Abstract
BackgroundGraphic health warnings on tobacco packaging and the plain packaging of tobacco products are key tobacco control interventions. This systematic review investigates the perceptions of adolescents towards these packaging interventions.MethodsPublished, original-research, English-language articles from 1 January 2000 to 1 September 2017 were identified through a systematic literature search of the PubMed, CINAHL, PsycINFO, Web of Science, and Scopus databases. Articles describing investigations into the perceptions of adolescents aged 11 to 19 years towards graphic health warnings and/or plain-packaged cigarettes were included in this review.ResultsNineteen articles, involving 15,935 adolescent participants, of which 72.85% were non-smokers or ex-smokers and 27.15% occasional or daily smokers, met the eligibility criteria. Graphic health warnings were perceived as more effective than text-only warnings, with warnings depicting lung cancer, and oral diseases being perceived as particularly effective. Health warnings increased viewer fear, anxiety, shock, and guilt and were considered effective in preventing non-smokers from experimenting with tobacco and prompting current smokers to quit. Plain packaging reduced the attractiveness and other positive attributes of cigarette packaging, with darker colours found to be the most effective. When used in combination, plain packaging increased the visibility of graphic health warnings, with participants also perceiving them as having an increased tar content and having more serious health risks, and increased thoughts of quitting amongst smokers.ConclusionsGraphic health warnings and plain packaging appear to increase adolescent awareness of the dangers of tobacco use. Further research into the most effective warnings to use in combination with plain packaging is needed to ensure the greatest reduction in tobacco use and prevent tobacco-attributable morbidity and mortality in this vulnerable population.
Highlights
Graphic health warnings on tobacco packaging and the plain packaging of tobacco products are key tobacco control interventions
Other reasons for exclusion included the presentation and evaluation of text-only warnings on tobacco products, studies which did not gather self-reported adolescent participants’ perceptions, studies that did not include graphic health warnings (GHW) and plain packaging (PP) perceptions as their primary outcome measure, and studies which asked participants to recall warnings they had seen in day-to-day life
Graphic health warnings Graphic image versus text warnings Nine studies in this review reported on adolescent perceptions on the effectiveness of text warnings compared to GHWs [26,27,28, 30, 31, 34] and/or between different GHWs on cigarette packaging [28,29,30,31,32,33,34]
Summary
Graphic health warnings on tobacco packaging and the plain packaging of tobacco products are key tobacco control interventions. Multiple forms of cancer and cardiovascular and respiratory diseases are the adverse outcomes of greatest concern, with their risk and severity being influenced by individual patient factors, alongside the cumulative (2019) 8:25 contributes to the majority of active adult smokers having started smoking during their teenage years [7, 8] This issue is compounded by a long history of tobacco industry marketing tactics targeting adolescents and young adults in preference over older adults, as they are vital to the survival of the industry as the ‘generation’ of smokers [9,10,11,12]. The use of attractive packaging, filters, and variant descriptors such as ‘light’, ‘mild’, and ‘smooth’ have been shown to create misconceptions amongst both smokers and non-smokers on the relative safety of different cigarette brands and variants within brands [9,10,11]
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