Metabolic Changes Following Smoking Cessation in Patients with Type 2 Diabetes Mellitus.

BACKGROUND: Smoking cessation is crucial for reducing complications of type 2 diabetes mellitus (T2DM), but associated weight gain can worsen glycemic control, discouraging quitting attempts. Varenicline, a partial agonist of α4ß2 nicotinic receptors, aids smoking cessation. This study examines the effects of varenicline on body weight and metabolic parameters in patients with T2DM and prediabetes. METHODS: Fifty-three patients were enrolled, of which 32 successfully quit smoking after a three-month course of varenicline and were examined after an additional month with no medication. Measurements taken at baseline, 2.5 months, and 4 months included body weight, blood pressure, resting metabolic rate (RMR), glycated hemoglobin (HbA1c), fasting glucose, blood lipids, C-reactive protein (CRP), appetite-related hormones, and physical activity. RESULTS: Post-treatment, there were no significant changes in body weight, blood pressure, RMR, or glycemic control. Total (CHOL) and low-density lipoprotein (LDL-C) cholesterol decreased significantly at 4 months of the study (from 168 to 156 mg/dL, p = 0.013, and from 96 to 83 mg/dL, p = 0.013, respectively). Leptin levels increased (from 11 to 13.8 ng/dL, p = 0.004), as did glucagon-like peptide-1 (GLP-1) levels (from 39.6 to 45.8 pM, p = 0.016) at 4 months of follow-up. The percentage of participants who reported moderate-intensity activity increased from 28% to 56%, while those reporting high-intensity activity increased from 19% to 22%, respectively (p = 0.039). CONCLUSIONS: Our study showed that smoking cessation with varenicline in smokers with T2DM and prediabetes led to significant improvements in lipid profile, significant increase in plasma leptin and GLP-1 levels, and increased physical activity, without significant weight gain. Thus, smoking cessation without weight gain or deteriorated glycemic control is feasible for these smokers, with added benefits to lipid profiles, GLP-1 regulation, and physical activity.

Particle emissions from heated tobacco products.

INTRODUCTION: This study determines the particle emissions from five heated tobacco products (HTPs). METHODS: An aethalometer is used for the determination of black carbon (BC) and an aerosol monitor for total particulate matter (PM) concentration and also PM fractions (1, 2.5, 4, and 10 µm) in the mainstream emissions of 5 HTPs: IQOS, LIL, PULZE, ILUMA, and GLO. Fifteen different flavors were used, five sticks per flavor, which were smoked using a peristaltic pump under both ISO and Canadian smoking regimes. The method repeatability was determined using 15 sticks of one flavor for each brand for each smoking regime. RESULTS: All HTPs emit particles, and more than 99.7% of the particles emitted are smaller than 1 µm. Both BC and PM emissions show quite low repeatability. Particle emissions increase in relation to the heating temperature and the intensity smoking regime, and are depending on the flavor used. BC corresponds to a small percentage of total PM. CONCLUSIONS: Although HTPs are promoted as products of reduced risk compared to conventional cigarettes, high particle concentrations are detected in their emissions, depending on the smoking regime, the flavor used, and the operation parameters. PM emissions vary significantly between different brands under the ISO smoking regime, probably due to the heating temperature. In contrast, PM emissions under the Canadian smoking regime do not vary significantly between different brands. This could probably be attributed to the fact that increased puff frequency does not allow the device to cool down between puffs, resulting in an increase in PM emissions for all the brands, but not dependent on the maximum heating temperature of the device. BC emissions only consist of a very small fraction of PM and do not vary significantly between different brands under both smoking regimes.

Clarithromycin for early anti-inflammatory responses in community-acquired pneumonia in Greece (ACCESS): a randomised, double-blind, placebo-controlled trial.

BACKGROUND: Addition of macrolide antibiotics to ß-lactam antibiotics for the treatment of patients in hospital with community-acquired pneumonia is based on results from observational studies and meta-analyses rather than randomised clinical trials. We investigated if addition of the macrolide clarithromycin to treatment with a ß-lactam antibiotic in this population could improve early clinical response-the new regulatory endpoint for community-acquired pneumonia-and explored the possible contribution of modulation of the inflammatory host response to that outcome. METHODS: The ACCESS trial was a phase 3 prospective, double-blind, randomised controlled trial, in which adults in hospital with community-acquired pneumonia who had systemic inflammatory response syndrome, Sequential Organ Failure Assessment (SOFA) score of 2 or more, and procalcitonin 0·25 ng/mL or more were enrolled in 18 internal medicine departments of public Greek hospitals. Patients were randomly assigned (1:1) by computer-generated block randomisation to standard of care medication (including intravenous administration of a third-generation cephalosporin or intravenous administration of ß-lactam plus ß-lactamase inhibitor combination) plus either oral placebo or oral clarithromycin 500 mg twice daily for 7 days. Investigators, staff, and patients were masked to group allocation. The primary composite endpoint required that patients fulfilled both of the following conditions after 72 hours (ie, day 4 of treatment): (1) decrease in respiratory symptom severity score of 50% or more as an indicator of early clinical response and (2) decrease in SOFA score of at least 30% or favourable procalcitonin kinetics (defined as ≥80% decrease from baseline or procalcitonin <0·25 ng/mL), or both, as an indicator of early inflammatory response. Participants who were randomly assigned and received allocated treatment were included in the primary analysis population. This trial is complete and is registered with the EU Clinical Trials Register (2020-004452-15) and ClinicalTrials.gov (NCT04724044). FINDINGS: Patients were enrolled between Jan 25, 2021, and April 11, 2023, and 278 individuals were randomly allocated to receive standard of care in combination with either clarithromycin (n=139) or placebo (n=139). 134 patients in the clarithromycin group (five withdrew consent) and 133 patients in the placebo group (six withdrew consent) were included in the analysis of the primary endpoint. The primary endpoint was met in 91 (68%) patients in the clarithromycin group and 51 (38%) patients in the placebo group (difference 29·6% [95% CI 17·7-40·3]; odds ratio [OR] 3·40 [95% CI 2·06-5·63]; p<0·0001). Serious treatment-emergent adverse events (TEAEs) occurred in 58 (43%) patients in the clarithromycin group and 70 (53%) patients in the placebo group (difference 9·4% [95% CI -2·6 to 20·9]; OR 0·67 [95% CI 0·42 to 1·11]; p=0·14). None of the serious TEAEs was judged to be related to treatment assignment. INTERPRETATION: Addition of clarithromycin to standard of care enhances early clinical response and attenuates the inflammatory burden of community-acquired pneumonia. The mechanism of benefit is associated with changes in the immune response. These findings suggest the importance of adding clarithromycin to ß-lactams for treatment of patients in hospital with community-acquired pneumonia to achieve early clinical response and early decrease of the inflammatory burden. FUNDING: Hellenic Institute for the Study of Sepsis and Abbott Products Operations.

Challenges and perspectives of tobacco cessation in special groups of patients and populations.

During the first 2 years of the coronavirus disease 2019 pandemic, health systems worldwide were put under extreme pressure, and healthcare professionals had to manage unprecedented health crises as well as provide healthcare services to an increased number of patients. Therefore, public health policies with respect to smoking and education of the general population regarding the harmful effects of active and second-hand smoking may not have received adequate attention during this period. More specifically, certain subpopulations suffering from chronic diseases may not have received adequate information about the effects of smoking on the course and outcome of their disease; high-level, evidence-based pharmaceutical therapies; and the potential for follow-up. However, adequate education and awareness regarding short- and long-term health benefits from smoking cessation for the general population as well as special subgroups remains of utmost importance. Healthcare professionals should understand that it is only through high-quality evidence and results from independent studies that they will be able to provide their expertise and scientific knowledge concerning newer tobacco products and their effects on human health.

A Giant solitary fibrous tumour resected through median sternotomy.

Solitary fibrous tumour of the pleura (SFT) is rare neoplasms and consist less than 5% of the primary tumours of the pleura. In the English literature, very few cases of giant solitary fibrous tumours have been described. We report a clinical case of an intrathoracic giant SFT of the pleura in a 62-year-old female patient. Additionally, we reviewed the clinical, imaging and histopathological features, the therapeutic management and the clinical course of giant SFTs published in the English literature. For this, we conducted a comprehensive electronic search at the PubMed using the key words giant, huge, big and enormous.

The Effect of Smoking Cessation on Body Weight and Other Metabolic Parameters with Focus on People with Type 2 Diabetes Mellitus.

Smokers with diabetes mellitus substantially lower their risks of microvascular and macrovascular diabetic complications, in particular cardiovascular disease, by quitting smoking. However, subsequent post-smoking-cessation weight gain may attenuate some of the beneficial effects of smoking cessation and discourage attempts to quit. Weight gain can temporarily exacerbate diabetes and deteriorate glycemic control and metabolic profile. The molecular mechanisms by which quitting smoking leads to weight gain are largely associated with the removal of nicotine's effects on the central nervous system. This review addresses mechanisms of post-smoking-cessation weight gain, by reviewing the effects of nicotine on appetite, food intake, eating behaviour, energy expenditure, fat oxidation and appetite-regulating peptides. We also highlight correlations between post-cessation weight gain and risk of type 2 diabetes, consequences of weight gain in people with type 2 diabetes and the role of pharmacotherapies, which combine treatment of nicotine addiction and promotion of weight control.

Depression, Insomnia and Post-Traumatic Stress Disorder in COVID-19 Survivors: Role of Gender and Impact on Quality of Life.

Evidence to date suggests that a significant proportion of COVID-19 patients experience adverse psychological outcomes and neuropsychiatric complications. The aim of this study was to evaluate the effect of SARS-CoV-2 infection and subsequent hospitalization on the mental health, sleep, and quality of life of COVID-19 survivors. Patients were assessed 1−2 months after hospital discharge using standardized screening tools for depression and anxiety (HADS), post-traumatic stress disorder (IES-R), insomnia (AIS), and quality of life (EQ-5D-5L). Sociodemographic factors, comorbidities, disease severity and type of hospitalization were also collected. Amongst the 143 patients included, mental health symptoms were common (depression­19%; anxiety­27%; traumatic stress­39%; insomnia­33%) and more frequently reported in female than in male patients. Age, smoking status, comorbidities and illness severity were not found to significantly correlate with the presence of mood, sleep, or stress disorders. Finally, quality of life was worse for patients requiring ICU (p = 0.0057) or a longer hospital stay (p < 0.001) but was unaffected by factors such as sex and other measured outcomes. These findings highlight the need for appropriate intervention to properly manage the immediate and enduring mental health complications of COVID-19.

Studying stimuli and smoking behaviors among self-identified gifted smokers and strategies for customizing cessation support.

INTRODUCTION: The aim of the study was to examine smoking habits and triggers among self-identified gifted (inner experiences and awareness qualitatively different from the norm in terms of asynchronous development, advanced cognitive abilities, and heightened intensity) adults in order to customize smoking cessation support. METHODS: A total of 123 participants were enrolled through Facility-Based and Snowball Sampling. Quantitative analysis focused on the relationship between overexcitabilities, nicotine dependence, motivation to quit, and smoking triggers, using the following questionnaires: the Overexcitability Questionnaire (OEQ-II) an indicator of areas of overexcitability, a heightened response and lowered threshold to stimuli; the Fagerström Test for Nicotine Dependence; a Cessation Motivation Questionnaire; and a Smoking Triggers Questionnaire. Qualitative analysis drew on six semi-structured interviews. Participant experiences of the relationship between smoking behaviors and experiences of multiple areas of overexcitability were analyzed using process coding. RESULTS: The quantitative data indicate that self-identified gifted smokers who rate themselves as having 3-5 'High' or 'High Average' overexcitabilities (OEs), are less likely to smoke in response to pattern, social, and addiction focused triggers than those self-reporting as having 0-2 OEs (Fisher's exact test, p<0.1). In the interviews, we observed a high level of complexity in stimulation and smoking behavior, with all interviewees explicitly connecting their smoking habits with experiences of overexcitability. Two interviewees had given up smoking prior to the research and of the four who still smoked, three quit within a few days of the interview. CONCLUSIONS: We found that psychometric testing and interviews designed to increase self-knowledge about the relationship between overexcitabilities and triggers for smoking have the potential to improve outcomes for smoking cessation among the gifted.

Secondhand Smoke Exposure in European Countries With Different Smoke-Free Legislation: Findings From the EUREST-PLUS ITC Europe Surveys.

INTRODUCTION: Exposure to secondhand smoke (SHS) poses serious and extensive health and economic-related consequences to European society and worldwide. Smoking bans are a key measure to reducing SHS exposure but have been implemented with varying levels of success. We assessed changes in the prevalence of self-reported SHS exposure and smoking behavior in public places among smokers in six European countries and the influence of the country's type of smoking ban (partial or total ban) on such exposure and smoking behavior. AIMS AND METHODS: The EUREST-PLUS ITC Europe Surveys were conducted among adult smokers in Germany, Greece, Hungary, Poland, Romania, and Spain in 2016 (Wave 1, n = 6011) and 2018 (Wave 2, n = 6027). We used generalized estimating equations models to assess changes between Waves 1 and 2 and to test the interaction between the type of smoking ban and (1) self-reported SHS exposure, (2) self-reported smoking in several public places. RESULTS: A significant decrease in self-reported SHS exposure was observed in workplaces, from 19.1% in 2016 to 14.0% in 2018 (-5.1%; 95% CI: -8.0%; -2.2%). Self-reported smoking did not change significantly inside bars (22.7% in Wave 2), restaurants (13.2% in Wave 2) and discos/nightclubs (34.0% in W2). SHS exposure in public places was significantly less likely (adjusted odds ratio = 0.35; 95% CI: 0.26-0.47) in the countries with total bans as compared to those countries with partial bans. CONCLUSION: The inverse association between smoking in public places and smoking bans indicates an opportunity for strengthening smoke-free legislation and protecting bystanders from exposure to SHS in public places. IMPLICATIONS: Prevalence of smokers engaging in and being exposed to smoking in public places varied by type of smoke-free legislation across six European Union countries in our study; those with total smoke bans reported significantly less exposure to SHS than those with partial or no bans. Our results indicate room for improvement, not only to decrease the prevalence of exposure to SHS in Europe but also to diminish the variability between countries through common, more restrictive smoke-free legislation, and importantly, strong and sustained enforcement.

Beyond the European Union Tobacco Products Directive: smokers' and recent quitters' support for further tobacco control measures (2016-2018).

BACKGROUND: Several measures recommended by the WHO Framework Convention on Tobacco Control have not been implemented in the European Union, despite changes in the legislation such as the Tobacco Products Directive (TPD). This study aims to understand smokers' and recent quitters' levels of support for tobacco control measures that go beyond the TPD during and after its implementation. METHODS: Data from wave 1 (2016, n=6011) and wave 2 (2018, n=6027) of the EUREST-PLUS International Tobacco Control Policy Evaluation Project Six European Countries Survey, a cohort of adult smokers in Germany, Greece, Hungary, Poland, Romania, Spain were used to estimate the level of support for seven different tobacco control measures, overall and by country. RESULTS: In 2018, the highest support was for implementing measures to further regulate tobacco products (50.5%) and for holding tobacco companies accountable for the harm caused by smoking (48.8%). Additionally, in 2018, 40% of smokers and recent quitters supported a total ban on cigarettes and other tobacco products within ten years, if assistance to quit smoking is provided. Overall, support for tobacco control measures among smokers and recent quitters after the implementation of the TPD remained stable over time. CONCLUSION: There is considerable support among smokers and recent quitters for tobacco control measures that go beyond the current measures implemented. A significant percentage of smokers would support a ban on tobacco products in the future if the government provided assistance to quit smoking. This highlights the importance of implementing measures to increase smoking cessation in conjunction with other policies.

Barriers to Smoking Cessation and Characteristics of Pregnant Smokers in Greece.

Objectives: Nicotine addiction and the inability of a large part of pregnant smokers to quit is one of the main preventable causes of morbidity and mortality during the perinatal period. The aim of this study is to investigate nicotine dependence and overall smoking habits of pregnant smokers and to possibly correlate them with smokers' social and demographic characteristics. Materials and methods: One hundred and fourteen pregnant smokers answered an electronic questionnaire consisting of 59 questions, which was divided into six sections. The questionnaires were filled out by participants from many regions of Greece and Cyprus. Results:Before their pregnancy, women smoked 19 cigarettes per day on average, while during their pregnancy they dropped to eight cigarettes per day; 65.8% of respondents stated that their husband smoked, while 58.8% answered that they had been exposed to secondhand smoke; 13.2% of pregnant smokers stated that they had had depression at some point in their lives and 14.9% reported having undergone domestic violence; 55.3% of respondents acknowledged that smoking was responsible for a variety of adverse effects to the fetus; and 97.4% of pregnant women did not follow a smoking cessation counseling program, compared to just 2.6% who did. Conclusions:The pregnant smokers in our study did not have appropriate information about the available smoking cessation services, which were not generally considered to be useful for them, and consequently they did not utilize cessation assistance. The resistance towards quitting smoking, which was observed in the sample, may also be attributed to the lack of specialized smoking cessation services in maternity hospitals in Greece.

Electronic Cigarettes and Asthma: What Do We Know So Far?

Electronic cigarettes (EC) are a novel product, marketed as an alternative to tobacco cigarette. Its effects on human health have not been investigated widely yet, especially in specific populations such as patients with asthma. With this review, we use the existing literature in order to answer four crucial questions concerning: (1) ECs' role in the pathogenesis of asthma; (2) ECs' effects on lung function and airway inflammation in patients with asthma; (3) ECs' effects on asthma clinical characteristics in asthmatics who use it regularly; and (4) ECs' effectiveness as a smoking cessation tool in these patients. Evidence suggests that many EC compounds might contribute to the pathogenesis of asthma. Lung function seems to deteriorate by the use of EC in this population, while airway inflammation alters, with the aggravation of T-helper-type-2 (Th2) inflammation being the most prominent but not the exclusive effect. EC also seems to worsen asthma symptoms and the rate and severity of exacerbations in asthmatics who are current vapers, whilst evidence suggests that its effectiveness as a smoking cessation tool might be limited. Asthmatic patients should avoid using EC.

Plitidepsin: Mechanisms and Clinical Profile of a Promising Antiviral Agent against COVID-19.

Current standard treatment of COVID-19 lacks in effective antiviral options. Plitidepsin, a cyclic depsipeptide authorized in Australia for patients with refractory multiple myeloma, has recently emerged as a candidate anti-SARS-CoV-2 agent. The aim of this review was to summarize current knowledge on plitidepsin's clinical profile, anti-tumour and anti-SARS-CoV-2 mechanisms and correlate this with available or anticipated, preclinical or clinical evidence on the drug's potential for COVID-19 treatment.PubMed, Scopus, CENTRAL, clinicaltrials.gov, medRxiv and bioRxiv databases were searched.Plitidepsinexerts its anti-tumour and antiviral properties primarily through acting on isoforms of the host cell's eukaryotic-translation-elongation-factor-1-alpha (eEF1A). Through inhibiting eEF1A and therefore translation of necessary viral proteins, it behaves as a "host-directed" anti-SARS-CoV-2 agent. In respect to its potent anti-SARS-CoV-2 properties, the drug has demonstrated superior ex vivo efficacy compared to other host-directed agents and remdesivir, and it might retain its antiviral effect against the more transmittable B.1.1.7 variant. Its well-studied safety profile, also in combination with dexamethasone, may accelerate its repurposing chances for COVID-19 treatment. Preliminary findings in hospitalized COVID-19 patients, have suggested potential safety and efficacy of plitidepsin, in terms of viral load reduction and clinical resolution. However, the still incomplete understanding of its exact integration into host cell-SARS-CoV-2 interactions, its intravenous administration exclusively purposing it for hospital settings the and precocity of clinical data are currently considered its chief deficits. A phase III trial is being planned to compare the plitidepsin-dexamethasone regimen to the current standard of care only in moderately affected hospitalized patients. Despite plitidepsin's preclinical efficacy, current clinical evidence is inadequate for its registration in COVID-19 patients.Therefore, multicentre trials on the drug's efficacy, potentially also studying populations of emerging SARS-CoV-2 lineages, are warranted.

Could adolescents be the vehicle that transfers a no-smoking rule from school to home?

INTRODUCTION: Banning smoking at home, schools, children's playgrounds and indoor environments, constitutes an integral part of tobacco control efforts to prevent uptake of smoking among young teenagers. We aimed at exploring the role of teenagers as facilitators of change in enforcing a home no-smoking rule following school-based anti-tobacco programs and examining the effect of home no-smoking rule on teenagers' intention to smoke. METHODS: A school-based intervention-control study was implemented during the 2016-2017 academic year among middle-school students in Athens, Greece. The experiential learning intervention was delivered using an interdisciplinary approach, bridging excerpts from ancient classical Greek myths and ancient classical literature, with their decoded archetypal symbols applied in a smoking and tobacco control paradigm. An anonymous selfadministered questionnaire was used at baseline, and at follow-up at 3 months to evaluate program effectiveness. A chi-squared test was used for categorical variables and a t-test for continuous variables. Cohen's distance (d) was employed to examine the intervention effect size. A two-tailed p≤0.05 was considered statistically significant using IBM SPSS V.22. RESULTS: In all, 351 students participated. At baseline, 47.5% in the intervention group reported a home no-smoking rule and 86% indicated being unlikely to smoke, these increased to 61.3% (p=0.016) and 98.2% (p<0.001) at followup, respectively. Cohen's d value was calculated to estimate the effect size of intervention. A large effect size of intervention was found in the intervention group (d=1.24), whilst d=0.19 in the control group. CONCLUSIONS: Our study showed that our intervention led to the increase of no-smoking rules at home and to a negative intention towards smoking of adolescents. Consequently, we provide evidence that students are effective vehicles for carrying anti-smoking messages to their home environment including the no-smoking rule. Additionally, we confirmed previous reports that home no-smoking rule is associated with a negative intention to smoke and risk of smoking.

Evaluation of a school-based, experiential-learning smoking prevention program in promoting attitude change in adolescents.

INTRODUCTION: School-based tobacco control programs exhibit great variety. Our study aimed to evaluate the effectiveness of an experiential learning smoking prevention program in facilitating knowledge acquisition, forging healthy attitudes, and decreasing intention to smoke. METHODS: A school-based intervention-control study was implemented during the 2016-2017 academic year among middle-school students in Athens, Greece. The experiential learning intervention was delivered using an interdisciplinary approach, bridging excerpts from ancient classical Greek myths, Aesop fables and ancient classical literature (Aristotle, Herodotus, Plutarch, Xenophon, Homer's Epics), with their decoded archetypal symbols applied in a smoking and tobacco control paradigm. An anonymous self-administered questionnaire was used at baseline and at follow-up at 3 months to evaluate program effectiveness. RESULTS: A total of 351 students participated in our study; 181 (51.6%) in the intervention group and 170 (48.4%) in the control group. The mean age of student participants was 13 years (SD=0.96). Students in the intervention group were more likely to improve their knowledge of the adverse effects of smoking, develop attitudes against smoking and report a negative intention to smoke in the first year following the intervention, compared to the control group. CONCLUSIONS: This study provides evidence that school-based experiential learning smoking prevention programs improve smoking-related knowledge, enhance anti-smoking attitudes and reinforce negative intentions toward tobacco products.

Can Coagulation System Disorders and Cytokine and Inflammatory Marker Levels Predict the Temporary Clinical Deterioration or Improvement of Septic Patients on ICU Admission?

Although coagulation disorders and immune/inflammatory response have been associated with the final outcome of patients with sepsis, their link with thetemporaryclinical deterioration or improvement of patients is unknown. We aimed to investigate this link. We prospectively included consecutive patients admitted to the intensive care unit (ICU) with a suspected diagnosis of infection and evaluated within the first 24 h from admission. Blood levels of many cytokines and inflammatory and coagulation factors were measured and their predictive value was assessed by calculating the Area Under the Receiver Operating Characteristic (AUROC) curves. Patients (n = 102) were allocated in five groups, i.e., sepsis (n = 14), severe sepsis (n = 17), septic shock (n = 28), Systemic Inflammatory Response Syndrome (SIRS) without infection (n = 17), and trauma/surgery without SIRS or infection (n = 26). In septic shock, coagulation factors FVII and FIX and Protein C had AUROCs 0.67-0.78. In severe sepsis, Antithrombin III, Protein C, C-reactive protein, Procalcitonin and Thrombopoietin had AUROCs 0.73-0.75. In sepsis, Tumor Necrosis Factor a, and Interleukins 1ß and 10 had AUROCs 0.66-0.72. In patients admitted to the ICU with a suspected diagnosis of infection, coagulation factors and inhibitors, as well as cytokine and inflammatory marker levels, have substantial predictive value in distinct groups of septic patients.

Smokers' support for the ban on sale of slim cigarettes in six European countries: findings from the EUREST-PLUS ITC Europe Surveys.

Background: Efforts to regulate tobacco products and reduce consumption in the European Union (EU) include the European Tobacco Products Directive (TPD), which went into force in May 2016. Despite the initial discussion to include a ban on sale of slim cigarettes, it was excluded in the final TPD. The main goal of this study was to examine support for a ban on slim cigarettes among smokers in six European Countries. Methods: Data from the 2018 (Wave 2) International Tobacco Control Policy Evaluation Project 6 European Country (ITC 6E) EUREST-PLUS project survey, a cross sectional study of adult smokers (n=5592) from Germany, Greece, Hungary, Poland, Romania, and Spain, was analysed. Descriptive statistics were used to estimate support for a ban on slim cigarettes by sociodemographic characteristics and smoking behaviors. Logistic regression analysis was used to examine factors associated with support for a ban on slim cigarettes and perceptions of harm. Results: Support for a ban on slims varied across countries, with highest support in Romania (33.8%), and lowest in Greece (18.0%). Female smokers (OR=0.78; 95%CI=0.67-0.91, daily smokers (OR=0.68; 95%CI=0.47-0.97), menthol smokers (OR=0.55; 95%CI=0.36-0.86), and smokers who did not have plans to quit within next six months (OR=0.45; 95%CI=0.36-0.56) had significantly lower odds of supporting a ban on slim cigarettes. Overall, 21% of smokers perceived slim cigarettes as less harmful than regular cigarettes. Conclusions: Support for a ban of slim cigarettes was relatively low among smokers, while misperceptions that slim cigarettes are less harmful is high, particularly among countries where slim cigarette use is more prevalent. Findings support a ban on slim cigarettes to reduce misperceptions around slim cigarettes being less harmful.

Changes in electronic cigarette use and label awareness among smokers before and after the European Tobacco Products Directive implementation in six European countries: findings from the EUREST-PLUS ITC Europe Surveys.

BACKGROUND: Article 20 of the European Tobacco Product Directive (TPD), which went into effect in May 2016, regulates electronic cigarettes (e-cigarettes) in the European Union (EU). The aim of this study was to evaluate changes in e-cigarette use, design attributes of the products used and awareness of e-cigarette labelling and packaging among smokers from six EU Member States (MS) before and after TPD implementation. METHODS: Data come from Wave 1 (2016, pre-TPD) and Wave 2 (2018, post-TPD) of the ITC Six European Country Survey among a sample of smokers and recent quitters who use e-cigarettes from six EU MS. Weighted logistic generalized estimating equations regression models were estimated to test the change in binary outcomes between Waves 1 and 2 using SAS-callable SUDAAN. RESULTS: In 2018, current daily/weekly e-cigarette use among adult smokers was just over 2%, but this varied from the highest in Greece (4%) to lowest in Poland (1.2%). From Waves 1 to 2, there was a significant increase in respondents reporting noticing and reading health and product safety information on leaflets inside e-cigarette packaging (8.39-11.62%, P < 0.001). There were no significant changes between waves of respondents reporting noticing or reading warning labels on e-cigarette packages/vials. CONCLUSIONS: e-cigarette use among smokers in these six EU countries is low. Although reported noticing and reading leaflets included in the packaging of e-cigarettes increased significantly from before to after the TPD, there was no significant change in reported noticing and reading of warning labels. Findings indicate the importance of continued monitoring of TPD provisions around e-cigarettes.

Evaluating the impact of introducing standardized packaging with larger health-warning labels in England: findings from adult smokers within the EUREST-PLUS ITC Europe Surveys.

BACKGROUND: The European (EU) Tobacco Product Directive (TPD) was implemented in May 2016 to regulate the design and labelling of cigarettes and roll-your-own tobacco. At the same time, the UK introduced standardized packaging measures, whereas Germany, Greece, Hungary, Poland, Romania and Spain did not. This study examines the impact of introducing standardized packaging in England using a quasi-experimental design. METHODS: Data from adult smokers in Waves 1 (2016; N=9547) and 2 (2018; N=9724) from the International Tobacco Control Policy Evaluation surveys (England) and EUREST-PLUS surveys (Germany, Greece, Hungary, Poland, Romania and Spain) were used. Generalized estimating equations were used to estimate changes in pack/brand appeal, salience of health-warning labels (HWLs) and perceived relative harm of different brands in England (where larger HWLs and standardized packaging were implemented), vs. each EU country (where only larger HWLs were implemented). RESULTS: There was an increase in the percentage of respondents from Germany, Hungary and Poland reporting they did not like the look of the pack (4.7%, 9.6%, and 14.2%, respectively), but the largest increase was in England (41.0%). Moreover, there was a statistically significant increase in the salience of HWLs in Hungary, Poland and Romania (17.0%, 13.9%, and 15.3%, respectively), but the largest increase was in England (27.6%). Few differences were observed in cross-country comparisons of the perceived relative harm of different brands. CONCLUSIONS: Findings suggest that standardized packaging reduces pack appeal and enhances the salience of HWLs over and above the effects of larger HWLs. Findings provide additional evidence and support for incorporating standardized packaging into the EU TPD.