Background
Globally, in 2015, over 1.1 billion people smoked tobacco [
1]. Tobacco use whether smoked (manufactured cigarette, kretek and hand-rolled cigarette) or smokeless (snuff tobacco, electronic cigarette and chew tobacco) was responsible for the mortality (mostly premature) of about six million people per year according to the World Health Organization (WHO) [
2]. Cigarettes have been sold in tins, cartons, packs, small/kiddie packs and as loose sticks [
3]. Small/kiddie cigarette packaging (hereafter referred to as kiddie packs) consists of less than 20 cigarettes [
4]. It has been sold in packages of 15, 10 or 5 cigarettes in many countries [
5]. Among the countries where kiddie packs are available include Indonesia, Thailand and Philippines [
6].
According to the British American Tobacco (2004) [
7], smaller packs might encourage underage smoking but a pack of 10s might support moderation and encourage quit smoking among heavy smokers. However, it can also encourage the low-income consumers, mainly teens and minors to purchase kiddie packs as prices plunge with quantity reduction [
3]. Studies have shown that tobacco consumption dropped in response to higher prices [
8‐
10]. Based on 2014 Global Youth Tobacco Survey, three out of five Indonesian students aged between 13 and 15 could buy cigarettes easily probably due to the availability of single sticks [
11]. This was supported by another study conducted in Bali, where more than half of retailers in Denpasar sold cigarettes, in single sticks to young people as it is affordable and more accessible [
12].
Based on the above stated debates, the WHO Framework Convention on Tobacco Control (FCTC) recommends countries to eliminate sale of kiddie packs and single sticks. In addition, Article 16 the WHO’s framework Convention on Tobacco Control (FCTC) [
13] states that comprehensive policies and effective enforcement strategies are recommended in order to stop the sale of single stick cigarettes and kiddie packs. In 2012, 84 countries (of the FCTC) had policies to prevent the sales of single sticks or kiddie packs [
14].
The government of South Australia was the first in the world to establish a ban on kiddie packs in 1986 [
15] followed by Canada in 1994 [
16]. In Asia, Singapore (2002), Brunei (2005), Laos (2009), Malaysia (2010), Cambodia (2015) and Vietnam (2016) had banned kiddie packs from the market to prevent teens from smoking [
17]. Despite the ban on kiddie packs in some countries, the tobacco industry is trying to reintroduce kiddie packs with the excuse of combatting the surge of contraband cigarettes [
18].
There is a need to expand the scope of such findings to arrive at an evidence-based conclusion. To our knowledge, there is no published systematic review that addresses our questions, which are as follows: (1) What is the impact of kiddie packs on initiation of smoking in the general population? (2) What is the impact of kiddie packs on urge/tendency to buy cigarette in the general population? (3) What is the impact of kiddie packs on attempt to reduce cigarette consumption among current smokers? (4) What is the prevalence of smoking kiddie packs among current smokers? We have addressed our objectives through a comprehensive protocol targeting all studies (randomised controlled trials, quasi experimental and experimental studies, observational cross sectional and cohort studies) in this area from all years, in order to identify the impacts of kiddie packs on the initiation of smoking and urge/tendency to buy cigarettes in the general population, and attempt to reduce cigarette consumption and prevalence of smoking kiddie packs among current smokers.
Discussion
This systematic review will provide evidence to support the impact of kiddie packs on smoking in terms of smoking initiation, smoking prevalence and the urge/tendency to buy cigarettes and attempt to reduce cigarette consumption. Based on the findings, this will help the policymakers to regulate kiddie packs as an effective tobacco control initiative. Each party needs to protect the public health policies on tobacco control from commercial and other tobacco industry interests based on the national law of the country.
Acknowledgements
We would like to express our gratitude to the Director of Institute for Public Health for his continuous support in preparing this paper and Dr Nor Asiah Muhamad from the Institute for Public Health for her support and technical guidance in developing this protocol.
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