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Changes in responses to nicotine vaping product warnings and leaflets in England compared with Canada, the US and Australia: findings from the 2016–2018 ITC Four Country Smoking and Vaping Surveys
  1. Eve Violet Taylor1,
  2. Katherine A East1,2,
  3. Ann McNeill1,3,
  4. Michael Cummings4,5,
  5. James Thrasher6,7,
  6. Geoffrey T Fong2,8,9,
  7. Anne C K Quah8,
  8. Máirtín McDermot1,
  9. Grace Li8,
  10. Ron Borland10,11,
  11. David Hammond2,
  12. Sarah Aleyan1,2,
  13. Sara C Hitchman1
  1. 1 Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
  2. 2 School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
  3. 3 Shaping Public Health Polices to Reduce Inequalities and Harm (SPECTRUM), London, UK
  4. 4 Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
  5. 5 Hollings Cancer Centre, Medical University of South Carolina, Charleston, South Carolina, USA
  6. 6 Health Promotion, Education and Behavior, School of Public Health, University of South Carolina, Columbia, South Carolina, USA
  7. 7 Tobacco Research Department, Centre for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico
  8. 8 Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada
  9. 9 Ontario Institute for Cancer Research, Toronto, Ontario, Canada
  10. 10 Melbourne Centre for Behaviour Change, School of Psychological Sciences, University of Melbourne, Melbourne, Victoria, Australia
  11. 11 Cancer Council Victoria, Melbourne, Victoria, Australia
  1. Correspondence to Eve Violet Taylor, Addictions Department, King's College London, London WC2R 2LS, UK; eve.v.taylor{at}


Background and aims In May 2017, black-and-white text nicotine addiction warning labels (‘warnings’) and health and safety leaflets (‘leaflets’) became mandatory for nicotine vaping products (NVPs) in England, in accordance with the European Union’s Tobacco Products Directive. We compared changes over time in noticing warnings and leaflets, recall of warnings about nicotine and concerns about using NVP due to noticing warnings in England, compared with Canada, the US and Australia, where no warnings and leaflets were mandated.

Design 19 005 adult (aged 18+) NVP users, smokers and quitters of cigarettes and NVP from the 2016 and 2018 International Tobacco Control Four Country Smoking and Vaping Surveys in England, Canada, the US and Australia, recruited via probability and non-probability sampling.

Findings Noticing warnings increased in England from 4.9% (2016) to 9.4% (2018) (adjusted OR/AOR=1.64, 95% CI=1.15–2.36); this change was larger than changes in Canada (AOR=2.51, 95% CI=1.71–3.69) and the US (AOR=2.22, 95% CI=1.45–3.39). Recall of a nicotine warning increased in England from 86% (2016) to 94.9% (2018) (AOR=5.50, 95% CI=1.57–19.27) but not significantly elsewhere. Noticing leaflets increased in England from 14.6% (2016) to 19.1% (2018) (AOR=1.42, 95% CI=1.15–1.74); this change was larger than in Canada (AOR=1.42, 95% CI=1.12–1.79), the US (AOR=1.55, 95% CI=1.17–2.06) and Australia (AOR=1.51, 95% CI=1.02–2.22). Among those noticing warnings, concern about NVP use did not change significantly between 2016 and 2018 (all countries p>0.081).

Conclusions Introduction of mandatory NVP warnings and leaflets in England was associated with small increases in noticing them but not with changes in concerns about NVP use.

  • electronic nicotine delivery devices
  • packaging and labelling
  • public policy

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  • Contributors This paper was supervised by SCH and AM. SA and KAE assisted with statistical analysis, planning and revisions of the paper. MM reviewed and revised the paper. MC, JT, GTF, ACKQ, GL, RB and DH were involved in the design of the ITC study and reviewed and revised the paper.

  • Funding This study was supported by grants from the US National Cancer Institute (P01 CA200512), the Canadian Institutes of Health Research (FDN-148477), and by the National Health and Medical Research Council of Australia (APP 1106451). GTF was supported by a Senior Investigator Grant from the Ontario Institute for Cancer Research.

  • Competing interests MC has received payment as a consultant to Pfizer for service on an external advisory panel to assess ways to improve smoking cessation delivery in healthcare settings. MC also has served as paid expert witness in litigation filed against the tobacco industry. GTF, DH and JT have served as expert witnesses on behalf of governments in litigation involving the tobacco industry. AM is a UK National Institute for Health Research (NIHR) Senior Investigator.

  • Provenance and peer review Not commissioned; externally peer reviewed.