Should cigarette pack sizes be capped?

BackgroundCigarette pack sizes vary globally between 10 and 50 cigarettes per pack. Many countries have introduced tobacco control legislation that mandates a minimum size to reduce affordability and youth smoking. By contrast, very few countries regulate maximum pack size. Larger, non-standard sizes are increasingly being introduced by the tobacco industry. Larger portion sizes increase food consumption; larger cigarette packs may similarly increase tobacco consumption. Here we consider the evidence for legislation to cap cigarette pack size to reduce tobacco-related harm.Argument and analysisWe first describe the regulations regarding minimum and maximum pack sizes in the 12 countries that have adopted plain packaging legislation and describe the range of sizes available. We then discuss evidence for two key assumptions that would support capping pack size. First, regarding the causal nature of the relationship between pack size and tobacco consumption, observational evidence suggests that people smoke fewer cigarettes when using smaller packs. Second, regarding the causal nature of the relationship between reducing consumption and successful cessation, reductions in number of cigarettes smoked per day are associated with increased cessation attempts and subsequent abstinence. However, more experimental evidence is needed to infer the causal nature of these associations among general populations of smokers.ConclusionPack size is associated with consumption, and consumption is associated with cessation. Based on limited evidence of the causal nature of these associations, we hypothesise that Government regulation to cap cigarette pack sizes would positively contribute to reducing smoking prevalence.