Effectiveness of tobacco warning labels before and after implementation of the European Tobacco Products Directive—findings from the longitudinal EUREST-PLUS ITC Europe surveys

Shannon Gravely; Pete Driezen; Christina N. Kyriakos; Mary E. Thompson; James Balmford; Tibor Demjén; Esteve Fernández; Ute Mons; Yannis Tountas; Kinga Janik-Koncewicz; Witold Zatonski; Antigona C. Trofor; Constantine I. Vardavas; Geoffrey T. Fong; Andrea Glahn; Dominick Nguyen; Katerina Nikitara; Cornel Radu-Loghin; Polina Starchenko; Aristidis Tsatsakis; Charis Girvalaki; Chryssi Igoumenaki; Sophia Papadakis; Aikaterini Papathanasaki; Manolis Tzatzarakis; Alexander I. Vardavas; Nicolas Bécuwe; Lavinia Deaconu; Sophie Goudet; Christopher Hanley; Oscar Rivière; Judit Kiss; Anna Piroska Kovacs; Yolanda Castellano; Marcela Fu; Sarah O. Nogueira; Olena Tigova; Ann McNeill; Katherine East; Sara C. Hitchman; Sarah Kahnert; Panagiotis Behrakis; Filippos T. Filippidis; Christina Gratziou; Paraskevi Katsaounou; Theodosia Peleki; Marc Willemsen; Hein De Vries; Karin Hummel; Gera E. Nagelhout; EUREST-PLUS consortium

doi:10.1093/eurpub/ckaa039

Effectiveness of tobacco warning labels before and after implementation of the European Tobacco Products Directive—findings from the longitudinal EUREST-PLUS ITC Europe surveys

Shannon Gravely, Pete Driezen, Christina N. Kyriakos, Mary E. Thompson, James Balmford, Tibor Demjén, Esteve Fernández, Ute Mons^*, Yannis Tountas, Kinga Janik-Koncewicz, Witold Zatonski, Antigona C. Trofor, Constantine I. Vardavas, Geoffrey T. Fong, Andrea Glahn, Dominick Nguyen, Katerina Nikitara, Cornel Radu-Loghin, Polina Starchenko, Aristidis TsatsakisCharis Girvalaki, Chryssi Igoumenaki, Sophia Papadakis, Aikaterini Papathanasaki, Manolis Tzatzarakis, Alexander I. Vardavas, Nicolas Bécuwe, Lavinia Deaconu, Sophie Goudet, Christopher Hanley, Oscar Rivière, Judit Kiss, Anna Piroska Kovacs, Yolanda Castellano, Marcela Fu, Sarah O. Nogueira, Olena Tigova, Ann McNeill, Katherine East, Sara C. Hitchman, Sarah Kahnert, Panagiotis Behrakis, Filippos T. Filippidis, Christina Gratziou, Paraskevi Katsaounou, Theodosia Peleki, Marc Willemsen, Hein De Vries, Karin Hummel, Gera E. Nagelhout, EUREST-PLUS consortium

^*Corresponding author for this work

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Abstract

Background: Tobacco product packaging is a key part of marketing efforts to make tobacco use appealing. In contrast, large, prominent health warnings are intended to inform individuals about the risks of smoking. In the European Union, since May 2016, the Tobacco Products Directive 2014/40/EU (TPD2) requires tobacco product packages to carry combined health warnings consisting of a picture, a text warning and information on stop smoking services, covering 65% of the front and back of the packages. Methods: Key measures of warning label effectiveness (salience, cognitive reactions and behavioural reaction) before and after implementation of the TPD2, determinants of warning labels’ effectiveness and country differences were examined in a longitudinal sample of 6011 adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (EUREST-PLUS Project) using longitudinal Generalized Estimating Equations (GEE) models. Results: In the pooled sample, the warning labels’ effectiveness increased significantly over time in terms of salience (adjusted OR ¼ 1.18; 95% CI: 1.03–1.35), while cognitive and behavioural reactions did not show clear increases. Generally, among women, more highly educated smokers and less addicted smokers, the effectiveness of warning labels tended to be higher. Conclusion: We found an increase in salience, but no clear increases for cognitive and behavioural reactions to the new warning labels as required by the TPD2. While it is likely that our study underestimated the impact of the new pictorial warning labels, it provides evidence that health messages on tobacco packaging are more salient when supported by large pictures. .........................................................................................................

Original language	English
Pages (from-to)	III84-III90
Number of pages	7
Journal	European Journal of Public Health
Volume	30
DOIs	https://doi.org/10.1093/eurpub/ckaa039
Publication status	Published - 1 Jul 2020

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Gravely, S., Driezen, P., Kyriakos, C. N., Thompson, M. E., Balmford, J., Demjén, T., Fernández, E., Mons, U., Tountas, Y., Janik-Koncewicz, K., Zatonski, W., Trofor, A. C., Vardavas, C. I., Fong, G. T., Glahn, A., Nguyen, D., Nikitara, K., Radu-Loghin, C., Starchenko, P., ... EUREST-PLUS consortium (2020). Effectiveness of tobacco warning labels before and after implementation of the European Tobacco Products Directive—findings from the longitudinal EUREST-PLUS ITC Europe surveys. European Journal of Public Health, 30, III84-III90. https://doi.org/10.1093/eurpub/ckaa039

@article{88f6211088904bd686f4e3ee70fb8ebf,

title = "Effectiveness of tobacco warning labels before and after implementation of the European Tobacco Products Directive—findings from the longitudinal EUREST-PLUS ITC Europe surveys",

abstract = "Background: Tobacco product packaging is a key part of marketing efforts to make tobacco use appealing. In contrast, large, prominent health warnings are intended to inform individuals about the risks of smoking. In the European Union, since May 2016, the Tobacco Products Directive 2014/40/EU (TPD2) requires tobacco product packages to carry combined health warnings consisting of a picture, a text warning and information on stop smoking services, covering 65% of the front and back of the packages. Methods: Key measures of warning label effectiveness (salience, cognitive reactions and behavioural reaction) before and after implementation of the TPD2, determinants of warning labels{\textquoteright} effectiveness and country differences were examined in a longitudinal sample of 6011 adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (EUREST-PLUS Project) using longitudinal Generalized Estimating Equations (GEE) models. Results: In the pooled sample, the warning labels{\textquoteright} effectiveness increased significantly over time in terms of salience (adjusted OR ¼ 1.18; 95% CI: 1.03–1.35), while cognitive and behavioural reactions did not show clear increases. Generally, among women, more highly educated smokers and less addicted smokers, the effectiveness of warning labels tended to be higher. Conclusion: We found an increase in salience, but no clear increases for cognitive and behavioural reactions to the new warning labels as required by the TPD2. While it is likely that our study underestimated the impact of the new pictorial warning labels, it provides evidence that health messages on tobacco packaging are more salient when supported by large pictures. .........................................................................................................",

author = "Shannon Gravely and Pete Driezen and Kyriakos, {Christina N.} and Thompson, {Mary E.} and James Balmford and Tibor Demj{\'e}n and Esteve Fern{\'a}ndez and Ute Mons and Yannis Tountas and Kinga Janik-Koncewicz and Witold Zatonski and Trofor, {Antigona C.} and Vardavas, {Constantine I.} and Fong, {Geoffrey T.} and Andrea Glahn and Dominick Nguyen and Katerina Nikitara and Cornel Radu-Loghin and Polina Starchenko and Aristidis Tsatsakis and Charis Girvalaki and Chryssi Igoumenaki and Sophia Papadakis and Aikaterini Papathanasaki and Manolis Tzatzarakis and Vardavas, {Alexander I.} and Nicolas B{\'e}cuwe and Lavinia Deaconu and Sophie Goudet and Christopher Hanley and Oscar Rivi{\`e}re and Judit Kiss and Kovacs, {Anna Piroska} and Yolanda Castellano and Marcela Fu and Nogueira, {Sarah O.} and Olena Tigova and Ann McNeill and Katherine East and Hitchman, {Sara C.} and Sarah Kahnert and Panagiotis Behrakis and Filippidis, {Filippos T.} and Christina Gratziou and Paraskevi Katsaounou and Theodosia Peleki and Marc Willemsen and {De Vries}, Hein and Karin Hummel and Nagelhout, {Gera E.} and {EUREST-PLUS consortium}",

note = "Funding Information: The EUREST-PLUS project has received funding from the European Union{\textquoteright}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 (FDN148477). S.K. is supported by the German Federal Ministry of Health. G.T.F. was supported by a Senior Investigator Grant from the Ontario Institute for Cancer Research. E.F. 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. E.F. thanks CERCA Programme Generalitat de Catalunya for the institutional support to IDIBELL. Publisher Copyright: {\textcopyright} The Author(s) 2020. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.",

year = "2020",

month = jul,

day = "1",

doi = "10.1093/eurpub/ckaa039",

language = "English",

volume = "30",

pages = "III84--III90",

journal = "European Journal of Public Health",

issn = "1101-1262",

publisher = "Oxford University Press",

}

Gravely, S, Driezen, P, Kyriakos, CN, Thompson, ME, Balmford, J, Demjén, T, Fernández, E, Mons, U, Tountas, Y, Janik-Koncewicz, K, Zatonski, W, Trofor, AC, Vardavas, CI, Fong, GT, Glahn, A, Nguyen, D, Nikitara, K, Radu-Loghin, C, Starchenko, P, Tsatsakis, A, Girvalaki, C, Igoumenaki, C, Papadakis, S, Papathanasaki, A, Tzatzarakis, M, Vardavas, AI, Bécuwe, N, Deaconu, L, Goudet, S, Hanley, C, Rivière, O, Kiss, J, Kovacs, AP, Castellano, Y, Fu, M, Nogueira, SO, Tigova, O, McNeill, A, East, K, Hitchman, SC, Kahnert, S, Behrakis, P, Filippidis, FT, Gratziou, C, Katsaounou, P, Peleki, T, Willemsen, M , De Vries, H, Hummel, K, Nagelhout, GE & EUREST-PLUS consortium 2020, 'Effectiveness of tobacco warning labels before and after implementation of the European Tobacco Products Directive—findings from the longitudinal EUREST-PLUS ITC Europe surveys', European Journal of Public Health, vol. 30, pp. III84-III90. https://doi.org/10.1093/eurpub/ckaa039

Effectiveness of tobacco warning labels before and after implementation of the European Tobacco Products Directive—findings from the longitudinal EUREST-PLUS ITC Europe surveys. / Gravely, Shannon; Driezen, Pete; Kyriakos, Christina N. et al.
In: European Journal of Public Health, Vol. 30, 01.07.2020, p. III84-III90.

Research output: Contribution to journal › Article › Academic › peer-review

TY - JOUR

T1 - Effectiveness of tobacco warning labels before and after implementation of the European Tobacco Products Directive—findings from the longitudinal EUREST-PLUS ITC Europe surveys

AU - Gravely, Shannon

AU - Driezen, Pete

AU - Kyriakos, Christina N.

AU - Thompson, Mary E.

AU - Balmford, James

AU - Demjén, Tibor

AU - Fernández, Esteve

AU - Mons, Ute

AU - Tountas, Yannis

AU - Janik-Koncewicz, Kinga

AU - Zatonski, Witold

AU - Trofor, Antigona C.

AU - Vardavas, Constantine I.

AU - Fong, Geoffrey T.

AU - Glahn, Andrea

AU - Nguyen, Dominick

AU - Nikitara, Katerina

AU - Radu-Loghin, Cornel

AU - Starchenko, Polina

AU - Tsatsakis, Aristidis

AU - Girvalaki, Charis

AU - Igoumenaki, Chryssi

AU - Papadakis, Sophia

AU - Papathanasaki, Aikaterini

AU - Tzatzarakis, Manolis

AU - Vardavas, Alexander I.

AU - Bécuwe, Nicolas

AU - Deaconu, Lavinia

AU - Goudet, Sophie

AU - Hanley, Christopher

AU - Rivière, Oscar

AU - Kiss, Judit

AU - Kovacs, Anna Piroska

AU - Castellano, Yolanda

AU - Fu, Marcela

AU - Nogueira, Sarah O.

AU - Tigova, Olena

AU - McNeill, Ann

AU - East, Katherine

AU - Hitchman, Sara C.

AU - Kahnert, Sarah

AU - Behrakis, Panagiotis

AU - Filippidis, Filippos T.

AU - Gratziou, Christina

AU - Katsaounou, Paraskevi

AU - Peleki, Theodosia

AU - Willemsen, Marc

AU - De Vries, Hein

AU - Hummel, Karin

AU - Nagelhout, Gera E.

AU - EUREST-PLUS consortium

N1 - Funding Information: 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 (FDN148477). S.K. is supported by the German Federal Ministry of Health. G.T.F. was supported by a Senior Investigator Grant from the Ontario Institute for Cancer Research. E.F. 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. E.F. thanks CERCA Programme Generalitat de Catalunya for the institutional support to IDIBELL. Publisher Copyright: © The Author(s) 2020. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.

PY - 2020/7/1

Y1 - 2020/7/1

N2 - Background: Tobacco product packaging is a key part of marketing efforts to make tobacco use appealing. In contrast, large, prominent health warnings are intended to inform individuals about the risks of smoking. In the European Union, since May 2016, the Tobacco Products Directive 2014/40/EU (TPD2) requires tobacco product packages to carry combined health warnings consisting of a picture, a text warning and information on stop smoking services, covering 65% of the front and back of the packages. Methods: Key measures of warning label effectiveness (salience, cognitive reactions and behavioural reaction) before and after implementation of the TPD2, determinants of warning labels’ effectiveness and country differences were examined in a longitudinal sample of 6011 adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (EUREST-PLUS Project) using longitudinal Generalized Estimating Equations (GEE) models. Results: In the pooled sample, the warning labels’ effectiveness increased significantly over time in terms of salience (adjusted OR ¼ 1.18; 95% CI: 1.03–1.35), while cognitive and behavioural reactions did not show clear increases. Generally, among women, more highly educated smokers and less addicted smokers, the effectiveness of warning labels tended to be higher. Conclusion: We found an increase in salience, but no clear increases for cognitive and behavioural reactions to the new warning labels as required by the TPD2. While it is likely that our study underestimated the impact of the new pictorial warning labels, it provides evidence that health messages on tobacco packaging are more salient when supported by large pictures. .........................................................................................................

AB - Background: Tobacco product packaging is a key part of marketing efforts to make tobacco use appealing. In contrast, large, prominent health warnings are intended to inform individuals about the risks of smoking. In the European Union, since May 2016, the Tobacco Products Directive 2014/40/EU (TPD2) requires tobacco product packages to carry combined health warnings consisting of a picture, a text warning and information on stop smoking services, covering 65% of the front and back of the packages. Methods: Key measures of warning label effectiveness (salience, cognitive reactions and behavioural reaction) before and after implementation of the TPD2, determinants of warning labels’ effectiveness and country differences were examined in a longitudinal sample of 6011 adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (EUREST-PLUS Project) using longitudinal Generalized Estimating Equations (GEE) models. Results: In the pooled sample, the warning labels’ effectiveness increased significantly over time in terms of salience (adjusted OR ¼ 1.18; 95% CI: 1.03–1.35), while cognitive and behavioural reactions did not show clear increases. Generally, among women, more highly educated smokers and less addicted smokers, the effectiveness of warning labels tended to be higher. Conclusion: We found an increase in salience, but no clear increases for cognitive and behavioural reactions to the new warning labels as required by the TPD2. While it is likely that our study underestimated the impact of the new pictorial warning labels, it provides evidence that health messages on tobacco packaging are more salient when supported by large pictures. .........................................................................................................

U2 - 10.1093/eurpub/ckaa039

DO - 10.1093/eurpub/ckaa039

M3 - Article

SN - 1101-1262

VL - 30

SP - III84-III90

JO - European Journal of Public Health

JF - European Journal of Public Health

ER -

Effectiveness of tobacco warning labels before and after implementation of the European Tobacco Products Directive—findings from the longitudinal EUREST-PLUS ITC Europe surveys

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