A content analysis of nicotine descriptors on the front of vape packaging in the United Kingdom.

INTRODUCTION: The Tobacco and Related Products Regulations (TRPR) 2016 require consumers in the United Kingdom (UK) to be informed about the presence of nicotine in vaping products. However, there is misunderstanding among some young people and adults around the strength of products. We examined how nicotine content is displayed on the front of vape packaging in the UK. METHODS: Between August and December 2022, we systematically analysed a representative, stratified selection of vapes and refill packs (n=156) on the UK market to assess TRPR compliance. This paper presents an analysis of free-text responses collected to indicate the presence of nicotine information on the front-of-pack including metric, percentage, graphic, and text indicators. Data were analysed using descriptive statistics produced for the sample as a whole and for five product categories. RESULTS: Most packs (n=126, 81%) displayed at least one front-of-pack nicotine descriptor, including the majority of disposables (n=43, 90%), e-liquid (n=42, 88%) and refill pods (n=36, 100%). Many packs (n=107, 69%) contained a nicotine-related metric (e.g. mg/ml), a quarter (n=37, 24%) included a percentage indicator and most (n=126, 81%) displayed at least one of these. Almost two-fifths (n=57, 37%) mentioned nicotine beyond the warning. Less observed indicators included graphic and textual depictions of strength, dosage information, and equivalent number of cigarettes. CONCLUSION: The front of vape packaging communicates important product information to consumers. There is inconsistency in how nicotine content is currently displayed. Future research should examine how best to display nicotine content to promote consumer understanding and informed decision-making. IMPLICATIONS: This pack analysis of a representative sample of UK vape packaging highlights the varied way in which nicotine content and strength is currently communicated to consumers on the front of vape packaging. The inconsistent presentation of nicotine content on the front of packs may contribute to misperceptions around product strength. A consistent and easily understood way of communicating nicotine content on the front of vape packaging may help consumers make more informed choices about vape products.

The Role of e-Cigarette Packaging as a Health Communications Tool: A Focus Group Study With Adolescents and Adults in England and Scotland.

INTRODUCTION: In the United Kingdom, e-cigarette and refill packaging must display a nicotine addiction warning. This study explored how this message is perceived, responses to alternative on-pack messages, and other options for using e-cigarette packaging to discourage youth and people who neither smoke nor use e-cigarettes while encouraging smokers to switch. AIMS AND METHODS: Between August and September 2022, 16 focus groups (n = 70) were conducted to explore these topics with adolescents (n = 31, aged 11-17 years) and adults (n = 39, nonsmokers, smokers that use e-cigarettes, smokers that do not use e-cigarettes) in England and Scotland. RESULTS: While several participants thought the current nicotine addiction warning could help increase awareness of nicotine addiction, most reported that it failed to capture attention and was not a deterrent. Alternative messages shown on packs (about harm, toxicity, wellness, litter, or relative risk) received mixed responses. Relative risk messages were perceived as most beneficial for smokers switching but also thought to potentially encourage uptake among nonsmokers. Some participants considered certain harm and toxicity messages to potentially dissuade uptake. Participants proposed several ideas to reduce the appeal of e-cigarette packaging and devices to deter youth uptake, including more prominent warnings, standardized packaging, and devices that are plain or include health messages. CONCLUSIONS: Packaging can play a crucial role in communicating product and health messages to different consumer groups. Further consideration of how packaging and labeling can meet the needs of non-nicotine users while simultaneously reaching those who may benefit from using e-cigarettes to stop smoking is warranted. IMPLICATIONS: While some viewed the nicotine addiction warning required on e-cigarettes and refill packaging in the United Kingdom as helpful in raising awareness of nicotine addiction, it did not resonate with most of our sample of adolescents and adults. The findings suggest that e-cigarette packaging could be better used to encourage smokers to switch to a less harmful alternative, with relative risk messages showing promise. Furthermore, strengthening on-pack messaging (eg increasing salience and rotating messages) and reducing the appeal of packaging (eg drab colors) and devices (eg including warnings) may help increase awareness of e-cigarette harms while deterring use among adolescents and nonsmokers.

Restricting the content of alcohol advertising and including text health warnings: A between-group online experiment with a non-probability adult sample in the United Kingdom.

BACKGROUND: Statutory options for restricting alcohol advertising include limiting it to product-orientated information and requiring health warnings. We assess the impact of removing positive contextual factors from alcohol advertising and including a health warning among adults in the United Kingdom (UK). METHODS: We conducted a 2 × 2 online between-group experiment with adults (18+) (n = 2421) recruited from a non-probability research panel in the United Kingdom. Participants were randomized to see an alcohol (vodka) advertisement (advert) which varied by context (no context vs. imagery depicting positive social interactions around alcohol) and message (multiple text health warning vs. "drink responsibly"). The multiple text health warning, based on recent legislation in Ireland, comprised three separate warnings (liver disease, cancers, drinking during pregnancy) and a web address for alcohol-related information and support. The "drink responsibly" control reflected the self-regulatory messages commonly used by alcohol companies. Participants rated the advert on 7-point scales for advert attractiveness, product appeal, trial intentions, perceived harm, and whether it made drinking alcohol seem enjoyable. RESULTS: Removing the positive social context reduced positive advert and product reactions (difference in estimated marginal means [EMM]: -1.57 [makes drinking alcohol seem enjoyable] to -0.23 [intention to try]). Including the multiple text health warning also reduced positive advert and product reactions (difference in EMM: -0.55 [advert attractiveness] to -0.25 [intention to try]) and increased perceived product harm (difference in EMM: +0.25). There were no interactions between advert context and message for any outcome. CONCLUSIONS: Restricting content and including a multiple text health warning (compared to a "drink responsibly" message) may attenuate the persuasive impact of alcohol advertising and increase perceived product harm. Further research is needed to examine different degrees of content restrictions, alternative warning content and design, generalizability to different alcohol products and advert formats, and whether the impact of content controls varies among population subgroups.

Perceptions of novel warnings compared with current warning on tobacco packs, and warnings on cigarette sticks: A cross-sectional survey of college students in Southern India.

INTRODUCTION: In India there is insufficient knowledge of the risks associated with tobacco use. Increasing awareness of these risks is critical, with pictorial warnings on tobacco packs a cost-effective way to communicate this information. We explored perceptions of the current warning, 'Tobacco causes cancer', displayed on packs in India and four novel warnings about other potential impacts of tobacco use including social, financial, and environmental, but also complications with diabetes. As loose cigarette sales are common in India, we also explored perceptions of warnings on cigarette sticks. METHODS: A cross-sectional survey of college students aged ≥18 years in Karnataka, India, was conducted between January 2019 and February 2020. Participants were asked about salience, believability, and cognitive processing of warnings currently on packs. They were then shown an image of one current and four novel warnings and asked about their perceived effectiveness in preventing uptake and reducing and stopping tobacco use. They were then asked about warnings on cigarette sticks. RESULTS: Most participants (70.2%) recalled warnings on packs and considered them believable (55.7%), but only 12.0% read and 12.4% thought about them often. Warnings about the health impacts of tobacco use were viewed as most effective in preventing uptake, and reducing and stopping tobacco use. Nevertheless, at least a third of participants rated warnings pertaining to financial, social, and environmental impacts effective in preventing uptake, and reducing and stopping tobacco use. Approximately one-fifth (22.0%) thought that warnings on cigarette sticks would deter initiation. CONCLUSIONS: Our results suggest that health warnings are perceived as most effective in discouraging tobacco use among college students in Karnataka. While viewed as less effective than health warnings, novel non-health related messages were viewed as effective in preventing uptake, and reducing and stopping tobacco use by at least one in three participants. Warnings on cigarette sticks may help complement warnings on cigarette packs.

Have Restrictions on Alcohol Advertising in Ireland Affected Awareness Among Adults? A Comparative Observational Study Using Nonprobability Repeat Cross-Sectional Surveys.

OBJECTIVE: Since November 2019, Ireland has restricted alcohol advertising at the cinema and outdoors (e.g., near schools) and banned alcohol advertising on public transport. Although awareness of such advertising had decreased 1 year after the restrictions, measures to limit COVID-19 transmission complicated interpretation. We examined (a) changes in awareness 2 years after restrictions, when COVID-19 mitigation measures had eased, and (b) how changes in Ireland compared with Northern Ireland, where the restrictions did not apply. METHOD: Repeat cross-sectional surveys were conducted with adults recruited from nonprobability online panels, with three waves in Ireland (October 2019 [before restrictions] and October 2020/2021 [after restrictions]; n = 3,029) and two in Northern Ireland (October 2020/2021; n = 1,011). Participants self-reported past-month awareness of 13 alcohol marketing activities, including public transport, cinema, and outdoor advertising (coded as any past-month awareness, no awareness, or not sure). RESULTS: In Ireland, the odds of reporting no past-month awareness (vs. any) were higher in both 2021 and 2020 versus 2019 for all restricted advertising activities (e.g., 2021 vs. 2019 for public transport: adjusted OR = 1.88, 95% CI [1.53, 2.32]). Interactions between wave and jurisdiction indicated that in 2021, compared with 2020, the odds of reporting no past-month awareness of public transport and cinema advertising (vs. any) were higher in Ireland than in Northern Ireland, despite increased opportunities for exposure in both jurisdictions through eased pandemic mitigation measures. There was no interaction for outdoor advertising, suggesting between-wave trends did not differ by jurisdiction. CONCLUSIONS: Ireland's restrictions have reduced past-month awareness of alcohol advertising at the cinema and on public transport but not outdoors. Continued monitoring is required.

Impact of standardised packaging in the UK on warning salience, appeal, harm perceptions and cessation-related behaviours: a longitudinal online survey.

INTRODUCTION: In the UK, since 20 May 2017, tobacco companies must sell cigarettes and rolling tobacco in standardised packs. METHODS: Three waves of a longitudinal online survey with smokers (≥16) before standardised packaging (wave 1 (W1): April to May 2016) and after standardised packaging (wave 2 (W2): September to November 2017; wave 3 (W3): May to July 2019). Of the 6233 smokers at W1, 4293 responded at W2 and 3175 at W3. We explored smokers' response to warning salience, appeal (appeal, quality, value, satisfaction and taste compared with a year ago), harm (harmfulness compared with a year ago, harm compared with other brands and whether some brands have more harmful substances), and quit plans, attempts and quitting. RESULTS: Compared with W1, the proportions noticing warnings first on packs, and rating cigarettes/rolling tobacco less appealing and worse value than a year ago, were higher at W2 and W3. Disagreeing that some brands contain more harmful substances was higher at W2. Interactions between social grade and survey wave for warning salience, and each appeal and harm outcome, were non-significant. Smokers switching from not noticing warnings first at W1 to noticing warnings first at W2, or who had a lower composite appeal score at W2, were more likely to plan to quit and to have made a quit attempt at W2. Smokers who switched to disagreeing that some brands contain more harmful substances at W2, after giving a different response at W1, were more likely to quit at W3. CONCLUSIONS: Standardised packaging appears to be having the intended impacts.

Youth perceptions of Brand variant names on standardised cigarette packs, and responses to replacing these with numbers: a focus group study in Britain.

Tobacco companies use brand variant name on cigarette packaging to differentiate, and create interest in, their products. We explored young peoples' reactions to brand variant names on cigarette packs and perceptions of replacing these with numbers, a proposed policy in Turkey. Twelve focus groups, segmented by gender, age (11-12, 13-14, 15-16) and social grade (ABC1, C2DE), were conducted across Britain from May-July 2018 (n = 89). Participants were asked what they thought about brand names in general, and on cigarette packs, and perceptions of replacing the brand variant name on cigarette packs with a number. Brand (variant) name was considered important for products, including cigarettes, and thought to communicate information about the product, image, price, and taste, and encourage purchase. Although replacing brand variant names on cigarette packs with numbers caused confusion, several participants mentioned that it would eliminate any remaining marketing power that the pack may have. They thought that numbered cigarette packs could be off-putting due to the absence of a familiar brand name, although the impact on smokers was considered negligible. Although adolescents were not clear on the rationale for numbered cigarette packs, some suggested that this would reduce one of the few remaining promotional features on standardised packs.

Alcohol Packaging As a Promotional Tool: A Focus Group Study With Young Adult Drinkers in Scotland.

OBJECTIVE: Little research has been conducted on consumer perceptions of alcohol packaging as a marketing tool. The aim of this study was to explore how young adults view and engage with alcohol packaging. METHOD: Eight focus groups were conducted in Glasgow (Scotland) with current drinkers (n = 50), segmented by age (18-24, 25-35), gender (female, male), and social grade (ABC1, C2DE). Participants were shown, allowed to handle, and asked about a range of alcoholic products. RESULTS: Five main themes emerged from the data. The first was the ubiquity of alcohol packaging, with frequent exposure reported in different settings, such as shops and drinking venues, and via marketing. The second was appeal, with pack graphics (e.g., color), structure (e.g., shape, size), and promotions (e.g., gifts, limited editions) allowing alcohol packs to catch attention, enabling products to stand out on shelves, and helping to create product and brand liking, interest, and choice. Third, alcohol packaging was frequently associated with specific occasions and activities. Fourth, alcohol packaging informed perceptions of product-consumer targeting, suitability, and intended drinker profiles. Fifth, alcohol packaging also engaged nonvisual senses (e.g., touch, sound, smell), guiding expectations of product taste and palatability. CONCLUSIONS: For young adult drinkers in Scotland, alcohol packaging can capture attention, create appeal, and help shape perceptions of the product, drinker, and drinking experience.

Reasons for Using Roll-Your-Own Tobacco and Perceptions of Health-Promoting Pack Inserts: A Focus Group Study with Roll-Your-Own Tobacco Smokers in Scotland.

INTRODUCTION: Use of roll-your-own (RYO) tobacco is increasing in most regions, but few qualitative studies have explored why RYO smokers use this product, and no study has considered their views of health-promoting pack inserts. METHODS: Eight focus groups were conducted with 18-35-year-old RYO smokers (n = 50) in Greater Glasgow (Scotland) in February-March 2020 to explore reasons for using RYO and perceptions of health-promoting inserts. Participants were shown four inserts adapted from those required in cigarette packs in Canada, with all encouraging quitting, and two RYO-specific inserts explaining that RYO is not less harmful than cigarettes. RESULTS: Lower price, better taste, the pleasure of rolling and ability to customize roll-ups, and the belief that RYO was less harmful than cigarettes were drivers for use. There were mixed perceptions of the extent to which inserts would capture attention if included in RYO packs. The positive messaging used on the Canadian inserts was considered motivational and inspirational, and contrasted with the on-pack warnings. The messaging on the RYO inserts, in comparison, was viewed unfavorably and generally dismissed. Participants, most of whom were not interested in quitting, did not feel that inserts would lead them to change their smoking behavior. However, some felt that the Canadian inserts could be helpful for those thinking about quitting and young people contemplating smoking. CONCLUSIONS: Inserts with positive messaging about quitting, rather than messaging explicating the harms of RYO, were preferred by RYO smokers. What, if any, RYO-specific messaging resonates with RYO smokers merits further attention. IMPLICATIONS: Aside from price, taste, and the pleasure associated with rolling and ability to individualize roll-ups, the erroneous belief that RYO is less harmful than cigarettes was a key reason for use. While inserts with positive messaging about quitting, as used on the Canadian inserts, were viewed as potentially helpful, inserts that challenged the idea that RYO was not less harmful than cigarettes were generally dismissed. Research is needed to understand what types of RYO-specific messaging could most effectively be used on inserts, or indeed in other media, to challenge the misperceptions that many RYO smokers hold.

Non-smoking adolescents' perceptions of dissuasive cigarettes.

Introduction: Dissuasive cigarettes, cigarettes with an unappealing colour or displaying a health warning label, may deter young people from smoking uptake. Methods: Two online surveys were conducted with non-smokers aged 12-17 to explore perceptions of cigarette appeal, harm and product trial. Study 1 was a within-subject study which examined perceptions of four cigarettes with different coloured paper, and four cigarettes displaying a warning. Study 2 was a between-subject study (with limited power), in which respondents were randomized to one of four cigarettes: (1) regular cigarette; (2) least favourable warning from Study 1; (3) least favourable colour from Study 1; or (4) a combination of the least favourable warning and colour from Study 1. Warnings or colours were considered least favourable when they had lower scores on appeal, harm, and product trial. Results: In Study 1, a cigarette featuring the warning 'cancer, heart disease, stroke' and a drab dark brown cigarette were rated lowest on appeal and trial intentions, and highest on perceived harm. In Study 2, there were no significant differences in perceptions of appeal, harm or trial intentions between the regular and dissuasive cigarettes. Conclusions: Findings from our within-subject study suggest that a cigarette displaying the text 'cancer, heart disease, stroke' and a drab dark brown coloured cigarette are most dissuasive for Dutch non-smoking adolescents. Whether dissuasive cigarettes reduce appeal, reduce product trial, or increase perceptions of harm compared to a regular cigarette should be further examined in larger between-subject studies.

The role of alcohol packaging as a health communications tool: An online cross-sectional survey and experiment with young adult drinkers in the United Kingdom.

INTRODUCTION: Alcohol packaging is a potentially valuable means of communicating product and health-related information, with growing academic and political interest in its role as a health communications vehicle. METHODS: An online cross-sectional survey and experiment were conducted with a non-probability sample of 18-35-year-old drinkers in the United Kingdom (n = 1360). The survey assessed exposure to, and engagement with, current messaging on packs, and support for displaying product and health-related information. For the randomised experiment, participants were shown, and asked questions about, a vodka bottle with either no warnings (control), small text warnings, large text warnings or pictorial (image-and-text) warnings; the main binary outcome measures were negative product appeal and social acceptability, and positive cognitive and behavioural impact. RESULTS: Two-fifths of the sample rarely or never saw on-pack health-related information, with almost three-quarters rarely or never reading or looking closely at this. There was strong support for displaying a range of product and health-related information (e.g. units, ingredients) on packs. Relative to the control, products with warnings were more likely to be perceived as unappealing and socially unacceptable, and to positively impact alcohol-related cognitions and behaviours. For example, pictorial warnings were 10 times as likely to positively influence cognitions and behaviours (AOR = 10.01, 95% CI: 8.09, 17.46). DISCUSSION AND CONCLUSIONS: Alcohol packaging could have an important role in delivering health messaging. Large pictorial or text warnings may help counteract the appeal and social acceptability of alcohol products and increase awareness of risks, potentially supporting a reduction in consumption and related harms.

Plain tobacco packaging: progress, challenges, learning and opportunities.

The aim of this paper is to overview progress made with respect to the adoption of plain (or standardised) packaging, key challenges faced, evaluative evidence and opportunities for extending this policy. It has been a decade since Australia became the first country to require tobacco products to be sold in plain packaging; after slow initial uptake, 16 countries have now fully implemented this policy. Since 2020, plain packaging laws have become more comprehensive in some countries, expanding coverage beyond traditional tobacco products to include heated tobacco, tobacco accessories (rolling papers) and other nicotine-containing products (e-cigarettes). Laws have also become more innovative: some now ban non-biodegradable filters, include provision for a periodic change of the pack colour or require both plain packaging and health-promoting pack inserts. The tobacco industry has and will continue to use multi-jurisdictional strategies to oppose this policy. Evaluations suggest that plain packaging has improved health outcomes and has not burdened retailers, although research is limited to early policy adopters and important gaps in the literature remain. While the power of packaging as a sales tool has diminished in markets with plain packaging, tobacco companies have exploited loopholes to continue to promote their products and have increasingly focused on filter innovations. Opportunities exist for governments to strengthen plain packaging laws.

Prevalence of Menthol and Menthol Capsule Cigarette Use Among 11-16 Year Olds in Wales Prior to a Ban on Characterizing Flavors in Cigarettes: Findings From the 2019 Student Health and Wellbeing Survey.

INTRODUCTION: The use of flavored cigarettes has increased in many countries because of the inclusion of one or more frangible flavor-changing capsules in the filter. Research suggests that these "capsule" cigarettes appeal most to youth, but little is known about how prevalent their use is among children. METHODS: A cross-sectional school survey was conducted between September and December 2019 with 11-16 year-olds (N = 119 388) from 198 secondary schools across Wales; the sample represented approximately two-thirds of all 11-16 year-olds in the country. The sample was asked about smoking behavior, with a quarter (N = 26 950) also asked about awareness of menthol cigarettes, and use of menthol and menthol capsule cigarettes if a current smoker (N = 1447). RESULTS: Current smoking prevalence was 5.7% among the entire sample and 5.9% among the analytical sample (those also asked about menthol and menthol capsule cigarettes). For the analytical sample, almost all current smokers (93.2%) were aware of menthol cigarettes, with three-fifths (60.5%) reporting having used menthol cigarettes in the past 30 days (42.3% capsule cigarettes, 18.2% noncapsule cigarettes). In comparison to nonmenthol smokers, those using menthol cigarettes (capsule and noncapsule) were more likely to be frequent smokers, with those using menthol capsule cigarettes more likely to have smoked for longer. CONCLUSIONS: While past research suggests that flavored cigarettes appeal to youth, this study shows just how popular these products, and capsule cigarettes, in particular, were among young smokers in Wales. It also raises questions about why capsule cigarettes have received such limited public health attention. IMPLICATIONS: That three in five 11-16 year-old smokers reported using menthol cigarettes in the past 30 days highlights how appealing these products are to young people, particularly capsule cigarettes, used by seventy percent of menthol smokers. Capsule cigarettes are one of the most successful tobacco product innovations in decades, even in countries with comprehensive bans on tobacco marketing and standardized packaging. The dearth of research on capsule cigarettes is a failure of global public health. Evaluation of the ban on characterizing flavors in the United Kingdom and across the European Union is critical.

Awareness of alcohol marketing one year after initial implementation of Ireland's Public Health (Alcohol) Act and during the COVID-19 pandemic.

BACKGROUND: The Republic of Ireland is introducing new controls on alcohol marketing, starting in November 2019 with restrictions on some outdoor and cinema advertising, and a ban on public transport advertising. We examined changes in marketing awareness one year after initial implementation and during the COVID-19 pandemic. METHODS: Repeat online cross-sectional surveys with adults in Ireland conducted October 2019 (n = 1,007) and October 2020 (n = 1,020). Participants self-reported past-month awareness of alcohol marketing and completed the Alcohol Use Disorders Identification Test-Concise (AUDIT-C). Current drinkers were categorised as those reporting heavy episodic drinking at least monthly and higher-risk drinkers (≥5 AUDIT-C). RESULTS: In both waves, most participants recalled some marketing awareness (94.1% vs. 93.8%). For 9/13 activities measured in both waves, there were decreases in the proportion reporting any awareness and frequency of awareness, including for the newly restricted activities. For example, any awareness of public transport advertising decreased between waves (ORAdj = 0.66, 95%CI: 0.53-0.81). In both waves, higher past-month awareness was associated with at least monthly heavy episodic drinking and higher-risk consumption. CONCLUSION: We recommend a precautionary interpretation. It is plausible that both Ireland's initial controls and COVID-19 restrictions contributed to decreases in awareness, but longer-term evaluation is required to determine relative contribution.