Background Several measures recommended by the WHO Framework Convention on Tobacco Control have not been implemented in the European Union, despite changes in the legislation such as the Tobacco Products Directive (TPD). This study aims to understand smokers’ and recent quitters’ levels of support for tobacco control measures that go beyond the TPD during and after its implementation.
Methods Data from wave 1 (2016, n=6011) and wave 2 (2018, n=6027) of the EUREST-PLUS International Tobacco Control Policy Evaluation Project Six European Countries Survey, a cohort of adult smokers in Germany, Greece, Hungary, Poland, Romania, Spain were used to estimate the level of support for seven different tobacco control measures, overall and by country.
Results In 2018, the highest support was for implementing measures to further regulate tobacco products (50.5%) and for holding tobacco companies accountable for the harm caused by smoking (48.8%). Additionally, in 2018, 40% of smokers and recent quitters supported a total ban on cigarettes and other tobacco products within ten years, if assistance to quit smoking is provided. Overall, support for tobacco control measures among smokers and recent quitters after the implementation of the TPD remained stable over time.
Conclusion There is considerable support among smokers and recent quitters for tobacco control measures that go beyond the current measures implemented. A significant percentage of smokers would support a ban on tobacco products in the future if the government provided assistance to quit smoking. This highlights the importance of implementing measures to increase smoking cessation in conjunction with other policies.
- public opinion
- public policy
- end game
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The prevalence of smoking in European Union (EU) Member States (MS) has decreased over the past decades. However, 26% of EU adults still smoke and approximately 810 000 die prematurely every year due to smoking.1 2 In recent years, progress has been made in tackling the tobacco epidemic in the EU through policy. The most recent EU Tobacco Products Directive (TPD), implemented in 2016, introduced new regulation regarding tobacco products labelling, packaging, ingredients and additives.3 Despite the introduction of the TPD, other measures recommended by the WHO Framework Convention on Tobacco Control (FCTC)4 and its guidelines have not been implemented homogeneously across EU MS.
Public opinion influences the impact of tobacco control measures; it plays a role in measures’ adoption,5 effective implementation6 and in policy-related changes in smoking behaviours.7 As smokers constitute approximately one in four of the EU adult population and are affected by tobacco control measures, it is important to understand their level of support for such measures. Therefore, we examine support for seven tobacco control measures that go beyond the EU TPD in nationally representative samples of adult smokers in six EU MS during and after the implementation of the TPD.
We used data from the International Tobacco Control Policy Evaluation Project Six European Countries (ITC 6E) Survey, a prospective cohort study of representative samples of smokers from Germany, Greece, Hungary, Poland, Romania and Spain.8–11
Wave 1 data were collected between June and September 2016, the year of TPD implementation, and the wave 2 data between February and May 2018, post-TPD implementation. Computer-assisted interviews were conducted face to face. The samples comprise current smokers (at least monthly smokers who smoked >100 cigarettes in their lifetime) aged 18 or older. Respondents were recruited using a multistage stratified random sampling procedure of the general population of smokers to produce nationally representative samples of smokers. The respondents participating in wave 1 (N=6011) were recontacted in wave 2, given they had provided consent to be recontacted. Respondents not successfully recontacted (N=2816) were replaced by newly recruited smokers (N=2832) from newly sampled households selected with the same sampling frame and design. Hence, a total of 6027 individuals participated in wave 2. Further details about the ITC 6E methodology can be found elsewhere.8–11
Outcomes were seven indicators of support for different tobacco control measures. Participants were asked about their support for, or agreement with, the following measures: (1) Tobacco products being subjected to more rules and regulations; (2) a total ban on tobacco products within 10 years, if the government provided assistance to help smokers quit; (3) holding tobacco companies accountable for the harm caused by smoking; (4) plain cigarette packaging; (5) restricting the number of places where cigarettes could be purchased; (6) a ban on all slim cigarettes; (7) cigarettes display ban at points of sale. Responses to these questions were dichotomised as ‘strongly support’ or ‘support’ vs otherwise (measures #2, 5, 6), ‘strongly agree’ or ‘agree’ vs otherwise (measures #1,3,4), and ‘a lot’ vs otherwise (measure #7). The otherwise category comprised the responses ‘no’ and ‘don’t know’. Online supplemental table S1 shows a full description of all the outcome measures.
All analyses were weighted to ensure the sample represented the population of adult smokers in each country and accounted for the complex multistage sampling design.9 11 We estimated percentages of support for each tobacco control measure, overall and by country for each wave of the survey. All respondents from wave 1 and wave 2 were included in the analysis, irrespective of their smoking status by wave 2. A Bonferroni correction adjusted for multiple testing of country differences in support between waves. Regression models were used to examine the association between sociodemographic factors, smoking-related beliefs and behaviours, and binary outcome measures of support at wave 2. Online supplemental table S3 presents details on this analysis.
Figure 1 presents the percentages and 95% CIs of support for tobacco control measures by country and overall at both survey waves. Overall, support was highest for measures to further regulate tobacco products (50.5%; 95% CI 47.9% to 53.3% in wave 2), and for holding tobacco companies accountable for the harms caused by smoking (48.7%; 95% CI 45.9% to 51.5% in wave 2). Almost 40% of participants (37.8%; 95% CI 35.3% to 40.4% in wave 2) supported a total ban on tobacco products within 10 years if assistance to quit smoking is provided. Support for plain cigarette packaging was reported by 34.2% (95% CI 31.7% to 36.7% in Wave 2) of the overall sample.
Across all countries combined, the rates of support for tobacco control measures after the TPD implementation presented no significant changes. In country-specific analysis, there was a significant increase between waves in the percentage of participants supporting the adoption of plain cigarette packaging in Spain (from 28.3%; 95% CI 23.5% to 33.6% in wave 1 to 40.9%; 95% CI 34.9% to 47.1% in wave 2), as also in supporting further accountability of the tobacco industry for the harms caused by smoking (from 38.1%; 95% CI 33.1% to 43.4% in wave 1 to 55.1%; 95% CI 48.7% to 61.3% in wave 2). Online supplemental table S3 shows results of sociodemographic factors and smoking-related beliefs and behaviours associated with support for all evaluated tobacco control measures in 2018.
This study examined support for tobacco control measures beyond the EU TPD current scope. Overall, support for tobacco control measures among smokers and recent quitters after TPD implementation remained stable, except for Spain where an increase in support for a few measures was observed.
In 2018, there was considerable variation in the support for different measures across countries, although some measures were endorsed by most smokers and recent quitters. The measure with the highest support was more regulation of tobacco products (50.6% in wave 2). Also, approximately 50% of smokers and recent quitters in all countries, with exception of Germany (33.5%), were in favour of the tobacco industry being held accountable for the harms caused by smoking. One of the most striking results was that almost 50% of smokers and recent quitters supported a total ban on tobacco products sales within 10 years if the government provided cessation aids. Our findings support the possibility for innovative tobacco control measures to be proposed and supported by smokers. For instance, policies aligned with tobacco endgame strategies aiming for a tobacco-free future,15 such as lowering the nicotine content of tobacco products to make them less addictive,16 17 and/or restricting sales of cigarettes to citizens born in or after a certain year with the goal of phasing out the sale of cigarettes in the future.18
Variations were observed in the country-specific results with some measures reaching very high rates of endorsement, while others were supported by a restricted number of smokers and recent quitters. For instance, 80.2% of smokers and recent quitters in Greece and 64.7% in Spain supported more tobacco products regulation. In contrast, the lowest support overall was for the ban on display of cigarettes at point of sale, with rates varying from 7.8% in Germany to 23.4% in Hungary. As previously pointed out, differences in support for tobacco control measures might reflect respondents’ ambivalence about their efficacy, practicality and effectiveness19 and/or the lack of knowledge about the benefits such measures could bring to smokers and non-smokers. Therefore, we assume that the low levels of support in Germany might be influenced by its generally protobacco environment, as exemplified by heavy marketing for tobacco products due to limited marketing restrictions,20 which normalises smoking and diminishes smokers’ harm perception.
The levels of support for tobacco control measures among smokers in European countries tend to be lower than in the general population,1 21–24 Nevertheless, population-based studies have shown an increase in support among smokers for diverse tobacco control measures after their adoption. For instance, in Australia, support for plain packaging among smokers has increased significantly after its implementation, from 28.2% in 2008–2009 to 49.0% in 2013.25 Therefore, our findings should not be used to argue against the introduction of further tobacco control measures. In fact, the countries in our study, as Parties of the WHO FCTC treaty, are encouraged to implement measures beyond those required by the Convention and its protocols.4
This study has some limitations. First, question wording might have influenced respondents’ answers. For instance, one of the tobacco control measures assessed was: ‘Do you support complete bans on displays of cigarettes inside shops and stores?’, which aims to assess whether tobacco products should be kept ‘out of sight in points of sale’. A question with the latter wording was asked to smokers in the Eurobarometer Survey of 2017 in which 39.0% of smokers supported the measure while only 15.4% of smokers in our study supported it. Both measures touch very similar points, but the wording of the question might bias the response. Second, there were different levels of attrition across countries between waves, with retention rates ranging from 35.7% in Hungary to 70.5% in Germany and Spain, with an average of 53.2% for the total sample. Despite these limitations, our study is, to the best of our knowledge, the most thorough evaluation of support for these tobacco control measures, with nationally representative samples of smokers in the six European countries included in the survey.
There is considerable support among smokers for approaches to tobacco control that go beyond the current measures implemented. Most smokers support stronger government action to control the tobacco epidemic and many of them believe the tobacco industry should be held accountable for the harms caused by smoking. Additionally, a significant percentage of smokers would support a ban on tobacco products in the future if the government provided assistance to quit smoking. This highlights the importance of implementing measures to increase smoking cessation in conjunction with other policies.
What this paper adds
What is already known on this topic
Public opinion plays an important role in adoption and effective implementation of tobacco control measures’ and their effect on tobacco-related behaviours.
What important gaps in knowledge exist on this topic
There is limited research on smokers’ and recent quitters’ support for tobacco control measures in European countries.
What this paper adds
Using data from six European Union Member States, this study found considerable support among smokers and recent quitters for approaches to tobacco control that go beyond the current implemented measures, including Tobacco Endgame measures.
Patient consent for publication
Study procedures and material including the survey questionnaires were approved by the ethics research committee at the University of Waterloo (Ontario, Canada—ID: ORE # 21262), and ethics committees in Germany (Ethikkommission der Medizinischen Fakultat Heidelberg - ID: 196/2016), in Greece (Medical School, University of Athens—Research and Ethics Committee—ID: 1516023880), in Hungary (Medical Research fCouncil—Scientific and Research Committee—ID: 46344), in Poland (State College of Higher Vocational Education—Committee and Dean of the Department of Healthcare and Life Sciences - ID:1/2016), in Romania (Iuliu Hatieganu University of Medicine and Pharmacy - ID: 114/5.04.2016), and in Spain (Clinical Research Ethics Committee of Bellvitge, Hospital Universitari de Bellvitge, Catalonia—ID: PR100/2016).
IDIBELL Investigators thank CERCA Programme / Generalitat de Catalunya for institutional support.
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Collaborators EUREST-PLUS Consortium: Andrea Glahn, Dominick Nguyen, Katerina Nikitara, Cornel Radu-Loghin, Polina Starchenko (European Network on Smoking and Tobacco Prevention (ENSP), Belgium). Aristidis Tsatsakis, Charis Girvalaki, Chryssi Igoumenaki, Sophia Papadakis, Aikaterini Papathanasaki, Manolis Tzatzarakis, Alexander I Vardavas (University of Crete (UOC), Greece). Nicolas Bécuwe, Lavinia Deaconu, Sophie Goudet, Christopher Hanley, Oscar Rivière (Kantar Public, Belgium). Judit Kiss, Anna Piroska Kovacs (Smoking or Health Hungarian Foundation (SHHF), Hungary). Ann McNeill, Katherine East (Kings College London (KCL), United Kingdom). Sarah Kahnert (Cancer Prevention Unit and WHO Collaborating Centre for Tobacco Control, German Cancer Research Center (DKFZ), Germany). Yannis Tountas, Panagiotis Behrakis, Filippos T Filippidis, Christina Gratziou, Theodosia Peleki, Ioanna Petroulia, Chara Tzavara (National and Kapodistrian University of Athens (UoA, Greece). Marius Eremia, Lucia Lotrean, Florin Mihaltan (Aer Pur Romania, Romania). Esteve Fernández, Olena Tigova, Yolanda Castellano, Marcela Fu, Sarah O. Nogueira (Catalan Institute of Oncology, ICO; Bellvitge Biomedical Research Institute, IDIBELL, Catalonia, Spain).
Gernot Rohde, Tamaki Asano, Claudia Cichon, Amy Far, Céline Genton, Melanie Jessner, Linnea Hedman, Christer Janson, Ann Lindberg, Beth Maguire, Sofia Ravara, Valérie Vaccaro, Brian Ward (European Respiratory Society, ERS, Switzerland). Marc Willemsen, Hein de Vries, Karin Hummel, Gera E Nagelhout (Maastricht University, the Netherlands). Witold A Zatoński, Aleksandra Herbeć, Kinga Janik-Koncewicz, Krzysztof Przewoźniak (Health Promotion Foundation, HPF, Poland). Thomas K Agar, Shannon Gravely, Mary E Thompson (University of Waterloo, UW, Canada).
Contributors Conceptualised and designed the study: SON, PD, UM, TD, ACT, KP, PK, GF, CIV and EF. Contributed to the strategy of analysis: SON, PD, UM, MF, OT, YC and EF. Analysed data: PD. Interpreted data results: SON, PD, MF, UM, SCH, CK, MZZ and EF. Drafted manuscript: SON. Critically revised manuscript: All authors. Approved final manuscript version: All authors.
Funding The EUREST-PLUS project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 681 109 (CIV) and the University of Waterloo (GF). Additional support was provided to the University of Waterloo by the Canadian Institutes of Health Research (FDN-148477). GF was supported by a Senior Investigator Grant from the Ontario Institute for Cancer Research. The Tobacco Control research Group (IDIBELL) is partly supported by Ministry of Universities and Research, Government of Catalonia (2017SGR319). EF is partly supported by the Instituto Carlos III and cofunded by the European Regional Development Fund (FEDER) (INT16/00211 and INT17/00103), Government of Spain. SON has received funding from the European Union’s 2020 research and innovation programme under the Marie Sklodowska-Curie grant agreement No. 713 673. SON has received financial support through the 'La Caixa' INPHINIT Fellowship Grant for Doctoral studies at Spanish Research Centres of Excellence, 'La Caixa' Banking Foundation, Barcelona, Spain (LCF/BQ/DI17/11620022).
Disclaimer The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.
Competing interests GF has served as an expert witness on behalf of governments in litigation involving the tobacco industry. KP reports grants and personal fees from the Polish League Against Cancer, outside the submitted work.
Provenance and peer review Not commissioned; externally peer reviewed.
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