of counterfeit cigarettes were negative, with concerns expressed about content and taste. All participants said that if pack appearance was standardised they would continue to smoke the same brand of legitimate cigarettes that they currently smoke or down-trade to cheaper legitimate brands. Non-users of counterfeit cigarettes indicated that they would remain non-users should all cigarettes come in uniform packaging. Counterfeit users, at least those willing to smoke counterfeit cigarettes again, indicated that they would still buy counterfeit cigarettes if pack appearance was standardised, primarily due to the lower price. For young women smokers in this study, plain packaging had no bearing on perceived appeal of counterfeit cigarettes.

Adolescent girls and young adult women's perceptions of superslims cigarette packaging: a qualitative study.

Objectives To explore perceptions of superslims packaging, including compact ‘lipstick’ packs, in line with 3 potential impacts identified within the impact assessment of the European Union (EU) Tobacco Products Directive: appeal, harm perceptions and the seriousness of warning of health risks. Design Qualitative focus group study. Setting Informal community venues in Scotland, UK. Participants 75 female non-smokers and occasional smokers (age range 12–24). Results Compact ‘lipstick’-type superslims packs were perceived most positively and rated as most appealing. They were also viewed as less harmful than more standard sized cigarette packs because of their smaller size and likeness to cosmetics. Additionally, ‘lipstick’ packs were rated as less serious in terms of warning about the health risks associated with smoking, either because the small font size of the warnings was difficult to read or because the small pack size prevented the text on the warnings from being displayed properly. Bright pack colours and floral designs were also thought to detract from the health warning. Conclusions As superslims packs were found to increase appeal, mislead with respect to level of harm, and undermine the on-pack health warnings, this provides support for the decision to ban ‘lipstick’-style cigarette packs in the EU and has implications for policy elsewhere.

Tobacco companies’ use of retailer incentives after a ban on point-of-sale tobacco displays in Scotland

Introduction Incentives have been used by tobacco companies for many years to encourage retailers to sell and promote their products. However, few studies have examined the use of retailer incentives in countries with a ban on the open display of tobacco products in stores. Methods As part of the DISPLAY(Determining the Impact of Smoking Point of Sale Legislation Among Youth) study, annual qualitative interviews were conducted with 24 small retailers in four Scottish communities. This article focuses on data collected in June to July 2015 and June to July 2016 after a ban on the open display of tobacco was fully implemented in Scotland. Results Retailers described being offered and benefiting from a range of financial and other incentives, typically offered via tobacco company representatives (‘reps’). Most of the retailers received tobacco manufacturer support for converting their storage unit to be compliant with the new regulations, and several participated in manufacturer ‘loyalty’ or ‘reward’ schemes. Incentives were additionally offered for maintaining stock levels and availability, positioning brands in specified spaces in the public-facing storage units (even though products were covered up), increasing sales, trialling new products and participating in specific promotions, such as verbally recommending specific brands to customers. Conclusions Even in a market where the open display of tobacco is prohibited, tobacco companies continue to incentivise retailers to sell and promote their brands and have developed new promotional strategies. For countries that have implemented tobacco display bans, or are considering doing so, one option to combat these practices would be to ban promotional communications between manufacturers and retailers.

Alcohol Marketing during the UEFA EURO 2016 Football Tournament: A Frequency Analysis

This study examined the frequency and nature of alcohol marketing references in broadcasts of the 2016 UEFA (Union of European Football Associations) European Championships football tournament in the United Kingdom (UK). Eighteen matches from across the tournament were recorded in full as broadcast in the UK, including all four matches featuring the English national team and all seven featuring the French national team. All visual and verbal references to alcohol marketing were recorded using a tool with high inter-rater reliability. A total of 2213 alcohol marketing references were recorded, an average of 122.94 per broadcast and 0.65 per broadcast minute (0.52 per minute in-play and 0.80 per minute out-of-play). Almost all references were visual (97.5%), with 77.9% occurring around the pitch border. Almost all (90.6%) were indirect references to alcohol brands (e.g., references to well-known slogans), compared to only 9.4% direct references to brands (e.g., brand names). The frequency of references to alcohol marketing was high. Although the overall proportion of direct brand references was low, the high proportion of indirect references demonstrates that alcohol producers were able to circumvent the French national law governing alcohol marketing (the Loi Évin) using indirect “alibi marketing”. To ensure the spirit of the Loi Évin regulations are achieved, stricter enforcement may be required to limit exposure to alcohol marketing, particularly for young people.

The Online Bingo Boom in the UK: A Qualitative Examination of Its Appeal.

Online bingo has seen significant growth in recent years. This study sought to increase understanding of this growth by exploring the appeal of online bingo. Our aim was to examine the content of ten online bingo websites in the UK and analyse a qualitative secondary dataset of 12 female bingo players to investigate the appeal of online bingo. Using two distinct data sources allowed us to assess how the key messages online websites are trying to convey compare with actual players’ motivation to play bingo. Our analysis of bingo websites found a common theme where websites were easy to navigate and structured to present a light-hearted, fun, reassuring, social image of gambling. In addition, the design decisions reflected in the bingo sites had the effect of positioning online bingo as a benign, child-like, homely, women-friendly, social activity. Comparison of the website content with our participants’ reasons to play bingo showed congruence between the strategies used by the bingo websites and the motivations of bingo players themselves and the benefits which they seek; suggesting that bingo websites strive to replicate and update the sociability of traditional bingo halls. Online bingo differs from traditional forms of bingo in its ability to be played anywhere and at any time, and its capacity to offer a deeply immersive experience. The potential for this type of online immersion in gambling to lead to harm is only just being investigated and further research is required to understand how the industry is regulated, as well as the effects of online bingo on individual gambling ‘careers.’