From packs to games: a qualitative study on children's experiences and perceptions of cigarette card games in China.

Background: The lack of plain packaging and pictorial warnings on cigarette packs in China has provided a window for children to play and collect cards made from cigarette packages. This study examined children's participation in cigarette card (CC) games and parents' views on packaging regulations.

Methods: Between September and December 2024, semistructured interviews were conducted with 21 child-parent dyads (19 boys, 2 girls; 17 mothers, 4 fathers) using purposive and snowball sampling in nine provinces in China. Eligible children aged 6-12 years had played CC games in the past month. Separate child and parent interviews were conducted using tailored guides to minimise bias. Interviews were transcribed verbatim and analysed through thematic analysis with dual coding and triangulation.

Results: Five key themes emerged: (1) attractive designs as a gateway to gameplay, (2) development of brand knowledge through gameplay, (3) packaging as a marker of social value, (4) neglect of text-based warnings by children and (5) parental demands for pictorial warnings. Vibrant packaging colours and logos primarily motivated children's participation. Card collection normalised smoking by increasing brand knowledge and enabling peer status competition through card ownership. Parents observed that textual warnings failed to deter gameplay but emphasised that pictorial warnings showing health risks could reduce the game's popularity among children.

Conclusions: Attractive cigarette packaging drives children's involvement in CC games, which in turn normalises smoking by promoting brand familiarity and social exchange among peers. China must urgently implement pictorial warnings and plain packaging to reduce tobacco's appeal and protect the younger generations.