Executive Summary
January 2021
Prepared for:
Health Canada
Supplier Name: Quorus Consulting Group Inc.
Contract Award Date: August 24, 2020
Delivery Date: January 2021
Contract Amount (incl. HST): $178,490.66
Contract #: HT372-202964/001/CY
POR Number: 026-20
For more information, please contact:
hc.cpab.por-rop.dgcap.sc@canada.ca
Ce rapport est aussi disponible en français.
Prepared for Health Canada
Supplier name: Quorus Consulting Group Inc.
January 2021
This public opinion research report presents the results of focus groups conducted by Quorus Consulting Group on behalf of Health Canada. The research study was done using qualitative focus groups. The research entailed a total of 28 online focus groups and 1 individual interview conducted with people who smoke cigarettes daily or occasionally, as well as youth non-smokers. The research was conducted between October 13 and November 10, 2020.
Cette publication est aussi disponible en français sous le titre : Recherche qualitative de 2020 sur les options de mises en garde sur les cigarettes
This publication may be reproduced for non-commercial purposes only. Prior written permission must be obtained from the Health Canada. For more information on this report, please contact the Health Canada at: hc.cpab.por-rop.dgcap.sc@canada.ca or at:
Department of Health
200 Eglantine Driveway
A.L. 1915C
Ottawa, Ontario
K1A 0K9
Catalogue Number:
H14-335/2020E-PDF
International Standard Book Number (ISBN):
ISBN 978-066-032511-8
Related publications (registration number: POR 026-20):
Catalogue Number H14-335/2020F-PDF (Final Report, French)
ISBN 978-0-660-32512-5
© Her Majesty the Queen in Right of Canada, as represented by the Minister of Health, 2021
I hereby certify as Senior Officer of Quorus Consulting Group Inc. that the deliverables fully comply with the Government of Canada political neutrality requirements outlined in the Policy on Communications and Federal Identity and the Directive on the Management of Communications - Appendix C.
Specifically, the deliverables do not include information on electoral voting intentions, political party preferences, standings with the electorate or ratings of the performance of a political party or its leaders.
Signed:
Rick Nadeau, President
Quorus Consulting Group Inc.
In accordance with Canada's Tobacco Strategy, the Government of Canada has announced a target of less than 5% tobacco use by 2035 to help reduce the death and disease burden associated with the use of tobacco products. Tobacco package labelling is a well-established strategy to raise awareness of the health hazards and effects associated with tobacco use. Recently, new measures to protect young persons and others from inducements to use tobacco products have also been introduced with the implementation of plain and standardized appearance measures for tobacco products and tobacco packaging.
As an extension of the current tobacco package labelling and plain and standardized appearance measures, Health Canada is exploring the concept of health warnings displayed on the filter overwrap of individual cigarettes. The objective of this measure is to protect Canadians, particularly young persons and others, from inducement to use tobacco products, and to enhance public awareness of the health hazards of using tobacco products.
This approach is novel on a global scale and the research base is currently limited, particularly in a Canadian context. Health Canada commissioned Quorus to conduct qualitative research through a series of focus groups to further explore opinions on the concept of warnings on individual cigarettes, to assess the effectiveness of specific warnings, and to assess options for how to display the warnings on cigarettes. Additionally, Health Canada is exploring new concepts for health warning labels for cigarette packages.
This report is based on 28 online focus groups and 1 individual interview that Quorus completed between October 13 and November 10, 2020. Participants were grouped according to the following segments: "Youth non-smokers" 15 to 19 year old non-smokers, "Youth" 15 to 19 year old smokers, "Young adults" 20 to 24 year old smokers, and, "Adult" smokers 25 years of age or older. In total, 188 individuals participated in the research. English sessions were conducted with participants in Toronto, Halifax/St. John's, Saskatoon/Regina, Vancouver, Nunavut and rural Alberta/Manitoba. French sessions were conducted with participants in Quebec City and Moncton.
Qualitative research is designed to reveal a rich range of opinions and interpretations rather than to measure what percentage of the target population holds a given opinion. The results are directional in nature; and the results of qualitative research are not statistically projectable to a specific target audience.
Participants were presented a series of images of what a package of cigarettes could look like in the future, including a new front-of-pack health warning concept, new placement for a health information message as an extension of the upper lip of the cigarette package and warnings displayed on the filter overwrap of individual cigarettes. Participants were first struck by the image on the cover of the package as well as by the message on the filter of individual cigarettes.
By the end of the sessions, participants had concluded that the addition of warnings on individual cigarettes made the overall health messaging on cigarette packages more complete and impactful, particularly among youth non-smokers, youth occasional smokers, or youth smokers wanting to quit smoking. Supporters of the idea explained that there cannot be enough messaging to discourage smoking. They also felt that the unavoidable placement of the messaging directly on cigarette filters will have a lasting impact on people who smoke. Conversely, when the information is limited to the package, the health warning can be placed out of sight after the cigarette has been pulled. Some youth participants also supported the idea because of the way that cigarettes are typically handed out individually in social situations, such as parties or events. In most of those situations, youth explained that they never saw the package and were not exposed to the front-of-pack health warning, while warnings directly on the cigarettes themselves might get them to think about the risks of smoking, making the cigarette less attractive.
Participants also felt there was a social element to how they reacted to the idea of messaging on each cigarette. While most smokers indicated they do not care what others around them think, there are some who do believe that the messaging will start conversations around quitting or it will be used as further ammunition for others to convince smokers to quit. There were also some specific messages tested that smokers would not want others around them seeing (e.g. Cigarettes harm sexual health; Cigarettes harm children).
Participants who smoke regularly seemed to feel that the approach was excessive, expressing that there was already enough "warning" on the package. Smokers seemed to feel that while they would definitely read the on-cigarette message the first time they saw it, they would probably ignore it moving forward. Smokers emphasized that they are aware of the health hazards of smoking and felt the additional messages on individual cigarettes would have little to no impact on their decision to continue smoking. While many young and adult smokers did not feel the messaging would have an impact on their own propensity to smoke, a few felt that it might be effective in dissuading youth from smoking. A few felt the messages would be more effective if they were motivational instead of informative, i.e. "Put it down!", "Is it worth it?", or "You can quit!"
Figure A – Series of cigarette sticks shown to participants to demonstrate what cigarettes could look like in the future
Text Description - Figure A
An image of four different cigarettes. "A" is white with a white filter, "B" is white with an imitation cork filter, "C" is white with the text "Cigarettes cause cancer" displayed horizontally on a white filter, and "D" is white with the text "Cigarettes cause cancer" displayed horizontally on an imitation cork filter portion.
The appeal and attractiveness of cigarettes with warnings was explored with all participants by presenting an image of four different cigarettes. Two of the cigarettes were displayed in a format as they are currently sold in Canada - one with a white filter and one with an imitation cork filter. The other two cigarettes are similar, however, each cigarette had a message displayed on the two types of filters. When asked which cigarette they would least want to smoke, participants were most likely to select the cigarette with the warning on the cork filter, followed by the cigarette with the warning on the white filter. The text on the cigarettes was a clear factor in determining the cigarette they would least want to smoke or be seen smoking.
Participants typically chose the white filter cigarette without a message when asked if one cigarette appeared less harmful than the others. Participants explained that it was mostly because of its simple design and that it is entirely white without a warning.
The effectiveness of specific warning messages at: 1) warning participants about the health hazards of cigarettes and, 2) dissuading them from using cigarettes, was explored with all participants. Participants were presented with the following eighteen messages that could appear on the filter end of individual cigarettes. Messages were presented in three themes for discussion purposes. The order in which these themes were presented and discussed varied from group to group.
| Theme A | Theme B | Theme C |
|---|---|---|
| A1. Cigarettes cause diseases | B1. Cigarettes cause liver cancer | C1. 7000 chemicals in every puff |
| A2. Cigarettes damage your organs | B2. Cigarettes cause emphysema | C2. Poison in every puff |
| A3. Cigarettes harm everyone | B3. Cigarettes harm sexual health | C3. Tobacco smoke contains poison |
| A4. Cigarettes cause chronic bronchitis | B4. Cigarettes cause pancreatic cancer | C4. Second-hand smoke is toxic |
| A5. Cigarettes cause cancer | B5. Cigarettes cause leukemia | C5. Each cigarette is harmful |
| A6. Cigarettes harm children | B6. Cigarettes cause lip cancer | C6. Cigarettes are addictive |
A few common reactions emerged from the messages proposed. All of the messages presented were considered at least somewhat effective by the majority of participants, both as an effective health warning and at dissuading them from smoking. Furthermore, how a message performed in terms of effectively warning someone about the health hazards of smoking tended to suggest how well it would perform in terms of being dissuasive. The better a message performed on one criteria, the better it would perform on the other.
Participants were more inclined to consider messages with "specific information" or "severe" forms of health conditions (e.g. Cigarettes cause leukemia) as more effective at warning them of the health risks and at dissuading them from smoking compared to messages that were seen as conveying more "general" information (e.g. Cigarettes cause diseases). Messages that were not only specific but also presented new information were also impactful.
Youth non-smokers tended to feel that all messages had some merit, and that all of them were believable. Smokers, irrespective of age, were more likely to suggest that certain messages would not be effective and should not be used by Health Canada. This was mostly because smokers felt the message was too general, over used, or common knowledge.
If participants did not recognize the health condition in the message, they mostly ignored it.
All of the messages were perceived as credible. The general credibility of messages was based on the perception that the information conveyed was considered either well known or established knowledge; it was something that they had heard many times before about smoking; or, because they had noticed that the message was coming from Health Canada. All age groups found Health Canada to be a recognized authority and credible source of information.
Participants, especially women and some youth, felt that A3 (Cigarettes harm everyone) and A6 (Cigarettes harm children) were effective since it made them think about the impact of smoking on those around them and not just on themselves.
The specificity of message A2 (Cigarettes damage your organs) made it a popular choice among participants who found it to be both effective at warning about the health hazards of smoking and at dissuading from smoking.
The specific nature of "chronic bronchitis" also struck a chord with some although not everyone knew what this condition was. As well, a few did not consider chronic bronchitis as a sufficiently detrimental or harmful consequence of cigarettes that would make them think twice about smoking.
Many participants ranked A5 (Cigarettes cause cancer) as an effective message, although a common sentiment was that it was a general message and did not present new information. An example of a generalized message that respondents did not consider effective was A1 (Cigarettes cause diseases).
Messages B1 (Cigarettes cause liver cancer), B4 (Cigarettes cause pancreatic cancer), B5 (Cigarettes cause leukemia), and, B6 (Cigarettes cause lip cancer) were seen as effective for the specific nature of the information they conveyed (all related to cancer). Participants would gravitate to the one they seemed to relate to the most, either because someone they know/knew had the specific form of cancer, or by personal awareness of the severity of the cancer.
Message B6 (Cigarettes cause lip cancer) was one of the most effective health warnings and dissuasive messages among women, including female youth. These participants explained that lip cancer was the only disease listed that would have an impact on their physical appearance, whereas the other diseases were seen as causing internal health conditions.
Many, especially youth smokers and non-smokers, were affected by B3 (Cigarettes harm sexual health). While many were not quite certain how cigarettes could harm their sexual health, this information was both new and relevant to them and it was not the kind of message they would want others around them seeing.
Many participants, especially youth smokers and non-smokers, did not know what emphysema was, which lessened the effectiveness of B2 (Cigarettes cause emphysema).
By far the most impactful and effective message in this group was C1 (7000 chemicals in every puff). It not only conveyed new information but also a powerful message. The number "7000" and the reference to "every puff" combined to make many participants think long and hard about cigarettes. Some smokers did call into question the credibility of the number – they felt that "7000" just seemed too perfect or too outlandish to be believable.
The messages that contained the word "poison" caught the attention of many participants although some felt that "Poison in every puff" (C2) sounded too much like a marketing slogan and therefore it came across as less serious.
Message C5 (Each cigarette is harmful) was almost always selected as a message that Health Canada should not consider, mostly because it is too general and common knowledge.
Message C6 (Cigarettes are addictive) was more likely to be considered effective among non-smokers who, when combining this information with other messages shown in this group, recognized that the harmful effects of cigarettes can persist far beyond the first cigarettes.
The format and design of how warnings on the filter of individual cigarettes could be displayed was explored with all participants. Many participants felt warnings on the cigarettes with white filters were considered easier to read than the warnings on cigarettes with cork filters. Those who disagreed tended to find that the cork filter had a "highlighting" effect on the text which made it both more noticeable and easier to read.
When asked to indicate the cigarette they would least want to smoke, participants almost always chose the cigarettes with warnings with the largest font and in bold as this combination made the messages the clearest and easiest to read, thus making them less appealing.
Cigarettes that appeared less harmful than others were almost always the cigarettes with the warnings on the white filter with the smallest or least legible text.
Participants generally felt that the Health Canada attribution added credibility to the messaging. Health Canada was seen as the organization with the most authority in Canada to which the message should be attributed. This was true even among participants who said the attribution had no impact on how they viewed the information. Only a few participants felt that Health Canada faced a risk by having their name below each message, in terms of a possible perception that it might be seen as approving the cigarette or approving smoking.
Participants were presented with four health warning (HW) concepts for cigarette packages. Most participants found the concepts were effective at informing them of the health hazards and health effects of tobacco use though overall they lacked impact due to limitations of the images. Irrespective of the concept presented, most participants believed the images need to shock them and none of the images presented did this sufficiently, mainly because they were not considered real pictures.
In terms of other label design aspects, the bright colours used on the health warning, such as the yellow background for the text and the orange background for the "WARNING" banner were considered effective at getting attention and novel compared to the designs on current cigarette packages.
In terms of the texts presented, participants expressed a clear preference for shorter texts in large fonts using impactful messaging. Many of the concepts were seen as having too much text which made them less likely to want to read it in full. As well, the main headline text needed to be specific and ideally provide new information to be impactful and draw attention.
For the most part, the information on the quitline (i.e., toll-free phone number, web address and tagline to inform of available cessation services) was considered noticeable, easy-to-read and well positioned. Many smokers were pleased to see it featured more prominently on the front of the package, in comparison with how quitline information is currently displayed on cigarette packages.
The information provided on the health warning concepts was considered credible and easy to understand.
Specific feedback for each of the draft HWs is summarized below:
General impression: This concept received mixed reviews. For reasons largely associated with the text used, some participants felt this was the least effective of the four concepts, especially older participants who were dismissive of the information since they felt this was common knowledge.
Image: While some felt that the x-ray style imagery was both new and relevant, others did not find the image to be impactful. While some appreciated the use of the colour green to represent illness or poison, many others did not think that green in the graphic was appropriate since it reminded them of nature or that "green means go." Participants were inclined to suggest that an image of an actual organ impacted by cigarette smoking would be more appropriate and impactful.
Text: The headline was not considered effective because it was too general and did not provide new information. On the other hand, the subtext was considered more insightful and should be featured more prominently. Many assumed that only the lungs were affected by smoking cigarettes so reading that chemicals enter the bloodstream and spreads to other organs was new, relevant and impactful information.
General impression: For many, this concept was the most effective of the four presented mostly because of the more "graphic" nature of the image used. Other elements that added to the effectiveness were: the specificity of the information; the information was considered new to many; the overall text was short; and, the text and image went well together.
Image: The imagery was perceived as the most graphic of all concepts tested. Nonetheless, a few participants suggested that an image of an actual stomach would be more effective at getting their attention and at dissuading them from smoking. Another suggestion to better connect smoking with stomach cancer was to include a cigarette or smoke in the image. The imagery was perceived as the most graphic of all concepts tested. Nonetheless, a few participants suggested that an image of an actual stomach would be more effective at getting their attention and at dissuading them from smoking. Another suggestion to better connect smoking with stomach cancer was to include a cigarette or smoke in the image.
Text: Most participants felt that the title was eye-catching due to the large red font of the words "stomach cancer" set on a bright yellow background. The information was considered new among most participants, and complimentary to the image as a specific message being conveyed. Although the text was easy to understand, suggesting that the disease "can grow slowly" might remove any sense of urgency around quitting smoking.
General impression: Youth felt that this concept was targeting their demographic which made the information more relevant to them. Conversely, young and adult smokers did not feel the concept was very relevant to them.
Image: Many were not clear of the message being conveyed by the image. Most felt the image should be replaced because there was no clear connection to smoking and it could apply to a variety of other common conditions or ailments (e.g. headaches, depression, etc.). A few suggested an image of a real brain would be more impactful.
Text: For some participants, the title was not very impactful since they believed that everyone is already aware cigarettes are both addictive and harmful. A few felt the title did not relate directly with the subtext. This is another concept where the subtext was found to be more interesting and impactful than the headline. The subtext also tended to be new information to participants. A few suggested that the first sentence of the subtext might actually motivate youth to smoke: "10 seconds after you take a puff, nicotine reaches your brain."
General impression: This health warning was considered the second most effective among the four concepts, based primarily on layout and colouring, while providing a cohesive relationship between the image, title and subtext.
Image: The concept of an x-ray image drew attention and was interesting to participants, and the choice of colour in the image (a shade of brown) was generally seen as more effective over the green used in concept A which had a similar image.
Text: The use of and emphasis on the word "poison" is what connected the most with participants. Otherwise, the subtext was not particularly impactful, nor did it provide participants with any new information. The line that reads "The nicotine is what keeps people smoking" seemed to some participants unrelated to the title.
There was some debate regarding whether it would be better to have the text and image in the same enclosure or if they should be in separate boxes (as in concepts B, C and D). The benefit of having them together, as in this concept, is that there it was seen to provide greater cohesiveness to the concept. The disadvantage is that some did like the visual impact of the bright colours behind the text in the other concepts.
Qualitative research seeks to develop insight and direction rather than quantitatively projectable measures. The purpose is not to generate "statistics" but to hear the full range of opinions on a topic, understand the language participants use, gauge degrees of passion and engagement and to leverage the power of the group to inspire ideas. Participants are encouraged to voice their opinions, irrespective of whether or not that view is shared by others.
Due to the sample size, the special recruitment methods used, and the study objectives themselves, it is clearly understood that the work under discussion is exploratory in nature. The findings are not, nor were they intended to be, projectable to a larger population.
Specifically, it is inappropriate to suggest or to infer that few (or many) real world users would behave in one way simply because few (or many) participants behaved in this way during the sessions. This kind of projection is strictly the prerogative of quantitative research.
Supplier Name: Quorus Consulting Group Inc.
Contract number: HT372-202964/001/CY
Contract Award Date: August 24, 2020
Contract Amount (including HST): $178,490.66
For more information, please contact Health Canada at: hc.cpab.por-rop.dgcap.sc@canada.ca