• China has the perfect burden of tobacco-caused morbidity and mortality on this planet, and cigarette pack advertising and marketing, together with using deceptive health-related appeals (eg, mild colors) has been related to decrease perceived hurt of cigarette use which may give a contribution to consistently top charges of smoking in China.

  • Little analysis has characterized options of cigarette packs bought in China, in particular using culturally particular imagery, colors and claims that might counsel merchandise are ‘wholesome’ or ‘just right for you’.


  • We used an idea mapping option to increase a codebook of culturally particular fitness options (eg, imagery of uncommon animals) that was once utilized to 1023 cigarette packs bought in China throughout 2013 and 2017.

  • Roughly 8 out 10 cigarette packs within the learn about pattern contained no less than one culturally particular fitness characteristic (eg, botanics, uncommon animals, vivid colors), suggesting this can be a not unusual advertising and marketing tactic hired by means of Chinese language tobacco firms.


  • Findings from this learn about can tell tobacco keep watch over coverage interventions in China, together with growth of present tobacco packaging and labelling necessities and different restrictions on branding (together with simple packaging) that might assist cut back smoking.


In 2018, 26.6% of Chinese language adults used tobacco (roughly 300 million present people who smoke).1 2 Advertising actions by means of the tobacco business account partially for the top price of tobacco use.3 4 Research from China counsel that exposures to tobacco advertising and marketing actions are related to upper ranges of tobacco intake,5 and higher charges of smoking susceptibility and initiation amongst younger folks.5 6

In 2015, China up to date the Nationwide Promoting Regulation to limit tobacco advertising and marketing actions in all public puts and on mass media (eg, radio, billboards, tv).7 Then again, few rules cope with advertising and marketing and labelling at the cigarette pack itself. Tobacco firms are required to incorporate a text-only fitness caution label that covers 35% of the back and front panels of the packs.8 Moreover, using deceptive phrases on cigarette packs that can put across decrease hurt (eg, ‘delicate’, ‘low tar’, ‘environmental coverage’) are prohibited, and tobacco firms will have to come with element knowledge (eg, numeric tar yields) on packs.8 As promoting on different media platforms turns into extra limited, the pack stays the most important promoting medium to attraction to shoppers.9

The imagery, colors and textual content integrated on a cigarette pack can affect shoppers’ smoking-related perceptions and behavior.10–12 As an example, tobacco firms have traditionally used descriptive phrases comparable to ‘silver’, ‘natural’ or ‘blue’,13–17 in addition to lighter pack colors (eg, mild blue, silver) to connote {that a} specific emblem is a ‘lighter’ emblem variant.18 19 Cigarette packs that come with most of these textual content or color appeals had been related to lowered smoking-related chance perceptions.19–21

Within the context of China, little proof is to be had to characterise the level to which cigarette pack advertising and marketing accommodates imagery, colors and textual content that might probably misinform shoppers and counsel merchandise are decrease chance. There may be some proof that cigarette firms in China use culturally particular imagery (eg, cranes, waterfall scenes, ‘double happiness’ imagery used to rejoice weddings22) and textual content (eg, poems) on cigarette packs that is probably not utilized in different international locations.5 Then again, the level to which those options and others may sign {that a} product is wholesome or one way or the other just right for the shopper is unknown.

The present learn about used a mixture of workforce thought mapping and content material research to (1) establish packaging options that put across a product is ‘wholesome’ or ‘just right for you’ amongst a pattern of Chinese language shoppers and (2) code a selection of cigarette packs bought throughout China for recognized options. Given the numerous function of the cigarette pack as a advertising and marketing software, this learn about can elaborate at the presence of doubtless deceptive fitness options on cigarette packs bought in China.


This learn about is a part of the bigger Tobacco Pack Surveillance Machine (TPackSS) undertaking (https://globaltobaccocontrol.org/tpackss/), which purchases distinctive tobacco packs bought in low-income and middle-income international locations and screens compliance with fitness caution label necessities.23 Knowledge had been revealed on caution label compliance24 and the presence of various advertising and marketing appeals (eg, lowered hurt imagery, female appeals, flavour appeals).25–28

Learn about pattern

We tested 1023 cigarette packs bought in China thru TPackSS. Most effective packs legally bought in China, outlined as having the specified mainland Chinese language executive caution label, had been integrated; 168 packs had been excluded as a result of they had been illicit packs from different international locations or particular areas, like Hong Kong. Packs had been bought in 2013 (wave 1, n=424) and 2017 (wave 2, n=599) from 5 of the ten maximum populous towns in China: Beijing, Chengdu, Guangzhou, Kunming and Shanghai. A sampling body of neighbourhoods by means of socioeconomic strata (low, medium and top) was once created in keeping with census and assets worth knowledge. We then purposively decided on 4 neighbourhoods inside of every stratum that had been various on the subject of geographic location across the town. Knowledge creditors visited 12 neighbourhoods inside of every town for a complete of 60 neighbourhoods throughout China.

Knowledge creditors adopted the similar standardised protocol to systematically acquire tobacco packs. An in depth rationalization of knowledge collector coaching and the TPackSS method can also be discovered within the learn about by means of Smith et al.23 Tobacco packs had been bought from preselected supplier sorts fashionable in China, together with supermarkets, comfort shops, tobacco stores and stalls. Seller variety was once in keeping with nationwide surveillance knowledge on assets of tobacco purchases and key informant enter. The primary supplier knowledge creditors visited served because the index supplier for all different shops. Knowledge creditors bought all distinctive packs from this venue and took a photograph of the entrance panel of every pack to create a picture archive. Groups then visited as much as 5 distributors in every of the rest neighbourhoods and acquired any new packs now not already provide within the archive. The picture archive was once ceaselessly up to date with every new spherical of purchases. Total, packs had been regarded as distinctive if that they had no less than one external distinction in branded pack design (eg, pack dimension, emblem identify presentation, colors).

Codebook building

Staff thought mapping

We used a bunch thought mapping option to increase an general conceptual framework from which an preliminary codebook for health-related options on cigarette packs that was once related to the original cultural context of product advertising and marketing in China was once extracted and therefore utilized. Idea mapping allowed us to crowd-source knowledge on what product advertising and marketing options may sign a product is ‘wholesome’ or ‘just right for you’ at once from a pattern of grownup Chinese language shoppers.

In short, workforce thought mapping is a mixed-methods, structured framework option to generate, organise and price statements from a pattern of individuals round a selected assemble, like ‘fitness’.29 30 To facilitate mapping knowledge assortment and research, we used groupwisdom, an internet platform designed in particular for workforce thought mapping research. The process comes to 3 stages of knowledge assortment: brainstorming, sorting and ranking. We recruited a comfort pattern of 106 adults (elderly 18–65 years) in China in the course of the survey panel platform, NetEase. All individuals lived in city spaces (packs had been accrued in city spaces), and we recruited a enough pattern of people who smoke: 47.2% of individuals (n=50) these days smoked. All through the brainstorming segment, individuals had been requested to offer as many distinctive statements as imaginable to finish the next suggested: When I’m searching for a product, one thing particular at the packaging or promoting that makes me assume the product is wholesome or just right for me is… Our suggested was once deliberately huge to seize quite a lot of concepts about merchandise and/or their corresponding promoting. As well as, the time period ‘wholesome’ and word ‘just right for me’ had been intended to paintings in combination to help individuals in figuring out particular options that may point out a product is wholesome or just right for the person the use of the product.

Total, individuals generated 160 distinctive statements in keeping with the suggested. The statements had been then translated into English and two researchers—one a local Chinese language speaker (YC) and one a local English speaker (LC)—reviewed the statements in Chinese language and English, respectively, to make sure that the reaction was once related to the suggested and to take away any reproduction statements. An instance of a reaction that was once regarded as inappropriate to the suggested was once ‘sure’; an instance of reproduction responses integrated ‘vivid colors’, ‘vivid colors comparable to yellow and inexperienced’ and ‘the full color tone must be vivid’, the place ‘vivid colors’ was once retained as it was once probably the most whole and least advanced. After assessment, 61 statements had been retained (on-line supplemental desk 1).

We then requested the 106 individuals who finished the brainstorming segment to finish the sorting and ranking stages. Usually, fewer individuals are anticipated throughout the sorting and ranking stages given the time dedication required to finish the duties. All through sorting, individuals (n=28) taken care of or grouped statements into piles in keeping with perceived similarity the use of as many piles as they needed, with the one restriction being that each one piles had been required to have no less than two statements. At once following sorting, individuals (n=28) finished the ranking task, reviewing every observation and ranking how strongly they agreed (1=strongly disagree; 7=strongly agree) that the ‘particular packaging or promoting characteristic described within the observation suggests a product is wholesome or just right for you’. The sorting and ranking actions had been unbiased. Legitimate responses had been 27 and 28 for the sorting and ranking actions, respectively. One player taken care of all statements into their very own person pile and those knowledge had been got rid of from the research; then again, the player’s ranking knowledge had been legitimate (ie, no ‘straight-lining’) and retained.

Subsequent, we performed multidimensional scaling on a 61×61 similarity matrix, which contained the aggregated kind knowledge from the 27 individuals. A two-dimensional level map was once plotted appearing the proximity of taken care of statements to each other, in keeping with the frequency the statements had been taken care of in combination by means of individuals. This research led to an acceptable goodness-of-fit worth (rigidity=0.26), related to result of meta-analyses of different thought mapping research.31 Then, hierarchical cluster research was once performed the use of the observation location at the level map as enter. The research utilized Ward’s set of rules for figuring out cluster club of the statements to derive a sequence of ‘cluster’ map ‘answers’ that partitioned the proximity knowledge into non-overlapping observation groupings or clusters. An preliminary set of cluster answers was once recognized, starting from 4 to 9 clusters, which have been decided to be probably the most suitable to check and succeed in consensus at the ultimate type. Every cluster-map answer on this set was once reviewed towards the standards of ‘interpretability’ and ‘parsimony’ to make sure the idea that map with the least selection of clusters with a novel which means was once preserved.32 33 Our ultimate cluster-map integrated seven distinctive clusters that bounded the 61 statements. On-line supplemental desk 1 lists the clusters and corresponding statements, and the typical ranking ranking for every cluster (reasonable throughout statements) and every observation (reasonable throughout individuals). As a last sensitivity research, we examined for variations within the reasonable cluster ranking ranking by means of player smoking standing and located no statistically important variations (p<0.05).

Commentary assessment procedure

We requested (1) professionals on Chinese language tradition and (2) tobacco keep watch over researchers/coauthors to check the general, seven-cluster thought map and statements to validate whether or not the cluster classes and statements had been (1) culturally related and (2) related to tobacco merchandise and tobacco advertising and marketing. To make sure cultural relevance, two authors (YC and ZD) grounded in Chinese language tradition reviewed the conceptual framework and spoke with a comfort pattern of 7 Chinese language colleagues concerning the cluster classes and statements. To make sure tobacco keep watch over relevance, 3 coauthors (KW, JEC and KCS) reviewed the statements to spot which of the 61 statements had been maximum related to present and historical tobacco advertising and marketing practices.

In keeping with this assessment, we retained all 7 cluster classes however lowered the 61 statements into 15 statements associated with the bigger classes. Many statements had been got rid of as a result of they represented normal advertising and marketing ways now not particular sufficient to fitness and/or cigarette advertising and marketing in line with professionals (eg, ‘subtle packaging’, ‘heat existence scenes’, ‘position identify’, ‘easy and noteworthy slogan’). Different statements that had been extra intently associated with fitness, like ‘healthy-looking fashions’, ‘health folks’ doing workout actions or ‘imagery of smiles’ had been additionally got rid of. Even supposing this sort of imagery has been utilized by the tobacco business in cigarette promoting, the statements had been got rid of as a result of coauthors felt it was once not going such imagery would seem at the cigarette pack itself. One tobacco-specific observation, ‘Hand over smoking language’ was once got rid of as it referred to legally required caution labels. In any case, some statements had been mixed right into a unmarried code. As an example, ‘botanical imagery’, ‘imagery of plants’, ‘imagery of garden/grass’ and ‘imagery of greens’ had been mixed into the code Botanics. Ultimate definitions of the wider attraction classes and the 15 particular pack characteristic codes are supplied in desk 1.

Desk 1

Definitions of analysis codebook by means of ‘wholesome’ or ‘just right for me’ appeals class and related pack characteristic codes

Coding for ‘wholesome’ or ‘just right for me’ options

Two skilled coders (YC and ZD) who’re local Chinese language audio system one at a time coded the pattern of 1023 cigarette packs the use of pack pictures to be had on-line (https://globaltobaccocontrol.org/tpackss/China). Any variations in coding had been mentioned between the coders first after which resolved by means of assembly with a reviewer (LC) who was once now not a Chinese language speaker. The codebook was once revised to mirror adjustments mentioned after which systematically re-applied around the pattern of packs. Total, the coders had a reasonable to just about very best settlement throughout all codes (0.601–0.998). Since the color of the pack in a web-based symbol might seem in a different way throughout laptop monitors, the 2 coders met in-person to check the bodily cigarette packs and reconcile variations in color coding.

Statistical research

We used χ2 and Fisher’s precise checks of affiliation to inspect variations within the presence of ‘wholesome’ or ‘just right for you’ options over the years. Fisher’s precise checks had been used when cellular pattern dimension was once <50. We additionally performed a secondary exploratory research to know patterns within the presence or absence of options around the 117 cigarette manufacturers in our pattern. Assessments of affiliation had been two-sided (p<0.05).


Total, 83.5% (854/1023) of Chinese language cigarette packs in our pattern contained no less than one ‘wholesome’ or ‘just right for me’ characteristic, and the presence of those options on packs remained consistent between wave 1 (83.5%, nwave 1=354/424 packs) and wave 2 (83.5%, nwave 2=500/599 packs; p=1.00). Roughly 90% of cigarette manufacturers within the pattern (n=105/117) integrated no less than one emblem variant with a health-related characteristic (on-line supplemental desk 2).

Throughout each waves, the most typical huge attraction classes provide on packs had been product fabrics (38.9%, nwave 1=165; 37.4%, nwave 2=224), vigorous (34.0%, nwave 1=144; 24.9%, nwave 2=149), contemporary parts (33.3%, nwave 1=141; 41.9%, nwave 2=251) and China symbolism and standard medication (30.4%, nwave 1=129; 28.4%, nwave 2=170) (determine 1). Presence of contemporary parts options considerably higher over the years (p=0.006), whilst the percentage of vigorous options considerably diminished over the years (p=0.002). Using high quality certification-related (p=0.045) and fitness and advertising and marketing claims-related (p=0.030) options higher considerably between waves however had been normally provide on a smaller share of cigarette packs.

Figure 1
Determine 1

Percentage of cigarette packs bought in China by means of ‘wholesome’ or ‘just right for me’ attraction class throughout wave 1 (2013, n=424 packs) and wave 2 (2017, n=599 packs). *Statistically important variations between waves had been discovered for contemporary parts (p=0.005), vigorous (p=0.002), fitness and advertising and marketing claims (p=0.300) and high quality certification (p=0.045).

Total, recycling (38.0%, noverall=390), vivid colors (28.6%, noverall=293) and uncommon animal (28.3%, noverall=290) had been the most typical options provide on cigarette packs (desk 2). The presence of recycling and uncommon animal options remained solid over each waves, and the presence of vivid colors diminished from wave 1 to wave 2 (p=0.002). The presence of aquatic (p<0.001), sure description (p=0.030) and high quality same old (p=0.002) options considerably higher between the 2 waves. The presence of Botanics options additionally higher over the years: 14.9% of packs in wave 1 (nwave 1=63) contained botanical options vs 20% of packs in wave 2 (nwave 2=126, p=0.014). No packs integrated sports-related options. The typical selection of options in keeping with pack higher from wave 1 (imply=1.61, vary: 0–4) to wave 2 (imply=1.73, vary: 0–6).

Desk 2

Percentage of cigarette packs (n=1023 packs) bought in China by means of ‘fitness’ or ‘just right for me’ options* by means of attraction class throughout wave 1 (2013) and wave 2 (2017)

Determine 2 gifts examples of ‘wholesome’ or ‘just right for me’ options. On the whole, there was once some overlap between coded options. A supplementary research discovered that aquatic, skyscape and panorama imagery (all within the contemporary parts class) had been weakly to somewhat correlated with every different (r2=0.28–0.46; see correlation matrix heatmap in on-line supplemental determine 1). As well as, tar and blank colors (r2=0.29), panorama and botanics (r2=0.22) and sure description and herbal color (r2=0.24) had been weakly correlated.

Figure 2
Determine 2

Examples of cigarette packs bought in China throughout ‘wholesome’ or ‘just right for me’ attraction classes and contours.* *Packs in every appeals class could have ‘fitness’/‘just right for you’ options from different classes. CTO, qualified natural tobacco.


Maximum cigarette packs bought in China in waves 1 (83.5%) and a couple of (83.5%) contained no less than one characteristic that might indicate the product was once ‘wholesome’ or ‘just right for me’, suggesting constant use of culturally particular health-related options by means of tobacco firms throughout a complete set of manufacturers over the learn about time-period. Our findings align with prior analysis and file the presence of health-related options on Chinese language cigarette packs like the ones used on cigarette packs bought in different international locations (eg, lighter colors,13 17 use of natural descriptors,18 tar degree descriptions34). Importantly, our learn about additionally paperwork the presence of distinctive health-related options particular to Chinese language tradition together with imagery of uncommon animals, culturally particular herbs (eg, ginseng) or botanicals (eg, bamboo), vivid colors and nature scenes (eg, landscapes), all of that have the prospective to put across {that a} specific cigarette pack could also be wholesome to Chinese language shoppers. Given the tobacco business’s historical past of the use of pack branding to steer client hurt perceptions, it’s in all probability unsurprising that just about each pack reviewed on this learn about integrated no less than one component that individuals would imagine ‘wholesome’ or ‘just right’ for them.

The top occurrence and numerous vary of health-related options on our pattern of cigarette packs might mirror the restricted restrictions on pack branding in China. Even supposing present provisions limit using specific phrases that might misinform shoppers (eg, ‘low tar’, ‘mild’), those restrictions don’t observe to imagery or different implicit text-based appeals that may form folks’s fitness perceptions.8 Effects from this learn about counsel that tobacco firms promoting cigarettes in China can be benefiting from barriers within the present legislation. For example, a notable selection of packs integrated textual descriptions of tar content material (eg, ‘<6 mg tar’) past the specified tar yield knowledge and sensory expectancies (eg, cool, refreshing, blue) that might indicate ‘low tar’ or ‘mild’ cigarettes to shoppers,35 however would now not be explicitly prohibited below the legislation. Our findings additionally point out that tobacco firms are the use of different, culturally particular fitness options now not lined within the present restrictions that may be uniquely related to health-related perceptions amongst shoppers in China. As an example, this learn about and others documented the presence of fast reaction (QR) codes on Chinese language cigarette packs that hyperlink to on-line programmes verifying the authenticity or high quality of the pack,36 which will beef up client belief of the security of a shopper just right, like cigarettes.37 38

Using phrases associated with ‘environmental coverage’ may be these days prohibited in China.8 We discovered that over one-third (39%) of cigarette packs in our pattern contained recycling imagery (eg, tidy guy, recycling arrows), which might indicate environmental coverage and likewise sign a product could also be ‘wholesome’ or ‘just right for you’. Rising proof suggests using greenwashing appeals, like product recycling, could also be hired by means of the tobacco business to create a fitness halo round tobacco manufacturing that might symbolically switch decrease chance perceptions of product use to shoppers.39–41 A contemporary learn about discovered that the presence of pro-environment advertising and marketing on a US cigarette pack (Herbal American Spirit), which integrated a three-arrow recycling image, diminished perceived hurt of the pack as opposed to a comparability pack (Pall Mall), which failed to come with pro-environment advertising and marketing however was once matched on color, description of tobacco energy and flavour and made by means of the similar producer.42 Those findings additional mirror the restrictions of the present packaging and labelling restrictions in China and spotlight how the ongoing use of the options documented on this learn about might misinform shoppers concerning the smoking-related dangers.

The presence of many of the health-related options tested on this learn about remained an identical over the years. Then again, there was once a notable build up within the share of packs with botanic, aquatic and high quality same old (eg, QR code) imagery, and an build up within the share of packs together with sure descriptions of sensory expectations related to product use. The higher presence of those options suggests they could also be in particular salient in shaping client perceptions of the ‘healthiness’ of cigarette packs. Long run analysis must construct in this learn about to inspect Chinese language client perceptions of the attraction of and perceived hurt of cigarette packs that emphasise those particular options.

Effects from this learn about can tell China’s cigarette pack labelling and branding insurance policies, that have now not modified since 2007.8 Our findings spotlight essential barriers within the present packaging and labelling requirements that may be addressed or even expanded to incorporate further textual content and imagery that experience the prospective to misinform shoppers. This learn about additionally issues to the prospective want for more potent pack branding requirements in China. Many nations, like Australia and Thailand, have carried out simple and standardised packaging. More potent tobacco packaging necessities, comparable to simple packaging, may assist cut back the affect of fitness interesting options on cigarette packs bought in China.43–47

This learn about is matter to barriers. First, even though we hired a complete workforce thought mapping and knowledgeable assessment option to increase our codebook, it won’t mirror all related health-related options that can be integrated on cigarette packs in China. Moreover, our suggested was once deliberately huge and now not in particular framed round ‘wholesome’ or ‘just right for me’ options on cigarette packs which will have influenced player responses. 2nd, we examined for variations in workforce thought mapping effects by means of smoking standing however can’t account for variations in different demographic traits (eg, gender, revenue) as a result of this knowledge was once now not accrued. 3rd, packs had been accrued from probably the most populated towns in China and hottest supplier sorts; the pattern won’t mirror packs to be had in smaller towns, rural spaces and not more fashionable supplier sorts, which might affect our estimate of the percentage of distinctive packs with health-related options bought in China. Fourth, our knowledge assortment is meant to seize the breadth of packs to be had; the proportions offered aren’t weighted to mirror the relative marketplace proportion of every emblem or emblem variant. Moreover, our findings mirror tendencies for cigarettes and can’t be utilized to different nicotine-containing merchandise. As well as, we solely tested cigarette packaging options in 2013 and 2017. It’s imaginable that the presence of health-related options, in particular the ones related to more moderen advances in generation like QR codes, have modified or higher over the years. Long run research must file fresh tendencies within the presence of the options highlighted on this learn about on Chinese language cigarette packs and experimentally examine the affect of such options on people who smoke’ and non-smokers’ perceptions of (eg, perceived hurt) and intentions to make use of a branded cigarette pack.


This learn about means that advertising and marketing options on Chinese language cigarette packs that can counsel the product is ‘wholesome’ or ‘just right for you’ are not unusual. The findings spotlight the presence of health-related options which can be recognized business ways to cut back hurt perceptions (eg, mild colors). We additionally file the presence of health-related options on cigarette packs which can be particular to shoppers in China (eg, uncommon animal imagery, herbs/botanical imagery). Lately, China targets to cut back smoking occurrence by means of 20% to fulfill its Wholesome China 2030 function.48 Findings from this learn about can tell tobacco keep watch over coverage interventions in China, together with growth of present tobacco packaging and labelling necessities and different restrictions on branding (together with simple packaging) that might assist cut back smoking.

Knowledge availability observation

Knowledge are to be had on cheap request. Knowledge sharing requests can also be made to LC ([email protected]) or Institute for World Tobacco Regulate ([email protected]).

Ethics statements

Affected person consent for newsletter

Ethics approval

This learn about comes to human individuals however Johns Hopkins Faculty of Public Well being Institutional Evaluate Board (Reference Quantity: 15344) exempted this learn about.