Undesirable events during electronic cigarette use prior to the implementation of Article 20 of the European Union Tobacco Products Directive: Findings from the EUREST-PLUS ITC Europe Surveys

Introduction: Article 20 of the European Union (EU) Tobacco Products Directive (TPD) sets forth provisions on electronic cigarette (e-cigarette) product regulation, such as child-proof packaging and protection against e-liquid refilling without leakage. The aim of the current study was to examine frequencies and correlates of experiencing undesirable events during e-cigarette use related to e-cigarette product design parameters prior to the implementation of the EU TPD. Material and Methods: The EUREST-PLUS ITC Europe Wave 1 survey was conducted with adult cigarette smokers from June to September 2016 across Germany, Greece, Hungary, Poland, Romania, Spain. Results: Among our sample of adult cigarette smokers, one in five reported having ever used e-cigarettes. Prevalence of current e-cigarette use (daily or weekly) was very low (1.5%). Major undesirable events, such as battery exploding or catching fire (1.9%) or overheating (11%) were uncommon. Among those reporting at least monthly use and whose usual/current brand has a tank that you fill with liquids, 18.8% experienced spilling during refill and 18.5% experienced e-liquid leaking during use. Nearly one-quarter reported that the e-liquid cap was easy for a child to open. Conclusions: In light of the EU TPD establishing standards around e-cigarette design parameters to mitigate undesirable events and risks during e-cigarette use, these findings further support the need for its implementation, as well as for monitoring undesirable events experienced during e-cigarette use once Article 20 is fully implemented

The Victorian anti-vaccination discourse corpus (VicVaDis): construction and exploration

This article introduces and explores the 3.5-million-word Victorian Anti-Vaccination Discourse Corpus (VicVaDis). The corpus is intended to provide a (freely accessible) historical resource for the investigation of the earliest public concerns and arguments against vaccination in England, which revolved around compulsory vaccination against smallpox in the second half of the 19th century. It consists of 133 anti-vaccination pamphlets and publications gathered from 1854 to 1906, a span of 53 years that loosely coincides with the Victorian era (1837–1901). This timeframe was chosen to capture the period between the 1853 Vaccination Act, which made smallpox vaccination for babies compulsory, and the 1907 Act that effectively ended the mandatory nature of vaccination. After an overview of the historical background, this article describes the rationale, design and construction of the corpus, and then demonstrates how it can be exploited to investigate the main arguments against compulsory vaccination by means of widely accessible corpus linguistic tools. Where appropriate, parallels are drawn between Victorian and 21st-century vaccine-hesitant attitudes and arguments. Overall, this article demonstrates the potential of corpus analysis to add to our understanding of historical concerns about vaccination

Perceptions, Predictors of and Motivation for Quitting among Smokers from Six European Countries from 2016 to 2018: Findings from EUREST-PLUS ITC Europe Surveys

The European Tobacco Products Directive (TPD) was introduced in 2016 in an effort to decrease prevalence of smoking and increase cessation in the European Union (EU). This study aimed to explore quitting behaviours, motivation, reasons and perceptions about quitting, as well as predictors (reported before the TPD implementation) associated with post-TPD quit status. A cohort study was conducted involving adult smokers from six EU countries (n= 3195). Data collection occurred pre-(Wave 1; 2016) and post-(Wave 2; 2018) TPD implementation. Bivariate and logistic regression analyses of weighted data were conducted. Within this cohort sample, 415 (13.0%) respondents reported quitting at Wave 2. Predictors of quitting were moderate or high education, fewer cigarettes smoked per day at baseline, a past quit attempt, lower level of perceived addiction, plans for quitting and the presence of a smoking-related comorbidity. Health concerns, price of cigarettes and being a good example for children were among the most important reasons that predicted being a quitter at Wave 2. Our findings show that the factors influencing decisions about quitting may be shared among European countries. European policy and the revised version of TPD could emphasise these factors through health warnings and/or campaigns and other policies

Evaluating the European Union (EU) Tobacco Products Directive: Findings from the EUREST-PLUS ITC cohort study among six EU Member States (MS)

Efforts to mitigate the devastation of tobacco-attributable morbidity and mortality in the European Union (EU) consist of its newly adopted Tobacco Products Directive (TPD) along with the first-ever health treaty, the WHO Framework Convention on Tobacco Control (FCTC). The aim of this Horizon 2020 project entitled European Regulatory Science on Tobacco: Policy Implementation to Reduce Lung Disease (EUREST-PLUS) is to monitor and evaluate the impact of the implementation of the TPD across the EU, within the context of WHO FCTC ratification. The EUREST-PLUS ITC cohort study of adult smokers in six EU MS (Germany, Greece, Hungary, Poland, Romania, Spain), uses a pre- vs. post-TPD implementation study design, evaluating the impact of several tobacco control policy provisions, including but not limited to health warning labels, smoke free areas and electronic cigarettes. The study is designed to generate strong inferences about the effectiveness of tobacco control policies, as well as to elucidate the mechanisms and factors by which policy implementation translates to population impact. Findings from EUREST-PLUS have potential global implications for implementation of innovative tobacco control policies and its impact on the prevention of lung diseases

Quitting behaviors and cessation assistance used among smokers with anxiety or depression: Findings among six countries of the EUREST-PLUS ITC Europe Surveys

Introduction: The current study explores quitting behaviours and use of cessation assistance among adult tobacco users with probable anxiety or depression (PAD) and in six European (EU) Member States (MS). Material and Methods: The EUREST-PLUS ITC Wave 1 Europe Survey was conducted with a nationally representative cross-sectional sample of 6,011 adult cigarette smokers from six European Union (EU) Member States (MS) (Germany, Greece, Hungary, Poland, Romania, Spain) in 2016. Results: Our study found that one in five smokers sampled from six EU MS had a diagnosis, treatment or positive screen for anxiety or depression, with rates of PAD varying between EU MS. Results of the multivariable logistic regression analysis showed that respondents with PAD were more likely to have made a quit attempt in the last 12 months (AOR 1.75; 95%CI 1.45-2.11), compared to respondents without PAD. Among those respondents with PAD who used support the most frequently reported quit method was prescription-based quit smoking pharmacotherapy (15.4%) followed by e-cigarettes (13.7%) and NRT (11.3%). Person-to-person behavioral support (i.e. local quit services, face-to-face advice from a doctor or other health care professional, telephone or quitline services) was reported significantly more frequently among respondents with PAD compared to those without PAD. Conclusions: Given both pharmacological and non-pharmacological quit smoking aids have been shown to be safe, acceptable and effective for people with and without mental illness it is important that their use be promoted among smokers with anxiety and depression alongside behavioral counseling. Our findings support the need for interventions targeting health care professionals in providing smoking cessation assistance among this population of smokers

Dependence, plans to quit, quitting self-efficacy and past cessation behaviours among menthol and other flavoured cigarette users in Europe: The EUREST-PLUS ITC Europe Surveys

INTRODUCTION: This study characterises smoking and cessationrelated behaviours among menthol and other flavoured cigarette users in Europe prior to the implementation of the European Tobacco Products Directive (TPD) ban on the sale of flavoured cigarettes. METHODS: An analysis of cross-sectional data from the 2016 EUREST-PLUS ITC Europe Surveys was conducted among a sample of 10760 adult smokers from eight European Union Member States. Respondents were classified as menthol, other flavoured, unflavoured, or no usual flavour cigarette users and compared on smoking and cessation behaviours and characteristics. Data were analysed in SPSS Complex Samples Package using bivariate and multivariate regression analyses adjusted for sociodemographic characteristics, dependence, and country. RESULTS: In bivariate analyses, cigarette flavour was significantly associated with all outcomes (p<0.001). After adjusting for sociodemographic characteristics, these associations attenuated but remained significant and in the same direction for dependence, self-efficacy, plans to quit, past quit attempts, and ever e-cigarette use. In fully adjusted models, compared to smokers of non-flavoured cigarettes, menthol smokers were less likely to smoke daily (AOR=0.47, 95% CI: 0.32–0.71), smoke within 30 min of waking (0.52,0.43–0.64), consider themselves addicted (0.74,0.59–0.94), and more likely to have ever used e-cigarettes (1.26,1.00–1.57); other flavoured cigarette smokers were less likely to smoke daily (0.33,0.15–0.77), and have higher self-efficacy (1.82,1.20–2.77); no usual flavour smokers were less likely to smoke daily (0.34,0.22–0.51), smoke within 30 min of waking (0.66,0.55–0.80), consider themselves addicted (0.65,0.52–0.78), have ever made a quit attempt (0.69,0.58– 0.84), have ever used e-cigarettes (0.66,0.54–0.82), and had higher self-efficacy (1.46,1.19–1.80). CONCLUSIONS: Smokers of different cigarette flavours in Europe differ on smoking and cessation characteristics. The lower dependence of menthol cigarette smokers could lead to greater success rates if quit attempts are made, however cross-country differences in smoking behaviours and quitting intentions could lead to the TPD ban on cigarette flavours having differential impact if not accompanied by additional measures, such as smoking cessation support

Cigarette brand loyalty among smokers in six European countries - findings from the EUREST-PLUS ITC Survey

INTRODUCTION This study aims to describe the degree of smokers' loyalty to a specific brand of tobacco products and the variables related to choosing a specific brand among smokers in six European countries. METHODS A cross-sectional analysis was conducted for a representative sample of adult smokers from Germany, Greece, Hungary, Poland, Romania, and Spain (approximately 1000 smokers per country). The prevalence of smokers' having a usual brand of cigarettes smoked (factory-made or roll-your-own cigarettes), the brand of choice, the factors for choosing a specific brand and the degree of loyalty to that brand (not at all, a little, somewhat and a lot) were assessed by country, sociodemographics and smoking-related variables. RESULTS In total, 86.6% of the smokers reported having a usual brand. In three out of the six countries, one brand holds the loyalty of between 17.8% and 24.5% of the smokers that reported having a usual brand for factory-made cigarettes. Most participants reported being loyal 'a lot' to their brand of choice (44.4%). The reasons most reported for choosing a cigarette brand were the taste (83.2%) and the price (51.7%). CONCLUSIONS Brand loyalty is high among factory-made and roll-your-own cigarette smokers in six European countries. Future research on longitudinal trends of brand loyalty to evaluate the effect of tobacco control policies in these European countries is warranted

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

INTRODUCTION 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. METHODS 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. RESULTS 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. CONCLUSIONS 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