Megan Bayly

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.

AIMS We tested whether prevalence of cigarette pack display and smoking at outdoor venues and pack orientation changed following the introduction of plain packaging and larger pictorial health warnings in Australia. METHODS Between October and April 2011-12 (pre-plain packaging, pre-PP) and 2012-13 (post-plain packaging, post-PP), we counted patrons, smokers and tobacco packs at cafés, restaurants and bars with outdoor seating. Pack type (fully branded, plain or unknown) and orientation were noted. Rates of pack display, smoking and pack orientation were analysed using multi-level Poisson regression. RESULTS Pack display declined by 15% [adjusted incident rate ratio (IRR) = 0.85, 95% confidence interval (CI) = 0.79-0.91, P < 0.001], driven by a 23% decline in active smoking (IRR = 0.77, 95% CI = 0.71-0.84, P < 0.001) between phases. The decline in pack display coincided with the full implementation of plain packaging from December 2012, was stronger in venues with children present and was limited to mid and high socio-economic status (SES) areas. The proportion of packs orientated face-up declined from 85.4% of fully branded packs pre-PP to 73.6% of plain packs post-PP (IRR = 0.87, 95% CI = 0.79-0.95, P = 0.002). Alternatively, the proportions concealed by telephones, wallets or other items (4.4% of fully branded packs pre-PP and 9.5% of plain packs post-PP; IRR = 2.33, 95% CI = 1.72-3.17, P < 0.001) and in an external case (1.5-3.5% of all packs; IRR = 2.79, 95% CI = 1.77-4.40, P < 0.001) increased. Low SES areas evidenced the greatest increase in pack concealment and the greatest decline in face-up pack orientation. CONCLUSIONS Following Australias 2012 policy of plain packaging and larger pictorial health warnings on cigarette and tobacco packs, smoking in outdoor areas of cafés, restaurants and bars and personal pack display (packs clearly visible on tables) declined. Further, a small proportion of smokers took steps to conceal packs that would otherwise be visible. Both are promising outcomes to minimize exposure to tobacco promotion.

Time series analysis of the impact of tobacco control policies on smoking prevalence among Australian adults, 2001?2011

OBJECTIVE To determine the impact of tobacco control policies and mass media campaigns on smoking prevalence in Australian adults. METHODS Data for calculating the average monthly prevalence of smoking between January 2001 and June 2011 were obtained via structured interviews of randomly sampled adults aged 18 years or older from Australias five largest capital cities (monthly mean number of adults interviewed: 2375). The influence on smoking prevalence was estimated for increased tobacco taxes; strengthened smoke-free laws; increased monthly population exposure to televised tobacco control mass media campaigns and pharmaceutical company advertising for nicotine replacement therapy (NRT), using gross ratings points; monthly sales of NRT, bupropion and varenicline; and introduction of graphic health warnings on cigarette packs. Autoregressive integrated moving average (ARIMA) models were used to examine the influence of these interventions on smoking prevalence. FINDINGS The mean smoking prevalence for the study period was 19.9% (standard deviation: 2.0%), with a drop from 23.6% (in January 2001) to 17.3% (in June 2011). The best-fitting model showed that stronger smoke-free laws, tobacco price increases and greater exposure to mass media campaigns independently explained 76% of the decrease in smoking prevalence from February 2002 to June 2011. CONCLUSION Increased tobacco taxation, more comprehensive smoke-free laws and increased investment in mass media campaigns played a substantial role in reducing smoking prevalence among Australian adults between 2001 and 2011.

Potential effectiveness of specific anti-smoking mass media advertisements among Australian Indigenous smokers

Aboriginal and Torres Strait Islander Australians (Indigenous Australians) have more than twice the smoking prevalence of non-Indigenous Australians. Anti-smoking campaigns have demonstrated success in the general population but little is known about their impact among Indigenous people. A total of 143 Indigenous and a comparison group of 156 non-Indigenous smokers from South Australia were shown 10 anti-smoking advertisements representing a range of advertisements typically aired in Australia. Participants rated advertisements on a five-point Likert scale assessing factors including message acceptance and personalized effectiveness. On average, Indigenous people rated the mainstream advertisements higher than non-Indigenous people and were more likely to report that they provided new information. Advertisements with strong graphic imagery depicting the health effects of smoking were rated highest by Indigenous smokers. Advertisements featuring real people describing the serious health consequences of smoking received mixed responses. Those featuring an ill person were rated higher by Indigenous people than those featuring the family of the person affected by a smoking-related disease. With limited Indigenous-specific messages available and given the finite resources of most public health campaigns, exposure to mainstream strong graphic and emotive first-person narratives about the health effects of smoking are likely to be highly motivating for Indigenous smokers.

Standardised packaging and new enlarged graphic health warnings for tobacco products in Australia—legislative requirements and implementation of the Tobacco Plain Packaging Act 2011 and the Competition and Consumer (Tobacco) Information Standard, 2011

This paper describes the development, content and implementation of two pieces of Australian tobacco control legislation: one to standardise the packaging of tobacco products and the other to introduce new, enlarged graphic health warnings. It describes the process of legislative drafting, public consultation and parliamentary consideration. It summarises exactly how tobacco products have been required to look since late 2012. Finally, it describes implementation, most particularly, the extent to which packs compliant with the legislation became available to consumers over time.

Availability of illicit tobacco in small retail outlets before and after the implementation of Australian plain packaging legislation

Objective We aimed to assess change in the availability of illicit tobacco in small mixed business retail outlets following the December 2012 introduction of plain packaging in Australia. Methods 303 small retail outlets were visited in June and September 2012 (baseline months), and in December 2012 and February, April and July 2013. Fieldworkers requested a particular low-cost brand of cigarettes and then pressed the retailer for an ‘even cheaper’ brand. The cheapest pack of cigarettes offered was purchased and later examined to assess any divergence from prescribed Australian packaging regulations. The price paid was compared with tax liability and recommended retail price for the particular brand and pack size. In a sub-set of 179 stores, fieldworkers then asked the retailer about availability of unbranded (chop-chop) tobacco. Results Thirteen (2.2%) of 598 packs purchased pre-plain packaging were either non-compliant with Australian health warnings and/or suspiciously priced. Four packs (1.3%) of 297 met either or both criteria in the December implementation month, and five (0.6%) of 878 did so in the three collection months following implementation. Chop-chop was offered upon enquiry on 0.6% (n=2) of 338 occasions prior to implementation, 0.6% (n=1) of 170 occasions in the December 2012 implementation month, and 0.6% (n=3) of 514 occasions postimplementation. The likelihood of a ‘positive’ response (either an offer to sell or information about where unbranded tobacco may be purchased) did not differ across preimplementation, during-implementation and postimplementation waves. Conclusions Overall, packs judged likely to be illicit were sold in response to requests for cheapest available packs on fewer than one percent of occasions. Offers to sell unbranded tobacco were rare. No change in availability of illicit tobacco was observed following implementation of plain packaging.

Changes in use of types of tobacco products by pack sizes and price segments, prices paid and consumption following the introduction of plain packaging in Australia

Objectives To describe changes among smokers in use of various types of tobacco products, reported prices paid and cigarette consumption following the standardisation of tobacco packaging in Australia. Methods National cross-sectional telephone surveys of adult smokers were conducted from April 2012 (6 months before transition to plain packaging (PP)) to March 2014 (15 months afterwards). Multivariable logistic regression assessed changes in products, brands and pack types/sizes; multivariable linear regression examined changes in inflation-adjusted prices paid and reported cigarette consumption between the pre-PP and three subsequent periods—the transition phase, PP year 1 and PP post-tax (post a 12.5% tax increase in December 2013). Results The proportion of current smokers using roll-your-own (RYO) products fluctuated over the study period. Proportions using value brands of factory-made (FM) cigarettes increased from pre-PP (21.4%) to PP year 1 (25.5%; p=0.002) and PP post-tax (27.8%; p<0.001). Inflation-adjusted prices paid increased in the PP year 1 and PP post-tax phases; the largest increases were among premium FM brands, the smallest among value brands. Consumption did not change in PP year 1 among daily, regular or current smokers or among smokers of brands in any market segment. Consumption among regular smokers declined significantly in PP post-tax (mean=14.0, SE=0.33) compared to PP year 1 (mean=14.8, SE=0.17; p=0.037). Conclusions Introduction of PP was associated with an increase in use of value brands, likely due to increased numbers available and smaller increases in prices for value relative to premium brands. Reported consumption declined following the December 2013 tax increase.

Potential effectiveness of anti-smoking advertisement types in ten low and middle income countries: Do demographics, smoking characteristics and cultural differences matter?

Unlike high income countries, there is limited research to guide selection of anti-tobacco mass media campaigns in low and middle income countries, although some work suggests that messages emphasizing serious health harms perform better than other message types. This study aimed to determine whether certain types of anti-smoking advertisements are more likely to be accepted and perceived as effective across smokers in 10 low to middle income countries. 2399 18-34 year old smokers were recruited in Bangladesh, China, Egypt, India, Indonesia, Mexico, Philippines, Russia, Turkey and Vietnam to view and rate 10 anti-tobacco ads. Five ads were shown in all countries and five ads were chosen by country representatives, providing a total of 37 anti-smoking ads across all countries (10 graphic health effects ads, 6 simulated health effects, 8 emotional stories of health effects, 7 other health effects and 6 non-health effects). Smokers rated ads on a series of 5-point scales containing aggregated measures of Message Acceptance and Perceived Effectiveness. All ads and materials were translated into the local language of the testing regions. In multivariate analysis, graphic health effects ads were most likely to be accepted and perceived as effective, followed by simulated health effects ads, health effects stories, other health effects ads, and then non-health effects ads. Interaction analyses indicated that graphic health effects ads were less likely to differ in acceptance or perceived effectiveness across countries, gender, age, education, parental status and amount smoked, and were less likely to be affected by cultural differences between characters and contexts in ads and those within each country. Ads that did not emphasize the health effects of smoking were most prone to inconsistent impact across countries and population subgroups. Graphic ads about the negative health effects of smoking may be most suitable for wide population broadcast in low and middle income countries.

The silent salesman: an observational study of personal tobacco pack display at outdoor café strips in Australia.

Objective We sought to determine the relative frequency and nature of personal display of cigarette packs by smokers in two Australian cities where 30% front-of-pack and 90% back-of-pack health warnings have been used since 2006 and comprehensive tobacco marketing restrictions apply. Methods An observational study counted patrons, active smokers and tobacco packs at cafés, restaurants and bars with outdoor seating. Pack orientation and use of cigarette cases were also noted. Results Overall, 18 954 patrons, 1576 active smokers and 2153 packs were observed, meaning that one out of every 12.0 patrons was actively smoking, and one of every 8.8 patrons displayed a pack. Packs were more frequently observed in lower socio-economic neighbourhoods, reflecting the higher prevalence of smoking in those regions. Packs were displayed less often in venues where children were present, suggesting a greater tendency not to smoke around children. Most packs (81.4%) were oriented face-up, permitting prominent brand display. Only 1.5% of observed packs were cigarette cases, and 4.2% of packs were concealed by another item, such as a phone or wallet. Conclusions Tobacco packs are frequently seen on table-tops in café strips, providing many opportunities for other patrons and passers-by to be incidentally exposed to cigarette brand names and imagery. Use of cigarette cases is rare, suggesting that smokers eventually habituate to pictorial warnings on branded packs and/or find repeated decanting of each newly purchased branded pack into a case to be inconvenient.

Product retrieval time in small tobacco retail outlets before and after the Australian plain packaging policy: real-world study

Objective We aimed to assess change in cigarette pack retrieval time in small retail outlets following the introduction of plain packaging in Australia in 1 December 2012. Methods A sample of 303 milk bars, convenience stores, petrol stations and newsagents was selected in four capital cities, stratified by area socioeconomic status. In June and September (baseline months), the first 2 weeks of December 2012, and February 2013, stores were visited by trained fieldworkers who requested a cigarette pack of a pre-determined brand, variant and pack size, unobtrusively recording the time from the end of the request to when the pack was scanned or placed on the counter. Results In multivariate analysis, December retrieval time (12.43 s) did not differ from June (10.91 s; p=0.410) or February (10.37 s; p=0.382), but was slower than September (9.84 s; p=0.024). In December, retrieval time declined as days after plain packaging implementation increased (β=−0.21, p=0.011), returning to the baseline range by the second week of implementation. This pattern was not observed in baseline months or in February. Sensitivity analyses showed that results were robust to the variability in purchasing circumstances in tobacco retail outlets. Conclusions Retailers quickly gained experience with the new plain packaging legislation, evidenced by retrieval time having returned to the baseline range by the second week of implementation and remaining so several months later. The long retrieval times predicted by tobacco industry-funded retailer groups and the consequent costs they predicted would fall upon small retailers from plain packaging are unlikely to eventuate.

The advertised price of cigarette packs in retail outlets across Australia before and after the implementation of plain packaging: a repeated measures observational study

Objective This study monitored the advertised price of the most prominently promoted and the cheapest single packs of cigarettes in Australian retail outlets before and after the implementation of plain packaging. Methods A panel of 421 outlets in four large Australian cities was visited monthly from May 2012 to August 2013 and the brand, pack size and price of the most-prominently listed and lowest-priced single cigarette pack were recorded from each stores tobacco price board. Changes in the inflation-adjusted stick price were examined using linear mixed models, controlling for fixed effects of city, store type, area socioeconomic status and random effects of time. The adjusted stick price was also examined over time by tobacco manufacturer and pack size. Results The inflation-adjusted stick price of the most-prominently advertised single packs was significantly higher than in May–July 2012 from August–October 2012 for mainstream and premium brands and from February–April 2013 for value brands. Adjusted average stick prices of lowest-priced packs in August 2013 were