International Journal of Behavioral Medicine

, Volume 23, Issue 1, pp 94–101 | Cite as

Larger and More Prominent Graphic Health Warnings on Plain-Packaged Tobacco Products and Avoidant Responses in Current Smokers: a Qualitative Study

  • Sarah J. Hardcastle
  • Derwin C. K. Chan
  • Kim M. Caudwell
  • Sarwat Sultan
  • Jo Cranwell
  • Nikos L. D. Chatzisarantis
  • Martin S. Hagger
Article

Abstract

Background

The introduction of tobacco plain packaging legislation in Australia meant that all tobacco products were to be sold in plain dark-brown packaging with 75 % front-of-pack graphic health warnings and standardised font type and size for brand name and product variant. The change in the size and prominence of the warnings has been proposed as a reason for behaviour change in smokers in terms of increased intentions to quit and quit attempts.

Purpose

The current research examined attitudes and beliefs of cigarette smokers toward the increased size and prominence of the warnings and effects on their behaviour.

Method

Participants (N = 160) completed open-ended responses to questions on beliefs, attitudes and responses to plain packaging. Responses were subjected to inductive thematic content analysis for key themes.

Results

Four themes emerged from the analysis: emotional response to packaging, scepticism of health warnings, warnings and cessation behaviour, and avoidant coping behaviours. Participants reported increased negative emotional responses to the packaging and made specific reference to the graphic health warnings. Some participants attempted to discredit the messages. Others reported increased intentions to quit or quitting attempts. There were pervasive reports of avoidant responses including covering or hiding the warnings.

Conclusion

Consistent with theories of illness perceptions and coping, current findings indicate that the larger, prominent graphic health warnings on plain-packaged tobacco products had pervasive effects on threat perceptions and subsequent behavioural responses. While some of the reported responses were adaptive (e.g. attempts to quit), others were maladaptive (e.g. avoiding the warnings).

Keywords

Tobacco plain packaging Smoking cessation Graphic health warnings Affective responses Coping responses 

References

  1. 1.
    White C, Hammond D, Thrasher J, Fong GT. The potential impact of plain packaging of cigarette products among Brazilian young women: an experimental study. BMC Public Health. 2012;12:737. doi:10.1186/1471-2458-12-737.PubMedCentralCrossRefPubMedGoogle Scholar
  2. 2.
    Moodie C, Stead M, Bauld L, McNeill A, Angus K, Hinds K, et al. Tobacco plain packaging: a systematic review. London: Public Health Research Consortium; 2012.Google Scholar
  3. 3.
    Moodie CS, Mackintosh AM, Hastings G, Ford A. Young adult smokers’ perceptions of plain packaging: a pilot naturalistic study. Tob Control. 2011;20:367–73. doi:10.1136/tc.2011.042911.CrossRefPubMedGoogle Scholar
  4. 4.
    Wakefield MA, Hayes L, Durkin S, Borland R. Introduction effects of the Australian plain packaging policy on adult smokers: a cross-sectional study. BMJ Open. 2013;3, e003175. doi:10.1136/bmjopen-2013-003175.PubMedCentralCrossRefPubMedGoogle Scholar
  5. 5.
    Borland R, Yong HH, Wilson N. How reaction to cigarette packet health warning influence quitting: findings from the ITC four Country survey. Addiction. 2009;104:669–75. doi:10.1111/j.1360-0443.2009.02508.x.PubMedCentralCrossRefPubMedGoogle Scholar
  6. 6.
    Schneider S, Gadinger M, Fischer A. Does the effect go up in smoke? A randomized controlled trial of pictorial warnings on cigarette packaging. Patient Educ Couns. 2012;86:77–83. doi:10.1016/j.pec.2011.03.005.CrossRefPubMedGoogle Scholar
  7. 7.
    Willemsen MC. The new EU cigarette health warnings benefit smoker who want to quit the habit: results from the Dutch Continuous Survey of Smoking Habits. Eur J Public Health. 2005;15:389–92. doi:10.1093/eurpub/cki061.CrossRefPubMedGoogle Scholar
  8. 8.
    Wakefield MA, Germain D, Durkin S, Hammond D, Goldberg M, Borland R. Do larger pictorial health warnings diminish the need for plain packaging of cigarettes? Addiction. 2012;107:1159–67. doi:10.1111/j.1360-0443.2012.03774.x.CrossRefPubMedGoogle Scholar
  9. 9.
    Peters G-JY, Ruiter RAC, Kok G. Threatening communication: a critical re-analysis and a revised meta-analytic test of fear appeal theory. Health Psychol Rev. 2013;7:S8–S31. doi:10.1080/17437199.2012.703527.PubMedCentralCrossRefPubMedGoogle Scholar
  10. 10.
    Leventhal H, Meyer D, Nerenz D. The common sense model of illness danger. In: Rachman S, editor. Medical Psychology. New York: Pergamon Press; 1980. p. 7–30.Google Scholar
  11. 11.
    Milne S, Sheeran P, Orbell S. Prediction and intervention in health-related behavior: a meta-analytic review of protection motivation theory. J Appl Soc Psychol. 2000;30:106–43. doi:10.1111/j.1559-1816.2000.tb02308.x.CrossRefGoogle Scholar
  12. 12.
    Orbell S, Verplanken S. The strength of habit. Health Psychol Rev. 2015. doi:10.1080/17437199.2014.992031.PubMedGoogle Scholar
  13. 13.
    Hagger MS, Orbell S. A meta-analytic review of the common-sense model of illness representations. Psychol Health. 2003;18:141–84. doi:10.1080/088704403100081321.CrossRefGoogle Scholar
  14. 14.
    Ruiter RAC, Kok G. Saying is not (always) doing: cigarette labels are useless. Eur J Public Health. 2005;15:329. doi:10.1093/eurpub/cki095.CrossRefGoogle Scholar
  15. 15.
    de Hoog N, Stroebe W, de Wit JBF. The impact of vulnerability to and severity of a health risk on processing and acceptance of fear-arousing communications: a meta-analysis. Rev Gen Psychol. 2007;11:258–85. doi:10.1037/1089-2680.11.3.258.CrossRefGoogle Scholar
  16. 16.
    Witte K. Putting the fear back into fear appeals: the extended parallel process model. Commun Monogr. 1992;59:329–49. doi:10.1080/03637759209376276.CrossRefGoogle Scholar
  17. 17.
    Neuendorf K. The content analysis guidebook. Thousand Oaks, CA: Sage; 2001.Google Scholar
  18. 18.
    Hardcastle SJ, Legge E, Laundy CS, Egan SJ, French R, Watts GF, et al. Patients’ perceptions and experiences of familial hypercholesterolemia, cascade genetic screening and treatment. Int J Behav Med. 2015;22:92–100. doi:10.1007/s12529-014-9402-x.CrossRefPubMedGoogle Scholar
  19. 19.
    Hardcastle SJ, Tye M, Glassey R, Hagger MS. Exploring the perceived effectiveness of a life skills development program for high-performance athletes. Psychol Sport Exerc. 2015;16:139–49. doi:10.1016/j.psychsport.2014.10.005.CrossRefGoogle Scholar
  20. 20.
    Hardcastle S, Hagger MS. “You can’t do it on your own”: experiences of a motivational interviewing intervention on physical activity and dietary behaviour. Psychol Sport Exerc. 2011;12:314–23. doi:10.1016/j.psychsport.2011.01.001.CrossRefGoogle Scholar
  21. 21.
    Sparkes AC, Smith B. Qualitative research methods in sport, exercise and health. London: Routledge; 2014.Google Scholar
  22. 22.
    Krane V, Anderson MB, Strean WB. Issues of qualitative research methods and presentation. J Sport Exerc Psychol. 1997;19:213–8.Google Scholar
  23. 23.
    McCool J, Webb L, Cameron LD, Hoek J. Graphic warning labels on plain cigarette packs: will they make a difference to adolescents? Soc Sci Med. 2012;74:1269–73. doi:10.1016/j.socscimed.2011.12.043.CrossRefPubMedGoogle Scholar
  24. 24.
    Moodie C, Bauld L, Ford A, Mackintosh AM. Young women smokers’ response to using plain cigarette packaging: qualitative findings from a naturalistic study. BMC Public Health. 2014;14:812–20.PubMedCentralCrossRefPubMedGoogle Scholar
  25. 25.
    Moodie CS, Mackintosh AM. Young adult women smokers’ response to using plain cigarette packaging: a naturalistic approach. BMJ Open. 2013;3, e002402. doi:10.1136/bmjopen-2012-002402.PubMedCentralCrossRefPubMedGoogle Scholar
  26. 26.
    Carver CS, Scheier MF, Pozo C. Conceptualizing the process of coping with health problems. In: Friedman HS, editor. Hostility, coping, and health. Washington, DC: APA; 1992. p. 167–87.CrossRefGoogle Scholar
  27. 27.
    Hagger MS, Orbell S. Illness representation and emotion in people with abnormal screening results. Psychol Health. 2006;21:183–209. doi:10.1080/14768320500223339.CrossRefPubMedGoogle Scholar
  28. 28.
    Orbell S, Hagger MS, Brown V, Tidy J. Comparing two theories of health behavior: a prospective study of non-completion of treatment following cervical cancer screening. Health Psychol. 2006;25:604–15. doi:10.1037/0278-6133.25.5.604.CrossRefPubMedGoogle Scholar
  29. 29.
    Evans D, Norman P. llness representations, coping and psychological adjustment to Parkinson’s disease. Psychol Health. 2009;24:1181–96. doi:10.1080/08870440802398188.CrossRefPubMedGoogle Scholar
  30. 30.
    Orbell S, Hagger MS, Brown V, Tidy J. Appraisal theory and emotional sequelae of first visit to colposcopy following an abnormal cervical screening result. Br J Health Psychol. 2004;9:533–56. doi:10.1348/1359107042304560.CrossRefPubMedGoogle Scholar
  31. 31.
    Monarrez-Espino J, Bojing L, Greiner F, Bremberg S, Galanti R. Systematic review of the effect of pictorial warnings on cigarette packages in smoking behaviour. Am J Public Health. 2014;104:11–30. doi:10.2105/AJPH.2014.302129.CrossRefGoogle Scholar
  32. 32.
    Chatzisarantis NLD, Hagger MS, Wang CKJ. An experimental test of cognitive dissonance theory in the domain of physical exercise. J Appl Sport Psychol. 2008;20:97–115. doi:10.1080/10413200701601482.CrossRefGoogle Scholar
  33. 33.
    Festinger L, Carlsmith JM. Cognitive consequences of forced compliance. J Abnorm Soc Psychol. 1958;58:203–10. doi:10.1037/h0041593.CrossRefGoogle Scholar
  34. 34.
    Hastings G, MacFadyen L. Controversies in tobacco control: the limitations of fear messages. Tob Control. 2002;11:73–5. doi:10.1136/tc.11.1.73.PubMedCentralCrossRefPubMedGoogle Scholar
  35. 35.
    Rooke S, Malouff JM, Copeland J. Effects of repeated exposure to a graphic smoking warning image. Curr Psychol. 2012;31:282–90. doi:10.1007/s12144-012-9147-0.CrossRefGoogle Scholar
  36. 36.
    Brennan E, Durkin SJ, Cutter T, Harper T, Wakefield MA. Mass media campaigns designed to support new pictorial health warnings on cigarette packets: evidence of a complementary relationship. Tob Control. 2011;20:412–8. doi:10.1136/tc.2010.039321.CrossRefPubMedGoogle Scholar
  37. 37.
    Cantrell J, Vallone DM, Thrasher JF. Impact of tobacco-related health warning labels across socioeconomic, race and ethnic groups: results from a randomised web-based experiment. PLoS One. 2013;8:5206. doi:10.1371/journal.pone.0052206.CrossRefGoogle Scholar
  38. 38.
    Hagger MS, Luszczynska A. Implementation intention and action planning interventions in health contexts: state of the research and proposals for the way forward. Appl Psychol-Health Well Being. 2014;6:1–47. doi:10.1111/aphw.12017.CrossRefPubMedGoogle Scholar
  39. 39.
    Hagger MS. Self-regulation: an important construct in health psychology research and practice. Health Psychol Rev. 2010;4:57–65. doi:10.1080/17437199.2010.503594.CrossRefGoogle Scholar
  40. 40.
    Hagger MS, Chatzisarantis NLD, Harris J. The process by which relative autonomous motivation affects intentional behavior: comparing effects across dieting and exercise behaviors. Motiv Emot. 2006;30:306–20. doi:10.1007/s11031-006-9046-5.CrossRefGoogle Scholar
  41. 41.
    Hagger MS, Chatzisarantis NLD, Barkoukis V, Wang CKJ, Hein V, Pihu M, et al. Cross-cultural generalizability of the theory of planned behavior among young people in a physical activity context. J Sport Exerc Psychol. 2007;29:2–20.PubMedGoogle Scholar
  42. 42.
    Oakes W, Chapman S, Borland R, Balmford J, Trotter L. "Bulletproof skeptics in life’s jungle": which self-exempting beliefs about smoking most predict lack of progression towards quitting? Prev Med. 2004;39:776–82. doi:10.1016/j.ypmed.2004.03.001.CrossRefPubMedGoogle Scholar
  43. 43.
    Heikkinen H, Patja K, Jallinoja P. Smokers’ accounts on the health risks of smoking: why is smoking not dangerous for me? Soc Sci Med. 2010;71:877–83. doi:10.1016/j.socscimed.2010.05.036.CrossRefPubMedGoogle Scholar
  44. 44.
    Peretti-Watel P, Constance J, Guilbert P, Gautier A, Beck F, Moatti J-P. Smoking too few cigarettes to be at risk? Smokers’ perceptions of risk and risk denial, a French survey. Tob Control. 2007;16:351–6. doi:10.1136/tc.2007.020362.PubMedCentralCrossRefPubMedGoogle Scholar
  45. 45.
    Peretti-Watel P, Halfen S, Grémy I. Risk denial about smoking hazards and readiness to quit among French smokers: an exploratory study. Addict Behav. 2007;32:377–83. doi:10.1016/j.addbeh.2006.04.002.CrossRefPubMedGoogle Scholar
  46. 46.
    Gough B, Fry G, Grogan S, Conner M. Why do young adult smokers continue to smoke despite the health risks? A focus group study. Psychol Health. 2009;24:203–20. doi:10.1080/08870440701670570.CrossRefPubMedGoogle Scholar
  47. 47.
    Hammond D, Fong GT, McDonald PW, Brown KS, Cameron R. Graphic Canadian cigarette warning labels and adverse outcomes: evidence from Canadian smokers. Am J Public Health. 2004;94:1442–5. doi:10.2105/ajph.94.8.1442.PubMedCentralCrossRefPubMedGoogle Scholar
  48. 48.
    Koval JJ, Aubut JA, Pederson LL. The potential effectiveness of warning labels on cigarette packages: the perceptions of young adult Canadians. Can J Public Health. 2005;96:353–6.PubMedGoogle Scholar
  49. 49.
    Moodie C, Ford A, Mackintosh AM, Hastings G. Young people’s perceptions of cigarette packaging and plain packaging: an online survey. Nicotine Tob Res. 2012;14:98–105. doi:10.1093/ntr/ntr136.CrossRefPubMedGoogle Scholar
  50. 50.
    Haines-Saah RJ, Bell K, Dennis S. A qualitative content analysis of cigarette health warning labels in Australia, Canada, the United Kingdom and the United States. Am J Public Health. 2015;105:e61–e9. doi:10.2105/AJPH.2014.302362.CrossRefPubMedGoogle Scholar

Copyright information

© International Society of Behavioral Medicine 2015

Authors and Affiliations

  1. 1.Health Psychology and Behavioural Medicine Research Group, School of Psychology and Speech Pathology, Faculty of Health SciencesCurtin UniversityPerthAustralia
  2. 2.Department of Applied PsychologyBahauddin Zakariya UniversityMultanPakistan
  3. 3.School of Medicine, Division of Epidemiology and Public HealthUniversity of NottinghamNottinghamUK

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