Introduction: Plain cigarette packaging as a tobacco control measure is to be implemented in Australia on December 1st 2012. There is mounting evidence for its likely impact on smokers and potential smokers. Yet Australia’s integrated model of smoking cessation and the particular role and opportunities it has created for primary healthcare have not yet been subject to policy analysis in leading international journals. This policy analysis paper explores these new Australian policy developments and debates in ways that identify their international relevance to primary healthcare. Policy analysis: There are 57 studies about plain cigarette packaging published since 2002. Of these, 27 looked at the impact of health warnings. These studies support the introduction of plain packaging as a tobacco control measure, by increasing the efficacy of health warnings and reducing misconceptions about cigarettes. However, the Australian tobacco control reforms are not limited to plain cigarette packaging. They include other evidence-based tobacco control measures as part of its primary health care strategy: for example, increasing tobacco excises, a mass media campaign focusing on high-risk and hard-to-reach groups, and a national summit on smoking in prisons. The Australian government has acknowledged the key role of primary health care in health promotion activities, establishing a network of regional primary health care organisations (“medicare locals”) in 2011-2012, and expanding the role of nurses in general practice. These initiatives offer general practice a chance to seize “golden opportunities to intervene with smoking patients”. Conclusions: Whether the combined impact of the Australian government’s recent tobacco control reforms and its previous measures will be sufficient to reduce daily smoking prevalence to 10% or less by 2020, only time will tell. What is more certain is that the Australian experience of plain packaging offers international colleagues in general practice key lessons about the importance of “whole-of-system” approaches, integrating efforts at the local to national levels, to tackle smoking cessation. The achievement of Australia’s political leaders in plain cigarette packaging is an extraordinary testament to political will but there is no room for complacency. Primary healthcare sectors must continue to lobby political leaders around the world to tackle smoking at the system level where the motivations and beliefs about smoking are being shaped, especially among disadvantaged groups with lower health literacy.
Plain cigarette packaging was first proposed in Canada and New Zealand in the late 1980s [
In 2005, the WHO Framework Convention on Tobacco Control (FCTC) came into force, specifying a range of evidence-based measures to reduce the supply of, and demand for, tobacco products in nations signatory to the Convention. In October 2008, the FCTC strengthened its guidelines for cigarette package labelling (Article 11), recommending the use of plain packaging [
In November 2011, the Australian Parliament passed two amended Tobacco Plain Packaging bills [
There are 57 studies about plain cigarette packaging published packaging since 2002. Of these, 27 looked at the impact of health warnings. Their findings demonstrated that large pictorial warnings were more effective in communicating health risks than text-only messages, particularly for populations with low literacy, and inclusion of a quit-line number was associated with significant increases in calls for assistance from smokers. The remaining studies looked at pack design features, such as branding, pack colour, and product descriptors and what effect these had on the cigarettes’ appeal to smokers. Their findings indicated that the use of descriptors such as “light”, “smooth”, “slim”, “gold”, etc., were frequently associated with a perception of reduced harm. Even the pack colour itself was associated with misperceptions about health risk, lighter colours being seen as an indication of lower cigarette strength, enabling tobacco companies to effectively bypass FCTC’s Article 11 about banning misleading or deceptive descriptors [4- 6].
Tobacco companies’ own market testing studies reveal how identical cigarettes presented in packs with different colours and designs could lead consumers to “experience and evaluate them differently when they were smoked” [
These studies support the introduction of plain packaging as a tobacco control measure, for reasons well summarised by Hammond: “increasing the effectiveness of health warnings, reducing false health beliefs about cigarettes, and reducing brand appeal especially among youth and young adults” [
Notwithstanding the evidence for the role played by packaging in appealing to, and misleading, smokers and potential smokers, all the plain packaging studies to date have utilised experimentally altered packs [
After plain packaging legislation is implemented in Australia in December 2012 and any novelty effect wears off, the true impact of this measure will be apparent. The most important and hoped for outcome will be eliminating the image connotations that branded packageing has for young people, thus removing one avenue for recruiting new initiates to tobacco smoking. The UK government’s 2009 review of young people and smoking in England, commissioned to inform its tobacco control strategy, also concluded that “the tobacco industry is exploiting the pack as a medium for advertising the product” and deemed generic packaging an essential step in a youth oriented approach to tobacco control [
As well as plain cigarette packaging, Australia has been introducing other evidence-based tobacco control measures since 2010 as part of its primary health care strategy [
But will these be enough to reduce daily smoking from 15.1% in 2010 [
Along with targeting particular populations in the media campaign, the Australian government has allocated additional funding for identified groups, including:
• Indigenous Australians, The high prevalence of smoking (50%) by indigenous Australians [
• People with mental illness. In surveys conducted in Australia and the US, adults with a mental illness were found to be twice as likely to smoke as those without a mental disorder [
• Prisoners. To begin tackling the unacceptably high rate of smoking in Australian prisons, estimated to be 85% [
In addition to fiscal, regulatory, social marketing and other targeted population approaches, the Australian government acknowledged the key role of primary health care in health promotion activities and agreed to strengthen the sector’s capacity to tackle lifestyle risk factors more systematically through establishment of a network of primary health care organisations (Medicare Locals) in 2011-2012, and expansion of the role of nurses in general practice [
Despite clear evidence for the effectiveness of brief smoking cessation advice from physicians, with or without nicotine replacement therapy (NRT) or non-nicotine pharmacotherapies such as Bupropion and Varenicline [
The Australian government’s tobacco reforms, together with its measures to strengthen primary health care, make this an ideal time for general practice to tackle smoking cessation more systematically. The Australian Primary Care Collaboratives [
Some of the smokers identified will undoubtedly belong to the “treatment-resistant” group described in the literature [
For some smokers, advice and treatment may only result in temporary cessation, or reduction rather than elimination of their cigarette intake, but this is still beneficial to their health and may provide an eventual “gateway to quitting” [
Whether the combined impact of the Australian government’s recent tobacco control reforms and its previous measures will be sufficient to reduce daily smoking prevalence to 10% or less by 2020, only time will tell. What is more certain is that such reforms offer primary health care a powerful new policy framework to reinforce more systematic approaches to smoking cessation. The Australian government’s tobacco reforms, together with its measures to strengthen primary health care, make this an ideal time for general practice to tackle smoking cessation more systematically. The Australian experience of plain packaging offers international colleagues in general practice key lessons about what is needed at the systemic policy level to make a bigger difference to smoking cessation. The achievement of Australia’s political leaders in plain cigarette packaging is an extraordinary testament to political will but there is no room for complacency. Primary healthcare sectors must continue to lobby political leaders around the world to tackle smoking at the system level where the motivations and beliefs about smoking are being shaped, especially among disadvantaged groups with lower health literacy.
This paper was funded by the Primary Healthcare Research and Development Program, funded by the Australian government’s Department of Health and Ageing.