Dissuasive measures on tobacco products: a rapid review of global evidence

Abstract

New and innovative measures are needed to combat tobacco industry marketing strategies and reduce the harm caused by tobacco products. This rapid review aimed to identify and synthesize global evidence relating to dissuasive tobacco product measures, defined as unappealing colours and/or messages directly applied to individual tobacco products to discourage uptake and motivate cessation. Scopus, PubMed, Ovid, and Google were systematically searched from January 2000 to September 2024 to capture all published evidence relating to dissuasive measures, regardless of study design and tobacco product investigated. ‘Forward’ and ‘backward’ citation searching was also conducted. Studies were assessed for quality using JBI critical appraisal tools. Forty-seven eligible publications from 6011 titles/abstracts were included, all relating to conventional cigarettes: 37 peer-reviewed journal articles, including 2 reviews, 29 empirical studies (19 quantitative, 9 qualitative, 1 mixed-methods) and 6 commentaries, 8 government publications, 1 market research report and 1 doctoral thesis. Evidence largely related to perceptions of dissuasive products and their likely impacts. No empirical evidence regarding the relation of dissuasive measures to tobacco control outcomes was located. When compared with standard cigarettes, darker coloured cigarettes—often brown and green—were perceived to be less appealing, whilst cigarettes with messages related to the impact of smoking on finances, others, mortality, and life expectancy were viewed as novel and effective, and capable of inciting behavioural change. The available evidence is generally supportive of dissuasive cigarettes as a tobacco control measure, although a lack of empirical evidence on tobacco control outcomes limits the findings.

Contribution to Health Promotion.

• Tobacco use remains a leading cause of death and disability globally. Novel measures are required to accelerate tobacco control.

• Commissioned by government, this rapid review synthesized global evidence on dissuasive measures on tobacco products as a novel measure, identifying 47 publications across electronic databases and grey literature.

• Evidence generally supports implementation of dissuasive measures (as Canada and Australia have recently), by simultaneously stripping products of aspects of marketing and promotion and reducing their appeal and desirability.

• Identified gaps include a lack of empirical evidence on tobacco control outcomes and assessment of behavioural intentions as opposed to actual behaviour.

Introduction

Tobacco use is the leading readily preventable cause of death and disability globally, responsible for over seven million deaths each year (WHO 2025a). Since the adoption of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) in 2003 (WHO 2003), many countries have strengthened their tobacco control policies, contributing to declines in smoking prevalence (WHO 2025b). However, the tobacco industry continues to innovate, meaning that new measures are needed to maintain and accelerate tobacco control.

Health warnings on tobacco product packaging have been shown to decrease product appeal, increase knowledge about health effects and contribute to cessation knowledge and intentions (Essence Communications 2018, van Mourik et al. 2020, Pang et al. 2021, Gantiva et al. 2022, Kaai et al. 2023). However, people who smoke may conceal or cover the packaging, use a case, or purchase individual cigarettes, meaning that health warnings are avoided. The tobacco industry has facilitated this avoidance behaviour through the sale of purpose-built tins, stickers and split-packs (Swanson 2006, Chapman 2007, Davies 2017). People who smoke, and those around them, see the individual tobacco product more frequently and intimately than the packaging, with an estimate of up to 73 000 views of a cigarette per year for a person who smokes one pack per day (Smith et al. 2017). In certain jurisdictions, cigarettes may be adorned with a brand name/logo or decorative feature, or vary in length, diameter, colour, flavour, or aroma, facilitating product promotion and appeal to carefully selected target markets (Boyd et al. 2003, Cook et al. 2003, Borland and Savvas 2013, Smith et al. 2017). Furthermore, cigarettes often remain visible long after their use and are the most littered item globally (WHO 2022).

These factors highlight the potential of dissuasive measures on tobacco products: the application of unappealing design elements, such as repellent colours and/or messages, to individual tobacco products to prevent uptake and encourage cessation (Fig. 1a). These measures could preclude the tobacco industry from using marketing and promotional features on tobacco products and complement existing measures such as graphic health warnings and plain packaging. They may be particularly useful in settings where individual tobacco products are sold frequently.

Figure 1.

a, Dissuasive cigarettes compared with a standard cigarette (pictured at top). Created in a focus group study in Scotland where stickers were designed and applied to the cigarettes. Reprinted with permission: Taylor & Francis (https://tandfonline.com) (from: Mitchell et al. 2020). b, The eight on-product messages on cigarettes in Australia. Source: Cancer Council Victoria.

A guiding principle of the WHO FCTC (WHO 2003) and a fundamental consumer right (Chapman and Liberman 2005) is accurate information about the harms of tobacco use. Dissuasive measures support this right and are also relevant to Article 11 (WHO 2013a) (guidelines: ‘health warnings and messages to be printed on the filter overwrap portion of cigarettes’) and Article 13 (WHO 2013b) (guidelines: ‘packaging, individual cigarettes or other tobacco products should carry no advertising or promotion, including design features that make products attractive’) of the WHO FCTC.

Despite being included in WHO FCTC guidelines, Canada (Health Canada 2023) and Australia (Australian Government 2024) are the only two nations to mandate dissuasive on-product messages (Fig. 1b). Canadian legislation, as of 1 August 2023, requires messages (in both English and French) be applied to standard- and king-size cigarettes and little cigars with tipping paper and tubes (Health Canada 2023, Campaign for Tobacco-Free Kids 2025). In Australia, as of 1 April 2025, cigarettes with filters must display one of eight messages, such as ‘Damages DNA’ and ‘Causes 16 cancers’. Dissuasive cigarettes have been a topic of debate in UK Parliament (most recently in 2022) (UK Parliament 2022) and were mentioned as a potential regulatory action in Scotland’s 2018 tobacco control action plan (Scottish Government 2018).

There is limited synthesized evidence on dissuasive tobacco measures. A systematic review published in 2018 (Drovandi et al. 2018b), and a scoping review published in 2023 (Al-Zalabani et al. 2023) are, to the best of our knowledge, the only synthesized evidence available globally. There is a need to review the contemporary evidence regarding the likely effectiveness of these measures. The Australian Government Department of Health, Disability and Ageing commissioned this rapid review regarding the likely effectiveness of dissuasive measures as novel tobacco control measures in 2023 to inform Australian policy development, with an update in late 2024.

Methods

Search strategy

This rapid review was conducted according to guidance and methodological considerations from King et al. 2022. In May 2023, Scopus, PubMed, and Ovid (Journals@Ovid, MEDLINE, APA PsycInfo) databases were searched for English-language (due to time constraints) research on dissuasive measures on tobacco products published between January 2000 and May 2023 (see Supplementary File S1 for search strategy). These databases were selected due to their comprehensive collections of public health literature.

In addition, ‘forward’ (identifying relevant research citing the included publication) and ‘backward’ (identifying relevant research that the included publication cited) citation searches were conducted in May 2023. In June 2023, Google was used for the grey literature search, with no date restrictions on inclusion (see Supplementary File S2 for search strategy). Updated searches were conducted in September 2024 following the same procedures.

Inclusion and exclusion criteria

Due to the paucity of evidence, the Department requested all published evidence on dissuasive on-product tobacco measures—regardless of design and outcome—be included in this review. Therefore, primary and secondary research and commentary papers were all eligible for inclusion. Research on all conventional tobacco products (e.g. cigarettes, cigarillos) was eligible for inclusion.

Data screening and extraction

Database search results were imported into EndNote, where duplicates were identified and removed, before being imported into Covidence where remaining duplicates were removed. In May 2023, one review author (S.B.) screened all titles, abstracts, and full texts in Covidence and extracted relevant data into a prespecified Microsoft Excel template. In September 2024, two review authors (A.I., S.B.) independently screened titles, abstracts, and full texts in Covidence with discrepancies resolved through discussion. Two review authors (A.I., A.V.) extracted data. For the grey literature and ‘forward’ and ‘backward’ citation searches, search results were manually screened and extracted by one review author (S.B.).

Quality assessment

Two review authors (A.I., A.V.) conducted quality assessment—using JBI critical appraisal tools—for eligible studies. For the purposes of quality assessment, we considered quantitative studies involving an intervention without randomized controls, and studies investigating reactions to dissuasive cigarettes e.g. choice experiments, as quasi-experimental studies (see Supplementary File S4 for quality assessment methods and findings).

Data synthesis

Pooled analysis, such as meta-analysis, was not conducted due to heterogeneity in interventions, outcomes, and designs. Key findings are grouped and narratively summarized by type of dissuasive measure (colour, message, or both) or policy/government considerations. Within each section, quantitative results are described first, followed by qualitative findings.

Results

Overview of included publications

After removal of duplicates, 6011 publications had their titles and abstracts screened. From these, 47 eligible publications were identified (Table 1, Fig. 2, Supplementary Table S1). More than three-quarters (77%) were published in 2016 or later. Publications were from Australia (n = 7), Scotland (n = 7), UK (n = 7), Canada (n = 3), France (n = 2), New Zealand (n = 2), Singapore (n = 2), Colombia (n = 1), India (n = 1), The Netherlands (n = 1), Norway (n = 1), Saudi Arabia (n = 1), US (n = 1), or multiple nations (n = 2) (n = 9 had a global focus). Thirty-seven were peer-reviewed journal articles, including 2 reviews, 29 empirical studies (19 quantitative, 9 qualitative, 1 mixed-methods), and 6 commentaries, 8 were government publications, 1 was a market research report, and 1 was a doctoral thesis. All publications related to conventional cigarettes: 6 focused on colour, 16 on messages, 10 on both, and 15 were related to policy/government.

Table 1.

Key findings from included studies, grouped by type of dissuasive measure (colour, message, or both) and type of data (quantitative, qualitative, or mixed-methods).

Author and year of publication	Product investigated		Key finding
Dissuasive colours-quantitative studies (n = 3)
Borland and Savvas 2013	Plain cork cigarette White tip cigarette Blue tip cigarette Cork cigarette with gold band Cigarette with fancy embossed tip		Perceptions: % Most attractive: cork with gold band (46) Least attractive: blue tip (46) Highest quality: cork with gold band (44) Lowest quality: blue tip (26)	Strongest tasting: cork with gold band (33) Weakest tasting: white tip (42) Most preferred: cork with gold band (47) Least preferred: blue tip (47)
Gallopel-Morvan et al. 2019b	Grey cigarette vs. standard cigarette Grey cigarette vs. slim cigarette Grey cigarette vs. pink cigarette		Grey vs. standard Most appealing: standard* Most dangerous: grey* Most impact on behaviour: grey* Grey vs. slim Most appealing: slim* Most dangerous: grey* Most impact on behaviour: grey*	Grey vs. pink Most appealing: pink* Most dangerous: grey* Most impact on behaviour: grey* *P < 0.001
O’Connor et al. 2015	Filtered cigarette, 85 mm, cork tip Filtered cigarette, 85 mm, white tip Unfiltered cigarette, 70 mm		Perceptions: % Expect to have best taste: cork tip (43.3)* Most likely to attract attention: cork tip (60.9)* Most dangerous to health: unfiltered (61.5)*	Least dangerous to health: white tip (40.2)* Most willing to try: cork tip (42.7)* *P < 0.001
Dissuasive colours-qualitative studies (n = 3)
Ford et al. 2014	Longer brown cigarette, gold More brand name and band Superking-size cigarette, imitation cork filter, Superkings brand name and symbol Slim-size cigarette, white tip, purple decorative design Superslim-size cigarette, white tip, purple floral design	5. Superslim-size cigarette, white tip, Vogue brand name in blue decorative font 6. King-size cigarette, imitation cork filter, Mayfair brand name 7. King-size cigarette, white tip, green Mayfair brand name 8. Shorter filterless cigarette, Woodbine brand name	Brown cigarette Unattractive, stronger and more harmful product. Described as ‘disgusting’ and ‘old fashioned’.
Hoek and Robertson 2015	Focus groups: currently available cigarettes 1. White, three gold bands 2. White, two gold bands 3. White/embellished, gold band 4. White/embellished (slim) 5. Tan 6. Tan, red bands 7. Tan, red band 8. Tan, gold band 9. Tan/embellished, gold band 10. Tan (slim) Focus groups: cigarettes created for study 1. Gold 2. Orange 3. Tangerine 4. Silver-white 5. Light red 6. Red-brown 7. Bright red 8. Light green 9. Dark green 10. Lilac	Interviews: cigarettes designed for study Very dark green, ‘slime green’ filter Dark brown-green, ‘slime green’ filter Mid-green, ‘slime green’ filter Light green, ‘slime green’ filter Mid-brown, ‘slime green’ filter Tan, ‘slime green’ filter Dark brown, dark brown filter Light brown, dark tan filter Tan, dark tan filter Light tan, standard tan filter	White/slim cigarettes Associated with cleanliness, glamour and safety. Darker coloured cigarettes Off-putting and highly aversive. Green and brown particularly unappealing, affecting perceptions of smoking.	Smoking behaviour Perception that dissuasive cigarettes would decrease initiation and consumption.
Moodie et al. 2015a	Standard cigarette, cork filter Standard cigarette, cork filter Pink cigarette Brown cigarette Demislim cigarette Slim cigarette	7. Superslim cigarette 8. Microslim cigarette 9. Aromatized black cigarette 10. Menthol cigarette 11. Cigarette with menthol capsule in filter	Standard cigarettes Low appeal, more harmful than pink, less harmful than brown/black, ‘plain’, ‘boring’. Pink cigarette Favourable, highly appealing, pleasant tasting, least harmful, ‘lovely’, ‘young’, ‘pretty’, ‘delicate’.	Brown cigarette Least appealing, unpleasant tasting, most harmful, ‘disgusting’. Black cigarette Harmful, mixed response for appeal/taste, unappealing (strong taste and harm) and appealing (unusual, ‘classy’, ‘expensive’, expected liquorice/vanilla taste) remarks.
Dissuasive messages-quantitative studies (n = 10)
Al-Ahmadi et al. 2024	Messages adapted from Drovandi et al. 2023 and translated into Arabic Theme 1: mortality statistics Theme 2: health condition consequences Theme 3: social and financial consequences Theme 4: supportive messages to quit smoking		Effectiveness scores: mean (SD) (1: ineffective to 5: very effective) Packaging warnings Preventing uptake: 2.8 (1.2) Prompting quitting: 2.5 (1.2) Mortality statistics Preventing uptake: 3.2 (1.1) Prompting quitting: 2.9 (1.1)	Health condition consequences Preventing uptake: 3.2 (1.1) Prompting quitting: 3.0 (1.2) Social and financial consequences Preventing uptake: 3.3 (1.2) Prompting quitting: 2.9 (1.2) Supportive messages to quit smoking Preventing uptake: 3.0 (1.2) Prompting quitting: 2.9 (1.2)
Drovandi et al. 2018a	See Drovandi et al. 2023 for messages on cigarettes	Theme 1: mortality statistics Theme 2: health condition consequences Theme 3: social and financial consequences Theme 4: supportive messages to quit smoking	Perceived effectiveness in preventing uptake and encouraging quitting: OR (95% CI); P-value Ref: current packaging warnings	Theme 1: 2.77 (1.67–4.62); P < 0.001 Theme 3: 1.54 (0.92–2.56); P = 0.095 Theme 2: 0.81 (0.50–1.32); P = 0.405 Theme 4: 0.28 (0.17–0.47); P < 0.001
Drovandi et al. 2019c	Your minutes of life lost…11-7-3…From each cigarette smoked Smoking harms your children…Your smoke affects your pets…Smoking hurts your family Smoking kills half of users…7 million people per year…And reduces quality of life I contain addictive chemicals…Smoking is highly addictive…Don’t suffer from addiction	5. Smoking one pack per day…Costs nearly $5 000 per year…What could you buy instead? 6. Smoking isn’t cool anymore…Sick of being forced outside?…Why miss out on all the fun? 7. Don’t give in to cravings…Go for a quick walk instead…The craving will pass soon 8. You don’t need me anymore…Start your quit plan today…For help call 1-877-513-5333	Perceived effectiveness in prompting quitting: OR (95% CI); P-value Ref: current packaging warnings Cost: 3.42 (2.75–4.25); P < 0.001 Others: 2.85 (2.29–3.55); P < 0.001 Mortality: 2.15 (1.73–2.66); P < 0.001 Minutes: 2.06 (1.66–2.56); P < 0.001	Quit: 1.25 (1.01–1.55); P = 0.044 Addiction: 0.95 (0.76–1.17); P = 0.614 Cravings: 0.80 (0.64–0.99); P = 0.041 Social: 0.70 (0.57–0.88); P = 0.002
Drovandi et al. 2020	Theme 1: immediate and short-term consequences of smoking Your minutes of life lost…15-10-5…From each cigarette smoked Smoking harms your children…Your smoke affects your pets…Smoking hurts your family Smoking stains your fingers…Smoking gives you bad breath…Smoking yellows your teeth Theme 2: long-term and mortality consequences of smoking 4. Smoking causes lung cancer…Smoking causes heart disease…Smoking causes emphysema 5. Smoking kills half of users…7 million people per year…And reduces quality of life 6. I contain addictive chemicals…Smoking is highly addictive…Don’t suffer from addiction	Theme 3: social and financial consequences of smoking 7. Smoking one pack per day…Costs over $11 000 per year…What could you buy instead? 8. Sick of being forced outside?…Missing out on the fun?…Quit smoking today 13 78 48 9. Smokers get sick more often…Stop wasting your sick days…Visit quitnow.gov.au for help Theme 4: supportive messages to quit smoking 10. See your pharmacist to quit…See your doctor to quit…Call Quitline 13 78 48 11. Don’t give in to cravings…Go for a quick walk instead…The craving will pass soon 12. You don’t need me anymore…Start your quit plan today…Help is available call 13 78 48	Perceived effectiveness in discouraging uptake and encouraging quitting: OR (95% CI); P-value Ref: current packaging warnings Theme 1: 5.93 (4.51–7.80); P < 0.001 Theme 2: 3.60 (2.79–4.64); P < 0.001 Theme 3: 2.86 (2.21–3.69); P < 0.001 Theme 4: 0.61 (0.47–0.81); P < 0.001
Drovandi et al. 2023	Theme 1: mortality statistics Half of all smokers…Will die from a smoking…Related health issue Smoking kills over…6 million people per year…Don’t be one of them Minutes of life lost…15-10-5…From this cigarette Theme 2: health condition consequences   4. Smoking causes heart disease…Smoking causes cancer…Smoking causes stroke 5. Smoking causes emphysema…Smoking causes asthma…Smoking causes bronchitis 6. Smoking causes lung cancer…Smoking causes lung cancer…Smoking causes lung cancer	Theme 3: social and financial consequences 7. Smoking one pack per day…Costs your wallet over…$11 000 per year 8. Smoking one pack per day…Reduces your life expectancy…By one day per week 9. Smoking harms others…Damages your car and home…Hurts your reputation Theme 4: supportive messages to quit smoking 10. See your pharmacist to quit…See your doctor to quit…Call Quitline 13 78 48 11. Nicotine replacement therapy…Can help you quit…Visit a doctor or pharmacist 12. Quit smoking now…Quit smoking now…Quit smoking now	Perceived effectiveness in preventing uptake and prompting quitting: OR (95% CI); P-value Ref: current packaging warnings Theme 3: 2.61 (1.73–3.94); P < 0.001 Theme 1: 1.99 (1.35–2.95); P < 0.001 Theme 2: 1.86 (1.23–2.81); P < 0.01 Theme 4: 0.38 (0.25–0.57); P < 0.001
Guindon et al. 2024	Experiment 1 (three licit alternatives) Packaging: plain packaging vs. packaging with branding Health message on cigarette: with vs. without (‘Smoking causes cancer’) Price in Canadian dollars: $12.00 vs. $13.20 vs. $14.50 vs. $15.95 vs. $17.50	Experiment 2 (two licit alternatives, one illicit alternative) Introduced pack (25 cigarettes) of illicit cigarettes (Canadian Goose) which did not display any mandated health warnings on the packaging. Only varied price (Can$3.00 and Can$6.00)	See Guindon et al. 2024—results too large for table.
Hassan and Shiu 2015	Study 1 (colour photograph) Standard cigarette Minute cigarette: ‘Each puff reduces your life expectancy’ and 1–11-minute markings Toxic cigarette: ‘arsenic, benzene, formaldehyde, pesticides, tar’ Study 2 (physical cigarette) Minute cigarette		Study 1 Quitting intentions*: mean (95% CI) Standard cigarette Pre-exposure: 3.00 (2.10–3.90) Post-exposure: 3.13 (2.23–4.02) t test (P-value): 1.81 (0.083) Minute cigarette Pre-exposure: 3.26 (2.62–3.91) Post-exposure: 3.94 (3.35–4.53) t test (P-value): 3.81 (<0.001) Toxic cigarette Pre-exposure: 3.83 (3.16–4.51) Post-exposure: 4.07 (3.44–4.69) t test (P-value): 2.25 (0.032)	Study 2 Quitting intentions*: mean Minute cigarette Pre-exposure: 2.44 Post-exposure: 2.83 t test (P-value): 4.90 (<0.001) *Intention to stop smoking (0: not at all to 6: very strong)
Moodie et al. 2017	‘Smoking kills’ cigarette		Perceptions: n (%) Would put people off starting to smoke: 844 (71)	Would make people want to give up smoking: 620 (53) All cigarettes should have a warning on them: 1007 (85)
Mullapudi et al. 2023	‘Smoking kills’ cigarette		Perceptions: n (%) Would put people off starting to smoke: 386 (22.0)	Would make people want to give up smoking: 564 (32.1) All cigarettes should have a warning on them: 624 (35.5)
Rodríguez-Lesmes et al. 2024	Design A (only licit tobacco pack alternatives) Package: standard package vs. plain package with large pictorial HWL Cigarette: branded vs. dissuasive message (‘Smoking causes cancer’) Price in USD (presented in Colombian pesos during experiment): $3.14 vs. $2.61 vs. $2.37 vs. $2.16 vs. $1.97 vs. $1.79	Design B (licit and illicit alternatives) Package: standard package Cigarette: branded Price in USD (presented in Colombian pesos during experiment): $1.84 vs. $0.79	See Rodríguez-Lesmes et al. 2024—results too large for table.
Dissuasive messages-qualitative studies (n = 5)
Drovandi et al. 2019b	Your minutes of life lost…15-10-5…From each cigarette smoked Smoking harms your children…Your smoke affects your pets…Smoking hurts your family Smoking stains your fingers…Smoking gives you bad breath…Smoking yellows your teeth Smoking causes lung cancer…Smoking causes heart disease…Smoking causes emphysema Smoking kills half of users…7 million people per year…And reduces quality of life I contain addictive chemicals…Smoking is highly addictive…Don’t suffer from addiction	7. Smoking one pack per day…Costs over $11 000 per year…What could you buy instead? 8. Sick of being forced outside?…Missing out on the fun?…Quit smoking today 13 78 48 9. Smokers get sick more often…Stop wasting your sick days…Visit quitnow.gov.au for help 10. See your pharmacist to quit…See your doctor to quit…Call Quitline 13 78 48 11. Don’t give in to cravings…Go for a quick walk instead…The craving will pass soon 12. You don’t need me anymore…Start your quit plan today…Help is available call 13 78 48	Major theme one Novelty of the messages (most participants expressed interest and support due to visibility when smoking, however some concerns about repetitive exposure).	Major theme two Proximal/tangible messages most likely to influence smoking behaviour (financial burden of smoking most effective, as well as impact of smoking on personal appearance—particularly for young adults—and loss of time per cigarette).
Informa Market Research 2006	Canada Duty Paid Tobacco kills Every cigarette causes you damage Quit smoking—Save money		Effectiveness in getting attention and prompting thoughts about impact of smoking: mean (1: very ineffective to 10: very effective) Canada Duty Paid: 1.64 Quit smoking—Save money: 5.71 Every cigarette causes you damage: 6.43 Tobacco kills: 7.07	Reactions Shock, disbelief, rejection, acceptance. Questions about toxicity, removal. Some felt the messages were excessive. Prompted thoughts about their smoking behaviour. Vertical messages easier to read than horizontal. Smoking affecting others another possible message.
Moodie et al. 2015b	‘Smoking kills’ cigarette		General perceptions Some felt message would be constant visual reminder, others thought ‘stupid’ or ‘desperate’ and people who smoke sufficiently aware of risks. Perceived impact on smoking behaviour Embarrassed to display in public, perceived social awkwardness may reduce appeal of smoking.	Best way to display message Printed once—horizontal or vertical—easily concealed/obscured when smoking. Message on filter considered stronger-visible once cigarette finished, but not when being smoked. Most effective: message printed vertically on both sides of cigarette paper (most salient).
Moodie 2016	‘Smoking kills’ cigarette		Perceptions ‘Brilliant’, ‘fantastic’, ‘powerful’, surprised not yet a regulatory requirement, feasible (inexpensive, non-toxic, vegetable-based inks), would increase message exposure, be a constant reminder of risks of smoking and be visible to others. Mention of rotating messages.
Moodie et al. 2020	‘Smoking kills’ cigarette		Salience Message prominent and difficult to miss, prolongs health message, constant reminder, potential desensitisation with time. Avoidance Avoidance behaviour more difficult. Appeal and image Considered horrible, antithesis of fashion. Perceived response from others Message visible to others-may be questioned or judged, less likely to smoke in front of others.	Emotional response Embarrassed to hold/smoke them, messages depressing, worrying, frightening. Impact on behaviour Question smoking behaviour, stub out early, reduce consumption, some would not alter behaviour (already purchased, aware of risks, lack willpower, or addicted). Impact on young people and people who do not smoke Communicate health message to those not exposed to packaging.
Dissuasive messages-mixed-methods study (n = 1)
Drovandi et al. 2019a	See Drovandi et al. 2023 for messages on cigarettes	Theme 1: mortality statistics Theme 2: health condition consequences Theme 3: social and financial consequences Theme 4: supportive messages to quit smoking	Perceived effectiveness in discouraging uptake and prompting quitting: OR (95% CI); P-value Ref: current packaging warnings Theme 1: 2.23 (1.12–4.42); P = 0.02 Theme 3: 1.97 (1.01–3.84); P = 0.04 Theme 2: 0.80 (0.41–1.56); P = 0.51 Theme 4: 0.29 (0.14–0.59); P < 0.001	Major themes The need for messages describing appearance-related effects of smoking, short-term consequences, and smoking’s impact on others.
Dissuasive colours and messages-quantitative studies (n = 6)
Hoek et al. 2016	Standard cigarette: white stick with cork filter ‘Feminine’ cigarette: white stick with white filter Coloured cigarette: slimy green Coloured cigarette: faecal yellow-brown Message cigarette: ‘Smoking kills’ Message cigarette: ‘Minutes of life lost’		Most/least likely to buy: OR (95% CI) Ref: standard cigarette ‘Feminine’: 0.42 (0.36–0.48)* ‘Smoking kills’: 0.36 (0.31–0.42)* Faecal yellow-brown: 0.29 (0.24–0.34)* Slimy green: 0.27 (0.23–0.32)* ‘Minutes of life lost’: 0.21 (0.18–0.25)* *P < 0.05	Stick appearance: mean score (95% CI) (−5: very unattractive to +5: very attractive) ‘Minutes of life lost’: −1.32 (−1.65 to −1.00) ‘Smoking kills’: −0.95 (−1.24 to −0.67) Slimy green: −0.89 (−1.23 to −0.56) Faecal yellow-brown: −0.80 (−1.09 to −0.50) ‘Feminine’: 1.13 (0.86 to 1.39) Standard: 2.66 (2.41 to 2.91)
Lund and Scheffels 2018	Cork tip cigarette White tip cigarette Yellow cigarette Green cigarette ‘Minutes life lost’ cigarette ‘Smoking kills’ cigarette		Appeal: mean score (1: very low appeal to 11: very high appeal) Green: 2.39 Yellow: 2.61 ‘Minutes life lost’: 3.58 ‘Smoking kills’: 3.78 Cork tip: 4.54 White tip: 4.74	Which cigarette has the best taste?: % White tip (33.6), cork tip (25.3), yellow (2.1), green (1.7), ‘Minutes life lost’ (1.2), ‘Smoking kills’ (0.4) Which cigarette would you want to try?: % White tip (43.0), cork tip (22.5), ‘Minutes life lost’ (6.8), green (5.6), yellow (2.0), ‘Smoking kills’ (0.8) Which cigarette looks more harmful?: % Green (43.3), yellow (22.4), ‘Minutes life lost’ (18.4), cork tip (2.5), ‘Smoking kills’ (1.8), white tip (0.4)
Mitchell et al. 2021	Standard cigarette Dark green cigarette ‘Smoking kills’ in red writing, white cigarette paper ‘TOXIC’ in black writing, yellow skull and crossbones image, white cigarette paper		Overall negative reaction: n (%) ‘Toxic’: 497 (96) ‘Smoking kills’: 492 (94) Dark green: 480 (93) Standard: 445 (85)	Would not trial the cigarette: n (%) ‘Toxic’: 512 (91) Dark green: 508 (90) ‘Smoking kills’: 502 (89) Standard: 478 (84)
Moodie et al. 2018	Standard cigarette (SC) Green cigarette (CC) ‘Smoking kills’ cigarette (MC)		Perceptions: % Harmful to health: CC (70.2)†, MC (69.1)†, SC (38.8) Think of dangers: MC (58.1)†‡, CC (53.5)†, SC (20.9) Unattractive: CC (68.7)†, MC (61.7)†, SC (25.2) Unstylish: CC (69.4)†, MC (66.0)†, SC (37.4)	Not nice to be seen with: CC (60.2)†, MC (55.2)†, SC (19.8) Not appealing to people my age: CC (57.4)†, MC (51.5)†, SC (17.8) Unlikely to try (personally): CC (66.5)†, MC (45.4)†, SC (8.9) Unlikely to try (for people who have never smoked): CC (71.6)†, MC (63.3)†, SC (14.8) †Sig. difference with SC (P < 0.001) ‡Sig. difference with CC (P < 0.05)
Moodie et al. 2019	Standard cigarette Green cigarette ‘Smoking kills’ cigarette		Overall perception: median (IQR); P-value compared with standard cigarette (8: unfavourable to 56: favourable) People who do not smoke Standard: 23.00 (15.00) Green: 17.00 (16.00); P < 0.001 Message: 20.00 (15.50); P < 0.001 People who smoke Standard: 31.00 (10.00) Green: 26.00 (17.75); P < 0.001 Message: 26.00 (14.00); P < 0.001	Trial: median (IQR); P-value compared with standard cigarette (0: low chance to 10: certainty) People who do not smoke Standard: 3.80 (5.20) Green: 0.80 (3.15); P < 0.001 Message: 0.90 (3.00); P < 0.001 People who smoke Standard: 6.70 (3.80) Green: 2.80 (4.78); P < 0.001 Message: 3.80 (5.10); P < 0.001
van Mourik et al. 2022	Study 1 ‘Smoking is addictive’ (C1) ‘Smoking kills’ (C2) ‘Impotence, yellow teeth, bad breath’ (C3) ‘Cancer, heart disease, stroke’ (C4) Drab dark brown (C5) Green (C6) Grey (C7) Blue (C8)	Study 2 Standard (C9) Least favourable message from Study 1: ‘Cancer, heart disease, stroke’ (C10) Least favourable colour from Study 1: drab dark brown (C11) Combination of least favourable message and colour from Study 1 (C12)	Study 1 Appeal: mean (SD) (6: least appealing to 42: most appealing) C4: 8.57 (4.81), C3: 9.02 (5.12), C2: 9.82 (5.83), C1: 11.28 (6.37) C5: 10.80 (7.31), C6: 11.83 (7.66), C7: 13.06 (8.44), C8: 14.01 (9.05) Harm: mean (SD) (3: least harmful to 21: most harmful) C1: 15.67 (5.40), C2: 16.80 (5.40), C3: 17.05 (5.13), C4: 17.62 (5.34) C8: 14.81 (5.72), C7: 15.32 (5.42), C6: 15.33 (5.60), C5: 16.14 (5.49) Interest in product trial: mean (SD) (0: no chance/almost no chance to 10: certain/practically certain) C4: 1.64 (1.53), C3: 1.77 (1.53), C2: 1.91 (1.77), C1: 1.97 (1.66) C5: 1.78 (1.70), C6: 1.87 (1.72), C7: 2.00 (1.86), C8: 2.09 (1.99)	Study 2 Appeal: mean (SD) (P = 0.762) C10: 10.94 (6.06), C9: 11.15 (6.45), C12: 11.61 (7.08), C11: 11.72 (6.56) Harm: mean (SD) (P = 0.510) C11: 14.52 (6.22), C9: 14.67 (5.85), C12: 15.60 (5.66), C10: 15.63 (5.51) Interest in product trial: mean (SD) (P = 0.701) C12: 1.88 (2.02), C9: 1.99 (1.58), C11: 2.02 (1.74), C10: 2.30 (2.19)
Dissuasive colours and messages-qualitative studies (n = 2)
Gallopel-Morvan et al. 2019a	First set: 10 cigarettes (five ‘standard’ shaped and five slim) Marlboro [Vogue for the slim] Dark green filter, white stick Dark brown filter, white stick Dark green fully coloured stick Dark brown fully coloured stick	Second set: 18 cigarettes (nine ‘standard’ shaped and nine slim) Marlboro [Vogue for the slim] Dark green filter, ‘Smoking kills’ (lower case) Dark green filter, ‘Smoking kills’ (upper case) Dark green filter, ‘Smoking kills’ (lower case), skull and crossbones pictogram Fully dark green stick, ‘Smoking kills’ (lower case), skull and crossbones pictogram Dark brown filter, ‘Smoking kills’ (lower case) Dark brown filter, ‘Smoking kills’ (upper case) Dark brown filter, ‘Smoking kills’ (lower case), skull and crossbones pictogram Fully dark brown stick, ‘Smoking kills’ (lower case), skull and crossbones pictogram	Colour Dark green: negative and positive reactions. Dark brown: mostly negative reactions. Around half would consider quitting, reduce consumption, or not start if only coloured cigarettes available. Full colouring: perceived as stronger and more dangerous/repulsive/chemical than coloured filters. Colour and message Messages combined with colours generated more negative reactions than coloured cigarettes alone. Skull and crossbones: provoked fear, thoughts of disease, toxicity, and chemical products.	‘Smoking kills’: less associated with danger (regularly seen on tobacco packaging). Smoking behaviour Marlboro/Vogue: positive reactions (less dangerous, more attractive, better quality) and as a result, more likely to stimulate smoking. Fully dark green/brown stick, ‘Smoking kills’, skull and crossbones pictogram: most effective for preventing uptake, reducing consumption, quitting.
Mitchell et al. 2020	Standard cigarette Dark green cigarette Lighter green cigarette ‘Smoking kills’ in red writing ‘TOXIC’ in black writing and yellow skull and crossbones image		Initial reactions and perceptions Green cigarettes: embarrassing, ugly, unattractive, bland, dull. Cigarettes with messages: reduced the appeal of smoking, off-putting, embarrassing, scary. Harm perceptions ‘TOXIC’ cigarette rated most harmful in most of the groups.	Perceived impact on smoking attitudes and behaviour Would impact people who do not smoke and people starting to smoke. Least impact on those with established smoking habit and may diminish with time.

CI, confidence interval; HWL, health warning label; IQR, interquartile range; OR, odds ratio; SD, standard deviation.

Figure 2.

Selection of publications for inclusion in the review.

No studies of the direct empirical relation of policies and regulations to smoking prevalence, uptake, and quitting were identified. Studies generally provided participants with examples of potentially dissuasive cigarettes—typically photographs/images of cigarettes in the online cross-sectional studies and physical cigarettes in the qualitative studies—and asked them to rate factors such as attractiveness, appeal, quality, taste, strength, and harm. Other outcomes included perceived impact on smoking behaviour, intent or interest in purchasing/trialling/quitting, and level of support. Sample sizes were generally small, ranging from 9 to 1766 participants. Studies were conducted in adolescent, youth, and adult populations, in people who do and do not smoke.

Thirty-two publications were eligible for quality assessment. In two publications, two cross-sectional studies were conducted, and each had their quality assessed. No evidence was excluded from the review on the basis of quality and no publications were rated high quality. The systematic and scoping reviews were both rated medium quality as neither assessed the likelihood of publication bias and the criteria for appraising studies was not appropriate (Supplementary Table S2). Of the 22 quasi-experimental studies, 10 were rated medium quality and 12 were rated low quality, many of which did not use control groups or provide sufficient information to determine whether outcomes were measured in a reliable way (Supplementary Table S3). Of the 10 qualitative studies, 9 were rated medium quality and 1 low quality, largely due to lack of exploration of the cultural and theoretical positions of the researchers and their potential influence on the research (Supplementary Table S4).

Perceptions of dissuasive colours on cigarettes

Three quantitative and three qualitative studies investigated dissuasively coloured cigarettes.

In an Australian cross-sectional study, a cork cigarette with gold band was rated most attractive, highest quality, strongest tasting and most preferred compared to a plain cork cigarette, white-tip cigarette, blue-tip cigarette, and cigarette with fancy embossed tip. The blue-tip cigarette was rated least attractive, lowest quality, and least preferred (Borland and Savvas 2013). In a French cross-sectional study, grey cigarettes were perceived to have a greater impact on smoking behaviour (preventing initiation, reducing consumption, and motivating cessation) than standard, slim, or pink cigarettes. Standard, slim, and pink cigarettes were also viewed as more expensive, tastier, and higher quality than grey cigarettes, which were considered the most dangerous. Females were significantly more likely than males to select grey cigarettes as the most effective for preventing initiation, reducing consumption, and motivating cessation (Gallopel-Morvan et al. 2019b). A US cross-sectional study compared two cigarettes with filters (one cork and one white, both 85 mm in length) and an unfiltered 70 mm cigarette. The cork-tip cigarette was most frequently selected for attractiveness and taste, whilst the white-tip cigarette was selected as least dangerous. The unfiltered cigarette was selected as most dangerous (O’Connor et al. 2015).

In Scottish focus groups, brown cigarettes were consistently viewed as the least appealing, most unpleasant tasting, and most harmful, described as ‘old fashioned’ and ‘disgusting’ [compared with cork, pink, and black cigarettes in one study (Moodie et al. 2015a), and cigarettes of various lengths, diameters, and colours in another (Ford et al. 2014)]. Pink cigarettes—viewed as highly appealing, pleasant tasting, and least harmful—were seen as ‘fun’ and ‘pretty’. Black cigarettes received mixed responses for appeal and taste, whilst the two cork cigarettes generally had low appeal (Moodie et al. 2015a).

Cigarettes of dark shades—particularly brown and green—were regarded as ‘disgusting’, ‘gross’, and ‘weird’ and a reminder of the risks of smoking, whilst white cigarettes were described as ‘clean’, ‘healthy’, and ‘pure’ in New Zealand qualitative research (Hoek and Robertson 2015). Brightly coloured and pastel cigarettes were seen as novel and attractive. Some participants thought changes in cigarette appearance could confound their desired social identity, challenge their reasons for smoking, and trigger quit attempts. Others believed a dependence on nicotine would override the measure (Hoek and Robertson 2015).

Perceptions of dissuasive messages on cigarettes

Ten quantitative studies, five qualitative studies, and one mixed-methods study compared perceptions of a range of dissuasive messages—generally relating to health and mortality impacts, social and financial consequences, and support for quitting.

In Australian cross-sectional research, participants perceived that cigarettes displaying mortality statistics and the social and financial consequences of smoking would be more effective than current packaging warnings in discouraging smoking uptake and encouraging quitting (Drovandi et al. 2018a, 2019a, 2020, 2023). Supportive messages to quit were rated less effective, whilst health risk messages were rated equally effective in two studies and more effective in one. The ‘Minutes of life lost’ cigarette was rated particularly effective across the studies. In general, there were no differences in perceived effectiveness by age, gender, or smoking status. Support for inclusion on cigarettes ranged from 78.7% to 91.4%, with support greater among people who do not smoke and people who formerly smoked relative to people who currently smoke (Drovandi et al. 2018a, 2019a, 2020, 2023).

In a cross-sectional study of people who smoke from Australia, Canada, the UK, and the US, five on-product cigarette messages were perceived to be more effective than current packaging warnings in prompting them to quit (in descending order): financial cost of smoking; effect of smoking on others; risk of mortality from smoking; minutes of life lost; and planning to quit (Drovandi et al. 2019c). ‘Dealing with cravings’ and ‘social issues with smoking’ cigarettes were rated less effective and ‘risk of addiction from smoking’ was equally effective. Males, those from the UK (relative to Australia), and those perceiving smoking as quite/very harmful (relative to some harm) were significantly more likely to perceive the messages as being effective, whilst those smoking ≥21 cigarettes per day (relative to occasional smoking) were significantly less likely. Around half (50.7%) of participants agreed or strongly agreed with the measure (Drovandi et al. 2019c).

In a Saudi Arabian cross-sectional study, cigarettes from all four themes (messages adapted from Drovandi et al. 2023) were perceived to be more effective than packaging warnings in preventing smoking uptake and prompting quitting (Al-Ahmadi et al. 2024). Those with secondary education and lower (relative to university education and higher) were significantly more likely to perceive the messages as effective. There were no differences by age, gender, or employment status. Most participants (71.6%) either agreed or strongly agreed with the measure, with people who do not smoke three times as likely as people who do smoke to support (Al-Ahmadi et al. 2024).

In a Scottish cross-sectional study, the ‘minute’ (‘Each puff reduces your life expectancy’ and 1–11-minute markings) and ‘toxic’ (‘arsenic, benzene, formaldehyde, pesticides, tar’) cigarettes were rated less attractive than a standard cigarette (Hassan and Shiu 2015). Quitting intentions increased after exposure to both cigarettes, although to a greater extent for the ‘minute’ cigarette. In a second cross-sectional study in Greece, quitting intentions increased after participants held a ‘minute’ cigarette (Hassan and Shiu 2015).

Seventy-one per cent and 22% of participants in UK and Indian cross-sectional studies respectively thought ‘Smoking kills’ cigarettes would put people off starting to smoke (Moodie et al. 2017, Mullapudi et al. 2023). Fifty-three per cent thought it would make people want to give up smoking (32% in Indian study) and 85% thought all cigarettes should have a message on them (36% in Indian study). In general, there were no differences in perceptions by age or gender. The UK study found that people who have never smoked and people who formerly smoked or experimented were significantly more likely than people currently smoking to support the measure and perceive that it would put people off starting to smoke and make people want to give up smoking (Moodie et al. 2017, Mullapudi et al. 2023).

Cigarettes displaying ‘Smoking causes cancer’ were included as an attribute in two discrete choice experiments (DCEs) (Guindon et al. 2024, Rodríguez-Lesmes et al. 2024). In a Canadian DCE, plain packaging and the dissuasive cigarette decreased the probability of a purchasing preference for around 20% of participants. Risk perceptions were not affected by any product or attribute (Guindon et al. 2024). A Colombian DCE found that the dissuasive cigarette did not affect perceptions of risk and had a limited role in terms of choice (Rodríguez-Lesmes et al. 2024).

In Australian qualitative research, cigarettes displaying the financial burden of smoking, impact of smoking on physical appearance and others, and reduced life expectancy (‘Minutes of life lost’) were perceived to be particularly novel and effective when shown to individuals of any smoking status, but to a greater extent among people who do not smoke (Drovandi et al. 2019a, 2019b). Messages describing more proximal and tangible consequences of smoking were perceived to be the most likely to influence smoking behaviour, with some participants not identifying with the distal threats of chronic disease (Drovandi et al. 2019a, 2019b).

In two focus group studies in Scotland, participants indicated they would feel embarrassed to display a ‘Smoking kills’ cigarette in public (Moodie et al. 2015b, Moodie et al. 2020). Some participants thought they may be questioned, judged, perceived negatively, or appear foolish (Moodie et al. 2020). Several participants indicated they would question their smoking behaviour, reduce consumption, or stub cigarettes out early, whilst others stated they would not alter their smoking behaviour as they have already made the purchase, are addicted, aware of the health risks, or lack the willpower to quit (Moodie et al. 2020). Some participants thought the cigarette was ‘desperate’ or claimed those who smoke are already cognisant of the risks (Moodie et al. 2015b).

UK packaging and marketing experts viewed ‘Smoking kills’ cigarettes as ‘powerful’ and ‘brilliant’, more difficult to avoid than packaging warnings, and a constant reminder of smoking’s risks (Moodie 2016). There was a general view that they could have a powerful psychological impact, affecting the image of smoking, particularly for young people. Combining messages with unpleasant black, brown, or dark green colours was suggested, as colours elicit meaning and association and can influence taste. Inexpensive, non-toxic vegetable-based inks were mentioned (Moodie 2016).

In Canadian market research, ‘Tobacco kills’ cigarettes were rated most effective in gaining attention and prompting thoughts about the impact of smoking, followed by ‘Every cigarette causes you damage’, ‘Quit smoking—Save money’, and ‘Canada Duty Paid’ (Informa Market Research 2006). Shock was a common initial reaction—likened to the introduction of packaging warnings—and some participants wondered if they could remove the message or if the dye is toxic. Messages centring on the adverse effects of smoking on children and people who do not smoke were also considered viable (Informa Market Research 2006).

Perceptions of dissuasive colours and messages on cigarettes

Two reviews (one systematic, one scoping), six quantitative studies, and two qualitative studies either compared perceptions of cigarettes with colours and cigarettes with messages, or investigated perceptions of cigarettes that featured both.

The 2018 systematic review (Drovandi et al. 2018b), and 2023 scoping review (Al-Zalabani et al. 2023) both concluded that dissuasive cigarettes represent a potentially effective tobacco control measure.

Two UK cross-sectional studies compared perceptions of ‘Smoking kills’, green, and standard cigarettes (Moodie et al. 2018, Moodie et al. 2019). In one study, green cigarettes had the lowest likelihood of trial (Moodie et al. 2019). People who do not smoke rated the green cigarette most unfavourable, whilst people who smoke rated the green and ‘Smoking kills’ cigarettes equally unfavourable (Moodie et al. 2019). In the other study—involving people who smoke—the green cigarette was rated least appealing and least likely to trial (Moodie et al. 2018). The green cigarette was rated most harmful to health and the ‘Smoking kills’ cigarette made more participants think about the dangers of smoking (Moodie et al. 2018). Both dissuasive cigarettes were rated less desirable (more harmful, less appealing, and less likely to be tried) than the standard cigarette. Females and those of low socioeconomic status were significantly more likely to view all three cigarettes as undesirable, compared with males and those not of low socioeconomic status, respectively (Moodie et al. 2018).

A Scottish cross-sectional study found that more participants had an overall negative reaction to the ‘toxic’ cigarette (‘TOXIC’ and a skull and crossbones) (96%), compared with the ‘Smoking kills’ (94%), dark green (93%), and standard (85%) cigarettes (Mitchell et al. 2021). Most participants indicated they would not trial the ‘toxic’ (91%), dark green (90%), ‘Smoking kills’ (89%), or standard (84%) cigarettes. Younger adolescents (versus older adolescents) and people who have never smoked (versus people who have ever smoked) were significantly more likely to have negative reactions to and no trial intentions for all four cigarettes (Mitchell et al. 2021).

In a New Zealand choice experiment, participants were most likely to purchase a standard cigarette (cork filter), followed by ‘feminine’ (white filter), ‘Smoking kills’, faecal yellow-brown, slimy green, and ‘Minutes of life lost’ cigarettes (Hoek et al. 2016). Cigarettes from most to least appealing, were: standard; ‘feminine’; faecal yellow-brown; slimy green; ‘Smoking kills’; and ‘Minutes of life lost’. Females rated the faecal yellow-brown and slimy green cigarettes significantly less appealing than males did. Older people (relative to younger) rated the ‘Smoking kills’ and slimy green cigarettes significantly less appealing (Hoek et al. 2016).

In a Norwegian cross-sectional study, appeal was the highest for a white-tipped cigarette, followed by cork-tip, ‘Smoking kills’, ‘Minutes life lost’, yellow, and green cigarettes (Lund and Scheffels 2018). There were no age or gender differences for appeal; however, people who do not smoke found three of the dissuasive cigarettes significantly less appealing than people who smoke did. White-tip (33.6%) was considered best tasting [‘Smoking kills’ (0.4%) had the lowest proportion], green (43.3%) was considered most harmful [white-tip (0.4%) had the lowest proportion] and the greatest proportion wanted to try white-tip (43.0%) [‘Smoking kills’ (0.8%) had the lowest proportion]. There were no gender differences for taste or harm; however, females were significantly less likely to want to try the dissuasive cigarettes. People who do not smoke were significantly less likely than people who do smoke to nominate the dissuasive cigarettes as best tasting (Lund and Scheffels 2018).

The ‘Cancer, heart disease, stroke’ (‘cancer’) cigarette (compared to ‘Smoking is addictive’, ‘Smoking kills’, and ‘Impotence, yellow teeth, bad breath’ cigarettes) and the drab dark brown cigarette (compared to green, grey, and blue cigarettes) were rated least appealing and most harmful and had the lowest interest in product trial in a Dutch cross-sectional study (van Mourik et al. 2022). Overall, coloured cigarettes were rated more appealing and less harmful than cigarettes with messages. In a second study, the ‘cancer’ cigarette was rated least appealing and most harmful when compared to a standard cigarette, drab dark brown cigarette, and drab dark brown cigarette with the cancer message. There were no significant differences between standard and dissuasive cigarettes for appeal, harm, or trial intentions (van Mourik et al. 2022).

On-cigarette messages (‘Smoking kills’ and ‘TOXIC’ with a skull and crossbones) reduced the appeal of smoking and were viewed as off-putting and embarrassing in Scottish focus groups (Mitchell et al. 2020). The ‘TOXIC’ cigarette was viewed negatively by most participants and was described as a constant reminder of the harms of smoking. Some thought ‘Smoking kills’ would be less effective than ‘TOXIC’ as the message is commonly seen on tobacco packaging. Dark and lighter green cigarettes were seen as horrible, embarrassing, and unattractive. All four dissuasive cigarettes were rated more harmful and less attractive than a standard cigarette; however, the cigarettes with messages were considered more off-putting than the green cigarettes (Mitchell et al. 2020).

In a French qualitative study, dark brown cigarettes generated mostly negative reactions, reminding participants of tar and petrol (Gallopel-Morvan et al. 2019a). Dark green cigarettes elicited both positive (plants and leaves) and negative (algae and drugs) associations. Around half of participants indicated that they would consider quitting, reduce consumption, or not start if dissuasively coloured cigarettes were the only ones available. Dark green and dark brown cigarettes that also displayed messages (‘Smoking kills’ and skull and crossbones) generated more negative reactions than coloured cigarettes alone. The skull and crossbones evoked fear and thoughts of death, poison, and toxicity, whilst ‘Smoking kills’ was less associated with danger and received fewer reactions. Two-thirds of participants indicated they would feel embarrassed to smoke cigarettes with such messages in public. One-third of participants thought upper case messages increased both message visibility and the perceived danger of tobacco. Marlboro and Vogue cigarettes were viewed as tastier, more attractive, less dangerous, and better quality than the dissuasive cigarettes (Gallopel-Morvan et al. 2019a).

The potential of dissuasive cigarettes in tobacco control policy

Six commentaries and one doctoral thesis discussed the potential of dissuasive cigarettes in tobacco control policy. Commentary pieces argued that dissuasive cigarettes are a logical extension of existing policy (Moodie 2018). As a constant reminder of the health harms of smoking, they are visible ‘every puff of every cigarette’ (Cunningham 2022). Dissuasive measures could reduce the psychological distance between a cigarette’s appearance and its effects (Hoek and Gendall 2017). Given that tobacco companies already place their branding on cigarettes, the measure is evidently feasible, and potentially low-cost if borne by industry (Moodie 2018). Physical and psychological avoidance behaviour—as can occur with packaging warnings—would be more difficult (Moodie 2018). They could increase warning exposure for those with less exposure to tobacco packaging, such as people experimenting with single cigarettes, often youth (Moodie 2018), and those in locations such as Southeast Asia where the sale of individual cigarettes is prevalent (Sarode et al. 2024). Messages could be tailored to high-use populations as a pro-equity measure (Houghton et al. 2019). One commentary noted the importance of implementing a comprehensive policy to limit industry’s ability to exploit regulatory loopholes (van der Eijk 2024). A doctoral thesis from The Netherlands evaluated health warnings and dissuasive cigarettes in the European Union and included a cross-sectional study (identified in the database search as a peer-reviewed journal article) assessing perceptions of dissuasive cigarettes (van Mourik 2019).

Government consideration of dissuasive cigarettes

Eight government-related publications were identified in the search.

In a 2018 Health Canada public consultation, most respondents, other than those from the tobacco industry, supported dissuasive cigarettes (Health Canada 2019). Key suggestions included: focusing on concise messages related to health impacts and smoking cessation; using large, impactful font and different colours for different types of messages; tailoring messages to high-use populations; and ensuring cultural appropriateness. Two respondents not affiliated with the tobacco industry thought the measure was disrespectful to people who smoke, whilst industry expressed concerns regarding ink toxicity, a lack of evidence, and the cost of changing printing machinery and inks (Health Canada 2019).

In an impact analysis by Australia’s Office of Impact Analysis, dissuasive cigarettes were a proposed policy option to drive continued reductions in smoking prevalence (Office of Impact Analysis 2023). Potential costs to government included establishing a new regulatory framework, ongoing monitoring and enforcement, and other costs. Potential costs to manufacturers and importers included re-engineering products to ensure compliance with regulations. The total estimated compliance costs for business, which included manufacturers, retailers, and wholesalers, averaged $2.1 million annually (Office of Impact Analysis 2023).

The ‘Cigarette Stick Health Warnings Bill [HL]’, a Private Member’s Bill brought from the UK House of Lords, proposed eight messages for individual cigarettes and cigarette rolling papers (UK Parliament 2022). Mentions of dissuasive cigarettes appear in the House of Lords Hansard (UK Parliament 2020) and House of Commons Hansard (UK Parliament 2013). Scotland’s 2018 tobacco control action plan listed ‘making cigarettes less attractive’—through changes to colour, composition, and/or warning messages—as a potential regulatory action to restrict demand (Scottish Government 2018). Since March 2013, all cigarettes sold in Singapore have been required to display the letters ‘SDPC’ (Singapore Duty-Paid Cigarette) and a series of vertical bars (Singapore Customs 2008, 2012). Designed to curb the sale, purchase, and possession of duty-unpaid (contraband) cigarettes, the markings reveal an added benefit of dissuasive cigarettes in helping distinguish licit and illicit products.

Discussion

This review was conducted to identify evidence of the likely effectiveness of dissuasive measures on tobacco products, with the purpose of rapidly informing Australian policy. Reflecting the lack of global implementation sufficient to allow policy evaluation, evidence to date is largely limited to perceptions/ratings of various qualities of dissuasive cigarettes, such as harm, strength, appeal, and taste and perceived behavioural impact, including purchase, trial/initiation, consumption, and cessation.

The available evidence is largely supportive of dissuasive cigarettes as a strategy to reduce the desirability of cigarettes. In general, darker coloured cigarettes, particularly green and brown, were least preferred, whilst standard (white and cork), pink, and other brightly coloured cigarettes were viewed as most appealing. Cigarettes bearing certain messages, especially the financial consequences of smoking and impact of smoking on others, were perceived to be the most novel and effective, as were messages that centred on mortality and reduced life expectancy, such as the ‘Minutes of life lost’ cigarette. ‘Smoking kills’ was a commonly used message that was generally perceived to be effective, however some participants [from Scottish (Mitchell et al. 2020) and French qualitative studies (Gallopel-Morvan et al. 2019a)] thought it may not produce the optimal response as it is commonly included on tobacco packaging. Participants indicated dissuasive cigarettes could challenge their smoking behaviour, reduce the appeal of smoking, and reduce consumption, with embarrassment and fear of judgement or ridicule cited. Furthermore, the available evidence suggests the impact of dissuasive cigarettes may be more pronounced in people who do not smoke or who formerly smoked, relative to people who do smoke. Commentaries frequently highlighted that dissuasive measures could act as a constant reminder of the harms of smoking, in addition to making avoidant behaviour more difficult, including for those who consume/purchase individual cigarettes. A majority (21/34) of studies were rated medium in quality assessment, and no studies were rated high quality.

Various theories and models were put forward by the authors of the included publications as putative mechanisms. Borland and Savvas (2013) cite the ‘sensation transfer technique’, a testing methodology often used by the tobacco industry which has shown that perceptions of cigarette attributes, such as taste, vary depending on elements of cigarette design and branding. The health belief model describes how an individual’s perceptions can influence their health-related decisions and behaviours (Janz and Becker 1984). Cue consistency theory relates to the impact of inconsistent/disruptive cues (Slovic 1966). When a green cigarette is presented instead of a white one for instance, a consumer’s expectations and consumption experience are potentially subverted. Cognitive dissonance theory may also be relevant: dissuasive measures could generate cognitive dissonance, a state of tension where inconsistent beliefs or attitudes are held (Festinger 1957). Construal level theory describes how thought and behaviour are shaped by ‘psychological distance’ (either time, space, social distance, or hypothetically), whereby individuals use concrete/detailed low-level construals for proximal events and abstract high-level construals for distant events (Trope et al. 2007).

This review has also highlighted significant gaps in the research literature. No empirical evidence on the relation of dissuasive measures to tobacco control outcomes was located as only Canada and Australia have very recently implemented policies. As such, studies measured behavioural intentions or perceptions as opposed to actual behaviour. All tobacco products were eligible for inclusion; however, no data relating to non-cigarette products were identified. Studies were almost exclusively conducted in high-income Western settings. Studies were generally small and in nonrepresentative populations, limiting the generalizability of the findings. Exposure to the cigarettes was brief, failing to replicate a real-world situation of repeated exposures over time. Similarly, cigarettes were not presented alongside the packaging they are typically contained in. Many studies used photographs/images of cigarettes, preventing tactile interaction. Participant responses may have been influenced by the novelty of the cigarettes, the order in which they were presented, and socially desirable responding. Visibility of known brand names may also have influenced responses. Given the policy/advocacy-driven nature of the topic, there is the possibility of publication bias. Key limitations of this review itself were the rapid nature of the review (meaning that not all papers were screened and appraised by two reviewers), the heterogeneity of identified studies (meaning that pooled analyses were not feasible), and restriction to English language research (meaning that relevant non-English evidence may have been missed). A key strength of the review was its use of grey literature, enabling more extensive insight into the topic.

Future research should be conducted in a wider range of settings, focusing on low- and middle-income countries and those where the sale of individual cigarettes is commonplace. This is particularly important in light of evidence that colour perceptions are culture-specific (Aslam 2006). Large longitudinal studies that assess the impact of repeated exposure to dissuasive cigarettes over time are needed. Research should expose participants to packaging and dissuasive cigarettes simultaneously, more accurately replicating real-world exposure. There is scope to investigate other outcomes, such as attention and comprehension and the impact of typographical variations; an included study found that upper case messages increased message visibility and perceived danger (Gallopel-Morvan et al. 2019a), with marketing research not identified in this review suggesting perceptions of brand friendliness are heightened by lower case text (Xu et al. 2017).

Tobacco companies are motivated by the generation of profit and the transfer of this wealth to shareholders and investors (Wood et al. 2023). As the most consumed nicotine-delivery product globally (WHO 2025a), conventional cigarettes are a major driver of company profits (Branston 2021, Tobacco Tactics 2025). It is therefore in the interests of tobacco companies to make cigarettes as appealing and addictive as possible in order to continue maximizing sales and company profits. Visual elements of cigarette design, including branding, decorative features, and colour contribute to their appeal (Borland and Savvas 2013, Smith et al. 2017). The potential of dissuasive cigarettes as a tobacco control measure lies in their ability to make cigarettes less appealing in two ways: first by applying unappealing colours and/or messages, and second by obstructing the appealing elements mentioned above.

Dissuasive cigarettes, and any other measure that reduces the appeal and desirability of cigarettes—a major contributor to tobacco-related morbidity and mortality—should be considered in public health policy. The tobacco industry has a long history of litigating, or threatening to litigate, governments in order to obstruct the implementation of tobacco control measures (George et al. 2018). Policymakers and governments intending to legislate dissuasive on-product measures should be aware of and prepare for industry interference, a major barrier to WHO FCTC implementation (WHO 2021).

Conclusion

This review has identified dissuasive cigarettes to be a promising strategy in tobacco control policies. However, direct empirical evidence investigating the relation of dissuasive cigarettes to tobacco control outcomes is lacking as only Canada and Australia have implemented policies. Additionally, included evidence was rated low/medium in quality assessment. When used in parallel with strategies such as plain packaging and health promotion inserts, dissuasive cigarettes could stymie promotional product features and create a negative consumption experience from when the pack is purchased through to the last puff. This review was commissioned by the Australian Government, with the findings informing subsequent policy development. Findings of the review can inform tobacco control policy in other jurisdictions.

Author contributions

S.B., A.V., and E.B. conceptualized the study. S.B. conducted the database, grey literature, and forward/backward citation searches and performed screening and data extraction. A.I. screened publications in the updated search. A.I. and A.V. extracted data and performed quality assessments. S.B. and A.V. drafted the initial manuscript. S.B. reviewed and edited subsequent versions of the manuscript. A.V. and E.B. provided supervision throughout. All authors approved the final/submitted version of the manuscript.

Sinan Brown (Conceptualization, Formal analysis, Investigation, Project administration, Writing—original draft, Writing—review and editing), Emily Banks (Conceptualization, Funding acquisition, Supervision, Writing—review & editing), Angelina Inthavong (Formal analysis, Investigation), and Amy Villarosa (Conceptualization, Formal analysis, Investigation, Supervision, Writing—original draft, Writing—review & editing)

Supplementary material

Supplementary material is available at Health Promotion International online.

Conflicts of interest

None declared.

Funding

The report which preceded this article was supported by the Australian Government Department of Health, Disability and Ageing in 2023. S.B. was supported by an Australian Government Research Training Program (RTP) Stipend Scholarship. E.B. was supported by the National Health and Medical Research Council [reference 2017742]. These funding sources had no role in the design or execution of the study.

Data availability

No new data were created in this study. Data for this review are available within the article and Supplementary material.

Ethical approval

This study is a review of existing evidence. As such, ethical approval was not required.