Commentary
Tobacco plain packaging: Evidence based policy or public health advocacy?

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Abstract

In December 2012, Australia became the first country to require all tobacco products be sold solely in standardised or ‘plain’ packaging, bereft of the manufacturers’ trademarked branding and colours, although retaining large graphic and text health warnings. Following the publication of Sir Cyril Chantler's review of the evidence on the effects of plain tobacco packaging, the Ministers of the United Kingdom Parliament voted in March 2015 to implement similar legislation. Support for plain packaging derives from the belief that tobacco products sold in plain packs have reduced appeal and so are more likely to deter young people and non-smokers from starting tobacco use, and more likely to motivate smokers to quit and stay quit. This article considers why support for the plain packaging policy has grown among tobacco control researchers, public health advocates and government ministers, and reviews Australian survey data that speak to the possible introductory effect of plain packaging on smoking prevalence within Australia. The article concludes by emphasising the need for more detailed research to be undertaken before judging the capacity of the plain packaging policy to deliver the multitude of positive effects that have been claimed by its most ardent supporters.

Introduction

Advocates for tobacco control have been lobbying governments around the world to implement legislation that would require all tobacco products to be sold in uniformly drab cartons, bereft of company logos and bright colours, although retaining large graphic and text health warnings. Support for standardised tobacco packaging, a term used interchangeable with ‘plain packaging’, stems largely from the belief that tobacco products sold in plain packs will, by reducing the appeal of smoking, increasing the salience of health warnings, and correcting misperceptions about the harms associated with tobacco use, decrease the number of young people starting smoking and increase the number of people who quit smoking and stay quit.

In 2012, the Australian Government became the first to legislate that all tobacco products to be sold in plain packs. Despite this limited application, support for plain packaging has been ubiquitous and unwavering among academics, public health practitioners, and global health leaders. In 2013, several of the UK's most influential tobacco control researchers authored an article in the British Medical Journal titled: “UK government's delay on plain tobacco packaging: how much evidence is enough?” (Moodie et al., 2012). Similarly, in a recently published article, Pechey, Spiegelhalter, and Marteau (2013) asked 33 “internationally renowned” tobacco control experts (from the UK, Australasia and North America) to provide their estimate of the likely size of the impact of plain packaging on the prevalence of smoking among adults and children. According to Pechey et al.:

In the absence of direct evidence for the impact of plain packaging of tobacco products, this sample of tobacco control experts believe such a policy is likely to lead to a decline in smoking prevalence, and in particular, to a decline in the number of children trying smoking, two years after the introduction of plain packaging. No experts felt that the most likely outcome would be an increase in rates for either adults or children…indicating a strong consensus that plain packaging would not increase consumption, assuming all else stayed equal. (Pechey et al., 2013: 5)

In 2012, the Director General of the World Health Organisation (WHO), Dr. Margaret Chan, signalled her support for the plain packaging policy in a press release from the WHO: “We must make plain packaging a big success so that it becomes the success of the world” (WHO, 2012). The phrasing here is interesting in expressing the commitment on the part of the WHO to ensuring that the health policy is made to work, rather than simply observing the extent to which it works. In its submission to the UK government's independent review of plain packaging (Chantler, 2013), Public Health England reported the findings of a survey that demonstrated the level of support for pain packaging among local directors of public health:

94% of directors agreed that standardised packaging would have a positive impact on reducing health inequalities, particularly in relation to children and young people, those from deprived communities, people with health needs, such as mental health and long-term conditions, respiratory illness. (Public Health England, 2014:4)

The claimed benefits of plain packaging were reported by Public Health England without any supporting evidence to show that the directors’ beliefs were well founded. Moreover, the claimed consensus of support for plain packaging was actually based on a survey that achieved only a 50% response rate; in other words, support for plain packaging was expressed to Public Health England by 94% of 50% of all local directors, not 94% of 100% of directors as was suggested by the submission.

In 2013, the UK government instituted a review of the evidence on the impact of plain packaging (Chantler, 2013) with a view to considering whether the UK should implement a similar policy. On concluding the review, Sir Cyril Chantler wrote to the UK Secretary of State for Health setting out his recommendations:

Having reviewed the evidence it is in my view highly likely that standardised packaging would serve to reduce the rate of children taking up smoking and implausible that it would increase the consumption of tobacco. I am persuaded that branded packaging plays an important role in encouraging young people to smoke and in consolidating the habit irrespective of the intentions of the industry. Although I have not seen evidence that allows me to quantify the size of the likely impact of standardised packaging, I am satisfied that the body of evidence shows that standardised packaging, in conjunction with the current tobacco control regime, is very likely to lead to a modest but important reduction over time on the uptake and prevalence of smoking and thus have a positive impact on public health. (Chantler, 2014:6)

On 11th March 2015, the UK Parliament voted in favour of implementing plain packaging legislation, with implementation scheduled for May 2016. Just weeks before the UK Parliament vote, the parliament of the Republic of Ireland also voted to implement a plain packaging policy.

While support for plain packaging has gathered pace in recent years, the proposal to limit the marketing of tobacco products in this way has been advocated for decades:

In 1992, Health Canada commissioned an expert panel to examine plain and generic packaging of tobacco products and the role it plays in marketing, consumer choice, and uptake or cessation of smoking. The panel found that “plain and generic packaging of tobacco products…through its impact on image formation and retention, recall and recognition, knowledge, and consumer attitudes and perceived utilities, would likely depress the incidence of smoking uptake by non-smoking teens, and increase the incidence of smoking cessation by teens and adult smokers” (WHO, 2015:4).

Given the emphasis that has been placed on ensuring that public policy is based on the best available evidence, it is important to consider the strength of the evidence in support of the plain packaging policy.

Section snippets

Plain packaging research

A systematic review published by researchers at the University of Stirling in 2012 identified 37 individual studies of the effects of plain packaging; 15/37 were published in 2011 and 8/37 were unpublished manuscripts at the time of their inclusion in the review (Moodie et al., 2012). The execution and reporting of the study search were excellent in terms of its exhaustive search, specification of terms, and screening procedure. The authors searched 21 electronic databases of journal articles,

Salience of health warnings: plain and branded packs compared

One of the most widely studied questions has related to whether the branding and livery on tobacco products reduces the salience of the pack's warnings about the risks of smoking. This is an important question because the health warnings appearing on tobacco products are seen as an essential means of informing individuals of the dangers of smoking. It has been estimated, for example, that these warnings are viewed in excess of 7000 times per year by smokers (Fong, 2001).

Beede, Lawson, and

Packaging and the assessments of health harm

Considerable research has studied the relative capacities of plain and branded tobacco packaging to influence individuals’ perceptions of the health risks associated with different tobacco products. There is a degree to which tobacco companies themselves have sought to use this phenomenon in their own marketing through use of terms such as ‘menthol’, ‘mild’ and ‘light’, which have been found to suggest to consumers a lower risk of using certain tobacco products. Consequently, the use of these

Attitudes towards smoking: plain and branded packs compared

There has been extensive research on the impact of tobacco packaging on attitudes towards smoking, and perceptions of the smoking experience. An online survey in Australia by Wakefield, Germain, and Durkin (2008) found that non-branded packs were consistently rated as less attractive than branded packs. Similarly, White and Hammond (2011) found that respondents’ ratings of the appeal of cigarette packs steadily reduced as the researchers removed elements of the branding from the packs they were

Smoking behaviour: plain and branded packs compared

One of the most significant questions relating to the policy of tobacco plain packaging concerns whether it will significantly reduce smoking prevalence and/or the volume of tobacco consumed by a population. The fact that plain packaging has been implemented only in Australia so far means there are very few opportunities to assess whether the policy is yielding the targeted effects. One UK naturalistic study that sought to address this question (Moodie & Mackintosh, 2013) asked a sample of

Smoking prevalence data collected by Australian State Governments

While the findings from the NDSHS have drawn worldwide attention, much less attention has been paid to the findings from a series of surveys undertaken by or on behalf of the governments of Australian states. In Queensland, data have been collected on patterns of smoking and smoking prevalence annually by Queensland Health through its Self Reported Health Status Survey. In New South Wales, smoking prevalence data have been collected by the Ministry of Health since 1997 through its Adult

Tobacco control research: evidence or advocacy

According to Mair and Kierans (2007), tobacco control research is a distinctive area of empirical enquiry in the tendency of tobacco control researchers to see themselves as engaged in a fight against the tobacco industry:

For those who are actively involved in tobacco control…. tobacco research has come to represent as much a moral activity as an investigative one, a weapon used by the “researcher-activist” in the “fight against tobacco” (Mair & Kierans, 2007:104).

Bell (2013) has similarly

Conclusions

In the face of what seems likely to be the further extension of the plain packaging policy beyond Australia, Ireland, and the United Kingdom, there has always been the necessity to ensure that high quality research is being planned and conducted to evaluate the effectiveness of plain packaging in reducing smoking prevalence in a given population set against any unintended health, social and economic consequences. Although seemingly obvious to state, we must be mindful that evidence of changes

Funding

This article was funded by the Centre for Drug Misuse Research. No funding was received by any tobacco company to prepare or submit this article for publication.

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