Last updated: November 2018
Suggested citation: Greenhalgh, EM, & Scollo, MM. InDepth 11A.8 Experimental research on the effects of plain packaging. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2018. Available from: http://www.tobaccoinaustralia.org.au/chapter-11-advertising/11a-8-experimental-research-on-the-effects-of-plai
Prior to its implementation, evidence about the possible impact of plain packaging legislation was derived from experimental studies where people were typically presented with both branded and mocked-up plain packs and asked about their perceptions of the products. In 1995, an expert panel provided to the Canadian Department of Health the first comprehensive review of the likely effects of plain packaging.1 On the basis of a detailed analysis of the five studies to that time, the panel concluded:
‘Virtually all the findings of these five studies converge on the following conclusions: Plain and generic packaging of tobacco products (all other things being equal), 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 teen and adult smokers. This impact would vary across the population. The extent of change in incidence is impossible to assess except through field experiments conducted over time.’
Canadian Expert Panel report 1 p158
Since the Canadian expert review, many studies have examined the potential effects of plain packaging on tobacco use, primarily looking at its effect on awareness, recall and impact of health warnings; on perceptions of riskiness of tobacco products; and on the appeal of brands and products. An Australian study published in 2008 involving more than 800 adult smokers examined the effects on the appeal of tobacco products when progressively reducing the amount of pack branding design information. As illustrated in Figure 11A.8.1, the plainest packs were seen as less attractive, smokers of the packs were seen as significantly less stylish and sociable, and the cigarettes in the packs were thought to be less satisfying and of lower quality.2 A similar study with Australian adolescents also found that progressively removing brand elements resulted in seeing packs as less appealing, having more negative expectations of cigarette taste, and rating attributes of a typical smoker of the pack less positively.3
Level of attractiveness of increasingly plainer tobacco packaging
Source: Wakefield et al 20082
Over the past decade a number of systematic reviews and meta-analyses have been published examining the perceptions, impact, and effectiveness of plain packaging.4-13 Australian researchers concluded in an early review that plain packaging would remove a key remaining strategy used by the tobacco industry to promote its products, and noted that the legislation is consistent with the FCTC’s recommendation to ban all tobacco promotions.4 Subsequent reviews concluded that there is strong evidence to support the propositions set out in the FCTC relating to the role of plain packaging in helping to reduce smoking rates; that is, that plain packaging would reduce the attractiveness and appeal of tobacco products, it would increase the noticeability and effectiveness of health warnings, and it would reduce misperceptions about the relative harmfulness of products.5, 6, 11 Others have highlighted additional likely benefits for public health, including helping to further denormalise tobacco use.8 One noted that it is highly likely that plain packaging would serve to reduce the rate of children taking up smoking, and implausible that it would increase the consumption of tobacco.7 Early evidence also suggests that plain packaging may be a potentially effective intervention in low- and middle-income settings, and that it can reach otherwise difficult to reach populations.9
A Cochrane review of the effect of plain packaging on tobacco use uptake, cessation and reduction published in 2017 summarised the potential outcomes of plain packaging as including both primary (changes in tobacco use prevalence) and secondary (behaviours, attitudes, perceptions and beliefs relevant to tobacco use) outcomes—see Figure 11A.8.2. Most research to date does not aim to measure the direct effectiveness of plain packaging on tobacco use prevalence (particularly given the recency of its implementation); rather, it generally examines its impact on a set of proxies or determinants (i.e., secondary outcomes) that are known to contribute to reducing smoking prevalence within a comprehensive tobacco control strategy. The review concluded that plain packaging may reduce smoking prevalence, with the most consistent evidence for its role in reducing the appeal of the products. The authors did not find any evidence suggesting plain packaging may increase tobacco use.10
Mediation model for package labelling policies
Source: McNeill et al. 201710
A growing body of research has been carried out examining the effects of plain packaging in Australia since its implementation in 2012—see Section 11A.9 for an overview of ‘real-world’ research.
Even after the implementation of plain packaging, various product features remain that can distinguish and promote misperceptions of cigarette products. Following the introduction of plain packaging in Australia, there was a rapid increase in brand variant names and descriptors,14 and in the years that followed the tobacco industry continued to release new types of products (e.g, cigarette filter features such as menthol capsules), brand extensions, and novel pack sizes.15 As with the packaging itself, brand and variant names can enhance the appeal of tobacco products,16, 17 and create misperceptions about relative harmfulness and ease of quitting; in turn undermining some of the aims of plain packaging.18, 19 For example, descriptors such as ‘smooth’ and ‘blue’ continue to mislead consumers.20, 21 Cigarette sticks can also be used as a promotional tool by tobacco companies, and can increase perceptions about the quality and desirability of products.22, 23
Researchers have suggested a number of innovative options for countries planning to introduce plain packaging that would extend and strengthen existing legislation: restricting or banning brand variant names and colour descriptors (such as in Uruguay, where only one brand variant is permitted per brand family24); developing larger and more salient on-pack warnings; developing tobacco products themselves that are dissuasive (e.g., altering the appearance of the cigarette); and using packaging to create cessation portals that direct tobacco users to quit support, such as pack inserts that promote cessation.25, 26
1. Goldberg M, Kindra G, Lefebvre J, Tribu L, Liefeld J, et al. When packages can't speak: Possible impacts of plain and generic packaging of tobacco products. Legacy Tobacco Documents, University of California, San Francisco, 1995. Last update: Viewed Available from: http://legacy.library.ucsf.edu/tid/rce50d00.
2. Wakefield M, Germain D, and Durkin S. How does increasingly plainer cigarette packaging influence adult smokers' perceptions about brand image? An experimental study. Tobacco Control, 2008; 17(6):416−21. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/17/6/416
3. Germain D, Wakefield MA, and Durkin SJ. Adolescents' perceptions of cigarette brand image: Does plain packaging make a difference? Journal of Adolescent Health, 2010; 46(4):385−92. Available from: www.jahonline.org/article/S1054-139X(09)00341-3/abstract
4. Freeman B, Chapman S, and Rimmer M. Review: The case for the plain packaging of tobacco products. Addiction, 2008; 103(4):580–90. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18339104
5. Cancer Council Victoria. Plain packaging of tobacco products: A review of the evidence. Melbourne: Cancer Council Victoira, 2011. Available from: http://www.cancervic.org.au/plainfacts/browse.asp?ContainerID=plainfacts-evidence.
6. Moodie C, Stead M, Baulda L, McNeill A, Angusa K, et al. Plain tobacco packaging: A systematic review. Stirling, Scotland: University of Stirling, 2011. Available from: http://phrc.lshtm.ac.uk/project_2011-2016_006.html.
7. Chantler C. Report of the independent review into standardized packaging of tobacco. London Kings College, 2014. Available from: http://www.kcl.ac.uk/health/10035-TSO-2901853-Chantler-Review-ACCESSIBLE.PDF.
8. Hammond D. Standardized packaging of tobacco products: Evidence review. Prepared on behalf of the Irish Department of Health. Waterloo, Ontario, Canada: University of Waterloo, 2014. Available from: http://hdl.handle.net/10147/575325
9. Hughes N, Arora M, and Grills N. Perceptions and impact of plain packaging of tobacco products in low and middle income countries, middle to upper income countries and low-income settings in high-income countries: A systematic review of the literature. BMJ Open, 2016; 6(3):e010391. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27000787
10. McNeill A, Gravely S, Hitchman SC, Bauld L, Hammond D, et al. Tobacco packaging design for reducing tobacco use. Cochrane Database of Systematic Reviews, 2017; 4:CD011244. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28447363
11. Hammond D. Plain packaging regulations for tobacco products: the impact of standardizing the color and design of cigarette packs. Salud Pública de México, 2010; 52(suppl. 2 ):226–32. Available from: http://www.scielosp.org/pdf/spm/v52s2/a18v52s2.pdf
12. Stead M, Moodie C, Angus K, Bauld L, McNeill A, et al. Is consumer response to plain/standardised tobacco packaging consistent with Framework Convention on Tobacco Control guidelines? A systematic review of quantitative studies. PLoS ONE, 2013; 8(10):e75919. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24146791
13. Lilic N, Stretton M, and Prakash M. How effective is the plain packaging of tobacco policy on rates of intention to quit smoking and changing attitudes to smoking? ANZ J Surg, 2018. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29873162
14. Scollo M, Occleston J, Bayly M, Lindorff K, and Wakefield M. Tobacco product developments coinciding with the implementation of plain packaging in Australia. Tobacco Control, 2015; 24(e1):e116-22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24789601
15. Scollo M, Bayly M, White S, Lindorff K, and Wakefield M. Tobacco product developments in the australian market in the 4 years following plain packaging. Tobacco Control, 2017. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28993520
16. Skaczkowski G, Durkin S, Kashima Y, and Wakefield M. Influence of premium vs masked cigarette brand names on the experienced taste of a cigarette after tobacco plain packaging in australia: An experimental study. BMC Public Health, 2018; 18(1):295. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29526164
17. Skaczkowski G, Durkin S, Kashima Y, and Wakefield M. Influence of premium versus value brand names on the smoking experience in a plain packaging environment: An experimental study. BMJ Open, 2017; 7(1):e014099. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5253579/
18. Hoek J, Gendall P, Eckert C, Kemper J, and Louviere J. Effects of brand variants on smokers' choice behaviours and risk perceptions. Tobacco Control, 2016; 25(2):160-5. Available here: https://tobaccocontrol.bmj.com/content/25/2/160
19. Dewhirst T. Into the black: Marlboro brand architecture, packaging and marketing communication of relative harm. Tobacco Control, 2018; 27(2):240-2. Available from: http://tobaccocontrol.bmj.com/content/tobaccocontrol/27/2/240.full.pdf
20. Leas EC, Ayers JW, Strong DR, and Pierce JP. Which cigarettes do Americans think are safer? A population-based analysis with wave 1 of the PATH study. Tobacco Control, 2017; 26(e1):e59-e60. Available from: https://tobaccocontrol.bmj.com/content/tobaccocontrol/26/e1/e59.full.pdf
21. Yong H-H, Borland R, Cummings KM, Lindblom EN, Li L, et al. US smokers’ beliefs, experiences and perceptions of different cigarette variants before and after the fsptca ban on misleading descriptors such as “light,” “mild,” or “low”. Nicotine & Tobacco Research, 2016; 18(11):2115-23. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5055739/
22. Moodie C, Gendall P, Hoek J, MacKintosh AM, Best C, et al. The response of young adult smokers and non-smokers in the united kingdom to dissuasive cigarettes: An online survey. Nicotine & Tobacco Research, 2017. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29190398
23. Gallopel-Morvan K, Moodie C, Guignard R, Eker F, and Beguinot E. Consumer perceptions of cigarette design in France: A comparison of regular, slim, pink and plain cigarettes. Nicotine & Tobacco Research, 2018. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29800331
24. DeAtley T, Bianco E, Welding K, and Cohen JE. Compliance with Uruguay’s single presentation requirement. Tobacco Control, 2018; 27(2):220-4. Available from: http://tobaccocontrol.bmj.com/content/tobaccocontrol/27/2/220.full.pdf
25. Hoek J and Gendall P. Policy options for extending standardized tobacco packaging. Bull World Health Organ, 2017; 95(10):726-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29147047
26. Moodie C, Hoek J, Scheffels J, Gallopel-Morvan K, and Lindorff K. Plain packaging: Legislative differences in Australia, France, the UK, New Zealand and Norway, and options for strengthening regulations. Tobacco Control, 2018. Available from: https://tobaccocontrol.bmj.com/content/tobaccocontrol/early/2018/08/01/tobaccocontrol-2018-054483.full.pdf