Tobacco plain packaging: The A ustralian experience

More than six decades after incontrovertible evidence on the lethal consequences of smoking,1, 2 around the world some six million people still die each year because they smoked.3 Even in developed countries where smoking has declined, it remains the largest preventable cause of mortality and morbidity. A recent report by the McKinsey Global Institute lists tobacco as the leading global social burden generated by human beings—ahead even of armed violence, war and terrorism.4 The main vector of tobacco disease, the global tobacco industry, remains powerful, profitable, ruthless in its determination to sell as much of the product as possible, increasingly focused on growing markets in low- and middle-income countries and implacably opposed to any action that might be effective in reducing smoking. In Australia, the latest high-profile battle between governments, health authorities and the tobacco industry has been over the recent successful introduction of ‘plain packaging’ of all tobacco products. ‘Plain packaging’ is of course a euphemism—the packs are dominated by strong, graphic warnings; the pack design and colour are carefully researched to be as unattractive as possible; and the overall impact is to turn the pack into something neither children nor adults want to be associated with (Fig. 1). Australian plain packaging template. © Commonwealth of Australia. On 1 December 2012, Australia became the first country in the world to require all tobacco products to be sold with plain packaging. The Australian plain packaging story is well described by Chapman and Freeman in their book, ‘Removing the Emperor's Clothes: Australia and Tobacco Plain Packaging’.5 The Irish and UK governments have recently legislated to introduce plain packaging; other countries have declared an interest in following their example, and the battleground has shifted from Australia to those countries and international trade disputes. Plain packaging was never seen as the magic bullet for tobacco cessation: it was and remains part of a comprehensive approach to tobacco control that includes taxation, regulation (for example on advertising bans, point-of-sale promotion and protection from the harms of passive smoking) and strong, sustained public education campaigns. The primary aim of plain packaging was to discourage future generations from starting to smoke. As stated by the Health Minister who supported plain packaging through the Australian Parliament, Nicola Roxon, ‘… of course we're targeting people who have not yet started, and that's the key to this plain packaging announcement—to make sure we make it less attractive for people to experiment with tobacco in the first place’.6 The impacts of plain packaging should therefore be considered in a long-term context. However, early indications show a wide range of positive impacts relating to adults, children and adolescents. Peer-reviewed research shows many beneficial outcomes including in areas such as outdoor smoking, reductions in noticeable public display of packs, calls to telephone support and coaching services aimed at smoking cessation (e.g. Quitline), propensity to smoke, attitudes to brand image and support among smokers.5 Australian Treasury figures showed a 3.4% fall in 2013 tobacco consumption when compared with 20127 and a further 7.7% was seen in 2014.8 The Australian Bureau of Statistics reports that total consumption of tobacco and cigarettes fell to ‘the lowest ever recorded’.7 The National Drug Household Survey has shown a fall in prevalence between 2010 and 2013 from 15.1% to 12.8%, with smokers smoking less and the average age of the first completed cigarette rising.7 While clearly plain packaging and the public debate surrounding its introduction were not the sole contributors to these developments (Fig. 2), they have equally clearly played an important role. Smoking prevalence rates for smokers 14 years or older and key tobacco control measures in Australia from 1990 to 2017. Data source: National Drug Strategy Household Survey reports: 1991, 1993, 1995, 1998–2013. Figure reproduced with permission of the Department of Health, Australian Government. Before the implementation of plain packaging, the main focus of the tobacco companies' public attacks was on all the catastrophic outcomes they predicted would eventuate. Through massive advertising, public relations and lobbying campaigns the tobacco industry and its allies tried to foster the notion that plain packaging would bring with it a range of harmful consequences for the community at large and for specific sectors. These arguments are now being assiduously and misleadingly promoted in other countries9 despite evidence to the contrary from Australia. Negative outcomes predicted by the tobacco industry and the actual consequences are summarized below. Claim: Plain packaging would be rejected by Australian courts as being unconstitutional, with huge consequential costs for the Federal Government. Outcome: The High Court rejected the industry's arguments, awarding costs to the Australian Government.10 Claim: There would be significant problems for retailers in identifying the newly packaged brands, with consequent delays in serving customers. Outcome: Peer-reviewed research shows no such problems.11 Claim: There would be a shift in sales of tobacco products from small retail outlets to supermarkets. Outcome: Peer-reviewed research and independent data show that there has been no such shift.11-13 Claim: Smokers would cover up the plain packs with newly purchased special covers. Outcome: Peer-reviewed research shows minimal use of any such covers.14 Claim: There would be a massive increase in the illicit tobacco trade. Outcome: Government reports and peer-reviewed studies show no such increase.7, 13, 15, 16 Claim: There would be an increase in counterfeiting of the new plain packs. Outcome: Independent reports and Customs statements show no such increase,16 and evidence from British American Tobacco to the Chantler review in the UK confirmed no increase.17 Claim: There would be a substantial drop in prices. Outcome: Industry financial data show no such drop; indeed, because of the introduction of plain packaging, tobacco companies have reportedly aggressively increased prices.18 Claim: There would be a shift to low-cost Asian brands of cigarettes. Outcome: Peer-reviewed research shows no such shift.13, 18 Claim: Tobacco sales would increase (although the rationale for this claim was never clearly articulated). Outcome: Official data and industry data show a decline in sales.7 Claim: There would be in-store crime, as shop staff would take so long to identify specific brands that they would not be able to observe shoplifting. Outcome: There is no evidence for this having occurred.19 In global terms, Australia is a small tobacco market. The epic fight against plain packaging in Australia was never simply about preserving that small, local market. It was rather an attempt to avoid the creation of this successful precedent for action elsewhere. For more than 2 years, there are important lessons from the Australian experience for other countries. Plain packaging has been described as ‘a case book example of effective tobacco control—a policy measure driven by evidence, carefully designed and now rigorously assessed’.20 It is clear that it can bring substantial benefits to the community as part of a comprehensive approach to tobacco control. The tobacco industry's arguments failed in Australia; they should not be allowed to become zombie arguments—killed off in one country, but brought back to life in others in the hope that credulous decision-makers will not be aware of experience elsewhere. Governments should follow expert health advice and implement this important, evidence-based public health measure.