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Submission on the Smoke-free Environments
(Tobacco Plain Packaging) Amendment Bill
March 2014
Professor Janet Hoek (lead author and contact person for oral submissions)
Emeritus Professor Philip Gendall
Professor Richard Edwards
Professor Julian Crane
Professor Chris Cunningham
Associate Professor George Thomson
Associate Professor Nick Wilson
Dr Ninya Maubach
Dr El-Shadan Tautolo
Dr Richard Jaine
Dr Heather Gifford
Rebecca Gray
Anaru Waa
ii
Contents
Executive Summary ................................................................................................................................. 1
Submitter Background ............................................................................................................................ 3
Introduction ............................................................................................................................................ 4
Tobacco Packaging as a Marketing Medium .......................................................................................... 6
Symbolic Consumption and “Badge” Products ................................................................................... 7
Primary and Secondary Demand ........................................................................................................ 8
Summary of Research into Tobacco Packaging .................................................................................. 9
Reducing the Appeal of Tobacco and the Acceptability of Smoking .................................................... 10
Communicating Aspirational Imagery to Young People ................................................................... 10
Awareness of Tobacco Brands among Children ............................................................................... 11
Branding and the Development of Attractive Attributes ................................................................. 12
Specific Attribute Connotations ........................................................................................................ 13
Perceived Attractiveness .............................................................................................................. 13
Perceived Quality .......................................................................................................................... 15
Summary: Reducing the Appeal of Tobacco ..................................................................................... 15
Salience of Health Warnings Featured on Tobacco Packaging ............................................................. 17
Effect of Plain Packaging on Warning Label Recall ........................................................................... 17
Effect of Plain Packaging on Warning Label Attributes .................................................................... 18
Potential Benefits of Larger Warning Labels..................................................................................... 18
Tobacco Industry Responses to Pictorial Warning Labels ................................................................ 18
Summary of Plain Packaging and Warning Labels ............................................................................ 19
Reducing Misleading Perceptions of Tobacco Products ....................................................................... 20
Tar and Nicotine Delivery .................................................................................................................. 20
Perceived Harm ................................................................................................................................. 20
Tobacco Company Responses ........................................................................................................... 20
Summary of Plain Packaging and Misleading Perceptions ............................................................... 20
Likely Effects of Plain Packaging ........................................................................................................... 22
Effects of Plain Packaging on the Appeal of Tobacco Products and Smoking .................................. 22
Public Support for Plain Packaging ................................................................................................... 22
Effects of Plain Packaging on Behaviour ........................................................................................... 23
Australian Experience ....................................................................................................................... 23
New Zealand’s International Obligations .............................................................................................. 26
Do Recent or Alternative Policy Changes Obviate the Need for Plain Packaging? ........................... 27
Areas for Further Investigation ............................................................................................................. 28
Dissuasive Sticks ................................................................................................................................ 28
Limiting Variant Names ..................................................................................................................... 28
iii
More Diverse Warning Messages ..................................................................................................... 29
Salience of Quitline Information ....................................................................................................... 29
Additional Suggestions ...................................................................................................................... 30
References ............................................................................................................................................ 31
1
Submission to the Health Select Committee
Smoke-free Environments (Tobacco Plain Packaging) Amendment Bill
Executive Summary
Plain packaging is a scientifically well-supported, logical, proportionate, and important step in
preventing children and young people from experimenting with smoking and becoming
addicted to nicotine. Adoption of this policy would help shift New Zealand closer to the
forefront of tobacco control worldwide. The research evidence on likely impact, tobacco
industry documents, marketing theory, and findings from Australia suggest that plain
packaging will help protect the health of New Zealanders. We consider there are at least five
key reasons why plain packaging should be introduced as soon as possible.
First, evidence that tobacco companies have used on-pack branding to promote smoking as
attractive and aspirational comes from their own internal documents. Packaging’s relative
importance as a marketing medium has increased since traditional mass media
communications have been restricted. Smokers often display packaging conspicuously, by
placing their packs where these can be seen by others, thus non-smokers, including children,
are often exposed to tobacco branding. Allowing this exposure to continue effectively
breaches New Zealand’s obligations under the Framework Convention on Tobacco Control
(FCTC), under which we agreed to introduce a comprehensive ban on all tobacco advertising,
promotion and sponsorship.
Second, experimental studies, branding theory and the tobacco industry’s own documents
provide strong evidence that plain packaging will reduce the appeal of tobacco products and
smoking and increase the noticeability and effectiveness of on-pack pictorial warnings. Plain
packaging is not simply the removal of brand imagery, but the replacement of on-pack livery
with dissuasive colours and larger health warnings. Rather than actively appeal to children and
young people, as is currently the case, dissuasive packaging deters experimentation and the
subsequent addiction and misery that almost invariably results.
Third, plain packaging allows cigarette packs to feature larger pictorial warnings with stronger
visual impact, because distracting brand imagery does not divert attention away from them.
Experimental studies have shown that pictorial warnings have greater salience and impact
when featured on packs from which brand paraphernalia has been removed.
Fourth, plain packaging has the potential to reduce the misleading perceptions of reduced
harm created by some brand variants. The use of colours such as white and silver to connote
2
“light” and blue to connote “mild” perpetuates a well-documented deception that has led
some smokers to believe variants packaged in these colours are less harmful than others.
Fifth, despite tobacco companies’ claims that plain packaging would lead to extended
transaction times, the demise of small retailers, and the proliferation of black markets,
Australian experience suggests none of these arguments has any substance. Emerging
evidence from Australia suggests plain packaging has diminished the experience of smoking
and stimulated a large increase in Quitline calls. Both outcomes suggest that plain packaging’s
effects are in the health protecting direction that researchers predicted.
Although the tobacco industry claims that plain packaging should not be introduced because
its effects have not yet been proven, this claim lacks any face validity as it is logically
impossible to evaluate the effects of a policy that has not yet been introduced. Tobacco
companies have consistently opposed other proportionate and effective tobacco control
measures, arguing that these lack an appropriate evidence base. Evaluations of measures they
have opposed, such as pictorial health warnings, reveal they have promoted awareness of
smoking’s harms, stimulated quit-related thoughts, and increased actual quit attempts.
Tobacco companies have a dismal track record in predicting the effectiveness of tobacco
control measures and their assertions about plain packaging should be regarded with
considerable scepticism.
Our conclusions are straightforward:
Research evidence supporting the immediate introduction and implementation of plain
packaging is clear. We do not consider that New Zealand should wait for the outcome of
international litigation over plain packaging, as the tobacco industry have used this tactic
deliberately, to delay adoption of the policy.
Plain packaging is the logical next step in achieving the New Zealand Government’s
objective of achieving a Smokefree Aotearoa /New Zealand by 2025 and meeting its FCTC
obligation to remove all forms of tobacco advertising.
3
Submitter Background
The ASPIRE2025 collaboration is a University of Otago Research Theme, recognised for its
research excellence in tobacco control. ASPIRE2025 includes researchers from the University
of Otago, Massey University, AUT University, and Whakauae Research for Māori Health and
Development. Team members represent multiple disciplines, including marketing, public
health, clinical medicine, Māori and Pacific health, and public policy. We have an extensive and
longstanding interest in tobacco control research; within the last five years, we have published
more than 100 peer-reviewed journal articles on tobacco control. Members have given invited
keynote and plenary speeches on tobacco control to national and international audiences.
Our collaboration is the leading New Zealand source of research examining limits on tobacco
marketing and we have undertaken numerous studies evaluating tobacco control policy
options. We have published five refereed journal articles on plain packaging, presented several
papers at international conferences, organised a seminar about plain packaging with a leading
international speaker, and received HRC funding to investigate plain packaging. Team
members have attracted further funding to support tobacco control research from the Royal
Society of New Zealand’s Marsden Fund, the Health Research Council, Heart Foundation,
Asthma Foundation and Cancer Society. We have provided expert advice on tobacco control to
New Zealand Government Select Committees, international governments, and NGOs. Copies
of team members’ curriculum vita are available on request.
We note that this submission draws on knowledge we have gained through research we
undertake in our roles as academics and community researchers and representatives. The
arguments we advance do not necessarily represent official views held by the University of
Otago, Massey University, AUT University, or Whakauae Research for Māori Health and
Development.
4
Introduction
The Smoke-free Environments (Tobacco Plain Packaging) Amendment Bill sets out four
objectives that plain packaging is expected to address. These are:
Reducing the appeal of tobacco products and smoking, particularly for young people;
Reducing further any wider social acceptance and approval of smoking and tobacco
products;
Increasing the noticeability and effectiveness of mandated health warning messages and
images, and
Reducing the likelihood that consumers might acquire false perceptions about the harms
caused by tobacco products.
More generally, the government aims to improve public health by:
Discouraging people from taking up smoking or using tobacco products;
Encouraging people to give up smoking and stop using tobacco products;
Discouraging people who have given up smoking, or who have stopped using tobacco
products, from relapsing;
Reducing people’s exposure to smoke from tobacco products, and
Supporting New Zealand to meet its international commitments and obligations under the
WHO Framework Convention on Tobacco Control (the FCTC), particularly in relation to the
guidelines developed to support implementation of Articles 11 and 13 of the FCTC.
Members of the ASPIRE2025 collaboration unanimously support the plain packaging of
tobacco products. Tobacco is a uniquely harmful consumer product responsible for the
premature death of half its long-term users.[1] No other legal consumer product causes such
widespread harm; the research evidence shows smoking harms nearly all body organs and
remains a leading cause of cancer, heart disease and respiratory illnesses.[2] As Hecht notes,
this harm arises because of the unique combination of nicotine and the more than 4000
chemicals contained within tobacco; he writes:
The devastating link between tobacco products and human cancers results from a
powerful alliance of two factors — nicotine and carcinogens. Without either one of
these, tobacco would be just another commodity, instead of being the single
greatest cause of death due to preventable cancer. (p 733).[3]
Of these chemicals, 60 are known or suspected carcinogens, including cadmium and hydrogen
cyanide.[3]
Smoking remains the leading cause of avoidable morbidity and mortality, and of health
inequalities, in New Zealand and is estimated to cause (directly and indirectly) between 4500
and 5000 deaths every year.[4 5] Globally, tobacco use causes more than five million deaths
each year.[6]
New Zealand governments have introduced several evidence-based measures to reduce
smoking prevalence and the harm caused by smoking. Measures introduced in the last 25
years include the Smoke-free Environments Act 1990, which banned tobacco advertising and
5
sponsorship and began introducing smoke-free workplaces. Amendments to this legislation
introduced additional workplace smoking bans in 2004; pictorial health warnings in 2007, and
required the removal of tobacco retail displays in 2011. Despite claims by tobacco companies
that each of these measures was unnecessary, lacked supporting evidence, and would be
ineffective, smoking prevalence has reduced significantly over the last two decades.[7]
Tobacco use causes enormous harm to New Zealanders’ health and undermines New
Zealand’s economy; achieving the 2025 goal is crucial to our social, economic and physical
well-being and will require bold interventions. Plain packaging is a logical and evidence-based
extension of existing marketing control policies, which include excise tax increases, enhanced
on-pack warnings, and the expansion of smoke-free places. We consider that the existing
scientific evidence around plain packaging and its likely effects show it is both proportionate
and practical, and very likely to contribute to further reductions in smoking prevalence.
We begin by explaining how on-pack brand imagery functions as marketing and briefly review
the research evidence. We then examine the evidence in relation to each of the four
objectives noted earlier. Finally, we outline New Zealand’s obligations under the FCTC, identify
additional factors that could be included in the Bill and offer conclusions.
6
Tobacco Packaging as a Marketing Medium
Marketers have long recognised the power of packaging to influence consumers’ behaviour;
packaging’s soubriquet “the silent salesperson” gives an insight into the effect it can have at
the point-of-purchase.[8] This moniker recognises how packaging functions to capture
attention, both in highly competitive retail environments and in all other settings where
products could appeal to users and potential users.
For products like tobacco, which no longer have traditional broadcast and print media
available, packaging is a pivotal medium that retains tobacco companies’ ability to
communicate directly with existing and future users.[9] In jurisdictions such as New Zealand,
packaging is the only major means tobacco companies have to advertise their products and
encourage experimentation with smoking. Examination of tobacco industry documents shows
that, irrespective of policies that limit traditional media, such as advertising and sponsorship,
packaging enables tobacco companies to promote brand attributes and appeal to potential
new users.[10-12]
Packaging not only maintains communication channels, but promotes a crucial point of
difference that enables consumers to recognise, and affiliate themselves with, different
brands. A Philip Morris document illustrates the tobacco industry’s understanding of
packaging’s role:
“Our final communication vehicle with our smoker is the pack itself. In the absence
of any other Marketing messages, our packaging -- comprised of the trademark,
our design, color and information -- is the sole communicator of our brand essence.
Put another way -- when you don't have anything else -- our packaging is our
Marketing.”[13]
Evidence from industry documents also reveals the meticulous care tobacco companies have
taken to research their brands’ packaging.[11 14] The colours, imagery, logos, fonts, sheen and
texture that constitute tobacco packages are carefully tested to maximise the appeal of
packaging to specific audiences.[15] The resulting brands exemplify aspirational attributes,
such as glamour and sophistication, or ruggedness and masculinity.[15 16]
Brand imagery creates rich symbolic meanings and then links these aspirations, attributes and
values to functional products and services; these relationships mean consumers buy branded
products as much for their symbolic value as for their utility.[17 18] This process is evident
from tobacco brand names such as Holiday – an evocative name for a lower price point brand
that represents the time out that smoking breaks provide for lower income smokers. Similarly,
Horizon connotes the realisation of dreams that might seem beyond a lower income smoker
who has fewer qualifications or career prospects.
Brand names, and the on-pack livery that reinforce these, offer opportunities and provide
important and valued distractions that offer respite from the banality of everyday life.
Consuming a given brand therefore provides users with a conduit to its specific attributes and
explains why tobacco brands are regarded as “badge” products that smokers use to construct
and project a social identity.[14] Packaging is pivotal in conveying these desirable attributes,
enhancing the appeal of smoking, and encouraging experimentation.
7
Symbolic Consumption and “Badge” Products
Theories of symbolic consumption explain how brands exert a powerful influence on
consumers’ behaviour. The associations and images that physical brand insignia give rise to
have become critical points of differentiation for tobacco products, which are functionally
similar and so rely on emotional and symbolic attributes for their appeal.[16] More specifically,
consumers use physical brand attributes to construct imagery that they draw on and
personalise, and use to co-create an identity they project to others.[19] Consumers actively
construe brand insignia using a reflexive process in which they simultaneously define the
imagery, and then use it to define themselves.[20]
This identity creation process enables tobacco manufacturers to sell status, social acceptance,
glamour, and adventure, rather than a mere nicotine delivery device.[15 16 21] Young people
place particular value on brands’ symbolic properties and use them to construct social persona
that they then communicate to their peers. [22-24]
Internal tobacco industry documents reflect a deep understanding of symbolic consumption
and reveal detailed research into pack designs, brand insignia, and images, and consumers’
responses to these marketing stimuli.[11 16 25 26] Furthermore, these documents highlight
the importance the tobacco industry places on young adult smokers and the need for brands
that appeal to this group’s uncertainties and aspirations.[27]
Industry documents also make it clear that packaging functions as a powerful and persistent
form of advertising to smokers and others in their vicinity. A Brown and Williamson employee
stated:
“… if you smoke, a cigarette pack is one of the few things you use regularly that
makes a statement about you. A cigarette pack is the only thing you take out of
your pocket 20 times a day and lay out for everyone to see. That’s a lot different
than buying your soap powder in generic packaging.”[28]
What Effect Does Tobacco Branding Have?
Branding, now communicated via packaging alone in New Zealand, continues to perform
important roles for tobacco companies. Attractive imagery and aspirational brand names, such
as those discussed above, create the impression that smoking is less harmful and more normal
than is the case. There are striking and anomalous differences between tobacco branding and
marketing and the branding and marketing of other toxic products such as poisonous
chemicals. The latter have a distinct lack of brand imagery so the potential harm of the
product is clearly communicated while warning labels are highly visible and undiluted by
competing pack imagery. The fact that tobacco, a product responsible for around 5000 New
Zealanders’ deaths every year, continues to use evocative imagery is illogical and inconsistent
when compared to other harmful products.
There is strong evidence that exposure to tobacco branding stimulates cravings among those
smokers who are attempting to become smoke free.[29] In New Zealand research, a former
smoker described the experience of seeing “his” brand thus:
8
There’s a connection made, you know, between observing, seeing the packet, and
then knowing what the packet feels like. And then you can start by getting
warmed up about opening the packet and smelling the cigarettes and lighting one
up and what that means for you. And, you know, there’s whole number of
connections that are made. It’s advertising. (p.336).[30]
These reflections are not unique to New Zealand smokers; a participant in a recent Norwegian
study of tobacco branding and plain packaging summed up the role branding plays in smoking
initiation:
“It’s like, if I see someone smoking white Kent, and another smoking Teddys, then I
see the difference. It says something about the person. I’m thinking, you start
using a brand because you feel you belong to it, that you’re connecting with it. It
has something to do with the logo, I think.”[31]
Many smokers report their first experience of smoking as distasteful and even unpleasant.
They continue to experiment, at least in part, because of the “coolness” they associate with
smoking, a perception that is directly linked to the appeal of the package and the social
prestige and status this confers on them. Specific design features resonate with smokers and
enable them to construct and communicate the social identities they value, following the
process outlined above. Innovations in pack design, such as “lipstick” packs (targeted
specifically at young women), wallets and slide-opening packs reinforce these positive brand
impressions and provide additional reasons for smokers to draw on “their” brand when
representing themselves to others.
Primary and Secondary Demand
Tobacco companies reject much of this evidence, at least in their public proclamations, and
hold to the view that on-pack imagery fosters brand recognition, enables smokers to
differentiate between brands and promotes brand switching among adult smokers. However,
research evidence, as well as the industry’s own internal documents, question the claim that
branding simply stimulates brand switching and alters secondary, not primary, demand.
First, research shows that brand switching is rare, as smokers show unusually high levels of
brand loyalty; indeed, despite being exposed to numerous brands, many consume only one
brand (that is, they are sole brand loyal)[32] and any brand switching that does occur is at
much lower levels than other fast-moving consumer goods.[33] Second, because smoking kills
half its long term users, the tobacco industry’s long term survival requires on-going
replenishment of its customer base. That is, to maintain business as usual, tobacco companies
must replace those smokers who die prematurely of their addiction (i.e., before they deliver
maximum profit). To grow the overall market size, tobacco companies must recruit new users
at a faster rate than existing users die.
Tobacco companies must therefore generate primary demand (i.e., recruit new users) or face
the prospect that their market will steadily decline. Evidence from tobacco industry
documents reveals two crucial points. First, how acutely aware tobacco companies are of this
reality. Second, their dependence on packaging to attract new users, especially in markets
9
where other promotion options have been curtailed.[34] Industry documents reveal the
crucial importance of attracting new smokers; a document from RJ Reynolds adduced in the
Mangini case states:
“Younger adult smokers have been the critical factor in the growth and decline of
every major brand and company of the last 50 years. They will continue to be just
as important to brands/companies in the next 50 years for two simple reasons:
The renewal of the market stems almost entirely from 18-year-old smokers. No
more than 5% of smokers start after age 24;
The brand loyalty of 18-year old smokers far outweighs any tendency to switch
with age.”[35]
Quotes such as these, which are evident in other documents housed in the Legacy Collection
(a repository of over 70 million formerly secret tobacco industry documents), confirm that
tobacco packages are designed to appeal to potential purchasers, including young people who
may not yet be smoking, but who could become attracted to it, and seriously question the
tobacco industry’s proclaimed focus on brand-switching.
Summary of Research into Tobacco Packaging
Evidence from industry documents, marketing theory, and empirical studies, clearly
demonstrate that tobacco packaging functions as a marketing medium and communicates
aspirational and attractive brand attributes. On-pack branding works in many ways; it reduces
the perceived risk of smoking by making tobacco appear just like any other product, it deflects
attention from warning labels, conveys desired imagery, and induces lapsing among smokers
trying to quit.
Attractive on-pack attributes help tobacco companies recruit the new users they require to
survive as commercial businesses. Tobacco industry claims that on-pack branding does
nomore than stimulate brand-switching lack empirical support and overlook the imperative all
tobacco companies have to attract new smokers.
In an environment where other marketing media are no longer available, the tobacco
industry’s own documents reveal the pivotal importance tobacco packaging has assumed.
Plain packaging would remove this last bastion of tobacco marketing.
10
Reducing the Appeal of Tobacco and the Acceptability of Smoking
In this section, we examine in more detail how tobacco companies have used the marketing
tools at their disposal to promote tobacco and smoking to young people, a crucial market they
must access to ensure their long-term survival. We focus in particular on packaging, which is
the only mainstream medium still available to tobacco companies operating in New Zealand,
and explain how introducing plain packaging would contribute to reducing the appeal of
tobacco, and approval of smoking, particularly with respect to young people.
Communicating Aspirational Imagery to Young People
Tobacco companies have long recognised the importance of focussing on young people as the
next generation of smokers. New recruits are vital to replace those smokers who die
prematurely from smoking and thus ensure the on-going profitability of tobacco companies’
business. Evidence from modelling studies demonstrate that, in order to reduce and maintain
very low levels of smoking prevalence long term, reductions in smoking uptake must occur as
well as substantial increases in quitting among current smokers. [36]
Very marked declines in regular smoking among New Zealand children have occurred; 2013
data show smoking prevalence is less than 4% among 14-15 year olds. However, smoking
among young adults has declined only very slowly, suggesting that substantial uptake of
smoking is continuing at a later age. Thus in the New Zealand Health Survey daily smoking
prevalence among 18-24 year olds in 2006/7 and 2011/12 was virtually unchanged at 24.6%
and 24.3% respectively. This finding is further supported by longitudinal data that shows
smoking uptake is common among young adults up to 25 years, and thereafter rare. [37]
Analysis of industry documents has revealed how sophisticated the marketing strategies used
to target youth and young adults are. Following an analysis of formerly secret industry
documents, Ling et al. wrote:
We analyzed the documents to find why and how the tobacco industry markets to
young adults and drew three conclusions. First, the industry views the transition
from smoking the first cigarette to becoming a confirmed pack-a-day smoker as a
series of stages (28–30) that may extend to age 25, (31) and it has developed
marketing strategies not only to encourage initial experimentation (often by teens)
but also to carry new smokers through each stage of this process. (28, 32–36)
Second, industry marketers encourage solidification of smoking habits and
increases in cigarette consumption by focusing on key transition periods when
young adults adopt new behaviors—such as entering a new workplace, school, or
the military–and, especially, by focusing on leisure and social activities. (33,37,38)
Third, tobacco companies study young adults' attitudes, social groups, values,
aspirations, role models, and activities and then infiltrate both their physical and
their social environments. (37,39–43).[27]
Tobacco companies have ensured they are intimately acquainted with young people’s
uncertainties, concerns, transition times and goals. They have used this knowledge to create
brands that target each of these life phases, provide reassurance about anxieties, and ease
11
transition times. A chart taken from RJ Reynold’s planning documents reveals how tobacco
brands targeted each life stage, from recruiting new smokers to deterring long-term smokers
from quitting:
Figure 1: Chart from RJ Reynolds Documenting Brand-Life Phase Relationships
Source: Ling et al.[27]
Awareness of Tobacco Brands among Children
Analysis of a 2004 Health Sponsorship Council national survey of 10 and 11 year old children
currently being undertaken at the University of Otago also illustrates the impact of tobacco
packaging on children and lends further support to plain packaging. Top line results indicate
that for three tobacco brand names 25%, 40% and 54% of 10-11 year old children already
recognised that these brands were related to smoking. This finding was likely due to tobacco
product packaging exposure, as, by 2004, all tobacco advertising and sponsorship had been
banned for around a decade. The proportions of children correctly identifying specific tobacco
brands were mostly aligned to the market share of those brands in 2004, supporting the
inference that exposure to packs was a key cause of the high awareness for tobacco brands
levels observed. For example, the most commonly identified brand (Holiday, 54% correctly
identified) was also the brand with the highest market share. In addition, those children who
had parents or caregivers who smoked were more likely to correctly identify five out of six of
the tobacco brands as related to smoking (e.g. 62% vs 44% for Holiday).
12
While part of the impact of tobacco product packaging in 2004 was likely to be through point
of sale tobacco displays (still present at the time), the finding of greater awareness among
children where one or more parent smoked suggests that exposure to packs outside of the
retail setting was a major influence on levels of tobacco brand awareness. Plain packaging
would minimise exposure to tobacco pack imagery and brand names that occurs despite retail
display restrictions, thereby reducing development of the positive attribute associations that
make tobacco products appear appealing and encourage smoking.
Branding and the Development of Attractive Attributes
On-pack tobacco imagery positions tobacco brands and smoking as attractive, normal and
desirable. Branding also creates and promotes desirable attributes that young adults draw on
when developing and communicating their own social identity. [20] Young people’s use of
brand imagery to construct their public persona first stimulated interest in plain packaging
nearly two decades ago when Canadian and New Zealand researchers independently
examined how young people perceived plain packaging.[38] Researchers reported that young
people had consistently more negative impressions of plain packs relative to branded cigarette
packs.[39] These findings are consistent with international research, which concluded that
adolescent and young adult respondents regarded plain packages as old fashioned and boring,
and thought fewer people would smoke if cigarettes were sold in plain packages.[40-42] Since
these initial studies, several projects, using different methods and different samples, and
conducted in different countries, have concluded that reducing on-pack brand insignia would
diminish the physical and social attractiveness of tobacco products and smoking, promote
cessation among some smokers, and reduce initiation among those experimenting with
tobacco.[43-46]
Our recent New Zealand studies confirm these findings and lend further support to the
conclusion that packaging functions as advertising in developing positive brand attributes that
facilitate smoking initiation and foster continued smoking. Using in-depth interviews and focus
groups conducted with young adult smokers and non-smokers, we found that tobacco brand
imagery appealed to young adults while plain packaging rendered tobacco products dull and
unattractive.[20 47 48] In a study examining brand-attribute associations, we found
participants associated distinctive attributes with tobacco brands on the basis of packaging
alone, and irrespective of their past exposure to the brand. That is, even with no smoking
history and no knowledge of the brand shown, participants could easily construct an identity
for the type of person to whom the brand would appeal.[21] [48] Indeed, and contrary to our
expectations, we found non-smokers made more favourable brand-attribute associations than
smokers. However, both groups described Basic, a near generic brand, as ‘plain’ or ‘budget’,
with no attractive features.[48] These studies provide further evidence of packaging’s role in
communicating attributes that enhance the appeal of tobacco brands and illustrate how
removal of these attributes elicits negative associations. Figure 2 below illustrates the diverse
attributes young adult smokers and non-smokers associate with tobacco brands on the basis
of their packaging alone. Figure 2 also shows the location of the near generic brand (Basic)
located in the bottom right quadrant, away from other brands and linked to the “plain” and
“budget” attributes.
13
Figure 2: Smokers’ and Non-smokers’ Brand Attribute Associations Following Exposure to
Tobacco Packaging
Source: Gendall et al.[47]
Specific Attribute Connotations
Several studies have examined the attributes connoted by packaging and explored the
influence these may have. These attributes include perceived attractiveness and product
quality.
Perceived Attractiveness
Researchers have examined the effect progressive removal of branding components has on
perceptions of the packs featured, the experience of smoking a cigarette from those packs,
and assumptions about the individuals who would purchase those packs. Australian studies
with adults and adolescents found that as packs became plainer (i.e., had progressively fewer
brand elements), participants were significantly less likely to rate these as attractive relative to
a fully branded pack.[45 46] A study of adolescent and young adult women in Brazil reached
similar conclusions and found that pack appeal declined as branding elements reduced; plain
packs were significantly less appealing and cigarettes from these were less desirable to be
seen smoking relative to sticks from branded packs.[49] Recent studies using EU,[50-53]
UK,[54] NZ,[20 47 48] and US,[43 55] samples have all consistently found that plain packages
are seen as less attractive and less appealing than branded packs.
14
Many of the studies cited above have explored how participants perceive packs, either using
criteria provided by the researchers or by exploring perceptions using unstructured interviews.
These studies have been criticised for failing to provide insights into behavioural outcomes.
New Zealand research we conducted therefore used a different method to estimate young
adult smokers’ choice behaviours.[56] Like the other studies, we manipulated the level of
branding present; we also manipulated the size of the health warning shown on each pack.
Participants viewed cards containing four pack options and selected the one they would be
most likely to choose and the one they would be least likely to choose, if they were purchasing
tobacco. Plain packs with large health warnings were significantly less likely to be chosen than
fully branded packs with smaller warnings.
A novel UK line of research has also taken a more behaviourally-oriented approach and used
naturalistic methods to examine smokers’ experiences of smoking cigarettes from a plain
pack.[57 58] Moodie and colleagues found that the young adult smokers who participated in
their study rated plain packages significantly more negatively than their own brand on the
following dimensions: stylishness, fashionability, coolness, attractiveness and appeal. Another
behavioural study used an experimental auction to estimate the likely price respondents
would pay for packs featuring different levels of branding and found fully-branded packs were
more highly valued (i.e., attracted a higher price) than plain packs.[55]
Studies that did not involve comparisons of plain and branded packaging have found that plain
packs are regarded as unattractive, uncool, and likely to be smoked by unpopular people.[54]
Research focussing on specific populations groups, such as young women, also concluded that
plain packs were significantly less appealing than branded packs.[44 59]
Qualitative studies have consistently concluded that plain packaging is less appealing than
branded packaging. Negative feelings generated by plain packaging lead smokers to feel less
attached to their brand; as one participant in a UK study noted:
Everybody has a cigarette they smoke, a brand they like in their own packet. It [plain
packaging] takes away the identity of it and makes it a little bit less appealing. [60]
Not only does plain packaging take away the identity created through branding, it replaces
that identity with negative connotations. Our research found that plain packaging removed
the glamorous connotations that disguised the harm caused by smoking, and exposed tobacco
as the toxic and pernicious product it is:
“It looks so boring and…you sort of see the cigarette for what it is…They just look
kind of very plain and filthy sorts of things”.[20]
Smokers lost the cultural cachet they gleaned from branding:
“It loses that whole alternative explanation for being, like looking trendy or cool. . .
. It just presents you as, ‘I’m smoking because I’m addicted.’”[20]
As well as the general finding that plain packaging is consistently seen as less attractive and
less appealing than branded packaging, research also shows that the attributes associated
15
with plain packages are repeatedly more negative than those associated with branded
packaging. Importantly, smokers of plain packages are regarded as less sociable, less trendy
and less mature, perceptions that became consistently more negative as the packaging shown
had fewer branding elements.[46] Several other studies report similar findings: plain packaging
elicits fewer positive attribute associations and more negative attribute associations than fully
branded packaging.[44 45 61]
Those studies that examined the perceived effects of plain packaging on smokers and non-
smokers found that non-smokers and intermittent smokers were more likely to find plain
packaging dissuasive than regular smokers. Although all groups found plain packaging less
appealing than branded packs, regular smokers generally reported that their addiction would
lead them to continue purchasing tobacco, though plain packaging would diminish their
experience of smoking. By contrast, intermittent smokers thought plain packaging would lead
them to quit smoking and non-smokers felt they would be even less likely to experiment with
smoking. This evidence suggests plain packaging will decrease smoking initiation,
experimentation, and subsequent addiction among young people. It will increase the
dissonance many addicted smokers already feel and, for some, may be a trigger to quit.
However, its primary benefit will be in reducing youth initiation.
Perceived Quality
Researchers have also examined how pack appearance generates connotations regarding
product quality. Qualitative research examining dark brown pack colours found these elicited
strong negative perceptions; participants associated the packs with excrement and dirt,
among other things.[60] Even studies conducted prior to the Australian legislation, where the
stimuli used were often other than a dissuasive dark brown or green colour, found packages
that had no branding present elicited negative quality connotations and were associated with
cigarettes regarded as less satisfying, of lower quality, and likely to have a reduced flavour.[45
46 49] Other studies exploring taste perceptions in more detail reported that cigarettes in
plain packs were perceived as “worse tasting” than those in branded packs.[59] Evidence from
a naturalistic study found cigarettes from plain packages were regarded as of poorer quality
than those from branded packs.[60]
Summary: Reducing the Appeal of Tobacco
Our considered view is that there are three key reasons why young people require protection
from tobacco marketing, including the marketing messages conveyed via on-pack branding.
First, there is now a detailed body of research that illustrates the attractive attributes brand
imagery communicates and the fact young people find these attributes highly desirable.
Second, there is clear evidence from the tobacco industry’s own documents that tobacco
companies have deliberately and systematically used marketing to recruit new smokers. Third,
removing brand imagery from tobacco packaging not only eliminates this source of social
cachet but diminishes the experience of smoking.
Several studies have now examined the effect plain packaging would have on the overall
appeal of smoking and perceptions of smokers. Irrespective of the methods used, the research
findings are highly consistent: plain packaging sharply reduces the appeal of tobacco brands.
16
Studies undertaken with young people conclude they associate plain packaging with negative
connotations, which they are unwilling to draw on when creating their own social identities.
Instead of providing young people with access to aspirational attributes, plain packaging
actively detracts from their identity and reduces their perceived experience of smoking.
In summary, the evidence to date strongly supports the proposition that plain packaging will
reduce the appeal of tobacco products and approval of smoking; these effects are likely to
be particularly evident among young people.[62]
17
Salience of Warnings Featured on Tobacco Packaging
The second key argument supporting plain packaging is that it will enhance the visual impact
and effect of on-pack warnings. There is clear evidence that pictorial warnings elicit stronger
responses than text-only warnings.[63] Research has shown pictorial warnings promote
awareness of smoking’s harms, stimulate quit-related thoughts, and increase actual quit
attempts.[64-68] Given the evidence that pictorial warning labels are more effective than text-
only warnings, it is logical to assume that removing visual clutter, such as branding, that
competes for attention would further improve the impact of warning labels.
Early studies into plain packaging and warnings, including New Zealand research, supported
this proposition and concluded that removing brand imagery would increase the impact of
health warnings.[39 41] Since this early work, several studies have compared text-only and
pictorial health warnings (see Hammond for a review of this work).[63] Plain packaging’s
relative recency means fewer studies have examined how it would affect the recall and
salience of pictorial warnings. We summarise and discuss some key findings below and
examine attributes of pictorial warnings and the effect plain packaging has on warning recall
and other responses.
Hammond’s comprehensive review of tobacco warning labels reported several findings
relevant to plain packaging.[63] He concluded that the salience of pictorial warnings depends
on their size and position and found:
“Youth and adults are more likely to recall larger warnings, rate larger warnings as
having greater impact, and often equate the size of the warning with the
magnitude of the risk.” (p. 3 online version).
Importantly, Hammond noted graphical features that differentiated the warning message
from the pack design increased the impact of the warning. He examined techniques such as
using boxes around the warning to create a visual demarcation between the warning and
brand elements. These findings can be logically applied to plain packaging, where perimeters
will no longer be required to distinguish the warning from the brand. Further, plain packaging
provides a natural opportunity to introduce much larger warning labels so that these, rather
than alluring branding, dominate pack surfaces.
Effect of Plain Packaging on Warning Label Recall
Studies examining the salience of warning labels on plain packages have used varied
approaches. One that varied pack colour and branding (white, grey, brown or branded pack)
and found that the warning label was significantly more prominent in the plain pack
conditions, while the brand name was significantly less prominent.[69] A cross-sectional study
conducted in Australia compared warning recall after participants had viewed one of four
packs that varied in its branding level and warning size.[45] Although this study did not report
differences between the branded and plain packs, the use of an existing, and high impact,
warning is likely to have confounded the study and inflated recall across all conditions (thus
reducing the likelihood of differences emerging between conditions).
18
Effect of Plain Packaging on Warning Label Attributes
The debriefing of participants in a naturalistic study explored the seriousness, salience and
believability of warning labels.[57] Although this phase of the study had a low response rate,
of those respondents who did participate (approximately a third of the original 140), most
reported that the warnings shown on plain packages were more salient and they viewed these
as more serious, than when the same warnings were shown on branded packs. However, the
perceived believability of the warnings did not differ across pack conditions.
Qualitative studies examining warning labels generally report that the removal of branding
paraphernalia from packaging reduces the visual clutter present, thus making warning labels
more salient. Further, the reported dullness of plain packaging also generally enhances the
seriousness and believability of the warnings.[53]
Potential Benefits of Larger Warning Labels
Recent evidence shows that warning labels help prevent relapse among smokers who have
become smokefree[70] (this effect is likely to be enhanced when warning labels are supported
by strong mass media campaigns[71]). Because pack warnings will be visible in situations when
smokers might be tempted to resume smoking (such as social settings where alcohol is being
consumed),[72] it is important that they are as visually impactful and salient as possible to
reduce the risk of relapse. As plain packaging enhances the visual impact of warnings, it is
logical to infer that it will also help prevent relapse among smokers who might otherwise
resume smoking.
Tobacco Industry Responses to Pictorial Warning Labels
International evidence suggests tobacco companies are using pack innovations to attract
attention and interest, and prompt experimentation. A recent Australian study found bevelled
and rounded pack shapes were seen as most attractive (more attractive than standard square
cornered packs).[73] The bevelled shape was also seen as more distracting to pictorial
warnings, particularly relative to the square shaped packs. UK research has also highlighted
the specific appeal particular pack designs have, notably the “perfume” shaped packages
designed to attract young women.[60]
Comments on packaging websites also provide insights into how tobacco companies are using
pack designs to reduce the impact and effect of pictorial warnings. One commentator
compared:
“Plain white cartons with horrendous graphics popping off the packs [with] high-
technology printed beautiful cartons, which without doubt will soften the impact
of the same horrendous graphics.”[74]
Evidence presented in a recent ASPIRE2025 seminar showed how pack designs extended into
health warnings so these were less obvious and appeared to merge into the brand design.
Figure 3 below illustrates this phenomenon.
19
Figure 3: Example of Reduced Impact Health Warnings
Source: Wakefield, M. ASPIRE2025 presentation, 18 September, 2012.
Evidence that tobacco companies are using brand imagery to reduce the visual impact of on-
pack warnings provides further justification for plain packaging and much larger health
warnings. Dissuasive backgrounds could not visually merge with health warnings and larger
warnings would dominate the pack surface, thus maximising the attention paid to the
messages featured, and the potential influence these could exert.
Summary of Plain Packaging and Warning Labels
Logically, the more warnings stand out, the higher the recall levels they will generate. The
relative recency of pictorial warning policies and plain packaging proposals means the body of
research examining how plain packaging will affect warning label salience is more limited.
There is very strong evidence that pictorial elements increase the salience and impact of
warning labels.[64 75] Studies conducted thus far suggest removing competing visual elements
in the form of brand imagery and logos will further enhance the impact of pictorial warnings.
Evidence that the tobacco industry has deliberately introduced pack designs using similar
colours to those shown in some warnings suggests an attempt to dilute warning label
effectiveness. Plain packaging would eliminate this opportunity to dilute warning labels’
effectiveness by providing a non-distracting canvas on which larger warnings could be
displayed.
20
Reducing Misleading Perceptions of Tobacco Products
Since regulations restricting the use of misleading descriptors such as “light” and “mild”,
tobacco companies have turned to colour to evoke erroneous “reduced harm”
connotations.[76-78] Red is widely used to suggest a “full strength” variant, blue indicates a
“mild” option, while white and silver connote “light” and “extra light”, respectively.
Several studies have examined how tobacco branding has created misleading perceptions
about the harms caused by tobacco products. This deception has occurred in two ways: first,
through the use of misleading variant names, particularly “light” and “mild” and, second, by
exploring perceptions of colours used on packaging. Studies have typically shown participants
different pack images and asked them to estimate the tar and nicotine a cigarette from these
packs would deliver; in addition, they have explored the relative perceived harm respondents
associate with cigarettes from plain and branded packs. Again, because interest in plain
packaging has re-emerged comparatively recently, fewer studies examining harm perceptions
have thus far been reported.
Tar and Nicotine Delivery
Darker coloured packs were typically associated with increased tar and nicotine delivery, [59]
although white plain packs did not differ significantly from fully branded packs in this
respect.[43 44] This is an important finding because it illustrates the importance of replacing
branding with a dissuasive colour. Replacing branding with a colour, such as white or grey,
which tobacco companies have already conditioned smokers to associate with reduced harm
products, risks perpetuating the incorrect belief that lighter coloured packs are less harmful
than those featuring darker colours.
Perceived Harm
As noted earlier, the varied pack colours used in plain packaging studies appears very likely to
have influenced study outcomes, particularly given tobacco companies’ use of colour to create
specific variant connotations. In general, studies using darker pack colours elicited stronger
perceptions of harm while lighter coloured packs were seen as less harmful.[43 46 59 69 78]
Tobacco Company Responses
Since the introduction of plain packaging in Australia, some tobacco companies have
introduced more detailed and evocative variant names.[79] These have the potential to re-
create the connotations formerly generated by on-pack branding and merit further analysis
since they represent a potential loop-hole (see section on Additional Measures below).
Summary of Plain Packaging and Misleading Perceptions
Evidence tobacco companies have obfuscated information that might reveal the nature and
extent of harm caused by smoking is well documented.[80] Several studies have examined the
effects coloured packaging and variant descriptors have on perceptions of harm and
consistently report that variant names, and the use of colours to connote variants, have
generated and supported mistaken beliefs about the relative harms of different tobacco brand
21
variants. Plain packaging would eliminate the explicit use of colour to create misleading
perceptions, while stricter regulations regarding the use of variant descriptors would eliminate
another strategy used to promulgate deceptive beliefs about harm.
22
Likely Effects of Plain Packaging
The research evidence suggests plain packaging will reduce the appeal of tobacco products
and smoking, impede smokers’ ability to draw on brand attributes as they construct their own
social personae; influence their smoking and cessation behaviour, and be important in
addressing health inequalities. We examine each of these factors below.
Effects of Plain Packaging on the Appeal of Tobacco Products and Smoking
Research examining the attractiveness of tobacco branding and the effect plain packaging has
on perceptions of pack attractiveness has consistently found that progressive removal of
brand elements results in predictable declines in perceived pack attractiveness.[45 46 56 81]
Irrespective of whether studies measure attribute associations, choices or evaluations of
actual experiences, the conclusions reached have been identical: plain packaging reduces the
appeal of tobacco products and diminishes the experience of smoking.
Public Support for Plain Packaging
In a 2012 study, we found strong public support for plain packaging:
“Although tobacco companies question the benefits of plain packaging, New
Zealanders strongly support this measure and believe attractive packaging
encourages smoking experimentation among young people. Respondents
supported suggestions that tobacco products should feature large warnings and
were not persuaded by industry arguments that plain packaging misappropriated
their intellectual property” (p.406).[82]
The 2012 Health and Lifestyle Survey found 72% of New Zealanders supported plain packaging
and only 17% opposed it (including 49% support even among smokers). [83]
Research examining adolescents’ (aged 14-15 years) support for plain packaging using ASH
Year 10 data found support had increased over time and by 2012, there was majority support
for plain packaging among all ethnicities. Figure 4 below outlines the trends in support over
time.
23
Figure 4: Adolescents’ Support for Plain Packaging 2009-2012
Plain packaging is a well-supported measure and we expect support to increase post-
implementation, as has been the case with other tobacco control measures (such as the
implementation of smoke-free bars and restaurants). Importantly, support comes not only
from adults, but from the young people who will be the primary beneficiaries of the smoke-
free 2025 goal.
Effects of Plain Packaging on Behaviour
New Zealand research has used a choice-based methodology to estimate the effects of
progressive reductions in brand elements and employed a probability scale to estimate the
likely effects on cessation related behaviours.[56] The findings suggest plain packaging would
significantly increase the likelihood that smokers will seek support to quit, reduce the number
of cigarettes they smoke, and make a quit attempt. A European study supports these
conclusions and found that plain packages were seen as most likely to promote cessation
among smokers who intended to quit.[84]
Naturalistic research assessing smokers’ responses to plain packaging reported that plain
packaging increased the likelihood smokers would avoid displaying tobacco packaging (either
by hiding or covering the pack). [85] In addition, plain packaging stimulated other cessation-
linked behaviours, such as forgoing cigarettes and smoking less around others, and increased
thoughts about quitting. In reporting on the longitudinal International Tobacco Control (ITC)
study, Borland had earlier found these latter behaviours predictive of quit attempts and
subsequent cessation.[86]
Australian Experience
Plain packaging was implemented in Australia in December 2012; initial evidence allows
preliminary conclusions with respect to its effects on the appeal of smoking, retailing,
cessation and illicit trade.
24
A study conducted during the phase-in of plain packaging found the policy detracted from the
experience of smoking. Smokers who were using tobacco from plain packs were more likely
than those still using branded packs to perceive their cigarettes as of lower quality and
delivering less satisfaction. Smokers using plain packs were also more likely to be thinking
about quitting and they were more supportive of the plain packaging policy.[87] A second
study, also conducted prior to the full implementation of plain packaging, examined lower
income smokers’ perceptions of this policy. Those exposed to a plain pack treatment gave
significantly lower ratings when assessing positive pack, smoker, and taste characteristics,
though there were no significant differences for negative smoker characteristics or harm
perceptions. However, those exposed to branded packaging had significantly higher odds of
purchasing than those who viewed a plain package.[88] The authors concluded that plain
packaging could reduce positive perceptions of tobacco packages among a group of very socio-
economically disadvantaged smokers.
Philip Morris International commissioned a report by a UK consultancy that administered:
“online questionnaires through a number of local suppliers in possession of Australian panels of
potential respondents at various points before and after the introduction of plain packaging”
(p. 1) [sic].[89] The report concluded that smoking prevalence had not declined, despite plain
packaging and the “increase in the noticeability of the new health warnings” (p.1). However, a
review undertaken by the Cancer Council Victoria documents several deficiencies in the PMI-
commissioned study, not least of which was the assumption that plain packaging should result
in rapid declines in smoking prevalence among heavily addicted smokers.[90]
Tobacco companies and retailers’ associations have claimed that plain packaging would
increase the transaction time of tobacco purchases. Studies examining this proposition have
reported quite different conclusions. An experimental study concluded prior to the
implementation of plain packaging tested the time taken to retrieve either plain or branded
cigarette packages from a display stand containing 50 different brands.[91] Contrary to
industry arguments, the authors reported that the average transaction time was significantly
faster when participants were required to retrieve plain, rather than branded, packs. Further,
those selecting from plain packs made significantly fewer selection errors than those choosing
from branded packs. Research undertaken prior to, during and post- plain pack
implementation time recorded and then compared pack retrieval times.[92] Retrieval times
during the phase-in did not vary from the first baseline period, though were slower than the
second baseline period. However, these differences disappeared by the second week of
implementation and remained at pre-implementation levels three months post-
implementation. The authors concluded there was no evidence that transaction times had
increased as predicted by tobacco companies and retailer groups.
One study has reported on a time-series analysis examining calls to the Quitline prior to and
following the introduction of plain packaging. [93] The authors reported a 78% increase in calls
to the Quitline following implementation of plain packaging; the analyses were adjusted for
seasonal trends, smoke-free and cessation advertising campaigns, price and smoking numbers.
This increase paralleled that observed following the introduction of pictorial warning labels,
although the study found that plain packaging has had a more sustained effect.
25
Tobacco companies have frequently claimed that plain packaging will increase illicit trade in
tobacco, leading to a loss in legitimate government revenue.[94 95] A UK analysis found
industry claims of increased illicit trade were inconsistent with both historical trends and
recent data, and questioned the validity of the surveys presented by tobacco companies.[95]
In October 2013, BAT Australia released a report commissioned from KPMG that used a
consumer survey and analysis of empty packs to assess the size of the illicit tobacco market.
The study concluded that illicit consumption had increased from 11.8 percent to 13.3 percent
in the year up to June 2013.[96] Quit Victoria and Cancer Council Victoria prepared a detailed
analysis of the KPMG report and outlined several limitations including the survey
representativeness, accuracy of response categories provided to respondents, and the
calculations presented.[97] In addition, the review queried the pack analysis methodology and
noted several factors that limited the approach taken in the KPMG report. Overall, the review
concluded that the total market for illicit tobacco was likely to be substantially smaller than
that estimated by KPMG.
The multi-national tobacco industry’s record of deceiving governments and citizens is evident
from industry documents and has been documented in several academic studies.[98 99] More
recently, Judge Gladys Kessler, who presided over the case taken by the US Department of
Justice against tobacco companies, found these companies had: “violated the civil provisions
of the Racketeer Influenced and Corrupt Organizations Act (“RICO”) by engaging in a massive
conspiracy to defraud the public by knowingly producing dangerous and addictive products
and misleading the public about the risks associated with these products” (reported, p.1)
[100].
The comprehensive examples of deceptive conduct outlined in Judge Kessler’s findings suggest
tobacco companies’ assertions cannot be relied upon. A recent study by Ulucanlar et al.
analysed tobacco companies’ submissions on UK proposals to introduce plain packaging; the
research reviewed critiques of the scientific public health evidence contained within industry
submissions. The authors found that:
“The companies submitted a very large volume of evidence, reported studies in an
inaccurate and misleading fashion, and sought to diminish the value and
exaggerate the shortcomings of studies by using mimicked scientific critique.”
(p.11)[101]
They went on to state:
“In formulating their response to the stakeholder consultation on SP, the tobacco
companies reframed prevailing scientific norms and practices as somehow
substandard and corrupt, seeking to impress on policy makers their own—
distorted—interpretation of science and the scientific method.” (p.11)[101]
We urge the Health Select Committee to assess tobacco industry submissions in the context of
the RICO findings and in the light of Ulucanlar et al.’s conclusions.
26
New Zealand’s International Obligations
New Zealand is a signatory to the Framework Convention on Tobacco Control (FCTC), which
defines tobacco advertising and promotion and states:
Article 1 (c): “tobacco advertising and promotion” means any form of commercial
communication, recommendation or action with the aim, effect or likely effect of promoting a
tobacco product or tobacco use either directly or indirectly.”
New Zealand has further agreed to provisions set out in Articles 11 and 13:
Article 11 (extract)
Adopt and implement, in accordance with its national law, effective measures to ensure that:
(a) tobacco product packaging and labelling do not promote a tobacco product by any
means that are false, misleading, deceptive or likely to create an erroneous impression
about its characteristics, health effects, hazards or emissions, including any term,
descriptor, trademark, figurative or any other sign that directly or indirectly creates the
false impression that a particular tobacco product is less harmful than other tobacco
products. These may include terms such as “low tar”, “light”, “ultra-light”, or “mild”;
and
(b) each unit packet and package of tobacco products and any outside packaging and
labelling of such products also carry health warnings describing the harmful effects of
tobacco use, and may include other appropriate messages. These warnings and messages:
i) shall be approved by the competent national authority,
(ii) shall be rotating,
(iii) shall be large, clear, visible and legible,
iv) should be 50% or more of the principal display areas but shall be no less than 30% of
the principal display areas,
(v) may be in the form of or include pictures or pictograms.
Article 13 (extract)
As a minimum, and in accordance with its constitution or constitutional principles, each Party
shall:
(a) prohibit all forms of tobacco advertising, promotion and sponsorship that promote a
tobacco product by any means that are false, misleading or deceptive or likely to create an
erroneous impression about its characteristics, health effects, hazards or emissions.
By functioning in the same way as advertising, on-pack branding breaches Article 13 of the
FCTC and refutes tobacco companies’ claims that pack livery serves only as an identifying
device that simplifies existing smokers’ decision-making or stimulates brand-switching. Given
this evidence, there is a strong case for New Zealand to mandate the plain packaging of all
tobacco products immediately; this policy would be consistent with our FCTC obligations to
eliminate all tobacco advertising and promotion.[102]
27
Do Recent or Alternative Policy Changes Obviate the Need for Plain Packaging?
The Smoke-free Environments (Controls and Enforcement) Amendment Act 2011 has reduced,
but not eliminated, children’s and non-smokers’ exposure to tobacco products. This Act, which
requires tobacco products to be stored in closed display units, greatly diminished the
pervasive presence tobacco brands formerly had in retail stores and was strongly opposed by
the tobacco industry in New Zealand and internationally. Covering “power-walls” means the
large tobacco retail displays formerly positioned behind store counters are no longer able to
communicate directly with smokers and quitters,[30] or with children and young people.[103]
However, while this important measure has reduced exposure to tobacco products, children,
non-smokers and quitters continue to see tobacco packs in numerous other settings, including
public spaces, their homes, and as litter.[72 104] A recent Australian study that observed
smoking and pack display in al fresco dining areas reported that, of the nearly 19,000
individuals observed, 8.3% were actively smoking and 11.4% were displaying tobacco
packages.[72] This on-going exposure means on-pack branding can still communicate desirable
connotations to users and non-users and constitutes an important reason why plain packaging
is required as an additional measure to reduce exposure to tobacco packs that occurs outside
the retail environment. A study from Australia after the implementation of plain packs
reported that pack display had declined significantly (by 15%) and smoking in outdoor al fresco
dining areas had also declined.[104] Both outcomes are important in firstly reducing exposure
to tobacco marketing and, secondly, reducing exposure to second-hand smoke.
Suggestions that plain packaging would be unnecessary if larger on-pack warnings were
introduced are also not supported by the research evidence. Even residual branding in the
context of larger health warnings increases the appeal of a pack relative to a completely plain
pack that features no branding at all.[81]
The research evidence supporting the immediate introduction and implementation of plain
packaging is clear. Plain packaging is the logical next step in achieving the New Zealand
Government’s objective of achieving a Smokefree Aotearoa /New Zealand by 2025. Plain
packaging will complement and extend existing measures and is urgently needed to eliminate
the on-going tobacco marketing that still occurs, despite existing laws, and hence will enable
us to fulfil our international commitments under the Framework Convention on Tobacco
Control. Because the evidence base is strong and well-developed with respect to the first
objective of the Bill, which we regard as the primary benefit the legislation will bring, we
strongly recommend that the Bill is passed and implemented without delay. We do not
consider that New Zealand should await the outcome of international litigation over plain
packaging, as these cases are being pursued deliberately by the tobacco industry to delay
adoption of the policy. Ironically, commitments by governments to await the outcome of this
litigation creates an incentive to postpone the resolution of these cases and a means by which
the industry can delay implementation almost indefinitely.
28
Areas for Further Investigation
Our informed view is that there are at least four areas where New Zealand could improve on
the plain packaging policy implemented in Australia:
Requiring dissuasive cigarette sticks;
Specifying the brand and variant names that may be used and restricting these to those
currently in use (i.e., avoiding the ‘poetry on a package’ that appears likely to occur in
Australia);
Introducing a wider and frequently replaced array of well-researched pictorial warnings
(including up to 95% of the front of pack), and
Reformatting the Quitline information so this is more visually salient and more effectively
stimulates access of Quit services, and exploring other ways by which the pack can be
made a vehicle for promoting and supporting quitting (such as mandating quit advice
inserts).
In addition, we strongly recommend that the Ministry of Health put in place a multi-faceted
evaluation to gauge plain packaging’s effects on perceptions of smoking, impact of warnings,
understanding of smoking’s harms, and smoking behaviour. We recommend discussion with
Australian researchers, who have a very detailed evaluation programme underway.
Dissuasive Sticks A small scale qualitative study revealed that dissuasively coloured cigarette sticks further
reduced the appeal of smoking and would be likely to deter smoking initiation.[105] Further
work is underway to test these findings among a wider sample of smokers. Given the strong
reactions against dissuasively coloured sticks, which social smokers found particularly
unattractive, we recommend consideration be given to this potential measure.
Limiting Variant Names
As noted above, evidence from Australia suggests tobacco companies have responded to plain
packaging by extending the variant names they associate with tobacco brands. The effect of
this will be to incorporate evocative descriptions on tobacco packages. Figure 5 provides an
example of variant name changes tobacco companies made in Australia in anticipation of the
introduction of plain packaging there.
Figure 5: Extension of Cigarette Brand Variant Names in Australia
Source: Wakefield, M. ASPIRE2025 presentation, 18 September, 2012.
29
Preliminary work we have undertaken suggests variant names enhance pack appeal and could
potentially undermine the intention of plain packaging.[106] We believe there is no public
health justification for allowing the introduction of any new variant names, as new variants are
designed to function as marketing tools and hence can only undermine public health measures
aimed at discouraging smoking uptake and encouraging quitting.
More Diverse Warning Messages
The most cost-effective messages are clearly those that have a wide population effect and
resonate with and influence smokers from different demographic groups. However, recent
research indicates that warning messages do ‘wear out’ and require refreshment;[63]
furthermore, emerging findings suggest the health themes that have dominated pictorial
warning labels (PWLs) may resonate less effectively with younger smokers, who use self-
exempting strategies to distance themselves from the effects depicted.[107] We are leading
an HRC funded project that is addressing this question.
Salience of Quitline Information
When PWLs were introduced in 2008, the Quitline number and a cessation support message
were included on packs. Evidence from Quitline suggests this policy led to an increase in the
number of callers citing the tobacco package as the source of Quitline information.[108]
However, the information provided lacks visual salience and two recent studies we have
undertaken suggest reformatted information could be more easily understood and more likely
to stimulate calls to the Quitline.[109] Figure 6 contrasts the current and a potential format.
Figure 6: Current and Re-formatted Quitline Information
Opportunities may also exist to make tobacco packages quit portals. Just as the tobacco
industry have used cigarette pack design to promote smoking, plain packs could be used to
promote quitting; for example, they could contain supportive messages about quitting , and
provide tips to maximise the chances of successful quitting.
30
We recommend that plain pack implementation be accompanied by a review of how Quit
information is presented in on-pack warnings and the potential for inclusion of smart-phone
readable QR codes that would provide a direct connection to the Quitline website ; as well as
investigation of other approaches by which the pack can be used as a vehicle to encourage and
support smokers to quit.
Additional Suggestions
The Ministry of Health should be able to require new warnings on packs through a simple
and straightforward regulatory process (with minimal need for consultation and no
requirement for additional legal amendments).
Given that, for decades, the multi-national tobacco industry has provided misleading
information to the public and to governments, there is a strong case for the Government
to have full access to all tobacco industry internal documents on marketing and other
activities. The current Bill provides an important opportunity for building these powers of
document access into New Zealand law.
31
References
1. Doll R, Peto R, Boreham J, et al. Mortality in relation to smoking: 50 years' observations on
male British doctors. BMJ 2004;328(7455):1519
2. US Department of Health and Human Services. The health consequences of smoking: a
report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services,
Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention
and Health Promotion, Office on Smoking and Health 2004;62
3. Hecht SS. Tobacco carcinogens, their biomarkers and tobacco-induced cancer. Nature
Reviews Cancer 2003;3(10):733-44
4. Ministry of Health. Tobacco Use in New Zealand: Key findings from the 2009 New Zealand
Tobacco Use Survey. Wellington: Ministry of Health, 2010.
5. Ministry of Health. Health Loss in New Zealand: A report from the New Zealand Burden of
Diseases, Injuries and Risk Factors Study, 2006–2016. In: Ministry of Health, ed. Wellington:
Ministry of Health,, 2013.
6. World Health Organization. WHO Report on the Global Tobacco Epidemic. Warning About
the Dangers of Tobacco In: World Health Organization, ed. Geneva: : World Health
Organization,, 2011.
7. Ministry of Health. The Health of New Zealand Adults 2011/12: Key findings of the New
Zealand Health Survey. In: Health Mo, ed. Wellington: Ministry of Health, 2012.
8. Pilditch J. The Silent Salesman: How to Develop Packaging that Sells. London: Harper and
Row, 1961.
9. Ford A, Moodie C, Hastings G. The role of packaging for consumer products: Understanding
the move towards' plain'tobacco packaging. Addiction Research & Theory 2012;20(4):339-
47
10. Wakefield M, Letcher T. My pack is cuter than your pack. Tobacco Control 2002;11:154-56
11. Wakefield M, Morley C, Horan J, et al. The cigarette pack as image: New evidence from
tobacco industry documents. Tobacco Control 2002;11(Suppl i:):i73-i80 doi:
10.1136/tc.11.suppl_1.i73[published Online First: Epub Date]|.
12. Freeman B, Chapman S, Rimmer M. The case for the plain packaging of tobacco products.
Addiction 2008;103:580-90 doi: 10.1111/j.1360-0443.2008.02145.x[published Online First:
Epub Date]|.
13. Hulit M. Marketing issues corporate affairs conference. Secondary Marketing issues
corporate affairs conference 1994. http://legacy.library.ucsf.edu/tid/jga42e00
14. Pollay RW. How cigarette advertising works: Rich imagery and poor information., 2000b.
32
15. Carter S. The Australian cigarette brand as product, person, and symbol. Tobacco Control
2003;12:79-86 doi: 10.1136/tc.12.suppl_3.iii79[published Online First: Epub Date]|.
16. Dewhirst T, Davis B. Brand strategy and integrated marketing communication. Journal of
Advertising 2005;34:81-92
17. Aaker J. Dimensions of brand personality. Journal of Marketing Research
1997;34(August):347-57
18. Sabbane LI, Lowrey TM, Chebat J-C. The effectiveness of cigarette warning label threats on
nonsmoking adolescents. Journal of Consumer Affairs 2009;43(2):332- doi:
doi/10.1111/j.1745-6606.2009.01142.x/full[published Online First: Epub Date]|.
19. Belk R. Posessions and the extended self. Journal of Consumer Research 1988;15:139-68
20. Hoek J, Gendall P, Gifford H, et al. Tobacco Branding, Plain Packaging, Pictorial Warnings,
and Symbolic Consumption. Qualitative Health Research 2012;22(5):630-39 doi:
10.1177/1049732311431070[published Online First: Epub Date]|.
21. Eadie D, Hastings G, Stead M, et al. Branding: Could it hold the key to future tobacco
reduction policy? Health Education 1999;3(May):103-09
22. Lennon A, Gallois C, Owen N, et al. Young Women as Smokers and Nonsmokers: A
Qualitative Social Identity Approach. Qualitative Health Research 2005;15(10):1345-59 doi:
10.1177/1049732305277844[published Online First: Epub Date]|.
23. Scheffels J, Lund KE. Occasional Smoking in Adolescence: Constructing an Identity of
Control. Journal of Youth Studies 2005;8(4):445 - 60
24. Scheffels J, Schou KC. To be one who continues to smoke: Construction of legitimacy and
meaning in young adults’ accounts of smoking. Addiction Research & Theory
2007;15(2):161-76 doi: doi:10.1080/16066350601179464[published Online First: Epub
Date]|.
25. Chapman S, Carter S. Avoid health warnings on all tobacco products for just as long as we
can”: A history of Australian tobacco industry efforts to avoid, delay and dilute health
warnings on cigarettes. Tobacco Control 2003;12(Suppl. III):iii3-iii22 doi:
10.1136/tc.12.suppl_3.iii13[published Online First: Epub Date]|.
26. Cummings K, Morley C, Horan J, et al. Marketing to America’s youth: Evidence from
corporate documents. Tobacco Control 2002;11(Suppl. I):i5-i17 doi:
10.1136/tc.11.suppl_1.i5 [published Online First: Epub Date]|.
27. Ling PM, Glantz SA. Why and How the Tobacco Industry Sells Cigarettes to Young Adults:
Evidence From Industry Documents. Am J Public Health 2002;92(6):908-16 doi:
10.2105/ajph.92.6.908[published Online First: Epub Date]|.
28. Brown & Williamson Tobacco Company. Speech Notes. Secondary Speech Notes 1998.
http://legacy.library.ucsf.edu/tid/knn70f00.
33
29. Vangeli E, Stapleton J, West R. Residual attraction to smoking and smoker identity
following smoking cessation. Nicotine & Tobacco Research:ntq104 doi:
10.1093/ntr/ntq104[published Online First: Epub Date]|.
30. Hoek J, Gifford H, Pirikahu G, et al. How do tobacco retail displays affect cessation
attempts? Findings from a qualitative study. Tobacco Control 2010;19(4):334-37 doi:
10.1136/tc.2009.031203[published Online First: Epub Date]|.
31. Scheffels J, Sæbø G. Perceptions of Plain and Branded Cigarette Packaging Among
Norwegian Youth and Adults: A Focus Group Study. Nicotine & Tobacco Research 2012 doi:
10.1093/ntr/nts153[published Online First: Epub Date]|.
32. DiFranza JR, Eddy JJ, Brown LF, et al. Tobacco acquisition and cigarette brand selection
among youth. Tobacco Control 1994;3(4):334
33. Dawes J. Cigarette brand loyalty and purchase patterns: an examination using US
consumer panel data. Journal of Business Research 2013
34. Krugman DM, Quinn WH, Sung Y, et al. Understanding the role of cigarette promotion and
youth smoking in a changing marketing environment. Journal of Health Communication
2005;10(261-278)
35. R.J. Reynolds Tobacco Company. Younger Adult Smokers: Strategies and Opportunities.
Secondary Younger Adult Smokers: Strategies and Opportunities 1998.
http://legacy.library.ucsf.edu/tid/krx52d00.
36. Gartner C, Barendregt J, Hall W. Predicting the future prevalence of cigarette smoking in
Australia: How low can we go and by when? Tobacco Control 2009;18(3):183-89 doi:
10.1136/tc.2008.027615 [published Online First: Epub Date]|.
37. Edwards R, Peace J, Carter K, et al. An examination of smoking initiation rates by age:
results from a large longitudinal study in New Zealand. Australia and New Zealand Journal of
Public Health 2013;37(6):516-19
38. Laugesen M. Tobacco promotion through product packaging In: Board NZTS, ed.
Wellington: Department of Health, 1989.
39. Beede P, Lawson R. The effect of plain packages on the perception of cigarette health
warnings. Public Health 1992;106:315-22
40. Rootman I, Flay B. A study on youth smoking. In: Promotion CfH, ed. Toronto: University of
Toronoto, 1995:Bates No. 2047549321-336.
41. Goldberg M, Kindra G, Lefebvre J, et al. When packages can’t speak: possible impacts of
plain and generic packaging of tobacco products: Expert Panel Report prepared at request
of Health Canada, 1995.
42. Goldberg M, Liefield J, Madill J, et al. The effect of plain packaging on response to health
warnings. American Journal of Public Health 1999;89:1434
34
43. Bansal-Travers M, Hammond D, Smith P, et al. The impact of cigarette pack design,
descriptors, and warning labels on risk perception in the US. American Journal of Preventive
Medicine 2011;40(6):674-82
44. Doxey J, Hammond D. Deadly in pink: the impact of cigarette packaging among young
women. Tobacco Control 2011;20(5):353-560 doi: 10.1136/tc.2010.038315[published
Online First: Epub Date]|.
45. Germain D, Wakefield M, Durkin S. Adolescents’ perceptions of cigarette brand image:
does plain packaging make a difference? Journal of Adolescent Health 2010;46:385-92 doi:
doi:10.1016/j.jadohealth.2009.08.009[published Online First: Epub Date]|.
46. Wakefield M, Germain D, Durkin S. How does increasingly plainer cigarette packaging
influence adult smokers' perceptions about brand image? An experimental study. Tobacco
Control 2008;17(6):416-21 doi: 10.1136/tc.2008.026732[published Online First: Epub
Date]|.
47. Gendall P, Hoek J, Edwards R, et al. Young Adults’ Interpretations of Tobacco Brands:
Implications for Tobacco Control. Nicotine & Tobacco Research 2011;13(10):911-18 doi:
10.1093/ntr/ntr094[published Online First: Epub Date]|.
48. Gendall P, Hoek J, Edwards R, et al. A cross-sectional analysis of how young adults perceive
tobacco brands: implications for FCTC signatories. BMC public health 2012;12(1):796
49. White CM, Hammond D, Thrasher JF, et al. The potential impact of plain packaging of
cigarette products among Brazilian young women: an experimental study. BMC public
health 2012;12(1):737
50. Gallopel-Morvan K, Gabriel P, Le Gall-Ely M, et al. Plain packaging and public health: The
case of tobacco. Journal of Business Research 2013;66(1): 133–36
51. Scheffels J, Sæbø G. Perceptions of Plain and Branded Cigarette Packaging Among
Norwegian Youth and Adults: A Focus Group Study. Nicotine & Tobacco Research
2013;15(2):450-56 doi: 10.1093/ntr/nts153[published Online First: Epub Date]|.
52. Brose LS, Chong CB, Aspinall E, et al. Effects of standardised cigarette packaging on craving,
motivation to stop and perceptions of cigarettes and packs. Psychology & Health 2014:1-12
doi: 10.1080/08870446.2014.896915[published Online First: Epub Date]|.
53. Van Hal G, Van Roosbroeck S, Vriesacker B, et al. Flemish adolescents’ perceptions of
cigarette plain packaging: a qualitative study with focus group discussions. BMJ Open
2012;2(6) doi: 10.1136/bmjopen-2012-001424[published Online First: Epub Date]|.
54. Moodie C, Ford A, Mackintosh AM, et al. Young People’s Perceptions of Cigarette
Packaging and Plain Packaging: An Online Survey. Nicotine & Tobacco Research
2012;14(1):98-105 doi: 10.1093/ntr/ntr136[published Online First: Epub Date]|.
35
55. Thrasher JF, Rousu MC, Hammond D, et al. Estimating the impact of pictorial health
warnings and “plain” cigarette packaging: evidence from experimental auctions among
adult smokers in the United States. Health Policy 2011;102(1):41-48
56. Hoek J, Wong C, Gendall P, et al. Effects of dissuasive packaging on young adult smokers.
Tobacco Control 2011;20(3):183-88 doi: 10.1136/tc.2010.037861[published Online First:
Epub Date]|.
57. Moodie C, Mackintosh AM, Hastings G, et al. Young adult smokers' perceptions of plain
packaging: a pilot naturalistic study. Tobacco Control 2011;20(5):367-73 doi:
10.1136/tc.2011.042911[published Online First: Epub Date]|.
58. Moodie CS, Mackintosh AM. Young adult women smokers’ response to using plain
cigarette packaging: a naturalistic approach. BMJ open 2013;3(3)
59. Hammond D, Doxey J, Daniel S, et al. Impact of Female-Oriented Cigarette Packaging in the
United States. Nicotine & Tobacco Research 2011;13(7):579-88 doi:
10.1093/ntr/ntr045[published Online First: Epub Date]|.
60. Moodie C, Ford A. Young adult smokers’ perceptions of cigarette pack innovation, pack
colour and plain packaging. Australasian Marketing Journal (AMJ) 2011;19(3):174-80
61. Hammond D, Daniel S, White CM. The effect of cigarette branding and plain packaging on
female youth in the United Kingdom. Journal of Adolescent Health 2013;52(2):151-7 doi:
10.1016/j.jadohealth.2012.06.003[published Online First: Epub Date]|.
62. Stead M, Moodie C, Angus K, et al. Is Consumer Response to Plain/Standardised Tobacco
Packaging Consistent with Framework Convention on Tobacco Control Guidelines? A
Systematic Review of Quantitative Studies. PloS one 2013;8(10):e75919
63. Hammond D. Health warning messages on tobacco products: a review. Tobacco Control
2011;20(5):327-37 doi: 10.1136/tc.2010.037630[published Online First: Epub Date]|.
64. Fong GT, Hammond D, Hitchman SC. The impact of pictures on the effectiveness of
tobacco warnings. Bulletin of the World Health Organization 2009;87(8):640-3 doi: S0042-
96862009000800026 [pii][published Online First: Epub Date]|.
65. Hammond D, Fong GT, Borland R, et al. Text and Graphic Warnings on Cigarette Packages:
Findings from the International Tobacco Control Four Country Study. American Journal of
Preventive Medicine 2007;32(3):202-09
66. Hammond D, Fong GT, McDonald PW, et al. Graphic Canadian cigarette warning labels and
adverse outcomes: Evidence from Canadian smokers. American Journal of Public Health
2004;94(8):1442-45
67. Hammond D, Fong GT, McDonald PW, et al. Impact of the graphic Canadian warning labels
on adult smoking behaviour. Tobacco Control 2003;12:391-95
36
68. Hammond D, Fong GT, McNeill A, et al. Effectiveness of cigarette warning labels in
informing smokers about the risks of smoking: findings from the International Tobacco
Control (ITC) Four Country Survey. Tobacco Control 2006;15(Suppl III):19-25
69. Gallopel-Morvan K, Moodie C, Rey J. Demarketing cigarettes through plain cigarette
packaging. Actes du Congre`s International de l’AFM (Association Franc¸aise du Marketing).
Le Mans, France: Universite´ du Mans, 2010.
70. Partos TR, Borland R, Yong H-H, et al. Cigarette packet warning labels can prevent relapse:
findings from the International Tobacco Control 4-Country policy evaluation cohort study.
Tobacco Control 2012 doi: 10.1136/tobaccocontrol-2011-050254[published Online First:
Epub Date]|.
71. Wakefield MA, Spittal MJ, Yong H-H, et al. Effects of mass media campaign exposure
intensity and durability on quit attempts in a population-based cohort study. Health
Education Research 2011 doi: 10.1093/her/cyr054[published Online First: Epub Date]|.
72. Wakefield MA, Zacher M, Bayly M, et al. The silent salesman: an observational study of
personal tobacco pack display at outdoor café strips in Australia. Tobacco Control 2013 doi:
10.1136/tobaccocontrol-2012-050740[published Online First: Epub Date]|.
73. Borland R, Savvas S, Sharkie F, et al. The impact of structural packaging design on young
adult smokers' perceptions of tobacco products. Tobacco Control 2011 doi:
10.1136/tobaccocontrol-2011-050078[published Online First: Epub Date]|.
74. Anonymous. Horrendous Graphics Softened by High-Technology Printing. Secondary
Horrendous Graphics Softened by High-Technology Printing 2009.
http://bestinpackaging.com/2009/09/18/horrendous-graphics-softened-by-high-
technology-printing/.
75. Borland R, Wilson N, Fong G, et al. Impact of graphic and text warnings on cigarette packs:
Findings from four countries over five years. Tobacco Control 2009;18(5):358-64
76. Peace J, Wilson N, Hoek J, et al. Survey of descriptors on cigarette packs: still misleading
consumers? Journal of the New Zealand Medical Association 2009;122(1303)
77. Hammond D, Parkinson C. The impact of cigarette package design on perceptions of risk.
Journal of Public Health 2009;31(3):345-53 doi: doi:10.1093/pubmed/fdp066[published
Online First: Epub Date]|.
78. Hammond D, Dockrell M, Arnott D, et al. Cigarette pack design and perceptions of risk
among UK adults and youth. European Journal of Public Health 2009;19(6):631-37 doi:
10.1093/eurpub/ckp122[published Online First: Epub Date]|.
79. Borland R, Savvas S. The effects of variant descriptors on the potential effectiveness of
plain packaging. Tobacco control 2014;23(1):58-63
80. Proctor RN. Golden holocaust: origins of the cigarette catastrophe and the case for
abolition: University of California Pr, 2012.
37
81. Wakefield M, Germain D, Durkin S, et al. Do larger pictorial health warnings diminish the
need for plain packaging of cigarettes? Addiction 2012;107(6):1159-67 doi: 10.1111/j.1360-
0443.2012.03774.x[published Online First: Epub Date]|.
82. Hoek J, Gendall P, Maubach N, et al. Strong public support for plain packaging of tobacco
products. Australian and New Zealand Journal of Public Health 2012;36(5):405-07
83. Health Promotion Agency. Public opinion about tobacco plain packaging. In: Health
Promotion Agency, ed. In Fact: Research facts from the HPA. Wellington: Health Promotion
Agency,, 2013.
84. Gallopel-Morvan K, Moodie C, Hammond D, et al. Consumer perceptions of cigarette pack
design in France: a comparison of regular, limited edition and plain packaging. Tobacco
Control 2012;21(5):502-06
85. Moodie C, Mackintosh AM, Hastings G, et al. Young adult smokers' perceptions of plain
packaging: a pilot naturalistic study. Tobacco Control 2011 doi:
10.1136/tc.2011.042911[published Online First: Epub Date]|.
86. Borland R, Yong H, Wilson N, et al. How reactions to cigarette packet health warnings
influence quitting: findings from the ITC Four-Country survey. Addiction 2009;104(4):669-75
87. Wakefield MA, Hayes L, Durkin S, et al. Introduction effects of the Australian plain
packaging policy on adult smokers: a cross-sectional study. BMJ open 2013;3(7)
88. Guillaumier A, Bonevski B, Paul C, et al. Socioeconomically disadvantaged smokers’ ratings
of plain and branded cigarette packaging: an experimental study. BMJ Open 2014;4(2) doi:
10.1136/bmjopen-2013-004078[published Online First: Epub Date]|.
89. London Economics. An analysis of smoking prevalence in Australia. Final. London: London
Economics,, 2013:10.
90. Cancer Council Victoria. Comments on the Philip Morris-funded London Economics report
“An analysis of smoking prevalence in Australia, Final”. Melbourne: Cancer Council Victoria,,
2013.
91. Carter OBJ, Mills BW, Phan T, et al. Measuring the effect of cigarette plain packaging on
transaction times and selection errors in a simulation experiment. Tobacco Control 2011
doi: 10.1136/tobaccocontrol-2011-050087[published Online First: Epub Date]|.
92. Wakefield M, Bayly M, Scollo M. Product retrieval time in small tobacco retail outlets
before and after the Australian plain packaging policy: real-world study. Tobacco Control
2014;23(1):70-76 doi: 10.1136/tobaccocontrol-2013-050987[published Online First: Epub
Date]|.
93. Young JM, Stacey I, Dobbins TA, et al. 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
38
94. Jarman H. Attack on Australia: Tobacco industry challenges to plain packaging. Journal of
public health policy 2013;34(3):375-87
95. Rowell A, Evans-Reeves K, Gilmore A. Tobacco industry manipulation of data on and press
coverage of the illicit tobacco trade in the UK. Tobacco control 2014:tobaccocontrol-2013-
051397
96. British American Tobacco Australia. Illicit tobacco in Australia, 2013.
97. Quit Victoria and Cancer Council Victoria. Analysis of KPMG LLP report on use of illicit
tobacco in Australia. Melbourne: Quit Victoria and Cancer Council Victoria, 2013/2014.
98. Bero LA. Tobacco industry manipulation of research. Public Health Reports
2005;120(2):200
99. Hammond D, Collishaw NE, Callard C. Secret science: tobacco industry research on smoking
behaviour and cigarette toxicity. The Lancet 2006;367(9512):781-87
100. Guardino S, Banthin C, Daynard R. USA v. Philip Morris USA, Inc., et al.: Analysis of Judge
Kessler’s Final Opinion and Order: Boston: Tobacco Control Resource Center, 2007.
101. Ulucanlar S, Fooks GJ, Hatchard JL, et al. Representation and Misrepresentation of
Scientific Evidence in Contemporary Tobacco Regulation: A Review of Tobacco Industry
Submissions to the UK Government Consultation on Standardised Packaging. PLoS Med
2014;11(3):e1001629 doi: 10.1371/journal.pmed.1001629[published Online First: Epub
Date]|.
102. Wilson N, Hoek J, Thomson G, et al. Plain packaging for tobacco in New Zealand: local
evidence and arguments. New Zealand Medical Journal 2011;124(1338):120-25
103. Paynter J, Edwards R, Schluter P, et al. Point of sale tobacco displays and smoking among
14-15 year olds in New Zealand: a cross-sectional study. Tobacco Control 2009;18(268-274)
104. Zacher M, Bayly M, Brennan E, 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 doi:
10.1111/add.12466[published Online First: Epub Date]|.
105. Hoek J, Robertson C. How Do Young Adult Female Smokers Interpret Dissuasive Cigarette
Sticks? A Qualitative Analysis. Journal of Social Marketing (In press)
106. Hoek J, Gendall P, Kemper J. How do brand variant names affect perceptions of risk and
quitting ease? Society for Nicotine & Tobacco Research Conference. Seattle, United States,
2014.
107. Hoek J, Hoek-Sims A, Gendall P. A qualitative exploration of young adult smokers'
responses to novel tobacco warnings. BMC Public Health 2013;13(609) doi: 10.1186/1471-
2458-13-609[published Online First: Epub Date]|.
39
108. Li J, Grigg M. New Zealand: new graphic warnings encourage registrations with the
quitline. Tobacco Control 2009;18(1):72
109. Hoek J, Tatton L. An Evaluation of Alternative On-pack Quitline Information Formats. 15th
World Conference on Tobacco or Health. Singapore: World Conference on Tobacco or
Health, 2012.