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Should plain packaging of cigarettes be tested, first?

Today’s Crikey bulletin has a most informative yarn about Labor’s links to Big Tobacco.

This comes in the wake of publicity about the Liberal Party ties of some of those involved in a tobacco industry-funded campaign against the Government’s plans to introduce plain packaging of cigarettes by 2012.

For those in need of reminding, plain packaging of cigarettes was one of a raft of recommendations from the National Preventative Health Taskforce that are aimed at reducing smoking rates from the present 16 per cent to 10 percent or less.

Meanwhile, health policy analyst Jennifer Doggett is not convinced that plain packaging will have the intended effect, and wants to see it trialled. She writes:

“Plain paper packaging for cigarettes is the sort of policy made for election campaigns. It is easy to explain to voters, it looks like the government (or potential government) is taking action on a serious health problem and it appears to cost voters nothing.

Too bad there is no evidence that it actually works.

Neither supporters nor opponents of the plain packaging proposal have made a case that stands up to any level of scrutiny.

The clumsy attempt by tobacco producers and retailers to argue both that generic packaging would not reduce cigarette consumption yet would seriously harm retailers’ profits is laughable.

No-one could take seriously the argument that stacking plain-label cigarettes on shelves will take $8-an-hour teenage employees so much longer that it will cause the wages bill for corner stores and service stations to skyrocket to the point that the viability of these businesses is threatened or we will all end up paying $5 a litre for milk.

If the ‘masterminds’ of this campaign are indeed ex-liberal party strategists, as reported in the media, Tony Abbott must be eternally grateful that they decided to move on from politics to give the tobacco industry the benefit of their muddleheaded advice.

However, the arguments put forward by supporters of this proposal are not much better.

No country has introduced plain packaging so we don’t actually know what effect it has over the longer term on cigarette consumption. The research cited by supporters to support the policy is usually based on studies where people are asked to compare a packet of cigarettes in plain and branded packaging and asked which they find more appealing (or some variation thereof).

These studies create an artificial situation (given that if generic packaging were introduced consumers would not be given a choice) and make any number of spurious assumptions about how smokers’ behaviour would change over the long term, given their views on cigarette packaging.

This sort of research is useful for academics wanting to publish papers in public health journals but tells us little about real life policy outcomes.

Intuitively, it seems odd that a smoker, not deterred by the prospect of a painful and premature death, would be dissuaded from their habit by unattractive packaging.

It also seems unlikely that a reduction in competition between tobacco companies, through preventing promotional opportunities, would reduce consumption rates (as commonly argued by advocates for plain packaging).

Anyone who lived through or visited the former Soviet Union, where the state had a monopoly on cigarette manufacturing and retailing and male smoking rates approached 70%, would be wary of linking competition within the tobacco market to closely to smoking rates.

It could be argued that, given the serious harms resulting from tobacco use, we should give any harm reduction strategy a go, regardless of whether or not it is likely to reduce consumption rates.

However, this is the wrong approach. It is precisely because of the high levels of harm caused by smoking that we cannot afford to adopt policies which are not based on evidence. We need to ensure that the resources we put into reducing tobacco-related harms deliver the maximum possible benefit and this can only occur if we ensure policy decisions are based on evidence.

Therefore, rather than diving headlong into an untested plain packaging strategy, the Government and Opposition should commit to a ‘suck it and see’ policy trial.

This would involve a number of selected locations, including capital cities and smaller regional centres, around the country with half randomly allocated to sell only plain packaged cigarettes for a defined period. At the end of this time – 12 months would be a decent length – the level of tobacco sales between the two groups would be measured and compared.

A study such as this would give the government the evidence it needs to pursue a generic packaging strategy or allocate resources to an alternative harm reduction strategy.

If the tobacco industry has the courage of its convictions, perhaps it could donate the $5 million it has allegedly pledged to bankroll the election campaign to fund a policy trial of generic packaging and call on both major parties to commit to road-testing the policy.

This would be both smart politics and smart policy and provide a secure evidence-based for future tobacco harm reduction strategies.”

Update: Interesting to see that Mia Freedman has also picked up on this issue at her Mamamia blog. (Which I’m sure is far more widely read than little ol’ Croakey…)

Comments 19

  1. Mike Daube says:

    The history of tobacco control is littered with arguments that new approaches shouldn’t be tried because nobody had done them before – ad bans, decently funded and well run public education, graphic health warnings – even tax increases.

    Just over a century ago, W.H. Cornford wrote in his classic work Microcosmographia Academica, ““Every public action which is not customary either is wrong, or if it is right it is a dangerous precedent. It follows that nothing should ever be done for the first time”.

    If we wanted any evidence that plain packaging would work, the tobacco industry’s desperate efforts to oppose this measure would be enough to convince anybody objective.

    Jennifer Doggett is right in pointing to the unbelievably clumsy way the international tobacco companies have tried to buy in to the Australian election on this issue. But she is wrong to suggest that they should be involved in any measures aimed at reducing smoking – that is the role of governments and health authorities, not an industry with a 60 year track record of trying to oppose and undermine anything that might adversely affect their sales to adults or kids.

    Mike Daube, President, Australian Council on Smoking and Health

  2. Sittting Tall says:

    Question: Why are tobacco companies pouring money into an Australian election campaign?

    Answer: Because they are alarmed at the thought of plain packets for tobacco products.

    Its not rocket science, is it? They are absolutely terrified of the precedent this will set and the fact that other countries will follow Australia’s lead.

    Plain packaging has been on the cards for many years and tobacco companies have been anticipating it with dread.

    I say bring it on!

    I look forward to the day when tobacco is a totally controlled substance that can only be sold to registered nicotine addicts. Then we will be much closer to seeing the end of this industry that profits by killing half of its loyal long term customers prematurely.

  3. annej says:

    Waiting for a truckload of evidence would be ok if tobacco only killed a few score people a year. Since it kills 15,000 Australians and 5 m people worldwide pa, then we have good reason to go with the evidence we already have amassed. The tobacco industry is not so concerned about the Australian market as small and declining – they dont want this policy to domino as thet need tobacco advertising on the packs to suck smokers in from poor countries. When we had no seat belts and several thousand road deaths a year, I dont think the policy advisers sat around for yonks saying we need more evidence before we inconvenience car manufacturers by manadating seat belts.

  4. simon.chapman says:

    Plain packaging is intended as a strategy that will add significantly to the weight of denormalisation of tobacco as just another grocery item, appropriately sold from any corner store, on open display, in boxes thoroughly tested to maximise their appeal to people starting to smoke — ie mainly kids. The idea is to permanently signal that it is an exceptionally dangerous product that is appropriately regulated in the way that products causing such harm should be, short of being banned (as any product invented tomorrow with tobacco’s risk profile would be). Look how we regulate prescribed drugs which are intended to promote health & save lives. You need a “license” to get them (ie a prescription); you get limited supplies; access is controlled by professionals with 4 & 6 year degrees (chemists and drs); they are stored out of sight, and they come in plain packs; and anyone supplying them to someone without a prescription would be struck off and probably gaoled for repeat offences.

    Ask yourself why the industry is spending this money to combat this move. They know its potential to radically change over a generation the way that tobacco products are seen by whole populations. It is not a strategy that anyone is arguing will have rapid impact on adult smokers, many of whom are addicted and “over” brand image. It is about making smoking less intruiging to kids, with the same logic that advertising bans were introduced. Australian kids smoking today is lower than it has ever been recorded, in the total absence of any youth-targetted advertising campaigns. It has happened almost entirely via denormalisation and price.

    The idea that you could setup some dinky little experimental study, with tobacco industry funding no less, which would cough up unequivocal results in 12 months, while the neutral, disinterested tobacco industry sat by with never a thought of how they could corrupt the study by massive cross-border price discounting, viral marketing on social media sites of branded products to make them prestigiuous etc.

    Why molly-coddle this pernicious industry with a strategy that they would seriously work hard to undermine because of the size of the global implications they risked?

    Not a very sensible article Jennifer, sorry. Has the industry put the call through yet?

  5. Becky Freeman says:

    I’ll declare right up front that my published paper on this topic is handily, if dismissively, provided by Jennifer in her post above.

    We already know that graphic health warnings work to reduce smoking. We already know that advertising bans work to reduce smoking.

    We have evidence in the bucket loads to support these two policies – see some comprehensive reviews here: http://www.tobaccolabels.ca/toolkit and http://cancercontrol.cancer.gov/tcrb/monographs/19/index.html.

    Plain packaging simply strengthens and extends this two proven health policies.

    The proposed policy trial sounds like a classic delay tactic and a funding suck. However – wasting time and resources is the least of my worries, let’s just get on with preventing the next generation of smokers becoming addicted.

    Becky Freeman – Tobacco Control Researcher USyd

  6. Becky Freeman says:

    I’ll declare right up front that my published paper on this topic is handily, if dismissively, provided by Jennifer in her post above.

    We already know that graphic health warnings work to reduce smoking. We already know that advertising bans work to reduce smoking.

    We have evidence in the bucket loads to support these two policies.Plain packaging simply strengthens and extends this two proven health policies.

    The proposed policy trial sounds like a classic delay tactic and a funding suck. However – wasting time and resources is the least of my worries, let’s just get on with preventing the next generation of smokers becoming addicted.

    Becky Freeman – Tobacco Control Researcher USyd

  7. Cajela says:

    One thing that I haven’t seen discussed is why we currently ban the e-cigarettes. I’m hearing from several friends in America who have successfully given up smoking tobacco with these devices. While they’re still getting a nicotine fix, at least there’s no second hand smoke and no tar, and (anecdotally) no smoker’s cough. It seems a perfect harm reduction measure, and not so drastically different to the nicotine gum or patches in concept. So why are we opposing it? Are we choosing prohibitionist moralising over harm reduction?

  8. Margo says:

    You could hardly describe this as a made-for-an-election-campaign policy. ‘Generic packaging’ for tobacco products has featured in public health policy considerations, as well as in research (within confines described by others above), in Australia and elsewhere for more than 20 years. Yes, it’s the nicotine (and its enhancers) that cause the physiological addiction. But tobacco brand identity — like branding for other consumer products — is calculated to provides users with constant reminders and reinforcements of ‘belonging’ to the brand. The packaging conveys an image which is supported through other available promotional mechanisms — especially important when there is not a lot to differentiate your little cylinder of toxins from all the other ones.
    As for the alleged burden on retail staff, don’t sell the stuff and you won’t have a problem. Maybe I missed it, but I don’t recall hearing similar protests from pharmacists about their having to deal with thousands of pharmaceutical products sold in very plain packages.

  9. SmokeFree says:

    Good idea. Let us trial it in Australia by making tobacco packaging poo brown with really disgusting health warnings. We could run this pilot in the whole of Australia with all packaging for – say – five years starting on September 1 2010 – and if it doesn’t work no other country need follow it.

    The tobacco industry seem to have no trouble changing their packaging for “special events” like grand prix and other stuff. They should easily be able to do this very quickly.

  10. Ron Borland says:

    As others have clearly said, the argument that plain packaging will not work is severely flawed. All the evidence and teheory-based arguments are that it will. It is an important step forward in reducing te horrendous tol of tobacco-caused disease and death. Although they are highly addictive products, cigarettes operate in most other ways like other consumer products. Users are sensitive to the costs in relation to the immediate benefits they get. The benefits of smoking are part from the pleasures of the nicotine, but this has been augmented by the imagery surrounding the brand and this adds to the vaue. This is part of the reason why Smokers are very brand loyal, even though most brands are probably indistinuishable if smoked blind. It is also why other branded products sell at a premium to identical unbranded ones.
    Reducing the added value (the measures will not eliminate it, as the Brand name will still be allowed), will reduce the allure a bit and encourage some smokers to quit and probably help a few to stay quit. However, it is likely to have a bigger effect on reducing kids uptake, as it helps make smoking seem even less cool.
    As Mike Daube says, you can never do something for the first time and have evidence (from real life) that it will work. However, the studies that have been done on pack imagery are to my reading unanimous in not finding any evidence of any downside (I have read many of them). Most find clear evidence that they are likely to produce the positive effects I argued for above.
    Away from evidence, it is immoral, and should be illegal for anyone to deliberately add to the allure of a product which kills half or more of its long term users when used as intended. The only real question in this debate is how the tobacco industry managed to get away with it for so long.

  11. Jennifer Doggett says:

    These comments all gave me some food for thought – I’ve responded briefly below.

    Mike – Of course we should try new public policies, they just should be ones based on evidence – as far as possible. As you say, a policy shouldn’t be rejected just because it is new. But equally we shouldn’t accept all new policy ideas uncritically. Currently we spend a great deal of money on tobacco harm-reduction measures without knowing exactly what effect most of them have. Had we trialed them before introduction we would be able to spend less to achieve the same outcome or spend the same amount and achieve more.

    Mike/Sitting Tall/Simon – I disagree that tobacco industry’s objection to plain packaging is evidence that it will reduce consumption. There are plenty of other reasons why the industry might object to such a policy, for example that it reduces companies’ ability to increase their share of the existing market or – as some of you pointed out – affect policies in other countries where consumption rates are rising. I agree that these may be good reasons to support a generic packaging policy, if you believe that Australia should play a role in influencing other countries’ tobacco control policies, but in that case they should be argued for within that policy context, not as a strategy to reduce domestic consumption.

    AnneJ – I would argue that given the numbers of deaths caused by tobacco use we need to ensure that resources we put into harm reduction efforts are those which deliver maximum gains.

    Simon – I take your point that a policy trial would have problems. But surely even a trial that is imperfect and possibly subject to manipulation by the tobacco industry would provide some evidence for the impact of generic packaging in a real life situation. Surely that would be better than no evidence at all?

    Becky – Apologies if my mention of your paper was dismissive – the points you make certainly deserve more discussion but it is difficult to do this in a blog post. Thanks for the references – I’m familiar with this research and I don’t believe that the most conclusions drawn from the research are justified (I’m not saying the research was poorly conducted just that I think there are significant limitations to what can be concluded from these types of studies) – obviously others disagree.

    Ron – I don’t follow the logic of your argument. If tobacco is so addictive then surely existing smokers will persist in smoking regardless of changes in packaging? If they are so sensitive to the reduction in ‘allure’ through the removal of branding that they give up or cut down then I don’t see how they can be considered addicted. Whether or not plain packaging makes smoking less attractive to children is an important question I agree, but not one that I feel is well enough answered by existing research to support the proposed policy.

  12. Jennifer Doggett says:

    Also in relation to Margo’s comments on pharmacists and generic packaging, actually the pharmacy sector has in the past vigorously protested against having to stock generic pharmaceuticals and as actively lobbied against proposals to require pharmacies to stock more than one generic (so that consumers can receive the same brand each time they fill their prescription – to reduce medication errors). Their arguments have not been about difficulties in stacking shelves but about a lack of storage space to keep products in stock (clearly they need lots of room for all those soft toys and sunglasses…….)

  13. Shooba says:

    Jennifer,

    Plain packaging is directly targeting young people who do not yet smoke. As such, there will be very little “bang for your buck” in the early trial. Only in 5, 10 years down the track will we see results. This is a long term strategy not aimed at current smokers. Despite your assertion, this policy HAS been critically examined by countless experts, none of whom stand to profit from the introduction of plain packaging. They have the burden of cancer on the community at heart. Forgive me if I take their word over yours or the word of Big Tobacco.

    Trials, surveys and experiments have shown that glossy packaging is the last effective marketing tool that Tobacco companies have. As such, they utilise it to maximum benefit. They can spit rhetoric nonstop about “just trying to increase market share” or “packaging is important for brand loyalty” but in reality their packets play a small but significant role in young peoples’ impressions of cigarettes.

    Over time this strategy will drain the tobacco industry of the next generation of smokers. This terrifies Big Tobacco. Also terrifying for them – the potential for Canada and the UK (in the short term) and other nations (in the long term) to follow Australia’s lead.

    I would definitely disagree with you that we need to seek the most effective interventions to commit resources to. When the enemy is tobacco, the correct policy is to hit it with everything you have. Plain packaging, graphic warning labels, advertising restrictions – none of these alone will be able to deliver a knockout blow to tobacco… but together they can make small inroads (Note: they don’t appear quite as small if your son or daughter is the one who turns down a cigarette in their teens, thus avoiding a 50% chance of premature death)

    What you have failed to address is the fact that this is not about making people quit; that is the main aim of graphic pictures on packets. This plain packaging is to reduce UPTAKE of tobacco smoking by non-smokers. As such, it has definite potential and is worth every cent of the cost (which I think I read somewhere has been placed at 2c per packet).

    As for your rebuttal of Ron Borland, well, I understood his argument perfectly and it is sound. Also, for someone such as yourself who routinely writes papers about health advocacy, the research to find research linking plain packaging with a change in teen attitutes to cigarettes shouldn’t be too hard to find. I suggest Google. There is ample evidence that teenagers view cigarettes differently and smokers “taste” cigarettes differently, depending on the packaging.

    Frankly, and I doubt I’m alone, I have my suspicions about your motives Jennifer. It comes with the territory – anybody agreeing with big tobacco is viewed with suspicion. This is not necessarily unfair… after all, they have been known to bend the rules, ignore their moral responsibilities, and plant seeds of doubt through nefarious means. Misdirection is their greatest weapon these days, and they use it masterfully to cloud a clear-cut decision with unnecessary trivialities.

  14. gplay says:

    Simon, you lambast people who must be sided with ‘Big Tobacco’, those who are waiting for evidence based reasoning before barrelling into legislation; but yet your own research is riddled with funding from big-pharmaceuticals and non-peer reviewed work. A furthur look reveals if the anti-tobacco work isn’t sponsored by big-pharmaceuticals (which are even more evil then big-tobacco in my mind, how many natural remedies that solve real health problems have they swept under the carpet) then it’s sponsored by single-issue social health moralists who are usually strongly religious and comment on firearms, alcohol and drugs too (equally academically fraudulent with their absurdity of one-sided attack).

    Time to target the number 1 cause of premature death and disease; that of Obesity. Every cigarette is doing you harm? Well these obese people eat less meals then tobacco smokers smoke cigarettes – so everyone of these meals must be doing more damage.

    Cajela – E-Cigarettes like chewing or snorting tobacco is alot healthier (in this case nearly 100% healthy) then smoked tobacco, but non-evidence based reasoning (like what will probably go ahead with plain-packaging) stopped their path and disadvantaged all smokers.

    Give it a rest, you are destroying the image of Australia as a laidback place. the 2/3 to 3/4 of Russians mentioned in the first article certainly will have trouble with plain packaging – will this make them recommend and return to Australia? Or think we’re a country of retards who don’t respect other adults to make adult decisions.

  15. Jennifer Doggett says:

    Hi Shooba

    If you are implying that I am being funded by the tobacco industry to put forward my views then I can assure you I am not. I am quite capable of coming up with these ideas on my own!

    One thing I value about Croakey is that it provides a forum for people like me to present my (perhaps mistaken!) views on an issue and to receive the benefit of others’ knowledge and experience. It’s one of the few public arenas where debate and discussion among people with diverse views on health policy can occur with respect and objectivity.

    Let’s keep it that way!

    Cheers Jennifer

  16. Croakey says:

    I second that motion Jennifer. Croakey is a place for healthy debate. That means robust AND respectful.

  17. simon.chapman says:

    Gplay — I’m interested to know which of my research is “riddled with funding from big-pharmaceuticals and non-peer reviewed work.”

  18. krzystoff says:

    this move might raise the ire of the tobacco industries’ investors, such as many liberal party MPs, but the fact is, it is guaranteed to succeed (provided it gets through parliament). it will turn away teens/tweens in their droves, having to look at ugly packaging with its uglier images is decidedly uncool, and aside from a niche of suicidal emo-types, there is going to be no future market for tobacco once the current generations fall off their perch over the coming decades.

    existing long-term smokers are hardened already — no amount of effort is going to make them give up, as long as they have the means and they won’t be sacked for ‘loitering with the laneway smoko lepper colony’. many of my peers and relatives continue to burn their money with cigarettes, contented that ‘they’re going to die soon anyway’ and I doubt if fears of impotence are not sufficient to convince them, nothing will.

    there is also the ever popular cigarette cases — they are often beautiful designer pieces with integrated lighters, and once fully loaded with the cancer sticks, you’re set for the day without fear of having to confront ugly imagery. I imagine the tobacco companies have a plan to give them away free with every carton of 24, so serious smoker need not see the olive-green packets after they have bought them.

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