Lessons the developing world can learn: how plain cigarette packets can reduce smoking
Selling cigarettes in plain packaging has the ability to reduce tobacco use by making smoking less appealing, its packets less attractive and the legally required health warnings more prominent.
In Australia, for example, smoking prevalence halved from about 26% in 1991 to 13% in 2013.
In the past decade, there has been an increased focus on plain packaging among tobacco control researchers in high-income countries. In addition to Australia, Ireland has also introduced plain packaging. But several other countries have policies and mechanisms in place. This includes New Zealand, Canada, the UK, Norway, Belgium, France, and Italy.
Each year, over 5 million people die from tobacco use across the world. Nearly two-thirds of these people live in developing countries. And these countries have high tobacco use. In India, for example, 26% of adults use smokeless tobacco, and 14% of adults smoke tobacco.
By 2030, 70% of the people who die from tobacco use will be from the developing world.
Introducing plain packaged cigarettes may be an effective intervention in low and middle-income countries, and among difficult to reach populations.
But the challenge is that the potential effect of this plain packaging is less well understood in these settings and developing countries have a different and diverse set of challenges, which need to be considered.
Changing the agenda
The World Health Organisation’s Framework Convention on Tobacco Control (FCTC) is a global plan to reduce tobacco consumption.
The framework recommends several strategies to combat tobacco consumption. Two strategies suggest controls on tobacco advertising promotion and sponsorship, and packaging and labelling. Its article 11 recommends the introduction of plain packaging.
Its plain packaged cigarette box proposal includes colourful graphic health warnings but otherwise no colours, brand imagery or corporate logos. The cigarette’s brand name is printed in a mandated size, font and location making the pack relatively indistinguishable.
The proposal is to counter the attempts of tobacco companies which, according to research, have increasingly used cigarette packets to target and advertise to consumers — particularly women and young people.
A review of the studies on plain packaged cigarettes looked at how plain packaging affected tobacco use — both on impact and perception. It included smoking behaviour, appeal, prominence, effectiveness of health warnings, response to plain packs, attitudes towards quitting or likelihood of smoking in low-income settings, were identified.
The review was done by researchers at the Nossal Institute for Global Health, The University of Melbourne, Australia and the Health Promotion Division of the Public Health Foundation of India.
The review found that removing brand colour and descriptors reduced appeal. The best effect was when there was no brand imagery or descriptors. Among some, the pack and brand was seen as a status symbol.
One of the focus groups confirmed that colourful packaging lured people across age and all socioeconomic divides. Over 75% of people involved in the survey found tobacco packs were attractive.
Another study which looked at smoking patterns in Australia after plain cigarette packs were introduced found that those who smoked cigarettes from plain packets found the quality of the cigarettes had dropped and the cigarettes tasted worse. This would not have an impact on their smoking patterns.
But both studies suggests that plain packaging could reduce the number of people who take up smoking and prevent people from initiating the habit and experimenting. But it would have less of an effect on people who are already smoking.
Developing world challenges
Tobacco control experts recommend incremental changes in tobacco control policy. In many low and middle income and middle to upper income countries research and policy has been focused on tobacco control interventions, such as increasing taxes or introducing pictorial health warnings.
But tobacco control advocates who implement plain packaging policies in developing countries are bound to come up against several challenges. For low and middle income countries it may take many years to introduce plain packaging.
Firstly, there is a substantial lack of research of tobacco control initiatives in non-high income countries. Building up and a significant amount of supporting research will take time.
They are also likely to come up against considerable political challenges to implement these tobacco control policies. What this means is that for them to succeed, specific research is crucial to shepherd plain packaging through parliament.
Thy will also have to be able to defend legal challenges. Australia, as a resource-rich country has faced heavy legal challenges after implementing legislation around plain packaging. Research shows that the tobacco industry has an appetite for litigation even in cases where legal success is unlikely. Lower resourced countries will need contextual evidence to defend any such legislation.