Declines in tobacco brand recognition and ever-smoking rates among young children following restrictions on tobacco advertisements in Hong Kong

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1 Journal of Public Health Vol. 26, No. 1, pp DOI: /pubmed/fdh118 Printed in Great Britain Declines in tobacco brand recognition and ever-smoking rates among young children following restrictions on tobacco advertisements in Hong Kong R. Fielding, Y. Y. Chee, K. M. Choi, T. K. Chu, K. Kato, S. K. Lam, K. L. Sin, K. T. Tang, H. M. Wong and K. M. Wong Abstract Background We compared the recognition of tobacco brands and ever-smoking rates in young children before (1991) and after (2001) the implementation of cigarette advertising restrictions in Hong Kong and identified continuing sources of tobacco promotion exposure. Methods A cross-sectional survey of 824 primary school children aged from 8 to 11 (Primary classes 3 4) living in two Hong Kong districts was carried out using self-completed questionnaires examining smoking behaviour and recognition of names and logos from 18 tobacco, food, drink and other brands common in Hong Kong. Results Ever-smoking prevalence in 2001 was 3.8 per cent (1991, 7.8 per cent). Tobacco brand recognition rates ranged from 5.3 per cent (Viceroy name) to 72.8 per cent (Viceroy logo). Compared with 1991, in 2001 never-smoker children recognized fewer tobacco brand names and logos: Marlboro logo recognition rate fell by 55.3 per cent. Similar declines were also seen in ever-smoker children, with recognition of the Marlboro logo decreasing 48 per cent. Recognition rates declined amongst both boys and girls. Children from nonsmoking families constituted 51 per cent (426) of the sample, whereas 34.5 per cent (284), 8.5 per cent (70), 1.7 per cent (14) and 4.4 per cent (36) of the children had one, two, three or more than three smoking family members at home, respectively. Tobacco brand recognition rates and ever-smoking prevalence were significantly higher among children with smoking family members compared with those without. Among 12 possible sources of exposure to cigarette brand names and logos, retail stalls (75.5 per cent; 622), indirect advertisements (71.5 per cent; 589) and magazines (65.3 per cent; 538) were ranked the most common. Conclusion Advertising restrictions in Hong Kong have effectively decreased primary-age children s recognition of tobacco branding. However, these children remain vulnerable to branding, mostly through exposure from family smokers, point-of-sale tobacco advertisement and occasional promotions. Action to curb these is now required. Keywords: children, smoking, tobacco brand recognition, advertising Introduction Advertising restrictions are an important public health strategy for discouraging tobacco use among children. 1 4 In April 2003, the UK government extended tobacco advertising restrictions comparable with the staged introduction that Hong Kong implemented over the past decade. What benefits are likely to accrue among children for the uptake of tobacco from introducing advertising restrictions and how long is it likely to take before any benefits become apparent? Since 1982, the Hong Kong government phased in control measures to regulate tobacco use. In 1990 tobacco advertising on broadcast media was prohibited, and later billboard bans were instituted. Most recently, the Smoking (Public Health) Ordinance (Cap. 371) regulations included bans of print media advertisements in 1997, effective December The current restrictions exempt point of sale advertising. None the less, tobacco companies continue to promote brand awareness principally via sports sponsorship and branded clothing and music. Health Behaviour Research Group, Department of Community Medicine & Unit for Behavioural Science, Patrick Manson Building (South Wing), The University of Hong Kong, 7, Sassoon Road, Pokfulam, Hong Kong, China R. Fielding, Senior Lecturer Faculty of Medicine, The University of Hong Kong, 7, Sassoon Road, Pokfulam, Hong Kong, China Y. Y. Chee, Medical Student K. M. Choi, Medical Student T. K. Chu, Medical Student K. Kato, Medical Student S. K. Lam, Medical Student K. L. Sin, Medical Student K. T. Tang, Medical Student H. M. Wong, Medical Student K. M. Wong, Medical Student Address correspondence to R. Fielding. Fielding@hkusua.hku.hk Journal of Public Health 26(1) Faculty of Public Health 2004; all rights reserved.

2 TOBACCO BRAND RECOGNITION BY YOUNG CHILDREN 25 Consequently, in Hong Kong children less than 10 years old have had less exposure than their counterparts of several years ago to public forms of tobacco branding. If this translates into reduced brand awareness and smoking, it justifies the implementation of existing restrictions and prompts further extensions. Tobacco logo recognition is associated with increasing age in children, but is unrelated to the smoking habits of their parents. 5 Tobacco logos and brand names are widely recognized by children in Hong Kong, 6 and in Turkish 7 children, more so among boys 6 and in children with smoking experience (eversmokers). 6,7 Emri suggested that the high recognition rates of cigarette brand names and logos probably results from tobacco advertising and promotion. 7 We did not find any papers that demonstrated a change in tobacco brand recognition among children following the implementation of advertising bans. However, such information would provide a strong incentive for governments to introduce bans to protect young people and reinforce the UK s tobacco advertising restriction policy. The data for the Peters et al. study 6 were collected in Hong Kong in 1990, before most tobacco advertising restrictions were introduced. Comparing the 1990 rates reported by Peters et al. with those of 2001 following advertising restrictions will reveal changed brand awareness and smoking behaviour among children under 11 years old. Methods This 2001 study replicated Peters et al. s protocol to gather cross-sectional data on the recognition rates of cigarette brand names and logos by young children in Primary classes 3 4 (aged 8 10) in Hong Kong. 6 Subjects The sample size of 800 was derived using EpiInfo. Primary school students, aged 8 10 but less than 11 (Primary classes 3 to 4), in Kwai Tsing and Southern districts of Hong Kong were chosen as the study population. The same districts and sampling procedures as reported by Peters et al. were utilized. Invitation letters were sent to the head teachers of six schools. Four primary schools responded and subsequently students from these schools participated. One school was in Kwai Tsing and three schools in Southern district. Within each school, whole classes were enrolled, following consent from the school head, in loco parentis. Design We hypothesized three things. First, if advertising is an important factor promoting children s tobacco brand and smoking awareness, then effective advertisement restrictions reduce children s brand awareness and recognition. However, recognition rates for unrestricted non-cigarette brands would remain unchanged. Second, if children s smoking was also influenced by tobacco brand awareness, reduced brand awareness should be accompanied by reduced ever-smoking rates. Third, if family smoking behaviour is unimportant in children s tobacco brand awareness, then brand recognition and smoking rates amongst children from households with smoking and non-smoking members would be comparable. Employing Peters et al. s protocol we undertook a crosssectional survey in a classroom setting using questionnaires with guidance by a team member presenting each question on an overhead transparency and explaining in advance of each section what was required of the participants. Questionnaires were distributed to whole classes at a time, at different times of the day for different classes. Children were told that all questionnaire information was strictly confidential and anonymous. There was no collusion between children, and no teachers were present during the data collection process. Data collection was supervised by two trained research workers. The questionnaire was piloted to ensure question clarity, and to verify the validity and reliability of self-reported cigarette smoking. Questionnaire and procedure Children classified eight brand names presented in their common Chinese forms (Wang Wang (snack food), Marlboro, Coca-Cola, Carlsberg, Salem, Kowloon Dairy (dairy products), Colgate and Viceroy), and 10 colour-reproduced logos (Carlsberg, Colgate, Coca-Cola, Garden (bakery), HSBC, Marlboro, Nike, Pringles (potato crisps), Salem and Viceroy) into one of five categories: food, drink, cigarette, others or not known. Six of the brands (Marlboro, Coca-Cola, Carlsberg, Salem, Colgate and Viceroy) were presented independently both as a brand name and as a brand logo. Non-cigarette brand names and logos were chosen because they are advertised widely on TV and radio and, where possible, were the same as those used by Peters et al. in However, since 1990, brand prominence has changed, so two non-tobacco brands (HSBC and Nike) differed from those used by Peters et al. Subsequently, the questionnaire asked for demographic details and about parent s and other household smokers current smoking status. Children were also asked about their own current smoking status, age at starting to smoke, number of cigarettes smoked and sources of cigarettes, and about cigarette brand exposure from a variety of sources. Data analysis The data regarding the recognition of logos and brand names were scored one for a correct name or logo classification and zero for an incorrect classification. Scores were derived, by summing correct answers, for: total brand recognition (maximum score 18), all brand names (eight), all brand logos (10), and each product category: drinks (five), cigarette (six), food (three) and others (four). For cigarettes, total name and logo scores were also calculated separately. Recognition rates of cigarette names and logos within the 2001 sample were analysed using Wilcoxon s test. Rates by gender and smoking status were next

3 26 JOURNAL OF PUBLIC HEALTH compared with those obtained by Peters et al., using 2 or log linear analysis to adjust for sample differences between the two studies, with 95 per cent confidence intervals (95 per cent CI) calculated for all point estimates. Multiple linear or multinomial regression examined adjusted predictors of brand recognition rates. All analyses were made using SPSS10 or 11. Results The study population In the 2001 study, four schools comprising 922 children participated. All 922 children answered the questionnaires but 98 questionnaires (11 per cent) were excluded because of either a failure to indicate smoking status or blank or multiple answers. Hence, completed questionnaires from 824 children (304 boys, 520 girls) were analysed. In all, 203 (25 per cent) children were recruited in Kwai Tsing and 621 (75 per cent) in Southern district, with boys constituting 48 per cent (97) in Kwai Tsing and 33 per cent (207) in Southern district ( , df 1, p <0.001). The mean age of the children was 10.1 years (95 per cent CI ) in Kwai Tsing, compared with 9.2 years (95 per cent CI ) in Southern district (t 13.5, df 348.2, p <0.001). Smoking prevalence A total of 31 (4 per cent, 95 per cent CI ) children reported being ever-smokers. Log linear analysis revealed significantly lower smoking prevalence in both boys (8 per cent versus 15 per cent) and girls (2.5 per cent versus 7 per cent) after adjustment for age differences in the 2001 data relative to the 1991 study (likelihood ratio , df 4, p < ). Brand recognition Overall, the successful recognition rate of individual brand names and logos was 69 per cent (95 per cent CI per cent), ranging from 5 per cent (4 7 per cent) for the Viceroy name to 99 per cent ( per cent) for the Wang Wang name. The three most frequently recognized brands were all food and drinks: the Wang Wang name (99 per cent, per cent), the Coca-Cola name (99 per cent, per cent), and the Pringles logo (98 per cent, per cent). Recognition rates of the Marlboro name and logo were 45 per cent (41 48 per cent) and 20 per cent (18 23 per cent), respectively; of the Salem name and logo 33 per cent (30 36 per cent) and 53 per cent (50 57 per cent), respectively; and of the Viceroy name and logo 5 per cent (4 7 per cent) and 73 per cent (70 76 per cent), respectively. Tobacco brand logos were significantly more likely to be correctly identified than were their names (Z 16.69, p <0.001). Polynomial regression of cigarette logo recognition by smoking status after adjustment for age and gender revealed ever-smoking status to be of only marginal significance as a predictor of tobacco logo recognition (log likelihood , df 3, p 0.054), probably because of insufficient statistical power. Recognition of tobacco brand names was more strongly predicted by age and gender than by smoking status. Recognition of tobacco brand names (Z 5.08, p <0.001) and logos (Z 3.03, p 0.002) differed by gender. In general, more boys than girls correctly identified tobacco brand names and logos. The greatest difference was observed for the Marlboro name, which 53 per cent (47 58 per cent, 160) of boys identified correctly, compared with 40 per cent (36 44 per cent, 208) of girls, a difference of 13 per cent ( ). Other cigarette branding that boys were more successful in recognizing included the Viceroy logo, the Salem name and the Marlboro logo. Except for the Garden name and the Nike logo, there were no gender differences in recognition of any other brand names or logos of the other categories (Table 1). Family smoking status In all, 51 per cent (48 55, 426) of children were from nonsmoking families, whereas 34 per cent (31 38, 284), 8 per cent (7 10, 70), 2 per cent (1 3, 14) and 4 per cent (3 6, 36) of the children had one, two, three, or more than three smoking family members at home, respectively. Children s ever-smoking status was greater among those within smoking families than among those in non-smoking families ( , df 1, p <0.005). Brand identification by family smoking status Half (49 per cent, 46 52, 404) of the children had family members who smoked. Overall, there were significant differences in tobacco brand name and logo recognition between children from smoking and non-smoking families. Children from smoking families more successfully recognized all tobacco brand names and logos, except for the Salem name. The Marlboro name showed the greatest difference, with 60 per cent (55 64, 241) of children from smoking families identifying it correctly, compared with 30 per cent (26 35, 127) of those from nonsmoking families. In contrast, there was no significant difference between these two groups of children in recognition of the other 11 brand names and logos in the food, drinks and others categories, excepting the Coca-Cola name (Table 2). Multivariate analyses Total name and logo cigarette recognition scores were regressed independently for boys and girls on ever-smoking status, reported advertisement exposure, peer smokers seen and number of smokers at home. Among girls, number of smokers at home, peer smoking seen, advertisement seen and age accounted for an adjusted R 2 of Among boys, age, number of smokers at home and advertisements seen accounted for an adjusted R 2 of Comparison between 1991 and 2001 results Brand identification by smoking behaviour The 2001 sample never-smokers recognition rates for all tobacco names and logos were significantly lower than those

4 TOBACCO BRAND RECOGNITION BY YOUNG CHILDREN 27 Table 1 Correct brand recognition rates among male and female participants Boys Girls % 95% CI n % 95% CI n All brands All logos * 24 All names Cigarettes Marlboro a *** 208 Marlboro b * 94 Salem a ** 149 Salem b Viceroy a Viceroy b *** 355 Food Wang Wang a Garden b * 504 Pringles b Drinks Coca-Cola a Coca-Cola b Carlsberg a Carlsberg b Kowloon Dairy a Others Colgate a Colgate b HSBC b Nike b * 409 *p <0.05, **p <0.01, ***p <0.001, gender comparison. reported in The Marlboro logo recognition rate showed the greatest difference, being 51 per cent (52 58 per cent, p <0.001) lower in the 2001 sample. However, excepting the Carlsberg brand and the Colgate logo, all other recognition rates were comparable with those of Recognition rates of the Coca-Cola logo (p <0.001) and the Colgate name (p <0.001) were higher in the 2001 sample than in the 1990 sample (Table 3). Similarly, ever-smokers in 2001 showed significantly lower recognition rates for all tobacco brand names and logos than in the 1991 sample. For example, the Marlboro logo recognition rate was 48 per cent (27 69 per cent) lower in 2001 than in 1991, but, excepting the Carlsberg name and the Colgate logo, recognition rates for the other items again remained comparable (Table 3). However, declines in tobacco brand name and logo recognition rates were less among ever-smokers than among never-smokers, whereas this trend was reversed for non-tobacco brands. Brand identification by gender Because the gender proportions in Peters et al. s 1990 sample and the present 2001 sample differ, and recognition rates between genders differ, gender comparison more accurately tests change in brand recognition. Cigarette (Marlboro and Salem) brand and logo recognition rates were consistently lower in both genders in the 2001 sample than in the 1991 sample. Among boys, recognition of the Marlboro logo was 58 per cent lower (54 62 per cent). In girls, recognition of the Marlboro name was 54 per cent (51 57 per cent) lower (Table 4). Excepting the Carlsberg logo and brand name and the Colgate logo, which were lower, recognition rates for all other brand names and logos were comparable with, whereas that for the Coca- Cola logo was higher than, those reported in Students reporting prior exposure to tobacco advertising were more likely to obtain correct scores on tobacco names (Z 2.51, p 0.12) and logos (Z 2.69, p 0.007), and drinks names and logos (Z 3.16, p 0.002) but not other category names or logos. Among the 12 sources of exposure to tobacco advertising, the three most frequently cited sources were, in descending order: newspaper and tobacco stalls, indirect advertisements (in which cigarette brand names and logos are shown on television in non-tobacco related advertising, such as for Kent Holiday and the Salem Tennis Tournament) and

5 28 JOURNAL OF PUBLIC HEALTH Table 2 Recognition rates of brands between children with and without smokers in families Brand recognition rates Smokers in family No smoker in family % n % n Cigarettes Marlboro a *** Marlboro b ** Salem a Salem b * Viceroy a ** Viceroy b *** Food Wang Wang a Garden b Pringles b Drinks Coca-Cola a * Carlsberg a Kowloon Dairy a Carlsberg b Coca-Cola b Others Colgate a Colgate b Hong Kong Bank b Nike b *p <0.05, **p <0.01, ***p < magazines. As many as 75 per cent (72 78 per cent, 622) of the children had seen point-of-sale cigarette advertisements at street stalls, 71 per cent (68 75 per cent, 589) had seen brands via indirect advertising and 65 per cent (62 68 per cent, 538) had seen magazine advertisements. Other sources of exposure included movies (38 per cent), outdoor buildings (31 per cent), the Internet (25 per cent), soccer games (20 per cent), tennis competitions (18 per cent), motor racing (15 per cent), boutiques (13 per cent), cartoons (11 per cent) and swimming competitions (9 per cent). Discussion Our sample (8 10 years) was not significantly younger than Peters et al. s 1991 sample (8 11 years). We limited the upper age to 10 years for two reasons. As most recent restrictions were implemented in early 1999 (billboard and print media, 1999), younger children were likely to have lower exposure and hence recognition was expected to be lower. No child in the 2001 sample would have been exposed to the restricted tobacco adverts after age seven. Higher recognition rates occur among older compared with younger children, so the slight age difference of the two samples may slightly inflate the effect size, but the effect size observed is too large to be accountable by this modest sample difference alone. Changes in the recognition rates before and after cigarette advertisement restrictions Marlboro and Salem brand name and logo recognition rates were significantly lower in 2001 than in However, except for Carlsberg and Colgate brands, all other brand name and logo recognition rates were comparable with or higher than Table 3 Comparison of recognition with those in previous study Never smokers Ever smokers Recognition Recognition Recognition Recognition n % n % (%) n % n % (%) Marlboro a ** ** Marlboro b ** ** Salem a ** ** Salem b ** ** Coca-Cola b ** Carlsberg a ** ** Carlsberg b ** Garden b Colgate a * Colgate b ** ** Data for 1990 were extracted from Peters et al. (1991, table 3). *p <0.01, **p <0.001.

6 TOBACCO BRAND RECOGNITION BY YOUNG CHILDREN 29 Table 4 Comparison of recognition rates in boys with previous study Boys Girls Recognition Recognition Recognition Recognition rate 1991 rate 2001 rate 1991 rate 2001 n % n % (%) n % n % (%) Marlboro a ** ** 54 Marlboro b ** ** 51 Salem a ** ** 16 Salem b ** ** 43 Coca-Cola b ** ** 15 Carlsberg a ** ** 14 Carlsberg b ** ** 8 Garden b Colgate a Colgate b ** ** 25 **p < those in It is likely that younger children have lower tobacco brand awareness following tobacco advertising restrictions. Ever-smoking rates were 50 per cent lower than 1991 levels. Marlboro, formerly a heavily advertised brand, was recognized far less often than was Salem. Salem brand awareness probably results from continued indirect advertising through the televised annual Salem Tennis Tournaments (since discontinued). Marlboro is indirectly advertised through branded adult clothing outlets, which are likely to be of less interest to children. As both brands extensively use point-of-sale advertising, permitted by the existing Smoking (Public Health) Ordinance, it is possible that the difference between recognition rates for Marlboro and Salem can be solely attributed to the continued television coverage of the Salem Tennis Tournament. Logo recognition rates were substantially higher than name recognition rates. This aspect of brand identity seems to have greater market penetration among young children. Family smokers Contrary to earlier US studies, 5 children in smoking families had higher tobacco brand recognition and ever-smoking rates. Parental smoking affects children s health directly through passive smoking exposure and may also encourage children s active smoking through raising awareness of both brand and smoking behaviour. Hence, it is important to target parents regarding these adverse effects of their smoking behaviour. Insufficient control of tobacco advertisement and promotion Despite existing restrictions on tobacco advertising in Hong Kong, children are still exposed to tobacco branding, with between 20 and 50 per cent of children being able to identify Marlboro and Salem tobacco brands, respectively. When exposure through family smokers was excluded, recognition rates fell only slightly to 15 per cent for Marlboro but remained at 50 per cent for Salem. Therefore, despite current advertising restrictions there is continued exposure to tobacco branding in Hong Kong. Point-of-sale and indirect televised advertising expose children to tobacco branding and should be controlled. Print advertising was the third commonest (65.3 per cent) source of brand exposure cited by these children. Print cigarette advertisements were banned in December The impact of this exposure therefore remains fresh even after 2 years. These data demonstrate that restricted tobacco branding is associated with reduced recognition rates among children. Delaying tobacco brand awareness among children may lead to delays in, or lowered uptake of smoking by children and teenagers. Second, the data also illustrate that branding strategies utilizing televised sports events continue to affect children. These, together with point-of-sale advertising, should be subject to further restriction with immediate effect. In conclusion, after a decade of phased tobacco advertising restrictions, tobacco brand recognition rates among primary children are around per cent lower than before the restrictions were introduced. This lower recognition rate is accompanied by a 49 per cent lower self-reported ever-smoking rate in children under 11 years old. Finally, higher recognition and smoking rates in smoking than in non-smoking families indicate that home exposure contributes to both brand awareness and smoking behaviour. Based on the Hong Kong experience, the United Kingdom and other countries restricting tobacco advertising can now expect to see declines in tobacco brand recognition by children. These declines are likely to be accompanied by reduced eversmoking rates among older children and pre-teens. However,

7 30 JOURNAL OF PUBLIC HEALTH continued exposure through indirect advertising, including televised sporting events, is likely to remain. As tobacco companies will look for ever more creative ways to expose young people to smoking and tobacco branding the public health message is clear: restricting such exposure is accompanied by reduced eversmoking among this very impressionable group. Acknowledgement The study was carried out as a third year medical student project and supported by a small seed grant from the Hong Kong Council on Smoking and Health. Contributors Y. Y. Chee, K. M. Choi, T. K. Chu, K. Kato, S. K. Lam, K. L. Sin, K. T. Tang, H. M. Wong and K. M. Wong carried out the data collection and analysis, and contributed to writing the manuscript. R. Fielding initiated the idea for the study, advised on the instrument and design, carried out additional analyses, and contributed extensively to the manuscript. References 1 Smee C. Effect of tobacco advertising on tobacco consumption. A discussion document reviewing the evidence. London: Economics and Operational Research Division, Department of Health, Charlton A. Children s advertisement awareness related to their views on smoking. Hlth Educ J 1986; 45: Potts H, Gillies P, Herbert M. Adolescent smoking and opinion of cigarette advertisements. Hlth Educ Res 1: Aitken P, Leathar D, O Hagan F, Squair S. Children s awareness of cigarette advertisements and brand imagery. Br F Addict 1987; 82: Fisher M, Schwartz MP, et al. Brand logo recognition by children aged 3 to 6 years. Mickey Mouse and Old Joe the Camel. JAMA 1991; 266: Peters J, Betson CL, Hedley AJ, et al. Recognition of cigarette brand names and logos by young children in Hong Kong. Tobacco Control 1995; 4: Emri S, Bagci T, Karakoca Y, Baris E. Recognition of cigarette brand names and logos by primary schoolchildren in Ankara, Turkey. Tobacco Control 1998; 7: Conflict of interest R. Fielding is an ex-smoker. Accepted on 4 November 2003