11A.9.1 Effects on smokers
The introduction of plain packaging legislation in Australia was informed by an understanding of the way packaging affects perceived appeal of tobacco products, noticeability and impact of health warnings, and perceptions of relative harmfulness.1 Experimental research conducted prior to implementation of the Tobacco Plain Packaging Act 2011, 2 showed that, when compared with fully branded packs, plain packs made smoking and products less appealing to smokers, increased the effectiveness of health warnings, and (when packs were darker in colour) reduced misperceptions about relative harmfulness of cigarettes3 (see Section 11A.8).
Since being implemented, research has begun to investigate the effects of plain packaging on each of the intended mechanisms by which the Act was intended to contribute to its Objects,2 including:
i. Reducing the appeal of tobacco products
Research in Victoria conducted over the phase-in period of plain packaging found that plain pack smokers perceived their cigarettes to be of lower quality and less appealing, and were more likely to think about and prioritise quitting when compared with branded pack smokers.4 A large survey of NSW smokers showed a significant increase in negative perceptions about packs in the months following implementation of the policy, including strong disagreement that the packs are attractive, fashionable, and influence their choice of brand.5 National research comparing smokers’ attitudes pre- and post-implementation supported these preliminary results; one year after plain packaging, more smokers disliked their pack, perceived lower pack appeal, lower cigarette quality, lower satisfaction, and lower value, and disagreed brands differed in prestige.6 The percentage of Australian smokers who don’t like the look of their pack remained high in 2016 (70%) and 2018 (70%).7
Another study found that Australian smokers experienced a significant decrease in the extent to which they identified with their cigarette brand following the introduction of plain packaging, and this was associated with lower smoking behaviours and increased intentions to quit.8 Although exposure to plain packaging appears to be more variable (due to purchasing duty free or online), cigar and cigarillo smokers also report reduced product appeal post-implementation.9 Among Aboriginal and Torres Strait Islander peoples, compared with pre-plain packaging, younger people post-implementation of the policy were less likely to view some brands as more prestigious than others.10
The appeal of cigarette packs also decreased significantly among Australian adolescents in the year following the introduction of plain packaging. Findings also suggested that plain packs were beginning to reduce the pack’s ability to communicate messages about the brands and cigarettes; adolescents reported higher levels of uncertainty regarding whether brands differed in their ease of being smoked, and more disagreement that some brands have better looking packs.11 These effects appear to have been maintained over time. Among Australian adolescents, negativity towards cigarette packs increased and characteristics associated with different cigarette brands (such as how appealing the brand is and how ‘cool’ the smokers of it are) were less positive in 2017 compared with 2011.12
Elsewhere, research on the effects of plain packaging has also found changes in smoking-related perceptions among adolescents. Research in France found that one year after the introduction of plain packaging, there was an increase in the perceived harmfulness of smoking among adolescents, a decrease in the acceptance of smoking, and among young smokers, a decrease in attachment to their tobacco brand.13 In Scotland, adolescent never smokers reported negative reactions to plain packs across measures of appeal (e.g. attractiveness), user-perceptions (e.g. cool and fashionable), and perceived negative effects (e.g. off-putting and harmful) post-implementation.14
Among adults, following implementation of plain packaging in England, there was a large increase in the percentage of smokers who said they did “not at all” like the look of their cigarette pack (from 16% in 2016 to 53% in 2018).7 Other studies have consistently found that plain packaging has reduced the appeal of the packaging and smoking in England.15 Longitudinal research in England found that compared with pre-implementation, smokers considered their cigarettes less appealing and worse value 4–6 months and two years post-implementation. However, this proportion declined between the two post-implementation time points, perhaps due to smokers becoming accustomed to the packs and/or the emergence of product innovations that help to increase appeal.16 Following the implementation of plain packaging in Canada, there was a significant increase in the percentage of smokers who did not like the look of their pack, from 29% in 2018 to 45% in 2020.17
The combination of plain packaging and enlarged health warnings appears to reduce the appeal of products to a greater extent than either measure alone. In 2018, disliking the look of the pack was substantially higher in Australia (70%) than in countries without plain packaging (Canada (25%) and the US (8%)) but also higher than in England (53%), where graphic health warnings are not as large.7 The implementation of plain packaging in England was associated with a greater increase in not liking the look of the pack than in countries that only increased the size of the warning labels without introducing plain packaging (Germany, Greece, Hungary, Poland, Romania and Spain).18
ii. Increasing the effectiveness of health warnings
The introduction of plain packs was associated with a greater salience and self-reported impact of the health warnings among a large sample of NSW smokers. Compared with pre-policy, smokers were more likely to report thoughts and concerns about quitting, seeing only the warnings on the packs, and feeling like they should hide their packs. These responses were comparable to those measured when pictorial health warnings were first introduced on packs in 2006, suggesting that an additional benefit of plain packs has been reversing a decline over time in the impact of the warnings.5 Research post-implementation also found that Australian smokers preferentially attended to and noticed the larger warnings more than they did pre-implementation.19 Similarly, one year post-implementation, more smokers noticed health warnings and attributed their motivation to quit to the warnings. Smokers also avoided specific health warnings when purchasing cigarettes.6 Cigar and cigarillo smokers exposed to plain packaging also report greater noticeability of graphic health warnings (GHWs).9
Australian adolescents’ acknowledgement of the health risks of smoking remained high before and after the implementation of plain packs, and the new health warnings significantly increased their awareness that smoking causes bladder cancer.20
Following the implementation of plain packaging in England, there was a substantial increase in the percentage of smokers who said they usually notice warning labels first when they look at a cigarette pack (from 24% in 2016 to 52% in 2018).7 The proportion of smokers in England noticing warnings first on packs remained significantly higher two years post-implementation (2019).16 A synthesis of two systematic reviews in 2021 concluded that plain packaging increased the salience of health warnings in the UK.15
Researchers comparing the impact of health warnings in different European countries have found that plain packaging in England increased the salience of health warnings over and above the effects of larger health warning labels that were implemented in other European countries on branded packs (Germany, Greece, Hungary, Poland, Romania and Spain).18 The increase in health warning salience, thoughts, and behavioural reactions in the UK was not observed in Norway following the implementation of plain packaging, where the same pre-implementation warnings were maintained (text-only, 43% of pack front; pictorial, 53% of pack reverse). In the UK, warnings were strengthened to 65% of the main display areas. Findings suggest that for countries looking to implement plain packaging, combining this with large novel pictorial warnings is the most effective approach.21 In Canada, which also maintained its existing health warnings (that had been implemented eight years earlier, in 2012) on plain packs, there was no change in the effectiveness of health warnings following implementation of plain packaging.17
iii. Reducing the ability of the packaging to mislead consumers about the harmful effects of tobacco use
Evaluation of changes in beliefs following implementation suggested some (if more limited) impact on misperceptions about the relative harmfulness of tobacco products.
Prior to implementation, several of the manufacturers reassured smokers that the product itself would not change following implementation.22 Not surprisingly, there was no increase in the proportion of smokers who believed that products were more harmful than they were a year ago. The variant names were allowed to remain on the packs (for example, red, blue, light blue, silver, white),22 so it was also not surprising that there was no decline in the proportion of smokers who believe that brands differ in strength. Despite these two mitigating factors, there was a small increase in the proportion of smokers who believed that brands do not differ in harm.6 Surveys of Aboriginal and Torres Strait Islander peoples aged 12+ years living in the ACT and surrounding regional areas before and after the implementation of plain packaging found that following implementation there was a significant reduction in misperceptions that some brands are healthier than others.10
Research on the long-term impact of plain packaging on adolescents found that five years after implementation, fewer agreed that brands differed in addictiveness, harmfulness or ease of smoking. However, adolescents reported greater uncertainty about differences between brands, perhaps due to the tobacco industry’s proliferation of new products and brand names since plain packaging was implemented.12
Following implementation of plain packaging in England, there was a small increase in perceptions that one’s own brand did not differ in harshness compared with other brands, but no change in perceptions of relative harmfulness.18 Another English study found an increase 4–6 months post-implementation in the proportion of smokers disagreeing that some brands contain more harmful substances, but no changes in other measures of perceived harm.16 Other studies in England have similarly found mixed results on harm perceptions.15
Effects on uptake, cessation, relapse, and exposure?
Uptake
Research conducted on the effects of regulating packaging among secondary school students provides some encouraging evidence of a disruption in uptake. Studies of secondary school students in two large Australian states examined changes between 2011 and 2013 in exposure to packs, attitudes, and beliefs about packs and brands,11 and beliefs about health effects.20 These studies also reported incidentally on smoking status. Among those who had seen cigarette packs in the previous six months, the percentage of students defined as non-susceptible never smokers (i.e., had never smoked a cigarette and were certain they would not smoke in the next year) significantly increased and the proportions defined as experimental (had at least a puff of a cigarette, but had not smoked in the last week) and committed smokers declined significantly. A more recent Australian study similarly found that the proportion of non-susceptible never smoker students was significantly greater in 2013, 2014, and 2017 than in 2011. There was also a decrease in experimental and past month smoking between 2011 and 2017.12
A study funded by the Government of France concluded that compared to immediately before introduction of plain packs, French adolescents were more likely to report fear of the consequences of smoking and that smoking is dangerous one year after the implementation of plain packaging. They were also less likely to report that their friends and family accept smoking. Additionally, smoking initiation significantly decreased and smokers’ attachment to their tobacco brand also decreased.13
Several studies have examined Scottish adolescents’ reactions to plain packaging. One found that never smokers who were susceptible to smoking generally reported the same negative reactions to plain packs following implementation as non-susceptible youth.14 Another found that plain packaging reduced the attractiveness of packs and increased the salience of health warnings among those who smoked and among those at risk of becoming smokers.23 Plain packs are considered off-putting and embarrassing among teenagers, though brand variant names that imply coolness and sophistication may undermine some of these effects.24 A review of several studies concluded that plain packaging in the UK may help to deter youth from smoking or continuing to smoke via increased salience of health warnings, the appearance of packs, and negative image created by packs.15
Cessation
There was also evidence of increased cessation activity among adult smokers. A study examining “Quitline” calls in the Australian state of New South Wales found, similar to the pattern after the initial introduction of GHWs in 2006, calls increased by 78%, peaking four weeks after the start of the transition to PP. Notably though, calls remained elevated for six months, a longer time than that observed after the introduction of the 2006 GHWs.25 Among a large sample of Australian adult smokers, plain packaging increased short-term rates of quit intentions, pack avoidance, stopping themselves from smoking, and quit attempts during the transition period.26 During the first 12 months after policy implementation, reduced appeal and increased effectiveness of graphic health warnings in response to the new packs also predicted one month later quitting-related thoughts and behaviours such as increased levels of pack avoidance, stubbing out prematurely and quit attempts.27
In the UK, plain packaging was associated with increased thoughts of quitting among smokers during the transition period.15 , 28 Longitudinal research in the UK found that quitting intentions and behaviours were more likely among smokers for whom plain packaging made health warnings more salient, cigarettes less appealing, or reduced misperceptions of harm.16 Another UK study that examined household purchases associated with the implementation of plain packaging and minimum pack size legislation found that while some smokers switched to lower priced tobacco products, the likelihood of switching to non-tobacco nicotine products or of stopping purchasing nicotine products altogether also increased.29 In France, the proportion of smokers who reported feeling embarrassed taking out their pack increased following the introduction of plain packaging, particularly among women. The pack’s appearance and the associated embarrassment were associated with an increased motivation to quit.30
Exposure to modelling of smoking
Following the implementation of plain packaging, a significant decrease was observed in smoking and the number of packs clearly visible on tables at outdoor café strips. A minority of smokers also actively concealed their packs. The authors suggested that plain packaging was helping to reduce exposure of young people to tobacco promotion and reduce perceptions of smoking prevalence.31 One year later, a sustained reduction in visible smoking and packs at outdoor café strips was observed, again suggesting that plain packaging may be changing norms about smoking. Such changes in norms may in turn support quit attempts, reduce the risk of relapse, and reduce exposure to tobacco and uptake by young people.32 Another study two years post-implementation found that the effects of plain packaging on pack display and smoking were sustained at venues where children were present, but not at venues where children were not present. The authors suggest that more regular refreshment of graphic health warnings may be needed to prolong the positive effects of plain packaging on these behaviours.33
Research in New Zealand found that during the end of the phase-in period for plain packaging, there was a reduction in the number of visible packs per active smoker, and a reduction in face-up positioning of packs at hospitality venues. Pack and pouch display and active smoking were higher at venues without children present, compared with venues with children present.34
Industry assessments of this evidence
Tobacco companies have been highly critical of research funded by the Australian Department of Health conducted in Australia.35 They have commissioned critiques of the research and submitted these to the post-implementation review of plain packaging in Australia,36 to a Senate Inquiry on personal liberty in Australia,37 and to parliamentary and departmental consultations considering legislation in other countries.38-40 Some of the major critiques were promoted on company websites including here.
Effects on prevalence?
Plain packaging is one in a comprehensive set of tobacco control measures that, together, aim to reduce the prevalence of smoking. Its long-term contribution to these efforts will likely be through achieving its goals of reducing the appeal of tobacco products, increasing the efficacy of health warnings, and reducing the ability of packaging to mislead consumers.41
Data from the Australian Secondary School Survey on Smoking Alcohol and Drugs showed a substantial decline in smoking among secondary school students between 2011 and 2014.42 While many factors—including many other elements of tobacco control policy—would have contributed to this decline, the changes in smoking status between 2011 and 2013 reported above (during a period where there were no real increases in prices and no other major changes in policy) are suggestive of a contribution from plain packaging.
Data from the National Drugs Strategy Household Survey in 2013 indicated a historic low in smoking prevalence following the implementation of plain packaging, with only 12.8 % smoking daily43 and a decline between 2013 and 2010 that was substantially larger than previous three-yearly falls. Although there was no overall decline between 2013 and 2016, there was a significant decrease in smoking prevalence among 18–24 year olds, and among the most disadvantaged Australians. There was also a significant increase in never smokers (see Chapter one and Cancer Council Victoria’s fact sheet).
Researchers based in Europe reconstructed and analysed Roy Morgan monthly smoking prevalence data that they obtained from industry-funded reports purporting to show no decrease in smoking prevalence following the introduction of plain packaging. In contrast to the industry-funded conclusions, they found that between 2001 and 2013, the three key tobacco control measures that were introduced (comprehensive smoke-free policies, the large tax increase of April 2010 and plain packaging) were all associated with a significant reduction in smoking prevalence. In particular, the reduction in prevalence following the introduction of plain packaging appears to have been even greater than expected.44 A similar study, this time looking at smoking prevalence among children, also contradicted industry-funded findings and concluded that there was a decline in youth smoking prevalence following the introduction of plain packaging in Australia.45
The Post-Implementation Review of plain packaging legislation in Australia36 includes expert analysis of smoking prevalence also based on Roy Morgan Company’s single source survey between 2001 and 2015. Controlling for the effects of tax increases and a range of other policies over this period, the analysts conclude that plain packaging policy contributed approximately 0.55% of the 2.2% decline in smoking prevalence over the 34 months following implementation.
Research in England examining smoking prevalence between 2006 and 2019 has also found that the implementation of plain packaging commencing in May 2016 was associated with a larger than expected reduction in the prevalence of smoking, followed by ongoing declines in smoking prevalence.46
Public support?
Several studies have also found widespread public support for plain packaging legislation in Australia. One found a substantial increase in support from pre- to post-implementation among Australian smokers,47 while another found consistently high support among adults in the state of Victoria, along with decreasing disapproval over time.48 Support for plain packaging also increased from pre- to post-implementation among adolescents and young adults.49
In England, support for plain packaging among adult smokers increased from 32% before the law (2016) to 44% after implementation (2018). The percentage of smokers who disagreed that cigarettes should be sold in plain packs also decreased (from 32% to 18%).7 Support for plain packaging increased among Canadian smokers following implementation of the policy, from 26% in 2018 to 34% in 2020.17 Research in Europe found that public support for plain packaging was substantially higher in countries that had implemented the legislation (71%), compared with those that had only legislated it (57%) and those with no legislation (41%). Support had also increased over time in countries that had implemented or legislated plain packaging, particularly among non-smokers.50
11A.9.2 Effects on sales
In the lead up to the implementation of plain packaging, the tobacco industry argued that the legislation would cause: a decrease in the use of premium and mainstream brands and an increase in use of value brands; a decline in prices paid for tobacco products, particularly for premium brands; and in turn, an increase in the consumption of tobacco products.51-53
Since the legislation has come into effect, there have been a number of analyses of data relevant to these predictions.
Brand share and prices
Recommended retail prices of tobacco products increased across the market following the implementation of plain packaging.54 A study that looked at the advertised prices in retail outlets across Australia found that the price of cigarettes most prominently promoted on price boards did not fall in the months following implementation of plain packaging (as was predicted by the tobacco industry); rather, retail prices continued to increase, even at the lowest-priced end of the market.55 Results from large cross-sectional surveys of adult smokers showed an increase in the proportion of people using value brands following the introduction of plain packaging, which was attributed largely to the increased availability and affordability of such brands in smaller pack sizes. However, contrary to tobacco industry predictions, prices paid for cigarettes increased, with the largest increases among premium brands.
Reported consumption by smokers and total population consumption and sales
Even with the increased availability and use of value brands, reported consumption did not change significantly among remaining smokers following implementation.56
Data from independent market intelligence companies and reports by tobacco companies to their shareholders suggest at least an immediate decline in sales following the implementation of plain packaging in Australia.57 Tobacco companies point to steady wholesale shipment figures of tobacco products over the period of implementation,58 , 59 however it is difficult to interpret these figures given that the policy itself required companies to provide extra stock during the implementation period in order to comply with the legislation. Official Australian government data shows reductions in sales, customs clearances, and population spending on tobacco products following implementation.60 , 61 (For a detailed analysis, see Cancer Council Victoria’s fact sheet).
Given that reported numbers of cigarettes smoked per day did not appear to decline among smokers following implementation of plain packaging,56 the reduction in sales, government clearances and population spending on tobacco products was likely due to a decline in the prevalence of smoking in Australia. Official government data from 2014 and beyond suggest a continuing decline in per capita consumption of tobacco products in Australia.57 The extent of reduction in clearances over 2014–15 following two substantial increases in excise/customs duty on tobacco products suggests a rate of decline greater than would be predicted based on established estimates of price elasticity alone.57
In the UK, the simultaneous introduction of plain packaging and a minimum excise tax was associated with significant decline in sales and in tobacco industry revenues. Sales of cheaper factory-made brands, which had previously been increasing, stopped growing following implementation.62 Although roll-your-own volumes continued to grow,62 , 63 this was not able to compensate for the accelerating decline in factory-made cigarettes.62
11A.9.3 Effects on use of illicit tobacco
One of the tobacco industry’s predictions regarding plain packaging was that it would allow for easier and therefore increased counterfeiting; illicit tobacco would ‘spiral out of control’ and lead to greater uptake and use.64 It argued that organised crime gangs would experience unprecedented profits, while the new legislation would disadvantage honest retailers and smokers.65 , 66 Australian tobacco companies have commissioned many reports67-80 estimating very high levels of use of illicit tobacco in Australia, which do not correspond with estimates derived from Australian Government surveys81-86 or assessments by Australian Government revenue collection agencies.87 Critiques of these reports have identified fundamental problems with the internet and litter surveys upon which estimates of prevalence of use of illicit tobacco are based (see the reports and their critiques here. For a detailed analysis, see Cancer Council Victoria’s fact sheet).
Research independent of the tobacco industry has consistently found minimal use of illicit tobacco in Australia, both before and after the introduction of plain packaging. Data from the National Drug Strategy Household Survey in 2016 found that only 3.8% of smokers aged 14 years and older reported currently using unbranded loose tobacco, a similar proportion to 2013 (3.6%) and lower than pre-implementation (4.9% in 2010).88 Cross-sectional surveys of smokers interviewed before, during, and one year after implementation showed no significant changes across time in the proportion of smokers reporting current use of unbranded illicit tobacco.89 A study exploring the availability of illicit tobacco in small retail outlets found no increase in retailers’ willingness to sell illicit tobacco post-implementation, and overall numbers of purchased illicit packs were negligible.90 A large national survey of current cigarette smokers conducted continuously from six months before implementation to 15 months after found no evidence of increased use of contraband cigarettes, no increase in purchase from informal sellers, and no increased use of illicit tobacco.91
Research in Europe has found no evidence that levels of illicit trade in tobacco have risen after implementation of plain packaging. The frequency of being offered illicit cigarettes declined between 2015 and 2018 in countries with and without plain packaging, with no differences between the two groups.92
11A.9.4 Effects on retailers
Since the implementation of plain packaging, a number of studies have tested opponents’ predictions that the legislation would have a range of negative outcomes on retailers. Suggestions that serving times would significantly increase due to the products being difficult to locate and differentiate have not been born out; one study found that plain packaging actually resulted in modest gains in retailer efficiency.93 Others found a small, temporary increase in cigarette pack retrieval times immediately following plain packaging implementation, which quickly returned to baseline. Thus, effects were minor and short-lived.94 , 95 The majority of retailers interviewed in Scotland reported that transaction times had not increased following plain packaging implementation, and any confusion was more likely caused by the changes in brand variant names by the tobacco industry than by pack appearance.96
Opponents of the legislation also argued that the longer serving times would result in consumers shifting their custom from small retailers to large supermarkets.While smokers in Australia have been shifting their custom from small retailers to large supermarkets in the wake of large increases in tobacco taxes and prices, there was no evidence of an acceleration of that trend after the introduction of plain packaging.89 , 97 ,98
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References
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