Final Report - Qualitative Testing of New Health Warnings and Contact Information Taglines for Cigarette Packages – 2017

POR Number: 028-17
Contract Number: HT372-173280-001-CY
Contract Award Date: 2017-09-22
Date of Submission: 2018-03-27

Prepared for: Health Canada

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

March 2018

Ce rapport est aussi disponible en français

Table of Contents

• Executive Summary
• Introduction
• Background and Objectives
• Methodology
• Detailed Findings
  • 1. Contextual Information
  • 2. Review of HWs for Cigarette Packages
  • 3. Review of Specific Health Warnings
  • 4. Review of Taglines
• Annex 1: Recruitment Screener
• Annex 2: Moderator's Guide
• Annex 3: In-Group Materials

Executive Summary

Health Canada commissioned Phoenix SPI to conduct qualitative research to test mock-ups of 39 potential health warnings (HWs) for cigarette packages, and 11 potential taglines designed to appear on cigarette packages as part of the pan-Canadian toll-free quitline number and the Web portal section (Quitline section) of HWs. The research was conducted with members of each of the following populations:

1. Youth non-smokers (aged 15-19)
2. Youth smokers (aged 15-19)
3. Young adult smokers (aged 20-24)
4. Adult smokers (aged 25+).

The research consisted of a set of 48 focus groups conducted from November 20 to December 16, 2017, in four cities (12 groups per city): Halifax, Toronto, Vancouver, and Quebec City (French). More details on the methodology can be found in the Methodology section of the Introduction.

Four different sets of HWs were rotated across groups in order to ensure adequate review of all 39 messages. With one exception, each set included 10 potential HWs¹ (divided into two groups of five to minimize the response burden on participants). Within each set, one group of HWs was presented to participants in flip top cigarette package format and the other in slide and shell format, with the order of presentation rotated across groups. In total, each of the four sets was tested in 12 groups (three times with each of the four audiences).

The results from this research only provide an indication of participants’ views about the issues explored and cannot be generalized to the full population of any of the groups represented in the study.

Research shows that, for HWs to be effective, they must be memorable, noticeable, and engaging. The administration and enforcement of the Tobacco Act and its regulations is Health Canada’s responsibility.

Findings from this research will: 1) test the effectiveness of proposed new HW, and provide information on which regulatory decisions can be made with respect to new labelling requirements; 2) help to generate a better understanding of varying literacy levels with regards to the effectiveness of the new HW approach; and 3) help Health Canada to better inform Canadians about health impacts and health hazards of tobacco use.

Review of HWs for Cigarette Packages

There was widespread agreement that the textual part of the HWs are clear and easy to understand (i.e. headlines and sub-text). While participants sometimes offered suggestions to improve the textual part of the HWs, they tended to focus on the length of the text or the possibility of adding emphasis (i.e. bolding), as opposed to improving clarity and ease of understanding. They routinely emphasized the contribution of short, direct, to-the-point text in making a message effective.

Participants were also of the opinion that the picture and the text in most HWs work together or convey the same message. The HWs in which text and picture were most frequently described as not working together were the three testimonials (i.e. HWs 14, 28, and 30). It was routinely observed that the pictures do not depict someone suffering from the conditions described in the text. It should be noted that all testimonials featured the actual persons who are suffering from tobacco-related illnesses.

Similarly, participants tended to view the information provided in the HWs as credible and believable. The only circumstances in which the credibility of information came into question involved conditions perceived as so extreme as to be improbable as a result of smoking alone. For example, in reaction to the gangrenous foot depicted in HW20 some participants observed that such an extreme condition could not be brought on by smoking alone, or that it was unlikely that anyone could smoke the number of cigarettes required to bring on such an extreme condition.

Participants made it clear that much of the information in the HWs was not new to them. Information identified as new tended to be consistent across locations and age groups. To the extent that there was any noticeable difference in awareness, it tended to be by age group, with youth smokers and non-smokers more likely to describe information about the health effects and health hazards as new. New information contained in the HWs was routinely described by participants as relevant and useful.

In the course of discussing the HWs, participants identified two factors related to the images that contribute to their effectiveness. First, graphic images were generally viewed as an effective way to convey the health effects and/or hazards associated with smoking. Clear evidence of this is the fact that the HWs judged to be most effective in each and every group in which they were tested all contain graphic health/disease-related images. In addition, images and pictures depicting the effects of smoking on babies (including the unborn) also tended to resonate with participants both because of the emphasis on harm done to others (as opposed to oneself) and because of the impression that this harm is inflicted on innocent and vulnerable beings unable to protect themselves. These factors were identified regardless of whether the HWs were tested in SS or FT format.

The fact that there is no single, overriding theme or type of HW that resonates with all smokers and youth non-smokers was also evident in differences regarding which colours and styles of presentation were most likely to contribute to the effectiveness of the HWs. There was enough positive feedback to suggest that, when it comes to ‘WARNING’, white text on red background and black text on yellow background would be effective as would including the message once and/or twice (with participants more likely to think that including it three times is excessive or unnecessary). In addition, participants across all locations and age groups routinely identified framed text and bolded text as factors contributing to the effectiveness of HWs.

The HWs most likely to be considered effective in terms of informing people about the health effects and hazards associated with smoking include the following:

• HW10: Cigarettes cause colorectal cancer.
• HW12: Cigarettes cause stomach cancer.
• HW15: Cigarettes cause oral cancer.
• HW16: Cigarettes cause oral disease.
• HW20: Cigarettes damage your blood vessels.

What these HWs all have in common is that they contain graphic health/disease-related pictures and short categorical statements. In addition, they tended to contain information that was new to participants and aspects of their colour/layout were described as vivid and attention-grabbing

The HWs least likely to be considered effective include the following:

• HW01: Smoked to death.
• HW38: Second-hand smoke kills babies too.
• HW31: Thought you would only try it once?
• HW33: Cigarettes are highly addictive, but you can break free.
• HW34: The ugly side of smoking.
• HW13: This product is addictive and causes deadly cancers.
• HW37: Tobacco kills up to half its users.
• HW21: Smoking clogs your arteries.
• HW35: Smoking causes pancreatic cancer.
• HW32: Nicotine in cigarettes is highly addictive. Break the chains of your addiction
• HW36: Cigarettes are a trap.
• HW28: It is irreversible.

These HWs tended to rate poorly due mainly to a perceived weak picture and/or poor coordination between text and image. Additional criticism focused on a lack of new information and aspects of design and color.

Review of Taglines for Quitline Section of Health Warnings

Nearly all participants believe that the Quitline section of the HW would be more effective or more noticeable if a tagline accompanied the phone number and web address. Two reasons were routinely provided for retaining a tagline. One reason is motivational, specifically the impression that a tagline could be effective in encouraging smokers to use the cessation services. The other reason is informational, specifically the impression that a tagline provides contextual information making clear the purpose of the phone number and website address.

The following taglines were most often considered effective: 

• You can quit. We can help.
• No judgement. Just help to quit.
• Don’t fight smoking alone.
• Need help to quit?

Among Francophone participants, two of these taglines were also among those considered most effective: You can quit. We can help/Vous pouvez arrêter. Nous pouvons vous aider, and No judgement. Just help to quit/Pas de jugement. Juste de l’aide pour arrêter. Two additional taglines ranked among those considered most effective in Francophone groups: Ne cessez jamais d’essayer, vous pouvez y arriver/Never quit quitting and Vous avez la volonté. Nous pouvons vous aider/You have the will. There is a way.

Participants who consider these taglines effective tended to point to their emphasis on support or available assistance in combating smoking. Two of these taglines (You can quit. We can help and No judgement. Just help to quit) were also described as effective because they include a motivational factor (the idea that quitting is possible in the former, and the absence of a guilt trip in the latter).

The most noticeable difference between language groups regarding assessment of the taglines is that Never quit quitting (Ne cessez jamais d’essayer, vous pouvez y arriver) was more likely to be included among the most effective taglines in Quebec City. Reasons provided to explain its effectiveness included recognition that quitting is difficult (i.e. it can take many attempts before being successful, accompanied by hope and a motivational factor (i.e. keep trying because success is possible).

The following two taglines were least likely to be considered effective:

• Take the next step. Click or call.
• Don’t stall. Click or call.

Those who did not consider them effective tended to describe them as too slogan-like or cliché-like. Many also suggested that the call to action in both taglines is too vague or general (i.e. why click or call?). Both were most likely to be considered effective by youth participants. Reasons included their emphasis on smokers taking the initiative and the ‘catchiness’ of the phrasing. In other words, the absence of an explicit rationale for clicking or calling and the jingle-like nature of these taglines did not bother these youth.

Conclusions and Implications

One of the main findings to emerge from this research is that there is no single, overriding theme or type of HW that resonates with smokers and youth non-smokers. Rather, it was apparent that a range of themes or approaches is considered effective. While a variety of approaches work, feedback from participants makes it clear that there are specific things to keep in mind related to the creation and/or improvement of HWs. These include:

• Pictures should be realistic and relevant: Participants routinely suggested that the effectiveness of pictures depends on their realism and relevance. For example, graphic images are considered appropriate to the extent that they depict a situation or condition considered realistic (i.e. likely or probable). The more a situation or condition is perceived as improbable or extreme, the less effective the message. This emphasis on realism also manifests itself as criticism of what are perceived as ‘staged’ images. The effectiveness of pictures also depends on participants’ ability to relate to pictures personally or experientially. In the case of youth participants for example, this was routinely conveyed in suggestions that HWs depict young people in HWs. It was also conveyed by participants who observed that HWs on the theme of the effects of second-hand smoke do not resonate with them because they do not smoke around other people.
• Text should be short and specific/concrete: As noted above, participants routinely emphasized the contribution of short, direct, to-the-point text in making a message effective. Long text and general/vague references do not resonate, in part because they are not memorable.
• Developing HWs on the theme of addiction is challenging: Based on feedback from this research, developing effective HWs based on the theme of addiction will be a challenge. Most HWs dealing with the theme of addiction in this research did not rate well in terms of perceived effectiveness. Two reasons routinely given to explain their limited effectiveness were the absence of any depiction of the adverse effects or consequences of smoking, and the lack of new information. Two other reasons were occasionally provided to explain the limited effectiveness of HWs focusing on the theme of addiction. One was provided mainly by older smokers, who suggested that the theme of addiction does not resonate with them because they have been smoking for too long. Another was provided by youth smokers and non-smokers who suggested that the theme of addiction might be more effective as a public information campaign instead of on cigarette packages (i.e. before people begin smoking rather than once they have begun to smoke).
• Targeted HWs are a double-edged sword: HWs perceived as targeting a specific group (e.g. pregnant women, people who smoke around non-smokers) sometimes elicited mixed assessments in terms of their perceived effectiveness (i.e. they can be effective in relation to members of the targeted group, but they will be less effective or ineffective among non-members).

The contract value was $249,949.22 (including applicable taxes).

I hereby certify as a Senior Officer of Phoenix Strategic Perspectives that the deliverables fully comply with the Government of Canada political neutrality requirements outlined in the Communications Policy of the Government of Canada and Procedures for Planning and Contracting Public Opinion Research. Specifically, the deliverables do not contain any reference to electoral voting intentions, political party preferences, standings with the electorate, or ratings of the performance of a political party or its leader.

Alethea Woods
President
Phoenix Strategic Perspectives Inc.

Introduction

Phoenix Strategic Perspectives (Phoenix SPI) was commissioned to conduct qualitative research to test new health warnings (HWs) and contact information tagines for cigarette packages.

Background and Objectives

The leading cause of preventable death and disease in Canada is tobacco use. It is a contributor to serious chronic diseases, such as cancer, respiratory ailments, and heart disease. Approximately fifty percent of long-term smokers die prematurely from smoking-related diseases, amounting to over 45,000 deaths in Canada each year.

Canada was the first country in the world to require pictorial HWs on tobacco packages. These are an important tool in raising awareness about the health effects of smoking because they have potential to be seen by millions of people a day. Research shows that, for HWs to be effective, they must be memorable, noticeable, and engaging.

The Tobacco Products Labelling Regulations (Cigarettes and Little Cigars) (TPLR-CLC) were adopted under the Tobacco Act in September 2011 and replaced the previous requirements of the Tobacco Products Labelling Regulations (TPIR) (adopted in 2000) that applied to cigarettes and little cigars. The TPLR-CLC consists of a combination of HWs, Health Information Messages, and Toxic Emissions Statements, whereas, the TPIR stipulate that labelling consists of combination of HWs, Health Information, and Toxic Emissions Information and Toxic Constituents Information to inform tobacco users.

The TPLR-CLC requires at least 75% of the space on the front and back panels of cigarette and little cigar packages to have HWs. Additionally, they must be displayed in both official languages in the same manner. HWs specify information in relation to the health effects and hazards of tobacco use; testimonials from smokers on the effects of smoking; or tobacco products and their emissions. They also show a tagline, a pan-Canadian toll-free Quitline number and a link to the cessation Web portal.

The Minister of Health committed in 2011 to “rotate the messages regularly to ensure they remain effective over a longer period of time”, when announcing the TPLR-CLC. The World Health Organization Framework Convention on Tobacco Control, to which Canada is a Party, requires HWs on packages to be rotated. Research and analysis has shown that updating and refreshing health-related labels on tobacco products helps to maintain their effectiveness.

Health Canada is developing new suites of HWs for tobacco products. Among its purposes, the HWs are intended to: 1) inform Canadians, both tobacco users and potential users, about the health effects and hazards arising from the use of tobacco products or its emissions; and 2) raise awareness of the pan-Canadian Quitline. HWs were developed based on the following themes:

• Addiction;
• Health impacts or diseases resulting from smoking, including specific cancers;
• Health impacts from pre- and post-natal tobacco use;
• Health impacts from second-hand smoke; and
• Smoking attributable mortality.

The HW also contains a tagline to encourage people to call the pan-Canadian toll-free Quitline number or visit the Web portal to get help to quit smoking.

Health Canada commissioned qualitative research to assess reactions to the proposed new mock-ups of HWs and potential taglines. The objectives were to:

• explore reactions to, and understanding and impressions of, the new HW mock-ups to determine if the concepts:
  • are noticeable;
  • are credible and relevant for the target audiences;
  • are in plain language and understood by the target audiences;
  • are culturally appropriate for the target audiences;
  • are effective in informing and educating Canadians about the health effects and hazards of tobacco use; and
  • are leaving a memorable impact on the target audiences.
• assess the target audiences’ reactions to potential textual taglines for the pan-Canadian Quitline to determine if they are noticeable, memorable, easy to read and garner interest from people to call the toll-free number or visit the website to get help to quit smoking.

Findings from this research will: 1) provide information on which regulatory decisions can be made with respect to new labelling requirements; 2) help to generate a better understanding of varying literacy levels with regards to the effectiveness of the new HW approach; and 3) help Health Canada to better inform Canadians about health impacts and health hazards of tobacco use.

Methodology

A set of 48 focus groups were conducted with smokers and non-smokers in the following four locations: Vancouver (English), Toronto (English), Halifax (English), and Quebec City (French). In each location, a total of 12 focus groups were conducted, three groups with each of the following populations:

1. Youth non-smokers (aged 15-19)
2. Youth smokers (aged 15-19)
3. Young adult smokers (aged 20-24)
4. Adult smokers (aged 25+).

Each group included a mix of participants by age, educationmoking status, gender and ethnicity. In each group, a total of eleven individuals were recruited by phone. Between five and nine participants took part in each group for a total of 369 participants. Groups lasted two hours and participants received an honorarium of $100 in appreciation of their time. Parental consent was obtained for all 15 year olds who participated in one of the focus group discussions. The recruiters spoke first to a parent or guardian before speaking to the participant to garner verbal consent to participate. In addition, the recruiters emailed Consent Forms to the parent/guardian with instruction to either return via email or to bring along a signed copy with the participant on arrival for the group. At the groups, all participants were asked for identification to verify their identity and consent forms were collected.

All steps of the project complied with the Marketing Research Intelligence Association (MRIA) industry standards as well as The Standards for the Conduct of Government of Canada Public Opinion Research.

Four different sets of HWs were rotated across groups to ensure adequate review of all 39 messages. With one exception, each set included 10 potential HWs² (divided into two groups of five to minimize the response burden on participants).

Set A

SET A1

HW# Main Text
HW01 Smoked to death.
HW38 Second-hand smoke kills babies too.
HW31 Thought you would only try it once?
HW20 Cigarettes damage your blood vessels.
HW08 Cigarettes cause deadly heart disease.

SET A2

HW# Main Text
HW03 Smoking causes cancer and other diseases. It is a slow and painful death.
HW23 Smoking when pregnant increases risk of miscarriage or stillbirth.
HW05 A stroke can change your life in an instant.
HW09 Cigarettes cause bladder cancer.

Set B

SET B1

HW# Main Text
HW34 The ugly side of smoking…
HW13 This product is addictive and causes deadly cancers.
HW24 Smoking when pregnant can cause a baby to be born too early….
HW29 You smoke, they suffer.
HW10 Cigarettes cause colorectal cancer.

SET B2

HW# Main Text
HW26 Children see, children do.
HW04 Heart surgery in your plans?
HW02 Cigarettes cause over 80% of lung cancers.
HW14 I can’t swallow food and I have to sleep sitting up.
HW32 Nicotine in cigarettes is highly addictive. Break the chains of your addiction.

Set C

SET C1

HW# Main Text
HW06 Cigarettes cause strokes.
HW27 You’re making them sick.
HW25 When you smoke, they suffer.
HW18 Smokers are at risk of suffering from chronic breathing problems.
HW36 Cigarettes are a trap.

SET C2

HW# Main Text
HW28 It is irreversible.
HW35 Smoking causes pancreatic cancer.
HW11 Smoking causes throat cancer.
HW16 Cigarettes cause oral disease.
HW37 Tobacco kills up to half of its users.

Set D

SET D1

HW# Main Text
HW12 Cigarettes cause stomach cancer.
HW17 Cigarettes make it hard to breathe.
HW21 Smoking clogs your arteries.
HW33 Cigarettes are highly addictive, but you can break free.
HW39 You wouldn’t feed this to your child, so why make them breathe it?

SET D2

HW# Main Text
HW40 Don’t plunge into the poison.
HW30 I have terminal lung cancer.
HW22 Smoking affects blood flow to your penis making it difficult to get an erection.
HW19 Smoking can damage your eyes. You could go permanently blind.
HW15 Cigarettes cause oral cancer.

Within each set, one group of HWs was presented to participants in flip top (FT) format and the other in slide and shell (SS) format, with the order of presentation rotated across groups. The HWs in FT format tested in Quebec were designed to reflect the current provincial labelling requirements.

In total each of the four sets was tested in 12 groups (three times with each of the four audiences) as follows:

The investigators for this study were Philippe Azzie and Alethea Woods. Both moderators contributed to the final report.

This research was qualitative in nature, not quantitative. As such, the results provide an indication of participants’ views about the issues explored, but they cannot be generalized to the full population of members of the general public or members of the targeted audience segments.

Detailed Findings

1. Contextual Information

This section provides background information on focus group participants.

Smokers

Length of time smoking

Not surprisingly, the length of time smokers say they have been smoking cigarettes varies by age group and increases with age. The length of time participants in each age group have been smoking is presented below in two ways: first, the range within which smokers in each age group said they have been smoking; second, the approximate length of time most participants in each age group said they have been smoking.

• The length of time youth smokers said they have been smoking ranged from as little as two months to as long as five years, with most reporting that they have been smoking for 2-3 years.
• The length of time young adult smokers said they have been smoking ranged from two years to 13, with most reporting that they have been smoking for 4-5 years.
• The length of time adult smokers said they have been smoking ranged from five years to as much as 50 years, with most reporting that they have been smoking for at least 20 years.

Most smokers involved in the research were daily as opposed to occasional smokers. In addition, some specified that they had quit smoking at some point in time but had started again. This was most often the case among adult smokers.

Knowledge of current HWs

To begin the session, and in order to start a discussion focusing on HWs, participants were asked if they could recall HWs on current cigarette packages.³ Many were able to recall at least one image⁴, and in most cases, these were graphic images. This was consistent across age groups and locations. In recalling these images, participants mainly referred to diseased or damaged organs, body parts or images showing the impacts of treatments for smoking-related illnesses, such as a breathing tube or wheelchairs. A few smokers also remembered a HW showing Barb Tarbox, the anti-smoking activist, whose picture shows her condition shortly before dying.

At least a few participants in every group with smokers identified images that were memorable without necessarily being graphic. These revolved around the theme of second-hand smoke or the effect of smoking on others and most often involved images with children or babies.

Aspects of HWs other than images or pictures were infrequently recalled by smokers in any age group. Some did recall textual elements of HWs, but these tended to be general recollections of messages related to the harm caused by smoking, the possibility of getting cancer, and the message that cigarettes kill. A few youth smokers recalled the Quitline or tagline on their cigarette package, while few adult smokers recalled testimonial HWs (primarily the image, but sometimes, the text), as well as the red ‘WARNING’ message on their cigarette package.

Youth non-smokers

All youth non-smokers said they know people who smoke, including family members and friends. Virtually all youth non-smokers recalled seeing warning messages about the risks associated with smoking.  Like smokers, what they tended to recall were graphic images. In addition to this, a few recalled certain public anti-smoking advertisements, such as one that likened smoking cigarettes to consuming tar.

Asked where they recalled seeing these messages, youth non-smokers routinely identified the following: school, social media, television, bulletin boards, bus shelters, and public transportation (e.g. buses, subway cars). Some recalled seeing HWs on cigarette packages as well.

2. Review of HWs for Cigarette Packages

This section reports on participants’ reactions to and impressions of potential HWs.⁵ This includes feedback that was provided by participants routinely, across all age groups and locations for most, if not all, of the HWs. The findings are presented according to each of the evaluation criteria. First, however, is a discussion of the factors, overall, that contribute to the effectiveness of HWs.

As noted in the introduction, four different sets of HWs were rotated across groups in order to ensure adequate review of all 39 messages. With one exception, each set included 10 potential HWs⁶ (divided into two groups of five in order to minimize the response burden on participants). Within each set, one group of HWs was presented to participants in flip top format and the other in slide and shell format, with the order of presentation rotated across groups. In total each of the four sets was tested in 12 groups (three times with each of the four audiences).

Factors that contribute to effectiveness of HWs

Clear and consistent feedback emerged regarding a variety of factors that contribute to the perceived effectiveness of messaging. In what follows, we identify these common elements.

• Graphic images viewed as effective in conveying health effects and hazards of smoking: Graphic images were generally viewed as an effective way to convey the health effects and/or hazards associated with smoking. Clear evidence of this is the fact that the HWs judged to be most effective in each and every group in which they were tested all contain graphic health/disease-related images (see next section). The capacity of such images to plant a lasting image in the mind is underscored by the fact that aspects or elements of HWs that participants were most likely to recall involved graphic pictures or images (see context section above).
• Images depicting harm to babies viewed as effective in conveying health effects and hazards of smoking: Images and pictures depicting the effects of smoking on babies (including the unborn) also tended to resonate with participants both because of the emphasis on harm done to others (as opposed to oneself) and because of the impression that this harm is inflicted on innocent and vulnerable beings unable to protect themselves. Clear evidence of this is the fact that among the HWs touching on the theme of harm/damage to others, those most likely to be considered effective focused on harm to babies or the unborn (see next section). The capacity of such images to plant a lasting image in the mind is underscored by the fact that next to graphic images, aspects or elements of HWs that participants were most likely to recall involved pictures or images related to babies or children (see context section above).
• Effectiveness of images reinforced by realism and relevance: The effectiveness of pictures or images was typically reinforced by two additional elements:
  • Perceived realism of images/pictures: A recurring theme in relation to the effectiveness of images concerned the extent to which they were perceived as realistic. In the case of graphic images, this usually manifested itself as a distinction between what was considered appropriately graphic and gratuitously graphic. Generally-speaking, graphic images were considered appropriate to the extent that they depicted a situation or condition considered realistic (i.e. likely or probable). The more a situation or condition was perceived as improbable or extreme, the less effective the message. As noted above, the only circumstances in which the credibility of information presented in graphic HWs came into question involved conditions perceived as so extreme as to be improbable (i.e. the gangrenous foot depicted in HW20 and the teeth depicted in HW16). The emphasis on realism also manifested itself on occasion as criticism of what were perceived as ‘staged’ images. Such images were usually described as prioritizing creativity over realism. This was the case, for example, in relation to the graphic images in HWs 04 and 09. In the case of images related to babies this was often noted in relation to HWs 24 and 39.
  • Images/pictures resonate with participants if they can relate to them personally: In addition to being appropriate, the effectiveness of images depends in part on participants being able to relate to them personally or experientially. This personal connection results in making them think about the implications of smoking. In the case of youth participants for example, this impression was routinely conveyed in suggestions that HWs depict young people in HWs (see below).
• HWs with images perceived as lacking seriousness were generally considered ineffective and/or inappropriate: Just as there was a widespread sense that a graphic image might be inappropriate because it is too extreme, so was there a widespread sense that an image might be inappropriate because it is too light hearted or comical. Examples include HWs 31 (Thought you would only try it once?) and HW37 (Tobacco kills up to half its users)⁷.
• Short, to-the-point text: Participants routinely emphasized the contribution of short, direct, to-the-point text in making a message effective. In particular, they tended to draw attention to two things: 1) headlines tend to be more effective than sub-text in conveying a message; and 2) shorter text in the sub-text is more effective than lengthy text. One characteristic of short, to-the-point text was the expression of a direct causal link (e.g. ‘smoking causes …’, ‘cigarettes cause …’).
• Framed and bolded text considered effective: Participants across all locations and age groups routinely identified framed text and bolded text as factors contributing to the effectiveness of HWs. While there were differences of opinion about which text or section of text in a particular HW should be bolded, bolding itself was commonly identified as effective.
• Statistical data resonate, especially with young participants: Presenting the health effects and hazards associated with smoking through the use of statistics or data tended to resonate strongly with young participants (i.e. young adults and youth). Indeed, this was one of the most frequently suggested improvements to a number of HWs (see below).
• New information contributes to effectiveness of HWs: While the extent to which information presented in the HWs was new might vary across groups, it was commonly noted by participants that new information contributes to the effectiveness of HWs. This is because new information draws one’s attention while commonly known information is easy to ignore.
• Prominent Quitline section: The Quitline section of HWs was often identified as an element contributing to the effectiveness of a specific HW. Two approaches for the Quitline section were consistently seen as effective across locations and audiences: the use of the blue background fill with the white lettering and/or the double line format (blue on top white on the bottom) and/or upper-case lettering for the tagline. Regardless of the preference, there was widespread agreement that the Quitline section should span the HW from edge to edge.
• Different styles and colours considered effective: As is usually the case in focus group research, there were differences of opinion on which colours and styles of presentation were most likely to contribute to the effectiveness of the HWs. However, there was enough positive feedback on various approaches to suggest that each one would work. First, when it came the colour of the ’WARNINGS’, there was enough support for each of two basic variations (i.e. white text on red background and black text on yellow background) to suggest that both would be effective. Second, when it came to the number of times the expression ‘WARNING’ was used, there was ample support for including the message once and/or twice.

HW Elements: Text

What follows below is a discussion of the text of the HWs.

Language of text characterized as clear & easy to understand

There was widespread agreement that the textual parts of the potential HWs (i.e. headlines and sub-text) are clear and easy to understand. This includes the font being big enough and readable given the colours. While participants sometimes offered suggestions to improve the textual part of the HWs, they tended to focus on the length of the text or the possibility of adding emphasis (i.e. bolding), as opposed to improving clarity and ease of understanding.

HWs identified as lacking textual clarity for one reason or another included the following:

• HW04: A few adult smokers in Quebec City were unclear about the meaning or intent of the headline ‘Songez-vous à une chirurgie cardiaque?’, with one suspecting that it was a literal translation from English. When participants were presented with the English version ‘Heart surgery in your plans?’ it was observed that the ironic intent is much clearer in English than French.
• HW11: A few youth participants in Quebec City were unfamiliar with the expression ‘ablation’.
• HW14: On occasion it was observed that the white subtext against the greyish background makes the text a little more difficult to read.
• HW20: Some youth participants were unfamiliar with the term ‘gangrene’.
• HW25: Some were unclear as to how the fact that children breathe faster results in their inhaling more poisons (i.e. wouldn’t the actual number of poisons be the same in all cases).
• HWs. 32 and 33: Some participants suggested that the main message in both of these HWs is contradictory or sends a mixed message. Specifically, it was suggested that these messages recognize that smoking is addictive while at the same time making quitting sound easy.
• HW38: On occasion it was observed that the white subtext appearing in part against a white image (i.e. a coffin) makes it more difficult to read. In addition, it was suggested that the message in this HW appears to be mixed. Specifically, the main message states that second-hand smoke kills babies, but the subtext states that babies exposed to second-hand smoke are at a higher risk of sudden ‘unexplained’ death, which is a medical term replacing Sudden Infant Death Syndrome (SIDS). The question this raised was: if second-hand smoke is the problem, how can the death be unexplained?

Information considered credible and believable

In addition to finding the text clear and easy to understand, participants considered the information provided in the HWs as credible and believable. In some instances, participants expressed surprise at some of the information provided because it was new to them, but this did not tend to translate into scepticism or incredulity. Two reasons were routinely offered to explain why the information in the messages is credible.

• Source of information: One reason relates to the source of the information (i.e. Health Canada). Participants in general tend to regard the department as a credible source of information on this topic.

• Prior awareness or familiarity with the information provided: Participants routinely noted that much if not all of the information included in the HWs is not new to them or that it is commonly known. In other words, prior awareness of and exposure to this information has helped to foster credibility.

Although identified much less frequently, another reason mentioned by at least a few participants in many groups was a personal connection to some of the information provided. This includes acquaintance with or exposure to someone suffering from a condition caused by smoking or their own personal experience with smoking. For example, in relation to HW 26 (Children see children do) some participants observed that they themselves began smoking because their parents smoked. While not sceptical of the information per se, some participants, usually adult smokers, observed that smoking is not the only cause of some of the conditions or diseases identified (e.g. lung cancer, sudden unexplained death of babies, heart disease).

The only circumstances in which the credibility of information came into question involved conditions perceived as so extreme as to be improbable as a result of smoking alone. For example, in reaction to the gangrenous foot depicted in HW20 some participants observed that such a condition could not be brought on by smoking alone, or that it was unlikely that anyone could smoke the number of cigarettes required to bring on such an extreme condition. It was also suggested at times that such a condition would have been treated in Canada long before it reached this extreme.

Some participants had a similar reaction to the teeth depicted in HW16 (i.e. the impression that smoking alone could not be responsible for such an extreme condition). In other words, there was a sense among some participants that some of the information provided was exaggerated in order to serve as a scare tactic. However, in reaction to such comments made in relation to HW16, other participants sometimes observed that they knew people whose teeth resembled those depicted as a result of smoking. This is another example of the personal connection to information identified by some participants (see above).

Some new information/learning, much known before

As noted already, most of the information about the health effects smoking provided in the HWs was described by participants as information they already knew. Information described as new tended to be mixed. Sometimes it included general information and sometimes it involved specific details related to commonly-known information.

Information identified as new tended to be so across locations and age groups. To the extent that there was any noticeable difference in awareness, it tended to be by age group, with youth smokers and non-smokers more likely to describe information as new.

Below is a list of HWs identified as including new information:

With two exceptions, HWs routinely identified as including new general information had to do with lesser-known types of cancer caused by smoking. This includes the following:

• HW09: Cigarettes cause bladder cancer.
• HW10: Cigarettes cause colorectal cancer.
• HW12: Cigarettes cause stomach cancer.
• HW35: Smoking causes pancreatic cancer.

Not surprisingly, specific details associated with this general information also tended to be new. In the case of HW10, the fact that colorectal cancer could result in the use of a colostomy bag was more likely to be new information to youth participants. In the case of HW12, vomiting blood being a symptom of stomach cancer tended to be new information across age groups.

In addition to these, the following HWs were also routinely identified as including new general knowledge:

• HW19: Smoking can damage one’s eyes, resulting in blindness.
• HW22: Smoking can result in erectile dysfunction.

Smoking’s link to both conditions was more likely to be new to younger participants (i.e. youth and young adults).

HWs identified as including new specific information or details include the following:

• HW15: While oral cancer was widely known to be caused by smoking, the possible removal of the jaw bone was new information to many participants, particularly younger ones (i.e. youth and young adults).
• HW20: While most participants said they were aware that cigarettes damage blood vessels, many said they did not know that a loss of circulation can cause gangrene. This was particularly so among younger participants, some of whom acknowledged that they did not know what gangrene is.
• HW27: While there was widespread awareness of the dangers of second-hand smoke, the fact that second-hand smoke causes ear infections was new to many across all locations and age groups.
• HW38: Many participants said they did not know that babies exposed to second-hand smoke are at a higher risk of dying.
• HW40: While there was widespread awareness that smoking results in chemicals being released into one’s system, the information that smoking results in hundreds of toxic chemicals reaching every organ in one’s body was acknowledged as new by many participants.

New information contained in HWs was routinely described by participants as relevant and useful.

HW Elements: Images

What follows is a discussion of the images of the HWs.

Picture and text mostly described as complementary

Participants were of the opinion that the picture and the text in many HWs work together or convey the same message/idea. In some instances, the text and image were described as complementary in the sense that the text helped clarify the picture. This was the case in relation to HWs 03, 06, 09, 10, 12, 13, 19, 21, 24, and 39.

The HWs in which text and picture were most frequently described as not working together were the three testimonials (i.e. HWs 14, 28, and 30). It was routinely observed that the pictures do not depict someone suffering from the conditions described in the text.  It is important to note that all testimonial providers were in fact actual sufferers of disease related to tobacco use. Other HWs in which text and picture were sometimes described as not working together, or in which improvements could be made in this regard, included the following:

• HW01: The text is ‘Smoked to death’ but the person in the picture is alive.
• HW04: The text refers to heart surgery but the picture, while graphic, does not depict heart surgery.
• HW08: The text refers to cigarettes causing heart disease but there is no indication that the person in the picture is a smoker.
• HW23: The text refers to ‘miscarriage’ and ‘stillbirth’ but the picture seems to depict a baby coughing.
• HW29: The text refers to suffering caused by second-hand smoke, but the picture does not convey any suffering on the part of the supposedly affected individual.
• HW34: The text refers to ‘The ugly side of smoking’ but the picture conveys the idea of aging rather than ugliness caused by smoking. The text also refers to the effect of smoking on teeth, but the picture does not show them.
• HW35: The connection between the reference in the text to pancreatic cancer and the picture of a man with a mask was unclear to many.
• HW37: While the main issue with this HW was the image itself, the connection between the text ‘Tobacco kills up to half its users’ and the picture of a wheel of fortune was also unclear to many.
• HW40: The text is ‘Don’t plunge into the poison’, but the picture shows someone who has taken the plunge.

HW images often require text to convey health effects

Just over one-quarter of the HWs reviewed were routinely described by participants as standing on their own, meaning that participants would understand the health effect and hazard the HW is trying to tell them if they just saw the picture on its own. These include:

• HW02: Cigarettes cause over 80% of lung cancers.
• HW03: Smoking causes cancer and other diseases.
• HW06: Cigarettes cause strokes.
• HW11: Smoking causes throat cancer.
• HW16: Cigarettes cause oral disease.
• HW17: Cigarettes make it hard to breathe.
• HW18: Smokers are at risk of suffering from chronic breathing problems.
• HW22: Smoking affects blood flow to your penis.
• HW25: When you smoke, they suffer.
• HW26: Children see, children do.
• HW27: You’re making them sick.

For just over one-third of the HWs, participants indicated that the picture clearly depicts a serious problem, condition, or situation, though it is unclear what exactly it is. This is the case regarding the following:

• HW01: Smoked to death.
• HW04: Heart surgery in your plans?
• HW05: A stroke can change your life in an instant.
• HW08: Cigarettes cause deadly heart disease.
• HW09: Cigarettes cause bladder cancer.
• HW10: Cigarettes cause colorectal cancer.
• HW12: Cigarettes cause stomach cancer.
• HW15: Cigarettes cause oral cancer.
• HW20: Cigarettes damage your blood vessels.
• HW21: Smoking clogs your arteries.
• HW23: Smoking when pregnant increases risk of miscarriage or stillbirth.
• HW29: You smoke, they suffer.
• HW38: Second-hand smoke kills babies too.
• HW39: You wouldn’t feed this to your child, so why make them breathe it?

HWs which participants were most likely to describe as requiring the text to understand the picture include:

• HW13: This product is addictive and causes deadly cancers.
• HW14: I can’t swallow food and I have to sleep sitting up.
• HW19: Smoking can damage your eyes. You could go permanently blind.
• HW24: Smoking when pregnant can cause a baby to be born too early….
• HW28: It is irreversible.
• HW30: I have terminal lung cancer.
• HW31: Thought you would only try it once?
• HW32: Nicotine in cigarettes is highly addictive. Break the chains of your addiction.
• HW33: Cigarettes are highly addictive, but you can break free.
• HW34: The ugly side of smoking…
• HW35: Smoking causes pancreatic cancer.
• HW36: Cigarettes are a trap.
• HW37: Tobacco kills up to half of its users.
• HW40: Don’t plunge into the poison.

Personal testimonials - effective approach, but images and text did not necessarily resonate with participants

Participants who reviewed HWs that include personal testimonials (i.e. HWs 14, 28, and 30) were generally critical of how the image and the text related to each other. However, they tended to describe the approach itself (i.e. the use of testimonials) as effective. In explaining why this is an effective approach, it was routinely suggested that this approach personalizes the message, making it easier to relate to by having it emanate from the mouth of a concrete individual.

Criticism of these HWs focused on two things: pictures and text. First, the pictures of testimonial providers were routinely described as unrealistic or unconvincing depictions of people suffering from the conditions in question. In other words, many participants were not convinced that these were real people telling their story. Second, the textual part of the HW (the testimonial provider’s story) was described as too long and detailed. It is important to note that these were indeed the people suffering from tobacco-related illness and their experiences in their own works.

Design

What follows is a discussion of the design of the HWs.

Framed and bolded text considered effective

Participants across all locations and age groups routinely identified framed text and bolded text as factors contributing to the effectiveness of HWs. While there were differences of opinion about which text or section of text in a particular HW should be bolded, bolding and framed text were identified as factors contributing to effectiveness in every HW in which they are used.

Different styles and colours considered effective

As is usually the case in focus group research, there were differences of opinion on which colours and styles of presentation were most likely to contribute to the effectiveness of the HWs. However, there was enough positive feedback on various approaches to suggest that each one would work. Below we provide more detail.

• Colour of ‘WARNING’: When it came the colour of the ‘WARNINGS’, there was enough support for each of two basic variations (i.e. white text on red background and black text on yellow background) to suggest that both would be effective. Some young adults said that the use of red and yellow reminds them of McDonald’s, and some young adults and youth in Quebec City said it reminds them of the official colours of Laval University. However, in neither case was this seen as adversely affecting the effectiveness of the ’WARNINGS’.
• Frequency of usage of ‘WARNING’: When it came to the number of times the expression ‘WARNING’ was used, there was ample support for including the message once and/or twice. While some felt the use of ‘WARNING’ three times contributed to the effectiveness of the HW, participants were more likely to think that this was excessive or unnecessary.
• General layout: When it came to the general layout of the HWs, there was no marked preference for either of the basic approaches (sometimes identified as the ‘box approach’ and the ‘stacked approach’). The ‘stacked approach’ refers to the style that generally includes the black ‘WARNING’ on yellow background, yellow text/white subtext, and some form of dark background (i.e. HWs 03, 05, 06, 14,16, 20, 21, 25, 29, 30, 35, 38, 39). This approach was often described as flowing well in terms of design and making it easy to grasp the HW as a whole in one intuition. The ‘box approach’ refers to the style that generally includes the white ‘WARNING’ on red background, black text (framed and unframed) on yellow background, occasionally with a general red background. Depending on the specific HW in question, this approach was sometimes described as ‘busy’ or ‘disorienting’ in terms of where to focus one’s attention.
  • Regarding the ‘stacked approach’, the only notable difference between the FT and SS versions was the following: while both versions use yellow font which draws attention to the text, there are versions in FT format that also set the text against a black background which is not the case in the SS format (e.g. HWs16, 21). Wherever this black background is used in FT format it is identified as effective in drawing attention to the text.
  • Regarding the ‘box approach’, there are two differences between the FT and SS versions. One relates to versions in FT format where the Quitline section spans the HW from edge to edge which is not the case in the SS version (e.g. HWs 4, 8). Where this is the case for the FT version, the Quitline is routinely identified as rendering the Quitline section prominent/visible.
  • The other difference relates to the number of times the ‘WARNING’ appears in the HW, where the ‘WARNING’ appears twice (English SS version and French FT version). In such cases it is routinely identified as attention-grabbing. By comparison, use of the ‘WARNING’ message three times in the English FT version is routinely considered unnecessary, while including it once in the French SS version is less likely to elicit a reaction.

General suggestions for improving HWs

Some suggestions for improving the HWs either applied to the messages in general or came up in a recurring fashion. These relate primarily to the text and pictures used in the messages and include the following:

• Make text short, pithy: Participants routinely suggested that the text used in both headings and sub-text in the HWs should be as short and pithy as possible. It was suggested that this would make the messages more effective and memorable. Related to this, it was suggested that text should be as direct and categorical as possible (e.g. smoking will cause … rather than smoking may cause …).
• Add emphasis in text: Participants often suggested adding emphasis to the text of the HWs (i.e. bolding, underlining, framing) and/or changing the text that should be highlighted.
• Include pictures/more pictures of young/younger people: Participants, particularly young adults and youth, suggested that using young/younger people would make HWs more effective by making it easier for young people to relate to them.
• Make pictures/depictions realistic: Participants suggested improving HWs by making the pictures more realistic (e.g. show a real prematurely born baby instead of an image of a baby trying to push out of its mother's womb; show an operation on a real heart instead of a fake wound full of cigarette butts). Related to this emphasis on realism, it was routinely suggested that conditions from which people suffer should be depicted (e.g. make people look sadder/sick, show effects of SHS by showing someone using a puffer, people coughing, or smoke in people’s faces).
• Include statistics: Youth and young adults in particular suggested using statistics whenever relevant or possible (e.g. %/proportion of smokers dying from lung cancer, statistics on miscarriages related to smoking).
• Ensuring Quitline is prominent: Participants regularly emphasized that the Quitline section should be more prominent. Suggestions include increasing its font size, having it run the full length of the HW, making sure that it is visible against the background colour, and moving it to the top of the HW. In the case of HWs emphasizing addiction it was sometimes suggested that the Quitline be incorporated into the main message.

3. Review of Specific Health Warnings

This section presents specific feedback related to each of the HWs. It includes feedback on both the English and French versions of each HW, as well as the Slide and Shell (SS) and Flip-top (FT) package formats. Where applicable, differences by language and package type are presented. The HWs in FT format tested in Quebec were designed to reflect the current provincial labelling requirements. In order to facilitate review, feedback for each HW is grouped into three categories: text, image and design. HWs are presented in numerical order

HW01: Smoked to death

Description Image 1:

A woman who is visibly sick, wearing a hospital gown and has a breathing tube in her nose. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Smoked to death.

Lung cancer caused by cigarettes killed Louise at age 57.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 2:

Une femme, visiblement malade, porte une blouse d’hôpital et a un tube respiratoire dans le nez. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

Fumer jusqu’à en mourir.

À l’âge de 57 ans, Louise est décédée d’un cancer du poumon causé par la cigarette.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW tended to rate poorly in terms of effectiveness in informing and educating about the health effects and health hazards of smoking due mainly to a perceived weak picture and poor coordination between text and image.

• Text: The main text was considered effective because it is short and emphasizes the ultimate consequence of smoking (i.e. death). The subtext was considered effective because it personalizes the message by providing the name and age of the person in the image, making the image easier to relate to (i.e. this is a real person). That said, the effectiveness of the text was limited by the absence of any new information.
• Image: The perceived lack of effectiveness of this HW was most often linked to the image. Factors routinely identified as limiting the effectiveness of the image included the impression that the person does not look very ill and the impression that the theme/approach is overused (i.e. a person with breathing tube in a hospital gown).

A number of youth/young adults also said they have difficulty relating to images of older people.

Another factor seen as limiting the effectiveness of this HW is lack of connection between text and image. Specifically, the main text says ‘Smoked to death’ but the person in the picture is alive.

• Design: The background color was seen as limiting the effectiveness of this HW because it is drab, and too similar in color to the image of the person. As a result, the image does not stand out well. Design features contributing to the effectiveness of this HW include the use of bolding and framing to highlight the text and the design of the Quitline section in the FT version which makes the Quitline prominent. This includes the double line format (blue on top/white on bottom), upper-case lettering for the tagline, and the Quitline section spanning the HW from edge to edge.

HW02: Cigarettes cause over 80% of lung cancers

Description Image 2:

A lung X-ray superimposed on a man with arrows and circles pointing to three tumours. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Cigarettes cause over 80% of lung cancers.

Most people with lung cancer will die of it.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 2:

Une radiographie pulmonaire superposée à un homme, avec des flèches et des cercles pointant vers trois tumeurs. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

La cigarette cause plus de 80 % des cancers du poumon.

La plupart des personnes qui ont le cancer du poumon en mourront.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in two-thirds of the groups in which it was tested. The perceived effectiveness of this HW was based primarily on the text and design.

• Text: Both the main text and subtext in this HW were described as effective. The main text was considered effective because it is short, clear and easy to understand in both English and French, makes a direct link between cigarettes and lung cancer, and includes statistics that provide new information, something that resonates particularly with youth and young adults. The subtext was described as effective because it focuses on the probable outcomes of the condition identified in the main text.
• Image: While elements of the image were seen as contributing to the effectiveness of this HW, participants were more likely to react critically or indifferently to it. The limited effectiveness of the image was based mainly on two factors: it looks staged (i.e. the person looks indifferent or unconcerned and does not look ill), and the tumours are not clear resulting in the effects of smoking not being evident. The most frequently identified aspect of the image seen as contributing to the effectiveness of this HW was that the person looks relatively young, suggesting that lung cancer can strike someone at any age. It was also suggested that the picture speaks for itself (i.e. one does not need to read the text to understand the message).
• Design: Design features contributing to the effectiveness of this HW include the use of bolding to highlight the main text, the color scheme of the ‘WARNING’ message (white text on red background), and including the message twice (English SS version and French FT version). Both the color scheme of the ‘WARNING’ and including it twice were identified as attention-grabbing. Conversely, use of the ‘WARNING’ message three times in the English FT version was considered unnecessary.

The most frequently made suggested improvement to this HW focused on the image and included making the person look sicker or more concerned, making the tumours more visible, and changing the image to a picture of cancerous lungs. It was also routinely suggested that the Quitline section be made more noticeable.

HW03: Smoking causes cancer and other diseases. It is a slow and painful death

Description Image 3:

A body on a stretcher in a morgue. The sheet on top of the body is orange and white, resembling a cigarette. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Smoking causes cancer and other diseases. It is a SLOW and PAINFUL DEATH.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 3:

Un corps sur une civière dans une morgue. La feuille sur le dessus du corps est orange et blanche, ressemblant à une cigarette. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

Fumer cause le cancer et d’autres maladies. C’est une MORT LENTE et DOULOUREUSE.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in at least three-quarters of the groups in which it was tested. Factors contributing to its effectiveness include text, image, and design, though there was mixed feedback on the effectiveness of text and image.

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in at least three-quarters of the groups in which it was tested. Factors contributing to its effectiveness include text, image, and design, though there was mixed feedback on the effectiveness of text and image.

• Text: The text was described as effective because it is short, to the point, and categorical in both English and French, and broad-based in terms of messaging (i.e. it is relevant to all smokers). On the other hand, some suggested that the effectiveness of the text is limited by being too general and vague.
• Image: The image was described as effective primarily because it is attention-grabbing, depicts the end result of smoking, and stands on its own (i.e. there is no need to read the text). Some also described it as effective because of its creative depiction of a death shroud. Some however felt that the effectiveness of the image in general is limited by an approach that is too cliché (i.e. a body on stretcher in morgue).
• Design: A variety of design features were identified as contributing to the effectiveness of the HW. The use of yellow font was identified as drawing attention to the text by highlighting the words ‘Slow’ and ‘Painful Death’. The ‘WARNING’ message was described as attention-grabbing because of the use of black text on yellow background. The design of the Quitline section was also identified as contributing to the HW’s effectiveness by making the Quitline prominent through use of a blue background fill with white lettering spanning the HW. It was also observed that overall design of this HW flows well, blending the various parts together in a way that facilitates a full grasp of HW. Finally, it was observed that the colour scheme makes the image clear and distinct and the text easy to read.

Suggested improvements to this HW included depicting a person dying on death bed to better match the text and showing loved ones/family members around the stretcher.

HW04: Heart surgery in your plans?

Description Image 4:

An image of a heart surgery. The chest is cut open and the wound is filled with cigarette butts. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Heart surgery in your plans?

Cigarette smoking causes blocked arteries, which can lead to heart disease, suffering and death.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 4:

Une image d’une chirurgie cardiaque. La poitrine est ouverte et la plaie est remplie de mégots de cigarettes. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

Songez-vous à une chirurgie cardiaque?

L’usage de la cigarette bloque les artères, ce qui peut causer des maladies du cœur, de la souffrance et la mort.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in at least three-quarters of the groups in which it was tested. Factors contributing to its effectiveness include text, image, and design, but primarily image and design. Moreover, participants routinely identified aspects of text and image limiting the effectiveness of the HW.

• Text: The main text was described as effective because it poses a rhetorical question, motivating readers to read the subtext. The subtext was considered effective because of references to ‘suffering’ and ‘death’, described as attention-grabbing. The main text was less likely to be viewed as effective in Quebec City because the ironic intent of the headline does not work well in French. Moreover, while specific expressions in the subtext contribute to its effectiveness, it was also considered too general because smoking is not the only thing that can block arteries, and weakened by use of the term ‘can’ (i.e. ‘can lead’ instead of ‘does lead’).
• Image: The image was described as effective because it is graphic and depicts the consequences of smoking in a creative manner (i.e. the body as an ashtray). However, this was counterbalanced by the impression that the image lacks realism and that its meaning is not immediately evident, both of which make it difficult to relate to the image.

Another factor limiting the effectiveness of this HW is lack of connection between text and image. Specifically, the text refers to heart surgery, but the picture does not appear to depict heart surgery in an accurate way (not accounting for the cigarettes in the wound).

• Design: Design features contributing to the effectiveness of this HW include the use of bolding and framing to highlight the text and the design of the Quitline section in the FT version which makes the Quitline prominent. This includes the double line format (blue on top/white on bottom), upper-case lettering for the tagline, and the Quitline section spanning the HW from edge to edge.

The most frequently made suggested improvements to this HW included making the image more realistic by showing surgery on an actual heart and making the Quitline section in the SS version span the HW.

HW05: A stroke can change your life in an instant

Description Image 5:

A before and after image of a man. The healthy man shown on the left is wearing a dress shirt and tie. The same man is shown on the right with a drooping face and wearing a hospital gown and oxygen mask. The bottom 25% of the package is dark brown.

The text reads:

WARNING

A stroke can change your life in an instant.

Cigarettes cause strokes that can leave you severely disabled.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 5:

Une image avant et après d’un homme. L’homme en bonne santé montré à gauche porte une chemise et une cravate. Le même homme est montré à droite avec un visage affaissé et portant une blouse d’hôpital et un masque à oxygène. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

Un AVC peut changer votre vie en un instant.

La cigarette cause des AVC pouvant vous laisser gravement handicapé.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in two-thirds of the groups in which it was tested. Factors contributing to its effectiveness include text, image, and design, though feedback on the effectiveness of the image tended to be mixed.

• Text: The text in this HW was described as effective for a variety of reasons. The text was seen as being short and forceful in both English and French, and it establishes a clear causal connection and clear consequences (i.e. cigarettes cause strokes that can leave you severely disabled). It was also observed that the text is effective because easy to relate to based on personal experience (i.e. acquaintance with stroke victims), and broad-based in terms of messaging (i.e. it is relevant to all smokers because this could happen to anyone). The only limitation in terms of effectiveness is that the text contains no new information.
• Image: The image was described as effective because it is attention-grabbing and realistic and uses a ‘before/after’ approach. It was also suggested that although the image does not convey what the health condition is without having to read the text, the message and picture complement each other, depicting the life-altering consequences of smoking. This was seen as contributing to the effectiveness of the HW. On the other hand, it was also suggested that the effectiveness of the image is limited by the fact that the person does not look very different after his stroke. In this sense, the image is not very effective in complementing the text which refers to the life-altering consequences of smoking.
• Design: Design features contributing to the effectiveness of this HW include the impression that the background colours in the image evoke the situation (i.e. red symbolizing imminent danger and black evoking the new ‘dark’ reality), an attention grabbing ‘WARNING’ message (i.e. black text on yellow background), and the use of yellow font against black background drawing attention to the main text in the SS version. The design of the Quitline section was also identified as contributing to the HW’s effectiveness by making the Quitline prominent through use of a blue background fill with white lettering spanning the HW.

Suggested improvements to this HW included making the person look sicker/more ill in the “after” picture, as well as changing the background colours to better match the message, i.e. blue for before and red/black for after.

HW06: Cigarettes cause strokes

Description Image 6:

A woman smoking a cigarette with smoke around her head. The brain is visible in the skull and is bright red. The bottom 25% of the package is dark brown.

The text reads:

WARNING

CIGARETTES CAUSE STROKES

A stroke can leave you with permanent brain damage.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 6:

Une femme fumant une cigarette, avec de la fumée autour de la tête. Le cerveau est visible dans le crâne et est rouge vif. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

LA CIGARETTE CAUSE DES AVC

Un AVC peut causer des lésions permanentes au cerveau.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in two-thirds of the groups in which it was tested. Factors contributing to its effectiveness include text, image, and design, though feedback on the effectiveness of text and image was mixed.

• Text: The main text was described as effective because it is short, clear and easy to understand in both English and French, and makes a direct link between cigarettes and strokes. The subtext was described as effective because it is short and focuses on the possible consequences of a stroke. The text in general was also described by some as effective because they can relate to it (i.e. they know stroke victims). Criticism of the text’s effectiveness focussed on the lack of new information and the impression that it is too generic (i.e. many things can cause strokes).  
• Image: The image was routinely described as effective because it speaks for itself by depicting smoking’s damage to brain through the depiction of a bright coloured brain. Some added that the bright colour contributes to the effectiveness of the message by signalling danger. The image was also routinely described as effective because it shows a person with a cigarette, depicting a clear link to smoking. Another factor contributing to the image’s effectiveness is the depiction of a relatively young person because it suggests that one can suffer a stroke at any age. Criticism of the image’s effectiveness was based on the impression that the depiction of smoke around the brain is too dramatic and that the person appears too young to suffer a stroke.
• Design: A variety of design features were identified as contributing to the effectiveness of the HW. The use of large yellow font against black background was identified as drawing attention to the text by highlighting it. The ‘WARNING’ message was described as attention-grabbing because of the use of black text on yellow background. The design of the Quitline section was also identified as contributing to the HW’s effectiveness by making the Quitline prominent through use of a blue background fill with white lettering spanning the HW. It was also observed that overall design of this HW flows well, blending the various parts together in a way that facilitates a full grasp of HW. Finally, it was suggested that the colour scheme uses sombre tones which complements the sombre message in the text.

Suggested improvements to this HW included removing the smoke around the person’s head, and showing smoke coming from the cigarette.

HW08: Cigarettes cause deadly heart disease

Description Image 7:

A paramedic performing CPR and using a defibrillator on a man who has suffered a heart attack. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Cigarettes cause deadly heart disease.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 7:

Un ambulancier paramédical pratiquant la RCR et utilisant un défibrillateur sur un homme qui a subi une crise cardiaque. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

La cigarette cause des maladies cardiaques mortelles.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in two-thirds of the groups in which it was tested. Factors contributing to its effectiveness include text, image, and design, though feedback on the effectiveness of text and image was mixed.

• Text: The text was described as effective because it is short, clear and easy to understand in both English and French, and makes a direct link between cigarettes and heart disease. The use of the term ‘deadly’ was also identified as making this HW message effective. Criticism of the text’s effectiveness focussed on the lack of new information and the impression that it is too generic (i.e. many things can cause heart disease).  
• Image: Factors contributing to the perceived effectiveness of the image included the impression that it is attention-grabbing without being graphic, the fact that the person is relatively young and African-Canadian, suggesting this can happen to anyone, and the fact that he is wearing a wedding ring, which indicates a connection to others and makes one think about the suffering caused to others as well as to oneself by the effects of smoking. Criticism of the image’s effectiveness was based on the impression that it depicts no clear connection to smoking.

  Although the image does not convey what the health condition is without having to read the text it was described as drawing attention to the text, something seen as contributing to the effectiveness of the HW.

• Design: Design features contributing to the effectiveness of this HW include the use of bolding and framing to highlight the text and the design of the Quitline section in the FT version which makes the Quitline prominent. This includes the double line format (blue on top/white on bottom), upper-case lettering for the tagline, and the Quitline section spanning the HW from edge to edge.

Young adults and youth often suggested including statistics related to smoking and heart disease. It was also suggested that the image be replaced with a medical image comparing a healthy heart with a heart damaged by smoking

HW09: Cigarettes cause bladder cancer

Description Image 8:

A lit cigarette superimposed on the bladder of a woman in underwear. There is a burn spot where the cigarette ends in the location of the bladder. The bottom 25% of the package is dark brown.

The text reads:

WARNING

CIGARETTES CAUSE BLADDER CANCER

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 8:

Une cigarette allumée est superposée à la vessie d’une femme en sous-vêtements. Il y a une tache de brûlure où la cigarette se termine à l’emplacement de la vessie. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

LA CIGARETTE CAUSE LE CANCER DE LA VESSIE

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in at least three-quarters of the groups in which it was tested. Factors contributing to its effectiveness include text, image, and design, but primarily text and design. While the image was seen as including aspects contributing to the effectiveness of the HW, participants also routinely identified aspects seen as limiting its effectiveness.

• Text: The text was described as effective because it is short, clear and easy to understand in both English and French, makes a direct link between cigarettes and bladder cancer, and contains new information.
• Image: Factors contributing to the perceived effectiveness of the image included its graphic attention-grabbing nature and the impression that it depicts the consequences of smoking in a creative manner. Although the image does not convey what the health condition is without having to read the text it was also described as drawing attention to the text, something seen as contributing to the effectiveness of the HW. However, this was counterbalanced by widespread impressions that the image is too graphic (described at times as violent), lacks realism, and that its meaning is not self-evident, all of which make it difficult to relate to. It was also routinely described as inappropriate based on the assumption that it depicts a woman in underwear.
• Design: Design features contributing to the effectiveness of this HW include the use of bolding and framing to highlight the text and the design of the Quitline section in the FT version which makes the Quitline prominent. This includes the double line format (blue on top/white on bottom), upper-case lettering for the tagline, and the Quitline section spanning the HW from edge to edge.

The most frequently made suggested improvements to this HW included making the image more realistic by showing a cancerous bladder and making the Quitline section in the SS version span the HW. Young adults and youth often suggested including statistics related to smoking and bladder cancer.

HW10: Cigarettes cause colorectal cancer

Description Image 9:

A person with a colostomy bag on the right side of his body with a scar running through the middle of his stomach. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Cigarettes cause colorectal cancer.

You may need to use a bag as a toilet for the rest of your life.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 9:

Une personne avec une poche pour colostomie sur le côté droit de son corps, avec une cicatrice au milieu de l’estomac. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

La cigarette cause le cancer colorectal.

Vous pourriez devoir utiliser un sac au lieu d'une toilette pour le reste de votre vie.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in all groups in which it was tested. Factors contributing to its effectiveness include text, image, and design.

• Text: Both the main text and subtext in this HW were described as effective. The main text was described as effective because it is short, clear and easy to understand in both English and French, and makes a direct link between cigarettes and colorectal cancer. The subtext was described as effective because it is short, with a focus on concrete life-altering consequences of colorectal cancer. Finally, the main text and subtext were considered effective because they contain new information.
• Image: The image was described as effective because it is graphic and realistic (i.e. it depicts a condition considered likely or probable as a result of smoking). Although the image does not convey what the health condition is without having to read the text it was described as drawing attention to the text, which was seen as contributing to the effectiveness of the HW.
• Design: Design features contributing to the effectiveness of this HW include the use of bolding and framing to highlight the text, and the red and yellow color scheme. The red background was described as attention-grabbing and contributing to the distinctness of the image. The yellow background was described as making the text easy to read.  The design of the Quitline section in the FT version was identified as contributing to the HW’s effectiveness by making the Quitline prominent. This includes the double line format (blue on top/white on bottom), upper-case lettering for the tagline, and the Quitline section spanning the health warning from edge to edge.

The most frequently made suggested improvement to this HW was making the Quitline section in the SS version span the HW. Young adults and youth often suggested including statistics related to smoking and colorectal cancer.

HW11: Smoking causes throat cancer

Description Image 10:

Man in a hospital gown with a breathing tube attached to his throat. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Smoking causes throat cancer.

The removal of your vocal cords will affect your ability to speak normally.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 10:

Un homme en blouse d’hôpital avec un tube respiratoire attaché à la gorge. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

L’usage du tabac cause le cancer de la gorge.

L’ablation de vos cordes vocales affectera votre capacité à parler normalement.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in at least three-quarters of the groups in which it was tested. Factors contributing to its effectiveness include text, image, and design, though there was mixed feedback on the effectiveness of the image.

• Text: Both the main text and subtext in this HW were described as effective. The main text was described as effective because it is short, clear and easy to understand in both English and French, and makes a direct link between cigarettes and throat cancer. The subtext was described as effective because it is short, with a focus on concrete consequences of throat cancer. Finally, the subtext was considered effective because they contain new information.
• Image: The image was considered effective for a variety of reasons: it is realistic, easy to relate to, and speaks for itself (i.e. no need of text to understand the message). Another factor contributing to its effectiveness is the fact that it depicts someone relatively young, suggesting that throat cancer from smoking can people at any age. Critical feedback on the effectiveness of the image was based on the impression that it looks staged rather than realistic.
• Design: Design features contributing to the effectiveness of this HW include the use of bolding to highlight the main text, the color scheme of the ‘WARNING’ message (white text on red background) and including the message twice (English SS version and French FT version). Both the color scheme of the ‘WARNING’ and including it twice were identified as attention-grabbing. Conversely, use of the ‘WARNING’ message three times in the English FT version was considered unnecessary.

The most frequently made suggestion for improving this HW was to show the person’s face in full. It was also suggested that the person be made to look sicker/more ill looking, and that the term “ablation” in the French version be replaced with a more common expression.

HW12: Cigarettes cause stomach cancer

Description Image 11:

A woman vomiting blood in her hand with it going through her fingers. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Cigarettes cause stomach cancer.

Vomiting blood can be a symptom.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 11:

Une femme vomissant du sang dans sa main, avec le sang qui passe entre ses doigts. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

La cigarette cause le cancer de l’estomac.

Vomir du sang peut être un symptôme.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in all groups in which it was tested. Factors contributing to its effectiveness include text, image, and design.

• Text: The main text which was described as effective for the following reasons: it is short, clear and to the point in both English and French, makes a direct link between cigarettes and stomach cancer, and contains new information. The subtext, while clear, did not tend to be seen as contributing to the effectiveness of this HW because it focuses on symptoms rather than consequences.
• Image: The image was described as effective because it is graphic, but it was also observed that it looks staged and lacks realism, something that limits its effectiveness. In particular, it was observed that the blood looks unrealistic. A number of young adults and youth observed that the person in the image looks relatively young, something that contributes to its effectiveness by making it easier for younger people to relate to it. Although the image does not convey what the health condition is without having to read the text it was described as drawing attention to the text which was seen as contributing to the effectiveness of the HW.
• Design: Design features contributing to the effectiveness of this HW include the use of bolding to highlight the text, the red and yellow color scheme, the color scheme of the ‘WARNING’ message (white text on red background) and including it twice (English SS version and French FT version). The red background was described as attention-grabbing and contributing to the distinctness of the image, while the yellow background was described as making the text easy to read. The color scheme of the WARNING message and including it twice were described as attention grabbing, but including it three times in the English FT version was usually considered unnecessary.

Frequently made suggestions to improve this HW included making the blood look more realistic and less prominent (e.g. including bloodstains on a handkerchief), as well as making the Quitline section in the SS version span the HW. Young adults and youth often suggested including statistics related to smoking and stomach cancer.

HW13: This product is addictive and causes deadly cancers

Description Image 12:

A skeleton hand holding cigarettes. The bottom 25% of the package is dark brown.

The text reads:

WARNING

This product is addictive and causes deadly cancers.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 12:

Un squelette tenant des cigarettes. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

Ce produit cause la dépendance et des cancers mortels.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW tended to rate poorly in terms of effectiveness in informing and educating about the health effects and health hazards of smoking due mainly to an impression that the image is weak and that there is a lack of coordination between text and image. Impressions that it is effective were based mainly on text and design features, though there were mixed impressions about the effectiveness of the text.

• Text: The text in this HW was considered effective because it is short, references ‘deadly cancers’, and focuses on the theme of addiction which is relevant to all smokers. Perceptions that the text lacks effectiveness were based on the impression that the message is commonplace and contains no new information.
• Image: The perceived lack of effectiveness of this HW was most often linked to the image. Factors routinely identified as limiting the effectiveness of the image included the impression that it is meaningless on its own and requires the text to help understand it, does not complement the text, and is unrealistic and therefore difficult to relate to.
• Design: Design features contributing to the effectiveness of this HW include the use of bolding and framing to highlight the text, the red attention-grabbing background, and the design of the Quitline section in the FT version which makes the Quitline prominent. This includes the double line format (blue on top/white on bottom), upper-case lettering for the tagline, and the Quitline section spanning the HW from edge to edge.

Suggested improvements to this HW included changing the picture to something more realistic and connected to the text, and identifying some forms of deadly cancers.

HW14: I can’t swallow food and I have to sleep sitting up

Description Image 13:

A testimonial of a man who had esophageal cancer due to smoking. The bottom 25% of the package is dark brown.

The text reads:

"I can’t swallow food and I have to sleep sitting up."

"At 46 I was diagnosed with esophageal cancer from smoking. My esophagus was removed and my stomach was attached to the bottom of my throat."
- Dony

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 13:

Le témoignage d’un homme atteint d’un cancer de l’œsophage dû au tabagisme. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

« Je ne peux plus avaler de nourriture solide et je dois dormir en position assise. »

« À 46 ans, j’ai reçu un diagnostic de cancer de l’œsophage lié au tabagisme. Mon œsophage a été enlevé et mon estomac a été fixé au fond de ma gorge. »
- Dony

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in fewer than half of the groups in which it was tested, and tested better among youth and young adults than among adults. The general approach (i.e. the use of a testimonial) tended to be viewed as effective because it personalizes the message, making it easier to relate to. That being said, the application of the approach in this particular HW tended to be viewed as lacking effectiveness due mainly to the text and the image.

• Text: While the main text in this HW was considered effective because of its focus on the life-altering consequences of smoking, this was counterbalanced by the widespread impression that the subtext is too long and detailed, limiting the likelihood that it will be read.
• Image: The perceived lack of effectiveness of this HW was most often linked to the image, routinely described as unconvincing because the individual does not look like he is suffering from the condition in question. In other words, the effectiveness of the HW is limited by a perceived lack of connection between text and image.
• Design: The use of large yellow font in the main text was identified as effective because it draws attention to the text by highlighting it. By contrast, it was observed that the effectiveness of the subtext is limited in part because it does not stand out well against the grey background colour.
• The design of the Quitline section was also identified as contributing to the HW’s effectiveness by making the Quitline prominent through use of a blue background fill with white lettering spanning the HW.

Suggested improvements to this HW included making the person look sicker given his conditions, depicting the person in an appropriate setting (e.g. sitting up in bed), and shortening the subtext.

HW15: Cigarettes cause oral cancer

Description Image 14:

An image of a man who had surgery to remove his jaw bone. The bottom 25% of the package is dark brown.

The text reads:

WARNING

CIGARETTES CAUSE ORAL CANCER

This can lead to the removal of your jaw bone.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 14:

Une image d’un homme qui a subi une intervention chirurgicale pour enlever l’os de sa mâchoire. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

LA CIGARETTE CAUSE LE CANCER DE LA BOUCHE

Une partie de l'os de la mâchoire pourrait être enlevé.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in all groups in which it was tested. Factors contributing to its effectiveness include text, image, and design.

• Text: Both the main text and subtext in this HW were described as effective. The main text was described as effective because it is short, clear and easy to understand in both English and French, and makes a direct link between cigarettes and oral cancer. The subtext was described as effective because it is short, with a focus on concrete life-altering consequences of oral cancer. Finally, the subtext was considered effective because it contains new information, particularly to youth and young adults.
• Image: The image was described as effective for a variety of reasons. It is graphic and realistic (i.e. it depicts a condition considered likely or probable as a result of smoking), focuses on smoking’s damage to the face, something about which people are sensitive, and while graphic it also elicits sympathy. Although the image does not convey what the health condition is without having to read the text it was described as drawing attention to the text, something seen as contributing to the effectiveness of the HW.
• Design: Design features contributing to the effectiveness of this HW include the use of bolding to highlight the text, the color scheme of the ‘WARNING’ message (white text on red background), and including the message twice (English SS version and French FT version). Both the color scheme of the ‘WARNING’ and including it twice were identified as attention-grabbing. Conversely, use of the ‘WARNING’ message three times in the English FT version was considered unnecessary.

The most frequently made suggested improvement to this HW was showing the person’s face in full. Young adults and youth often suggested including statistics related to smoking and oral cancer.

HW 16: Cigarettes cause oral disease

Description Image 15:

An image of a mouth with black discolouration of gums and teeth due to oral disease. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Cigarettes cause oral disease.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada
© Dr. Martin T. Tyler

Description Image 15:

Une image d’une bouche avec une décoloration noire des gencives et des dents due à une maladie bucco-dentaire. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

La cigarette cause des maladies buccales.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada
© Dr. Martin T. Tyler

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in all groups in which it was tested. Factors contributing to its effectiveness include text, image, and design.

• Text: The text was described as effective because it is short, clear and easy to understand in both English and French and makes a direct link between cigarettes and oral disease.
• Image: The image was described as effective for a variety of reasons. It is graphic and realistic (i.e. it depicts a condition considered likely or probable as a result of smoking), focuses on smoking’s damage to the mouth (effective because people are sensitive to smoking’s effect on their face), and conveys what the health condition is without having to read the text. For some, the graphic nature of the image limits its effectiveness because they feel it is exaggerated and that such an advanced condition could not be the result of smoking alone.
• Design: A variety of design features were identified as contributing to the effectiveness of the HW. The use of yellow font was identified as drawing attention to the text by highlighting it. In the case of the FT version a large font size and use of yellow text against black background were also identified as drawing attention to the text. The ‘WARNING’ message was described as attention-grabbing because of the use of black text on yellow background. The design of the Quitline section was also identified as contributing to the HW’s effectiveness by making the Quitline prominent through the use of a blue background fill with white lettering spanning the HW. Finally, it was observed that overall design of this HW flows well, blending the various parts together in a way that facilitates a full grasp of HW.

The most frequently made suggested improvements to this HW included showing more of the person’s face to make it easier to relate to. Young adults and youth often suggested including statistics related to smoking and oral disease, while some participants in the Quebec City groups also suggested changing ‘maladies buccales’ to ‘maladies de la bouche’. It was also suggested that the font size in the text for the SS version be increased.

HW17: Cigarettes make it hard to breathe

Description Image 16:

A man wearing a hospital gown and oxygen mask. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Cigarettes cause oral disease.

You may suffer from a chronic cough with phlegm and permanent lung damage.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 16:

Un homme portant une blouse d’hôpital et un masque à oxygène. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

LA CIGARETTE REND LA RESPIRATION DIFFICILE

Vous pourriez souffrir de toux et de mucosités chroniques, mais aussi de dommages permanents aux poumons.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in two-thirds of the groups in which it was tested. Its perceived effectiveness was based primarily on factors related to image and design, though feedback on the image was mixed at times. Feedback on the effectiveness of the text was also mixed.

• Text: The main text in this HW was described as effective because it is short, clear, and easy to understand in both English and French. While the subtext was described as effective because of its reference to ‘permanent lung damage’, the reference to ‘chronic cough with phlegm’ tended to be seen as superfluous or irrelevant, resulting in the subtext being too long.
• Image: Factors routinely identified as contributing to the effectiveness of the image in this HW include the impression that it conveys what the health condition is without having to read the text, its simplicity and realism (i.e. it shows someone in a hospital gown wearing an oxygen mask), and the person’s attention-grabbing direct stare. It was also suggested that the use of lighting and contrast make the image stand out clearly and distinctly and that the depiction of an African-Canadian suggests that smoking does not discriminate. Criticism of the image was based mainly on the impression that the person does not look ill and that depicting someone in a hospital gown and wearing an oxygen mask is a commonly used theme in HWs.
• Design: Design features contributing to the effectiveness of this HW include the use of bolding and framing to highlight the text and the design of the Quitline section in the FT version which makes the Quitline prominent. This includes the double line format (blue on top/white on bottom), upper-case lettering for the tagline, and the Quitline section spanning the HW from edge to edge.

Suggested improvements to this HW included making the person look sicker, as well as cutting the subtext or shortening it by removing reference to “chronic cough with phlegm”.

HW18: Smokers are at risk of suffering from chronic breathing problems...

Description Image 17:

An older man with an oxygen tube, struggling to breathe as he walks up the stairs. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Smokers are at risk of suffering from chronic breathing problems that lead to permanent lung damage.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 17:

Un homme âgé avec un tube à oxygène et un réservoir d’oxygène, qui respire avec difficulté pendant qu’il monte les escaliers. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

Les fumeurs risquent de souffrir de problèmes respiratoires pouvant causer des lésions pulmonaires permanentes.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in at least three-quarters of the groups in which it was tested. Its perceived effectiveness was based primarily on image and design elements, though feedback on the image was mixed. Text was not considered a key factor in the effectiveness of this HW.

• Text: Feedback on the textual part of this HW tended to be neutral. While the reference to permanent lung damage was considered effective, the text as a whole tended to be seen as containing no new information and being too general.
• Image: Factors routinely identified as contributing to the effectiveness of the image in this HW include the impression that it conveys what the health condition is without having to read the text, the depiction of an oxygen tank and breathing tube, and the impression that the person depicted looks like he is struggling. The depiction of the oxygen tank and breathing tube and the impression that the person is struggling were described as complementing the text, thereby emphasizing the message of this HW. Criticism of the image was based mainly on the impression that the picture looks staged (i.e. the person does not look like he is struggling).
• Design: Design features contributing to the effectiveness of this HW include the use of bolding and framing to highlight the text and the design of the Quitline section in the FT version which makes the Quitline prominent. This includes the double line format (blue on top/white on bottom), upper-case lettering for the tagline, and the Quitline section spanning the HW from edge to edge.

Suggested improvements to this HW included making the person look sicker, as well as making the Quitline section more noticeable (SS version).

HW19: Smoking can damage your eyes. You could go permanently blind

Description Image 18:

Mother and daughter celebrating a birthday with a cake. A black blurred area is in the center of vision. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Smoking can damage your eyes. You could go permanently BLIND.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 18:

Une mère et sa fille célèbrent un anniversaire avec un gâteau. Une zone floue noire se trouve au centre de la vision. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

L’usage du tabac peut endommager vos yeux. Vous pouvez PERDRE LA VUE de façon permanente.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in at least three-quarters of the groups in which it was tested. Factors contributing to its effectiveness include text, image, and design, though there was mixed feedback on the effectiveness of the image.

• Text: The main factor contributing to the effectiveness of the text in this HW is its focus on the theme of damage to eyes (something about which people are very sensitive), and the possibility of permanent blindness (i.e. the focus on life-altering consequences of smoking). The text as also considered effective because it contains new information (i.e. many people did not know that smoking can lead to blindness).
• Image: The image was described as effective because it is powerful without being graphic. It was described as powerful because it focuses on the idea of missing out on important moments in family life (i.e. child’s birthday), something easy to relate to. That said, the effectiveness of the image was limited for many by confusion or uncertainty about the meaning of the black spot in the picture. (e.g. does it depict burn mark?). In other words, instead of reflecting on the message in the picture they were trying to decipher it.
• Design: Design features contributing to the effectiveness of this HW include the use of bolding and framing to highlight the text, the color scheme of the ‘WARNING’ message (white text on red background), and the design of the Quitline section in the FT version which makes the Quitline prominent. This includes the double line format (blue on top/white on bottom), upper-case lettering for the tagline, and the Quitline section spanning the HW from edge to edge.

The most frequently made suggestion for improving this HW was to provide a more effective portrayal of loss of sight (e.g. replace the black spot with a blurry image). It was also suggested that the Quitline section be made more noticeable (SS version).

HW20: Cigarettes damage your blood vessels

Description Image 19:

A gangrene foot with visible redness, swelling and rotting skin. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Cigarettes damage your blood vessels.

This can lead to a loss of circulation in your legs or feet that can cause gangrene.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 19:

Un pied gangrené avec rougeur visible, gonflement et peau pourrie. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

La cigarette endommage vos vaisseaux sanguins.

La perte de circulation sanguine dans vos jambes ou dans vos pieds peut causer la gangrène.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in all groups in which it was tested. Factors contributing to its effectiveness include text, image, and design, though there was also critical feedback related to the effectiveness of the text and image.

• Text: The text was described as effective because both the main text and subtext are short and easy to understand (though some youth participants were unfamiliar with the term ‘gangrene’ in English and ‘gangrène’ in French). The subtext was also considered effective because it identifies possible consequences resulting from damaged blood vessels and includes new information. That said, some participants questioned the credibility of the new information provided in the subtext. Specifically, they questioned the possibility of contracting gangrene as a result of smoking alone.
• Image: While the graphic nature of this image contributed in large part to its effectiveness, it also served to limit its effectiveness in the opinion of many participants. Specifically, it was routinely observed that the image depicts a situation so extreme as to be improbable. As a result, the message loses some of its effectiveness because it is difficult to relate to (i.e. participants cannot imagine that this can happen to them).
• Design: A variety of design features were identified as contributing to the effectiveness of the HW. The use of yellow font was identified as drawing attention to the text by highlighting it (though some suggested it does not stand out distinctly enough against the yellow background in the warning message). The ‘WARNING’ message was described as attention-grabbing because of the use of black text on yellow background. The design of the Quitline section was also identified as contributing to the HW’s effectiveness by making the Quitline prominent through the use of a blue background fill with white lettering spanning the HW. Finally, it was observed that overall design of this HW flows well, blending the various parts together in a way that facilitates a full grasp of HW.

The most frequently made suggested improvement to this HW was to use a less extreme image.

HW21: Smoking clogs your arteries

Description Image 20:

Creative image of a man's legs with visible arteries. The arteries are blocked with cable ties and the lower half of his legs are grey. The bottom 25% of the package is dark brown.

The text reads:

WARNING

SMOKING CLOGS YOUR ARTERIES

This can lead to tissue death and in severe cases, amputation.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 20:

Une image créative des jambes d’un homme avec des artères visibles. Les artères sont bloquées par des attaches de câble et la moitié inférieure de ses jambes est grise. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

L’USAGE DU TABAC BLOQUE VOS ARTÈRES

Cela peut causer la mort des tissus, et même mener à l’amputation dans les cas sévères.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW tended to rate poorly in terms of effectiveness in informing and educating about the health effects and health hazards of smoking due mainly to a perceived weak picture and poor coordination between text and image.

• Text: The main text in this HW was considered effective because it is short and categorical. The subtext was considered effective because it identifies negative consequences of smoking, particularly the possibility of amputation. That said, it was often suggested that the text and subtext be combined into one sentence.
• Image: Two factors were routinely identified as limiting the effectiveness of the image. One was the impression that the image is unclear or difficult to decipher (i.e. it is not evident how it depicts clogged arteries, and the elastics often elicited puzzlement). The other is that the picture looks unrealistic. It was also observed that the image does not stand out well against the grey background.
• Design: The grey background was seen as limiting the effectiveness of this HW because it is drab and makes the subtext less noticeable. Design features identified as contributing to the effectiveness of this HW include the following:
  • Use of yellow font which draws attention to the text by highlighting it. This was particularly the case for the FT version where the text is set off against a black background. That said, some noted that the yellow text is somewhat muted against the yellow background of the WARNING message.
  • The ‘WARNING’ message which was described as attention-grabbing because of the use of black text on yellow background.
  • The design of the Quitline section was also identified as contributing to the HW’s effectiveness by making the Quitline prominent through use of a blue background fill with white lettering spanning the HW.

The most frequently made suggested improvement to this HW was to use a more realistic image that complements text (e.g. picture of an amputee). It was also suggested that text and subtext be combined into one sentence.

HW22: Smoking affects blood flow to your penis

Description Image 21:

A nude man holding an 'out of order' sign in front of his torso. The bottom 25% of the package is dark brown.

The text reads:

WARNING

OUT OF ORDER

Smoking affects blood flow to your penis, making it difficult to get an erection.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 21:

Un homme nu tenant une pancarte « hors d’usage » devant son torse. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

HORS D'USAGE

L’usage du tabac diminue la circulation sanguine vers le pénis, limitant votre capacité à avoir une érection.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in half of the groups in which it was tested. Factors contributing to its effectiveness include text, image, and design.

• Text: The text in this HW was considered effective because it is short and consequential and contains new information.
• Image: The image was considered effective because it is an attention-grabbing picture that conveys what the health condition is without having to read the main text. Moreover, despite the fact that it stands on its own it was also seen as complementing the text.
• Design: Design features contributing to the effectiveness of this HW include the use of bolding to highlight the message in the image, the color scheme of the ‘WARNING’ message (white text on red background), and including the message twice (English SS version and French FT version). Both the color scheme of the ‘WARNING’ and including it twice were identified as attention-grabbing. Conversely, use of the ‘WARNING’ message three times in the English FT version was considered unnecessary.

The overall effectiveness of this HW was identified by many as limited by two factors: one is the possibility that the theme of erectile dysfunction might lend itself to ridicule by being seen as humorous; the other is the perception that it is of limited relevance because it targets men.

HW23: Smoking when pregnant increases risk of miscarriage or stillbirth

Description Image 22:

A baby in the mother's womb is surrounded by smoke and is coughing. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Smoking when pregnant increases the risk of miscarriage or stillbirth.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 22:

Un bébé dans le ventre de sa mère est entouré de fumée et tousse. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

Fumer pendant la grossesse accroît le risque de fausse couche ou d’accoucher d’un enfant mort-né.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in at least three-quarters of the groups in which it was tested. Factors contributing to its effectiveness include text, image, and design, though reaction to the text and image was mixed at times.

• Text: The text was described as effective because it is short and focuses on harm to babies.
• Image: The image was described as effective because it is attention-grabbing (i.e. it depicts a baby in distress). However, this was counterbalanced by the impression that the image lacks realism because it depicts a foetus coughing and surrounded by smoke in way that seems overly dramatic or cliché. This perceived lack of realism was described by some as making it difficult to relate to the image.

Another factor seen by some as limiting the effectiveness of this HW is lack of coordination between text and image. Specifically, the text refers to ‘miscarriage’ and ‘stillbirth’ but the image depicts a baby or foetus coughing.

• Design: Design features contributing to the effectiveness of this HW include the use of bolding and framing to highlight the text and the design of the Quitline section in the FT version which makes the Quitline prominent. This includes the double line format (blue on top/white on bottom), upper-case lettering for the tagline, and the Quitline section spanning the HW from edge to edge. Some also described the ‘WARNING’ message as attention-grabbing because of the white text against red background.

The overall effectiveness of this HW was identified by some as limited because it targets women who smoke during pregnancy. Some also felt that the focus on the theme of miscarriages is too extreme and could affect the credibility of the HW (i.e. people may question the extent to which smoking causes miscarriages).

The most frequently made suggestion to improve this HW was to use a more realistic picture.

HW24: Smoking when pregnant can cause a baby to be born too early …

Description Image 23:

A baby's face trying to push itself out of the stomach. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Smoking when pregnant can cause a baby to be born too early, which could lead to serious health problems.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 23:

Un visage de bébé poussant sur le ventre pour sortir. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

Fumer pendant la grossesse peut mener à la naissance d’un enfant prématuré pouvant souffrir de graves problèmes de santé.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in at least three-quarters of the groups in which it was tested. Factors contributing to its effectiveness include text, image, and design, though reaction to the text and image was mixed.

• Text: Feedback on the text was mixed. The text was described as effective because it focuses on harm to babies and includes a single sentence. On the other hand, it was routinely suggested that the impact of the text is weakened by the fact that it is general (i.e. it refers to ‘serious health problems’ without identifying any).
• Image: The image was described as effective because it is attention-grabbing and depicts the consequences of smoking on babies in a creative manner. However, this was counterbalanced by the impression that the image lacks realism and that its meaning is not immediately evident, both of which make it difficult to relate to. In this regard, it was also routinely observed that in order to understand the image one must read the text.
• Design: Design features contributing to the effectiveness of this HW include the use of large font and bolding to highlight the text, the color scheme of the ‘WARNING’ message (white text on red background), and including the message twice (English SS version and French FT version). Both the color scheme of the ‘WARNING’ and including it twice were identified as attention-grabbing. Conversely, use of the ‘WARNING’ message three times in the English FT version was considered unnecessary. Finally, the Quitline section was described as lacking visibility.

The overall effectiveness of this HW was identified by some as limited because it targets women who smoke during pregnancy.

The most frequently made suggestions to improve this HW was to use a more realistic picture (e.g. showing a prematurely born baby in an incubator) and identify concrete/specific health problems. It was also suggested that the picture be made clearer/more distinct by removing the smoke and providing better color contrast.

HW25: When you smoke they suffer

Description Image 24:

A crying baby is surrounded by a cloud of smoke. The smoke forms the shape of a skull. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Children breathe faster so they inhale more poisons from smoke, putting their health at risk.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 24:

Un bébé en pleurs est entouré d’un nuage de fumée. La fumée a la forme d’un crâne. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

Lorsque vous fumez, ils fument aussi.

Les enfants respirent plus rapidement. Ils inspirent ainsi plus de poisons provenant de la fumée. C’est un risque pour leur santé.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in at least three-quarters of the groups in which it was tested. Factors contributing to its effectiveness include text, image, and design.

• Text: The text was described as effective primarily because of the headline. The headline was described as effective because it is short and pithy and focuses on harm/damage to others, specifically babies or children. By contrast, the subtext was sometimes described as lacking clarity (i.e. how does the fact that children breathe faster result in their inhaling more poisons?), and being too vague because it refers to ‘health risks’ in general as opposed to specifics.
• Image: The image was described as effective because it is attention-grabbing (i.e. it depicts a baby clearly in distress surrounded by smoke) and conveys what the health condition is without having to read the text.
• Design: A variety of design features were identified as contributing to the effectiveness of the HW. The use of yellow font was identified as drawing attention to the text by highlighting it (with the large font size also identified in the case of the SS version). The ‘WARNING’ message was described as attention-grabbing because of the use of black text on yellow background. The design of the Quitline section was also identified as contributing to the HW’s effectiveness by making the Quitline prominent through use of a blue background fill with white lettering spanning the HW. It was also observed that overall design of this HW flows well, blending the various parts together in a way that facilitates a full grasp of HW. Finally, it was observed that the colour scheme makes the image clear and distinct and the text easy to read.

The overall effectiveness of this HW was identified by some as limited by it lacks relevance because most people do not smoke around children. The most frequently made suggested improvement to this HW was to identify specific health risks. The following suggestions were also made: make the smoke look more realistic by removing the spectre of the skull, including a cigarette in the picture (e.g. parent smoking next to the child), changing the main text to ‘When you smoke, they suffer’, removing the subtext, and replacing ‘Children’ with ‘Babies’ in subtext.

HW26: Children see, children do

Description Image 25:

A mother and daughter are sitting beside each other. The daughter is imitating the mother who is smoking a cigarette. The smoke from the mother's cigarette connects to the smoke from the daughter's fingers. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Children see children do.

Your kids are much more likely to become smokers if you smoke around them. Smokers often suffer from cancer and heart disease.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 25:

Une mère et sa fille sont assises l’une à côté de l’autre. La fille imite la mère qui fume une cigarette. La fumée de la cigarette de la mère est reliée à celle qui monte des doigts de la fille. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

Vos enfants vous imitent.

Les enfants sont beaucoup plus susceptibles de devenir fumeurs si vous fumez en leur présence. Les fumeurs souffrent souvent de cancers et de maladies du cœur.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in fewer than half of the groups in which it was tested, and primarily among youth non-smokers. While aspects of text, image and design were considered effective there was a widespread assumption that this HW has limited relevance because it targets parents who smoke in the presence of their children, something that many believe does not happen anymore (i.e. the HW does not seem realistic).

• Text: The main text in this HW was described as effective because it is short, forceful, and true in both English and French. In addition, the fact that it is seen to be true makes it easy to relate to. By contrast, the subtext was considered less effective because its first sentence is simply a weaker re-statement of the main message and the second sentence is unconnected to the main message. The latter point was made in relation to both the English and French versions of the HW.
• Image: The image was described as effective because it conveys what the health condition is without having to read the text and it complements the main message (i.e. the child is looking up to her mother and they are linked by cigarette smoke).
• Design: A variety of design features were identified as contributing to the effectiveness of this HW. The use of large yellow font was seen as drawing attention to the text by highlighting it. The ‘WARNING’ message was described as attention-grabbing because of the use of black text on yellow background. Finally, the design of the Quitline section was identified as contributing to the HW’s effectiveness by making the Quitline prominent through the use of a blue background fill with white lettering spanning the HW.

Suggestions for improving this HW included removing the subtext, removing the second sentence in the subtext, changing the background to show a family setting (e.g. a living room), and making the young girl look more like her mother.

HW27: You’re making them sick

Description Image 26:

A male teenager holding as asthma inhaler. There is a shadow of a man smoking in the background and both are surrounded by smoke. The bottom 25% of the package is dark brown.

The text reads:

WARNING

You’re making them sick.

Second-hand smoke causes ear infections and can trigger asthma attacks in children.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 26:

Un adolescent tient un inhalateur pour l’asthme. Il y a l’ombre d’un homme qui fume à l’arrière-plan et les deux sont entourés de fumée. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

Vous les rendez malades.

Chez les enfants, la fumée secondaire cause des infections aux oreilles et peut déclencher des crises d’asthme.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in fewer than half of the groups in which it was tested and based more on text and design than image.

• Text: The text in this HW was most often identified as effective because the main text is short and categorical. Some also found the main text effective because it focuses on the effect of smoking on others and assignment of responsibility. Others suggested that assigning responsibility limits the effectiveness of the main text by appealing to guilt, something considered inappropriate. While the reference in the subtext to SHS causing ear infections was often identified as new information, it was also often described as superfluous.
• Image: The image in this HW was more likely to be seen as limiting the effectiveness of this HW. While depicting the effects of smoking on a young person was seen as contributing to the effectiveness of this HW, it was counterbalanced by the impression that the image looks staged/unrealistic. This includes depicting the adult as an ominous shadowy figure in the background, an unrealistic depiction of cigarette smoke, and use of a yellow background rather than a realistic setting.

Another factor limiting the effectiveness of this HW is a perceived lack of connection between text and image. This includes the impression that the young person looks bored or depressed rather than sick, and the fact that the subtext refers to children while the image depicts an adolescent.

• Design: Design features contributing to the effectiveness of this HW include the main text being highlighted through bolding as well as the color of the ‘WARNING’ message and including it twice (English SS version and French FT version). Conversely, use of the ‘WARNING’ message three times in the English FT version was considered unnecessary.

The overall effectiveness of this HW was identified by some as limited by a lack relevance because most people do not smoke around others. The most frequently made suggested improvement to this HW was to depict a more realistic scenario showing the effects of SHS (e.g. make person affected look ill or show him using puffer). It was also suggested that a child be depicted instead of an adolescent, to complement text, and removing the subtext or removing the reference to ear infections in subtext.

HW28: It is irreversible

Description Image 27:

A testimonial of a woman who is suffering from health effects due to smoking. The women does not look visibly sick. The bottom 25% of the package is dark brown.

The text reads:

"It is irreversible."

"Even after lung cancer and having one lung removed, I still suffer from emphysema. I have no lung capacity because of this addiction and smoking."
- Micheline

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 27:

Le témoignage d’une femme qui souffre des effets du tabagisme sur la santé. La femme n’a pas l’air visiblement malade. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

« C’est irréversible. »

« Même après avoir eu un cancer du poumon et l’ablation d'un poumon, je continue à souffrir d’emphysème. Je n'ai aucune capacité pulmonaire à cause de cette dépendance à fumer. »
- Micheline

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in fewer than half of the groups in which it was tested.  The general approach (i.e. the use of a testimonial) tended to be viewed as effective because it personalizes the message, making it easier to relate to. That being said, this particular HW tended to be viewed as lacking effectiveness due mainly to the text and the image and the lack of connection between them.

• Text: While the main text in this HW was routinely described as effective because it is short and forceful, this was counterbalanced by the widespread impression that the subtext is too long and detailed, limiting the likelihood that it will be read.
• Image: The perceived lack of effectiveness of this HW was most often linked to the image, routinely described as unconvincing because the individual does not look like she is suffering from the condition identified in the subtext. In other words, the effectiveness of the HW is limited by a perceived lack of connection between text and image.
• Design: The background color was seen as limiting the effectiveness of this HW because it is drab and too similar in color to the image of the person. As a result, the image does not stand out well. The large font size and use of bolding in the main text were identified as effective because they draw attention to the text by highlighting it. The use of black text against yellow background was also identified as drawing attention to the text by highlighting it.

Suggested improvements to this HW included making the person look sicker given her condition, depicting a younger person, and shortening the subtext.

HW29: You smoke, they suffer

Description Image 28:

A man and a women sitting on a couch, the man is smoking a cigarette and the women is wearing a gas mask. The bottom 25% of the package is dark brown.

The text reads:

YOU SMOKE, THEY SUFFER

Second-hand smoke causes disease and death in non-smokers.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 28:

Un homme et une femme sont assis sur un canapé. L’homme fume une cigarette et la femme porte un masque à gaz. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

TU FUMES, ILS SOUFFRENT

La fumée secondaire cause des maladies et la mort chez les non-fumeurs.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in fewer than half of the groups in which it was tested and mainly among youth smokers and non-smokers. Its effectiveness was based more on text and design than image.

• Text: The text was most often identified as effective because the main text is short, categorical, and focuses on the effect of smoking on others. While the reference in the subtext to ‘death’ was also seen as contributing to the effectiveness of the message, the reference to ‘disease’ was considered too vague/general.
• Image: The image in this HW was more likely to be seen as limiting its effectiveness. This was due mainly to a widespread impression that it looks staged and unrealistic (i.e. a totally indifferent looking smoker sitting beside a person wearing a gas mask). This was seen as making the image difficult to relate to.

Another factor limiting the effectiveness of this HW is the impression that the main text and image do not complement each other because the text refers to suffering caused by second-hand smoke but the image does not depict any suffering.

• Design: Various design features were identified as contributing to the effectiveness of this HW. The use of yellow font and capital letters were seen as drawing attention to the main text by highlighting it. In the FT version use of a black background was also identified as highlighting the text. The ‘WARNING’ message was described as attention-grabbing because of the use of black text on yellow background. Finally, the design of the Quitline section was identified as contributing to the HW’s effectiveness by making the Quitline prominent through the use of a blue background fill with white lettering spanning the HW.

The most frequently made suggestion for improving this HW included depicting a more realistic scenario showing the effects of SHS, for example a child or younger person being affected by SHS (e.g. using a puffer).

HW30: I have terminal lung cancer

Description Image 29:

A testimonial of a man suffering from terminal lung cancer. The bottom 25% of the package is dark brown.

The text reads:

"I have terminal lung cancer."

"I had my right lung removed. The cancer moved into my left lung and spread to my lymph nodes. I also have bladder cancer, congestive heart failure and chronic obstructive pulmonary disease. All these diseases come from smoking cigarettes."
- Archie

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 29:

Le témoignage d’un homme atteint d’un cancer du poumon en phase terminale. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

« Je suis atteint d’un cancer du poumon en phase terminale. »

« On m’a retiré mon poumon droit. Puis, le cancer s’est propagé vers mon poumon gauche et mes ganglions lymphatiques. J’ai aussi un cancer de la vessie, une insuffisance cardiaque congestive et une maladie pulmonaire obstructive chronique. Toutes ces maladies sont causées par le tabagisme. »
- Archie

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in half of the groups in which it was tested. The general approach (i.e. the use of a testimonial) tended to be viewed as effective because it personalizes the message, making it easier to relate to. That being said, this particular HW tended to be viewed as lacking effectiveness due mainly to the text and the image and the lack of connection between them.

• Text: While the main text in this HW was routinely described as effective because it is short, categorical, and personal (in both English and French), this was counterbalanced by the widespread impression that the subtext is too long and detailed, limiting the likelihood that it will be read.
• Image: The perceived lack of effectiveness of this HW was most often linked to the image, routinely described as unconvincing because the individual does not look like he is suffering from the conditions identified in the subtext. In other words, the effectiveness of the HW is limited by a perceived lack of connection between text and image.
• Design: The large yellow font in the main text was identified as effective because it draws attention to the main text by highlighting it. The design of the Quitline section was also identified as contributing to the HW’s effectiveness by making the Quitline prominent through the use of a blue background fill with white lettering spanning the HW.

Suggestions for improving this HW included making the person look sicker or sadder given his conditions, depicting the person in an appropriate setting given his condition (e.g. a hospital bed), showing a younger person, and making the Quitline section more noticeable by changing colour of person’s shirt in picture (i.e. Quitline and section and shirt are currently a similar colour).

HW31: Thought you would only try it once?

Description Image 30:

A man is lighting the 25 cigarettes he has in his mouth. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Thought you would only try it once?

Nicotine in tobacco is highly addictive.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 30:

Un homme allume les 25 cigarettes qu’il a dans sa bouche. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

Vous pensiez que vous ne l’essaieriez qu’une fois?

La nicotine dans le tabac crée une forte dépendance.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW tended to rate poorly in terms of effectiveness in informing and educating about the health effects and health hazards of smoking due mainly to the impression that the image is inappropriate for a HW and does not depict the adverse effects of smoking or addiction.

• Text: Although the text in this HW is clear and easy to understand, it’s effectiveness is limited because it contains no new information and makes no reference to the adverse effects of smoking or the consequences of addiction.
• Image: There was a widespread impression that the image in this HW is ineffective because it is inappropriate. Specifically, it was routinely described as too light-hearted or comical in tone.
• Design: Design features contributing to the effectiveness of this HW include the main text being highlighted through bolding as well as the color of the ‘WARNING’ message and including it twice (English SS version and French FT version). Conversely, use of the ‘WARNING’ message three times in the English FT version was considered unnecessary.

The most frequently made suggested improvement to this HW was to use an image depicting the consequences/effects of addiction (e.g. a timeline image depicting growing addiction, or a graph depicting the amount of money spent on cigarettes).

HW32: Nicotine in cigarettes is highly addictive. Break the chains…

Description Image 31:

A teenager is chained around his chest to a large burning cigarette. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Nicotine in cigarettes is highly addictive.

BREAK THE CHAINS OF YOUR ADDICTION.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 31:

Un adolescent est enchaîné autour de sa poitrine à une grosse cigarette allumée. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

La nicotine contenue dans la cigarette crée une forte dépendance.

LIBÉREZ-VOUS DE VOTRE DÉPENDANCE.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW tended to rate poorly in terms of effectiveness in informing and educating about the health effects and health hazards of smoking primarily because of the image.

• Text: Feedback on the effectiveness of the text in this HW was mixed. The bolded text was described as effective because it contains a positive and empowering message. On the other hand, the text contains no new information and makes no reference to the adverse effects of smoking or the consequences of addiction. It was also suggested that the text contains a contradictory message because it states that cigarettes are highly addictive, but then call on people to break the addiction. Some added that this makes quitting sound easy, which it is not.
• Image: Feedback on the image in this HW tended to be critical. The image was routinely described as conveying nothing meaningful related to addiction, making it difficult to relate to. While some described the image as a creative depiction of addiction, many felt that its meaning is not self-evident and that it does not depict the adverse effects of addition. One feature described as contributing to the effectiveness of the image is the inclusion of a young person.
• Design: Design features contributing to the effectiveness of this HW include the main text being highlighted through bolding as well as the color of the ‘WARNING’ message and including it twice (English SS version and French FT version).

The most frequently made suggested improvement to this HW was to use a different picture which depicts addiction in a meaningful, relevant manner. It could be an image depicting the struggles and sacrifices addiction brings with it (e.g. choosing between buying food or cigarettes). It was also suggested that the non-bolded text be removed (i.e. Nicotine in cigarettes is highly addictive).

HW33: Cigarettes are highly addictive, but you can break free

Description Image 32:

Two hands are surrounded by smoke in the shape of handcuffs. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Cigarettes are highly addictive, but you can break free.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 32:

Deux mains sont entourées de fumée en forme de menottes. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

La cigarette crée une forte dépendance, mais vous pouvez vous en libérer.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW tended to rate poorly in terms of effectiveness in informing and educating about the health effects and health hazards of smoking primarily because of the image.

• Text: Feedback on the effectiveness of the text in this HW was mixed. It was described as effective because it contains a positive and empowering message. On the other hand, the text contains no new information and makes no reference either to the adverse effects of addiction or the benefits of breaking free. As with the previous HW, it was also suggested that the text contains a contradictory message because it states that cigarettes are highly addictive but states that you can break free. Some added that this makes quitting sound easy, which it is not.
• Image: Feedback on the image in this HW was mixed, but mainly critical. While the approach was described as a creative, it was criticized for not focussing on consequences or results. In most cases it was criticized for not depicting the results or consequences of breaking free of addiction, though in some cases it was criticized for not depicting the adverse effects of addiction. In both instances however, the focus was on depicting consequences or results. Some also said they do not like the use of hand cuffs because they associate them with criminal activity. Others observed that it is not clear if the person is actually breaking free of her cuffs as is suggested in the text.
• Design: Design features contributing to the effectiveness of this HW include the use of bolding and framing to highlight the text and the design of the Quitline section in the FT version which makes the Quitline prominent. This includes the double line format (blue on top/white on bottom), upper-case lettering for the tagline, and the Quitline section spanning the HW from edge to edge.

The most frequently made suggested improvement to this HW was to use a different image depicting the consequences/effects of breaking the addiction to smoking (e.g. a ‘before/after’ approach with two pictures: one showing some aspect of life while dependent on cigarettes and the other showing the same aspect after breaking the dependence).

HW34: The ugly side of smoking

Description Image 33:

A young woman looks into a mirror and sees her reflection with effects on her face caused by cigarettes. The bottom 25% of the package is dark brown.

The text reads:

WARNING

The ugly side of smoking…

Cigarettes harm your entire body including your skin, eyes and teeth.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 33:

Une jeune femme se regarde dans un miroir et voit son reflet avec des effets sur son visage causés par la cigarette. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

Le côté sombre du tabagisme…

La cigarette affecte tout votre corps dont votre peau, vos yeux et vos dents.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW tended to rate poorly in terms of effectiveness in informing and educating about the health effects and health hazards of smoking primarily because of the image and a perceived lack of coordination between text and image.

• Text: The text in this HW was described as effective because of its focus on appearances, something easy to relate to. Some youth and young adults emphasized that this is particularly the case for young people who tend to be concerned about their appearance. The subtext in particular was described as effective because it focuses on the adverse effects of smoking on appearance. That said, the effectiveness of the text was limited by the absence of any new information.
• Image: The perceived lack of effectiveness of this HW was routinely linked to the image, described as unconvincing or poorly executed because the younger and older versions of the woman look like different people altogether. Other reasons explaining why the image is not effective included the impression that there is no connection to smoking in the image, that the blemishes on the woman’s face look more like pimples, and that the reflection in the mirror is not a correct (i.e. the hand in the reflection is not at the right spot on the face).

  Another factor routinely identified as limiting the effectiveness of this HW is lack of coordination between text and image. Specifically,

  • the English text refers to the ‘ugly side of smoking’ but the picture conveys the idea of aging rather than ugliness caused by smoking.
  • the text refers to the effect of smoking on teeth, but the picture does not show the person’s teeth.
• Design: Design features contributing to the effectiveness of this HW include the main text being highlighted through bolding as well as the color of the ‘WARNING’ message and including it twice (English SS version and French FT version).

The most frequently made suggestion to improve this HW was to use a different image better depicting consequences/effects of smoking on appearances and more attuned to main message (i.e. ‘The ugly side of smoking’). The following suggestions were also made: showing the person’s teeth, including a timeline (e.g. the effect of smoking after five years, 10 years, etc.), including a cigarette in person’s hand to establish link to smoking, replacing the term ‘ugly’, and creating another version showing the person looking in the mirror badly affected by smoking but seeing her reflection as she thinks she looks.

HW35: Smoking causes pancreatic cancer.

Description Image 34:

A bald man wearing a medical face mask. His skin and eyes are visibly yellow. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Smoking causes PANCREATIC CANCER.

If you get pancreatic cancer, it is almost certain you will die from it.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 34:

Un homme chauve porte un masque médical. Sa peau et ses yeux sont visiblement jaunes. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

L’usage du tabac cause le CANCER DU PANCRÉAS.

Si vous êtes atteints du cancer du pancréas, il est presque certain que vous en mourrez.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW tended to rate poorly in terms of effectiveness in informing and educating about the health effects and health hazards of smoking primarily because of the image and a perceived lack of coordination between text and image.

• Text: Both the main text and subtext in this HW were described as effective. The main text was described as effective because it is short, clear and easy to understand in both English and French, and makes a direct link between cigarettes and pancreatic cancer. The subtext was described as effective because it is short, with a focus on consequences. Finally, the text was considered effective because it contains new information.
• Image: The perceived lack of effectiveness of this HW was routinely linked to the image which was routinely described as meaningless. Specifically, it was observed that the image makes no direct relation to smoking or its consequences, the person in the picture does not look sick or ill, and that it is unclear who the person in the picture is supposed to be and why they are wearing a mask. All of these factors make the image difficult to relate to.

  Another factor routinely identified as limiting the effectiveness of this HW is lack of coordination between text and image. Specifically, the connection between pancreatic cancer and the person wearing a mask is unclear.

• Design: The grey background was seen as limiting the effectiveness of this HW because it is drab, provides no meaningful context for the image, and makes the subtext less noticeable. Features identified as contributing to its effectiveness include the following:
  • Use of yellow font which draws attention to the text by highlighting it.
  • The ‘WARNING’ message, described as attention-grabbing because of the use of black text on yellow background.
  • The design of the Quitline section, identified as contributing to the HW’s effectiveness by making the Quitline prominent through use of a blue background fill with white lettering spanning the HW.

The most frequently made suggested improvement to this HW was to change the image. The following suggestions were also made: include a more relevant picture that complements the text and shows a direct connection to smoking (e.g. cancerous pancreas), making the person look sicker, and combining the text and subtext into one sentence.

HW36: Cigarettes are a trap

Description Image 35:

A hand is reaching into a metal trap containing a cigarette. The bottom 25% of the package is dark brown.

The text reads:

WARNING

CIGARETTES ARE A TRAP

But you can break free from the addiction.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 35:

Une main s’engage dans un piège métallique contenant une cigarette. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

LA CIGARETTE EST UN PIÈGE

Vous pouvez vous libérer de la dépendance.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW tended to rate poorly in terms of effectiveness in informing and educating about the health effects and health hazards of smoking mainly because of the image.

• Text: The main text in this HW was identified as effective because it is short and true. The subtext was identified as effective because it includes a positive and empowering message. Criticism of the text included the impression that it contains no new information and that the main text is too slogan-like.
• Image: While the image was routinely described as attention-grabbing, there was a widespread impression that it is inappropriate and/or disturbing because of the use of a trap. This included the impression that the image is too violent (an impression the red background contributes to according to some), that traps are illegal, and that the trap conjures up images of slavery. The image was also routinely criticized for not depicting any adverse effects or consequences of smoking or addiction.
• Design: Design features identified as contributing to the effectiveness of this HW include the following:
  • Use of yellow font which draws attention to the text by highlighting it.
  • The ‘WARNING’ message, described as attention-grabbing because of the use of black text on yellow background.
  • The design of the Quitline section, identified as contributing to the HW’s effectiveness by making the Quitline prominent through use of a blue background fill with white lettering spanning the HW.

The most frequently made suggested improvement to this HW was to use a different image to convey the idea of cigarettes as a trap and the idea of breaking free from addiction (e.g. a ‘before/after’ approach depicting some aspect of someone’s life as a smoker compared to the same aspect once free of smoking).

HW37: Tobacco kills up to half its users

Description Image 36:

A colourful wheel of fortune with seven health effects of smoking including heart disease, emphysema, lung disease, cancer, heart attack, stroke, chronic bronchitis along with the words "Tobacco kills" in the middle. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Tobacco kills up to half of its users.

Add years to your life by quitting smoking.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 36:

Une roue de fortune colorée, sur laquelle apparaissent sept effets du tabagisme sur la santé : maladies cardiaques, emphysème, maladies pulmonaires, cancer, crise cardiaque, accident vasculaire cérébral et bronchite chronique. Les mots « Le tabac tue » sont inscrits au milieu. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

Le tabac tue près de la moitié des personnes qui fument.

Vivez plus longtemps en arrêtant de fumer.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW tended to rate poorly in terms of effectiveness in informing and educating about the health effects and health hazards of smoking mainly because of the image and poor coordination between text and image.

• Text: The main text in this HW was identified as effective because it is short, categorical, to the point, and uses data. The subtext was identified as effective because it strikes a positive note.
• Image: The perceived lack of effectiveness of this HW was most often linked to the image. A variety of factors were routinely identified as limiting the effectiveness of the image. They included the following:
  • The image lacks a meaningful connection to the text (i.e. there is no connection between the text and the image of a wheel of fortune).
  • The image of a wheel of fortune is an inappropriate image for a HW. This includes the impression that such an image is too light-hearted and the impression that it alludes to gambling, which like smoking can become an addiction like smoking.
  • The image is difficult to decipher (i.e. one has to rotate the image sideways to read the text in the picture).
• Design: The overall design of this HW tended to be seen as making it ineffective in informing and educating about the health effects and health hazards of smoking because it is too distracting/disorienting. Specifically, it was routinely observed that it is too ‘busy’ which makes it difficult to focus on particular features. Design features contributing to the effectiveness of this HW include the main text being highlighted through bolding as well as the color of the ‘WARNING’ message and including it twice (English SS version and French FT version). Conversely, use of the ‘WARNING’ message three times in the English FT version was considered unnecessary.

The most frequently made suggested improvement to this HW was to use a different image.

HW38: Second-hand smoke kills babies too.

Description Image 37:

A man holding a small coffin for a baby with flowers on the left side of the coffin. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Second-hand smoke kills babies too.

Babies exposed to second-hand smoke are at a higher risk of sudden unexplained death.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 37:

Un homme tient un petit cercueil pour bébé, avec des fleurs sur le côté gauche du cercueil. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

La fumée secondaire tue aussi les bébés.

Le risque d'un décès soudain inexpliqué est plus élevé chez les bébés exposés à la fumée secondaire.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW tended to rate poorly in terms of effectiveness in informing and educating about the health effects and health hazards of smoking mainly because of the image.

• Text: The main text was described as effective because it is short and focuses on harm to babies. The subtext was described as effective because it contains new information. That said, the message was described by some as unclear or mixed (i.e. if second-hand smoke kills babies, how is the sudden death of babies exposed to it unexplained?). Some also felt the reference to killing babies is inappropriate or extreme.
• Image: The perceived lack of effectiveness of this HW was most often linked to the image, often described as weak because it is not clear that the coffin is that of a baby and the face of the person behind the coffin is not shown. Regarding the latter point it was observed that the image would be easier to relate to if the person’s face were shown.
• Design: Design features identified as contributing to the effectiveness of this HW include the following:
  • Use of yellow font which draws attention to the main text by highlighting it. In the FT version use of a black background was also identified as highlighting the text.  By comparison, the subtext in the SS version was described at times as difficult to read because it is similar in colour to the background (i.e. the coffin).
  • The ‘WARNING’ message, described as attention-grabbing because of the use of black text on yellow background.
  • The design of the Quitline section, identified as contributing to the HW’s effectiveness by making the Quitline prominent through use of a blue background fill with white lettering spanning the HW.

The overall effectiveness of this HW was identified by some as limited by two additional factors. One is the impression that it targets people who smoke around babies even though most smokers do not do this anymore. The other is the impression that that theme of ‘killing babies’ is extreme and could affect the credibility of the messaging by making it difficult to relate to.

Suggestions for improving this HW included showing a clearer picture of the coffin, including something connected to the baby in the picture (e.g. a toy), showing the person’s face or grieving parents, replacing the main text with the subtext, using a different colour for subtext to make it stand out more against picture of white coffin, and removing the reference to ‘killing babies.

HW39: You wouldn’t feed this to your child, so why make them breathe it?

Description Image 38:

A crying baby is being fed cigarette butts on a spoon. The bottom 25% of the package is dark brown.

The text reads:

WARNING

You wouldn’t feed this to your child, so why make them breathe it?

Tobacco smoke damages their immune system and weakens their lungs.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 38:

Un bébé en pleurs est nourri avec des mégots de cigarettes sur une cuillère. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

Vous ne donneriez pas cela à manger à votre enfant. Alors, pourquoi leur faire respirer?

La fumée secondaire de cigarette affaiblit leur système immunitaire et leurs poumons.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in two-thirds of the groups in which it was tested. The perceived effectiveness of this HW was based primarily on image and design, though reaction to the image was mixed.

• Text: Feedback on the text was mixed. The main text was described as effective because it focuses on harm to babies and makes people reflect on what is contained in tobacco smoke. By contrast, the subtext tended to be viewed as too general.
• Image: The image was described as effective because it is attention-grabbing, depicts the consequences of smoking on babies in a creative manner, and conveys what the health condition is without having to read the main text However, this was counterbalanced by the impression that the image lacks realism, making it difficult to suspend disbelief (i.e. no one actually feeds cigarette butts to babies). This perceived lack of realism was described as making the image difficult to relate to. Some felt that the image lacks realism because the image looks too crafted or photo-shopped
• Design: Design features identified as contributing to the effectiveness of this HW include the following:
  • Use of yellow font which draws attention to the main text by highlighting it. By comparison the subtext was described at times as more difficult to read because it does not stand out against the background color in which it is set.
  • The ‘WARNING’ message, described as attention-grabbing because of the use of black text on yellow background.
  • The design of the Quitline section, identified as contributing to the HW’s effectiveness by making the Quitline prominent through use of a blue background fill with white lettering spanning the HW. That said, it was also observed that the Quitline section does not stand out well against the image because they are similar in color (i.e. two shades of blue).

The overall effectiveness of this HW was identified by some as limited by its lack of relevance because it targets people who smoke during pregnancy. The impression was that most people do not do this.

Suggested improvements to this HW included making the picture more realistic (e.g. show baby in car surrounded by smoke or in a hospital on a respirator), including a cigarette in the picture (e.g. parent smoking next to the child), and identifying concrete/specific health risks in subtext.

HW40: Don’t plunge into the poison

Description Image 39:

A distressed, teenage girl is surrounded by dirty water filled with cigarette butts. The bottom 25% of the package is dark brown.

The text reads:

WARNING

Don’t plunge into the poison.

When you smoke, hundreds of toxic chemicals reach every organ in your body.

You can quit. We can help.
1-866-366-3667
gosmokefree.gc.ca/quit
Health Canada

Description Image 39:

Une adolescente en détresse est entourée d’eau sale remplie de mégots de cigarettes. Le quart inférieur du paquet est brun foncé.

Le texte est le suivant :

AVERTISSEMENT

Ne plonger pas dans le poison.

Lorsque vous fumez, des centaines de substances toxiques atteignent chaque organe de votre corps.

Vous pouvez arrêter. Nous pouvons vous aider.
1 866 JARRETE (1 866 527-7383)
vivezsansfumee.gc.ca/abandon
Santé Canada

This HW was rated as effective in informing and educating about the health effects and health hazards of smoking by most participants in fewer than half of the groups in which it was tested, and primarily among youth and young adults. The perceived effectiveness of this HW was based primarily on image and design, though reaction to the image was mixed.

• Text: Feedback on the effectiveness of the text in this HW was mixed. The main text was described as effective because it includes a call to action, while the subtext was considered effective through its reference to hundreds of toxins affecting every organ. Moreover, the information in the subtext was described as new by many participants, adding to its effectiveness.
• Image: Feedback on the image in this HW was mixed. It was described as effective because it is attention-grabbing, depicts a young person, and evokes a sense of despair or fear. However, this was counterbalanced by the impression that the image lacks realism, making it difficult to relate to. In this regard it was observed that the image depicts no adverse effects or consequences of smoking and that the pool of cigarette butts in which the person is mired does not look realistic.

Another factor routinely identified as limiting the effectiveness of this HW is lack of coordination between text and image. Specifically, the text says ‘Don’t plunge into the poison’ but the picture shows someone who has taken the plunge.

• Design: Design features contributing to the effectiveness of this HW include the main text being highlighted through bolding as well as the color of the ‘WARNING’ message and including it twice (English SS version and French FT version). Conversely, use of the ‘WARNING’ message three times in the English FT version was considered unnecessary.

The most frequently made suggestions for improving this HW included using a picture depicting consequences of addiction and making sure that the picture complements the text (e.g. show someone about to plunge). It was also frequently suggested that the subtext be changed to identify some of the effects of toxins on organs.

4. Review of Taglines

This section provides feedback on a set of potential taglines designed to appear on cigarette packages as part of the Quitline section of HWs. Participants in each group were asked to review a set of 11 potential taglines and assess them in terms of their effectiveness in drawing smokers’ attention to the pan-Canadian toll-free quitline number and the Web portal section and encouraging them to use the cessation services.

Near unanimous agreement that taglines should be included in Quitline section

Nearly all participants believe that the Quitline section of the HW would be more effective or more noticeable if a tagline accompanied the phone number and web address, even if removal of the tagline resulted in the phone number and web address being made larger. It is important to note that the French versions of the Quitline phone number appearing in the HWs shown to participants, unlike the English versions, contained the word J’ARRETE (e.g. 1-866 J’ARRETE). To some francophone participants in Quebec City this design feature made retention of a tagline seem redundant and consequently they favoured removal of the tagline. However, nearly all of these same participants felt that a tagline should be retained if the Quitline phone number were not to contain the word J’ARRETE.

Two reasons were routinely provided for retaining a tagline. One reason was motivational, specifically the impression that a tagline could be effective in encouraging smokers to use the cessation services. The other reason was informational, specifically the impression that a tagline provides contextual information making clear the purpose of the phone number and website address. For example, many participants suggested that without an accompanying tagline people might be under the impression that the phone number and website address provide contact coordinates for cigarette companies or manufacturers of cigarettes.

Participants who favoured removal of the tagline provided one or another of the following three reasons to explain their position:

• a tagline is not necessary from an informational point of view because it is relatively self-evident what the phone number and website address are for.
• a tagline is not effective from a motivational point of view because smokers who decide to access the services will do so for reasons of their own and not because of a tagline.
• the absence of a tagline might induce some people to call the number or visit the website out of sheer curiosity (i.e. to find out what they are about).

Supportive and motivational taglines viewed as most effective

Given the number of taglines participants were asked to assess, it is not surprising that there were differences of opinion concerning which were considered most effective. That being said, four taglines were most often considered effective: 

• You can quit. We can help.
• No judgement. Just help to quit.
• Don’t fight smoking alone.
• Need help to quit?

Participants who consider these taglines effective tended to point to their emphasis on support or available assistance in combating smoking. Many added that taglines that emphasize help or support also implicitly recognize that it is difficult to quit smoking. Two of these taglines ‘You can quit. We can help.’ and ‘No judgement. Just help to quit’ were also described as effective because they include a motivational factor (the idea that quitting is possible in the former, and the absence of a guilt trip in the latter).

The following second set of taglines tended to elicit mixed assessments.

• Never quit quitting.
• You have the will. There is a way.
• Tell smoking “It’s over!”.
• Break the addiction.
• Today is your day to quit!

Participants who described one or more of the taglines in this set as effective tended to point to their motivational power/positive messaging, particularly their emphasis on smokers taking the initiative. Participants who did not find them effective tended to describe them as too slogan-like. In addition, with the exception of ‘Never quit quitting’, participants often felt that taglines in this set give the false impression that it is easy to quit smoking.

The following two taglines were least likely to be considered effective:

• Take the next step. Click or call.
• Don’t stall. Click or call.

Both were most likely to be considered effective by youth participants. Reasons included their emphasis on smokers taking the initiative and the ‘catchiness’ of the phrasing. Those who did not consider them effective tended to describe them as too slogan-like or cliché-like. Many also suggested that the call to action in both taglines is too vague or general (i.e. why click or call?).

The most noticeable difference between language groups regarding assessment of the taglines is that Never quit quitting (Ne cessez jamais d’essayer, vous pouvez y arriver) was more likely to be included among the most effective taglines in Francophone groups than elsewhere. Reasons provided by participants in Quebec City to explain its effectiveness included recognition that quitting is difficult (i.e. it can take many attempts before being successful), accompanied by hope and a motivational factor (i.e. keep trying because success is possible). It is perhaps noteworthy that this explicit reference to success is not included in the English version. This may account in part for this tagline’s more positive assessment in Francophone groups.

In Francophone groups, ‘Today is your day to quit!’ (Aujourd’hui j’arrête!) also tested better than elsewhere. Francophone participants who liked this tagline pointed mainly to its emphasis on smokers taking the initiative, Part of the reason it tested better in Francophone groups may have to do with the French formulation as a first-person statement, which clearly emphasizes individual initiative (i.e. Today I stop!).

Finally, You can Quit. We can help (Vous pouvez arrêter. Nous pouvons vous aider) did not test as well in Francophone groups as elsewhere.

Annex 1: Recruitment Screener

Specifications

• 48 focus groups will be conducted with smokers and non-smokers in the following four locations:
  • Vancouver (English)
  • Toronto (English)
  • Halifax (English)
  • Quebec City (French)
• In each group, there will be a mix of participants by smoking status (occasional and daily), gender, age, education and ethnicity.
• 12 groups will be conducted in each of the cities as follows, with 3 focus groups per target population:
  1. Youth non-smokers (aged 15-19)
     • Former smokers
     • At risk youth
  2. Youth smokers (aged 15-19)
  3. Young adult smokers (aged 20-24)
  4. Adult smokers (aged 25+)
• Recruit 11 participants.
• Participants to be paid $100.
• 2 groups per day.
• The WEEKDAY timing will be as follows:
  • Youth (15-19)
  • Group 1: 5:00 pm
  • Group 2: 7:30 pm
  • Adults (20 and older)
  • Group 1: 5:30 pm
  • Group 2: 8:00 pm
• The WEEKEND timing will be as follows:
  • Group # Time
  • Group 1 10:00 am
  • Group 2 12:30 pm
• Groups to last 2 hours.

Questionnaires for Recruitment

Screener 1: Adults (Smokers Age 18 and Older)

INTRO: Hello/Bonjour, my name is [RECRUITER]. I’m calling from CRC/Research House, a Canadian research company. We’re organizing a series of discussion groups on behalf of the Government of Canada with smokers in your area.

Would you prefer that I continue in English or French? / Préférez-vous continuer en français ou anglais?

RECRUITER 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."

Is there anyone in your household 18 years of age or older who smokes cigarettes? If so, may I speak with this individual?

No THANK/DISCONTINUE

Yes:
Same person CONTINUE
Someone else

1. ASK TO SPEAK TO SMOKER
2. REPEAT INTRO
3. CONFIRM THIS PERSON SMOKES CIGARETTES
4. GO TO DESCRIPTION

Not available SCHEDULE CALL-BACK

DESCRIPTION: 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. 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 research professional with up to 11 participants. All opinions will remain anonymous and participation is voluntary. The information collected will be used for research purposes only and handled according the Privacy Act of Canada. The full names of participants will not be provided to the government or any other third party. Would you be interested in taking part in this study?

Yes CONTINUE
No THANK/DISCONTINUE

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 groups. This will take 5 minutes. May I continue?

Yes CONTINUE
No THANK/DISCONTINUE

Q1. Record gender by observation. [50/50 SPLIT]

Female
Male

Q2. We’ve been asked to speak to participants of all different ages. May I have your age please? [RECORD AGE]

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.”

Q3. Do you, or any member of your immediate family, work for…? [READ LIST]

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

Yes THANK/TERMINATE IF YES TO ANY
No CONTINUE

Q4. At the present time, do you smoke cigarettes every day or occasionally?

Every day GO TO Q6
Occasionally CONTINUE

VOLUNTEERED: Not at all THANK/TERMINATE

Q5. In the past 30 days, did you smoke any cigarettes?

Yes [OCCASIONAL SMOKER] MAXIMUM OF 3 PER GROUP
No THANK/TERMINATE

Q6. How long have you been smoking? [GET MIX, AS APPROPRIATE FOR AGE GROUP]

Less than 2 years
2-5 years
6-10 years
11-20 years
Over 20 years

Q7. Have you ever tried any of the following? [READ LIST; RECORD YES/NO]

A little cigar or cigarillo
A tobacco pipe
Chewing tobacco, pinch or snuff
A tobacco water-pipe, such as a hookah, to smoke tobacco
An e-cigarette or vaping device

GO TO DEMOGRAPHICS AND INDUSTRY QUESTIONS

Screener 2: Youth (15 year olds – Smokers and Non-Smokers)

INTRO: Hello/Bonjour, my name is [RECRUITER]. I’m calling from CRC/Research House, a Canadian research company. We are looking for a group of young people to take part in a study that is being done for the Government of Canada.

Would you prefer that I continue in English or French? / Préférez-vous continuer en en français ou anglais?

RECRUITER 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."

Is there anyone in your household who is currently 15 years of age?

Yes CONTINUE
No THANK/DISCONTINUE

IF ADULT: Are you the parent or guardian for that teen?

Yes CONTINUE
No ASK TO SPEAK TO ADULT
REINTRODUCE/CONTINUE

IF CHILD: May I speak to your parent or guardian?

[PARENT CONSENT] 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 HWs for cigarette packages. For this study, we’re organizing discussion groups which are scheduled to run for 2 hours in the evening. The discussion groups involve a small number of teens who will be asked to look at HWs, 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 names of your child will not be provided to the government or any other third party.

May we have your permission to ask your child some questions to see if s/he qualifies for the discussion group which will take place on [INSERT DATE] at [TIME]?

Yes CONTINUE
No THANK/DISCONTINUE

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

Q1A: 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 CONTINUE
No THANK/DISCONTINUE

Q1B: There may be some people from Health Canada who have been 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 CONTINUE
No THANK/DISCONTINUE

Q1C. Do you, or any member of your immediate family, work for …? [READ LIST]

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

Yes THANK/TERMINATE IF YES TO ANY
No CONTINUE

Q1D. Has your child ever attended a discussion group or taken part in interview on any topic that was arranged in advance and for which s/he received money for participating?

Yes
No GO TO Q1H

Q1E. When did your child last attend one of these discussion groups or interviews?

Within the last 6 months THANK/TERMINATE
Over 6 months ago

Q1F. Thinking about the groups or interviews that your child has taken part in, what were the main topics discussed?

RECORD:
THANK/TERMINATE IF RELATED TO TOBACCO

Q1G. How many discussion groups or interviews has your child attended in the past 5 years?

Fewer than 5
Five or more THANK/TERMINATE

Q1H. What is your child’s name?

RECORD:

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

[YOUTH INTRO] Hi [INSERT NAME OF CHILD], I'm [RECRUITER] of CRC/Research House, 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 HWs for cigarette packaging.

Q2. At the present time, do you smoke cigarettes every day, occasionally, or not at all?

Every day [DAILY SMOKER]
Occasionally [OCCASIONAL SMOKER]
Not at all [NON-SMOKER]

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. The discussion groups involve a small number of teens who will be asked to look at HWs and images, complete a short questionnaire 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. Would you be interested in taking part in this study?

Yes CONTINUE
No THANK/DISCONTINUE

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 CONTINUE
No THANK/DISCONTINUE

ASK Q3 OF OCCASIONAL SMOKERS ONLY:

Q3. In the past 30 days, did you smoke any cigarettes?

Yes MAXIMUM OF 3 PER SMOKER GROUP
No THANK/TERMINATE

ASK EVERYONE:

Q4. Have you ever tried any of the following? [READ LIST; RECORD YES/NO]

A little cigar or cigarillo
A tobacco pipe
Chewing tobacco, pinch or snuff
A tobacco water-pipe, such as a hookah, to smoke tobacco
An e-cigarette or vaping device

ASK NON-SMOKERS; SMOKERS GO TO DEMOGRAPHICS AND INDUSTRY QUESTIONS

Q5. Have you ever smoked cigarettes?

Yes [FORMER SMOKER; MAXIMUM OF 4 PER GROUP]
No

Q6. Does anyone in your household, or do any of your friends, use tobacco products? This could cigarettes, electronic cigarettes, also know as e-cigarettes, cigars, pipes, or tobacco water pipes, such as a hookah. [GET MIX OF AT RISK AND NON-SMOKERS]

Yes [AT RISK YOUTH NON-SMOKER]
No [NON-SMOKER]

GO TO DEMOGRAPHICS AND INDUSTRY QUESTIONS

Screener 3: Youth (16-17 year olds – Smokers and Non-Smokers)

INTRO: Hello/Bonjour, my name is [RECRUITER]. I’m calling from CRC/Research House, a Canadian research company. We are looking for a group of young people ages 16 and 17 to take part in a study that is being done for the Government of Canada.

Would you prefer that I continue in English or French? / Préférez-vous continuer en en français ou anglais?

RECRUITER 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."

Is there anyone in your household who is currently 16 or 17 years of age? If so, may I speak with this individual?

Yes CONTINUE
No THANK/DISCONTINUE

Q1. At the present time, do you smoke cigarettes every day or occasionally, or not at all?

Every day [YOUTH SMOKER-DAILY]
Occasionally [YOUTH SMOKER-OCCASIONAL]
Not at all [YOUTH NON-SMOKER]

We are conducting a research study for Health Canada, a department of the Government of Canada, to help them develop HWs for cigarette packaging. 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 which are scheduled to run for 2 hours in the evening. The discussion groups involve a small number of teens who will be asked to look at HWs, complete a short questionnaire about the messages, 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 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. Would you be interested in taking part in this study?

Yes CONTINUE
No THANK/DISCONTINUE

Q2. Do you, or any member of your immediate family, work for …? [READ LIST]

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

Yes THANK/TERMINATE IF YES TO ANY
No CONTINUE

ASK Q3 OF OCCASIONAL SMOKERS ONLY:

Q3. In the past 30 days, did you smoke any cigarettes?

Yes MAXIMUM OF 3 PER SMOKER GROUP
No THANK/TERMINATE

ASK EVERYONE:

Q4. Have you ever tried any of the following? [READ LIST; RECORD YES/NO]

A little cigar or cigarillo
A tobacco pipe
Chewing tobacco, pinch or snuff
A tobacco water-pipe, such as a hookah, to smoke tobacco
An e-cigarette or vaping device

SMOKERS GO TO DEMOGRAPHICS AND INDUSTRY QUESTIONS

NON-SMOKERS CONTINUE

Q5. Have you ever smoked cigarettes?

Yes [FORMER SMOKER; MAXIMUM OF 4 PER GROUP]
No

Q6. Does anyone in your household, or any of your friends, use tobacco products? This could be cigarettes, electronic cigarettes, also know as e-cigarettes, cigars, pipes, or tobacco water pipes, such as a hookah. [GET MIX OF AT RISK AND NON-SMOKERS]

Yes [AT RISK YOUTH NON-SMOKER]
No [NON-SMOKER]

NON-SMOKERS GO TO DEMOGRAPHICS AND INDUSTRY QUESTIONS

Demographics and Industry Questions

ASK QD1 OF ADULTS ONLY (18 years and older):

QD1. Could you please tell me what is the last level of education that you have completed? [READ LIST; GET MIX]

Some high school
Completed high school
Some college/technical school/CEGEP
Graduated college/technical school/CEGEP
Some university
Graduated university
Graduate studies

QD2. Do you consider yourself to be a member of a visible ethno-cultural group?

Yes CONTINUE
No GO TO QI1

QD3. What is your ethnic background? 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).

QI1. 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
No GO TO QI5

QI2. When did you last attend one of these discussion groups or interviews?

Within the last 6 months THANK/TERMINATE
Over 6 months ago

QI3. 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

QI4. How many discussion groups or interviews have you attended in the past 5 years?

Fewer than 5
Five or more THANK/TERMINATE

QI5. Participants will be asked to look at some items, write out short comments and voice their opinions in front of others? Do you feel comfortable doing this?

Yes CONTINUE
No THANK/TERMINATE

QI6: 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 CONTINUE
No THANK/TERMINATE

QI7: There may be some people from Health Canada who have been 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 CONTINUE
No THANK/TERMINATE

GO TO INVITATION TO PARTICIPATE

Invitation to Participate

Thank you. We would like to invite you to attend one of the discussion groups, which will be lead by a researcher from the national public opinion research firm, Phoenix SPI. 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.

Are you willing to attend?

Yes CONTINUE
No 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 INLCUDE: 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 [HE/SHE] 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 arrives 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!

Annex 2: Moderator’s Guide

Introduction (5 minutes)

• Introduce moderator 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 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 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.
    • 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.
    • Recordings will not be shared with anyone without written consent.
  • Observers.
    • There are observers from the Government of Canada who will be watching behind the one-way mirror.  Other Government of Canada observers and the creative company who developed the materials you will be shown today/tonight will be watching 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: Please tell us your first name and a hobby you have.

Contextual Issues (5 minutes)
Smokers

What you all have in common, and part of the reason you are here, is that you are all smokers.

1. How long have you been smoking?
2. Thinking about the health warning on cigarette packages, which ones are most memorable…that is, which ones are you most likely to remember and why?
   • Probe if necessary on if it was colour, message or image that was most effective in making it memorable.

Non-Smokers

As I mentioned, we’re going to be discussing cigarette packaging and labelling, but before we get started…

1. Do any of you have family members or friends who smoke?
2. Have you ever seen warning messages about the risks associated with smoking? What are some of the messages that you remember?
   • Probe: Were they on cigarette packages or somewhere else (i.e. media campaign, social media)?

Review of Health Warnings (85 minutes)

Tonight/today, we’ll be talking about the health warning found on the front and back of cigarette packages. The focus of the discussion will be the health warning themselves and their effectiveness, not the design of the packaging. Cigarette companies are required by law to put health warning on all cigarette packages. The design and colour, as well as the brand name and other elements of the package, are decided by the cigarette companies.

As you may know, plain packaging has been proposed for all tobacco products.

SHOW 3D PLAIN PACKAGES (FLIP-TOP AND SLIDE-AND-SHELL). POINT TO THE DESIGN FEATURES: WRITING (CIGARETTE / KING SIZE CIGARETTE, NUMBER OF CIGARETTES IN THE PACKAGE AND THE BRAND NAME) AND THREE DIFFERENT LABELS CURRENTLY REQUIRED BY HEALTH CANADA: THE HEALTH WARNING, THE TOXIC STATEMENTS ON THE SIDE OF THE PACKAGE, AND THE HEALTH INFORMATION MESSAGES INSIDE THE PACKAGE. FOR FLIP-TOP THESE ARE INSERTS AND FOR SLIDE-AND-SHELL THESE ARE PRINTED DIRECTLY ON THE PACKAGE.

This means all cigarette packages will have the same plain colour, without any design features, such as company logos or slogans.

The draft health warning that I’m going to show you are presented in a booklet that uses proposed plain package colours in place of the brand name. We are only asking for your feedback on the health warning; not the plain package colours or design. Is this clear to everyone? In total, we’ll be looking at 10 health warning. [9 HW FOR SET A SESSIONS]

I’d now like you to turn over the materials in front of you—there is a set of 5 health warning and an exercise booklet [HAND-OUT 1]. Please take a few minutes to look at the health warning on your own, in silence. When you’re done reviewing the mock-ups, I’d like you to open the exercise booklet and complete the first set of questions. OPEN BOOKLET AND POINT TO QUESTIONS. When you’re finished with the exercise booklet, please close it so I know you are finished. We’ll talk about it as a group when everyone has finished.

Also, please do not write on any of the health warning that you are shown throughout the session – we will need to use them again.

ALLOW UP TO 15 MINUTES FOR PARTICIPANTS TO REVIEW THE HEALTH WARNING AND FILL OUT THE EXERCISE SHEETS.

Ok, it looks like everyone is finished. Let’s go around the room and start with overall impressions.

3. What do you think about this set of health warning? Are there any that are more memorable? Why? ALLOW PARTICIPANTS TO RESPOND IN AN OPEN-ENDED MANNER, BUT BE BRIEF.

4. Now to be more specific, let’s start with a show of hands … how many people gave scores of for ? NOTE THE HEALTH WARNING THAT RECEIVE THE MOST POSITIVE (SCORES OF 4-5) AND NEGATIVE (SCORES OF 1-2) RATINGS.

Let’s start with… DISCUSS FIRST HEALTH WARNING. THIS WILL BE THE FIRST OF TWO HEALTH WARNING WITH THE HIGHEST NUMBER OF POSITIVE RATINGS.

5. What makes this health warning effective?

6. What if anything caught your attention and why?

1. IF IT’S NOT THE SAME THING THAT MAKES IT EFFECTIVE, ASK: Does this contribute to its effectiveness or not? Why/why not?
2. What else do you notice/catches your attention (probe for colour, message, image)? Does this/do these contribute to its effectiveness? If so, how?

7. Would you understand the health effect the warning is trying to tell you if you just saw the picture on its own?

8. Is the language of the text easy to understand? Is the font big enough? Is it readable given the colour? What about how it is bolded/not bolded?

9. Does the picture convey the same thing as the text? Do they go together?

10. Is the Quitline section noticeable? Is there anything you would suggest to make it more visible?

11. Does the health warning provide you with information you may not have known about the health effects of smoking? Is this useful information?

12. Is the health warning credible…do you believe what it is saying? Why/why not?

IF THIS IS A TESTIMONIAL HEALTH WARNING:

1. Do you believe that this is a real person telling his/her story? If not, why?
2. Is this health warning more or less effective than a medical image or a conceptual graphic? IF NEEDED, POINT TO EXAMPLES FROM AMONG THE HEALTH WARNING. Why/Why not?

13. What changes, if any, would you suggest for this warning to make it more effective or easier to understand?

REPEAT QUESTIONS 5-13 FOR THE SECOND HEALTH WARNING.

We’ve just discussed two of the health warning. Now I’d like to briefly talk about the other health warning in this set.

MODERATOR: ENSURE THAT ALL HEALTH WARNING IN THE SET ARE DISCUSSED IN THE GROUP. PROBE AS NEEDED IF PARTICIPANTS HAVE NOT DISCUSSED ONE OR MORE OF THE HEALTH WARNING: “What about…”.

ROTATE Q14 AND Q15 BASED ON DISTRIBUTION OF POSTIVE/NEGATIVE SCORES.

14. What, if anything, do you like about these health warning? Why? POINT TO THE HEALTH WARNING NOT ALREADY DISCUSSED IN DETAIL.

Probe: What, if anything, catches your attention about these health warning? Is it the image/picture, colour, text or layout?

15. What, if anything, do you not like about these health warning? Why? FOCUS ON HEALTH WARNING WITH MOST NEGATIVE SCORES.

1. What could be done to improve it ? Probe for text, image, colour, layout.

16. Is the Quitline section noticeable in these health warning? How could this section be improved?

COLLECT SET 1 OF THE HEALTH WARNING AND HAND-OUT SET 2.

Now I’m going to hand out a second set of 5 health warning and ask that you review them just as you did the first set and then flip to the next page in the exercise booklet [SHOW PAGE] and answer the same questions for this next set of health warning. I remind you not to discuss the health warning or react to them until we’re ready for the group discussion.

ALLOW UP TO 15 MINUTES FOR PARTICIPANTS TO REVIEW THE HEALTH WARNING AND FILL OUT THE EXERCISE SHEETS. REPEAT QUESTIONS 3 TO 16 FOR THE 2nd SET OF HEALTH WARNING.

COLLECT SET 2 OF THE HEALTH WARNING.

Health Warning Specific Probes [EXPAND AS NEEDED]:

HW05-06 – FRENCH ONLY – What does the acronym, AVC, mean? Should the acronym be written out in full: “accident vasculaire cérébral”?

HW27 – How many of you know what a “puffer” is? And, what’s it used for? Should the image show the child actively using the puffer?

17. Now that you’ve looked at both sets of health warning…. can you think of any better ideas or suggestions for new health warning? Probes if necessary – specific diseases, images, testimonials?

Review of Taglines (15 minutes)

I’d now like to switch topics. In the health warning that we looked at so far, there is a Quitline tagline included to encourage people to call the toll-free number or visit the website. SHOW PARTICIPANTS PACKAGE AND POINT OUT TAGLINE. WHEN DESCRIBING THE TAGLINE, INCLUDE THE FOLLOWING:

• It’s a short sentence that appears as part of the tobacco package health warning.
• It introduces the pan-Canadian toll free Quitline phone number and web address.
• The tagline should draw the reader’s attention to the Quitline phone number and web address and encourage them to use the cessation services.

New taglines may appear on the health warning found on cigarette packages, so we’d like your feedback on the taglines under consideration. I’m now going to hand out a sheet that contains a list of 11 possible taglines [HAND-OUT 2]. I’d like you to read these taglines on your own, in silence, and then open the exercise booklet in front of you to this page [SHOW PAGE TO PARTICIPANTS] and complete the questions. Once everyone is finished, we’ll discuss the taglines as a group.

ALLOW UP TO 5 MINUTES FOR PARTICIPANTS TO REVIEW THE TAGLINES AND FILL OUT THE EXERCISE SHEETS.

I’m going to read each tagline and I’d like you to tell me if it was among your top three. Now I’d like to discuss the taglines that most of you rated as effective: READ TOP TAGLINES.

ASK QUESTIONS 18-20 FOR EACH OF THE TOP 3 CHOICES.

18. What is it you like about this wording? Would it get you to call the number or visit the website? Anything else?

19. Is there anything you don’t like about it? If so, what?

20. What changes would you make to this tagline to make it more effective in encouraging you/someone^* to call the toll-free number or visit the website?

ONCE TOP TAGLINES HAVE BEEN REVIEWED, CONTINUE.

21. What makes these taglines more effective than the others we have shown you at encouraging you/someone to call the Quitline number or visit the website?

Probe: what works/doesn’t work across all messages?

22. Do you have any other suggestions that you think would be effective in terms of encouraging you to call the helpline or visit the website? If so, what might these be?

23. Consideration is being given to removing the tagline completely and only including the phone number and web address. What do you think of this approach? MODERATOR: ALLOW FOR TOP OF MIND FEEDBACK BEFORE ASKING FOLLOW-UP. Do you think the Quitline section of the health warning would be more effective or more noticeable if the tagline was removed and the phone number and web address were larger? Why/why not?

COLLECT THE PARTICIPANT ASSESSMENT BOOKLETS AND HAND-OUT 2.

Conclusion (5 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 has last thoughts that you want to give the Government of Canada about discussion topic.

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

24. 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. 1ST GROUP ONLY, ADD: When you leave the room, please don’t discuss the topic. Participants for the second group will be in the waiting room.

Annex 3: In-group Materials

Exercise Booklet

Please answer the following questions about Health Warning XX – XXXXXXXXX.

1. What, if anything, do you like about this health warning?

2. What, if anything, do you dislike about this health warning?

3. Do you believe that this is a real person’s story about the health effects of smoking? [TESTIMONIALS ONLY]

• Yes
• No

4. If the cigarette package you were given at a store had this health warning, would you ask for a different package? [SMOKERS ONLY]

• Yes
• No

5. Please rate the effectiveness of this health warning in the following areas:

6. Overall, how effective is this health warning in terms of informing and educating about the health effects and health hazards of smoking?

Taglines

1. Today is your day to quit!
2. Never quit quitting.
3. You can quit. We can help.
4. Take the next step. Click or Call.
5. Break the addiction!
6. Don’t stall. Click or Call.
7. You have the will. There is a way.
8. Tell smoking "It's Over!"
9. Don’t fight smoking alone.
10. Need help to quit?
11. No judgement. Just help to quit.