Personal tobacco pack display before and after the introduction of plain packaging with larger pictorial health warnings in Australia: an observational study of outdoor cafe strips

Aims We tested whether prevalence of cigarette pack display and smoking at outdoor venues and pack orientation changed following the introduction of plain packaging and larger pictorial health warnings in Australia. Methods Between October and April 2011-12 (pre-plain packaging, pre-PP) and 2012-13 (post-plain packaging, post-PP), we counted patrons, smokers and tobacco packs at cafes, restaurants and bars with outdoor seating. Pack type (fully branded, plain or unknown) and orientation were noted. Rates of pack display, smoking and pack orientation were analysed using multi-level Poisson regression. Results Pack display declined by 15% [adjusted incident rate ratio (IRR) = 0.85, 95% confidence interval (CI) = 0.79-0.91, P < 0.001], driven by a 23% decline in active smoking (IRR = 0.77, 95% CI = 0.71-0.84, P < 0.001) between phases. The decline in pack display coincided with the full implementation of plain packaging from December 2012, was stronger in venues with children present and was limited to mid and high socio-economic status (SES) areas. The proportion of packs orientated face-up declined from 85.4% of fully branded packs pre-PP to 73.6% of plain packs post-PP (IRR = 0.87, 95% CI = 0.79-0.95, P = 0.002). Alternatively, the proportions concealed by telephones, wallets or other items (4.4% of fully branded packs pre-PP and 9.5% of plain packs post-PP; IRR = 2.33, 95% CI = 1.72-3.17, P < 0.001) and in an external case (1.5-3.5% of all packs; IRR = 2.79, 95% CI = 1.77-4.40, P < 0.001) increased. Low SES areas evidenced the greatest increase in pack concealment and the greatest decline in face-up pack orientation. Conclusions Following Australia's 2012 policy of plain packaging and larger pictorial health warnings on cigarette and tobacco packs, smoking in outdoor areas of cafes, restaurants and bars and personal pack display (packs clearly visible on tables) declined. Further, a small proportion of smokers took steps to conceal packs that would otherwise be visible. Both are promising outcomes to minimize exposure to tobacco promotion.