Citation

Tigova, O., Amalia, B., Castellano, Y., Fu, M., Nogueira, S.O., Kyriakos, C.N., Mons, U., Trofor, A., Zatoński, W.A., Przewoźniak, K., Demjén, T., Tountas, Y., Quah, A.C.K., Fong, G.T., Fernández, E., Vardavas, C.I., on behalf of the EUREST-PLUS Consortium. (2019). Secondhand exposure to e-cigarette aerosols among smokers: a cross-sectional study in six European countries of the EUREST-PLUS ITC Survey. Tobacco Induced Disease, 16(Suppl 2), 124-134.

Abstract

Introduction: Electronic cigarette (e-cigarette) use has grown significantly in some European Union (EU) Member States (MS). A better understanding of the exposure to secondhand e-cigarette aerosols (SHA) is necessary to develop and implement comprehensive regulations on e-cigarette use in public places. This study aims to assess the observation of e-cigarette use in public places, the self-reported exposure to SHA, and the level of users’ comfort using e-cigarettes in the presence of others.

Methods: This is a cross-sectional study of the Wave 1 International Tobacco Control 6 European Countries Survey recruiting adult smokers (n=6011) across six EU MS: Germany, Greece, Hungary, Poland, Romania, and Spain, within the EURESTPLUS Project. A descriptive analysis was conducted to estimate the prevalence (%) of observed e-cigarette use in different places, frequency of self-reported exposure to SHA, and level of comfort using e-cigarettes in the presence of others.

Results: In all, 31.0% of smokers observed others using e-cigarette in public places, 19.7% in indoor places where smoking is banned, and 14.5% indoors at work. Almost 37% of smokers reported to be ever exposed to SHA, ranging from 17.7% in Spain to 63.3% in Greece. The higher prevalence of observed ecigarette use and passive exposure to SHA was reported by smokers of younger age, of higher educational level and those being current or former e-cigarette users. Part (8.8%) of the smokers who were also e-cigarette users reported feeling uncomfortable using e-cigarettes in the presence of others.

Conclusions: A third of smokers from six EU MS reported being exposed to SHA. Prevalence differences were observed among the countries. In the context of scarce evidence on long-term health effects of exposure to SHA, precautionary regulations protecting bystanders from involuntary exposure should be developed.

Citation

Nogueira, S., Tigova, O., Castellano, Y., Mons, U., Kyriakos, C.N., McNeill, A., Trofor, A., Zatoński, W.A., Przwozniak, K., Demjén, T., Tountas, Y., Quah, A.C.K., Fong, G.T., Fu, M., Vardavas, C.I., Fernández, E., on behalf of the EUREST-PLUS Consortium. (2019). Cigarette brand loyalty among smokers in six European countries: findings from the EUREST-PLUS ITC Survey. Tobacco Induced Diseases, 16(Suppl 2), 135-144.

Abstract

Introduction: This study aims to describe the degree of smokers’ loyalty to a specific brand of tobacco products and the variables related to choosing a specific brand among smokers in six European countries.

Methods: A cross-sectional analysis was conducted for a representative sample of adult smokers from Germany, Greece, Hungary, Poland, Romania, and Spain (approximately 1000 smokers per country). The prevalence of smokers’ having a usual brand of cigarettes smoked (factory-made or roll-yourown cigarettes), the brand of choice, the factors for choosing a specific brand and the degree of loyalty to that brand (not at all, a little, somewhat and a lot) were assessed by country, sociodemographics and smoking-related variables.

Results: In total, 86.6% of the smokers reported having a usual brand. In three out of the six countries, one brand holds the loyalty of between 17.8% and 24.5% of the smokers that reported having a usual brand for factory-made cigarettes. Most participants reported being loyal ‘a lot’ to their brand of choice (44.4%). The reasons most reported for choosing a cigarette brand were the taste (83.2%) and the price (51.7%).

Conclusions: Brand loyalty is high among factory-made and roll-your-own cigarette smokers in six European countries. Future research on longitudinal trends of brand loyalty to evaluate the effect of tobacco control policies in these European countries is warranted.

Citation

Zatoński, M., Herbec, A., Zatoński, W., Przewoźniak, K., Janik-Koncewicz, K., Mons, U., Fong, G.T., Demjén, T., Tountas, Y., Trofor, A., Fernández, E., McNeill, A., Willemsen, M.C., Hummel, K., Quah, A.C.K., Kyriakos, C.N., Vardavas, C. (2018). Characterising smokers of menthol and flavoured cigarettes, their attitudes towards tobacco regulation, and the anticipated impact of the Tobacco Products Directive on their smoking and quitting behaviours: The EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 34-46.

Abstract

Introduction: Little research exists on the sociodemographic characteristics of menthol and flavoured cigarette (MFC) smokers in Europe. This study assessed the proportion of MFC smokers in Europe, their sociodemographic characteristics, and their attitudes towards tobacco control measures.

Methods: Cross-sectional data were collected in 2016 among 10760 adult current smokers from 8 European countries (ITC Europe Project and EUREST-PLUS). Smokers of menthol, other flavoured, unflavoured tobacco, or no usual brand were compared on sociodemographic characteristics, attitudes towards a range of tobacco control measures (e.g. ban on flavouring), and on intentions regarding their smoking behaviour following the ban on flavoured tobacco. Data were analysed in SPSS Complex Samples Package using univariate analyses.

Results: Among the respondents, 7.4% smoked menthol cigarettes and 2.9% other flavoured tobacco, but large differences existed between countries (e.g. 0.4% smokers smoked menthol cigarettes in Spain vs 12.4% in England). Compared to other groups, menthol cigarette smokers were younger, more likely to be female, better educated, had higher household income, and smoked fewer cigarettes (all p<0.001). A quarter of menthol smokers supported a ban on additives, compared with almost half of all other smokers (p<0.001). In case of a ban on flavourings, around a fifth of all MFC smokers intended to switch to another brand, and a third to reduce the amount they smoked or to quit smoking, but there was no consistent pattern across MFC smokers among the countries.

Conclusions: The ban on flavourings introduced by the EU Tobacco Products Directive (extended to 2020 for menthols) will affect one in ten smokers in the countries surveyed, which provides an opportunity for targeting these groups with cessation programmes. However, smokers of menthol and flavoured cigarettes in the different European countries are a heterogeneous group and may need different approaches.

Citation

Fu, M., Castellano, Y., Tigova, O., Kyriakos, C.N., Fong, G.T., Mons, U., Zatonzki, W.A., Agar, T., Quah, A.C.K., Trofor, A., Demjén, T., Przewoźniak, K., Tountas, Y., Vardavas, C., Fernández, E., on behalf of the EUREST-PLUS Consortium. (2018). Prevalence and correlates of different smoking bans in homes and cars among smokers in 6 countries of the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 85-97.

Abstract

Introduction: Second-hand smoke exposure has decreased in a number of countries due to widespread smoke-free legislation in public places, but exposure is still present in private settings like homes and cars. Our objective was to describe to what extent smokers implement smoking rules in these settings in six European Union (EU) Member States (MS).

Methods: A cross-sectional survey was conducted with a nationally representative sample of adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (ITC six European countries survey, part of the EUREST-PLUS Project). We analysed data from 6011 smokers regarding smoking rules in their homes and in cars with children (no rules, partial ban, total ban). We described the prevalence of smoking rules by EU MS and several sociodemographic and smoking characteristics using prevalence ratios (PR) and 95% confidence intervals (CI) derived from Poisson regression models.

Results: In homes, 26.5% had a total smoking ban (from 13.1% in Spain to 35.5% in Hungary), 44.7% had a partial ban (from 41.3% in Spain to 49.9% in Greece), and 28.8% had no-smoking rules (from 20.2% in Romania to 45.6% in Spain). Prevalence of no-smoking rules in cars with children was 16.2% (from 11.2% in Germany to 20.4% in Spain). The correlates of not restricting smoking in homes and cars included: low education (PR=1.51; 95%CI: 1.20-1.90 and PR=1.55; 95%CI: 1.09-2.20), smoking >30 cigarettes daily (PR=1.53; 95%CI: 1.10-2.14 and PR=2.66; 95%CI: 1.40-5.05) and no attempts to quit ever (PR=1.18; 95%CI: 1.06-1.31 and PR=1.28; 95%CI: 1.06-1.54).

Conclusions: Among smokers in six EU MS, no-smoking rules were more prevalent in homes than in cars with children. Whilst awareness about the health effects of exposure to tobacco smoke on children seemed to be high, more research is needed to better understand the factors that promote private smoke-free environments.

Citation

Kyriakos, C.N., Filippidis, F., Hitchman, S.C., Girvalaki, C., Tzavara, C.K., Demjén, T., Fernández, E., Mons, U., Trofor, A., Tountas, Y., Zatoński, M., Zatoński, W., Fong, G.T., Vardavas, C., on behalf of the EUREST-PLUS Consortium. (2018). Characteristics and correlates of electronic cigarette product attributes and undesirable events during e-cigarette use in six countries of the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 21-33

Abstract

Introduction: This study assessed characteristics and correlates associated with e-cigarette product attributes and identified correlates of experiencing undesirable events during e-cigarette use among adult smokers across six European Union (EU) Members States (MS) prior to the implementation of the Tobacco Products Directive (TPD) in 2016.

Methods: We conducted a cross-sectional survey with a nationally representative sample of adult cigarette smokers from six EU MS (Germany, Greece, Hungary, Poland, Romania, Spain) reporting e-cigarette use; randomly selected through a multistage cluster sampling design from June to September 2016. Stepwise logistic regressions were used to identify factors associated with use of flavors, noticing health warnings, mixing e-liquids, experiencing ‘dry puff’, e-liquid leaking during use and e-liquid spilling during refill.

Results: Current daily or weekly prevalence of e-cigarette use among this sample of adult smokers was 7.5%. The most common attributes of e-cigarettes used included those that are flavored, contain nicotine, and are of tank style. Noticing health warnings on e-cigarette packaging and leaflets, respectively, was low (10.2% and 28%, respectively). Use of e-liquid refill nozzle caps, described as easy for a child to open, was associated with spilling during refill (OR=6.73; 95% CI: 2.02–22.37). Participants who adjusted occasionally or regularly the power (voltage) or temperature of their e-cigarette had greater odds of ever experiencing a ‘dry puff’ (OR=6.01; 95% CI: 2.68–13.46). Mixing different e-liquids was associated with leaking during use (OR=7.78; 95% CI: 2.45–24.73) and spilling during refill (OR=8.54; 95% CI: 2.29–31.88).

Conclusions: Ongoing evaluation of factors associated with e-cigarette attributes and of the correlates of experiencing e-cigarette undesirable events during use, related to product design, is crucial to monitoring the impact of the implementing Acts of the EU TPD.

Citation

Hummel, K., Nagelhout, G.E., Fong, G.T., Vardavas, C., Papadakis, S., Herbec, A., Mons, U., van den Putte, B., Borland, R., Fernández, E., de Vries, H., McNeill, A., Gravely, S., Przewoźniak, K., Kovacs, P., Trofor, A., Willemsen, M.C., on behalf of the EUREST-PLUS Consortium. (2018). Quitting activity and use of cessation assistance reported by smokers in eight European countries: Findings from the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 57-73.

Abstract

Introduction: There is clear evidence that the use of cessation aids significantly increases the likelihood of successful smoking cessation. The aim of this study was to examine quitting activity and use of cessation aids among smokers from various European countries. Subgroup differences were also examined for sex, income, education, and age in each country.

Methods: Cross-sectional data were collected in 2016 from 10683 smokers in eight European countries participating in the ITC Project: England (n=3536), Germany (n=1003), Greece (n=1000), Hungary (n=1000), the Netherlands (n=1136), Poland (n=1006), Romania (n=1001), and Spain (n=1001). We measured quitting activity, including quit attempts in the previous 12 months and intention to quit, use of cessation aids (i.e. medication, quitlines, internet, local services, e-cigarettes), and whether respondents had received advice from health professionals about quitting and e-cigarettes.

Results: Quit attempts were most common in England (46.3%) and least common in Hungary (10.4%). Quit intention was highest in England and lowest in Greece. Use of e-cigarettes to quit was highest in England (51.6%) and lowest in Spain (5.0%). Use of cessation aids was generally low across all countries; in particular this was true for quitlines, internet based support, and local services. Receiving health professional advice to quit was highest in Romania (56.5%), and lowest in Poland (20.8%); few smokers received advice about e-cigarettes from health professionals. No clear differences were found for sex and income groups. Across countries, smokers with lower education reported less quitting activity.

Conclusions: Quitting activity and use of cessation methods were low in most countries. Greater quit attempts and use of cessation aids were found in England, where large investments in tobacco control and smoking cessation have been made. Health professionals are important for motivating smokers to quit and promoting the effectiveness of various methods, but overall, few smokers get advice to quit.

Citation

Nogueira, S., McNeill, A., Fu, M., Kyriakos, C.N., Mons, U., Fernández, E., Zatoński, W., Trofor, A., Demjén, T., Tountas, Y., Przwozniak, K., Quah, A.C.K., Fong, G.T., Hitchman, S.C., Vardavas, C., on behalf of the EUREST-PLUS Consortium. (2018). Impact of anti-smoking advertising on health-risk knowledge and quit attempts across 6 European countries from the EUREST-PLUS ITC Europe Survey. Tobacco Induced Diseases, 16(Suppl 2), 47-56.

Abstract

Introduction: Exposure to anti-smoking advertising and its effects differ across countries. This study examines the reported exposure to anti-smoking advertising among smokers and its relation to knowledge of smoking harms and quit attempts in six European countries.

Methods: Data come from Wave 1 of the International Tobacco Control (ITC) 6 European Country (6E) Survey (Germany, Greece, Hungary, Poland, Romania, Spain) carried out among smokers between June and September 2016 (n=6011). Key measures included whether participants had noticed anti-smoking advertising in the last six months in 6 different channels, their knowledge of 13 adverse smoking/second-hand smoking health effects and if they had made at least one quit attempt in the last 12 months. Multivariate logistic regression models were used in the analysis.

Results: Across the six countries, only 35.2% of smokers reported being exposed to any anti-smoking advertising. Television was the most common channel identified (25.7%), followed by newspapers and magazines (13.8%), while social media were the least reported (9.5%). Participants 18–24 years old were significantly more likely to have noticed advertisements on the Internet than participants >55 years old (24.3% vs 4.9%; OR=5.15). Participants exposed to anti-smoking advertising in all six channels were twice more likely to have a higher knowledge of smoking risks than those not exposed (2.4% vs 97.6%, respectively; OR=2.49). The likelihood of making a quit attempt was increased by 10% for each additional channel through which smokers were exposed to anti-smoking advertising.

Conclusions: Knowledge of health risks of smoking tended to be higher in countries that aired a campaign in recent years. Exposure to anti-smoking advertising, in the six channels combined, was related to higher smoking knowledge of risks and to more quit attempts. Future anti-smoking mass media campaigns should consider advertising in all dissemination channels to increase the awareness of the dangers of smoking.

Citation

Petroulia, I., Kyriakos, C.N., Papadakis, S., Tzavara, C.K., Filippidis, F., Girvalaki, C., Peleki, T., Katsaounou, P., McNeill, A., Mons, U., Fernández, E., Demjén, T., Trofor, A., Herbec, A., Zatoński, W., Tountas, Y., Fong, G.T., Vardavas, C., on behalf of the EUREST-PLUS Consortium. (2018). Patterns of tobacco use, quit attempts, readiness to quit and self-efficacy among smokers with anxiety or depression: Findings among six European Union Member States. Tobacco Induced Diseases, 16(Suppl 2), 98-110.

Abstract

Introduction: We compared smoking behaviors, past quit attempts, readiness to quit and beliefs about quitting among current cigarette smokers with probable anxiety or depression (PAD) to those without PAD, from six European Union (EU) Member States (MS).

Methods: A nationally representative cross-sectional sample of 6011 adult cigarette smokers from six EU MS (Germany, Greece, Hungary, Poland, Romania, Spain) was randomly selected through a multistage cluster sampling design in 2016. Respondents were classified as having PAD based on self-reported current diagnosis or treatment for anxiety or depression, or a positive screen for major depression, according to a validated two-item instrument. Sociodemographic characteristics, patterns of tobacco use, past quitting, readiness to quit, self-efficacy and beliefs about quitting were assessed for patients with and without PAD. Logistic regression was used to examine predictors of PAD. All analyses were conducted using the complex samples package of SPSS.

Results: Among smokers sampled, 21.0% (95% CI: 19.3–22.9) were identified as having PAD. Logistic regression analyses controlling for socioeconomic variables and cigarettes smoked per day found smokers with PAD were more likely to have made an attempt to quit smoking in the past (AOR=1.48; 95% CI: 1.25–1.74), made a quit attempt in the last 12 months (AOR=1.75; 95% CI: 1.45–2.11), and report lower self-efficacy with quitting (AOR=1.83; 95% CI: 1.44–2.32) compared to smokers without PAD. Additionally, it was found that individuals with PAD were more likely to report having received advice to quit from a doctor or health professional and having used quitline support as part of their last quit attempt.

Conclusions: Smokers with PAD report a greater interest in quitting in the future and more frequent failed quit attempts than smokers without PAD; however, the high rates of untreated anxiety or depression, nicotine dependence, low confidence in the ability to quit, infrequent use of cessation methods, as well as socioeconomic factors may make quitting difficult.

Citation

Fong, G.T., Thompson, M.E., Boudreau, C., Bécuwe, N., Driezen, P., Agar, T.K., Quah, A.C.K., Zatoński, W., Przewoźniak, K., Mons, U., Demjén, T., Tountas, Y., Trofor, A., Fernández, E., McNeill, A., Willemsen, M., Vardavas, C., on behalf of the EUREST-PLUS Consortium. (2018). The conceptual model and methods of Wave 1 (2016) of the EUREST-PLUS ITC 6 European Countries Survey. Tobacco Induced Diseases, 16(Suppl 2), 11-20.

Abstract

Population-level interventions represent the only real approach for combatting the tobacco epidemic. There is thus great importance in conducting rigorous evaluation studies of tobacco control policies and regulations such as those arising from the WHO Framework Convention on Tobacco Control (FCTC) and the European Union’s 2014 Tobacco Products Directive (TPD). The ITC 6 European Countries Survey, a component of the Horizon 2020 Project entitled European Regulatory Science on Tobacco: Policy Implementation to Reduce Lung Disease (EUREST-PLUS), was created to evaluate and impact of the TPD in six EU Member States: Germany, Greece, Hungary, Poland, Romania, and Spain. In each country, a cohort survey of a representative national sample of 1000 smokers was conducted. This paper describes the conceptual model, methodology, and initial survey statistics of Wave 1 of the ITC 6E Survey, which was conducted June–September 2016. The ITC 6E Survey’s conceptual model, methodology, and survey instrument, were based on the broader 29-country ITC Project cohort studies, which have been conducted since 2002. The commonality of methods and measures allow a strong potential for cross-country comparisons between the 6 EU countries of the ITC 6E Project and 3 other EU countries (England, France, The Netherlands) in the ITC Project, as well as the broader set of ITC countries outside the EU.

Citation

Vardavas, C., Bécuwe, N., Demjén, T., Fernández, E., McNeill, A., Mons, U., Tountas, Y., Trofor, A., Tsatsakis, A., Rohde, G., Willemsen, M.C., Prezewozniak, K., Zatoński, W., Fong, G.T., on behalf of the EUREST-PLUS Consortium. (2018). Study protocol of European Regulatory Science on Tobacco (EUREST-PLUS): policy implementaton to reduce lung disease. Tobacco Induced Diseases, 16(Suppl 2), 3-10.

Abstract

Efforts to mitigate the devastation of tobacco-attributable morbidity and mortality in the European Union (EU) are founded on its newly adopted Tobacco Products Directive (TPD) along with the first-ever health treaty, the WHO Framework Convention on Tobacco Control (FCTC). The aim of this Horizon 2020 Project entitled European Regulatory Science on Tobacco: Policy Implementation to Reduce Lung Disease (EURESTPLUS) is to monitor and evaluate the impact of the implementation of the TPD across the EU, within the context of WHO FCTC ratification. To address this aim, EUREST-PLUS consists of four objectives: 1) To create a cohort study of 6000 adult smokers in six EU MS (Germany, Greece, Hungary, Poland, Romania, Spain) within a pre-TID vs post- TPD implementation study design; 2) To conduct secondary dataset analyses of the Special Eurobarometer on Tobacco Survey (SETS); 3) To document changes in e-cigarette product parameters (technical design, labelling/packaging and chemical composition) pre-TID vs post-TPD; and 4) To enhance innovative joint research collaborations on chronic non-communicable diseases. Through this methodological approach, EUREST-PLUS is designed to generate strong inferences about the effectiveness of tobacco control policies, as well as to elucidate the mechanisms and factors by which policy implementation translates to population impact. Findings from EUREST-PLUS have potential global implications for the implementation of innovative tobacco control policies and its impact on the prevention of lung diseases.

Citation

Kahnert, S., Demjén, T., Tountas, Y., Trofor, A., Przewoźniak, K., Zatónski, W.A., Fernández, E., McNeill, A., Willemsen, M.C., Kyriakos, C.N., Fong, G.T., Vardavas, C. Mons, U., on behalf of the EUREST-PLUS Consortium. (2018). Extent and correlates of self-reported exposure to tobacco advertising, promotion, and sponsorship in smokers: findings from the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 74-84.

Abstract

Introduction: Tobacco advertising, promotion and sponsorship (TAPS) are known to promote tobacco consumption and to discourage smoking cessation. Consequently, comprehensive TAPS bans are effective measures to reduce smoking. The objective of this study was to investigate to what extent smokers are exposed to TAPS in general, and in various media and localities, in different European countries.

Methods: A cross-sectional analysis of national representative samples of adult smokers in 2016 from Germany, Greece, Hungary, Poland, Romania, and Spain (EUREST-PLUS Project, n=6011), as well as England (n=3503) and the Netherlands (n=1213) (ITC Europe Surveys) was conducted. Prevalence of self-reported TAPS exposure is reported by country, and socioeconomic correlates were investigated using logistic regression models.

Results: Self-reported exposure to TAPS varied widely among the countries, from 15.4 % in Hungary to 69.2 % in the Netherlands. In most countries, tobacco advertising was most commonly seen at the point of sale, and rarely noticed in mass media. The multivariate analysis revealed some variation in exposure to TAPS by sociodemographic factors. Age showed the greatest consistency across countries with younger smokers (18–24 years) being more likely to notice TAPS than older smokers.

Conclusions: TAPS exposure tended to be higher in countries with less restrictive regulation but was also reported in countries with more comprehensive bans, although at lower levels. The findings indicate the need for a comprehensive ban on TAPS to avoid a shift of marketing efforts to less regulated channels, and for stronger enforcement of existing bans.

Citation

Trofor, A., Papadakis, S., Lotrean, L.M., Radu-Loghin, C., Eremia, M., Mihaltan, F., Driezen, P., Kyriakos, C.N., Mons, U., Demjén, T., Nogueira, S.O., Fernández, E., Tountas, Y., Przewoźniak, K., McNeill, A., Fong, G.T., Vardavas, C., on behalf of the EUREST-PLUS Consortium. (2018). Knowledge of the health risks of smoking and impact of cigarette warning labels among tobacco users in six European countries. Tobacco Induced Diseases, 16(Suppl 2), 111-123.

Abstract

Introduction: The aim of this study was to examine knowledge of health effects of smoking and the impact of cigarette package warnings among tobacco users from six European Union (EU) Member States (MS) immediately prior to the introduction of the EU Tobacco Products Directive (TPD) in 2016 and to explore the interrelationship between these two factors.

Methods: Cross-sectional data were collected via face-to-face interviews with adult smokers (n=6011) from six EU MS (Germany, Greece, Hungary, Poland, Romania, Spain) between June–September 2016. Sociodemographic variables and knowledge of health risks of smoking (KHR) were assessed. Warning salience, thoughts of harm, thoughts of quitting and foregoing of cigarettes as a result of health warnings were assessed. The Label Impact Index (LII) was used as a composite measure of warning effects. Linear and logistic regression analyses were used to examine sociodemographic predictors of KHR and LII and the inter-relationship between knowledge and LII scores.

Results: The KHR index was highest in Romania and Greece and lowest in Hungary and Germany. While the majority of smokers knew that smoking increases the risk for heart diseases, lung and throat cancer, there was lower awareness that tobacco use caused mouth cancer, pulmonary diseases, stroke, and there were very low levels of knowledge that it was also associated with impotence and blindness, in all six countries. Knowledge regarding the health risks of passive smoking was moderate in most countries. The LII was highest in Romania and Poland, followed by Spain and Greece, and lowest in Germany and Hungary. In almost all countries, there was a positive association between LII scores and higher KHR scores after controlling for sociodemographic variables. Several sociodemographic factors were associated with KHR and LII, with differences in these associations documented across countries.

Conclusions: These data provide evidence to support the need for stronger educational efforts and policies that can enhance the effectiveness of health warnings in communicating health risks and promoting quit attempts. Data will serve as a baseline for examining the impact of the TPD.