Evaluating the impact of the Tobacco Products Directive within the context of the FCTC in Europe—findings from the EUREST-PLUS ITC Europe Surveys: introductory Commentary

Tobacco use is the single most significant cause of preventable morbidity and mortality in the European Union (EU), attributable to 700 000 deaths annually.1,2 The largest population-level efforts to reduce tobacco use in the EU include the World Health Organization Framework Convention on Tobacco Control (WHO FCTC)3 and the European Tobacco Products Directive (TPD).2 Implementation of the revised TPD, in which EU Member States were required to transpose into National law by May 2016,2 offered a unique window of opportunity to evaluate the impact of its provisions. The aim of the Horizon 2020 project entitled, European Regulatory Science on Tobacco: Policy Implementation to Reduce Lung Disease (EUREST-PLUS), was to monitor and evaluate the implementation of the TPD within the context of the WHO FCTC at the EU level.4 A primary component of the EUREST-PLUS Project was the creation of an International Tobacco Control (ITC) Policy Evaluation Project 2-wave cohort of ∼6000 adult smokers from six EU countries: Germany, Greece, Hungary, Poland, Romania and Spain—the ITC 6 European Country (6E) Surveys.5 The aim of the 6E cohort surveys was to evaluate the psychosocial and behavioural impact of the implementation of the EU TPD Articles, with an assessment before6–20 and after the TPD. The strong methodological approach of the ITC Project further allowed for comparable cross-country analyses with the addition of two other ITC cohort studies involving European countries—England, as part of the ITC Four Country Smoking and Vaping Survey, and the ITC Netherlands Survey.21,22 This Supplementary Material contains 15 articles assessing population-level data on perceptions, behaviours and other impacts after the implementation of the TPD using where possible, cohort-level data. The Supplementary Material begins with a description of the methodology of the EUREST-PLUS ITC Europe Surveys.23 It goes on to provide a landscape of product use in the EU, including transitions between products, before and after TPD implementation,24 such as to and from roll-your-own tobacco.25 In addition, data on quitting behaviours and smoking cessation methods used in the EU are presented,26 and specifically among users of menthol and other flavoured cigarettes.27 A number of articles examine electronic cigarettes (e-cigarettes/vaping), including perceptions of harmfulness28 and social norms,29 exposure to e-cigarette advertising, promotion and sponsorship,30 awareness of TPD provisions regarding packaging of e-cigarettes,31 and support for e-cigarette policies.32 Awareness and use of heated tobacco products are further examined.33 Other TPD policies assessed are tobacco warning labels,34 and, for the first time, the additional impact of standardized packaging over enhanced warning labels,35 and awareness of other changes to cigarette packaging design.36 In addition to its focus on EU TPD policies and regulations, the 6E survey also allowed for the evaluation of an FCTC policy that is not also a part of the EU TPD—policies to reduce second-hand smoke.37 This Supplementary Material thus contains a landmark set of scientific papers, which has created a repository of evidence that can be used not only by the participating countries and the European Commission to inform future policy provisions and evidence-based interventions to reduce the burden of tobacco in Europe but could also be useful to other countries around the world. The authors gratefully acknowledge several members of the EUREST-PLUS Consortium for their assistance in preparing this Supplementary Material. In particular, we thank Anne C.K. Quah (ITC Managing Director and Senior Research Scientist, University of Waterloo), Thomas K. Agar (Project Manager of the EUREST-PLUS ITC 6 European Countries Surveys, University of Waterloo) and C.N.K. (Project Manager, European Network for Smoking and Tobacco Prevention). EUREST-PLUS Consortium Members: European Network on Smoking and Tobacco Prevention (ENSP), Belgium: C.I.V., Andrea Glahn, C.N.K., Dominick Nguyen, Katerina Nikitara, Cornel Radu-Loghin and Polina Starchenko; University of Crete (UOC), Greece: Aristidis Tsatsakis, Charis Girvalaki, Chryssi Igoumenaki, Sophia Papadakis, Aikaterini Papathanasaki, Manolis Tzatzarakis and Alexander I. Vardavas; Kantar Public, Belgium: Nicolas Bécuwe, Lavinia Deaconu, Sophie Goudet, Christopher Hanley and Oscar Rivière; Smoking or Health Hungarian Foundation (SHHF), Hungary: Tibor Demjén, Judit Kiss and Anna Piroska Kovacs; Tobacco Control Unit, Catalan Institute of Oncology (ICO) and Bellvitge Biomedical Research Institute (IDIBELL), Catalonia: Esteve Fernández, Yolanda Castellano, Marcela Fu, Sarah O. Nogueira and Olena Tigova; King’s College London (KCL), UK: A.M., Katherine East and Sara C. Hitchman; Cancer Prevention Unit and WHO Collaborating Centre for Tobacco Control, German Cancer Research Center (DKFZ), Germany: Ute Mons and 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 and Chara Tzavara; Aer Pur Romania, Romania: Antigona Carmen Trofor, Marius Eremia, Lucia Lotrean and Florin Mihaltan; European Respiratory Society (ERS), Switzerland: Gernot Rohde, Tamaki Asano, Claudia Cichon, Amy Far, Céline Genton, Melanie Jessner, Linnea Hedman, Christer Janson, Ann Lindberg, Beth Maguire, Sofia Ravara, Valérie Vaccaro and Brian Ward; Maastricht University, The Netherlands: Marc Willemsen, Hein de Vries, Karin Hummel and Gera E. Nagelhout; Health Promotion Foundation (HPF), Poland: Witold A. Zatoński, Aleksandra Herbeć, Kinga Janik-Koncewicz, Krzysztof Przewoźniak and Mateusz Zatoński; University of Waterloo (UW), Canada: G.T.F., Thomas K. Agar, Pete Driezen, Shannon Gravely, Anne C. K. Quah and Mary E. Thompson. The EUREST-PLUS project has received funding from the EU’s Horizon2020 research and innovation programme under grant agreement No. 681109 (CIV) and the University of Waterloo (G.T.F.). Additional support was provided to the University of Waterloo by a foundation grant from the Canadian Institutes of Health Research (FDN-148477). 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. The England arm of the ITC 4 Country Smoking and Vaping Survey was supported by grants from the US National Cancer Institute (P01 CA200512) and the Canadian Institutes of Health Research (FDN-148477). The ITC Netherlands Surveys were supported by the Dutch Cancer Foundation (KWF) (UM 2014-7210). Conflicts of interest: G.T.F. has served as an expert witness on behalf of governments in litigation involving the tobacco industry. A.M. is a UK National Institute for Health Research (NIHR) Senior Investigator. The views expressed in this article are those of A.M. and not necessarily those of the NIHR, or the UK Department of Health and Social Care. 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. Methods of the International Tobacco Control (ITC) EUREST-PLUS ITC Europe Surveys—Mary T. Thompson. Transitions in product use during the implementation of the European Tobacco Products Directive: Cohort study findings from the EUREST-PLUS ITC Europe Surveys—Constantine I. Vardavas. Transitions from and to roll-your-own tobacco, perceptions and health beliefs among smokers: Findings from the EUREST-PLUS ITC Europe Surveys—Filippos T Filippidis. Quitting behaviours and smoking cessation methods used in the EU in 2017: Findings from the EUREST-PLUS ITC Europe Surveys—Sophia Papadakis. Cessation behaviours among smokers of menthol and flavoured cigarettes following the implementation of the EU Tobacco Products Directive: findings from the EUREST-PLUS ITC Europe Surveys—Mateusz Zatoński. European adult smokers’ perceptions of the harmfulness of e-cigarettes relative to combustible cigarettes: Cohort findings from the 2016 and 2018 EUREST-PLUS ITC Europe Surveys—Shannon Gravely. Social norms for e-cigarettes and smoking: associations with initiation of e-cigarette use, intentions to quit smoking and quit attempts. Findings from the EUREST-PLUS ITC Europe Surveys—Máirtín S McDermott. Impact of the Tobacco Products Directive on self-reported exposure to e-cigarette advertising, promotion and sponsorship in smokers: Findings from the EUREST-PLUS ITC Europe Surveys—Sarah Kahnert. Awareness of e-cigarette packaging and labelling introduced by the Tobacco Products Directive in 6 European countries: Findings from the EUREST-PLUS ITC Europe Surveys—Katerina Nikitara. Support for e-cigarette policies in seven European countries: Findings from the EUREST –PLUS ITC Europe Surveys—Janet Chung-Hall. Awareness and use of heated tobacco products among adult smokers in six European countries: Findings from the EUREST-PLUS ITC Europe Surveys—Lucia M Lotrean. Changes in the effectiveness of tobacco warning labels after implementation of the European Tobacco Products Directive: Findings from the EUREST-PLUS ITC Europe Surveys—Sarah Kahnert. Evaluating the impact of introducing standardised packaging with larger health warning labels in England: Findings from adult smokers within seven European countries—Sarah Aleyan. Awareness and correlates of noticing changes to cigarette packaging design after implementation of the European Tobacco Products Directive: Findings from the EUREST-PLUS ITC Europe Surveys—Christina NKyriakos. Do smokers want to protect non-smokers from the harms of secondhand smoke in cars? Results from the Eurest-Plus ITC surveys in six European countries—Sarah O Noguiera.

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