Do larger pictorial health warnings diminish the need for plain packaging of cigarettes?

Aims To assess the effects on brand appeal of plain packaging and size of pictorial health warnings (PHWs). Design Three (30%, 70% and 100% size front‐of‐pack PHWs) by two (branded versus plain) between‐subjects online experiment. Setting Australia. Participants A total of 1203 adult smokers. Measurements Rating of cigarette brands, smoking attitudes and intentions, purchase intent. Findings Compared to branded packs, plain packs reduced smokers' ratings of ‘positive pack characteristics’ (P < 0.001), ‘positive smoker characteristics’ (P < 0.001) and ‘positive taste characteristics’ (P = 0.039). Plain packs were rated as being smoked by people who were more ‘boring’ than those who smoked branded packs (P = 0.001). By contrast, increasing size of PHW above 30% only reduced ratings of ‘positive pack characteristics’ (P = 0.001), but also decreased ratings of smokers as being ‘boring’ (P = 0.027). Plainness and size of PHW interacted in predicting ratings of ‘positive pack characteristics’ (P = 0.008), so that when packs were plain, increasing the size of PHW above 30% did not further reduce ratings. Presentation of only plain packs increased the likelihood that smokers would not choose to purchase any pack (20.3%) compared to presentation of only branded packs (15.3%) (odds ratio = 1.4; P = 0.026), while size of PHWs had no influence upon purchase choice. Conclusions Plain packaging probably plays a superior role in undermining brand appeal and purchase intent to increasing health warning size. Policymakers should not rely solely upon large health warnings, which are designed primarily to inform consumers about smoking harms, to also reduce brand appeal: both strategies are likely to be required.     

Advertising, price, income and publicity effects on weekly cigarette sales in New Zealand supermarkets

Total cigarettes (all brands) sold weekly by a panel of 60 New Zealand supermarkets were monitored electronically for 42 weeks, a period when cigarette advertisements were in plain format with strong, varied disease warnings. Real cigarette price, newspaper advertising of old, regular and upmarket brands, and the number of newspaper news items on smoking issues were inversely associated with cigarette sales. Tending to increase total sales (all brands) were: more non-shopping days in the current week, and in the week following; volume of grocery items purchased, to indicate income and store traffic; and real advertising expenditure in newspapers for new downmarket cigarette brands, particularly one heavily-advertised brand (Peter Jackson) which was in late 1989 smoked by 4% of teenage smokers. All factors when interacting, explained 93% of changes in weekly cigarette sales. Most of the change occurred in the same week, and was 90% in place after a further 3 weeks. Newspapers, by doubling news coverage of smoking issues or by banning cigarette advertisements, can lower cigarette consumption as much as can a 10% price increase.     

Plain packaging increases visual attention to health warnings on cigarette packs in non-smokers and weekly smokers but not daily smokers

Aims To assess the impact of plain packaging on visual attention towards health warning information on cigarette packs. Design Mixed‐model experimental design, comprising smoking status as a between‐subjects factor, and package type (branded versus plain) as a within‐subjects factor. Setting University laboratory. Participants Convenience sample of young adults, comprising non‐smokers (n = 15), weekly smokers (n = 14) and daily smokers (n = 14). Measurements Number of saccades (eye movements) towards health warnings on cigarette packs, to directly index visual attention. Findings Analysis of variance indicated more eye movements (i.e. greater visual attention) towards health warnings compared to brand information on plain packs versus branded packs. This effect was observed among non‐smokers and weekly smokers, but not daily smokers. Conclusion Among non‐smokers and non‐daily cigarette smokers, plain packaging appears to increase visual attention towards health warning information and away from brand information.     

Introduction of standardised tobacco packaging and minimum excise tax on in the UK: a prospective study

BackgroundStandardised packaging for factory made and roll your own tobacco was implemented in the UK in May, 2017, alongside a minimum excise tax for factory made products. As other jurisdictions attempt to implement standardised packaging, the tobacco industry continues to suggest that it would be counterproductive, in part by leading to falls in price due to commoditisation. Here, we assess the impact of the introduction of these policies on the UK tobacco market.MethodsWe did a prospective study of UK commercial electronic point-of-sale data from 11 constituent geographic areas. The main outcomes were changes in sales volumes, volume-weighted real prices, and tobacco industry revenue. These were assessed using trend estimation from generalised additive mixed models. Products distributed to less than 10% of stores were excluded for sample design reasons; nevertheless, the analysis included an estimated 91% of the UK tobacco market products. The study did not require ethical approval.Findings107 572 monthly observations of products from May, 2015, to April,2018were included in the analysis. Introduction of standardised packaging and a minimum excise tax was associated with a doubling of the rate of sales decline. The most marked change in sales volumes was among the cheapest factory-made brands, where substantial sales growth stopped and prices rose markedly (prices increased by 0·035 p for the cheapest factory-made brands compared with 0·016 p across all factory-made brands and a 0·004 p increase across all products from May, 2015, to April, 2018). There was no evidence of commoditisation as market segmentation (price differentiation and different price trajectories for premium and lower priced products) continued. Company monthly net revenues declined from GBP £231 million (95% CI £222 million to £240 million) in May, 2015, to £192 million (£182 million to £201 million) in April, 2018.InterpretationThe concurrently introduced policies of standardised packaging and minimum excise tax were associated with declining tobacco sales and tobacco industry revenue, which might underpin the tobacco industry's opposition to the policies. Prices at the end of the period were higher than the at the start, implying no long-term price falls. A minimum excise tax might limit the tobacco industry's ability to keep low-priced tobacco, which is popular with young and disadvantaged smokers, available. The complementary introduction of standardised packaging and the minimum excise tax meant effects could not be distinguished statistically.FundingCancer Research UK and British Heart Foundation (grant number C27260/A23168).     

Smoker preference for "elastic cigarettes" in the Canadian cigarette market

Elastic cigarettes are characterized by yields of constituents that increase proportionally faster than smoke volume as cigarettes are smoked more intensely. Elasticity may function to overcome physical limitations in increasing puff volume during nicotine-seeking behaviour. The purpose of this study was to determine if there are elastic cigarettes in the Canadian cigarette market and to determine smoker preference for elastic cigarettes. Elasticity was calculated for 115 brands in the Canadian filtered cigarette market for puff volumes of 44 and 56 ml. Puff volumes, nicotine and tar deliveries were obtained from earlier published documents. Sales data were used as a proxy for smoker preference. Ordinary least squares regression was used to determine the association of sales and elasticity in the Canadian cigarette market. The cigarette brands ranged from a mean elasticity value of 1.21 to 0.67. Of the 115 Canadian cigarette brands tested, 23 brands had a mean elasticity value significantly over 1.00, making them elastic. After adjusting for brand, the average elastic cigarette sold an average of 361 million cigarettes while an inelastic cigarette sold 89.5 million cigarettes (p<0.0001). The difference in sales between elastic and inelastic cigarettes was independent of tar yield and filter type. Elasticity was not associated with tar yield (p=0.2734). There are elastic cigarettes in the Canadian cigarette market and the results suggest a possible smoker preference for elastic cigarettes. Utilizing elasticity may be valuable in the development of future harm reduction strategies.     

Youth attitudes towards tobacco control: a preliminary assessment

The attitudes of Ontario youth toward the sale and price of cigarettes, making smoking against the law, and tobacco company truthfulness were assessed in 2001 and compared to adult attitudes in 2000 and youth attitudes in 2003. Youth were more supportive of restricting cigarette sales and raising prices than adults, and more likely to agree that the government should make smoking against the law, but they were less distrustful of tobacco companies. In 2003, youth were more supportive of sales restrictions and making smoking illegal, and more distrustful of tobacco companies, than in 2001. More comprehensive assessments and continued monitoring of youth attitudes are needed.     

Reducing the standard serving size of alcoholic beverages prompts reductions in alcohol consumption

Aims

To test whether reducing the standard serving size of alcoholic beverages would reduce voluntary alcohol consumption in a laboratory (study 1) and a real‐world drinking environment (study 2). Additionally, we modelled the potential public health benefit of reducing the standard serving size of on‐trade alcoholic beverages in the United Kingdom.

Design

Studies 1 and 2 were cluster‐randomized experiments. In the additional study, we used the Sheffield Alcohol Policy Model to estimate the number of deaths and hospital admissions that would be averted per year in the United Kingdom if a policy that reduces alcohol serving sizes in the on‐trade was introduced.

Setting

A semi‐naturalistic laboratory (study 1), a bar in Liverpool, UK (study 2).

Participants

Students and university staff members (study 1: n = 114, mean age = 24.8 years, 74.6% female), residents from local community (study 2: n = 164, mean age = 34.9 years, 57.3% female).

Interventions and comparators

In study 1, participants were assigned randomly to receive standard or reduced serving sizes (by 25%) of alcohol during a laboratory drinking session. In study 2, customers at a bar were served alcohol in either standard or reduced serving sizes (by 28.6–33.3%).

Measurements

Outcome measures were units of alcohol consumed within 1 hour (study 1) and up to 3 hours (study 2). Serving size condition was the primary predictor.

Findings

In study 1, a 25% reduction in alcohol serving size led to a 20.7–22.3% reduction in alcohol consumption. In study 2, a 28.6–33.3% reduction in alcohol serving size led to a 32.4–39.6% reduction in alcohol consumption. Modelling results indicated that decreasing the serving size of on‐trade alcoholic beverages by 25% could reduce the number of alcohol‐related hospital admissions and deaths per year in the United Kingdom by 4.4–10.5% and 5.6–13.2%, respectively.

Conclusions

Reducing the serving size of alcoholic beverages in the United Kingdom appears to lead to a reduction in alcohol consumption within a single drinking occasion.     

Do graphic health warning labels have an impact on adolescents’ smoking‐related beliefs and behaviours?

AIMS: To assess the impact of the introduction of graphic health warning labels on cigarette packets on adolescents at different smoking uptake stages. DESIGN: School-based surveys conducted in the year prior to (2005) and approximately 6 months after (2006) the introduction of the graphic health warnings. The 2006 survey was conducted after a TV advertising campaign promoting two new health warnings. SETTING: Secondary schools in greater metropolitan Melbourne, Australia. PARTICIPANTS: Students in year levels 8-12: 2432 students in 2005, and 2050 in 2006, participated. MEASURES: Smoking uptake stage, intention to smoke, reported exposure to cigarette packs, knowledge of health effects of smoking, cognitive processing of warning labels and perceptions of cigarette pack image. FINDINGS: At baseline, 72% of students had seen cigarette packs in the previous 6 months, while at follow-up 77% had seen packs and 88% of these had seen the new warning labels. Cognitive processing of warning labels increased, with students more frequently reading, attending to, thinking and talking about warning labels at follow-up. Experimental and established smokers thought about quitting and forgoing cigarettes more at follow-up. At follow-up intention to smoke was lower among those students who had talked about the warning labels and had forgone cigarettes. CONCLUSIONS: Graphic warning labels on cigarette packs are noticed by the majority of adolescents, increase adolescents' cognitive processing of these messages and have the potential to lower smoking intentions. Our findings suggest that the introduction of graphic warning labels may help to reduce smoking among adolescents.     

Tar and Nicotine Yields of U.K. Cigarettes 1972–1983: Sales-weighted Estimates from Non-industry Sources

We have estimated sales-weighted tar and nicotine yields of cigarettes in the United Kingdom from 1972 to 1983 using sources outside the tobacco industry. Our estimates are shown to be valid and accurate, and can be quickly updated. The data show a substantial decline of 27 per cent in overall sales-weighted tar yields from an average of 20.5mg per cigarette in 1972 to 15.0mg in 1983, whereas the sales-weighted nicotine yields over this period have remained static at about 1.3mg per cigarette. Likewise, the proportion of smokers who smoke a low-tar brand (<11mg) has stuck at about 15 per cent since 1977. This suggests a barrier to consumer acceptability which appears to be linked mare closely to nicotine than to tar. Finally, there has been an overall 26 per cent reduction in the ratio of tar yield to nicotine yield, from a sales-weighted average of 15.5 in 1972 to 11.5 in 1983. Thus it appears that, without having to reduce their nicotine intake, British smokers may now be exposed to about a quarter less tar than in 1972, and this includes the majority who have not switched to a low tar brand.     

"Plain packaging" regulations for tobacco products: the impact of standardizing the color and design of cigarette packs

Tobacco packaging and labeling policies have emerged as prominent and cost-effective tobacco control measures. Although packaging policies have primarily focused on health warnings, there is growing recognition of the importance of packaging as a marketing tool for the tobacco industry. The current paper reviews evidence on the potential impact of standardizing the color and design of tobacco packages -so called "plain" packaging. The evidence indicates three primary benefits of plain packaging: increasing the effectiveness of health warnings, reducing false health beliefs about cigarettes, and reducing brand appeal especially among youth and young adults. Overall, the research to date suggests that "plain" packaging regulations would be an effective tobacco control measure, particularly in jurisdictions with comprehensive restrictions on other forms of marketing.     

A Comparative Study of the Amount of Smoke Absorbed From Low Yield ('Less Hazardous') Cigarettes.

Twenty-two smokers (≥20 cigarettes per day with an average nominal nicotine delivery of .96 mg) were split randomly into treatment (16 subjects) and control (6 subjects) groups. During the first two-week period (P₁), all subjects smoked their usual brand. For the next three weeks (P₂) the treatment group switched to a cigarette averaging .64 mg, while the control group switched to another brand within ± .1 mg of their usual brand. During the last three weeks (P3) the treatment group switched to a still lower vented cigarette (.38 mg nicotine) while the control group switched to another brand again having a nominal delivery within ± .1 mg of their usual brand. Both treatment and control groups were dissatisfied with their substitute brands suggesting that the dissatisfaction may be to the act of switching cigarettes rather than to any decrease in cigarette yield. The non-invasive exposure measures employed (average number of cigarettes per day, daily mouth level nicotine intake, butt length, expired air carbon monoxide and saliva thiocyanate) demonstrated that the almost complete compensation of the treatment group was achieved with a combination of increased cigarette consumption, smoking intensity and depth of inhalation. Thus, the assumed health advantage for relatively heavy smokers switching to lower delivery cigarettes is largely offset by the tendency of smokers to compensate.     

Do cigarette prices motivate smokers to quit? New evidence from the ITC survey

Aims To examine the importance of cigarette prices in influencing smoking cessation and the motivation to quit. Design We use longitudinal data from three waves of the International Tobacco Control Policy Evaluation Survey (ITC). The study contrasts smoking cessation and motivation to quit among US and Canadian smokers and evaluates how this relationship is modified by cigarette prices, nicotine dependence and health knowledge. Different price measures are used to understand how the ability to purchase cheaper cigarettes may reduce the influence of prices. Our first model examines whether cigarette prices affect motivation to quit smoking using Generalized Estimating Equations to predict cessation stage and a least squares model to predict the change in cessation stage. The second model evaluates quitting behavior over time. The probability of quitting is estimated with Generalized Estimating Equations and a transition model to account for the ‘left‐truncation’ of the data. Settings US and Canada. Participants 4352 smokers at Wave 1, 2000 smokers completing all three waves. Measurements Motivation to quit, cigarette prices, nicotine dependence and health knowledge. Findings Smokers living in areas with higher cigarette prices are significantly more motivated to quit. There is limited evidence to suggest that price increases over time may also increase quit motivation. Higher cigarette prices increase the likelihood of actual quitting, with the caveat that results are statistically significant in one out of two models. Access to cheaper cigarette sources does not impede cessation although smokers would respond more aggressively (in terms of cessation) to price increases if cheaper cigarette sources were not available. Conclusions This research provides a unique opportunity to study smoking cessation among adult smokers and their response to cigarette prices in a market where they are able to avoid tax increases by purchasing cigarettes from cheaper sources. Higher cigarette prices appear to be associated with greater motivation to stop smoking, an effect which does not appear to be mitigated by cheaper cigarette sources. The paper supports the use of higher prices as a means of encouraging smoking cessation and motivation to quit.     

Taxation and tobacco control: the cases of Brazil and Mexico

This study analyzes the achievements, obstacles and challenges related to cigarette taxes in Brazil and Mexico. Both countries have increased cigarette taxes in recent years and have included a specific tax, which allows maximizing the impact of tax increases on prices. However, it seems they have not taken full advantage of these measures. Three recommendations follow from these experiences: 1) specific taxes must represent a significant percentage of final prices; 2) specific taxes must be regularly adjusted to keep pace with cumulative inflation; and 3) specific taxes must be adjusted to compensate increases in personal income. It is also important to consider that taxes on legal substitutes of cigarettes must be similar to cigarette taxes. As for illegal substitutes, the issue is to reduce the incentives for illicit trade and to make illegal transactions more difficult. Modifications to national legislation and international cooperation constitute key elements to achieve this.     

What would menthol smokers do if menthol in cigarettes were banned? Behavioral intentions and simulated demand

Aims The US Food and Drug Administration must consider whether to ban the use of menthol in cigarettes. This study examines how current smokers might respond to such a ban on menthol cigarettes. Design Convenience sample of adolescent and adult smokers recruited from an online survey panel. Setting United States, 2010. Participants A total of 471 adolescent and adult current cigarette smokers. Measurements Respondents were asked a series of questions about how they might react if menthol cigarettes were banned. In addition, participants completed a simulation purchase task to estimate the demand for menthol and non‐menthol cigarettes across a range of prices. Findings Overall, 36.1% of respondents said they always (18.9%) or usually (17.2%) smoked menthol cigarettes. When asked how they might respond to a ban on menthol cigarettes, 35% of current menthol smokers said they would stop smoking, and 25% said they would ‘find a way to buy a menthol brand’. Those who reported they might quit tended to have greater current intentions to quit [odds ratio (OR) = 4.47], while those who reported that they might seek illicit menthol cigarettes were far less likely to report current intentions to quit (OR = 0.06). Estimates for demand elasticity for preferred cigarette type were similar for menthol (α = 0.0051) and non‐menthol (α = 0.0049) smokers. Demand elasticity and peak consumption were related to usual cigarette type and cigarettes smoked per day, but did not appear to differ by race, gender or age. Conclusions Preliminary evidence suggests that a significant minority of smokers of menthol cigarettes in the United States would try to stop smoking altogether if such cigarettes were banned.     

Smoking, HIV status, and HIV risk behaviors in a respondent-driven sample of injection drug users in Baltimore, Maryland: The BeSure Study

Tobacco use is the largest preventable cause of death in the United States. Associations between cigarette smoking and HIV risk behaviors were examined among 669 injection drug users (IDU) in the 2006 wave of the National HIV Behavioral Surveillance System in Baltimore, Maryland, using respondent-driven sampling. The adjusted prevalence of smoking among IDU was 92.1%, with 32.7% smoking < 1 pack of cigarettes per day (light smoking) and 59.3% smoking ≥ 1 packs per day (heavy smoking). Self-reported HIV prevalence decreased as smoking frequency increased (p = 0.001). In multivariate analysis, heavy smokers were more likely to report painkiller use and binge drinking and less likely to report anal sex or health care use in the past year than light smokers. Results suggest that health care use mediates the relationship between heavy smoking and self-reported HIV. Integrating smoking cessation with HIV prevention services could address unmet health needs in IDU.     

U.S. Tobacco Taxes: behavioural effects and policy implications

This paper examines U.S. tobacco taxation, the effect of cigarette taxes on smoking and on the health effects of smoking, and equity and efficiency considerations that arise when cigarette excise taxes are used to reduce smoking. Cigarette excise taxes, imposed by the Federal Government, all Stale governments, and nearly 400 cities and counties, add approximately 34 cents per pack to the price of cigarettes. Real cigarette excise tax rates have fallen because tax increases have not kept pace with inflation. Increases in the price of cigarettes decrease smoking, particularly by adolescents. An estimated 100,000 additional persons may live to the age of 65 as a result of doubling the Federal cigarette tax in 1983. Because cigarette taxes are regressive and are borne primarily by smokers, inequities may arise when they are used to reduce smoking. Success in achieving a tobacco-free society will require that tobacco taxes be replaced with alternative sources of revenue.     

Pre‐diagnosis cigarette smoking and overall survival in non‐Hodgkin lymphoma

We examined whether smoking prior to non‐Hodgkin lymphoma (NHL) diagnosis was associated with overall survival (OS) and conducted a meta‐analysis to assess the evidence relating pre‐diagnosis cigarette smoking with OS. Among 523 NHL patients, worse OS was suggested for greater pre‐diagnostic smoking habits when compared to never smokers. In the meta‐analysis (n = 5 patient populations), inferior OS was observed for greater number of cigarettes smoked per day, years of cigarette smoking, and pack‐years of cigarette smoking. The inferior survival was more pronounced for follicular than for diffuse large B cell lymphoma. Pre‐diagnosis cigarette smoking may adversely impact the survival of NHL patients.     

Relationships between hand‐rolled cigarettes and primary lung cancer: A Norwegian experience

Introduction: Detailed smoking history of patients developing lung cancer is rarely known, especially not for users of hand‐rolled cigarettes. In Norway, smoking hand‐rolled tobacco is still popular, accounting for one‐third of the total tobacco consume. Methods: A questionnaire‐based study revealing detailed information about tobacco consume with consecutive inclusion of all persons developing lung cancer in Southern Norway 2002–2005. Results: In this unselected population with 479 patients with newly diagnosed lung cancer, 95% had a smoking history and 88% of ever‐smokers had smoked primarily hand‐rolled cigarettes. The hand‐rolled cigarette smokers had smoked fewer cigarettes daily (15) and less pack‐years of tobacco (34) than fabricated cigarette smokers (20, P < 0.0001 and 42, P = 0.021, respectively). Smoking hand‐rolled cigarettes was considerably more frequent than expected from official sales statistics. Hand‐rolled cigarette smoking revealed an odds ratio of 13 for developing lung cancer compared with smoking fabricated cigarettes. Conclusion: In this unselected population with newly diagnosed lung cancer, nine out of 10 ever‐smokers had smoked primarily hand‐rolled cigarettes. Patients smoking hand‐rolled cigarettes had a smoking history of fewer daily cigarettes and less pack‐years tobacco consumed than fabricated cigarette smokers. In this study, hand‐rolled cigarettes are more frequently used than shown in national statistics. Smokers of hand‐rolled cigarettes may have a greatly increased risk for lung cancer compared with smokers of fabricated cigarettes. Please cite this paper as: Rolke HB, Bakke PS and Gallefoss F. Relationships between hand‐rolled cigarettes and primary lung cancer: A norwegian experience. The Clinical Respiratory Journal 2009; 3: 152–160.