Background: Tobacco use kills more people worldwide than any other preventable cause of death. The best way to reduce tobacco use is by stopping people from starting to use tobacco and encouraging and helping existing users to stop. This can be done by introducing policies that can reach a wide number of people in a country, together with offering individual treatment and support to individuals who are already using tobacco to help them to stop. Many countries have introduced bans on tobacco advertising but have not controlled the look of the tobacco pack itself. Tobacco packs can be colourful and attractive, with exciting new shapes and sizes. Standardised tobacco packaging is a government policy which removes these bright designs by, for example, only allowing tobacco packs to be in one colour, shape or size. Standardised packaging generally involves the use of the same uniform colour on all tobacco packs, with no brand imagery, and the brand name written in a specified font, colour and size. Health warnings and other information that governments wish to put on the packs can remain. Australia was the first country to introduce standardised tobacco packaging by December 2012. France was the second by January 2017. Several other countries are introducing standardised packaging or planning to do so. We examined whether standardised packaging reduces tobacco use.

Study characteristics: We searched nine databases for articles evaluating standardised packaging that had been already reviewed by academics and published before January 2016. We also checked references in those papers to other studies and contacted the authors where necessary.

Key results: We found 51 studies involving approximately 800,000 participants. These studies varied considerably. Some studies focused on the effect of standardised packaging in Australia, and included looking at overall smoking levels, whether smokers altered their behaviour such as by cutting down the number of cigarettes they smoked, and whether smokers were making more quit attempts. We also included experiments in which people used or viewed standardised tobacco packs and examined their responses, compared to when they were viewing branded packs. We also included studies that assessed people’s eye movements when they looked at different packs and how willing people were to buy, and how much they were willing to pay for, standardised compared to branded packs.

Only five studies looked at our key outcomes. One study in Australia looked at data from 700,000 people before and after standardised packaging was introduced. This study found that there was a half a percentage point drop in the proportion of people who used tobacco after the introduction of standardised packaging, compared to before, when adjusting for other factors which could affect this. Four other studies looked at whether current smokers changed the number of cigarettes they smoked. Two studies from Australia looked at this, one using surveys which included 8811 current smokers, and found no change in the number of cigarettes smoked. The three smaller studies found mixed results. Two further studies looked at quit attempts and observed increases in these in Australia after standardised packaging was introduced. The remainder of the studies looked at other outcomes, and the most consistent finding was that standardised packaging reduced how appealing people found the packs compared with branded packs. No studies reported the number of people who quit using tobacco, the number of people who started using tobacco, or the number of people who returned to using tobacco after quitting.

Quality of the evidence: Certainty in these findings is limited for several reasons, including the difficulties involved in studying national policies like standardised packaging. However, findings suggesting standardised packaging may decrease tobacco use are supported by routine data from the Australian government and studies looking at other outcomes. For example, in our included studies people consistently found standardised packs less appealing than branded packs. We did not find any evidence suggesting standardised packaging may increase tobacco use