Citation

Geboers, C., Nagelhout, G.E., de Vries, H., Candel, M.J.J.M., Driezen, P., Mons, U., Andler, R., Fong, G.T., Willemsen, M.C. (2022). Price minimizing behaviours by smokers in Europe (2006-2020): evidence from the International Tobacco Control Project. European Journal of Public Health, 32(6), 905-912. doi:10.1093/eurpub/ckac115

Abstract

Background: Effectiveness of tobacco taxation can be undermined through smokers applying price-minimizing behaviours rather than quitting or reducing consumption. Common price-minimizing strategies are buying cheaper tobacco [discount brands or roll-your-own (RYO) tobacco], bulk buying and cross-border purchasing. This study analyses trends in and factors associated with such behaviours in four European countries from 2006 to 2020.

Methods: Data came from adult smokers participating in the International Tobacco Control (ITC) Surveys conducted between 2006 and 2020 in England (9 waves, n = 768-4149), France (4 waves, n = 1415-1735), Germany (5 waves, n = 513-1515) and the Netherlands (10 waves, n = 1191-2177). Country-specific generalized estimating equation regression models were fit to assess trends in smoking RYO tobacco, discount brands, bulk buying and cross-border purchasing within the European Union.

Results: Buying discount brands or RYO tobacco was the most common strategy in all countries, except France. Except for buying discount brands, estimates of price-minimizing behaviours were highest in France (2019: RYO = 27.2%, discount brands = 17.3%, bulk buying = 34.1%, cross-border purchasing = 34.2%), and lowest in Germany (2018: RYO = 18.6%, discount brands = 43.7%, bulk buying = 8.0%, cross-border purchasing = 9.8%). Direction and magnitude of trends differed by country, and behaviour. Young smokers were less likely to buy in bulk. Low-income and low-education smokers were more likely to purchase RYO tobacco or discount brands. The association with discount brands was not found for French low-income smokers.

Conclusions: Smoking cheaper tobacco is the most prevalent price-minimizing strategy in three countries (England, Germany and Netherlands), and more prevalent among low-income individuals. Harmonizing prices across products and countries would reduce switching to cheaper tobacco.

Citation

Przewoźniak, K., Kyriakos, C.N., Hiscock, R., Radu-Loghin, C., Fong, G.T. (2021). Effects of and challenges to bans on menthol and other flavours in tobacco products. Tobacco Prevention & Cessation, 7, 68.

Abstract

In May 2020, the European Tobacco Products Directive (TPD), which bans characterizing flavors in cigarettes and roll-your-own tobacco (RYO) in the European Union (EU), extended its application to menthol1,2. Countries which were early adopters of flavor bans include Brazil, Canada, Ethiopia, the United Kingdom (UK), amongst others3. Two main regulatory approaches exist: a ban on characterizing flavors that allows for the presence of additives but not at detectable sensory levels (e.g. EU, UK), and a total ban on flavor additives that eliminates their presence altogether (e.g. Brazil, Canada). As more countries work towards adopting tobacco flavor bans, it is critical to understand how these policies are implemented, ascertain their population-level impact, and identify the regulatory challenges.

Citation

Hummel, K., van den Putte, B., Mons, U., Willemsen, M.C., Fong, G.T., Andler, R., de Vries, H., Nagelhout, G.E. (2019). The role of income and psychological distress in the relationship between job loss and smoking cessation: findings from three International Tobacco Control (ITC) Europe countries. Tobacco Prevention & Cessation, 5(November), 42.

Abstract

Introduction: The relationship between work loss and smoking has not been studied extensively, and underlying factors are often not examined. The aim of this study was to test two hypotheses. First, work loss is associated with greater intention to quit and more likelihood of smoking cessation, and this relationship is moderated by a decrease in income. Second, work loss is associated with lower quit intention and lower rates of smoking cessation, and this relationship is moderated by an increase in psychological distress.

Methods: We used pooled data from three countries participating in the ITC Project: France, Germany and the Netherlands (n=2712). We measured unemployment, income and psychological distress at two consecutive survey waves, and calculated changes between survey waves. We first conducted multiple logistic regression analyses to examine the association between work loss and smoking cessation behavior. Next, we added income decrease and psychological distress increase to the models. Finally, we added interaction terms of work loss by income decrease and work loss by distress increase to the model.

Results: Work loss was not associated with quit intention, quit attempts, and quit success. When income decrease and psychological distress increase were added to the model, we found a positive association between distress increase and quit attempts. The interactions, however, were not statistically significant.

Conclusions: Our results indicate that smokers who become unemployed and face a decrease in income are not less likely to quit smoking than smokers who are employed.

Citation

Ngo, A., Fong, G.T., Craig, L., Shang, C. (2019). Analysis of gender differences in the impact of taxation and taxation structure on cigarette consumption in 17 ITC countries. International Journal of Environmental Research and Public Health, 16(7), e1275.

Abstract

Although increasing taxes has been established as the most effective tobacco control policy, it is not clear whether these policies reduce cigarette consumption equally among women and men. In this study, we examine whether the association between taxation/taxation structure and cigarette consumption differs by gender. The data is from the International Tobacco Control Policy Evaluation (ITC) Projects in 17 countries. Cigarette consumption was measured by gender for each ITC country. Generalized estimating equations (GEE) were employed to investigate gender differences in the association between cigarette consumption and tax structures, while controlling for time-variant demographic characteristics such as unemployment rates, proportions of adults, and percent of female population. Tiered tax structures are associated with higher cigarette consumption among both males and females. Female smokers are more responsive to an average tax increase than male smokers. Among males, higher ad valorem share in excise taxes is associated with lower cigarette consumption, but it is not the case for females. Females may not be as responsive to the prices raised by ad valorem taxes, despite being responsive to average taxes, suggesting that smokers by gender may face different prices.

Citation

Shang, C., Myung Lee, H., Chaloupka, F., Fong, G.T., Thompson, M.E., O’Connor, R.J. (2019). Association between tax structure and cigarette consumption: findings from the International Tobacco Control Policy Evaluation (ITC) Project. Tobacco Control, 28(Suppl 1), S31-S36.

Abstract

Background: Recent studies show that greater price variability and more opportunities for tax avoidance are associated with tax structures that depart from a specific uniform one. These findings indicate that tax structures other than a specific uniform one may lead to more cigarette consumption.

Objective: This paper aims to examine how cigarette tax structure is associated with cigarette consumption.

Methods: We used survey data taken from the International Tobacco Control Policy Evaluation Project in 17 countries to conduct the analysis. Self-reported cigarette consumption was aggregated to average measures for each surveyed country and wave. The effect of tax structures on cigarette consumption was estimated using generalised estimating equations after adjusting for sociodemographic characteristics, average taxes and year fixed effects.

Findings: Our study provides important empirical evidence of a relationship between tax structure and cigarette consumption. We find that a change from a specific to an ad valorem structure is associated with a 6%–11% higher cigarette consumption. In addition, a change from uniform to tiered structure is associated with a 34%–65% higher cigarette consumption. The results are consistent with existing evidence and suggest that a uniform and specific tax structure is the most effective tax structure for reducing tobacco consumption.

Citation

Chyderiotis, S., Beck, F., Andler, R., Hitchman, S.C., Benmarhnia, T. (2019). How to reduce biases coming from a before and after design: the impact of the 2007-2008 French smoking ban policy. European Journal of Public Health, 29(2), 372-377.

Abstract

Background: Smoke-free laws aim at protecting against second-hand smoke and at contributing to change smoking behaviors. Impact evaluation studies can help understand to what extent they reach their goals. Simple before and after designs are often used but cannot isolate the effect of the policy of interest.

Methods: The short-term impact of the French smoking ban (2007-08) on smoking behavior outcomes was evaluated among smokers with data from the ITC project. We first conducted a before and after design on the French sample. Second, we added the UK (excluding Scotland) as a control group and finally used external pre-policy data from national surveys to control for bias arising from pre-policy trends.

Results: After one year post-implementation, the smoking ban led to a decrease in seeing people smoking in bars, restaurants and workplaces [estimated risk ratios (RR) of 8.81 IC95% (5.34-14.71), 2.02 (1.79-2.31) and 1.24 (1.16-1.33), respectively], as well as an increase in support for the smoke-free policy, but only in bars and restaurants [RR of 1.35 (1.15-1.61) and 1.25 (1.16-1.35)], respectively. No impact was found on smoking behaviors and on having a strict no smoking policy at home. The simple before and after design systematically overestimated the smoking ban's impact [e.g. RR of 29.9 (20.06- 44.56) for observed smoking in bar, compared to 13.21 (7.78-22.42) with the control group, and 8.81 (5.34-14.71) with the correction from external data].

Conclusion: When data are lacking to conduct quasi-experimental designs for impact evaluation, the use of external data could help understand and correct pre-policy trends.

Citation

Nagelhout, G.E., Willemsen, M.C., de Vries, H., Mons, U., Hitchman, S.C., Kunst, A. E., Guignard, R., Siahpush, M., Yong, H.H., van den Putte, B., Fong, G.T., Thrasher, J.F. (2016). Educational differences in the impact of pictorial cigarette warning labels on smokers: Findings from the International Tobacco Control (ITC) Europe Surveys. Tobacco Control, 25(3), 325-332.

Abstract

Objective: To examine (1) the impact of pictorial cigarette warning labels on changes in self-reported warning label responses: warning salience, cognitive responses, forgoing cigarettes and avoiding warnings, and (2) whether these changes differed by smokers’ educational level.

Methods: Longitudinal data of smokers from two survey waves of the International Tobacco Control (ITC) Europe Surveys were used. In France and the UK, pictorial warning labels were implemented on the back of cigarette packages between the two survey waves. In Germany and the Netherlands, the text warning labels did not change.

Findings: Warning salience decreased between the surveys in France (OR=0.81, p=0.046) and showed a non-significant increase in the UK (OR=1.30, p=0.058), cognitive responses increased in the UK (OR=1.34, p<0.001) and decreased in France (OR=0.70, p=0.002), forgoing cigarettes increased in the UK (OR=1.65, p<0.001) and decreased in France (OR=0.83, p=0.047), and avoiding warnings increased in France (OR=2.93, p<0.001) and the UK (OR=2.19, p<0.001). Warning salience and cognitive responses decreased in Germany and the Netherlands, forgoing did not change in these countries and avoidance increased in Germany. In general, these changes in warning label responses did not differ by education. However, in the UK, avoidance increased especially among low (OR=2.25, p=0.001) and moderate educated smokers (OR=3.21, p<0.001).

Conclusions: The warning labels implemented in France in 2010 and in the UK in 2008 with pictures on one side of the cigarette package did not succeed in increasing warning salience, but did increase avoidance. The labels did not increase educational inequalities among continuing smokers.

Citation

Hummel, K., Nagelhout, G.E., Willemsen, M.C., Driezen, P., Springvloet, L., Mons, U., Kunst, A.E., Guignard, R., Allwright, S., van den Putte, B., Hoving, C., Fong, G.T., McNeill, A., Siahpush, M., de Vries, H. (2015). Trends and socioeconomic differences in policy triggers for thinking about quitting smoking: Findings from the International Tobacco Control (ITC) Europe Surveys. Drug and Alcohol Dependence, 155, 154-162.

Abstract

Introduction: The aim of the current study is to investigate trends and socioeconomic differences in policy triggers for thinking about quitting in six European countries.

Methods: Data were derived from all available survey waves of the International Tobacco Control (ITC) Europe Surveys (2003-2013). France conducted three survey waves (n=1420-1735), Germany three waves (n=515-1515), The Netherlands seven waves (n=1420-1668), Ireland three waves (n=582-1071), Scotland two waves (n=461-507), and the rest of the United Kingdom conducted seven survey waves (n=861-1737). Smokers were asked whether four different policies (cigarette price, smoking restrictions in public places, free or lower cost medication, and warning labels on cigarette packs) influenced them to think about quitting. Generalized Estimating Equation (GEE) models were estimated for each country.

Results: Cigarette price was mentioned most often in all countries and across all waves as trigger for thinking about quitting. Mentioning cigarette price and warning labels increased after the implementation of price increases and warning labels in some countries, while mentioning smoking restrictions decreased after their implementation in four countries. All studied policy triggers were mentioned more often by smokers with low and/or moderate education and income than smokers with high education and income. The education and income differences did not change significantly over time for most policies and in most countries.

Conclusions: Tobacco control policies work as a trigger to increase thoughts about quitting, particularly in smokers with low education and low income and therefore have the potential to reduce health inequalities in smoking.

Citation

Brown, A., Nagelhout, G.E., van den Putte, B., Willemsen, M.C., Mons, U., Guignard, R., Thompson, M.E. (2015). Trends and socioeconomic differences in roll-your-own tobacco use: Findings from the ITC Europe Surveys.Tobacco Control, 24(Suppl 3), iii11-iii16.

Abstract

Objectives: To examine if exclusive Roll-Your-Own (RYO) tobacco use relative to factory-made (FM) cigarette use has been rising over time, to determine the extent to which economic motives and perceptions that RYO cigarettes are less harmful act as primary motivations for use, and to examine the association of income and education with the level of RYO tobacco use among smokers in four European countries.

Methods: Data were obtained from the International Tobacco Control (ITC) Europe Surveys, and a cohort sample of 7070 smokers from the Netherlands, Germany, France and UK were interviewed between June 2006 and December 2012. Generalised estimating equations (GEE) were used to assess trends in RYO use, and whether RYO consumption varied by socioeconomic variables.

Results: Exclusive RYO use over the study period has increased significantly in the UK from 26.4% in 2007 to 32.7% in 2010 (p<0.001); France from 12.2% in 2006 to 19.1% in 2012 (p<0.001); and Germany from 12.7% in 2007 to 18.6% in 2011 (p=0.031), with increased borderline significantly in the Netherlands (31.7% to 34.3%, p=0.052), from 2008 to 2010. Over three-quarters of users in each of the study countries indicated that lower price was a reason why they smoked RYO. Just over a fourth of smokers in the UK, less than a fifth in France, and around a tenth in Germany and the Netherlands believed that RYO is healthier. Compared with exclusive FM users, exclusive RYO users were more likely to have lower incomes and lower education.

Conclusions: Effective tobacco tax regulation is needed in the European Union and elsewhere to eliminate or reduce the price advantage of RYO tobacco. Additional health messages are also required to correct the misperception that RYO tobacco is healthier than FM cigarettes.

Citation

Springvloet, L., Willemsen, M.C., Mons, U., van den Putte, B., Kunst, A.E., Guignard, R., Hummel, K., Allwright, S., Siahpush, M., de Vries, H., Nagelhout, G.E. (2015). Educational differences in associations of noticing anti-tobacco information with smoking-related attitudes and quit intentions: Findings from the International Tobacco Control (ITC) Europe Surveys. Health Education Research, 30(5), 719-730.

Abstract

This study examined educational differences in associations of noticing anti-tobacco information with smoking-related attitudes and quit intentions among adult smokers. Longitudinal data (N = 7571) from two waves of six countries of the International Tobacco Control (ITC) Europe Surveys were included. Generalized estimating equation analyses and multiple linear and logistic regression analyses were conducted. Higher educated smokers noticed anti-tobacco information slightly more often than lower educated smokers (F(2) = 25.78, P < 0.001). Noticing anti-tobacco information was associated with more negative smoking-related attitudes (β = 0.05, P < 0.001) and more quit intentions (OR = 1.08, P < 0.001). Among smokers without a quit intention at baseline, a positive association was found for noticing antitobacco information at baseline with follow-up quit intention (OR = 1.14, P = 0.003). No other longitudinal associations were found. No educational differences were found in the association of noticing antitobacco information with smoking-related attitudes but associations with quit intentions were found only among low (OR = 1.12, P = 0.001) and high educated respondents (OR = 1.11, P < 0.001) and not among moderate educated respondents (OR = 1.02, P = 0.43). Noticing anti-tobacco information may positively influence quit intentions and possibly smoking-related attitudes. Lower educated smokers were as likely to be influenced by anti-tobacco information as higher educated smokers but noticed antitobacco information less often; increasing reach of anti-tobacco information may increase impact in this group.

Citation

Shang, C., Chaloupka, F., Zahra, N., Fong, G.T. (2014). The distribution of cigarette prices under different tax structures: Findings from the International Tobacco Control Policy Evaluation (ITC) Project. Tobacco Control, 23(Suppl 1), i23-i29.

Abstract

Background: The distribution of cigarette prices has rarely been studied and compared under different tax structures. Descriptive evidence on price distributions by countries can shed light on opportunities for tax avoidance and brand switching under different tobacco tax structures, which could impact the effectiveness of increased taxation in reducing smoking.

Objective: This paper aims to describe the distribution of cigarette prices by countries and to compare these distributions based on the tobacco tax structure in these countries.

Methods: We employed data for 16 countries taken from the International Tobacco Control Policy Evaluation Project to construct survey-derived cigarette prices for each country. Self-reported prices were weighted by cigarette consumption and described using a comprehensive set of statistics. We then compared these statistics for cigarette prices under different tax structures. In particular, countries of similar income levels and countries that impose similar total excise taxes using different tax structures were paired and compared in mean and variance using a two-sample comparison test.

Findings: Our investigation illustrates that, compared with specific uniform taxation, other tax structures, such as ad valorem uniform taxation, mixed (a tax system using ad valorem and specific taxes) uniform taxation, and tiered tax structures of specific, ad valorem and mixed taxation tend to have price distributions with greater variability. Countries that rely heavily on ad valorem and tiered taxes also tend to have greater price variability around the median. Among mixed taxation systems, countries that rely more heavily on the ad valorem component tend to have greater price variability than countries that rely more heavily on the specific component. In countries with tiered tax systems, cigarette prices are skewed more towards lower prices than are prices under uniform tax systems. The analyses presented here demonstrate that more opportunities exist for tax avoidance and brand switching when the tax structure departs from a uniform specific tax.

Citation

Rennen, E., Nagelhout, G.E., van den Putte, B., Janssen, E., Mons, U., Guignard, R., Beck, F., de Vries, H., Thrasher, J.F., Willemsen, M.C. (2014). Associations between tobacco control policy awareness, social acceptability of smoking and smoking cessation: findings from the International Tobacco Control (ITC) Europe Surveys. Health Education Research, 29(1), 72-82.

Abstract

This study examined whether awareness of tobacco control policies was associated with social unacceptability of smoking and whether social unacceptability had an effect on smoking cessation in three European countries. Representative samples (n = 3865) of adult smokers in France, the Netherlands and Germany were used from two survey waves of the longitudinal International Tobacco Control Europe Surveys. Associations were examined of aspects of social unacceptability of smoking (i.e. feeling uncomfortable, important people disapproval and societal disapproval) with tobacco policy awareness (i.e. awareness of warning labels, anti-tobacco information and smoking restrictions at work) and smoking cessation. Only the positive association of awareness of anti-tobacco information with feeling uncomfortable about smoking was significant in each of the three countries. Important people disapproval predicted whether smokers attempted to quit, although this did not reach significance in the French and German samples in multivariate analyses. Our findings suggest that anti-tobacco information campaigns about the dangers of second-hand smoke in France and about smoking cessation in the Netherlands and Germany might have reduced the social acceptability of smoking in these countries. However, campaigns that influence the perceived disapproval of smoking by important people may be needed to ultimately increase attempts to quit smoking.

Citation

Fong, G.T., Craig, L., Guignard, R., Nagelhout, G.E., Tait, M., Driezen, P., Kennedy, R.D., Boudreau, C., Wilquin, J.L., Deutsch, A., Beck, F. (2013). Evaluating the effectiveness of France's indoor smoke-free law 1 year and 5 years after implementation: Findings from the ITC France Survey. PLOS One, 8(6), 66692.

Abstract

France implemented a comprehensive smoke-free law in two phases: Phase 1 (February 2007) banned smoking in workplaces, shopping centres, airports, train stations, hospitals, and schools; Phase 2 (January 2008) banned smoking in hospitality venues (bars, restaurants, hotels, casinos, nightclubs). This paper evaluates France’s smoke-free law based on the International Tobacco Control Policy Evaluation Project in France (the ITC France Project), which conducted a cohort survey of approximately 1,500 smokers and 500 non-smokers before the implementation of the laws (Wave 1) and two waves after the implementation (Waves 2 and 3). Results show that the smoke-free law led to a very significant and near-total elimination of observed smoking in key venues such as bars (from 94–97% to 4%) and restaurants (from 60–71% to 2–3%) at Wave 2, which was sustained four years later (6–8% in bars; 1–2% in restaurants). The reduction in self-reported smoking by smoking respondents was nearly identical to the effects shown in observed smoking. Observed smoking in workplaces declined significantly after the law (from 41–48% to 18–20%), which continued to decline at Wave 3 (to 14–15%). Support for the smoke-free laws increased significantly after their implementation and continued to increase at Wave 3 (p,.001 among smokers for bars and restaurants; p,.001 among smokers and p = .003 for non-smokers for workplaces). The findings demonstrate that smoke-free policies that are implemented in ways consistent with the Guidelines for Article 8 of the WHO Framework Convention on Tobacco Control (WHO FCTC) lead to substantial and sustained reductions in indoor smoking while also leading to high levels of support by the public. Moreover, contrary to arguments by opponents of smoke-free laws, smoking in the home did not increase after the law was implemented and prevalence of smoke-free homes among smokers increased from 23.2% before the law to 37.2% 5 years after the law.

Citation

Nagelhout, G.E., van den Putte, B., Allwright, S., Mons, U., McNeill, A., Guignard, R., Beck, F., Siahpush, M., Joossens, L., Fong, G.T., de Vries, H., Willemsen, M.C. (2014). Socioeconomic and country variations in cross-border cigarette purchasing as tobacco tax avoidance strategy: Findings from the ITC Europe Surveys. Tobacco Control, 23(Suppl 1), i30-i38.

Abstract

Background: Legal tobacco tax avoidance strategies such as cross-border cigarette purchasing may attenuate the impact of tax increases on tobacco consumption. Little is known about socioeconomic and country variations in cross-border purchasing.

Objective: To describe socioeconomic and country variations in cross-border cigarette purchasing in six European countries.

Methods: Cross-sectional data from adult smokers (n=7873) from the International Tobacco Control (ITC) Surveys in France (2006/2007), Germany (2007), Ireland (2006), The Netherlands (2008), Scotland (2006) and the rest of the UK (2007/2008) were used. Respondents were asked whether they had bought cigarettes outside their country in the last 6 months and how often.

Findings: In French and German provinces/states bordering countries with lower cigarette prices, 24% and 13% of smokers, respectively, reported purchasing cigarettes frequently outside their country. In non-border regions of France and Germany, and in Ireland, Scotland, the rest of the UK and The Netherlands, frequent purchasing of cigarettes outside the country was reported by 2-7% of smokers. Smokers with higher levels of education or income, younger smokers, daily smokers, heavier smokers and smokers not planning to quit smoking were more likely to purchase cigarettes outside their country.

Conclusions: Cross-border cigarette purchasing is more common in European regions bordering countries with lower cigarette prices and is more often reported by smokers with higher education and income. Increasing taxes in countries with lower cigarette prices, and reducing the number of cigarettes that can be legally imported across borders could help to avoid cross-border purchasing.

Citation

Fong, G.T., Craig, L., Guignard, R., Nagelhout, G.E., Tait, M., Driezen, P., Kennedy, R.D., Boudreau, C., Wilquin, J.L., Deutsch, A., Beck, F. (2013). Évaluation de l’interdiction de fumer dans les lieux publics en France un an et cinq ans après sa mise en œuvre: Résultats de l’enquête ITC France. Bulletin Epidémiologique Hebdomadaire, 20(21), 217-223.

Abstract

France implemented a comprehensive smoke-free policy in public places in February 2007 for workplaces, shopping centres, airports, train stations, hospitals and schools. On January 2008, it was extended to meeting places (bars, restaurants, hotels, casinos, nightclubs). This paper evaluates France’s smoke-free law based on the International Tobacco Control Policy Evaluation Project in France (the ITC France Project), which conducted a cohort survey of approximately 1,500 smokers and 500 non-smokers before the implementation of the laws (Wave 1, conducted December 2006 to February 2007) and two waves after the implementation (Wave 2, conducted between September-November 2008; and Wave 3, conducted between September-December 2012). Results show that the smoke-free law led to a very significant and near total elimination of indoor smoking in key venues such as bars (from 95.9% to 3.7%) and restaurants (from 64.7% to 2.3%) at Wave 2, which was sustained four years later at Wave 3 (1.4% in restaurants; 6.6% in bars). Smoking in workplaces declined significantly after the law (from 42.6% to 19.3%), which continued to decline at Wave 3 (to 12.8%). Support for the smoke-free law increased significantly after their implementation and continued to increase at Wave 3 (among smokers for bars and restaurants; among smokers and non-smokers for workplaces). The findings demonstrate that smoke-free policies that are implemented in ways consistent with the Guidelines for Article 8 of the WHO Framework Convention on Tobacco Control (WHO FCTC) lead to substantial and sustained reductions in tobacco smoke in public places while also leading to high levels of support by the public.

En France, l’interdiction de fumer dans les lieux publics a été mise en œuvre en février 2007 pour les lieux de travail, les centres commerciaux, les aéroports, les gares, les hôpitaux et les écoles. En janvier 2008, elle a été étendue aux lieux de convivialité (bars, restaurants, hôtels, casinos, discothèques). L’évaluation proposée dans cet article s’inscrit dans le cadre du volet français d’International Tobacco Control (ITC), projet d’évaluation des politiques publiques de lutte antitabac. Une enquête de cohorte d’environ 1 500 fumeurs et 500 non-fumeurs a été mise en place avant la mise en œuvre de la loi (vague 1, de décembre 2006 à février 2007); la vague 2 a eu lieu entre septembre et novembre 2008, et la vague 3, entre septembre et décembre 2012. Les résultats de la vague 2 montrent que la législation antitabac a conduit, dès la fin 2008, à une élimination quasi totale du tabagisme à l’intérieur d’endroits clés tels que les bars (de 95,9% à 3,7%) et les restaurants (de 64,7% à 2,3%), persistant quatre ans plus tard (1,4% dans les restaurants, 6,6% dans les bars à la vague 3). Le tabagisme sur le lieu de travail a diminué de façon significative après la loi (de 42,6% à 19,3%) et a continué de baisser (12,8%) à la vague 3. Le soutien à l’interdiction de fumer dans les lieux publics a augmenté de façon significative après sa mise en œuvre et a continué d’augmenter à la vague 3 (parmi les fumeurs concernant les bars et restaurants, parmi les fumeurs et les non-fumeurs concernant les lieux de travail). Les résultats démontrent que les politiques antitabac mises en œuvre de manière cohérente avec les lignes directrices relatives à l’article 8 de la Convention-cadre de l’OMS pour la lutte antitabac (CCLAT) conduisent à des réductions substantielles et durables du tabagisme passif dans les lieux publics, ainsi qu’à des niveaux de soutien élevés par la population.

Citation

Sansone, G., Fong, G.T., Hall, P.A., Guignard, R., Beck, F., Mons, U., Pötschke-Langer, M., Yong, H.H., Thompson, M.E., Omar, M., Jiang, Y. (2013). Time perspective as a predictor of smoking status: Findings from the International Tobacco Control (ITC) Surveys in Scotland, France, Germany, China, and Malaysia. BioMed Central Public Health, 13(1), 346.

Abstract

Background: Prior studies have demonstrated that time perspective—the propensity to consider shortversus long-term consequences of one’s actions—is a potentially important predictor of health-related behaviors, including smoking. However, most prior studies have been conducted within single highincome countries. The aim of this study was to examine whether time perspective was associated with the likelihood of being a smoker or non-smoker across five countries that vary in smoking behavior and strength of tobacco control policies.

Methods: The data were from the International Tobacco Control (ITC) Surveys in five countries with large probability samples of both smokers (N=10,341) and non-smokers (N=4,955): Scotland, France, Germany, China, and Malaysia. The surveys were conducted between 2005 and 2008. Survey respondents indicated their smoking status (smoker vs. non-smoker) and time perspective (future oriented vs. not future-oriented) and provided demographic information.

Results: Across all five countries, non-smokers were significantly more likely to be future-oriented (66%) than were smokers (57%), χ2 (1, N = 15,244) = 120.64, p < .001. This bivariate relationship between time perspective and smoking status held in a multivariate analysis. After controlling for country, age, sex, income, education, and ethnicity (language in France), those who were future-oriented had 36% greater odds of being a non-smoker than a smoker (95% CI: 1.22 to 1.51, p<.001).

Conclusion: These findings establish time perspective as an important predictor of smoking status across multiple countries and suggest the potential value of incorporating material to enhance future orientation in smoking cessation interventions.

Citation

Mons, U., Nagelhout, G.E., Guignard, R., McNeill, A., van den Putte, B., Willemsen, M.C., Brenner, H., Pötschke-Langer, M., Breitling, L.P. (2012). Comprehensive smoke-free policies attract more support from smokers in Europe than partial policies. European Journal of Public Health, 22(Suppl 1), 10-16.

Abstract

Objectives: To measure changes in prevalence and predictors of home smoking bans (HSBs) among smokers in four European countries after the implementation of national smoke-free legislation.

Design: Two waves of the International Tobacco Control Policy Evaluation Project Europe Surveys, which is a prospective panel study. Pre- and post-legislation data were used from Ireland, France, Germany and the Netherlands. Two pre-legislation waves from the UK were used as control. Participants: 4634 respondents from the intervention countries and 1080 from the control country completed both baseline and follow-up and were included in the present analyses.

Methods: Multiple logistic regression models to identify predictors of having or of adopting a total HSB, and Generalised Estimating Equation models to compare patterns of change after implementation of smoke-free legislation to a control country without such legislation.

Results: Most smokers had at least partial smoking restrictions in their home, but the proportions varied significantly between countries. After implementation of national smoke-free legislation, the proportion of smokers with a total HSB increased significantly in all four countries. Among continuing smokers, the number of cigarettes smoked per day either remained stable or decreased significantly. Multiple logistic regression models indicated that having a young child in the household and supporting smoking bans in bars were important correlates of having a pre-legislation HSB. Prospective predictors of imposing a HSB between survey waves were planning to quit smoking, supporting a total smoking ban in bars and the birth of a child. Generalised Estimating Equation models indicated that the change in total HSB in the intervention countries was greater than that in the control country.

Conclusions: The findings suggest that smoke-free legislation does not lead to more smoking in smokers' homes. On the contrary, our findings demonstrate that smoke-free legislation may stimulate smokers to establish total smoking bans in their homes.

Citation

McNeill, A., Craig, L., Willemsen, M.C., Fong, G.T. (2012). Tobacco control in Europe: A deadly lack of progress. European Journal of Public Health, 22(Suppl 1), 1-3.

Abstract

Cigarettes are uniquely dangerous, killing half of all those who regularly use them and damaging the health of those who breathe in users’ smoke, particularly children. Just under a third of European adults currently smoke, and smoking has become increasingly associated with poverty, contributing significantly to widening health inequalities across the EU. In 2004, the ASPECT report, a comprehensive review of tobacco use and tobacco control policies in the EU, found that tobacco use caused well over half a million deaths in Europe annually and on top of that constituted a huge economic burden, estimated conservatively at €98-130 billion a year.1 This review also identified that whilst some European countries were observing declines in tobacco use and mortality, in other countries tobacco use was still increasing, particularly among women. The ASPECT report identified 43 recommendations to combat the epidemic, covering tobacco control policy, interventions and research. Yet to date, few of these recommendations have been implemented, and as a result, future prospects for curbing the smoking epidemic across Europe are currently very bleak.

Citation

Borland, R., Li, L., Driezen, P., Wilson, N., Hammond, D., Thompson, M.E., Fong, G.T., Mons, U., Willemsen, M.C., McNeill, A., Thrasher, J.F., Cummings, K.M. (2012). Cessation assistance reported by smokers in 15 countries participating in the International Tobacco Control (ITC) Policy Evaluation Survey. Addiction, 107(1), 197-205.

Abstract

Aims: To describe some of the variability across the world in levels of quit smoking attempts and use of various forms of cessation support.

Design: Use of the International Tobacco Control Policy Evaluation Project surveys of smokers, using the 2007 survey wave (or later, where necessary).

Settings: Australia, Canada, China, France, Germany, Ireland, Malaysia, Mexico, the Netherlands, New Zealand, South Korea, Thailand, United Kingdom, Uruguay and United States.

Participants: Samples of smokers from 15 countries.

Measurements: Self-report on use of cessation aids and on visits to health professionals and provision of cessation advice during the visits.

Findings: Prevalence of quit attempts in the last year varied from less than 20% to more than 50% across countries. Similarly, smokers varied greatly in reporting visiting health professionals in the last year (<20% to over 70%), and among those who did, provision of advice to quit also varied greatly. There was also marked variability in the levels and types of help reported. Use of medication was generally more common than use of behavioural support, except where medications are not readily available.

Conclusions: There is wide variation across countries in rates of attempts to stop smoking and use of assistance with higher overall use of medication than behavioural support. There is also wide variation in the provision of brief advice to stop by health professionals.

Citation

Hitchman, S.C., Guignard, R., Nagelhout, G.E., Mons, U., Beck, F., van den Putte, B., Crone, M.R., de Vries, H., Hyland, A., Fong, G.T. (2012). Predictors of car smoking rules among smokers in France, Germany, and the Netherlands. European Journal of Public Health, 22(Suppl 1), 17-22.

Abstract

Background: As exposure to tobacco smoke pollution (TSP) has been identified as a cause of premature death and disease in non-smokers, and studies have demonstrated that smoking in cars produces high levels of TSP, this study will investigate smokers’ rules for smoking in their cars, and predictors of car smoking rules, including potentially modifiable correlates.

Methods: Data were drawn from nationally representative samples of current smokers from the International Tobacco Control Policy Evaluation Project surveys in France (2007), Germany (2007), and the Netherlands (2008). Smokers in France and Germany were asked about smoking rules in their cars, and smokers in the Netherlands were asked about smoking rules in cars carrying children.

Results: In France and Germany, 59% and 52% of smokers respectively, allowed smoking in their cars. In the Netherlands, 36% of smokers allowed smoking in cars carrying children. Predictors of allowing smoking in cars included: being a daily vs. non-daily smoker, being younger vs. older age, having no (young) children in the home, being a heavier smoker, and allowing smoking in the home. In the Netherlands, smokers who agreed that TSP is dangerous to nonsmokers were less likely to allow smoking in cars carrying children.

Conclusion: Overall, a sizeable proportion of smokers allowed smoking in their cars across the three countries. Media campaigns with information about the dangers of TSP may increase the adoption of smoke-free cars. These media campaigns could target smokers who are most likely to allow smoking in cars.

Citation

Hitchman, S.C., Mons, U., Nagelhout, G.E., Guignard, R., McNeill, A., Willemsen, M.C., Driezen, P., Wilquin, J.L., Beck, F., Du-Roscoat, E., Pötschke-Langer, M., Hammond, D., Fong, G.T. (2012). Effectiveness of the European Union text-only cigarette health warnings: Findings from four countries. European Journal of Public Health, 22(5), 693-699.

Abstract

Background: The European Commission requires tobacco products sold in the European Union to display standardized text health warnings. This article examines the effectiveness of the text health warnings among daily cigarette smokers in four Member States.

Methods: Data were drawn from nationally representative samples of smokers from the International Tobacco Control Policy Evaluation Project surveys in France (2007), Germany (2007), the Netherlands (2008) and the UK (2006). We examined: (i) smokers' ratings of the health warnings on warning salience, thoughts of harm and quitting and forgoing of cigarettes; (ii) impact of the warnings using a Labels Impact Index (LII), with higher scores signifying greater impact; and (iii) differences on the LII by demographic characteristics and smoking behaviour.

Results: Scores on the LII differed significantly across countries. Scores were highest in France, lower in the UK, and lowest in Germany and the Netherlands. Across all countries, scores were significantly higher among low-income smokers, smokers who had made a quit attempt in the past year and smokers who smoked fewer cigarettes per day.

Conclusion: The impact of the health warnings varies greatly across countries. Impact tended to be highest in countries with more comprehensive tobacco control programmes. Because the impact of the warnings was highest among smokers with the lowest socioeconomic status (SES), this research suggests that health warnings could be more effective among smokers from lower SES groups. Differences in warning label impact by SES should be further investigated.

Citation

Brown, A., McNeill, A., Mons, U., Guignard, R. (2012). Do smokers in Europe think all cigarettes are equally harmful? European Journal of Public Health, 22(Suppl 1), 35-40.

Abstract

Background: Despite the ban on misleading descriptors such as light or mild cigarettes in Europe, there are still widespread misperceptions of the relative harmfulness of different brands of cigarettes among smokers. This study examined the extent to which smokers in three European countries believed that some cigarette brands are less harmful and why, using data from the International Tobacco Control (ITC) Europe surveys.

Methods: Cross-sectional analyses were completed among nationally representative samples of 4,956 current smokers (aged_18) from Germany (n = 1,515), France (n = 1,735) and the United Kingdom (n = 1,706) conducted between September 2006 and November 2007. Logistic regression models examined whether outcomes, including beliefs that some cigarettes could be less harmful than others, varied by socio-demographic and country of residence.

Findings: Around a quarter of smokers in the UK and France, and a third in Germany believed some cigarettes are less harmful than others. Overall, of smokers who falsely believed that some cigarettes are less harmful, 86.3% thought that tar/ nicotine yields, 48.7% taste, and 40.4% terms on packs such as ‘smooth’ or ‘ultra’ indicated less harmful brands. About a fifth of smokers across all countries chose their brand based on health reasons, and a similar proportion gave tar yields as a reason for choosing brands.

Conclusions: Our research suggests that the current European Tobacco Products Directive is inadequate in eliminating misperceptions about the relative risk of brand descriptors on cigarettes. There is therefore an urgent need to protect smokers in Europe from these misperceptions via stronger measures such as plain packaging regulations.

Citation

Kennedy, R.D., Behm, I., Craig, L., Thompson, M.E., Fong, G.T., Guignard, R., Beck, F. (2012). Outdoor smoking behaviour and support for outdoor smoking restrictions before and after France's national smoking ban. European Journal of Public Health, 22(Suppl 1), 29-34.

Abstract

Background: On January 1, 2008, the French government implemented a national ban on indoor smoking in hospitality venues. Survey results indicate the indoor ban has been successful at dramatically reducing indoor smoking; however, there are reports of an increased number of outdoor hospitality spaces (patios) where smoking can take place. This study sought to understand if the indoor ban simply moved smoking to the outdoors, and to assess levels of support for smoking restrictions in outdoor hospitality settings after the smoke-free law.

Methods: Telephone interviews were conducted among 1067 adult smokers before and after the 2008 indoor ban as part of the International Tobacco Control (ITC) France Survey. Among other topics, this survey measures how the smoking ban has influenced smoking behaviour relevant to outdoor sections of hospitality venues. In addition, 414 non-smoking adults and 164 respondents who had quit smoking between waves were also asked about support for outdoor smoking restrictions.

Results: Reported smoking outdoors at cafes/pubs/bars increased from 33.6% of smokers at Wave 1 to 75.9% at Wave 2. At restaurants, smoking outdoors increased from 28.9% to 59.0%. There was also an increase in reported non-smoking for both visits to cafe´ s/pubs/bars, and restaurants from 13.4% to 24.7%, and 30.4% to 40.8% respectively. The majority of smokers (74.5%), non-smokers (89.4%) and quitters (74.0%) support a partial or complete ban on smoking in outdoor areas of restaurants.

Conclusion: The indoor smoking ban moved smoking to outdoor spaces; however, the ban is also associated with increased non-smoking behaviour. The majority of respondents support outdoor smoking restrictions in patio environments.

Citation

Kennedy, R.D., Behm, I., Craig, L., Thompson, M.E., Fong, G.T., Guignard, R., Beck, F. (2012). Smoking cessation interventions from health care providers before and after the national smoke-free law in France. European Journal of Public Health, 22(Suppl 1), 23-28.

Abstract

Background: Smoking cessation advice from health care providers (HCP) is well-known to be associated with increased quitting. This study sought to understand the extent to which smokers in France who visited a HCP around the time of the implementation of the national ban on smoking received encouragement to quit from a HCP and what kinds of intervention were provided. HCP may have a unique opportunity during the implementation phase of smoke-free laws to address their patients’ smoking behaviours to increase the likelihood of success at a time when smokers’ readiness and interest in quitting may be higher.

Methods: Telephone interviews were conducted among adult smokers (n = 1067) before and after the two-phase 2007 and 2008) national ban on indoor smoking as part of the International Tobacco Control (ITC) France Survey. In the survey, smokers were asked whether they had visited a HCP in the past 6 months and, if so, whether they had received cessation encouragement, and/or other interventions to support quitting such as prescriptions for stop-smoking medication.

Results: Most smokers (61%) reported visiting a HCP in the 6 months prior to the first phase of the national smoke-free ban, and 58% after the time of the hospitality ban. Of these, most reported they did not receive any assistance from a HCP before (54%) or after (64%) the smoke-free law. Among those who reported an intervention, the most common were only encouragement to quit (58% in Wave 1 and 49% in Wave 2), or receiving both encouragement and a pamphlet (31% in both Wave 1 and 2). The combination of prescriptions for stop-smoking medicine and encouragement to quit increased from 8% in 2007 to 22% in 2008. The smokers who received an intervention were more likely (OR 1.9, 95% CI: 1.2–2.9) to report that they were thinking about quitting.

Discussion: This study demonstrates that HCP in France are well positioned to provide smoking cessation encouragement and other interventions to a majority of smokers and thus the importance of taking measures to increase their involvement, particularly when populationlevel tobacco control policies, such as smoke-free laws, are being implemented.

Citation

Nagelhout, G.E., Mons, U., Allwright, S., Guignard, R., Beck, F., Fong, G.T., de Vries, H., Willemsen, M.C. (2011). Prevalence and predictors of smoking in smoke-free bars: Findings from the International Tobacco Control (ITC) Europe Surveys. Social Science & Medicine, 72(10), 1643-1651.

Abstract

National level smoke-free legislation is implemented to protect the public from exposure to second-hand tobacco smoke (SHS). The first aim of this study was to investigate how successful the smoke-free hospitality industry legislation in Ireland (March 2004), France (January 2008), the Netherlands (July 2008), and Germany (between August 2007 and July 2008) was in reducing smoking in bars. The second aim was to assess individual smokers’ predictors of smoking in bars post-ban. The third aim was to examine country differences in predictors and the fourth aim was to examine differences between educational levels (as an indicator of socioeconomic status). This study used nationally representative samples of 3147 adult smokers from the International Tobacco Control (ITC) Europe Surveys who were surveyed pre- and post-ban. The results reveal that while the partial smoke-free legislation in the Netherlands and Germany was effective in reducing smoking in bars (from 88% to 34% and from 87% to 44%, respectively), the effectiveness was much lower than the comprehensive legislation in Ireland and France which almost completely eliminated smoking in bars (from 97% to 3% and from 84% to 3% respectively). Smokers who were more supportive of the ban, were more aware of the harm of SHS, and who had negative opinions of smoking were less likely to smoke in bars post-ban. Support for the ban was a stronger predictor in Germany. SHS harm awareness was a stronger predictor among less educated smokers in the Netherlands and Germany. The results indicate the need for strong comprehensive smoke-free legislation without exceptions. This should be accompanied by educational campaigns in which the public health rationale for the legislation is clearly explained.