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. 2017 Apr 27;4(4):CD011244.
doi: 10.1002/14651858.CD011244.pub2.

Tobacco packaging design for reducing tobacco use

Ann McNeill  1 , Shannon Gravely #  2 , Sara C Hitchman #  1 , Linda Bauld  3 , David Hammond  4 , Jamie Hartmann-Boyce  5
Affiliations

Tobacco packaging design for reducing tobacco use

Ann McNeill et al. Cochrane Database Syst Rev. .

Abstract

Background: Tobacco use is the largest single preventable cause of death and disease worldwide. Standardised tobacco packaging is an intervention intended to reduce the promotional appeal of packs and can be defined as packaging with a uniform colour (and in some cases shape and size) with no logos or branding, apart from health warnings and other government-mandated information, and the brand name in a prescribed uniform font, colour and size. Australia was the first country to implement standardised tobacco packaging between October and December 2012, France implemented standardised tobacco packaging on 1 January 2017 and several other countries are implementing, or intending to implement, standardised tobacco packaging.

Objectives: To assess the effect of standardised tobacco packaging on tobacco use uptake, cessation and reduction.

Search methods: We searched MEDLINE, Embase, PsycINFO and six other databases from 1980 to January 2016. We checked bibliographies and contacted study authors to identify additional peer-reviewed studies.

Selection criteria: Primary outcomes included changes in tobacco use prevalence incorporating tobacco use uptake, cessation, consumption and relapse prevention. Secondary outcomes covered intermediate outcomes that can be measured and are relevant to tobacco use uptake, cessation or reduction. We considered multiple study designs: randomised controlled trials, quasi-experimental and experimental studies, observational cross-sectional and cohort studies. The review focused on all populations and people of any age; to be included, studies had to be published in peer-reviewed journals. We examined studies that assessed the impact of changes in tobacco packaging such as colour, design, size and type of health warnings on the packs in relation to branded packaging. In experiments, the control condition was branded tobacco packaging but could include variations of standardised packaging.

Data collection and analysis: Screening and data extraction followed standard Cochrane methods. We used different 'Risk of bias' domains for different study types. We have summarised findings narratively.

Main results: Fifty-one studies met our inclusion criteria, involving approximately 800,000 participants. The studies included were diverse, including observational studies, between- and within-participant experimental studies, cohort and cross-sectional studies, and time-series analyses. Few studies assessed behavioural outcomes in youth and non-smokers. Five studies assessed the primary outcomes: one observational study assessed smoking prevalence among 700,000 participants until one year after standardised packaging in Australia; four studies assessed consumption in 9394 participants, including a series of Australian national cross-sectional surveys of 8811 current smokers, in addition to three smaller studies. No studies assessed uptake, cessation, or relapse prevention. Two studies assessed quit attempts. Twenty studies examined other behavioural outcomes and 45 studies examined non-behavioural outcomes (e.g. appeal, perceptions of harm). In line with the challenges inherent in evaluating standardised tobacco packaging, a number of methodological imitations were apparent in the included studies and overall we judged most studies to be at high or unclear risk of bias in at least one domain. The one included study assessing the impact of standardised tobacco packaging on smoking prevalence in Australia found a 3.7% reduction in odds when comparing before to after the packaging change, or a 0.5 percentage point drop in smoking prevalence, when adjusting for confounders. Confidence in this finding is limited, due to the nature of the evidence available, and is therefore rated low by GRADE standards. Findings were mixed amongst the four studies assessing consumption, with some studies finding no difference and some studies finding evidence of a decrease; certainty in this outcome was rated very low by GRADE standards due to the limitations in study design. One national study of Australian adult smoker cohorts (5441 participants) found that quit attempts increased from 20.2% prior to the introduction of standardised packaging to 26.6% one year post-implementation. A second study of calls to quitlines provides indirect support for this finding, with a 78% increase observed in the number of calls after the implementation of standardised packaging. Here again, certainty is low. Studies of other behavioural outcomes found evidence of increased avoidance behaviours when using standardised packs, reduced demand for standardised packs and reduced craving. Evidence from studies measuring eye-tracking showed increased visual attention to health warnings on standardised compared to branded packs. Corroborative evidence for the latter finding came from studies assessing non-behavioural outcomes, which in general found greater warning salience when viewing standardised, than branded packs. There was mixed evidence for quitting cognitions, whereas findings with youth generally pointed towards standardised packs being less likely to motivate smoking initiation than branded packs. We found the most consistent evidence for appeal, with standardised packs rating lower than branded packs. Tobacco in standardised packs was also generally perceived as worse-tasting and lower quality than tobacco in branded packs. Standardised packaging also appeared to reduce misperceptions that some cigarettes are less harmful than others, but only when dark colours were used for the uniform colour of the pack.

Authors' conclusions: The available evidence suggests that standardised packaging may reduce smoking prevalence. Only one country had implemented standardised packaging at the time of this review, so evidence comes from one large observational study that provides evidence for this effect. A reduction in smoking behaviour is supported by routinely collected data by the Australian government. Data on the effects of standardised packaging on non-behavioural outcomes (e.g. appeal) are clearer and provide plausible mechanisms of effect consistent with the observed decline in prevalence. As standardised packaging is implemented in different countries, research programmes should be initiated to capture long term effects on tobacco use prevalence, behaviour, and uptake. We did not find any evidence suggesting standardised packaging may increase tobacco use.

PubMed Disclaimer

Conflict of interest statement

AM is a trustee of, and receives grants from, various organisations whose goal is to reduce the mortality and morbidity caused by smoking and which support the implementation of a comprehensive tobacco control strategy including measures such as standardised packaging. The opinions of these organisations do not affect this review.

SG receives grants from organisations whose goal is to reduce the mortality and morbidity caused by smoking. The opinions of these organisations do not affect this review.

SCH receives grants from various organisations whose goal is to reduce the mortality and morbidity caused by smoking and which support the implementation of a comprehensive tobacco control strategy including measures such as standardised packaging. SCH has also received grants for the study of cigarette packaging. The opinions of these organisations do not affect this review.

LB receives grants from various organisations whose goal is to reduce the mortality and morbidity caused by smoking and which support the implementation of a comprehensive tobacco control strategy including measures such as standardised packaging. The opinions of these organisations do not affect this review.

DH has received research grants on studies of cigarette packaging. He has also served as a consultant, paid speaker and Advisor to a number of agencies involved in tobacco policy, including Health Canada, the European Commission, the UK Department of Health, and the US Centers for Disease Control and Prevention. He has served as a paid expert witness in several cases associated with the tobacco industry, including on behalf governments in Australia, the UK, and Ireland in plain packaging legal challenges. The opinions of these organisations do not affect this review.

JHB has no known conflicts of interest.

Figures

1
1
Mediation model for package labelling policies (adapted from IARC 2008)
2
2
Study flow diagram
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD011244

References

References to studies included in this review

Adkison 2014 {published data only}
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Babineau 2015 {published data only}
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Balmford 2015 {published data only}
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Borland 2013 {published data only}
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Brennan 2015 {published data only}
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Doxey 2011 {published data only}
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Ford 2013 {published data only}
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Gallopel‐Morvan 2011 {published data only}
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Gallopel‐Morvan 2012 {published data only}
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Gallopel‐Morvan 2015a {published data only}
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Gallopel‐Morvan 2015b {published data only}
    1. Gallopel‐Morvan Karine, Moodie Crawford, Eker Figen, Beguinot Emmanuelle, Martinet Yves. Efficacité des paquets de cigarettes neutres sur des fumeuses en France: Une étude dans un contexte réel de consummation. Bulletin épidémiologique hebdomadaire 2015;17:308‐15.
Germain 2010 {published data only}
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Guillaumier 2014 {published data only}
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Hammond 2009 {published data only}
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Hammond 2011 {published data only}
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Hammond 2013 {published data only}
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Hammond 2014 {published data only}
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Hogarth 2015 {published data only}
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Kotnowski 2015 {published data only}
    1. Kotnowski K, Fong GT, Gallopel‐Morvan K, Islam T, Hammond D. The impact of cigarette packaging design among young females in Canada: findings from a discrete choice experiment. Nicotine & Tobacco Research 2016;18(5):1348‐56. - PubMed
Maynard 2013 {published data only}
    1. Maynard OM, Munafò MR, Leonards U. Visual attention to health warnings on plain tobacco packaging in adolescent smokers and non‐smokers. Addiction 2013;108(2):413‐9. - PubMed
Maynard 2014 {published data only}
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Maynard 2015 {published data only}
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Mays 2015 {published data only}
    1. Mays D, Niaura RS, Evans WD, Hammond D, Luta G, Tercyak KP. Cigarette packaging and health warnings: the impact of plain packaging and message framing on young smokers. Tobacco Control 2015;24(e1):e87‐92. - PMC - PubMed
Miller 2015 {published data only}
    1. Miller CL, Ettridge KA, Wakefield MA. “You're made to feel like a dirty filthy smoker when you're not, cigar smoking is another thing all together.” Responses of Australian cigar and cigarillo smokers to plain packaging. Tobacco Control 2015;24:ii58‐65. - PMC - PubMed
Moodie 2011 {published data only}
    1. Moodie C, Mackintosh AM, Hastings G, Ford A. Young adult smokers' perceptions of plain packaging: A pilot naturalistic study. Tobacco Control 2011;20(5):367‐73. - PubMed
Moodie 2012 {published data only}
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Moodie 2013 {published data only}
    1. Moodie CS, Mackintosh AM. Young adult women smokers' response to using plain cigarette packaging: a naturalistic approach. BMJ Open 2013;3(3):e002402. - PMC - PubMed
Munafò 2011 {published data only}
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Nagelhout 2015 {published data only}
    1. Nagelhout GE, Osman A, Yong HH, Huang LL, Borland R, Thrasher JF. Was the media campaign that supported Australia's new pictorial cigarette warning labels and plain packaging policy associated with more attention to and talking about warning labels?. Addictive Behaviors 2015;49:64‐7. - PMC - PubMed
Nicholson 2015 {published data only}
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Rousu 2013 {published data only}
    1. Rousu MC, Thrasher JF. Demand reduction from plain and pictorial cigarette warning labels: evidence from experimental auctions. Applied Economic Perspectives and Policy 2013;35:171‐84.
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Scollo 2015 {published data only}
    1. Scollo M, Zacher M, Coomber K, Bayly M, Wakefield M. Changes in use of types of tobacco products by pack sizes and price segments, prices paid and consumption following the introduction of plain packaging in Australia. Tobacco Control 2015;24:II66‐75. - PMC - PubMed
Shankleman 2015 {published data only}
    1. Shankleman M, Sykes C, Mandeville KL, Costa S, Yarrow K. Standardised (plain) cigarette packaging increases attention to both text‐based and graphical health warnings: experimental evidence. Public Health 2015;129(1):37‐42. - PMC - PubMed
Wakefield 2008 {published data only}
    1. Wakefield M, Germain D, 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. - PMC - PubMed
Wakefield 2012 {published data only}
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Wakefield 2013 {published data only}
    1. Wakefield MA, Hayes L, Durkin S, Borland R. Introduction effects of the Australian plain packaging policy on adult smokers: a cross‐sectional study. BMJ Open 2013;3(7):e003175. - PMC - PubMed
Wakefield 2015 {published data only}
    1. Wakefield M, Coomber K, Zacher M, Durkin S, Brennan E, Scollo M. Australian adult smokers’ responses to plain packaging with larger graphic health warnings 1 year after implementation: results from a national cross‐sectional tracking survey. Tobacco Control 2015;24:ii17‐25. - PMC - PubMed
White 2012 {published data only}
    1. White CM, Hammond D, Thrasher JF, Fong GT. The potential impact of plain packaging of cigarette products among Brazilian young women: an experimental study. BMC Public Health 2012;12:737. - PMC - PubMed
White 2015a {published data only}
    1. White V, Williams T, Faulkner A, Wakefield M. Do larger graphic health warnings on standardised cigarette packs increase adolescents' cognitive processing of consumer health information and beliefs about smoking‐related harms?. Tobacco Control 2015;24:II50‐7. - PMC - PubMed
    1. White V, Williams T, Wakefield M. Has the introduction of plain packaging with larger graphic health warnings changed adolescents' perceptions of cigarette packs and brands?. Tobacco Control 2015;24:II42‐9. - PMC - PubMed
Yong 2015 {published data only}
    1. Yong HH, Borland R, Hammond D, Thrasher JF, Cummings KM, Fong GT. Smokers’ reactions to the new larger health warning labels on plain cigarette packs in Australia: findings from the ITC Australia project. Tobacco Control 2015;25(2):181‐7. - PMC - PubMed
Young 2014 {published data only}
    1. Young JM, Stacey I, Dobbins TA, Dunlop S, Dessaix AL, Currow DC. Association between tobacco plain packaging and Quitline calls: a population‐based, interrupted time‐series analysis. Medical Journal of Australia 2014;200(1):29‐32. - PubMed
Zacher 2014 {published data only}
    1. Zacher M, Bayly M, Brennan E, Dono J, Miller C, Durkin S, et al. Personal tobacco pack display before and after the introduction of plain packaging with larger pictorial health warnings in Australia: An observational study of outdoor cafe strips. Addiction 2014;109(4):653‐62. - PubMed
Zacher 2015 {published data only}
    1. Zacher M, Bayly M, Brennan E, Dono J, Miller C, Durkin S, et al. Personal pack display and active smoking at outdoor cafe strips: assessing the impact of plain packaging 1 year postimplementation. Tobacco Control 2015;24:II94‐7. - PMC - PubMed

References to studies excluded from this review

Bayly 2015 {published data only}
    1. Bayly M, Scollo M, Wakefield M. No lasting effects of plain packaging on cigarette pack retrieval time in small Australian retail outlets. Tobacco Control 2015;24(e1):e108‐9. - PubMed
Chester 2013 {published data only}
    1. Chester MM. The answer is in the evidence: plain packaging, graphic health warnings, and the Family Smoking Prevention and Tobacco Control Act. Syracuse Journal of Internationall Law and Commerce surface.syr.edu/cgi/viewcontent.cgi?article=1399&context=jilc 2013 (accessed 8th March 2017); Vol. 41, issue 2:413.
Davidson 2014 {published data only}
    1. Davidson S, Silva A. The plain truth about plain packaging: An econometric analysis of the Australian 2011 tobacco plain packaging Act. Agenda: A Journal of Policy Analysis and Reform; press‐files.anu.edu.au/downloads/press/p302941/pdf/The‐Plain‐Truth‐about‐Plain... 2014; Vol. 21, issue 1:27‐43.
Fooks 2013 {published data only}
    1. Fooks G, Gilmore AB. International trade law, plain packaging and tobacco industry political activity: the Trans‐Pacific Partnership. Tobacco Control 2013;23(1):e1. - PMC - PubMed
Ford 2014 {published data only}
    1. Ford A, Moodie C, MacKintosh AM, Hastings G. Adolescent perceptions of cigarette appearance. European Journal of Public Health 2014;24(3):464‐8. - PubMed
Gallopel‐Morvan 2015c {published data only}
    1. Gallopel‐Morvan K. [Is tobacco plain packaging effective in tobacco control?]. La Revue due Praticien 2015;65(8):1018‐20. - PubMed
Gendall 2011 {published data only}
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Gendall 2012 {published data only}
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Griffin 2010 {published data only}
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Henriksen 2012 {published data only}
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Hoek 2012 {published data only}
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Hoek 2013 {published data only}
    1. Hoek J, Healey B, Gendall P, Edwards R, Jaine R. How do adolescents perceive plain packaging?. New Zealand Medical Journal 2013;126(1383):100‐3. - PubMed
Mannocci 2015 {published data only}
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Martin 2014 {published data only}
    1. Martin Natasha, McHugh Hugh, Murtagh Jono, Oliver‐Rose Connor, Panesar Div, Pengelly Harriet, et al. Observational study of the visibility of branded tobacco packaging and smoking at outdoor bars/cafés in Wellington, New Zealand. The New Zealand Medical Journal (Online) 2014;127:27. - PubMed
Moodie 2011a {published data only}
    1. Moodie C, Ford A. Young adult smokers' perceptions of cigarette pack innovation, pack colour and plain packaging. Australasian Marketing Journal (AMJ) 2011;19:174‐80.
Moodie 2012b {published data only}
    1. Moodie C, Hastings G, Joossens L. Young adult smokers' perceptions of illicit tobacco and the possible impact of plain packaging on purchase behaviour. European Journal of Public Health 2012;22(2):251‐3. - PubMed
Scheffels 2008 {published data only}
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Scheffels 2013 {published data only}
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References to studies awaiting assessment

Dunlop 2016 {published data only}
    1. Dunlop S, Perez D, Dessaix D, Currow D. Australia's plain tobacco packs: anticipated and actual responses among adolescents and young adults 2010‐2013. Tobacco Control 2016 Nov;pii:tobaccocontrol‐2016‐053166 [Epub ahead of print]. - PubMed
Gallopel‐Morvan in press {published data only}
    1. Gallopel‐Morvan K, Hoek J, Rieunier S. Do plain packaging and pictorial warnings affect smokers and non‐smokers' behavioural intentions. Journal of Consumer Affairs (in press).
Maynard 2016 {published data only}
    1. Maynard OM, Brooks JC, Munafò MR, Leonards U. Neural mechanisms underlying visual attention to health warnings on branded and plain cigarette packs. Addiction 2017;112(4):662‐72. - PMC - PubMed
Mutti 2016 {published data only}
    1. Mutti S, Hammond D, Reid JL, White CM, Thrasher JF. Perceptions of branded and plain cigarette packaging among Mexican youth. Health Promotion International 201 Jan 29; Vol. pii:dav117 [Epub ahead of print]. - PMC - PubMed
Nonnemaker 2016 {published data only}
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Skaczkowski 2017 {published data only}
    1. Skaczkowski G, Durkin S, Kashima Y, Wakefield M. Influence of premium versus value brand names on the smoking experience in a plain packaging environment: an experimental study. BMJ Open 2017 Jan 16;7(1):e014099. - PMC - PubMed

References to ongoing studies

Bogdanovica 2016 {unpublished data only}
    1. Study of the effects of standardised packaging and the 2014 European Union Tobacco Products Directive on tobacco product pricing, consumption and smoking prevalence. Ongoing study Fellowship. Finishes 2022.
Diethelm 2016 {unpublished data only}
    1. Re‐analysis of tobacco‐industry funded research on the effect of plain packaging on minors in Australia. Ongoing study Starting date of trial not provided. Contact author for more information.
Gilmore 2016 {unpublished data only}
    1. Using Nielsen data to evaluate the impact of standardised packaging of tobacco in the UK. Ongoing study 2016 (finishes 2019).
Hitchman/Moodie 2015 {unpublished data only}
    1. Adult Tobacco Policy Survey.An evaluation of standardised packaging in the UK. Ongoing study 2014 ‐ 2016.

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References to other published versions of this review

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