Effective beats dramatic: A commentary on Australia's plain packaging of cigarettes - SWEANOR - 2011 - Drug and Alcohol Review - Wiley Online Library
Effective beats dramatic: A commentary on Australia's plain packaging of cigarettes
Drug Alcohol Rev. 2011 Sep 23. doi: 10.1111/j.1465-3362.2011.00370.x. [Epub ahead of print]
There is a long history behind the quest for plain packaging for cigarettes, and it is one where I have been personally involved for over 25 years. My interest began when trying to understand why the generic cigarettes sold by a major Canadian grocery retailer in the mid-1980s had few purchasers despite these products being equal in quality but markedly cheaper than brand names. When subsequently reading through an issue of Forbes in early 1987  the importance of package imagery was driven home by the report of a study that showed only 21% of regular Marlboro smokers were willing to buy half price Marlboros that came in generic packages. Clearly, the marketing of cigarettes was heavily tied to imagery and the package was an essential part of that marketing. Reducing package imagery seemed a logical extension of cigarette ad bans that should reduce uptake, continuation and relapse of smoking. By 21 January 1988 I was promoting plain packaging in testimony before a committee of Canada's House of Commons.
Many public policy campaigns take a long time to achieve success, but for a wide range of reasons the battle to strip cigarette packs of their allure has been more convoluted than most. Indeed, plain packaging may have become an issue where the public health opportunity costs outweigh the value of the measure itself, and do so largely because of strategic decisions made by tobacco control advocates. Still, if properly implemented, there is potentially much to be gained by Australia leading the way by finally plunging forward on this issue. But such a measure will be more effective in reducing harms from tobacco smoking, will be easier to justify and will make subsequent action by other nations far easier if it is not taken in isolation. It is important for policies on nicotine to provide multiple alternative paths for smokers to move away from the deadly effects of cigarette smoking, including paths other than complete nicotine abstinence.
The reasoning behind plain packaging is solid. Cigarettes in much of the world are, like the infamous snake-oil products of a century ago, differentiated primarily by the package rather than its contents. Ending the advertising and promotion of such products should, over time, greatly diminish the power of the associated imagery, but this process is greatly accelerated by removing the imagery on the package itself. This destroys the ‘store of value’ the packaging has from the years of image making. The hope is that the reduction in positive imagery will reduce smoking. Lives will thus be saved.
This is a huge threat to various vested interests. Among them are the multinational cigarette companies that have created a virtual money-printing machine by being able to use their trademarks to compete on image rather than price and, taking advantage of market failures, make extraordinary returns on investment . But the cigarette companies are not the only potential source of opposition. Governments, the broader business community and members of the public are also often concerned about plain packaging due to such things as the risk of lost revenue or criminality from cheaper or illicit substitutes as cigarettes become commoditised and the risk of appearing to not value intellectual property rights.
To achieve plain packaging will require governments and courts of law to make some important decisions about the trade-off between the associated risks and benefits. This is where things start to get dicey. Although the exact language used by policy-makers, courts and philosophers differs, they come to essentially the same point. The problems our policy measures create for others should be kept to the least intrusive level that is consistent with achieving a recognised social benefit, and there needs to be proportionality between the burdens imposed and the gain achieved. So the questions raised by plain packaging are whether the projected health gain can be achieved through less intrusive means and whether the measure is justified when its potential benefits are seen in relation to the harm its implementation does to other interests.
We face significant hurdles. With concerns about intellectual property rights, potentially crippling compensation under international law and fears of unintended consequences, such as a growth in contraband, it will likely not be enough to show that such a measure will, say, have an overall impact equivalent to another small tax increase. Oddly, making the case for plain packaging might be harder now than in the 1980s. Firstly, we have already largely destroyed the imagery of cigarette packages in many markets through large graphic health warnings, mandatory toxicity labelling, bans on descriptors and package imagery and the end to the cigarette advertising that was linked to the packaging. Secondly, and far more important, the ongoing battle between a public health approach and the abstinence-only approach to tobacco/nicotine now sadly associated with the formerly general moniker ‘tobacco control’ has led to anti-smoking measures being far less effective than they could otherwise be. If we undermine the ability of our measures to maximally reduce death and disease we undermine the basis for more intrusive interventions, such as plain packaging.
A public health campaign is focused on reducing death, injury and/or disease. In seeking such an endpoint there are only four broad, and interrelated, strategies. We can prevent onset of the dangerous activity in question, we can get those engaging in it to stop, we can protect third parties from harm and we can reduce the risks for those who will engage in the activity. The presence or absence of that fourth strategy is (as we can all usually see clearly when looking at campaigns on illicit drug use, alcohol or sexual activity) a clear indication of whether we are looking at a pragmatic public health effort or facing something based on a moralistic agenda. Essentially it comes down to whether we are trying to make people better or make better people.
In the case of nicotine use, any refusal to offer cigarette smokers viable alternatives to total and near-immediate cessation of all forms of tobacco and nicotine, despite unassailable evidence of the vastly lower risks of non-combustion and medicinal nicotine products , moves our policy quest into the realm of morality rather than public health. We have just cut off one of the four legs of a comprehensive public health intervention. The resulting failure to combine measures that motivate risk-reducing behaviour change with measures that best facilitate that change is a tragic loss. Not only does it put our field in the uncomfortable company of ‘just say no’ campaigns in areas such as illicit drugs, alcohol or sex outside of marriage, but the loss of efficiency in turning dissonant smokers into former smokers creates further unintended consequences. It means that our efforts may be great at creating dissonance amongst smokers and even lead to an increase in reported attempts at tobacco/nicotine abstinence, but the very low success rate of such attempts means that our ultimate effectiveness is greatly stymied. From a purely pragmatic standpoint this reduced effectiveness of our interventions undermines the anti-smoking measures we seek to implement, thus making it harder to counter those who claim we will be doing too much harm for the gain we can reasonably expect to achieve.
Surmounting the significant hurdles we face in achieving plain packaging in countries around the world will not be easy. Getting a precedent set in a single country is a huge hurdle, but if the public health results are not impressive due to a failure to give smokers viable alternatives to their cigarettes the subsequent hurdles in other countries will be even greater. Surely it is time to take a public health approach to dealing with smoking, abandon an abstinence-only view on nicotine, give smokers truthful and non-misleading information and a range of options, and thus allow our interventions to deliver far greater health gains and thus be far easier to achieve and defend. Fighting for politically and legally difficult measures like plain packaging without having in place a comprehensive public health agenda that includes consumer acceptable nicotine risk reduction strategies puts us in the unenviable position of being our own worst enemy. Like horses, public health interventions have four legs, and if the course is tough and the hurdles are high, always opt for a four legged horse.
Declaration concerning interests
In the past 5 years D.S. has received payments or reimbursement of expenses or other benefits from developers or sellers of smoking dependence treatment products or from entities funded by these companies. D.S. has also received payments from governmental bodies and non-governmental organisations with an interest in issues of tobacco and health. In addition, D.S. has received payments as a result of assistance given to law firms engaged in litigation against tobacco companies and from investment advisors seeking his views on issues related to tobacco/nicotine.
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