Roll-your-own smokers' reactions to cessation-efficacy messaging integrated into tobacco packaging design: a sequential mixed-methods study

Background: Although loss-framed pictorial warning labels (PWLs) have increased knowledge of the health harms caused by smoking, they may elicit maladaptive responses among some smokers who have tried repeatedly, yet unsuccessfully, to quit smoking. However, research suggests that maladaptive responses may diminish if warnings are complemented with efficacy enhancing messages. Therefore, we explored New Zealand (NZ) adult roll-your-own (RYO) loose tobacco smokers' reactions to self-efficacy and response efficacy messages integrated into the RYO packaging structure and designed to complement PWLs.

Design: We used a sequential mixed-methods design. In-depth interviews gauged participants' (n=22) acceptance of the designs and informed stimuli development for an online survey. The survey (n=785) compared self-efficacy and response efficacy designs to standard Quitline information, and examined agreement with emotions, beliefs and projected behaviours associated with quit attempts.

Results: Our findings suggest placing gain-framed response efficacy messages on the inside flap of RYO tobacco pouches may stimulate specific emotional reactions, beliefs and projected behaviours associated with future quit attempts more effectively than NZ's status quo Quitline information. Those potentially more likely to benefit include smokers who have high baseline response efficacy and who intend to make a quit attempt.

Conclusions: Integrating cessation-related messaging within tobacco packaging could be a high reach, just-in-time micro-intervention at the point of decision-making. Enhanced efficacy messages could complement and enhance PWLs, and support quitting among groups where smoking prevalence is especially high.