Responding to health inequities in New Zealand: the potential of dissuasive cigarettes
Frank Houghton 1 4 , Bruce Duncan 2 , Sharon Houghton 3 , Diane O’Doherty 1 , Derek McInerney 11 HEALR Research Group, Limerick Institute of Technology, Limerick, Ireland
2 Hauora Tairawhiti, 110 Peel Street, Gisborne 4010, New Zealand
3 Department of Psychology, University of Limerick, Limerick, Ireland
4 Corresponding author. Email: Frank.Houghton@LIT.ie
Journal of Primary Health Care 11(4) 311-314 https://doi.org/10.1071/HC19013
Published: 24 October 2019
Journal Compilation © Royal New Zealand College of General Practitioners 2019 This is an open access article licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License
Dissuasive cigarettes attempt to de-normalise smoking by portraying cigarettes as a repellent product in counter advertising.1 Emerging research is developing an evidence base that suggests that dissuasive cigarettes may offer significant potential in combating smoking.2–7 Much of this research has been led by researchers in New Zealand,8–12 but further research has also been conducted in Norway4 and the United Kingdom.13
There are several means to portray cigarettes as repellent, including proposals to remove additives such as sugar and menthol, ensuring that cigarettes taste bitter and far less palatable to smokers. However, the current leading proposals designed to modify cigarettes to create ‘dissuasive sticks’ focus on two key areas.9 The first of these are proposals to print warnings directly onto the cigarettes themselves. Suggestions for the warnings include messages such as ‘Smoking kills’ or ‘This causes cancer’.3,6,10 The second approach is to colour the cigarette paper itself a repellent colour. Recent research has explored the use of colours such as grey,5 ‘slimy green’, and most successfully of all to date ‘faecal yellow brown’.9
It has long been understood by ‘Big Tobacco’ that the size, length, thickness and colour of cigarettes are all vital considerations in marketing their products.14–17 As well as marketing pink cigarettes to appeal to women, the tobacco industry has also successfully used filter tip colour and printing a gold band on cigarette sticks to heighten their allure.18,19 Dissuasive cigarettes are designed to undermine the symbolic consumption of particular cigarettes brands and their associated group membership, which forms an important element of social identity. This discordance in the smoker’s identity is reinforced through the second function of dissuasive cigarettes, which is to provide health education through their display of warnings such as ‘FUMER CAUSE LE CANCER / SMOKING CAUSES CANCER’, as proposed for Canada.9,20
Dissuasive cigarettes are designed to combat tobacco use in several ways. First, they attempt to undermine positive images associated with cigarettes, most notably through branding of cigarette packs.9,21 The importance of branding for ‘Big Tobacco’ is demonstrated by its expenditure on advertising, which currently runs to over US$750 million per month.22 Reducing the appeal of branded cigarette packs has a direct effect on symbolic consumption of a brand identity; in removing a shared group membership and identity, smokers are less likely to misconstrue brands as elegant or masculine.4,11
Combatting the negative effects of tobacco use is crucial, given their impact on mortality and morbidity globally.23–25 Smoking remains the world’s leading cause of preventable premature death.26 As well as the impact of smoking on the health of smokers themselves, there are also negative effects of second-hand24 and third-hand smoke,27,28 and emotional,29 economic30–32 and environmental costs,33–36 and the opportunity costs of its use and treatment. The New Zealand Ministry of Health suggests that tobacco-related illnesses account for 9% of all illness, disability and premature mortality in New Zealand.37 The Ministry of Health estimates that the largest proportion of smokers are in the population cohorts aged 18–24 years (19.7%) and 25–34 years (22.3%). It is also estimated that 15% of the total population (581,000 people) are current smokers.37 The financial scale of the damage caused by tobacco is estimated to be NZ$3257 million in direct and indirect (lost productivity through premature mortality and morbidity) costs per annum.38
The burden of tobacco use is not shared equally across the population of New Zealand. A concerted effort to reduce smoking is important because of both its negative effects and the inequitable distribution of its burden on Māori,39 and people with mental health issues.40 Although the smoking rate among Māori is now significantly lower than in the past, more than one-third (35%) of Māori still smoke.41–44 This rate is significantly higher than among people of New Zealand European and Pacific ethnicity. It has previously been suggested that one-quarter of the health gap between Māori and non-Māori is attributable to the impact of smoking.44 The gender dimension of smoking among Māori is also notable; 38% of Māori women smoke, compared with 32% of Māori men.45 Few populations have higher smoking rates among women than men.45 Proposed dissuasive cigarette sticks could be viewed as a pro-equity measure, with messages on these sticks specifically targeting the female Māori population. A 2015 study highlighted how dissuasive cigarettes challenged female smokers’ view on cleanliness and social acceptability of smoking.11 If cigarette sticks and packs are seen as dissuasive or symbolically valuable, this may affect female smoking prevalence, including the female Māori population.
Given the intense scrutiny of tobacco promotion, advertising and sponsorship that exists in many countries including New Zealand, combined with precise controls requiring the display of graphic and anti-smoking text warnings, the lack of attention, to date, on developing dissuasive cigarettes is surprising.9 Cigarette sticks have been termed ‘valuable real estate’,46 demonstrating the potential importance of this resource as a vehicle for health promotion. The emerging attention given to dissuasive cigarettes is tardy given the large number of viewings dissuasive cigarettes could achieve. Based on an average consumption of a pack per day,47,48 with each cigarette achieving 10 viewings based on this number of inhalations (‘puffs’), this could result in 73,000 exposures to dissuasive anti-smoking ‘messages’ per year.46 Viewings will also be dependent on the number of other people present with smokers; these people are also a prime target for the messages. The reach of messages on cigarette sticks is much higher than for carton packaging alone.47,48
Based on current trends, New Zealand will not achieve its target of becoming smoke-free by 2025.41 Not only will it probably fail to meet this target by a considerable length of time (decades),41 but compared to other countries, such as Finland, the target itself is relatively unambitious in the first place, causing continued disadvantage to already marginalised populations.49 Combating the inequitable threat of tobacco has been a commendable tenet of New Zealand Government policy for some time; however, it is clear that the current decline in smoking prevalence is both too slow and too inequitable to justify more of the same. A comprehensive approach should be adopted to reduce smoking rates; reduce the initial smoking appeal by the implementation of dissuasive cigarettes, increase taxation to reduce affordability of tobacco products and limit accessibility to minors through increased local and national policies. The continuing damage from tobacco is such that new and innovative responses are urgently required.
Competing interests
The authors declare no competing interests.
Acknowledgement
This work did not receive any specific funding.
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