Qualitative Testing of New Health Information Messages, Including Placement Options, as well as the Thematic Linking of Labelling Elements – 2019 – Final Report

Health Canada

Final Report

October 2019

Prepared for:
Health Canada
Supplier Name: Quorus Consulting Group Inc.
Contract Award Date: June 13, 2019
Delivery Date: October 2019
Contract Amount (incl. HST): $145,661.24
Contract #: HT372-192561/001/CY
POR Number: 025-19

For more information, please contact:
hc.cpab.por-rop.dgcap.sc@canada.ca

Ce rapport est aussi disponible en français.

Qualitative Testing of New Health Information Messages, Including Placement Options, as well as the Thematic Linking of Labelling Elements – 2019
Final Report
Prepared for Health Canada
Supplier name: Quorus Consulting Group Inc.
October 2019

This public opinion research report presents the results of focus groups conducted by Quorus Consulting Group on behalf of Health Canada. The research study was done using qualitative focus groups. The research entailed a total of 15 in-facility focus groups conducted with people who smoke cigarettes daily or occasionally. The research was conducted between July 13 and 27, 2019.

Cette publication est aussi disponible en français sous le titre : Évaluation qualitative de nouveaux messages d'information sur la santé, y compris les options de placement, ainsi que la relation thématique des éléments d'étiquetage - 2019

This publication may be reproduced for non-commercial purposes only. Prior written permission must be obtained from the Health Canada. For more information on this report, please contact the Health Canada at: hc.cpab.por-rop.dgcap.sc@canada.ca or at:

Department of Health
200 Eglantine Driveway
A.L. 1915C
Ottawa, Ontario
K1A 0K9

Catalogue Number:
H14-335/2020E-PDF

International Standard Book Number (ISBN):
ISBN 978-066-032511-8

Related publications (registration number: POR 025-19):
Catalogue Number H14-335/2020F-PDF (Final Report, French)
ISBN 978-0-660-32512-5

Political Neutrality Statement

I hereby certify as Senior Officer of Quorus Consulting Group Inc. that the deliverables fully comply with the Government of Canada political neutrality requirements outlined in the Policy on Communications and Federal Identity and the Directive on the Management of Communications - Appendix C.

Specifically, the deliverables do not include information on electoral voting intentions, political party preferences, standings with the electorate or ratings of the performance of a political party or its leaders.

Signed:

Rick Nadeau, President
Quorus Consulting Group Inc.

Executive Summary
Background
Research Purpose and Objectives
Review of Health Information Messages
- Common Reactions Across HIMs
- Reactions to HIMs on Vaping
Detailed Results
- HIM #6 – Lower your risk of diabetes
- HIM #17 – Thinking of quitting?
- HIM #21 – Know your triggers
- HIM #23 – What happens when you quit?
- HIM #24 – Wondering about vaping?
- HIM #25 – Become tobacco-free by switching
- HIM #26 – Trying to quit smoking?
- HIM #27 – Improve your skin health
Review of Health Information Message Placement
Thematic Linking
Methodology
Appendices
- Recruitment Screener
- Moderation Guide
- Handout 1
- Handout 2

Executive Summary

Background and Research Objectives

Health Canada is developing a new suite of HIMs, and once they are developed and regulatory processes are in place for them, the current suite of HIMs will retire. Health Canada commissioned Quorus to conduct qualitative research through a series of focus groups to gain clarity and understanding of new draft HIM mock-ups, identify the optimal location for noticeability, assess the relevance of thematic linking across the messages in and/or on packages and provide information on regulatory decisions.

Methodology

This report is based on 15 in-person focus groups that Quorus completed between July 13 and July 27, 2019. All participants were people who smoke cigarettes either daily or occasionally and were grouped according to the following segments: "Youth" 15 to 19 years old, "Young adults" 20 to 24 years old, and, "Adults" 25 years of age or older. In total, 132 individuals participated in the focus groups. English sessions were held in Toronto, Winnipeg, Edmonton, and St. John's and French sessions were held in Quebec City. More details can be found in the Methodology section of the report.

Qualitative research is designed to reveal a rich range of opinions and interpretations rather than to measure what percentage of the target population holds a given opinion. The results are directional in nature; and the results of qualitative research are not statistically projectable of a specific target audience.

Review of Health Information Messages

Very few participants said they pay attention to the HIMs when they purchase a new package of cigarettes. Furthermore, very few purchase "slide-and-shell" packages – most purchase "flip top" packages in which the HIMs are inserted as a card that many participants remove and throw out.

Participants were presented with eight draft HIMs and were asked to score each one using a scale from one to ten with respect to:

How effective the HIMs are in terms of informing and educating about the benefits of quitting smoking; and
How effective the HIMs are in terms of making participants think about quitting smoking.

While there were specific comments for each HIM tested, a variety of reactions apply across all concepts. For starters, participants were more likely to react positively to concepts that conveyed a meaningful benefit of quitting over ones that focused mostly or entirely on tips to help them quit. As well, participants preferred short and impactful bullets over blocks of text.

From a design perspective, graphics and certain colours (especially those that deviated from what they usually see on their packages of cigarettes such as orange, light blue, and purple) can be useful in terms of getting someone's attention. However, images that lacked personal relevance or perceived authenticity weakened the HIM.

Most preferred teasers that featured a question or an image, especially when compared to teasers that only featured contact information.

With the exception of a few terms (e.g. NRT, coronary), the concepts were easy to understand.

The quitline information was almost always seen as relevant, however, few participants seemed to agree that it should be prominently shown in the teaser. The preference was for the website and the telephone number to always be shown together and, in that format, the website always be shown ahead of the telephone number. While the quitline information is noticeable at the bottom of the main HIM, some did concede that they probably would not open their cigarette pack that far and would miss it. Finally, short text such as "Connect now" and "For non-judgmental support" that accompanied the quitline information were often considered clutter and adding limited value.

Reactions to HIMs on Vaping

Three HIMs suggested that switching completely to vaping can reduce exposure to harmful chemicals in cigarette smoke and could be a potential method to quit smoking cigarettes. A good number of participants could relate to using vaping as a strategy to quit smoking cigarettes entirely. However, many felt that these HIMs either did not have enough information about vaping or that they have heard too many bad things about vaping (e.g. the chemicals it contains, exploding devices, popcorn or bubble lung, etc.) for it to be considered a viable alternative to smoking cigarettes. While most could appreciate that vaping may be different from smoking cigarettes, most also felt it was like replacing one addiction or "evil" for another. In the end, most would agree that the "jury is still out" and that the long-term effects of vaping have yet to be understood.

As such, very few felt comfortable with the idea of replacing cigarette smoking with vaping and most were also quite uncomfortable, even upset, with what they perceived as Health Canada recommending, endorsing, or promoting vaping. In the end, only a few felt that it was a strategy worth suggesting, especially coming from Health Canada.

Review of Health Information Message Placement

Five mock-up packages were shown to the participants to see how noticeable the HIM was on each one. The packages were all the same except for the placement of the HIM. Option A (which is the current HIM placement on "slide-and-shell" packages) had the HIM on the back of the slide. Option B had the HIM as an interior insert, located in front of the cigarettes in the package. Option C was very similar to "B", however the HIM was a sticker covering the foil of the cigarettes. The HIM in Option D was an extension of the interior tab. Finally, Option E was an extension of the top flap that went over top of the cigarettes.

Option E was by far the most noticeable approach. Participants explained that seeing the HIM was considered inevitable and that the contrast with today's format, in terms of noticeability, is significant. Some also explained that they would tear or cut off the extended flap.

Option B was very similar to what they currently see in their packs (flip top packages) and as such most stated they would discard the insert the same way they do today. The fact that the insert is not attached to the pack and that it can be easily discarded hindered how noticeable it was.

Options C and D were considered equally noticeable and much less "annoying" as E since nothing got in the way of accessing the cigarettes.

Option A was by far the least "noticeable" approach, mostly because participants did not believe they would ever turn their pack around to look at the information. Many participants were flip top users, therefore, while this option was the status quo, this format was still new to them.

Thematic Linking

Three series of HWs, HIMs and toxic statements (TS) were presented to participants who were then asked to rate how effective each series was in terms of helping them understand the link between tobacco use and the particular health conditions shown. Series A contained information in the HW, HIM and TS that was linked by a theme (in this case the respiratory system). Series B contained information in the HW and TS that were linked by theme (again, the respiratory system) with a different HIM (related to the quitline services). The three labelling elements in Series C were unrelated by theme.

Although many indicated they had noticed that Series A followed a theme, they did not necessarily flag this as the reason they felt this series was effective. For that series, participants were more likely to flag the quality of the HIM as the main reason behind its effectiveness. More precisely the image of the lungs, the red text next to the lungs and the timeline approach to the supporting text.

The specificity in the TS in Series C was considered more impactful than the general information in the other two series.

When prompted, most participants believed that having all three types of messages linked by a theme would be preferred over one that does not follow a theme. They believed it would be more impactful since it addressed the same issue from different perspectives.

When the moderator challenged participants by reminding them that they said they rarely read one of the messages, let alone all three, participants reinforced the following:

If a specific theme is in fact relevant to them, they are likely to read about it;
If the type, location or format of the information on or in the packages changes, they are more likely to notice the change and continue reading the information.

The few in favour of touching on a variety of topics in the 3 message formats explained that this variety increased the odds of at least one of the messages being relevant to them. Others simply agreed that they would not read all three so any value in a linked theme would be lost on them.

Supplier Name: Quorus Consulting Group Inc.
Contract number: HT372-192561/001/CY
Contract Award Date: June 13, 2019
Contract Amount (including HST): $145,661.24
For more information, please contact Health Canada at: hc.cpab.por-rop.dgcap.sc@canada.ca

Background

Tobacco use is the leading preventable cause of death and disease in Canada. It contributes to a variety of diseases such as cancer, respiratory ailments and heart disease. Every year, more than 45,000 Canadians die from illnesses caused by tobacco use; that is about one Canadian every 12 minutes².

Health Canada is responsible for the administration and enforcement of the Tobacco and Vaping Products Act and its regulations. This includes displaying health-related information on tobacco product packaging which has been shown to be one of the best approaches in raising awareness on the health risks of tobacco use. The Tobacco Products Labelling Regulations (Cigarettes and Little Cigars) (TPLR-CLC) were adopted in 2011 and replaced the previous requirements of the Tobacco Products Information Regulations (TPIR) (adopted in 2000) that applied to cigarettes and little cigars. The TPLR-CLC require a combination of Health Warnings (HW), Health Information Messages (HIM), and Toxic Emissions Statements (TS) to be displayed on or in all packages of cigarettes and little cigars sold in Canada. The TPIR stipulate that certain other tobacco products (e.g., smokeless and cigars) display HW, HIM, and Toxic Emissions Information and Toxic Constituents Information (collectively referred to as Toxic Statements). Labels on tobacco product packages help inform tobacco users of the health hazards and health effects of using tobacco products.

The TPLR-CLC require HIMs to be displayed on the inside of cigarette packages, specifically on the back of the sliding portion of "slide-and-shell" packages or on a leaflet inserted in flip-top packages. The English and French versions of the HIMs appear side by side on the back panel of the sliding portion. For the leaflet, the English message is displayed on one side, while the French appears on the reverse side. HIMs include the following two components:

Teaser: a short message on the upper-slide flap of "slide-and-shell" type packages or on the upper part of a leaflet for "flip-top" packages. This message is in both English and French and refers the reader to the health information on the back of the sliding portion of the "slide-and-shell" package and on the leaflet. The teaser may contain an illustration.
Health Information Message: the main message located on the back panel of the sliding portion of "slide-and-shell" type packages, or on a leaflet included inside "flip-top" packaging. Some include an illustration and/or a picture.

Health Canada is considering implementing several rotating suites of health labelling for tobacco products. Health Canada is developing a new suite of HIMs, and once they are developed and regulatory processes are in place for them, the current suite of HIMs will retire. They are also testing the placement and design for HIMs as well as thematically linking the HW, HIM and TS on each package.

Research Purpose and Objectives

Health Canada commissioned Quorus to conduct qualitative research through a series of focus groups to gain clarity and understanding of new HIM mock-ups, identify the optimal location for noticeability and provide information on regulatory decisions. The research will provide information on updated labelling and additional information about linking labelling elements (HW, HIM and TS).

The main objectives of the qualitative research were as follows:

To explore reactions to, understanding and impressions of 8 HIM mock-ups to determine if the concepts:
- are noticeable;
- are credible and relevant for the target audiences;
- are in plain language and understood (in the intended way) by the target audiences;
- clearly inform and educate Canadians about the health hazards and health effects of tobacco use;
- are leaving a memorable impact on the target audiences; and
- encourage positive attitudes towards cessation of tobacco.
To assess reactions of people who smoke to different HIM placement options, more specifically:
- To gather feedback on different formats and placement options of the HIM for its salience and readability.
- To gather participants' views of design elements, including the impact of different formats, placement and colours (i.e., for background, border, certain text) and whether they improve noticeability.
To assess reactions of people who smoke to thematic linking of labels, more specifically:
- To explore perceptions of people who smoke of thematically linked labelling elements (vs. non-linked elements) to help determine if thematic linking…
  - Enhances understanding of the health conditions presented,
  - Increases the packages' ability to inform and educate Canadians about the health hazards and health effects of tobacco use, and encourage positive attitudes towards cessation, and/or,
  - Leaves a memorable impact on the target audiences.

Review of Health Information Messages

Each session began by explaining to participants that they would be focusing on Health Information Messages (HIMs) and not the Health Warnings (HW) or the Toxic Emission Statements (TS) found on cigarette packages.

To gain an initial understanding of reactions to current HIMs, participants were asked if any of them had ever read the HIM on their cigarette packages. Few participants, regardless of age, reported reading the HIM on packages. Most participants do not currently use the "slide-and-shell" type of cigarette package; they are more likely to use the "flip tops" where the HIMs are inserted as a leaflet. Most revealed that they either throw it out or they wouldn't read it, and if it was read at all, it only tended to happen once and was not read again. For a few participants in each session, these cards were used for other purposes, such as filters for marijuana joints. The few who reported reading HIMs before said it was usually when they were bored or waiting for something, but could not recall what they had read.

Participants were then handed a booklet with 8 draft HIMs that they were asked to review and rate on two metrics: how effective they were in educating/informing about the benefits of quitting smoking, and, how effective they were in making them think about quitting smoking. All HIMs were tested using the plain and standardized appearance colour scheme³ in the "slide-and-shell" format. Half of the groups reviewed the HIMs in order from the front to the back of the booklet and the other half reviewed the HIMs in order from the back to the front of the booklet. After all participants had finished reviewing all 8 HIMs, the moderator explored each HIM individually through a guided, open discussion.

Common Reactions Across HIMs

Overall, there were some common reactions across all HIMs.

With the exception of HIMs that featured vaping, all HIMs were generally seen as credible. Credibility in those instances was attributed to the fact that it was Health Canada who was responsible for the information.

In terms of formatting, participants preferred to read the text in bullet form rather than in a paragraph because it was easier to read and absorb the messaging. Many revealed they would not read the information if they saw a paragraph.

Another set of reactions pertained to the quitline information. For the most part, participants preferred if the telephone number and website were always shown together, with the website appearing first. The majority of participants agreed that the website should be shown ahead of the quitline, as they are more likely to use this information. A few participants (mostly older adults) among all groups thought it would be a good idea to have access to a QR code. Most participants agreed they would not call in so they would rather see the website to find more information. Short text accompanying the quitline information such as "for non-judgmental support" or "connect now" was widely dismissed as they added clutter and were deemed unnecessary. In some cases, participants felt the short text made it harder to find the quitline information.

Initially, most participants liked seeing the quitline information in the teaser because it was easy to see right away. Their thoughts changed, however, when asked if they would keep reading the rest of the message. Participants felt it would not entice them to keep reading. Conversely, while participants felt it was most noticeable at the bottom of the main message, a few stressed that they would likely not open the pack the whole way and would probably miss it.

Most also seemed to prefer teasers that featured a question or an image, especially when compared to teasers that only featured contact information.

Participants were more likely to value concepts that conveyed a meaningful benefit of quitting over ones that focused mostly or entirely on tips to help them quit.

Graphics and certain colours can be useful in terms of getting someone's attention. Participants explained that they tended to notice graphics (e.g. someone smiling, a cartoon-style image) and colours and colour schemes (e.g. light blue, orange, gradients of colours) not typically seen on or in packages of cigarettes. Conversely, images that looked staged or fake and images that lacked relevance to the main message weakened the HIM in terms of initial appeal and attention retention.

With the exception of a few terms (e.g. NRT, coronary), the concepts were easy to understand.

Reactions to HIMs on Vaping

One of the biggest reactions came from the discussion around vaping. Three HIMs (#17, #24 and #25) suggested that switching completely to vaping can reduce exposure to harmful chemicals in cigarette smoke and could be a potential method to quit smoking cigarettes. Vaping elicited mixed reactions when participants read these parts of the HIMs. While a good number of participants could relate to using vaping as a strategy to quit smoking cigarettes, most were reluctant to accept the idea of positioning vaping as an alternative to smoking in the HIMs. This reluctance was in large part driven by concerns that the long-term health effects of vaping are unknown. Many also mentioned that they had come across too many conflicting reports about the benefits and harmful effects of the product. Many felt they did not have enough information about vaping and that they have heard too many bad things about vaping (e.g. the chemicals it contains, exploding devices, popcorn or bubble lung, etc.) for it to be considered a viable alternative to smoking cigarettes. As far as participants could tell, they felt that switching from smoking cigarettes to vaping was switching from one addiction or bad habit to another.

Participants were especially concerned about seeing vaping messages on HIMs put out by Health Canada. They felt that Health Canada was "endorsing" or "promoting" vaping and this left them feeling uneasy and, in some cases, upset. For many, this left them questioning the credibility of Health Canada. For a few participants having seen other Health Canada messaging describing the ill effects of vaping, seeing these HIMs left them wondering if Health Canada was "talking out of both sides of its mouth."

Conversely, not all reactions about vaping were negative. There were a few participants in each city who didn't mind seeing vaping as an alternative to smoking in the HIMs. Some participants felt it was good to see Health Canada suggest an alternative to smoking cigarettes directly in a HIM, rather than just recommending to quit cold turkey. A few participants had done a lot of research about vaping and agreed with the HIMs that vaping would be better than smoking cigarettes. A few also emphasized that vaping was much more affordable than smoking cigarettes, and that as a benefit to quitting smoking cigarettes, the financial angle could be discussed in the HIMs in addition to the health-related ones.

In general, participants wanted to see more public education about vaping before they would consider switching to vaping. They wanted specific statistics rather than general statements.

Some common questions were:

How is it better than cigarettes?
What are the chemicals in vape liquids?
What are the long-term effects of vaping?
What is the success rate among those switching completely from smoking cigarettes to vaping?

More specific reactions to the HIMs are described in the following pages.

Detailed Results

HIM #6 – Lower your risk of diabetes

Overall Impressions

The information presented in this HIM was new to most participants. Associating diabetes or the risk of diabetes with smoking was seen as a new health effect for participants. This especially resonated with participants who either had diabetes or have a family history of diabetes (although it is difficult to assess if participants were distinguishing between the different types of diabetes when they considered the information in the HIM).

"I like how specific it had, the 30-40% chance. I liked the data in there and the thing about 8-weeks after quitting it starts to decrease. I like how it was very targeted and specific." – Adult, Edmonton

Though the information was new, participants without a family history tended to quickly dismiss this message. They did not feel like the message was relevant to them. In fact, many participants felt this HIM was exclusively targeting individuals with diabetes or a family history of diabetes.

"The last paragraph speaks very specifically to people who already have diabetes or are an older age group, so it is immediately dismissed because it's not relatable. It's too specific." – Young Adult, Winnipeg

Younger participants were especially apt to dismiss the information since they felt this wasn't something that would happen to them or that diabetes is only a concern for older people.

The picture received mixed reviews – while some felt that an older man speaking with a physician was relevant, others did not find the image particularly engaging or novel and a few did not notice that he was speaking with a physician. The picture also made a few younger participants feel the message was directed towards older adults, and therefore not relevant to them.

« Un médecin avec un patient. Tout le monde sait que ce n'est pas bon de fumer des cigarettes… C'est un peu cliché. » - Young Adult, Québec City [A doctor with a patient. Everyone knows it's not good to smoke cigarettes… It's a bit cliché.]

Noticeability

The teaser was effective in grabbing the attention of some participants, especially those who have diabetes or have a family history of diabetes. The reference to diabetes was new and, not being typically associated with smoking, enticed some to read further.

From a design perspective, the blue framing wasn't exciting or eye-catching to participants. They found the colour dull and common since it is the colour scheme used by a few cigarette brands.

The quitline information was noticeable to most participants. They noted that the contrast of the yellow writing on a blue background made it more noticeable, but the font size could be increased.

Clarity/Easy to Understand

In general, participants felt the information was easy to understand. Once they reached the main message, the information was interesting but many wished it was more streamlined. The mere sight of a "block of text" dissuaded some from reading the main message. Most participants did not like that the teaser was repeated in the header of the main message because it was seen as redundant and they felt the space could be better used for new information. Finally, there was some debate over the statistics in the text:

While most liked that research was featured, some participants wanted to see a citation or a reference to give the findings greater credence.
A few participants, especially youth, did not find "30%-40% more likely" particularly dissuasive and that this is a risk they were prepared to live with.
A few also questioned that the text focused exclusively on smoking as a possible cause of type 2 diabetes – they wondered why other factors, like lifestyle and nutrition, were not considered.
Some were surprised that their family physician had never raised diabetes in their discussions related to smoking.

Credibility

Overall, the participants felt the information was credible and this stemmed mostly from the fact that it was coming from Health Canada.

Helps Understand the Benefits of Quitting

In the end, this HIM made almost everyone learn about a benefit of quitting smoking, although it was not compelling for many participants.

Helps Motivate to Quit Smoking

As noted above, the message was more likely to motivate individuals either with diabetes or with a family history of diabetes. Among these individuals, the message was quite impactful.

Participant Suggestions

In order to improve this concept, participants suggested the following:

Avoid repeating the same information from the teaser in the main message.
Replace the paragraph with a few key statistics in bullet form, making one bullet relevant to those with diabetes and the other bullet clearly relevant to those without diabetes.
Change the image to increase the universal relevance of type 2 diabetes (e.g. someone getting their insulin injection).
Change the colour of the blue background.

HIM #17 – Thinking of quitting?

Overall Impressions

Initial reactions to this HIM were related to the colours. They felt the colours were bright and inviting which made them want to read the message. Once participants reached the main message, they appreciated the information in bullet form rather than paragraph form because it is easy to read. Upon reading the message, however, there were mixed reactions. Some liked the idea of four options clearly presented for where to go if you want to quit, and they could consult the list if they were thinking of quitting. On the other hand, some participants felt this information was common sense and nothing that they haven't heard many times before. There was also significant debate surrounding the bullet "switching completely to vaping".

"I think this is nice because it tells you where to go. The other ones tell you what to do, but this is like your first step, so you're trying to quit? Okay call this number or talk to a health care provider." – Young Adult, Toronto

"It's still a chemical you put in you, and I get it: to quit is hard to do cold turkey. But it's mental and if we're ready we'll do it. But to be telling me to switch to something else, how will I get off that after?" – Adult, Toronto

The picture at the bottom was relevant among those who understood the meaning of it. Many participants who noticed the arrows and made the connection between four arrows and four "roads to quitting", really appreciated the graphic. This was not, however, obvious to all participants. Those who did not understand the graphic did not think it was relevant. A few also felt the colours were childish.

From an overall relevance perspective, many participants actively answered "no" to the question posed in the teaser ("Thinking of quitting?") and this largely determined whether or not they would read the main message and the overall effectiveness of the concept. Participants largely agreed that this concept is only relevant to individuals who are already thinking about quitting.

Noticeability

As noted above, participants felt the bright colours caught their attention right away. Looking at the teaser, many participants liked that an image was used. It was considered quite effective in getting their attention since they don't typically see images like this inside the pack of cigarettes. Having a question in the teaser was also a positive aspect, and many revealed it would make them want to keep reading.

This HIM was the only one to present the quitline information within the text (rather than in the teaser or at the bottom of the main message). Most were accepting of this approach, however felt that the telephone number and website needed to stand out more through the use of bolding or a different font style. A few participants didn't notice the quitline information until the discussion began, and preferred it be separate from the rest of the information. A few also suggested moving this information to the bottom of the list since they are so accustomed to seeing it already and is not new to them.

"Website and number are not noticeable – they blend in with the text and don't stand out. If it was bolded, bigger size or a different colour it would be good in this spot." – Young Adult, Winnipeg

Clarity/Easy to Understand

For the most part, the information was clear and easy to understand. A few participants, specifically in Toronto, had either never heard of a nicotine inhaler or did not know there was a difference between that and a vape. A few others, mainly younger participants, did not know what the word "lozenge" meant.

Credibility

Overall, participants felt most of the information was credible as it came from Health Canada, but there was no new or headline-worthy information in the text. Many questioned the credibility of the vaping bullet and suggested it be removed.

Helps Understand the Benefits of Quitting

Most participants did not feel that this message helped them think about benefits of quitting. While they appreciated the tips, they felt this did not tell them anything they didn't already know. Most participants recognized that "adding years to your life" was a benefit to quitting, however they felt it was not very impactful. This is common sense in their minds and something they've been told many times as a person who smokes cigarettes.

"It's not pushing me anymore than I already would have been." – Youth, St. John's

Helps Motivate to Quit Smoking

The tips in the main message were not as effective as the tips in HIM #21. Only a few said this would motivate them to think about quitting smoking.

Participant Suggestions

In order to improve this concept, participants suggested the following:

Remove the bullet about vaping to increase credibility.
Separate the quitline information from the bullets, or use bolding to ensure this content is more noticeable.
Move the quitline information to the bottom of the list – many disconnect when they see the quitline information because they've seen it so many times before.
Enhance the graphic in the main message to make it more obvious that the arrows represent different "paths" and that they are ultimately arrows pointing towards the same goal.
Insert more impactful benefits to quitting smoking or at least ones that they have not heard repeated time and again (which is the case with "adding years to your life").

HIM #21 – Know your triggers

Overall Impressions

At first glance, many participants found this HIM to be uninteresting and bland. A few compared the overall look to a poster you would see in a gym class or a recreation center, which did not resonate with them. This HIM was not compelling among youth participants.

A few of the tips in the main message were consistently considered unrealistic, in particular "when a craving hits, change immediately to a different activity" and "change up your routine". For those who smoke all the time (i.e. at work or when driving), changing to a different activity or changing up their routine was considered a very difficult thing to do.

"'Know your triggers' but then it doesn't talk about triggers, it talks about what to do when a craving hits. Instead, put common triggers and what to do in those situations." – Adult, St. John's

For some, the HIM reminded them or reinforced how difficult it might be to quit smoking which left them a bit discouraged about even trying. Conversely, many participants liked the part that reads "you've got what it takes" as they felt it was a strong, motivating and powerful message.

"I like [the use of the term] 'triggers'. It's effective to talk about this in that way. I think it gets to the moment where you're able to make a choice between smoking and not smoking, so the language I quite like." – Adult, Toronto

The images were a popular point of conversation with this HIM. Some participants found them too distracting, and their eyes went right to them without even reading the message. Participants who liked the images recognized that they were showing the activities one could be doing instead of smoking. There were a few images that were confusing to most participants though, such as the apple and the phone. By contrast, some associated some of the images with smoking, such as looking at their phone, reading, and doing exercise (physically active participants said they often look forward to having a cigarette after they finish exercising). Overall though, many seemed to agree that the concept could do with fewer images.

"What does a phone or crossword have to do with knowing triggers?" – Edmonton, Young Adult

Noticeability

This HIM was one of the only ones that participants noticed "see the back" in the teaser, which was due to the contrast of the red and blue. While the colours were well received, the quitline information located on the teaser would not make them want to keep reading. The information itself was not new to them and they would feel as though the quitline information was the extent of the information being conveyed. If this information were to stay in the teaser, a few suggested changing "Connect now" for "Quit now" or "Want help quitting?" to make it more relevant to the main message. The preferred teaser would be to remove the quitline information altogether and replace it with "Know your triggers" / "Do you know your triggers?" to make it more effective.

The graphics were very noticeable in this HIM, but in some ways, they were too distracting and took away from the overall message for some.

Clarity/Easy to Understand

In the main message, participants liked most of the tips and how they were encouraging. Participants could understand almost all of them, except almost all participants (regardless of age or language) did not know what "Nicotine Replacement Therapy (NRT)" meant. Most thought this was a form of physical or psychotherapy that they had not heard of before.

Credibility

Overall, participants felt the information was credible as it came from Health Canada.

Helps Understand the Benefits of Quitting

In the end, this message did not help participants think about benefits of quitting smoking. Many participants felt this HIM was more targeted towards people who were already thinking of quitting.

Helps Motivate to Quit Smoking

While it did not help the participants think about the benefits, it was effective for some in encouraging them to think about quitting as it gives them some ideas and strategies. Participants could also relate to their "triggers" and felt that focusing on those was an interesting and relevant strategy.

Participant Suggestions

In order to improve this concept, participants suggested the following:

Remove some of the icons at the bottom (e.g. the apple and the phone).
Put "Know your triggers" / "Do you know your triggers?" in the teaser instead of the quitline information.
Rather than using the term "NRT", explain it the same way as it is in HIM #17 by listing the actual products: nicotine patches, lozenges, gum or inhalers.
Change the white in the main message to a different colour to make the concept more distinct and noticeable.

HIM #23 – What happens when you quit?

Overall Impressions

This HIM elicited immediate positive responses regarding how relevant, interesting and noticeable this concept is. This concept also had universal appeal – it was liked irrespective of gender or age.

The main message was interesting for virtually all participants and nearly everyone confirmed that they learned something new through this HIM. They liked the timelines, since it gave them realistic and tangible "milestones" or "goals." Most appreciated the near-term or short-term timelines (i.e. 8 hours and 24 hours) since it made the goals more attainable and seem less daunting. The fact that results could be seen so quickly was also very positive. However, some noted the gap between 45 days and 1 year was too long and would rather see more short to medium-term outcomes.

"It gives you immediate (8 hours) and longer term (1 year). The shorter time limit makes you feel like you can actually do it." – Young Adult, Winnipeg

Many participants felt that the specific information and timeline in this HIM suggested more research had been done by Health Canada on the positive health effects of quitting. This was much more valuable to them than a few other concepts that seemed to just list broad and vague statements.

"It's going to keep you motivated… it helps you see progression of what you're actually doing." –Youth, Edmonton

The picture used in this HIM led to mixed reactions. Some participants liked seeing a real person, rather than a cartoon, and enjoyed how happy he looked as it made them feel that he had quit smoking. They also liked the contrast between his blue shirt and the orange background. Others, however, felt he looked somewhat "goofy" and even under the influence of drugs and that he doesn't add anything to the overall message.

Noticeability

Participants felt that the teaser would not entice them to read beyond the quitline and website. This didn't deter them from finding the HIM effective to understand the health benefits of quitting smoking. However, many suggested replacing it with the question "what happens when you quit?" and putting the quitline information in the header of the main message or the very bottom.

"Timeline is great but the 'connect now' teaser is not selling what is going on in the message. Could be something 'what happens 8 hours after you quit' or something along those lines to catch my attention. The idea of suggesting something without giving it all away." – Youth, Winnipeg

This concept caught everyone's attention immediately due to the colours used and the overall layout. The bright colours were attractive and unique, and the orange gradient made it more visually appealing than a solid colour. Some also noticed and appreciated that there was a particular "glow" around the image of the young man, perhaps hinting at the improvement in his health since he's quit smoking. The bold phrases on top of each small paragraph was another part they really liked. This segmented the information in a user-friendly and inviting manner and, even though there is a lot to read, participants did not shy away from reading it.

Clarity/Easy to Understand

For the most part, this HIM was clear and easy to understand. The only one term that was not understood (in both English and French) by a few participants was "coronary"/ "coronarienne."

Credibility

Overall, participants felt the information was credible as it came from Health Canada.

Helps Understand the Benefits of Quitting

The information in this HIM was interesting and new to most participants. It made virtually everyone think about the benefits of quitting.

Helps Motivate to Quit Smoking

Almost all revealed this HIM would be effective in making them think about quitting. The timeline gives them short-term and realistic goals to strive for and the benefits were considered relevant and tangible.

Participant Suggestions

In order to improve this concept, participants suggested the following:

Replace the teaser with "What happens when you quit?" and move the quitline/website information to the header or the bottom of the main message.
Provide more short and medium-term goals and outcomes instead of the big gap in the timeline from 45 days to one year.
Change the image to someone with a different expression or an image that relates to the main message (i.e. a question mark).
Replace the term "coronary/coronienne" with more everyday language.

HIM #24 – Wondering about vaping?

Overall Impressions

This HIM was overshadowed by the debate each group ended up having around vaping. It was dismissed immediately by many participants who said they had no interest in switching to vaping. Young adults especially discounted the impact of this concept.

« Un mal pour un autre mal. » - Young Adult, Québec City [One wrong for another wrong.]

The colours and overall design were well received for the most part. Participants found the bullet format (regardless of the content) and the overall layout to be noticeable and easy to read, although some participants suggested replacing the "mustard yellow" because it was an "aggressive colour." However, others liked the blue and yellow together. In terms of the graphic, while it was widely appreciated in the teaser, it was considered less relevant in the main message – some felt it could be removed and more information about vaping could be added in its place. The teaser itself was also considered quite appealing and relevant since many do have questions about vaping.

"The colours are nice and bright, it caught my attention." – Youth, Toronto

Once participants read the main message, the positive reactions tended to fade. Most participants felt the message didn't answer their questions, as the teaser hinted it would. The content in the bullets was considered both vague and contradictory. They felt that the first bullet, which tells them that nicotine is addictive, is not only common sense but that it also contradicts the third bullet, which tells them to switch to vaping (and is also described as containing nicotine). For this reason, they felt the first bullet could be removed and/or switched with something more informative about vaping. Most participants were expecting the message to give them facts or statistics about vaping to make it clearer to them why switching would be better.

Noticeability

One of the most positive parts of this HIM was the teaser. Participants liked the question asked in the teaser, since many participants do have questions about vaping. This question makes them want to read the rest of the message to have some of their questions answered.

While for the most part the colours were noticeable, a few said that the colours would not grab their attention since yellow is already prominently used on certain cigarette packages.

The quitline information was noticeable to participants. Some mentioned this was due to the colour contrast of blue and yellow which separated the main text and the quitline information. Almost all participants felt that removing "connect now" and "non-judgmental support" would make the contact information more noticeable.

Clarity/Easy to Understand

The language used was clear and understood. However, participants across most groups were confused by the content of the messages. In particular, they found bullets one and three contradictory and confusing as explained above.

Credibility

Similar to the two other HIMs that included content related to vaping, participants struggled with Health Canada suggesting that switching completely to vaping can reduce exposure to harmful chemicals in cigarette smoke. This hindered the overall credibility of the HIM.

Helps Understand the Benefits of Quitting

Participants did not find that the information presented in this HIM presented benefits to quitting smoking or switching to vaping. Most did not find it informative, suggesting this information is already well known.

Helps Motivate to Quit Smoking

Participants would not be motivated to think about quitting after reading this HIM. They felt there were not enough facts or information about vaping itself to compel them to quit smoking. They would rather see concrete facts that educate them about vaping. Many participants believed the message that comes across from this HIM wasn't to encourage people to quit smoking, but rather encourage them to start vaping. Many participants across all target groups and locations expressed concern and hesitation about a suggestion to switch from one addiction to another.

Participant Suggestions

In order to improve this concept, participants suggested the following:

Add more statistics about vaping and the long-term effects.
Add more information to answer the "wondering about vaping?" question.
Remove the text above the quitline and website.
Change the graphic to something more informative about vaping and vaping devices – such as a diagram to break down the components of a vape.

HIM #25 – Become tobacco-free by switching

Overall Impressions

Similar to HIM #24, this HIM was overshadowed by the focus on vaping. Participants felt it gave more information about vaping compared to the other HIMs on vaping (#17 and #24) but they wanted more facts and statistics. It was still too vague to prompt them to start thinking about vaping as an alternative. Young adults were especially likely to discount the impact of this concept.

"'Reduce exposure to chemicals' …There is still something else with vaping that I am ingesting into my body, some of those may be more healthy but how much more, I don't know. Those are numbers I want to see." – Young Adult, Winnipeg

The main message caused some debate since the teaser was repeated in the header. Participants felt this space could have been put to better use and included something about vaping. Overall, they felt the message had a positive feel to it but still wasn't enough information to compel them to think about vaping.

"It's a push into another bad habit." – Young Adult, St. John's

The graphic above the text elicited mixed reactions. A few participants appreciated that it was two people having a conversation in nature, and they could be talking about vaping. Others felt that the overall look was too dark, the picture did not speak to vaping and it seemed staged or fake. They felt it should be lighter and more relevant to the overall message. To them, it looked like two men talking randomly, which wasn't effective at portraying the benefits to switch completely to vaping.

Noticeability

The teaser was a positive aspect of this HIM. While it's not a question, it left the participants asking the question "switching to what?", which enticed them to want to read more. The French teaser includes the term vaping and was still effective in making participants want to keep reading and learn more.

While many could locate the quitline information, they felt that it was getting a little lost in the clutter causes by the text preceding it.

Clarity/Easy to Understand

The information in this HIM was very clear and easy to understand.

Credibility

Similar to the two other HIMs that included information about vaping, participants struggled with Health Canada suggesting that switching completely to vaping can reduce exposure to harmful chemicals in cigarette smoke. This hindered the overall credibility of the HIM.

Helps Understand the Benefits of Quitting

Participants felt this HIM would not make them think of the benefits as there is not enough information to educate them.

"Other than the exposure to many chemicals, it's a bit weak. One or two stats/percentages would go a long way." – Adult, Winnipeg

Helps Motivate to Quit Smoking

A few participants revealed this would get them thinking about quitting smoking as it gives them an alternative rather than having to quit cold turkey. However, the majority felt it would not motivate them to think about quitting smoking.

Participant Suggestions

In order to improve this concept, participants suggested the following:

Take out the first sentence in the main message to reduce the amount of text.
Include more statistics and facts about vaping.
Change the picture to something more relevant to vaping such as an image of someone vaping or a vape.
Remove or change the header so that it is not the same as the teaser.
Remove "for non-judgmental support" above the quitline and website.
Brighten the overall look of the HIM and change the blue background colour.
For the main message, participants would prefer bullet points rather than a paragraph.

HIM #26 – Trying to quit smoking?

Overall Impressions

This HIM was seen as one that specifically targets individuals who are already thinking about quitting and was perceived as less relevant and therefore less effective for those who are not.

Many participants liked the supportive nature of the bullets in the main message. The header ("Stay strong – withdrawal symptoms will pass") was seen as a positive and supportive message which most participants appreciated. Some of the tips were however seen as vague or unrealistic. For instance, regarding "Avoid situations you associate with smoking", many admitted that eating or driving were situations that they associated with smoking and they could not avoid those since they are part of their daily routine.

"I like the fact that they focus on feelings you get and symptoms. None of the other ones talk about that." – Youth, St. John's

For some, the HIM reminded them or reinforced how difficult it might be to quit smoking which left them a bit discouraged about trying.

While about half said they felt the overall design reminded them of a gym advertisement and they didn't like the cartoon image, others appreciated it, especially since it is not the type of graphic design they see in or on their cigarette packages. A few who disliked the image felt it trivialized the serious nature of quitting smoking. Those who liked the image thought it stood out, it was relevant and it represented strength and willpower. Adults particularly appreciated the image in this concept compared to younger participants.

Even though they could relate to and appreciate the bullets, this HIM was seen as text heavy by many participants. Some suggested removing the first paragraph since the information it offers is well known and didn't add value to the overall message.

Noticeability

The teaser was effective in grabbing participants' attention but would not make everyone keep reading - only a few said they might keep reading. They liked that the teaser asked a question, but many participants felt it appeared as though the quitline was the answer to the question, which would dissuade them from seeking out any other information and reading the main message. Many also felt they've seen this type of teaser many times before so it was not overly original. A few suggested the quitline website, if anything, should be featured in the teaser instead of the telephone number since they are more likely to visit a website than call the quitline. Most participants, however, preferred keeping the telephone number and website together at the bottom of the main message.

The blue colour didn't stand out – for some it too closely matched the colour schemes of current cigarette packs while for others it was too boring. They would have preferred something warmer or more striking to grab their attention.

"Feels like I'm staring at a poster at school that I don't want to stare at, too plain." – Young Adult, Winnipeg

Clarity/Easy to Understand

Participants reported that the language used was clear and easy to understand in the intended way.

Credibility

Overall, most participants felt the information was credible as it came from Health Canada.

Helps Understand the Benefits of Quitting

Most participants did not find that this HIM helped them understand the benefits of quitting smoking – the HIM was supportive for people already thinking of quitting rather than educational for other people who smoke.

Helps Motivate to Quit Smoking

Only a few participants said this would make them think of the quitting. Many thought this might help people who are already on the path to quitting but wouldn't motivate them to start thinking about it.

"I think you already have to have a desire to quit and if you saw something like this to reinforce it." – Adult, Toronto

Participant Suggestions

In order to improve this concept, participants suggested the following:

Change the background colour to something more noticeable or more striking.
Change the picture to something that is less "childish" or not cartoon – many could not think of a specific alternative but the general sense was that an image of a real person would be more relevant or impactful.
Add more metrics – "After 24 hours, this feeling will pass" was suggested.
Keep the quitline telephone number and website together in the main message

HIM #27 – Improve your skin health

Overall Impressions

This HIM resonated most with young female adults. It was a topic that most had not thought of as a benefit to quitting or previously associated with smoking and was a topic of interest to them. Many participants felt this HIM was specifically targeting women instead of men.

"That is something I never would have thought about in terms of quitting, and then when I read that I thought that is so true. I had never thought of skin health. Whenever I think of how bad smoking is, I'm a runner so I think of my lungs." – Young Adult, Toronto

The paragraph in the main message was seen as text heavy to some participants, and they suggested removing the first sentence and bolding the remaining text to make it easier to read. Women generally felt the HIM was relevant to them and many suspected that it would be more relevant to women compared to men in general. Although some men in the sessions also found it relevant, men were typically more likely to dismiss the main message. The header ("The health of your skin improves after 1 month of quitting") caught the attention of most participants since it refers to a realistic timeline and it conveys new information. They liked that they'd already learned something before even reaching the paragraph below. Some participants who weren't interested in the overall topic thought the header alone was enough and the paragraph wasn't even necessary. Those who were interested in this topic thought the HIM was effective because it made them think about the external physical effects of smoking rather than just the "typical" health effects.

"I like that it's not like the typical 'you will get cancer', it's a softer way to say that – softer approach to a serious thing."- – Youth, Winnipeg

"Even if you get rid of the paragraph and leave 'the health of your skin improves after 1 month' it's powerful and in your face. You've already learned something and that alone is effective." – Adult, Edmonton

The overall design for this HIM was well received. Regardless of their interest in the topic, almost all participants found the colour of the background and the gradient effect noticeable. It's different than what they are used to seeing and it would stand out on any cigarette pack. However, a few participants said the colour should be different to make it more universal rather than what was perceived as being geared towards women. The graphic elicited mixed feelings. Some appreciated how happy the model looked and that it was very relevant. Others felt it looked like a stock photo and wished the woman was wearing a different colour shirt that didn't match the background.

Noticeability

The teaser caught most participants' attention since it touched on something new to them. Regardless of their interest in the main message, most people thought the teaser was catchy and they would read on.

The quitline information was very noticeable in this HIM since there wasn't additional text surrounding it, it was bolded and it was separated from the paragraph.

Clarity/Easy to Understand

There was nothing unclear or hard to understand for participants.

Credibility

Overall, most participants felt the information was credible as it came from Health Canada. A few questioned the credibility of the "1 month" timeline and would want to see a reference that supported this fact.

Helps Understand the Benefits of Quitting

Most participants said this HIM helped them understand the benefits of quitting smoking, because whether or not it resonated with them, it was still new information.

Helps Motivate to Quit Smoking

While many participants agreed the HIM helped them understand the benefits of quitting smoking, the level of agreement was more limited when it came to motivating them to start thinking about quitting. Most young female participants found this HIM motivating to think about quitting. Most other participants suggested that the quality of their skin was not particularly important or they felt that the impact on their skin as described in the HIM was not a compelling reason for them to quit smoking. A few even described that they can easily hide or manage the impact on their skin with skin products.

Participant Suggestions

In order to improve this concept, participants suggested the following:

Change the colour of the shirt of the woman in the picture.
Make the picture and the background colour more gender neutral.
Shorten the full text paragraph by either organizing it in bullets or removing it all together.
Add a reference for the "1 month" timeline to increase credibility.

Review of Health Information Message Placement

The next exercise involved assessing the noticeability of a HIM on a standard "slide-and-shell" cigarette package. Participants were asked to go through five options (labelled A to E) and rate each one based on how noticeable the HIM was. Each package was designed to resemble an actual, three-dimensional package of cigarettes. The "slide-and-shells" were fully functional, the packaging resembled what is currently available in the market and mock cigarettes were created using a 3-D printer and were covered by a silver lining within each package. The same HIM and teaser were used in each of the package options however their location changed across the options. The five options are described below:

Option A: Outside of top flap (D), back of slide (E) [this is the current HIM placement on "slide-and-shell" packages]

Option B: Outside of top flap (D), inside of top flap (A), interior insert (B)

Option C: Outside of top flap (D), inside of top flap (A), interior sticker covering foil

Option D: Outside of top flap (D), inside of top flap (A), extension of interior tab

Option E: Extension of top flap (D), inside of extended top flap (A)

Participants rated Option E as the most noticeable of all options. Participants felt they were "forced" to see the HIM, and they couldn't get to their cigarettes without seeing it first. After being prompted by the moderator, participants confirmed that, compared to what is used today (Option A), the difference is significant.

A few participants could not immediately find the HIM on Option A; some even questioned if one was in fact included in the package. Just as nearly everyone selected Option E in terms of being most noticeable, the same could be said for Option A in terms of being considered least noticeable.

With an insert approach, Option B was considered quite similar to what participants would experience with their current "flip top" packs and most suspected they would do the same as what they currently do with their inserts, which is throw it away without paying much attention to what is on it. A few also mentioned that since it is loose, when they slide up the pack, the card stays at the bottom so they might not even see it.

Option C (sticker covering the foil) and Option D (extension of the interior tab) were considered very similar in terms of noticeability. A few noted that, depending on how the HIM is presented, they may not see what is at the bottom of the message since they only need to push the sleeve up part way in order to pull out a cigarette. This is quite different from Option E where the full message is noticed in order to get to the cigarettes, but also considered less "annoying".

While they rated Option E as the most noticeable, it was also considered the most frustrating to participants - so much so that a few in each group agreed they would alter the package after opening it (e.g. by ripping or cutting the HIM right off and throwing it away). Only a few felt they would start opening the cigarette package from the bottom. These reactions came both in an unprompted context as well as when the moderator specifically asked if they would change how they would use their package of cigarettes. But these same people also agreed that they would in fact need to "notice" the HIM in order to go through the trouble of ripping or cutting it off.

Thematic Linking

Three series of HWs, HIMs and TSs were presented to participants who were then asked to rate how effective each series was in terms of helping them understand the link between tobacco use and the particular health conditions shown. The order of the series varied from group to group. Series A contained information that was linked by a theme (in this case the respiratory system. Series B contained information in the HW and TS that was linked by theme (again, the respiratory system) with an unlinked HIM (related to the quitline services). The three labelling elements in Series C were unrelated by theme.

Participants were asked which series they considered most effective. Most chose Series A as the most effective, although rarely did they mention it was due to the thematic linking. As noted further below, many participants had noticed the thematic linking on their own but were more apt to focus on other aspects of Series A when asked why that series was most effective. Participants were more likely to flag the quality of the HIM as the main reason behind its effectiveness. More precisely the image of the lungs, the red text next to the lungs and the timeline approach to the supporting text all contributed in making the HIM more impactful, relevant and appealing.

Participants also appreciated the specificity of the TS in Series C as it specifically names the harmful chemical. That TS was considered more impactful than the one used in the other two series. Many participants therefore suggested combining the HIM from Series A with the TS from Series C. Based on that suggestion alone, it suggests that the exercise demonstrates that thematic linking was not a predominant consideration for these participants. The exercise did however reveal the types of information that generally resonate with people who smoke as they consider the three different types of messages.

Participants were told, if it had not already been brought up, that the information in Series A was linked by a theme. Many participants confirmed that they had noticed this and thought it was another reason to select Series A as the most effective. They thought it made the entire series more seamless and connected rather than disjointed. Some said they were more likely to read the other parts if there was a theme, especially a theme that resonates with them or to which they feel a particular connection.

In the end, most participants believed that having all three types of messages linked by a theme would be more effective at informing about the health hazards and health effects of tobacco use compared to messages that do not link thematically. They believed it would be more impactful and interesting since it addresses the same issue from different perspectives.

When the moderator challenged participants by reminding them that they said they rarely read one of the messages, let alone all three, participants reinforced the following:

If a specific theme is relevant to them, they are likely to read about it;
If the type, location or format of the information on or in the packages were to change from what is currently on the market, they would likely notice it.

The few in favour of touching on a variety of topics in the messages explained that this variety increased the odds of at least one of them being relevant to them. Others simply agreed that they would not read all three types of messages so any value in a linked theme would be lost on them.

Methodology

The research methodology consisted of 15 traditional, in-person focus groups. Quorus was responsible for coordinating all aspects of the research project including designing and translating the recruitment screener and the moderation guide, coordinating all aspects of participant recruitment, facilities and related logistics, moderating all sessions, and delivering required reports at the end of data collection.

The target population for this research consisted of Canadian at least 15 years of age who smoke cigarettes either daily or occasionally. More specifically, the research targeted a mix of the following types of individuals:

Youth (age 15-19)
Young adults (age 20-24)
Adults (age 25+)

Participants invited to participate in the focus groups were recruited by telephone from the general public as well as from an opt-in database. To augment recruitment, a general advertisement targeting people who smoke was posted in social media channels and online but no specific references were made to the Government of Canada, to Health Canada or to the nature of the study in a few centres. Those interested in participating in a focus group were asked to contact the recruitment team and from that point on the full screening process was undertaken.

In the design of the recruitment screener, specific questions were inserted to clearly identify whether participants qualify for the research program and to ensure a good representation of ages, gender and diversity within each segment. Specific questions were also added to identify people who smoke. According to the Canadian Tobacco, Alcohol and Drugs Survey (CTADS), current cigarette smokers were individuals who say they smoke "every day" or "occasionally" in response to the following question: "At the present time do you smoke cigarettes every day, occasionally or not at all?"

In addition to the general participant profiling criteria noted above, additional screening was done to ensure quality respondents, such as:

No participant (nor anyone in their immediate family or household) worked in an occupation that has anything to do with a tobacco or e-cigarette company, smoking cessation, a legal or law firm, federal or provincial government departments/agencies, nor in advertising, marketing research, public relations or the media (radio, television, newspaper, film/video production, etc.).
In addition, consideration was given to excluding a participant who has worked in any such occupation in the past 5 years, as appropriate to the specific research objectives.
No participants acquainted with each other were knowingly recruited for the same study, unless they are in different sessions that are scheduled separately.
No participant was recruited who has attended a qualitative research session within the past six months.
No participant was recruited who has attended five or more qualitative research sessions in the past five years.
No participant was recruited who has attended, in the past two years, a qualitative research session on the same general topic as defined by the researcher/moderator.

Data collection consisted of in-person focus groups, each lasting 2 hours. For each focus group, Quorus attempted to recruit 12 participants to achieve 8 to 10 participants per focus group. Challenges were encountered recruiting youth in general, and especially in Winnipeg and Edmonton. Generally, youth are reluctant to admit to smoking cigarettes especially those 15 years of age since they need the consent of a parent or guardian to participate.

All focus groups were held in the evenings on weekdays or Saturdays during the day in focus group facilities that allowed the client team to observe the sessions. The research team also used a customized audio-visual setup (a microphone and webcam connected to a laptop inside the focus group room) to enable client remote viewing using Adobe Connect. Recruited participants were offered an honorarium of $100 for their participation.

The recruitment of focus group participants followed the screening, recruiting and privacy considerations as set out in the Standards for the Conduct of Government of Canada Public Opinion Research–Qualitative Research. Furthermore, recruitment respected the following requirements:

All recruitment was conducted in the participant's official language of choice, English and French, as appropriate.
Upon request, participants were informed on how they can access the research findings.
Upon request, participants were provided Quorus' privacy policy.
Recruitment confirmed each participant had the ability to speak, understand, read and write in the language in which the session was to be conducted.
Participants were informed of their rights under the Privacy and Access to Information Acts and ensure that those rights were protected throughout the research process. This included: informing participants of the purpose of the research, identifying both the sponsoring department or agency and research supplier, informing participants that the study will be made available to the public in 6 months after field completion through Library and Archives Canada, and informing participants that their participation in the study is voluntary and the information provided will be administered according to the requirements of the Privacy Act.

At the recruitment stage and at the beginning of each focus group, participants were informed that the research was for the Government of Canada/Health Canada. Participants were informed of the recording of their session in addition to the presence of Health Canada observers/ listeners. Quorus ensured that prior consent was obtained at the recruitment stage and before participants entered the focus group room. Written participants' consent was developed by Quorus and by Health Canada and was obtained from each in-person focus group participant prior to any recording. Furthermore, all participants 15 years of age were provided a parental/guardian consent form which needed to be completed and signed by one of their parents or guardians and produced at the facility prior to their participation in their focus group.

A total of 15 in-person focus groups were conducted across Canada with 132 people who smoke, as per the table below:

Location	Segment	Language	Number of participants	Date and Time*
Toronto, ON	Youth (15-19 years old)	English	9	July 13 @ 10:00 am
Toronto, ON	Young adults (20-24 years old)	English	7	July 13 @ 1:00 pm
Toronto, ON	Adults (25+ years old)	English	8	July 13 @ 3:00 pm
Winnipeg, MB	Youth (15-19 years old)	English	5	July 15 @ 5:30 pm
Winnipeg, MB	Young adults (20-24 years old)	English	10	July 15 @ 7:30 pm
Winnipeg, MB	Adults (25+ years old)	English	10	July 16 @ 5:30 pm
Edmonton, AB	Youth (15-19 years old)	English	9	July 17 @ 5:30 pm
Edmonton, AB	Young adults (20-24 years old)	English	7	July 17 @ 7:30 pm
Edmonton, AB	Adults (25+ years old)	English	10	July 18 @ 5:30 pm
Quebec City, QC	Youth (15-19 years old)	French	7	July 24 @ 5:30 pm
Quebec City, QC	Young adults (20-24 years old)	French	9	July 24 @ 7:30 pm
Quebec City, QC	Adults (25+ years old)	French	9	July 25 @ 5:30 pm
St. John's, NL	Youth (15-19 years old)	English	12	July 27 @ 10:00 am
St. John's, NL	Young adults (20-24 years old)	English	10	July 27 @ 1:00 pm
St. John's, NL	Adults (25+ years old)	English	10	July 27 @ 3:00 pm

*all times are local times

All focus groups were moderated by Rick Nadeau, one of Quorus' bilingual senior researchers on the Government of Canada Standing Offer.

Appendices

Recruitment Screener

Specifications

15 focus groups will be conducted with people who smoke in the following five locations:
- Toronto
- Winnipeg
- Edmonton
- Quebec City
- St. John's
Recruit 12 participants per group
Participants to be paid $100
3 groups in each location will be held with the split based on participants' age, one group with youth, one with young adults and one with adults
- "Youth" is defined as anyone from age 15 to 19 years old.
- "Young adult" is defined as anyone from 20 to 24 years old.
- "Adult" is defined as anyone 25 years or older.
All participants are people who smoke cigarettes daily or occasionally.

Group 1	Group 2	Group 3
Toronto	Toronto	Toronto
July 13 10:00 am Youth (15-19 years old)	July 13 1:00 pm Young adults (20-24 years old)	July 13 3:00 pm Adults (25+ years old)

Group 4	Group 5	Group 6
Winnipeg	Winnipeg	Winnipeg
July 15 5:30 pm Youth (15-19 years old)	July 15 7:30 pm Young adults (20-24 years old)	July 16 5:30 pm Adults (25+ years old)

Group 7	Group 8	Group 9
Edmonton	Edmonton	Edmonton
July 17 5:30 pm Youth (15-19 years old)	July 17 7:30 pm Young adults (20-24 years old)	July 18 5:30 pm Adults (25+ years old)

Group 10	Group 11	Group 12
Quebec City	Quebec City	Quebec City
July 24 5:30 pm Youth (15-19 years old)	July 24 7:30 pm Young adults (20-24 years old)	July 25 5:30 pm Adults (25+ years old)
Group 13	Group 14	Group 15
St. John's	St. John's	St. John's
July 27 10:00 am Youth (15-19 years old)	July 27 1:00 pm Young adults (20-24 years old)	July 27 3:00 pm Adults (25+ years old)

IMPORTANT: IF A HOUSEHOLD HAS MEMBERS WHO FALL INTO MORE THAN ONE OF "YOUTH", "YOUNG ADULT" OR "ADULT" CATEGORIES, WE WANT TO AVOID RECRUITING TWO PEOPLE FROM THE SAME HOUSEHOLD – WE CAN RECRUIT ONE AS A BACKUP IF THEY WOULD BE IN SEPARATE GROUPS. IT IS DEFINITELY NOT ALLOWED IF THEY WOULD BE IN THE SAME FOCUS GROUP.

Questionnaire

A. Introduction

Hello/Bonjour, my name is [NAME] and I am with Quorus Consulting Group, a Canadian market research company. We're planning a series of discussion groups on behalf of the Government of Canada with people in your area. Would you prefer to continue in English or French? / Préférez-vous continuer en anglais ou en français?

[INTERVIEWER NOTE: FOR ENGLISH GROUPS, IF PARTICIPANT WOULD PREFER TO CONTINUE IN FRENCH, PLEASE RESPOND WITH, "Malheureusement, nous recherchons des gens qui parlent anglais pour participer à ces groupes de discussion. Nous vous remercions de votre intérêt." FOR FRENCH GROUPS, IF PARTICIPANT WOULD PREFER TO CONTINUE IN ENGLISH, PLEASE RESPOND WITH, "Unfortunately, we are looking for people who speak French to participate in this discussion group. We thank you for your interest."]

[INTERVIEWER NOTE 2: If someone is asking to participate in French/English but no group in this language is available in this area, talk to your supervisor.]

As I was saying – we are planning a series of discussion groups on behalf of the Government of Canada with people in your area. The groups will last up to two hours and people who take part will receive a cash gift to thank them for their time.

Participation is completely voluntary. We are interested in your opinions. No attempt will be made to sell you anything or change your point of view. The format is a "round table" discussion led by a research professional with up to ten participants. All opinions will remain anonymous and will be used for research purposes only in accordance with laws designed to protect your privacy.

[INTERVIEWER NOTE: IF ASKED ABOUT PRIVACY LAWS, SAY: "The information collected through the research is subject to the provisions of the Privacy Act, legislation of the Government of Canada, and to the provisions of relevant provincial privacy legislation. For more information about our privacy practices, please contact Health Canada's Privacy Coordinator at 613-948-1219 or privacy-vie.privee@hc-sc.gc.ca."]

1. Before we invite anyone to attend, we need to ask you a few questions to ensure that we get a good mix of people in each of the groups. This will take 5 minutes. May I continue?

Yes 1 CONTINUE
No 2 THANK/DISCONTINUE

B. Qualification

FOR YOUTH GROUPS – 15-17 YEARS OLD (PEOPLE WHO SMOKE)

2. Are you the parent or guardian of a child who is between the ages of 15 and 17 years old or is there someone else in the household who is? If so, may I speak with this person?

No 1 CONTINUE
Yes, self 2 GO TO YOUTH 15-19 SCREENER SECTION
Yes, someone else 3 ASK TO SPEAK TO THAT PERSON AND REPEAT INTRO

FOR YOUTH GROUPS – 18-19 YEARS OLD (PEOPLE WHO SMOKE)

3. Is anyone in your household either 18 or 19 years old? If so, may I speak with this person?

No 1 CONTINUE
Yes, self 2 GO TO Q17 IN YOUTH 15-19 SCREENER SECTION
Yes, someone else 3 ASK TO SPEAK TO THIS PERSON AND REPEAT INTRO

FOR YOUNG ADULTS 20-24 GROUPS (PEOPLE WHO SMOKE) AND ADULTS 25+ (PEOPLE WHO SMOKE)

4. Is anyone in your household 20 years of age or older who smokes cigarettes? If so, may I speak with this person?

No 1 THANK & TERMINATE
Yes, self 2 CONTINUE
Yes, someone else 3 ASK TO SPEAK TO SMOKER AND START AGAIN

C. SCREENER QUESTIONS

YOUNG ADULTS 20-24 GROUPS (PEOPLE WHO SMOKE) AND ADULTS 25+ (PEOPLE WHO SMOKE)

I'd like to tell you about the study to see if you might be interested in taking part in a discussion group. The groups will last up to two hours and will be conducted in the evening (during the day if Saturday). People who take part will receive a cash gift to thank them for their time and light refreshments will be served. The format is a "round table" discussion led by a facilitator with up to 10 participants. All opinions will remain anonymous and participation is voluntary. The information collected will be used for research purposes only and handled according to the Privacy Act of Canada. The full names of participants will not be provided to the government or any other organizations other than the research firms involved. The study is being conducted to help Health Canada develop health information messages for cigarette packaging.

5. Would you be interested in taking part in this study?

Yes 1
No 2 THANK & TERMINATE

6. Before we invite you to attend, I need to ask you a few questions to make sure we are getting a good mix of people for each session. This will take 5 minutes. May I continue?

Yes 1
No 2 THANK & TERMINATE

7. Record gender by observation.

Female 1 RECRUIT 6 PER GROUP
Male 2 RECRUIT 6 PER GROUP

8. We are looking to include people of various ages in the group discussion. May I have your age please? RECORD AGE: ______________

AGE	GROUP	RECRUITMENT SPECIFICATIONS
20-24	YOUNG ADULT GROUPS	GOOD MIX OF AGES IN EACH GROUP
25+	ADULT GROUPS	Mix of ages 25-34 35-44 45-54 55-64 65-74 75+ THANK/TERMINATE

RECRUITER NOTE: WHEN TERMINATING AN INTERVIEW, SAY: "Thank you very much for your cooperation. We are unable to invite you to participate because we have enough participants who have a similar profile to yours."

9. Do you, or any member of your immediate family, work for…? [READ LIST]

…a marketing research, public relations, or advertising firm? 1
…the media (radio, television, newspapers, magazines, etc.)? 2
…the federal or provincial government? 3
…a tobacco or e-cigarette company? 4
…a smoking cessation company? 5
…a legal or law firm? 6

IF YES TO ANY, THANK & TERMINATE

10. At the present time, do you smoke cigarettes every day or occasionally?

Every day 1
Occasionally 2
VOLUNTEERED:
Not at all 3 THANK & TERMINATE

11. How long have you been smoking? [GET MIX, AS APPROPRIATE FOR AGE GROUP]

Less than 2 years 1
2-5 years 2
6-10 years 3
11-20 years 4
Over 20 years 5

GO TO DEMOGRAPHICS AND INDUSTRY QUESTIONS

15-19 YEAR OLDS WHO SMOKE

ASK PARENTS OR GUARDIANS OF YOUTH 15-17 YEARS OLD:

We are conducting a research study for Health Canada that includes youth 15 to 19 years of age. The study is being conducted to help the department develop health information messages for cigarette packaging. For this study, we're organizing discussion groups which are scheduled to run for 2 hours in the evening (during the day if Saturday). The discussion groups involve a small number of teens who will be asked to look at health information messages, complete a short questionnaire about the messages and images, and then share their opinions with others in the discussion group. All opinions will remain anonymous and participation is voluntary. Those who take part will receive $100 for their time and light refreshments will be served. The information collected will be used for research purposes only and handled according to the Privacy Act of Canada. The full name of your child will not be provided to the government or any other third party.

12. May we have your permission to ask your child some questions, including questions about his or her smoking habits, to see if he or she qualifies for the discussion group which will take place on [INSERT DATE] at [TIME]?

Yes 1
No 2 RETURN TO Q3
Yes but they are not available 3 RESCHEDULE

Thank you. Before I speak with your child, I have a few more questions for you.

13. Do you, or any member of your immediate family, work for …? [READ LIST]

…a marketing research, public relations, or advertising firm? 1
…the media (radio, television, newspapers, magazines, etc.)? 2
…the federal or provincial government? 3
…a tobacco or e-cigarette company? 4
…a smoking cessation company? 5
…a legal or law firm? 6

IF YES TO ANY, THANK & TERMINATE

14. The discussion group will be video-recorded. These recordings are used to help analyze the findings and write the report. The results from the discussions will be grouped together in the research report, which means that individuals will not be identified in anyway. Neither your child's name nor his/her specific comments will appear in the research report. Is this acceptable?

Yes 1
No 2 THANK & TERMINATE

15. There may be some people from Health Canada and other observers involved in this project observing the session in-person or remotely via a webcam set-up. They will not take part in the discussion and they will not know your child's name. Is this acceptable?

Yes 1
No 2 THANK & TERMINATE

16. What is your child's first name? RECORD: _______________

Thank you. Now I would like to speak to [INSERT NAME OF CHILD] to make sure [SHE/HE] is interested and feels comfortable about taking part in a group discussion. Once I've done that, I would like to speak to you again.

ASK YOUTH 15-19 YEARS OLD

YOUTH 15-17 YEARS OLD: Hi [INSERT NAME OF CHILD], I'm [RECRUITER] of [RESEARCH FIRM], a Canadian research company. Your mother/father/guardian gave me permission to talk to you about a research study.

We are conducting research with young people ages 15 to 19 for Health Canada, to help the department develop health information messages for cigarette packaging.

17. At the present time, do you smoke cigarettes every day, occasionally, or not at all?

Every day 1
Occasionally 2
Not at all 3 RETURN TO Q4

I'd like to tell you a little bit about the study to see if you might be interested in taking part. For this study, we're organizing discussion groups, each of which is scheduled to run for 2 hours in the evening (during the day if Saturday). The discussion groups involve a small number of teens who will be asked to look at health information messages, complete handout exercises about the messages, and share their opinions with others in the discussion group. All opinions will remain anonymous and participation is voluntary. Those who take part will receive a cash gift for their time and light refreshments will be served. The information collected will be used for research purposes only and handled according to the Privacy Act of Canada. The full names of participants will not be provided to the government or any other third party, other than the research firms.

18. Would you be interested in taking part in this study?

Yes 1
No 2 THANK & TERMINATE

19. Before we invite you to attend, I need to ask you a few questions to make sure we are getting a good mix of people for each discussion group. This will take 5 minutes. May I continue?

Yes 1
No 2 THANK & TERMINATE

20. We are looking to include people of various ages in the group discussion. May I have your age please?

Mix of ages

15 years old 1
16 years old 2
17 years old 3
18 years old 4
19 years old 5

21. ASK 18-19 YEARS OLD: Do you, or any member of your immediate family, work for …? [READ LIST]

…a marketing research, public relations, or advertising firm? 1
…the media (radio, television, newspapers, magazines, etc.)? 2
…the federal or provincial government? 3
…a tobacco or e-cigarette company? 4
…a smoking cessation company? 5
…a legal or law firm? 6

IF YES TO ANY, THANK & TERMINATE

D. DEMOGRAPHICS AND INDUSTRY QUESTIONS

22. ASK ADULTS 18+ ONLY: Could you please tell me what is the last level of education that you have completed? [READ LIST; GET MIX]

Some high school 1
Completed high school 2
Some college/technical school/CEGEP 3
Graduated college/technical school/CEGEP 4
Some university 5
Graduated university 6
Graduate studies 7

23. Do you consider yourself to be a member of a visible ethno-cultural group?

Yes 1
No 2 GO TO Q25

24. What is your ethnic background? RECORD

RECORD ETHNICITY: ______________

RECRUIT AT LEAST TWO PER GROUP WHO ARE OF NON-EUROPEAN DESCENT OR WHO ARE OTHER VISIBLE MINORITIES (I.E. CHINESE OR SOUTH ASIAN, BUT COULD INCLUDE ABORIGINAL PEOPLE OR AFRO-CANADIANS AS WELL).

25. Have you ever attended a discussion group or taken part in interview on any topic that was arranged in advance and for which you received money for participating?

Yes 1
No 2 GO TO Q29

26. When did you last attend one of these discussion groups or interviews?

Within the last 6 months 1 THANK & TERMINATE
Over 6 months ago 2

27. Thinking about the groups or interviews that you have taken part in, what were the main topics discussed?

RECORD: _______________ THANK/TERMINATE IF RELATED TO TOBACCO OR VAPING

28. How many discussion groups or interviews have you attended in the past 5 years?

Fewer than 5 1
Five or more 2 THANK & TERMINATE

29. Participants in group discussions are asked to voice their opinions and thoughts, how comfortable are you in voicing your opinions in a group discussion with others your age? Are you... READ OPTIONS

Very comfortable 1 MIN 5 PER GROUP
Fairly comfortable 2
Not very comfortable 3 THANK & TERMINATE
Very uncomfortable 4 THANK & TERMINATE

30. Sometimes participants are also asked to write out their answers on a questionnaire. Is there any reason why you could not participate? If you need glasses to read, please remember to bring them. (Add hearing impairment.)

Yes 1 THANK & TERMINATE
No 2

TERMINATE IF RESPONDENT OFFERS ANY REASON SUCH AS SIGHT OR HEARING PROBLEM, A WRITTEN OR VERBAL LANGUAGE PROBLEM, A CONCERN WITH NOT BEING ABLE TO COMMUNICATE EFFECTIVELY.

31. The discussion group will be video-recorded. These recordings are used to help with analyzing the findings and writing the report. The results from the discussions will be grouped together in the research report, which means that individuals will not be identified in anyway. Neither your name nor your specific comments will appear in the research report. Is this acceptable?

Yes 1
No 2 THANK & TERMINATE

32. There may be some people from Health Canada and other observers involved in this project observing the session in-person or remotely via a webcam set-up. They will not take part in the discussion and they will not know your name. Is this acceptable?

Yes 1
No 2 THANK & TERMINATE

E. INVITATION TO PARTICIPATE

PARTICIPANTS 16+:

Thank you. We would like to invite you to attend one of the discussion groups, which will be led by a researcher from the national public opinion research firm, Quorus Consulting Group. The group will take place on [DAY OF WEEK], [DATE], at [TIME] and it will last two hours. Following your participation, you will receive $100 to thank you for your time.

33. Are you interested and available to attend?

Yes 1
No 2 THANK & TERMINATE

Do you have a pen handy so that I can give you the address where the group will be held? It will be held at [INSERT FACILITY]. I would like to remind you that the group is at [TIME] on [DATE]. We ask that you arrive 15 minutes early, at [INSERT TIME]. At the facility, you will be asked to produce photo identification, so please remember to bring something with you (for example, a driver's license). [16 AND OLDER INCLUDE: In order to participate, you will also be asked to read and sign a consent form when you arrive at the facility.]

Finally, if you use glasses to read, please bring them with you.

As we are only inviting a small number of people to attend, your participation is very important to us. If for some reason you are unable to attend, please call us so that we can get someone to replace you. You can reach us at [INSERT NUMBER] at our office. Please ask for [INSERT NAME].

Someone from our company will call you the day before to remind you about the session. To do that, we need to have your contact information.

PARTICIPANT

First name:
Last Name:
Daytime phone number:
Evening phone number:
Email:

Thank you!

15 YEAR OLDS ONLY:

In the next few days, we will be sending your parent or legal guardian a letter by email. The letter will have instructions on what you need to do for the discussion group, as well as a consent form that your parent or guardian must sign and return to us in advance of the group. Now I need to talk to your parent/guardian again. Would you please put [HER/HIM] back on the phone?

Thank you for allowing me to speak with [INSERT NAME OF CHILD]. [SHE/HE] would like to participate in the study. Here are a few other details about the group discussion:

The discussion will last 2 hours, starting at: [INSERT TIME].
We ask that participants arrive 15 minutes early, that is by [INSERT TIME].
Following their participation, [INSERT NAME OF CHILD] will be given $100.
The discussion group will be held at: [FACILITY NAME + ADDRESS]

In the next few days, we would like to send you a letter by email. The letter will have instructions on what your child needs to do for the discussion group, as well as a consent form that you must sign and return to us in advance of the group. To send the letter, may we please have your contact information?

PARENT/GUARDIAN

First name:
Last Name:
Daytime phone number:
Evening phone number:
Email:

One last thing. Someone from our company will call your child the day before to remind [HIM/HER] about the session.

Thank you!

Moderation Guide

Qualitative testing of new Health Information Messages, including Placement Options, as well as the Thematic Linking of Labelling Elements – Summer 2019

A. Introduction (10 minutes)

Introduce moderator/firm and welcome participants to the focus group.
- Thanks for attending/value your being here.
- Tonight/today, we're conducting research on behalf of Health Canada.
- We will be seeking your opinion on various aspects of cigarette package labelling.
- The discussion will last approximately 2 hours.
- If you have a cell phone or other electronic device, please turn it off.
Describe focus group.
- A discussion group is a "round table" discussion. We will also be asking you to fill out a short questionnaire to help guide the discussion.
- My job is to facilitate the discussion, keeping us on topic and on time.
- Your job is to offer your opinions on cigarette package labelling covered tonight/today.
- There are no right or wrong answers. This is not a knowledge test.
- Everyone's opinion is important and should be respected.
- We want you to speak up even if you feel your opinion might be different from others. Your opinion may reflect that of other Canadians who are not in the room tonight/today.
Explanations.
- Comments treated in confidence.
  - Please note that anything you say during these groups will be held in the strictest confidence. We do not attribute comments to specific people. Our report summarizes the findings from the groups but does not mention anyone by name. Please do not provide any identifiable information about yourself.
  - The report can be accessed through the Library of Parliament or Archives Canada.
- Your responses will in no way affect your dealings with the Government of Canada.
- The session is being audio-video recorded. The recordings remain in our possession and will not be released to anyone, even to the Government of Canada, without your written consent.
  - Recording is for report writing purposes / verify feedback.
- Observers.
  - There are observers from Health Canada [IF NEEDED: and other observers involved in this project] who will be watching behind the one-way mirror or online.
  - Purpose: oversee the research process and see your reactions first-hand.
Any questions?
Please note that the moderator is not an employee of the Government of Canada and may not be able to answer questions about what we will be discussing. If questions do come up over the course of the group, we will try to get answers for you before you leave.
Roundtable introduction: What you all have in common, and part of the reason you are here, is that you all smoke cigarettes. Please tell us your first name and what you enjoy doing in your spare time.

B. Introduction to Health Information Messages (3 minutes)

[USE MOCK-UP "SLIDE-AND-SHELL" PACKAGE TO SHOW WHICH LABEL PORTION WILL BE DISCUSSED. NOTE PROPOSED PLAIN PACKAGE DESIGN AND THE FACT THIS IS NOT PART OF THE DISCUSSION]

As I mentioned, tonight/today we'll be talking about labelling on cigarette packages. Cigarette packages include three types of health-related information:

the health warning (HW),
the health information message (HIM), and,
the toxic emission statement (TS).

The focus of our discussion will be the health information message, not the toxic emission statements or the health warnings.

Health information messages (HIMs) provide information about the health benefits of quitting tobacco use and are displayed on the inside of cigarette packages. [MODERATOR: NOTE DIFFERENT INTENTION/PURPOSE OF HW AND HIM]. They have two parts:

The short message, or teaser, [POINT TO WHERE THIS IS FOUND ON THE PACKAGE] is in both English and French and refers the reader to the health information [POINT TO WHERE THIS IS FOUND ON THE PACKAGE].
The main message [POINT TO WHERE THIS IS FOUND ON THE PACKAGE] includes an illustration and/or a picture. The English and French versions appear side by side on the back panel of the sliding portion.

Tonight/today, we'll be asking you to review versions of health information messages that could appear on cigarette packaging.

Before we do… Do any of you look at or read any of the health information messages on the cigarette packages that you purchase? For those who look at or read messages, what type of information draws your attention and why?

[NOTE TO MODERATOR: This is specific to the HIM. If the participants discuss the HW re-direct to the HIM].

C. Review of Health Information Messages (75 minutes)

The draft health information messages [SHOW AGAIN ON THE PACKAGE] that you're going to look at use plain package colours for the brand area (the area of the tobacco package that does not contain any health-related information mandated by Health Canada). Again, we are only asking for your feedback on the health information messages; not the plain package colours or design. Is this clear to everyone? In total, we'll be looking at eight health information messages.

[PARTICIPANTS ARE GIVEN A SET OF 8 HIMs – THE SAME HIMs WILL BE EVALUATED IN EACH SESSION BUT PRESENTED IN A DIFFERENT ORDER

FOR MODERATOR REFERENCE ONLY: 8 health information messages and their numbering:

HIM 6 – Lower your risk of diabetes
HIM 17* – Thinking of quitting?
HIM 21 – Know your triggers
HIM 23 – What happens when you quit?
HIM 24* – Wondering about vaping?
HIM 25* – Become tobacco-free by switching
HIM 26 – Trying to quit smoking?
HIM 27 – The health of your skin improves 1 month after quitting

*vaping-related HIMs

I'd now like you to turn to the materials in front of you—there is a set of health information messages and an exercise sheet [HAND-OUT A SET OF HIMs + THE ASSOCIATED EXERCISE SHEET, HANDOUT 1, WITH THE HIMs NUMBERED IN THE SAME ORDER IN WHICH THEY ARE PRESENTED IN THE HIM SET].

Here is what we will do:

This is an individual exercise so please refrain from voicing any opinions or reactions out loud as you do this exercise.
Take a minute to look at the first page and rate the health information message using the exercise sheet. You need to provide two ratings for each health information message – one using the top grid and one using the bottom grid.
When you are done that one, move on to the next health information message, so on and so forth.
When everyone is finished, we'll talk about it as a group.

Please do not write on any of the health information messages—we will need to use them again.

ALLOW UP TO 10 MINUTES FOR PARTICIPANTS TO REVIEW THE HIMs AND COMPLETE THE EXERCISE SHEET.

Ok, it looks like everyone is finished. [DISCUSSION - ALLOW UP TO 6 MINUTES PER HIM]. Let's start with the health information message on the first page:

1. What's your first impression of this health information message? What, if anything, caught your attention and why?

Probe if not raised by participants:

Does the teaser on the HIM catch your attention? Why/why not?
- What aspect of the teaser catches your attention and why?
Does the teaser make you want to read the rest of the message?
- If so, what is it about the teaser that makes you want to read the message?
Does the main message catch your attention?
Is the quitline/website information noticeable? Do you have any input or thoughts on where that information is located in the concept?
By focusing specifically on the design of the concept (NOT the package design!), do you have any feedback on the layout, the image, the colours used, etc.
- AS NEEDED: In what ways, if at all, are the design features helpful?
IF ANYONE SAYS THE HIM IS TOO LONG: How can we shorten the text and make sure the message still gets through?

2. Now let's focus specifically on the information:

What's the main message conveyed by the text? Is the text clear and easy to understand? If not, why not? Are there any words that you don't understand? Anything difficult to read or see?

Probe if not raised by participants:

Is the information credible? Do you believe what it is saying? Why/why not?
What about the source…is the information coming from a credible source?

3. Does the picture convey the same message as the text?

IF NOT:

What message does the picture convey?
What picture would you suggest instead?

4. Does it make you think about, or help you understand, the benefits of quitting smoking? Why/why not? To what extent would this health information message motivate you to think about quitting smoking? Why/why not?

Probe if not raised by participants:

What part of it would motivate you?

5. Is any of this information new to you? If so, what?

6. Is this information relevant or useful to you? Why/why not?

For HIM #17, 24 and 25 [VAPING-SPECIFIC PROBING – EXPLORE THOROUGHLY]:

Does this information correspond to what you already knew about vaping? If not, how is it different?
Does this information change your perspective or views on vaping? If so, how?

Now thinking about the health information message in its entirety:

7. What changes, if any, would you suggest to make the message easier to understand or more effective in terms of encouraging people to think about quitting?

Let's move to the next health information message. [MODERATOR MAKES SURE ALL PARTICIPANTS ARE ON THE SAME PAGE]

REPEAT SEQUENCE FOR EACH HIM.

D. Review of Health Information Message Placement (20 minutes)

3-D LIFE-SIZE "SLIDE-AND-SHELL" PACKAGES THAT PARTICIPANTS CAN MANIPULATE WILL BE MOCKED-UP. PARTICIPANTS WILL BE BROKEN OUT INTO 4 DIFFERENT GROUPS AND EACH GROUP WILL GET A SET OF PACKAGES.

EACH PACKAGE WILL HAVE A STICKER ON IT WITH THE LETTERS A THROUGH E, WHICH CONNECTS THE PACKAGE WITH THE EVALUATION FORM.

We will now turn our attention to where the health information message could be located in a "slide-and-shell" package of cigarettes.

This is another part of the session that you will start off working in silence as each of you explores each of the five different packages in front of you and complete the evaluation form [HANDOUT 2]. Each of you needs to complete your own evaluation sheet – you are broken up into teams because we have a limited number of mock-ups, not because we want one set of feedback from each team. Do not share your opinions with those in your team and don't help them figure out each package.

ALLOW UP TO 4 MINUTES FOR PARTICIPANTS TO REVIEW THE PACKAGES AND COMPLETE THE EXERCISE SHEET.

Option A: Outside of top flap (D), back of slide (E) [this is the current HIM placement]

Option B: Outside of top flap (D), inside of top flap (A), interior insert (B)

Option C: Outside of top flap (D), inside of top flap (A), interior sticker covering foil

Option D: Outside of top flap (D), inside of top flap (A), extension of interior tab

Option E: Extension of top flap (D), inside of extended top flap (A)

Ok, it looks like everyone is finished.

1. FLIPCHART TALLY: Which one did you select as the most effective in terms of helping you notice the health information message?

[DISCUSSION FOCUSED ON TWO MOST EFFECTIVE CONCEPTS - ALLOW UP TO 8 MINUTES PER PACKAGE].

Let's discuss what the group has voted as the most effective one – that would be Concept {X}:

2. What's your first impression of this placement option? What, if anything, caught your attention and why?

3. [ONLY ASK FOR PACKAGES B-E; SHOW OF HANDS] Compared to where the health information message is located on packages today, who believes this approach make the health information message more noticeable? What in particular works / does not work?

4. Is the message easy or difficult to read when it is positioned this way?

5. If this approach were to be used, would you see yourself using or opening the package any differently than you do today? If so, how would it change?

[DISCUSSION IS REPEATED FOR THE CONCEPT VOTED 2ND MOST EFFECTIVE].

E. Thematic Linking (10 minutes)

We are going to move on to a new, quick exercise now.

TO TEST THE CONCEPT OF THEMATICALLY LINKING ELEMENTS ON TOBACCO PACKS, WE PRESENT THREE EXISTING HWS AND MIX & MATCH WITH EXISTING HIMS AND TSS. THE SAME SETS WILL BE PRESENTED TO ALL PARTICIPANTS IN ALL SESSIONS BUT THE ORDER OF THE SERIES WILL VARY FROM SESSION TO SESSION*. PARTICIPANTS WILL USE THE BACK OF HANDOUT 2 TO RATE THE THREE ROWS OF ELEMENTS.

Series A	HW1	HIM1	TS1	Linked by theme
Series B	HW1	HIM3	TS1	Not linked by theme
Series C	HW1	HIM2	TS2	Not linked by theme

*Set 1 = A, B, C; Set 2 = B, C, A; Set 3 = C, A, B

[BACK OF HANDOUT 2 – INFORMATION SERIES]

Quick exercise: On the back of the last exercise sheet I gave you, I'd like you to rate the three rows of information featured on the sheet I just handed out. Please do not write on any of the health information messages—we will need to use them again.

How well does each series help you understand the link between tobacco use and the particular health condition(s) shown?
- Is one series more effective than the others?
IF NOT MENTIONED: Did any of you notice that Series [A, B or C] focused on a specific theme? How effective is that at helping you understand the link between tobacco use and the particular health condition(s) shown?

F. Conclusion (2 minutes)

We've covered a lot today/tonight and I really appreciate you taking the time to come and share your opinions. I'm going to leave the room now to check with the observers to see if there are any last questions for you. When I come back, I'm going to ask whether any of you have any last suggestions or thoughts that you want to share with the Government of Canada about what we discussed tonight/today.

MODERATOR WILL LEAVE THE ROOM AND CHECK WITH OBSERVERS TO SEE IF THERE ARE LAST QUESTIONS.

Does anyone have any last thoughts or feedback to share with the Government of Canada about the topic? Thank you very much for your time. This concludes the discussion group.

Handout 1

(Front to Back)

Circle one rating in each row	How effective are each of these health information messages in terms of informing and educating about the benefits of quitting smoking?
Circle one rating in each row	Not at all Very effective effective
HIM #6	1	2	3	4	5	6	7	8	9	10
HIM #17	1	2	3	4	5	6	7	8	9	10
HIM #21	1	2	3	4	5	6	7	8	9	10
HIM #23	1	2	3	4	5	6	7	8	9	10
HIM #24	1	2	3	4	5	6	7	8	9	10
HIM #25	1	2	3	4	5	6	7	8	9	10
HIM #26	1	2	3	4	5	6	7	8	9	10
HIM #27	1	2	3	4	5	6	7	8	9	10

Circle one rating in each row	How effective are each of these health information messages in terms of making you think about quitting smoking?
Circle one rating in each row	Not at all Very effective effective
HIM #6	1	2	3	4	5	6	7	8	9	10
HIM #17	1	2	3	4	5	6	7	8	9	10
HIM #21	1	2	3	4	5	6	7	8	9	10
HIM #23	1	2	3	4	5	6	7	8	9	10
HIM #24	1	2	3	4	5	6	7	8	9	10
HIM #25	1	2	3	4	5	6	7	8	9	10
HIM #26	1	2	3	4	5	6	7	8	9	10
HIM #27	1	2	3	4	5	6	7	8	9	10

(Back to Front)

Circle one rating in each row	How effective are each of these health information messages in terms of informing and educating about the benefits of quitting smoking?
Circle one rating in each row	Not at all Very effective effective
HIM #27	1	2	3	4	5	6	7	8	9	10
HIM #26	1	2	3	4	5	6	7	8	9	10
HIM #25	1	2	3	4	5	6	7	8	9	10
HIM #24	1	2	3	4	5	6	7	8	9	10
HIM #23	1	2	3	4	5	6	7	8	9	10
HIM #21	1	2	3	4	5	6	7	8	9	10
HIM #17	1	2	3	4	5	6	7	8	9	10
HIM #6	1	2	3	4	5	6	7	8	9	10

Circle one rating in each row	How effective are each of these health information messages in terms of making you think about quitting smoking?
Circle one rating in each row	Not at all Very effective effective
HIM #27	1	2	3	4	5	6	7	8	9	10
HIM #26	1	2	3	4	5	6	7	8	9	10
HIM #25	1	2	3	4	5	6	7	8	9	10
HIM #24	1	2	3	4	5	6	7	8	9	10
HIM #23	1	2	3	4	5	6	7	8	9	10
HIM #21	1	2	3	4	5	6	7	8	9	10
HIM #17	1	2	3	4	5	6	7	8	9	10
HIM #6	1	2	3	4	5	6	7	8	9	10

Handout 2

Circle one rating in each row	How much do you notice the health information message?
Circle one rating in each row	Not noticeable Very noticeable at all
PACKAGE A	1	2	3	4	5	6	7	8	9	10
PACKAGE B	1	2	3	4	5	6	7	8	9	10
PACKAGE C	1	2	3	4	5	6	7	8	9	10
PACKAGE D	1	2	3	4	5	6	7	8	9	10
PACKAGE E	1	2	3	4	5	6	7	8	9	10

Rank the five packages in terms of how noticeable the health information message is:

PACKAGE	______	MOST NOTICEABLE
PACKAGE	______
PACKAGE	______
PACKAGE	______
PACKAGE	______	LEAST NOTICEABLE

Circle one rating in each row	How effective are each series in terms of helping you understand the health hazards and health effects of smoking and the benefits of quitting?
Circle one rating in each row	Not at all Very effective effective
Series 1	1	2	3	4	5	6	7	8	9	10
Series 2	1	2	3	4	5	6	7	8	9	10
Series 3	1	2	3	4	5	6	7	8	9	10

Qualitative Testing of New Health Information Messages, Including Placement Options, as well as the Thematic Linking of Labelling Elements – 2019 – Final Report

Table of Contents

Executive Summary

Background and Research Objectives

Methodology

Review of Health Information Messages

Reactions to HIMs on Vaping

Review of Health Information Message Placement

Thematic Linking

Background

Research Purpose and Objectives

Review of Health Information Messages

Common Reactions Across HIMs

Reactions to HIMs on Vaping

Detailed Results

HIM #6 – Lower your risk of diabetes

Overall Impressions

Noticeability

Clarity/Easy to Understand

Credibility

Helps Understand the Benefits of Quitting

Helps Motivate to Quit Smoking

Participant Suggestions

HIM #17 – Thinking of quitting?

Overall Impressions

Noticeability

Clarity/Easy to Understand

Credibility

Helps Understand the Benefits of Quitting

Helps Motivate to Quit Smoking

Participant Suggestions

HIM #21 – Know your triggers

Overall Impressions

Noticeability

Clarity/Easy to Understand

Credibility

Helps Understand the Benefits of Quitting

Helps Motivate to Quit Smoking

Participant Suggestions

HIM #23 – What happens when you quit?

Overall Impressions

Noticeability

Clarity/Easy to Understand

Credibility

Helps Understand the Benefits of Quitting

Helps Motivate to Quit Smoking

Participant Suggestions

HIM #24 – Wondering about vaping?

Overall Impressions

Noticeability

Clarity/Easy to Understand

Credibility

Helps Understand the Benefits of Quitting

Helps Motivate to Quit Smoking

Participant Suggestions

HIM #25 – Become tobacco-free by switching

Overall Impressions

Noticeability

Clarity/Easy to Understand

Credibility

Helps Understand the Benefits of Quitting

Helps Motivate to Quit Smoking

Participant Suggestions

HIM #26 – Trying to quit smoking?

Overall Impressions

Noticeability

Clarity/Easy to Understand

Credibility

Helps Understand the Benefits of Quitting

Helps Motivate to Quit Smoking

Participant Suggestions

HIM #27 – Improve your skin health

Overall Impressions

Noticeability

Clarity/Easy to Understand

Credibility

Helps Understand the Benefits of Quitting

Helps Motivate to Quit Smoking

Participant Suggestions

Review of Health Information Message Placement