Qualitative Testing of Revised Health Warnings for Cigarette Packages and on Cigarette - 2019

Final Report

Prepared by: Corporate Research Associates Inc.

Prepared for: Health Canada

POR Registration Number: 126-18
PSPC Contract Number: HT372-184423
Contract Award Date: February 21, 2019
Delivery Date: May 3, 2019
Contracted Cost: $228,966.25

Ce rapport est aussi disponible en français.

For more information on this report, please email:  hc.cpab.por-rop.dgcap.sc@canada.ca

CRA Corporate Research Associates
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Supplier Name: Corporate Research Associates Inc.

April 2019

This public opinion research report presents the results of focus groups conducted by Corporate Research Associates Inc. on behalf of Health Canada. The research study was done using qualitative focus groups. The research entailed a total of forty focus groups comprised of four categories. Ten groups were conducted with each of the following audiences: youth non-smokers ages 15-19; youth smokers ages 15-19; young adult smokers ages 20-24; and adult smokers ages 25 and older. The research was conducted between March 18 and 29, 2019.

Cette publication est aussi disponible en français sous le titre : Évaluation qualitative des avertissements relatifs à la santé révisés pour les paquets de cigarettes et sur les cigarettes.

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

Catalogue Number: H14-325/2019E-PDF
International Standard Book Number (ISBN): 978-0-660-30858-6
Related publications (registration number: POR-037-18): Catalogue Number H14-325/2019F-PDF (Final Report, French) 978-0-66030859-3

© Her Majesty the Queen in Right of Canada, as represented by the Minister of Health, 2019

Table of Contents

• Executive Summary
• Introduction
• Research Methodology
  • Context of Qualitative Research
• Detailed Analysis
  • Health Warning Testing
  • General Considerations About Health Warnings for Cigarette Packages
  • On-Cigarette Health Warnings
• Appendices:
  • Appendix A – Concept Rotation Schedule
  • Appendix B - Recruitment Screener
  • Appendix C – Moderator’s Guide

Executive Summary

Corporate Research Associates Inc.
Contract Number: HT372-184423
POR Registration Number: 126-18
Contract Award Date: February 21, 2019
Contracted Cost: $228,966.25

Background, Objectives and Methodology

Tobacco use is the leading preventable cause of premature death and disease in Canada. Pictorial health warnings have been determined to be effective in broadening awareness of the hazards associated with tobacco use. Health Canada has created several refreshed pictorial health warnings, and was interested in assessing reactions to the concepts being considered, including new pictorial health warnings, as well as warning text directly onto individual cigarettes. Research was needed to determine whether the concepts would be effective in informing and educating Canadians about the health hazards and health effects of tobacco use.

To achieve these objectives, a qualitative research approach was undertaken. This entailed a total of forty in-person focus groups conducted from March 18 to 29, 2019 in Toronto, Vancouver, Halifax and Montreal. Ten focus groups were conducted for each of four audiences: youth non-smokers ages 15-19; youth smokers ages 15-19; young adult smokers ages 20-24; and adult smokers ages 25 and older. Participants in the research included a mix of gender and ages within each age group.

The Montreal focus groups were conducted in French, while discussions in all other locations were conducted in English. Each focus group lasted approximately 2 hours and participants each received $100 (Monday-Thursday) or $125 (Friday-Saturday) in appreciation for their time. A total of twelve (12) participants were recruited per group (with a goal of 10 attending the discussion). Across locations, 369 participants actually attended the discussions.

All participants were recruited per the recruitment specifications for the Government of Canada. Recruitment was conducted through qualitative panels stored on Canadian servers, with follow up calls to confirm the details provided and to ensure quotas were met. This report presents the findings from the study. Caution must be exercised when interpreting the results from this study, as qualitative research is directional only. Results cannot be attributed to the overall population under study, with any degree of confidence.

Political Neutrality Certification

I hereby certify as a Representative of Corporate Research Associates Inc. that the deliverables fully comply with the Government of Canada political neutrality requirements outlined in the Directive on the Management of Communications. Specifically, the deliverables do not include information on electoral voting intentions, political party preferences, standings with the electorate or ratings of the performance of a political party or its leaders.

Signed
Margaret Brigley, President & COO | Corporate Research Associates
Date: May 3, 2019

Key Findings and Conclusions

Findings from the Qualitative Testing of Revised Health Warnings for Cigarette Packages and on Cigarette – 2019 reveal that a number of elements related to the imagery, the messaging, and the layout are important in determining the impact of health warnings for cigarette packages. These conclusions are drawn from the review of reactions to a total of 44 health warnings (consisting of the review of 11 health warnings per group on a rotation schedule), and a total of 52 on-cigarette health warnings (with 13 reviewed per group on a rotation schedule).

Results confirm that messaging that is short, unexpected and serious in its potential personal impact garnered attention. Further, messaging that presents one specific health effect of smoking was generally considered clearer, easier to understand and more compelling than messaging that introduces multiple topics and lengthier explanations.

Feedback received in the focus groups suggests that imagery plays an important role in attracting initial attention on the health warning and greatly influences a message’s impact and credibility. Images that are meaningful and have the ability to clearly communicate the health effect of smoking without the assistance of the text were generally considered most impactful. Likewise, health warnings that feature a realistic image were generally considered more believable. As might be expected, unusual images or those never having been seen before were most likely to elicit attention. At the same time, imagery targeted at specific segments of the population was considered most relevant to the target audience.

While graphic and gruesome imagery effectively grab attention, they appear to sometimes lessen a health warning’s impact. Specifically, reactions varied during the focus groups from ignoring the warning for being accustomed to seeing these types of labels on cigarette packages, to avoiding looking at it altogether if it was felt to be too gruesome.

While the image plays an important role in the initial attention paid to the health warning, the accompanying text is also of importance in establishing the message’s relevance and credibility. A short message using plain language that identifies the health effect of smoking upfront, followed by a short explanation or rationale, was considered of interest. Moreover, attention was more acute for new or less-known information, as long as it is clearly explained in a simple manner. Health Canada endorsement also contributed to enhancing the message’s credibility on the health warnings reviewed.

Health warnings about nicotine addiction and the effects of second-hand smoke were considered less compelling by the target audience, as participants believed that both of those topics have been heavily promoted in recent years in various public education campaigns. Finally, health consequences that were not seen as potentially life-threatening (e.g., impotence, ear infections, asthma, pneumonia) were considered less likely to make someone think about their smoking. By comparisons, health warnings that present serious health effects on babies and fetuses elicited attention.

Further, realism, personal relevance, definitive statements and the use of statistics are key in generating credibility in a health warning. Having personally experienced a health effect of smoking or knowing someone who has enhances the perceived credibility of a health warning. Briefly explaining less-known health effects, as well as providing meaningful statistics helped improve the health warning’s credibility. Qualifying words were also questioned (e.g., preference expressed for “smoking causes cancer” rather than “smoking may cause cancer”) and introduced some doubt regarding the credibility of the claim.  

In the case of health warnings that showed a health effect of smoking that could occur in the future, it was most important to young people to see the impact on a person’s health or lifestyle when they are in their forties (considered mid-life) rather than when they are in their sixties or later in life (considered closer to the end of life). Implying a reduced or dramatically changed lifestyle as a result of a health consequence, or suffering, grabbed young people’s attention, as long as the effects are considered realistic and common consequences of smoking, and not unique or extreme situations.

Testimonials were generally seen as ineffective at grabbing attention and eliciting interest. This may be due to the situation described being seen as unique to the person featured and people’s general inability to imagine themselves in those situations. Further, the imagery on those health warnings did not adequately convey the health consequences discussed in the text and generally lacked emotional appeal. Credibility was also lessened by the use of uncommon and perceived unrealistic names (e.g., Tarbox¹).

In terms of the design and layout of a health warnings for cigarette packages, findings show that the preferred placement of elements depends on how individuals process information (e.g., reading from left to right or top to bottom) and what design elements they are drawn to (e.g., image or text). Further, contrasting red and yellow colours appear to have the strongest visual impact, and were most commonly associated with the implied intent of a warning (i.e., stop, danger). Black text on yellow background stood out, as did yellow text on a dark background. Positioning the warning banner at the top of the health warning spanning the entire width of the design was considered most visible. That said, the right justification of the word “warning” was questioned, with most expecting it to be centered. On the French health warnings, the term “avertissement” was considered more appropriate than “attention” for a health warning, for being formal and commonly associated with the ideal of prevention.
The quitline section of the health warning was generally noticed and highly appreciated. In terms of format, capitalizing and bolding the letters gave the message more prominence, while black lettering on a white background was considered most visible, eye-catching, and easier to read than white lettering on a blue background. 

Once the review of health warnings for cigarette packages was completed, a short discussion regarding on-cigarette health warnings ensued. Reactions to having health warnings printed directly on cigarettes were viscerally negative among people who smoke, as they are considered unnecessary to warn those who smoke and a costly approach. However, the presence of on-cigarette health warnings made smoking less attractive to people who smoke and less frequent smokers expressed mixed opinion regarding its potential to impact awareness of health hazards. 

Across groups, participants reviewed a total of 52 on-cigarette health warnings, with each group reviewing 13 different versions. In general, short on-cigarette messages and those that highlight the health impact of each puff were most noticed and considered most memorable. Health warnings that spoke of a broad health effect, those that identified death as the ultimate consequence of smoking, and those that suggested suffering were also considered most compelling. Versions with quitline information were also often selected among the most memorable. Addiction-related statements also held appeal among English-speaking participants. On-cigarette health warnings were generally considered credible, although those that presented health effects on body parts not readily associated with smoking (e.g., eyes), claims considered too vague or that provides limited explanation were considered less credible. New or less-known information about the health effects of smoking included the potential for stomach, bladder, kidney or lip cancer, damages on the eyes, impotence, and the large number of chemicals contained in cigarette smoke. Apart from the use of the acronym “COPD/MPOC”, the claim that smoking damages the eyes and the lack of clear consequence of having tar in every puff, the on-cigarette health warnings were considered clear and easy to understand.

Finally, in terms of how the health warning would appear on the cigarette, designs that included icons or red text were considered most eye-catching. In addition, having a health warning printed on the cigarette filter was considered most effective in ensuring the message remains visible and top-of-mind for people who smoke. The use of the colour yellow was also considered effective at grabbing attention.

Introduction

Tobacco use is the leading preventable cause of premature death and disease in Canada. Tobacco use contributes to cancer, heart disease and respiratory illnesses. One-half of long-term smokers die prematurely from smoking-related diseases, resulting in over 45,000 deaths in Canada every year. 

Canada was the first country in the world to mandate pictorial health warnings (HW) on tobacco packages. The effectiveness of pictorial health warnings is dependent on the memorable, noticeable, and engaging nature of the HW. Research demonstrates that updating health-related labels on tobacco products increases the effectiveness of the warnings. This refreshing is also mandated by the World Health Organization Framework Convention on Tobacco Control. 

The Tobacco Products Labelling Regulations (Cigarettes and Little Cigars) (TPLR-CLC) requires that the pictorial HW appears on 75% of the front and back panels of cigarette, as well as little cigar packages. The pictorial HW must appear in both official languages in the same manner. In addition to information related to health effects and hazards of tobacco use, the HW provides testimonials from smokers, a tagline, a pan-Canadian toll-free quitline number and a link to the cessation Web portal.

The Minister of Health announced her interest in extending health warning labels onto tobacco products, specifically on cigarettes individually, during a speech to launch the Canada Tobacco Strategy on World No Tobacco Day (May 31, 2018). No country has yet required this practice.

Among its purposes, the HW are intended to:

• inform Canadians, both tobacco users and potential users, about the health hazards and health effects arising from the use of tobacco products or its emissions; and
• raise awareness of the pan-Canadian quitline.

As a result of the reasons discussed above, Health Canada has developed new pictorial health warnings for tobacco products. Health Canada plans to use the new HW when developing future labelling regulations for tobacco products. In order to achieve this goal, Health Canada required a qualitative study to the reactions of Canadians towards the proposed revised mock-ups of HW.  There was also a need for further research about the effectiveness of on-cigarette labelling in informing and educating Canadians of the health effects of smoking, as well as being memorable, noticeable, and engaging.

As a result of these research needs, a total of 40 in-person focus groups were conducted across four locations, namely Montreal, Halifax, Toronto, and Vancouver. In Montreal, 16 focus groups were conducted in French, while 24 English focus groups were conducted across Toronto, Halifax and Vancouver. Feedback was obtained on the pictorial HW concepts, messaging and effectiveness, of both the pictorial health warnings as well as the on-cigarette messaging.

Objectives

The specific qualitative research objectives were to explore reactions to; and understanding and impressions of 44 new HW mock-ups and 52 on-cigarette labels to determine if the labels are:

• noticeable;
• credible and relevant for the target audiences;
• in plain language and understood (in the intended way) by the target audiences;
• culturally appropriate for the target audiences;
• effective in informing and educating Canadians about the health hazards and health effects of tobacco use; and
• leave a memorable impact on the target audiences.

This report presents the findings of the research. It includes a high-level executive summary, the description of the detailed methodology used, the detailed findings of the focus group discussions, and considerations derived from the analysis of research findings. The working documents are appended to the report, including the recruitment screeners and the moderator’s guides.

Research Methodology

Target Audiences

There were four target audiences for this study, namely:

• Youth non-smokers (ages 15-19)
• Youth smokers (ages 15-19)
• Young adult smokers (ages 20-24)
• Adult smokers (ages 25+)

For the context of this project, current cigarettes smokers included those who smoke daily or occasionally. A daily or occasional smoker refers to those who responded "every day" or “occasionally” to the question "At the present time do you smoke cigarettes every day, occasionally or not all?”

Research Approach

The study included a total of 40 in-person focus groups; eight groups in each of Toronto, Vancouver, and Halifax, and sixteen groups in Montreal. All sessions held in Montreal were conducted in French, while sessions in all other locations were conducted in English. Specifically, two groups in each location were conducted with each of the four target audience groups, except for Montreal where there were four groups, as identified above.

Participants in the research included a mix of gender, education, ethnicity and ages within each age group.  Groups with smokers included a mix of smoking status (occasional and daily) and number of years they have been smoking. Among youth non-smokers, participants included a mix of those considered “at risk”, as defined by Health Canada. The focus groups were conducted from March 18 to March 29, 2019. All participants across both phases reported having lived in their respective markets for a period of at least two years. A total of twelve (12) participants were recruited per group (with a goal of 10 attending each session). Across locations, 369 participants actually attended the discussions (see summary table by location that follows).

All participants were recruited per the recruitment specifications for the Government of Canada. Recruitment was conducted through qualitative panels stored on Canadian servers, with follow up calls to confirm the details provided and to ensure quotas were met. An additional confirmation call was done approximately one day prior to each focus group. Participants were also asked to sign a consent form upon their arrival to the focus group (or their parents or guardians for those 15 years old). In each location, participants were asked to show a piece of ID to confirm their identity. Those who took part in the discussion each received a compensation of $100 (Monday-Thursday) or $125 (Friday-Saturday) as a token of appreciation for their time, as per market standards. Group discussions each lasted approximately 2 hours.

The following provides a summary of participation in each location:

The following provides a breakdown of groups by location, language and audiences:

Approach to Concept Review

To eliminate presentation biases, the presentation order of Health Warnings and on-cigarette messages was changed across groups. More specifically, four different sets of 11 health warnings for cigarette packages were presented, totalling 44 health warnings across groups. Each focus group was presented with only one set of health warnings to ensure proper rotation. The order of each one was also rotated inside each set. More detailed information on the rotation approach is presented in Appendix A.

Concerning the messages on-cigarettes, 4 sets of 13 messages were also rotated across the groups (sets a, b, c, d). The 11 design options for the messages on-cigarettes were shown in half of the groups (set ab), while the other half were shown the 9 placement options (set cd). More details on the rotation approach is presented in Appendix A.

Context of Qualitative Research

Qualitative discussions are intended as moderator-directed, informal, non-threatening discussions with participants whose characteristics, habits and attitudes are considered relevant to the topic of discussion.  The primary benefits of individual or group qualitative discussions are that they allow for in-depth probing with qualifying participants on behavioural habits, usage patterns, perceptions and attitudes related to the subject matter.  This type of discussion allows for flexibility in exploring other areas that may be pertinent to the investigation.  Qualitative research allows for more complete understanding of the segment in that the thoughts or feelings are expressed in the participants’ “own language” and at their “own levels of passion.”  Qualitative techniques are used in marketing research as a means of developing insight and direction, rather than collecting quantitatively precise data or absolute measures.  As such, results are directional only and cannot be projected to the overall population under study.

Detailed Analysis

The following section provides an overview of the findings from the English and French focus groups. Where appropriate, differences in opinions are outlined by each of the key audiences under this study.

An overall review of the considerations regarding health warning designs and layouts is presented in the General Consideration sub-section of the report, which follows the individual review of all 44 health warnings.

Health Warning Testing

The following sections present, in numeric order, reactions to each of the 44 health warnings tested.

HW08 - Cigarettes cause deadly heart disease.

Overall Reactions

There were mixed opinions across audiences about this health warning. Across all four audiences, participants were moderately drawn to this health warning, although most believed what it says. For the most part, the health warning is seen as clear and credible across all four audiences, while opinions are clearly divided in terms of the health warning’s ability to communicate a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Opinions were mixed as to whether or not this health warning would grab attention.  Across all audiences, some indicated that they would pay attention to this health warning if they saw it on a cigarette package, primarily because of its limited text and action-oriented image.  More specifically, the visual shows that there has been an accident with an apparently healthy and younger person and viewers are curious to learn about the situation.  Across all audiences, a number of participants felt the image looked too staged, appearing as a movie scene, or an advertisement for paramedics, and thus lacking in interest.   The dark colours and grey background of the visual also contributed to the design’s unattractiveness, although some felt the yellow warning label effectively caught attention. Young adults who smoke generally considered the scenario too generic, similar to a CPR training image, and unrelated to smoking. 

Credibility

Participants who smoke across age groups (youths, young adults, and adults) generally believed this health warning, primarily because the words were credible and familiar, indicating a fact that is not in doubt.  However, across audiences, participants criticized the visual for looking staged or fake and not clearly highlighting the effect smoking has on heart disease or the role it plays in increasing risks.

A number of young adults that smoke who were visible minorities considered the warning more believable and relatable because the individual shown in the image is black. That said, the lack of clear connection to smoking as a cause of his need for medical attention, and the fact that he was in apparent good physical health, made it less credible.

Clarity / Ease of Understanding

While participants across audiences generally understood the written text associated with this health warning, the warning’s message was not totally clear. It was felt that the image on its own does not necessarily communicate the message.  Indeed, there was a lack of connection between the individual and smoking so many did not make the connection that smoking caused his health predicament.  Some felt that the individual was too young and physically fit for the message to be clear.

While the text helped to clarify the image, it was still considered too vague to be meaningful.  Further, young adults and adults who smoke felt the words blended into the background (having black lettering on grey background) and as such the message did not stand out.  

Ability to Communicate a Health Effect

All four audiences indicated that the health warning communicates a health effect of smoking, namely that smoking causes heart disease. This opinion was most pronounced among youth and young adults who smoke.  That said, across audiences it was generally felt that the claim presented in the health warning is too vague for anyone to have learned anything, particularly because it does not clarify the risks of a heart disease caused by smoking.

Participants’ Suggestions

• Participants suggested the following changes to the health warning:
• Move the warning banner to the middle (rather than justify it to the right)
• Make a better connection to smoking (e.g. show him with a cigarette pack in his hand)
• Change the colouring of the visual (too grey / dark)
• Show someone older or in worse physical shape to make the image more believable

HW11 - Smoking causes throat cancer.

Overall Reactions

Across audiences, this health warning was widely considered attention-grabbing, believable, and clear and easy to understand. In addition, nearly all participants believed that it communicated a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

This health warning was considered effective at grabbing attention by most youth who do not smoke, as well as youth and young adults and adult who smoke. Across all four audiences, the image drew attention, with youth (regardless of smoking status) and young adults who smoke being most struck by the suggestion of suffering. Indeed, saying that physical pain is a potential consequence of smoking-induced illnesses was considered a scary consequence by those young participants. In addition, seeing the hole in the throat was considered impressive by many participants, who were able to envision the limitations of this condition on everyday activities, including eating, talking, and breathing. Some young adults who smoke considered the health warning especially effective because it showed a younger person, making it more relevant to them personally. Further, the simple layout of this health warning grabbed the attention of many, with its contrasting yellow and red colours, and the red warning banner attracted the visual attention of all audiences.

The few participants who did not believe that this health warning stands out considered the approach of showing a sick person overused and repetitive with existing health warnings. A few youth who smoke did not feel any empathy for the person featured, and thus would pay little attention to the health warning, as they believed the condition was self-inflicted, and this individual was solely responsible for his condition.

Credibility

Nearly all participants across audiences and locations (with the exception of one youth and one adult who smoke) believed this health warning. Overall, the image appeared realistic, in the manner in which the illness, pain, and emotion of distress are portrayed. Across audiences many also recalled having seen or heard about this type of condition being a negative effect of smoking, and thus believed the health warning. Adults who smoke also mentioned that the obvious link between throat cancer and smoking (because smoke goes down the throat) contributes to the health warning’s believability.

The few who were doubtful of this health warning mentioned that the claim is too affirmative (“smoking causes throat cancer” rather than that it ‘may’ cause cancer), thus implying that smoking will definitely result in cancer, something they do not believe.

Clarity / Ease of Understanding

This health warning was considered clear and easy to understand by youth who do not smoke, as well as youth, young adults and adults who smoke. Participants who smoke across all age groups generally felt that the image communicates the message on its own, in part due to their awareness of the potential risk of throat cancer. In Montreal, youth who do not smoke offered mixed opinions in that regard, as some believed that the image did not clarify that smoking was the cause of throat cancer. Nonetheless, across all four audiences, the text and image were widely considered as working hand-in-hand at delivering the message.

Although the health warning was deemed clear and easy to understand, a few youth and adults who smoke felt the health warning included too many words and that the second sentence was not necessary to convey the message. For the most part, participants did not learn anything new with this health warning. A few young adults and youth who smoke mentioned not knowing that the larynx could be affected or removed as a result of throat cancer.

Ability to Communicate a Health Effect

With the exception of one youth who smoke, all participants across groups believed that this health warning effectively communicated a health effect of smoking, namely throat cancer.

Participants’ Suggestions

• Participants suggested the following changes to the health warning:
• In the French version, remove the word “si”, as it suggests that if you do not remove the larynx, you are ok
• Make the image more graphic (cutting the throat)
• Show the full face to make the visual more personable
• Show the person smoking or surrounded by smoke to clarify the reason for his condition

HW14 - Testimonial – Dony Paudash

Overall Reactions

Overall, this health warning was not considered attention-grabbing across all four audiences. It was moderately seen as credible, thought to limited extent. Mixed opinions were offered in terms of the health warning being clear and easy to understand. That said, it was generally considered as communicating a health effect of smoking.  Opinions regarding the health warning’s credibility, clarity and ease of understanding were more positive among English-speaking participants than among those in French-speaking groups.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Most participants across all four audiences believed this health warning would not catch their attention. The overall approach was described as bland, too wordy, lacking visual interest, and not sufficiently meaningful to be memorable. The man looked ‘like a regular guy’ who did not look sick, and it did not appear he was necessarily sick from smoking, so there was a lack of interest in reading more.

Credibility

Youths (regardless of smoking status) were only moderately likely to believe this health warning, while opinions were divided among young adults and adults who smoke. The fact that an actual person is shown and that the health warning was endorsed by Health Canada made the storyline and the health warning believable. Further, a few youth who smoke felt that the situation described was so extreme that it must be true, since it was felt that a simpler situation would have been described in a made-up story.

Many, however, had a hard time understanding or imagining how a stomach could be attached to a throat, thus making the concept less believable.  Young adults who smoke were also doubtful that someone could not lie down to sleep and felt that the impacts on everyday life were exaggerated given the advance in modern medicine which surely would have found a fix. Further, they felt that the man did not look that sick in the photo. A few youth and adults who smoke in Montreal thought the name sounded funny or unusual, thus affecting the story’s credibility.

Clarity / Ease of Understanding

Mixed opinions were offered across audiences in terms of the health warning’s clarity and ease of understanding. Most participants felt that the image was not self-explanatory, although the explanation below the initial quote was considered to be clearer and more impactful. That said, the image did not add to the message and did not work well with the text. As mentioned earlier, there was confusion as to how a stomach could be connected directly to the throat.

Ability to Communicate a Health Effect

It was generally believed that the health warning communicated a health effect of smoking, namely oesophageal cancer. Many, especially among youths and young adults, learned of the possible consequences of cancer on daily activities. Many were also unaware of the risk of oesophageal cancer and the resulting health consequences (especially having to sleep sitting up).

Participants’ Suggestions

• Participants suggested the following changes to the health warning:
• Show him looking more sick
• Show the actual surgery or physical evidence of it
• Show how he actually eats
• Reverse the text to explain the disease first, followed by the consequences

HW15 - Cigarettes cause oral cancer.

Overall Reactions

This health warning was generally deemed attention-grabbing, credible, clear, easy to understand, and communicating a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

This health warning was generally considered attention-grabbing across all audiences, albeit slightly less so among youth who do not smoke. The deformed face shown was considered disturbing and as such it elicited some curiosity. Moreover, seeing the face missing a jaw as a permanent consequence of smoking was shocking to some. Further, imagining that this situation could happen to them in the future caused many to pay attention and read the health warning to find out more about the condition depicted.

That said, a number of participants felt that the image on its own would not grab their attention, as at a glance, it looks like it is showing an elderly person with a deformity or missing teeth. Some also felt that the health warning has limited impact, as it did not specify the daily consequences of missing a jaw. 

Credibility

Participants across audiences generally believed the health warning. The concept was deemed credible for showing the image of a real person, and for illustrating a condition that was generally well-known, especially among participants who smoke. That said, some felt that the image lacks clarity in identifying that a piece of the jaw is missing rather than just showing an elderly person perhaps with their teeth missing, thus causing some confusion and questions regarding its credibility. Indeed, it was felt that to improve credibility and clarity, a person with a more severe condition should be shown. That said, a few adults who smoke mentioned that the fact that they had not known anyone with this condition reduced the message’s relevance.

Clarity / Ease of Understanding

The overall concept was considered clear and easy to understand by most across audiences. The photo on its own was felt to be mysterious and caused curiosity, but didn’t tell a story on its own without the text. Across audiences, participants said they would not know what was wrong without reading the explanation. That said, the text effectively explained the image in a clear and simple manner.

Ability to Communicate a Health Effect

In general, the health warning was believed to communicate a health effect of smoking, namely oral cancer. The health effect of oral cancer was clearly communicated in the health warning, and the graphic and permanent physical consequence of this was clearly shown. The image of what someone would look like without a jaw was new to many youths and young adults who were also not aware that oral cancer could result in the need to remove part of the jawbone. Questions were raised regarding the risk of oral cancer among young people, and many felt that knowing this would help make the message more personally relevant.

Participants’ Suggestions

• Participants suggested the following changes to the health warning:
• Show the person’s eyes
• Better show what his face looks like (show center of his face)
• Mention the risk of oral cancer among younger people (in their forties)
• Include statistics of how common the condition is among participants who smoke

HW16 - Cigarettes cause infections and cancer inside the mouth 

Overall Reactions

Overall, this health warning was widely seen by most youths, young adults and adults who smoke as grabbing attention. Across all audiences, this health warning was considered believable, clear and easy to understand, and as communicating a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Regardless of smoking status, youths’ attention was widely drawn to this health warning. To a lesser extent, young adults and adults who smoke indicated that they would pay attention to it. Across all four audiences, the grossness of the picture garnered the greatest attention. Seeing teeth in that condition was shocking to some, and unexpected to a few youth who do not smoke. While the graphic depiction attracted the eye of most young adult and adults who smoke, a few recalled having seen similar health warnings, and thus felt that this health warning did not stand out as a result.

Credibility

Across audiences, this health warning was generally considered believable. For the most part, mouth cancer and tooth decay were seen as realistic consequences of smoking, given that cigarettes and smoke are in direct contact with these body parts. Young adults and adults who smoke were also more likely to mention having heard in the past of these kinds of potential consequences, thus believing this could happen. One youth who do not smoke mentioned that not being able to recognize the person shown made it more personally relevant, as you could easily envision yourself in this situation.

Despite the health warning generally seen as credible, a few young adults and adults who smoke expressed some doubt regarding the cause of the tooth decay. Those participants felt that if someone who smokes had a good dental and oral hygiene, there was little risk of this situation happening. One young adult who smoke mentioned that having the name of a doctor specified on the image enhanced the health warning’s credibility.

Clarity / Ease of Understanding

Nearly everyone across groups indicated that this health warning was clear and easy to understand. Indeed, the image was seen as clearly illustrating a potential health effect of smoking and the text was short, direct, and easy to read and understand. Both the image and the text were considered as supporting one another and participants across audiences felt that nothing was confusing or incomplete about this health warning.

In just a few instances, young adults and adults who smoke felt that the image did not clearly illustrate the mouth cancer referred to in the text. That said, they concurred that it effectively illustrated teeth decay and mouth infections.

Ability to Communicate a Health Effect

Nearly everyone across audiences felt that this health warning communicates a health effect of smoking, namely negative impacts inside the mouth. While the image effectively illustrated mouth infection or decaying teeth, it was not clearly illustrating mouth cancer. Nonetheless, it was generally felt that this health consequence was easy to envision with the image shown, and that the text and image together adequately communicated these health effects.

Participants’ Suggestions

• Participants suggested the following changes to the health warning:
• Show context – age of individual, how much they smoked
• Show the whole face, and add a name, an age and a storyline, to enhance credibility
• Keep the face anonymous to make it more personally relatable
• Include a “before” and “after” image
• Add shock value (use a more gruesome image)

HW19 - Smoking damages your eyes…

Overall Reactions

Overall, this health warning moderately attracted the attention of youth, young adult, and adults who smoke, while it generally did not grab the attention of youth who do not smoke. In terms of credibility, mixed opinions were offered. Across all age groups, participants who smoke generally felt that the health warning is clear and easy to understand, while youth who do not smoke offered mixed opinions in that regard. Finally, across all four audiences, it was believed that this health warning communicates a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

This health warning did not strongly attract the attention of participants. Specifically, while young adults and adults who smoke were most likely to have paid attention to the health warning, youth (regardless of smoking status) were less likely to have been drawn to it.

Among those who felt compelled by this health warning, many were curious to find out why the image was out of focus, which led them to read the explanation text, which stood out because of the bright yellow background. In addition, participants across audiences mentioned that the capitalized and bolded text stood out from the rest, and thus grabbed their attention. The health effect itself – namely that smoking can lead to vision problems or loss of sight – was also compelling to many adults who smoke who considered their vision health as being important. Fewer youth who smoke shared a similar opinion.

Those who would not pay attention to this health warning indicated that the blurry section in the image looks like a smudge, a misprint, or a cigarette burn which made the image unrealistic. As such, their spontaneous reaction was to ignore the health warning rather than trying to decipher the image.

Credibility

Mixed views were offered in terms of the health warning’s credibility. While most youths (regardless of smoking status) believed it, young adults who smoke offered equally divided opinions between those who felt this was true and others who were doubtful about it. Adults who smoke generally did not believe this health warning. It should be noted that the concept’s believability is more pronounced among English-speaking participants than among those who took part in the French language focus groups.

The message’s simplicity – namely, if you smoke, you could damage or lose your sight – was credible to some, especially when endorsed by Health Canada. A few youth who smoke also mentioned knowing someone who experienced vision problems as a result of smoking, while some also felt that the claim is believable since they personally feel discomfort when smoke gets in their eyes.

On the contrary, those who did not believe this health warning felt that it was exaggerated by presenting the worst-case scenario (blindness from smoking) which was felt to be a rare occurrence. Further, the image was felt to be unrealistic, whereas a loss of vision would have broad impact rather than affect only a centralized area, as shown.

Clarity / Ease of Understanding

While participants of all ages who smoke generally felt that this health warning is clear and easy to understand, youth who do not smoke offered mixed opinion in that regard. While the text was considered simple, direct, and easy to understand, the image lacked clarity, as discussed above. Apart from the meaning of the area that is out-of-focus, some questioned the presence of a birthday cake in the photo and what message it was supposed to send. It was widely believed across all four audiences that the text was essential in explaining the image. The text’s large font, capitalization and use of bold text in some areas helped improve readability.

Ability to Communicate a Health Effect

Participants across all four audiences generally believed that this health warning communicated a health effect of smoking, namely permanent vision loss. Many across all four audiences reported that this is new information to them.

Participants’ Suggestions

Participants recommended the following changes to the health warning:

• Incorporate a statistic to make it more impactful and scary
• Change the way vision loss is illustrated in the image to make it more realistic/clearer
• Use a different picture/ change the image

HW20 - Cigarettes damage your blood vessels. 

Overall Reactions

Overall, this health warning was considered attention-grabbing across all audiences. Most participants also believed what it says.  In terms of clarity and ease of understanding, participants of all ages who smoke (youths, young adults, and adults) thought the health warning was effective, while this was the opinion of fewer youth who do not smoke. Finally, youths (regardless of smoking status) and young adults who smoke were most likely to believe that a health effect of smoking was communicated by the health warning.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

This health warning was widely considered attention-grabbing across all four audiences primarily because of its gruesome image. This visual caused a visceral reaction by some to look away – it was an image they wanted to avoid.  Some adults and youth who smoke indicated that the image would not compel them to read on because it was too gross.

For most participants, the contrasting colours shown on the health warning (red banner, yellow text box and blue fabric in background) also helped to grab attention.

Credibility

There were mixed opinions across audiences when contemplating if the health warning was believable.  While many participants across all four audiences considered the health warning to be credible given its use of a real photo and clear messaging, others felt the image showed a condition that was too extreme, isolated and rare. Some adults and young adults who smoke were quick to identify that the image could have been the result of other health conditions such as diabetes, gangrene or frost bite. Further, some youth (regardless of smoking status) felt that it would be unlikely that a condition caused by poor circulation would progress to this point with proper medical attention as it develops.

Clarity / Ease of Understanding

Across audiences, those who smoke (including youths, young adults, and adults) widely believed that the health warning was clear and easy to understand, although there was a general perception that the image does not clearly communicate the message on its own. That said, participants believed that the text and the image work well together to clearly communicate the health effect. Youth who do not smoke also shared this opinion, although to a lesser extent in comparison.

Ability to Communicate a Health Effect

Youth (regardless of smoking status), and young adults who smoke widely believed that this health warning communicated a health effect of smoking, namely poor circulation leading to body decay. This was also the opinion of adults who smoke, though to a lesser extent in comparison.   Consistently, participants indicated that they had not been aware of this as a health effect of smoking.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Specify the age of the person
• Position the warning banner at the top instead of on the side
• Make the doctor’s name bigger to add credibility
• Include a statistic to improve credibility (how often does it happen?)

HW22 - Smoking affects blood flow to your penis…

Overall Reactions

Overall, this health warning was considered attention-grabbing by participants, although less so among youth who smoke. It was also moderately considered credible, although most felt that it is clear and easy to understand. This health warning was considered by youths (regardless of smoking status) and young adults who smoke as communicating a health effect of smoking, while adults who smoke were divided on this.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Youth who do not smoke and young adults who smoke widely considered that this health warning grabbed attention, an opinion also shared by adults who smoke, but to a lesser extent. By contrast, fewer youth who smoke felt that the health warning would catch their attention.

Showing a naked man and referencing his genitals was considered suggestive and thus attention-grabbing. At the same time, the humour communicated by the “out of order” sign caught some people’s attention and made them curious to read the explanation. Some felt it would be a conversational piece among friends, and enjoyed the comic element of the health warning. The simple image and the bright and contrasting colours also caught the attention of participants. The few who said that the health warning did not stand out felt that it lacked shock value, that the link to smoking was unclear at a glance, and that the situation was not something relevant to them personally.  Across audiences, males generally were more impacted by this health warning than women.

Credibility

Participants across locations were moderately likely to believe what the health warning is saying. Some saw it as credible, as the text explains how the condition happens. Further, the endorsement by Health Canada enhanced the message’s credibility. A few adults also mentioned already being aware of this health effect, thus believing the claim. Others, however, expressed doubt about smoking causing erectile dysfunction, as this condition could have many other causes.  For them it would be difficult to claim with any degree of certainty that it is caused by smoking. Most say they have never heard of or experienced this condition, thus further reducing the claim’s believability. 

Clarity / Ease of Understanding

Youth who do not smoke, and participants of all ages who smoke (youths, young adults, and adults) widely considered the health warning as clear and easy to understand. To some, the image communicates the message on its own, without the need for further explanation. Others, notably those unaware of this health effect, considered that the text provides a needed explanation, and that the image does not effectively communicate the health effect on its own.

Ability to Communicate a Health Effect

The health warning was widely seen by youth (regardless of smoking status), and young adults who smoke as communicating a health effect of smoking, namely erectile dysfunction. Adults who smoke were divided on this front. Many participants across audiences, notably among youths and young adults, were unaware that smoking can cause erectile dysfunction. It should be noted that a few youth who do not smoke were curious about how blood flow is restricted. Some adults and young adults who smoke made light of the suggested health effect, indicating that alcohol also inhibits sexual performance.  Further, it was felt that such a condition could be easily treated with ‘a little blue pill’, thus not being overly serious.

Participants' Suggestions

Participants suggested the following changes to the health warning:

• Show clearer link to smoking in the image to strengthen the message
• Shorten the text to make it more impactful
• Provide statistics to show the proportion of those who smoke with this condition
• Change the order of the text, identifying the condition (erectile dysfunction) first, then providing the explanation (restricted blood flow)

HW23 - Smoking when pregnant can cause a baby…

Overall Reactions

This health warning was considered attention-grabbing across audiences, as well as being widely seen as believable and communicating a health effect of smoking. Most across all four audiences also felt that the health warning was clear and easy to understand.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

This health warning grabbed the attention of nearly all youths (regardless of smoking status) and of most young adults and adults who smoke. Seeing a baby illustrated on a cigarette package health warning was considered novel and thus grabbed the attention of viewers. Further, the baby being evidently sick evoked a strong emotional response. That said, many felt anger towards the mother or pregnant mothers smoking in general, rather than reflecting on their own smoking behaviours. A few young adults and adults who smoke found that the health warning did not provide new information, and as such it would not attract their attention.

Credibility

This health warning was widely considered as credible across all audiences, primarily due to the existing knowledge that smoking during pregnancy can harm the fetus. Further, the baby illustrated is evidently sick, a further reminder of the impact on the most innocent of all in society. That said, a few youth (regardless of smoking status) and young adults who smoke believed there could be multiple reasons a baby is born prematurely, thus shedding doubts on the severity of the impact of smoking during pregnancy.

Clarity / Ease of Understanding

This health warning was seen as clear and easy to understand, notably when considering the image and the text together. The text was felt to be essential in explaining the image, though it was believed to include too many words to be attention-grabbing. It was also deemed too vague, as it does not identify specific health conditions.

The small size of the white text was considered difficult to read or not standing out by some youth (regardless of smoking status) and adults who smoke. A few youths also questioned the severity of consequences of smoking on babies, as the health warning does not provide sufficient details in that regard.

Ability to Communicate a Health Effect

The health warning was considered as effectively communicating a health effect of smoking, namely resulting deaths, diseases or disabilities for babies. That said, a few adults and youth who smoke commented that the health warning did not convey any impact of smoking on themselves, but rather on others. Accordingly, for some it lacked personal relevance.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• State that the baby didn’t have a choice in being exposed to smoke, or that “nobody wants to hurt their children”, to further engage the attention of those who smoke
• Simplify and reduce text
• Include statistics to show prevalence of risk
• Change “une maladie” for “la maladie” in the French version

HW 24 - When you smoke during pregnancy…

Overall Reactions

This health warning was widely seen as attention-grabbing, and as being clear and easy to understand. It was also seen as believable, and effective at communicating a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Across audiences, this health warning’s provocative image effectively grabbed viewers’ attention.  Seeing the baby footprints on the pregnant mom’s belly while she smoked evoked a strong emotional response, with participants considering it shocking, scary and surprising. This health warning was especially impactful to females and those who are near or in their childbearing years.

Credibility

This health warning was widely seen as credible across audiences, and sharing a well-known fact that smoking during pregnancy is harmful.  It was deemed realistic that whatever a pregnant woman eats or breaths in goes directly to the fetus. That said, some youth who do not smoke questioned if it is realistic to have a footprint shown on a stomach.

Clarity / Ease of Understanding

Across all four audiences, this health warning was seen as being clear and easy to understand. That said, participants felt that too much text was included and brevity would make it less ambiguous.  Some adults who smoke felt introducing chemicals in the text overly complicated the message.

Ability to Communicate a Health Effect

Across all four audiences, this health warning was deemed effective at communicating a health effect of smoking, namely that the health of an unborn baby is put at risk by smoking.   This opinion was strongest among participants of all ages who smoke (youths, young adults, and adults).  Participants considered the health warning’s image clear and self-explanatory, although the text effectively supports the message.

Participants’ Suggestions

• Participants suggested the following changes to strengthen the health warning:
• Remove the feet from the image as they do not look real (assuming photo-shopped)
• Move the warning banner to the top
• Add something to suggest the child has not chosen to smoke
• Shorten text, removing “like carbon monoxide”

HW25 - Children breathe faster so they inhale…

Overall Reactions

Overall, this health warning was generally believed to grab attention, show credible, clear and easy to understand information, and to some extent, present a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Across audiences, participants were generally drawn to this health warning. This was particularly the case of youth who do not smoke, as well as young adults and adults who smoke. Seeing a traumatized baby on a cigarette package health warning was widely seen as unusual, and the image of the skull next to the baby was evocative of death, and implied that the baby is at risk of dying. The baby’s traumatized face elicited emotion as well. Those who were not drawn to this health warning felt the text is too long and that this was not relevant to them as they did not smoke next to children or have children.

Credibility

This health warning was also widely seen as credible by youth who do not smoke and by participants across age groups who smoke (youths, young adults and adults). The message made sense and was seen as logical based on existing knowledge, and the explanation was clear. That said, the image’s lack of realism (specifically the smoke shaped as a skull) took away credibility for many and added an unrealistic and overly dramatic element to the health warning. Further, the manner in which the smoke goes into the baby’s nostrils was considered unrealistic and exaggerated.

Some adults who smoke and youth who do not smoke felt that the baby looked too healthy to be at risk, and did not believe the baby was suffering.

Clarity / Ease of Understanding

Participants across audiences felt that this health warning is clear and easy to understand. Specifically, the image on its own clearly communicates the dire health risks of babies inhaling smoke, while the text clarified the potential health effect (i.e., severe asthma).

That said, the phrasing “putting them at risk” was felt by a few youth who do not smoke as being vague or exaggerated.  Indeed, some youth who do not smoke felt that while asthma is not good, it was not considered a serious health risk. In addition, a few in each of the four audiences felt that the image on its own speaks of the risk of dying, while the text refers to potential asthma. It should be noted that a number of young adults and adults who smoke felt that the baby’s expression and eyebrows, along with the photo-shopped skull, resulted in the image looking like a meme on Instagram.

Ability to Communicate a Health Effect

In general, it was believed that this health warning communicates a health effect of smoking, namely severe asthma in children. That said, as mentioned, the risk of asthma was not believed to be definite enough, although the information about babies breathing faster was new and clear to youth, young adults and adults who smoke.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Show a smoking mother with a baby in a stroller (felt to be commonly seen)
• Show a baby in a car with parents smoking
• Show a sleeping child to portray innocence and vulnerability
• Show a less healthy baby
• Take away skull which looks unrealistic and irrelevant to the overall messaging
• Replace the skull by an actual adult’s hand smoking a cigarette
• Reduce and simplify the text (in English, but especially in French)

HW30 - Testimonial- Archie Stewart   

Overall Reactions

This health warning was generally considered as not attention-grabbing, although it was believed to be somewhat credible, and clear and easy to understand to a limited extent. This health warning was considered as communicating a health effect of smoking, though to varying degree across all audiences.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Most participants across audiences indicated that this health warning did not grab their attention. It was generally felt that the large amount of text, combined with the lack of clear or compelling message communicated by the image rendered this health warning boring. Further, it was believed that the image does not convey any emotion, apparent health crisis, nor does it show shocking elements. That said, a few adults who smoke indicated they would pay brief attention to the image as it is not gruesome. It was also mentioned among youth who do not smoke that the larger and contrasting yellow text on the dark background would catch the eye.

Credibility

Most participants across audiences indicated that they believed this health warning, most notably English-speaking participants. Showing a real person and identifying them by name helped convey that the testimonial reflected a real-life story. The fact that the storyline referenced lung cancer which is commonly associated with smoking, contributed to making the story credible. Further, the testimonial appeared as though it told a real story, thus further enhancing the overall health warning’s credibility. Youth who do not smoke also mentioned that the description of health conditions and the fact that the person shown is identified by name enhanced the overall credibility of the message.

That said, many participants across audiences did not believe this health warning or felt that it was not relevant to them. Youth who do not smoke did not feel personally concerned, given the older age of the man shown. Many young adults and adults who smoke felt that the health warning’s credibility was diminished by the long list of diseases, and by the difficulty in understanding some of them (i.e., COPD) or the perceived weak relationship of others to smoking (i.e., bladder cancer). It should be noted that many youth and young adults who smoke thought the man illustrated looked relatively healthy (i.e., healthy weight; no breathing machine), thus questioning the severity of his condition. These participants felt that the image was depressing and him a ‘random, sad old man’.

Clarity / Ease of Understanding

In general, the health warning was considered clear and easy to understand, though many across audiences expressed concerns in that regard. It should be noted, that across languages, English-speaking participants were far more likely than those in French-speaking groups to find the health warning clear and easy to understand.

Although the photo was felt to communicate regret and depression, it did not clearly show anything else without the accompanying text explaining the situation, according to many. The words were clear but not felt to be believable or understandable because there were too many things listed. Further, some questioned if all conditions listed were actually related to smoking.

A number of youth (regardless of smoking status s) and young adults who smoke did not know what congestive heart failure or lymphoma was. At the same time, COPD was not well understood across audiences.

Ability to Communicate a Health Effect

In general, the health warning was considered as communicating many health effects of smoking, notably all of the diseases and conditions listed. Across audiences, nearly all youth who do not smoke and young adults who smoke believed that health effects were being communicated, while fewer youth and adults who smoke were of that opinion.

A number of youth (regardless of smoking status), and young adults who smoke across locations mentioned having learned of at least one of the conditions or illnesses listed as related to smoking. It was believed, however, that too many were listed to effectively grab their attention. Indeed, it was believed that listing too many conditions without explaining each properly did not strengthen the message. In fact, some felt that focusing on a few health conditions by explaining them well would have more impact than listing a long list of conditions with little explanation of each.

Adults who smoke were generally more familiar with the list of health effects, though many did not know what COPD stood for. In a few instances, youth (regardless of smoking status) felt that the lack of clear explanation of the diseases listed, how they relate to smoking, and what tangible impact they have on someone’s life made the message uncompelling.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Show a connection to smoking in the image
• Make him look sicker or place him in a hospital setting
• List the diseases and conditions in point form
• Shorten and simplify the text by eliminating some of the diseases listed
• Show the testimonial of a younger person to enhance personal relevance
• Include a warning banner

HW40 - Smoking puts your health at risk

Overall, this health warning elicited mixed opinions. While the health warning’s layout and text were generally considered attention-getting and believable, the image caused some confusion across audiences, resulting in a lack of credibility overall.  Further, there were mixed opinions as to whether or not the health warning effectively communicated a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Young adults who smoke generally felt this health warning grabbed attention primarily because of its unusual photo. Seeing the girl looking in distress and seeing all the cigarette butts floating in the water piqued their curiosity. This sentiment was less pronounced among adults who smoke, as they felt the image lacked seriousness and was easily ignored. 

Youth (regardless of smoking status) were divided with respect to the health warning’s ability to attract their attention. Some in these audiences felt the visual effectively grabbed their attention because of its unusual and creative design and were intrigued to find out what was going on in the picture. That said, a few questioned if it was intending to be humorous.  Others considered the image too artistic and confusing, resulting in its inability to hold attention.  Further, some in these audiences felt the text was too vague in terms of what substances are implicated or what organs are affected, and subsequently, they did not feel compelled to think about it.

Across audiences, the red warning and the yellow text box effectively grabbed attention and encouraged further reading of the bolded headline.

Credibility

Mixed opinions were expressed when considering the credibility of this health warning.  Across audiences, the health warning’s text was generally considered logical and believable, although many adults and young adults who smoke and youth who do not smoke felt the information outlined was too generic and that inclusion of “all organs” in the text was an exaggerated, unrealistic claim and seemed overblown. Further, adults who smoke were critical of the text focusing too much on cigarettes having toxic substances, as they believed most things include some level of toxic substances. Youth (regardless of smoking status) generally believed the text, an opinion that was shared to a lesser extent by young adults who smoke, due to its perceived exaggeration.

While this health warning’s text, albeit generic, was largely considered credible, the image proved problematic. Across audiences, the visual was criticized for looking unrealistic, fake, too staged, and unbelievable.  The image’s artistic design did not portray a clear message, and was dependent on the text to communicate its intent.  Adults who smoke felt the vagueness of image, and the fact that it did not say anything on its own, resulted in it lacking credibility. 

Clarity / Ease of Understanding

The health warning’s written text was considered clear and easy to understand by most youth (regardless of smoking status). Young adults and adults who smoke shared mixed views in that regard, once again, primarily because of the exaggeration of ‘all organs’ and the lack of believability that smoking is to blame for all the toxic chemicals in your body.  Within the French groups, the term ‘ainsi’ proved problematic and suggested that the image should illustrate what the text is saying.

As mentioned, the image proved confusing across audiences primarily because it did not reflect what the text was saying.  Participants questioned what the image was trying to say, with numerous youth (regardless of smoking status) and young adults who smoke interpreting it as a depressed, scared girl who is drowning.  Across audiences, a few participants questioned why the visual would only show a face (of an apparent healthy youth) when the text spoke of how smoking impacted the entire body or all organs. It was generally felt that the visual required too much effort to decipher what it means and what is being communicated.

A number of adults who smoke felt the image related primarily to youths or young teenagers given the age of the girl shown in the visual.

Ability to Communicate a Health Effect

This health warning was considered not overly effective at communicating a direct and clear health effect of smoking cigarettes, primarily because the text and visual did not work well together. 

The text was considered generic to most and young adults and adult who smoke questioned if smoking could realistically be blamed for putting hundreds of toxics chemicals into your body and for harming every organ. Those audiences felt that people who smoke know they are at risk when smoking and did not believe this health warning communicated anything new.

Youth (regardless of smoking status) generally believed that the health warning’s text communicates a health effect of smoking, namely that smoking puts your health at risk, although they too felt that risk is already understood. 

Across audiences, it was felt that the image on this health warning does not effectively reflect the health warning’s message, and was too abstract in what it was trying to say.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Consider mentioning or showing what substances are harmful.
• Include a different visual:
  • Show toxic chemicals or organs affected in the image
  • Use a more realistic image to convey the message
  • Include a more visually graphic image

NHW01 - Cigarettes are highly addictive. 

Overall Reactions

Overall, this health warning was considered as moderately grabbing attention, somewhat credible, more or less clear and easy to understand, and communicating a health effect of smoking to varying degree. In general, English-speaking participants were more positive towards this health warning than French-speaking participants on all four aspects evaluated, notably in terms of attracting attention, being credible and being clear and easy to understand.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

This health warning was moderately considered to attract attention across all four audiences. A few youth who do not smoke felt drawn to look at this health warning as it was not gruesome, and they were curious to understand what situation was illustrated by the image. A few young adults who smoke mentioned knowing someone in this situation, thus being curious about the health warning, while a number of young adults who smoke expressed curiosity because the idea of having a hole in your throat was disturbing and undesirable.

That being said, across audiences many felt that they would pay little attention to this health warning and a number of reasons were cited to explain this opinion. Many youth (regardless of smoking status) did not see that the woman had a tracheostomy, at a glance, and thus would not be curious about the image. Some questioned if the image was simply photo-shopped to show something that is not possible. This was further compounded by the text not clearly explaining what was illustrated. Indeed, the relation between smoking through a tracheostomy and addiction was not evident to or understood by some youths, regardless of their smoking status, and among young adults who smoke.

It should be noted that a few youth who do not smoke mentioned that the lack of visual contrast in this health warning contributed to not grabbing attention.

Credibility

While most adults who smoke considered this health warning believable, all other participants expressed some level of doubt about it. Knowing someone with this condition was the most common reason cited to believe the health warning. By contrast, having never seen anyone smoking by tracheostomy was often cited across all four audiences to explain why participants did not believe the health warning. One youth who do not smoke did not believe that someone could physically manage to smoke through a tracheostomy, while others questioned what would cause someone who smoke to have a hole in their throat. While most adults who smoke believed that health warning, they questioned how common the situation would be and saw the health warning as illustrating an extreme case rather than something that commonly happens. As a result, they felt that the health warning had less personal relevance to them. Some youth and adults who smoke also shared similar viewpoints.

In a few instances, youth who smoke felt that if they were to end up with a tracheostomy, they would stop smoking and thus, the health warning as presented lacked some credibility to them. Indeed, it reflected an extreme case, rather than one that may represent their situation in the future.

Clarity / Ease of Understanding

Mixed opinions were offered in terms of the clarity and ease of understanding of this health warning. While adults who smoke generally felt that the image and the words were easily understandable, youth (regardless of smoking status), and young adults who smoke were less convinced of that. Many of the youth who do not smoke did not understand the image, including how a smoker would end up with a hole in their throat, and how they could successfully smoke through this hole. A few adults who smoke also mentioned that the tracheostomy, as illustrated, did not look like those they had seen in real life, and that an apparatus was missing around the hole.

At the same time, participants across audiences felt that the image on its own does not clearly speak of addiction. While the text provided insight in that regard, some time was required to understand the relationship between addiction and smoking with a tracheostomy. This primarily explains the lack of perceived clarity in the messaging.

Ability to Communicate a Health Effect

For the most part, participants of all ages who smoke (including youths, young adults, and adults) believed that this health warning is communicating a health effect of smoking, namely one resulting in the need for a tracheostomy. That said, the addiction referenced in the text is not considered a health effect. While addiction was considered a well-known effect of smoking, the fact that smoking can result in having a tracheostomy was new information for a number of youth (regardless of smoking status).

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Make the tracheostomy clearer/more realistic
• Consider including statistics of prevalence
• Provide more information on the story behind it (e.g., how much smoked and for how long; age)
• Include a red warning banner for greater colour contrast

NHW02 - There is no safe amount of second-hand smoke.

Overall Reactions

Overall, this health warning received mixed reactions in terms of attracting the attention of the target audience, having a greater impact on youth who do not smoke. That said, across all four audiences, the health warning was deemed believable, clear and easy to understand, although not overly impactful, as presented. Across audiences, this health warning was considered to communicate a health effect of smoking, especially among young adults who smoke.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

For the most part, this health warning grabbed the attention of youth who do not smoke, primarily because of its use of the red warning banner and the words in the bright yellow text box. They considered the words to clearly communicate to them, although some considered the text vague as presented.

By contrast, this health warning was less attractive to participants of all ages who smoke, especially among youth and young adults who smoke. For them this health warning would be something of more relevance to parents than to young people or adults without children.

While the red and yellow colours did grab attention, participants who smoke considered the danger of second-hand smoke to be well understood and something that most of those who smoke take action to prevent.  For the most part the image of the child did little to grab the attention of young adults who smoke. That said, some adults and youth who smoke thought it surprising to see a child on a cigarette package and accordingly, considered it to grab their attention.

Credibility

This health warning was generally viewed as credible across all four audiences, particularly because the dangers of second-hand smoke are well established and understood.  A number of adults who smoke, however, considered the message to be outdated as they felt it was arguable that there is no safe amount of second-hand smoke.  More so, most adults and young adults who smoke professed that people who smoke do not usually do so around children, so while the health warning may be believable; it was not relevant to most today.

The visual of the child did not necessarily add to the health warning’s credibility.  Across audiences, while some felt the child looked upset and concerned, most believed the boy appeared in good health and did not appear to suffer from any ailments.  Further, in each audience some participants criticized the image for looking staged with the boy lacking emotion and holding a photo-shopped sign. Accordingly, the health warning’s visual did not enhance the health warning’s believability.

Clarity / Ease of Understanding

Across all four audiences, the health warning was described as clear, straight forward and easy to understand.  The health warning’s design was easy to read although it offered no explanation of what the actual effect of second-hand smoke was on children. The text and the picture were generally considered to work well together, although most agreed that the picture could also work as effectively on its own, especially if it included a stronger and more pointed message. 

Ability to Communicate a Health Effect

While most young adults who smoke believed that the health warning communicated a health effect of smoking, this opinion was less pronounced among youth (regardless of smoking status) and adults who smoke.  As mentioned, many participants who smoke questioned how problematic second-hand smoke actually was for children, and most felt that people who smoke today typically avoid doing so around children.  By featuring a healthy child on the health warning, it was felt this health warning did not suggest that second-hand smoke was a serious health effect to children.

Participants’ Suggestions

• Participants suggested the following changes to the health warning:
• Show a sick child
• Add smoke in the image
• Show the effect of second-hand smoke, or how it has harmed the child
• Make it a testimonial
• Add statistics to make it sound more scientific and add credibility
• Make the image more realistic (not photo-shopped)

NHW03 - In a single year, exposure to second-hand smoke…

Overall Reactions

Mixed opinions were offered across audiences regarding this health warning’s ability to grab attention and its credibility. That said, it was generally considered as being clear and easy to understand, and as communicating a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Youth who do not smoke, as well as young adults and adults who smoke generally indicated that they would pay attention to this health warning. The image was considered intriguing, especially seeing a child on a cigarette package, and the intense accusatory look of the girl. Further, inclusion of the statistic (1,000 dead) provided a new piece of information that grabbed attention. That said, youth who do not smoke whose attention was not captured by this health warning indicated that the image is too simple or boring to have any impact, particularly for those without children. Adults who smoke who found that the health warning did not catch their attention felt that the image of the girl was not striking (i.e. the girl looked too healthy and unimpacted) and that the request of not smoking around children was ‘old news’ thus not standing out sufficiently.

Youth who smoke generally indicated that this health warning would not grab their attention. While some felt that the message was relevant and an important one to communicate, others felt that the image lacked meaning and did not illustrate the effects of second-hand smoke on children.

Young adults who smoke were generally drawn to the image, with a few exceptions. While showing an image of a child on a health warning was believed to be novel, the image was considered bland and lacking interest or meaning. A few also felt that the overall approach failed in its attempt to elicit emotion. It was also mentioned that the number of deaths referenced (1,000 per year) was low and thus lacked impact.

Credibility

This health warning was generally seen as believable by youth who do not smoke, and to a lesser extent, by young adults and adults who smoke. By contrast, youth who smoke generally did not believe what it says. While having a statistic included in the health warning contributed to making it believable to some participants across audiences, participants who smoke across age groups questioned how the information was determined (that is how they knew these deaths were caused by second-hand smoke). In addition, a number of youths and young adults who smoke felt that the image lacked credibility and looked staged, thus making the health warning somewhat unbelievable. A few adults who smoke did not believe that smoking near children would cause deaths, thus suggesting that the message was untrue.

Clarity / Ease of Understanding

In general, this health warning was considered clear and easy to understand. While the main point was considered clear and simple (namely second-hand smoke causes death), this health warning was considered lacking in sufficient details to be informative and educational. Specifically, youth who smoke questioned whether the 1,000 deaths referred only to children, or to all Canadians. Further, youth who do not smoke indicated they would like to better understand why people die from second-hand smoke, while a few adults who smoke expressed an interest to know where the statistic came from.

Ability to Communicate a Health Effect

Most participants across all four audiences believed that this health warning communicates a health effect of smoking, namely death from second-hand smoke. That said, a number of youth who do not smoke and young adults who smoke did not consider death a health effect and expressed an interest to find out more precise information on the causes of death.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Identify who might have smoked around the child (e.g., parent)
• Illustrate the gravity of the situation to better suggest death
• Add a comma after “in a single year”
• Show a sick child (potentially child in confined space like a car or small room) where there is smoking
• Somehow display helplessness that kids have around smoking – show the girl being exposed to smoke and use an encouraging message that says something like, “stop for her sake”
• In French, use a less formal verb tense to make it more personal (“Arrête de fumer” rather than “Arrêtez de fumer”)

NHW04 - Smoking causes oral disease

Overall Reactions

Overall, this health warning was considered attention-grabbing. That said, while youths (regardless of smoking status) and young adults who smoke believed what it says, adults who smoke were more doubtful. In general, the health warning was considered clear and easy to understand, as well as communicating a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Across all four audiences, this health warning was considered attention-getting due to the gruesome nature of the visual. In a few instances, the image was considered so impactful that it elicited visceral reactions. Despite the image effectively grabbing attention, a few participants found it so gross that they would not look further or read the text. One adult who smoke mentioned that they would not pay attention to it as the image was familiar to them, while a few youth who smoke mentioned that it was not clear at a glance that the image represented a tongue. In addition, the unfamiliarity with the term “hairy tongue” lessened the health warning’s credibility among adults who smoke.

Credibility

While youths (regardless of smoking status) and young adults who smoke generally believed this health warning, adults who smoke were less certain about it. The photo was considered realistic and therefore strongly contributed to making the message believable. One youth and one adult who smoke had already seen this condition and thus recognized it as credible. Adults who smoke were, however, more doubtful about whether or not the health warning was true. The perceived rarity of this health condition and the fact that it showed the condition at what was felt to be an advanced stage made them doubt the claim. The lack of supporting facts or statistics further contributed to their questioning. Adults who smoke were also under the impression that smoking would not be the only cause of the condition and that poor oral hygiene would also likely play a role.

A number of participants, notably youths (regardless of smoking status) and adults who smoke, felt that claiming that poor oral hygiene was a contributing factor to having a “hairy tongue” diminished the importance of smoking as a cause of this disease.

Clarity / Ease of Understanding

Most participants believed that this health warning was clear and easy to understand, though less so among youth who do not smoke and adults who smoke. That said, the image was at times seen as lacking clarity, as a tongue or mouth is not readily identifiable. In addition, many were unfamiliar with the term “hairy tongue” and found the visual helpful in clarifying this condition. As such, many felt that the text was essential to clarify the image, and that the image helped illustrate the unfamiliar concept of a “hairy tongue”. In essence, the image and text supported and completed one another.

Ability to Communicate a Health Effect

This health warning was generally seen as communicating a health effect of smoking, namely oral disease/hairy tongue, although this opinion was less pronounced among adults who smoke. Youths (regardless of smoking status) and young adults were generally unaware of this health effect, while awareness was generally higher among adults who smoke.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Bold the word “hairy” to grab attention
• Explain what hairy tongue is and what consequence there might be from it
• Remove or minimize reference to poor oral hygiene to enhance the health warning’s credibility
• Change the photo’s angle to make it clear that a tongue is shown (e.g., broaden the angle to show part of the face)

NHW05 - Smoking causes neck cancer    

Overall Reactions

This health warning was generally considered as attention-grabbing, presenting clear and easy to understand information, and communicating a health effect of smoking. Reactions were more muted in terms of the health warning’s perceived credibility.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

This health warning was generally considered as attention-grabbing by all four audiences. The shockingly graphic nature of the image caused most to pay attention to the health warning, although a few youth and adults who smoke found it too disturbing or horrifying to look at and as such they would only glance at it without reading the information. That said, the limited text made the words difficult to avoid. A few youth who do not smoke mentioned that the type of health effect illustrated appeared novel and not commonly thought of, thus being overall intriguing. Similarly, a number of young adults who smoke reported that the ‘gross’ and ‘nasty’ picture is needed to get their attention.  This audience, along with young adults who smoke, also pointed to the contrast of the yellow section/text on the black background having caught their eye.

In a few instances, youth who do not smoke indicated that the health warning did not clearly define the risk of neck cancer over time, thus making it less personally relevant to them, and further reducing the health warning’s ability to grab attention and elicit self-reflection. It was believed that additional information on the risk of developing neck cancer and the age of the person shown were required to improve relevance and credibility.

Credibility

Despite the concept eliciting attention, mixed opinions were offered in terms of its credibility. Across audiences, opinions were almost equally divided between those who believed what it says and those who did not. It should be noted that in a few instances, youth who do not smoke, as well as young adults and adults who smoke believed this health warning, as they recognized that smoking causes cancer and the image looks like it is showing a tumour.

Across all four audiences, those who were doubtful primarily considered that the image of the tumour is too exaggerated to be believable. It was generally viewed as a rare condition and to some extent, the “worst case scenario” thus not being fully believable. In addition, the term “neck cancer” was not well-known and considered by a few young adults who smoke as less believable as a result. A few youth who smoke were also under the impression that a tumour this extreme would only be the result of negligence on the part of people who smoke, thus reducing the perceived level of risk to them.

A few youth and young adults who smoke indicated that given that neck cancer is not a well-known effect of smoking, additional information or facts should be provided to help improve the health warning’s credibility. Among young adults who smoke, a suggestion was made to identify the person shown by name to increase the message’s credibility.

Clarity / Ease of Understanding

Despite concerns regarding the health warning’s credibility, participants across audiences widely considered the concept clear and easy to understand. In general, the photograph looked like it was representing a real person, although some youth (regardless of smoking status) and adults who smoke indicated that the health warning is somewhat misleading in saying that smoking causes neck cancer, as this may not be the only cause of this disease. Young adults who smoke suggested that the tumour looked painful and as such clearly told a story of pain and illness, but that the connection to smoking is only made through the text. As such, it was believed across audiences that the text supported the image by explaining the case of neck cancer. A few young adults who smoke indicated that the attribution on the photo was unclear and confusing.

Ability to Communicate a Health Effect

The concept was widely considered as communicating a health effect of smoking, namely neck cancer. The fact that it clearly identifies neck cancer in the text and that cancer in general is already recognized as a negative effect of smoking helped convey the message. Many participants across all four audiences did not know that neck cancer was a possible health effect of smoking, or they did not know how it physically manifested itself.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Explain what neck cancer is or change the term
• Indicate the age of the person to improve personal relevance
• Provide statistics to indicate the risks of contracting neck cancer and put into perspective
• Put headline in upper / lower case versus all capital letters to avoid a sense of yelling
• Make the image less severe/gruesome
• Mention the person’s name to enhance the message’s credibility

NHW06 – Smoking Causes Oral Cancer

Overall Reactions

Overall, this health warning was especially effective at grabbing attention across all audiences. With strong written and visual impact, this health warning was widely considered believable, clear and easy to understand. With only a few exceptions, all participants felt that it communicates a real health effect of smoking.

The following sections provide more detailed reactions to this health warning across audiences.

Ability to Grab Attention

Across all audiences, this health warning received a strong and consistent response.  The graphic visual was considered gross, disgusting and chilling, effectively grabbing viewers’ attention.  Including a real picture left nothing to participants’ imagination and many participants wanted to avoid looking at the visual. 

The yellow warning banner and yellow text headline (smoking causes oral cancer) also grabbed the attention across participants, regardless of age or smoking status.  The definitive statement (‘causes’ versus ‘may cause’) also effectively spoke to participants.

Credibility

Without exception, this health warning was considered believable across all four audiences. The realistic and impactful image visually added credibility to the written message, as did the conclusive statement that smoking caused oral cancer.  For most, this was believable given that cigarettes are in direct contact with the mouth.  Some adults who smoke questioned how common oral cancer was and felt it must be rare since they had never experienced or seen anything like the visual showed. 

Clarity / Ease of Understanding

All participants across audiences, with the exception of a few French-speaking adults who smoke, were of the opinion that the health warning is clear and easy to understand.  The health warning’s graphic nature and simple text resulted in no confusion, particularly given that cigarettes come in contact with a person’s mouth. 

While the picture was considered powerful on its own, the text was seen as working well with the image.  That said, some adults who smoke felt that less text is better and that the second paragraph or white text is not necessary given the visual’s clear impact.

Ability to Communicate a Health Effect

Across audiences, this health warning was deemed as clearly communicating a health effect of smoking – namely that smoking causes oral cancer.  More specifically, literally all youth who do not smoke and young adults who smoke, and nearly all youth and adults who smoke, considered that this health warning communicates a health effect of smoking.

Participants’ Suggestions

Participants suggested only the following changes to this health warning:

• White text not necessary
• Remove photo attribution

NHW07 - Testimonial – Pat Tarbox

Overall Reactions

Overall, this health warning received a mixed reaction in terms of its ability to grab attention and there were notable differences of opinions across audiences. This health warning was generally considered believable by youth and adults who smoke, but to a lesser extent by youth who do not smoke and young adults who smoke. Despite that, across all four audiences, most considered the health warning clear and easy to understand, and it was generally seen as communicating a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

There was great variability in this health warning’s ability to grab attention. Across audiences, mixed opinions were offered regarding the ability of the health warning to attract attention. For youth who do not smoke and young adults who smoke the health warning was considered text-heavy, bland in appearance, and looking too much like an obituary.  As a result, they felt it would likely not grab their attention.  The testimonial approach evoked little emotional response among these younger audiences and was considered a common approach that was of little personal relevance, easily disregarded by these groups. While youth who smoke generally felt that the image was boring and offered nothing of interest to grab their attention, they were more inclined than the other younger audiences to read the text.  Once they did, it generally stirred their emotions.

Most adults who smoke were more attracted to the testimonial or personal story approach than the other audiences and more likely to pay attention to this health warning, although they too considered the health warning to include too much text.  For many adults who smoke, Barb was familiar to them from past health warnings and they were intrigued to read more about her story.

With the exception of adults who smoke, French-speaking participants were more likely than English-speaking participants to say that this health warning would catch their eye, primarily because of the emotion it evoked.

Credibility

Across all four audiences, participants generally believed the story was true or could be real and this health warning was largely seen as credible.   That said, believability is strongest among youth and adults who smoke, and among English-speaking participants.

Within each audience a good number of participants criticized the name ‘Tarbox’² for being contrived or made up, which lessened the health warning’s credibility.  Some French adult participants who believed the name was made up suggested that a better name should be used that is relatable to both English and French participants who smoke (such as Louise, for example).

Varied perceptions of the visual attributed to some participants’ belief that this health warning lacks credibility.  Some youth and adults who smoke criticized the image of Barb’s hand/ arm saying that it looked odd or out of proportion. Further, a few adults who smoke believed the facial expression of Barb looked odd, or that she looked more like a man than a woman. Others felt the size of the pictures should be consistent, rather than having Barb notably larger than her husband. Finally, a few adults who smoke believed that having someone smoke in a hospital, which was what this appeared to show, was not allowed.  Altogether these factors led some participants to believe that while the story could be real, the health warning lacked some credibility as presented.

Addiction was considered a consequence of smoking and many young adults and adults who smoke saw the health warning as highlighting an addiction problem.  That said, they felt it was ok for Barb to continue smoking regardless of her illness because she was dying and that she should be allowed to smoke in her final days if that’s what she wanted to do.

Clarity / Ease of Understanding

Across all four audiences, this health warning was generally considered clear and easy to understand and English-speaking participants were moderately more likely than French-speaking participants to think so.

Some participants in each audience felt that the images do not stand on their own, and do not communicate any specific message in isolation of the text.  Clarity of the message was seen as dependant on reading the story that accompanied the images.

Within each audience, some participants questioned why one picture is in black and white and one is full colour.  Similarly, youth (regardless of smoking status) and young adults who smoke wondered what the relationship between the man and woman was, based solely on the visual.

Ability to Communicate a Health Effect

• Across all four audiences and across languages, this health warning was viewed as communicating a health effect of smoking, namely death from lung cancer.  The primary message of the health warning was not typically seen as being related to addiction.  Participants generally agreed that the health warning did not teach them anything that they did not already know, except perhaps that Barb had a husband.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Add an invitation to seek help before it is too late
• Change the picture of Barb to be more realistic/in proportion
• Show a younger person to make more relevant
• Consider changing the woman’s given name to something more common in French
• Use a less contrived name (those not knowing it was real)
• Reduce the amount of writing
• Add a warning banner

NHW08 - Testimonial – McKenzie Tarbox

Overall Reactions

Overall, this health warning received mixed reactions, holding less appeal among younger audiences. The testimonial format lacked personal relevance to some and did not grab attention for many. Some adult participants, however, considered the health warning emotionally impactful, causing them to consider their own family situation.  Across audiences, participants felt the health warning included too much text and could be easily overlooked.  That said, all four audiences, generally considered the health warning believable, clear, easy to understand and communicating a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Overall, this health warning received mixed reactions in terms of its ability to grab attention.  Most youth (regardless of smoking status) were not attracted to this health warning primarily because they were not interested in reading a story.  The testimonial format was considered sappy and held little personal relevance to them. Aside from the long text, the visuals did not compel these audiences to read on, and some likened the images to an ad for a retirement home.  The few youth (regardless of smoking status) who felt this grabbed their attention considered it emotionally engaging because it made them think of their parents or someone they know who had been ill.

This health warning evoked an emotional reaction among young adults and adults who smoke, although only moderately.  Having McKenzie looking straight at the reader and showing a stark contrast between a happy and sad face contributed to the emotional impact for some. A good number of adults who smoke with children indicated that this story made them ponder their own situation as they want to be there for their children’s milestones.  That said, these audiences also criticized the health warning for having too much text, being too bland / lacking colour and for being an approach that is overused, easily ignored and less impactful.

Credibility

This health warning was generally seen as believable across all four audiences. The situation itself looked credible and the story’s simplicity made it real and relatable.  For most, seeing the mother and daughter made the story believable, and showing the mother without hair clearly spoke of cancer. Across audiences, participants felt the image of the daughter was indisputably the same person in the colour photo, which added credibility to the story.  Further, showing a personal experience with ‘regular’ people helped make the health warning believable.

Across groups, a few factors were considered problematic or lacking credibility.  For some youth who smoke and a few young adults who smoke, the ‘Tarbox’ name seemed contrived, and a few adults who smoke felt that focusing on marriage as an important life milestone is outdated.

Clarity / Ease of Understanding

All four audiences generally considered this health warning clear and easy to understand, although across audiences, participants felt the image did not communicate the message effectively without the supporting text.  While the health warning’s text clearly explained the image, the words were not felt to be as strong without the picture.  In essence, the words and visual worked well together, but did not stand alone.  While participants easily understood the intent of the health warning, some youth who do not smoke felt it was unclear whether the number of cigarettes smoked per day or the number of years she smoked was the cause of her death.

Ability to Communicate a Health Effect

Most youth (regardless of smoking status) and young adults who smoke believed that this health warning communicates a health effect of smoking – namely that smoking causes cancer, which leads to death. This was also the opinion of adults who smoke, though to a lesser extent in comparison.  Across audiences, this story was considered a common occurrence and not sharing something that people do not know.  While the text speaks of death and cancer, some youth who do not smoke and young adults who smoke considered the tone of the health warning to focus more on loss than on health consequences, and accordingly, you had to read between the lines to consider the impact of smoking.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Make the text stand out more. Edit the text to be shorter
• Don’t use the last name as it causes confusion and lacks credibility
• Focus the text on cancer rather than the wedding
• Include a sadder picture
• Show the two healthy individuals and then the daughter with mother dying in hospital to better demonstrate loss
• Highlight a different milestone than marriage (e.g. graduation or birth of child)

 NHW09 - Barb smoked two packs a day for over 30 years…

Overall Reactions

This health warning was generally seen as attention-grabbing and credible, though less so by young adults who smoke than by the other three audiences. It was, however, broadly considered clear, easy to understand, and communicating a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Most youths (regardless of smoking status) and adults who smoke found that this health warning grabbed their attention. By contrast, young adults who smoke were less likely to think so. The image is generally what caught the attention of participants, notably the poor state of the woman shown. Some thought she already looked dead, while others were struck by the feeling of distress that transpired from her. A few adults who smoke also found the young age of death noteworthy. That said, it should be noted that a few adults who smoke felt desensitized to this type of information.

The few who were not touched by the health warning indicated that the design lacks visual contrast, that the image of Barb is familiar to them, thus less attention-grabbing. Further, they felt that her smoking habits (smoking two cigarette packages per day for 30 years) was uncommon, and unrealistic. 

Credibility

This health warning was generally felt to be credible across all four audiences, although less so among young adults who smoke. The photo’s realism in showing suffering, and the specific information on what behaviours caused her death, helped participants believe that this is a true story.

The few participants who did not believe this health warning felt that it was exaggerated. Indeed, upon reflection, they concurred that to have died at 42 years old having smoked for 30 years meant that she would have had to smoke 2 packs a day since the age of 12 years old, something they did not believe to be true. In Montreal, a few participants mentioned that the person’s name, Barb, was uncommon in Quebec which made them question if this health warning was presenting the situation of a real person or if it was a made-up story.

Clarity / Ease of Understanding

Participants across all four audiences felt that this health warning is clear and easy to understand. While the image on its own does not convey that Barb has lung cancer, it clearly suggests that she suffers from cancer (lost hair) and that she is dying.

Ability to Communicate a Health Effect

There was a widespread belief among all four audiences, that a health effect is being communicated by this health warning, namely death resulting from lung cancer. The text provided the complete information and explained the image, while the image injected emotions into the story. Overall, participants were aware that people who smoke were at higher risks of lung cancer, and as such, they did not learn anything from this health warning. That said, they still felt that it was relevant as a reminder, and was compelling due to the emotions conveyed by the story.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Include a statistic to show the risk of lung cancer or death caused by lung cancer
• Remove details regarding the number of packages smoked by Barb (just say she smoked for over 30 years)
• Add colour or visual interest to grab attention
• Add a warning banner

NHW10 - Nicotine is addictive.

Overall Reactions

Overall, this health warning held moderate appeal among participants who smoke, regardless of age (including youths, young adults and adults) while it generally did not grab the attention of youth who do not smoke. Nonetheless, the health warning was generally considered clear and easy to understand. It was generally believed that the health warning communicates a health effect of smoking, though adults who smoke offered divided opinions on that matter.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

To a moderate extent, participants across age groups who smoke (youths, young adults, and adults) felt that the health warning grabbed their attention. The image of people looking sick, perhaps being nearby a hospital, and yet still smoking piqued participants’ curiosity. At the same time, the yellow warning banner and the bold statement (“Nicotine is addictive”) were considered eye-catching.

By contrast, youth who do not smoke were less attracted by this health warning. Indeed, they believed that the image lacked clarity, that the warning banner was too small to be effectively noticed, and that the first part of the text – nicotine is addictive – is a well-known fact.  Some felt the health warning effectively showed smoking as a social behaviour. In essence, they felt that nothing was outstanding or new in this health warning.

Credibility

Youth (regardless of smoking status) and young adults who smoke generally believed this health warning, while adults who smoke expressed some doubts. In general, participants who smoke believed the situation of sick people smoking nearby a hospital, as they either had experienced it or had witnessed it in the past. For them, this situation also effectively illustrated the concept of nicotine addiction – that is the inability to stop smoking even when sick. 

By contrast, youth who do not smoke felt that the image lacked credibility as the people shown appear to have fun and do not look as though they are negatively impacted by smoking – in essence, the health warning portrayed the positive social aspect of smoking. This was also noted by a few youth and young adults who smoke. Another reason youth who do not smoke felt that the health warning lacked credibility was that they were under the impression that people are not allowed to smoke near hospitals. Adults who do not smoke also shared the same impression.

Clarity / Ease of Understanding

Participants across audiences generally believed that this health warning was clear and easy to understand, although some people expressed difficulty deciphering its messaging. In some instances, it was believed that the image lacks clarity on its own as people looked like they were having fun smoking together, without any clear health effect of smoking being shown. That said, participants across age groups who smoke were more likely than youth who do not smoke to reflect on the situation and realized that hospitalized people still smoking was a good visual illustration of nicotine addiction. Nonetheless, although the message was clearly understood and the image and text were seen by those participants as working well together, it was not felt to be strong, particularly because there was nothing new and the reason people were at the hospital was not specified.

Ability to Communicate a Health Effect

Youth (regardless of smoking status) and young adults who smoke believed that this health warning communicates a health effect of smoking, while adults who smoke were equally divided on this front. While the health warning was viewed as clearly communicating that nicotine addiction is an issue, some participants did not consider addiction a health effect.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Zoom in / improve picture to clearly see sick people smoking
• Show people who look unhealthy and unhappy
• Make the image less social
• Show a similar situation in bad (rainy) weather to better demonstrate addiction
• Show someone with an oxygen tank to imply their sickness results from smoking, and yet they continue smoking
• Put people in hospital gowns
• Change ‘nicotine’ to ‘smoking’ in the headline

NHW11 - Smoking doubles your risk of getting…

Overall Reactions

Overall, this health warning was considered attention-grabbing, believable, clear, easy to understand, and communicating a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Most participants across all four audiences indicated that this health warning grabbed their attention. Some felt that the image is gross and thus would catch their attention. Indeed, seeing blood in urine caused visceral reactions among some youth and young adults who smoke. The red warning banner, shown in a vertical direction and the words “bladder cancer” in bold also grabbed attention.

Despite the concept attracting the attention of most, some felt that the image is not clear (if they had not recognized the blood), while others indicated that seeing blood in urine grossed them out to the point of not wanting to read the explanation. Some also felt the health warning included too much text which did not encourage them to read on.

Credibility

This health warning was generally considered credible, notably among youth and young adults who smoke. The urine sample container was easily recognizable and familiar to most, and the blood looked real. A few youth who do not smoke and adults who smoke noted that the statistic (doubling) enhanced the claim’s credibility. One youth who does not smoke also mentioned that the Health Canada endorsement made the claim believable.

That said, participants in all French-speaking focus groups and some English adults who smoke mentioned that the reference to “pee” (“pipi”) rather than “urine” was childish and thus affected the overall claim’s credibility.

Clarity / Ease of Understanding

The health warning was widely considered clear and easy to understand by participants across all four audiences. The image was believed to communicate a health issue, though without clearly saying what is wrong, while the text provided the right level of explanation. Some felt, however, that the yellow liquid did not look like urine, and that the red parts did not readily look like blood. Further, the connection to smoking was not evident without the text. One youth who does not smoke questioned why the hand did not wear a glove (as would a hospital staff). A few youth who do not smoke indicated that the relationship between smoking and the bladder is not evident, while one young adult who smokes questioned what proportion is represented by the doubling of the risks.

Ability to Communicate a Health Effect

The health warning was widely seen as communicating a health effect of smoking, namely bladder cancer. The increased risk of bladder cancer from smoking was new information to a number of youth who do not smoke, while a few youth who smoke indicated having learned that the risk of bladder cancer could be doubled.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Show a hand wearing a glove for enhanced credibility
• Show a toilet bowl to provide context
• Say “this could be you” to enhance personal relevance
• Show consequences of bladder cancer on someone’s life
• Change the term “pipi” or “pee” to “urine” to enhance credibility

NHW12 - Smoking causes 80% of COPD deaths.

Overall Reactions

Overall, this health warning was generally considered attention-grabbing, credible, clear, and easy to understand among youth, young adults, and adults who smoke, and to a lesser extent among youth who do not smoke. That said all four audiences widely felt that it communicates a health effect of smoking.

The following sections provide reactions to this health warning across audiences.

Ability to Grab Attention

Youth, young adults, and adults who smoke were generally attracted to this health warning. The graphic visual, bright colours (red warning and yellow text box) and the prominent statistic effectively grabbed attention and encouraged them to read on. Among these audiences, most considered the visual different from what they are used to seeing and its perceived cartoonish graphic made them curious.  By contrast, some adults who smoke felt the health warning looked like the ‘old standard’ and presented nothing new.

The opinion of youth who do not smoke was more moderate in terms of the health warning’s ability to attract attention.  While the visual, red and yellow colours, and the statistic also generally caught their attention, this audience was less familiar with what COPD / MPOC was and accordingly sometimes disregarded the health warning.  Some also felt the animated image was less effective than including a real lung visual.

Credibility

This health warning was widely considered credible by youth, young adults, and adults who smoke. Fewer youth who do not smoke believed this health warning, despite most still finding it credible.  Across audiences, the health warning’s credibility was largely attributed to the inclusion of statistics (i.e. 80%) and mention of COPD/MPOC as a distinct disease. Indeed, many participants who were familiar with COPD/MPOC agreed with the correlation suggested between smoking and the disease, and had actually known individuals who had suffered from the disease.  The visual effectively explained what impact it has on people who smoke, although some felt it was ‘too cartoonish’ in its appearance.

That said, across audiences, those who did not consider the health warning credible were generally unaware of what COPD/MPOC was. Others found the health warning text excessive, and lacking a clear and necessary description of what the disease was.

Clarity / Ease of Understanding

Youth, young adults, and adults who smoke generally believed that this health warning is clear, obvious, quickly interpreted and easy to understand.  While most believed that the image and text work well together, participants were less likely to believe that the image can stand on its own.

Although youth who do not smoke shared these views, it was less prevalent among this group of people.  As mentioned, the primarily reason for confusion across this audience was their lack of awareness or familiarity with COPD/MPOC.  While they wanted to understand what COPD/MPOC is, they are reluctant to read extensive amount of text and would prefer clarity without excessive detail.

Ability to Communicate a Health Effect

Across all four audiences, the health warning was widely considered as communicating a health effect of smoking, namely the risk of dying from COPD/MPOC.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Show more realistic (and graphic) image of lungs to improve credibility
• Spell out CPOD (MPOC in French) to provide further clarity on the disease
• Show the percentage (80%) in bold text to attract attention to it
• Reduce the amount of text
• Center the red warning banner across the visual

NHW13 - The ugly side of smoking…

Overall Reactions

Overall, this health warning was considered attention-grabbing, with the exception of youth who do not smoke who were divided on this. Mixed opinions were offered, especially among youth who do not smoke, as well as youth and adults who smoke, on the credibility of this health warning. That said, across all four audiences, the health warning was widely seen as clear and easy to understand and it was believed to communicate a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

For the most part, youth, young adults and adults who smoke indicated that this health warning would grab their attention.  The ‘before and after’ approach piqued interest amongst these audiences, and because the visual was not too extreme, it suggested that such changes could happen even to those at a young age.  Showing the impact smoking has on teeth and skin was generally noticed. That said, some participants within each of these audiences indicated that the health warning did not grab their attention, primarily because the visual was not shocking or gruesome.

Youth who do not smoke were equally divided on this health warning, with as many saying they would pay attention to it as there were saying they would not. Those who indicated it grabbed their attention felt that showing how smoking impacts a person’s appearance is especially impactful among youth since young people are very concerned with how they look.  Other youth who do not smoke felt it did not grab their attention primarily because it looked fake, boring and unrealistic.

Across audiences, aside from the message and visual, the red warning banner and yellow text box contributed to this health warning grabbing participants’ attention.

Credibility

The health warning’s credibility varied by audience. Specifically, while most young adults who smoke believed what it says, this opinion was less pronounced among youth who smoke. By contrast, youth who do not smoke and adults who smoke were divided, with as many who considered the health warning as credible as those who did not.

Regardless, reasons for these perceptions were generally consistent.  Across audiences, those who considered the health warning credible generally felt the written text presented was believable based on what they have seen and experienced.  In particular, they agreed that the skin of people who smoke is often grey in appearance and that teeth and eyes are also impacted by smoking. 

By contrast, across audiences those who felt the health warning lacked credibility primarily attributed that perception to the health warning’s photo.  The visual was criticized for being too obviously photo-shopped, with many likening it to a zombie’s appearance.  Others felt that the image was similar to those used in an acne commercial.  The skin tone, wrinkling and teeth were too severe and unrealistic in presentation. More so, the fact that the ‘before and after’ was actually the same photo touched up versus two images of the same person at different points in time caused criticism and was too exaggerated to be credible and taken seriously.  Similarly, a few youth who smoke felt that the male shown was too young to realistically have experienced such damage to skin and eyes.   A number of young adults who smoke explained that the presentation of the ‘before and after’ visual was counterintuitive (i.e. the ‘after’ was presented on the left of the ‘before’), which caused the image to be less credible.

In addition, some adults who smoke were critical of the fact that cigarettes were being presented as the cause for all health risks, and believed the contrast of images were so fake that it looked like a joke. 

Clarity / Ease of Understanding

This written health warning was widely seen as being clear and easy to understand across all four audiences. That said, as outlined above, the health warning’s visual was largely criticized for its lack of realism, and being too overdone or exaggerated.  While the ‘before and after’ approach clearly portrayed impact, across audiences most felt that the image does not work on its own without the collaborating text, and in fact, the visual took away from the text’s message.  Further, the smiling male was considered inappropriate in communicating a health warning. As presented, the visual was considered easily reflective of other problems (acne, impact of drug use, etc.)

Ability to Communicate a Health Effect

There was widespread belief across all four audiences that this health warning communicates a health effect of smoking.  That said, the fact that smoking damages skin, eyes and teeth was generally well understood across the three audiences that smoke, and most reported that they did not learn anything new from this health warning.  By contrast, as few youth n who do not smoke were unaware that smoking can damage skin and eyes.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Focus on one aspect (eyes, skin, or teeth)
• Show a less exaggerated photo
• Don’t make the person as happy
• Show more teeth so the decay is more visible
• Better depict the damage/make it look more realistic
• Show a true before and after image (ensure photo is not the same photo touched up on one side)
• Show someone in their 30s or 40s to make the “after” image more realistic
• Ensure the “before” image is presented on the left, and the “after” image is on the right

NHW14 - Smoking reduces the amount of oxygen…

Overall Reactions

Overall, this health warning received mixed reactions in terms of its ability to grab attention and it generally lacked credibility. That said, it was generally considered clear and easy to understand, and communicating a health effect of smoking, although less so among adults who smoke than among the other audiences.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

While youths (regardless of smoking status) generally considered this health warning attention-grabbing, young adults and adults who smoke expressed divided opinions on this front. Youth who do not smoke and adults who smoke were particularly drawn to look at the difference between the “before and after” images. In addition, the “after” image’s similarity to a zombie grabbed the attention of a few youth who do not smoke even though it was not felt to be realistic. Some felt that the health warning grabbed their attention, but for the wrong reasons – namely because it looked contrived, exaggerated and unrealistic. 

Regardless of smoking status, a number of youth and young adults mentioned that they pay particular attention to their looks, and as such seeing what smoking could do to their skin made them pay attention to the health warning.

Young adults who smoke shared mixed views on this health warning. While some were drawn to the comparative images, others felt that the visual lacked sufficient realism to make them pay attention to it. This opinion was also more prevalent among adults who smoke.

Credibility

This health warning generally lacked credibility. The message was felt to be true and believable but the photo was unrealistic and considered ridiculous, taking away from the message. It was believed that such physical decay would result from heavy smoking over time, thus showing a young woman in this condition lacked credibility. Further, having the same shirt on in both sides suggested the same woman at the same age but in different physical condition, something considered unrealistic and confirming that the image was photo-shopped.

Clarity / Ease of Understanding

For the most part, participants across audiences considered this health warning clear and easy to understand, although less so among adults who smoke. The message was clear and easy to read, though felt by a few as being too wordy. Further, while the image clearly communicates the negative impacts of smoking on the health of the skin, eyes, and teeth, the concept does not clearly explain how someone could go from having a “healthy” look to having such an extreme “unhealthy” look. Young adults who smoke mentioned that it is odd to see the “after” photo preceding the “before” shot.

Ability to Communicate a Health Effect

Participants across audiences also believed that this health warning communicated a health effect of smoking, namely skin, eyes, and teeth damage. This opinion was, however, less pronounced among adults who smoke. A few youth who do not smoke and young adults who smoke mentioned that these are more physical, cosmetic effects than health conditions. A few youths and young adults learned that a lack of properly oxygenated body caused early aging of the skin.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Flip to show the “before” shot first (on the left), followed by the “after” picture (on the right)
• Make the image look more realistic (the “after” shot)
• Ensure that the pictures / individual is the same person but at different points in time (not wearing the same clothes)
• Say “smoking causes your skin to age more quickly” before explaining the cause

NHW15B - More than 8000 Canadian smokers…

Overall Reactions

This health warning was generally considered attention-grabbing, believable, clear, and easy to understand and communicating a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Participants across all four audiences were generally drawn to this health warning. The image of the large scar (often described as being “nasty”) caught most of the initial attention, with participants reading the explanation to find out what happened. In a few instances, the image elicited visceral reactions and implied a major operation had happened, and one that likely involved some pain. To a few youth and adults who smoke, the location of the scar implied heart disease, something they felt was of a serious nature, but not necessarily related to smoking. At the same time, the statistic was considered meaningful by some, further resulting in them reflecting on the situation.

The few participants in each group who did not feel compelled by the health warning indicated that the visual lacked shock value and the statistic was difficult to relate to.

Credibility

Nearly all of those who smoke across age groups (youths, young adults, and adults) believed this health warning, while this opinion was also common among youth who do not smoke, though to a lesser extent. The Health Canada endorsement, known impacts of smoking on the heart and the statistic supported impressions of believability. A few adults who smoke mentioned knowing someone with heart disease resulting from their smoking.

That said, the few adults who smoke who did not believe this health warning indicated that the number of deaths seemed too low to be accurate.

Clarity / Ease of Understanding

The health warning was widely considered clear and easy to understand across all audiences. It was believed that the image grabs attention, but the information is needed to contextualize it. The simplicity of the message and the clear font also contributed to making the health warning easy to understand.

Just a few adults who smoke and youth who do not smoke mentioned that they were unclear what connection there is between smoking and heart disease. Others were already aware of the potential risks.

Ability to Communicate a Health Effect

It was widely believed by nearly all participants across audiences that this health warning communicated a health effect of smoking, namely heart disease. Further, the extent of the situation – 8,000 deaths – clearly stands out and was new information.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Show the connection between heart disease and smoking
• Share statistics that show probability (e.g. 4 times as likely)
• In French, consider using the present tense (“qui décèdent chaque année” rather than “qui sont décédés”) to stress the seriousness of the situation
• In French, consider changing “sont décédés dû à une maladie cardiaque” for “sont décédés d’une maladie cardiaque”

NHW16 - Tobacco kills over 45,000 people…

Overall Reactions

Across all four audiences, this health warning was generally seen as believable, clear, easy to understand, and communicating a health effect of smoking. Opinions were mixed, however, with respect to the health warning’s ability to grab attention. While most youth (regardless of smoking status) felt the health warning caught their eyes, opinions in this regard were more divided among young adults and adults who smoke.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Youth (regardless of smoking status) and young adults who smoke were generally drawn to this health warning, primarily because of the brevity in messaging and the clear, straight-to-the-point toe tag visual which implied death. This was less so the case among adults who smoke, many of whom were desensitized to the cadaver visual and likened it to an image from a police TV drama, with no direct affiliation to smoking.

Within each audience, some participants felt the picture was overly dark in its colouring, which allowed them to easily avoid it, while others felt the visual was not shocking or gruesome enough as presented.

Across audiences, the 45,000 statistic was considered attention-grabbing, however perceptions of the statistic varied by audiences.  Youth (regardless of smoking status) generally considered the statistic to be large and alarming. Comparatively, some young adults who smoke considered the number too big to be realistic. By contrast, adults who smoke were less impacted by the number considering it not as significant when you contemplate the entire country.

The yellow warning banner was noticed across audiences and effectively grabbed attention.  Having the yellow text on the black box also helped to draw attention.

Credibility

Across audiences, the health warning was generally considered believable and thought provoking, although, within the young adults, youth and adults smoking audiences, participants were more likely to be cynical of the claim that 45,000 people die each year because of tobacco.  As mentioned, perceptions of the statistic varied with some considering it to be exaggerated. Regardless, the statistic did provide new information that most were not aware of.

The visual lacked credibility among some participants who smoke, regardless of age. While smoking was generally accepted as a health risk, some within these audiences were less inclined to believe that smoking or tobacco is actually the sole cause of death.  The morgue visual was not specific to smoking (i.e. the toe tag does not specify smoking as the cause of death) and it was felt the person could have died from any cause.

Clarity / Ease of Understanding

This health warning was widely considered to be clear and easy to understand across all four audiences, primarily because of the simple, straight forward message and the powerful image.  That said, while the image was considered effective, across groups many believed that it does not effectively stand on its own because it does not specify a cause of death related to smoking.

While some adults who smoke questioned the necessity of including the warning banner, some young adults and youth who smoke believed centering the warning banner would work better with the visual.

Ability to Communicate a Health Effect

Across all four audiences, this health warning was considered as communicating a health effect of smoking, namely the risk of dying.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Showing a tombstone would be a less cliché approach to visualizing death
• Add impact by comparing the number of deaths to make the number more personally relevant (e.g. to the size of a small town)
• Specify the cause of death beyond cigarette smoking
• Include mention of smoking as a cause of death on the toe tag
• Warning banner should be in red
• Center the warning banner

NHW17 - 45,000 Canadians die from smoking every year

Overall Reactions

This health warning was generally better received by youth (regardless of smoking status) and young adults who smoke than by adults who smoke. More specifically, it was deemed attention-grabbing by all four audiences, though less so by adults who smoke. Similarly, adults who smoke were equally divided in terms of whether or not the health warning was clear and easy to understand while all other audiences thought it was the case. The health warning was generally seen as communicating a health effect of smoking, though this opinion was less pronounced among adults who smoke. Finally, while most youth (regardless of smoking status) and young adults who smoke believed the health warning, most adults who smoke did not.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Most participants across locations indicated that this health warning grabbed their attention, although to a lesser extent among adults who smoke than among the three other audiences.  The health warning’s unusual and intriguing skull image encouraged many to read on and a number of young adults considered the visual cool, attractive and interesting.  The shocking statistics included in the health warning (death every 12 minutes; more than 45,000 Canadians die every year) contributed to the health warning’s ability to grab attention.  Further, the contrasting colours and the red warning banner encouraged viewers to read on.

Credibility

Despite the fact that the health warning grabbed attention, participants were divided when considering the health warning’s credibility. Across audiences, many participants were critical of the image, describing it as unrealistic, ridiculous, ‘a joke’, and a poorly done photo-shopped image.  Further, a few adults believed that some younger people would like to see this visual on their cigarette package for its artistic interest, and that it would make the package cool.

By contrast, the statistics shown were generally considered impactful, credible, straight forward and something that makes you think. Most youth, young adults and adults who smoke believed what the text said, although it was felt by some that including the word “approximate” makes them doubt the numbers.  Some felt that the words and the image did not match. Some youth who do not smoke thought that the health warning was not credible. For them, saying there is a death every 12 minutes did not have an impact, since many more people die every second from all kinds of causes.

Clarity / Ease of Understanding

For the most part, youth (regardless of smoking status) and young adults who smoke found this health warning clear and easy to understand. It was generally felt that the text and the image both spoke of cigarettes’ relationship with death, although there was some confusion with the image showing someone still alive. By contrast, the opinions of adults who smoke were equally divided in terms of the health warning’s clarity and ease of understanding.

Ability to Communicate a Health Effect

This health warning was generally seen as communicating the ultimate health effect of smoking, namely that smoking can kill you. Across audiences, this opinion was most pronounced among youth and young adults who smoke.  While participants consistently reported that they knew of the risks or consequences associated with smoking, the statistics were not known and had a clear impact.  Generally, referencing that a death happens every 12 minutes was considered more impactful than the mention of 45,000 deaths every year.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Mention the source for the statistics
• Improve the quality of the photo
• Illustrate 45,000 tombstones or graves for greater visual impact
• Focus on the concept of time; show clock image
• Show someone dying/dead instead of a computer-generated image
• Position the warning banner on top instead of on side

NHW18 - Over 120 Canadians die from smoking every single day.

Overall Reactions

Overall, this health warning was generally considered attention-grabbing, clear, easy to understand, and communicating a health effect of smoking. Youth and young adults who smoke widely believed this health warning. This was also the opinion of youth who do not smoke and adults who smoke, although to a lesser extent in comparison.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Across audiences, this health warning was considered attention-grabbing to most. The emotion elicited by seeing the image of a sad child holding on to a sick parent was what generally grabbed the attention of participants. Combined with the short text, it told a story that felt compelling to many. In general, youth who smoke felt that the scenario was personally relatable, as they were young enough to still feel a strong emotional dependence to their parents, and the thought of one of them dying affected them. Some participants, however, felt that the image looks too staged to be credible and thus did not grab their attention.

Credibility

In general, this health warning was considered credible. That said, it should be noted that youth and young adults who smoke widely believed its claim, while youth who do not smoke and adults who smoke were less convinced in comparison. To a few participants across all age groups who smoke (youths, young adults, and adults), the number of deaths (i.e., 120 deaths per day) helped make the message credible. By contrast, a few youth who do not smoke felt that this number was exaggerated.

Those who expressed doubts felt that the image did not look real. More specifically, they felt that the child’s emotional state was not as sad as they would anticipate if the parent was dead. Indeed, they felt that in a real-life situation, the child would be crying and in more obvious distress than what was shown. Further, the father did not physically look ill, but rather looked healthy and in good shape. Finally, while the text referred to deaths, the image showed someone who is ill. One young adult mentioned that the photograph looked old, which lowered the health warning’s credibility. Indeed, the clothes and hairdo were seen as more popular in the 1990’s rather than today.

Clarity / Ease of Understanding

Across all four audiences, this health warning was widely considered clear and easy to understand. Despite the image looking staged, it was felt that it communicated that smoking not only affect people who smoke, but also those around them. The text was considered clear and complete, and generally worked well to clarify the image.

Ability to Communicate a Health Effect

This health warning was commonly seen as communicating a health effect of smoking, namely death from smoking. While this was considered a well-known health effect of smoking, the statistic (120 deaths per day) was new to most participants and helped convey the prevalence of the consequence.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Improve the realism of the photograph (father looking more ill; child looking sadder/more desperate)
• Show the impact of a father’s death on the family
• Indicate why the dad is dying (what he is dying from)
• Rephrase part of the text to “smoking takes a special person out of your life” or “120 kids per day become an orphan due to smoking”, to heighten the emotional message
• Update the photography by showing people with modern clothes and hairdo

NHW19A - Nicotine in cigarettes is addictive.

Overall Reactions

Despite some differing opinions across all four audiences, this health warning was generally considered attention-grabbing, clear and easy to understand. Mixed opinions were expressed across audiences in terms of the health warning’s believability and its ability to communicate a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Most participants across audiences generally took notice of this health warning. Seeing a young child on a cigarette package was disturbing to some and effectively grabbed their attention and encouraged them to read on. The bold headline and claim that “children of people who smoke are more likely to become addicted” also captured attention.  By contrast, youth who smoke were less likely to think so.  Some youth who smoke indicated that given that they are not parents, the health warning did not speak to them, and a few mentioned that the small cigarette in the image went unnoticed.

Credibility

This health warning received mixed reactions related to credibility.  Some youth, young adults and adults who smoke considered the health warning’s text believable because it reflected their own family situation.  Others, however, believed the health warning lacked credibility because of the unnatural looking photo.  In fact, young adults who smoke, and youth (regardless of smoking status) were critical of the visual for being staged, too dramatic, and having the girl look scared and confuse rather than happy to be trying smoking.  Some felt the girl was not holding the cigarette properly, which further discredited the concept.  Finally, a few participants who do not smoke felt that discussion of addiction did not seem overly detrimental to the girl’s health and therefore the health warning was less believable.

Clarity / Ease of Understanding

Although this health warning was considered clear and easy to understand by participants of all ages who smoke (youths, young adults and adults), participants generally did not believe the image communicated the intended message on its own.  While the visual suggested to them that smoking can begin at a young age, it did not speak to the parental influence mentioned in the text, or the desire of young children to smoke like their parents.   Youth who do not smoke did not see the picture demonstrating a link between nicotine addiction and parental influence.

As mentioned, across audiences, the photo was felt to be staged, unrealistic and forced and not emotionally engaging.  The bright and cheery scenery distracted from the somber message.

Ability to Communicate a Health Effect

Perceptions were mixed when considering if this health warning effectively communicated a health effect of smoking.   While most across all four audiences felt the health warning taught them nothing that they did not already know, some young adults who smoke learned that if parents smoke, then children are more likely to become addicted.  Across audiences, participants questioned if nicotine addiction or parental influence are in fact health effects of smoking. 

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Show a child stealing cigarettes from a pack on a kitchen table or out of a parent’s purse / jacket (to demonstrate addiction in parent setting)
• Show consequences of addiction
• Show the passing of a cigarette from a parent to a child
• Make the image more realistic and less staged
• Show parents smoking next to their child

NHW19B - Your children are more likely to become addicted to tobacco…

Overall Reactions

This health warning was generally considered attention-grabbing across audiences. Most of those who smoke felt that the health warning was credible, while youth who do not smoke were divided on that front. The health warning was considered clear and easy to understand. That said, mixed opinions were offered across audiences in terms of its ability to communicate a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

This health warning generally grabbed participants’ attention across all four audiences. Many were attracted by the health warning, since seeing young children smoking is highly unusual. It generally elicited an emotional reaction, with a few young adult and adults who smoke (especially parents) being a little disturbed by it.  For some adults who smoke, the image was reminiscent of their youth and reminded them of when they had stolen cigarettes from their parents.

Those who were not drawn to this health warning mentioned that the image does not stand out and that the cigarettes are too small to be seen at a glance, thus having less visual impact.  For them the image looked like a stock photo.

Credibility

Most participants who smoke believed this health warning, while youth who do not smoke offered mixed opinions in that regard. In general, however, the text was felt to be believable more so than the image. English-speaking participants were more likely than those in French language discussions to believe this health warning.

It was widely recognized that children usually idolize their parents, and thus are often influenced by their behaviours.  In fact, a few of the youths (regardless of smoking status) recognized themselves in this situation. These impressions made the overall message believable.

That said, the manner in which the children are holding a cigarette was felt to be unnatural, thus affecting the concept’s credibility. Further, many thought it would be highly unlikely that children this young would smoke near a playground for fear of being caught by adults. Rather, a secluded area, such as an alleyway, or showing teenagers, was believed to be a more realistic setting. In addition, the cigarette not being lit further contributed to giving the impression of a staged image. A few youth who did not smoke and young adults who smoke questioned the relevance of this health warning, as they were under the impression that friends are more influential than parents for tweens and teenagers when it comes to smoking.

Clarity / Ease of Understanding

Altogether, this health warning was generally considered clear and easy to understand. That said, while the text was considered to explain the health warning, the image did not provide a clear indication of the intended message. It was believed that while the text specifies the role of parents in influencing their children’s behaviours, the image on its own speaks more of peer pressure. Although it was felt that the text provides clarity, it was believed that the image does not contribute to strengthening the message.

Ability to Communicate a Health Effect

Mixed opinions were offered across audiences regarding the ability of the health warning to communicate a health effect of smoking. While some felt that tobacco addiction could be seen as a health effect of smoking, others disagreed. The latter group of participants believed that the health warning was more focused on the social impact of smoking, peer pressure and parental influence rather than presenting a health effect.

It should be noted that a few adults who smoke in Montreal felt disturbed by seeing an image of children smoking intended for a cigarette package, and felt that this approach for a health warning was somewhat offensive or immoral.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Improve the photo’s credibility
• Show lit cigarettes
• Feature a more realistic setting (e.g., quiet alley)
• Include slightly older children (e.g. teenagers)
• Show some ethnic diversity
• Specify the percentage of children who take up smoking
• Show smoking parents in the visual to reinforce the messaging of parental influence

NHW20 – Second-hand smoke triggers severe asthma attacks.

Overall Reactions

For the most part, this health warning was considered attention-grabbing, clear, easy to understand, and communicating a health effect of smoking. It was, however considered as having some issues with credibility.

The following sections provide reactions to this health warning across audiences.

Ability to Grab Attention

Youth (regardless of smoking status) and adults who smoke generally reported that this health warning grabbed their attention. Showing a younger person in distress (i.e. an asthma attack) was considered a true validation of the impact of second-hand smoke. Young adults who smoke were less convinced that the health warning grabbed their attention, though most still believed they would pay some attention to this health warning.

Credibility

While the health warning was somewhat viewed as credible, there were issues reported with the believability of the image. Across audiences, many felt that seeing a child in what looks like a situation of crisis attracted attention. Not only was it considered as being unusual to see a child on a cigarette package, but the child’s distress also elicited attention. That said, a few youth who do not smoke felt that the boy’s expression was overdone, staged and comedic. The bright yellow also caught the eye of a few youth, young adults, and adults who smoke.

As mentioned, participants of all ages who smoke were not overly curious about this health warning. Many believed that asthma is not a serious health effect, but rather a common condition that can be quickly addressed with medication, and one that often improves over time as a child gets older. As such, they felt the health warning lacked impact, despite the extreme situation portrayed. A few adults who smoke also mentioned not being grabbed by this health warning as they have no children, while in one young adult group, it was mentioned that the child was too young to be relatable.

Clarity / Ease of Understanding

Across all four audiences, this health warning was widely seen as being clear and easy to understand. Clarity and credibility were heightened by the fact that smoking is seen as primarily affecting the lungs, and asthma being a disease of the lungs, it made sense to participants that second-hand smoke may cause asthma. A few young adults and adults who smoke also referenced personal experiences or having seen others in this condition, and thus believed the health warning.

By contrast, the few participants who thought the health warning lacked credibility felt that the image looked too extreme and staged or acted, and they were doubtful that second-hand smoke would cause such a serious asthma attack. Further, the picture on its own lacked clarity as it is only illustrating breathing difficulties without a clear connection to smoking or asthma. The text, however, provided sufficient message clarity.

Ability to Communicate a Health Effect

This health warning was widely seen as communicating a health effect of smoking, namely asthma. Despite clarity in messaging, many participants, especially among participants of all ages who smoke (youths, young adults and adults), expressed doubts that second-hand smoke is an important trigger of asthma.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Make the nurse seem more alarmed
• Use a photo that shows a more realistic situation (less staged or acted)
• Show a child having an asthma attack at home, rather than at the hospital, to improve credibility (less extreme)
• Consider using the term “causes” rather than “triggers”
• Show a younger child

NHW21 - Smoking doubles your risk of stroke.

Overall Reactions

Participants’ attention was generally drawn to this health warning. Across audiences, most believed what it said, and felt that the health warning communicates a health effect of smoking. Youths and adults, regardless of smoking status, generally considered the health warning to be clear and easy to understand, while this was less so the case among young adults who smoke.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

This health warning was generally considered eye-catching by most youths (regardless of smoking status) and adults who smoke and to a lesser extent, by young adults who smoke. The image is what was considered most attention-grabbing. Specifically, the young age of the man who had a stroke, along with him looking right at the viewer were noted. The potential for permanent disability and the high risks involved (“doubling”) also caught the attention of participants. Indeed, this health warning was felt to be a clear demonstration of a real effect of smoking.

To a few, the concept was too wordy to warrant their attention. A few youth who do not smoke also felt that the man’s expression was unclear, and the visual looked overly staged, thus being less attention-grabbing.

While some young adults who smoke felt that the health warning described an undesirable condition (being disabled) and presented clear factual information, most felt that the visual lacked impact and did not elicit strong emotions. Many were also puzzled to see a person with a disability trying to use a urinal, a situation they felt was unrealistic. In addition, a stroke was not felt to be as pressing a concern compared with lung cancer, and many did not consider it to be a condition that was directly or solely related to smoking.

Credibility

Across audiences, this health warning was generally deemed credible. Quantifying the risks and providing supporting statistics regarding the health effect strengthened the concept’s credibility. A few participants, notably one i young adult who smokes and one an adult who smoke, mentioned knowing someone who has had a stroke from smoking. The concept was, however, deemed by a few to lack credibility for a number of reasons. Most notably, the man portrayed was felt to be too young and too healthy looking to have had a stroke that resulted in being disabled. In addition, it was believed that there were many other causes of stroke besides smoking, lessening the believability.

Clarity / Ease of Understanding

Regardless of smoking status, youths, young adults and adults generally felt that this health warning is clear and easy to understand.  Indeed, the image clearly shows a disabled man and the resulting limitation on his daily activities. While it was not clear from the image that the health effect referred to is a stroke, the text clarified it quickly. Together, the words provide factual information while the image illustrated tangible consequences on people’s lives. That being said, many questioned the choice of situation illustrated, notably how a disabled man could stand up to use a urinal.

Ability to Communicate a Health Effect

This health warning was widely seen as communicating a health effect of smoking, namely a stroke. Providing statistics and factual information helped convey the health consequences of smoking. That said, a few youth who smoke questioned the use of the word “doubling” and wondered what percentage this would represent. They felt that doubling a 5% risk of stroke had less impact than doubling of 25% risk of stroke. As such, knowing the actual risk would help them assess the severity of the health warning.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Show actual risk and connection between smoking and strokes (how the cause could be narrowed to smoking)
• Improve the setting/scenario shown in the photo
• Identify the percentage of risks of having a stroke for people who smoke

NHW 22 - Cigarettes cause strokes

Overall Reactions

Overall, this health warning generally grabbed the attention of youth, young adults, and adults who smoke, while youth who do not smoke were divided about it. Across all four audiences, the health warning was considered credible, clear, and easy to understand, and communicated a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

For the most part, this health warning grabbed the attention of participants across age groups who smoke (including youth, young adults, and adults). The attention of participants who smoke was mostly drawn to the incongruity and uniqueness of an image of a brain split in two, as well as the bloody parts shown. That being said, some younger participants who smoke did not consider the visual to be a real picture of a brain, commenting that they did not know what the colouring or texture of a real brain would actually look like. A number of participants across age groups who smoke mentioned being accustomed to seeing damaged body parts on current cigarette package health warnings, and thus they expected to pay little attention to those kinds of messages.

Youth who do not smoke were divided regarding the health warning’s ability to grab their attention. For some, attention was mainly drawn to the bold “Warning” banner and to the image of a damaged brain. By contrast, other youth who do not smoke felt that showing an image of a damaged body part was overused on this type of health warning, and thus would not strike their attention. In addition, the perceived lack of gruesome or shocking details in the visual did not make the health warning stand out.

A few youth who do not smoke felt the visual looked ‘more cool than gross’ and that it resembled a ‘zombie brain’.  In essence, the visual looked animated, unbelievable and over the top to them.  Other youth who smoke were confused by the suggestion that blood in a brain would represent a stroke.

Many youth (regardless of smoking status) and young adults who smoke felt that the health warning lacked interest as the brain illustration looks fake. In addition, within those audiences, some felt that damage affecting the brain is not widely seen as a consequence of cigarette smoking, thus minimizing the visual message impact and interest.

Credibility

This health warning was widely considered believable across audiences and locations. In fact, nearly all youth (regardless of smoking status), as well as young adults and adults who smoke felt that the information and the facts presented were credible, as they are presented in a clear, concise, and factual manner. Further, across audiences, consequences of a stroke were clearly visually portrayed (i.e., leaving permanent brain damage).

For the most part, the message was believed to be clearly presented through the visual and text, thus having no reason to doubt what the health warning is saying. Across audiences, the few participants who expressed skepticism believed that the health warning presented a rare condition, thus making them question the seriousness or validity of cautioning people who smoke about this potential health effect. A few young participants and adults who smoke questioned if the headline should say “smoking causes strokes” rather than “cigarettes cause strokes”.

Clarity / Ease of Understanding

This health warning was widely considered clear and easy to understand, across locations and audiences. The brevity of text was appreciated and contributed to the clarity of the message, along with the all caps font, which was considered concise and clear. In general, the image was considered as clearly representing a damaged brain (despite lacking realism), and the words and expressions used in the text were easy to understand. At the same time, it was believed that the text and the image work well together, as the text explained the condition depicted.

That being said, it was generally believed that the image cannot stand on its own to communicate the health warning, as few people spontaneously associate strokes with brain damage or know what it looks like. Indeed, regardless of age or smoking status, a number of participants were under the impression that strokes affect the heart, not the brain.  In a few instances, participants mentioned that the health warning taught them something they did not know prior to the research – namely that smoking can cause strokes.

Ability to Communicate a Health Effect

All English-speaking participants and the vast majority of French-speaking participants (with the exception of one youth and one adult who smoke) believed that the health warning clearly communicates a health effect of smoking, namely that it causes increased risks of strokes.

Participants’ Suggestions

Participants recommended the following changes to the health warning:

• Increase the size of the quitline information to make it more visible
• Use a more realistic image of a brain to improve the overall credibility of the health warning
• Add statistics regarding the risks of a stroke caused by cigarette smoking
• Make the blood more prominent on the brain to make damage more evident

NHW23A - Second-hand smoke hurts children and pets.

Overall Reactions

Overall, mixed opinions were offered across all four audiences in terms of the health warning’s ability to attract attention. That said, it was modestly viewed as believable, clear and easy to understand, and it was generally seen as communicating a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Across all four audiences, reactions were mixed as to whether or not this health warning effectively grabbed attention. Adults who smoke were generally drawn by this health warning, while youth and young adults who smoke held mixed opinions and youth who do not smoke indicated that the health warning did not catch their attention.  Many were surprised at seeing a child and a dog on the pack and thus would investigate the reasons why. Others, however, considered the health warning’s layout to be scattered and lacking focus and as a result they would not read the health warning. 

With so much going on, participants were often unsure where to focus.  Many indicated that their eyes would default to the cute dog, ignoring the text.  Others indicated that they would disregard this health warning, as nothing in the photo stands out. For many, the suggested consequences were not considered serious enough to warrant paying attention to the health warning.

Credibility

The health warning’s text was only moderately seen as credible across all four audiences. Given the common nature of the child’s conditions mentioned (ear infection / slowing lung growth), participants felt that there is no reason for them not to believe what is said. A few, in fact questioned the extent to which second-hand smoke would cause ear infections as they believed there are many other triggers.
Interestingly, a number of adults who smoke commented that growing up, blowing cigarette smoke in an infected ear was considered a way to heal the ear.  Accordingly, they felt the claim that second-hand smoke causes ear infections to be false and unbelievable.

Smoking impacting pet cancer was also something that was generally not commonly understood, across audiences.  Given that many had not experienced this problem with their pets, this was a statement that was often considered unbelievable.

Clarity / Ease of Understanding

Mixed opinions were offered across all four audiences as to the extent to which the health warning is clear and easy to understand. The use of scattered text and lines was distracting for many, and created a sense of lack of focus or central message for the health warning.  That said, the information presented was considered simple, straightforward, and easy to understand.

Ability to Communicate a Health Effect

This health warning was generally considered to communicate a health effect of smoking, namely increased risk for children of developing chest and ear infections, and higher likelihood of pet cancer. Across audiences, pet cancer and ear infections being caused by smoking were new information.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Concentrated text to allow for clearer focus (rather than points/lines)
• Show sick child / pet to support message
• Provide statistics on incidence to put the health warning in context (e.g. likelihood of pets getting cancer; increased chances of ear infections, etc.)
• Reduce the amount of text

NHW 23B - Children exposed to second-hand smoke

Figure 38: NHW23B

Overall Reactions

Overall, this health warning was considered ineffective at grabbing attention, although some found the health warning attractive and pleasing to view. The text of the health warning was generally considered believable across audiences, but the visual did not accurately portray the risk.  The health warning was generally viewed as clear and easy to understand, and considered to communicate a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Across all four audiences, this health warning received a mixed reaction, although most participants felt that it did not grab their attention. Showing a healthy child and a cute dog, although considered an attractive cigarette package visual to some, was deemed too ‘playful’ for a health warning for most.  This health warning’s visual generally did not grab the attention of most participants who smoke (regardless of age) or did not smoke and accordingly, most did not feel compelled to read the text.  The photo did not stand out and the image was felt to be generic and lacking a clear message.

That said, across audiences, some were surprised at seeing a child and a dog on the pack and thus would investigate the reasons why. Some youth participants felt there was too much text and as a result they would not read the health warning.

Credibility

The written health warning was moderately seen as credible across all four audiences. The information presented spoke true to what many participants had experienced (i.e. common occurrences of bronchitis or pneumonia) so it was generally considered believable.  Having a statistic (twice as likely) added credibility to the health warning.

Clarity / Ease of Understanding

Across audiences, most considered the health warning clear and easy to understand. That said, while the text provided a clear health warning, the image did not appropriately reflect the message.  The dog created a notable distraction to viewers and the image of the young girl did not accurately portray an audience at risk. There was, however, confusion as to the presence of the dog in the image, especially as few were aware of the potential impact of second-hand smoke on pets.

Ability to Communicate a Health Effect

This health warning was generally considered to communicate a health effect of smoking, namely that children exposed to second-hand smoke are at greater health risk. Across audiences, the fact that children exposed to second-hand smoke have a greater level of health risk was generally accepted and well-understood.  However, the statistic that such children are sick twice as often was new information.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Show a sick child (girl with a mask or a puffer)
• Present a bold statement; less words
• Replace the image; exclude the dog or explain why it is shown
• Focus on reinforcing good behaviours of people who smoke (good idea not to smoke around children and pets) rather than focus on negative consequences

NHW23C - Children exposed to second-hand smoke… 

Overall Reactions

Overall, mixed opinions were offered across all four audiences in terms of the health warning’s ability to attract attention. That said, it was viewed as believable, and it was widely seen as communicating a health effect of smoking. To varying degree, the health warning was considered clear and easy to understand.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Across youth and adults who smoke, there were as many participants who were attracted to this health warning as there were who felt it did not catch their eye. By contrast, youth who do not smoke and young adults who smoke generally mentioned that they would pay little attention to this health warning. Many were surprised at seeing a child and a dog on the pack and thus would investigate the reasons why. Having the text on a yellow background also caught the attention of many, as did the bolded text.

That said, many would disregard this health warning, as nothing in the photo stands out. Further, the image was felt to be generic and lacking a clear message. Some youth participants also felt that there is too much text and as a result they would not read the health warning. While the risk of causing pet cancer grabbed the attention of some participants who smoke, others felt this was not a consequence serious enough for them to pay attention to the health warning.

Credibility

The health warning, notably the text description, was moderately seen as credible across all four audiences. Given the common nature of the disease mentioned, participants felt that there is no reason for them not to believe what is said. A few, however, questioned the extent to which second-hand smoke would cause ear infections as they believed there are many other triggers. Further, the diseases mentioned were not considered critical or life-threatening, thus the health warning was taken less seriously. Likewise, pet cancer was generally not seen as common nor serious, despite being a situation that is believable.

Interestingly, a number of adults who smoke commented that growing up, blowing cigarette smoke in an infected ear was considered a way to heal the ear.  Accordingly, they felt the claim that second-hand smoke causes ear infections to be false and unbelievable.

Clarity / Ease of Understanding

Participants across all age groups who smoke (youths, young adults, and adults) generally felt that the health warning is clear and easy to understand. By contrast, youth who do not smoke offered mixed views in that regard. In general, however, the text was considered to offer more clarity than the image. The information presented was considered simple, straightforward, and easy to understand. That said, the presence of the dog and reference to health consequences on pets were confusing so some.

Ability to Communicate a Health Effect

This health warning was generally considered to communicate a health effect of smoking, namely increased risk of children developing chest and ear infections, and higher likelihood of pet getting cancer. The fact that second-hand smoke can cause pets to get cancer and children to develop ear infections was new information to all participants.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Change the image to show a sick child and a sick dog
• Show parents smoking near the child and pet in the image to reinforce the visual reference
• Focus on reinforcing good behaviours of people who smoke (good idea not to smoke around children and pets) rather than focus on negative consequences
• Reduce the amount of text

NHW24 - Smoking causes colorectal cancer. 

Overall Reactions

Overall, this health warning was generally considered attention-grabbing, believable, clear and easy to understand, and communicating a health effect of smoking, though to various degree across audiences.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

Most participants across all four audiences indicated that they would pay attention to this health warning. The comparative photo and gruesome image were intriguing to many; enticing viewers to read on to better understand what it was saying. The bold headline and limited text also contributed to the health warning grabbing attention, as did the yellow warning banner.

Credibility

Participants generally felt that this health warning was credible. Across audiences, youth (regardless of smoking status), and young adults who smoke more strongly recognized the health warning’s believability than did adults who smoke.  Showing the realistic before and after images of the colon, and including a doctor’s name added credibility.

Some youth who smoke challenged the definitive statement ‘smoking causes colorectal cancer’, believing that smoking is only one of many factors that cause that type of cancer.  Further it was felt by these participants that genetics may have a much greater influence than smoking.

Clarity / Ease of Understanding

In general, the health warning was considered clear and easy to understand, although more so among young adults and adults who smoke, than among youths (regardless of smoking status). That said, despite its simple layout and limited text, it is important to note that some youth (regardless of smoking status) were unfamiliar with the term ‘colorectal’ and thus felt that the visual lacked clarity.  A few also questioned what a colon was and where it was located in the body. Across audiences, participants were generally unfamiliar with what a colon looks like.  Accordingly, the importance of including labels on the health warning was underscored.

Ability to Communicate a Health Effect

Across all four audiences, this health warning was widely seen as communicating a health effect of smoking, namely colorectal cancer. Further, this health warning communicated a new health effect, as most had not been aware that colon cancer was a health effect of smoking.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Better explain why / how smoking can have this effect
• Make the warning banner in red and move to middle
• Consider using the term, “colon cancer” instead of “colorectal cancer”
• Ensure labels are included to explain the images
• Change labels to “before cancer” and “after cancer”
• Indicate that smoking “may” cause colon cancer, vs. smoking “causes”

NHW25 - Smoking Causes Sexual Impotence.   

Overall Reactions

Mixed opinions were offered regarding this health warning’s ability to grab attention, provide clear, easy to understand and credible information. It was generally believed to be communicating a health effect of smoking, though to varying degree across all four audiences.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

The humour and suggestive nature of this visual grabbed the attention across most audiences. Young adults and adults who smoke, as well as youth who do not smoke generally considered the image original, unique, simple, direct and to the point. The yellow warning banner and the health warning’s bold and limited text also captured viewers’ attention.

This health warning appeared more effective at grabbing males’ attention than females’, with many male participants commenting that this image and message would cause them some concern.

Credibility

While adults who smoke generally believed this health warning, all other audiences were less likely to think this was the case.  Although many participants across audiences felt that the message was potentially credible, most questioned how a cigarette could cause sexual impotence.  Further, males consistently made light of the consequence, citing either that it ‘was not a problem they had experienced’ or that there was ‘a little blue pill for that’. 

For many, this health warning presented a fun fact more than a serious consequence and was considered a joke to some.  Its lack of relevance was generally disregarded, particularly to females.

Clarity / Ease of Understanding

Across audiences, most believed the visual for this health warning could not stand on its own and that accompanying text is necessary to put the visual in context and explain the health effect.  Young adults who smoke were widely of the opinion that this health warning is clear and easy to understand, as were most adults and youth who smoke.  Altogether the text and visual were deemed straightforward and working well together. Of note, a few youth who smoke were not familiar with term ‘impotence’ and questioned what it means.

Ability to Communicate a Health Effect

Most young adults and adults who smoke believed that this health warning communicates a health effect of smoking, although, as mentioned, many did not consider sexual impotence to be a serious health effect of smoking. This opinion is less pronounced among youth (regardless of smoking status), though still representing the most common opinion. Females were less likely than males to believe the health warning communicated a health effect. Across audiences, this health warning was generally considered a new health fact that they had been unaware of.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Make the image brighter
• Indicate what is the cause of impotence (by decreasing circulation, for example)

NHW26 - Cigarettes are addictive.

Overall Reactions

Overall, mixed opinions are offered in terms of this health warning being attention-grabbing and credible. Youth who do not smoke, as well as young adults and adults who smoke are generally drawn to it, while this is less so the case of youth who smoke. In terms of believability, young adults and adults who smoke generally believe the health warning, but this is less so the case of youth (regardless of smoking status). While this health warning is generally seen as clear and easy to understand, it was less effective at communicating a health effect of smoking.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

In general, this health warning grabbed the attention across all audiences.  The health warning’s limited text, yellow letters on black background and graphic image all drew viewers to the health warning. Across groups, the yellow fingers were considered gross, disgusting and reflective of a ‘hard core’ smoker.  That said, some youth and adults who smoke were less compelled by this health warning because the picture was fuzzy, unrealistic and looked fake, though still most indicated they would pay attention to it if seen on a cigarette package.

Some adult and youth who smoke considered the addiction message of the health warning to be vague, old news and forgettable.

Credibility

This health warning was deemed believable by most young adults and adults who smoke and to a lesser extent by youth who smoke. That said, across these three audiences, some participants considered the image to be extreme, unrealistic, of a very elderly person, and more indicative of someone with a poor hygiene problem rather than an addiction problem.  Further, youth and adults who smoke generally felt that people experience many different types of addiction.

By contrast, opinions of youth who do not smoke were divided, with some finding the health warning credible, while others not, primarily because they perceived the image to be photo-shopped to sensationalize something that is not actually so dramatic.  Most youth who do not smoke had not seen hands yellowed by nicotine and thus questioned the validity or truth of the statement.

It should be noted that the credibility of this health warning was stronger among English-speaking participants than among those who took part in the French focus groups.

Clarity / Ease of Understanding

Across all four audiences, this health warning was considered clear and easy to understand, however it was generally felt that the image spoke more of yellow fingers or staining as a side effect of smoking rather than addiction. Accordingly, across groups most participants believed that the text and the picture do not necessarily work well together, as the connection between yellowing fingers and addiction was not evident.

Ability to Communicate a Health Effect

Most young adults and adults who smoke believed that this health warning communicated a health effect of smoking, namely addiction (via the text) and yellowing skin (by the photo). Most did not believe that they learned anything new from the health warning, as it was considered well accepted that smoking is addictive.

By contrast, opinions were more divided among youth (regardless of smoking status), with many in both groups questioning if addiction was actually a health effect.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Increase size of font
• Rephrase the title as a question to draw attention on an issue that is already well-known
• Use a picture that better communicates addiction
• Ensure the image is realistic
• Make the health warning personally relevant or something that would be memorable (if you smoke, you smell; or if your fingers turn yellow, what’s it doing to your lungs?)
• Convey the message to look at your hands and imagine what smoking is doing inside of your body – to make viewers think of themselves

NHW27 - Cigarettes cause oral cancer. 

Overall Reactions

Although this health warning was widely considered attention-grabbing by participants from all four audiences, there was mixed opinions with respect to its believability. While young adults who smoke widely believed what it says, youth (regardless of smoking status) and adults who smoke were clearly divided on this. Across audiences, most considered the health warning clear and easy to understand. In terms of communicating a health effect of smoking, all young adults and most adults who smoke, as well as most youth who do not smoke were of the opinion that the health warning is effective in doing so, while this opinion was less pronounced among youth who smoke.

The following sections provide a more detailed description of reactions to this health warning across audiences.

Ability to Grab Attention

The graphic and gory imagery of this health warning effectively grabbed the attention of participants across audiences.  All youth and young adults who smoke indicated that this health warning grabbed their attention. This was also the opinion of the vast majority of youth who do not smoke and adults who smoke. Regardless of audience, the image was considered disturbing, disgusting and gruesome.  While some felt the photo seemed exaggerated, lacked context, and was difficult to decipher, others indicated that they would be curious to learn more about what happened. Across audiences, the bold headline, limited amount of text and yellow and red colouring also helped to capture attention.

Credibility

There was mixed opinion regarding the health warning’s credibility. Most young adults who smoke believed what it said, primarily because of the contact between cigarettes and a person’s mouth and the logical consequence of smoking. Some had heard of mouth or oral cancer as a side effect of smoking and felt the visual and supporting text reinforced what they had heard.  By contrast, youth (regardless of smoking status) and adults who smoke expressed mixed opinions on this health warning’s believability and these audiences were as likely to consider it credible as not.  Those who felt it was believable primarily attributed that to the health warning’s clear and indisputable text.  Many, however, felt the visual was too extreme and unusual to be believed, being more reflective of an isolated or rare occurrence rather than something that would be a realistic threat in their lifetime.  Indeed, no one had heard of someone having had their jaw removed because of smoking.

Clarity / Ease of Understanding

For the most part, participants across all four audiences indicated that the health warning is clear and easy to understand, despite some small issues.  To begin, it was felt that the image on its own is unclear and requires the text to explain what is happening.  Some young adults who smoke criticized the text for being mismatched to the visual, whereby it discussed ‘part of’ the jaw, while the photo showed the entire jaw. Others felt the image was unclear with many not understanding what was in the middle of the photo (the tongue), or where the front teeth had gone.  Finally, adults who smoke felt the image lacked clarity, given that it lacks context (i.e. a face) and needs attention to decipher it.

Ability to Communicate a Health Effect

All young adults who smoke and nearly all adults who smoke and who do not smoke believed that this health warning communicated a health effect of smoking, namely that oral cancer caused by smoking can result in having your jawbone removed. This opinion was also evident among youth who smoke, though to a lesser extent.  Across audiences, many participants were unaware that you could have your jawbone removed as a result of oral cancer.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Use a less graphic image
• Show a face with the jaw removed – make it more realistic
• Better describe what is happening in the photo
• Be less definitive in blaming smoking for cancer (i.e. use “may cause”)
• Fix the typo in the French “du machoire” should be “de la machoire”

NHW 28 - Smoking may cause breast cancer.

Overall Reactions

Overall, this health warning was moderately considered effective at grabbing attention. The concept elicited mixed reactions in terms of its credibility, with youth and young adults who smoke believing the health warning, while it held moderate credibility among youth who do not smoke. While most adults who smoke believe the health warning, they are the most doubtful of all four audiences. In terms of clarity and ease of reading, the health warning performed well across all four audiences. Finally, the health warning was widely seen as communicating a health effect of smoking, although this opinion was less pronounced among adults who smoke.

The following sections provide reactions to this health warning across audiences.

Ability to Grab Attention

This health warning was considered moderately effective in grabbing attention.  The clear and simple text generally grabbed attention, although both the topic and visual primarily attracted female viewers only.  Across audiences, males typically disregarded this health warning and considered it irrelevant to them personally.

The health warning’s visual was consistently considered bland, plain, lacking colour and not visually standing out. That said, across audiences, it was generally felt that the person in the image looked real and it didn’t seem contrived.  Overall, the health warning did not evoke an emotional response for most participants, as the image did not appear scary or threatening.  However, some participants within each audience appreciated the visual contrast of the tumour in the visual and felt that helped to draw attention to the image.  A few participants questioned the accuracy of the visual and believed a tumour would be better displayed as a white mass versus an orange and yellow icon.

Across audiences, youth (regardless of smoking status) were most likely to mention that this health warning caught their eye. Within these audiences, both the visual and text led some females to contemplate their own future and the importance of their breasts given their desire to have children. To a lesser extent, this was also the opinion of young adults who smoke. 

Credibility

The health warning’s credibility was strongest among youth and young adults who smoke, and to a lesser extent among youth who do not smoke. Within each of these audiences, female participants generally believed the message portrayed, although some felt that the use of ‘may’ lessens the message’s validity and limits the risk.

Adults who smoke were more divided on the topic, despite leaning towards believing the message.  Many adults who smoke commented that cigarettes are not the only thing that causes breast cancer and a good number challenged the claim that cigarettes actually cause breast cancer.  Rather, they felt many things cause breast cancer and it is impossible to isolate a direct cause to cigarettes.

Clarity / Ease of Understanding

For the most part, the health warning was considered clear and easy to understand across all four audiences, primarily because of the simple and limited text and the clear imagery. The image and the text were considered to work well together, although some youth and adults who smoke felt the image of tumour was hard to see and should be visually enhanced.

The health warning made sense to participants and was considered logical, although many questioned the true connectivity between the cancer and smoking as the actual cause.

Ability to Communicate a Health Effect

Across all four audiences, the health warning was also considered effective at communicating a health effect of smoking, namely the risk of breast cancer.  This was a health risk some in each audience had previously not been aware of.

Participants’ Suggestions

Participants suggested the following changes to the health warning:

• Use more attractive/contrasting colours to attract attention
• Support the claim with statistics about the prevalence of breast cancer caused by tobacco consumption
• Add a quote or testimonial to strengthen the message and make it more personal
• Show the woman smoking a cigarette to strengthen the message
• Show the tumour in white to make it more realistic

General Considerations About Health Warnings for Cigarette Packages

In addition to the findings specific to each of the 44 health warnings reviewed in the previous section of this report, this section presents general considerations that resulted from the combined review of all health warnings for cigarette packages.

Images

Imagery plays an important role in attracting initial attention to a health warning, and it greatly influences a message’s credibility.

Findings show that participants are consistently first drawn to the visuals on the health warning before looking at other components. In most instances, reactions to the visuals influenced the level of attention paid to the rest of the health warning. Participants were drawn to images that were meaningful and clearly communicated the intent of the health warning without needing an explanation from the accompanying text.

Across locations and audiences, overall findings show that the more gruesome images (e.g. gangrene foot; neck and tongue cancers; black teeth; hairy tongue) garnered more initial attention. Participants consistently indicated that they have become accustomed to seeing visuals that are graphic in nature and accordingly, imagery that lacks some degree of visual impact is often ignored.  Younger audiences in particular are used to seeing shocking presentation across mediums.  That said, across audiences some individuals found the most graphic visuals repulsive, and would take great lengths to avoid reading the text in the health warning or avoid looking at the health warning completely.  Indeed, in a few instances, participants commented that they typically keep their cigarette case in a plastic cover so they can avoid seeing the graphic images. It is worth noting that for some individuals, because of being used to these types of health warnings, those presented that showed a different approach (urine sample, out of order, for example) grabbed their attention for the fact that they were different than what they were used to seeing.

Perhaps not surprising, images targeted at specific segments of the population (e.g. pregnant woman, newborn baby, male erectile dysfunction) typically spoke most loudly to their intended audience.  Health warnings featuring children or babies elicited more acute emotional reactions on the part of parents or those who are interacting more frequently with children. That said, those health warnings had less of an emotional impact with young participants who do not have children or if they do not actively care for them.

The perceived realism of the image was also considered highly important in determining the credibility of the health warning, as well as contributing to its credibility. For example, images showing a photo of an actual body part were considered as showing a real consequence of smoking, albeit some skepticism was evident in a few instances regarding the prevalence of the conditions presented. In the case of images that included people’s faces, the mannerism, facial expressions, and overall look of the people shown were considered highly important in determining if the image is “real” or “staged” and if the health warning is believable or not.

Participants were asked if any of the health warnings they were shown would cause them to request a different package at the retailer.  Across locations and audiences, findings show that when purchasing a package of cigarettes, some individuals (most notably females) will ask a retailer for a different package so they can avoid a package with a specific health warning.  Across all participants, regardless of location, age, gender, or smoking status, health warnings that were gruesome or grotesque were the ones that would be replaced. 

While some would take this action because they were repelled by the image and personally wanted to avoid seeing it, others would ask for a replacement package to avoid having a young child see the undesirable image in their home. Some other participants indicated that they typically keep their cigarette case in a plastic cover that they purchase so they can avoid seeing the graphic images.

Messages

Messaging that is short, unexpected, and serious in its potential personal impact garners attention.

As discussed throughout the report, health warnings and messaging about second-hand smoke were generally considered less impactful, given the perceived increased prevalence of public education initiatives noticed by participants in recent years. With the removal of many public smoking places across the country, and common municipal bylaws addressing the same, participants who smoke felt that they already avoid smoking near non-smokers or children.  Accordingly, many considered these health warnings less relevant to them. By comparison, health warnings that clearly identified a serious health consequence of smoking on babies or fetuses generally elicited attention.

Cigarette package health warnings that focus on nicotine addiction were deemed trite and typical and as such considered relatively ineffective at raising awareness. In addition to being considered a well-known fact, nicotine addiction was often not seen as a health consequence, thus having limited impact. Further, it was consistently cited that there are many forms of addiction, all which potentially share varied risks (e.g. caffeine, sugar, and alcohol), causing participants to pay less attention to health warnings related to addiction to nicotine.

Health warnings that are different from what is currently in market (in terms of content or how it is being presented) were generally perceived to be more interesting and likely to be read out of curiosity.  Seeing something that is atypical or unexpected (e.g., urine sample, and ‘out of order’ sign), grabbed attention. That said, this approach was considered effective only if the overall message was clear, simple, well explained and credible.

Across locations, shorter text was considered more impactful than longer explanations. Having longer text was considered a deterrent to read the health warning. When additional information was deemed relevant and of use, the best approach was seen to highlight the consequences in a short, bold headline, followed by the explanation in smaller and less prominent text.

Credibility

Realism, personal relevance, definitive statements and statistics are key to generating credibility in a health warning.

Health warnings that focus on well-known consequences of smoking (oral or lung cancer) were generally considered credible. By contrast, believability was diminished for health warnings that referred consequences that are less well-known, despite those messages garnering attention.

Personal relevance and personal experience clearly impact an individual’s reaction to a health warning. Participants who smoke rely heavily on personal experience to judge what might happen as a result of their smoking. For example, if they had never seen someone with neck or oral cancer, they were less likely to see it as a potential consequence, or would write it off as an extreme and unlikely case. However, for newer and lesser-known consequences, believability was heightened by including a brief explanation of how the effect happens, (e.g. poor circulation is due to restricted blood flow / circulation) or statistics (e.g., smoking causes 80% of COPD deaths).

Staged, illustrated or photo-shopped images/visuals were less effective and criticized. Across audiences, participants reported that they are accustomed to seeing extreme photos and visuals and are highly critical of what they perceive to be a poorly executed imitation. Believability is heightened with real photos that show context. That said, illustrations were at times effective (e.g. A1 NHW12 - drawing showing lung restriction), in situation where showing a real-life image might not be possible or might lack clarity.

Definitive wording used in messaging was considered more credible (e.g., “is a cause of” rather than “may cause”). That said, being too definitive at times caused suspicious reactions from participants who felt that the consequences did not occur for all people (e.g., “will cause” or “causes” suggests a definite change of the consequence happening).

Findings also show that a perceived lack of seriousness of a health condition results in a message being disregarded or ignored to various degrees.  For example, conditions that are believed to be easily treated or corrected (e.g., ear infection, impotence, pneumonia, asthma) were seen as “not severe” and accordingly these health warnings were disregarded by some.

The use of statistics was strongly endorsed, both to grab attention and educate readers. That said, statistics that can personally impact the viewer were considered more impactful, as well as those that elicited strong imagery.  Further, for a situation to be relatable, it was believed that additional facts about the person portrayed should be available – including such information as, age, condition, and level of smoking.

Speaking of health consequences for someone in their 60s had less of an impact on young people than speaking of consequences in their 40s, as they perceived that specific milestone to be about halfway through their lifespan rather than near the end. Referring to health consequences that have an important impact on someone’s life mid-span was considered to help drive home the permanent impact of health consequences on someone’s health/lifestyle in the future. In general, implying death later in life was considered as having less impact than the implication of a changed or reduced lifestyle or of suffering earlier in someone’s life.

Testimonials

Despite varied impact levels, testimonials are generally not as effective at grabbing attention.

Findings also show that the testimonials are not as impactful as other types of health warnings for a number of reasons:

• Photos often include individuals who did not “look sick” to participants, thus reducing the impact of the health warning. It was believed that both Archie and Dony did not look sick.
• Unless the photos or stories held personal relevance, they were often ignored. Photos of individuals who were older and therefore less relatable or “at the end of their lives anyways” were deemed irrelevant by participants. By contrast, McKensie’s story established an emotional connection and relatability of a cancer death in the family to many, so was often considered more powerful.
• Some testimonials included multiple illnesses that added to a lack of credibility. Confluence of diseases that were felt to be potentially caused by other factors (not just smoking) were sometimes disregarded. Archie was felt to be “one in a million”.
• Participants were cynical of names that appeared made up.  For example, “Tarbox” was considered an unbelievable surname to many, despite its familiarity to many from previous health warnings. In French-language groups, the given name “Barb” was considered uncommon in Quebec, thus reducing the personal relevance of the situation described in the health warning. In some instances, French-speaking participants felt that if a name is not relatable, the corresponding story is less “tangible” to them or appears not as “close to home”.
• The layout and imagery were often considered “dull” and lacking interest. The images did not convey emotions, or did not portray the emotions that would be expected by the situation, as well as communicating little about the situation featured in the text.
• The text was often considered too long to be of interest, lacking sufficient focus on the health consequence.

Health Warning Designs and Layout

The use of red and yellow is deemed most effective in grabbing attention, although a ‘warning’ headline centered across the entire package with simplistic body text is also impactful.

Participants were asked to briefly consider three different design layouts for the health warnings. An example of each layout is presented below in Figure 45, although it should be noted that different health warnings were used across groups to illustrate the different layouts.

When considering the three layout options, findings show that the colour contrast and the placement of information are both influential in which layouts are considered best at communicating the health warning.

The layouts that featured the colours red and yellow together (Layout B and C) were most eye-catching across all four audiences. The colours were considered strong in grabbing attention and implying danger, “stop” or warning. Having black text on a yellow background was further considered eye-catching, as was yellow text on a dark background. That said, the preferred shade of yellow varied based on individual preferences.

The use of fewer colours together was generally seen as being more effective at highlighting particular information on the health warnings. As such, many felt the inclusion of four main colours in the Layout C (red, yellow, blue and white) made the design cluttered and distracted from the messaging.

In terms of layout of visuals and information on the health warning, mixed opinions were offered. Some preferred the horizontal format of Layout A, which helped structure the content in three distinct boxes: one for the warning banner, one for the message (text and image combined) and one for the quitline information. This approach was considered less visually cluttered, though at times lacking contrast between the words and the image background. This layout was also liked by some for its greater focus on the visual elements.

Some participants preferred Layout B, as their eyes were drawn from left to right, and thus they would read in the information in what they considered the proper order (i.e., warning banner first, then message, then image, then quitline). In general, when considering placement of information, Layout C was the least preferred as many participants felt that it appeared too “chopped up” due to each piece of information being framed by lines or colours.

When asked which warning banner they preferred, many identified that of Layout A for being positioned horizontally from side-to-side of the health warning, and for featuring big and bold lettering. That said, many participants questioned the reason for justifying the label on the right-hand side, rather than centering it.

French Warning Banner

The label, “Avertissement” was considered most appropriate for the cigarette package health warnings.

Participants in Montreal were asked to indicate their preference for the word “Attention” or “Avertissement” for the health warning label. Overall, the term, “Avertissement” was by far considered the most appropriate label for the health warnings for its formality and its association with preventative messages. It was also readily associated with the concept of advice, something that was believed to be reflective of the purpose of the health warnings.

By contrast, the term “Attention” elicited more immediate attention, however was most commonly associated with the concept of immediate danger which participants did not always see as reflective of a health warning. Indeed, it was believed that a health warning is more akin to advice to consider over time, rather than a warning to stop doing something or avoid immediate danger. Some participants who preferred the term “Avertissement” mentioned that the word “Attention” is overused and as such might lose its impact in the context of the health warnings.

It should however be noted that a few differences of opinions are evident across audiences. Young adults and adults who smoke were widely drawn to the term “Avertissement”, and to a lesser extent, this was also the preference of youth who smoke. By contrast, youth who do not smoke were equally divided in preference between the two terms.

Quitline Section

The preferred layout for the quitline information would feature capitalized and bold black lettering on a white background.

Participants were asked to briefly comment on the quitline section found on each of the health warnings reviewed. In general, capitalized and bold letters were considered more eye-catching, and black lettering on a white background was slightly preferred overall. While some participants liked the use of the blue background, it was generally believed that the white lettering on the royal blue background lacked sufficient contrast to catch attention. The layout that featured both the blue and white background colours, though preferred by some for its division of messaging and in its ability to stand out, visually, was seen as lacking clarity and being too visually cluttered for others.

Health Canada Endorsement

The inclusion of the Health Canada name on health warnings adds credibility to the claims and creates a sense of trustworthiness in the message.

Despite its small print size, the Health Canada endorsement on each health warning was commonly noticed by participants, although less so in Vancouver. When asked what the Health Canada attribution suggested, most believed that it provided a reputable and trusted source for the statistics.  Further, it was felt the reference ‘legitimizes the science’ and adds credibility to the factual information presented in the health warnings. Others felt a Health Canada reference implies seriousness and a sense of urgency on the topic. Health Canada was generally considered the authority on health issues in Canada, thus being respected and trustworthy.

That said, while having the health warnings endorsed by Health Canada provides a certain level of comfort in the health claims, in some instances, participants questioned the believability of some of the health warnings. Further, others would like to be able to access a website where it provides further details and supporting documentation on the claims being made.

On-Cigarette Health Warnings

The following section presents initial reactions to the on-cigarette health warning messages and layouts that were presented and briefly discussed in the focus groups.

Overall Reaction

Reactions to having health warnings printed directly on cigarettes are viscerally negative among participants who smoke, as they are considered unnecessary to warn those who smoke, and a costly approach. However, the presence of on-cigarette health warnings made smoking less attractive to people who smoke and less frequent smokers expressed mixed opinion regarding its potential to impact awareness of health hazards.

After having seen and briefly discussed initial options for on-cigarette health warnings (including potential messages, design options, and placement options), participants were asked for their reactions to the overall idea of having health warnings printed directly on each cigarette.

Reactions to the concept of printing health warnings directly on cigarettes varied by smoking behaviour.  Long-term, heavier smokers strongly criticized it for being a waste of money, increasing the cost of cigarettes, having no impact on behaviour, and in essence shaming people who smoke.  In fact, many expressed visceral negative reactions to this idea. Further, other participants who smoke with less frequency felt that on-cigarette messaging made smoking less attractive as you would continually be reminded of the harsh potential health impacts whenever smoking.   That said, heavier smokers anticipated that they would be quickly desensitized to such messaging and would ignore it. Some supported the idea, and felt it would make an impact on young or new smokers (making them reconsider smoking), despite varying degrees of personal support for the idea. There is an assumption that such a movement will drive cigarette purchases to the black market, US market or to Indigenous sales of cigarettes.  By contrast, participants who do not smoke expressed mixed opinions, with some seeing value in having health warnings printed on cigarettes, while others felt that it was repetitive with the on-packaging health warnings and would have little impact on their own choices given their desire not to smoke.

In general, reactions to the on-cigarette health warnings suggest that this approach would likely make smoking cigarettes less attractive to those who smoke. Across locations, there was agreement that messages on cigarettes make smoking and cigarettes less attractive. In some instances – mostly in English-speaking locations - those who smoke felt that it would be embarrassing for them to smoke cigarettes with messages, particularly around people who do not smoke, as they anticipated they would receive increased pressure or criticism from others. For the most part, the on-cigarette health warnings were generally seen as redundant to the health warning on the cigarette package, despite presenting different information. The exception to this was more pointed messaging (e.g. smokers die early) or those relating to the impact of each puff (e.g. poison in every puff), which underscored the impact of smoking at that point in time.

Messages

Short on-cigarette messages and those highlighting the impact of each puff were deemed especially impactful.

In each group, participants were presented with thirteen different health warnings. The following tables provide the grouping of health warnings presented, in both English and French. The health warnings identified with an asterisk represent the ones that were considered by participants as grabbing attention, based on the results from an individual exercise. Specifically, these health warnings were most commonly selected across groups.

HEALTH WARNINGS – GROUP A

ENGLISH:

1. SMOKING CAN KILL YOU – Health Canada
2. POISON IN EVERY PUFF – Health Canada*
3. CIGARETTES CAUSE CANCER – Health Canada
4. HIGHLY ADDICTIVE PRODUCT – Health Canada
5. SMOKING CAUSES LIP CANCER – Health Canada
6. SMOKING CAUSES LUNG CANCER – Health Canada
7. SMOKING CAUSES STOMACH CANCER – Health Canada
8. SMOKING CAUSES HEART ATTACKS – Health Canada
9. SMOKING CAUSES SUFFERING AND DEATH – Health Canada*
10. SMOKING DAMAGES YOUR TEETH – Health Canada
11. QUIT HELP 1-866-366-3667 – SMOKING CAUSES CANCER – Health Canada*
12. SMOKING CAUSES CANCER – Health Canada – QUIT HELP 1-866-366-3667*
13. SMOKING CAUSES CANCER – Health Canada - #IQUIT

FRENCH:

1. FUMER PEUT ÊTRE MORTEL – Santé Canada
2. POISON EN CHAQUE BOUFÉE – Santé Canada*
3. LA CIGARETTE CAUSE LE CANCER – Santé Canada
4. PRODUIT QUI CRÉE UNE FORTE DÉPENDANCE – Santé Canada
5. FUMER CAUSE LE CANCER DE LA LÈVRE – Santé Canada
6. FUMER CAUSE LE CANCER DU POUMON – Santé Canada
7. FUMER CAUSE LE CANCER DE L’ESTOMAC – Santé Canada
8. FUMER CAUSE DES CRISES CARDIAQUES – Santé Canada
9. FUMER CAUSE LA SOUFFRANCE ET LA MORT – Santé Canada*
10. FUMER ENDOMMAGE VOS DENTS – Santé Canada
11. JARRETE 1 866 527 7383 – FUMER CAUSE LE CANCER - Santé Canada*
12. FUMER CAUSE LE CANCER – Santé Canada – JARRETE 1 866 527 7383*
13. FUMER CAUSE LE CANCER – Santé Canada - #JARRETE

HEALTH WARNINGS – GROUP B

ENGLISH:

1. SMOKERS DIE EARLY – Health Canada*
2. EVERY PUFF IS HARMFUL TO YOUR HEALTH - Health Canada*
3. TOBACCO SMOKE IS TOXIC - Health Canada
4. WARNING: ADDICTIVE PRODUCT - Health Canada*
5. SMOKING CAUSES MOUTH CANCER - Health Canada*
6. SMOKING CAUSES KIDNEY CANCER - Health Canada
7. SMOKING CAUSES CATARACTS - Health Canada
8. SMOKING CLOGS YOUR ARTERIES - Health Canada
9. SMOKING CAUSES DEADLY DISEASES - Health Canada
10. SMOKING DAMAGES YOUR LUNGS - Health Canada
11. Help to quit 1-866-366-3667 – Health Canada – SMOKING CAUSES CANCER
12. SMOKING CAUSES CANCER - Health Canada – Help to quit 1-866-366-3667*
13. SMOKING CAUSES CANCER - Health Canada - #gosmokefree

FRENCH:

1. LES FUMEURS MEURENT PRÉMATURÉMENT – Santé Canada
2. CHAQUE BOUFÉE NUIT À VOTRE SANTÉ – Santé Canada*
3. LA FUMÉE DU TABAC EST TOXIQUE – Santé Canada
4. AVERTISSEMENT : PRODUIT QUI CRÉE UNE DÉPENDANCE – Santé Canada
5. FUMER CAUSE LE CANCER DE LA BOUCHE – Santé Canada
6. FUMER CAUSE LE CANCER DU REIN – Santé Canada
7. FUMER CAUSE DES CATARACTES – Santé Canada
8. FUMER BLOQUE VOS ARTÈRES – Santé Canada
9. FUMER CAUSE DES MALADIES MORTELLES – Santé Canada
10. FUMER ENDOMMAGE VOS POUMONS – Santé Canada*
11. Aide à arrêter 1 866 JARRETTE – FUMER CAUSE LE CANCER
12. FUMER CAUSE LE CANCER – Santé Canada – Aide à arrêter 1 866 JARRETE*
13. FUMER CAUSE LE CANCER – Santé Canada - #vivezsansfumee

HEALTH WARNINGS – GROUP C

ENGLISH:

1. SMOKING KILLS - Health Canada*
2. OVER 7000 CHEMICALS PER PUFF - Health Canada*
3. WARNING: TOBACCO SMOKE IS TOXIC - Health Canada
4. THIS PRODUCT IS ADDICTIVE - Health Canada*
5. SMOKING CAUSES THROAT CANCER - Health Canada
6. SMOKING CAUSES BLADDER CANCER - Health Canada
7. SMOKING CAUSES STROKE - Health Canada
8. SMOKING CAUSES HEART DISEASE - Health Canada
9. SMOKING DAMAGES YOUR WHOLE BODY - Health Canada
10. SMOKING DAMAGES YOUR EYES - Health Canada
11. Gosmokefree.gc.ca/quit – Health Canada – SMOKING CAUSES CANCER
12. SMOKING CAUSES CANCER - Health Canada – gosmokefree.gc.ca/quit
13. SMOKING CAUSES CANCER - Health Canada - #breakitoff

FRENCH:

1. FUMER TUE – Santé Canada*
2. PLUS DE 7000 PRODUITS CHIMIQUES PAR BOUFÉE – Santé Canada*
3. AVERTISSEMENT : LA FUMÉE DU TABAC EST TOXIQUE – Santé Canada
4. CE PRODUIT CRÉE UNE DÉPENDANCE – Santé Canada
5. FUMER CAUSE LE CANCER DE LA GORGE – Santé Canada
6. FUMER CAUSE LE CANCER DE LA VESSIE – Santé Canada
7. FUMER CAUSE DES AVC – Santé Canada
8. FUMER CAUSE DES MALADIES CARDIAQUES – Santé Canada
9. FUMER ENDOMMAGE TOUT VOTRE CORPS – Santé Canada*
10. FUMER ENDOMMAGE VOS YEUX – Santé Canada
11. Vivezsansfumee.gc.ca/abandon – FUMER CAUSE LE CANCER
12. FUMER CAUSE LE CANCER – Santé Canada – vivezsansfumee.gc.ca/abandon
13. FUMER CAUSE LE CANCER – Santé Canada - @jetelaisse

HEALTH WARNINGS – GROUP D

ENGLISH:

1. SMOKING CAUSES CANCER - Health Canada
2. TAR IN EVERY PUFF - Health Canada*
3. TOBACCO SMOKE HARMS CHILDREN - Health Canada*
4. NICOTINE IS HIGHLY ADDICTIVE - Health Canada*
5. SMOKING CAUSES ORAL CANCER - Health Canada
6. SMOKING CAUSES LIVER CANCER - Health Canada
7. SMOKING CAUSES IMPOTENCE - Health Canada
8. SMOKING CAUSES COPD - Health Canada
9. SMOKING DAMAGES YOUR ORGANS - Health Canada*
10. SMOKING DAMAGES YOUR SKIN - Health Canada
11. Quitsmoking.ca - Health Canada – SMOKING CAUSES CANCER*
12. SMOKING CAUSES CANCER - Health Canada – Canada.ca/quit
13. SMOKING CAUSES CANCER - Health Canada - @CANquit

FRENCH:

1. FUMER CAUSE LE CANCER – Santé Canada
2. DU GOUDRON EN CHAQUE BOUFÉE – Santé Canada*
3. LA FUMÉE DU TABAC NUIT AUX ENFANTS – Santé Canada
4. LA NICOTINE CRÉE UNE FORTE DÉPENDANCE – Santé Canada
5. FUMER CAUSE LE CANCER BUCCAL – Santé Canada
6. FUMER CAUSE LE CANCER DU FOIE – Santé Canada
7. FUMER CAUSE L’IMPUISSANCE – Santé Canada
8. FUMER CAUSE DES MPOC – Santé Canada
9. FUMER ENDOMMAGE VOS ORGANES – Santé Canada*
10. FUMER ENDOMMAGE VOTRE PEAU – Santé Canada
11. Jarreteletabac.ca – Santé Canada – FUMER CAUSE LE CANCER*
12. FUMER CAUSE LE CANCER – Santé Canada – Canada.ca/abandon*
13. FUMER CAUSE LE CANCER – Santé Canada - @jarrete*

Looking at the lists of health warnings above, it should be noted that health warnings that were short and direct were considered most memorable. In terms of messaging, a few common elements are noted. Specifically, health warnings that spoke of a broad health effect (i.e., on the body or organs: health warnings C9 and D9) were generally considered impactful. At the same time, those that identified death as the ultimate consequence of smoking (e.g., health warnings A9, B1, C1), or that suggest suffering (e.g., health warning A9) grabbed the attention of participants.

Health warnings that suggested the harm caused by each puff or the risk involved every time someone who smoke put a cigarette to their mouth (e.g., health warnings A2, B2, C2 and D2) were considered highly effective reminders of the health risks associated with smoking. More so, these health warnings were typically ones that they had not heard before. To a lesser extent, some of the health warnings were considered effective as they identified cancer to a body part that is in contact with the cigarette or the smoke, thus continually reminding people who smoke of the direct consequence of using the product (e.g., health warnings B5 (mouth) and B10 (lungs)).

The health warnings were generally considered credible. That said, a few adults who smoke questioned the claim that smoking has a negative health effect on body parts that are not touching the cigarette or its smoke (e.g., eyes). Some of the health warnings were also considered too vague to be believable, or providing insufficient explanation, namely, “smoking causes heart disease” (C8), “smoking damages your eyes” (C10), and “smoking causes impotence” (D7). Other health warnings felt inconsequential to participants, such as, “tar in every puff” (D2) and “warning: tobacco smoke is toxic” (C3),

Some of the health warnings were considered as presenting new or less-known information about the consequences of smoking, namely the potential to develop stomach, bladder, kidney or lip cancer, the damage to the eyes, or impotence. A few participants were also surprised to learn of the large number of chemicals contained in cigarette smoke.

The health warnings were generally considered clear and easy to understand, with a few exceptions. Specifically, some questioned the meaning or intent of using a hashtag, what the acronym “CPOD/MPOC” stood for, and what the word “cataracts” referred to. Further, some questioned how smoking damages the eyes and what the consequence or health effect from having tar in every puff would be.

To varying degrees, the various versions that included the quit help line or website were deemed as effective reminders to people who smoke. Addiction-related statements were often selected by English-speaking participants as having some impact in warning people who smoke about the risks of smoking (e.g., health warnings B4, C4 and D4). This was most commonly the case for newer or more occasional smokers.

When considering messaging inclusive of # and @, the suggestions of social media use were generally understood among youth and young adults (versus older adults), however youths were not inclined to see it as something that would prompt them to actively take part in a quit smoking social media initiative, and some found the use of a hashtag, particularly, to be outdated. Few youth who smoke had heard of the Break It Off campaign³ prior to the groups. The use of a hashtag was confusing to adults who smoke and youth who do not smoke who reportedly did not use social media.

Design Options

On-cigarette health warning designs that included icons and/or red text were considered more eye-catching.

In half of the groups, participants were shown design options for how the health warnings could be displayed on cigarettes, as shown in Figures 46 and 47 (Set ab). They were informed that each design option was presented on a cigarette with a cork-coloured filter (on the left hand-side) and on a cigarette with a white-coloured filter.

Participants were asked to focus only on the overall layout rather than the messaging. Before a brief group discussion on the various design elements, participants were asked to select up to three designs they believed are best at warning them about the health effects and health hazards of smoking.

In general, on-cigarette health warning designs that included red text and/or red icons were considered more eye-catching. Indeed, the design numbers 3, 7, 8, 10 and 11 were consistently identified across all four audiences as standing out. Not only was the colour standing out, but the presence of icons grabbed attention as they were perceived as communicating greater danger/risks.  Further, having the message in capital letters versus upper and lower case was also deemed most impactful.

By contrast, the colour blue was considered a soft, calm and positive colour, thus minimizing the negative impact of health warnings shown in that colour. Of note, participants who smoke often voiced preference for this colour in the design 5 because they found it less obtrusive and less noticeable.  Further, in Vancouver and to a lesser extent in Montreal, use of blue was associated with the Players brand.

Most participants across audiences believed that the health warnings were most visible on the cigarette with a cork-coloured filter.

Placement Options

Having a health warning printed on the cigarette filter was considered most effective in ensuring the message remains visible and top-of-mind for those who smoke. The use of the colour yellow was also considered effective at grabbing attention.

In half of the groups, participants were shown placement options for how the health warnings could be displayed on cigarettes, as shown in Figures 48 and 49 (set cd). They were informed that each placement option was presented on a cigarette with a cork-coloured filter (on the left hand-side) and on a cigarette with a white-coloured filter.

Participants were asked to focus only on the overall layout rather than the messaging. Before a brief group discussion on the various design elements, participants were asked to select up to three placement options they believed are best at warning them about the health effects and health hazards of smoking.

In general, messages positioned on cigarette filters were considered effective (e.g., placement option numbers 1, 2, 4 and 9), primarily for their lasting impression (e.g. seeing cancer or other messaging on filters in ashtrays or on the ground would reinforce the message). The filter was seen as the ‘first out of the pack’ and the ‘last remaining message’. Some also expressed concern over having ink on their mouth if printing is on the filter, making them think of the potential toxicity. This would make them pay more attention to what is printed on that part of the cigarette.  Note that participants were informed during the groups that the ink would be food-safe and perceptions regarding ink toxicity were not specifically questioned.

Designs that included bright yellow (e.g., notably placement option numbers 6 and 7) were also commonly identified as being eye-catching. Finally, many believed that the manner in which the health warning appeared in a diagonal direction on the placement option 9 means that the message would always remain visible regardless of how people who smoke hold their cigarette, thus rendering the health warning more top-of-mind.  Others, however, selected this version (option 9) as their preferred placement primarily because they considered it more visually attractive and the message less noticeable. 

Most felt that the health warnings are most visible on the cigarette with a cork-coloured filter, as the contrasting colours between the white and orange background grabs attention.

Appendices:   

Appendix A – Concept Rotation Schedule

Health Warnings for Cigarette Packages

The following table provides a description of the rotation approach by audience for the 44 Health Warnings for cigarette packaging that were reviewed:

The 44 health warnings for cigarette packages were divided into four sets, with each set including two booklets. The following provides a breakdown of health warnings by set (set A, B, C, and D):

On Cigarette Health Warnings

The 52 on cigarette health warnings were divided into four groups that each included 13 health warnings. One group was shown per focus group, following a rotation schedule. The following provides a breakdown of health warning per group (group A, B, C and D).

HEALTH WARNINGS – GROUP A

ENGLISH:

1. SMOKING CAN KILL YOU – Health Canada
2. POISON IN EVERY PUFF – Health Canada*
3. CIGARETTES CAUSE CANCER – Health Canada
4. HIGHLY ADDICTIVE PRODUCT – Health Canada
5. SMOKING CAUSES LIP CANCER – Health Canada
6. SMOKING CAUSES LUNG CANCER – Health Canada
7. SMOKING CAUSES STOMACH CANCER – Health Canada
8. SMOKING CAUSES HEART ATTACKS – Health Canada
9. SMOKING CAUSES SUFFERING AND DEATH – Health Canada*
10. SMOKING DAMAGES YOUR TEETH – Health Canada
11. QUIT HELP 1-866-366-3667 – SMOKING CAUSES CANCER – Health Canada*
12. SMOKING CAUSES CANCER – Health Canada – QUIT HELP 1-866-366-3667*
13. SMOKING CAUSES CANCER – Health Canada - #IQUIT

FRENCH:

1. FUMER PEUT ÊTRE MORTEL – Santé Canada
2. POISON EN CHAQUE BOUFÉE – Santé Canada*
3. LA CIGARETTE CAUSE LE CANCER – Santé Canada
4. PRODUIT QUI CRÉE UNE FORTE DÉPENDANCE – Santé Canada
5. FUMER CAUSE LE CANCER DE LA LÈVRE – Santé Canada
6. FUMER CAUSE LE CANCER DU POUMON – Santé Canada
7. FUMER CAUSE LE CANCER DE L’ESTOMAC – Santé Canada
8. FUMER CAUSE DES CRISES CARDIAQUES – Santé Canada
9. FUMER CAUSE LA SOUFFRANCE ET LA MORT – Santé Canada*
10. FUMER ENDOMMAGE VOS DENTS – Santé Canada
11. JARRETE 1 866 527 7383 – FUMER CAUSE LE CANCER - Santé Canada*
12. FUMER CAUSE LE CANCER – Santé Canada – JARRETE 1 866 527 7383*
13. FUMER CAUSE LE CANCER – Santé Canada - #JARRETE

HEALTH WARNINGS – GROUP B

ENGLISH:

1. SMOKERS DIE EARLY – Health Canada*
2. EVERY PUFF IS HARMFUL TO YOUR HEALTH - Health Canada*
3. TOBACCO SMOKE IS TOXIC - Health Canada
4. WARNING: ADDICTIVE PRODUCT - Health Canada*
5. SMOKING CAUSES MOUTH CANCER - Health Canada*
6. SMOKING CAUSES KIDNEY CANCER - Health Canada
7. SMOKING CAUSES CATARACTS - Health Canada
8. SMOKING CLOGS YOUR ARTERIES - Health Canada
9. SMOKING CAUSES DEADLY DISEASES - Health Canada
10. SMOKING DAMAGES YOUR LUNGS - Health Canada
11. Help to quit 1-866-366-3667 – Health Canada – SMOKING CAUSES CANCER
12. SMOKING CAUSES CANCER - Health Canada – Help to quit 1-866-366-3667*
13. SMOKING CAUSES CANCER - Health Canada - #gosmokefree

FRENCH:

1. LES FUMEURS MEURENT PRÉMATURÉMENT – Santé Canada
2. CHAQUE BOUFÉE NUIT À VOTRE SANTÉ – Santé Canada*
3. LA FUMÉE DU TABAC EST TOXIQUE – Santé Canada
4. AVERTISSEMENT : PRODUIT QUI CRÉE UNE DÉPENDANCE – Santé Canada
5. FUMER CAUSE LE CANCER DE LA BOUCHE – Santé Canada
6. FUMER CAUSE LE CANCER DU REIN – Santé Canada
7. FUMER CAUSE DES CATARACTES – Santé Canada
8. FUMER BLOQUE VOS ARTÈRES – Santé Canada
9. FUMER CAUSE DES MALADIES MORTELLES – Santé Canada
10. FUMER ENDOMMAGE VOS POUMONS – Santé Canada*
11. Aide à arrêter 1 866 JARRETTE – FUMER CAUSE LE CANCER
12. FUMER CAUSE LE CANCER – Santé Canada – Aide à arrêter 1 866 JARRETE*
13. FUMER CAUSE LE CANCER – Santé Canada - #vivezsansfumee

HEALTH WARNINGS – GROUP C

ENGLISH:

1. SMOKING KILLS - Health Canada*
2. OVER 7000 CHEMICALS PER PUFF - Health Canada*
3. WARNING: TOBACCO SMOKE IS TOXIC - Health Canada
4. THIS PRODUCT IS ADDICTIVE - Health Canada*
5. SMOKING CAUSES THROAT CANCER - Health Canada
6. SMOKING CAUSES BLADDER CANCER - Health Canada
7. SMOKING CAUSES STROKE - Health Canada
8. SMOKING CAUSES HEART DISEASE - Health Canada
9. SMOKING DAMAGES YOUR WHOLE BODY - Health Canada
10. SMOKING DAMAGES YOUR EYES - Health Canada
11. Gosmokefree.gc.ca/quit – Health Canada – SMOKING CAUSES CANCER
12. SMOKING CAUSES CANCER - Health Canada – gosmokefree.gc.ca/quit
13. SMOKING CAUSES CANCER - Health Canada - #breakitoff

FRENCH:

1. FUMER TUE – Santé Canada*
2. PLUS DE 7000 PRODUITS CHIMIQUES PAR BOUFÉE – Santé Canada*
3. AVERTISSEMENT : LA FUMÉE DU TABAC EST TOXIQUE – Santé Canada
4. CE PRODUIT CRÉE UNE DÉPENDANCE – Santé Canada
5. FUMER CAUSE LE CANCER DE LA GORGE – Santé Canada
6. FUMER CAUSE LE CANCER DE LA VESSIE – Santé Canada
7. FUMER CAUSE DES AVC – Santé Canada
8. FUMER CAUSE DES MALADIES CARDIAQUES – Santé Canada
9. FUMER ENDOMMAGE TOUT VOTRE CORPS – Santé Canada*
10. FUMER ENDOMMAGE VOS YEUX – Santé Canada
11. Vivezsansfumee.gc.ca/abandon – FUMER CAUSE LE CANCER
12. FUMER CAUSE LE CANCER – Santé Canada – vivezsansfumee.gc.ca/abandon
13. FUMER CAUSE LE CANCER – Santé Canada - @jetelaisse

HEALTH WARNINGS – GROUP D

ENGLISH:

1. SMOKING CAUSES CANCER - Health Canada
2. TAR IN EVERY PUFF - Health Canada*
3. TOBACCO SMOKE HARMS CHILDREN - Health Canada*
4. NICOTINE IS HIGHLY ADDICTIVE - Health Canada*
5. SMOKING CAUSES ORAL CANCER - Health Canada
6. SMOKING CAUSES LIVER CANCER - Health Canada
7. SMOKING CAUSES IMPOTENCE - Health Canada
8. SMOKING CAUSES COPD - Health Canada
9. SMOKING DAMAGES YOUR ORGANS - Health Canada*
10. SMOKING DAMAGES YOUR SKIN - Health Canada
11. Quitsmoking.ca - Health Canada – SMOKING CAUSES CANCER*
12. SMOKING CAUSES CANCER - Health Canada – Canada.ca/quit
13. SMOKING CAUSES CANCER - Health Canada - @CANquit

FRENCH:

1. FUMER CAUSE LE CANCER – Santé Canada
2. DU GOUDRON EN CHAQUE BOUFÉE – Santé Canada*
3. LA FUMÉE DU TABAC NUIT AUX ENFANTS – Santé Canada
4. LA NICOTINE CRÉE UNE FORTE DÉPENDANCE – Santé Canada
5. FUMER CAUSE LE CANCER BUCCAL – Santé Canada
6. FUMER CAUSE LE CANCER DU FOIE – Santé Canada
7. FUMER CAUSE L’IMPUISSANCE – Santé Canada
8. FUMER CAUSE DES MPOC – Santé Canada
9. FUMER ENDOMMAGE VOS ORGANES – Santé Canada*
10. FUMER ENDOMMAGE VOTRE PEAU – Santé Canada
11. Jarreteletabac.ca – Santé Canada – FUMER CAUSE LE CANCER*
12. FUMER CAUSE LE CANCER – Santé Canada – Canada.ca/abandon*
13. FUMER CAUSE LE CANCER – Santé Canada - @jarrete*

In addition, materials included two sets of design options for on cigarette health messages, with each focus group reviewing one set. The following provides an overview of the design option sets (set ab and cd):

Rotation Schedule for Presenting Health Warnings

The following table provides a description of the rotation approach by audience for the four sets of health warnings for cigarette packaging (set A, B, C, D), the four groups of on cigarette health warnings (set a, b, c, and d) and the two sets of on cigarette design and layout options (set ab and cd)

Appendix B - Recruitment Screener

Qualitative Testing of Revised Health Warnings for Cigarette Packages and on Cigarettes Recruitment Screener Final

• Name:
• Daytime phone:
• Evening phone:
• Cell phone:
• Email:
• Groups:  1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 – 11 – 12 – 13 – 14 – 15 – 16 – 17 – 18 – 19 – 20 - 21 – 22 – 23 – 24 – 25 – 26 – 27 – 28 – 29 – 30 – 31 – 32 – 33 – 34 – 35 – 36 – 37 – 38 – 39 - 40

FOCUS GROUPS:

Specification Summary

• Forty (40) in-person focus groups in total:
• Eight (8) English groups in each of Toronto, Halifax, and Vancouver
• Sixteen (16) French groups in Montreal
• In each group, there will be a mix of participants by smoking status (occasional and daily) and age, as per the schedule below
• In each group, mix of gender, education and ethnicity.
• All have lived in their respective market for at least two years
• Incentive: $100 per participant for groups Monday-Thursday
• Incentive: $125 per participants for groups Friday-Saturday
• 12 recruited per group
• Group discussion lasts up to 2 hours

The distribution by city and target population is the following:

INTRODUCTION

Hello/Bonjour, my name is [NAME] and I am with [RECRUITER], a Canadian market research company. We’re planning a series of discussion groups on behalf of the Government of Canada with people in your area.

Would you prefer 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."

We are looking to include people from various ages in these group discussions.

FOR YOUTH GROUPS – 15-17 YEARS OLD (SMOKERS AND NON-SMOKERS)

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

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

FOR YOUTH GROUPS – 18-19 YEARS OLD (SMOKERS AND NON-SMOKERS)

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

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

FOR YOUNG ADULTS 20-24 GROUPS (SMOKERS) AND ADULTS 25+ (SMOKERS)

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

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

SCREENER QUESTIONS: YOUNG ADULTS 20-24 SMOKERS, ADULTS 25+ SMOKERS

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

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

• Yes - 1   
• No - 2 - THANK & TERMINATE

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

• Yes - 1   
• No - 2 - THANK & TERMINATE E

6. Record gender by observation.

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

7. We are looking to include people of various ages in the group discussion. 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.”

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

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

IF YES TO ANY, THANK & TERMINATE

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

• Every day - 1 - GO TO Q11
• Occasionally - 2

VOLUNTEERED:

• Not at all - 3 - THANK & TERMINATE

10. ASK IF OCCASIONALLY IN Q9: In the past 30 days, did you smoke any cigarettes?

• Yes - 1 - [OCCASIONAL SMOKER] MAXIMUM OF 3 PER GROUP
• No - 2 - THANK & TERMINATE

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

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

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

• A little cigar or cigarillo - Yes: 1 - No: 2
• A tobacco pipe - Yes: 1 - No: 2
• Chewing tobacco, pinch or snuff - Yes: 1 - No: 2
• A tobacco water-pipe, such as a hookah, to smoke tobacco - Yes: 1 - No: 2
• An e-cigarette or vaping device - Yes: 1 - No: 2

GO TO DEMOGRAPHICS AND INDUSTRY QUESTIONS

SCREENER QUESTIONS: 15-19 YEARS OLD SMOKERS AND NON-SMOKERS

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

We are conducting a research study for Health Canada that includes youth 15 to 19 years of age. The study is being conducted to help the department develop health warnings for cigarette packaging. For this study, we’re organizing discussion groups which are scheduled to run for 2 hours in the evening (during the day if Saturday). The discussion groups involve a small number of teens who will be asked to look at health warnings, 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/$125 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.

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

Yes - 1   
No - 2    THANK & TERMINATE

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

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

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

IF YES TO ANY, THANK & TERMINATE

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

• Yes - 1
• No  - 2    THANK & TERMINATE

16. 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 - 1
• No - 2    THANK & TERMINATE
  

17. 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] is interested and feels comfortable about taking part in a group discussion. Once I’ve done that, I would like to speak to you again.

ASK YOUTH 15-19 YEARS OLD

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

YOUTH 15-19 YEARS OLD: We are conducting research with young people ages 15 to 19 for Health Canada, to help the department develop health warnings for cigarette packaging.

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

• Every day - 1 [DAILY SMOKER]
• Occasionally - 2 [OCCASIONAL SMOKER]
• Not at all - 3 [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 health warnings 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, other than the research firms.

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

• Yes - 1
• No - 2 THANK & TERMINATE

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

• Yes - 1
• No - 2    THANK & TERMINATE

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

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

IF YES TO ANY, THANK & TERMINATE

22. ASK OCCASIONAL SMOKERS ONLY BASED ON Q18: In the past 30 days, did you smoke any cigarettes?

• Yes - 1    MAXIMUM OF 3 PER SMOKER GROUP
• No - 2    THANK & TERMINATE

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

• A little cigar or cigarillo - Yes: 1 - No: 2
• A tobacco pipe - Yes: 1 - No: 2
• Chewing tobacco, pinch or snuff - Yes: 1 - No: 2
• A tobacco water-pipe, such as a hookah, to smoke tobacco - Yes: 1 - No: 2
• An e-cigarette or vaping device - Yes: 1 - No: 2

SMOKERS, GO TO DEMOGRAPHICS AND INDUSTRY QUESTIONS

 24. ASK NON-SMOKERS ONLY BASED ON Q18: Have you ever smoked cigarettes?

• Yes - 1    [FORMER SMOKER; MAXIMUM OF 4 PER GROUP]
• No - 2        

25. ASK NON-SMOKERS ONLY BASED ON Q18: 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 - 1    [AT RISK YOUTH NON-SMOKER]
• No - 2    [NON-SMOKER]

DEMOGRAPHICS AND INDUSTRY QUESTIONS

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

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

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

• Yes - 1
• No - 2    GO TO Q32

28. What is your ethnic background? RECORD

RECORD ETHNICITY:

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

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

• Yes - 1
• No - 2    GO TO Q36

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

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

31. 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

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

• Fewer than 5 - 1
• Five or more - 2 THANK & TERMINATE

33. 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 - 1
• No - 2    THANK & TERMINATE

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

• Yes - 1
• No - 2    THANK & TERMINATE

35. 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 - 1
• No - 2    THANK & TERMINATE

Invitation to Participate

Thank you. We would like to invite you to attend one of the discussion groups, which will be led by a researcher from the national public opinion research firm, Corporate Research Associates. 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/$125 to thank you for your time.

36. Are you interested and available to attend?

• Yes - 1
• No - 2    THANK & TERMINATE

Do you have a pen handy so that I can give you the address where the group will be held? It will be held at [INSERT FACILITY]. I would like to remind you that the group is at [TIME] on [DATE]. We ask that you arrive 15 minutes early, at [INSERT TIME]. At the facility, you will be asked to produce photo identification, so please remember to bring something with you (for example, a driver’s license). [16 AND OLDER 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 parent or guardian must sign and return to us in advance of the group. Now I need to talk to your parent/guardian again. Would you please put [HER/HIM] back on the phone?

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

• The discussion will last 2 hours, starting at: [INSERT TIME].
• We ask that participants arrives 15 minutes early, that is by [INSERT TIME].
• Following their participation, [INSERT NAME OF CHILD] will be given $100/$125.
• 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!

Appendix C – Moderator's Guide

Moderator’s Guide – Final

Health Warnings

Study Objectives (do not share with participants)

• To test and assess approximately 44 new health warning mock-ups and selected on-cigarette labelling options – on their own, without comparisons - to determine if the concepts:
• are noticeable;
• are credible and relevant for the target audiences;
• are in plain language and understood (in the intended way) by the target audiences;
• are culturally appropriate for the target audiences;
• are effective in informing and educating Canadians about the health hazards and health effects of tobacco use; and
• are leaving a memorable impact on the target audiences.

Introduction, 10 minutes

• Welcome: Introduce self & research firm & role as moderator (keep on time/on topic)
• Sponsor: Groups on behalf of the Government of Canada
• Length: Our discussion should last about 2 hours, excuse yourself if needed during the session
• Topic: Look at proposed new (draft) health warnings for cigarette packaging and on cigarettes themselves.
• Your Role: Share your opinions freely and honestly; no prep needed; not testing your knowledge
• Process: All opinions are important; looking to understand minority/majority of opinions; talk one at a time; interested in hearing from everyone
• Logistic: Audio/video taping for reporting; observation representing the government (mirror/video feed)
• Confidentiality: Your comments are anonymous; no names in reports; answers will not affect dealings with Government of Canada; Once finalized, the report can be accessed through the Library and Archives Canada.
• Participant Introduction: First name, who they live with, and [SMOKERS ONLY: how long have you been smoking cigarettes and how much do you smoke]; [NON-SMOKERS: do people around you - friends or close relatives, smoke cigarettes]

Cigarette Packages Health Warnings, 95 minutes

Tonight/today, we’ll be talking about the health warnings found on the front and back of cigarette packages. The focus of the discussion will be the health warnings themselves, which cigarette companies are required by law to put on all cigarette packages. We are only focussing on the health warnings today. I’ll warn you that some of the visuals I will be showing you are graphic in nature.

You may know that plain packaging has been proposed for all tobacco product packages. Plain packaging means all cigarette packages will have the same plain colour, without any design features, such as company logos or slogans.   In the future, cigarettes will not have any branding on them and will only be sold in what we will refer to as “slide-and-shell” packages. I’d like to show you an example so you can have a better idea of where the health warnings we will discuss today would appear on the packaging. We will not be discussing these plain packaging measures, only the health warnings themselves.

SHOW 3D PLAIN PACKAGE (SLIDE-AND-SHELL) AND EXPLAIN WHERE HEALTH WARNING WOULD APPEAR. [DO NOT PASS AROUND IN INTEREST OF TIME – HOLD UP ONE]

The draft health warnings that I’m going to show you are presented in a booklet that uses proposed plain package colours in place of the brand name. Again, 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 11 proposed health warnings.

DISTRIBUTE BOOKLET TO EACH PARTICIPANT AND DIRECT THEM TO THE HW TO BE DISCUSSED – ROTATE PRESENTATION ORDER OF BOOKLETS PER SCHEDULE. REMIND PARTICIPANTS TO STAY ON THE HW BEING DISCUSSED – NOT TO FLIP AHEAD.

FOR EACH HEALTH WARNING, ASK (1-2 minutes per HW):

Let’s have a look at the first health warning – I’d ask that you all take a minute to look at HW-X [Insert name of HW and explain where to find it in the booklet]. Before we discuss as a group, take a few seconds to answer four questions regarding this health warning:

• This grabs my attention
• This is believable
• This is clear and easy to understand
• This communicates a health effect of smoking

Now let’s talks about this health warning as a group.

FOR EACH HEALTH WARNING, ASK (6-7 minutes per HW):

• Who stated that this HW grabbed their attention? Why?
  • If it did not grab your attention, why?
• Did anyone think that this HW was not believable?  Why? 
  • If you did think it was believable why?
• Does the picture tell you anything without the words? If so, what does it say? If no, why not?
  • Would you understand the message/text without seeing the picture?
• Do the text and image work well together? Why/why not?
  • Is it easy to read? Ask for comments on font size and contrast.
• Is anything confusing, unclear or incomplete? Anything offensive or hurtful?
• Did you learn anything new? If so, what?
• Do you have any other suggestions to improve this health warning?

FOR THE 5 TESTIMONIAL HEALTH WARNINGS (HW14; HW30; NHW07; NHW08; NHW09), ASK:

• Do you believe that this is a real person telling his/her story? If not, why?

Now let’s have a look at another health warning. Again, remember that we are not comparing health warnings, so I will ask that you comment on the next one on its own, and not compared to those previously discussed.  REPEAT QUESTIONS FOR EACH OF THE HEALTH WARNINGS

[5 MIN] Now that you have reviewed all 11 Health Warnings…

• SMOKERS ONLY: If you were given a package with some of these health warnings when you bought your pack, would you ask for a different package with another health warning?  [probe: If so, for which type of warnings they would be more inclined to do so]
• We have seen three different layout styles. [review three layouts with HC contact on site] show three at once SHOW EXAMPLE OF EACH Do you have any comments on the design or styles?
  • Is a particular style better than another style at communicating the information? ASK FOR A SHOW OF HANDS Why?
  • Which colour combinations are the most eye-catching? ASK FOR A SHOW OF HANDS
  • Which ‘WARNING’ banner is most eye-catching? Which image layout is most eye-catching? ASK FOR A SHOW OF HANDS
• Do you have any comments on the quitline section – the area that shows a tagline, a quitline phone number and a website?
  • IF NOT MENTIONED: Is it readable? Easy to understand? Noticeable?
• ASK IN FRENCH GROUPS ONLY: Would the word “Attention” work better than “Avertissement”? Why/why not?
• You’ll see that Health Canada is mentioned on the Health warnings.  What if anything does that suggest to you?   What does the attribution mean?

[1-2 MIN] Before we wrap-up this section, I’d like you to jot down what one suggestion you have regarding the materials we just discussed. Anything for the Government of Canada to consider. I will give you a few minutes to do so. MODERATOR TO CHECK WITH BACKROOM [this is not to be included in the report]

Let’s put that aside and I will review your individual comments on my own later.

On-Cigarette Health Warnings, 15 minutes

In the future, cigarettes will only be able to be sold in regular and king sizes. They will have either white or cork filters, and will not be able to show any branding such as logos or colours. The Government of Canada is also considering printing health warnings directly on each individual cigarette. These health warnings would not replace those printed on cigarette packages. A food-safe ink would be used to print those messages. Let me show you some examples of what this might look like compared to cigarettes without health warnings. SHOW/PASS AROUND MOCK UPS WITH AND WITHOUT HEALTH WARNINGS FOR COMPARISON

[5 MIN] Let me show you a list of messages that could appear on each cigarette. DISTRIBUTE ONE LAMINATED SHEET (a, b, c or d) TO EACH PARTICIPANT – FOLLOW ROTATION ORDER PROVIDED.  I’d like you to read each statement and jot down which three messages are best at warning you about the health effects and health hazards of smoking (record number on exercise sheet) and then we will discuss them. 

Looking at the list...

• Which ones are best at warning you about the health effects and health hazards of smoking?
• Is anything confusing or unclear?
• Do you believe these statements?
• What information, if any, is new to you?
• You see a couple of statements with quit information. Would including this information directly on the cigarette help remind you of the quitline or website? Would it make you more likely to call/visit?   
• You see a statement with the hashtag (#) sign / the at (@) sign. What are they for in this context? What would you do with that information?
• [for 20-25 age group - if messages include @breakitoff ask: Have you heard of this program? (it’s a national youth smoking cessation program)

SHOW/DISCUSSION EITHER “SHEET AB” OR “SHEET BC” – NOT BOTH - FOLLOW ROTATION PROVIDED. 

[6 MIN] FOR SHEET AB: Let me show you some design options for how messages could be displayed on cigarettes. You will notice that the message printed on the cigarettes is the same so we will focus only on the design. First, quickly jot down which three designs are best at warning you about the health effects and health hazards of smoking (jot down the numbers on your exercise sheet).

• What colours, if any, catch your eye?
• Which is the easiest to read? Why is that?
  • Are there colours or lettering that make it easier or more difficult to read? How so?
• Are the health warnings noticeable on all cigarettes – whether they have a cork or white filter?
• Do the colours remind you of anything? (need to understand if they reinforce industry branding unintentionally). 
• Do you think one of these cigarettes would be less harmful than the others?
• Which one(s) do you find best at warning you about the health effects and health hazards of smoking?

At the bottom of the page, you see a few symbols on the cigarettes. 

• What do they mean in this context?
• Do they help reinforce the text message?
• Would a symbol be better placed on the filter or beside the message on the tobacco portion of the cigarette? Why is that?

[6 MIN] FOR SHEET CD:  Let me show you some placement options for how messages could be displayed on cigarettes. You will notice that the message printed on the cigarettes is the same so we will focus only on the placement of the message. First, quickly jot down which three placement options are best at warning you about the health effects and health hazards of smoking (jot down the numbers on your exercise sheet).

• Is there a layout that catches your eye? Which one and why?
• Which is the easiest to read?
• What do you think about including messages on the cigarette filter, the shaft or both – would one be more noticeable to you? To those around you?
• Which ones do you find best at warning people about the health effects and health hazards of smoking?
• Are the health warnings noticeable on all cigarettes – whether they have a cork or white filter?
• Do you have any other suggestions for how messages could be displayed directly on cigarettes?

  [2 MIN] ASK ALL GROUPS:

• Now that you have seen all of the different health warnings, what is your reaction to the idea of having information printed directly on cigarettes to remind people about the health effects and health hazards of smoking?
  • Does it make them more, less or as attractive as cigarettes without health warnings on them? Why? IF NOT MENTIONED: Does it make you want to pick it up or curious about trying it? Why/why not?
  • ASK SMOKERS IF NOT MENTIONED: How would you feel being seen smoking these cigarettes?

[2 MIN] Before we finish up, I’d like you to jot down any final considerations you might have for the Government of Canada as it considers putting health warnings on cigarettes.. I will give you a few minutes to do that. MODERATOR TO CHECK WITH BACKROOM

In the interest of time, I will review your suggestion on my own later.

Thanks & Closure

That concludes our discussion. On behalf of the Government of Canada, thank you for your time and input.

First Name:

• Health Warning 1
  • This grabs my attention
  • This is believable
  • This is clear and easy to understand
  • This communicates a health effect of smoking
    • Yes
    • No
• Health Warning 2
  • This grabs my attention
  • This is believable
  • This is clear and easy to understand
  • This communicates a health effect of smoking
    • Yes
    • No
• Health Warning 3 
  • This grabs my attention
  • This is believable
  • This is clear and easy to understand
  • This communicates a health effect of smoking
    • Yes
    • No
• Health Warning 4 
  • This grabs my attention
  • This is believable
  • This is clear and easy to understand
  • This communicates a health effect of smoking
    • Yes
    • No
• Health Warning 5 
  • This grabs my attention
  • This is believable
  • This is clear and easy to understand
  • This communicates a health effect of smoking
    • Yes
    • No
• Health Warning 6 
  • This grabs my attention
  • This is believable
  • This is clear and easy to understand
  • This communicates a health effect of smoking
    • Yes
    • No
• Health Warning 7 
  • This grabs my attention
  • This is believable
  • This is clear and easy to understand
  • This communicates a health effect of smoking
    • Yes
    • No
• Health Warning 8 
  • This grabs my attention
  • This is believable
  • This is clear and easy to understand
  • This communicates a health effect of smoking
    • Yes
    • No
• Health Warning 9 
  • This grabs my attention
  • This is believable
  • This is clear and easy to understand
  • This communicates a health effect of smoking
    • Yes
    • No
• Health Warning 10      
  • This grabs my attention
  • This is believable
  • This is clear and easy to understand
  • This communicates a health effect of smoking
    • Yes
    • No
• Health Warning 11      
  • This grabs my attention
  • This is believable
  • This is clear and easy to understand
  • This communicates a health effect of smoking
    • Yes
    • No
• Comments
• Messages
• Design / Placement
• Comments

Footnotes

1. Actual person’s name
2. The name Tarbox is an actual person’s surname.
3. Break It Off, funded by Health Canada and run by the Canadian Cancer Society, is a smoking cessation campaign targeting young adult smokers to end their relationship with smoking.