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

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

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

4. The Cancer Council Victoria Steps in evaluation Contextualising policy within a broader framework Identifying justifications for policy Theorising possible effects –Intended –Unintended positive –Unintended negative Studies to measure theorised effects

5. The Cancer Council Victoria Justifications for removing pack designs Form of promotion –Thus should be eliminated Distracts from warnings Encourages youth smoking Kylie’s paper details this fully

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

7. The Cancer Council Victoria Studies planned ITC study –Some measures tracked for several years –Others introduced in 2011 –Two waves of follow-up funded National monthly survey (smokers and recent quitters) –1 month follow-up for quit outcomes Monitoring of price and presence of PP –Observational study over period of implementation and shortly after Youth survey: ASSAD –3 yearly survey, some baseline measures collected in 2011, next survey due 2014 Other national data collections –Excise collections –National prevalence surveys Scream test –Already demonstrated that the tobacco industry think it will have marked effects

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

9. The Cancer Council Victoria Determinants of smoking Balance between experienced value of smoking and costs of doing so If use, act to maximise value of smoking for them

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

11. The Cancer Council Victoria What does branding do? Basis of building identity of brand and means of adding incidental value Allows for creation of different imagery for subsets of tobacco users –Curiously this can also be done within a brand

12. The Cancer Council Victoria How do smokers respond to branding? Affects their liking of the pack Their capacity to add user-value These evolve over time –Immediate preferences do not necessarily determine longer-term preferences

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

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

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

16. The Cancer Council Victoria Possible Effects Reduced value ═ Reduced preparedness to pay ═ Less consumption ═ More quitting BUT Industry may compensate by dropping prices Will reduce above effects, but unlikely to eliminate them –Reasons for not smoking will not decline

17. The Cancer Council Victoria Outcomes to measure Smoker-related Quit attempts Sustained quitting and relapse Quit-related thoughts Brand shifting Price paid Consumption Attitudes to smoking Reactions to health communications Perceptions about quality

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

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

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

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

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

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

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

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

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

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

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

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

32. The Cancer Council Victoria Addiction dilemma Some part of the motivational force to use is ego-alien If ego-consonant reasons for smoking are reduced, then dissonance theory would predict either cessation or dissonance- reducing strategies

33. The Cancer Council Victoria How do young people respond to branding? Very brand-driven for most consumer products Also attracted to things that are controversial and which offer interesting experiences Drugs have an appeal independent of any efforts to promote them

34. The Cancer Council Victoria Dissonance reduction Add user-generated value to smoking Accept the non-volitional (addictive) nature of use Avoid thinking about it Make smoking a more private activity Cover the packs or use alternative packaging (cigarette cases) Quit

35. The Cancer Council Victoria Mechanisms Plain packs Look less attractive Especially affect those where this is important Reduced diffrentiation between brands

36. The Cancer Council Victoria Warning labels: Modes of influence Avoid Read etc Think harms/ quit Forgo cigs Quit attempts Aware of warning labels Size, Position Graphic, Text only, Content Potency

37. The Cancer Council Victoria What might plain packaging achieve? Proximal effects Loss of added value –Less prepared to pay premium prices Reduction in acceptability of smoking Loss of identity as an X smoker Longer term consequential effects Reduced attractiveness of cigarettes, especially to young people Increased quitting activity Reduced prevalence