Perceptions and impact of plain packaging of tobacco products in low and middle income countries, middle to upper income countries and low-income settings in high-income countries: a systematic review of the literature

The Results section of the Abstract needs to be reworded to reflect the findings, as the current wording (“studies identified that plain packaging reduced appeal of tobacco products in low income settings”; p.4, lines 3-5) suggests a direction of effect that was only assessed in one study – the others are cross-sectional. Perhaps change the word “reduced” and/or rephrase to something like “plain packaging had lower/less appeal than branded packaging”. Introduction Data on smoking rates could be reworked slightly (p.5, lines 19-28). First, I don’t think the change in smoking rates in high income countries could necessarily be described as a “relentless decline” – in Australia the figures seem to have declined year on year, however recently smoking prevalence seems to have levelled off in recent years in the UK and USA, so perhaps this language could be tempered. Second, the data presented for India is not comparable as only data for males are presented – the WHO report gives data for males and females and overall, so the overall data need to be given instead, in order to make this comparable with the Australian figures. India is a complex example as fewer people there appear to smoke cigarettes (14% smoke tobacco; 5.7% smoke cigarettes according to the WHO report), whereas smokeless tobacco is more common in India (25.9% prevalence). You could also give examples of smoking prevalence among the lower income Eastern European countries, which tends to be higher than high income countries such as Australia, the UK and USA. If there is scope to do so, it might be helpful to provide more detail on the recent systematic review on plain packaging by Stead et al., 2013 (p.6, lines 50-55), as this seems to be a key piece of literature in the field. In the aims and objectives, it would be useful to clarify whether “all the published literature” includes quantitative, qualitative or both (p.7, lines 19-21). I think the inclusion of middle-upper income countries needs to be justified, as it is not clear currently why these countries would be more similar to low and middle income countries than they are to higher income countries and what the reasons are for grouping them with LMIC (p.7, lines 27-29). For clarity, it would be useful if a research question (with all group.bmj.com on October 19, 2017 Published by http://bmjopen.bmj.com/ Downloaded from