Social norms towards smoking and electronic cigarettes among adult smokers in seven European Countries: Findings from the EUREST-PLUS ITC Europe Surveys
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National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
UK Centre for Tobacco and Alcohol Studies, King’s College London (KCL), London, United Kingdom
Health Promotion Foundation (HPF), Warsaw, Poland
Department of Behavioural Science and Health, University College London, London, United Kingdom
National and Kapodistrian University of Athens (UoA), Athens, Greece
Kantar Public (TNS), Brussels, Belgium
Smoking or Health Hungarian Foundation (SHHF), Budapest, Hungary
Catalan Institute of Oncology (ICO), Barcelona, Spain
Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
Cancer Prevention Unit and WHO Collaborating Centre for Tobacco Control, German Cancer Research Center (DKFZ), Heidelberg, Germany
University of Medicine and Pharmacy ‘Grigore T. Popa’ Iasi, Iasi, Romania
Aer Pur Romania, Bucharest, Romania
European Observatory of Health Inequalities, President Stanisław Wojciechowski State University of Applied Sciences, Kalisz, Poland
Department of Psychology and School of Public Health and Health Systems, University of Waterloo (UW), Waterloo, Canada
Ontario Institute for Cancer Research, Toronto, Canada
European Network for Smoking and Tobacco Prevention (ENSP), Brussels, Belgium
University of Crete (UoC), Heraklion, Greece
Katherine A. East   

National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 4 Windsor Walk, London SE5 8BB, United Kingdom
Publish date: 2019-03-22
Tob. Induc. Dis. 2018;16(Suppl 2):A15
*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. Kovács 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
This study explores whether current smokers’ social norms towards smoking and electronic cigarettes (e-cigarettes) vary across seven European countries alongside smoking and e-cigarette prevalence rates. At the time of surveying, England had the lowest current smoking prevalence and Greece the highest. Hungary, Romania and Spain had the lowest prevalence of any e-cigarette use and England the highest.

Respondents were adult (≥18 years) current smokers from the 2016 EUREST-PLUS ITC (Romania, Spain, Hungary, Poland, Greece, Germany) and ITC 4CV England Surveys (N=7779). Using logistic regression, associations between country and (a) smoking norms and (b) e-cigarette norms were assessed, adjusting for age, sex, income, education, smoking status, heaviness of smoking, and e-cigarette status.

Compared with England, smoking norms were higher in all countries: reporting that at least three of five closest friends smoke (19% vs 65–84% [AOR=6.9–24.0; Hungary–Greece]), perceiving that people important to them approve of smoking (8% vs 14–57% [1.9–51.1; Spain–Hungary]), perceiving that the public approves of smoking (5% vs 6–37% [1.7–15.8; Spain–Hungary]), disagreeing that smokers are marginalised (9% vs 16–50% [2.3–12.3; Poland–Greece]) except in Hungary. Compared with England: reporting that at least one of five closest friends uses e-cigarettes was higher in Poland (28% vs 36% [2.7]) but lower in Spain and Romania (28% vs 6–14% [0.3–0.6]), perceiving that the public approves of e-cigarettes was higher in Poland, Hungary and Greece (32% vs 36–40% [1.5–1.6]) but lower in Spain and Romania in unadjusted analyses only (32% vs 24–26%), reporting seeing e-cigarette use in public at least some days was lower in all countries (81% vs 12–55% [0.1–0.4]; Spain–Greece).

Smokers from England had the least pro-smoking norms. Smokers from Spain had the least pro-e-cigarette norms. Friend smoking and disagreeing that smokers are marginalised broadly aligned with country-level current smoking rates. Seeing e-cigarette use in public broadly aligned with countrylevel any e-cigarette use. Generally, no other norms aligned with product prevalence.

The ITC 6 European Country Survey, a component of the EUREST-PLUS programme, is a Horizon 2020 project conducted by researchers from the six participating countries and the following institutional partners: the European Network on Smoking Prevention (Belgium), King’s College London (United Kingdom), German Cancer Research Centre (Germany), Maastricht University (The Netherlands), National and Kapodistrian National and Kapodistrian University of Athens (Greece), Aer Pur Romania (Romania), European Respiratory Society (Switzerland), University of Waterloo (Canada), Catalan Institute of Oncology (Catalonia, Spain), Smoking or Health Hungarian Foundation (Hungary), Health Promotion Foundation (Poland), University of Crete (Greece), and Kantar Public Brussels (Belgium).
The authors declare that they have no competing interests, financial or otherwise, related to the current work. A Herbec reports grants from Pfizer, outside the submitted work. CI 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.
The EUREST-PLUS project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 681109 (CIV) and the University of Waterloo (GTF). Additional support was provided to the University of Waterloo by a foundation grant from the Canadian Institutes of Health Research (FDN-148477). GTF was supported by a Senior Investigator Grant from the Ontario Institute for Cancer Research. EF is partly supported by Ministry of Universities and Research, Government of Catalonia (2017SGR319) and by the Instituto Carlos III and co-funded by the European Regional Development Fund (FEDER) (INT16/00211 and INT17/00103), Government of Spain. The PhD of KE is funded by the UK Centre for Tobacco and Alcohol studies (MR/K023195/1). The UK Public Health Research Consortium funded the development of some of the social-norms measures included in this study.
KE led the writing up of this manuscript and performed the data analyses reported, with input from SH and AM. SH, MM, AM and AH provided input on the analysis plan. SH, MM, AM, AH, MF, EF, UM, AT and CV reviewed and commented on manuscript drafts. SH, MM, AM, AH, MF and AT further reviewed and provided input on the manuscript following comments from reviewers. All authors were involved in the EUREST-PLUS project, including the design of the surveys and measures included in this manuscript.
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