Qualitative Testing of Health Messages for Tobacco Promotions

Health Canada

Final Report

July 2023

Prepared for:
Health Canada
Supplier name: Quorus Consulting Group Inc.
Contract award date: January 6, 2023
Delivery date: July 2023
Contract amount (incl. HST): $89,925.40
Contract #: CW2267531
POR number: 089-22

For more information, please contact:
cpab_por-rop_dgcap@hc-sc.gc.ca
Ce rapport est aussi disponible en français.

Qualitative Testing of Health Messages for Tobacco Promotions
Final Report
Prepared for Health Canada
Supplier name: Quorus Consulting Group Inc.
July 2023

This public opinion research report is based on 15 online focus groups that Quorus completed between April 24 and May 4, 2023. Sessions were held with individuals who smoke aged 18 to 24 and 25 or older and individuals who do not smoke and who are at least 18 years of age. Focus groups spanned the country and lasted approximately 90 minutes. All participants were informed the research was for the Government of Canada. A total of 96 individuals participated in this study.

Cette publication est aussi disponible en français sous le titre : Test qualitatif des messages liés à la santé sur les promotions du tabac

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: cpab_por-rop_dgcap@hc-sc.gc.ca

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

Catalogue Number:
H14-451/2023F-PDF

International Standard Book Number (ISBN):
ISBN 978-0-660-67767-5

Related publications (registration number: POR 089-22):
Catalogue Number H14-451/2023F-PDF (Final Report, French)
ISBN 978-0-660-67768-2

^© His Majesty the King in Right of Canada, as represented by the Minister of Health, 2023

Political Neutrality Statement

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

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

Signed:

May 29, 2023
Rick Nadeau, President
Quorus Consulting Group Inc.

Table of Contents

• Executive summary
• Qualitative research results
• Detailed Results
• Research purpose and objectives
• Qualitative research results
• Tobacco promotions – general discussion
• Draft warning / health message testing
• Most effective health warning / health message
• Draft warning / health message size
• Draft warning / health message placement
• Methodology
• Target audience and sample frame
• Description of data collection procedures
• Appendices
• Appendix A: Recruitment Screener
• Appendix B: Moderation Guide

Executive summary

Background and research objectives

Tobacco use continues to be the leading preventable cause of illness and premature death in Canada. While tobacco use has decreased, a significant number of Canadians still use tobacco. Approximately 48,000 Canadians die each year from tobacco use. The health and economic costs associated with tobacco use in Canada were estimated at $12.3 billion in 2017, with direct health care costs of $6.1 billion.

Under the Tobacco and Vaping Products Act (TVPA), tobacco promotion is restricted, but not prohibited. Some tobacco companies voluntarily apply health-related messages, but are not required to do so. Since 2020, a health warning must be conveyed on vaping product advertisements under the TVPA's Vaping Products Promotion Regulations.

Canada is a Party to the World Health Organization Framework Convention on Tobacco Control (FCTC), an international treaty that addresses a wide range of tobacco issues. Canada is not yet fully compliant with its obligations relating to tobacco advertising, promotion and sponsorship, as it does not "require that health or other appropriate warnings or messages accompany all tobacco advertising and, as appropriate, promotion and sponsorship", contrary to Article 13, paragraph 4, of the FCTC.

To inform future direction, Health Canada was interested in exploring the following elements for health-related messages that could appear on tobacco promotions:

• Message Size (percentage of the total surface area of the advertisement and promotion)
• Message Placement (location of the health message on the advertisement and promotion)
• Typography of Message (typeface and point sizes)
• Message Colours
• Message Content

Research objectives

The objective of the research was to gather feedback on a variety of draft health-related messages that could appear on tobacco promotions.

Specifically, to explore reactions to, and further the understanding of the impact of 6 draft health-related messages to determine if the concepts 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 at informing and educating Canadians about the health hazards and health effects of tobacco use; and
• memorable.

The research also gathered feedback assessing the impact of size and placement of the health-related messages on tobacco promotions.

Methodology

The research methodology consisted of 15 online focus groups with people who smoke as well as those who do not smoke in Canada. The focus groups were held between April 24 and May 4, 2023, and included individuals from across the country. Focus groups were segmented by age group and smoking status: young adults who smoke (aged 18-24), adults who smoke (aged 25 and older), and adult who do not smoke (aged 18 and older). Each focus group session lasted approximately 90 minutes. Participants were informed upfront that the research was being conducted on behalf of Health Canada and they each received an honorarium of $125 for their participation. In total, 96 individuals participated in the research.

Qualitative research results

Tobacco promotions – general discussion

At the beginning of each session, participants were asked if they had any personal experience where they recalled seeing promotions for tobacco products in the recent past. Overall, very few participants recalled seeing any sort of advertising for a tobacco product over the past few years. Among the very few who did recall seeing advertisements for tobacco products, they included the following:

• Advertising for "natural tobacco" on public transportation in the Vancouver area
• Online advertising for "knock off versions" of name brand cigarettes
• Online advertising for cigarette products available from Indigenous reserves

These advertisements were described by participants as ordinary, featuring mostly an image of the product. As well, they did not seem to recall seeing a health message or warning on the advertisement.

Health Warning/ Message Concepts

Participants were presented with six draft concepts developed by Health Canada. The draft concepts can be found in the detailed results section of the full report.

Each concept was presented and discussed individually. The order in which the concepts were shown changed from one session to the next.

Feedback and reactions were very consistent across regions and across the three target segments. The key strengths and weaknesses of each concept are presented below.

Concept 1 – Wondering about vaping?

Key strengths:

• The yellow background was eye-catching
• Effective formatting and visibility of "Wondering about vaping?"
• Considered relevant among a few participants who had used vaping to help them reduce their use of tobacco

Key weaknesses:

• The concept was considered to contain too much text
• The message lacked credibility – many participants believed that there wasn't enough research on the health effects of vaping to make any conclusions, and few seemed to believe that vaping is genuinely less harmful than smoking cigarettes
• The message seemed contradictory – on the one hand the message encourages vaping while on the other it discourages vaping
• Too many font variations were used
• The concept was perceived to be lacking an effective image, or that the image used (a large white question mark) is weak

Concept 2 – Impotence

Key strengths:

• Effective at capturing attention, the image was particularly effective at drawing attention
• Effective use of colour, including an impactful use of "Warning"
• Short text with a simple message was seen as effective
• The message was considered informative for some
• The concept was considered humourous by many. The approach was considered to be refreshing coming from a Government department and for a tobacco health warning

Key weaknesses:

• The concept has a narrow target audience – the concept only focuses on men's health
• The concept lacked some credibility among men who have not experienced what the message conveys
• Some participants felt the humourous approach to relay a serious message weakens the overall intent of the message
• A few participants felt there are probably more serious health impacts related to tobacco use that should be prioritized

Concept 3 – Quitting can help you get closer.

Key strengths:

• Participants appreciated an approach that uses positive reinforcement in an effort to reduce tobacco use
• Participants liked the approach as a reminder of how using tobacco can also impact the health of others. This connected with people who smoke, in particular with older participants

Key weaknesses:

• The visual appeal was considered moderate to weak overall
• Many participants did not understand or were not clear what the tag line "Quitting can help you get closer meant.
• Many did not understand the connection between the two sentences in the message. Most recommended removing the tagline "Quitting can help you get closer" entirely.
• The image was not well received – some felt using an image of an adult/ grandparent playing in the park with their child/grandchild would be more appropriate.
• Some participants who smoke did not believe that smoking hindered their ability to get close with others.

Concept 4 – Protect your baby

Key strengths:

• Effective use of image and colour to draw attention
• Strong layout and formatting of text which consisted of a short, impactful title, followed by a short and simple health-related message accompanied by a clear and an image that generated an emotional response
• Considered the best formatting approach for the contact / quit line information
• Resonated with participants even if they are not pregnant

Key weaknesses:

• A few felt it was focused on a very narrow target audience: pregnant women
• Seemed by some to be communicating information that should be well known
• Some confusion around whether the message also applied to health effects related to second-hand smoke exposure. Making this clear could make the concept more impactful since it broadens overall relevance.

Concept 5 – Difficulty concentrating?

Key strengths:

• Message on mental health was seen by many to be very relevant
• The message about impact of smoking on concentration was considered new information for some participants

Key weaknesses:

• Not effective from a visual standpoint, including a poor image selection
• The concept was not perceived to be effective at appearing as a warning
• The concept was considered to be more like an ad completely unrelated to harms related to smoking cigarettes (for instance, a tutoring service)
• The concept was not considered believable by most participants who smoke – in their opinion, smoking actually helps them concentrate
• The link to concentration was not seen as a sufficiently serious subject to be part of a health warning related to tobacco use

Concept 6 – Cigarettes aren't attractive as you think

Key strengths:

• Very effective at capturing attention
• Many participants were immediately drawn to the image, especially the mouth
• The approach to use a "checklist" was seen as effective

Key weaknesses:

• Image was perceived as fake or exaggerated by several participants, which weakened the credibility of the message
• The second sentence was considered unnecessary
• Few seemed to believe that there are people who consider cigarettes "attractive", which weakens the impact of the first sentence
• Many participants who smoke and some who do not smoke felt they recognized this concept and felt that something new would be needed to get their attention or have a meaningful impact
• Some felt the message should refer to more serious health impacts of tobacco use

At the end of review of concepts, participants were asked which concepts were most effective at drawing their attention and effective at informing them of the health impacts of tobacco use. Participants almost always selected concepts 2, 4 and 6 as the ones that were the most effective at drawing their attention away from the tobacco ad and as the ones that had the most impact on them.

The quit line information included on each of the concepts was noticed by most participants. While few would see themselves calling the quit line or accessing the cessation web site, most felt the information was important to include. The approach could be further improved by adding a QR code.

Almost all participants felt that including an image in the concept was an important factor in its effectiveness at catching their attention and making them want to read the content of a health warning.

Health Warning / Message Size

Participants were quickly shown three versions of the same concept one at a time, with the size of the health warning/message increasing each time. The sizes of health warning/messages took up 30%, 35%, and 40% of the space of the advertisement. The presentation of the three approaches was always the same, starting with the smallest footprint and ending with the largest of the three. These mock-ups can be found in the detailed results section of the full report.

Many did not feel that the health warning/message with the larger size have a significant impact on the noticeability or ease of reading of the concept. However, if they were to choose, the largest health warning/message approach was considered by most to be the most noticeable and the easiest to read.

Health Warning / Message Placement

Participants were quickly shown two versions of a concept one at a time, each with a different placement of the health warning/message. One with the health warning displayed at the top of the advertisement and another with the health warning displayed within and at the right side of the advertisement. The order of presentation of the two approaches alternated from session to session. These mock-ups can be found in the detailed results section of the full report.

Reactions to the two approaches were mixed with most gravitating to the approach with the health warning/message displayed at the top of the advertisement as the more effective approach. Those who preferred this approach felt it looked more like a "warning" and, because they are naturally inclined to read from top-to-bottom, this approach had them notice the warning before the tobacco advertisement portion. They also felt that the approach with the health warning/message imbedded within the advertisement seemed to make it look like the tobacco warning was a sticker or an afterthought whereas the vertical approach clearly shows the warning as a separate and distinct element at the top.

Those who preferred the health warning/message imbedded within the advertisement felt like that the warning appeared larger in that format and made it both more noticeable and easier to read. They also liked that the warning appears to overtake the visual elements of the tobacco advertisement.

Qualitative research disclaimer

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.

Detailed Results

Research purpose and objectives

Tobacco use continues to be the leading preventable cause of illness and premature death in Canada. While tobacco use has decreased, a significant number of Canadians still use tobacco. Approximately 48,000 Canadians die each year from tobacco use. The health and economic costs associated with tobacco use in Canada were estimated at $12.3 billion in 2017, with direct health care costs of $6.1 billion.

Under the Tobacco and Vaping Products Act (TVPA), tobacco promotion is restricted, but not prohibited. For example, tobacco promotions can appear in publications addressed and sent to a named adult (including online communications) or in places where young persons are legally not allowed to enter, such as casinos and bars. Some tobacco companies voluntarily apply health-related messages, but are not required to do so. As a result, adults may be exposed to tobacco promotions without being informed about the health hazards associated with tobacco use. Since 2020, a health warning must be conveyed on vaping product advertisements under the TVPA's Vaping Products Promotion Regulations.

Canada is a Party to the World Health Organization Framework Convention on Tobacco Control (FCTC), an international treaty that addresses a wide range of tobacco issues. Canada is not yet fully compliant with its obligations relating to tobacco advertising, promotion and sponsorship, as it does not "require that health or other appropriate warnings or messages accompany all tobacco advertising and, as appropriate, promotion and sponsorship", contrary to Article 13, paragraph 4, of the FCTC.

Health Canada was interested in exploring the following elements for health-related messages that could appear on tobacco promotions:

• Message Size (percentage of the total surface area of the advertisement and promotion)
• Message Placement (location of the health message on the advertisement and promotion)
• Typography of Message (typeface and point sizes)
• Message Colours
• Message Content

Research objectives

The objective of the research was to test a variety of health-related messages that could appear on tobacco promotions.

Specifically, to explore reactions to, and further the understanding of the impact of 6 draft health-related messages to determine if the concepts 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 at informing and educating Canadians about the health hazards and health effects of tobacco use; and
• memorable.

The research also gathered feedback assessing the impact of size and placement of the health-related messages on tobacco promotions.

Qualitative research results

Tobacco promotions – general discussion

At the beginning of each session, participants were asked if they recalled seeing promotions for tobacco products recently. Overall, very few participants recalled seeing any sort of advertising for a tobacco product over the past few years. Some of the few who shared about tobacco advertising they could recall mentioned advertisements or sponsorships they could remember from several years ago.

Among the very few who did recall seeing something, they tended to be the following:

• Advertising for "natural tobacco" on public transportation in the Vancouver area
• Online advertising for "knock off versions" of name brand cigarettes
• Online advertising for cigarette products available from Indigenous reserves

These ads were described by participants as ordinary, featuring mostly an image of the product. As well, they did not seem to include any sort of health message or warning.

Additionally, one participant faintly remembered seeing a cigarette poster in a corner store and another an ad in a bar.

Draft warning / health message testing

In this exercise, participants were presented with six draft concepts developed by Health Canada. Each concept was presented and discussed individually.

For each concept, follow up questions were used to evaluate the following:

• Whether the message was clear and easy to understand
• Credibility of the message
• Relevance of the message
• Whether anything new or useful was learned from the message
• Whether the message prompted thoughts about the health hazards of using tobacco
• Whether the message prompted thoughts about quitting or reducing tobacco use (for participants who smoke)

The order in which the concepts were shown changed from one session to the next.

Feedback and reactions to the concepts were very consistent across regions and across the three target segments.

Concept 1 – Wondering about vaping?

From a visual perspective, many considered this concept effective at capturing attention, particularly with the yellow background, red font, and the tagline "Wondering about vaping?" which some said draws their eyes more to the warning than to the advertisement below. Participants felt the formatting and visibility of the tagline were effective.

The message conveyed in this health warning was considered accurate among a few participants who had used vaping to help them reduce their use of tobacco.

One participant perceived the message as a good reminder of the harmful chemicals in cigarette smoke.

"I feel like the whole 'you will immediately reduce your exposure to harmful chemicals' is a reminder of what you're actually smoking." – Female, 24, person who smokes, New Brunswick

On the other hand, those who shared criticism for this concept felt that the message was too wordy and looked busy. From a visual perspective, some felt that there were too many font variations, and it lacked an eye-catching image. The use of both red and black font within the same sentence was also confusing to some.

The message was said to be contradictory by some. These participants felt that the message was encouraging vaping while simultaneously discouraging vaping. A few felt that the message was a strange way of encouraging quitting smoking, and the message should focus on quitting entirely rather than substituting smoking cigarettes with vaping. A few voiced both surprise and concern that this advice is coming from Health Canada.

While some participants who had used vaping to reduce their use of tobacco felt the message was credible, many participants were skeptical, suggesting that there has not been enough research done on the health effects of vaping. Among people who smoke as well as those who do not smoke, many stated that in their opinion, vaping is just as harmful as smoking cigarettes. Thus, they felt the message lacked credibility.

Despite the effectiveness of the use of colour, many participants felt this concept was not particularly engaging or relevant. A few participants expressed that if they saw this warning on an advertisement, they would ignore it after reading the tagline "wondering about vaping" as they would lose interest.

Despite being considered "wordy", the concept was typically considered to be clear and easy to understand.

For most, the concept did not effectively convey the health hazards of using tobacco products and few participants who smoke felt it prompted thoughts about quitting or reducing tobacco use.

Concept 2 - Impotence

From a visual perspective, this concept was said to be very effective at capturing attention, especially due to the "provocative" image used. The image effectively grabbed attention and encouraged participants to want to read the message. Most found this concept humorous, with many giggling as they discussed the image.

This concept was also effective at visually drawing attention due to the use of bright high contrasting colours and including an impactful presentation of the word "Warning". Participants liked that this concept used short messages with easy to understand text, especially when compared to some of the other concepts that had longer messages.

Some participants were not aware that impotence is a health effect associated with smoking cigarettes, and thus it was new and informative to these individuals.

As well, the humourous and "cheeky" image used was considered a refreshing approach for a Government of Canada department and for a tobacco health warning.

Conversely, some found the humourous approach weakened the overall impact by reducing the seriousness of health message. In addition, a few participants felt there are more serious health consequences related to smoking cigarettes that should be prioritized in these warnings.

"Putting a statistic or a fact like that on a box where it's supposed to be a little more serious than erectile dysfunction… They should be more so posing the cancer risks and stuff. It is only based on one gender as well… girls are still going to smoke when they see that." – Male, 21, person who smokes, Nova Scotia

In terms of the content of the health message, the concept lacked some credibility among men who indicated they have not experienced what the message conveys. As well, many participants, especially women brought up that the message has a narrow target audience as it only focuses on men's health. With that being said, a few women expressed that they could still resonate with the ad in the sense that the health consequence discussed could affect people they care about, including through second-hand smoke exposure.

Overall, almost all participants agreed that this concept caught their attention and was easy to understand.

Across the groups, there were quite a few participants who said this concept made them think about the health consequences of smoking cigarettes. With that being said, when those who smoke were asked whether this health warning would lead them to consider quitting or reducing their use of tobacco, the number who agreed was lower.

When probed, participants did not feel that this concept was stigmatising.

Concept 3 – Quitting can help you get closer

When it comes to strengths of this health message, many appreciated the positive reinforcement approach found in the message and felt this approach was different than the usual "gross" images found in many health warnings or those that only mention negative health consequences of smoking.

"I think it's a different take, a more psychological take rather than seeing how it can affect your physical health. It got my attention in terms of having never seen this type of information from Health Canada. The health warnings that I've seen, its just like gross pictures." – Female, 21, person who smokes, British Columbia

Some participants perceived the message as one that gets people thinking about how tobacco use also has an impact on others around us. This made the message more relatable and created a connection among people who smoke, especially older participants.

"It kind of makes me think of the emotional side of when you lose somebody from smoking… Usually it's more of a physical thing… but this is more like how it's going to affect the other people in your life, your loved ones." – Female, 54, person who smokes, British Columbia

A few participants liked that the concept featured family, as they felt this was important to them. One participant felt that the messaging could be improved by changing the wording to "your [daughter/son/child/grandchild] wants you to live a longer, healthier life".

Conversely, the concept created some confusion among participants, particularly when it came to the tagline. Many did not understand the meaning of "Quitting can help you get closer." It prompted many to ask, "closer to what?" As well, many participants did not understand the connection between the two sentences in the message. Most recommended removing the first line entirely.

The overall visual appeal for this concept was considered weak to moderate across all segments. There was criticism when it came to the visual elements. The image was not considered effective, with some uncomfortable or unclear what it was portraying. Some participants felt that an image of a couple would make more sense with the tagline that discusses getting closer. Some felt using an image of an adult/ grandparent playing in the park with their child/grandchild would be more appropriate and make more sense. An image featuring an older adult or grandparent would be more suitable and effective given the context of the message that encourages living a longer and healthier life.

As well, the colours used were not considered as eye-catching as other concepts shown, which made it less appealing and impactful overall.

"The colour scheme is a little different from the previous [concepts], the previous two were a little brighter. So, when I first saw this, because of the colour tones are darker, it doesn't feel like it's as impactful. Usually if it's a warning it would be brighter, like red or yellow… You don't feel that it's important." – Female, 28, person who does not smoke, British Columbia

Some participants, especially, but not limited to people who smoke, did not believe that smoking hindered one's ability to get close with others.

"I also agree that "Quitting can help you get closer" […] are the wrong words. It's making it sound like if you smoke, you're at a distance from everyone, you have no relationships… It just doesn't sound right." – Female, 47, person who does not smoke, British Columbia

"That to me is bad messaging… I think you could say if you don't smoke, you may have longer to spend with your loved ones. But to imply that [people who smoke] are not as close to their loved ones is not fair." – Female, 72, person who does not smoke, Prince Edward Island

Overall, this concept was not considered to be particularly attention grabbing.

Some considered this health message to be unclear or difficult to understand, mainly due to the tagline as well as the image used.

Credibility of the health warning was moderate to high. Those who felt it was less credible disagreed with the implications of the message, that it is harder to be close with your loved ones if you smoke, which also made this concept less likely to resonate with them.

Very few said they learned anything new from this health warning. One participant suggested that the warning could include a statistic about life expectancy which would make it more effective.

Some participants said that this concept made them think about the health hazards of smoking and for some of those who smoke, it made them think about quitting or reducing their tobacco use.

Concept 4 – Protect your baby

This concept was deemed by many to be very effective from a visual standpoint and impactful due to the message.

Visually, many participants described how the layout and formatting, consisting of a short, impactful title, followed by a short and simple health-related message accompanied by a clear and image that elicited an emotional impact worked very well. This health message was also considered to have the most effective formatting approach for the cessation contact and quit line information.

In terms of the content of this message, it was said to be impactful. The message resonated with many participants and generated an emotional response even if they themselves were not pregnant. Many participants, including some of the male participants, discussed how they want to have children at some point in the future, so they felt the message was important and effective at raising awareness of the health hazards noted.

Some weaknesses of the concept were also brought up. A few felt that the health warning was focused on a very narrow target audience: notably pregnant women. The message was also critiqued by some who felt that the message that cigarette smoke is harmful to a baby's brain and lungs should already be common sense, so the warning did not provide any new information.

"I think it's desensitized. This is something that is well known. I think that me seeing this, I get bored of the same old messages. Tell me something new about smoking, or some new stats, something. This to me is not of any interest because it is common knowledge." – Female, 47, person who smokes, Alberta

There was also some confusion around whether the message also applied to second-hand smoke exposure. Participants felt that if the message was clearer about second-hand smoke health effects, it would be more impactful to a wider audience since it broadens the overall relevance.

Overall, most participants felt that this concept caught their attention and found it easy to understand, and to be credible.

Few participants said that they learned anything new from this health warning, with many discussing that this information is well known and for most, common knowledge. With that being said, the lack of new information did not diminish the effectiveness of the message or participants' ability to resonate with the concept. Participants, especially females, relayed that this is still an important message that should be conveyed.

Many participants said that this health message made them think about the health hazards of smoking. However, when those who smoke were asked, few said that it made them consider quitting or reducing their use of tobacco.

Concept 5 – Difficulty concentrating?

This concept received mixed feedback from participants, and typically received more negative feedback than positive among most groups, particularly among younger participants.

In terms of what this concept did well, many participants liked that it brings up the subject of mental health and not just physical health, which many saw as a very relevant issue these days, especially post-pandemic.

The messages link to concentration was new information for some who were not aware of this potential health consequence of smoking cigarettes.

This message was relatable to a few participants who had smoked in the past and experienced this side effect.

"As a former smoker… It hits home to me because that is some of the stuff I experienced. I found that I would be working on something, and I would have to go for a smoke. It would break my concentration." – Male, 63, person who does not smoke, Ontario

A few participants liked the non-threatening approach of this health warning, which was a different take than many other health warnings.

Although many approved of the message's connection to mental health, several participants, particularly younger participants who smoke, did not seem to think this message was credible. In their experience, they often use cigarettes to help them concentrate, such as when studying.

As well, participants did not consider the impact of cigarettes on concentration to be a sufficiently serious health consequence which they felt weakened the effectiveness of the warning.

"When you think about all of the different negative side effects of smoking… difficulty concentrating seems a little low on the list." – Male, 65, person who smokes, British Columbia

This concept was also considered to be weak from a visual standpoint. Participants felt that this health message had poor overall visual appeal and impact. For starters, the use of colours was not as eye catching and the presentation was not perceived as a health warning when compared to some of the other concepts presented. It was generally agreed that the concepts which made use of bright colours such as yellow did a better job at drawing the viewers' eyes up to the warning instead of the advertisement.

The image received a fair amount of criticism as it was not eye catching and did not seem to relate to a health message about tobacco or cigarettes. Many felt that it did not look like a health warning and did not appear to even be related to smoking cigarettes. Some felt that it looked like an advertisement for a tutoring service, or a mobile app to help people concentrate.

Among those who smoke, this concept was typically said to be unlikely to motivate participants to decrease their use of tobacco or quit smoking, mainly because the message was not seen as a significant health risk.

"I think this is not the most severe side effect of smoking. So, if the more severe side effects of smoking haven't made me quit yet, then the concentration piece probably isn't going to put me over the edge to actually quit." – Female, 45, person who smokes, Manitoba

"Not being able to concentrate as well as I could is way less of a deterrent than somebody having lung cancer. It doesn't seem that serious." – Female, 54, person who smokes, British Columbia

One older participant said they would maybe do some research on their own to better understand the correlation between smoking and concentration, as this was new information for them. However, this participant expressed that they probably would opt to do a Google search rather than using the website or helpline provided in the message.

Overall, few said that this warning would catch their attention. As well, few felt that this health message resonated with them or that they learned anything new.

The extent to which the warning was credible was mixed, with the most skepticism coming from younger participants, particularly those who smoke. A fair number of older participants and participants who do not smoke seemed to believe that lack of concentration was a health consequence of smoking.

Concept 6 – Cigarettes aren't as attractive as you think

This concept was said to have very strong visual impact and appeal, catching the eye of the viewer and encouraging them to read the message. Specifically, many participants were immediately drawn to the image, especially the mouth area.

Participants also found the "checklist" approach used in this health message to be effective. This approach was deemed by many to be relevant health consequences related to smoking cigarettes.

On the other hand, participants also flagged several weaknesses of this health warning. Firstly, the image used was said to appear "fake" and exaggerated which weakened the credibility of the message. For example, a few discussed how the woman in the image does not look like an actual person who smokes. Some also mentioned that they recognized the image from previous health warning campaigns felt it was over-used, leading many to believe that it would not get their attention.

"The whole face thing… they used to have similar ones on the packages back in the day and I always just felt that they were almost over-exaggerated… It's like they are pushing an agenda too hard, and its not realistic." – Female, 63, person who does not smoke, Saskatchewan

Few participants seemed to believe that there are people who actually consider cigarettes "attractive", which weakens the impact of the first sentence/tagline. Additionally, when it comes to the messaging, some felt that the second sentence, "Chemicals in tobacco smoke damage your whole body," was unnecessary.

If the intent of the concept was to focus exclusively on the impact of smoking cigarettes on a person's appearance, this was not immediately understood by some participants. Some felt that the message would be more effective if it also referred to more serious health impacts in the checklist, such as cancer or lung-related diseases. Some participants, particularly in the younger groups, viewed the health consequences discussed in this warning, such as bad breath, to be "manageable", and thus, not very concerning.

Overall, most participants felt that this warning grabbed their attention and was easy to understand. Of the very few participants who felt this message was not fully clear, they typically mentioned the small font size used for the second sentence. However, once they read the message, they had no problems understanding the information presented.

Most participants did not feel that they learned anything new through this health warning.

For many participants, this health warning made them think about the health hazards of smoking. As well, for participants who smoke, many said that it made them think about quitting or reducing their use of tobacco.

Most effective health warning / health message

At the end of the review of the six messages, participants were asked which ones were most effective at drawing their attention and considered the most impactful. Participants almost always selected concepts 2 ("Impotence"), 4 ("Protect your baby") and 6 ("Cigarettes aren't as attractive as you think") as the ones that were the most effective at drawing their attention away from the tobacco advertisement and as the ones that had the most impact on them. A general trend showed that men most often selected concepts 2 ("Impotence") and 6 ("Cigarettes aren't as attractive as you think") while women most often selected concepts 4 ("Protect your baby") and 6 ("Cigarettes aren't as attractive as you think").

The quit line information was considerable noticeable by most participants, with the visual approach from concept 4 ("Protect your baby") consistently selected as the most appealing. Generally, few participants see themselves using it, however, most felt the information should be available, nonetheless. A few suggested that the approach would be further improved by adding a QR code to access the cessation information.

When asked what general approach would be most effective at catching their attention and making them read the content of a health warning, participants near-unanimously opted for an approach that combined text with an image over an approach without an image. Participants emphasized that "a picture is worth a thousand words", an image helps establish a quick connection with the reader, an image can help support the text, and an effective image can help the health warning/message better compete for attention with the creative that the tobacco company would be using in their promotion.

Draft warning / health message size

In this exercise, the impact of different health warning/message sizes was explored with participants. Participants were quickly shown three versions of the same concept (as shown below), one at a time, with the size of the health warning/message increasing each time. The sizes of the three health warning/messages took up 30%, 35%, and 40% of the space of the advertisement. The presentation order of the three approaches was always the same, starting with the smallest size of health warning, gradually increasing in size and taking up more of the advertising space.

Many participants did not feel that the difference in health warning/message size had a meaningful impact on noticeability or ease of reading the message. In other words, the size of the health warning, as presented, did not make a significant difference in how quickly they would grasp the message. Some participants said they did not notice the size difference at first viewing.

However, after more consideration the third approach was considered by most to be the most noticeable and the easiest to read due to the larger size.

"Obviously the bigger is better. I mean the bigger it is the more focus it will take away from [the advertisement]." – Male, 44, person who does not smoke, Alberta

Draft warning / health message placement

In this exercise, the impact of different placements for health warning/message within an advertisement was explored with participants. Participants were quickly shown two versions of a concept (as shown below), one at a time, each with a different placement of the health warning/message. One approach showed the health warning/message concept displayed at the top of the advertisement, while the other approach showed the health warning/message displayed in a box on the right-hand side and within the advertisement. The presentation of the two approaches alternated from session to session.

Reactions to the two approaches were mixed with most gravitating to the vertical approach – where the health warning/message was displayed at the top of the advertisement. Those who preferred that approach felt it looked more like a "warning" and also because they are naturally inclined to read top-to-bottom, this approach had them notice the warning before the tobacco advertisement. They also felt that the horizontal approach – where the health warning/message was displayed in a box within the message - seemed like the tobacco warning looked like a sticker or afterthought whereas the vertical approach clearly shows the warning as a separate and distinct element.

For some the display in the horizontal approach gave the impression that the warning is an integrated part of the tobacco advertisement which was effective and impactful for those who preferred that approach. They also perceived the warning to be larger in this format than the one in the vertical approach, which made it both more noticeable and easier to read. They also found in this format the warning appeared to overtake the visual elements of the tobacco advertisement which made this approach more effective than the vertical approach.

Methodology

All research work was conducted in accordance with the professional standards established by the Government of Canada Public Opinion Research Standards, as follows:

Quorus was responsible for coordinating all aspects of the research project including working with Health Canada in designing and translating the recruitment screener and the moderation guide, coordinating all aspects of data collection logistics, including participant recruitment, providing the online focus group platform and moderating all focus groups and delivering required reports at the end of data collection. The research approach is outlined in greater detail below.

Target audience and sample frame

The target audience for this research study consisted of individuals who smoke cigarettes from the following regions:

• Eastern Canada (NL, PEI, NS, NB, QC, ON) (English)
• Quebec (French)
• Prairies (MB, SK, AB) (English)
• Western Canada (BC, Territories) (English)
• Eastern Canada outside Quebec (NL, PEI, NS, NB, ON) (French)

Three groups were held in each region, segmented based on participants' age and smoking status:

• Individuals who smoke (age 18-24)
• Individuals who smoke (age 25+)
• Individuals who do not smoke (18+)

In the design of the recruitment screener, specific questions were inserted to clearly identify whether participants qualified for the research program and to ensure, where applicable, a good representation by age, region, gender, ethnicity and 2SLGBTQI+ status.

In addition to the general participant profiling criteria noted above, additional screening measures to ensure quality respondents include the following:

• No participant (nor anyone in their immediate family or household) was recruited who worked in related government departments/agencies, nor in advertising, marketing research, public relations, a tobacco or vaping company, a smoking cessation company, a legal or law firm, a cannabis-related company, or the media (radio, television, newspaper, film/video production, etc.).
• No participant acquainted with another participant was knowingly recruited for the same study, unless they were recruited into separately scheduled sessions.
• No participant was recruited who had attended a qualitative research session within the past six months.
• No participant was recruited who had attended five or more qualitative research sessions in the past five years.
• No participant was recruited who had attended a qualitative research session on the same general topic as defined by the Researcher/Moderator in the past two years.

Description of data collection procedures

Data collection consisted of online focus groups with individuals who smoke cigarettes as well as those who do not smoke. Each focus group lasted approximately 90 minutes.

For each focus group, Quorus recruited 8 participants with the goal of achieving 6-8 participants per session. All individuals who participated in a focus group received an honorarium of $125.

Participants invited to participate in the focus groups were recruited by telephone through random digit dialing of the general public as well as through the use of a proprietary opt-in database.

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

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

At the recruitment stage and at the beginning of each focus group, participants were informed that the research was being conducted for the Government of Canada and Health Canada. Participants were informed of the audio/video recording of their session and of the presence of Health Canada observers. Quorus ensured that prior consent was obtained at the recruitment stage and before participants began their focus group.

All sessions were conducted in the evening after regular business hours. The research team used the Zoom platform to host and record focus group sessions (through microphones and webcams connected to the moderator and participants electronic devices, such as their laptop, tablet or smartphone) enabling client remote viewing.

A total of 15 online focus groups were conducted across Canada between April 24 and May 4, 2023. The details of these groups are outlined in the table below.