Citation

Gravely, S., Cummings, K.M., Hammond, D., Lindblom, E., Smith, D.M., Martin, N., Loewen, R., Borland, R., Hyland, A., Thompson, M.E., Boudreau, C., Kasza, K.A., Ouimet, J., Quah, A.C.K., O’Connor, R.J., Fong, G.T. (2020). The association of e-cigarette flavors with satisfaction, enjoyment, and trying to quit or stay abstinent from smoking among regular adult vapers from Canada and the United States: Findings from the 2018 ITC Four Country Smoking and Vaping Survey. Nicotine and Tobacco Research, 22(10), 1831-1841.

Abstract

Introduction: This study examined whether non-tobacco flavors are more commonly used by vapers (ecigarette users) compared to tobacco flavor, described which flavors are most popular, and tested whether flavors are associated with: vaping satisfaction relative to smoking, level of enjoyment with vaping, reasons for using e-cigarettes, and making an attempt to quit smoking by smokers.

Methods: This cross sectional study included 1,603 adults from Canada and the US who vaped at least weekly, and were either current smokers (concurrent users) or former smokers (exclusive vapers). Respondents were categorized into one of seven flavors they used most in the last month: tobacco, tobacco-menthol, unflavored, or one of the non-tobacco flavors: menthol/mint, fruit, candy, or ‘other’ (e.g. Coffee).

Results: Vapers use a wide range of flavors, with 63.1% using a non-tobacco flavor. The most common flavor categories were fruit (29.4%) and tobacco (28.7%), followed by mint/menthol (14.4%) and candy (13.5%). Vapers using candy (41.0%, p<0.0001) or fruit flavors (26.0%, p=0.01) found vaping more satisfying (compared to smoking) than vapers using tobacco flavor (15.5%) and rated vaping as very/extremely enjoyable (fruit: 50.9%; candy: 60.9%) than those using tobacco flavor (39.4%). Among concurrent users, those using fruit (74.6%, p=0.04) or candy flavors (81.1%, p=0.003) were more likely than tobacco flavor users (63.5%) to vape in order to quit smoking. Flavor category was not associated with the likelihood of a quit attempt (p=0.46). Among exclusive vapers, tobacco and non-tobacco flavors were popular; however, those using tobacco (99.0%) were more likely than those using candy (72.8%, p=0.002) or unflavored (42.5%, p=0.005) to vape in order to stay quit.

Conclusions: A majority of regular vapers in Canada and the US use non-tobacco flavors. Greater satisfaction and enjoyment with vaping is higher among fruit and candy flavor users. While it does not appear that certain flavors are associated with a greater propensity to attempt to quit smoking among concurrent users, non-tobacco flavors are popular among former smokers who are exclusively vaping. Future research should determine the likely impact of flavor bans on those who are vaping to quit smoking or to stay quit.

Implications: Recent concerns about the attractiveness of e-cigarette flavors among youth have resulted in flavor restrictions in some jurisdictions of the United States and Canada. However, little is known about

the possible consequences for current and former smokers if they no longer have access to their preferred flavors. This study shows that a variety of nontobacco flavors, especially fruit, are popular among adult vapers, particularly among those who have quit smoking and are now exclusively vaping. Limiting access to flavors may therefore reduce the appeal of e-cigarettes among adults who are trying to quit smoking or stay quit.

Citation

Li, L., Borland, R., Cummings, K.M., McNeill, A., Heckman, B.W., Fong, G.T., O’Connor, R.J., Driezen, P. (2020). Are health conditions and concerns about health effects of smoking predictive of quitting? Findings from the ITC 4CV Survey (2016-2018). Tobacco Prevention & Cessation, 6(October), 60.

Abstract

Introduction:

Limited research has investigated the relationship between multiple health conditions and subsequent quitting activities at the population level. This study examines whether nine health conditions and concerns related to smoking are predictive of quit attempts and success among those who tried.

Methods:

Data came from the International Tobacco Control Four Country Smoking and Vaping Survey conducted in Australia, Canada, England and the US. A total of 3998 daily smokers were surveyed in 2016 and recontacted in 2018. Respondents were asked in 2016 whether they had a medical diagnosis for depression, anxiety, alcohol problems, obesity, chronic pain, diabetes, heart disease, cancer, and chronic lung disease, and whether they had concerns about past/future health effects of smoking. Outcomes were quit attempts and success (having been abstinent for at least one month between surveys).

Results:

Across all four countries, 44.4% of smokers tried to quit between the two survey years, and of these 36.8% were successful. Concerns about past (adjusted odds ratio, AOR=1.66, 95% CI: 1.32–2.08, p<0.001) and future effects of smoking (AOR=2.17, 95% CI: 1.62–2.91, p<0.001) and most health conditions predicted quit attempts, but were mostly unrelated to quit success, with concerns about future effects (AOR=0.59, 95% CI: 0.35–0.99, p<0.05), chronic lung conditions (AOR=0.56, 95% CI: 0.37–0.86, p<0.01) and chronic pain (with a trend) being associated with lower success.

Conclusions:

Having a major chronic health condition does, generally, motivate making quit attempts, but in some cases it is associated with failure among those who try. More effective cessation support is required for these high priority groups.

Citation

Gravely, S., Meng, G., Cummings, K.M., Hyland, A., Borland, R., Hammond, D., O’Connor, R.J., Goniewicz, M., Kasza, K.A., McNeill, A., Thompson, M.E., Hitchman, S.C., Levy, D., Thrasher, J.F., Quah, A.C.K., Martin, N., Ouimet, J., Boudreau, C., Fong, G.T. (2020). Changes in smoking and vaping over 18 months among smokers and recent ex-smokers: Longitudinal findings from the 2016 and 2018 ITC Four Country Smoking and Vaping Surveys. International Journal of Environmental Research and Public Health, 17(19), E7084.

Abstract

This descriptive study of smokers (smoked at least monthly) and recent ex-smokers (quit for ≤2 years) examined transitions over an 18 month period in their smoking and vaping behaviors. Data are from Waves 1 (W1: 2016) and 2 (W2: 2018) of the ITC Four Country Smoking and Vaping Survey, a cohort study of adult (≥18+) smokers, concurrent users (smoke and vape), and recent ex-smokers from Australia, Canada, England, and the United States (US). Respondents (N = 5016) were classified according to their smoking and vaping status, which resulted in eight subgroups: (1) exclusive daily smokers (2) exclusive non-daily smokers; (3–6) concurrent users (subdivided into four groups by each combination of daily/non-daily smoking and daily/non-daily vaping); (7) ex-smokers who vape; (8) ex-smokers not vaping. The analyses focused first on describing changes between groups from W1 to W2. Second, transition outcomes were assessed based on changes in smoking and vaping between W1 and W2. Transitions focused on smoking were: no change in smoking (continued smoking at the same frequency); decreased smoking; increased smoking; discontinued smoking; relapsed (ex-smokers at W1 who were smoking at W2). Transitions focused on vaping were: initiated vaping; switched from smoking to vaping. Overall, this study found that the vast majority of smokers were smoking 18 months later. Non-daily smokers were more likely than daily smokers to have discontinued smoking (p < 0.0001) and to have switched to exclusive vaping (p = 0.034). Exclusive non-daily smokers were more likely than exclusive daily smokers to have initiated vaping (p = 0.04). Among all W1 daily smokers, there were no differences in discontinued smoking between daily smokers who vaped (concurrent users) and exclusive daily smokers; however, concurrent users were more likely than exclusive daily smokers to have decreased to non-daily smoking (p < 0.001) or to have switched to vaping by W2 (p < 0.001). Among all W1 non-daily smokers, there were no significant differences in increased smoking or discontinued smoking between concurrent users or exclusive smokers. Most ex-smokers remained abstinent from smoking, and there was no difference in relapse back to smoking between those who vaped and those who did not.

Citation

Sutanto, E., Miller, C., Smith, D.M., O’Connor, R.J., Gravely, S., Hammond, D., Hyland, A., Cummings, K.M., Quah, A.C.K., Fong, G.T., Agar, T.K., Goniewicz, M. (2020). Perceived relative harm of heated tobacco products (IQOS), e-cigarettes, and cigarettes among adults in Canada: Findings from the ITC Project. Tobacco Induced Diseases, 18(September), 81.

Abstract

Introduction:

Tobacco companies have introduced heated tobacco products (HTPs), such as IQOS, which may compete with e-cigarettes among smokers interested in switching to potentially reduced-risk products. Non-smokers may also start using IQOS if they believe this product is less harmful than other nicotine products. Smokers' and non-smokers' decisions may be driven by relative harm perceptions of emerging nicotine products. We aimed to examine relative harm perceptions between IQOS, e-cigarettes, and cigarettes, among nicotine product users and non-users.

Methods:

We conducted a web survey with Canadian respondents (aged >/ 20 years; n=268) in September-October 2018. Perceptions about relative harm between IQOS (available for sale since 2017 and subject to the same comprehensive marketing restrictions as cigarettes in Canada), e-cigarettes, and cigarettes, were assessed among nonusers (n=79), exclusive smokers (n=78), exclusive e-cigarette users (n=32), and dual users (n=79). Multiple logistic regression explored the association between relative harm perceptions and nicotine-use status, adjusting for sociodemographic variables.

Results:

Over half of respondents perceived IQOS as equally or more harmful than e-cigarettes (53.7%), while almost a quarter either reported IQOS as less harmful than e-cigarettes or were uncertain (22.7% and 23.5%, respectively). Two-thirds of respondents (65.7%) perceived e-cigarettes as less harmful than cigarettes, yet only half (48.1%) perceived IQOS as less harmful than cigarettes. Both exclusive and dual e-cigarette users, but not exclusive smokers, had higher odds of perceiving IQOS as more harmful than e-cigarettes and less harmful than cigarettes compared to non-users.

Conclusions:

Most nicotine users and non-users perceive differential health risk across IQOS, e-cigarettes, and cigarettes. Although e-cigarettes are generally viewed as less harmful than cigarettes, the perceived harm of IQOS was unclear.

Citation

Aleyan, S., Driezen, P., McNeill, A., McDermott, M., Kahnert, S., Kyriakos, C.N., Mons, U., Fernández, E., Trofor, A.C., Zatoński, M., Demjén, T., Katsaounou, P.A., Przewoźniak, K., Balmford, J., Filippidis, F.T., Fong, G.T., Vardavas, C.I., Hitchman, S.C. (2020). Evaluating the impact of introducing standardized packaging with larger health warning labels in England: Findings from adult smokers within the EURESTPLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl 3), iii91-iii97.

Abstract

Introduction: The European (EU) Tobacco Product Directive (TPD) was implemented in May 2016 to regulate the design and labelling of cigarettes and roll-your-own tobacco. At the same time, the UK introduced standardized packaging measures, whereas Germany, Greece, Hungary, Poland, Romania and Spain did not. This study examines the impact of introducing standardized packaging in England using a quasi-experimental design.

Material and Methods: Data from adult smokers in Waves 1 (2016; N=9547) and 2 (2018; N=9724) from the International Tobacco Control Policy Evaluation surveys (England) and EUREST-PLUS surveys (Germany, Greece, Hungary, Poland, Romania and Spain) were used. Generalized estimating equations were used to estimate changes in pack/brand appeal, salience of health-warning labels (HWLs) and perceived relative harm of different brands in England (where larger HWLs and standardized packaging were implemented), vs. each EU country (where only larger HWLs were implemented).

Results: There was an increase in the percentage of respondents from Germany, Hungary and Poland reporting they did not like the look of the pack (4.7%, 9.6%, and 14.2%, respectively), but the largest increase was in England (41.0%). Moreover, there was a statistically significant increase in the salience of HWLs in Hungary, Poland and Romania (17.0%, 13.9%, and 15.3%, respectively), but the largest increase was in England (27.6%). Few differences were observed in cross-country comparisons of the perceived relative harm of different brands.

Conclusions: Findings suggest that standardized packaging reduces pack appeal and enhances the salience of HWLs over and above the effects of larger HWLs. Findings provide additional evidence and support for incorporating standardized packaging into the EU TPD.

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

Chung-Hall, J., Fong, G.T., Vardavas, C.I., Meng, G., Craig, L., McNeill, A., Hitchman, S.C., Fernández, E., Mons, U., Trofor, A.C., Przewoźniak, K., Zatoński, W.A., Demjén, T., Katsaounou, P.A., Kyriakos, C.N. (2020). Support for e-cigarette policies among smokers in seven European countries: Longitudinal findings from the 2016–18 EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl 3), iii68-iii77.

Abstract

Background:

The 2016 European Tobacco Products Directive (TPD) required Member States (MS) to implement new regulations for electronic cigarettes (ECs). We conducted a longitudinal study to assess changes over 2 years in smokers’ support for EC policies and identify predictors of support in seven European countries after TPD implementation.

Methods:

Prospective cohort surveys were conducted among adult smokers in Germany, Greece, Hungary, Poland, Romania, Spain and England in 2016 (n = 9547; just after TPD) and 2018 (n = 10 287; 2 years after TPD). Multivariable logistic regression models employing generalized estimating equations assessed changes in support for four EC policies, and tested for country differences and strength of key predictors of support.

Results:

Banning EC use in smoke-free places was supported by 53.1% in 2016 and 54.6% in 2018 with a significant increase in Greece (51.7–66.0%) and a decrease in Spain (60.1–48.6%). Restricting EC/e-liquid nicotine content was supported by 52.2 and 47.4% in 2016 and 2018, respectively, with a significant decrease in England (54.2–46.5%) and Romania (52.5–41.0%). An EC promotion ban was supported by 41.1 and 40.2%. A flavour ban was supported by 33.3% and 32.3% with a significant increase in Hungary (34.3–43.3%). Support was generally higher in Poland, Hungary and Greece vs. England. Support was lower among dual and EC-only users, and low-income smokers.

Conclusions:

Smokers in all countries strongly supported banning EC use in smoke-free places and restricting nicotine content after TPD implementation, with no clear trends for changes in policy support.

Citation

Gravely, S., Driezen, P., Kyriakos, C.N., Thompson, M.E., Balmford, J., Demjén, T., Fernández, E., Mons, U., Tountas, Y., Janik-Koncewicz, K., Zatoński, W.A., Trofor, A.C., Vardavas, C.I., Fong, G.T. (2020). European adult smokers’ perceptions of the harmfulness of e-cigarettes relative to combustible cigarettes: Cohort findings from the 2016 and 2018 EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl_3), iii26-iii33.

Abstract

Background:

This study presents perceptions of the harmfulness of electronic cigarettes (e-cigarettes) relative to combustible cigarettes among smokers from six European Union (EU) countries, prior to the implementation of the EU Tobacco Products Directive (TPD), and 2 years post-TPD.

Methods:

Data were drawn from the EUREST-PLUS ITC Europe Surveys, a cohort study of adult smokers (≥18 years) from Germany, Greece, Hungary, Poland, Romania and Spain. Data were collected in 2016 (pre-TPD: N = 6011) and 2018 (post-TPD: N = 6027). Weighted generalized estimating equations were used to estimate perceptions of the harmfulness of e-cigarettes compared to combustible cigarettes (less harmful, equally harmful, more harmful or 'don't know').

Results:

In 2016, among respondents who were aware of e-cigarettes (72.2%), 28.6% reported that they perceived e-cigarettes to be less harmful than cigarettes (range 22.0% in Spain to 34.1% in Hungary). In 2018, 72.2% of respondents were aware of e-cigarettes, of whom 28.4% reported perceiving that e-cigarettes are less harmful. The majority of respondents perceived e-cigarettes to be equally or more harmful than cigarettes in both 2016 (58.5%) and 2018 (61.8%, P > 0.05). Overall, there were no significant changes in the perceptions that e-cigarettes are less, equally or more harmful than cigarettes, but 'don't know' responses significantly decreased from 12.9% to 9.8% (P = 0.036). The only significant change within countries was a decrease in 'don't know' responses in Spain (19.3-9.4%, P = .001).

Conclusions:

The majority of respondents in these six EU countries perceived e-cigarettes to be equally or more harmful than combustible cigarettes.

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

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

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

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

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

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

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

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

Edwards, R., Stanley, J., Waa, A., White, M., Kaai, S.C., Ouimet, J., Quah, A.C.K., Fong, G.T. (2020). Patterns of use of vaping products among smokers: Findings from the 2016-2018 ITC New Zealand Surveys. International Journal of Environmental Research and Public Health, 17(18), 6629.

Abstract

Alternative nicotine products like e-cigarettes could help achieve an end to the epidemic of ill health and death caused by smoking. However, in-depth information about their use is often limited. Our study investigated patterns of use of e-cigarettes and attitudes and beliefs among smokers and ex-smokers in New Zealand (NZ), a country with an ‘endgame’ goal for smoked tobacco. Data came from smokers and ex-smokers in Waves 1 and 2 of the International Tobacco Control (ITC) NZ Survey (Wave 1 August 2016–April 2017, 1155 participants; Wave 2, June–December 2018, 1020 participants). Trial, current and daily use of e-cigarettes was common: daily use was 7.9% among smokers and 22.6% among ex-smokers in Wave 2, and increased between surveys. Use was commonest among 18–24 years and ex-smokers, but was similar among Māori and non-Māori participants, and by socio-economic status. Most participants used e-cigarettes to help them quit or reduce their smoking. The most common motivating factor for use was cost and the most common barrier to use cited was that e-cigarettes were less satisfying than smoking. The findings could inform developing interventions in order to maximize the contribution of e-cigarettes to achieving an equitable smoke-free Aotearoa, and to minimize any potential adverse impacts.

Citation

Soneji, S., Knutzen, K.E., Gravely, S., Elton-Marshall, T., Sargent, J., Lambert, E., Hilmi, N., Sharma, E., Jackson, K.J., Wang, B., Robinson, J., Driezen, P., Bover-Manderski, M., Bansal-Travers, M., Hyland, A., Travers, M.J., Yang, D-H., Dang, R., Fong, G.T. (2020). Transitions in frequency of hookah smoking among youth and adults: Findings from Wave 1 and Wave 2 of the Population Assessment of Tobacco and Health (PATH) Study, 2013-2015. Addiction, [Published online, doi:https://doi.org/10.1111/add.15250].

Abstract

Background and aims:

The prevalence of hookah smoking has increased in the United States since at least 2010, especially among youth and young adults. This study assessed self-reported reasons for hookah smoking cessation and transition to or maintenance of high-frequency hookah smoking among current hookah smokers.

Design:

Separately analyzed data from the Population Assessment of Tobacco and Health (PATH) Study, a longitudinal cohort study. Frequency of and reasons for hookah smoking were ascertained at Wave 1 (2013-2014); frequency of hookah smoking and past-year cessation were ascertained at Wave 2 (2014-2015). Weighted multivariable logistic and ordinal logistic regression models were fit to predict hookah smoking cessation and frequency of hookah smoking at Wave 2, respectively, accounting for demographic and behavioral risk factors, reasons for hookah smoking, and frequency of hookah smoking at Wave 1.

Setting:

USA

Participants:

A total of 693 youth and 4400 adult past-year hookah smokers. Measurements: Self-reported tobacco-use patterns and associated health behaviors were measured via audio computer-assisted self-interviews (ACASI).

Findings:

At Wave 1, 5.9% of youth and 7.5% of adults were past-year hookah smokers. Across all age groups, the leading reasons for hookah smoking were enjoyment of socializing while smoking, availability of appealing flavors, and believing that it was less harmful than cigarette smoking. The odds of cessation were lower for adults who liked hookah flavors (adjusted odds ratio [aOR]=0.62; 95% confidence interval [CI]: 0.45-0.84) compared with adults who did not like hookah flavors. The odds of transitioning to, or maintaining, monthly-or-more-frequent hookah smoking at Wave 2, compared with cessation or less-than monthly smoking, were higher for adults who liked hookah flavors (adjusted proportional odds ratio [aPOR]=1.47; 95% CI: 1.16-1.88) and enjoyed socializing while smoking hookah (aPOR =1.48; 95% CI: 1.01-2.18) compared with adults who did not like hookah flavors or socializing.

Conclusion:

The availability of appealing flavors, affordability, and socialization while smoking hookah in the US are associated with reduced likelihood of cessation and increased likelihood of high-frequency hookah smoking.

Citation

Pierce, J., Benmarhnia, T., Chen, R., White, M., Abrams, D.B., Ambrose, B.K., Blanco, C., Borek, N., Choi, K., Coleman, B., Compton, W., Cummings, K.M., Delnevo, C.D., Elton-Marshall, T., Goniewicz, M., Gravely, S., Fong, G.T., Hatsukami, D., Henrie, J., Kasza, K.A., Kealey, S., Kimmel, H., Limpert, J., Niaura, R., Ramôa, C., Sharma, E., Silveira, M., Stanton, C., Steinberg, M.B., Taylor, E., Bansal-Travers, M., Trinidad, D.R., Gardner, L.D., Hyland, A., Soneji, S., Messer, K. (2020). Role of e-cigarettes and pharmacotherapy during attempts to quit cigarette smoking: The PATH Study 2013-16. PLOS One, 15(9), e0237938.

Abstract

Background:

More smokers report using e-cigarettes to help them quit than FDA-approved pharmacotherapy.

Objective:

To assess the association of e-cigarettes with future abstinence from cigarette and tobacco use.

Design:

Cohort study of US sample, with annual follow-up.

Participants:

US adult (ages 18+) daily cigarette smokers identified at Wave 1 (W1; 2013-14) of the PATH Study, who reported a quit attempt before W2 and completed W3 (n = 2443).

Exposures:

Use of e-cigarettes, pharmacotherapy (including nicotine replacement therapy), or no product for last quit attempt (LQA), and current daily e-cigarette use at W2.

Analysis:

Propensity score matching (PSM) of groups using different methods to quit.

Outcome measures:

12+ months abstinence at W3 from cigarettes and from all tobacco (including e-cigarettes). 30+ days abstinence at W3 was a secondary outcome.

Results:

Among daily smokers with an LQA, 23.5% used e-cigarettes, 19.3% used pharmacotherapy only (including NRT) and 57.2% used no product. Cigarette abstinence for 12+ months at W3 was ~10% in each group. Half of the cigarette abstainers in the e-cigarette group were using e-cigarettes at W3. Different methods to help quitting had statistically comparable 12+ month cigarette abstinence at W3 (ecigarettes vs no product: Risk Difference (RD) = 0.01, 95% CI: -0.04 to 0.06; e-cigarettes vs pharmacotherapy: RD = 0.02, 95% CI:-0.04 to 0.09). Likewise, daily e-cigarette users at W2 did not show a cessation benefit over comparable no-e-cigarette users and this finding was robust to sensitivity analyses. Abstinence for 30+ days at W3 was also similar across products.

Limitations:

The frequency of e-cigarette use during the LQA was not assessed, nor was it possible to assess continuous abstinence from the LQA.

Conclusion:

Among US daily smokers who quit cigarettes in 2014-15, use of e-cigarettes in that attempt compared to approved cessation aids or no products showed similar abstinence rates 1-2 years later.

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

Bommelé, J., Hopman, P., Hipple Walters, B., Geboers, C., Croes, E., Fong, G.T., Quah, A.C.K., Willemsen, M.C. (2020). The double-edged relationship between COVID-19 stress and smoking: Implications for smoking cessation. Tobacco Induced Diseases, 18(July), 63.

Abstract

Introduction: Although recent research shows that smokers respond differently to the COVID-19 pandemic, it offers little explanation of why some have increased their smoking, while others decreased it. In this study, we examined a possible explanation for these different responses: pandemic-related stress.

Material and Methods: We conducted an online survey among a representative sample of Dutch current smokers from 11–18 May 2020 (n=957). During that period, COVID-19 was six weeks past the (initial) peak of cases and deaths in the Netherlands. Included in the survey were measures of how the COVID-19 pandemic had changed their smoking, if at all (no change, increased smoking, decreased smoking), and a measure of stress due to COVID-19.

Results: Overall, while 14.1% of smokers reported smoking less due to the COVID-19 pandemic, 18.9% of smokers reported smoking more. A multinomial logistic regression analysis revealed that there was a dose-response effect of stress: smokers who were somewhat stressed were more likely to have either increased (OR=2.37; 95% CI: 1.49–3.78) or reduced (OR=1.80; 95% CI: 1.07–3.05) their smoking. Severely stressed smokers were even more likely to have either increased (OR=3.75; 95% CI: 1.84–7.64) or reduced (OR=3.97; 95% CI: 1.70–9.28) their smoking. Thus, stress was associated with both increased and reduced smoking, independently from perceived difficulty of quitting and level of motivation to quit.

Conclusions: Stress related to the COVID-19 pandemic appears to affect smokers in different ways, some smokers increase their smoking while others decrease it. While boredom and restrictions in movement might have stimulated smoking, the threat of contracting COVID-19 and becoming severely ill might have motivated others to improve their health by quitting smoking. These data highlight the importance of providing greater resources for cessation services and the importance of creating public campaigns to enhance cessation in this dramatic time.

Citation

Hawkins, S., Chung-Hall, J., Craig, L., Fong, G.T., Borland, R., Cummings, K.M., Levy, D., Hitchman, S.C. (2020). Support for minimum legal sales age laws set to 21 across Australia, Canada, England and US: Findings from the 2018 ITC Four Country Smoking and Vaping Survey. Nicotine and Tobacco Research, 22(12), 2266-2270.

Abstract

Introduction: Although the United States has seen a rapid increase in tobacco minimum legal sales age (MLSA) laws set to age 21, there is wide variation across high-income countries and less is known about policy support outside of the United States. We examined the prevalence of support for tobacco MLSA 21 laws as well as associations by sociodemographic, smoking, and household characteristics among current and former adult smokers.

Methods: In this cross-sectional analysis, we used the 2018 International Tobacco Control Four Country Smoking and Vaping Survey to examine support for MLSA 21 laws among 12 904 respondents from Australia, Canada, England, and United States.

Results: Support for raising the legal age of purchasing cigarettes/tobacco to 21 ranged from 62.2% in the United States to 70.8% in Canada. Endorsement also varied by age, such that 40.6% of 18–20 years old supported the policy compared with 69.3% of those aged ≥60 years. In the adjusted regression model, there was also higher support among respondents who were female than male, non-white than white, those who did not allow smoking in the household than those that did, and those who had children in the household than those that did not. There were no differences by household income, education, or smoking status.

Conclusions: Most current and former smokers, including a sizable minority of those aged ≤20 years, support raising the legal age of purchasing cigarettes/tobacco to 21.

Implications: There was strong support for MLSA 21 laws among smokers and former smokers across Australia, Canada, England, and the United States, providing evidence for the increasing public support of the passage of these laws beyond the United States.

Citation

Hammond, D., Reid, J., Burkhalter, R., Rynard, V.L. (2020). E-cigarette marketing regulations and youth vaping: Cross-sectional surveys, 2017-2019. Pediatrics, 146(1), e20194020.

Abstract

Background

Increased electronic cigarette (e-cigarette) use among young people is often attributed to industry marketing practices; however, the effectiveness of regulations that limit e-cigarette advertising and promotions has yet to be examined. New federal legislation that liberalized the Canadian e-cigarette market in May 2018, along with differences in provincial regulations, provides an opportunity to examine the impact of regulatory restrictions on e-cigarette marketing.

Methods

Repeat cross-sectional surveys of 12 004 16- to 19-year-olds in Canada, completed online in 2017, 2018, and 2019. Logistic regression models were used to examine differences over time in exposure to e-cigarette marketing and e-cigarette use, including between provinces with differing strengths of marketing restrictions. Results: The percentage of youth surveyed who reported noticing e-cigarette promotions often or very often approximately doubled between 2017 and 2019 (13.6% vs 26.0%; adjusted odds ratio [AOR] = 2.24, 95% confidence interval [CI] = 1.97-2.56). Overall exposure to marketing was generally more prevalent in provinces with fewer regulatory restrictions. Respondents who reported noticing marketing often or very often were more likely to report vaping in the past 30 days (AOR = 1.41, 95% CI = 1.23-1.62), past week (AOR = 1.44, 95% CI = 1.22-1.70), and ≥20 days in the past month (AOR = 1.42, 95% CI = 1.11-1.81, P = .005). Provinces with low restrictions on marketing had higher prevalence of vaping in the past 30 days (AOR = 1.50, 95% CI = 1.25-1.80, P < .001), and in the past week (AOR = 1.65, 95% CI = 1.332.05, P < .001).

Conclusions

Exposure to marketing and the prevalence of vaping increased among Canadian youth after the liberalization of the e-cigarette market in 2018. Comprehensive provincial restrictions on e-cigarette marketing were associated with lower levels of exposure to marketing and lower prevalence of e-cigarette use

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.