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BACKGROUND AND AIMS: Smoking fewer cigarettes per day may increase the chances of stopping smoking. Capping the number of cigarettes per pack is a promising policy option, but the causal impact of such a change is unknown. This study aimed to test the hypothesis that lowering cigarette pack sizes from 25 to 20 reduces the number of cigarettes smoked. DESIGN: This randomized controlled cross-over trial had two 14-day intervention periods with an intervening 7-day period of usual behaviour. Participants purchased their own cigarettes. They were instructed to smoke their usual brand from either one of two sizes of pack in each of two 14-day intervention periods: (a) 25 cigarettes and (b) 20 cigarettes. Participants were randomized to the order in which they smoked from the two pack sizes (a-b; b-a). SETTING: Canada. PARTICIPANTS: Participants were adult smokers who smoked from pack sizes of 25, recruited between July 2020 and June 2021. Of 252 randomized, 240 (95%) completed the study and 236 (94%) provided sufficient data for the primary analysis. MEASUREMENTS: Cigarettes smoked per participant per day. FINDINGS: Participants smoked fewer cigarettes per day from packs of 20 cigarettes [n = 234, mean = 15.7 standard deviation (SD) = 7.1] than from packs of 25 (n = 235, mean = 16.9, SD = 7.1). After adjusting for pre-specified covariates (baseline consumption and heaviness of smoking), modelling estimated that participants smoked 1.3 fewer cigarettes per day [95% confidence interval (CI) = -1.7 to -0.9], equivalent to 7.6% fewer (95% CI = -10.1 to -5.2%) from packs of 20 cigarettes. CONCLUSIONS: Smoking from packs of 20 compared with 25 cigarettes reduced the number of cigarettes smoked per day.

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BACKGROUND: We conducted a discrete choice experiment (DCE) among young adult cigarette smokers in the period July-August 2018 to examine their preference for cigarillos in response to various packaging-related attributes, including flavor, flavor description, quality descriptors, pack size, and prices. METHODS: A convenience sample of 566 US young adult cigarette smokers aged 18-34, among whom 296 were current little cigar and cigarillo (LCC) smokers, were recruited using Facebook ads and invited to participate in an online (Qualtrics) tobacco survey containing DCE and tobacco use questions. In the experiment, participants chose among two cigarillo products or "neither" (opt-out). RESULTS: We analyzed preferences for LCCs using multinomial, nested, random parameter logit models. Results showed that young adult cigarette smokers preferred grape over menthol, tobacco/regular, and wine flavors; "color only" and "color and text" flavor depictions over text only; "smooth" and "sweet" quality descriptors over "satisfying"; and larger pack sizes and lower prices. CONCLUSIONS: Regulating packaging-related features will impact LCC choices among US young adult smokers. FDA regulation over these packaging-related features may impact LCC use among young adult smokers.

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BACKGROUND: Observational evidence suggests that cigarette pack size - the number of cigarettes in a single pack - is associated with consumption but experimental evidence of a causal relationship is lacking. The tobacco industry is introducing increasingly large packs, in the absence of maximum cigarette pack size regulation. In Australia, the minimum pack size is 20 but packs of up to 50 cigarettes are available. We aimed to estimate the impact on smoking of reducing cigarette pack sizes from ≥25 to 20 cigarettes per pack. METHOD: A two-stage adaptive parallel group RCT in which Australian smokers who usually purchase packs containing ≥25 cigarettes were randomised to use only packs containing either 20 (intervention) or their usual packs (control) for four weeks. The primary outcome, the average number of cigarettes smoked per day, was measured through collecting all finished cigarette packs, labelled with the number of cigarettes participants smoked. An interim sample size re-estimation was used to evaluate the possibility of detecting a meaningful difference in the primary outcome. RESULTS: The interim analysis, conducted when 124 participants had been randomised, suggested 1122 additional participants needed to be randomised for sufficient power to detect a meaningful effect. This exceeded pre-specified criteria for feasible recruitment, and data collection was terminated accordingly. Analysis of complete data (n = 79) indicated that the mean cigarettes smoked per day was 15.9 (SD = 8.5) in the intervention arm and 16.8 (SD = 6.7) among controls (difference - 0.9: 95%CI = - 4.3, 2.6). CONCLUSION: It remains unclear whether reducing cigarette pack sizes from ≥25 to 20 cigarettes reduces cigarette consumption. Importantly, the results of this study provide no evidence that capping cigarette pack sizes would be ineffective at reducing smoking. The limitations identified in this study can inform a more efficient RCT, which is urgently required to address the dearth of experimental evidence on the impact of large cigarette pack sizes on smoking. TRIAL REGISTRATION: https://doi.org/10.1186/ISRCTN34202533.

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In multipredator systems, group sizes of social carnivores are shaped by the asymmetric intraguild interactions. Subordinate social carnivores experience low recruitment rates as an outcome of predation pressure. In South and Southeast Asia, the Tiger (Panthera tigris), Dhole (Cuon alpinus), and Leopard (Panthera pardus) form a widely distributed sympatric guild of large carnivores, wherein tigers are the apex predators followed by dhole and leopard. In this study, we attempted to understand the variation in pack size of a social carnivore, the dhole, at two neighboring sites in the Central Indian landscape. We further evaluated local-scale patterns of variation in pack size at a larger scale by doing a distribution-wide assessment across the dhole ranging countries. At the local scale, we found an inverse relationship between the density of tiger and pack size of dhole while accounting for variability in resources and habitat heterogeneity. Larger dhole packs (16.8 ± 3.1) were observed at the site where the tiger density was low (0.46/100 km2), whereas a smaller pack size (6.4 ± 1.3) was observed in the site with high tiger density (5.36/100 km2). Our results for the distribution-wide assessment were concordant with local-scale results, showing a negative association of pack size with the tiger densities (effect size -0.77) and a positive association with the prey abundance (effect size 0.64). The study advances our understanding to answer the age-old question of "what drives the pack size of social predators in a multipredator system?" This study also highlights the importance of understanding demographic responses of subordinate predator for varying competitor densities, often helpful in making informed decisions for conservation and management strategies such as population recovery and translocation of species.

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BACKGROUND: Very few countries regulate maximum cigarette 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. AIMS AND ANALYSIS: We 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. Secondly, 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. CONCLUSION: Cigarette pack size is positively associated with consumption and consumption is negatively associated with cessation. Based on limited evidence of the causal nature of these associations, we hypothesize that government regulations to cap cigarette pack sizes would positively contribute to reducing smoking prevalence.

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BACKGROUND: Reducing sugar in packaged foods and beverages could help protect children's future health. Clear methods for the development of feasible yet impactful sugar reduction program targets are needed. OBJECTIVES: To outline methods for the development of program targets that would reduce, by 20%, the total sugar content of packaged foods and beverages commonly consumed by children. New Zealand (NZ) is used as a case study. METHODS: Sugar content and pack size targets were developed using a 6-step process informed by the UK sugar and salt reduction programs. Food groups contributing ≥2% to children's total sugar intake were identified using national dietary survey data. Consumption volume, sugar content, and pack size were obtained from household panel data linked with a packaged food composition database. Category-specific targets were set as 20% reductions in sales-weighted means adjusted for feasibility, i.e., ∼1/3 of products already meeting the target, and alignment with existing, relevant targets. RESULTS: Twenty-two food groups were identified as major contributors to NZ children's total sugar intake. Mean reductions required in sugar content and pack size to meet the targets were 5.2 g  per 100 g/mL (26%) and 61.2 g/mL/pack (23%), respectively. The percentage of products already meeting the sugar targets ranged from 14% for electrolyte drinks and flavored dairy milk to 50% for cereal bars, and for pack size targets compliance ranged from 32% for chocolate confectionary to 62% for fruit juices and drinks. Estimated reductions in annual household sugar purchases if the sugar and pack size targets were met were 1459 g (23%) and 286 g (6%), respectively. CONCLUSIONS: Methods for the development of sugar and pack size reduction targets are presented, providing a robust, step-by-step process for countries to follow. The results of the case study provide a suggested benchmark for a potential national sugar reduction program in NZ.

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INTRODUCTION: In South Africa there is an easy access to over-the-counter (OTC) medicines and expenditure is high. Certain OTC products are available to the public in general stores, while others may only be available at pharmacies. It is also common for OTC medicines to be prescribed by a doctor for treatment of minor illnesses. Individuals with medical insurance usually have cover for these products, but typically only to a limited extent. AIM: To investigate the utilization patterns in two medical insurance schemes of OTC analgesic products in the Anatomical Therapeutic Chemical (ATC) category N02BE51 which includes medicines containing paracetamol and varying combinations of codeine, caffeine and antihistamines. METHODOLOGY: Data were obtained for two benefit plans, one with generous, high benefits (HI), the other with lower benefits (LO). Data covered utilization of OTC medicines in the N02BE51 group, indicating whether the medicines were purchased at a pharmacy or dispensed by a doctor. Doctors were further categorised as contracted/network or non-network providers. Product costs and volumes were analysed according to access directly by the beneficiary, recommendation by a pharmacist, or prescription from a doctor. RESULTS: Compared to doctors, pharmacists issued more-expensive products. Average costs were higher in the HI plan compared to the LO plan. Pharmacists showed a preference for dispensing larger and more expensive pack sizes. Doctors showed better cost containment: the average cost of products in HI was twice that of LO. Doctors dispensing directly to patients issued smaller pack sizes and lower-priced products. Contracted network doctors did not appear to impact on costs. CONCLUSION: Among the privately-insured individuals studied, the avaiIability, cost and formulation of N02BE51 OTC products appeared to be poorly regulated, whether by the consumer, pharmacist, medical insurance scheme or legislation. Doctors demonstrate better cost containment by prescribing less costly, smaller pack-size alternatives compared to pharmacists.

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BACKGROUND: Several jurisdictions in the US and abroad limit the minimum number of cigars that can be sold per package. Research has not evaluated whether small packages might result in cigar use initiation, or whether adding cigars to packages might result in purchasers smoking more cigars. METHODS: Using nationally representative US adult data from Waves 1 and 2 of the Population Assessment of Tobacco and Health (PATH) Study, we assessed links between cigar package quantity (number of cigars in the package a person usually buys) and (1) price, and (2) cigar and cigarette use over time, for three cigar types: filtered cigars, cigarillos, and large cigars. RESULTS: Smaller quantity packages (i.e., packages with fewer cigars) were cheaper per-pack than larger quantity packages but more expensive per-stick for all three cigar types. For filtered cigars, past-year starters tended to buy smaller quantity packages compared to longer-term users (geometric mean = 6.31 vs. 11.75, respectively; b = -.18, 95%CI: -.32, -.04). Also, those who bought smaller quantity packages of filtered cigars tended to smoke fewer cigars over time compared to those who bought larger quantity packages (b = 1.16, 95%CI: 0.45, 1.87). Neither of these associations was observed for cigarillos or large cigars. We also found little evidence that buying larger quantity packages predicted continuing to use cigars or using cigarettes. CONCLUSIONS: Although we found consistent associations between package quantity and price, we found few associations between package quantity and changes in cigar smoking behaviors over time, particularly for cigarillos and large cigars. Key limitations include our adult-only analyses and inability to determine the package quantity that cigar users initiated with. Future studies could examine whether package quantity plays a causal role in filtered cigar use initiation or consumption rates.

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BACKGROUND: Density estimation is a key issue in wildlife management but is particularly challenging and labour-intensive for elusive species. Recently developed approaches based on remotely collected data and capture-recapture models, though representing a valid alternative to more traditional methods, have found little application to species with limited morphological variation. We implemented a camera trap capture-recapture study to survey wolf packs in a 560-km2 area of Central Italy. Individual recognition of focal animals (alpha) in the packs was possible by relying on morphological and behavioural traits and was validated by non-invasive genotyping and inter-observer agreement tests. Two types (Bayesian and likelihood-based) of spatially explicit capture-recapture (SCR) models were fitted on wolf pack capture histories, thus obtaining an estimation of pack density in the area. RESULTS: In two sessions of camera trapping surveys (2014 and 2015), we detected a maximum of 12 wolf packs. A Bayesian model implementing a half-normal detection function without a trap-specific response provided the most robust result, corresponding to a density of 1.21 ± 0.27 packs/100 km2 in 2015. Average pack size varied from 3.40 (summer 2014, excluding pups and lone-transient wolves) to 4.17 (late winter-spring 2015, excluding lone-transient wolves). CONCLUSIONS: We applied for the first time a camera-based SCR approach in wolves, providing the first robust estimate of wolf pack density for an area of Italy. We showed that this method is applicable to wolves under the following conditions: i) the existence of sufficient phenotypic/behavioural variation and the recognition of focal individuals (i.e. alpha, verified by non-invasive genotyping); ii) the investigated area is sufficiently large to include a minimum number of packs (ideally 10); iii) a pilot study is carried out to pursue an adequate sampling design and to train operators on individual wolf recognition. We believe that replicating this approach in other areas can allow for an assessment of density variation across the wolf range and would provide a reliable reference parameter for ecological studies.

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An increase in the package size of food has been shown to lead to an increase in energy intake from this food, the so-called pack size effect. Previous research has shown that providing diet-concerned individuals with a reminder, or prime, of their dieting goal can help them control their consumption. Here, we investigated if providing such a prime is also effective for reducing the magnitude of the pack size effect. We conducted two experiments in which the cover of a dieting magazine (Experiment 1) and diet-related commercials (Experiment 2) served as diet goal primes. Both experiments had a 2 (pack size: small vs. large) × 2 (prime: diet vs. control) × 2 (dietary restraint: high vs. low) between participants design. We measured expected consumption of four snack foods in Experiment 1 (N = 477), and actual consumption of M&M's in Experiment 2 (N = 224). Results showed that the diet prime reduced the pack size effect for both restrained and unrestrained eaters in Experiment 1 and for restrained eaters only in Experiment 2. Although effect sizes were small, these findings suggest that a diet prime motivates restrained eaters to limit their consumption, and as a result the pack size has less influence on the amount consumed. We discuss limitations of this research as well as potential avenues for further research and theoretical and practical implications.

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Larger portions as well as larger packs can lead to larger prospective consumption estimates, larger servings and increased consumption, described as 'portion-size effects' and 'pack size effects'. Although related, the effects of pack sizes on portion estimates have received less attention. While it is not possible to generalize consumer behaviour across cultures, external cues taken from pack size may affect us all. We thus examined whether pack sizes influence portion size estimates across cultures, leading to a general 'pack size effect'. We compared portion size estimates based on digital presentations of different product pack sizes of solid and liquid products. The study with 13,177 participants across six European countries consisted of three parts. Parts 1 and 2 asked participants to indicate the number of portions present in a combined photographic and text-based description of different pack sizes. The estimated portion size was calculated as the quotient of the content weight or volume of the food presented and the number of stated portions. In Part 3, participants stated the number of food items that make up a portion when presented with packs of food containing either a small or a large number of items. The estimated portion size was calculated as the item weight times the item number. For all three parts and across all countries, we found that participants' portion estimates were based on larger portions for larger packs compared to smaller packs (Part 1 and 2) as well as more items to make up a portion (Part 3); hence, portions were stated to be larger in all cases. Considering that the larger estimated portions are likely to be consumed, there are implications for energy intake and weight status.

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People eat more from large than from small packs, which is known as the pack size effect. We hypothesized that providing a serving size recommendation would reduce the influence of the pack size on consumption and would thus diminish the pack size effect. Moreover, we hypothesized that a pictorial serving size recommendation, displaying food amounts visually, would be more effective than a non-pictorial recommendation that communicates the recommended amount in grams only. We tested these hypotheses in two online experiments (N = 317 and N = 324) and in one lab experiment (N = 89). In the online experiments, participants were shown a small or a large pack of unhealthy snacks, with or without a serving size recommendation. The main outcome measure was expected consumption. Replicating the pack size effect in an online setting, we found that participants expected to consume more food from large than from small packs. Furthermore, the pack size effect was considerably stronger for men than for women. Importantly, when including portion size preferences as a covariate, the pictorial serving size recommendation significantly reduced expected consumption, especially when placed on a large pack, as hypothesized. The non-pictorial serving size recommendation had no effect. In the lab experiment, students received a large bag of M&M's which did or did not contain the pictorial serving size recommendation. We again included general portion size preferences as a covariate. The serving size recommendation significantly lowered the amount of M&M's that participants served themselves, but only when participants reported to have noticed the serving size recommendation. We conclude that providing a pictorial serving size recommendation can be an effective intervention strategy to reduce the pack size effect, if it attracts sufficient attention.

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In 1998 the United Kingdom limited the availability of paracetamol sold over-the-counter in an effort to reduce serious paracetamol overdose. Since that time debate has continued on the effectiveness of this policy in reducing what is acknowledged as a major public health problem. This commentary reviews recent publications on this topic which suggest that the effects were small. Reasons for this are discussed using data from recent work.

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