Balancing fear with hope: A more effective way of promoting smoking cessation?

For decades, tobacco companies used on-pack branding to evoke images of femininity, ruggedness, comfort, success and acceptance. These brand personalities appealed to particular groups of people and fostered strong emotional connections with “their” tobacco brand.^1-4 Plain packaging removed these branding symbols and replaced iconic imagery with dissuasive colours and large pictorial warning labels (referred to as graphic images/images).^5-9 The images typically feature diseased body organs showing the serious harms caused directly by smoking; they aim to educate people about the dangerous effects of smoking, encourage quit attempts among those who smoke, and prevent young people from starting to smoke.

Evaluations of these graphic images show these have prompted people to quit smoking, helped make smoking seem less normal, and contributed to decreases in smoking rates seen in many countries.^10-12 However, people who feel unable to quit may discount or ignore the warnings and try to convince themselves that the risks shown do not apply to them.¹³

Policy makers can address these reactions by balancing the negative emotions aroused by the graphic images with positive messages that aim to inspire confidence and hopefulness.¹⁴ Efficacy inserts, adopted by Canada more than two decades ago, recognise that some people who smoke could be more likely to make a quit attempt if packaging also offered advice that made quitting easier or showed the many benefits of becoming smokefree. In Canada, tobacco packaging includes efficacy inserts, small cards that feature practical tips on quitting and reinforce the benefits that will follow. Studies of efficacy inserts suggest people who read these more often feel more confident about quitting and have stronger beliefs that becoming smokefree will bring benefits, relative to people who read these inserts less often.¹⁵ 

New research in Aotearoa

Recently, we explored what people in Aotearoa New Zealand who smoke think about efficacy labels and asked them to develop labels they felt would be helpful.¹⁶ Our participants strongly endorsed efficacy labels, which they saw as messages of hope and encouragement that would motivate and empower people to think about quitting. They thought efficacy labels would be more likely to support quit attempts than the negative images currently on tobacco packages. 

We identified two main themes that could inform new policies. First, participants felt efficacy labels created a “safety net” and offered hope, while the graphic images alone seemed, in the words of one participant, “all bad news”. Feeling hopeful built confidence that quitting was possible, created an action pathway, and helped participants move beyond feeling judged or ashamed about smoking. Efficacy labels saw people who smoked not as irresponsible, or having made bad choices, but as complex and valuable human beings who shared the same aspirations as people who did not smoke. These messages valued people, acknowledged how difficult quitting can be, and created confidence that meeting the challenge would bring positive change. The second theme focussed on the agency people require to quit smoking. Some participants had tried many times to quit and valued practical advice that would help them complete their cessation journey and become smokefree. 

Participants also thought that existing graphic images, which have not been updated since their introduction in 2018, have become less noticeable and convincing over time.¹³ As we have previously noted, reviewing the images so these incorporate more diverse and culturally relevant themes could make labels more trustworthy and more effective in encouraging people to quit.^13,17

Aotearoa’s smokefree goal of reducing smoking prevalence to less than five percent among all population groups is now unlikely to be achieved. The repeal of the endgame measures introduced in the Smokefree Environments (Regulated Products) Amendment Act created a policy vacuum.¹⁸ While other countries, such as Australia, are following Canada’s example,¹⁹ Aotearoa has failed to replace the repealed measures with any meaningful substitute. Current policy settings are missing an opportunity to make the images more meaningful and effective, and failing to provide people who smoke with support that could increase their chances of quitting. 

Policy makers could draw on these findings, alongside evidence from Canada, and follow Australia’s initiative by introducing efficacy labels and developing new images that illustrate smoking’s harmful effects on people’s financial wellbeing and family connections, as well as their health. Offering positive messages and tips on quitting could complement the harsh depictions of smoking’s harms shown in graphic images, reduce the negative judgment people who smoke feel, and create the confidence and resilience needed to quit for good.

Authors details 

Prof Janet Hoek, Co-Director of ASPIRE Aotearoa Research Centre, and Department of Public Health, University of Otago Wellington | Ōtākou Whakaihu Waka, Pōneke 
Lani Teddy, Research Fellow,  ASPIRE Aotearoa Research Centre, and Department of Public Health, University of Otago Wellington | Ōtākou Whakaihu Waka, Pōneke