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

Going 'Super Value' in New Zealand: cigarette pricing strategies during a period of sustained annual excise tax increases

BACKGROUND

Between 2010 and 2020, the New Zealand (NZ) Government increased tobacco excise tax by inflation plus 10% each year. We reviewed market structure changes and examined whether NZ tobacco companies shifted excise tax increases to maintain the affordability of lower priced cigarette brands.

METHODS

We cluster-analysed market data that tobacco companies supply to the NZ Ministry of Health, created four price partitions and examined the size and share of these over time. For each partition, we analysed cigarette brand numbers and market share, calculated the volume-weighted real stick price for each year and compared this price across different price partitions. We calculated the net real retail price (price before tax) for each price partition and compared these prices before and after plain packaging took effect.

RESULTS

The number and market share of Super Value and Budget brands increased, while those of Everyday and Premium brands decreased. Differences between the price of Premium and Super Value brands increased, as did the net retail price difference for these partitions. Following plain packaging's implementation, Super Value brand numbers more than doubled; contrary to industry predictions, the price difference between these and higher priced brands did not narrow.

CONCLUSIONS

Between 2010 and 2020, NZ tobacco companies introduced more Super Value cigarette brands and shifted excise tax increases to reduce the impact these had on low-priced brands. Setting a minimum retail price for cigarettes could curtail tobacco companies' ability to undermine tobacco taxation policies designed to reduce smoking.

Effects of cigarette package colors and warning labels on marlboro smokers' risk beliefs, product appraisals, and smoking behavior: a randomized trial

OBJECTIVE

Plain packaging and graphic warning labels are two regulatory strategies that may impact cigarette risk beliefs and reduce consumption, but data are needed to better understand how smokers respond to such regulations.

METHODS

Adult, daily, Marlboro non-menthol smokers (Red [n = 141] or Gold [n = 43]) completed a mixed factorial randomized trial. Participants smoked their usual cigarettes during baseline (5-days) and were randomized to receive cigarette packs with a warning label manipulation (graphic vs. text-only). Within each warning label condition, participants completed three within-subjects pack color manipulations (red, gold, plain), each lasting 15 days. Participants were blinded to the fact that all packs contained their usual cigarettes. Mixed-effects models examined between- and within-subject differences on risk beliefs, product perceptions, and smoking behavior.

RESULTS

Warning type and package color did not impact cigarette consumption or subjective ratings. However, use increased in all conditions (2.59-3.59 cigarettes per day) relative to baseline. While smokers largely held correct risk beliefs at baseline (Mean = 6.02, SE = 0.17, Range:0-8), the cumulative number of incorrect or uncertain cigarette risk beliefs increased from baseline in all pack color manipulations in the text (IRR range = 1.70-2.16) and graphic (IRR range = 1.31-1.70) warning conditions. Across all pack color periods, those in the graphic (vs. text) warning condition had reduced odds of reporting their study cigarettes as 'safer' than regular cigarettes (OR range = 0.22-0.32).

CONCLUSIONS

Pack color modification may increase uncertainty about several key cigarette risk beliefs, though graphic warnings may attenuate these effects. Regulatory agencies could consider supporting policy changes with information campaigns to maximize public knowledge.

TRIAL REGISTRATION

November 25, 2014; Registration number: NCT02301351.

Tobacco purchasing in Australia during regular tax increases: findings from the International Tobacco Control Policy Evaluation Project

OBJECTIVE

We examined Australian tobacco purchasing trends, the average self-reported price paid within each purchase type and the association between type of tobacco product purchased and participant characteristics, including quit intentions, between 2007 and 2020.

METHODS

We analysed data collected from adults who smoked factory-made and/or roll-your-own (RYO) cigarettes in nine waves (2007-2020) of the International Tobacco Control Policy Evaluation Project Australia Survey (nsample=5452, nobservations=11 534). The main outcome measures were type of tobacco products purchased: RYO, carton, pack or pouch size and brand segment. Logistic regression, fit using generalised estimating equations, was estimated the association between the outcome and participant characteristics.

RESULTS

The reported price-minimising purchasing patterns increased from 2007 to 2020: any RYO (23.8-43.9%), large-sized pack (2007: 24.0% to 2016: 34.3%); shifting from large-sized to small-sized packs (2020: 37.7%), and economy brand (2007: 37.2% to 2020: 59.3%); shifting from large (2007: 55.8%) to small economy packs (2014: 15.3% to 2020: 48.1%). Individuals with a lower income, a higher nicotine dependence level and no quit intention were more likely to purchase RYO and large-sized packs.

CONCLUSION

RYO, large-sized packs and products with a low upfront cost (eg, small RYO pouches and small-sized economy brand packs) may appeal to people on low incomes. Australia's diverse tobacco pack and pouch sizes allow the tobacco industry to influence tobacco purchases. Standardising pack and pouch sizes may reduce some price-related marketing and especially benefit people who have a low income, are highly addicted and have no quit intention.

Plain tobacco packaging: progress, challenges, learning and opportunities

The aim of this paper is to overview progress made with respect to the adoption of plain (or standardised) packaging, key challenges faced, evaluative evidence and opportunities for extending this policy. It has been a decade since Australia became the first country to require tobacco products to be sold in plain packaging; after slow initial uptake, 16 countries have now fully implemented this policy. Since 2020, plain packaging laws have become more comprehensive in some countries, expanding coverage beyond traditional tobacco products to include heated tobacco, tobacco accessories (rolling papers) and other nicotine-containing products (e-cigarettes). Laws have also become more innovative: some now ban non-biodegradable filters, include provision for a periodic change of the pack colour or require both plain packaging and health-promoting pack inserts. The tobacco industry has and will continue to use multi-jurisdictional strategies to oppose this policy. Evaluations suggest that plain packaging has improved health outcomes and has not burdened retailers, although research is limited to early policy adopters and important gaps in the literature remain. While the power of packaging as a sales tool has diminished in markets with plain packaging, tobacco companies have exploited loopholes to continue to promote their products and have increasingly focused on filter innovations. Opportunities exist for governments to strengthen plain packaging laws.

Where to next for countries with high tobacco taxes? The potential for greater control of tobacco pricing through licensing regulation

Optimising the taxation of tobacco products should be among the highest priorities for health and hence economic policy in every country. The WHO Technical Manual on Tobacco Tax Policy and Administration released in April 2021 provides invaluable advice, including 26 best practice recommendations on policy design, administrative efficiency and addressing industry tactics to circumvent tobacco tax increases. Introducing and increasing tobacco taxes is the most important tobacco control measure for any jurisdiction. The effects of simple tax structures, high tax levels, and frequent above-inflation increases in specific excise duties can be enhanced through strict controls on packaging (including pack size), product design, and discounting. However, even with such measures, tobacco companies can continue to undermine the effectiveness of tax policy by offering some products in their ranges at very low prices, as well as gradually and selectively increasing the prices of some but not all products after tax increases. This paper is aimed at policymakers in countries that have already adopted best practice tax policy. It explores the idea of wholesale price capping combined with retail licensing to address the problems of brand proliferation, dispersion of prices, cushioning and strategic under/overshifting of tax increases, thereby radically and sustainably increasing the effectiveness of tobacco tax policy while also raising additional tax revenue for governments by reducing industry profitability.

Longitudinal evaluation of the impact of standardised packaging and minimum excise tax on tobacco sales and industry revenue in the UK

BACKGROUND

Standardised packaging for factory-made cigarettes (FM) and roll-your-own tobacco (RYO), and a minimum excise tax (MET) were fully implemented in the UK in May 2017 following a 12-month transition period. This paper is the first to examine effects on tobacco sales volumes and company revenues.

METHODS

Analysis of UK commercial supermarket and convenience store electronic point of sale data on tobacco sales. FM and RYO products' data (May 2015-April 2018) yielded 107 572 monthly observations. Expected values from additive mixed modelling were used to calculate trends in: (1) volumes of tobacco sold overall, by cigarette type (FM and RYO) and by seven market segments; and (2) company net revenues. A 10-month period (June 2015-March 2016) before the transition to standardised packs was compared with a 10-month period after the introduction of the MET and full implementation of standardised packs (June 2017-March 2018).

RESULTS

Postimplementation, the average monthly decline in stick sales was 6.4 million (95% CI 0.1 million to 12.7 million) sticks faster than prelegislation, almost doubling the speed of decline. Sales of cheap FM brands, previously increasing, plateaued after implementation. Company monthly net revenues declined from a stable £231 million (95% CI £228 million to £234 million), prelegislation, to £198 million (95% CI £191 million to £206 million) in April 2018.

CONCLUSIONS

The concurrent introduction of standardised packaging and MET in the UK was associated with significant decline in sales and in tobacco industry revenues, and the end of the previous growth in cheap cigarette brands that appeal to young and price conscious smokers.

Australian Smokers' Sensory Experiences and Beliefs Associated with Menthol and Non-Menthol Cigarettes

Many current smokers incorrectly believe that menthol cigarettes are less harmful, likely due to the biological and sensory effects of menthol, which can lead smokers to have favourable sensory experiences. In this study, we measured the extent to which Australian smokers associate certain sensory experiences with smoking menthol and non-menthol cigarettes, and their beliefs about how damaging and enjoyable they find cigarettes with each of these sensory experiences. A sample of 999 Australian 18–69-year-old weekly smokers was recruited from a non-probability online panel; this study focuses on the 245 respondents who currently smoked menthol cigarettes at least once per week. Current menthol smokers were four to nine times more likely to experience menthol rather than non-menthol cigarettes as having favourable sensory experiences, including feeling smooth, being soothing on the throat, fresh-tasting and clean-feeling. Menthol smokers perceived cigarettes with these favourable sensations as less damaging and more enjoyable than cigarettes with the opposite more aversive sensory experience. Efforts to correct these misperceptions about risk will likely require messages that provide new information to help smokers understand that these sensations do not indicate a lower level of risk. Banning menthol in tobacco products—as has recently been done in some nations—would also be a timely and justified strategy for protecting consumers.

Effect of UK plain tobacco packaging and minimum pack size legislation on tobacco and nicotine product switching behaviour

BACKGROUND AND AIMS

The introduction of plain tobacco packaging and minimum pack size legislation in the United Kingdom between May 2016 and May 2017 was accompanied by substantial changes in tobacco product diversity and pricing. This study investigates the extent to which these changes were associated with consumer switching between tobacco product types and price segments, and from tobacco to non-tobacco nicotine products.

DESIGN

Longitudinal study (changing trends in product and price choices) and survey (reasons for consumer choices).

SETTING

Great Britain PARTICIPANTS: We used 11 695 British households from Kantar Worldpanel who purchased tobacco and non-tobacco nicotine products from March 2011 to December 2017.

MEASUREMENTS

Product choice was defined using household's monthly purchases of tobacco (cigarettes, roll-your-own (RYO) tobacco, cigar/cigarillo and pipe tobacco) and non-tobacco nicotine products (e-cigarettes and nicotine replacement therapy), while price was defined using price paid by pack size and by price quartiles. Our switching analysis considered three switching alternatives: switching to a different tobacco product or to a combination of tobacco products, switching to any non-nicotine tobacco product, and switching out of our dataset. We explored changes in price quartile purchasing behaviour using binary variables for whether a household purchased or not from each price quartile monthly. Finally, self-declared consumer's choice was assessed through survey responses.

FINDINGS

The introduction of plain packaging and minimum pack sizes coincided with major switching to purchasing of pack sizes of 20 cigarettes or 30 g or larger RYO tobacco (>99% of purchases in December 2017) and a migration towards lower-price cigarettes, as for cigarettes, around 80% of purchases were in the lowest price quartiles at the end of the study period compared to about 50% at the start of the study period. During the first 6 months of implementation there was also a marked increase in the likelihood that cigarette smokers would switch to non-tobacco nicotine (OR 1.74, 95% CI: 1.18 to 2.57), predominantly e-cigarettes, compared with the period before May 2016. Survey results suggest that price was the main driver of changes in purchasing behaviour.

CONCLUSIONS

Implementation of plain packaging and minimum pack size legislation in the UK appears to have been associated with tobacco users switching to lower price tobacco products and to e-cigarettes.

Size matters: An analysis of cigarette pack sizes across 23 European Union countries using Euromonitor data, 2006 to 2017

INTRODUCTION

The tobacco industry (TI) has used small cigarette pack sizes to encourage brand-switching and consumption, and to mitigate the impacts of tobacco tax increases. Since 2016, the European Union (EU) Tobacco Products Directive (TPD) specifies a minimum pack size of 20 cigarettes. We examined cigarette pack sizes in the EU and whether pack size composition differed between cheap and expensive price segments, as well as the impact of the revised TPD.

METHODS

We conducted a longitudinal analysis of pricing data from 23 EU countries between 2006-2017. We examined pack sizes over time to assess the impact of the TPD, differences in pack size composition between cheap and expensive price segments, and compared gaps in median prices between products using actual and 'expected' prices (price if all packs contained 20 sticks).

RESULTS

Cigarette pack sizes changed over time, across the EU. The distribution of pack sizes varied between price segments, with small pack sizes especially frequent in the cheap segment of the cigarette market, but this varied over time and across countries. Packs of <20 cigarettes almost disappeared from the data samples after implementation of the TPD.

CONCLUSION

Implementation of the TPD appears to have virtually eliminated packs with <20 cigarettes, restricting their use by the TI. Our analysis suggests pack sizes have been used differentially across the EU. Country-level analyses on the industry's use of pack sizes, consumer responses, and evaluations of restricting certain pack sizes are needed to confirm our findings and strengthen policy.

Changes in roll-your-own tobacco and cigarette sales volume and prices before, during and after plain packaging legislation in the UK

BACKGROUND

Plain packaging and minimum pack size legislation for tobacco products was introduced in the UK in May 2016, with a 1-year sell-off period until May 2017, during which both fully branded and plain packs of various sizes were legally available. This study investigates trends in prices of roll-your-own tobacco (RYO) before, during and after implementation of this legislation, and compares trends with those observed in the cigarette market.

METHODS

We used Nielsen Scantrack data for the period from March 2013 to June 2018 to describe trends in UK inflation-adjusted prices and volumes of both RYO and cigarettes, and linear regression to estimate changes in prices associated with the introduction of plain packaging and the minimum pack sizes of 30 g RYO and 20 cigarettes.

RESULTS

In contrast to a downward trend in cigarette sales volumes, RYO volumes rose throughout the study period. By the time plain packs accounted for 75% or more of sales, the average price of products sold in equivalent pack sizes had increased, relative to average prices in the year before implementation and with adjustment for tax changes, from 34.9 to 38.8 pence per gram for RYO (mean difference 4.26, 95% CI 3.99 to 4.53 pence, 12% increase), and from 38.6 to 41.13 pence for cigarettes (mean difference 2.53, 95% CI 2.24 to 2.83 pence, 7% increase) per cigarette.

CONCLUSIONS

New legislation resulted in higher prices for RYO and manufactured cigarettes. However, sales volumes of RYO continued to increase throughout the study period, perhaps because RYO remains a less expensive means of smoking tobacco.

The educational gap in tar and nicotine content in purchases of cigarettes: An observational study using large-scale representative survey data from Japan

The intensity of tobacco use is commonly measured by the number of cigarettes, which is inaccurate because it masks the heterogeneity and substances contained in tobacco. Unlike existing studies, this study adopted the tar and nicotine content of purchased cigarettes as proxies for smoking intensity and elicited socioeconomic disparities from the participants regarding tobacco use. Using a nationally representative consumer panel survey of Japan from 2010 to 2014, we found that socioeconomic disparities in smoking are more pronounced when tar and nicotine content in cigarettes is considered. University graduates purchased 26% fewer cigarettes, and 40% less tar or nicotine than their secondary school-educated counterparts. Low education groups purchased more tar-rich cigarettes, which cost less than low-tar cigarettes. The public health recommendations for reducing socioeconomic health inequalities might be understated because they are drawn from evidence based on the number of cigarettes smoked.

Prospective longitudinal study of tobacco company adaptation to standardised packaging in the UK: identifying circumventions and closing loopholes

OBJECTIVES

UK standardised packaging legislation was introduced alongside pack size and product descriptor restrictions of the European Union Tobacco Products Directive to end tobacco marketing and misinformation via the pack. This paper aims to assess compliance with the restrictions and identify attempts to continue to market tobacco products and perpetuate misperceptions of harm post legislation.

DESIGN, SETTING AND INTERVENTION

A prospective study of the introduction of standardised packaging of tobacco products to the UK.

PARTICIPANTS AND OUTCOMES

We analysed commercial sales data to assess whether the legally required changes in pack branding, size and name were implemented. To explore any adaptations to products and packaging we analysed sales data, monthly pack purchases of factory-made (FM) cigarettes and roll-your-own (RYO) tobacco, tobacco advertisements from retail trade magazines and articles on tobacco from commercial literature (retail trade, market analyst and tobacco company publications).

RESULTS

One month after full implementation of the UK and European Union policies, 97% FM and 98% RYO was sold in compliant packaging. Nevertheless, tobacco companies made adaptations to tobacco products which enabled continued brand differentiation after the legislation came into force. For example, flavour names previously associated with low tar were systematically changed to colour names arguably facilitating continued misperceptions about the relative harms of products. Tobacco companies used the 1-year sell-through to their advantage by communicating brand name changes and providing financial incentives for retailers to buy large volumes of branded packs. In addition, tobacco companies continued to market their products to retailers and customers by innovating exemptions to the legislation, namely, filters, packaging edges, seals, multipack outers, RYO accessories, cigars and pipe tobacco.

CONCLUSIONS

Tobacco companies adapted to packaging restrictions by innovating their tobacco products and marketing activities. These findings should enable policy makers globally to close loopholes and increase the potential efficacy of standardised packaging policies.

Pricing of tobacco products during, and after, the introduction of standardized packaging: an observational study of retail price data from independent and convenience (small) retailers in the United Kingdom

BACKGROUND AND AIMS

Tobacco companies claimed that standardized packaging, phased in/introduced May 2016-May 2017, would reduce prices and increase consumption. We: (1) describe changes in price-per-cigarette and price-per-gram during, and after, the introduction of standardized packaging; (2) describe price changes by cigarette price segment; and (3) analyse price changes by stage of implementation.

DESIGN

An observational study, using electronic point-of-sale data, monitored price trends in three periods: (1) May-September 2016, start of transition period; (2) October 2016-May 2017, when fully branded and standardized products were sold and duty escalators implemented; and (3) June-October 2017, when standardized packaging was mandatory.

SETTING

United Kingdom.

PARTICIPANTS

Small retailers (n = 500) stratified by region and deprivation. Data were monitored for 20 leading fully branded tobacco products [15 factory-made cigarettes (FMC), 5 roll-your-own (RYO)] and their standardized equivalents.

MEASUREMENT

Price-per-cigarette and price-per-gram, based on monthly average Recommended Retail Price (RRP) and actual sale price, adjusted for inflation using the Consumer Pricing Index (CPIH). Net changes (£GBP, %) were analysed by product type (FMC versus RYO) and FMC price segment (value, mid-price, premium).

FINDINGS

Between May 2016 and October 2017, the average inflation-adjusted RRP/price-per-cigarette and price-per-gram increased for FMC (all price segments) and RYO. For example, sales price-per-cigarette increased +4.64%, with the largest increases for value (+6.81%), premium (+5.32%) and mid-price FMCs (+3.30%). Net sales price-per-cigarette and price-per-gram increases were largest in period 2, when fully branded and standardized products were sold and duty escalators were implemented (FMC = +4.70%; RYO = +3.75%). There were small decreases in sales price-per-cigarette and price-per-gram once standardized packaging became mandatory (FMC = -1.14%; RYO = -0.88%).

CONCLUSION

In the United Kingdom, the price of leading roll-your-own and factory-made cigarette brands sold by small retailers increased as standardized packaging was phased in, with increases larger than expected through duty escalation.

Tweeting about public health policy: Social media response to the UK Government's announcement of a Parliamentary vote on draft standardised packaging regulations

BACKGROUND

Standardised tobacco packaging has been, and remains, a contentious policy globally, attracting corporate, public health, political, media and popular attention. In January 2015, the UK Government announced it would vote on draft regulations for the policy before the May 2015 General Election. We explored reactions to the announcement on Twitter, in comparison with an earlier period of little UK Government activity on standardised packaging.

METHODS

We obtained a random sample of 1038 tweets in two 4-week periods, before and after the UK Government's announcement. Content analysis was used to examine the following Tweet characteristics: support for the policy, purpose, Twitter-user's geographical location and affiliation, and evidence citation and quality. Chi-squared analyses were used to compare Tweet characteristics between the two periods.

RESULTS

Overall, significantly more sampled Tweets were in favour of the policy (49%) in comparison to those opposed (19%). Yet, at Time 2, following the announcement, a greater proportion of sampled tweets opposed standardised packaging compared to the period sampled at Time 1, prior to the announcement (p<0.001). The quality of evidence and research cited in URLs linked at Time 2 was significantly lower than at Time 1 (p<0.001), with peer-reviewed research more likely to be shared in positive Tweets (p<0.001) and in Tweets linking to URLs originating from the health sector (p<0.001). The decline in the proportion of positive Tweets was mirrored by a reduction in Tweets by health sector Twitter-users at Time 2 (p<0.001).

CONCLUSIONS

Microblogging sites can reflect offline policy debates and are used differently by policy proponents and opponents dependent on the policy context. Twitter-users opposed to standardised packaging increased their activity following the Government's announcement, while those in support broadly maintained their rate of Twitter engagement. The findings offer insight into the public health community's options for using Twitter to influence policy and disseminate research. In particular, proliferation of Twitter activity following pro-public health policy announcements could be considered to ensure pro-health messages are not overshadowed by anti-regulation voices.

Who uses rollies? Trends in product offerings, price and use of roll-your-own tobacco in Australia

Objective

We examined the roll-your-own (RYO) tobacco product market in Australia from 2001 to 2016. Trends in use of RYO tobacco among Australian adults were examined for 2004–2016.

Methods

Changes in brand availability, pouch sizes and lowest priced products were noted from trade magazines. Prevalence of smoking of RYO and factory-made (FM) cigarettes among those 18 years and older was obtained from five consecutive waves of a large (n>21 000) nationally representative triennial survey from 2004 to 2016. Trends in cigarette use were examined using logistic regression.

Results

Changes in the Australian RYO market from 2001 to 2016 included a doubling in the number of brands, progressively smaller pouch sizes with smaller increases in price than in traditional RYO and comparable FM products. While use of FM cigarettes declined between 2004 and 2016, the proportion of adults exclusively using RYO tobacco linearly increased with each survey wave (OR 1.03, 95% CI 1.02 to 1.05, p<0.001), from 1.2% in 2004 to 1.7% in 2016. Exclusive RYO use among current smokers increased more among females than males, and young adults compared with those aged 30 years or older, but did not differ by socioeconomic status.

Conclusions

In contrast to substantial declines in FM cigarette use, exclusive use of RYO cigarettes increased in Australians since 2004, particularly among females and young adults. This has corresponded to a period of substantial changes to the RYO market, including progressively smaller and relatively more affordable products. Policy action to reduce price-related marketing and correct consumer misinformation about RYO tobacco are urgently required.

Association Between Cigarette Smoking Prevalence and Income Level: A Systematic Review and Meta-Analysis

Introduction

Previous evidence linked low socioeconomic status with higher smoking prevalence. Our objective was to assess the strength of this association in the world population, updating a previous work.

Methods

Systematic review and meta-analysis of observational studies. Subgroup analyses included continents, WHO regions, country mortality levels, gender, age, risk of bias, and study publication date. Independent reviewers selected studies, assessed potential bias and extracted data. We searched MEDLINE, EMBASE, CENTRAL, SOCINDEX, AFRICAN INDEX MEDICUS, and LILACS, and other sources from 1989 to 2013 reporting direct measurements of income and current cigarette smoking.

Results

We retrieved 13,583 articles and included 93 for meta-analysis. Median smoking prevalence was 17.8% (range 3-70%). Lower income was consistently associated with higher smoking prevalence (odds ratio [OR]: 1.45; 95% confidence interval [CI]: 1.35-1.56). This association was statistically significant in the subgroup analysis by WHO regions for the Americas (OR: 1.54; 95% CI: 1.42-1.68), South East Asia (OR: 1.53; 95% CI: 1.10-2.00), Europe (OR: 1.45; 95% CI: 1.29-1.63), and Western Pacific (OR: 1.32; 95% CI: 1.02-1.72), and in studies conducted during 1990s (OR: 1.42; 95% CI: 1.24-1.62) and 2000s (OR: 1.48; 95%CI: 1.30-1.64). Likewise, it was noted in low-mortality countries (OR: 1.48; 95% CI: 1.37-1.60) and for both genders. Prevalence was highest in the lowest income levels compared to the middle (OR: 1.69; 95% CI: 1.49-1.92), followed by the middle level compared to the highest (OR: 1.31; 95% CI: 1.20-1.43).

Conclusions

Our results show that current cigarette smoking was significantly associated with lower income worldwide and across subgroups, suggesting a dose-response relationship.

Implications

This unique updated systematic review shows a consistent inverse dose-response relationship between cigarette smoking and income level, present among most geographical areas and country characteristics. Public health measures should take into account this potential inequity and consider special efforts directed to disadvantaged populations.

Influence of premium vs masked cigarette brand names on the experienced taste of a cigarette after tobacco plain packaging in Australia: an experimental study

Background

Few studies have experimentally assessed the contribution of branding to the experience of smoking a cigarette, compared with the inherent properties of the product. This study examined the influence of cigarette brand name on the sensory experience of smoking a cigarette.

Methods

Seventy-five Australian smokers aged 18–39 years smoked two ‘premium’ cigarettes, one with the brand variant name shown and one with the brand variant name masked (which provided ‘objective’ ratings). Unknown to participants, the two cigarettes were identical. At recruitment, participants rated their expected enjoyment, quality and harshness of several premium cigarette brands.

Results

Branded cigarettes were rated as having a significantly more favorable taste (M(SE) = 64.14(2.21)) than masked cigarettes (M(SE) = 58.53(2.26), p = .031). Branded cigarettes were also rated as being less stale (M(SE) = 36.04(2.62)) than masked cigarettes (M(SE) = 43.90(2.60), p = .011). Purchase intent tended to be higher among those shown the branded cigarette compared to the masked cigarette (χ² (1) = 3.00, p = .083). Expected enjoyment and quality of the brand variant (enjoyment: b = 0.31, 95%CI = 0.11, 0.51, p < .01; quality: b = 0.46, 95%CI = 0.21, 0.72, p < .01) contributed to the perceived smoking experience more than the objective enjoyment and quality of the cigarette (enjoyment: b = 0.23, 95%CI = 0.05, 0.41, p < .05; quality: b = 0.08, 95%CI = − 0.13, 0.30, p > .05). This pattern was not observed for cigarette harshness.

Conclusions

A premium brand variant name can enhance the subjective experience of a cigarette. Further, smokers’ expectations of such brand variants contribute to the smoking experience as much, if not more than, the actual qualities of the product.

Awareness of Standardised Tobacco Packaging among Adults and Young People during the Final Phase of Policy Implementation in Great Britain

Background: In May 2016, along with the latest European Tobacco Products Directive (TPD), standardised packaging legislation was implemented in the UK. During the following 12-month transition period, both new and old types of packaging were allowed on the market. This study aimed to assess awareness of standardised packaging and other TPD changes in the UK population in March 2017, when both forms of packaging were in widespread use. Methods: We conducted two surveys-one in adults and one in young people-investigating awareness of plain packaging legislation. In young people, we also measured susceptibility to smoking using previously validated questions. We asked smokers whether they had recently changed the product they used and also whether they used any of the products that are banned by the new legislation. Results: In the adult survey, 73.5% (95% CI: 71.5-75.5%) of the participants were aware of the new legislation and 32.4% (95% CI: 30.3-34.5%) had noticed changes in tobacco packaging, this proportion being considerably higher among smokers (83.7%; 95% CI: 78.9-87.5%) than never smokers (20.7%; 95% CI: 18.2-23.4%). More than half (52.4%; 95% CI: 46.5-58.4%) were using pack sizes or shapes (typically less than 20 cigarettes or 30 g loose tobacco), that would become illegal after full TPD implementation, and 31.4% (95% CI: 26.2-37.1%) reported switching to a different product since October 2016, in most cases to a cheaper brand. Among young people, 20.2% (95% CI: 17.8-22.7%) reported that they had noticed standardised packaging, comprising 16.2% (95% CI: 13.7-19.0%) of non-susceptible never smokers, 25.6% (95% CI: 18.0-35%) of susceptible never smokers, and 49% (95% CI: 37.8-60.2%) of ever smokers. Conclusions: In the final stages of implementation, awareness of the introduction of standardised packs was highest among smokers. The TPD will cause nearly half of adult smokers to purchase larger packs, and may cause many smokers to switch to cheaper brands.

Tobacco price boards as a promotional strategy-a longitudinal observational study in Australian retailers

BACKGROUND

Price boards in tobacco retailers are one of the few forms of tobacco promotion remaining in Australia. This study aimed to examine how these boards were used to promote products over a period of rapidly rising taxes.

METHODS

Observations were made in a panel of 350 stores in Melbourne, Australia, in November of 2013 (just before) and in 2014 and 2015 (after 12.5% increases in tobacco duty). Fieldworkers unobtrusively noted the presence and characteristics of price boards, and the brand name, size and price of the product at the top of each board.

RESULTS

Price boards were common in all store types apart from newsagent/lottery agents. The characteristics of the top-listed product changed notably over time: premium brands accounted for 66% of top-listed products in 2013, significantly declining to 43% in 2015, while packs of 20 cigarettes increased in prominence from 32% to 45%. The prevalence of packs of 20 cigarettes in budget market segments tripled from 2013 (13%) and 2014 (11%) to 32% in 2015, with no change in the proportion of packs that were under $A20 from 2014 (37%) to 2015 (36%). The rate of increase in the average price of the top-listed pack correspondingly flattened from 2014 to 2015 compared with 2013-2014.

CONCLUSIONS

Price boards promote tobacco products in ways that undermine the effectiveness of tax policy as a means of discouraging consumption. Communication to consumers about prices should be restricted to information sheets provided to adult smokers on request at the point of sale.

Tobacco packaging design for reducing tobacco use

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.

Influence of premium versus value brand names on the smoking experience in a plain packaging environment: an experimental study

OBJECTIVE

To examine the effect of branding, as indicated by brand name, on evaluation of the cigarette smoking experience.

DESIGN

Between-subjects and within-subjects experimental study. Participants were randomly allocated to smoke a cigarette from a pack featuring a premium brand name and a cigarette from a pack featuring a value brand name. Within each condition, participants unknowingly smoked two identical cigarettes (either two premium or two value cigarettes).

SETTING

Australia, October 2014, 2 years after tobacco plain packaging implementation.

PARTICIPANTS

81 current cigarette smokers aged 19-39 years. From apparently premium and value brand-name packs, 40 smokers were allocated to smoke the same actual premium cigarettes and 41 were allocated to smoke the same actual value cigarettes.

PRIMARY OUTCOME MEASURES

Experienced taste (flavour, satisfaction, enjoyment, quality, liking, mouthfeel and aftertaste), harshness, dryness, staleness, harm/strength measures (strength, tar, lightness, volume of smoke), draw effort and purchase intent.

RESULTS

Cigarettes given a premium brand name were rated as having a better taste, were less harsh and less dry than identical cigarettes given a value brand name. This pattern was observed irrespective of whether the two packs actually contained premium or value cigarettes. These effects were specific: the brand name did not influence ratings of cigarette variant attributes (strength, tar, volume of smoke, lightness and draw effort).

CONCLUSIONS

Despite the belief that brand names represent genuine differences between cigarette products, the results suggest that at least some of this perceived sensory difference is attributable to brand image.

Reducing tobacco use among low socio-economic status youth in Delhi, India: outcomes from project ACTIVITY, a cluster randomized trial

To test the efficacy of an intervention to reduce tobacco use among youth (10-19 years old) in slum communities in Delhi, India. This community-based cluster-randomized trial included 14 slums composed of purposely built resettlement colonies and adjacent inhabitant-built Jhuggi Jhopris. Youth in the intervention received a 2 year multiple-component intervention: (a) youth and adult leader training; (b) peer-led interactive activities and outreach; (c) tobacco cessation camps; and (d) enforcement of India's Tobacco Control Law (smoke-free environments and youth access). Overall, no differences between the intervention and control conditions were observed over time; self-reported tobacco use declined in both groups. However, when stratified by type of residence, a significant decrease was observed among youth in the resettlement colonies in the intervention group for overall tobacco use (slope = -0.69) and cigarette and bidi smoking (slope = -0.66), compared to an increase in the control group (slope = 0.24 and 0.12, respectively) (P < 0.001). No differences in smokeless tobacco (SLT) use were observed for either group. Comprehensive community-based interventions that engage youth can be effective in reducing smoking among disadvantaged youth in India. More intensive interventions, like tax increases or large-scale media campaigns, appear warranted for the most marginalized in this context and for SLT products.

Standardised packaging and new enlarged graphic health warnings for tobacco products in Australia-legislative requirements and implementation of the Tobacco Plain Packaging Act 2011 and the Competition and Consumer (Tobacco) Information Standard, 2011

This paper describes the development, content and implementation of two pieces of Australian tobacco control legislation: one to standardise the packaging of tobacco products and the other to introduce new, enlarged graphic health warnings. It describes the process of legislative drafting, public consultation and parliamentary consideration. It summarises exactly how tobacco products have been required to look since late 2012. Finally, it describes implementation, most particularly, the extent to which packs compliant with the legislation became available to consumers over time.

Did the recommended retail price of tobacco products fall in Australia following the implementation of plain packaging?

OBJECTIVES

This study aimed to assess the extent of any fall in recommended retail prices (RRPs) of tobacco products sold in Australia following the 2012 implementation of plain packaging.

METHODS

RRPs published in price lists by the New South Wales Retail Tobacco Traders Association covering the months of November 2011, November 2012 and November 2013 were recorded for all listed brands and pack sizes. Average prices per stick were computed in 2013 dollars for cigarette brands in each of 10 possible pack sizes, for each major tobacco manufacturer, and across market segments. Average prices per gram in Australian dollars adjusted to 2013 prices (AUD2013) were calculated for roll-your-own (RYO) tobacco brands for each major manufacturer.

RESULTS

Inflation-adjusted average RRPs per stick in November 2013 were on average 6.4% higher than in November 2011 and 3.4% higher than in November 2012. The average RRP per gram of RYO products in November 2013 was 10.2% and 5.4% higher than in November 2011 and November 2012, respectively. Within cigarette brands, the highest increases in RRP from 2011 to 2013 were seen among mainstream and premium brands (10.0% and 10.1%, respectively) and among packs of 30s (18.3%) and 50s (12.5%).

CONCLUSIONS

The RRPs of tobacco products were higher in real terms 1 year after Australia's plain packaging legislation was implemented. These increases exceeded increases resulting from Consumer Price Index (CPI) indexation of duty and occurred across all three major manufacturers for both factory made and RYO brands, all three cigarette market segments and all major pack sizes.

The advertised price of cigarette packs in retail outlets across Australia before and after the implementation of plain packaging: a repeated measures observational study

OBJECTIVE

This study monitored the advertised price of the most prominently promoted and the cheapest single packs of cigarettes in Australian retail outlets before and after the implementation of plain packaging.

METHODS

A panel of 421 outlets in four large Australian cities was visited monthly from May 2012 to August 2013 and the brand, pack size and price of the most-prominently listed and lowest-priced single cigarette pack were recorded from each store's tobacco price board. Changes in the inflation-adjusted stick price were examined using linear mixed models, controlling for fixed effects of city, store type, area socioeconomic status and random effects of time. The adjusted stick price was also examined over time by tobacco manufacturer and pack size.

RESULTS

The inflation-adjusted stick price of the most-prominently advertised single packs was significantly higher than in May-July 2012 from August-October 2012 for mainstream and premium brands and from February-April 2013 for value brands. Adjusted average stick prices of lowest-priced packs in August 2013 were $0.02 (95% CI $0.02 to $0.03, p<0.001) higher than in May-July 2012 ($Aug13). A large real increase in stick price was seen in February-April 2013 across all major manufacturers, market segments and pack size categories.

DISCUSSION

The price of cigarettes most prominently promoted on price boards did not decrease in the months following implementation of Australia's plain packaging legislation. Retail prices continued to increase above the level resulting from automatic indexation of excise/customs duty even at the lowest-priced end of the Australian market.

Plain packaging: a logical progression for tobacco control in one of the world's 'darkest markets'

The Australian approach to tobacco control has been a comprehensive one, encompassing mass media campaigns, consumer information, taxation policy, access for smokers to smoking cessation advice and pharmaceutical treatments, protection from exposure to tobacco smoke and regulation of promotion. World-first legislation to standardise the packaging of tobacco was a logical next step to further reduce misleadingly reassuring promotion of a product known for the past 50 years to kill a high proportion of its long-term users. Similarly, refreshed, larger pack warnings which started appearing on packs at the end of 2012 were a logical progression of efforts to ensure that consumers are better informed about the health risks associated with smoking. Regardless of the immediate effects of legislation, further progress will continue to require a comprehensive approach to maintain momentum and ensure that government efforts on one front are not undermined by more vigorous efforts and greater investment by tobacco companies elsewhere.