Research commentary

Tobacco and Smoking

doi: 10.1111/j.1753-6405.2012.00907.x

Strong public support for plain packaging of tobacco products

Janet Hoek , Philip Gendall, Ninya Maubach
Department of Marketing, University of Otago, New Zealand

Richard Edwards
Department of Public Health, University of Otago, New Zealand

nternationally, smoking remains a serious public health problem. The World Health Organization (WHO) estimates that deaths from smoking will rise to more than eight million by 2030 and reach one billion in the 21st century.1 Governments around the world have responded to the threat tobacco poses by adopting progressive measures that will reduce smoking initiation, prompt cessation and lower overall smoking rates. One such strategy, tobacco denormalisation, exposes tobacco as a toxic product peddled by an unscrupulous industry and undermines the social cachet of smoking.2 Denormalisation reframes smoking as socially unacceptable and challenges the connotations of glamour, sophistication and ruggedness that tobacco brands have used to attract young people. Over time, denormalisation reduces smokings aspirational attributes, undermines the value tobacco brands deliver to smokers and reduces tobacco consumption.3,4 Plain packaging extends this approach by moving beyond smokefree social marketing campaigns to focus directly on tobacco packages, which represent a tangible symbol of the emotional benefits smokers derive from their brand.5 These measures reflect increased knowledge of the role packaging plays in promoting smoking, the meticulous research undertaken into branding and packaging by tobacco companies, and the tobacco industrys growing reliance on packaging as promotion in traditional mass media becomes more restricted.6 The tobacco industry has strongly opposed plain packaging; it argues this measure lacks proportionality and supporting evidence, and claims it will impose unfair costs on manufacturers.7 When Australia proposed plain packaging, tobacco companies launched marketing campaigns entitled No Nanny State and I Deserve to be Heard to muster opposition to the legislation. Philip Morris adopted the same tactic when launching the My Opinion Counts site in New Zealand to coincide with the release of the governments consultation document on plain packaging. These campaigns draw on deep-seated concerns over measures that curtail individual freedoms and suggest plain packaging will stigmatise smokers, who are depicted as marginalised and disenfranchised. However, when these initiatives failed to elicit the Australian publics sympathy the tobacco companies moved to the legal arena and introduced suits challenging the constitutionality of plain packaging and its compliance with international trade agreements.
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Because not all countries may have Australias resolve in the face of well-funded and vocal opposition, these moves could deter the introduction of plain packaging elsewhere. In these situations, strong public support may provide politicians with an additional mandate to act. To understand tobacco companies arguments and public sympathy for these, we analysed two claims they have repeatedly made: as packaging only promotes brand switching, plain packaging will neither persuade smokers to quit, nor dissuade young people from starting to smoke; and plain packaging misappropriates brand assets and denies fair use of these. We reviewed the public health counter-arguments: that a toxic product such as tobacco requires prominent warnings without distracting brand imagery; and that attractive branding promotes experimentation and continued smoking. To test how the public regard these claims, we conducted a survey that compared New Zealand smokers and non-smokers perceptions of plain packaging, and examined their views on policy measures.

Tobacco branding: implications, effects and rights

Brands function by linking aspirations, attributes and values to products and services, which consumers buy as much for their symbolic value as for their utility. Smokers use the symbols and imagery evoked by brand attributes to construct and communicate an identity. Branding thus enables tobacco manufacturers to sell status, social acceptance and glamour, rather than a mere nicotine delivery device. Internal documents available as part of US legal settlements reveal tobacco companies reliance on brandings symbolic values and expose their meticulous research into pack designs and brand imagery. Industry documents also make explicit the importance tobacco companies have placed on recruiting young adult smokers by developing brands that appeal to them. Furthermore, these once-confidential documents illustrate the growing importance of packaging as a communications medium in markets where traditional mass media channels are restricted. Given how brands function, and the research undertaken to ensure their effectiveness, tobacco companies reaction against plain packaging is predictable. Either directly or through front groups and consultants, they have argued there is no evidence that plain
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Research commentary

packaging will reduce smoking prevalence. Since no country has implemented plain packaging, it is tautologically true that no direct evidence of plain packagings effectiveness exists: none can until the policy is implemented and evaluated. However, experimental studies show plain packaging decreases brand attractiveness, reduces peoples preferences, and increases the salience and impact of health warnings.8-10 Tobacco companies argue that branding only promotes brand switching by current smokers (while simultaneously having no effect on primary demand). This claim stands in contrast to empirical evidence that smokers have unusually high brand loyalty and industry documents that reveal brandings role in attracting new users.11,12 Legal experts have questioned claims that plain packaging misappropriates tobacco companies intellectual property and point out that, as governments have no wish to use tobacco companies brands, they can hardly be misappropriating them.13 To examine how the public assess these competing claims, we examined support for public health or tobacco industry arguments and addressed the following questions: Do the New Zealand general public support public health claims that toxic products such as tobacco require large health warnings? Do they support industry claims that plain packaging will have little effect on smoking initiation or quitting? Do they support industry claims that plain packaging misappropriates their brand assets and denies fair use of these?

Method
We obtained a sample of 418 smokers and 418 non-smokers from a commercial Internet panel (Research Now) and conducted an online survey in March 2012. Data were weighted before analysis using SPSSs Weight Cases function so the age, sex, ethnicity and smoking status of respondents in the sample matched the proportions in the New Zealand population, according to the most recent census data (2006). The survey tested the industry and public health arguments outlined above, which we phrased as statements that respondents evaluated using five-point, fully labelled agree-disagree scales. The scales were anchored by Strongly disagree and Strongly agree, with a Neither disagree nor agree mid-point and a Dont know/Cant choose option. We also estimated support for plain packaging using an 11-point scale ranging from 0 (no support at all) to 10 (full support). The scale was numbered from 0 to 10 but labelled only at each end. First, to examine whether views on plain packaging varied by smoking status, we analysed smokers and non-smokers separately. Then we analysed support for the introduction of plain packaging overall and among different age, gender, ethnicity and smoking status groups. For the purposes of analysis, the support scale values were multiplied by 10 so the results could be presented as percentages.

warnings on them and thought attractive tobacco packaging encouraged young people to experiment with smoking (57%). Non-smokers had significantly higher levels of agreement with these statements than smokers. Although respondents felt less certain about the role of packaging in encouraging smokers to try new brands, or the likely effects of plain packaging, they were more likely to agree than disagree with public health arguments. The only exception was plain packagings effects on cessation, where equal proportions agreed and disagreed that this policy would encourage smokers to quit and a nearly equal number were undecided. Predictably, there were large differences in the attitudes of smokers and non-smokers. Smokers rejected the tobacco industrys argument that packaging encouraged them to experiment with new brands; less than a third agreed with this claim compared to just over half the non-smokers. Around a fifth of smokers believed plain packaging would promote quitting or deter initiation, while more than twice as many non-smokers believed these outcomes would eventuate. Neither smokers nor non-smokers accepted claims that plain packaging unfairly denied tobacco companies use of their brand imagery and, overall, respondents were nearly three times more likely to reject than accept this argument. Table 1 contains the details of these findings. The general level of support for plain packaging, estimated at 69%, was consistent with respondents attitudes to plain packaging. Non-smokers support for plain packaging was 30 percentage points higher than smokers and support among women was 10 percentage points higher than among men. These differences are large and statistically significant. Support for plain packaging among Mori and Pacific people was higher than among other ethnicities, and younger and older respondents were more supportive than those aged between 25 and 64, but these differences are relatively small and non-significant.

Conclusions and Implications

Although tobacco companies question the benefits of plain packaging, New Zealanders strongly support this measure and believe attractive packaging encourages smoking experimentation among young people. Respondents supported suggestions that tobacco products should feature large warnings and were not persuaded by industry arguments that plain packaging misappropriated their intellectual property. Interestingly, a higher proportion of respondents (57%) felt attractive packaging encouraged experimentation than thought plain packaging would discourage this behaviour (39%). This discrepancy may arise from the perception that some young people will always take risks, irrespective of arguments to dissuade them. The fact that more than a third of respondents thought plain packaging would reduce this innate tendency is important, as too is the need for complementary measures that reduce tobaccos affordability and accessibility, such as increased excise taxes and fewer retail outlets. Non-smokers showed consistently higher support for public health arguments than smokers, who were less likely to attribute benefits to plain packaging. Although empirical data suggests plain

Results
Most respondents (77%) agreed or strongly agreed that harmful products such as cigarettes and tobacco should have very large
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Tobacco and Smoking

Public support for plain packaging of tobacco products

Table 1: Agreement with statements about tobacco plain packaging.

Statement Percent Agreement and Disagreement1 (5-point scale from Strongly Disagree to Strongly Agree) Total sample (n=836) Smokers (n=418) Non-smokers2 (n=418)
Agree % 77 57 48 39 36 20 Disagree % 7 23 23 30 36 54 Agree % 51 31 29 22 18 33 Disagree % 22 45 44 49 53 35 Agree % 84 63 52 43 41 16 Disagree % 4 17 18 26 31 58

Harmful products like cigarettes and tobacco should have very large warnings on them Attractive tobacco packaging encourages young people to experiment with smoking Tobacco packaging encourages smokers to try new brands Plain packaging would discourage young people from trying smoking Plain packaging would encourage smokers to try and quit Plain packaging is unfair because it would stop tobacco companies using their brands and logos to promote their products

1. Analyses based on weighted data, as outlined. Agree = sum of Strongly agree and Agree; Disagree = sum of Strongly disagree and Disagree. 2. All differences between smokers and non-smokers per cent agreement and disagreement significant at p<0.001.

packaging will promote cessation, smokers stance may reflect their nicotine addiction, which influences their behaviour more directly than a policy measure such as plain packaging. Similarly, smokers weaker agreement with statements regarding the role of packaging in smoking initiation may reflect their desire to assert control over their behaviour and corresponding reluctance to acknowledge the role of external factors. Despite their lower levels of agreement, a substantial minority of smokers (around 20%) believed plain packaging would deter smoking initiation and promote cessation. Given more than 80% of smokers regret having started smoking and wish they were smokefree, plain packaging has the potential to trigger a quit attempt among a sizeable group, many of whom will already be contemplating quitting.14 Perhaps most importantly, few respondents (20%) agreed with industry claims that plain packaging would be unfair, while more than half (54%) disagreed with this proposition. Together with the high support for very large warnings on tobacco products, this finding suggests the tobacco industrys freedom of choice arguments have no traction among the New Zealand public. Instead, the findings offer little support for claims that plain packaging would impinge on either commercial or individual freedoms. Our findings are consistent with other public opinion surveys, which show strong support for measures that tobacco companies have argued impinge on individuals rights.15,16 Given the tobacco industry claims to serve the publics interest by protecting individual freedoms, we suggest they view these findings as a mandate to embrace plain packaging and work with government to implement this measure. Such a move would align their public actions with their private knowledge and demonstrate their commitment to reducing the serious health risks they acknowledge their products present.

References
1. World Health Organisation. Tobacco: Factsheet Number 339 [Internet]. Geneva (CHE): WHO; 2012 [cited 2012 Jun 3]. Available from: http://www.who.int/ mediacentre/factsheets/fs339/en/index.html 2. Chapman S, Freeman B. Markers of the denormalization of smoking and the tobacco industry. Tob Control. 2008;17(1):25-31. 3. Alamar B, Glantz SA. Effect of increased social unacceptability of cigarette smoking on reduction in cigarette consumption. Am J Public Health. 2006;96(8):1359. 4. Hoek J, Gendall P, Gifford H, Pirikahu G, McCool J, Pene G, et al. Tobacco Branding, Plain Packaging, Pictorial Warnings, and Symbolic Consumption. Qual Health Res. 2012;22(5):630-9. 5. Wakefield M, Letcher T. My pack is cuter than your pack. Tob Control. 2002;11:154-6. 6. Wakefield M, Morley C, Horan J, Cummings K. The cigarette pack as image: New evidence from tobacco industry documents. Tob Control. 2002;11 Suppl i:73-80. 7. Philip Morris. Plain Packaging of Tobacco Products [Internet]. Richmond (VA): PM USA; 2010 [cited 2010 May 1]. Available from: http://www.plainpackaging.com/ 8. Hoek J, Wong C, Gendall P, Louviere J, Cong K. Effects of dissuasive packaging on young adult smokers. Tob Control. 2011;20(3):183-8. 9. Wakefield M. Germain D, Durkin S, Hammond D, Goldberg M, Borland R. Do larger pictorial health warnings diminish the need for plain packaging of cigarettes? Addiction. 2012;107(6):1159-67. 10. Wakefield M, Germain D, Durkin SJ. How does increasingly plainer cigarette packaging influence adult smokers perceptions about brand image? An experimental study. Tob Control. 2008;17(6):416-21. 11. Siegel M, Nelson D, Peddicord J, Merritt R, Giovino G, Eriksen M. The Extent of Cigarette Brand and Company Switching: Results From the Adult Use-ofTobacco Survey. Am J Prev Med. 1996;12(1):14-6. 12. Pollay RW. Targeting youth and concerned smokers: evidence from Canadian tobacco industry documents. Tob Control. 2000;9(2):136-47. 13. Davison M. Plain Packaging of Cigarettes: Would it Be Lawful. Monash University Faculty of Law Legal Studies Research Paper No 25. Aust Intellect Prop Law Bull. 2010;23(105). 14. Wilson N, Edwards R, Weerasekera D. High levels of smoker regret by ethnicity and socioeconomic status: national survey data. N Z Med J. 2009;122(1292): 99-100. 15. Rosenberg M, Pettigrew S, Wood L, Ferguson R, Houghton S. Public support for tobacco control policy extensions in Western Australia: a cross-sectional study. BMJ Open. 2012;2:e000784 doi:10.1136/bmjopen-2011-000784. 16. Wilson N, Edwards R, Thomson G, Weerasekera D, Talemaitoga A. High support for a tobacco endgame by Pacific peoples who smoke: national survey data. N Z Med J. 2010;123(1316):131-4.

Acknowledgment
We thank Dr James Stanley, biostatistician, for his advice on data analysis.

Correspondence to: Phil Gendall, Department of Marketing, University of Otago, PO Box 56, Dunedin 9054, New Zealand; e-mail: philip.gendall@otago.ac.nz

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