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Evaluating the impact of introducing standardized packaging with larger health-warning labels in England: findings from adult smokers within the EUREST-PLUS ITC Europe Surveys

Aleyan, Sarah ; Driezen, Pete ; McNeill, Ann ; [et al.]

Oxford University Press (OUP) ; 2020

In: European Journal of Public Health Vol. 30, No. Supplement_3 ( 2020-07-01), p. iii91-iii97

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In: European Journal of Public Health, Oxford University Press (OUP), Vol. 30, No. Supplement_3 ( 2020-07-01), p. iii91-iii97

Abstract: The European (EU) Tobacco Product Directive (TPD) was implemented in May 2016 to regulate the design and labelling of cigarettes and roll-your-own tobacco. At the same time, the UK introduced standardized packaging measures, whereas Germany, Greece, Hungary, Poland, Romania and Spain did not. This study examines the impact of introducing standardized packaging in England using a quasi-experimental design. Methods Data from adult smokers in Waves 1 (2016; N=9547) and 2 (2018; N=9724) from the International Tobacco Control Policy Evaluation surveys (England) and EUREST-PLUS surveys (Germany, Greece, Hungary, Poland, Romania and Spain) were used. Generalized estimating equations were used to estimate changes in pack/brand appeal, salience of health-warning labels (HWLs) and perceived relative harm of different brands in England (where larger HWLs and standardized packaging were implemented), vs. each EU country (where only larger HWLs were implemented). Results There was an increase in the percentage of respondents from Germany, Hungary and Poland reporting they did not like the look of the pack (4.7%, 9.6%, and 14.2%, respectively), but the largest increase was in England (41.0%). Moreover, there was a statistically significant increase in the salience of HWLs in Hungary, Poland and Romania (17.0%, 13.9%, and 15.3%, respectively), but the largest increase was in England (27.6%). Few differences were observed in cross-country comparisons of the perceived relative harm of different brands. Conclusions Findings suggest that standardized packaging reduces pack appeal and enhances the salience of HWLs over and above the effects of larger HWLs. Findings provide additional evidence and support for incorporating standardized packaging into the EU TPD.

Type of Medium: Online Resource

ISSN: 1101-1262 , 1464-360X

URL: Article

DOI: 10.1093/eurpub/ckaa053

Language: English

Publisher: Oxford University Press (OUP)

Publication Date: 2020

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Impact of the Tobacco Products Directive on self-reported exposure to e-cigarette advertising, promotion and sponsorship in smokers—findings from the EUREST-PLUS ITC Europe Surveys

Kahnert, Sarah ; Driezen, Pete ; Balmford, James ; [et al.]

Oxford University Press (OUP) ; 2020

In: European Journal of Public Health Vol. 30, No. Supplement_3 ( 2020-07-01), p. iii55-iii61

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In: European Journal of Public Health, Oxford University Press (OUP), Vol. 30, No. Supplement_3 ( 2020-07-01), p. iii55-iii61

Abstract: Advertising, promotion and sponsorship of electronic cigarettes (ECAPS) have increased in recent years. Since May 2016, the Tobacco Products Directive 2014/40/EU (TPD2) prohibits ECAPS in various advertising channels, including media that have cross-border effects. The objective of this study was to investigate changes in exposure to ECAPS in a cohort of smokers from six European Union member states after implementation of TPD2. Methods Self-reported exposure to ECAPS overall and in various media and localities was examined over two International Tobacco Control Policy Evaluation survey waves (2016 and 2018) in a cohort of 6011 adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (EUREST-PLUS Project) using longitudinal generalized estimating equations models. Results Self-reported ECAPS exposure at both timepoints varied between countries and across examined advertising channels. Overall, there was a significant increase in ECAPS exposure [adjusted odds ratio (aOR): 1.25, 95% CI: 1.09–1.44]. Between waves, no consistent patterns of change in ECAPS exposure across countries and different media were observed. Generally, ECAPS exposure tended to decline in some channels regulated by TPD2, particularly on television and radio, while exposure tended to increase in some unregulated channels, such as at points of sale. Conclusions The findings suggest that the TPD2 was generally effective in reducing ECAPS in regulated channels. Nonetheless, further research is warranted to evaluate its role in reducing ECAPS exposure, possibly by triangulation with additional sources of data.

Type of Medium: Online Resource

ISSN: 1101-1262 , 1464-360X

URL: Article

DOI: 10.1093/eurpub/ckaa055

Language: English

Publisher: Oxford University Press (OUP)

Publication Date: 2020

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Support for e-cigarette policies among smokers in seven European countries: longitudinal findings from the 2016–18 EUREST-PLUS ITC Europe Surveys

Chung-Hall, Janet ; Fong, Geoffrey T ; Meng, Gang ; [et al.]

Oxford University Press (OUP) ; 2020

In: European Journal of Public Health Vol. 30, No. Supplement_3 ( 2020-07-01), p. iii68-iii77

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In: European Journal of Public Health, Oxford University Press (OUP), Vol. 30, No. Supplement_3 ( 2020-07-01), p. iii68-iii77

Abstract: The 2016 European Tobacco Products Directive (TPD) required Member States (MS) to implement new regulations for electronic cigarettes (ECs). We conducted a longitudinal study to assess changes over 2 years in smokers’ support for EC policies and identify predictors of support in seven European countries after TPD implementation. Methods Prospective cohort surveys were conducted among adult smokers in Germany, Greece, Hungary, Poland, Romania, Spain and England in 2016 (n = 9547; just after TPD) and 2018 (n = 10 287; 2 years after TPD). Multivariable logistic regression models employing generalized estimating equations assessed changes in support for four EC policies, and tested for country differences and strength of key predictors of support. Results Banning EC use in smoke-free places was supported by 53.1% in 2016 and 54.6% in 2018 with a significant increase in Greece (51.7–66.0%) and a decrease in Spain (60.1–48.6%). Restricting EC/e-liquid nicotine content was supported by 52.2 and 47.4% in 2016 and 2018, respectively, with a significant decrease in England (54.2–46.5%) and Romania (52.5–41.0%). An EC promotion ban was supported by 41.1 and 40.2%. A flavour ban was supported by 33.3% and 32.3% with a significant increase in Hungary (34.3–43.3%). Support was generally higher in Poland, Hungary and Greece vs. England. Support was lower among dual and EC-only users, and low-income smokers. Conclusions Smokers in all countries strongly supported banning EC use in smoke-free places and restricting nicotine content after TPD implementation, with no clear trends for changes in policy support.

Type of Medium: Online Resource

ISSN: 1101-1262 , 1464-360X

URL: Article

DOI: 10.1093/eurpub/ckaa085

Language: English

Publisher: Oxford University Press (OUP)

Publication Date: 2020

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Methods of the International Tobacco Control (ITC) EUREST-PLUS ITC Europe Surveys

Thompson, Mary E ; Driezen, Pete ; Boudreau, Christian ; [et al.]

Oxford University Press (OUP) ; 2020

In: European Journal of Public Health Vol. 30, No. Supplement_3 ( 2020-07-01), p. iii4-iii9

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In: European Journal of Public Health, Oxford University Press (OUP), Vol. 30, No. Supplement_3 ( 2020-07-01), p. iii4-iii9

Abstract: The EUREST-PLUS ITC Europe surveys aim to evaluate the impact of the European Union’s Tobacco Products Directive (EU TPD) implementation within the context of the WHO FCTC. This article describes the methodology of the 2016 (Wave 1) and 2018 (Wave 2) International Tobacco Control 6 European (6E) Country Survey in Germany, Greece, Hungary, Poland, Romania and Spain; the England arm of the 2016 (Wave 1) and 2018 (Wave 2) ITC 4 Country Smoking and Vaping (4CV) Survey; and the 2016 (Wave 10) and 2017 (Wave 11) ITC Netherlands (NL) Survey. All three ITC surveys covering a total of eight countries are prospective cohort studies with nationally representative samples of smokers. Methods In the three surveys across the eight countries, the recruited respondents were cigarette smokers who smoked at least monthly, and were aged 18 and older. At each survey wave, eligible cohort members from the previous waves were retained, regardless of smoking status, and dropouts were replaced by a replenishment sample. Results Retention rates between the two waves of the ITC 6E Survey by country were 70.5% for Germany, 41.3% for Greece, 35.7% for Hungary, 45.6% for Poland, 54.4% for Romania and 71.3% for Spain. The retention rate for England between ITC 4CV1 and ITC 4CV2 was 39.1%; the retention rates for the ITC Netherlands Survey were 76.6% at Wave 10 (2016) and 80.9% at Wave 11 (2017). Conclusion The ITC sampling design and data collection methods in these three ITC surveys allow analyses to examine prospectively the impact of policy environment changes on the use of cigarettes and other tobacco products in each country, to make comparisons across the eight countries.

Type of Medium: Online Resource

ISSN: 1101-1262 , 1464-360X

URL: Article

DOI: 10.1093/eurpub/ckz212

Language: English

Publisher: Oxford University Press (OUP)

Publication Date: 2020

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Transitions from and to roll-your-own tobacco, perceptions and health beliefs among smokers: findings from the EUREST-PLUS ITC Europe Surveys

Filippidis, Filippos T ; Driezen, Pete ; Kyriakos, Christina N ; [et al.]

Oxford University Press (OUP) ; 2020

In: European Journal of Public Health Vol. 30, No. Supplement_3 ( 2020-07-01), p. iii18-iii25

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In: European Journal of Public Health, Oxford University Press (OUP), Vol. 30, No. Supplement_3 ( 2020-07-01), p. iii18-iii25

Abstract: The prevalence of roll-your-own tobacco (RYO) in Europe has been increasing. The aim of this study was to investigate transitions between factory-made (FM) cigarettes and RYO in a longitudinal sample of European smokers, and their perceptions of relative harmfulness and knowledge of health effects. Methods We used data collected from the EUREST-PLUS ITC 6 European Country (6E) Surveys in 2016 (n = 6011 smokers) and in 2018 (n = 6027) in Germany, Greece, Hungary, Poland, Romania and Spain. A total of 3195 cohort respondents were interviewed in both years. Use of RYO and FM, knowledge of health effects of smoking as well as perceptions about RYO were assessed. We used logistic regression models to explore sociodemographic correlates of transitions from one product to the other, of perceptions and knowledge related to smoking health effects. Results Approximately 7.4% of exclusive FM smokers transitioned to RYO and 29.5% of exclusive RYO smokers transitioned to FM cigarettes from 2016 to 2018. RYO use in 2018 was more frequent among smokers of low education and income, but none of these factors were associated with transitions. Most RYO smokers perceived RYO as cheaper than FM and 21.7% of them considered RYO to be less harmful than FM. Knowledge of the health effects of smoking was not associated with type of product smoked. Conclusions RYO is popular among European smokers; its lower cost seems to be a major factor for RYO users; reasons for transitions to and from RYO are less clear and need to be further investigated.

Type of Medium: Online Resource

ISSN: 1101-1262 , 1464-360X

URL: Article

DOI: 10.1093/eurpub/ckz214

Language: English

Publisher: Oxford University Press (OUP)

Publication Date: 2020

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Secondhand Smoke Exposure in European Countries With Different Smoke-Free Legislation: Findings From the EUREST-PLUS ITC Europe Surveys

Nogueira, Sarah O ; Fernández, Esteve ; Driezen, Pete ; [et al.]

Oxford University Press (OUP) ; 2022

In: Nicotine & Tobacco Research Vol. 24, No. 1 ( 2022-01-01), p. 85-92

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In: Nicotine & Tobacco Research, Oxford University Press (OUP), Vol. 24, No. 1 ( 2022-01-01), p. 85-92

Abstract: Exposure to secondhand smoke (SHS) poses serious and extensive health and economic-related consequences to European society and worldwide. Smoking bans are a key measure to reducing SHS exposure but have been implemented with varying levels of success. We assessed changes in the prevalence of self-reported SHS exposure and smoking behavior in public places among smokers in six European countries and the influence of the country’s type of smoking ban (partial or total ban) on such exposure and smoking behavior. Aims and Methods The EUREST-PLUS ITC Europe Surveys were conducted among adult smokers in Germany, Greece, Hungary, Poland, Romania, and Spain in 2016 (Wave 1, n = 6011) and 2018 (Wave 2, n = 6027). We used generalized estimating equations models to assess changes between Waves 1 and 2 and to test the interaction between the type of smoking ban and (1) self-reported SHS exposure, (2) self-reported smoking in several public places. Results A significant decrease in self-reported SHS exposure was observed in workplaces, from 19.1% in 2016 to 14.0% in 2018 (−5.1%; 95% CI: −8.0%; −2.2%). Self-reported smoking did not change significantly inside bars (22.7% in Wave 2), restaurants (13.2% in Wave 2) and discos/nightclubs (34.0% in W2). SHS exposure in public places was significantly less likely (adjusted odds ratio = 0.35; 95% CI: 0.26–0.47) in the countries with total bans as compared to those countries with partial bans. Conclusion The inverse association between smoking in public places and smoking bans indicates an opportunity for strengthening smoke-free legislation and protecting bystanders from exposure to SHS in public places. Implications Prevalence of smokers engaging in and being exposed to smoking in public places varied by type of smoke-free legislation across six European Union countries in our study; those with total smoke bans reported significantly less exposure to SHS than those with partial or no bans. Our results indicate room for improvement, not only to decrease the prevalence of exposure to SHS in Europe but also to diminish the variability between countries through common, more restrictive smoke-free legislation, and importantly, strong and sustained enforcement.

Type of Medium: Online Resource

ISSN: 1469-994X

URL: Article

DOI: 10.1093/ntr/ntab157

Language: English

Publisher: Oxford University Press (OUP)

Publication Date: 2022

detail.hit.zdb_id: 2020202-7

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Effectiveness of tobacco warning labels before and after implementation of the European Tobacco Products Directive—findings from the longitudinal EUREST-PLUS ITC Europe surveys

Kahnert, Sarah ; Driezen, Pete ; Balmford, James ; [et al.]

Oxford University Press (OUP) ; 2020

In: European Journal of Public Health Vol. 30, No. Supplement_3 ( 2020-07-01), p. iii84-iii90

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In: European Journal of Public Health, Oxford University Press (OUP), Vol. 30, No. Supplement_3 ( 2020-07-01), p. iii84-iii90

Abstract: Tobacco product packaging is a key part of marketing efforts to make tobacco use appealing. In contrast, large, prominent health warnings are intended to inform individuals about the risks of smoking. In the European Union, since May 2016, the Tobacco Products Directive 2014/40/EU (TPD2) requires tobacco product packages to carry combined health warnings consisting of a picture, a text warning and information on stop smoking services, covering 65% of the front and back of the packages. Methods Key measures of warning label effectiveness (salience, cognitive reactions and behavioural reaction) before and after implementation of the TPD2, determinants of warning labels’ effectiveness and country differences were examined in a longitudinal sample of 6011 adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (EUREST-PLUS Project) using longitudinal Generalized Estimating Equations (GEE) models. Results In the pooled sample, the warning labels’ effectiveness increased significantly over time in terms of salience (adjusted OR = 1.18; 95% CI: 1.03–1.35), while cognitive and behavioural reactions did not show clear increases. Generally, among women, more highly educated smokers and less addicted smokers, the effectiveness of warning labels tended to be higher. Conclusion We found an increase in salience, but no clear increases for cognitive and behavioural reactions to the new warning labels as required by the TPD2. While it is likely that our study underestimated the impact of the new pictorial warning labels, it provides evidence that health messages on tobacco packaging are more salient when supported by large pictures.

Type of Medium: Online Resource

ISSN: 1101-1262 , 1464-360X

URL: Article

DOI: 10.1093/eurpub/ckaa039

Language: English

Publisher: Oxford University Press (OUP)

Publication Date: 2020

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European adult smokers’ perceptions of the harmfulness of e-cigarettes relative to combustible cigarettes: cohort findings from the 2016 and 2018 EUREST-PLUS ITC Europe Surveys

Gravely, Shannon ; Driezen, Pete ; Kyriakos, Christina N ; [et al.]

Oxford University Press (OUP) ; 2020

In: European Journal of Public Health Vol. 30, No. Supplement_3 ( 2020-07-01), p. iii38-iii45

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In: European Journal of Public Health, Oxford University Press (OUP), Vol. 30, No. Supplement_3 ( 2020-07-01), p. iii38-iii45

Abstract: This study presents perceptions of the harmfulness of electronic cigarettes (e-cigarettes) relative to combustible cigarettes among smokers from six European Union (EU) countries, prior to the implementation of the EU Tobacco Products Directive (TPD), and 2 years post-TPD. Methods Data were drawn from the EUREST-PLUS ITC Europe Surveys, a cohort study of adult smokers (≥18 years) from Germany, Greece, Hungary, Poland, Romania and Spain. Data were collected in 2016 (pre-TPD: N = 6011) and 2018 (post-TPD: N = 6027). Weighted generalized estimating equations were used to estimate perceptions of the harmfulness of e-cigarettes compared to combustible cigarettes (less harmful, equally harmful, more harmful or ‘don’t know’). Results In 2016, among respondents who were aware of e-cigarettes (72.2%), 28.6% reported that they perceived e-cigarettes to be less harmful than cigarettes (range 22.0% in Spain to 34.1% in Hungary). In 2018, 72.2% of respondents were aware of e-cigarettes, of whom 28.4% reported perceiving that e-cigarettes are less harmful. The majority of respondents perceived e-cigarettes to be equally or more harmful than cigarettes in both 2016 (58.5%) and 2018 (61.8%, P & gt; 0.05). Overall, there were no significant changes in the perceptions that e-cigarettes are less, equally or more harmful than cigarettes, but ‘don’t know’ responses significantly decreased from 12.9% to 9.8% (P = 0.036). The only significant change within countries was a decrease in ‘don’t know’ responses in Spain (19.3–9.4%, P = .001). Conclusions The majority of respondents in these six EU countries perceived e-cigarettes to be equally or more harmful than combustible cigarettes.

Type of Medium: Online Resource

ISSN: 1101-1262 , 1464-360X

URL: Article

DOI: 10.1093/eurpub/ckz215

Language: English

Publisher: Oxford University Press (OUP)

Publication Date: 2020

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Awareness and use of heated tobacco products among adult smokers in six European countries: findings from the EUREST-PLUS ITC Europe Surveys

Maria Lotrean, Lucia ; Trofor, Antigona ; Radu-Loghin, Cornel ; [et al.]

Oxford University Press (OUP) ; 2020

In: European Journal of Public Health Vol. 30, No. Supplement_3 ( 2020-07-01), p. iii78-iii83

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In: European Journal of Public Health, Oxford University Press (OUP), Vol. 30, No. Supplement_3 ( 2020-07-01), p. iii78-iii83

Abstract: The study assessed awareness and use of heated tobacco products (HTPs) and factors that influenced these issues among cigarette smokers from six European countries in 2016 (Wave 1) and 2018 (Wave 2). Methods A survey was conducted among a nationally representative sample of cigarette smokers aged 18 years or older from Germany, Greece, Hungary, Poland, Romania and Spain in 2016 (N = 6011) and 2018 (N = 6027; 53% of smokers from the previous wave were retained, regardless of smoking status and dropouts were replaced by a replenishment sample of smokers). Data were collected through face-to-face interviews. Estimates were produced using weighted data. The study presents the cross-sectional results. Results Awareness of HTPs increased from 8% to 17% between the two waves. At Wave 1, 1.1% of the smokers declared having used HTPs at least once during their lifetime; and at Wave 2, this increased to 1.9% (around 1% or less in four countries, except for Greece and Romania where it was around 4%). Factors associated with HTPs use among those who had ever heard about these products at Wave 1 were country of residence, being a daily cigarette smoker and ever use of electronic cigarettes. At Wave 2, ever use of HTPs was significantly higher among those who had tried to quit smoking combustible cigarettes in the last 12 months, had tried electronic cigarettes during lifetime and perceived HTPs as less dangerous than combustible cigarettes; the country of residence was also associated with HTPs use. Conclusion This study offers insights into the behaviours and perceptions of European adult smokers regarding HTPs, an important emerging issue in the field of tobacco control.

Type of Medium: Online Resource

ISSN: 1101-1262 , 1464-360X

URL: Article

DOI: 10.1093/eurpub/ckz228

Language: English

Publisher: Oxford University Press (OUP)

Publication Date: 2020

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Cessation behaviours among smokers of menthol and flavoured cigarettes following the implementation of the EU Tobacco Products Directive: findings from the EUREST-PLUS ITC Europe Surveys

Zatoński, Mateusz ; Herbeć, Aleksandra ; Zatoński, Witold ; [et al.]

Oxford University Press (OUP) ; 2020

In: European Journal of Public Health Vol. 30, No. Supplement_3 ( 2020-07-01), p. iii34-iii37

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In: European Journal of Public Health, Oxford University Press (OUP), Vol. 30, No. Supplement_3 ( 2020-07-01), p. iii34-iii37

Abstract: The European Tobacco Products Directive (TPD) introduced a ban on characterizing flavours in cigarettes (2016), including menthol (2020). The longitudinal data analysis of the EUREST-PLUS International Tobacco Control (ITC) Project Europe Surveys (n = 16 534; Wave 1 in 2016 and Wave 2 in 2018) found significant but small declines in the weighted prevalence of menthol (by 0.94%; P = 0.041) and other flavoured cigarette use (by 1.32%; P & lt; 0.001) following the 2016 TPD. The declines tended to be driven primarily by the menthol and flavoured cigarette (MFC) smokers switching to unflavoured tobacco. Cigarette consumption declined between waves, but there were no statistically significant difference in decline between MFC and unflavoured tobacco smokers on smoking and cessation behaviours between the waves.

Type of Medium: Online Resource

ISSN: 1101-1262 , 1464-360X

URL: Article

DOI: 10.1093/eurpub/ckaa050

Language: English

Publisher: Oxford University Press (OUP)

Publication Date: 2020

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