Long-term impact of plain packaging of cigarettes with larger graphic health warnings: findings from cross-sectional surveys of Australian adolescents between 2011 and 2017.

OBJECTIVE: To assess the long-term impact of plain packaging (PP) of cigarettes with larger graphic health warnings (HW) introduced in December 2012 on adolescents' relevant tobacco-related perceptions. METHODS: Cross-sectional school-based surveys of 12 to 17 year olds in 2011 (n=4413), 2013 (n=4423), 2014 (n=4576) and 2017 (n=4266). Students rated the character of four popular cigarette brands, indicated their agreement regarding brand differences in smoking ease, quitting, addictiveness, harmfulness and pack attractiveness and positive/negative perceptions of pack image. The frequency of students reading, attending to, thinking and talking about HW was assessed. Responses of students seeing cigarette packs in the previous 6 months (2011: 63%; 2013: 67%, 2014: 56%, 2017: 56%) were examined. RESULTS: Smoking prevalence declined from 2011 to 2017. Among students who had recently seen packs, cigarette packs were rated less positively and more negatively in 2017 than in 2011 (p<0.001) with ratings similar between 2013 and 2017. Positive character ratings for each brand reduced between 2011 and 2013 (ps<0.05) with further reductions between 2013 and 2017 (ps<0.05). Fewer students agreed, and more were uncertain, that brands differed in their smoking ease, addictiveness, harmfulness and pack attractiveness in 2017 than 2011. The frequency of students reading, attending, talking or thinking about HW did not change between 2011 and 2017. CONCLUSIONS: PP's initial impact in reducing adolescent's positive perceptions of cigarette packs and brand differences continued in the following years with tobacco packaging less appealing to young people in 2017 than 2011 and students more uncertain about brand differences.

What Factors are Associated with Electronic Cigarette, Shisha-Tobacco and Conventional Cigarette Use? Findings from a Cross-Sectional Survey of Australian Adolescents?

BACKGROUND: Adolescents' use of electronic cigarettes and shisha-tobacco increased in several countries during the 2000s, including in the United States, United Kingdom and Canada. Few studies have examined the factors associated with exclusive e-cigarette or shisha-tobacco use and whether adolescents using these substances exclusively differ from those using traditional cigarettes. OBJECTIVES: To examine the socio-demographic and behavioural correlates of exclusive e-cigarette and exclusive shisha-tobacco use to those found for users of tobacco cigarettes and multiple nicotine products in Australian adolescents. METHODS: Cross-sectional survey of smoking behaviours of a random sample of 4,576 students in the Australian state of Victoria aged 12-17 conducted between June 2014 and December 2014. RESULTS: Overall, 14% of students had used an e-cigarette with 3% using e-cigarettes exclusively. 13% had used shisha-tobacco, with 2% using shisha-tobacco exclusively. Most students (65%) using e-cigarette and shisha-tobacco (67%) had also used tobacco cigarettes. After adjusting for demographic factors, students using e-cigarettes only were more likely to have never used cannabis or drink alcohol in the past year compared to tobacco cigarette users. Compared to tobacco cigarette users, students using only shisha-tobacco were younger, less likely to use cannabis or alcohol or have friends or parents who smoke. CONCLUSIONS: Most Australian adolescents who use alternative nicotine and tobacco-related products do so in conjunction with tobacco cigarettes. Students using e-cigarettes or shisha-tobacco exclusively were less likely to use other substances. Australian longitudinal studies are needed to determine whether this group of students are on a pathway to traditional tobacco use.

The relationship between Australian harm minimisation alcohol education and student uptake, consumption and harm.

BACKGROUND: Alcohol use by young people is a public health concern in Australia because of the disproportionate harm they experience. Accordingly, governments have sought to protect young people, with school identified as an appropriate site for drug, including alcohol, prevention through education. School-based drug education programmes, however, have not been particularly effective, and even when individual programs report prevention benefits they can be criticised for being developed and evaluated by the same group. METHODS: This study involved secondary analysis of alcohol data from the 2011 and 2014 Australian Secondary Students Alcohol and Drug (ASSAD) surveys, to examine the relationship between the amount of alcohol education students reported receiving and their patterns of use and harm. Associations between the amount of alcohol education remembered and alcohol uptake, consumption, risky consumption and alcohol-related harm were measured using Logistic and Tobit regression techniques. As most alcohol education in Australia reflects harm minimisation aims, this research provides an independent, proxy assessment of the effect of harm minimisation education. RESULTS: In the 12- to 17-year-old student group, as a whole, there was a significant positive association between having tried alcohol and the level of alcohol education recalled. There were significant negative associations between the amount of alcohol consumed and the level of alcohol education recalled for drinkers and risky drinkers. There were no significant associations between alcohol-related harm and the level of alcohol education recalled for drinkers and risky drinkers. CONCLUSION: Providing more harm minimisation alcohol education did not persuade students to abstain from alcohol, but rather the reverse. Providing more harm minimisation education was influential in reducing consumption by students, particularly those drinking at risky levels. This should be considered indirectly beneficial in terms of minimising harm. However, the alcohol education provided to Australian students has not directly influenced their alcohol-related harm.

Do larger graphic health warnings on standardised cigarette packs increase adolescents' cognitive processing of consumer health information and beliefs about smoking-related harms?

OBJECTIVE: To examine the impact of plain packaging of cigarettes with enhanced graphic health warnings on Australian adolescents' cognitive processing of warnings and awareness of different health consequences of smoking. METHODS: Cross-sectional school-based surveys conducted in 2011 (prior to introduction of standardised packaging, n=6338) and 2013 (7-12 months afterwards, n=5915). Students indicated frequency of attending to, reading, thinking or talking about warnings. Students viewed a list of diseases or health effects and were asked to indicate whether each was caused by smoking. Two-'kidney and bladder cancer' and 'damages gums and teeth'-were new while the remainder had been promoted through previous health warnings and/or television campaigns. The 60% of students seeing a cigarette pack in previous 6 months in 2011 and 65% in 2013 form the sample for analysis. Changes in responses over time are examined. RESULTS: Awareness that smoking causes bladder cancer increased between 2011 and 2013 (p=0.002). There was high agreement with statements reflecting health effects featured in previous warnings or advertisements with little change over time. Exceptions to this were increases in the proportion agreeing that smoking was a leading cause of death (p<0.001) and causes blindness (p<0.001). The frequency of students reading, attending to, thinking or talking about the health warnings on cigarette packs did not change. CONCLUSIONS: Acknowledgement of negative health effects of smoking among Australian adolescents remains high. Apart from increased awareness of bladder cancer, new requirements for packaging and health warnings did not increase adolescents' cognitive processing of warning information.

Has the introduction of plain packaging with larger graphic health warnings changed adolescents' perceptions of cigarette packs and brands?

OBJECTIVE: To examine the impact of plain packaging of cigarettes with enhanced graphic health warnings on adolescents' perceptions of pack image and perceived brand differences. METHODS: Cross-sectional school-based surveys conducted in 2011 (prior to introduction of new cigarette packaging) and in 2013 (7-12 months afterwards). Students aged 12-17 years (2011 n=6338; 2013 n=5915) indicated whether they had seen a cigarette pack in previous 6 months. Students rated the character of four popular cigarette brands, indicated level of agreement regarding differences between brands in ease of smoking, quitting, addictiveness, harmfulness and look of pack; and indicated positive and negative perceptions of pack image. Changes in responses of students seeing cigarette packs in the previous 6 months (2011: 60%; 2013: 65%) were examined. RESULTS: Positive character ratings for each brand reduced significantly between 2011 and 2013. Changes were found for four of five statements reflecting brand differences. Significantly fewer students in 2013 than 2011 agreed that 'some brands have better looking packs than others' (2011: 43%; 2013: 25%, p<0.001), with larger decreases found among smokers (interaction p<0.001). Packs were rated less positively and more negatively in 2013 than in 2011 (p<0.001). The decrease in positive image ratings was greater among smokers. CONCLUSIONS: The introduction of standardised packaging has reduced the appeal of cigarette packs. Further research could determine if continued exposure to standardised packs creates more uncertainty or disagreement regarding brand differences in ease of smoking and quitting, perceived addictiveness and harms.