Observed smoking and tobacco pack display in Australian outdoor cafés 2 years after implementation of plain packaging

Observed smoking and tobacco pack display in Australian outdoor cafés 2 years after... Abstract Background Implementation of tobacco plain packaging (PP) in Australia in December 2012 was associated with significant reductions in the percentage of patrons at outdoor cafés observed to be displaying tobacco packs and actively smoking, immediately post-implementation and 1 year later. This study examines whether these positive effects were sustained through to 2 years post-PP. Methods An observational study conducted at cafés, restaurants and bars with outdoor seating in Melbourne, Australia documented the number of: patrons; patrons actively smoking; tobacco packs on display; orientation and type of displayed packs and whether or not children were present. Data were collected pre-PP (2012), early post-PP (2013), 1 year post-PP (2014) and 2 years post-PP (2015). Multilevel Poisson regressions analyzed changes in each outcome, adjusting for important covariates. Results Overall, positive effects of PP implementation on tobacco pack display and active smoking were not fully sustained through to 2 years post-PP for the total sample. Interactions between phase and the presence of children indicated that pack display and active smoking were lower in all post-implementation phases (compared with pre-PP) at venues where children were present but not at venues where children were not present. Conclusions Children at outdoor cafés were still being exposed to less tobacco packaging and active smoking, 2 years after implementation of the packaging changes. More regular refreshment of graphic health warnings is likely to be required to sustain these effects, and to reduce pack display behaviour at venues with no children. Introduction In 2012, as the latest step in pursuing a comprehensive approach to tobacco control,1 the Australian government implemented plain packaging (PP) for tobacco products2 with new larger graphic health warnings (GHWs).3 A growing number of countries have since followed suit. In April 2014, the European Union adopted the Tobacco Products Directive, which allows member states the option of implementing PP. As of June 2017, PP regulations had been debated, approved or implemented in France, Hungary, Ireland, Norway, Slovenia and the United Kingdom.4 In Australia, studies evaluating the impact of PP and larger GHWs have indicated these interventions led to reductions in the appeal of tobacco products, and increases in GHW effectiveness and quitting-related cognitions and behaviours.5–15 It has also been estimated that as of September 2015, PP implementation had led to a statistically significant decline in smoking prevalence of 0.55 percentage points.16 These post-implementation findings from Australia are broadly consistent with the results from experimental tests demonstrating the potential effectiveness of PP, conducted in countries such as France and the United Kingdom.17–22 In two previous studies, we assessed the impact of PP by observing the behaviour of patrons at outdoor drinking and dining venues.23,24 Between October 2011 and April 2012 (pre-PP), and October 2012 and April 2013 (early post-PP), we counted patrons, smokers and tobacco packs at cafés, restaurants and bars with outdoor seating in two Australian capital cities, Melbourne (Victoria) and Adelaide (South Australia).23 We observed reduced rates of smoking and pack display from pre-PP to early post-PP, particularly at venues where children were present. We also found that, at early post-PP, packs were less commonly oriented face-up and were more likely to be concealed or in an external case.23 A continuation of this study reported on observations made 1 year post-implementation. Data were gathered between January and April 2014 (1 year post-PP), and compared with observations made over the same summer months pre-PP (January–April 2012) and early post-PP (January–April 2013).24 This study found that declines in the rate of smoking and pack display observed in the early post-PP period were maintained 1 year post-PP, with these findings again more pronounced in venues where children were present. By 1 year post-PP, rates of face-up pack display, pack concealment and external cases had returned to pre-PP levels.24 This study further extends data collection through to 2 years post-implementation (2 years post-PP), in Melbourne, Australia’s second largest city. We were interested in whether the effect of PP on denormalising smoking—as suggested by the early post-PP and 1 year post-PP findings23,24—would still be apparent 2 years post-implementation, or alternatively, if there would be evidence that this effect had started to wane. We were also interested in whether effects continued to be more pronounced at venues where children were present. Methods Details of the venue sampling and data collection procedure have been described elsewhere.23–25 Briefly, to establish the sample of venues we selected 17 street segments (‘café strips’) from a range of socioeconomic areas in Melbourne that were known to have many popular cafés, restaurants and bars; the same 17 café strips were visited in all four phases. Café strips contained between 6 and 50 eligible venues each and observations were made at every eligible venue: to be eligible, the venue had to be a café, restaurant or bar with outdoor seating visible from the footpath where smoking was permitted. New venues within a café strip were added to the sample if they opened between PP phases; venues that closed between phases were not necessarily replaced (i.e. if a new venue did not open in their place). For each of 2012 (pre-PP), 2013 (early post-PP), 2014 (1 year post-PP) and 2015 (2 years post-PP), fieldworkers made five waves of observations at each café strip at ∼2-week intervals between mid-January and mid-April; in each wave, data were collected once at each venue within the café strip. At each venue, the fieldworker slowly walked along the footpath, or found an unobtrusive spot to stand, while they discreetly counted the number of seated patrons, the number of patrons smoking, holding, rolling or lighting a cigarette (‘active smokers’) and the number of tobacco packs. They counted the number of tobacco packs that were fully branded, plain or of an indeterminate type. They also noted the number of packs that were oriented face-up (with the brand name visible), concealed by an object like a wallet or phone, concealed in an external case (including cigarette tins) or that were in an unknown orientation due to the distance of the observation. Finally, fieldworkers recorded whether any children who looked to be of approximately primary school age or younger (i.e. <13 years of age) were present at the venue at the time of observation. During the early post-PP phase of data collection, a fieldwork coordinator accompanied four different fieldworkers as they made their observations. Inter-rater reliability analyses revealed high levels of consistency between the observations made by each of these fieldworkers and the coordinator,23 thereby establishing the reliability of the data collection protocol. We used the Australian Bureau of Statistics’ Socioeconomic Indices for Areas (SEIFA) Index of Relative Disadvantage26 to determine socioeconomic status (SES) for each café strip (low SES: café strips in the lowest two quintiles of the index for the state of Victoria; mid-SES: third and fourth quintiles and high SES: fifth quintile). Weather information (temperature and wind speed) was recorded at the time of data collection using a smartphone application. Statistical analysis Multilevel Poisson models were employed in Stata 14.1 to test for differences between pre-PP and each subsequent phase and between early post-PP and each subsequent phase. Random intercepts were included for café strip and venue in all models to adjust standard errors for correlations among venues within the same café strip and for multiple observations over time at each venue. All models adjusted for the presence of children, café strip SES, month (January/February vs. March/April), day and time (weekdays before 16:00 h, weekdays after 16:00 h and weekends) and the temperature (<22°C, 22–27°C, ≥28°C) and wind speed (km/h) at the time of observation. To analyze first the number of packs observed as the rate of packs to patrons, and then the number of active smokers as the rate of smokers to patrons, the number of patrons was included in the model as an offset term and the sample was limited to venue observations at which at least one patron was observed. We also examined the rate of packs to smokers, using the number of smokers as the offset term and only including venue observations with one or more smokers present. We compared rates of face-up orientation and pack concealment among packs that were compliant with the legislation currently in effect (i.e. branded packs at pre-PP and plain packs in the post-PP phases). In these analyses, only venue observations for which at least one known-orientation branded (pre-PP) or plain (post-PP) pack was recorded were analyzed (i.e. packs in external cases and in an unknown orientation were excluded). Observed rates of external cases were analyzed out of all observed packs; accordingly, at least one pack had to be observed at the venue for the observation to be included in the analysis. Finally, observed rates of branded packs were analyzed out of all packs of a known type (either branded or plain), so at least one branded or plain pack had to be observed for the venue observation to be included in the analysis. We tested for interactions between PP phase and the presence of children at venues. Where the P values for the interaction term was P < 0.05, we explored the pattern of effects using stratified models adjusted for the same covariates listed earlier. Results Sample characteristics Over the four phases in Melbourne, we collected data at 3808 venues at which at least one patron was present at the time of observation, and this sample formed the denominator for analyses of the rate of packs to patrons and active smokers to patrons. Fewer observations were used in analyses of the rates of packs to active smokers (n = 1169 venue observations with at least one active smoker), external cases to all packs (n = 1421 venue observations with at least one pack), branded packs to all known-type packs [n = 1346 venue observations with at least one pack of known type (branded or plain)] and face-up and concealed packs to known-orientation branded (pre-PP) or plain (post-PP) packs (n = 1321 venue observations with at least one known-orientation pack). Table 1 presents the size of these venue sub-samples in each phase, and the characteristics of venues at which at least one patron was present. Table 1 Number of eligible venue observations and characteristics of venues at which observations were made 2012 pre-PP 2013 early post-PP 2014 1 year post-PP 2015 2 years post-PP n n n n Venues with at least 1 patrona 958 926 962 962 Venues with at least 1 active smokerb 340 273 288 268 Venues with at least 1 packc 415 330 349 327 Venues with at least 1 pack of a known typed 395 306 330 315 Venues with at least 1 pack in a known orientatione 395 303 317 306 Characteristics of venues with at least 1 patron n (%) n (%) n (%) n (%) Total 958 926 962 962 Children     Not present 835 (87.2) 826 (89.2) 843 (87.6) 866 (90.0)     Present 123 (12.8) 100 (10.8) 119 (12.4) 96 (10.0) SES     Low SES (high disadvantage) 369 (38.5) 364 (39.3) 350 (36.4) 427 (44.4)     Mid 202 (21.1) 189 (20.4) 222 (23.1) 224 (23.3)     High SES (low disadvantage) 387 (40.4) 373 (40.3) 390 (40.5) 311 (32.3) Month     January/February 540 (56.4) 463 (50.0) 476 (49.5) 385 (40.0)     March/April 418 (43.6) 463 (50.0) 486 (50.5) 577 (60.0) Day and time     Weekday, after 4:00 pm 227 (23.7) 251 (27.1) 264 (27.4) 355 (36.9)     Weekday, before 4:00 pm 264 (27.6) 230 (24.8) 227 (23.6) 225 (23.4)     Weekend 467 (48.8) 445 (48.1) 471 (49.0) 382 (39.7) Temperature     Under 22C 287 (30.0) 168 (18.1) 596 (62.0) 677 (70.4)     22–27C 495 (51.7) 512 (55.3) 290 (30.2) 158 (16.4)     28C and above 176 (18.4) 246 (26.6) 76 (7.9) 127 (13.2) Wind speed (km/h) M = 12.6 (SD = 5.7) M = 13.0 (SD = 5.3) M = 12.8 (SD = 5.4) M = 11.2 (SD = 6.4) 2012 pre-PP 2013 early post-PP 2014 1 year post-PP 2015 2 years post-PP n n n n Venues with at least 1 patrona 958 926 962 962 Venues with at least 1 active smokerb 340 273 288 268 Venues with at least 1 packc 415 330 349 327 Venues with at least 1 pack of a known typed 395 306 330 315 Venues with at least 1 pack in a known orientatione 395 303 317 306 Characteristics of venues with at least 1 patron n (%) n (%) n (%) n (%) Total 958 926 962 962 Children     Not present 835 (87.2) 826 (89.2) 843 (87.6) 866 (90.0)     Present 123 (12.8) 100 (10.8) 119 (12.4) 96 (10.0) SES     Low SES (high disadvantage) 369 (38.5) 364 (39.3) 350 (36.4) 427 (44.4)     Mid 202 (21.1) 189 (20.4) 222 (23.1) 224 (23.3)     High SES (low disadvantage) 387 (40.4) 373 (40.3) 390 (40.5) 311 (32.3) Month     January/February 540 (56.4) 463 (50.0) 476 (49.5) 385 (40.0)     March/April 418 (43.6) 463 (50.0) 486 (50.5) 577 (60.0) Day and time     Weekday, after 4:00 pm 227 (23.7) 251 (27.1) 264 (27.4) 355 (36.9)     Weekday, before 4:00 pm 264 (27.6) 230 (24.8) 227 (23.6) 225 (23.4)     Weekend 467 (48.8) 445 (48.1) 471 (49.0) 382 (39.7) Temperature     Under 22C 287 (30.0) 168 (18.1) 596 (62.0) 677 (70.4)     22–27C 495 (51.7) 512 (55.3) 290 (30.2) 158 (16.4)     28C and above 176 (18.4) 246 (26.6) 76 (7.9) 127 (13.2) Wind speed (km/h) M = 12.6 (SD = 5.7) M = 13.0 (SD = 5.3) M = 12.8 (SD = 5.4) M = 11.2 (SD = 6.4) Note. PP, plain packaging; M, mean; SD, standard deviation. a Denominator for analysis of the rate of packs to patrons and active smokers to patrons. b Denominator for analysis of the rate of packs to active smokers. c Denominator for analysis of the rate of external cases to all packs. d Denominator for analysis of the rate of fully branded packs to all packs of a known type (fully branded or plain). e Denominator for analysis of the rate of face-up packs to all packs in a known orientation, and concealed packs to all packs in a known orientation. For these analyses, the denominator of known orientation packs is limited to fully branded packs at pre-PP and plain packs in the three post-PP phases. Table 1 Number of eligible venue observations and characteristics of venues at which observations were made 2012 pre-PP 2013 early post-PP 2014 1 year post-PP 2015 2 years post-PP n n n n Venues with at least 1 patrona 958 926 962 962 Venues with at least 1 active smokerb 340 273 288 268 Venues with at least 1 packc 415 330 349 327 Venues with at least 1 pack of a known typed 395 306 330 315 Venues with at least 1 pack in a known orientatione 395 303 317 306 Characteristics of venues with at least 1 patron n (%) n (%) n (%) n (%) Total 958 926 962 962 Children     Not present 835 (87.2) 826 (89.2) 843 (87.6) 866 (90.0)     Present 123 (12.8) 100 (10.8) 119 (12.4) 96 (10.0) SES     Low SES (high disadvantage) 369 (38.5) 364 (39.3) 350 (36.4) 427 (44.4)     Mid 202 (21.1) 189 (20.4) 222 (23.1) 224 (23.3)     High SES (low disadvantage) 387 (40.4) 373 (40.3) 390 (40.5) 311 (32.3) Month     January/February 540 (56.4) 463 (50.0) 476 (49.5) 385 (40.0)     March/April 418 (43.6) 463 (50.0) 486 (50.5) 577 (60.0) Day and time     Weekday, after 4:00 pm 227 (23.7) 251 (27.1) 264 (27.4) 355 (36.9)     Weekday, before 4:00 pm 264 (27.6) 230 (24.8) 227 (23.6) 225 (23.4)     Weekend 467 (48.8) 445 (48.1) 471 (49.0) 382 (39.7) Temperature     Under 22C 287 (30.0) 168 (18.1) 596 (62.0) 677 (70.4)     22–27C 495 (51.7) 512 (55.3) 290 (30.2) 158 (16.4)     28C and above 176 (18.4) 246 (26.6) 76 (7.9) 127 (13.2) Wind speed (km/h) M = 12.6 (SD = 5.7) M = 13.0 (SD = 5.3) M = 12.8 (SD = 5.4) M = 11.2 (SD = 6.4) 2012 pre-PP 2013 early post-PP 2014 1 year post-PP 2015 2 years post-PP n n n n Venues with at least 1 patrona 958 926 962 962 Venues with at least 1 active smokerb 340 273 288 268 Venues with at least 1 packc 415 330 349 327 Venues with at least 1 pack of a known typed 395 306 330 315 Venues with at least 1 pack in a known orientatione 395 303 317 306 Characteristics of venues with at least 1 patron n (%) n (%) n (%) n (%) Total 958 926 962 962 Children     Not present 835 (87.2) 826 (89.2) 843 (87.6) 866 (90.0)     Present 123 (12.8) 100 (10.8) 119 (12.4) 96 (10.0) SES     Low SES (high disadvantage) 369 (38.5) 364 (39.3) 350 (36.4) 427 (44.4)     Mid 202 (21.1) 189 (20.4) 222 (23.1) 224 (23.3)     High SES (low disadvantage) 387 (40.4) 373 (40.3) 390 (40.5) 311 (32.3) Month     January/February 540 (56.4) 463 (50.0) 476 (49.5) 385 (40.0)     March/April 418 (43.6) 463 (50.0) 486 (50.5) 577 (60.0) Day and time     Weekday, after 4:00 pm 227 (23.7) 251 (27.1) 264 (27.4) 355 (36.9)     Weekday, before 4:00 pm 264 (27.6) 230 (24.8) 227 (23.6) 225 (23.4)     Weekend 467 (48.8) 445 (48.1) 471 (49.0) 382 (39.7) Temperature     Under 22C 287 (30.0) 168 (18.1) 596 (62.0) 677 (70.4)     22–27C 495 (51.7) 512 (55.3) 290 (30.2) 158 (16.4)     28C and above 176 (18.4) 246 (26.6) 76 (7.9) 127 (13.2) Wind speed (km/h) M = 12.6 (SD = 5.7) M = 13.0 (SD = 5.3) M = 12.8 (SD = 5.4) M = 11.2 (SD = 6.4) Note. PP, plain packaging; M, mean; SD, standard deviation. a Denominator for analysis of the rate of packs to patrons and active smokers to patrons. b Denominator for analysis of the rate of packs to active smokers. c Denominator for analysis of the rate of external cases to all packs. d Denominator for analysis of the rate of fully branded packs to all packs of a known type (fully branded or plain). e Denominator for analysis of the rate of face-up packs to all packs in a known orientation, and concealed packs to all packs in a known orientation. For these analyses, the denominator of known orientation packs is limited to fully branded packs at pre-PP and plain packs in the three post-PP phases. Pack display and active smoking Before the implementation of PP, one in every 8.0 patrons displayed a tobacco pack. In the early post-PP and 1 year post-PP phases, rates of pack display were lower compared with pre-PP (table 2). Pack display was also somewhat lower in the 2 year post-PP phase. The rate of pack display in the 2 year post-PP phase did not differ from that observed in the early post-PP phase (table 2). Table 2 Changes over time in rates of pack display, active smoking, pack orientation, pack concealment and branded pack use Outcome (rate of…) Rate Percentage of… Vs. pre-PP Vs. early post-PP Adj. IRRa 95% CIs Adj. IRRa 95% CIs Packs to patrons …patrons who displayed pack     Pre-PP 1: 8.0 12.6 Ref 1.20 [1.07, 1.33]     Early post-PP 1: 9.8 10.2 0.84 [0.75, 0.93] Ref     1 year post-PP 1: 10.5 9.5 0.82 [0.73, 0.92] 0.98 [0.87, 1.11]     2 years post-PP 1: 9.4 10.6 0.90 [0.79, 1.02] 1.07 [0.93, 1.24] Active smokers to patrons …patrons who were smoking     Pre-PP 1: 10.4 9.6 Ref 1.20 [1.05, 1.36]     Early post-PP 1: 13.3 7.5 0.84 [0.74, 0.95] Ref     1 year post-PP 1: 14.0 7.1 0.82 [0.72, 0.94] 0.99 [0.85, 1.14]     2 years post-PP 1: 12.4 8.1 0.93 [0.79, 1.08] 1.11 [0.94, 1.30] Face-up packs to all packsb …packsb that were face-up     Pre-PP 1: 1.2 84.3 Ref 1.16 [1.02, 1.32]     Early post-PP 1: 1.4 72.7 0.86 [0.76, 0.98] Ref     1 year post-PP 1: 1.2 82.9 0.98 [0.86, 1.10] 1.13 [0.97, 1.31]     2 years post-PP 1: 1.2 83.6 0.97 [0.84, 1.11] 1.12 [0.95, 1.32] Concealed packs to all packsb …packsb that were concealed     Pre-PP 1: 22.2 4.5 Ref 0.39 [0.25, 0.60]     Early post-PP 1: 8.7 11.5 2.57 [1.67, 3.98] Ref     1 year post-PP 1: 17.6 5.7 1.19 [0.72, 1.96] 0.46 [0.29, 0.74]     2 years post-PP 1: 28.4 3.5 0.73 [0.39, 1.36] 0.28 [0.15, 0.52] External cases to all packs …packs that were in cases     Pre-PP 1: 76.9 1.3 Ref 0.28 [0.13, 0.60]     Early post-PP 1: 25.0 4.0 3.52 [1.67, 7.45] Ref     1 year post-PP 1: 49.0 2.0 1.40 [0.61, 3.20] 0.40 [0.19, 0.83]     2 years post-PP 1: 18.4 5.4 2.75 [1.26, 6.00] 0.78 [0.38, 1.60] Fully branded packs to all packsc …packsc that were fully branded     Pre-PP 1: 1.0 100.0 Ref 22.74 [15.11, 34.21]     Early post-PP 1: 22.8 4.4 0.04 [0.03, 0.07] Ref     1 year post-PP 1: 16.6 6.0 0.06 [0.04, 0.09] 1.38 [0.82, 2.32]     2 years post-PP 1: 25.7 3.9 0.04 [0.03, 0.06] 0.89 [0.49, 1.59] Outcome (rate of…) Rate Percentage of… Vs. pre-PP Vs. early post-PP Adj. IRRa 95% CIs Adj. IRRa 95% CIs Packs to patrons …patrons who displayed pack     Pre-PP 1: 8.0 12.6 Ref 1.20 [1.07, 1.33]     Early post-PP 1: 9.8 10.2 0.84 [0.75, 0.93] Ref     1 year post-PP 1: 10.5 9.5 0.82 [0.73, 0.92] 0.98 [0.87, 1.11]     2 years post-PP 1: 9.4 10.6 0.90 [0.79, 1.02] 1.07 [0.93, 1.24] Active smokers to patrons …patrons who were smoking     Pre-PP 1: 10.4 9.6 Ref 1.20 [1.05, 1.36]     Early post-PP 1: 13.3 7.5 0.84 [0.74, 0.95] Ref     1 year post-PP 1: 14.0 7.1 0.82 [0.72, 0.94] 0.99 [0.85, 1.14]     2 years post-PP 1: 12.4 8.1 0.93 [0.79, 1.08] 1.11 [0.94, 1.30] Face-up packs to all packsb …packsb that were face-up     Pre-PP 1: 1.2 84.3 Ref 1.16 [1.02, 1.32]     Early post-PP 1: 1.4 72.7 0.86 [0.76, 0.98] Ref     1 year post-PP 1: 1.2 82.9 0.98 [0.86, 1.10] 1.13 [0.97, 1.31]     2 years post-PP 1: 1.2 83.6 0.97 [0.84, 1.11] 1.12 [0.95, 1.32] Concealed packs to all packsb …packsb that were concealed     Pre-PP 1: 22.2 4.5 Ref 0.39 [0.25, 0.60]     Early post-PP 1: 8.7 11.5 2.57 [1.67, 3.98] Ref     1 year post-PP 1: 17.6 5.7 1.19 [0.72, 1.96] 0.46 [0.29, 0.74]     2 years post-PP 1: 28.4 3.5 0.73 [0.39, 1.36] 0.28 [0.15, 0.52] External cases to all packs …packs that were in cases     Pre-PP 1: 76.9 1.3 Ref 0.28 [0.13, 0.60]     Early post-PP 1: 25.0 4.0 3.52 [1.67, 7.45] Ref     1 year post-PP 1: 49.0 2.0 1.40 [0.61, 3.20] 0.40 [0.19, 0.83]     2 years post-PP 1: 18.4 5.4 2.75 [1.26, 6.00] 0.78 [0.38, 1.60] Fully branded packs to all packsc …packsc that were fully branded     Pre-PP 1: 1.0 100.0 Ref 22.74 [15.11, 34.21]     Early post-PP 1: 22.8 4.4 0.04 [0.03, 0.07] Ref     1 year post-PP 1: 16.6 6.0 0.06 [0.04, 0.09] 1.38 [0.82, 2.32]     2 years post-PP 1: 25.7 3.9 0.04 [0.03, 0.06] 0.89 [0.49, 1.59] Note. PP, plain packaging; IRR, incident rate ratio; Ref, referent category in multilevel Poisson regression models. a Adjusted (Adj.) IRRs adjust for: presence of children, area SES, month (January/February or March/April), day and time (weekday before 4:00 pm, weekday after 4:00 pm or weekend; based on end time of fieldwork session), temperature (<22°C, 22–27°C, ≥28°C) and wind speed and are from multilevel Poisson regression models that included random intercepts for café strip and venue. b For the rates of face-up orientation and pack concealment, ‘all packs’ includes packs compliant with the legislation in effect at the time (fully branded packs at pre-PP, plain packs in all post-PP phases) for which an orientation was recorded. c For the rates of fully branded packs, ‘all packs’ includes packs of a known type (fully branded packs at pre-PP, branded or plain packs in all post-PP phases). Table 2 Changes over time in rates of pack display, active smoking, pack orientation, pack concealment and branded pack use Outcome (rate of…) Rate Percentage of… Vs. pre-PP Vs. early post-PP Adj. IRRa 95% CIs Adj. IRRa 95% CIs Packs to patrons …patrons who displayed pack     Pre-PP 1: 8.0 12.6 Ref 1.20 [1.07, 1.33]     Early post-PP 1: 9.8 10.2 0.84 [0.75, 0.93] Ref     1 year post-PP 1: 10.5 9.5 0.82 [0.73, 0.92] 0.98 [0.87, 1.11]     2 years post-PP 1: 9.4 10.6 0.90 [0.79, 1.02] 1.07 [0.93, 1.24] Active smokers to patrons …patrons who were smoking     Pre-PP 1: 10.4 9.6 Ref 1.20 [1.05, 1.36]     Early post-PP 1: 13.3 7.5 0.84 [0.74, 0.95] Ref     1 year post-PP 1: 14.0 7.1 0.82 [0.72, 0.94] 0.99 [0.85, 1.14]     2 years post-PP 1: 12.4 8.1 0.93 [0.79, 1.08] 1.11 [0.94, 1.30] Face-up packs to all packsb …packsb that were face-up     Pre-PP 1: 1.2 84.3 Ref 1.16 [1.02, 1.32]     Early post-PP 1: 1.4 72.7 0.86 [0.76, 0.98] Ref     1 year post-PP 1: 1.2 82.9 0.98 [0.86, 1.10] 1.13 [0.97, 1.31]     2 years post-PP 1: 1.2 83.6 0.97 [0.84, 1.11] 1.12 [0.95, 1.32] Concealed packs to all packsb …packsb that were concealed     Pre-PP 1: 22.2 4.5 Ref 0.39 [0.25, 0.60]     Early post-PP 1: 8.7 11.5 2.57 [1.67, 3.98] Ref     1 year post-PP 1: 17.6 5.7 1.19 [0.72, 1.96] 0.46 [0.29, 0.74]     2 years post-PP 1: 28.4 3.5 0.73 [0.39, 1.36] 0.28 [0.15, 0.52] External cases to all packs …packs that were in cases     Pre-PP 1: 76.9 1.3 Ref 0.28 [0.13, 0.60]     Early post-PP 1: 25.0 4.0 3.52 [1.67, 7.45] Ref     1 year post-PP 1: 49.0 2.0 1.40 [0.61, 3.20] 0.40 [0.19, 0.83]     2 years post-PP 1: 18.4 5.4 2.75 [1.26, 6.00] 0.78 [0.38, 1.60] Fully branded packs to all packsc …packsc that were fully branded     Pre-PP 1: 1.0 100.0 Ref 22.74 [15.11, 34.21]     Early post-PP 1: 22.8 4.4 0.04 [0.03, 0.07] Ref     1 year post-PP 1: 16.6 6.0 0.06 [0.04, 0.09] 1.38 [0.82, 2.32]     2 years post-PP 1: 25.7 3.9 0.04 [0.03, 0.06] 0.89 [0.49, 1.59] Outcome (rate of…) Rate Percentage of… Vs. pre-PP Vs. early post-PP Adj. IRRa 95% CIs Adj. IRRa 95% CIs Packs to patrons …patrons who displayed pack     Pre-PP 1: 8.0 12.6 Ref 1.20 [1.07, 1.33]     Early post-PP 1: 9.8 10.2 0.84 [0.75, 0.93] Ref     1 year post-PP 1: 10.5 9.5 0.82 [0.73, 0.92] 0.98 [0.87, 1.11]     2 years post-PP 1: 9.4 10.6 0.90 [0.79, 1.02] 1.07 [0.93, 1.24] Active smokers to patrons …patrons who were smoking     Pre-PP 1: 10.4 9.6 Ref 1.20 [1.05, 1.36]     Early post-PP 1: 13.3 7.5 0.84 [0.74, 0.95] Ref     1 year post-PP 1: 14.0 7.1 0.82 [0.72, 0.94] 0.99 [0.85, 1.14]     2 years post-PP 1: 12.4 8.1 0.93 [0.79, 1.08] 1.11 [0.94, 1.30] Face-up packs to all packsb …packsb that were face-up     Pre-PP 1: 1.2 84.3 Ref 1.16 [1.02, 1.32]     Early post-PP 1: 1.4 72.7 0.86 [0.76, 0.98] Ref     1 year post-PP 1: 1.2 82.9 0.98 [0.86, 1.10] 1.13 [0.97, 1.31]     2 years post-PP 1: 1.2 83.6 0.97 [0.84, 1.11] 1.12 [0.95, 1.32] Concealed packs to all packsb …packsb that were concealed     Pre-PP 1: 22.2 4.5 Ref 0.39 [0.25, 0.60]     Early post-PP 1: 8.7 11.5 2.57 [1.67, 3.98] Ref     1 year post-PP 1: 17.6 5.7 1.19 [0.72, 1.96] 0.46 [0.29, 0.74]     2 years post-PP 1: 28.4 3.5 0.73 [0.39, 1.36] 0.28 [0.15, 0.52] External cases to all packs …packs that were in cases     Pre-PP 1: 76.9 1.3 Ref 0.28 [0.13, 0.60]     Early post-PP 1: 25.0 4.0 3.52 [1.67, 7.45] Ref     1 year post-PP 1: 49.0 2.0 1.40 [0.61, 3.20] 0.40 [0.19, 0.83]     2 years post-PP 1: 18.4 5.4 2.75 [1.26, 6.00] 0.78 [0.38, 1.60] Fully branded packs to all packsc …packsc that were fully branded     Pre-PP 1: 1.0 100.0 Ref 22.74 [15.11, 34.21]     Early post-PP 1: 22.8 4.4 0.04 [0.03, 0.07] Ref     1 year post-PP 1: 16.6 6.0 0.06 [0.04, 0.09] 1.38 [0.82, 2.32]     2 years post-PP 1: 25.7 3.9 0.04 [0.03, 0.06] 0.89 [0.49, 1.59] Note. PP, plain packaging; IRR, incident rate ratio; Ref, referent category in multilevel Poisson regression models. a Adjusted (Adj.) IRRs adjust for: presence of children, area SES, month (January/February or March/April), day and time (weekday before 4:00 pm, weekday after 4:00 pm or weekend; based on end time of fieldwork session), temperature (<22°C, 22–27°C, ≥28°C) and wind speed and are from multilevel Poisson regression models that included random intercepts for café strip and venue. b For the rates of face-up orientation and pack concealment, ‘all packs’ includes packs compliant with the legislation in effect at the time (fully branded packs at pre-PP, plain packs in all post-PP phases) for which an orientation was recorded. c For the rates of fully branded packs, ‘all packs’ includes packs of a known type (fully branded packs at pre-PP, branded or plain packs in all post-PP phases). In a similar way, compared with pre-PP, the prevalence of active smoking was lower in the early post-PP and 1 year post-PP phases (table 2). Active smoking was also slightly lower in the 2 year post-PP phase. However, the prevalence of active smoking 2 years post-PP also did not differ from that observed in the early post-PP phase (table 2). The rate of pack display relative to active smokers (not shown in table 2) did not change between pre-PP and early post-PP [incident rate ratio (IRR) = 0.98, 95% confidence interval (CI) = 0.86–1.11], 1 year post-PP (IRR = 0.97, 95% CI = 0.85–1.10) or 2 years post-PP (IRR = 0.97, 95% CI = 0.84–1.13). It also did not differ between the early post-PP and 2 years post-PP phases (IRR = 0.99, 95% CI = 0.84–1.17). In each phase, we observed one pack for every 0.7–0.8 active smokers, indicating that some patrons displayed their pack even when they were not smoking. There was an interaction between phase and the presence of children in predicting the rate of pack display (χ2 = 11.76). Stratified analyses indicated that the effect of PP implementation on pack display was greater at venues with children present than at venues without children (figure 1a). Compared with pre-PP, there was a greater decline in the rate of pack display in each subsequent phase at venues with children present (early post-PP: IRR = 0.50, 95% CI = 0.35–0.71; 1 year post-PP: IRR = 0.56, 95% CI = 0.40–0.77; 2 years post-PP: IRR = 0.75, 95% CI = 0.51, 1.11) than at venues without children (early post-PP: IRR = 0.89, 95% CI = 0.79–1.00; 1 year post-PP: IRR = 0.86, 95% CI = 0.76–0.97; 2 years post-PP: IRR = 0.93, 95% CI = 0.81–1.07). There was a similar interaction between phase and the presence of children in predicting the rate of active smoking (χ2 = 20.86; figure 1b). Compared with pre-PP, there was a greater decline in the prevalence of active smoking in each subsequent phase at venues with children present (early post-PP: IRR = 0.45, 95% CI = 0.30–0.68; 1 year post-PP: IRR = 0.38, 95% CI = 0.26–0.56; 2 years post-PP: IRR = 0.49, 95% CI = 0.31–0.76) than at venues without children (early post-PP: IRR = 0.91, 95% CI = 0.79–1.04; 1 year post-PP: IRR = 0.91, 95% CI = 0.79–1.05; 2 years post-PP: IRR = 1.03, 95% CI = 0.87–1.22). Figure 1 View largeDownload slide Interaction between phase and presence of children, for the percentage of patrons who displayed a pack (figure 1a) and the percentage of patrons who were actively smoking (figure 1b). PP, plain packaging Figure 1 View largeDownload slide Interaction between phase and presence of children, for the percentage of patrons who displayed a pack (figure 1a) and the percentage of patrons who were actively smoking (figure 1b). PP, plain packaging Pack orientation and concealment In each phase, we recorded the orientation of packs that were compliant with the legislation currently in effect (i.e. branded packs at pre-PP and plain packs in each subsequent phase). Compared with pre-PP, the percentage of packs oriented face-up was not different in each post-PP phase (and did not differ between these phases; table 2). However, the percentage of packs concealed by an object like a wallet or phone was highest in the early post-PP phase (table 2). The percentage of packs in external cases fluctuated across the study period (table 2). From a low rate of use pre-PP, the use of cases increased in the early post-PP phase, decreased in the 1 year post-PP phase (not different to pre-PP), before increasing again in the 2 year post-PP phase (although not different to pre-PP or early post-PP; table 2). Presence of branded packs Compared with pre-PP—at which time, all packs of a known type were fully branded—the prevalence of fully branded packs was, unsurprisingly, lower in all post-PP phases (≤6.0% in each phase; table 2). The prevalence of fully branded packs did not change from the early post-PP phase to the two later post-PP phases (table 2). Discussion Overall, we found that PP implementation was associated with reduced rates of tobacco pack display and active smoking at outdoor cafés in the early post-PP and 1 year post-PP periods but these effects were not fully sustained 2 years post-PP. In the 2 year post-PP period, rates of pack display and active smoking were not lower than those observed pre-PP but were also not different from those observed in the early post-PP period. Taken together, these findings indicate that even though the initial reductions in these behaviours were not maintained 2 years post-implementation, rates also have not completely rebounded to those observed prior to implementation. These overall effects must also be interpreted in light of interactions between PP phase and the presence of children. Pack display and active smoking were lower in all post-implementation phases at venues where children were present but not at venues without children. This is a positive finding, indicating that 2 years after implementation, children are still being exposed to less smoking and less tobacco packaging than before PP. This finding is consistent with evidence that children provide smokers with a powerful cue not to smoke,27 perhaps due to their desire to protect children from secondhand smoke or the normalising effects of seeing adults smoke. As a result of this reduced visibility of tobacco, children may develop more accurate perceptions of smoking prevalence and the social acceptability of tobacco use, which may reduce smoking initiation down the track.28,29 We found little evidence that implementation of PP had an enduring effect on the way in which smokers displayed their packs. Across all phases, the majority of packs were displayed face-up, and although we observed an early increase in efforts by smokers to conceal their packs, this effect was not sustained through to 1 or 2 years post-implementation. Use of external cases was rare in all phases. Minimal levels of pack concealment may represent a positive outcome for public health, given that smokers and other patrons are exposed to the large GHWs on the displayed tobacco packs. On the other hand, smokers’ efforts to avoid looking at GHWs (e.g. by covering them up) are associated with increased frequency of thoughts about quitting30 such that our finding that pack concealment was at pre-PP levels in the 1- and 2-year post-implementation phases may indicate diminishing effectiveness of GHWs over time. Furthermore, in all post-implementation phases we found a low prevalence of fully branded packs. Potential sources of fully branded packs in the post-PP environment include international tourists or Australians returning from abroad who purchased packs overseas, and contraband cigarettes (i.e. fully branded cigarettes from another country that have been smuggled into the illicit market in Australia). Previous population surveys have reported consistently minimal use of contraband cigarettes since the introduction of PP in Australia.31,32 The most recent national survey also found low levels of purchasing tobacco products without PP and larger GHWs.33 The findings from this study are consistent with this evidence, and at odds with claims from the tobacco industry that PP would result in a proliferation of illicit tobacco.4 This innovative observational study was relatively inexpensive and easy to implement. It provided some of the first evidence that the packaging changes were affecting smokers’ behaviours,23,24 and has also proved useful in monitoring whether these effects may be weakening with time. A particular strength of this method is the use of validated objective measures that are not subject to social desirability bias or misreporting but instead reflect the visibility of tobacco products and behaviours in real-world scenarios. One study limitation is that we observed behaviours in only one metropolitan city, and so cannot generalise the results nationally. Unlike our earlier studies, we did not collect data in Adelaide since that state was actively debating bans on smoking in outdoor dining venues, reducing our sample size and therefore power to detect changes. Another limitation is that increases in tobacco excise and customs duties were implemented on 1 December 2013 and again on 1 September 2014, which could have reduced active smoking by encouraging lower consumption or attempts to quit.34,35 Increasing prices may have also reduced smokers’ willingness to display their pack, to avoid being asked to share their cigarettes. However, stronger effects at venues where children were present is more consistent with an interpretation that attributes changes in these behaviours to PP rather than price increases. In conclusion, these findings indicate a slight weakening of the effects of PP on rates of pack display and active smoking by 2 years post-implementation, although positive effects continued to be observed at venues where children were present. Other studies have demonstrated that the impact of GHWs declines with time,36–38 and maintaining salience is a key challenge for warning label policies.39 Australia’s GHW scheme tries to delay wear-out effects through the annual rotation of two sets of seven warning labels,3 although when the 2 year post-PP data were collected in early 2015, the first set of GHWs were already appearing for the second time. More frequent changes to the GHWs that appear on packs may help to prolong their salience and impact, thereby sustaining the processes through which smokers become reluctant to be seen smoking and displaying their packs in public. Further research is required to assess whether similar wear-out effects are observed on other measures of PP effectiveness in Australia and when PP is implemented in other countries. Acknowledgements The authors thank Associate Professor Sarah Durkin who contributed to earlier phases of this project. The authors also thank staff at Cancer Council Victoria who undertook data collection. These findings were presented at the Oceania Tobacco Control Conference, October 2015, Perth, Australia. Funding This work was supported by Cancer Council Victoria and Quit Victoria. Conflicts of interest: The authors wish to advise that M.A.W. was a member and M.S. a technical writer for the Tobacco Working Group of the Australian National Preventive Health Task Force and M.A.W. was a member of the Expert Advisory Committee on Plain Packaging that advised the Australian Department of Health on research pertaining to plain packaging legislation. Key points Past studies found reduced rates of tobacco pack display and active smoking at outdoor cafés immediately following and 1 year after implementation of plain packaging with larger graphic health warnings in Australia. This study found that while overall these positive effects were not fully maintained 2 years post-implementation, rates remained lower at venues where children were present. Governments implementing plain packaging should consider frequent rotation and refreshment of graphic health warnings to delay the wear out of effects. References 1 Scollo M , Bayly M , Wakefield M . Plain packaging–a logical progression for tobacco control in one of the world’s ‘darkest markets’ . Tob Control 2015 ; 24 : ii3 – 8 . Google Scholar CrossRef Search ADS PubMed 2 Tobacco Plain Packaging Act . No. 148, 2011 as amended. 2011 . Available at: http://www.comlaw.gov.au/Details/F2013C99598 (6 July 2017, date last accessed). 3 Competition and Consumer (Tobacco) Information Standard . F2013C00598. 2011 . Available at: http://www.comlaw.gov.au/Details/F2013C00598 (6 July 2017, date last accessed). 4 Cancer Council Victoria . Plain packaging. The facts. Available at: https://www.cancervic.org.au/plainfacts/default.asp (6 July 2017, date last accessed). 5 Wakefield MA , Hayes L , Durkin S , Borland R . Introduction effects of the Australian plain packaging policy on adult smokers: a cross-sectional study . BMJ Open 2013 ; 3 : e003175 . Google Scholar CrossRef Search ADS PubMed 6 Dunlop S , Dobbins T , Young JM , et al. Impact of Australia’s introduction of tobacco plain packs on adult smokers’ pack-related perceptions and responses: results from a continuous tracking survey . BMJ Open 2014 ; 4 : e005836 . Google Scholar CrossRef Search ADS PubMed 7 Young JM , Stacey I , Dobbins TA , et al. Association between tobacco plain packaging and Quitline calls: a population-based, interrupted time-series analysis . Med J Aust 2014 ; 200 : 29 – 32 . 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Impact of the introduction of standardised packaging on smokers’ brand awareness and identification in Australia . Drug Alcohol Rev 2016 ; 35 : 102 – 9 . Google Scholar CrossRef Search ADS PubMed 15 Yong H-H , Borland R , Hammond D , et al. Smokers’ reactions to the new larger health warning labels on plain cigarette packs in Australia: findings from the ITC Australia project . Tob Control 2016 ; 25 : 181 – 7 . Google Scholar CrossRef Search ADS PubMed 16 Chipty T . Study of the Impact of the Tobacco Plain Packaging Measure on Smoking Prevalence in Australia. Report of Dr. Tasneem Chipty . Canberra, Australia : Australian Government Department of Health , 2016 . Available at: http://ris.pmc.gov.au/sites/default/files/posts/2016/02/Tobacco-Plain-Packaging-PIR-Appendix-A.pdf (6 July 2017, date last accessed). 17 Moodie C , Mackintosh AM , Hastings G , Ford A . Young adult smokers’ perceptions of plain packaging: a pilot naturalistic study . Tob Control 2011 ; 20 : 367 – 73 . Google Scholar CrossRef Search ADS PubMed 18 Moodie CS , Mackintosh AM . Young adult women smokers’ response to using plain cigarette packaging: a naturalistic approach . BMJ Open 2013 ; 3 : e002402 . Google Scholar CrossRef Search ADS PubMed 19 Maynard OM , Leonards U , Attwood AS , et al. Effects of first exposure to plain cigarette packaging on smoking behaviour and attitudes: a randomised controlled study . BMC Public Health 2015 ; 15 : 240 . Google Scholar CrossRef Search ADS PubMed 20 Gallopel-Morvan K , Moodie C , Hammond D , et al. Consumer perceptions of cigarette pack design in France: a comparison of regular, limited edition and plain packaging . Tob Control 2012 ; 21 : 502 – 6 . Google Scholar CrossRef Search ADS PubMed 21 Gallopel-Morvan K , Moodie C , Eker F , et al. Perceptions of plain packaging among young adult roll-your-own smokers in France: a naturalistic approach . Tob Control 2015 ; 24 : e39 – 44 . Google Scholar CrossRef Search ADS PubMed 22 McNeill A , Gravely S , Hitchman SC , et al. Tobacco packaging design for reducing tobacco use . Cochrane Database Syst Rev 2017 ; CD011244 . doi:10.1002/14651858.CD011244. 23 Zacher M , Bayly M , Brennan E , et al. Personal tobacco pack display before and after the introduction of plain packaging with larger pictorial health warnings in Australia: an observational study of outdoor café strips . Addiction 2014 ; 109 : 653 – 62 . Google Scholar CrossRef Search ADS PubMed 24 Zacher M , Bayly M , Brennan E , et al. Personal pack display and active smoking at outdoor café strips: assessing the impact of plain packaging 1 year postimplementation . Tob Control 2015 ; 24 : ii94 – 7 . Google Scholar CrossRef Search ADS PubMed 25 Wakefield MA , Zacher M , Bayly M , et al. The silent salesman: an observational study of personal tobacco pack display at outdoor café strips in Australia . Tob Control 2014 ; 23 : 339 – 44 . 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Available at: http://www.aihw.gov.au/alcohol-and-other-drugs/data-sources/ndshs-2016/tobacco/ (6 July 2017, date last accessed). 34 Dunlop SM , Cotter TF , Perez DA . Impact of the 2010 tobacco tax increase in Australia on short-term smoking cessation: a continuous tracking survey . Med J Aust 2011 ; 195 : 469 – 72 . Google Scholar CrossRef Search ADS PubMed 35 Dunlop SM , Perez D , Cotter T . Australian smokers’ and recent quitters’ responses to the increasing price of cigarettes in the context of a tobacco tax increase . Addiction 2011 ; 106 : 1687 – 95 . Google Scholar CrossRef Search ADS PubMed 36 Hitchman SC , Driezen P , Logel C , et al. Changes in effectiveness of cigarette health warnings over time in Canada and the United States, 2002–2011 . Nic Tob Res 2014 ; 16 : 536 – 43 . Google Scholar CrossRef Search ADS 37 Li L , Borland R , Yong H , et al. Longer term impact of cigarette package warnings in Australia compared with the United Kingdom and Canada . Health Educ Res 2015 ; 30 : 67 – 80 . Google Scholar CrossRef Search ADS PubMed 38 Hammond D , Wakefield M , Durkin S , Brennan E . Tobacco packaging and mass-media campaigns: research needs for Articles 11 and 12 of the WHO Framework Convention on Tobacco Control . Nic Tob Res 2013 ; 15 : 817 – 31 . Google Scholar CrossRef Search ADS 39 World Health Organization . WHO Framework Convention on Tobacco Control. Guidelines for implementation of Article 11: Packaging and labelling of tobacco products. Available at: http://www.who.int/fctc/treaty_instruments/article_11/en/ (16 March 2018, date last accessed). © The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The European Journal of Public Health Oxford University Press

Observed smoking and tobacco pack display in Australian outdoor cafés 2 years after implementation of plain packaging

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
ISSN
1101-1262
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1464-360X
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10.1093/eurpub/cky051
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Abstract

Abstract Background Implementation of tobacco plain packaging (PP) in Australia in December 2012 was associated with significant reductions in the percentage of patrons at outdoor cafés observed to be displaying tobacco packs and actively smoking, immediately post-implementation and 1 year later. This study examines whether these positive effects were sustained through to 2 years post-PP. Methods An observational study conducted at cafés, restaurants and bars with outdoor seating in Melbourne, Australia documented the number of: patrons; patrons actively smoking; tobacco packs on display; orientation and type of displayed packs and whether or not children were present. Data were collected pre-PP (2012), early post-PP (2013), 1 year post-PP (2014) and 2 years post-PP (2015). Multilevel Poisson regressions analyzed changes in each outcome, adjusting for important covariates. Results Overall, positive effects of PP implementation on tobacco pack display and active smoking were not fully sustained through to 2 years post-PP for the total sample. Interactions between phase and the presence of children indicated that pack display and active smoking were lower in all post-implementation phases (compared with pre-PP) at venues where children were present but not at venues where children were not present. Conclusions Children at outdoor cafés were still being exposed to less tobacco packaging and active smoking, 2 years after implementation of the packaging changes. More regular refreshment of graphic health warnings is likely to be required to sustain these effects, and to reduce pack display behaviour at venues with no children. Introduction In 2012, as the latest step in pursuing a comprehensive approach to tobacco control,1 the Australian government implemented plain packaging (PP) for tobacco products2 with new larger graphic health warnings (GHWs).3 A growing number of countries have since followed suit. In April 2014, the European Union adopted the Tobacco Products Directive, which allows member states the option of implementing PP. As of June 2017, PP regulations had been debated, approved or implemented in France, Hungary, Ireland, Norway, Slovenia and the United Kingdom.4 In Australia, studies evaluating the impact of PP and larger GHWs have indicated these interventions led to reductions in the appeal of tobacco products, and increases in GHW effectiveness and quitting-related cognitions and behaviours.5–15 It has also been estimated that as of September 2015, PP implementation had led to a statistically significant decline in smoking prevalence of 0.55 percentage points.16 These post-implementation findings from Australia are broadly consistent with the results from experimental tests demonstrating the potential effectiveness of PP, conducted in countries such as France and the United Kingdom.17–22 In two previous studies, we assessed the impact of PP by observing the behaviour of patrons at outdoor drinking and dining venues.23,24 Between October 2011 and April 2012 (pre-PP), and October 2012 and April 2013 (early post-PP), we counted patrons, smokers and tobacco packs at cafés, restaurants and bars with outdoor seating in two Australian capital cities, Melbourne (Victoria) and Adelaide (South Australia).23 We observed reduced rates of smoking and pack display from pre-PP to early post-PP, particularly at venues where children were present. We also found that, at early post-PP, packs were less commonly oriented face-up and were more likely to be concealed or in an external case.23 A continuation of this study reported on observations made 1 year post-implementation. Data were gathered between January and April 2014 (1 year post-PP), and compared with observations made over the same summer months pre-PP (January–April 2012) and early post-PP (January–April 2013).24 This study found that declines in the rate of smoking and pack display observed in the early post-PP period were maintained 1 year post-PP, with these findings again more pronounced in venues where children were present. By 1 year post-PP, rates of face-up pack display, pack concealment and external cases had returned to pre-PP levels.24 This study further extends data collection through to 2 years post-implementation (2 years post-PP), in Melbourne, Australia’s second largest city. We were interested in whether the effect of PP on denormalising smoking—as suggested by the early post-PP and 1 year post-PP findings23,24—would still be apparent 2 years post-implementation, or alternatively, if there would be evidence that this effect had started to wane. We were also interested in whether effects continued to be more pronounced at venues where children were present. Methods Details of the venue sampling and data collection procedure have been described elsewhere.23–25 Briefly, to establish the sample of venues we selected 17 street segments (‘café strips’) from a range of socioeconomic areas in Melbourne that were known to have many popular cafés, restaurants and bars; the same 17 café strips were visited in all four phases. Café strips contained between 6 and 50 eligible venues each and observations were made at every eligible venue: to be eligible, the venue had to be a café, restaurant or bar with outdoor seating visible from the footpath where smoking was permitted. New venues within a café strip were added to the sample if they opened between PP phases; venues that closed between phases were not necessarily replaced (i.e. if a new venue did not open in their place). For each of 2012 (pre-PP), 2013 (early post-PP), 2014 (1 year post-PP) and 2015 (2 years post-PP), fieldworkers made five waves of observations at each café strip at ∼2-week intervals between mid-January and mid-April; in each wave, data were collected once at each venue within the café strip. At each venue, the fieldworker slowly walked along the footpath, or found an unobtrusive spot to stand, while they discreetly counted the number of seated patrons, the number of patrons smoking, holding, rolling or lighting a cigarette (‘active smokers’) and the number of tobacco packs. They counted the number of tobacco packs that were fully branded, plain or of an indeterminate type. They also noted the number of packs that were oriented face-up (with the brand name visible), concealed by an object like a wallet or phone, concealed in an external case (including cigarette tins) or that were in an unknown orientation due to the distance of the observation. Finally, fieldworkers recorded whether any children who looked to be of approximately primary school age or younger (i.e. <13 years of age) were present at the venue at the time of observation. During the early post-PP phase of data collection, a fieldwork coordinator accompanied four different fieldworkers as they made their observations. Inter-rater reliability analyses revealed high levels of consistency between the observations made by each of these fieldworkers and the coordinator,23 thereby establishing the reliability of the data collection protocol. We used the Australian Bureau of Statistics’ Socioeconomic Indices for Areas (SEIFA) Index of Relative Disadvantage26 to determine socioeconomic status (SES) for each café strip (low SES: café strips in the lowest two quintiles of the index for the state of Victoria; mid-SES: third and fourth quintiles and high SES: fifth quintile). Weather information (temperature and wind speed) was recorded at the time of data collection using a smartphone application. Statistical analysis Multilevel Poisson models were employed in Stata 14.1 to test for differences between pre-PP and each subsequent phase and between early post-PP and each subsequent phase. Random intercepts were included for café strip and venue in all models to adjust standard errors for correlations among venues within the same café strip and for multiple observations over time at each venue. All models adjusted for the presence of children, café strip SES, month (January/February vs. March/April), day and time (weekdays before 16:00 h, weekdays after 16:00 h and weekends) and the temperature (<22°C, 22–27°C, ≥28°C) and wind speed (km/h) at the time of observation. To analyze first the number of packs observed as the rate of packs to patrons, and then the number of active smokers as the rate of smokers to patrons, the number of patrons was included in the model as an offset term and the sample was limited to venue observations at which at least one patron was observed. We also examined the rate of packs to smokers, using the number of smokers as the offset term and only including venue observations with one or more smokers present. We compared rates of face-up orientation and pack concealment among packs that were compliant with the legislation currently in effect (i.e. branded packs at pre-PP and plain packs in the post-PP phases). In these analyses, only venue observations for which at least one known-orientation branded (pre-PP) or plain (post-PP) pack was recorded were analyzed (i.e. packs in external cases and in an unknown orientation were excluded). Observed rates of external cases were analyzed out of all observed packs; accordingly, at least one pack had to be observed at the venue for the observation to be included in the analysis. Finally, observed rates of branded packs were analyzed out of all packs of a known type (either branded or plain), so at least one branded or plain pack had to be observed for the venue observation to be included in the analysis. We tested for interactions between PP phase and the presence of children at venues. Where the P values for the interaction term was P < 0.05, we explored the pattern of effects using stratified models adjusted for the same covariates listed earlier. Results Sample characteristics Over the four phases in Melbourne, we collected data at 3808 venues at which at least one patron was present at the time of observation, and this sample formed the denominator for analyses of the rate of packs to patrons and active smokers to patrons. Fewer observations were used in analyses of the rates of packs to active smokers (n = 1169 venue observations with at least one active smoker), external cases to all packs (n = 1421 venue observations with at least one pack), branded packs to all known-type packs [n = 1346 venue observations with at least one pack of known type (branded or plain)] and face-up and concealed packs to known-orientation branded (pre-PP) or plain (post-PP) packs (n = 1321 venue observations with at least one known-orientation pack). Table 1 presents the size of these venue sub-samples in each phase, and the characteristics of venues at which at least one patron was present. Table 1 Number of eligible venue observations and characteristics of venues at which observations were made 2012 pre-PP 2013 early post-PP 2014 1 year post-PP 2015 2 years post-PP n n n n Venues with at least 1 patrona 958 926 962 962 Venues with at least 1 active smokerb 340 273 288 268 Venues with at least 1 packc 415 330 349 327 Venues with at least 1 pack of a known typed 395 306 330 315 Venues with at least 1 pack in a known orientatione 395 303 317 306 Characteristics of venues with at least 1 patron n (%) n (%) n (%) n (%) Total 958 926 962 962 Children     Not present 835 (87.2) 826 (89.2) 843 (87.6) 866 (90.0)     Present 123 (12.8) 100 (10.8) 119 (12.4) 96 (10.0) SES     Low SES (high disadvantage) 369 (38.5) 364 (39.3) 350 (36.4) 427 (44.4)     Mid 202 (21.1) 189 (20.4) 222 (23.1) 224 (23.3)     High SES (low disadvantage) 387 (40.4) 373 (40.3) 390 (40.5) 311 (32.3) Month     January/February 540 (56.4) 463 (50.0) 476 (49.5) 385 (40.0)     March/April 418 (43.6) 463 (50.0) 486 (50.5) 577 (60.0) Day and time     Weekday, after 4:00 pm 227 (23.7) 251 (27.1) 264 (27.4) 355 (36.9)     Weekday, before 4:00 pm 264 (27.6) 230 (24.8) 227 (23.6) 225 (23.4)     Weekend 467 (48.8) 445 (48.1) 471 (49.0) 382 (39.7) Temperature     Under 22C 287 (30.0) 168 (18.1) 596 (62.0) 677 (70.4)     22–27C 495 (51.7) 512 (55.3) 290 (30.2) 158 (16.4)     28C and above 176 (18.4) 246 (26.6) 76 (7.9) 127 (13.2) Wind speed (km/h) M = 12.6 (SD = 5.7) M = 13.0 (SD = 5.3) M = 12.8 (SD = 5.4) M = 11.2 (SD = 6.4) 2012 pre-PP 2013 early post-PP 2014 1 year post-PP 2015 2 years post-PP n n n n Venues with at least 1 patrona 958 926 962 962 Venues with at least 1 active smokerb 340 273 288 268 Venues with at least 1 packc 415 330 349 327 Venues with at least 1 pack of a known typed 395 306 330 315 Venues with at least 1 pack in a known orientatione 395 303 317 306 Characteristics of venues with at least 1 patron n (%) n (%) n (%) n (%) Total 958 926 962 962 Children     Not present 835 (87.2) 826 (89.2) 843 (87.6) 866 (90.0)     Present 123 (12.8) 100 (10.8) 119 (12.4) 96 (10.0) SES     Low SES (high disadvantage) 369 (38.5) 364 (39.3) 350 (36.4) 427 (44.4)     Mid 202 (21.1) 189 (20.4) 222 (23.1) 224 (23.3)     High SES (low disadvantage) 387 (40.4) 373 (40.3) 390 (40.5) 311 (32.3) Month     January/February 540 (56.4) 463 (50.0) 476 (49.5) 385 (40.0)     March/April 418 (43.6) 463 (50.0) 486 (50.5) 577 (60.0) Day and time     Weekday, after 4:00 pm 227 (23.7) 251 (27.1) 264 (27.4) 355 (36.9)     Weekday, before 4:00 pm 264 (27.6) 230 (24.8) 227 (23.6) 225 (23.4)     Weekend 467 (48.8) 445 (48.1) 471 (49.0) 382 (39.7) Temperature     Under 22C 287 (30.0) 168 (18.1) 596 (62.0) 677 (70.4)     22–27C 495 (51.7) 512 (55.3) 290 (30.2) 158 (16.4)     28C and above 176 (18.4) 246 (26.6) 76 (7.9) 127 (13.2) Wind speed (km/h) M = 12.6 (SD = 5.7) M = 13.0 (SD = 5.3) M = 12.8 (SD = 5.4) M = 11.2 (SD = 6.4) Note. PP, plain packaging; M, mean; SD, standard deviation. a Denominator for analysis of the rate of packs to patrons and active smokers to patrons. b Denominator for analysis of the rate of packs to active smokers. c Denominator for analysis of the rate of external cases to all packs. d Denominator for analysis of the rate of fully branded packs to all packs of a known type (fully branded or plain). e Denominator for analysis of the rate of face-up packs to all packs in a known orientation, and concealed packs to all packs in a known orientation. For these analyses, the denominator of known orientation packs is limited to fully branded packs at pre-PP and plain packs in the three post-PP phases. Table 1 Number of eligible venue observations and characteristics of venues at which observations were made 2012 pre-PP 2013 early post-PP 2014 1 year post-PP 2015 2 years post-PP n n n n Venues with at least 1 patrona 958 926 962 962 Venues with at least 1 active smokerb 340 273 288 268 Venues with at least 1 packc 415 330 349 327 Venues with at least 1 pack of a known typed 395 306 330 315 Venues with at least 1 pack in a known orientatione 395 303 317 306 Characteristics of venues with at least 1 patron n (%) n (%) n (%) n (%) Total 958 926 962 962 Children     Not present 835 (87.2) 826 (89.2) 843 (87.6) 866 (90.0)     Present 123 (12.8) 100 (10.8) 119 (12.4) 96 (10.0) SES     Low SES (high disadvantage) 369 (38.5) 364 (39.3) 350 (36.4) 427 (44.4)     Mid 202 (21.1) 189 (20.4) 222 (23.1) 224 (23.3)     High SES (low disadvantage) 387 (40.4) 373 (40.3) 390 (40.5) 311 (32.3) Month     January/February 540 (56.4) 463 (50.0) 476 (49.5) 385 (40.0)     March/April 418 (43.6) 463 (50.0) 486 (50.5) 577 (60.0) Day and time     Weekday, after 4:00 pm 227 (23.7) 251 (27.1) 264 (27.4) 355 (36.9)     Weekday, before 4:00 pm 264 (27.6) 230 (24.8) 227 (23.6) 225 (23.4)     Weekend 467 (48.8) 445 (48.1) 471 (49.0) 382 (39.7) Temperature     Under 22C 287 (30.0) 168 (18.1) 596 (62.0) 677 (70.4)     22–27C 495 (51.7) 512 (55.3) 290 (30.2) 158 (16.4)     28C and above 176 (18.4) 246 (26.6) 76 (7.9) 127 (13.2) Wind speed (km/h) M = 12.6 (SD = 5.7) M = 13.0 (SD = 5.3) M = 12.8 (SD = 5.4) M = 11.2 (SD = 6.4) 2012 pre-PP 2013 early post-PP 2014 1 year post-PP 2015 2 years post-PP n n n n Venues with at least 1 patrona 958 926 962 962 Venues with at least 1 active smokerb 340 273 288 268 Venues with at least 1 packc 415 330 349 327 Venues with at least 1 pack of a known typed 395 306 330 315 Venues with at least 1 pack in a known orientatione 395 303 317 306 Characteristics of venues with at least 1 patron n (%) n (%) n (%) n (%) Total 958 926 962 962 Children     Not present 835 (87.2) 826 (89.2) 843 (87.6) 866 (90.0)     Present 123 (12.8) 100 (10.8) 119 (12.4) 96 (10.0) SES     Low SES (high disadvantage) 369 (38.5) 364 (39.3) 350 (36.4) 427 (44.4)     Mid 202 (21.1) 189 (20.4) 222 (23.1) 224 (23.3)     High SES (low disadvantage) 387 (40.4) 373 (40.3) 390 (40.5) 311 (32.3) Month     January/February 540 (56.4) 463 (50.0) 476 (49.5) 385 (40.0)     March/April 418 (43.6) 463 (50.0) 486 (50.5) 577 (60.0) Day and time     Weekday, after 4:00 pm 227 (23.7) 251 (27.1) 264 (27.4) 355 (36.9)     Weekday, before 4:00 pm 264 (27.6) 230 (24.8) 227 (23.6) 225 (23.4)     Weekend 467 (48.8) 445 (48.1) 471 (49.0) 382 (39.7) Temperature     Under 22C 287 (30.0) 168 (18.1) 596 (62.0) 677 (70.4)     22–27C 495 (51.7) 512 (55.3) 290 (30.2) 158 (16.4)     28C and above 176 (18.4) 246 (26.6) 76 (7.9) 127 (13.2) Wind speed (km/h) M = 12.6 (SD = 5.7) M = 13.0 (SD = 5.3) M = 12.8 (SD = 5.4) M = 11.2 (SD = 6.4) Note. PP, plain packaging; M, mean; SD, standard deviation. a Denominator for analysis of the rate of packs to patrons and active smokers to patrons. b Denominator for analysis of the rate of packs to active smokers. c Denominator for analysis of the rate of external cases to all packs. d Denominator for analysis of the rate of fully branded packs to all packs of a known type (fully branded or plain). e Denominator for analysis of the rate of face-up packs to all packs in a known orientation, and concealed packs to all packs in a known orientation. For these analyses, the denominator of known orientation packs is limited to fully branded packs at pre-PP and plain packs in the three post-PP phases. Pack display and active smoking Before the implementation of PP, one in every 8.0 patrons displayed a tobacco pack. In the early post-PP and 1 year post-PP phases, rates of pack display were lower compared with pre-PP (table 2). Pack display was also somewhat lower in the 2 year post-PP phase. The rate of pack display in the 2 year post-PP phase did not differ from that observed in the early post-PP phase (table 2). Table 2 Changes over time in rates of pack display, active smoking, pack orientation, pack concealment and branded pack use Outcome (rate of…) Rate Percentage of… Vs. pre-PP Vs. early post-PP Adj. IRRa 95% CIs Adj. IRRa 95% CIs Packs to patrons …patrons who displayed pack     Pre-PP 1: 8.0 12.6 Ref 1.20 [1.07, 1.33]     Early post-PP 1: 9.8 10.2 0.84 [0.75, 0.93] Ref     1 year post-PP 1: 10.5 9.5 0.82 [0.73, 0.92] 0.98 [0.87, 1.11]     2 years post-PP 1: 9.4 10.6 0.90 [0.79, 1.02] 1.07 [0.93, 1.24] Active smokers to patrons …patrons who were smoking     Pre-PP 1: 10.4 9.6 Ref 1.20 [1.05, 1.36]     Early post-PP 1: 13.3 7.5 0.84 [0.74, 0.95] Ref     1 year post-PP 1: 14.0 7.1 0.82 [0.72, 0.94] 0.99 [0.85, 1.14]     2 years post-PP 1: 12.4 8.1 0.93 [0.79, 1.08] 1.11 [0.94, 1.30] Face-up packs to all packsb …packsb that were face-up     Pre-PP 1: 1.2 84.3 Ref 1.16 [1.02, 1.32]     Early post-PP 1: 1.4 72.7 0.86 [0.76, 0.98] Ref     1 year post-PP 1: 1.2 82.9 0.98 [0.86, 1.10] 1.13 [0.97, 1.31]     2 years post-PP 1: 1.2 83.6 0.97 [0.84, 1.11] 1.12 [0.95, 1.32] Concealed packs to all packsb …packsb that were concealed     Pre-PP 1: 22.2 4.5 Ref 0.39 [0.25, 0.60]     Early post-PP 1: 8.7 11.5 2.57 [1.67, 3.98] Ref     1 year post-PP 1: 17.6 5.7 1.19 [0.72, 1.96] 0.46 [0.29, 0.74]     2 years post-PP 1: 28.4 3.5 0.73 [0.39, 1.36] 0.28 [0.15, 0.52] External cases to all packs …packs that were in cases     Pre-PP 1: 76.9 1.3 Ref 0.28 [0.13, 0.60]     Early post-PP 1: 25.0 4.0 3.52 [1.67, 7.45] Ref     1 year post-PP 1: 49.0 2.0 1.40 [0.61, 3.20] 0.40 [0.19, 0.83]     2 years post-PP 1: 18.4 5.4 2.75 [1.26, 6.00] 0.78 [0.38, 1.60] Fully branded packs to all packsc …packsc that were fully branded     Pre-PP 1: 1.0 100.0 Ref 22.74 [15.11, 34.21]     Early post-PP 1: 22.8 4.4 0.04 [0.03, 0.07] Ref     1 year post-PP 1: 16.6 6.0 0.06 [0.04, 0.09] 1.38 [0.82, 2.32]     2 years post-PP 1: 25.7 3.9 0.04 [0.03, 0.06] 0.89 [0.49, 1.59] Outcome (rate of…) Rate Percentage of… Vs. pre-PP Vs. early post-PP Adj. IRRa 95% CIs Adj. IRRa 95% CIs Packs to patrons …patrons who displayed pack     Pre-PP 1: 8.0 12.6 Ref 1.20 [1.07, 1.33]     Early post-PP 1: 9.8 10.2 0.84 [0.75, 0.93] Ref     1 year post-PP 1: 10.5 9.5 0.82 [0.73, 0.92] 0.98 [0.87, 1.11]     2 years post-PP 1: 9.4 10.6 0.90 [0.79, 1.02] 1.07 [0.93, 1.24] Active smokers to patrons …patrons who were smoking     Pre-PP 1: 10.4 9.6 Ref 1.20 [1.05, 1.36]     Early post-PP 1: 13.3 7.5 0.84 [0.74, 0.95] Ref     1 year post-PP 1: 14.0 7.1 0.82 [0.72, 0.94] 0.99 [0.85, 1.14]     2 years post-PP 1: 12.4 8.1 0.93 [0.79, 1.08] 1.11 [0.94, 1.30] Face-up packs to all packsb …packsb that were face-up     Pre-PP 1: 1.2 84.3 Ref 1.16 [1.02, 1.32]     Early post-PP 1: 1.4 72.7 0.86 [0.76, 0.98] Ref     1 year post-PP 1: 1.2 82.9 0.98 [0.86, 1.10] 1.13 [0.97, 1.31]     2 years post-PP 1: 1.2 83.6 0.97 [0.84, 1.11] 1.12 [0.95, 1.32] Concealed packs to all packsb …packsb that were concealed     Pre-PP 1: 22.2 4.5 Ref 0.39 [0.25, 0.60]     Early post-PP 1: 8.7 11.5 2.57 [1.67, 3.98] Ref     1 year post-PP 1: 17.6 5.7 1.19 [0.72, 1.96] 0.46 [0.29, 0.74]     2 years post-PP 1: 28.4 3.5 0.73 [0.39, 1.36] 0.28 [0.15, 0.52] External cases to all packs …packs that were in cases     Pre-PP 1: 76.9 1.3 Ref 0.28 [0.13, 0.60]     Early post-PP 1: 25.0 4.0 3.52 [1.67, 7.45] Ref     1 year post-PP 1: 49.0 2.0 1.40 [0.61, 3.20] 0.40 [0.19, 0.83]     2 years post-PP 1: 18.4 5.4 2.75 [1.26, 6.00] 0.78 [0.38, 1.60] Fully branded packs to all packsc …packsc that were fully branded     Pre-PP 1: 1.0 100.0 Ref 22.74 [15.11, 34.21]     Early post-PP 1: 22.8 4.4 0.04 [0.03, 0.07] Ref     1 year post-PP 1: 16.6 6.0 0.06 [0.04, 0.09] 1.38 [0.82, 2.32]     2 years post-PP 1: 25.7 3.9 0.04 [0.03, 0.06] 0.89 [0.49, 1.59] Note. PP, plain packaging; IRR, incident rate ratio; Ref, referent category in multilevel Poisson regression models. a Adjusted (Adj.) IRRs adjust for: presence of children, area SES, month (January/February or March/April), day and time (weekday before 4:00 pm, weekday after 4:00 pm or weekend; based on end time of fieldwork session), temperature (<22°C, 22–27°C, ≥28°C) and wind speed and are from multilevel Poisson regression models that included random intercepts for café strip and venue. b For the rates of face-up orientation and pack concealment, ‘all packs’ includes packs compliant with the legislation in effect at the time (fully branded packs at pre-PP, plain packs in all post-PP phases) for which an orientation was recorded. c For the rates of fully branded packs, ‘all packs’ includes packs of a known type (fully branded packs at pre-PP, branded or plain packs in all post-PP phases). Table 2 Changes over time in rates of pack display, active smoking, pack orientation, pack concealment and branded pack use Outcome (rate of…) Rate Percentage of… Vs. pre-PP Vs. early post-PP Adj. IRRa 95% CIs Adj. IRRa 95% CIs Packs to patrons …patrons who displayed pack     Pre-PP 1: 8.0 12.6 Ref 1.20 [1.07, 1.33]     Early post-PP 1: 9.8 10.2 0.84 [0.75, 0.93] Ref     1 year post-PP 1: 10.5 9.5 0.82 [0.73, 0.92] 0.98 [0.87, 1.11]     2 years post-PP 1: 9.4 10.6 0.90 [0.79, 1.02] 1.07 [0.93, 1.24] Active smokers to patrons …patrons who were smoking     Pre-PP 1: 10.4 9.6 Ref 1.20 [1.05, 1.36]     Early post-PP 1: 13.3 7.5 0.84 [0.74, 0.95] Ref     1 year post-PP 1: 14.0 7.1 0.82 [0.72, 0.94] 0.99 [0.85, 1.14]     2 years post-PP 1: 12.4 8.1 0.93 [0.79, 1.08] 1.11 [0.94, 1.30] Face-up packs to all packsb …packsb that were face-up     Pre-PP 1: 1.2 84.3 Ref 1.16 [1.02, 1.32]     Early post-PP 1: 1.4 72.7 0.86 [0.76, 0.98] Ref     1 year post-PP 1: 1.2 82.9 0.98 [0.86, 1.10] 1.13 [0.97, 1.31]     2 years post-PP 1: 1.2 83.6 0.97 [0.84, 1.11] 1.12 [0.95, 1.32] Concealed packs to all packsb …packsb that were concealed     Pre-PP 1: 22.2 4.5 Ref 0.39 [0.25, 0.60]     Early post-PP 1: 8.7 11.5 2.57 [1.67, 3.98] Ref     1 year post-PP 1: 17.6 5.7 1.19 [0.72, 1.96] 0.46 [0.29, 0.74]     2 years post-PP 1: 28.4 3.5 0.73 [0.39, 1.36] 0.28 [0.15, 0.52] External cases to all packs …packs that were in cases     Pre-PP 1: 76.9 1.3 Ref 0.28 [0.13, 0.60]     Early post-PP 1: 25.0 4.0 3.52 [1.67, 7.45] Ref     1 year post-PP 1: 49.0 2.0 1.40 [0.61, 3.20] 0.40 [0.19, 0.83]     2 years post-PP 1: 18.4 5.4 2.75 [1.26, 6.00] 0.78 [0.38, 1.60] Fully branded packs to all packsc …packsc that were fully branded     Pre-PP 1: 1.0 100.0 Ref 22.74 [15.11, 34.21]     Early post-PP 1: 22.8 4.4 0.04 [0.03, 0.07] Ref     1 year post-PP 1: 16.6 6.0 0.06 [0.04, 0.09] 1.38 [0.82, 2.32]     2 years post-PP 1: 25.7 3.9 0.04 [0.03, 0.06] 0.89 [0.49, 1.59] Outcome (rate of…) Rate Percentage of… Vs. pre-PP Vs. early post-PP Adj. IRRa 95% CIs Adj. IRRa 95% CIs Packs to patrons …patrons who displayed pack     Pre-PP 1: 8.0 12.6 Ref 1.20 [1.07, 1.33]     Early post-PP 1: 9.8 10.2 0.84 [0.75, 0.93] Ref     1 year post-PP 1: 10.5 9.5 0.82 [0.73, 0.92] 0.98 [0.87, 1.11]     2 years post-PP 1: 9.4 10.6 0.90 [0.79, 1.02] 1.07 [0.93, 1.24] Active smokers to patrons …patrons who were smoking     Pre-PP 1: 10.4 9.6 Ref 1.20 [1.05, 1.36]     Early post-PP 1: 13.3 7.5 0.84 [0.74, 0.95] Ref     1 year post-PP 1: 14.0 7.1 0.82 [0.72, 0.94] 0.99 [0.85, 1.14]     2 years post-PP 1: 12.4 8.1 0.93 [0.79, 1.08] 1.11 [0.94, 1.30] Face-up packs to all packsb …packsb that were face-up     Pre-PP 1: 1.2 84.3 Ref 1.16 [1.02, 1.32]     Early post-PP 1: 1.4 72.7 0.86 [0.76, 0.98] Ref     1 year post-PP 1: 1.2 82.9 0.98 [0.86, 1.10] 1.13 [0.97, 1.31]     2 years post-PP 1: 1.2 83.6 0.97 [0.84, 1.11] 1.12 [0.95, 1.32] Concealed packs to all packsb …packsb that were concealed     Pre-PP 1: 22.2 4.5 Ref 0.39 [0.25, 0.60]     Early post-PP 1: 8.7 11.5 2.57 [1.67, 3.98] Ref     1 year post-PP 1: 17.6 5.7 1.19 [0.72, 1.96] 0.46 [0.29, 0.74]     2 years post-PP 1: 28.4 3.5 0.73 [0.39, 1.36] 0.28 [0.15, 0.52] External cases to all packs …packs that were in cases     Pre-PP 1: 76.9 1.3 Ref 0.28 [0.13, 0.60]     Early post-PP 1: 25.0 4.0 3.52 [1.67, 7.45] Ref     1 year post-PP 1: 49.0 2.0 1.40 [0.61, 3.20] 0.40 [0.19, 0.83]     2 years post-PP 1: 18.4 5.4 2.75 [1.26, 6.00] 0.78 [0.38, 1.60] Fully branded packs to all packsc …packsc that were fully branded     Pre-PP 1: 1.0 100.0 Ref 22.74 [15.11, 34.21]     Early post-PP 1: 22.8 4.4 0.04 [0.03, 0.07] Ref     1 year post-PP 1: 16.6 6.0 0.06 [0.04, 0.09] 1.38 [0.82, 2.32]     2 years post-PP 1: 25.7 3.9 0.04 [0.03, 0.06] 0.89 [0.49, 1.59] Note. PP, plain packaging; IRR, incident rate ratio; Ref, referent category in multilevel Poisson regression models. a Adjusted (Adj.) IRRs adjust for: presence of children, area SES, month (January/February or March/April), day and time (weekday before 4:00 pm, weekday after 4:00 pm or weekend; based on end time of fieldwork session), temperature (<22°C, 22–27°C, ≥28°C) and wind speed and are from multilevel Poisson regression models that included random intercepts for café strip and venue. b For the rates of face-up orientation and pack concealment, ‘all packs’ includes packs compliant with the legislation in effect at the time (fully branded packs at pre-PP, plain packs in all post-PP phases) for which an orientation was recorded. c For the rates of fully branded packs, ‘all packs’ includes packs of a known type (fully branded packs at pre-PP, branded or plain packs in all post-PP phases). In a similar way, compared with pre-PP, the prevalence of active smoking was lower in the early post-PP and 1 year post-PP phases (table 2). Active smoking was also slightly lower in the 2 year post-PP phase. However, the prevalence of active smoking 2 years post-PP also did not differ from that observed in the early post-PP phase (table 2). The rate of pack display relative to active smokers (not shown in table 2) did not change between pre-PP and early post-PP [incident rate ratio (IRR) = 0.98, 95% confidence interval (CI) = 0.86–1.11], 1 year post-PP (IRR = 0.97, 95% CI = 0.85–1.10) or 2 years post-PP (IRR = 0.97, 95% CI = 0.84–1.13). It also did not differ between the early post-PP and 2 years post-PP phases (IRR = 0.99, 95% CI = 0.84–1.17). In each phase, we observed one pack for every 0.7–0.8 active smokers, indicating that some patrons displayed their pack even when they were not smoking. There was an interaction between phase and the presence of children in predicting the rate of pack display (χ2 = 11.76). Stratified analyses indicated that the effect of PP implementation on pack display was greater at venues with children present than at venues without children (figure 1a). Compared with pre-PP, there was a greater decline in the rate of pack display in each subsequent phase at venues with children present (early post-PP: IRR = 0.50, 95% CI = 0.35–0.71; 1 year post-PP: IRR = 0.56, 95% CI = 0.40–0.77; 2 years post-PP: IRR = 0.75, 95% CI = 0.51, 1.11) than at venues without children (early post-PP: IRR = 0.89, 95% CI = 0.79–1.00; 1 year post-PP: IRR = 0.86, 95% CI = 0.76–0.97; 2 years post-PP: IRR = 0.93, 95% CI = 0.81–1.07). There was a similar interaction between phase and the presence of children in predicting the rate of active smoking (χ2 = 20.86; figure 1b). Compared with pre-PP, there was a greater decline in the prevalence of active smoking in each subsequent phase at venues with children present (early post-PP: IRR = 0.45, 95% CI = 0.30–0.68; 1 year post-PP: IRR = 0.38, 95% CI = 0.26–0.56; 2 years post-PP: IRR = 0.49, 95% CI = 0.31–0.76) than at venues without children (early post-PP: IRR = 0.91, 95% CI = 0.79–1.04; 1 year post-PP: IRR = 0.91, 95% CI = 0.79–1.05; 2 years post-PP: IRR = 1.03, 95% CI = 0.87–1.22). Figure 1 View largeDownload slide Interaction between phase and presence of children, for the percentage of patrons who displayed a pack (figure 1a) and the percentage of patrons who were actively smoking (figure 1b). PP, plain packaging Figure 1 View largeDownload slide Interaction between phase and presence of children, for the percentage of patrons who displayed a pack (figure 1a) and the percentage of patrons who were actively smoking (figure 1b). PP, plain packaging Pack orientation and concealment In each phase, we recorded the orientation of packs that were compliant with the legislation currently in effect (i.e. branded packs at pre-PP and plain packs in each subsequent phase). Compared with pre-PP, the percentage of packs oriented face-up was not different in each post-PP phase (and did not differ between these phases; table 2). However, the percentage of packs concealed by an object like a wallet or phone was highest in the early post-PP phase (table 2). The percentage of packs in external cases fluctuated across the study period (table 2). From a low rate of use pre-PP, the use of cases increased in the early post-PP phase, decreased in the 1 year post-PP phase (not different to pre-PP), before increasing again in the 2 year post-PP phase (although not different to pre-PP or early post-PP; table 2). Presence of branded packs Compared with pre-PP—at which time, all packs of a known type were fully branded—the prevalence of fully branded packs was, unsurprisingly, lower in all post-PP phases (≤6.0% in each phase; table 2). The prevalence of fully branded packs did not change from the early post-PP phase to the two later post-PP phases (table 2). Discussion Overall, we found that PP implementation was associated with reduced rates of tobacco pack display and active smoking at outdoor cafés in the early post-PP and 1 year post-PP periods but these effects were not fully sustained 2 years post-PP. In the 2 year post-PP period, rates of pack display and active smoking were not lower than those observed pre-PP but were also not different from those observed in the early post-PP period. Taken together, these findings indicate that even though the initial reductions in these behaviours were not maintained 2 years post-implementation, rates also have not completely rebounded to those observed prior to implementation. These overall effects must also be interpreted in light of interactions between PP phase and the presence of children. Pack display and active smoking were lower in all post-implementation phases at venues where children were present but not at venues without children. This is a positive finding, indicating that 2 years after implementation, children are still being exposed to less smoking and less tobacco packaging than before PP. This finding is consistent with evidence that children provide smokers with a powerful cue not to smoke,27 perhaps due to their desire to protect children from secondhand smoke or the normalising effects of seeing adults smoke. As a result of this reduced visibility of tobacco, children may develop more accurate perceptions of smoking prevalence and the social acceptability of tobacco use, which may reduce smoking initiation down the track.28,29 We found little evidence that implementation of PP had an enduring effect on the way in which smokers displayed their packs. Across all phases, the majority of packs were displayed face-up, and although we observed an early increase in efforts by smokers to conceal their packs, this effect was not sustained through to 1 or 2 years post-implementation. Use of external cases was rare in all phases. Minimal levels of pack concealment may represent a positive outcome for public health, given that smokers and other patrons are exposed to the large GHWs on the displayed tobacco packs. On the other hand, smokers’ efforts to avoid looking at GHWs (e.g. by covering them up) are associated with increased frequency of thoughts about quitting30 such that our finding that pack concealment was at pre-PP levels in the 1- and 2-year post-implementation phases may indicate diminishing effectiveness of GHWs over time. Furthermore, in all post-implementation phases we found a low prevalence of fully branded packs. Potential sources of fully branded packs in the post-PP environment include international tourists or Australians returning from abroad who purchased packs overseas, and contraband cigarettes (i.e. fully branded cigarettes from another country that have been smuggled into the illicit market in Australia). Previous population surveys have reported consistently minimal use of contraband cigarettes since the introduction of PP in Australia.31,32 The most recent national survey also found low levels of purchasing tobacco products without PP and larger GHWs.33 The findings from this study are consistent with this evidence, and at odds with claims from the tobacco industry that PP would result in a proliferation of illicit tobacco.4 This innovative observational study was relatively inexpensive and easy to implement. It provided some of the first evidence that the packaging changes were affecting smokers’ behaviours,23,24 and has also proved useful in monitoring whether these effects may be weakening with time. A particular strength of this method is the use of validated objective measures that are not subject to social desirability bias or misreporting but instead reflect the visibility of tobacco products and behaviours in real-world scenarios. One study limitation is that we observed behaviours in only one metropolitan city, and so cannot generalise the results nationally. Unlike our earlier studies, we did not collect data in Adelaide since that state was actively debating bans on smoking in outdoor dining venues, reducing our sample size and therefore power to detect changes. Another limitation is that increases in tobacco excise and customs duties were implemented on 1 December 2013 and again on 1 September 2014, which could have reduced active smoking by encouraging lower consumption or attempts to quit.34,35 Increasing prices may have also reduced smokers’ willingness to display their pack, to avoid being asked to share their cigarettes. However, stronger effects at venues where children were present is more consistent with an interpretation that attributes changes in these behaviours to PP rather than price increases. In conclusion, these findings indicate a slight weakening of the effects of PP on rates of pack display and active smoking by 2 years post-implementation, although positive effects continued to be observed at venues where children were present. Other studies have demonstrated that the impact of GHWs declines with time,36–38 and maintaining salience is a key challenge for warning label policies.39 Australia’s GHW scheme tries to delay wear-out effects through the annual rotation of two sets of seven warning labels,3 although when the 2 year post-PP data were collected in early 2015, the first set of GHWs were already appearing for the second time. More frequent changes to the GHWs that appear on packs may help to prolong their salience and impact, thereby sustaining the processes through which smokers become reluctant to be seen smoking and displaying their packs in public. Further research is required to assess whether similar wear-out effects are observed on other measures of PP effectiveness in Australia and when PP is implemented in other countries. Acknowledgements The authors thank Associate Professor Sarah Durkin who contributed to earlier phases of this project. The authors also thank staff at Cancer Council Victoria who undertook data collection. These findings were presented at the Oceania Tobacco Control Conference, October 2015, Perth, Australia. Funding This work was supported by Cancer Council Victoria and Quit Victoria. Conflicts of interest: The authors wish to advise that M.A.W. was a member and M.S. a technical writer for the Tobacco Working Group of the Australian National Preventive Health Task Force and M.A.W. was a member of the Expert Advisory Committee on Plain Packaging that advised the Australian Department of Health on research pertaining to plain packaging legislation. Key points Past studies found reduced rates of tobacco pack display and active smoking at outdoor cafés immediately following and 1 year after implementation of plain packaging with larger graphic health warnings in Australia. This study found that while overall these positive effects were not fully maintained 2 years post-implementation, rates remained lower at venues where children were present. Governments implementing plain packaging should consider frequent rotation and refreshment of graphic health warnings to delay the wear out of effects. References 1 Scollo M , Bayly M , Wakefield M . Plain packaging–a logical progression for tobacco control in one of the world’s ‘darkest markets’ . Tob Control 2015 ; 24 : ii3 – 8 . Google Scholar CrossRef Search ADS PubMed 2 Tobacco Plain Packaging Act . No. 148, 2011 as amended. 2011 . Available at: http://www.comlaw.gov.au/Details/F2013C99598 (6 July 2017, date last accessed). 3 Competition and Consumer (Tobacco) Information Standard . 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The European Journal of Public HealthOxford University Press

Published: Mar 27, 2018

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