Knowledge of the health risks of smoking and impact of cigarette warning labels among tobacco users in six European countries: Findings from the EUREST-PLUS ITC Europe Surveys
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University of Medicine and Pharmacy, ‘Grigore T. Popa’ Iasi, Iasi, Romania
Aer Pur România, București, România
University of Crete (UoC), Heraklion, Greece
Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Canada
Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
European Network for Smoking and Tobacco Prevention (ENSP), Brussels, Belgium
University of Medicine and Pharmacy 'Carol Davilla', Bucharest, Romania
Department of Psychology, University of Waterloo (UW), Waterloo, Canada
Cancer Prevention Unit and WHO Collaborating Centre for Tobacco Control, German Cancer Research Center (DKFZ), Heidelberg, Germany
Smoking or Health Hungarian Foundation (SHHF), Budapest, Hungary
Tobacco Control Unit, Catalan Institute of Oncology (ICO), Barcelona, Spain
Cancer Control and Prevention Group, Bellvitge Biomedical Research Institute, Barcelona, Spain
National and Kapodistrian University of Athens (UoA), Athens, Greece
Health Promotion Foundation (HPF), Warsaw, Poland
Maria Skłodowska-Curie Institute-Oncology Center (MSCI), Warsaw, Poland
National Addiction Centre, Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London (KCL), London, United Kingdom
UK Centre for Tobacco and Alcohol Studies, London, United Kingdom
School of Public Health and Health Systems, University of Waterloo (UW), Waterloo, Canada
Ontario Institute for Cancer Research, Toronto, Canada
Lucia M. Lotrean   

Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
Publish date: 2019-02-13
Tob. Induc. Dis. 2018;16(Suppl 2):A10
*EUREST-PLUS consortium members: European Network on Smoking and Tobacco Prevention (ENSP), Belgium: Constantine I. Vardavas, Andrea Glahn, Christina N. Kyriakos, Dominick Nguyen, Katerina Nikitara, Cornel Radu-Loghin, Polina Starchenko University of Crete (UoC), Greece: Aristidis Tsatsakis, Charis Girvalaki, Chryssi Igoumenaki, Sophia Papadakis, Aikaterini Papathanasaki, Manolis Tzatzarakis, Alexander I. Vardavas Kantar Public (TNS), Belgium: Nicolas Bécuwe, Lavinia Deaconu, Sophie Goudet, Christopher Hanley, Oscar Rivière Smoking or Health Hungarian Foundation (SHHF), Hungary: Tibor Demjén, Judit Kiss, Piroska A. Kovacs Catalan Institut of Oncology (ICO); Bellvitge Biomedical Research Institute (IDIBELL), Spain: Esteve Fernández, Yolanda Castellano, Marcela Fu, Sarah O. Nogueira, Olena Tigova Kings College London (KCL), United Kingdom: Ann McNeill, Katherine East, Sara C. Hitchman Cancer Prevention Unit and WHO Collaborating Centre for Tobacco Control, German Cancer Research Center (DKFZ), Germany: Ute Mons, Sarah Kahnert National and Kapodistrian University of Athens (UoA), Greece: Yannis Tountas, Panagiotis Behrakis, Filippos T. Filippidis, Christina Gratziou, Paraskevi Katsaounou, Theodosia Peleki, Ioanna Petroulia, Chara Tzavara Aer Pur Romania, Romania: Antigona C. Trofor, Marius Eremia, Lucia Lotrean, Florin Mihaltan European Respiratory Society (ERS), Switzerland; Goethe University Frankfurt, Germany: 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 Maastricht University, the Netherlands: Marc Willemsen, Hein de Vries, Karin Hummel, Gera E. Nagelhout Health Promotion Foundation (HPF), Poland: Witold A. Zatoński, Aleksandra Herbeć, Kinga Janik-Koncewicz, Krzysztof Przewoźniak, Mateusz Zatoński University of Waterloo (UW); Ontario Institute for Cancer Research, Canada: Geoffrey T. Fong, Thomas K. Agar, Pete Driezen, Shannon Gravely, Anne C. K. Quah, Mary E. Thompson
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.

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.

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.

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.

The authors declare that they have no competing interests, financial or otherwise, related to the current work. L. M. Lotrean reports grants from Aer Pur Romania, during the conduct of the study. K. Przewoźniak reports grants and personal fees from the Polish League Against Cancer, outside the submitted work. C. I. Vardavas reports that he is the Strategic Development Editor of TID and that there are no conflicts of interest with this current work. The rest of the authors have also completed and submitted an ICMJE form for disclosure of potential conflicts of interest.
World Health Organization. WHO Framework Convention on Tobacco Control. Geneva, Switzerland: WHO Document Production Services; 2003. Accessed May, 2018.
World Health Organization. Evidence Brief. How large pictorial health warning on the packing of tobacco products affects knowledge and behavior. Geneva: WHO; 2014. Accessed May, 2018.
Fong GT, Hammond D, Hitchman SC. The impact of pictures on the effectiveness of tobacco warnings. Bulletin of the World Health Organization. 2009;87:640-643. doi:10.2471/BLT.09.069575.
Hammond D, Fong GT, McNeill A, Borland R, Cummings KM. Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: findings from the International Tobacco Control (ITC) four country survey. Tob Control. 2006;15(Suppl 3):iii19-iii25. doi:10.1136/tc.2005.012294.
Monárrez-Espino J, Liu B, Greiner F, Bremberg S, Galanti R. Systematic review of the effect of pictorial warnings on cigarette packages in smoking behavior. Am J Public Health. 2014;104(10):e11-30. doi:10.2105/AJPH.2014.302129.
Fathelrahman AI, Li L, Borland R, et al. Stronger pack warnings predict quitting more than weaker ones: finding from the ITC Malaysia and Thailand surveys. Tob Induc Dis. 2013;11(September). doi:10.1186/1617-9625-11-20.
Borland R, Yong HH, Wilson N, et al. How reactions to cigarette packet health warnings influence quitting: Findings from the ITC four-country survey. Addiction. 2009;104:669-675. doi:10.1111/j.1360-0443.2009.02508.x.
Borland R, Wilson N, Fong GT, et al. Impact of graphic and text warnings on cigarette packs: findings from four countries over five years. Tobacco Control. 2009;18:358-364. doi:10.1136/tc.2008.028043.
Francis DB, Hall MG, Noar SM, Ribisl KM, Brewer NT. Systematic review of measures used in pictorial cigarette pack warning experiments. Nicotine & Tobacco Research. 2017;19(10):1127-1137. doi:org/10.1093/ntr/ntx082.
Directive 2014/40/EU of the European Parliament and of the Council of 3 April 2014 on the approximation of the laws, regulations and administrative provisions of the Member States concerning the manufacture, presentation and sale of tobacco and related products and repealing. Directive 2001/37/EC. OJ 2014 L 127/1. Accessed May, 2018.
Commission Implementing Decision (EU) 2015/1842 of 9 October 2015 on the technical specifications for the layout, design and shape of the combined health warnings for tobacco products for smoking. Accessed May, 2018.
European Commission. Product Regulation: Tobacco. Health warnings. Accessed May, 2018.
Vardavas CI, Bécuwe N, Demjén T, et al. Study Protocol of European Regulatory Science on Tobacco (EUREST-PLUS): Policy implementation to reduce lung disease. Tob Induc Dis. 2018:16(Suppl 2:A2). doi:10.18332/tid/93305.
Fong GT, Thompson ME, Boudreau C, et al. The Conceptual Model and Methods of Wave 1 (2016) of the EUREST-PLUS ITC 6 European Countries Survey. Tob Induc Dis. 2018;16(Suppl 2:Α3). doi:10.18332/tid/99881
Hitchman S, Mons U, Nagelhout GE, et al. Effectiveness of the European Union text-only cigarette health warnings: findings from four countries. Eur J Public Health. 2012;22(5):693-699. doi:10.1093/eurpub/ckr099.
Green AC, Kaai SC, Fong GT, Drizen P, Quah ACK, Burhoo P. Investigating the effectiveness of pictorial health warnings in Mauritius: Findings from the ITC Mauritius survey. Nicotine Tob Res. 2014;16(9):1240-1247. doi:10.1093/ntr/ntu062.
International Agency for Research on Cancer. Methods for Evaluating Tobacco Control Policies. Vol 12. Lyon, France: International Agency for Research on Cancer; 2008:287-317. Accessed May, 2018.
ITC Project. Health warnings on tobacco packages: ITC cross-country comparison report. Ontario, Canada: University of Waterloo; 2012. Accessed May, 2018.
Yang J, Hammond D, Pete Driezen P, Fong GT, Jiang Y. Health knowledge and perception of risks among Chinese smokers and non-smokers: findings from the wave 1 ITC China survey. Tob Control. 2010;19(Suppl 2):i18-i23. doi:10.1136/tc.2009.029710.
Siahpush M, McNeill A, Hammond D, Fong GT. Socioeconomic and country variations in knowledge of health risks of tobacco smoking and toxic constituents of smoke: results from the 2002 International Tobacco Control (ITC) Four Country Survey Tob Control. 2006;15(Suppl 3):iii65-iii70. doi:10.1136/tc.2005.013276.
Reid JL, Mutti-Packer S, Gupta PC, et al. Influence of health warnings on beliefs about the health effects of cigarette smoking, in the context of an experimental study in four asian countries. Int J Environ Res Public Health. 2017;14(8). doi:10.3390/ijerph14080868.
World Health Organization. European Tobacco Control Status Report 2014. Copenhagen, Denmark: World Health Organization Regional Office for Europe; 2014. Accessed May, 2018.
Trofor A, Man M, Marginean C, Filipeanu D, Trofor L. Smoking cessation for free: outcomes of a study in three Romanian clinics. Open Medicine. 2016;11(1):605-610. doi:10.1515/med-2016-0098.
Lotrean LM, Ailoaiei R, Popa M, de Vries H. Process evaluation of the first computer tailored program for smoking cessation among Romanian smokers. Asian Pac J Cancer Prev. 2014;15(20):8809-8814. doi:10.7314/apjcp.2014.15.20.8809
Nogueira SO, McNeill A, Fu M, et al. Impact of anti-smoking advertising on health-risk knowledge and quit attempts across 6 European countries from the EUREST-PLUS ITC Europe Survey. Tob Induc Dis. 2018;16(Suppl 2:A5). doi:10.18332/tid/96251
Demjén T, Kiss J, Kovács P, et al. The purchase sources of and price paid for cigarettes in six European countries: Findings from the EUREST-PLUS ITC Europe Surveys. Tob Induc Dis. In press.
Noar SM, Francis DB, Bridges C, et al. The impact of strengthening cigarette pack warnings: Systematic review of longitudinal observational studies. Soc Sci Med. 2016;164:118-129. doi:10.1177/1077699016674188.
Nagelhout GE, Willemsen MC, de Vries H, et al. Educational differences in the impact of pictorial cigarette warning labels on smokers: findings from the International Tobacco Control (ITC) Europe surveys. Tobacco Control. 2015;25. doi:10.1136/tobaccocontrol-2014-051971.