Post-implementation evidence from Australia

1. Introduction

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 a summary 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 post-implementation tobacco use.

A further compilation of the evidence can be found on Cancer Council Victoria’s “Plain Facts” website which includes some detailed fact sheets on both research and smoking statistics.

The research demonstrates that the policy is having 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 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 These reports have not been peer reviewed, have been undermined by academics and criticized by Courts.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)

2. Research into Attitudes and Behaviours

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. The studies in the BMJ edition together with the more recent 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
  
  A recently published study looked at the long term impact of plain packaging with findings from surveys of adolescents from 2011 – 2017. The study showed continuing long term impact on young peoples’ perceptions of cigarettes. Tobacco continued to be viewed as less appealing and the students were more uncertain about tobacco brands.⁴
  
  
• 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.⁵
  
  Research has also found a significant increase in the number of calls to the smoking cessation helpline, Quitline, in NSW and the ACT.⁶ 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.⁷
  
  
• 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.⁸
  
  
• 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.”⁹
  
  
• 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.¹⁰

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: Several studies have shown that plain packaging did not lead to lower prices for tobacco. A review of retail magazines 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).¹¹
  
  A later study tracked retail prices of leading brands before and up to three years after implementation. This concluded that prices of market leaders increased significantly over this period, above inflation and tax increases.¹²
  
  
• 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.¹³ And the total amount of tobacco intercepted by Border Service in 2014–15 was considerably lower than in recent years.¹⁴
  
  The tobacco companies have argued that use of illicit tobacco increased¹⁵ by relying on a report they commissioned from KPMG.¹⁶ 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.”¹⁷ Litter 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 implementation¹⁸ possibly because packs were now stored alphabetically.
  
  

3. Statistical Data: Smoking Prevalence and Tobacco Consumption Rates

Official statistics on smoking rates in Australia are provided here.

The key statistics on smoking prevalence rates and tobacco consumption since implementation of plain packaging -

Smoking prevalence rates decline:

Australian Institute of Health and Welfare (AIHW) National Drug Strategy Household Survey (latest survey results from 2019):

1. There has been a significant decrease in daily smokers aged 18 years or older in Australia, falling from 15.9% in 2010, to 13.3% in 2013, 12.8% in 2016 and 11.6% in 2019.
   
   
   Proportion of daily smokers and current smokers in Australia—Australians 18+, 2001 to 2019 Source: Australian Institute of Health and Welfare. Data tables: National Drug Strategy Household Survey 2019 – Table 2.7, 2. Tobacco smoking chapter, Supplementary data tables. Canberra: AIHW, 2020. Available from: https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/data.
   
   
2. Young people are delaying commencing smoking. The age at which 14 to 24 year olds smoked their first full cigarette increased from 15.4 years of age in 2010 to 16.6 in 2019.
3. The rate of smoking in young people continues to fall. 18-24 year olds who smoke daily dropped from 15.7% in 2010, to 13.4% in 2013, 11.6% in 2016, and 9.2% in 2019.
4. The proportion of 18 to 24 year olds who have never smoked increased significantly from 72% in 2010, to 77% in 2013 and to 79% in 2016.

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 following the introduction of plain packaging in 2012.¹⁹

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 1984.²⁰ 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 and 13.8% in 2017-18 was also shown in the Australia Bureau of Statistics' National Health Survey.²¹

Tobacco consumption declines:

Total consumption of tobacco and cigarettes in the March quarter of 2017 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:

• $7.174 billion in September 1959
• $4.712 billion in December 2012
• $3.415 billion in March 2017 ²²

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.²³

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.²⁴ An industry-funded report concerning estimates of use of illicit tobacco²⁵ also incidentally included an estimate of consumption of tax-paid tobacco (based on estimated weight 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)²⁶:

"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."

4. The Post-Implementation Review (PIR)

The Australian government published its Post-Implementation Review (PIR) in February 2016:

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.” ²⁷

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. Tasneem Chipty of Analysis Group, Inc.,²⁸ who undertook a regression analysis. This used Roy Morgan Single Source Survey Data²⁹ 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:

Notes

1. Gerard B Hastings and Crawford Moodie. Death of a salesman. Tob Control. 2015 Apr; 24(Suppl 2).
2. 1. 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.
   2. M. Wakefield, K. Coomber, M. Zacher, S. Durkin, E. Brennan, et al. “Australian adult smokers’ responses to plain packaging with larger graphic health warnings one year 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. 1. 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.
   2. 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. White VM, Guerin N, Williams T, et al. Long-term impact of plain packaging of cigarettes with larger graphic health warnings: findings from cross-sectional surveys of Australian adolescents between 2011 and 2017. Tobacco Control 2019;28:e77-e84. Available from: https://tobaccocontrol.bmj.com/content/28/e1/e77.
5. 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.
6. 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.
7. 1. 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.
   2. 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.
8. 1. 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.
   2. 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.
9. 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.
10. 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.
11. 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.
12. Egger S, Burton S, Ireland R, et al. Observed retail price of Australia’s market-leading cigarette brand before and up to 3 years after the implementation of plain packaging. Tobacco Control 2019;28:e86-e91. Available from: https://tobaccocontrol.bmj.com/content/28/e2/e86.
13. 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.
14. Australian Customs and Border Protection Service. Annual Report 2014–15. Canberra: ACBPS, 2014. Available from: https://www.homeaffairs.gov.au/reports-and-pubs/Annualreports/acbps-annual-report-2014-15.pdf
15. 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.
16. 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.
17. 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.
18. 1. 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.
    2. 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.
19. National Drug Strategy Household Survey; AIHW 2014. Available from: https://www.aihw.gov.au/getmedia/c2e94ca2-7ce8-496f-a765-94c55c774d2b/16835_1.pdf.
20. See https://www.cancervic.org.au/about/media-releases/2015-media-releases/november-2015/tobacco-use-secondary-school-students.html.
21. See http://www.abs.gov.au/ausstats/abs@.nsf/mf/4364.0.55.001.
22. Australian National Accounts: National Income, Expenditure and Product, Dec 2015 Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/5206.0Dec%202015?OpenDocument.
23. See http://www.health.gov.au/inter...
24. British American Tobacco. Annual report 2013. London 2014. Available from: www.bat.com/ar/2013/assets/pdfs/BAT_AR2013.pdf
25. KPMG LLP. Illicit tobacco in Australia: 2013 full-year report. Sydney 2014.
26. 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.
27. See http://www.jti.com/files/8614/5650/6649/Press_Release_Post-PIR_FINAL_26-02-2016.pdf.
28. An economic and business consulting firm with particular expertise and experience in econometric analysis.
29. 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.