Plain packaging: What it might do, and how we plan to find out what it does.

Plain packaging:What it might do, and how we plan to find out what it does. Ron Borland PhD The Cancer Council Victoria Ron.Borland@cancervic.org.au

Disclosure • I am a member of the Technical Advisory group set up to provide expert input to the Commonwealth Government on the Plain Packaging legislation. • This presentation is completely independent of that role.

Australian standardised packaging • Strong larger warnings (75% 0f front) • Rest in common dark olive-brown colour • Fixed pack sizes and shape • Only Brand and variant names, and number of cigarettes allowed on front

Steps in evaluation • Contextualising policy within a broader framework • Identifying justifications for policy • Theorising possible effects • Intended • Unintended positive • Unintended negative • Studies to measure theorised effects

Justifications for removing pack designs • Form of promotion • Thus should be eliminated • Distracts from warnings • Encourages youth smoking • Kylie’s paper details this fully

Good evaluation • Multiple baselines, where possible • Multiple post-policy observations • Obviously takes time • Controls • Either no policy • Different policy • Different timing of policy • Some combination of above • Mediational model • Measures mechanisms of effect, not just important outcomes

Studies planned • ITC study • Some measures tracked for several years • Others introduced in 2011 • Follow-up in 2012, around implementation; and in • 2013 about 1 year after full implementation • National monthly survey (smokers and recent quitters) • 1 month follow-up for quit outcomes • Monitoring of price and presence of PP • Observational study over period of implementation and shortly after • Youth survey: ASSAD • 3 yearly survey, some baseline measures collected in 2011, next survey due 2014 • Other national data collections • Excise collections • National prevalence surveys • Scream test • Already demonstrated that the tobacco industry think it will have marked effects

Possible effects • Immediate effects • Fairly certain and summarised in previous presentation • Longer-term effects • Some may be predictable from immediate effects • Some likely to differ • Can come to value what you didn’t like • These are what really matter

Determinants of smoking • Balance between experienced value of smoking and costs of doing so • If use, act to maximise value of smoking for them

Marketing Product Person Intrinsic features Product design Experiences Acquired features Product promotion & packaging Habits Tobacco use Cues to use Places where sold Expectations &beliefs Availability Price Price Values & norms Culture of use Tobacco marketing: ways it affects tobacco use

What does branding do? • Basis of building identity of brand and means of adding incidental value • Allows for creation of different imagery for subsets of tobacco users • Curiously this can also be done within a brand

How do smokers respond to branding? • Affects their liking of the pack • Their capacity to add user-value • These evolve over time • Immediate preferences do not necessarily determine longer-term preferences

Price and value • In economics the value of something is defined by the maximum price the person is prepared to pay • Paying more than the minimum indicates added value • Mostly likely incidental value • Reducing value should be associated with reduced prices • Increased price (relative to value) should lead to reduced consumption

Determinants of value Value = Intrinsic + Industry-added + User-added + Interactions Intrinsic = Value that comes directly from use of the product Industry-added = Value that is added by a company to make its brands more attractive to users User-added = Beliefs and activities that smokers engage in to get more value from smoking Interactions = Value from combinations of the above

How plain packaging might reduce value? • Reduced value of smoking overall • Packs seen as less attractive • Packs increase focus on harms • More focus on health warnings • Reduce reassurance from contrasting pack designs • Resulting in: • Increase product denormalisation • Less positive experiences of use • More negative experiences of use • Reduced brand-specific differentiation • Greater effects on premium brands?? • More industry-added value to start with • Reduced differentiation of smoker sub-groups • Reduced variant differentiation • Less cues to taste differentiation

Possible Effects • Reduced value • Reduced preparedness to pay • Less consumption • More quitting BUT • Industry may compensate by dropping prices • Will reduce above effects, but unlikely to eliminate them • Reasons for not smoking will not decline

Outcomes to measure Smoker-related • Quit attempts • Sustained quitting and relapse • Quit-related thoughts • Brand shifting • Price paid • Consumption • Attitudes to smoking • Reactions to health communications • Perceptions about quality

Possible effects on youth • More negative image of smoking • smoking more difficult / tastes worse • smoking less socially desirable • Less brand-driven use • Reduced brand-specific imagery • Less identification with in-group brands • Reduced experimentation • Reduced long-term uptake

Possible outcomes Industry-related • Illicit trade • Price discounting • Removal of some Brands/Variants from the market • Use of number of cigs per pack as a marketing device • Use of filters as a marketing device • Use of cigarette size (length, diameter) and shape (oval vs round) as marketing tools • Use of dark olive brown in lifestyle marketing for other products

Justifying smoking • Most people have a need to justify their smoking, if only to themselves • this creates challenges for the smoker • Some possible strategies to deal with this • Quit • Using justifications: • Addicted • It helps me; eg deal with stress • Risks exaggerated* • Part of who I am* • Reducing cues to think about the harms • Hide the packs • Using cigarette cases* • More smoking in private • Strengthening on “smoker identity” • Persecuted minority* * likely affected by plain packaging

Could there be negative effects? • Not likely Theoretical possibilities: • Defensive dissonance reduction • Increase in beliefs about the personal value of smoking • Reinforce common identity of smokers • Persecuted minority • Increased beliefs in being addicted • Thus less able to quit

Illicit trade Industry claims likely effects • Easier to counterfeit • Incentives for smuggling branded packaging • Makes chop-chop more attractive • These effects are unlikely to have any significant effect on the market

Possible effects • Reduced incidental value associated with branding • Packs seen as less attractive • Enhanced prominence of health warnings • NB: Aust. also increasing warning size • Reduced differentiation between sub-groups of smokers • Reduced identity as: X smoker • Reduced differentiation between variants

Tobacco industry arguments • That the plain packaging law will not work • That it will cost them billions • The more it works, the bigger the harm to them, but • The bigger the effect, the more justification for the law • They are caught on the horns of a dilemma • That it will lead to illicit trade • Hard to measure • Rationalisation for any drop in legal sales • The industry lose, the community gets nothing • Need to be able to counter this • They also fear it will squeeze profit per pack sold, by reducing their capacity to charge extra for premium brands

Questions • How much added value can the brand names support when stripped of supporting visual design and external promotion? • Are variants sufficiently different in taste to be maintained by only indirect variant descriptors?

Studies planned • ITC study • Some measures tracked for several years • Others introduced in 2011 • Follow-up in 2012, around implementation; and in • 2013 about 1 year after full implementation • National monthly survey (smokers and recent quitters) • 1 month follow-up for quit outcomes • Monitoring of price and presence of PP • Observational study over period of implementation and shortly after • Youth survey: ASSAD • 3 yearly survey, some baseline measures collected in 2011, next survey due 2014 • Official data collections • Excise collections • National prevalence surveys • Scream test

Summary Direct effects of Plain packaging on smoking prevalence will be very difficult to identify, unless they are huge. However, demonstrating mediated effects is likely: • They may strengthen reactions to health warnings and thus lead to more quitting • Difficult to evaluate given concurrent introduction of bigger health warnings • The may further denormalise smoking and both increase quitting and reduce uptake • But already highly denormalised • They may led to reduced pleasure of smoking and through this lead to more quitting • May have greater impact on those previously smoking premium brands • But may be reduced if prices for these drop relative to other brands • Tobacco may have more of a common identity We need to assess all this and more • The studies are largely in place • We just have to wait

Core support provided by the U.S. National Cancer Institute (P01 CA138389) Core support provided by the Canadian Institutes of Health Research (MOP-115016) Australian arm mainly supported by NHMRC

Tobacco industry Tobacco use control Constrain tobacco marketing • Information: • Mandated • Campaigns Programs to prevent uptake Cessation programs and aids Tax Smoke-free rules Biology Regulate tobacco products Tobacco use Norms for use Consequences of use Elements of tobacco control

Plain packaging: What it might do, and how we plan to find out what it does.