Is packaging the plain and simple answer?

Tobacco manufacturers could be forced to adopt so-called 'plain packaging' in England as soon as 2016, after Public Health Minister Jane Ellison outlined the Conservative-Lib Dem coalition government's move yesterday. MPs are expected to be given a free vote on the issue before Parliament is dissolved ahead of April's general election campaign, which begins in April. Wales has already voted to accept any Westminster legislation on the matter. Scotland and Northern Ireland are also expected to vote on whether to back the move. But does the psychological evidence suggest the change will be effective in reducing smoking? 

The UK government consulted on plain packaging in 2012, and last June we reported that the Department of Health had opened a six-week consultation and review of the evidence. Dr Olivia Maynard, a Research Associate at the University of Bristol, is part of the Tobacco and Alcohol Research Group in the School of Experimental Psychology. She told us: 'Our research contributed to evidence supplied to the consultation. Given the policy relevance of this research, it has been important to disseminate it to policy makers and other interest groups.'

Dr Maynard points to 'considerable scientific evidence supporting the introduction of plain packaging. Two systematic reviews (Moodie et al., 2012, 2013) have shown that plain packaging reduces the appeal of smoking, particularly among young people, increases the noticeability and effectiveness of the health warnings and prevents smokers from being misled about the relative health risks of smoking. The research we've conducted at the University of Bristol supports this and has found, using eye-tracking technology, that plain packaging increases attention directed towards health warnings among non-smokers and non-daily smokers (Munafo et al., 2011; Maynard et al., 2013). This is important, as we know that health warnings are key in educating both smokers and non-smokers about the health risks of smoking.'

But it's not just work conducted in the laboratory which has shown that plain packaging might be effective in changing smoking behaviour. Maynard points out that since being introduced in Australia in December 2012, research has found that plain packaging has reduced the appeal of smoking (Wakefield et al., 2013), and cut down the prevalence of smokers displaying their packs on tables (Zacher et al., 2014). She adds: 'Although it's still too early to determine the effect of plain packaging on actual smoking rates in the country, researchers have observed increased numbers of calls to the stop smoking Quitline in the months after the introduction of plain packaging (Young et al., 2014).'

However, not all are convinced that plain packaging will have an impact on current smokers. We spoke to Chris Armitage, Professor of Health Psychology at the University of Manchester and a member of the British Psychological Society Behaviour Change Advisory Group. He pointed out that Moodie and colleagues had actually found that regular smokers were less inclined to quit smoking in response to packaging in 2011 (after graphic images were introduced on packaging), compared to 2008 (before graphic images were introduced on packaging). Regarding young smokers, Professor Armitage said that before advertising bans on smoking, research tended to show that awareness of advertising and motivation to smoke were linked and therefore any reduced exposure to advertising is likely to reduce the chance of smoking uptake. But he added: 'One concern for the future is whether e-cigarette advertising and/or e-cigarette uptake ultimately turns out to be a precursor to future cigarette smoking. Although nicotine consumption per se does not appear to be related to increased risk of cancer, there is some evidence that nicotine disrupts brain reward mechanisms that could increase susceptibility to other drugs (e.g. Kenny & Markou, 2006; Yurasek et al., 2013).' (For more on this, see Lynne Dawkins' article in last May's issue).

When asked whether standardised packaging should be the priority for the Government in its attempts to stop people from smoking, Professor Armitage told The Psychologist: 'There is a large body of evidence, stretching back quite a few years (e.g. Peterson et al., 1992) suggesting that increased taxation will reduce both uptake and consumption of cigarettes. Given that all the regulatory mechanisms are already in place, increased taxation would seem to be a more straightforward way of preventing smoking uptake than developing new rules about packaging.'

Dr Maynard may not disagree with this, telling us: 'Despite the expected benefits of plain packaging, it is important to remember that it will be most effective as part of a comprehensive tobacco control strategy that includes other policies, such as access to stop smoking services, restrictions on sales to young people and effective taxation.'

References

Kenny, P.J. & Markou, A. (2006). Nicotine self-administration acutely activates brain reward systems and induces a long-lasting increase in reward sensitivity. Neuropsychopharmacology, 31, 1203 - 1211.

Maynard OM, Munafò MR, Leonards U. Visual attention to health warnings on plain tobacco packaging in adolescent smokers and non-smokers. Addiction. 2013;108(2):413-9.

Moodie C, Stead M, Bauld L, McNeill A, Angus K, Hinds K, et al. Plain Tobacco Packaging: A Systematic Review. 2012.

Moodie C, Angus K, Stead M, Bauld L. Plain Tobacco Packaging Research: An Update. Stirling, Scotland: Centre for Tobacco Control Research, Institute for Social Marketing, University of Stirling 2013.

Moodie, C., Mackintosh, A.M. & Hastings, G. (2013). Adolescents' response to pictorial warnings on the reverse panel of cigarette packs: a repeat cross-sectional study. Tobacco Control, Accessed at:http://tobaccocontrol.bmj.com/...2013-050999.abstract.

Munafo MR, Roberts N, Bauld L, Leonards U. Plain packaging increases visual attention to health warnings on cigarette packs in non-smokers and weekly smokers but not daily smokers. Addiction. 2011;106(8):1505-10.

Peterson, D.E., Zeger, S.L., Remington, P.L. & Anderson, A.H. (1992) The effect of state cigarette tax increases on cigarette sales, 1955 to 1988. American Journal of Public Health, 82[1], 94-96.

Wakefield MA, Hayes L, Durkin S, Borland R. Introduction effects of the Australian plain packaging policy on adult smokers: a cross-sectional study. BMJ Open. 2013;3(7).

Yurasek, A.m., Murphy, J.G., Clawson, A.H., Dennhardt, A.A. & MacKillop, J. (2013) Smokers Report Greater Demand for Alcohol on a Behavioral Economic Purchase Task. Journal of Studies on Alcohol and Drugs, 74[4], 626-634.

Young JM, Stacey I, Dobbins TA, Dunlop S, Dessaix AL, Currow DC. Association between tobacco plain packaging and Quitline calls: a population-based, interrupted time-series analysis. The Medical journal of Australia. 2014;200(1):29-32.

Zacher M, Bayly M, Brennan E, Dono J, Miller C, Durkin S, 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 café strips. Addiction. 2014;109(4):653-62.