Plain Packaging and Evidence

Otago's Public Health department and British American Tobacco seem to be talking past each other.

A few days ago, the usual bunch at Otago put out a press release about some surveys they conducted about tobacco labelling. The article is here; I've copied their main results table below.

This is the sum total of the paper, really. They ran the survey, these are the results. Again, I remain pretty amazed at how easy it is to get published in some outlets. Nothing on demographic covariates; nothing on education/smoking interactions on views... hard to see a there there.

What does the survey tell us?

1. Both smokers and non-smokers think there should be warning labels on tobacco products, though non-smokers are more likely to agree;
2. Non-smokers think attractive packaging encourages smoking initiation; smokers disagree. 
• Crampton's editorialising: Presumably smokers are more likely to know what got them started. 
3. Smokers do not think that tobacco packaging encourages smokers to try new brands; non-smokers disagree.
• Crampton's editorialising: Branded packs should encourage smokers to stay with their chosen brand - they're an effort to build customer loyalty in what's otherwise pretty easily a homogeneous commodity product.
4. Non-smokers are more likely to agree that plain packaging discourages smoking initiation; smokers just as strongly disagree.
• Crampton's editorialising: Again, why do we think that smokers would be wrong on this one? They remember what got them started on smoking.
5. Non-smokers lean slightly towards agreeing that plain packaging would encourage smokers to quit; smokers disagree pretty strongly.
6. Non-smokers think plain-packaging is fair; smokers are split.

The second survey, according to the press release, tells us that there are identities around brands. That isn't surprising; it's the point of branding.

Nothing in either survey really tells us what's likely to happen if plain packaging is imposed. Here, I put a lot more weight on basic theory than on surveys. And theory tells us that once you pull brands out, cigarettes become more homogeneous. Smokers then become more cost sensitive across brands and are more likely to shift downwards towards cheaper brands. When that happens, smoking rates among smokers may increase; Clarke, linked above, doesn't think the price shifts will be substantial enough to have large price effects - he reckons it can be offset by tax increases in any case. But neither he nor I really know the scale of likely effects. And Janet Hoek doesn't know either. 

The Otago Daily Times reports on BAT and Hoek's dispute. Recall that Hoek's evidence above is entirely survey stuff.

A University of Otago researcher has hit back at comments by a tobacco industry spokesman who said plain packaging would not reduce tobacco consumption.

On Wednesday British American Tobacco (BAT) general manager Steve Rush responded to the findings of Otago University's Aspire2025 research group, which found that two-thirds of respondents supported plain packaging. Mr Rush said the research did not prove plain packaging would reduce tobacco consumption.

"The research is attitudinal and is based on opinions. It's about how people think they might behave in the future. It's not about how people actually behave," he said.

Tobacco packaging did not influence why people started smoking or quitted, he said.

Prof Janet Hoek, from university's marketing department, hit back yesterday, saying Mr Rush's remarks about her team's research were "illogical, unsupported" and ignored a "well-established evidence base".

"He has trotted out the same tired arguments in a failed attempt to disguise the fact that there is very strong public support for plain packaging, and very little sympathy for the arguments his company is investing hundreds of thousands of dollars trying to promote.

She says people like plain packaging. He says there's no evidence that it'll work. She says he's ignoring the evidence that people like plain packaging. What evidence there is in the Hoek paper suggests, at least to me, that the cohort of people who are smokers don't think that plain packaging will do much to reduce uptake or to encourage quitting; I don't put much confidence in survey measures of this sort, but if I had to bet, I'd bet on the estimates from the folks who are smokers rather than the ones from the folks who aren't. And the rest of the international literature on which Hoek would draw suffers from the problem that, because nobody's ever tried plain packaging, we can't really tell what would happen.

I worry that most of the support for plain packaging comes less from potential effects on smoking rates but rather from this kind of sentiment:

@ericcrampton who cares if it works or not - any handicap put on tobacco companies is good in my books @metiria @dpfdpf @danylmc @keith_ng
— Stuart Maxwell (@stuartm) October 11, 2012

It's stuff like this that makes Baby Pareto cry.

Nobody really knows what the effects of plain packaging will be. If we and the Australians cared about finding out whether plain packaging had any effect, we'd be setting up a randomised control trial across the two countries such that some areas would get plain packages and others wouldn't. Instead, both countries seem to be bundling plain packaging with a host of other anti-smoking measures that will make it pretty hard to sort out later on whether any change in smoking rates was due to plain packaging, changes in tax rates, time trends, or something else.

I'm less than convinced by the argument that plain packaging encourages smuggling and black market cigarettes: you can always add anti-counterfeiting tax-stamp holograms to the packs to make it obvious which ones are legit.* But I can see a mechanism where black market cigarettes are encouraged: breaking brand loyalty and making smokers re-evaluate their consumption choice may lead some smokers to choose black market products as there will be less product differentiation. I have a hard time seeing other mechanisms driving it - it has to come from smokers being less reluctant to switch to black market products. If we start seeing divergences between excise counts on tobacco sales and self-reports of smoking behaviours in the households surveys, we just won't be able to tell whether increased use of illicit tobacco is due to plain packaging or the big set of price hikes that will hit the legal market.

Harry Clarke, who supports plain packaging, suggests that one of the main potential benefits of its adoption in Oz and NZ is figuring out whether the policy does anything:

This conclusion does not mean PP legislation will have strong effects in reducing demands. This depends on the dissuasive impact of PP on consumption. But it is very unlikely that such policies would be counterproductive in the sense of increasing demands. A weak argument endorsing Australia’s adoption of PP policies is that they will have some positive effect in reducing demand without causing any harmful effects. An important gain is determining whether such policies will be very effective or not. Such innovative policies provide a “global public good”. There is often a Prisoners’ Dilemma case against delivering such public goods but, because the policies are likely to be non-disadvantageous, there are no extra costs if Australia is the first country to try out such policies. Indeed Australia has advantages over other developed countries in performing such an experiment. It is remote and physically isolated compared with European, developed Asian or even North American nations. This reduces problems of illegal cigarettes and private importing. Possibly only New Zealand is better as a laboratory. Altruistic provision of global information on the effectiveness of PP should provide benefits in reducing smoking but, at worst, will cost Australia nothing and boost its image as a good global citizen.

But it sure will be hard to run that policy evaluation. We'll likely be able to say "the bundle of plain packaging and substantial excise hikes and other stuff led to X", but disentangling effects would require that there's reasonable ex ante price variation across Australian states so we'd have different proportional changes in total prices with the excise increases.

I'd also disagree pretty strongly with the "will cost Australia nothing" conclusion. Even if you just hate tobacco companies and count their utility negatively, every policy of this sort that's adopted increases the chances that it'll be adopted for other products. The UK Health Select Committee just a couple of months ago was talking about considering plain packaging for alcohol, while promising that they'll not consider it for food. I'm still nervous for Count Chocula. The policy buys some fights on trade policy that could well be pointless. And, it's another step down the road that says that even if we provide all the relevant information to consumers, consumers are incompetent to make their own choices and public health experts should get to choose for them. I don't like that road; every step on it is costly if you like consumer sovereignty.

* I generally concur [that's too strong as I've not gone through it in enough depth. Let's say "generally sympathetic to"] with the points Philip Morris makes in its submission. But the points on black market and plain packaging really seem to be an argument in favour of putting anti-counterfeiting measures on unbranded products. They really bring out the heavyweights on it: James Heckman is their consultant; he cites his Nobel on causal inference among his qualifications to be an expert. His report on youth smoking, the appendix to the submission, deserves its own post sometime soon.

Experiment on prisoners!

National's announced what sounds like a decent measure to reduce alcohol-related crime: better rehab treatment in prisons for offenders.

Budget 2012 will contribute to a 25 per cent reduction in reoffending by 2017, and 18,500 fewer victims of crime every year from 2017, Corrections Minister Anne Tolley and Associate Corrections Minister Dr Pita Sharples say.

The moves are part of the Prime Minister’s expectations for a more efficient and results-driven public service.

A boost in alcohol and drug treatment, alongside increased education, skills training and employment programmes for prisoners, including remand prisoners, will lead to safer communities and better value for money for taxpayers.

From 2017, there will also be 600 fewer prisoners in jail than in 2011, and 4,000 fewer community offenders.

“It’s time to get serious about breaking this vicious cycle of prison and reoffending,” Mrs Tolley says.

There have been a few stories out over the last few years about lack of availability of treatment options for offenders who have wanted to seek treatment; increasing availability is likely to help those offenders. But it would likely be wrong to extrapolate from results achieved by those seeking treatment to those that could be achieved among those who would be compelled to seek treatment. So while I'm not convinced that Tolley's projections around reductions in reoffending are right, it still seems a policy worth trying.

Even better, it's a policy possibly worth trying as a randomized control trial. If the total amount of funding available isn't sufficient to give drug and alcohol rehabilitation treatment to everyone they might wish to have it, or to provide employment and reintegration support to all prisoners leaving prison, randomize who gets to participate. Here's one potential approach.

Set up three groups for each type of intervention. The first is a control group - no treatment. The second is compelled to participate, but they get a lotto. Those wishing not to have treatment can ask for it, and some of those wishing to opt out will be able to opt out. The third gets a lotto: those wishing to select into treatment can ask for it, and some of those opting for it will get it.

What does this kind of design let you do?

1. What's the value of treatment for those who want to have treatment? Compare outcomes for those who indicated they want treatment but didn't get it with outcomes for those who won the lottery.

2. What's the value of treatment for those compelled to have treatment? Compare outcomes for those who are forced into treatment against their lottery-expressed wishes with those who are allowed to opt-out of compelled treatment.

3. What's the effect of changing the default option? Compare average outcomes between the two lottery treatments.

4. What's the average effect of compulsory treatment? Get the average rate of "wanting to be treated" across groups 2 & 3, the effect of treatment on the "want to be treated" groups in 2&3, the average rate of "not wanting to be treated" across 2 & 3, the effect of treatment on that group, take the weighted average outcomes across both, and compare to the control group. This would be what we'd expect as effect of a blanket "must be treated" rule.

It's great that the government's looking at targeting one of the real sources of alcohol and drug related external cost. It would be even better to set it up so we could learn something!

Alas, the Ministry of Justice and the Corrections Minister would likely have a hard time getting this done under the auspices of any of the universities due to likely quibbling from Human Ethics Review panels. But I'm sure there'd be a few folks around who'd find it interesting enough to do as a side project.

Tobacco policy experiment

New Zealand seems on course to mandate tobacco plain packaging legislation; we'll see how the Australian court challenge pans out.

There isn't any real-world evidence on the effects of cigarette plain packaging legislation, mostly because nobody's really done it yet. What we have are a bunch of surveys of smokers and non-smokers on how cigarette packaging makes them feel, whether they think different designs are more or less likely to encourage them to smoke, and the like. In other words, a bunch of hypothetical musings in low consequence environments.

If we're stuck having Tariana Turia's proposed legislation, let's do some good with it. Set it up as an experiment. Implement plain packaging in part of the country, but not elsewhere. Then see what happens. If it seems successful after a few years, implement it everywhere; if it doesn't, abandon it. Either way, publish all the results so we have a better handle on what works. So plain packaging in Christchurch but not in Dunedin, in Wellington but not in Rotorua. I'm sure there are plenty of folks who specialize in designing randomised control trials of this sort who'd be able to run things. We may need a third treatment group to avoid problems that can result when you know you're part of a treatment group as compared to the control, but other folks know more about these design issues than I do. We'd probably also need to compensate the tobacco companies for increased distribution costs over the duration of the trial - the excess of current tobacco excise revenues over demonstrable costs to the health system should provide plenty of money that could be used here.

If we apply plain packaging to the whole country at once, we have no way of knowing whether the policy does anything. A careful randomised control trial could tell us something useful.

I've reasonable "get off my lawn" opposition to the policy, but if we're going to be stuck with it, why not learn something at the same time?