Citation

Mechili, E.A., Przewoźniak, K., Driezen, P., Kyriakos, C.N., Girvalaki, C., Mons, U., Quah, A.C.K., Fernández, E., Trofor, A.C., Demjén, T., Katsaounou, P.A., Zatoński, W.A., Fong, G.T., Vardavas, C.I. (2023). Smokers' support for the ban on sale of slim cigarettes in six European countries: Findings from the EUREST PLUS ITC Europe Surveys. Open Research Europe, 1, 52. doi: 10.12688/openreseurope.13405.4.

Abstract

Background: Efforts to regulate tobacco products and reduce consumption in the European Union (EU) include the European Tobacco Products Directive (TPD), which went into force in May 2016. Despite the initial discussion to include a ban on sale of slim cigarettes, it was excluded in the final TPD. The main goal of this study was to examine support for a ban on slim cigarettes among smokers in six European Countries.

Methods: Data from the 2018 (Wave 2) International Tobacco Control Policy Evaluation Project 6 European Country (ITC 6E) EUREST PLUS project survey, a cross sectional study of adult smokers (n=5592) fro m Germany, Greece, Hungary, Poland, Romania, and Spain, was analysed. Descriptive statistics were used to estimate support for a ban on slim cigarettes by sociodemographic characteristics and smoking behaviors. Logistic regression analysis was used to examine factors associated with support for a ban on slim cigarettes and perceptions of harm.

Results: Support for a ban on slims varied across countries, with highest support in Romania (33.8%), and lowest in Greece (18.0%). Female smokers (OR=0.78; 95%CI=0. 67 0.91, daily smokers (OR=0.68; 95%CI=0.47 0.97), menthol smokers (OR=0.55; 95%CI=0.36 0.86), and smokers who did not have plans to quit within next six months (OR=0.45; 95%CI=0.36 0.56) had significantly lower odds of supporting a ban on slim cigarettes. Overall, 21% of smokers perceived slim cigarettes as less harmful than regular cigarettes.

Conclusions: Support for a ban of slim cigarettes was relatively low among smokers, while misperceptions that slim cigarettes are less harmful is high, particularly among countries where slim cigarette use is more revalent. Findings support a ban on slim cigarettes to reduce misperceptions around slim cigarettes being less harmful.

Citation

Nogueira, S.O., Fernández, E., Driezen, P., Fu, M., Tigova, O., Castellano, Y., Mons, U., Herbec, A., Kyriakos, C.N., Demjen, T., Trofor, A.C., Przewozniak, K., Katsaounou, P.A., Vardavas, C.I., Fong, G.T., on behalf of the EUREST-PLUS Consortium. (2022). Secondhand smoke exposure in European countries with different smoke-free legislation: Findings from the EUREST-PLUS ITC Europe Surveys. Nicotine and Tobacco Research, 24(1), 85-92.

Abstract

Introduction: 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.

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

Kyriakos, C.N., Driezen, P., Girvalaki, C., Hitchman, S.C., Filippidis, F.T., Gravely, S., Balmford, J., Nikitara, K., Mons, U., Fernández, E., Przewoźniak, K., Trofor, A.C., Demjén, T., Zatoński, W.A., Tountas, Y., Fong, G.T., Vardavas, C.I. (2020). Awareness and correlates of noticing changes to cigarette packaging design after implementation of the European Tobacco Products Directive: Findings from the EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl 3), iii98-iii107.

Abstract

Background:

The European Tobacco Products Directive (TPD), which went into effect in May 2016, regulates packaging design and labelling of cigarettes and roll-your-own (RYO) tobacco. The aim of the current study was to examine whether smokers and recent quitters in six European Union (EU) countries (Germany, Greece, Hungary, Poland, Romania and Spain) reported noticing TPD-related changes to packaging, and correlates of noticing these changes.

Methods:

Cross-sectional data from the Wave 2 of the ITC 6 European Country Survey in 2018 after implementation of the TPD. Bivariate analyses included adult smokers (n = 5597) and recent quitters (n = 412). Adjusted logistic regression analyses were restricted to the subset of current smokers (n = 5597) and conducted using SAS-callable SUDAAN.

Results:

Over half of smokers (58.2%) and 30% of quitters noticed at least one of five types of TPD related pack changes. Over one-quarter of all respondents noticed changes to health warnings (30.0%), standardized openings (27.7%), minimum pack unit size (27.9%), and the removal of tar, nicotine and carbon monoxide information (26.7%) on packaging. Cross-country differences were observed across all measures, with noticing all pack changes markedly lower in Spain than the other countries. Correlates of noticing specific pack changes included sociodemographic characteristics, smoking behaviours and related to packaging.

Conclusions:

This is one of the first cross-country studies to examine the extent to which TPD changes to cigarette and RYO tobacco packaging are being noticed by smokers and recent quitters. Findings indicate that the majority of smokers noticed at least one type of pack change, but this varied across countries and sub-populations.

Citation

Nikitara, K., Girvalaki, C., Kyriakos, C.N., Driezen, P., Filippidis, F.T., Kahnert, S., Hitchman, S.C., Mons, U., Fernández, E., Trofor, A.C., Przewoźniak, K., Demjén, T., Katsaounou, P.A., Zatoński, W.A., Fong, G.T., Vardavas, C.I. (2020). Changes in electronic cigarette use and label awareness among smokers before and after the European Tobacco Products Directive implementation in six European countries: Findings from the EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl_3), iii62-iii67.

Abstract

Background:

Article 20 of the European Tobacco Product Directive (TPD), which went into effect in May 2016, regulates electronic cigarettes (e-cigarettes) in the European Union (EU). The aim of this study was to evaluate changes in e-cigarette use, design attributes of the products used and awareness of e-cigarette labelling and packaging among smokers from six EU Member States (MS) before and after TPD implementation.

Methods:

Data come from Wave 1 (2016, pre-TPD) and Wave 2 (2018, post-TPD) of the ITC Six European Country Survey among a sample of smokers and recent quitters who use e-cigarettes from six EU MS. Weighted logistic generalized estimating equations regression models were estimated to test the change in binary outcomes between Waves 1 and 2 using SAS-callable SUDAAN.

Results:

In 2018, current daily/weekly e-cigarette use among adult smokers was just over 2%, but this varied from the highest in Greece (4%) to lowest in Poland (1.2%). From Waves 1 to 2, there was a significant increase in respondents reporting noticing and reading health and product safety information on leaflets inside e-cigarette packaging (8.39–11.62%, P < 0.001). There were no significant changes between waves of respondents reporting noticing or reading warning labels on e-cigarette packages/vials.

Conclusions:

E-cigarette use among smokers in these six EU countries is low. Although reported noticing and reading leaflets included in the packaging of e-cigarettes increased significantly from before to after the TPD, there was no significant change in reported noticing and reading of warning labels. Findings indicate the importance of continued monitoring of TPD provisions around e-cigarettes.

Citation

Vardavas, C.I., Kyriakos, C.N., Driezen, P., Girvalaki, C., Nikitara, K., Filippidis, F.T., Fernández, E., Mons, U., Przewoźniak, K., Trofor, A.C., Demjén, T., Katsaounou, P.A., Zatoński, W.A., Willemsen, M.C., Fong, G.T. (2020). Transitions in product use during the implementation of the European Tobacco Products Directive: Cohort study findings from the EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl_3), iii10-iii17.

Abstract

Background:

The emergence of new types of tobacco and tobacco-related products on the European Union (EU) market has precipitated the possibility for both poly-tobacco use and transitions between products. In the EU, the regulatory environment has shifted with the implementation of the European Tobacco Products Directive (TPD) in May 2016, which may influence consumer transitions between products.

Methods:

The aim of this paper was to examine trends and transitions in tobacco products from 2016 to 2018 -before and after implementation of the TPD in the EU. Data come from Wave 1 (preTPD) and Wave 2 (post-TPD) of the EUREST-PLUS ITC Six European Country Survey, a cohort study of adults who at the time of recruitment were smokers from six EU countries- Germany, Greece, Hungary, Poland, Romania, and Spain. D (N = 3195). Bivariate and logistic regression analyses of weighted data was conducted using SAS-callable SUDAAN

Results:

Overall, among those who smoked factorymade cigarettes (FM) only at Wave 1, 4.3% switched to roll-your-own tobacco (RYO) only. Among RYO only users at Wave 1, 17.0% switched to FM only, however compared to all other countries, respondents from Hungary had the highest percentage of FM only users at Wave 1 switch to RYO only at Wave 2 (18.0%).

Conclusions:

The most prominent transition overall was from smoking RYO exclusively at Wave 1 to smoking FM tobacco exclusively at Wave 2, however this varied across countries. As the tobacco control regulatory environment of the EU develops, it is important to continue to monitor transitions between types of products, as well as trends in cessation.

Citation

Vardavas, C. I., Kyriakos, C. N., McNeill, A., & Fong, G. T. (2020). Evaluating the impact of the Tobacco Products Directive within the context of the FCTC in Europe—findings from the EUREST-PLUS ITC Europe Surveys: introductory Commentary. European Journal of Public Health, 30(Supplement_3), iii1-iii3.

No abstract available.

Citation

Lotrean, L.M., Trofor, A.C., Radu-Loghin, C., Eremia, M., Mihaltan, F., Driezen, P., Kyriakos, C.N., Mons, U., Demjén, T., Fernández, E., Katsaounou, P.A., Przewoźniak, K., McNeill, A., Filippidis, F.T., Gravely, S., Fong, G.T., Vardavas, C.I. (2020). Awareness and use of heated tobacco products among adult smokers in six European countries: Findings from the EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl 3), iii78-iii83.

Abstract

Background:

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.

Citation

McDermott, M., East, K., Hitchman, S.C., McNeill, A., Tountas, Y., Demjén, T., Fernández, E., Mons, U., Trofor, A.C., Herbec, A., Janik-Koncewicz, K., Fong, G.T., Vardavas, C.I. (2020). Social norms for ecigarettes and smoking: Associations with initiation of e-cigarette use, intentions to quit smoking and quit attempts: Findings from the EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl_3), iii46-iii54

Abstract

Background:

Social norms have received little attention in relation to electronic cigarettes (EC). The current study examine social norms for EC use and smoking tobacco, and their associations with (i) initiation of EC use, (ii) intention to quit smoking and (iii) attempts to quit smoking.

Methods:

Cross-sectional and longitudinal data analysis from Waves 1 and 2 of the ITC 6 European Country Survey and corresponding waves from England (the ITC Four Country Smoking and Vaping Survey). Current smokers at baseline, who heard of ECs and provided data at both waves were included (n = 3702). Complex samples logistic regression examined associations between the outcomes and descriptive (seeing EC use in public, close friends using ECs/smoking) and injunctive (public approves of ECs/smoking) norms, adjusting for country, demographics, EC use and heaviness of smoking.

Results:

In longitudinal analyses, seeing EC use in public at least some days was the only social norm that predicted initiation of EC use between waves (OR = 1.66, 95%CI = 1.08–2.56). In the cross-sectional analysis, having an intention to quit was associated with seeing EC use in public (OR = 1.37, 95%CI = 1.04–1.81) and reporting fewer than three close friends smoke (OR = 0.59, 95%CI = 0.44–0.80). There was no association between any social norm and making a quit attempt between waves.

Conclusions:

Initiation of EC use is predicted by seeing EC use in public, which was also associated with greater intention to quit smoking. Friends’ smoking was associated with lower intention to quit. These findings may allay concerns that increased visibility of ECs is renormalizing smoking amongst current smokers.

Citation

Nogueira, S.O., Tigova, O., Driezen, P., Fu, M., Kyriakos, C.N., Zatoński, M., Mons, U., Quah, A.C.K., Demjén, T., Trofor, A.C., Przewoźniak, K., Katsaounou, P.A., Fong, G.T., Vardavas, C.I., Fernández, E. (2020). Do smokers want to protect non-smokers from the harms of secondhand smoke in cars? Findings from the EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl_3), iii108- iii112.

Abstract

Background:

There is currently no comprehensive legislation protecting non-smokers and children from second-hand smoke (SHS) exposure in private cars at the European Union (EU) level. This study aims to assess smokers’ support for smoke-free cars legislation in six EU countries.

Methods:

Data come from the EUREST-PLUS ITC Europe Surveys: Wave 1 (2016, n = 6011) and Wave 2 (2018, n = 6027) conducted in Germany, Greece, Hungary, Poland, Romania and Spain. Support for smoke-free cars carrying pre-school children and non-smokers and voluntary implementation of smoke-free cars were assessed among adult smokers. Generalized estimating equations models were used to assess changes in support between waves.

Results:

In 2018, 96.3% [95% confidence interval (CI) 95.4–97.0%] of the overall sample supported smoke-free legislation for cars carrying pre-school children, representing an increase of 2.4 percentage points in comparison to 2016. Smoke-free legislation for cars transporting non-smokers was supported by 85.2% (95% CI 83.1–87.1%) of smokers’ in 2016 and 90.2% (95% CI 88.6–91.7%) in 2018. Among smokers who owned cars, there was a significant 7.2 percentage points increase in voluntary implementation of smoke-free cars carrying children from 2016 (60.7%, 95% CI 57.2–64.0%) to 2018 (67.9%, 95% CI 65.1–70.5%). All sociodemographic groups of smokers reported support higher than 80% in 2018.

Conclusion:

The vast majority of smokers in all six EU countries support smoke-free legislation for cars carrying pre-school children and non-smokers. This almost universal support across countries and sociodemographic groups is a clear indicator of a window of opportunity for the introduction of comprehensive legislation to protect non-smokers and children from SHS exposure in cars.

Citation

Zatoński, M., Herbec, A., Zatoński, W.A., Janik-Koncewicz, K., Driezen, P., Demjén, T., Fernández, E., Fong, G.T., Quah, A.C.K., Kyriakos, C.N., McNeill, A., Willemsen, M.C., Mons, U., Tountas, Y., Trofor, A.C., Vardavas, C.I. (2020). 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. European Journal of Public Health, 30(Supplement_3), 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 < 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.

Citation

Kahnert, S., Driezen, P., Balmford, J., Kyriakos, C.N., Aleyan, S., Hitchman, S.C., Nogueira, S.O., Demjén, T., Fernández, E., Katsaounou, P.A., Trofor, A.C., Przewoźniak, K., Zatoński, W.A., Fong, G.T., Vardavas, C.I., Mons, U. (2020). Effectiveness of tobacco warning labels before and after implementation of the European Tobacco Products Directive: Findings from the longitudinal EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl 3), iii84-iii90

Abstract

Background:

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.

Citation

Papadakis, S., Katsaounou, P.A., Kyriakos, C.N., Balmford, J., Tzavara, C.K., Girvalaki, C., Driezen, P., Filippidis, F.T., Herbec, A., Hummel, K., McNeill, A., Mons, U., Fernández, E., Fu, M., Trofor, A.C., Demjén, T., Zatoński, W.A., Willemsen, M.C., Fong, G.T., Vardavas, C.I. (2020). Quitting behaviours and cessation methods used in eight European Countries in 2018: Findings from the EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Supplement_3), iii26-iii33

Abstract

Background:

We examined quit attempts, use of cessation assistance, quitting beliefs and intentions among smokers who participated in the 2018 International Tobacco Control (ITC) Europe Surveys in eight European Union Member States (England, Germany, Greece, Hungary, the Netherlands, Poland, Romania and Spain).

Methods:

Cross-sectional data from 11 543 smokers were collected from Wave 2 of the ITC Six European Country (6E) Survey (Germany, Greece, Hungary, Poland, Romania and Spain—2018), the ITC Netherlands Survey (the Netherlands—late 2017) and the Four Countries Smoking and Vaping (4CV1) Survey (England—2018). Logistic regression was used to examine associations between smokers’ characteristics and recent quit attempts.

Results:

Quit attempts in the past 12 months were more frequently reported by respondents in the Netherlands (33.0%) and England (29.3%) and least frequently in Hungary (11.5%), Greece (14.7%), Poland (16.7%) and Germany (16.7%). With the exception of England (35.9%), the majority (56–84%) of recent quit attempts was unaided. Making a quit attempt was associated with younger age, higher education and income, having a smoking-related illness and living in England. In all countries, the majority of continuing smokers did not intend to quit in the next 6 months, had moderate to high levels of nicotine dependence and perceived quitting to be difficult.

Conclusions:

Apart from England and the Netherlands, smokers made few quit attempts in the past year and had low intentions to quit in the near future. The use of cessation assistance was sub-optimal. There is a need to examine approaches to supporting quitting among the significant proportion of tobacco users in Europe and increase the use of cessation support as part of quit attempts

Citation

Girvalaki, C., Filippidis, F.T., Kyriakos, C.N., Driezen, P., Herbec, A., Mons, U., Papadakis, S., Mechili, A, Katsaounou, P.A., Przewoźniak, K., Fernández, E., Trofor, A.C., Demjén, T., Fong, G.T., Vardavas, C.I. (2020). Perceptions, predictors of and motivation for quitting among smokers from six European countries from 2016 to 2018: Findings from EUREST-PLUS ITC Europe Surveys. International Journal of Environmental Research and Public Health, 17(17), 6263.

Abstract

The European Tobacco Products Directive (TPD) was introduced in 2016 in an effort to decrease prevalence of smoking and increase cessation in the European Union (EU). This study aimed to explore quitting behaviours, motivation, reasons and perceptions about quitting, as well as predictors (reported before the TPD implementation) associated with post-TPD quit status. A cohort study was conducted involving adult smokers from six EU countries (n = 3195). Data collection occurred pre-(Wave 1; 2016) and post-(Wave 2; 2018) TPD implementation. Bivariate and logistic regression analyses of weighted data were conducted. Within this cohort sample, 415 (13.0%) respondents reported quitting at Wave 2. Predictors of quitting were moderate or high education, fewer cigarettes smoked per day at baseline, a past quit attempt, lower level of perceived addiction, plans for quitting and the presence of a smoking related comorbidity. Health concerns, price of cigarettes and being a good example for children were among the most important reasons that predicted being a quitter at Wave 2. Our findings show that the factors influencing decisions about quitting may be shared among European countries. European policy and the revised version of TPD could emphasize these factors through health warnings and/or campaigns and other policies.

Citation

Kahnert, S., Driezen, P., Balmford, J., Kyriakos, C.N., Demjén, T., Fernández, E., Katsaounou, P.A., Trofor, A.C., Przewoźniak, K., Zatoński, W.A., Fong, G.T., Vardavas, C.I., Mons, U. (2020). 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. European Journal of Public Health, 30(Supplement_3), iii55-iii61.

Abstract

Background

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.

Citation

Filippidis, F.T., Driezen, P., Kyriakos, C.N., Katsaounou, P.A., Petroulia, I., Girvalaki, C., Fu, M., Fernández, E., Mons, U., Trofor, A.C., Demjén, T., Przewoźniak, K., Zatoński, W.A., Fong, G.T., Tountas, Y., Vardavas, C.I. (2020). Transitions from and to roll-your-own tobacco, perceptions and health beliefs among smokers: Findings from the EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl 3), iii18-iii25.

Abstract

Background: 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.

Citation

Thompson, M.E., Driezen, P., Boudreau, C., Bécuwe, N., Agar, T.K., Quah, A.C.K., Zatoński, W.A., Przewoźniak, K., Mons, U., Demjén, T., Tountas, Y., Trofor, A.C., Fernández, E., McNeill, A., Willemsen, M.C., Vardavas, C.I., Fong, G.T. (2020). Methods of the International Tobacco Control (ITC) EURESTPLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl_3), iii4-iii9.

Abstract

Background: 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.

Citation

Herbec, A., Zatoński, M., Zatoński, W., Janik-Koncewicz, K., Mons, U., Fong, G.T., Quah, A.C.K., Driezen, P., Demjén, T., Tountas, Y., Trofor, A., Fernández, E., McNeill, A., Willemsen, M., Vardavas, C., Przewoźniak, K., on behalf of the EUREST-PLUS Consortium. (2019). Dependence, plans to quit, quitting self-efficacy and past cessation behaviours among menthol and other flavoured cigarette users in Europe – The EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 210-221.

Abstract

Introduction: This study characterises smoking and cessation related behaviours among menthol and other flavoured cigarette users in Europe prior to the implementation of the European Tobacco Products Directive (TPD) ban on the sale of flavoured cigarettes.

Methods: An analysis of cross-sectional data from the 2016 EUREST-PLUS ITC Europe Surveys was conducted among a sample of 10760 adult smokers from eight European Union Member States. Respondents were classified as menthol, other flavoured, unflavoured, or no usual flavour cigarette users and compared on smoking and cessation behaviours and characteristics. Data were analysed in SPSS Complex Samples Package using bivariate and multivariate regression analyses adjusted for sociodemographic characteristics, dependence, and country.

Results: In bivariate analyses, cigarette flavour was significantly associated with all outcomes (p<0.001). After adjusting for sociodemographic characteristics, these associations attenuated but remained significant and in the same direction for dependence, self-efficacy, plans to quit, past quit attempts, and ever e-cigarette use. In fully adjusted models, compared to smokers of non-flavoured cigarettes, menthol smokers were less likely to smoke daily (AOR=0.47, 95% CI: 0.32–0.71), smoke within 30 min of waking (0.52,0.43–0.64), consider themselves addicted (0.74,0.59–0.94), and more likely to have ever used e-cigarettes (1.26,1.00–1.57); other flavoured cigarette smokers were less likely to smoke daily (0.33,0.15–0.77), and have higher self-efficacy (1.82,1.20–2.77); no usual flavour smokers were less likely to smoke daily (0.34,0.22–0.51), smoke within 30 min of waking (0.66,0.55–0.80), consider themselves addicted (0.65,0.52–0.78), have ever made a quit attempt (0.69,0.58– 0.84), have ever used e-cigarettes (0.66,0.54–0.82), and had higher self-efficacy (1.46,1.19–1.80).

Conclusions: Smokers of different cigarette flavours in Europe differ on smoking and cessation characteristics. The lower dependence of menthol cigarette smokers could lead to greater success rates if quit attempts are made, however cross-country differences in smoking behaviours and quitting intentions could lead to the TPD ban on cigarette flavours having differential impact if not accompanied by additional measures, such as smoking cessation support.

Citation

Demjén, T., Kiss, J., Kovacs, P., Mons, U., Kahnert, S., Driezen, P., Kyriakos, C.N., Zatoński, M., Prezewoźniak, K., Fu, M., Fernández, E., McNeill, A., Willemsen, M.C., Tountas, Y., Trofor, A., Fong, G.T., Vardavas, C., on behalf of the EUREST-PLUS Consortium. (2019). The purchase sources of and price paid for cigarettes in six European countries: Findings from the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 184-192.

Abstract

Introduction: Tobacco tax policies have been proven to be effective in reducing tobacco consumption, but their impact can be mitigated through price-minimizing behaviours among smokers. This study explored the purchase sources of tobacco products and the price paid for tobacco products in six EU member states.

Methods: Data from Wave 1 of the EUREST-PLUS ITC Europe Survey collected from nationally representative samples of adult smokers in Germany, Greece, Hungary, Poland, Romania and Spain (ITC 6E Survey) were used. The ITC 6E Survey sample, conducted in 2016, randomly sampled 6011 adult cigarette smokers aged 18 years or older. Information on purchase sources of tobacco was examined by country. The difference in reported purchase price by purchase location (store vs non-store/other) was analysed using linear regression for each country.

Results: Tobacco purchasing patterns and sources varied widely between countries. Non-store/other purchases were very rare in Hungary (0.1%) while these types of purchases were more common in Germany (5.1%) and Poland (8.6%). Reported prices of one standard pack of 20 cigarettes were highest in Germany (4.80€) and lowest in Hungary (2.45€). While nonstore purchases were only made by a minority of smokers (>10% in all countries), the price differential was considerable between store and non-store/other sources, up to 2€ per pack in Greece and in Germany.

Conclusions: The results suggest a huge variation of purchasing sources and price differentials between store and non-store purchasing sources across the six EU member states examined. While the cross-sectional data precludes any causal inference, supply chain control through licensing as introduced in Hungary and the lack of such measures in the other countries might nevertheless be a plausible explanation for the large differences in the frequency of non-store purchases observed in this study.

Citation

East, K., Hitchman, S.C., McDermott, M., McNeill, A., Herbeć, A., Tountas, Y., Bécuwe, N., Demjén, T., Fu, M., Fernández, E., Mons, U., Trofor, A., Zatoński, W., Fong, G.T., Vardavas, C., on behalf of the EUREST-PLUS Consortium. (2019). Social norms towards smoking and electronic cigarettes among adult smokers in seven European Countries: Findings from the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 172-183.

Abstract

Introduction:
This study explores whether current smokers’ social norms towards smoking and electronic cigarettes (e-cigarettes) vary across seven European countries alongside smoking and e-cigarette prevalence rates. At the time of surveying, England had the lowest current smoking prevalence and Greece the highest. Hungary, Romania and Spain had the lowest prevalence of any e-cigarette use and England the highest.

Methods:
Respondents were adult (≥18 years) current smokers from the 2016 EUREST-PLUS ITC (Romania, Spain, Hungary, Poland, Greece, Germany) and ITC 4CV England Surveys (N=7779). Using logistic regression, associations between country and (a) smoking norms and (b) e-cigarette norms were assessed, adjusting for age, sex, income, education, smoking status, heaviness of smoking, and e-cigarette status.

Results:
Compared with England, smoking norms were higher in all countries: reporting that at least three of five closest friends smoke (19% vs 65–84% [AOR=6.9–24.0; Hungary–Greece]), perceiving that people important to them approve of smoking (8% vs 14–57% [1.9–51.1; Spain–Hungary]), perceiving that the public approves of smoking (5% vs 6–37% [1.7–15.8; Spain–Hungary]), disagreeing that smokers are marginalised (9% vs 16–50% [2.3–12.3; Poland–Greece]) except in Hungary. Compared with England: reporting that at least one of five closest friends uses e-cigarettes was higher in Poland (28% vs 36% [2.7]) but lower in Spain and Romania (28% vs 6–14% [0.3–0.6]), perceiving that the public approves of e-cigarettes was higher in Poland, Hungary and Greece (32% vs 36–40% [1.5–1.6]) but lower in Spain and Romania in unadjusted analyses only (32% vs 24–26%), reporting seeing e-cigarette use in public at least some days was lower in all countries (81% vs 12–55% [0.1–0.4]; Spain–Greece).

Conclusions:
Smokers from England had the least pro-smoking norms. Smokers from Spain had the least pro-e-cigarette norms. Friend smoking and disagreeing that smokers are marginalised broadly aligned with country-level current smoking rates. Seeing e-cigarette use in public broadly aligned with countrylevel any e-cigarette use. Generally, no other norms aligned with product prevalence.

Citation

Hedman, L., Katsaounou, P., Filippidis, F., Ravara, S., Lindberg, A., Janson, C., Gratziou, C., Rohde, G., Kyriakos, C.N., Mons, U., Fernández, E., Trofor, A., Demjén, T., Przwozniak, K., Tountas, Y., Fong, G.T., Vardavas, C., on behalf of the EUREST-PLUS Consortium. (2019). Receiving support to quit smoking and quit attempts among smokers with and without smoking related diseases: Findings from the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 160-171.

Abstract

Introduction: Having a chronic disease either caused or worsened by tobacco smoking does not always translate into quitting smoking. Although smoking cessation is one of the most cost-effective medical interventions, it remains poorly implemented in healthcare settings. The aim was to examine whether smokers with chronic and respiratory diseases were more likely to receive support to quit smoking by a healthcare provider or make a quit attempt than smokers without these diseases.

Methods: This population-based study included a sample of 6011 adult smokers in six European countries. The participants were interviewed face-to-face and asked questions on sociodemographic characteristics, current diagnoses for chronic diseases, healthcare visits in the last 12 months and, if so, whether they had received any support to quit smoking. Questions on smoking behavior included nicotine dependence, motivation to quit smoking and quit attempts in the last 12 months. The results are presented as weighted percentages with 95% confidence intervals (CI) and as adjusted odds ratios with 95% CI based on logistic regression analyses.

Results: Smokers with chronic respiratory disease, those aged 55 years and older, as well as those with one or more chronic diseases were more likely to receive smoking cessation advice from a healthcare professional. Making a quit attempt in the last year was related to younger age, high educational level, higher motivation to quit, lower nicotine dependence and having received advice to quit from a healthcare professional but not with having chronic diseases. There were significant differences between countries with smokers in Romania consistently reporting more support to quit as well as quit attempts.

Conclusions: Although smokers with respiratory disease did indeed receive smoking cessation support more often than smokers without disease, many smokers did not receive any advice or support to quit during a healthcare visit.

Citation

Driezen, P., Thompson, M.E., Fong, G.T., Demjén, T., Tountas, Y., Trofor, A., Przewoźniak, K., Zatónski, W.A., Fernández, F., Mons, U., Vardavas, C., on behalf of the EUREST-PLUS Consortium. (2019). Cross-border purchasing of cigarettes among smokers in six countries of the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 145-159.

Abstract

Introduction: The availability of lower-cost cigarettes in neighboring countries provides price-sensitive smokers with incentives to purchase cheaper out-of-country cigarettes. This study estimates the prevalence of and factors associated with cross-border purchasing of cheaper cigarettes among smokers from Germany, Greece, Hungary, Poland, Romania, and Spain. The prevalence of cross-border purchasing was estimated by residential location, defined as living in regions bordering a lower-price country (where prices were at least €1/pack lower), regions bordering a similar- or higher-price country, and internal non-border regions.

Methods: Data were from a survey of nationally representative samples of adult smokers (n=6011) from Germany, Greece, Hungary, Poland, Romania, and Spain. The primary outcome was purchasing cheaper out-of-country cigarettes in the previous six months. Residential location was defined using The Nomenclature of Territorial Units for Statistics (NUTS2 in Germany and NUTS3 in the other countries). Multivariable logistic regression tested differences in purchasing cheaper out-of-country cigarettes by country and residential location.

Results: Residential location was associated with purchasing cheaper out-of-country cigarettes in Germany and Poland (p<0.05): 31% of German and 11% of Polish smokers living in regions bordering lower-price countries reported purchasing cheaper out-of-country cigarettes in the previous six months. Smokers living in regions bordering lower-price countries had 4.21 times greater odds of purchasing cheaper out-of-country cigarettes compared to smokers living in non-border regions. Conclusions: Overall, only a minority of smokers in the six countries purchased cheaper cigarettes outside their country. However, smokers living in regions bordering countries where cigarettes were at least €1/pack lower than their home country had significantly higher odds of purchasing cheaper out-ofcountry cigarettes. This effect was especially prominent among German smokers. Tax harmonization policies designed to minimize crossborder price differentials can eliminate lower-priced alternatives for price-sensitive smokers.

Citation

East, K., Hitchman, S.C., McDermott, M., McNeill, A., Herbeć, A., Tountas, Y., Bécuwe, N., Demjén, T., Fu, M., Fernández, E., Mons, U., Trofor, A., Zatoński, W., Fong, G.T., Vardavas, C., on behalf of the EUREST-PLUS Consortium. (2019). Social norms towards smoking and electronic cigarettes among adult smokers in seven European Countries: Findings from the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 172-183.

Abstract

Introduction: This study explores whether current smokers’ social norms towards smoking and electronic cigarettes (e-cigarettes) vary across seven European countries alongside smoking and e-cigarette prevalence rates. At the time of surveying, England had the lowest current smoking prevalence and Greece the highest. Hungary, Romania and Spain had the lowest prevalence of any e-cigarette use and England the highest.

Methods: Respondents were adult (≥18 years) current smokers from the 2016 EUREST-PLUS ITC (Romania, Spain, Hungary, Poland, Greece, Germany) and ITC 4CV England Surveys (N=7779). Using logistic regression, associations between country and (a) smoking norms and (b) e-cigarette norms were assessed, adjusting for age, sex, income, education, smoking status, heaviness of smoking, and ecigarette status.

Results: Compared with England, smoking norms were higher in all countries: reporting that at least three of five closest friends smoke (19% vs 65–84% [AOR=6.9–24.0; Hungary–Greece]), perceiving that people important to them approve of smoking (8% vs 14–57% [1.9–51.1; Spain–Hungary]), perceiving that the public approves of smoking (5% vs 6–37% [1.7–15.8; Spain–Hungary]), disagreeing that smokers are marginalised (9% vs 16–50% [2.3–12.3; Poland–Greece]) except in Hungary. Compared with England: reporting that at least one of five closest friends uses e-cigarettes was higher in Poland (28% vs 36% [2.7]) but lower in Spain and Romania (28% vs 6–14% [0.3–0.6]), perceiving that the public approves of e-cigarettes was higher in Poland, Hungary and Greece (32% vs 36–40% [1.5–1.6]) but lower in Spain and Romania in unadjusted analyses only (32% vs 24–26%), reporting seeing e-cigarette use in public at least some days was lower in all countries (81% vs 12–55% [0.1–0.4]; Spain–Greece).

Conclusions: Smokers from England had the least pro-smoking norms. Smokers from Spain had the least pro-e-cigarette norms. Friend smoking and disagreeing that smokers are marginalised broadly aligned with country-level current smoking rates. Seeing e-cigarette use in public broadly aligned with countrylevel any e-cigarette use. Generally, no other norms aligned with product prevalence.

Citation

Fu, M., Castellano, Y., Tigova, O., Mons, U., Agar, T., Kyriakos, C.N., Trofor, A.C., Quah, A.C.K., Fong, G.T., Przewoźniak, K., Zatoński, W.A., Demjén, T., Tountas, Y., Vardavas, C.I., Fernández, E., on behalf of the EUREST-PLUS Consortium. (2019). Smoking in public places in six European countries: Findings from the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 203-209.

Abstract

Introduction: Surveillance of tobacco consumption in public places is an important measure to evaluate the impact of tobacco control interventions over time. The objective of this study was to estimate the prevalence of smoking as seen by smokers and their smoking behaviour in public places, in six European countries.

Methods: We used baseline data of the International Tobacco Control Six European countries (ITC 6E) Survey, part of the EUREST-PLUS Project, conducted in 2016 in national representative samples of about 1000 adult smokers aged 18 years and older in Germany, Greece, Hungary, Poland, Romania and Spain. For each setting (workplaces, restaurants, bars/pubs and discos) participants were asked whether they had seen someone smoking during their last visit there and whether they too had smoked there. We report the overall and by-country weighted prevalence of seeing someone smoking and the smokers’ own smoking behaviour at each setting. We also assess the relationship between seeing someone smoking and smoking themselves at these settings.

Results: The prevalence of smoking as seen by smokers was 18.8% at workplaces, with high variability among countries (from 4.7% in Hungary to 40.8% in Greece). Among smokers visiting leisure facilities in the last year, during their last visit 22.7% had seen someone smoking inside restaurants and 12.2% had smoked themselves there, while for bars/pubs the corresponding prevalences were 33.9% and 20.4%, and inside discos 44.8% and 34.8%.

Conclusions: Smoking is still prevalent at leisure facilities, particularly at discos in Europe, with high variability among countries. More extensive awareness campaigns and stricter enforcement are needed to increase the compliance of smokefree regulations, especially in leisure facilities.

Citation

Fu, M., Castellano, Y., Tigova, O., Mons, U., Agar, T., Kyriakos, C.N., Quah, A.C.K., Fong, G.T., Trofor, A.C., Przewoźniak, K., Zatoński, W.A., Demjén, T., Tountas, Y., Vardavas, C.I., Fernández, E., on behalf of the EUREST-PLUS Consortium. (2019). Correlates of the support for smoke-free policies among smokers: A cross-sectional study in six European countries of the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 193-202.

Abstract

Introduction: This report describes the support for smoke-free policies in different settings among smokers in six European countries and the relationship between their opinions about the places where smoking should be banned and their beliefs about the harms of secondhand smoke to non-smokers.

Methods: A cross-sectional survey (the ITC 6 European Country Survey, part of the EUREST-PLUS Project) was conducted using nationally representative samples of adult smokers in Germany, Greece, Hungary, Poland, Romania and Spain (n=6011). We describe the prevalence of agreement and support for smoke-free policies in different settings according to sociodemographics, smoking characteristics and beliefs about the danger of secondhand smoke to non-smokers.

Results: There was high agreement with smoking regulations in cars with preschool children and in schoolyards of primary/secondary schools (>90% overall) and low agreement with banning smoking in outdoor terraces of bars/pubs (8.6%; 95%CI: 7.5%-9.8%) and restaurants (10.1%; 95%CI: 8.9%-11.4%). The highest support for complete smoking bans inside public places came from smokers in Poland, among women, people aged ≥25 years, who had low nicotine dependence, and who tried to quit smoking in the last 12 months. About 78% of participants agreed that tobacco smoke is dangerous to nonsmokers, ranging from 63.1% in Hungary to 88.3% in Romania; the highest agreement was noted among women, the 25-54 age groups, those with higher education, low cigarette dependence, and those who tried to quit in the last 12 months. The support for complete smoking bans in public places was consistently higher among smokers who agreed that secondhand smoke is dangerous to non-smokers.

Conclusions: Smokers in six European countries declared strong support for smoke-free policies in indoor settings and in settings with minors but low support in outdoor settings, particularly leisure facilities. More education is needed to increase the awareness about the potential exposure to secondhand smoke in specific outdoor areas.