Differences in smokers' awareness of the health risks of smoking before and after introducing pictorial tobacco health warnings: findings from the 2012-2017 international tobacco control (ITC) Netherlands surveys.

BACKGROUND: As of May 2016, pictorial health warnings (PHWs) showing the harms of smoking were implemented in the European Union. After one year they had to be fully implemented. We studied changes in awareness of the health risks of smoking after implementation of PHWs among smokers from the Netherlands, whether the trend before the implementation changed after the implementation, and whether there were differences between subgroups. METHODS: We used survey data from six yearly waves of the International Tobacco Control (ITC) Netherlands Survey from 2012 to 2017. The number of participating smokers ranged between 1236 and 1604 per wave. Data were analyzed using Generalized Estimating Equations (GEE) analyses. RESULTS: Indicators of awareness of the health risks of smoking that did not change between 2015 and 2017 were perceived susceptibility (ß = 0.043, p = 0.059) and perceived severity (ß = - 0.006, p = 0.679) regarding lung problems. Perceived susceptibility, however, was more pronounced between 2015 and 2017 than between 2012 and 2015(p value of interaction: p = 0.044). Noticing information about the dangers of smoking (ß = 0.119, p < 0.001) and knowledge about the health risks of smoking (ß = 0.184, p < 0.001) increased between 2015 and 2017. These increases were both more pronounced when compared to 2012-2015 (p values of interactions: p = 0.002 and p < 0.001 respectively). Compared to high educated smokers, low educated smokers (ß = - 1.137, p < 0.001) and moderate educated smokers (ß = - 0.894, p < 0.001) were less knowledgeable about the health risks of smoking in 2016 and 2017. CONCLUSIONS: Introducing PHWs coincided with an increase in smokers' knowledge about the health risks of smoking. Dutch tobacco control policy and campaigns should focus on improving Dutch smokers' awareness of the health risks of smoking even more, especially among low educated smokers.

Support for a point-of-sale cigarette display ban among smokers: findings from the international tobacco control (ITC) Netherlands survey.

BACKGROUND: Displaying tobacco products at point-of-sale (PoS) has become an important marketing strategy for the tobacco industry. This study was designed to (1) examine how support for a PoS cigarette display ban changed among Dutch smokers between 2010 and 2015 and (2) identify the variables that predict support among smokers for a PoS cigarette display ban. METHODS: Longitudinal data from six annual survey waves (2010-2015) from the International Tobacco Control (ITC) Netherlands Survey were analyzed. The sample consisted of between 1279 and 1800 smokers per year. Smokers were asked whether they supported a complete ban on displays of cigarettes inside shops and stores. RESULTS: Support for a PoS cigarette display ban increased from 28.9% in 2010 to 42.5% in 2015 (OR = 1.40, p < 0.001). A multiple logistic regression analysis revealed that support for a PoS display ban of cigarettes was more likely among smokers who had more knowledge about the health risks of smoking (OR = 3.97, p < 0.001), believed smoking-related health risks to be severe (OR = 1.39, p < 0.001), had a more positive attitude towards quitting smoking (OR = 1.44, p = 0.006), reported stronger social norms to quit smoking (OR = 1.29, p = 0.035), had a higher self-efficacy for quitting smoking (OR = 1.31, p = 0.001), and had stronger intentions to quit smoking (OR = 1.23, p = 0.006). CONCLUSIONS: This paper showed that support for a PoS display ban of cigarettes increased among smokers in the Netherlands over the years. To further increase support, educational campaigns about the dangers of smoking, and campaigns that encourage quitting may be needed.

Non-smoking adolescents' perceptions of dissuasive cigarettes.

Introduction: Dissuasive cigarettes, cigarettes with an unappealing colour or displaying a health warning label, may deter young people from smoking uptake. Methods: Two online surveys were conducted with non-smokers aged 12-17 to explore perceptions of cigarette appeal, harm and product trial. Study 1 was a within-subject study which examined perceptions of four cigarettes with different coloured paper, and four cigarettes displaying a warning. Study 2 was a between-subject study (with limited power), in which respondents were randomized to one of four cigarettes: (1) regular cigarette; (2) least favourable warning from Study 1; (3) least favourable colour from Study 1; or (4) a combination of the least favourable warning and colour from Study 1. Warnings or colours were considered least favourable when they had lower scores on appeal, harm, and product trial. Results: In Study 1, a cigarette featuring the warning 'cancer, heart disease, stroke' and a drab dark brown cigarette were rated lowest on appeal and trial intentions, and highest on perceived harm. In Study 2, there were no significant differences in perceptions of appeal, harm or trial intentions between the regular and dissuasive cigarettes. Conclusions: Findings from our within-subject study suggest that a cigarette displaying the text 'cancer, heart disease, stroke' and a drab dark brown coloured cigarette are most dissuasive for Dutch non-smoking adolescents. Whether dissuasive cigarettes reduce appeal, reduce product trial, or increase perceptions of harm compared to a regular cigarette should be further examined in larger between-subject studies.

Quasi-experimentally examining the impact of introducing tobacco pictorial health warnings: Findings from the International Tobacco Control (ITC) 4C and Netherlands surveys in the Netherlands, Australia, Canada, United Kingdom, and the United States.

BACKGROUND: Our study evaluated the short-term impact of introducing European Union's tobacco pictorial health warnings (PHWs). METHODS: Longitudinal data were collected at two time-points from adult smokers, participating in the International Tobacco Control (ITC) surveys, conducted in the Netherlands, Australia, Canada, the United Kingdom and the United States. In the Netherlands, textual health warnings (THWs) were replaced by PHWs between both time-points. Health warning policies did not change in the other countries. Data from continuing smokers were used (N = 3,487) and analyzed using Generalized Estimating Equations. RESULTS: Between both time-points, only Dutch smokers showed increases in noticing health warnings (ß = 0.712, p < 0.001), self-reports of health warnings leading to a cognitive response such as thinking about smoking health-risks (SHRs) (OR = 1.834, p < 0.001), knowledge about SHRs (ß = 0.369, p < 0.001), and avoiding health warnings (OR = 9.869, p < 0.001). However, Dutch smokers showed no changes in attitude towards smoking (ß = 0.035, p = 0.518), intention to quit smoking (OR = 0.791, p = 0.157), self-efficacy to quit smoking (ß=-0.072, p = 0.286), or reporting that health warnings helped them to resist having a cigarette (OR = 1.091, p = 0.714). CONCLUSIONS: Results suggest that introducing the European PHWs was effective in provoking changes closely related to health warnings, but there was no direct impact on variables more closely related to smoking cessation.

Did E-Cigarette Users Notice the New European Union's E-Cigarette Legislation? Findings from the 2015-2017 International Tobacco Control (ITC) Netherlands Survey.

This study examined to what extent e-cigarette users noticed the European Union's new legislation regarding e-cigarettes, and whether this may have influenced perceptions regarding addictiveness and toxicity. Data were obtained from yearly surveys (2015-2017) of the International Tobacco Control (ITC) Netherlands Survey. Descriptive statistics and Generalized Estimating Equations were applied. About a third of the e-cigarette users noticed the text warning (28%) and the leaflet (32%). When compared to tobacco-only smokers, e-cigarette users showed greater increases in perceptions regarding addictiveness (ß = 0.457, p = 0.045 vs. ß = 0.135, p < 0.001) and toxicity (ß = 0.246, p = 0.055 vs. ß = 0.071, p = 0.010). In conclusion, the new legislation's noticeability should be increased.

How the New European Union's (Pictorial) Tobacco Health Warnings Influence Quit Attempts and Smoking Cessation: Findings from the 2016-2017 International Tobacco Control (ITC) Netherlands Surveys.

In 2016, the Netherlands was required to introduce new European Union (EU)'s (pictorial) tobacco health warnings. Our objective was to describe the pathways through which the new EU tobacco health warnings may influence quit attempts and smoking cessation among Dutch smokers. Longitudinal data from 2016 and 2017 from the International Tobacco Control (ITC) Netherlands Survey were used. Smokers who participated in both surveys were included (N = 1017). Structural equation modeling was applied to examine the hypothesized pathways. Health warning salience was positively associated with more health worries (ß = 0.301, p < 0.001) and a more positive attitude towards quitting (ß = 0.180, p < 0.001), which, in turn, were associated with a stronger quit intention (health worries: ß = 0.304, p < 0.001; attitude: ß = 0.340, p < 0.001). Quit intention was a strong predictor of quit attempts (ß = 0.336, p = 0.001). Health warning salience was also associated with stronger perceived social norms towards quitting (ß = 0.166, p < 0.001), which directly predicted quit attempts (ß = 0.141, p = 0.048). Quit attempts were positively associated with smoking cessation (ß = 0.453, p = 0.043). Based on these findings, we posit that the effect of the EU's tobacco health warnings on quit attempts and smoking cessation is mediated by increased health worries and a more positive attitude and perceived social norms towards quitting. Making tobacco health warnings more salient (e.g., by using plain packaging) may increase their potential to stimulate quitting among smokers.