Many countries have tobacco control legislation that establishes a minimum number of a box of cigarettes that can be included in a single pack.
In many countries that have regulated on this the minimum cigarette pack size is 20, e.g. in the United States (Code of Federal Regulations Title 21 Sec. 1140.16) and the European Union member states (EU Tobacco Products Directive, 2014/40/EU). The EU directive imposed a minimum number of a box of cigarettes per pack to increase the upfront cost of cigarettes and thereby make them less affordable for young people 1. By contrast, there is very little regulation regarding maximum pack size, which varies globally between 10 and 50 cigarettes per pack. Packs of 25 were introduced in Australia during the 1970s, and packs of 30, 35, 40 and 50 progressively entered the market over the subsequent two decades 2. In Ireland, pack sizes larger than 20 have grown steadily from 0% of sales in 2009 to 23% in 2018 3. In the United Kingdom, packs of 23 and 24 were introduced following the introduction of plain (standardized) packaging. Learning from these experiences, New Zealand mandated for just two standard pack sizes (20 and 25) as part of its legislation for plain packaging 4.
The availability of pack sizes larger than 20 a box of cigarettes is of particular interest because of growing evidence for the role of portion size in consumption of other products.
Consumption of food increases when people are offered larger, compared to smaller, portion sizes, with a Cochrane systematic review finding a small to moderate effect of portion size on food and soft‐drink consumption 5. The review also examined evidence for the effect of portion size on tobacco consumption. Only three studies met the inclusion criteria, all focused on a box of cigarettes length, with no studies examining the impact on consumption of cigarette pack size. The dearth of experimental evidence is a concern, because increasing availability of larger pack sizes could undermine improvements to public health achieved through other tobacco control policies.
To date, the success of tobacco control policies in many countries has largely been due to reducing uptake through price‐based interventions rather than promoting cessation, with cessation rates remaining relatively constant over time 6. This challenge emphasizes the need for policies that encourage cessation. Reducing the number of cigarettes per day that smokers consume may be an important precursor to successful cessation attempts, and while increasing prices is probably the most effective strategy, other tobacco control policies have also been important in decreasing consumption 7. Trends in smoking have shown that smokers can and have initiated and maintained reductions in consumption in many countries. For example, in the years when no‐smoking policies were increasingly being adopted in work‐places, smokers were more likely to stop smoking in smoke‐free work‐places compared to those that allowed smoking 8. Reported numbers of a box of cigarettes smoked per day has also declined over time in Australia, the United Kingdom and many other countries (2002–07) 9.
In England, the National Institute for Health and Care Excellence (NICE) guidelines (national evidence‐based health‐care recommendations) encourage smokers to reduce consumption on the basis that it is likely to increase chances of cessation. However, there is some concern that promoting reduction may undermine cessation and resistance to relapse 10. A systematic review of smoking cessation interventions found that cutting down prior to stopping, or stopping abruptly, had comparable cessation rates for smokers intending to stop 11. A subsequent trial found that cutting down to stop smoking was less effective than stopping smoking abruptly 12; however, the authors suggested that advice to reduce smoking may still be worthwhile if it increases engagement with the concept of receiving support. An environmental modification such as capping a box of cigarettes pack size has the potential to reduce consumption besides conscious awareness. It therefore presents an opportunity to deliver the benefits of reduced consumption without the smoker developing self‐exempting beliefs about reduced harm through reduction alone. Success has been demonstrated from policies to cap the maximum size, and number permitted in a single sale, of other harmful products. For example, reducing the number of analgesic pills per pack has been beneficial in the prevention of deaths by suicide 13.
This article aims to build on a recent Cochrane review 5 for which no experimental studies were found of the impact of cigarette pack size on tobacco consumption.
In the absence of direct evidence, we have identified existing variation in availability of a box of cigarettes sizes and synthesized the literature relevant to two key assumptions for capping pack size:
(i) reducing pack size can reduce consumption; and (ii) reducing consumption can increase cessation. The dearth of experimental studies to support these assumptions does not preclude the threat that increasingly large a box of cigarettes pack sizes (> 20) may pose to the success of other tobacco control policies. We contend that the regulatory focus regarding minimum pack size, without due consideration of whether there should be a mandatory maximum pack size, has essentially created a loophole that the tobacco industry can exploit. Based on indirect evidence we propose the hypothesis that Government regulation to cap cigarette packs to 20 cigarettes would contribute to national and global tobacco control policies to reduce smoking prevalence.
Post time: Jul-25-2024