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Beyond the European Union Tobacco Products Directive: smokers’ and recent quitters’ support for further tobacco control measures (2016–2018)
  1. Sarah O Nogueira1,2,3,
  2. Pete Driezen4,5,
  3. Marcela Fu1,2,3,6,
  4. Sara C Hitchman7,
  5. Olena Tigova1,2,3,6,
  6. Yolanda Castellano1,2,3,6,
  7. Christina N Kyriakos8,9,
  8. Mateusz Zygmunt Zatoński10,11,12,
  9. Ute Mons13,14,
  10. Anne C K Quah4,
  11. Tibor Demjén15,
  12. Antigona Carmen Trofor16,17,
  13. Krzysztof Przewozniak11,18,19,
  14. Paraskevi Katsaounou20,
  15. Geoffrey Fong4,5,21,
  16. Constantine I Vardavas9,22,
  17. Esteve Fernández1,2,3,6
  18. EUREST-PLUS Consortium
    1. 1Tobacco Control Unit, Cancer Epidemiology and Prevention Programme, Institut Catala d' Oncologia (ICO), L'Hospitalet de Llobregat, Catalunya, Spain
    2. 2School of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Catalunya, Spain
    3. 3Tobacco Control Research Group, Epidemiology and Public Health Programme (EPIBELL), Institut d'Investigació Biomèdica Mèdica (IDIBELL), Barcelona, Catalonia, Spain
    4. 4Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada
    5. 5School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
    6. 6Consortium for Biomedical Research in Respiratory Diseases (CIBERES), Madrid, Spain
    7. 7Department of Addictions, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
    8. 8Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, London, UK
    9. 9European Network for Smoking and Tobacco Prevention, Brussels, Brussels, Belgium
    10. 10Tobacco Control Research Group, Department for Health, University of Bath, Bath, UK
    11. 11Health Promotion Foundation, Warsaw, Poland
    12. 12Institute - European Observatory of Health Inequalities, Calisia University, Kalisz, Poland
    13. 13Heart Center, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
    14. 14Cancer Prevention Unit and WHO Collaborating Centre for Tobacco Control, German Cancer Research Centre, Heidelberg, Germany
    15. 15Smoking or Health Hungarian Foundation, Budapest, Hungary
    16. 16University of Medicine and Pharmacy ‘Grigore T. Popa’ Iasi, Iasi, Romania
    17. 17Aer Pur Romania, Bucharest, Romania
    18. 18Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
    19. 19Collegium Civitas, Warsaw, Poland
    20. 20Pulmonary and Critical Care Department, Medical School, National and Kapodistrian University of Athens, Athens, Greece
    21. 21Ontario Institute for Cancer Research, Toronto, Ontario, Canada
    22. 22Laboratory of Toxicology, School of Medicine, University of Crete, Heraklion, Crete, Greece
    1. Correspondence to Prof Esteve Fernández, Cancer Epidemiology and Prevention (Tobacco Control Unit), Institut Catala d' Oncologia, 08907 L'Hospitalet de Llobregat, Catalunya, Spain; efernandez{at}


    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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    • 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.

    • Patient consent for publication Not required.

    • Ethics approval 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).

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