Helping smokers quit: The case for tobacco pack inserts

Since the Smokefree Environments Act was first introduced in 1990, tobacco control policy has focussed on demand-side measures, particularly tax increases, health warnings, and reducing the visibility of tobacco products in stores. The effectiveness of demand-side measures has a strong evidence base and they have played a key role in prompting the long-term declines in smoking prevalence seen in NZ until 2023,^1-4when smoking prevalence plateaued.⁵

However, despite the success and importance of demand-side measures, population groups experiencing sustained inequities caused by smoking may reject policies they perceive as didactic, or react against measures they believe constrain their “choices”.^{6, 7} People who smoke and who have not been able to quit, despite multiple attempts, may interpret current policies as increasing the pressure to quit without supporting their capacity to do so. As a result, they may discount health information, exempt themselves from the risks shown, and become less likely to make a quit attempt.^{6, 8}

These rationalisations sit uneasily alongside the high regret that a large majority of people who smoke experience; many wish they had never started smoking and would like to become smokefree.^9-11 Managing the apparent contradiction between rationalisation and regret requires new policies that encourage smoking cessation by complementing measures that deter tobacco uptake and ongoing use.

We have conducted several studies examining whether efficacy messaging – messaging that increases people’s belief they can stop smoking and emphasises the benefits of not smoking -- could complement on-pack warnings and increase the likelihood people will make quit attempts. Preliminary work involving in-depth discussions with people who smoke found they would welcome advice that could help them quit.¹² We identified themes people would find motivating, including the importance of family, the financial burden of smoking, and maintaining good health.¹² We developed these ideas into pack efficacy insert prototypes, using ideas from Canada, which has required pack inserts for more than a decade,¹³ and Australia, which has just mandated these inserts,¹⁴ and then tested responses to insert components using two discrete choice experiments.¹⁵

Above: Example of health information messages on the inside of cigarettes, little cigars, and cigarette tobacco packages mandated in Canada. Source: Health Canada, 2026. Reproduced with the permission of the Minister of Health, 2026.

Our sample of 970 respondents included people who smoked daily or weekly, or who had recently quit smoking; we oversampled Māori respondents so we could compare response patterns from Māori and non- Māori respondents. Respondents evaluated sets of inserts that compare themes (price, health or family); headline styles (questions or statements) and message formats (informational or testimonial); they identified the elements they thought would increase confidence in quitting and be seen as helpful to someone thinking about quitting. 

We found strong support for affirming messages that could complement warning labels. Māori respondents, people aged under 35 and people with children aged under 16 were especially responsive to family-oriented themes – themes that emphasised the effect of smoking on whānau and intergenerational wellbeing. Many Indigenous populations understand smoking’s harms relationally and place a high priority on whānau wellbeing and the health and wellbeing of future generations; these themes resonated with Māori communities and parents, and could motive quit attempts more effectively than themes that focus on individual benefits. 

When considering specific efficacy messages, respondents saw price-related informational messages as most helpful. Given NZ’s high tobacco prices and cost-of-living pressures, financial themes have high salience and quitting offers a pathway to greater economic stability. Combining messages that promote financial savings alongside improved family wellbeing could capitalise on these dual concerns.

We also found headlines framed as questions performed better than statement headlines; questions appear to encourage reflection and, rather than direct a particular action, prompt people to consider their motivations and goals.¹⁶ Informational messages performed more strongly than testimonials, though further work to compare shorter and simpler messages is still required.

Our findings have important implications for tobacco control policy. Efficacy inserts would be relatively inexpensive to produce (costs would be borne by tobacco companies, in the same way as other packaging requirements are a cost of doing business). Inserts could feature multiple themes, be updated and extended easily as new evidence comes to light, and could be introduced alongside updated warning labels;¹⁷ NZ’s on pack warning labels have not been refreshed since their introduction in 2018 and are showing signs of wear out.⁶ Our study highlights the need for multiple communication themes and suggests varying insert themes, images and content could increase engagement with priority populations and reduce inequities. In particular, our work reinforces the need for approaches that will resonate with Māori, who continue to bear a heavy burden of harm from smoking. 

Instead of treating tobacco packaging solely as a harm communication medium, the Government has an opportunity to promote agency, foster hope, and outline the benefits of quitting. Failure to introduce efficacy inserts represents a missed opportunity to adopt international best practice and support the population groups most affected by smoking’s harms.

Authors details 

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

Dr Philip Gendall, ASPIRE Aotearoa Research Centre. Emeritus Professor (Massey University) and Honorary Senior Research Fellow in the Dept of Public Health, Ōtākou Whakaihu Waka | University of Otago