Personal pack display and active smoking at outdoor café strips: assessing the impact of plain packaging 1 year postimplementation

AIMS: We observed tobacco pack display and smoking at outdoor venues over three summers to assess changes in their prevalence following Australia's introduction of plain tobacco packaging with larger pictorial health warnings. METHODS: Between January and April 2012 (preplain packaging (PP)), 2013 (early post-PP) and 2014 (1 year post-PP), we counted patrons, smokers and tobacco packs at cafés, restaurants and bars with outdoor seating. Pack type (branded, plain or unknown) and orientation were noted. Rates of active smoking, pack display and pack orientation were analysed using multilevel Poisson regression. RESULTS: Prevalence of pack display among patrons declined from pre-PP (1 pack per 8.7 patrons) to early post-PP (1 pack per 10.4), and remained low 1 year post-PP (1 pack per 10.3). This appeared to be driven by a sustained decline in active smoking post-PP (pre-PP: 8.4% of patrons were smoking; early post-PP: 6.4%; 1 year post-PP: 6.8%). Notably, active smoking declined more in venues with children present than in those without. While early post-PP, plain packs were less often displayed face-up (74.0%) and more often concealed (8.9%) than branded packs pre-PP (face-up: 85.2%; concealed: 4.0%), this was not sustained 1 year post-PP (face-up: 85.7%; concealed: 4.4%). Also, external case use increased from pre-PP (1.2%) to early post-PP (3.5%), but returned to pre-PP levels 1 year post-PP (1.9%). CONCLUSIONS: This study demonstrated a sustained reduction in visibility of tobacco products and smoking in public, particularly in the presence of children, from pre-PP to 1 year post-PP. This effect is likely to reduce smoking-related social norms, thereby weakening an important influence on smoking uptake and better supporting quit attempts.