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12A.6 Evidence for the effects of health promotion inserts
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Winnall, WR. 12A.6 Evidence for the effects of health promotion inserts. In Greenhalgh, EM|Scollo, MM|Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne : Cancer Council Victoria; 2019. Available from https://www.tobaccoinaustralia.org.au/chapter-12-tobacco-products/attachment-12-1-health-warnings/12a-6-evidence-for-the-effects-of-health-promotion-inserts
Last updated: July 2025

12A.6 Evidence for the effects of health promotion inserts

Health promotion inserts are small cards placed inside a tobacco pack that provide information on the benefits of quitting and advice on how to quit.1 Both Canada and Australia require health promotion inserts for specific tobacco products. In Australia, from 1 July 2025, these inserts are required in the packs of cigarettes, bidis, pipe and roll-your own tobacco. There are 10 health promotion inserts currently used in Australia, as described in Section 12A.1.3 and shown in Figure 12A.1.10. An example of an Australian and a Canadian health promotion insert are shown in Figure 12A.6.1.

Health promotion inserts are designed to increase feelings of hope and of self-efficacy – a belief in one's own ability to succeed at a task. Messages that evoke fear and anger (such as graphic health warnings) are considered to be most effective when combined with strong efficacy cues (such as health promotion inserts).2

Canada was the first country to introduce health promotion inserts into tobacco packs as text-only messages in 2000.3 In June 2012, Canada implemented eight new inserts with coloured graphics. An evaluation of this policy collected data in fives waves separated by four-monthly intervals (September 2012 to January 2014).3,4 People who smoke and who read the inserts were more likely to be younger, female, higher income, as well as intend to quit, have recently tried to quit, and thought about health risks because of health warnings. Over the time of this study, those who read the health promotion inserts a few times or more over a month were more likely to attempt cessation in the next wave compared to those who didn’t read the inserts.3 Reading inserts more frequently was associated with stronger self-efficacy to quit and sustained quit attempts.4 These findings provide real-world evidence that the health promotion inserts added to tobacco packs in Canada increased quit attempts in people who smoke.

Randomised, short-term trials have also been used to test the effects of health promotion inserts. A 2-week trial found that cigarette packs with health promotion inserts encouraging cessation can promote cessation-related behaviours (forgoing or stubbing out cigarettes) among people who smoke, but were most effective among those with low impulsiveness.5 In another 2-week trial, people whose packs included inserts were more than twice as likely to report foregoing or stubbing out of cigarettes than those without inserts (a behaviour that predicts quitting).6 However, other predictors of cessation were not different between the two groups, such as self-efficacy, hopefulness, motivation to quit or conversations about smoking harms. The people in this study smoked heavily and had low quit intentions, which may have reduced the chances of the desired outcomes. Together these two trials provide some limited evidence that health promotion inserts can increase quitting behaviours after short term exposure.

A study in the US compared the responses of people who smoke to five different messages encouraging quitting in health promotion inserts as well as five different options for images for each message.7 Message topic was substantially more influential than image type when participants selected the most and least helpful/motivating inserts. The most favoured message topic was the importance of social support for cessation (Quitting is easier when you’re not alone).7

Focus groups studies with people who smoke have found that they generally support the use of health promotion inserts. Focus groups were conducted with adults who smoke from a wide range of age groups from Scotland.8 Participants described the positive style of the messaging as inspirational and likely to increase message engagement. They preferred the insert messages to the graphic health warnings used on packs. Some suggested that inserts could encourage them to stop smoking, and they were generally viewed as having the potential to discourage young people from smoking and encourage people who smoke to quit.8 In similar focus group studies of roll-your-own users in Scotland, most did not feel that roll-your-own-specific health promotion inserts would lead them to change their smoking behaviour, but these people still found Canadien inserts for cigarettes to be motivational and inspirational.9 However, most of these people were not interested in quitting. Some participants thought that the Canadian inserts could be helpful for people who were interested in quitting.9

The use of health promotion inserts is supported by the majority of the public in Australia1 (see Section 12A.9.3) and there is evidence that the use of cigarette pack inserts in Australia would be unlikely to create much additional litter (which was a concern prior to implementation).10

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References

1. Brennan E, Ilchenko E, Durkin SJ, and Wakefield MA. Public support for introducing cigarette pack inserts in Australia. Tobacco Control, 2021; 30(1):117-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32054727

2. Jesch E, Niederdeppe J, King AJ, Safi AG, and Byrne S. "I quit": Testing the added value and sequencing effects of an efficacy-focused message among cigarette warning labels. Journal of Health Communication, 2020; 25(5):361-73. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32476624

3. Thrasher JF, Osman A, Abad-Vivero EN, Hammond D, Bansal-Travers M, et al. The use of cigarette package inserts to supplement pictorial health warnings: An evaluation of the Canadian policy. Nicotine & Tobacco Research, 2015; 17(7):870-5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25480931

4. Thrasher JF, Swayampakala K, Cummings KM, Hammond D, Anshari D, et al. Cigarette package inserts can promote efficacy beliefs and sustained smoking cessation attempts: A longitudinal assessment of an innovative policy in Canada. Preventive Medicine, 2016; 88:59-65. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26970037

5. Thrasher JF, Hackworth EE, Ferguson SG, Xiong L, Kim M, et al. Differential responses to cigarette package labeling alternatives among adults who smoke: Results from a randomized trial. Nicotine & Tobacco Research, 2024; 26(12):1646-55. Available from: https://www.ncbi.nlm.nih.gov/pubmed/38850013

6. Thrasher JF, Ferguson SG, Hackworth EE, Wu CL, Lambert VC, et al. Combining inserts with warning labels on cigarette packs to promote smoking cessation: A 2-week randomized trial. Annals of Behavioral Medicine, 2024; 58(1):56-66. Available from: https://www.ncbi.nlm.nih.gov/pubmed/37738629

7. Thrasher JF, Islam F, Davis RE, Popova L, Lambert V, et al. Testing cessation messages for cigarette package inserts: Findings from a best/worst discrete choice experiment. International Journal of Environmental Research and Public Health, 2018; 15(2). Available from: https://www.ncbi.nlm.nih.gov/pubmed/29415523

8. Moodie C. Adult smokers' perceptions of cigarette pack inserts promoting cessation: a focus group study. Tobacco Control, 2018; 27(1):72-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28153959

9. Moodie C and O'Donnell R. Reasons for using roll-your-own tobacco and perceptions of health-promoting pack inserts: A focus group study with roll-your-own tobacco smokers in Scotland. Nicotine & Tobacco Research, 2022; 24(12):1937-44. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35907266

10. Gascoyne C, Li R, Scollo M, Wakefield MA, and Brennan E. Tobacco packaging littering behaviours among Australian adults who smoke: findings from cross-sectional and observational studies to inform the implementation of cigarette pack inserts. Tobacco Control, 2024. Available from: https://www.ncbi.nlm.nih.gov/pubmed/38448225

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Chapter 2