Open Access Research Perceptions and impact of plain packaging of tobacco products in low and middle income countries, middle to upper income countries and low-income settings in high-income countries: a systematic review of the literature Nicole Hughes,1 Monika Arora,2 Nathan Grills1 To cite: Hughes N, Arora M, ABSTRACT Strengths and limitations of this study Grills N. Perceptions and Objective: To review the current literature around the impact of plain packaging of potential impact, effectiveness and perceptions of plain ▪ tobacco products in low and This study provides supportive evidence of the packaging in low income settings. middle income countries, potential impact of plain tobacco packaging in middle to upper income Method: A systematic review of the literature. low-income settings to reduce packaging appeal. countries and low-income Data sources: 9 databases (PubMed, Global Health, ▪ A limitation of this review is the scarcity of settings in high-income Social Policy and Practice, Applied Social Sciences research in low-income settings, which limits the countries: a systematic review Index and Abstracts (ASSIA), CINAHL, PsycINFO, ability to draw conclusions for low and middle of the literature. BMJ Open British Library for Development Studies (BLDS), Global income countries (LMIC’s) more generally. 2016;6:e010391. Health Library and Scopus) were searched. The terms ▪ Further research on the impact, perceptions and doi:10.1136/bmjopen-2015- used for searching combined terms for smoking and effectiveness of plain packaging in LMICs and 010391 tobacco use with terms for plain packaging. low-income settings is required. Study selection: Studies investigating the impact of ▸ Prepublication history and plain packaging on the determinants of tobacco use, avoidable mortality around the world.1 From additional material is such as smoking behaviour, appeal, prominence, available. To view please visit as early as 1956, the negative health effects effectiveness of health warnings, response to plain the journal (http://dx.doi.org/ 2 packs, attitudes towards quitting or likelihood of of tobacco use were known, but today it 10.1136/bmjopen-2015- remains a highly utilised substance. There 010391). smoking in low-income settings, were identified. Studies must have been published in English and be are considerable differences in tobacco use original research of any level of rigour. and prevalence patterns across the world. In Received 28 October 2015 Data extraction: Two independent reviewers a number of high-income countries (HIC), Accepted 1 March 2016 assessed studies for inclusion and extracted data. there has been a significant decline in Data synthesis: The results were synthesised tobacco use (such as in Australia where qualitatively, with themes grouped under four key smoking prevalence has halved from 26.1% headings: appeal and attractiveness; salience of health in 1991 to 13.3% in 20133); however, in warnings and perceptions of harm; enjoyment and many low to middle income countries perceived taste ratings; and perceptions of the impact (LMIC), such as in India where 26% of on tobacco usage behaviour. adults use smokeless tobacco, and 14% of Results: This review has identified four articles that 4 adults smoke tobacco, this is not the case, met the inclusion criteria. Studies identified that with high tobacco use prevalence rates per- tobacco products in plain packaging had less appeal than in branded packaging in low-income settings. sisting. In a LMIC such as India, a large Conclusions: This review indicates that plain gender disparity exists in tobacco use, where packaging appears to be successful in reducing appeal 24% of males smoke tobacco, compared to 1Nossal Institute for Global of smoking and packets, and supports the call for plain only 2.9% of women. Recent global estimates Health, The University of packaging to be widely implemented in conjunction place the mortality burden from tobacco use Melbourne, Melbourne, 5 Victoria, Australia with other tobacco control policies. However, there are at over 5 million annually, with nearly 2Health Promotion Division, considerable gaps in the amount of research two-thirds of these deaths occurring in devel- Public Health Foundation of conducted outside high-income countries. oping countries.6 Further to this, by 2030, India, New Delhi, India 70% of the burden of death and disease INTRODUCTION from tobacco products will be in LMICs.178 Correspondence to ’ Nicole Hughes; Tobacco use is one of the leading prevent- The WHO s Framework Convention on [email protected] able causes of death, and the largest cause of Tobacco Control (FCTC) was the first treaty Hughes N, et al. BMJ Open 2016;6:e010391. doi:10.1136/bmjopen-2015-010391 1 Open Access – negotiated under the patronage of the WHO9 and mechanism or policy comes from HIC (eg, Australia,23 27 represents a global vigour towards a reduction in New Zealand,28 29 Canada,30 31 the UK,23 32 33 tobacco consumption. The aims of the FCTC are “to Norway,34 35 Belgium,36 France37 38 and Italy39 40). The protect present and future generations from the devas- potential effect of plain packaging is less well under- tating health, social, environmental and economic con- stood in LMIC. LMICs encounter a different and diverse sequences of tobacco consumption and exposure to set of challenges41 as they aim to combat high rates of tobacco smoke”.9 The FTCT recommends numerous smoking and the consequences of this—high mortality strategies to combat tobacco consumption, two of which and morbidity. demand controls on tobacco advertising promotion and The primary objective of this systematic review was to sponsorship, and packaging and labelling. Article 11 locate and review all the published literature relating to recommends the introduction of plain packaging, which the perceptions, potential impact and/or effectiveness involves the removal of all branding and advertising of plain packaging on tobacco use determinants in from the pack, such that packs are relatively indistin- LMICs. The secondary objective, if there was a lack of lit- guishable from one another, other than the brand name erature in LMIC, was to rerun the review and include in mandated text, size and style.10 middle to upper income countries (MUIC) and pur- In the past decade, there has been an increased focus posefully researched low-income settings in HIC. The on plain packaging among tobacco control researchers rationale to include MUIC and purposefully researched in HIC. This was a notion initially published in 1992,11 low-income settings in HIC was that there are similarities where the concept of removing the brand was hypothe- between these settings, such as higher prevalence of dis- sised to reduce the ability of the pack to be used as an advantage, poverty, illiteracy and marginalisation; price advertising mechanism. There is now considerable evi- elasticity; vulnerability to marketing and image; difficulty dence that tobacco companies are increasingly using the in accessing tobacco control interventions and generally pack as a way of advertising and targeting consumers,12 higher smoking rates compared to high-income set- for example, in subgroups such as women13 14 and tings.42 43 To the best of our knowledge, there are no youth.15 The pack has become a strategic instrument of studies that have reviewed the literature focusing on promotion, in which tobacco companies are focusing LMIC, MUIC or low-income settings in HIC. their marketing and communication strategies on consu- Recommendations from Stead et al12 suggest that further mers.14 The proposal of the plain pack includes colour- understanding of the effectiveness of plain packaging in ful graphic health warnings but otherwise no colours, LMICs would be informative and helpful. Therefore, the brand imagery or corporate logos, with brand name objective of this systematic review was to investigate, printed in a mandated size, font and location.16 Plain through the collation of all original research, the poten- packaging of tobacco products hopes to reduce and tial impact of plain packaging of tobacco products on remove the ability of tobacco companies to utilise the the determinants of tobacco use in LMIC, MUIC and pack for advertisements.17 low-income settings in HIC, such as appeal of the pack- From the introduction of health warning labels on aging or product; the salience and effectiveness of tobacco packaging in Canada in 1992, there has been health warnings; and tobacco use behaviour. significant progression in reducing the advertising cap- acity of the pack, such that plain packaging was legis- lated and enforced in Australia in 201218; has been METHODS legislated in Ireland19 and will be enforced from 2016; A search of the literature was undertaken across nine and is currently before the New Zealand parliament.20 databases, including PubMed, Global Health, Social The evidence for the use of plain packaging in HIC has Policy and Practice, Applied Social Sciences Index and exponentially grown in the past 10 years, and a recent Abstracts (ASSIA), CINAHL, PsycINFO, British Library comprehensive systematic review demonstrated that for Development Studies (BLDS), Global Health Library plain packaging reduces the attractiveness of packaging, and Scopus, using the search terms as defined in table 1. the appeal of smoking and that it will make the legally Reference lists of the literature were scanned to identify required health warnings to be more salient.12 Such further studies. A search for grey research literature was determinants (or associations) of tobacco use are typic- also conducted including searching web-based platforms ally the aim of plain packaging policies and the research such as Google scholar and governmental webpages with to determine its impact. The direct effect of plain pack- combinations of search terms as per table 1. Contact was aging on tobacco use prevalence is difficult to disaggre- made with leading tobacco control experts to enquire if gate and has not been the stated aim of plain packaging they were aware of any research that had been conducted polices.21 These findings, as listed above, were generally in LMIC, MUIC and low-income settings in HIC.