Research Evidence

>Introduction

These pages summarise the empirical research evidence that supports the implementation of plain packaging.

Over the course of 20-30 years there have been many peer reviewed scientific research studies looking at the impact that plain packaging of tobacco would have on smoking behaviours and attitudes and the likely consequential impact on smoking rates.

Research has been conducted in more than 10 different countries using a range of methodologies and each study taken in isolation only provides part of the picture.

The different types of research studies include:

• Behavioural studies aimed to test whether participants believed that plain packaging would change their purchasing behaviour.
• Surveys of consumer groups to consider the appeal of plain packs compared with branded packs.
• Studies using mock-ups of standardised packaging to see how smokers and potential smokers react to them.
• Eye tracking studies that looked at whether people focused more on the health warnings when branding was removed.
• Qualitative and survey research looking at the impact of removing branding on smoker image and product associations.
• Studies into whether and how perceptions of the harmfulness and strength of standardised packages differ from branded packs (and how different kinds of plain packages differ in this regard).
• Studies using a “pack-offer” task to assess the demand for plain packaging. In each of these studies, youth participants were offered a choice of packs.
• Naturalistic trials of plain packaging where smokers used brown ‘plain’ packs for two weeks and their regular packs for two weeks in “real-life” settings. The studies analysed avoidance behaviours, such as hiding or covering the pack.

This research is criticised by the tobacco industry because the studies consider attitudes, beliefs, and predictions of future behaviour but fail, they claim, to demonstrate a link with actual behaviour. They also criticise the methodology of individual studies. But the research is persuasive because of the high degree of consistency across more than 75 studies from numerous countries and using different methodologies.

The tobacco industry also criticises the research for failing to include a randomised control trial of plain packaging. But as has been pointed out, it would not be possible or ethical to undertake such a trial. To do so would require studies to be carried out within a suitably large and isolated population free of known confounding factors that influence smoking and prevalence. Such studies would expose a randomised group of children and/ or adults to nicotine exposure and addiction.

As is highlighted elsewhere in this toolkit, the tobacco industry is rarely, if ever, able to rely on peer reviewed studies to support its arguments that plain packaging will not be effective; and the tobacco companies have consistently refused to disclose any of their own research or behavioural studies into the likely effects of plain packaging.

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>Outcomes of the research

- Attractiveness of tobacco products and packaging as advertising

A substantial number of studies that examine plain packaging support the conclusions that the measure reduces the attractiveness and appeal of tobacco products.

This includes experimental studies from Australia,¹ Brazil,² Canada,³ New Zealand,⁴ and the USA;⁵ survey evidence from Australia,⁶ France,⁷ the UK,⁸ and the USA;⁹ and focus group studies from New Zealand¹⁰ and the United Kingdom.¹¹ Evidence also shows that the advertising function of tobacco packaging has also been specifically targeted at youth by the tobacco companies.¹²

- The effectiveness of health warnings

Studies show that colorful and attractive branding on packaging detracts and distracts from health warnings, thereby reducing their effectiveness.

A number of studies suggest that plain packaging increases the salience of health warnings, including experimental and survey studies from Australia and Canada,¹³ with impacts that go above and beyond simply introducing larger health warnings without plain packaging.¹⁴

- Misleading tobacco packaging

Studies have demonstrated there is a strong association between pack design and false consumer perceptions of risk.¹⁵

Tobacco branding can mislead consumers as to the relative harms of one product compared to other products. Many countries have banned terms such as “light” and “mild” for this reason, as all the evidence shows that these products are equally dangerous. However, smokers and non-smokers continue to hold mistaken beliefs about different tobacco products because of the tobacco companies’ use of colors and branding. Some pack designs preserve the branding used for prohibited brand variants. For instance, Marlboro Lights became Marlboro Gold, and Marlboro Ultra Lights became Marlboro Silver. Similar tactics were used by other companies. The color of packs in particular affects consumers’ perceptions of risk. Lighter packs are perceived as being less harsh and having lower tar levels than darker colors, even when there is identical products in them.¹⁶

Peer-reviewed studies from many countries show that plain packaging will minimize the ability of packaging and brand variants to mislead consumers about the relative harms of different products.¹⁷

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>Expert reviews of the research evidence

Australia, the UK, and Ireland, when considering plain packaging, commissioned independent reviews of the research evidence to ensure that there is a clear, complete, and balanced picture. More recently, Cochrane, a global independent non-profit organization, undertook a review of the research studies that evaluated plain or standardised packaging.

The five reviews show that the evidence on plain packaging is notable for its breadth and diversity of methods but also for the strong consistency of the results in supporting that plain packaging will contribute to its objectives. The evidence reviews were:

1. Cancer Council Victoria (Australia 2011)
2. The Stirling Review (United Kingdom 2012 and updated 2013)
3. The Chantler Review (United Kingdom 2014)
4. The Hammond Review (Ireland 2014)
5. The Cochrane Review (2017)

By the time of the Hammond Review commissioned by the Irish Government in 2014, a total of 69 original empirical studies were reviewed. Research continues to be undertaken throughout the world and there have also been many post-implementation studies conducted in Australia (see the Australia’s Post- Implementation Evidence page of the Tools and Resources).

This page summarises the findings of these five reviews and goes onto outline some of the additional research evidence that has been produced since 2014.

It is important to emphasize that these evidence reviews only considered peer-reviewed studies published in academic or medical journals.

- Obtain full copies of the reviews

For Ministry of Health officials considering taking plain packaging forward, it is recommended that full copies of these reviews are obtained and considered, and records kept of when the copies were obtained, when they were considered and by whom (See Guide 1.2 Establish a document record ). They should also consider those studies that have taken place since the latest evidence review (see below).

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1. Cancer Council Victoria Review

In 2011, Cancer Council Victoria in Australia produced a paper to present the findings of research over two decades and across five countries on the topic of plain packaging. It includes the results of more than 25 published experimental studies and summarizes the results of research papers that analyze industry arguments about barriers to legislation resulting from international law and trade agreements.

Read the Cancer Council Victoria Review.

This was the first evidence review that provided the support for Australia to move ahead with the policy. The more recent reviews looked at the studies considered in this paper as well as subsequent ones. To avoid repetition, these pages focuses on the outcomes of more recent reviews.

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2. The Stirling Review

BACKGROUND

In 2012,the UK Department of Health commissioned a systematic review of the evidence on plain tobacco packaging. The review was supported through the Public Health Research Consortium (PHRC), a network of researchers at the University of Stirling, the University of Nottingham, and the Institute of Education, London.

Screening led to 37 studies being analyzed. The resulting report was peer reviewed and published at the same time as the 2012 consultation. It was made clear that the PHRC report represented the work and views of the authors, not necessarily those of the UK Department of Health. An update was published in September 2013, which considered seventeen new studies published since the original Stirling Review in 2012.

Read the original Stirling Review.

Read the updated Stirling Review.

The Stirling Review found that:

"There is strong evidence to support the propositions. . . that plain packaging would reduce the attractiveness and appeal of tobacco products, it would increase the noticeability and effectiveness of health warnings and messages and it would reduce the use of design techniques that may mislead consumers about the harmfulness of tobacco products."

METHODOLOGY

The review aimed to examine all available current evidence on the effects of plain packaging in the areas of pack appeal; effectiveness of health warnings; and perceptions of product harm and strength. It employed systematic review methodology and examined studies from 1980 to the date of review.

A total of 4,518 citations were identified following initial searching, and, after screening and quality appraisal, 37 studies were included in the systematic review. Most of the studies included in the review were conducted in Australasia, North America, or Western Europe.

FINDINGS

• Appeal of cigarettes, packs and brands:
• All studies reported that plain packs were rated as less attractive than branded equivalent packs by both adults and children.
• Plain packs were perceived to be poorer quality, poorer tasting, and cheaper than branded equivalent packs.
• Positive impressions of smoker identity and personality attributes associated with specific brands were weakened or disappeared with plain packaging.
• Non-smokers and younger people responded more negatively to plain packs than smokers and older people.

- Effectiveness of health warnings:

Overall, the studies suggest that plain packaging tends to increase the recall of health warnings, the attention paid to them, and their perceived seriousness and believability.

Findings appear to be moderated by the type, size, and position of health warning used.

Only one study examined sub-group differences and reported that non-smokers and weekly smokers may pay more attention to warnings on plain packs than daily smokers.

- Perceptions of product harm and strength:

Plain packaging can reduce misperceptions about the relative harmfulness of different brands.

Colors of packs affect perceptions of product harm and strength. In general, plain packs are perceived as more harmful than branded packs if in a darker color, such as brown, and, conversely, less harmful than branded packs if in lighter colors, such as white. Red packs are perceived to contain stronger cigarettes than light-colored packs.

Use of descriptors, such as “gold” or “smooth,” on plain packs have the potential to mislead consumers, as they do on branded packs.

In general, smokers are more likely to have misperceptions about the harmfulness of packs, both branded and plain, than non-smokers.

- Smoking-related attitudes, beliefs, intentions, and behavior:

Plain packs appear to increase negative feelings about smoking.

Plain packs are generally perceived as likely to have a deterrent effect on the onset of smoking by young people and as likely to encourage existing smokers to reduce their consumption or to quit, although in some studies they are perceived as likely to have little impact.

Non-smokers, lighter smokers, and younger people are more likely to perceive that plain packs would discourage or reduce smoking.

CONCLUSIONS

The Stirling Review concluded that the evidence demonstrated that plain packaging had been shown to:

• Reduce pack and product appeal by making packs appear less attractive and of lower quality, and by weakening the positive smoker identity and personality attributes associated with branded packs;
• Increase the salience of health warnings in terms of improving the recall and perceived seriousness and believability of warnings; and
• Reduce the confusion about product harm that can result from branded packs.
• Plain packaging was also perceived as likely to have a deterrent effect on the onset of smoking by young people and as likely to encourage existing smokers to quit. The review also found some evidence that non-smokers and, to a lesser extent, smokers approved of the idea of plain packaging, with both groups feeling it would make smoking less attractive, particularly to young people.
• Despite some limitations of the review identified by the researchers, they say that it is worth emphasizing the remarkable consistency in study findings regarding the potential impact of plain packaging. Across studies using different designs, conducted in a range of countries, with young and older populations and with smokers and non-smokers the key findings are similar. This consistency of evidence can provide confidence about the observed potential effects of plain packaging.

UPDATE

The authors provided an update to this review, summarizing subsequent evidence, in 2013.¹⁸ The findings were consistent with the original review, and the overarching summary is laid out below:

"This update of the literature, which now includes 54 published studies (37 in our original review and 17 here) shows that since the systematic review the evidence base has continued to grow at considerable pace."

and

"The evidence summarised in this update of the literature, in general, provides further support for the proposed benefits of plain packaging."

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3. The Chantler Review

Background

In November 2013, the UK Department of Health commissioned Sir Cyril Chantler to undertake an independent review of whether or not the introduction of standardized packaging of tobacco was likely to have an effect on public health, in particular in relation to children.

The remit of this review was wider than the Stirling Review and included consideration of evidence on the impact in Australia as well as industry arguments and possible unintended consequences.

Methodology

The Chantler Review considered all the evidence relevant to whether or not the introduction of standardized packaging would be beneficial to public health. The validity of the Stirling systematic review was also considered.

The Chantler Review invited interested parties to submit research-based material and took evidence during two meetings. Separate meetings were held with the Smokefree Action Coalition, the Tobacco Manufacturers Association, and representatives of Philip Morris Ltd. Sir Cyril also visited Australia to study its experience of implementing plain packaging.

He commissioned further expert advice to assist in the analysis of the key evidence. In particular, two specific pieces of independent analysis on the qualitative and quantitative studies in the Stirling Review (and the subsequent update) using Critical Appraisal Skills Programme assessment tools. These were undertaken by academics at Southampton University and Kings College London, respectively.

Download the report of the Chantler Review, published in April 2014.

Read the full record of the meetings, evidence, and written submissions from the review

Findings

Sir Cyril Chantler’s overall conclusion was that it is -

"highly likely that standardised packaging would serve to reduce the rate of children taking up smoking and implausible that it would increase the consumption of tobacco . . . I am satisfied that the body of evidence shows that standardised packaging, in conjunction with the current tobacco control regime, is very likely to lead to a modest but important reduction over time on the uptake and prevalence of smoking and thus have a positive impact on public health."

On Tobacco Marketing and Branding the Chanter Report stated that:

"There is very strong evidence that exposure to tobacco advertising and promotion increases the likelihood of children taking up smoking. Industry documents show that tobacco packaging has for decades been designed, in the light of market research, with regard to what appeals to target groups. Branded cigarettes are ‘badge’ products, frequently on display, which therefore act as a “silent salesman.” Tobacco packages appear to be especially important as a means of communicating brand imagery in countries like Australia and the UK which have comprehensive bans on advertising and promotion. . .

 The tobacco industry argues that all of its marketing activity, including packaging, aims solely to persuade existing adult smokers to switch brand and never targets children or new smokers. However, in my opinion, whatever their intent, it is not plausible that the effect of branded packaging is only to encourage brand switching amongst adult smokers, and never to encourage non-smokers from taking up smoking. I have heard no coherent argument as to how this purported separation occurs in practice and in my opinion a ‘spillover effect’ is highly plausible whereby packages that are designed to appeal to a young adult, also, albeit inadvertently, appeal to children. It seems to me that children and non-smokers are not, and cannot be, quarantined from seeing tobacco packaging and in my view once they are exposed to this packaging, they are susceptible to its appeal whether it is intended to target them or not. In the light of these and other considerations set out in my report I believe that branded packaging contributes to increased tobacco consumption."

On the quality of the available  evidence the Chantler Report stated:

"There has been, as opponents of standardised packaging have rightly pointed out to me in the course of this Review, no randomised controlled trial carried out to test the impact of standardised packaging on the take up of smoking amongst children. I do not consider it to be possible or ethical to undertake such a trial. To do so would require studies to be carried out within a suitably large and isolated population free of known confounding factors that influence smoking and prevalence. Such studies would expose a randomised group of children to nicotine exposure and possible addiction. I see the importance of Stirling as being the consistency of its results on appeal, salience and perceptions of harm, most notably that standardised packaging is less appealing than branded packaging. This evidence is direct and not reliant on stated intentions. Evidence from other spheres shows a strong non-conscious link between appeal and subsequent behaviour regardless of stated intentions. I therefore conclude that, by reducing its appeal, standardised packaging would affect smoking behaviour."

Industry arguments

The Chantler Report commented on the key industry arguments -

Plain packaging will lead to price reductions:

"First, tobacco companies have argued that standardised packaging will result in falling prices that in turn will increase the consumption of tobacco. They argue that, in the long-run at least, standardised packaging will reduce brand loyalty, causing smokers to switch to cheaper brands and encouraging price competition between manufacturers. However, early evidence from Australia does not show falling prices; rather price rises have continued over and above tax increases. There is some evidence of trading down towards cheaper brands, but this appears to be a continuation of an ongoing market trend. Were all this to change, the Government can in any case mitigate any price reduction by increasing tobacco taxes."

Plain packaging will lead to price reductions:

"Second, I am not convinced by the tobacco industry’s argument that standardised packaging would increase the illicit market, especially in counterfeit cigarettes. There is no evidence that standardised packaging is easier to counterfeit, and indeed in Australia, hardly any counterfeit standardised packages have been found to date. The tobacco industry has a history of attacking new tobacco control measures on the basis that they will boost illicit sales, arguing that illicit suppliers benefit from not having to follow the same restriction"

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4. The Hammond Review

Background

In March 2014, Professor David Hammond, an associate Professor of health behaviour and health policy at the University of Waterloo, Canada, published an evidence review on standardized packaging, commissioned by the Irish Department of Health.

Read the Hammond Review.

It reviews the scientific evidence on standardized packaging and the extent to which standardized packaging regulations would help Ireland to achieve its tobacco control objectives.

Professor Hammond also included the results of important research into the evidence from millions of internal industry documents released through court disclosure, which contribute to the evidence base on tobacco packaging and the industry’s extensive use of packaging as a marketing tool. This part of his report is dealt with in detail on the Tobacco Branding page of the Tools and Resources.

Methodology

A total of 69 original empirical articles were reviewed as part of this report, in addition to evidence contained in corporate documents from the tobacco industry and the broader literature on tobacco advertising and marketing. The evidence on plain packaging is notable for its breadth and diversity: research has been conducted in 10 different countries using a range of methodologies, including consumer perceptions, eye-tracking technology, neuroimaging, measures of consumer demand, and behavioural tasks, as well as evidence on the impact of plain packaging in Australia. Public opinion articles, reviews and commentaries were excluded from this review.

Findings

Professor Hammond summarizes the academic literature with respect to six primary outcomes: health warnings, perceptions of risk, consumer appeal, measures of consumer demand and smoking behavior, post-implementation research from Australia, and research on differences in plain packaging colors. The findings are:

- Health warnings

"Overall, the evidence suggests that health warnings are more noticeable on plain packs, associated with greater recall of health messages, and may lead to greater cognitive processing, particularly among youth non-smokers. The evidence also indicates that the effect of package branding persists even in the context of large pictorial warnings, and that plain packaging and health warnings have complimentary, but independent effects on consumer perceptions."

- Perceptions of risk

"Many consumers continue to hold false beliefs that some cigarette brands are less harmful than others, despite scientific evidence to the contrary. Pack design and colour promote false beliefs about the relative risks between brands. A variety of experimental studies indicate that plain packaging is associated with fewer false health beliefs."

- Consumer appeal

"The evidence unequivocally demonstrates that plain packaging is perceived as less attractive and less appealing, particularly among youth and young adults, including smokers and non-smokers. Plain packaging is also associated with less positive brand imagery, including smoker traits, such as cool, stylish, thin. The findings suggest that plain packaging is less socially desirable and limits the ability of packaging to target sub-groups of youth and young adults."

- Measures of consumer demand and smoking behavior

"Evidence from a range of methodologies indicates that plain packaging reduces consumer demand. Evidence from a limited number of naturalistic studies suggest that plain packaging may promote smoking cessation among established smokers, although additional studies are required to demonstrate this effect. Findings from clinical studies also indicates that branded tobacco packaging is a reliable cue for smoking and can prompt urges to smoke among former smokers, and that exposure to plain packages reduces urges and motivation to smoke compared to branded packages."

- Post-implementation: the impact of plain packaging regulations in Australia

"Given the novelty of plain packaging regulations in Australia, there are few studies to assess the impact of plain packaging. To date, three published studies provide preliminary evidence suggesting that plain packaging has had a positive public health impact in Australia. Of the three studies, objective data indicating a significant increase in calls to the Quitline — an effective form of smoking cessation149 — are most compelling. No studies have examined the impact of plain packaging within the context of smoking initiation."

- Plain pack color

"Studies are consistent in demonstrating that darker, non-white colours are perceived as significantly less appealing and more effective. Therefore, while the primary objective of standardizing colour would be to have uniform appearance, to minimize the belief that some products are less harmful than others, using a darker colour may reduce the overall appeal of all packages."

CONCLUSIONS

The report draws some strong conclusions, which are in line with the conclusions of the Chantler Review:

"Tobacco advertising and marketing are among the most important factors in the rise of smoking in the 20th century. Industry marketing campaigns have sought to communicate three fundamental themes: 1) product satisfaction; 2) reassurance about the health concerns; and 3) positive associations between smoking and desirable outcomes, such as independence, social status, sexual attraction and thinness. Tobacco industry documents and independent evidence indicates that packaging has played a fundamental role in executing each of these themes, and has grown in importance as other forms of advertising and marketing have been prohibited.

 The scientific evidence on plain packaging includes more than 70 original empirical articles from a wide variety of research domains. Most of the research on plain packaging is experimental in nature and has been conducted in jurisdictions without plain packaging given that plain packaging regulations were only implemented in December 2012 in Australia. The evidence is highly consistent across different research domain and study designs, as well as between experimental and more recent “post-implementation” studies conducted in Australia. "

Overall, the Hammond Review found that existing evidence on plain packaging supports four primary conclusions:

1. Plain packaging will reduce smoking initiation among youth and young adults.
2. Plain packaging will promote smoking cessation among established smokers.
3. Plain packaging will support former smokers to remain abstinent.
4. Plain packaging will help to denormalize tobacco use

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5. The Cochrane Review

Cochrane is a non-profit, non-governmental organization formed to organize medical research findings to facilitate evidence-based choices about health interventions. The group conducts systematic reviews of health-care interventions and publishes them in The Cochrane Library.

Cochrane published a review in April 2017 which looked at the peer-reviewed published evidence assessing the effect of plain packaging on tobacco use, uptake, cessation, and reduction.

Methodology

The review searched nine databases for articles evaluating standardised packaging that had been already reviewed by academics and published before January 2016. We also checked references in those papers to other studies and contacted the authors where necessary. The research found 51 studies involving approximately 800,000 participants.

Primary Outcomes

The primary outcome measured by the review was changes in tobacco use prevalence including uptake, cessation and reduction in overall consumption.

The review found only 5 studies that addressed these primary outcomes. The reason for this is that, even in Australia, plain packaging is at an early stage of implementation to get reliable statistical data on the impacts of plain packaging on overall prevalence.

The only peer reviewed study that considered overall prevalence was the analysis by Professor Chipty that is included in Australia’s Post Implementation Review (see the pages on Australia Post Implementation Evidence in the Tools and Resources). That analysis of statistical data concluded that a drop of 0.55 percentage points in smoking prevalence was attributable to plain packaging over a 34 month period after introduction.

Three studies on consumption in Australia found little change in existing smokers’ consumption levels.

A national study of adult smoker quit attempts showed an increase from 20% prior to the introduction of plain packaging, compared to 26.6% 1 year after implementation. This was backed up by the fact that calls to quit lines increased by 78%.

Secondary Outcomes

The review anticipated very few studies on the primary outcome at this stage of implementation. The review therefore also looked at studies on secondary outcomes including:

• behaviours such as stubbing out cigarettes early, covering the packs, and eye tracking in experimental studies, and
• non-behavioural studies such as intentions of young people, pack appeal, recall of health warnings and perceptions of harm.

These studies found evidence of increased avoidance behaviours, increased attention to health warnings and reduced cravings. Studies also indicated that plain packs were less likely to motivate initiation among youth.

CONCLUSION

The review concluded that the evidence suggests that standardised packaging may reduce smoking prevalence. The review noted the limitations on the currently available data on the impact of plain packaging on smoking prevalence in Australia but concludes that a reduction in smoking behavior is supported by routinely collected data by the Australian government. Data on the effects of standardized packaging on non-behavioral outcomes (e.g. pack appeal and recall of health warnings) are clearer and provide plausible mechanisms for the observed decline in prevalence.

The review did not find any evidence suggesting standardized packaging may increase tobacco use.¹⁹

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> Further research evidence

Further research into likely impacts of tobacco plain packaging has continued to be undertaken around the world since these evidence reviews were published. The following is not intended to be a comprehensive review of this additional evidence but provides examples and information about the continued research into the likely impacts of plain packaging of tobacco products.

1. A systematic review of existing literature was undertaken in 2016 to consider the impact of plain packaging in low- and middle-income countries and in low-income settings in high-income countries. It concluded that plain packaging had less appeal than branded packaging in low- income settings.²⁰
   
   
2. A 2015 study undertook experimental research into the effects of plain packaging and graphic health warnings on adolescents in Spain, France, and the USA, and concluded that both policies impacted on cravings and evoked fear and thoughts of quitting.²¹
   
   
3. A study in France considered young roll-your-own smokers’ response to using plain packaging in real-world settings and found them to be associated with less-positive product perceptions, negative feelings about smoking, and increased reported feelings about reducing consumption and quit attempts.²²
   
   
4. Two experiments in the UK found that branded packs primed a greater percentage of tobacco seeking behavior in current smokers.²³
   
   
5. A study in Thailand used a variety of methods with students to look at the impact of plain packaging on health warning salience on cigarette packs.²⁴
   
   
6. A 2016 study led to results demonstrating that plain packaging and health warnings work independently and in unison to influence smokers’ and non-smokers’ behavioral intentions.²⁵
   
   
7. A 2016 study considered the impact of cigarette packaging design, such as “slims” branding and warning labels, on perceptions of taste harm and interest among young females in Canada. The study concludes that plain packaging may decrease demand and reduce misleading perceptions in young females.²⁶ 
   
   
8. A 2018 study looked at young adult smokers’ perceptions of plain packs in Turkey, concluding that plain packs were considered unappealing and off-putting. It also found that plain packs with bevelled edges were viewed more favourably than the straight-edged packs.²⁷
   
   
9. A 2017 study looked at the impact of plain packaging on the risk perception of Uruguayan smokers. It showed that plain packs enhanced the perceived risk of cigarettes, even in an environment where packs are already highly regulated such as Uruguay.²⁸
   
   

In addition, there is significant research into the impacts of the policy after it was implemented in Australia, which is set out on the Post-Implementation Evidence from Australia page.