Consumer Response to Standardized Tobacco Packaging in the United Kingdom: A Synthesis of Evidence from Two Systematic Reviews

Figures & data

Figure 1 Examples of flip-top cigarette packs and rolling tobacco pouches pre-standardized packaging (top row) and post-standardized packaging (bottom row).

Figure 2 Flow of information through the phases of the source and current reviews.

Table 1 Direction of Effect and/or Key Findings: Appeal and Perceptions of Harm

Study	Study Design and Data Collection	Population	Type of Comparison/Issues Explored	Direction of Effect (Measures Used) and/or Key Findings
Aleyan et al^Citation22	Longitudinal online survey Wave 1: Jul-Sep 2016 (early in transition period) Wave 2: Feb-Jul 2018 (nine-14 months after end of transition period)	Adult smokers 18+ years England, Germany, Greece, Hungary, Poland, Romania, Spain Wave 1: n=9547 Wave 2: n=9724	Smokers in England (Tobacco Products Directive new warnings and UK standardized packs) vs smokers in six other European countries (Tobacco Products Directive new warnings only) Perceptions of pack and brand appeal; perceptions of relative harm	Appeal: Significantly greater increase in participants in England who did not like the look of their pack post-standardized packaging in the UK. Perceptions of harm: No significant change in harm perceptions among participants in England post-standardized packaging in the UK.
MacGregor et al^Citation24	Focus groups Feb-Mar 2017, towards end of transition period	Young people 13–16 years Mix of current smokers, never smokers, and tried smoking Scotland 16 groups, n=82	Awareness of standardized packs, perceptions of their appeal, and potential impact on smoking attitudes and behavior	Appeal: Standardized packs were seen as ugly, and ability to differentiate between brands was reduced. Perceptions of harm: Removal of ‘clean’, ‘fresh’ colors perceived as reflecting harmfulness.
Mitchell et al^Citation25	Focus groups Between Nov 2017 (6 months after end of transition period) and Nov 2018 (18 months after end of transition period)	Young people 16–17 years Mix of ever and never smokers Scotland 8 groups, n=41	Awareness and perceptions of standardized packs, reactions to different standardized pack structures	Appeal: Standardized packs were seen as off-putting and embarrassing, but some pack structures were regarded less negatively than others. Perceptions of harm: Pack color thought to reflect harmfulness of cigarettes.
Mitchell et al^Citation23	Cross-sectional survey in schools Between Nov 2017 (6 months after end of transition period) and Nov 2018 (18 months after end of transition period)	Young people 12–17 years Never smokers Scotland n=507	Reactions to standardized cigarette packaging; whether permitted variations in pack structure (eg, slim packs or beveled-edged packs) influenced reactions. Perceptions of harm to health	Appeal: Standardized packs were consistently rated negatively on different appeal measures, but some pack structures were regarded less negatively than others. Perceptions of harm: Standardized packs consistently rated as harmful, with no significant differences between standardized packs with different structures.
Moodie et al^Citation26	Cross-sectional online survey Feb-Apr 2017, towards end of transition period	Current smokers 16–65+ years England n=1865	Smokers who currently used standardized packs vs smokers who had never used standardized packs (conducted Feb-Apr 2017 when both standardized and fully branded packs still on sale). Whether pack made respondents think about health risks of smoking	Perceptions of harm: Users of standardized packs were more likely than never users of standardized packs to indicate that pack made them think about health risks of smoking.

Table 2 Direction of Effect and/or Key Findings: Response to Health Warnings

Study	Study Design and Data Collection	Population	Type of Comparison/ Issues Explored	Direction of Effect (Measures Used) and/or Key Findings
Aleyan et al^Citation22	Longitudinal online survey Wave 1: Jul-Sep 2016 (early in transition period) Wave 2: Feb-Jul 2018 (nine-14 months after end of transition period)	Adult smokers 18+ years England, Germany, Greece, Hungary, Poland, Romania, Spain Wave 1: n=9547 Wave 2: n=9724	Smokers in England (Tobacco Products Directive new warnings and UK standardized packs) vs smokers in six other European countries (Tobacco Products Directive new warnings only)	Favors UK standardized packs (what participants report first noticing on packs). Warning salience increased significantly at Wave 2 in England. Increase in warning salience at Wave 2 was greater in England than in other six countries.
Drovandi et al^Citation27	Cross-sectional online survey Jun 2018 (approx. one year after end of transition period)	Smokers 19–74 years UK, Australia, Canada, USA n=155 UK n=532 other countries	Smokers in UK (UK standardized packs) vs smokers in Australia, Canada, USA (each countries’ own packs)	Favors UK standardized packs (perceived effectiveness of warnings in prompting smokers to quit). Perceived effectiveness of warnings higher in the UK; UK smokers less negative about effect of warnings on quitting.
MacGregor et al^Citation24	Focus groups Feb-Mar 2017, towards end of transition period	Young people 13–16 years Mix of current smokers, never smokers, and tried smoking Scotland 16 groups, n=82	Awareness of standardized packs, perceptions as to their appeal, and potential impact on smoking attitudes and behavior	Perceptions of warnings very negative.
Mitchell et al^Citation25	Focus groups Nov 2017 (6 months after end of transition period) and Nov 2018 (18 months after end of transition period)	Young people 16–17 years Mix of ever and never smokers Scotland 8 groups, n=41	Awareness and perceptions of standardized packs, reactions to pack structures	Warnings were perceived as clear, noticeable, believable and off-putting.
Moodie et al^Citation26	Cross-sectional online survey Feb-Apr 2017, towards end of transition period	Current smokers 16–65+ years England n=1865	Smokers who currently used standardized packs vs smokers who had never used standardized packs (conducted Feb-Apr 2017 when both standardized and fully branded packs still on sale)	Favors standardized packs (noticing, reading or looking closely at warning). Current users more likely to notice warnings and to read or look closely at them.
Poundall et al^Citation28	Cross-sectional survey Oct-Nov 2016 (early transition period)	University students England n=546	Fully branded packs vs standardized packs (conducted Oct-Nov 2016 when standardized packs not widely available)	Favors standardized packs (noticing warnings, whether warnings would put them off or make them want to quit).
Retzler et al^Citation29	Eye-tracking experimental study, within-subjects design Feb-May 2017 (late transition period)	Smokers 19–58 years England n=47	Fully branded packs vs standardized packs	Favors standardized packs (eye fixations on warnings). Participants attended more to warnings on standardized packs, in terms of looking at warnings first and for longer duration.

Table 3 Direction of Effect and/or Key Findings: Behaviors

Study	Study Design and Data Collection	Population	Type of Comparison/ Issues Explored	Direction of Effect (Measures Used) and/or Key Findings
MacGregor et al^Citation24	Focus groups Feb-Mar 2017, towards end of transition period	Young people 13–16 years Mix of current smokers, never smokers, and tried smoking Scotland 16 groups, n=82	The probable impact of standardized packs on smoking behavior among young people	Anticipated behaviors: Packs would affect never or occasional smokers, but established smokers would continue to smoke.
Mitchell et al^Citation25	Focus groups Between Nov 2017 (6 months after end of transition period) and Nov 2018 (18 months after end of transition period)	Young people 16–17 years Mix of ever and never smokers Scotland 8 groups, n=41	Reactions to different standardized cigarette pack structures and perceived impact on smoking behavior	Anticipated behaviors: Packs would put off people considering starting but not addicted smokers. Standardized slim pack and shoulder box would be less of a deterrent than regular packs.
Mitchell et al^Citation23	Cross-sectional survey in schools Between Nov 2017 (6 months after end of transition period) and Nov 2018 (18 months after end of transition period)	Young people 12–17 years Never smokers Scotland n=507	Reactions to standardized cigarette packaging; whether permitted variations in pack structure (eg, slim packs or beveled-edged packs) influenced reactions	Anticipated behaviors: Favors standardized packs (all packs would put them off smoking. Most would not select a pack when asked to pick one.) Elaborate pack structures were preferred over regular pack structures.
Poundall et al^Citation28	Cross-sectional survey Oct-Nov 2016 (early transition period)	University students England n=546	Would smokers make behavior changes such as quitting or switching to a cheaper brand or alternative products as a result of the legislation	Anticipated behaviors: Some smokers reported they were likely to switch products (to RYO, cheaper brands or e-cigarettes) in response to the legislation.
Breton et al^Citation30	Longitudinal panel survey Mar 2011-Dec 2017 (pre-legislation to 7 months after end of transition period)	Households who had purchased tobacco, e-cigarettes and Nicotine Replacement Therapy England, Scotland & Wales n=11,695 (average n=1741, range 1332 to 2186)	Comparing trends in household tobacco and non-tobacco nicotine product purchases before, during and after the introduction of plain packaging for consumers’ switching behaviors	Behaviors: Tobacco or non-tobacco nicotine products purchasing households more likely to leave the panel post-standardized packaging.
Breton et al^Citation30	Cross-sectional survey Mar-May 2018 (10–12 months after end of transition period)	Smokers who had changed tobacco product past month England, Scotland & Wales n=1061	Consumer’s choices after changes in product availability associated with implementation of standardized packaging	Behaviors: Among recent tobacco purchasers, most reported buying the same brand.
Bogdanovica et al^Citation31	Cross-sectional survey Mar 2017 (towards end of transition period)	Current smokers 18–55+ years England, Scotland & Wales n=2033	If smokers had changed the product they usually smoked in the last 6 months	Behaviors: Some smokers reported they had switched products (to cheaper brands, larger packs or e-cigarettes) in the last 6 months.
Moodie et al^Citation26	Cross-sectional online survey Feb-Apr 2017 (towards end of transition period)	Current smokers 16–65+ years England n=1865	Whether smokers had visited a stop-smoking website in the past month by use of standardized packs (a stop-smoking website is mandatory on standardized packs)	Behaviors: Favors standardized packs (more current and previous users of standardized packs had visited a stop-smoking website than non-users of standardized packs).

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