RESEARCH REPORT doi:10.1111/add.

14999

‘It’s like sludge green’: young people’s perceptions of

standardized tobacco packaging in the UK

Andy MacGregor1, Hannah Delaney2, Amanda Amos3 , Martine Stead4, Douglas Eadie4,
Jamie Pearce5, Gozde Ozakinci6 & Sally Haw7
ScotCen Social Research, Edinburgh, UK,1 School of Nursing and Midwifery, National University of Ireland, Galway and Trinity College Dublin, Ireland,2 Usher Institute,
University of Edinburgh, Edinburgh, UK,3 Institute for Social Marketing, University of Stirling, Stirling, UK,4 School of GeoSciences, University of Edinburgh, Edinburgh,
UK,5 School of Medicine, University of St Andrews, St Andrews, UK6 and Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK7

ABSTRACT

Background and Aims Standardized tobacco packaging was introduced in the United Kingdom in May 2016, together
with larger graphic warnings. This study explored young Scottish people’s awareness of and perceptions about standard-
ized tobacco packaging in the United Kingdom. Design Qualitative study using 16 focus groups conducted February–
March 2017. Setting Four schools in Scotland based in areas of differing socio-economic status (high versus
medium/low) and two levels of urbanity (large urban versus small town/other urban). Participants Eighty-two S2
(13–14 years) and S4 (15–16 years) students who were smokers or at-risk non-smokers. Measurements Focus groups
explored perceptions of standardized packaging and health warnings. The qualitative data underwent thematic analysis.
Findings Views about standardized packaging were generally negative. Packs were described as being unattractive, drab
and less appealing than non-standardized versions. The new health warnings generated negative affective, often aversive,
responses. These varied depending on the image’s perceived ‘gruesomeness’ and authenticity. Most participants thought
that the impact would be greatest on young non/occasional smokers. There were divergent views about whether
established smokers would be affected. Conclusions The introduction of standardized tobacco packaging and new larger
graphic health warnings in the United Kingdom seems have reduced the perceived attractiveness of cigarette packs among
young people in the United Kingdom who smoke or are at elevated risk of becoming smokers, disrupting positive brand
imagery (the brand heuristic), increasing the salience of health warnings and contributing to denormalizing smoking.

Keywords Adolescents, cigarette, health warnings, packaging, qualitative, tobacco.

Correspondence to: Amanda Amos, Usher Institute, University of Edinburgh, Edinburgh EH8 9AG, UK. E-mail: amanda.amos@ed.ac.uk
Submitted 29 October 2019; initial review completed 6 December 2019; final version accepted 31 January 2020

INTRODUCTION heuristic), is used to construct and project a desirable iden-

tity to peers and others in their social worlds [8–12]. Sys-
Reducing young people’s exposure to tobacco advertising tematic reviews of research with young people, including
and marketing is a major element of comprehensive na- qualitative studies and experimental study designs involv-
tional smoking prevention programmes [1,2]. A wealth of ing ‘mocked-up’ cigarette packs with different features,
research has revealed how tobacco companies have used have concluded that implementing standardized packag-
branding, including brand names, insignia, colours and ing which remove pack design elements would: reduce
symbols, to promote positive images of smoking to young the appeal of cigarette packs and cigarettes; increase the
people and to increase the allure of their products [2–4]. prominence and salience of health warnings; and
As more countries ban or restrict tobacco marketing, to- reduce the pack’s ability to mislead about product harm
bacco companies have focused their attention and promo- [13–15]. Five countries have implemented standardized
tional budgets on retail point-of-sale displays and cigarette (also known as plain) packaging [16], and evidence is be-
branding and packaging [5–7]. These marketing strategies ginning to emerge of the impact on young people in rela-
have created cigarette brand images that young smokers tion to these predicted effects.
use as a form of symbolic consumption whereby the ciga- Australia was the first country to mandate standardized
rette brand, and its perceived positive attributes (the brand packs in 2012. Four cross-sectional survey studies have

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 Young people and standardized tobacco packs 1737

explored the impact on young people. Three studies involv- therefore starting to emerge. However, it is limited in
ing national surveys of 12–17-year-olds found that stan- several important respects, such as exploring how na-
dardized packs reduced the appeal of cigarette packs and tional legislative differences [16] may have different ef-
brands and increased uncertainty about brand differences fects. For example, larger health warnings appear to
[12,17]. These effects were sustained 5 years after imple- have had little impact in Australia but some impact in
mentation [18]. However, increasing the size of health France. Furthermore, only one study has explored, using
warnings had no impact on adolescents’ attention to and qualitative methods, young people’s appraisal and inter-
processing of them [12,18]. A study of 12–24-year-olds pretation of standardized packs [22]. Qualitative studies
found greater than anticipated responses to standardized enable a more in-depth exploration of young people’s en-
packs, with 28% of smokers reporting some form of social gagement with standardized packs, generating poten-
denormalization behaviour (i.e. hiding their pack from tially important insights into how and why any effects
view, using a case to cover their pack and/or feeling are, or are not, being produced. For example, the study
embarrassed) [19]. Positive impacts also occurred in by Mitchell et al. [22] reveals how permutations in pack
France, where plain packaging and larger health warnings shape and structure which are permitted in the United
were introduced in 2017. A two-wave national survey of Kingdom (but not in Australia) may have
12–17-year-olds found that 8–11 months after implemen- moderated the impact of standardized packs on British
tation, smokers were less attached to the brand they adolescents.
smoked and less likely to think that their brand was less In the study reported here we used focus groups to ex-
harmful than other brands [20]. plore young people’s awareness of and exposure to stan-
The United Kingdom implemented standardized pack- dardized packs in the United Kingdom, their perceptions
aging and larger graphic warnings in May 2016 of these packs as to their appeal and probable impact on at-
[16,21]. Packs must contain at least 20 cigarettes and titudes to smoking and smoking behaviour among young
be a standard colour (drab green/brown), with branding people. This study differs from that of Mitchell et al.’s work
restricted to brand name and descriptor in standard [22] in three important respects. It was undertaken earlier
black font. Graphic warnings are required to make up (February–March 2017), 2–3 months before branded
65% of the front and back of packs (Fig. 1). Retailers packs were banned completely, when they were still more
had until May 2017 to sell old stock of the original commonly available than standardized packs [23]; partici-
branded packs. Two studies have explored the impact pants were younger [13–16] and therefore more likely to
on young people. A survey of 11–15-year-olds in En- be considering or trying smoking; and the salience of sev-
gland [21], 2 months before full implementation, found eral health warnings was explored. This work formed part
that 20% had noticed the new packs, with awareness of the DISPLAY study (Determining the Impact of Smoking
highest among ever-smokers (49%). A qualitative study Point of sale Legislation Among Youth), a 5-year longitudi-
of 16–17-year-olds in Scotland undertaken 6–18 months nal study evaluating the impact of the Scottish ban on
after full implementation found high awareness of the point-of-sale displays on young people’s smoking behav-
packs, which were perceived to be unappealing and iour, brand awareness and perceived acceptability of
off-putting [22]. An understanding of the ‘real world’ smoking in four communities with differing
impact of standardized packaging on adolescents is socio-economic profiles [24,25].

Figure 1 Images of the standardized cigarette packs used in the focus groups. [Colour figure can be viewed at wileyonlinelibrary.com]

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1738 Andy MacGregor et al.

METHODS Table 2 Focus group sample by school, school year and smoking
status.
Sample and procedure
Smoking status
The four schools, located in the central belt of Scotland, School
were purposively selected to represent two levels of urban- Current Tried Never
ization (large urban versus small town/other urban) and
C1
two levels of socio-economic deprivation (high versus
S2 male 3 0 0
medium/low) (Table 1). The social deprivation level for
S2 female 4 0 0
each school and its surrounding catchment was estimated S4 male 4 0 0
using uptake of free school meals and the Scottish Index of S4 female 3 0 0
Multiple Deprivation (SIMD) based on postcode C2
information. S2 male 1 0 5
Sixteen single-sex focus groups were conducted by an S2 female 0 0 5
S4 male 2 2 0
experienced female facilitator (I.M.) who had undertaken
S4 female 0 4 1
all the previous DISPLAY focus groups. There were four
C3
groups in each school, two with S2 (aged 13–14 years) S2 male 0 0 6
and two with S4 (aged 15–16 years) students. The S2 female 1 0 5
groups had three to eight participants, 82 in total, and S4 male 0 4 2
took on average 40 minutes. Participants were purpo- S4 female 0 3 3
sively recruited with the help of teachers to include stu- C4
dents who were smokers or had regular contact with S2 male 0 3 3
S2 female 0 0 5
smoking (e.g. family members or friends smoked). The
S4 male 2 0 3
aim was to include adolescents most at risk of becoming S4 female 8 0 0
adult smokers. These recruitment methods have been Total 28 16 38
successfully used in previous qualitative studies on
young people and smoking [6,26,27]. Twenty-eight par-
ticipants were current smokers, 16 had tried smoking
and 38 were never-smokers (Table 2). Parental opt-out Data analysis
consent was used. Potential participants could also opt Focus group discussions were fully transcribed and the
out on the day of the focus groups. Participants were as- data entered into the qualitative computer package NVivo,
sured of anonymity and ground rules established around version 10. The data were coded and inductive thematic
disclosure. Ethics approval was granted by NatCen Re- analysis undertaken according to Braun & Clarke’s itera-
search Ethics Committee. tive approach to thematic analysis [28]. The initial analysis
The focus groups were digitally audio-recorded with involved familiarization; transcripts were read and re-read
the participants’ permission. The topic guide included a by three authors (A.A., H.D., A.M.) and emergent themes
general discussion about the community, local smoking discussed. Codes were systematically compared to identify
behaviours and cultures, and the introduction of stan- cross-cutting themes and common experiences, as well as
dardized packaging. The facilitator explored participants’ differing views. The coding framework was further refined
awareness, knowledge and views of standardized packag- into key themes. This paper reports on the themes relating
ing if this was raised spontaneously when talking about to standardized packaging. The primary research question
smoking. In the second part of the focus groups partici- and analysis plan were not pre-registered on a publicly
pants were shown four examples of standardized ciga- available platform. The results should therefore be consid-
rette packs (Fig. 1), and their reactions and views ered exploratory. The source of each quotation (school,
about these were explored. Field notes were written after year, gender) and facilitator (F) or participant (P) are
each group. stated.

Table 1 School location and deprivation.

High deprivation Medium/low deprivation

Large urban C1 C2
Small town/other urban C3 C4

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 Young people and standardized tobacco packs 1739

RESULTS There was also a perception that these changes were

disrupting brand distinction and image by focusing atten-
The first section considers participants’ unprompted tion on the drab colour and more prominent graphic
awareness and perceptions of standardized packaging. health warnings.
The subsequent sections explore participants’ responses
It’s like a greeny-browny colour. It’s not, like, got loads
to examples of the packs.
of writing on it. It’s got like more dangers, and there’s a
little picture on it, and it’s got the brand name (C2, S4
Awareness girls).
Students in all but one of the focus groups had seen or were
aware of the standardized packs. Several who smoked had As highlighted in the quote below, this appeared to in-
purchased, or been given, cigarettes in or from standard- crease the potential potency and salience of health warn-
ized packs. For non-smokers, exposure to packs was mainly ings. Furthermore, the removal of key elements of
via family members or friends who smoked or seeing branding for some resulted in packs that ‘all look similar’,
discarded plain packs in litter on the ground. thereby greatly reducing the ability of the pack to act as a
While participants debated what the actual colour of brand heuristic.
the packs was, variously described as brownish or ‘sludge
green’, most descriptions were negative, with packs being P There’s not so much colour on the other [standard-
described in several groups as having become ‘dark’ or ized] packets, you’re automatically drawn to the
even having ‘no colour’. picture.
P And then also you can’t tell what kind it is, like from
F So thinking about the packets then, are they… what far away unless you were to actually read it. Like
colours are they? you can’t tell what kind it is so somebody could be
P They’ve got no colour. smoking like Benson & Hedges and they would give
P Black and white. one to you, and then you wouldn’t know unless you
P That brownish colour (C2, S2 boys). like read it on the cigarette because it’s black, so you
can’t tell because they all look similar (C1, S4 girls).
P It’s like sludge green.
P Is it army green or sludge green? (C4, S4 girls) Indeed, some participants were unsure whether the brand
name was still on the packs. These changes were perceived
This in turn appeared to be weakening branding and brand to have reduced the attractive ‘cool’ brand image and thus
identification: the pack appeal.

P Coz they don’t have brands on them. They’re just P You only see a bad image. You don’t see like fancy col-
black packets wi’ pictures… ours or bright colours that make you look… well, ‘Oh,
P I think … Have they not like changed colour though? that looks cool’.
Have they not like gone dark? (C4, S2 girls) P But do like some people actually care about that?
P People that smoke, I would say don’t care about it be-
Awareness of the new graphic health warnings ranged cause they just want to smoke, but for someone who’s
from general descriptions such as a ‘wee picture of like not tried it before… it will not tempt them so much I’d
lungs’ and the ‘smoking kills’ message to more detailed de- say. It is helpful to stop young people getting in to it in
scriptions of the different images. the first place (C2, S4 boys).

They’re not black but they’re like dark, dark green, or

dark, dark blue, and then they just have like a wee Pack appeal—colour and graphic warnings
smoking kills thing and a wee picture of like lungs or
When presented with four examples of the new packs, par-
something (C1, S4 girls).
ticipants’ reactions echoed the unprompted comments,
with the plain packs being described as unattractive, unap-
There’s one that says don’t smoke around children and pealing and indeed ‘really ugly’. In part, this was attributed
it has like a woman smoking around a child and it can to the drab, ‘dark’, ‘manky’ colour.
kill them. And then there’s like another one on which a
guy was getting surgery on his lungs because he was P They’re very depressing, you just want to sit there and
smoking too much (C2, S2 boys). slit your wrists.

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1740 Andy MacGregor et al.

F So what’s depressing about them? P They’re definitely faking it. Since when…
P Cos they’ve got dark colours and all that (C1, S2 boys). F I see you nodding your head there. You think?
P Since when do you do this mate? (pretending to throw
Most negative views related to the new large health warn- up, imitating the girl throwing up blood) (C1, S2
ings, with images variously described as being ‘disgusting’, boys).
‘minging’, ‘nasty’ and ‘horrible’. The images on packs 1
and 2 (Fig. 1) provoked the most negative reactions, with Packs 3 and 4 (Fig. 1) provoked more muted or no com-
most groups agreeing that these were ‘the most horrible ments. This appeared to reflect the view these images were
ones’. The pack featuring the tracheotomy (Pack 1, Fig. 1) less ‘gruesome’ than the other two, and portrayed illnesses
triggered the most extreme, often visceral aversive re- regarded as being commonplace and not necessarily asso-
sponses, with some participants refusing to look at the im- ciated with smoking. They were therefore perceived to be
age or moving the pack out of sight. not as memorable, and less likely to affect young people.

P Eww… like that’s so disgusting! I don’t really want to P That’s what happens to people anyway…Yeah like folk
see that. get heart attacks and strokes an’ that, and just…
P Is it on the other side? Can we turn it over?! It is on the That’s what happens.
other side. P It should be like more like… not gruesome, but like
P Oh. That is so bad. more like terrifying almost… coz I’ll remember that
P Makes me feel sick. (C2, S4 girls). (C4, S2, boys).

P That’s horrible! I wouldn’t look at that but I’d just

like… if I was going to get cigarettes I’d probably take Brands and branding
them out of the packet and put them somewhere else
Participants struggled to identify the brands of the packs
instead of looking at the packet (C1, S4 boys).
shown in the groups due to the changes in key brand iden-
tifiers—brand insignia, large brand names and brand col-
Some felt that the images were so shocking that younger our. Participants who were less familiar with plain packs
children should be protected from them. had to ask the facilitator or other participants how you
could tell which brand they were, or indeed where the
See my niece? She’d cry if she saw that. That’s not brand name was.
something you should expose children to (C4, S4 boys).
P You can’t even tell the make now.
Participants generally accepted these two graphic warnings as P Yeah, you can’t even see the brand (C2, S4 girls).
being ‘real’, although some participants had to explain to
others that the hole in the throat was due to cancer. P Because they’re just pure plain, you cannae see
what… you’ve got to actually read the wee thing at
P You actually get a hole in your neck? the bottom, that’s where the name of it is (C3, S4
P Yeah. boys).
P That one’s the worst, now that I know what it is
(C4, S2 girls). In comparison, the old coloured packs were not only ‘nicer’
but you ‘knew what they were’ (C1, S2 girls). Now the
However, two groups where all the participants were brand had become just ‘a name’, stripped of its wider man-
smokers, questioned these images’ authenticity, based on ifestations and perceived distinctiveness.
their own lived experience of smokers, and the effects of
smoking. Coz you can tell the difference between the brands by
the colour normally, but now it’s just a name (C4, S4
boys).
P That is disgusting… the hole in the throat. I know so
many people that smoke, and have smoked for like
60 years, and none of them have it (C4, S4 girls). Others talked about how pack design and colours had been
used not only to identify brands and brand variants, but
P They’re fake. I’ve never seen that happen to somebody that these conveyed positive brand imagery and attributes
in my life. (the brand heuristic) about both the product—‘what it is
F What do you think about them? like’ and its ‘coolness’, which users could draw on to ‘look

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 Young people and standardized tobacco packs 1741

sort of different’, contributing to a positive and sought-after that the packs would affect never or occasional smokers,
smoker identity: but that established smokers, including some participants,
would continue to smoke regardless. Reasons cited for this
The Marlboro Golds looked kinda clean, the white and were that: the health effects of smoking were already
the gold. They looked sort of fresh. And then sometimes widely known, changing the packaging would not discour-
they have like nice patterns. Like I know there used to age addicted smokers; and smokers could hide packs inside
be the, is it JPS Blues? And they came in this like royal a pocket or bag and ignore the imagery.
blue packet, which looked quite cool.
But a heavy smoker’s not gonna stop because o’ that I
don’t think… but a light smoker will. Like see someone
And later: who’s like a social smoker or something like that, I’m
pretty sure if they’ve looked at the packet, they would be
P The old boxes like sort of, like, you’d look sort of differ- like quite terrified (C4, S2 boys).
ent with a flashy coloured box or something. That you
sort of just, it’s just sort of like ‘Ah!’ I don’t really know
They’ll not like change anything because you look at
how to describe it.
the packet for two seconds, and then it’s back in your
P You can like straight away tell what it is like, coz of the
pocket. It doesn’t matter at all (C4, S4 boys).
colour of the box (C2, S4 boys).

While not stated explicitly, the removal of ‘clean’ and ‘fresh’ P Yeah. But just coz like they’ve changed the boxes and
colours may also indicate emerging changes in perceived stuff, like we’re gonna smoke, we’re still gonna smoke
harmfulness of certain brands. it!
The removal of attractive pack colours and the addition of P Like so they’ve changed it, but anyone that smokes is
new graphic health warnings meant that now packs were gonna smoke regardless of what the box looks like.
not something that you would want to be seen with or be P They’re not gonna give up just because of a fag packet
proud of. As a result, the ability of a brand to promote or (C4, S4 girls).
project a specific image or ‘smoker identity’ had been con-
siderably reduced. Never or occasional smokers were thought to be more sus-
Not the sort of thing you’d want to have in your pocket, ceptible to the negative imagery, health warnings and un-
to be honest (C2, S4 boys). attractive appearance, and therefore less likely to want to
try smoking or become an established smoker. However,
It wouldn’t be attractive to have that in your hand, or several participants raised the point that as tobacco prod-
like be proud to walk about with it. Like you know like ucts in shops were now hidden behind shutters, this could
the old Sterling packages were like bright silver? That’d dilute the potential impact of plain packaging, as the imag-
be nice to have in your hand, but that wouldn’t be (C3, ery and warnings were only visible after purchase.
S4 girls).

They’re already hid behind shutters, so like the only

Only one group viewed the colour change positively. How-
people that are gonna see them are smokers (C4, S4
ever, this was only in relation to the Golden Virginia rolling
boys).
tobacco brand, whose traditional brand colours of yellow
and green were perceived as projecting a negative stigmatized
image of both brand and user.
DISCUSSION
Golden Virginia – the old green packets—I used to hate
the look of them, and then when they changed it to This study is only the second to explore, using qualitative
black I was like… Coz people kinda, not ‘judge’ you on methods, young people’s awareness of and responses to
what you smoke, but like if you smoke Golden Virginia standardized packaging in a country where this is imple-
there’s an odd chance that looks sad! (C4, S4 girls). mented. Our findings suggest that, at least among young
people who are smokers or at risk of becoming smokers,
the introduction of standardized packs combined with
larger graphic health warnings in the United Kingdom, is
Perceived impact
likely to have reduced the perceived attractiveness of ciga-
Views diverged about the probable behavioural impact of rette packs and reinforced and/or increased negative per-
plain packaging. The most commonly expressed view was ceptions of smoking. Awareness of standardized packs

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1742 Andy MacGregor et al.

was high, consistent with surveys undertaken at approxi- covered, stating that they would put the cigarettes in an-
mately the same time of students in these four schools for other container so that they would not see the health
the DISPLAY study [25] and adolescents in England [21]. warning, or not wanting to have the packet in their hand
This was despite the evidence that tobacco companies de- or pocket. Covering or hiding cigarette packs from others
layed the appearance of standardized packs and removal or feeling uncomfortable have been identified as markers
of fully branded packaging for as long as possible [23]. of social denormalization [8]. In Australia, 8 months after
The main sources of exposure to the new packs were family standardized packs were introduced, one in four young
and friends who were smokers, and seeing them in litter on smokers reported one of these responses that indicated feel-
the streets. ings of social denormalization [8]. Our study suggests that
Standardized packs were uniformly described as being similar processes were taking place among smokers and at
less attractive and appealing than the non-standardized risk non-smokers in the United Kingdom. The removal of
packs, which is consistent with the findings of pre–post im- brand logos, colours and other insignia appeared to have
plementation surveys of young people in Australia and created difficulties in identifying brands, and this had fur-
France [8,18,20] and a qualitative study in Scotland ther reduced positive ‘cool’ brand imagery and attributes,
[22]. Participants were aware of the changes in the colour which are important influences on youth smoking uptake.
packs to a uniform drab ‘sludge green’ or dark colour, and When packs ‘all look similar’, and the brand is reduced to
the larger graphic health warnings. As predicted by previ- ‘just a name’, the brand’s ability to act as a heuristic is
ous experimental studies [9,29,30], both were perceived to greatly diminished.
have made cigarette packs unattractive, with young people There was a general consensus that plain packs’ re-
remarking spontaneously that the drab pack colour made duced attractiveness and appeal would be off-putting for
the graphic and textual warnings more pronounced than young non-smokers or occasional smokers. However, sev-
previously, potentially increasing their potency in the pro- eral participants, particularly smokers, doubted whether
cess. In contrast, brand names had become much less vis- plain packs and the new health warnings would have
ible. Responses to being shown examples of the packs any impact on smokers, whatever their age, because the
confirmed participants’ universally negative view of the need to smoke (i.e. addiction) trumped any negative feel-
packs and health warnings, but also revealed two addi- ings about the pack and health warnings, which could also
tional important findings—that responses to health warn- be easily hidden. In addition, some participants echoed the
ings might differ depending on the image and message, and views of young people when the point-of-sale ban was in-
that the combined effect of standardized packaging and troduced, that adolescents would no longer be exposed to
graphic health warnings might be contributing to the so- the health warnings on packs as they were no longer
cial denormalization of smoking. openly displayed in shops [6]. However, the findings from
Experimental studies have found that graphic warnings this study and those in Australia [18] indicate that young
can provoke negative affective reactions such as disgust people continue to be exposed to the warnings, even if peo-
and aversion and increase the perceived likelihood of harm ple in their social worlds do not smoke, mainly through
from smoking [30]. Furthermore, increasing the size of discarded packs in litter and that (as predicted) they are
graphic health warnings reduces adolescents’ ratings of now more noticeable.
positive pack characteristics [29]. As expected, participants As far as we are aware, this is the first qualitative study
often responded with shock and disgust when recalling or to explore 13–16-year-olds’ responses to the ‘real-life’ im-
responding to graphic health warnings. However, re- plementation of standardized packaging. Additional study
sponses varied in relation to not only the relative graphic strengths are the participation of young people from di-
nature of the images but also their novelty, relevance and verse socio-economic backgrounds and the inclusion of un-
perceived credibility. McCool et al. [10] have argued that prompted recall and views, as well as more in-depth
graphic warnings’ impact might be moderated if perceived exploration of responses to examples of standardized packs
by young people to be inauthentic or exaggerated. Our and health warnings. However, the study has several limi-
study suggests that the more hard-hitting ‘gruesome’ im- tations. Participants were not recruited to be representative
ages among those used in the United Kingdom may be of young people in the United Kingdom, so our findings
more memorable and evoke stronger negative affective may not be generalizable. Fully briefed teachers within
and aversive responses among adolescent smokers and the schools helped recruit participants, but it is possible
non-smokers. However, there was some indication that that they selected students whom they perceived to be
smokers might resolve their cognitive dissonance by more articulate or likely to engage with the discussion. Par-
dismissing such images and messages as being inauthentic ticipants were smokers and susceptible non-smokers, as
or fake. they are of most concern, and as such may also be more ex-
Several participants demonstrated aversive reactions to posed to and aware of standardized packs and health warn-
the health warnings, including asking for them to be ings. The study was undertaken 2–3 months before full

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 Young people and standardized tobacco packs 1743

implementation, thus our findings may under- or overesti- Prevention and Health Promotion, Office on Smoking and
Health; 2012.
mate the full impact of standardized packaging. For exam-
3. Wakefield M., Morley C., Horan J. K., Cummings K. M. The
ple, the negative feelings reported here might become more cigarette pack as image: new evidence from tobacco industry
entrenched or abate as standardized packs become the documents. Tob Control 2002; 11: i73–i80.
norm. Also, any impact on the perceived quality of ciga- 4. Pollay R. W. Targeting youth and concerned smokers:
rettes or changed perceptions of smokers, both of which evidence from Canadian tobacco industry documents. Tob
have been identified as possible consequences of standard- Control 2000; 9: 136–47.
5. Pollay R. More than meets the eye: on the importance of retail
ized packs [14,15], were not explored in this study. How-
tobacco merchandising. Tob Control 2007; 16: 270–4.
ever, there was some indication that the removal of what 6. van der Sluijs W., Haseen F., Miller M., MacGregor A.,
were perceived to be ‘fresh’ and ‘clean’ colours might be Sharp C., Amos A. et al. ‘It looks like an adult sweetie shop’:
starting to affect perceptions of brand harmfulness, as has point-of-sale tobacco display exposure and brand awareness
been suggested in France [20]. in Scottish secondary school students. Nicotine Tob Res
2016; 18: 1981–8.
In conclusion, the findings from this qualitative study
7. Moodie C., Hastings G. Making the pack the hero, tobacco
indicate that among young people who were smokers or industry response to marketing restrictions in the UK: findings
at risk of becoming smokers, the introduction of standard- from a long-term audit. Int J Ment Health Addict 2011; 9:
ized packs combined with graphic health warnings in the 24–38.
United Kingdom is likely to have reduced the perceived 8. Dunlop S., Perez D., Dessaix A., Currow D. Australia’s plain
tobacco packs: anticipated and actual responses among
attractiveness of cigarette packs, reinforced and/or in-
adolescents and young adults 2010–2013. Tob Control
creased negative perceptions of smoking and its harm, 2017; 26: 617–26.
and disrupted positive brand imagery. Further research is 9. Hoek J., Gendall P., Gifford H., Pirikahu G., McCool J., Pene G.
needed to investigate the longer-term impacts. This would et al. Tobacco branding, plain packaging, pictorial warnings,
include investigating whether subsequent increased and symbolic consumption. Qual Health Res 2012; 22:
familiarity with the health warnings reduces the ‘shock’ 630–9.
10. McCool J., Webb L., Cameron L. D., Hoek J. Graphic warning
aversive and social denormalization effects, and the percep- labels on plain cigarette packs: will they make a difference
tions of younger cohorts who have had little exposure to to adolescents? Soc Sci Med 2012; 74: 1269–73.
the old packaging and branding. 11. Moodie C., Bauld L., Ford A., Mackintosh A. M. Young women
smokers’ response to using plain cigarette packaging: qualita-
tive findings from a naturalistic study. BMC Public Health
Declaration of interests 2014; 14: 812–9.
12. White V., Williams T., Faulkner A., Wakefield M. Do larger
None. graphic health warnings on standardized cigarette packs in-
crease adolescents’ cognitive processing of consumer health
Acknowledgements information and beliefs about smoking-related harms? Tob
Control 2015; 24: ii50–ii57.
This project was funded by the UK National Institute for 13. Stead M., Moodie C., Angus K., Bauld L., McNeill A., Thomas
Health Research (NIHR) PHR project 10/3000/07. The J. et al. Is consumer response to plain/standardized tobacco
study sponsor had no influence on study design and the packaging consistent with framework convention on tobacco
collection, analysis and interpretation of data and the writ- control guidelines? A systematic review of quantitative
studies. PLOS ONE 2016; 8: e75919.
ing of the article and the decision to submit it for publica-
14. Moodie C, Stead M, Bauld L, McNeill A, Angus K, Hinds K.
tion. We would like to thank the schools and students et al. Plain tobacco packaging: a systematic review. Stirling:
who participated in the focus groups. We would also like University of Stirling. 2012. Available at: http://phrc.lshtm.
to thank Irene Miller who facilitated all the focus groups. ac.uk/papers/PHRC_006_Final_Report.pdf.
Finally, we would like to thank Roni Butcher and Karen 15. Hammond D., Daniel S., White C. M. The effect of cigarette
branding and plain packaging on female youth in the United
Stewart for carrying out the transcription and Lesley Birse
Kingdom. J Adolesc Health 2012; 52: 151–7.
for research support and administration. 16. Moodie C., Hoek J., Scheffels J., Gallopel-Morvan K., Lindorff K.
Plain packaging: legislative differences in Australia,
France, the UK, New Zealand and Norway, and options for
References
strengthening regulations. Tob Control 2019; 28: 485–92.
1. World Health Organization (WHO). MPOWER: six policies to 17. White V., Williams T., Wakefield M. Has the introduction of
reverse the tobacco epidemic. WHO report on the global to- plain packaging with larger graphic health warnings
bacco epidemic, 2008. Available at: https://www.who.int/ changed adolescents’ perceptions of cigarette packs and
tobacco/mpower/2008/en/ (accessed 24 October 2019). brands? Tob Control 2015; 24: ii42–ii49.
2. US Department of Health and Human Services Preventing To- 18. White V. M., Guerin N., Williams T., Wakefield M. A. Long-
bacco Use Among Youth and Young Adults: A Report of term impact of plain packaging of cigarettes with larger
the Surgeon General. Atlanta, GA: Department of Health and graphic health warnings: findings from cross-sectional sur-
Human Services, Centers for Disease Control and veys of Australian adolescents between 2011 and 2017. Tob
Prevention, National Center for Chronic Disease Control 2019; 28: e77–e84.

© 2020 Society for the Study of Addiction Addiction, 115, 1736–1744

1744 Andy MacGregor et al.

19. Dunlop S. M., Dobbins T., Young J. M., Perez D., Currow D. C. protocol for an evaluation of public health policy. BMC Public
Impact of Australia’s introduction of tobacco plain packs on Health 2014; 14: 251.
adult smokers’ pack-related perceptions and responses: results 25. Haw S., Currie D., Eadie D., Pearce J., MacGregor A., Stead M.
from a continuous tracking survey. BMJ Open 2014; 4: et al. The impact of the point of sale tobacco display ban on
e005836. young people in Scotland: before and after study.
20. El-Khoury Lesueur F., Bolze C., Gomajee R., White V., Public Health Research 2020; 8: https://doi.org/10.3310/
Melchior M. Plain tobacco packaging, increased graphic phr08010
health warnings and adolescents’ perceptions and initiation 26. Robinson J., Amos A. A qualitative study of young people’s
of smoking: DePICT, a French nationwide study. Tob Control sources of cigarettes and attempts to circumvent underage
2019; 28: e31–e36. sales laws. Addiction 2010; 105: 1835–43.
21. Bogdanovica I., Opazo Breton M., Langley T., Britton J. 27. Nuyts P. A. W., Hewer R. M. F., Kuipers M. A. G., Lorant V.,
Awareness of standardized tobacco packaging among adults Grard A., SILNE-R Consortium, et al. Youth access to ciga-
and young people during the final phase of policy implemen- rettes across seven European countries: a mixed-methods
tation in Great Britain. Int J Environ Res Pub Health 2017; 14: study. Nicotine Tob Res 2019; https://doi.org/10.1093/ntr/
858. ntz180.
22. Mitchell D., Moodie C., Critchlow N., Bauld L. Adolescents’ 28. Braun V., Clarke V., Hayfield N., Terry G. Thematic analysis.
perceptions of standardized cigarette packaging design and In: Liamputtong P., editor. Handbook of Research Methods in
brand variant name post-implementation: a focus group Health Social Sciences. Singapore: Springer; 2019, pp.
study in Scotland. BMC Public Health 2019; 19: 1227–35. 843–60.
23. Critchlow N., Stead M., Moodie C., Eadie D., MacKintosh A. M. 29. Germain D., Wakefield M. A., Durkin S. J. Adolescents’ percep-
Introduction of standardized tobacco packaging during a tions of cigarette brand image: does plain packaging make a
12-month transition period: findings from small retailers in difference? J Ado Health 2010; 46: 385–92.
the United Kingdom. Nicotine Tob Res 2019; 21: 871–8. 30. Noar S. M., Hall M. G., Francis D. B., Ribisl K. M., Pepper J. K.,
24. Haw S., Amos A., Eadie D., Frank J., MacDonald L., Brewer N. T. Pictorial cigarette pack warnings: a
MacKintosh A. M. et al. Determining the impact of smoking meta-analysis of experimental studies. Tob Control 2016; 25:
point of sale legislation among youth (DISPLAY) study: a 341–54.

© 2020 Society for the Study of Addiction Addiction, 115, 1736–1744