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How do tobacco retail displays affect cessation

attempts? Findings from a qualitative study
J Hoek, H Gifford, G Pirikahu, et al.

Tob Control 2010 19: 334-337

doi: 10.1136/tc.2009.031203

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Brief report

How do tobacco retail displays affect cessation

attempts? Findings from a qualitative study
J Hoek,1 H Gifford,2 G Pirikahu,2 G Thomson,3 R Edwards3
1
Department of Marketing, ABSTRACT quitting,14 24 identifying environmental factors
University of Otago, Dunedin, Background Tobacco retail displays promote smoking that inhibit cessation could inform more effective
New Zealand experimentation among youth; however, little is known policy development.
2
Whakauae Research,
Whanganui, New Zealand about their effect on smokers making a quit attempt. To date, few studies have explored whether or
3
Department of Public Health, Calls to ban tobacco retail displays would be how retail displays affect smokers, particularly
University of Otago, Wellington, strengthened if this measure would deter initiation and those making a quit attempt or who have recently
New Zealand support cessation. become smoke-free. Carter et al’s (2006) experi-
Correspondence to
Methods Semistructured in-depth interviews were mental study concluded that tobacco imagery
Janet Hoek, Department of conducted with 20 individuals, from two New Zealand affected adult smokers’ cravings for cigarettes.25
Marketing, University of Otago, provincial cities, who had attempted to quit smoking in Given that their test stimuli comprised only eight
PO Box 56, Dunedin 9054, New the last 6 months. cigarette packets arranged as an isolated group, full
Zealand; Results Tobacco products had high visibility, and elicited POS displays may have even stronger effects,
janet.hoek@otago.ac.nz
emotional and physical reactions that created on-going a suggestion supported by a survey of Australian
Received 27 April 2009 temptation, complicated cessation attempts and smokers, which concluded that tobacco retail
Accepted 29 January 2010 stimulated impulse purchases. Participants strongly displays stimulate impulse purchases and tempt
supported banning tobacco retail displays primarily those trying to quit.26
because they thought this would reduce youth initiation, Behaviour modification theory recognises that
promote greater consistency with smoke-free environmental variables, such as POS stimuli, cue
promotions and assist those attempting to quit. and maintain behaviour; logically, this theory
Conclusions The effects of tobacco retail displays on suggests that exposure to retail displays impedes
smokers making a cessation attempt are explored. The smoking cessation.27e29 Yet, despite theoretical
findings are consistent with experimental and survey and empirical evidence that POS displays could
research, and expand a growing evidence base that maintain smoking among smokers, few studies
supports government-mandated bans on tobacco retail have explored how former smokers and lapsed
displays. quitters understand, and are affected by, tobacco
retail displays. As this knowledge would inform
policy development and add a new dimension
The New Zealand Smoke-free Environments Act to existing findings, we investigated how lapsed
1990 banned tobacco advertising and sponsorship, quitters and former smokers perceived retail displays
leading tobacco companies to rely more heavily on and regulatory proposals that would limit these.
media that have fewer restrictions, such as retail
store displays and product branding.1e4 Point-of- METHODS
sale (POS) marketing maintains brand visibility and Twenty in-depth interviews were undertaken with
promotes sales, and provides tobacco companies 11 Maori and 9 non-Maori participants. All had
with undiscriminating reach and potentially high made a quit attempt in the last 6 months; 12 were
exposure to children.5e9 Analyses of industry still smoke-free while 8 had lapsed. The sample
documents suggest that retail marketing is a pivotal included a high proportion of Maori as smoking
medium in “dark markets”, where mainstream mass prevalence is disproportionately high among these
media are restricted.2 4 10e13 Displays position people (45.7% cf 20.6% among non-Maori) and
tobacco products as “a benign cultural common- results in serious health inequalities.30 Participants
place . on a par with milk and bread”,14 and their were purposively recruited to promote diversity
ubiquity facilitates initiation by suggesting that and were drawn from cessation providers, including
smoking is more prevalent than is actually the case, the NZ Quitline (8) and an iwi (indigenous Maori)
enhances perceptions of smoking and weakens non- health provider (10) and personal networks (2).
smoking intentions.15 Accumulating research find- Participants were aged between 23 and 59 years,
ings suggest that tobacco retail displays may attract came from varied socioeconomic backgrounds, had
new users, particularly children, and have prompted differing smoking histories and included both
calls to ban in-store tobacco marketing.16e22 genders. Interviewing continued until saturation of
Evidence that tobacco displays promote themes became apparent. Table 1 contains details of
smoking initiation raises the question of whether participants’ demographics and smoking history.
they may also maintain the salience of smoking Three interviewers (two Maori and one non-
and induce nicotine craving, thus impeding cessa- Maori) made telephone contact (including up to
tion and promoting relapse among recent quit- 10 callbacks) with potential participants. In total,
ters.23 Given the tobacco industry’s interest in 61 people were contacted; 4 refused to participate,
retaining concerned smokers, uneven compliance 9 had an inactive number, 23 had moved, 3 resided
with existing regulations, and the difficulty of with other participants, 2 were unavailable during

334 Tobacco Control 2010;19:334e337. doi:10.1136/tc.2009.031203

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Brief report

Table 1 Participants’ quitting history

Years No of quit attempts Longest period
Participant code Gender Ethnicity Age smoking last 12 months* S/F (ever)
1 F NZE 49 35 1 12 months
2 F NZE 58 40 0 2 years
3 F NZE 44 23 2 3 months
4 M NZE 47 24 0 4 years
5 F NZE 59 43 0 2 years
6 F NZE 49 34 2 3 days
7 F NZE 54 40 0 1 day
8 F Maori 43 27 0 9 months
9 M NZE 45 35 0 3 weeks
10 M NZE 59 40 2 0 days
11 F Maori 37 17 3 1 week
12 M Maori 45 31 1 1 year
13 F Maori 28 12 2 4 months
14 F Maori 35 16 0 6 months
15 M Maori 23 12 2 3 weeks
16 M Maori 57 42 0 4 weeks
17 F Maori 51 34 0
18 F Maori 33 12 2 7 days
19 M Maori 43 27 0
20 F Maori 32 21 3 4 months
Mean 45 28
*Excludes their most recent quit attempt.
NZE, New Zealand European; S/F, smokefree.

the fieldwork period and 20 were successfully interviewed. After linked to financial liberation, as it would release participants
deducting ineligible participants, the response rate was 83%.i from choice dilemmas, such as their need for tobacco versus
McCracken’s “long interview” approach provided an overall their responsibility to provide for their families.
protocol for the research, which began with a detailed literature
review and considerable reflection by research team members.31
Influences on quit attempts
As recommended, the semistructured interviews opened with
Participants’ environments and circumstances often complicated
biographical and behavioural questions, questioning then
their quit attempts; stressful situations, lack of preparation, on-
encouraging participants to review their quit experiences, the
going access and exposure to tobacco imagery had affected their
factors influencing these attempts, and the outcome. Partici-
ability to become (or remain) smoke-free. The high salience of
pants also commented on how they perceived retail environ-
tobacco products was a recurring theme, particularly the size
ments and explained whether they would support a ban on
and position of tobacco displays: “Oh yeah, they are right smack
point of sale tobacco displays.
bang in front of you, so you can’t miss them” [MML,23]. The
Interviews took place in participants’ homes or workplaces
prominence and position of tobacco displays ensured high visual
and lasted between 20 and 40 min. Each interview was recorded
salience: “When I go up to the counter, the first thing that
and transcribed verbatim, and two interviewers (one Maori and
catches your eyes, at the back of them [staff] is the cigarette
one non-Maori) used Braun and Clarke’s (2006) approach to
counter. [they] are in your face. they are right there in front
review transcripts and recordings, and identify themes.32
of you . in full view. in a big huge cabinet.” [MFQ,43] as did
Quotations illustrate emergent themes and note whether
the location of these: “It’s staring straight at you when you walk
participants were Maori (M) or non-Maori (NM), female (F) or
up to the counter.” [MMQ,43].
male (M), their smoking status quit (Q) or lapsed (L), and their
While a small group felt unaffected by displays, others felt
age. Ethical issues in the research protocol were reviewed and
tempted. Awareness of the display, the difficulty of avoiding
approved by the Department of Public Health, University of
seeing tobacco brands and the ease with which they could access
Otago.
these brands stimulated desire: “.there was a temptation
there. I knew what I was buying and my eyes would flash
RESULTS across to the display where the cigarettes were.” [MFQ,37] and
Factors motivating quit attempts “You are just thinking, “hmmm, I wish I could have some of
The interviews created a discussion context by exploring those”, cause they are right there.” [MML,23].
participants’ smoking history. On average, participants had Temptation created physical and emotional cravings: “Right
smoked for 28 years (range 12e40 years), made multiple quit behind the flaming counter, because when I gave up, that’s all I’d
attempts, and, at different stages in their lives, been smoke-free look at when I’d go to a dairy or petrol station for smokes .
for periods ranging from 1 day to 4 years. Participants’ desire to Yeah, it did make me long for a smoke when I saw them. It
re-assert control over their lives provided the strongest motiva- made me think, gosh, look what I’m missing out on.”
tion to quit. Many also wanted to avoid smoking-related harm, [NMFL,44]. Cravings prompted purchase: “Yeah, normally I see
particularly when they had first-hand experience of illnesses the smokes and then that’ll trigger me to buy a packet.”
attributable to smoking. Becoming smoke-free was also strongly [MFL,32].
Participants’ cravings went beyond physiological responses and
i
RR¼(20/61(9+23+3+2))100¼83%. were anchored by deep affective feelings: “It was in your face. it

Tobacco Control 2010;19:334e337. doi:10.1136/tc.2009.031203 335

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Brief report

would be like I could see a smoker and I would be. kind of drawn
to it in a sense.” [NMMQ,45]. Tobacco brand imagery exerted What this paper adds
a mesmerising influence as smokers accessed the persona they
created via the brand: “There’s a connection made, you know, < Calls for tobacco display bans are supported by experimental
between observing, seeing the packet, and then knowing what and survey evidence, but little is known about how displays
the packet feels like, and then you can start by getting warmed up affect quitters or why many support bans on these.
about opening the packet and smelling the cigarettes and lighting < This qualitative study found that tobacco retail displays
one up and what that means for you and you know there’s whole elicited emotional and physical responses, and undermined
number of connections that are made. it’s advertising.” quit attempts. Current and former smokers strongly supported
[NMMQ,45]. Exposure to tobacco imagery reminded quitters of banning tobacco displays, which they thought would assist
familiar behaviours and the benefits they derived, and created smokers attempting to quit and remove an on-going invitation
a powerful challenge to their cessation attempts. that encourages young people to experiment with tobacco.
Responses to policy proposals
Most participants supported proposals to ban tobacco retail
displays because these increased the difficulty of quitting: “I stimulated physical cravings and resurrected the emotional ties
would agree.that having them in your face, for those who are they had with “their” brand. The key themes are logically
trying to give up, [that] . it is harder for them.” [MFQ,43]. aligned with behaviour modification theory, and its recognition
Removing displays would thus remove a barrier quitters must of the role brand imagery and learned associations play in
overcome in their cessation journey: “I think it would be a hell of fostering purchase.
a lot easier if it wasn’t there. because you know, the tempta- On one level, participants’ support for a government ban on
tion’s not there.” [NMML,59]. Exposure to brand imagery tobacco retail displays, and the benefits they thought this would
challenged their quest to become (and remain) smoke-free: “I’d bring, reflects the difficulty of becoming and staying smoke-free.
be quite happy if they were all to go, under the counter, or in However, it also recognises the influence tobacco imagery exerts
a back room, or something like that. I felt very tempted. And it and their desire to protect future generations.
brought back to me what I was missing out on again, just that Our findings suggest that tobacco retail displays promote
emptiness.” [NMFL,44]. smoking and undermine cessation attempts. Given the difficulty
Participants also felt strongly that a ban on tobacco displays of quitting and the multiple attempts often required, policy
would protect children. Some thought it morally wrong to makers need to create supportive quitting environments by
expose children to toxic products: “I don’t think it’s right that eliminating stimuli that promote lapsing. Article 13 of the
those cigarettes are where they are. I don’t think. that chil- Framework Convention on Tobacco Control calls for
dren should be exposed to cigarettes.” [NMMQ,45]. Others a “comprehensive ban of all tobacco advertising, promotion and
believed removing displays would increase the chances that sponsorship” and requests signatories to go beyond the provi-
young people would not smoke: “I reckon it might be a good sions specified.33 Given that participants viewed POS displays as
chance of them not smoking, ’cause it’s not there when they advertising, our findings imply that bans on these displays
walk into a shop.” [MFQ,28]. Some projected their own feelings would be consistent with existing legalisation and Framework
of temptation and thought removing displays would reduce the Convention on Tobacco Control obligations. More generally, the
risk that young people might smoke: “It’s possibly encouraging findings align with results from experimental studies and
for younger people who are more easily tempted.” [NMMQ,47]. surveys and suggest that eliminating tobacco retail displays
In addition, several thought removing tobacco displays would would deter initiation and support addicted smokers seeking to
help promote consistent smoke-free messages: “The message is become smoke-free.
conflicting in the sense that we’ve stopped smoking in a pub,
we’ve stopped smoking on a bus, but we still let cigarettes be Acknowledgements We are grateful to the individuals who agreed to participate
retailed in just about every shop in New Zealand. That. seems in this research and whose detailed responses provided the basis of this article.
a paradox.” [NMMQ,45]. Funding New Zealand Cancer Society (PO Box 12700, Wellington 6144, New
Banning tobacco displays would challenge the view of Zealand) and Action on Smoking and Health (PO Box 99 126, Newmarket, New
Zealand).
smoking as “normal”: “It’s [allowing displays] doing, letting,
telling them it’s okay to smoke” [MFQ,43]. Participants thought Competing interests All authors have undertaken work for the Cancer Society of
making tobacco less visible would reduce perceived social New Zealand and Action on Smoking and Health New Zealand. Although we do not
consider it a competing interest, for the sake of full disclosure we note that all authors
approval of smoking, which would decrease the number who have undertaken tobacco-related research for the New Zealand Ministry of Health. All
began smoking: “Maybe then [once retail displays were authors have received funding for tobacco-related research from the Health Research
banned]. less people would take it up and it would be a thing Council of New Zealand.
that eventually. you don’t see that many people doing Patient consent Obtained.
anymore.” [NMMQ,45].
Ethics approval This study was conducted with the approval of the Department of
Public Health, University of Otago.
DISCUSSION AND CONCLUSIONS
Provenance and peer review Not commissioned; externally peer reviewed.
This study probed how lapsed quitters and former smokers view
tobacco POS displays and feel affected by them, and explored
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