The slow-burn, devastating impact of tobacco plain packs

It is three years since Australia fully implemented its historic tobacco plain packaging law. From December 1, 2012, all tobacco products have been required to be sold in the mandated standardised packs, which, with their large disturbing graphic health warnings, are anything but “plain”.

Ever since, there have been frenzied efforts by the tobacco industry and its ideological baggage carriers to discredit the policy as a failure.

The obvious subtext of this effort has been to megaphone a message to other governments that they should not contemplate introducing plain packaging because it has “failed”: smoking, it is claimed, has not fallen any faster in Australia after plain packaging that it was already falling before. All that has occurred, they argue, is that illicit trade has increased.

The supreme irony here is of course that if such criticism was correct, then to paraphrase Hamlet’s mother Gertrude, “The tobacco industry doth protest too much, methinks.” Why would the industry and its astro-turfed bloggers waste so much money and effort denigrating a policy which was having little or no impact?

Why take the Australian government to the High Court (and fail six to one) to try and block the law? Why invest in supporting minnow tobacco-growing states such as the Dominican Republic, Honduras and Cuba in their efforts to have the World Trade Organization rule against plain packaging?

Why not just ignore an ineffective policy instead of making it only too obvious to all by such actions that it is in fact a grave threat to your industry?

Two key assumptions have underscored efforts to discredit the impact of plain packaging. First, critics assume the impacts of the law should have been evident immediately as it was implemented: as one colleague put it recently “within ten seconds of the law passing”.

Second, they assume (but never actually state) that the impact of plain packaging on smoking by children (the principal target) and adults was supposedly going to be greater than anything we have previously observed in the entire history of tobacco control.

In 1999, the late Tony McMichael, professor of epidemiology at the Australian National University, published a classic paper called Prisoners of the Proximate where he wrote about the need to understand the determinants of population health in terms that extend beyond proximate single risk factors and influences.

In tobacco control, both proximal (discrete, recent and quick-acting) and distal (on-going, slow-burn) effects of policies and campaigns can occur. Price rises (and falls through discounting) can have both immediate and lasting effects, jolting smokers into sometimes unplanned quitting and also slowly percolating an unease about the costs of smoking that translate into quitting down the track.

Tobacco advertising bans are a good example of a policy that has such slow-burn effects across many years. Few if any quit smoking in direct response to tobacco advertising bans. They work instead by causing the next generations of kids to grow up in an environment devoid of massive promotional campaigns depicting smoking in positive ways.

I have often heard smokers say “plain packaging won’t make me quit smoking”. This is akin to the myopic self-awareness of those who swear “advertising (for any product) never influences me” while noting that it only influences the more impressionable.

Plain packs were unlikely to act suddenly in the way tax rises do, although the unavoidably huge graphic health warnings may well have acted like straws that broke the Camel’s back of worry about smoking. Their impact was far more likely to be of the slow-burn sort, where the constant reminder that tobacco, unique among all products, is the only consumer good treated this way by the law. It is exceptionally dangerous, with a recent estimate that two in every three long-term smokers will die from tobacco use.

In 1994 I wrote a now highly cited paper in the British Medical Journal which talked about the impossibility of “unravelling gossamer with boxing gloves” when it came to being certain about precisely why smokers quit. I took a day in the life of a smoker who quit, and pointed to the myriad of influences both distal and proximal that coalesce to finally stimulate a smoker to quit.

While a smoker might nominate a particular policy, conversation with a doctor or anti-smoking campaign as being “the reason” they quit, much of what went on before provides the broad shoulders of concern that carry the final attribution. There are synergies between all these factors and the demand to separate them all is like the demand to unscramble an omelette.

So what has happened to smoking in Australia since plain packs?

Data released this month from a national schools survey involving more than 23,000 high school children found smoking rates were the lowest ever recorded since the studies first commenced in 1984 (see graph). This momentum is starving the tobacco industry of new smokers, which is one important reason why all tobacco companies are now busily acquiring e-cigarette brands.

Proportion of 12- to 15-year-olds who smoke, 1984 to 2014

Trends in proportion of current (smoked in past seven days) and committed smokers (smoked on three or more of the past seven days) among 12 to 15-year old students, Australia, 1984-2014.National Drug Strategy report 2014.

With adults, National Accounts data just released show that for the 11 quarter-year periods since March 2013, consumption of tobacco products in aggregate fell an unprecedented 20.8%, while the previous 11 quarters it fell 15.7% and in the 11 before that, only 2.2%.

The latest available data on adult smoking prevalence we have is from 2013 and shows just 12.8% of Australians over 14 smoked on a daily basis. This is the lowest on record and again, the biggest percentage falls experienced since the surveys commenced (see graph).

Reductions in daily smoking among Australians aged over 14, 1991 to 2013

AIHW National Drug Strategy Household Survey 2013: preliminary findings. 2014Author-sourced.

Meanwhile, the tobacco industry plods along funding heavily lambasted studies which purport to show none of this is happening.

The argument that plain packaging would cause illicit trade to boom was made with monotonous regularity by Big Tobacco between April 2010 when plain packaging was announced and its December 2012 implementation. When the industry lost its case in the High Court, the argument was quietly dropped.

Today, the industry explains illicit trade entirely by the heinous government tobacco tax rises cloaked in a sanctimonious rhetoric of speaking up for poor smokers and corporate citizen concern about tax avoidance bleeding Treasury. In all this it fails to mention that it has long used tax rises as air cover to quietly raise its own profit margins.

As I wrote recently in The Conversation:

From August 2011 to February 2013, while excise duty rose 24¢ for a pack of 25, the tobacco companies’ portion of the cigarette price (which excludes excise and GST), jumped A$1.75 to A$7.10. While excise had risen 2.8% over the period, the average net price had risen 27%. Philip Morris’ budget brand Choice 25s rose A$1.80 in this period, with only 41¢ of this being from excise and GST.

Ireland, the United Kingdom and France have already passed laws to introduce plain packs. Norway and Canada will soon, and New Zealand, Chile, Turkey, South Africa and Brazil have also made high-level noises about joining in too. The world has a lot to thank Rudd and Gillard governments (and particularly Health Minister Nicola Roxon) for taking this initiative, and the subsequent Coalition government for continuing to support it strongly as it continues to come under attack from those it has and will continue to hurt.