evidence 2: australia-post-implementation-evidence
“Plain packaging in Australia has been a casebook example of effective tobacco control—a policy measure driven by evidence, carefully designed and implemented, and now rigorously assessed. Further, it is set within the context of wider Australian tobacco control, reinforcing the most basic lesson learned over the last half century: action has to be strategic and comprehensive. There are no silver bullets” 1
The information contained in this Reference Section gives just some examples of the observational, research and survey studies that have been conducted in Australia to assess the impact of plain packaging there, together with the statistical data on tobacco use.
A more comprehensive compilation of the evidence can be found on Cancer Council Victoria’s “Plain Facts” website: http://www.cancervic.org.au/plainfacts/ which includes some detailed fact sheets.
The research demonstrates that the policy is starting to have the anticipated impacts on the intended mechanisms of reducing tobacco appeal, increasing the effectiveness of health warnings and reducing misperceptions about the harms of tobacco products. It should nevertheless be recognized that it is a policy intended to have impacts over time. It was introduced at the same time as a number of other tobacco control measures and isolating the specific influence of plain packaging will also take time.
The tobacco industry has sought to highlight isolated anomalies in the statistical data to argue that plain packaging has not worked or is having a negative impact. These examples, set out below, have no statistical significance and should not detract from the vast majority of the evidence that all points to the policy working as intended. The tobacco industry has also commissioned reports that try to analyse the statistical data to show that plain packaging has not increased the existing rate of decline in smoking rates. These reports have not been peer reviewed, have been undermined by academics and criticized by Courts. (For more details on those reports see the‘No reliable evidence’ section of the Opposing Arguments (and how to counter them) pages in the Tools and Resources)
The British Medical Journal of Tobacco Control edition of April 2015 focused on the implementation and evaluation of the Australian plain packaging policy and included eighteen research papers.
Further peer-reviewed research studies have been published since then. Combined these studies show:
Reduced appeal of tobacco:A number of studies with adult smokers point to plain packaging fulfilling its core aims of reducing appeal, particularly among young adults, and increasing warning salience. 2
These research papers also suggest that plain packaging is severely restricting the ability of the pack to communicate and create appeal with adolescents and young people. For instance, school-based surveys with students aged 12–17 years old in 2011 and 2013 show that the removal of branding and uniformity of pack appearance has increased negative pack ratings and decreased positive ones. 3
Increased quit attempts: In a cross-sectional tracking survey of cigarette smokers, plain packaging was associated with increased thinking about quitting and quit attempts. In addition, dislike of the pack, lower satisfaction from cigarettes and attributing motivation to quit to the warnings predicted daily thoughts of quitting. 4
Research has also found a significant increase in the number of calls to the smoking cessation helpline, Quitline, in NSW and the ACT. 5 The research showed a 78% increase in the number of calls to the Quitline associated with the introduction of plain packaging. This research found the increase in calls was sustained and not attributable to anti-tobacco advertising activity, cigarette price increases, or any other identifiable causes.
Increased impact of health warnings: A number of studies using large national survey samples have found that more adult smokers noticed graphic health warnings and this led to increased pack avoidance, greater perceived harm, and an increased understanding of cancer risks. 6
Reduced pack displays: Studies of outdoor venues before and after implementation have showed that smokers were more likely to conceal their packs in outdoor venues after the introduction of plain packaging. 7
Reduced misperceptions: A recent study showed that following plain-packaging implementation, there was a significant reduction in perceptions that “some cigarette brands are more harmful than others.” 8
Increase in positive attitudes to plain packs: A recent study showed that the positive response of young people to plain packaging was greater than anticipated prior to its introduction, and support for plain packaging increased from pre-implementation to post-implementation among all groups of youth. 9
Unintended consequences. The research has also examined whether or not plain packaging had any of the unintended consequences that the tobacco industry alleged would occur:
Tobacco prices continue to rise in all sectors: Studies showed that there was no evidence that plain packaging led to lower prices for tobacco. A review of retail magazines, for instance, showed that following the introduction of plain packaging, average inflation-adjusted recommended retail prices actually increased for cigarettes in all price segments (value, mainstream, and premium). 10
No increase in illicit tobacco: The evidence clearly showed that the consumption of illicit “cheap white” cigarettes has remained consistently small or even declined after implementation of plain packaging. 11 And the total amount of tobacco intercepted by Border Service in 2014–15 was considerably lower than in recent years. 12
The tobacco companies have argued that use of illicit tobacco increased 13 by relying on a report they commissioned from KPMG. 14 However, those reports have been heavily criticized, and KPMG has stated that its report“has been somewhat misrepresented by others, without our consent, to suggest it supports the contention that plain paper packaging could lead of itself to an increase in tobacco smuggling.” 15Litter surveys have found no evidence of any counterfeit plain packs to date.
No increase in retail transaction time: Again, in contrast to the claims made by the tobacco companies that plain packs would increase the time that retailers took to find packs, real-life observational studies have showed that average transactions times declined for plain packs after implementation 16 possibly because packs were now stored alphabetically.
Official statistics on smoking rates and tobacco consumption in Australia are published on the Department of Health’s website:http://www.health.gov.au/internet/main/publishing.nsf/content/tobacco-kff
The key statistics on smoking rates and tobacco consumption since implementation of plain packaging are:
Australian Institute of Health and Welfare (AIHW) has published the key findings of the 2013 National Drug Strategy Household Survey.
Percentage of Australians 14 years and over reporting smoking daily, 2004 to 2013 Source: National Drug Strategy Household Survey
The drop in rates between 2010 and 2013 is more than twice as large as the average drop between surveys since 1991.The industry tries to argue that the decline in rates is just part of an existing trend. However, the statistics show a marked increase in the rate of decline. 17
Statistically insignificant anomalies. The figures for 12–17 year olds in the National Drug Strategy Household Survey was 0.9 percentage points higher in 2013 than in 2010. However, the sample size was very small and had a standard error of 25–50%, meaning there was no statistically significant change shown.
In 2011, 6.7% of children under 17 reported smoking in the last week. In 2014 this had dropped to 5.1%. This data came from the Australian Secondary Students’ Alcohol and Drug (ASSAD) survey, which used a far larger survey that the NDSHS and has just over 23,000 secondary students aged between 12 and 17 years participating in a national survey undertaken every three years since 1984. 18 This is the better data on adolescent smoking rates.
A drop in adult smoking rates from 16.1% in 2011–12 to 14.5% in 2014–15 was also shown in Australia’s 2014-15 National Health Survey. 19
Total consumption of tobacco and cigarettes in the March quarter 2014 was the lowest ever recorded. Figures from the Australian Bureau of Statistics (ABS) show the total consumption of tobacco and cigarettes as measured by estimated expenditure on tobacco products:
Tobacco excise and customs clearances fell by 3.4% in 2013 relative to 2012 and fell a further 7.9% in 2014 . Tobacco clearances provide a reliable indicator of overall tobacco volumes, and the treasury has advised that they have fallen a total of 11.0% since 2012, when tobacco plain packaging was introduced. 21
Tobacco company reports to shareholders indicate a decline in sales.In its annual report
to shareholders, British
American Tobacco (which has the largest market share of the three major companies
operating in Australia) stated
that volumes were lower for the 2013 reporting year. 22 An industry-funded
report concerning estimates
of use of
illicit tobacco 23 also incidentally included an estimate of consumption of
tax-paid tobacco (based on
of tobacco sold) at 0.5% lower in 2013 than in 2012.
In April 2013, the CEO of Imperial Tobacco noted a decline in tobacco product sales during the first half of the company’s October 1 to September 30 reporting cycle (from October 1, 2012, to March 31, 2013) 24:
“As I'm looking at Asia Pacific, I should also mention Australia, we've had the first six months of the plain pack environment in Australia. We've seen the market decline roughly 2% to 3%, so maybe not as bad as we might have anticipated.”
The Australian government published its Post-Implementation Review (PIR) in February 2016:https://ris.govspace.gov.au/2016/02/26/tobacco-plain-packaging/
The review concludes that “the measure has begun to achieve its public health objectives of reducing smoking and exposure to tobacco smoke in Australia and it is expected to continue to do so into the future.”
In line with Australian government guidance, the PIR examines the post-implementation evidence, data, and analysis of the broader costs and benefits to industry, government and the wider community, to evaluate the efficiency and effectiveness of the tobacco plain packaging measure. Much of this evidence and data is described in the first two parts of this Section. The PIR provides the Australian Government’s analysis of that evidence.
The summary of the PIR states that:
“While the full effect of the tobacco plain packaging measure is expected to be realised over time, the evidence examined in this PIR suggests that the measure is achieving its aims. This evidence shows that tobacco plain packaging is having a positive impact on its specific mechanisms as envisaged in the TPP Act. All of the major data sets examined also showed on-going drops in national smoking prevalence in Australia. These decreases cannot be entirely attributed to plain packaging given the range of tobacco control measures in place in Australia, including media campaigns and Australia’s tobacco excise regime.”
The PIR provides an analysis of peer-reviewed research studies into smoking attitudes and behaviors before and after the introduction of the policy. These show that it is having a positive impact on the three specific mechanisms of reducing the appeal of tobacco products, increasing the effectiveness of health warnings, and reducing the ability of the pack to mislead:
“Taken as a whole, the studies . . . provide early evidence that the tobacco plain packaging measure is having a positive impact on the three specific mechanisms of reducing the appeal of tobacco products, reducing the potential for tobacco packaging to mislead consumers, and enhancing the effectiveness of graphic health warnings. Studies also provide early evidence that the measure is resulting in positive changes to smoking behaviours. The body of evidence is diverse, including analyses conducted on a range of different groups (including adolescents, adults, cigarette smokers and cigar/cigarillo smokers) and using different datasets (including the National Tracking Survey, the NSW Tracking Survey, the ASSAD data, the ITC Project data and bespoke surveys).”
The report also reviews the available data and statistical analysis of smoking prevalence and tobacco consumption rates:
“All the major data sets show continuing declines in smoking prevalence with substantial declines in the period following the introduction of tobacco plain packaging. Analysis of the Roy Morgan Research data undertaken for the Department (described below) concludes that the 2012 packaging changes have already contributed to the overall decline in smoking prevalence and that over time these impacts will increase.”
The use of statistical data can be complex, and the tobacco industry has produced reports that seek to undermine the argument that large reductions in the smoking rates can be attributable to plain packaging of reduced smoking. Thus, for instance, the JTI response to the PIR has been to say that,“The report fails to properly take into account that smoking rates had been steadily declining for years, long before the introduction of this branding ban, and that the measure hasn’t accelerated this decline.” 25
Most of the evidence and studies that the PIR refers to and considers was already publicly available. However, the PIR was accompanied by a new detailed data analysis by Dr.TasneemChipty of Analysis Group, Inc., who undertook a regression analysis. This used Roy Morgan Single Source Survey Data to provide an average prevalence rate for the 34 months prior to implementation of plain packaging and the 34 months following implementation. Those figures were 19.4% and 17.2%, respectively — a 2.2% percentage point drop.
Dr Chipty’s analysis estimated that the packaging changes resulted in a “statistically significant decline in smoking prevalence of 0.55 percentage points over the post implementation period, relative to what the prevalence would have been without the packaging changes. This decline accounts for approximately one quarter of the total decline in average prevalence rates observed . . .”
Trying to use statistical analysis of survey data to separate out the effects of different tobacco-control measures is difficult, but it is this detailed report by Dr.Chipty that undermines the tobacco industry claims of no accelerated decline.
Dr.Chipty’s analysis was set out in figurative form in the following chart:
This chart plots the monthly overall smoking prevalence rates from the Roy Morgan data, with two separate trend lines for before and after the introduction of the 2012 packaging changes. The chart shows the overall decline in smoking prevalence in Australia over the last fifteen years and provides some indication that the “decline in prevalence has accelerated in recent years.” As regards the effects on the illicit market, the PIR considers the post- implementation data and peer-reviewed studies that found no change in smokers’ reported use of unbranded illicit tobacco, no evidence of increases in use of contraband cigarettes, low levels of use of cigarettes likely to be contraband, and no increase in purchases of tobacco from informal sellers.
The PIR concludes that:
“the measure has begun to achieve its public health objectives of reducing smoking and exposure to tobacco smoke in Australia and it is expected to continue to do so into the future
1Gerard B Hastings and Crawford Moodie Death of a salesmanTob Control. 2015 Apr; 24(Suppl 2)
2 i) V. White, T. Williams, A. Faulkner, and M. Wakefield. “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-ii57. Available from: http://tobaccocontrol.bmj.com/content/24/Suppl_2/ii50.full. ii) M. Wakefield, K. Coomber, M. Zacher, S. Durkin, E. Brennan, et al. “Australian adult smokers’ responses to plain packaging with larger graphic health warnings oneyear after implementation: Results from a national cross-sectional tracking survey.” Tobacco Control, 2015; 24:ii17-ii25. Available from:www.tobaccocontrol.bmj.com/content/24/Suppl_2/ii17.full.
3 i) V. White, T. Williams, and M. Wakefield. “Has the introduction of plain packaging with larger graphic health warnings changed adolescents’ perceptions of cigarette packs and brands?” Tobacco Control, 2015; 24:ii42-ii49. Available from: http://tobaccocontrol.bmj.com/content/24/Suppl_2/ii42.full. ii) S. Dunlop, D. Perez, A. Dessaix, and D. Currow. “Australia’s plain tobacco packs: Anticipated and actual responses among adolescents and young adults 2010–2013.” Tobacco Control, 2016. Available from: http://tobaccocontrol.bmj.com/content/early/2016/11/15/tobaccocontrol-2016-053166.abstract?papetoc.
4 S. Durkin, E. Brennan, K. Coomber, et al. “Short-term changes in quitting-related cognitions and behaviours after the implementation of plain packaging with larger health warnings: Findings from a national cohort study with Australian adult smokers.” Tobacco Control 2015;24:ii26–32.
5 J. M. Young, C. Currow, and S. Dunlop. “The association between tobacco plain packaging and Quitline calls.” Med J Aust. 2014;200(6):314–315. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24702081.
6 i) E. Brennan, S. Durkin, K. Coomber, M. Zacher, M. Scollo, et al. “Are quitting-related cognitions and behaviours predicted by proximal responses to plain packaging with larger health warnings? Findings from a national cohort study with Australian adult smokers.” Tobacco Control, 2015; 24:ii33-ii41. Available from:www.tobaccocontrol.bmj.com/content/24/Suppl_2/ii33.full. ii) V.White, T. Williams, A. Faulkner, and M. Wakefield.“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-ii57. Available from:www.tobaccocontrol.bmj.com/content/24/Suppl_2/ii50.full.
7 i) M. Zacher, M. Bayly, E. Brennan, 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):653–662. Available from:https://www.ncbi.nlm.nih.gov/pubmed/24428427. ii) M.Wakefield, M. Zacher, M. Bayly, E. Brennan, J. Dono, C. Miller, S. J. Durkin, and M. Scollo.“The silent salesman: An observational study of personal tobacco pack display at outdoor café strips in Australia.” Tobacco Control 2014. pp. 339–344. Available from http://tobaccocontrol.bmj.com/content/23/4/339.abstract.
8 R. Maddox et al. “Plain packaging implementation: perceptions of risk and prestige of cigarette brands among Aboriginal and Torres Strait Islander people.” 29 December 29, 2015 DOI: 10.1111/1753-6405.12489.
9 S. Dunlop, D. Perez, A. Dessaix, and D. Currow. “Australia’s plain tobacco packs: Anticipated and actual responses among adolescents and young adults, 2010–2013.” Tobacco Control doi:10.1136. Available from: http://tobaccocontrol.bmj.com/content/early/2016/12/11/tobaccocontrol-2016-053166.abstract?sid=38c19596-f457-4476-aeef-4b86e907b2d2.
10 M.Scollo, M.Bayly, and M. Wakefield. “The advertised price of cigarette packs in retail outlets across Australia before and after the implementation of plain packaging: a repeated measures observational study.” Tobacco Control 2015;24:ii82-ii89 doi:10.1136. Available from:http://tobaccocontrol.bmj.com/content/24/Suppl_2/ii82.abstract?sid=4499bd73-4881-4207-99b8-55dfbba4ecb6.
11 M. Scollo, M. Zacher, M. Coomber, and M. Wakefield. “Use of illicit tobacco following introduction of standardised packaging of tobacco products in Australia: Results from a national cross-sectional survey.” Tobacco Control, 2015; 24:ii76-ii81. Available from: http://tobaccocontrol.bmj.com/content/24/Suppl_2/ii76.full. See also a comprehensive analysis by Cancer Council Victoria available from: http://www.cancervic.org.au/downloads/plainfacts/Facts_sheets/Facts_Sheet_no_3_Illicit_tobacco31May2016.pdf.
12 Australian Customs and Border Protection Service. Annual Report 2014–15. Canberra: ACBPS, 2014. Available from: http://www.border.gov.au/about/reportspublications/reports/annual.
13 Philip Morris International. 2013 KPMG report: Black market in Australia reaches record highs. PMI, 2014. Available from: http://www.pmi.com/eng/media_center/media_kit/Pages/2013_kpmg_australia.aspx.
14 KPMG LLP. Illicit tobacco in Australia: 2015 full year report available from: https://home.kpmg.com/content/dam/kpmg/pdf/2016/04/australia-illict-tobacco-2015.pdf.
15 J. Doward. “How Big tobacco lost its final fight for hearts, lungs and minds. The Guardian, May 22, 2016. Available from: http://www.theguardian.com/society/2016/may/22/big-tobacco-final-fight-cigarette-branding-uk
16 i) O. Carter, M. Welch, B. Mills, T. Phan, and P. Chang. “Plain packaging for cigarettes improves retail transaction times.”In British Medical Journal. 2013;346:f1063. ii) M. Bayly, M. Scollo, and M. Wakefield. “No lasting effects of plain packaging on cigarette pack retrieval time in small Australian retail outlets.” Tobacco Control. 2015;24(e1):e108–e109.
17 National Drug Strategy Household Survey; AIHW 2014. Available from:http://www.aihw.gov.au/alcohol-and-other-drugs/ndshs/2013/data-and-references/.
20 5206.0 Australian National Accounts: National Income, Expenditure and Product, Dec 2015 Available at: Australian National Accounts: National Income, Expenditure and Product
22 British American Tobacco. Annual report 2013. London 2014. Available from: www.bat.com/ar/2013/assets/pdfs/BAT_AR2013.pdf
23 KPMG LLP. Illicit tobacco in Australia: 2013 full-year report. Sydney 2014.
24 Transcript of Imperial Tobacco half-year 2013 results; Interview with Alison Cooper, CEO, and Bob Dyrbus, FD. Available from: http://video.merchantcantos.com/media/202678/imperial_tobacco_half_year_results_transcript.pdf.
26 An economic and business consulting firm with particular expertise and experience in econometric analysis.
27 Roy Morgan Research conducts ongoing, nationally representative, monthly surveys on a range of topics, including smoking, and collects data about broader socio-demographic variables (such as financial position and marital status), which enable analysis of the smoking population in Australia.