The impact of the introduction of tobacco product plain packaging on consumer responses in Ireland: a real-world policy evaluation stratified by socioeconomic groups

Smoking prevalence remains high in Europe and widening socioeconomic group differences are driving health inequalities. While plain packaging policies disrupt tobacco industry tactics that sustain smoking, evidence of their equity impact is sparse. This study evaluated the implementation of plain packaging in Ireland in 2018 on consumer responses, overall and by the socioeconomic group. Consecutive nationally representative cross-sectional surveys (2018, n = 7701 and 2019, n = 7382) measured changes in 13 consumer responses among respondents who smoked across three domains: product appeal, health warnings effectiveness, and perceived harmfulness of smoking. Multiple logistic regression-derived adjusted odds ratios with 95% confidence intervals to compare responses post- versus pre-implementation adjusting for age, gender, educational level, and heaviness of smoking. A stratified analysis examined changes by socioeconomic group indexed using educational level. There were statistically significant changes in consumer responses to plain packaging policy implementation across 7/13 outcomes studied. Five changes were aligned with expected policy impacts (2/6 product appeal outcomes and 3/4 health warning effectiveness outcomes). Two responses were also observed which were not expected policy impacts (1 appeal-related and 1 perceived harm-related outcome). There was no change in five outcomes. Differences in consumer responses between educational groups were generally small, mixed in nature, and indistinguishable when interval estimates of effect were compared. Implementation of plain packaging in Ireland had intended impacts on consumer responses. Including plain packaging requirements in revising the European Union's legislative frameworks for tobacco control will help build progress towards a Tobacco-Free Europe without exacerbating smoking inequalities.