Evidence supports plain tobacco packaging to improve public health

Policymakers should heed the results of studies into the effect of cigarette packaging on smoking behaviour.

Plain cigarette packaging can contribute to reducing smoking rates, evidence shows

Tobacco companies rely heavily on packaging to create and drive brand image in order to attract new consumers to their products and create brand loyalty. Standardising pack appearance by introducing laws that enforce plain tobacco packaging may contribute to a reduction in smoking rates and improve public health.

Why packaging is important

Since the late 19th century, product packaging has been a valuable communications tool for tobacco companies[1]
, and it has become increasingly important in recent years for several reasons. Firstly, bans on tobacco advertising, promotion and sponsorship have left packaging as one of the few remaining ways for a tobacco company to distinguish its brand with consumers and create interest in its products — the ‘last chance marketing saloon’ as it has been referred to by tobacco industry analysts[2]
. Secondly, there are now a large variety of tobacco brands on the market, which was not always the case, and a growth in brand families, where a single brand can have more than a dozen variants. This makes packaging crucial for inter- and intra-brand differentiation. Thirdly, technological advancement has allowed greater innovation in pack appearance, especially in terms of pack structure (size, shape, closing mechanism) and non-visual sensory elements intended to create a multisensory appeal (such as textures or coatings to create tactile effects, aroma technology or auditory cues). Packaging innovation can reduce risk perceptions and enhance brand appeal, purchase interest, sales and market share[3],[4]
.

The public health argument

The issue with fully branded tobacco packaging, from a public health perspective, is that it can increase the appeal of the pack, the product and smoking, mislead consumers about how harmful the product is, and distract from the on-pack government health warnings. It was for these reasons that Australia implemented plain cigarette packaging in 2012 in accordance with the World Health Organization Framework Convention on Tobacco Control[5],[6]
. A number of other countries, including New Zealand, France, Finland, India and South Africa, are reported to be considering plain (also referred to as standardised) packaging. While Ireland appears firmly committed to introducing this measure, the UK government has yet to make a similar pledge; the Scottish government maintains that it will proceed independently should the UK government fail to do so.

Despite recent announcements, Australia remains the only country to have implemented plain packaging, which is surprising considering that the idea that all tobacco products come in “plain brown wrappers” was proposed by a group of Canadian doctors in the mid-1980s[7]
. This slow progress may be explained, at least in part, by the response of tobacco companies. Since the early 1990s, when the Plain Pack Working Group was established by tobacco companies to develop a global strategy against plain packaging, it has strongly opposed this measure and attempted to shape the debate. Within the UK, for instance, tobacco companies have lobbied the government and manipulated media coverage to claim plain packaging will have an adverse impact on retailers and boost the illicit tobacco trade, and have done so via misrepresentation of findings and use of third-party evidence (without disclosing financial links to this evidence)[8]
.

A lack of research on the potential impacts of plain packaging, at least until recently, is also a contributory factor. As of March 2014, the vast majority of primary plain packaging studies (53 studies out of a total of 62) have been conducted since 2007[9]
. There is now a body of evidence, with new research being published regularly, with findings that are generally consistent, irrespective of study date, location, design and sample. Results suggest that introducing plain packaging would: reduce the attractiveness and appeal of tobacco products; increase the noticeability of health warnings; and, at least for darker coloured plain packs, reduce the ability of packaging to mislead consumers about the harmful effects of smoking[10],[11]
. Regarding the potential impact on smoking-related attitudes, beliefs, intentions and behaviour, findings are mixed but tend to support plain packaging having a deterrent effect on smoking, with younger people, non-smokers and less heavy smokers more likely to think that plain packs would discourage smoking initiation, encourage cessation or reduce consumption[10],[11]
.

Smoking behaviour in Australia

Assessment of the impact of plain packaging on smoking prevalence is reliant upon recent findings from Australia, since it is the only country to have implemented this measure. The latest wave of the triennial National Drug Strategy Household Survey (NDSHS), with a nationally representative sample (N=23,855) of the Australian population aged 12 years and older, shows where there have been changes in smoking behaviours in Australia, including prevalence, between 2010 and 2013. The NDSHS found that for those aged 14 years and older — most analyses are conducted with those aged 14 years and older to allow for comparison with earlier surveys — fewer people reported smoking (18.1% to 15.8%) with fewer smoking daily (15.1% to 12.8%), weekly consumption of cigarettes decreased (111 cigarettes to 96 cigarettes), and there was an increase in average age of initiation (15.4 years to 15.9 years) and never smoking (57.8% to 60.1%)[12]
. Overall, the key indicators point to tobacco control in Australia being a resounding success.

There are several relevant points to consider when interpreting the NDSHS findings: smoking prevalence and consumption is in long-term decline in Australia; plain packaging was not introduced until late 2012; and, aside from plain packaging, other relevant tobacco control measures introduced from 2010 included a mass-media campaign, which accompanied the initial implementation of plain packaging[13]
, and a large (25%) increase in sales tax. Although this tax increase was introduced some months before the previous survey wave, in 2010, it may be a relevant factor.

The balance of evidence

Packaging is clearly an important and multipurpose marketing tool, a fact that has not been disputed by tobacco companies in the plain packaging debate. It is perhaps unsurprising, therefore, that the accumulating evidence suggests that plain tobacco packaging may have, and is having, a number of potential public health benefits, particularly because there is evidence that plain packaging is associated with cessation-related behaviours[14],[15],[16],[17],[18]
. Between 2010 and 2013, smoking prevalence in Australia experienced the greatest percentage decline as a proportion of the smoking population since the NDSHS began. This will serve to encourage policy interest in plain packaging elsewhere. 

The case for plain packaging is now stronger than it has ever been.

References

[1] Thibodeau M & Martin J. Smoke gets in your eyes: Branding, and design in cigarette packaging. New York: Abbeville Press, 2000.

[2] Hedley D. Smoke and mirrors and the smoking population. Tobacco Journal International 2011;68–69.

[3] Hedley D. The changing future and a new vocabulary for the tobacco industry. Tobacco Journal International 2012;4:89–94.

[4] Kotnowski K & Hammond D. The impact of cigarette pack shape, size and opening: evidence from tobacco company documents. Addiction 2013;108:1658–1668.

[5] World Health Organisation. Elaboration of guidelines for implementation of Article 11 of the Convention. Third session of the Conference of the Parties to the WHO Framework Convention on Tobacco Control. Durban, South Africa, 17–22 November 2008. 

[6] World Health Organisation. Elaboration of guidelines for implementation of Article 13 of the Convention. Third session of the Conference of the Parties to the WHO Framework Convention on Tobacco Control. Durban, South Africa, 17–22 November 2008. 

[7] Lee B. Sell tobacco in no-frills wrappers, urge doctors. The Journal 1986;15:5.

[8] Evans-Reeves K. Plain cigarette packaging: is the government stalling as election approaches? The conversation, 17th December 2014. 

[9] Moodie C, Bauld L, Ford A et al. Young women smokers’ response to using plain cigarette packaging: Qualitative findings. BMC Public Health 2014;14:812.

[10] Moodie C, Stead M, Bauld L et al. Plain tobacco packaging: A systematic review. Report prepared for the Department of Health. Stirling: Centre for Tobacco Control Research, University of Stirling, 2012.

[11] Moodie C, Angus K, Bauld L et al. Plain tobacco packaging research: An update. Stirling, Scotland: Centre for Tobacco Control Research, University of Stirling, 2013.

[12] Australian Institute for Health and Welfare. 2013 National Drug Strategy Household Survey detailed report 2013. Drug statistics series No. 28. Cat. No. PHE 183, Canberra: AIHW, 2014.

[13] Thrasher JT, Osman A, Moodie C et al. Promoting cessation resources through cigarette package warning labels: A longitudinal survey with adult smokers in Canada, Australia and Mexico. Tobacco Control (Published online, 22 July 2014).

[14] Moodie C, Hastings GB, Mackintosh AM et al. Young adult smokers’ perceptions of plain packaging: A pilot naturalistic study. Tobacco Control 2011;20:367–373.

[15] Moodie C, Mackintosh AM. Young adult women smokers’ perceptions of using plain cigarette packaging: A naturalistic approach. British Medical Journal Open 2013;3:e002402.

[16] Wakefield MA, Hayes L, Durkin S et al. Introduction effects of the Australian plain packaging policy on adult smokers: A cross-sectional study. British Medical Journal Open 2013;3:e003175.

[17] Young JM, Stacey I, Dobbins TA et al. Association between tobacco plain packaging and Quitline calls: A population-based, interrupted time-series analysis. Medical Journal of Australia 2014;200:29–32.

[18] Gallopel-Morvan K, Moodie C, Eker F et al. Perceptions of plain packaging among young adult roll-your-own smokers in France: A naturalistic approach. Tobacco Control (Published online, 11 June 2014).

 

Crawford Moodie is senior research fellow, Centre for Tobacco Control Research, Institute for Social Marketing, University of Stirling.

Linda Bauld is professor of health policy and director of the Institute for Social Marketing at the University of Stirling, and also deputy director of the UK Centre for Tobacco and Alcohol Studies, a UKCRC Centre for Public Health Excellence covering 13 Universities

 

 

Last updated
Citation
The Pharmaceutical Journal, PJ, 3/10 January 2015, Vol 294, No 7843/4;294(7843/4):DOI:10.1211/PJ.2015.20067505