small picture of australian plain tobacco pack with large warnings

Plain packaging – evidence arrives from Australia Reply

Earlier this month, public health Minister Anna Soubry told the Westminster Parliament that plans to implement plain, standardised packaging in the UK were to be put on hold to get more evidence about how things work out in Australia. In response the Scottish Government said it is committed to introducing standardised packaging independently. Some early evidence from Australia has now been published – what does it add?

A new study published in a free-to-access scientific journal from researchers in Australia provides the first research on the impact of standardised packaging on smokers in a country (at the moment, the only country) where the policy has actually been introduced.

The researchers used telephone surveys with just over 500 smoking adults from the Australian state of Victoria between the 1st of November and the 3rd of December 2012. The timing is important because in Australia the cut-off date when a shop could no longer sell conventional branded tobacco packs was December 1st. The new standardised packs (no branding, larger graphic warnings) were becoming increasingly common in Australian shops from early October (when they started appearing on the market) right till the legal cut-off date in December (where all packs had to be of the new, standardised, variety). All of which makes for a convenient natural experiment.

assortment of tobacco plain packs from australia

The researchers were interested in seeing if adult smokers who, at the time of being telephoned, were currently smoking cigarettes from the new standardised packs (pictured above) differed in ways they thought about their smoking from those who were smoking from conventional branded packs.

What they found (after trying to take account of other ways in which the ‘standardised pack’ smokers in their sample and the ‘usual branding’ smokers differed) was that ‘standardised pack’ smokers were more likely to have thought about quitting in the last week (about 37% of the standardised pack smokers thought this compared to 22% of the usual brand smokers) and they tended to rate quitting as a higher ‘priority in their lives’.

‘Standardised pack’ smokers were also more likely to support the introduction of standardised packs (though not larger graphic warnings) and to rate lower brand appeal and product quality than ‘usual branding’ smokers. When the researchers modified their analysis to take account of the fact that plain packs were becoming increasingly common over the month-long study period (as the implementation date loomed) the effect for brand appeal weakened, but the other associations – including those related to quitting – persisted.

There are some cautions. An obvious one is that this research is measuring short term effects only – we can’t be sure these effects will be maintained. Another limitation is that, because of its design, this research only measures intention to quit, not actual quitting or tobacco consumption (though common sense suggests intentions to quit are going to be positively related to actual quitting, and when we look at other studies this does seem to be the case).

This study can’t give all the answers – however the new information it does provide is supportive of the policy, and fits in quite well with existing evidence on the potential effects of standardised packaging on existing adult smokers. Of course the main target of the policy isn’t adult smokers, but young people – we’re looking forward to learning more of Australia’s experience with standardised packaging in this regard.

But when will the evidence be ‘enough’ for sceptics of standardised packaging? This leads to a broader point about the nature of evidence that critical commenters on twitter colourfully noted following the recent Coalition announcement to defer the implementation of standardised packs in the UK.

Sometimes it can seem that ‘evidence’ can be a bit of a moveable feast: one that is particularly dependent on perspective. All studies have limitations and singling out the effect of one intervention amidst the complex mish-mash of stuff going on in real life is a challenging business. Honestly acknowledged limitations by the authors of the systematic review on standardised packaging published alongside the UK consultation last year – summarising 37 studies on the subject – were set upon by campaign groups opposing the measure as damning fatal flaws. Not unsurprisingly, these groups ignored the review’s main conclusion – that the existing evidence provided consistent support for standardised packaging, within its limitations.

We need to be realistic about what level and quality of evidence we can reasonably expect before we are persuaded to adopt a measure like standardised packaging. Studies of interventions in complex environments will only ever be likely to reduce uncertainty over an outcome, rarely will they provide complete certainty. As Tom Chivers wrote in a Telegraph blog on the UK standardised packaging announcement, the evidence is of course not 100%, but the evidence is not 100% the sun will rise tomorrow: yet we, as reasonable people, are sufficiently confident to act as though it will.

It’s quite an easy task to be the one who demands the evidential hurdle always be set one notch higher while letting others do the hard work to surpass it. It’s also an easy game (and a fun one, I’ll give our campaigning opponents that) to poke holes in the methodology of research which, by its nature, will always have limitations. But when important issues are at stake, we need to take the more difficult road of weighing up carefully what existing research does tell us (rather than what it doesn’t) and be wary of getting caught in an endless game of chasing complete certainty.

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