Real-Life Effectiveness of Smoking Cessation Delivery Modes: A Comparison Against Telephone Counseling and the Role of Individual Characteristics and Health Conditions in Quit Success.

INTRODUCTION: Professional behavioral counseling for smoking cessation can be delivered in many forms, which may not work equally well for everyone. We aim to explore in a real-world setting whether different delivery modes yield different rates of quit success and whether quit success varies based on gender, age, educational level, and being treated for a health condition. AIMS AND METHODS: We used monitoring data (n = 13 747) from a smoking cessation counseling provider in the Netherlands (September 2018 to August 2021) to compare differences in quit success immediately after the end of counseling and at 12-month follow-up between telephone and other modes of counseling. Participants chose which mode of counseling they received. At the 12-month follow-up, we also examined differences in quit success based on demographic characteristics and whether one is being treated for various health conditions. RESULTS: Participants of in-person group counseling and online in-company group counseling were significantly more likely to have quit immediately after the counseling compared with telephone counseling (OR = 1.25, 95% CI = 1.08-1.44; OR = 1.63, 95% CI = 1.18-2.24). Analyses revealed no significant differences in quit success between telephone and other modes of counseling after 12 months. Those treated for a respiratory or psychological condition were less likely to have maintained quit success, as were women, and participants with a lower educational level. CONCLUSIONS: When chosen by oneself, the mode of smoking cessation counseling received does not appear to be important for long-term quit success. However, certain groups warrant extra support to prevent excessive program attrition and unsuccessful quit attempts. IMPLICATIONS: Our findings suggest that when chosen by oneself, the delivery mode of smoking cessation counseling does not appear to be important for long-term quit success. This finding is of particular relevance for those who are unable to attend in-person cessation counseling due to, for instance, reduced accessibility or mobility. We also found that women, lower educated, and younger participants were more likely to dropout of the cessation program or to not have maintained a quit attempt, signaling that disparities in smoking cessation persist when standardized counseling is given, and therefore more tailored counseling may be necessary for these groups.

Illicit purchasing and use of flavour accessories after the European Union menthol cigarette ban: findings from the 2020-21 ITC Netherlands Surveys.

BACKGROUND: The 2020 European Union (EU) menthol cigarette ban increased quitting among pre-ban menthol smokers in the Netherlands, but some reported continuing to smoke menthol cigarettes. This study examined three possible explanations for post-ban menthol use-(i) illicit purchasing, (ii) use of flavour accessories and (iii) use of non-menthol replacement brands marketed for menthol smokers. METHODS: Data were from the ITC Netherlands Cohort Surveys among adult smokers before the menthol ban (Wave 1: February-March 2020, N = 2067) and after the ban (Wave 2: September-November 2020, N = 1752; Wave 3: June-July 2021, N = 1721). Bivariate, logistic regression and generalized estimating equation model analyses were conducted on weighted data. RESULTS: Illicit purchasing remained low from pre-ban (2.4%, 95% CI: 1.8-3.2, Wave 1) to post-ban (1.7%, 1.2-2.5%, Wave 3), with no difference between menthol and non-menthol smokers from Wave 1 to Wave 3. About 4.4% of post-ban menthol smokers last purchased their usual brand outside of the EU and 3.6% from the internet; 42.5% of post-ban menthol smokers and 4.4% of smokers overall reported using flavour accessories, with greater odds among those aged 25-39 years vs. 55+ (aOR = 3.16, P = 0.002). Approximately 70% of post-ban smokers who reported using a menthol brand were actually using a non-menthol replacement brand. CONCLUSIONS: There was no increase in illicit purchasing or of smuggling outside the EU among menthol and non-menthol smokers in the Netherlands 1 year after the EU menthol cigarette ban. Use of flavour accessories and non-menthol replacement brands best explain post-ban menthol use, suggesting the need to ban accessories and ensure industry compliance.

Challenges and successes in the sustainment of Dutch community-level smoking cessation interventions for residents with a low socioeconomic position.

BACKGROUND: When health promotion interventions are implemented, the gains are often short-lived, as interventions are seldom successfully sustained. The current study explores how and under what conditions community-level smoking cessation interventions for people with a lower socioeconomic position can be sustained, drawing upon interventions delivered in Dutch neighbourhoods with a predominantly low socioeconomic position. METHODS: We conducted 15 semi-structured interviews with key stakeholders from three Dutch community-level smoking cessation interventions implemented at least three years prior. The topic guide was developed based on the Determinants of Innovation framework and transcripts were analysed thematically. RESULTS: We identified several factors that promote the sustainment of smoking cessation community-level interventions: 1) structural, long-term funding through the commitment of health insurers and policy makers; 2) continued stakeholder enthusiasm and involvement; 3) training and time for professionals to discuss smoking cessation, thereby also increasing the visibility of the intervention for professionals and residents; 4) integrating the intervention with existing initiatives and adapting it to be compatible with current working practices of executive staff; and 5) planning for sustainment as a team from the outset. CONCLUSIONS: The current study highlights challenges and successes in intervention sustainment for people with a lower socioeconomic position. Lack of structural funding was one of the most challenging aspects for intervention sustainment in which health insurers and policy makers can play an important role. Planning for sustainment from the outset would enable intervention coordinators to consider the abovementioned factors early on. This need not be done alone but can best be discussed within a team of stakeholders.

The delivery of Ask-Advise-Connect for smoking cessation in Dutch general practice during the COVID-19 pandemic: results of a pre-post implementation study.

BACKGROUND: The Ask-Advise-Connect approach can help primary care providers to increase the number of smokers that attempt to quit smoking and enrol into cessation counselling. The approach has not yet been implemented in general practice in the Netherlands. The aim of this study was to investigate the influence of a comprehensive implementation strategy on the delivery of Ask-Advise-Connect for smoking cessation within Dutch general practice during the COVID-19 pandemic. METHODS: A pre-post study was conducted between late 2020 and early 2022, and included 106 Dutch primary care providers (GPs, practice nurses and doctor's assistants). Participation lasted nine months: during the first three months participants delivered smoking cessation care as usual (pre-intervention); the implementation strategy came into effect after three months and participants were followed up for another six months (post-intervention). The implementation strategy consisted of two meetings in which participants were educated about Ask-Advise-Connect, made agreements on the implementation of Ask-Advise-Connect and reflected on these agreements. Participants also received online educational materials and a desk card as reminder. The changes in the proportions of 'Ask' and 'Advise' over time were modelled using linear mixed effects models. A descriptive analysis was conducted with regard to referrals to cessation counselling. RESULTS: Participants provided consultations to 29,112 patients (both smokers and non-smokers). Results of the linear mixed effects model show that the proportion of patients that were asked about smoking ('Ask') significantly decreased in the first three months (pre-intervention), but slightly increased again after the implementation strategy came into effect (post-intervention). No significant change over time was found with regard to the proportion of patients advised to quit smoking ('Advise'). Descriptive statistics suggested that more participants proactively (vs. passively) referred patients to cessation counselling post-intervention ('Connect'). CONCLUSIONS: The findings indicate that a comprehensive implementation strategy can support primary care providers in offering smoking cessation care to patients, even under stressful COVID-19 conditions. Additional implementation efforts are needed to increase the proportion of patients that receive a quit advice and proactive referral.

Implementation of ask-advise-connect for smoking cessation in Dutch general practice during the COVID-19 pandemic: a mixed-methods evaluation using the CFIR framework.

BACKGROUND: The Ask-Advise-Connect (AAC) approach can help primary care providers to increase the number of people who attempt to quit smoking and enrol into cessation counselling. We implemented AAC in Dutch general practice during the COVID-19 pandemic. In this study we describe how AAC was received in Dutch general practice and assess which factors played a role in the implementation. METHODS: A mixed-methods approach was used to evaluate the implementation of AAC. Implementation took place between late 2020 and early 2022 among 106 Dutch primary care providers (general practitioners (GPs), practice nurses and doctor's assistants). Quantitative and qualitative data were collected through four online questionnaires. A descriptive analysis was conducted on the quantitative data. The qualitative data (consisting of answers to open-ended questions) were inductively analysed using axial codes. The Consolidated Framework for Implementation Research was used to structure and interpret findings. RESULTS: During the study, most participants felt motivated (84-92%) and able (80-94%) to apply AAC. At the end of the study, most participants reported that the AAC approach is easy to apply (89%) and provides advantages (74%). Routine implementation of the approach was, however, experienced to be difficult. More GPs (30-48%) experienced barriers in the implementation compared to practice nurses and doctor's assistants (7-9%). The qualitative analysis showed that especially external factors, such as a lack of time or priority to discuss smoking due to the COVID-19 pandemic, negatively influenced implementation of AAC. CONCLUSIONS: Although AAC was mostly positively received in Dutch general practice, implementation turned out to be challenging, especially for GPs. Lack of time to discuss smoking was a major barrier in the implementation. Future efforts should focus on providing additional implementation support to GPs, for example with the use of e-health.

Lesson-drawing in tobacco control: A qualitative study of stakeholder perceptions in five North-Western European countries.

INTRODUCTION: The theory of 'family of nations' posits that countries draw policy lessons predominantly from similar countries. Lesson-drawing in tobacco control has, however, been primarily studied in the 'English-speaking' family. We examined in five diverse North-Western European countries whether the government engages in lesson-drawing regarding best practices in tobacco control, which countries they look at for guidance, and why these were chosen as a reference. METHODS: Perceptions of 29 policy participants from civil society and government were assessed by means of interviews conducted in Belgium, Finland, Germany, Ireland, and the Netherlands. Relevant excerpts were grouped according to country and a bottom-up thematic analysis was performed. RESULTS: The tobacco control instruments described by the policy participants were tobacco marketing bans (display ban and plain packaging) and smoke-free policies. German interviewees stated that the German federal government is not inclined to engage in foreign lesson-drawing. All other governments were perceived to look at Australia for lessons because of its global leadership in tobacco control. At the same time however, lessons from Australia were easily dismissed because it is an 'island' and far away. Irish interviewees observed their government to primarily look at other English-speaking countries. Governments in Belgium, Finland and the Netherlands were observed to primarily look at nearby European countries for lessons. CONCLUSIONS: Countries in North-Western Europe seem to draw policy lessons based on proximity and similarity to other countries concerning marketing bans and smoke-free policies. Proponents of tobacco control may use these findings to facilitate effective lesson-drawing in their countries.

Reducing the number and types of tobacco retail outlets in the Netherlands: Study protocol for a comprehensive mixedmethods policy evaluation.

The Netherlands plans to ban tobacco sales in supermarkets in 2024. In a comprehensive policy evaluation, we aim to examine: 1) the impact of the policy on the number and types of tobacco outlets, 2) the impact on attitudes and behaviors of smoking adults and non-smoking youth, and 3) the influence of the tobacco industry on the policy process and the retail environment. In addition, our study focusses on differential effects in disadvantaged neighborhoods, where both smoking rates and tobacco outlet density are typically highest. This study brings together economic, psychological, and journalistic research methods. We investigate the impact of the new legislation on the number and type of tobacco outlets, and on the number of smokers by using routinely collected population monitoring data. We examine the impact of the legislation on smoking susceptibility of non-smoking youth and on impulse tobacco purchases by smoking adults with yearly quantitative surveys and with qualitative interviews and discussion sessions. We describe whether these impacts differ for disadvantaged versus non-disadvantaged neighborhoods. We investigate what strategies the tobacco industry uses to influence the new legislation, policy processes, and the tobacco retail environment by performing a journalistic investigation, by means of documents obtained by Freedom of Information Act (FOIA) requests, (possibly) leaked documents from insider meetings, and interviews with insiders. The methods of our evaluation can be used as a model for other comprehensive public policy evaluations. REGISTRATION: Clinical Trials ID NCT05554120, Protocol ID KWF140282021-2. ABBREVIATIONS: FOIA: Freedom of Information Act. SES-WOA: socioeconomic scores of private households. MCID: minimal clinically important difference.

Smokers' strategies to reduce tobacco spending: self-reported use and differences across subgroups. Findings from the International Tobacco Control (ITC) Netherlands Survey.

BACKGROUND: The cost of tobacco is one of the most reported reasons for smoking cessation. Rather than quitting, smokers can use also strategies to reduce tobacco expenditure while continuing smoking, such as smoking less or using price-minimising strategies. The Netherlands announced to increase the price of a pack cigarettes from seven (2018) to ten euros (2023), to reduce tobacco prevalence and consumption. This study explores the self-reported strategies to reduce tobacco spending among Dutch smokers, and whether this differed per age, income, and education. Additionally, we analysed among quitters in these subgroups whether price played a role in their decision to quit. METHODS: Cross-sectional survey data from the International Tobacco Control (ITC) Netherlands Wave 2 (September-November 2020, N = 1915) was used. Strategies to reduce spending among smokers (N = 1790) were: reducing consumption, bulk buying, switching to cheaper products or buying from low-taxed sources. These were collapsed into: reducing consumption (solely or in combination with other behaviours), solely price-minimising behaviours (such as buying cheaper brands), or no strategies to reduce spending. Associations between strategies and characteristics were analysed through multinomial and binary logistic regression models. Second, we explored which subgroups were more likely to report that price played a role in their decision to quit among quitters (N = 125). RESULTS: The majority of smokers used strategies to reduce tobacco spending: 35.6% reduced consumption and 19.3% used solely price-minimising strategies. 82.1% of quitters reported that price played a role in their decision to quit. Low-income individuals were more likely to report price as a reason for quitting and reduce consumption, but also to buy cheaper products. Highly nicotine dependent smokers were more likely to use price-minimising behaviours, and less likely to reduce consumption. CONCLUSIONS: The majority reported using strategies to reduce spending or that price played a role in their decision to quit. Reducing consumption was the most reported strategy. Low-income smokers were more likely to reportedly reduce consumption, buy cheaper products, or quit. Price policies have the potential to reduce socioeconomic inequalities in smoking. To discourage price-minimising behaviours, such as switching to cheaper products, reducing price differences between products should be prioritized.

Content analysis of Dutch newspaper coverage of three tobacco control policies, 2017-2019.

OBJECTIVES: News media coverage can influence support for and implementation of tobacco control policies. This research aims to analyse and compare newspaper coverage of newly implemented policies: a substantial tobacco tax increase, point-of-sale display ban and plain packaging. DESIGN: We conducted a content analysis of articles covering the three policies from ten national Dutch newspapers. Articles published between November 2017 and November 2019 were coded for type and tone. The policy dystopia model was used to code arguments opposing the policies. Tobacco industry appearances in news articles were also analysed for frequency and type. RESULTS: A total of 134 news articles were analysed, of which the industry appeared in 28%. The majority of coverage was neutral in tone, although among articles that were coded as expressing a positive or negative tone, plain packaging and the point-of-sale ban were portrayed more negatively than positively. Negative coverage was predominantly accounted for by industry presence. Arguments opposing the policies focused on negative economic consequences, challenging the need for policy and adverse consequences for retailers for tax, plain packaging and the point-of-sale display ban, respectively. We identified six specific new arguments that fit within existing domains of the policy dystopia model. CONCLUSIONS: The tobacco industry and its allies still appear in a substantial proportion of news articles in relation to tobacco policy. This study identifies contemporary industry arguments against tobacco control policies in Europe which, alongside the policy dystopia model, can be used to predict and counter the tobacco industry's future attempts to oppose policies.

Understanding perceived addiction to and addictiveness of electronic cigarettes among electronic cigarette users: a cross-sectional analysis of the International Tobacco Control Smoking and Vaping (ITC 4CV) England Survey.

BACKGROUND AND AIMS: The addictive potential of electronic cigarettes (e-cigarettes) remains to be fully understood. We identified patterns and correlates of perceived addiction to e-cigarettes and perceived addictiveness of e-cigarettes relative to tobacco cigarettes (relative addictiveness) in dual users as well as exclusive e-cigarette users. DESIGN, SETTING AND PARTICIPANTS: Observational study using cross-sectional survey data from England (2016) from the International Tobacco Control Project (ITC) Four Country Smoking and Vaping (4CV) survey. The study comprised 832 current e-cigarette users who had been vaping for at least 4 months. MEASUREMENTS: Perceived addiction to e-cigarettes and relative addictiveness of e-cigarettes were examined. Socio-demographic factors were age, gender and education; markers of addiction included urge to vape, time to first vape after waking and nicotine strength used; vaping and smoking characteristics included frequency and duration of e-cigarette use, intention to quit, adjustable power or temperature, enjoyment, satisfaction relative to tobacco cigarettes and tobacco cigarette smoking status. FINDINGS: A total of 17% of participants reported feeling very addicted to e-cigarettes, while 40% considered e-cigarettes equally/more addictive than tobacco cigarettes. Those who felt very addicted had higher odds of regarding e-cigarettes as more addictive than tobacco cigarettes (odds ratio 3.4, 95% confidence interval 2.3-5.1). All markers of addiction, daily use and enjoyment were associated with higher perceived addiction, whereas time to first vape after waking, daily vaping and perceiving vaping as less satisfying than smoking were associated with relative addictiveness. CONCLUSIONS: Markers of addiction to e-cigarettes appear to correspond with perceived addiction to e-cigarettes, suggesting that self-reported perceived addiction might serve as an indicator of addiction. Prevalence both of markers of addiction and perceived addiction were comparatively low overall, suggesting a limited but relevant addictive potential of e-cigarettes. Additionally, positive and negative reinforcement, reflected here by enjoyment and relative satisfaction, might play a role in e-cigarette addiction.

Smoking Cessation Among Gender Minority Populations, Cis-women, and Cis-men: Findings From the International Tobacco Control Netherlands Survey.

INTRODUCTION: Little is known about smoking cessation among gender minority populations compared to cisgender individuals (whose gender matches their sex assigned at birth). We examined differences between smokers from gender minority populations, cis-women, and cis-men in the heaviness of smoking, quit intentions, use of cessation assistance, quit attempts (ever tried and number), and triggers for thinking about quitting. AIMS AND METHODS: We used cross-sectional data from the 2020 International Tobacco Control Netherlands Survey. Among smoking respondents, we distinguished (1) cis-women (female sex, identified as women, and having feminine gender roles; n = 670), (2) cis-men (male sex, identified as men, and having masculine gender roles; n = 897), and (3) gender minorities (individuals who were intersex, who identified as nonbinary, genderqueer, had a sex/gender identity not listed, whose gender roles were not feminine or masculine, or whose gender identity and/or roles were not congruent with sex assigned at birth; n = 220). RESULTS: Although gender minorities did not differ from cis-women and cis-men in the heaviness of smoking, plans to quit smoking, and quit attempts, they were significantly more likely to use cessation assistance (20% in the past 6 months) than cis-women (12%) and cis-men (9%). Gender minorities were also significantly more likely to report several triggers for thinking about quitting smoking, for example, quit advice from a doctor, an anti-smoking message/campaign, and the availability of a telephone helpline. CONCLUSION: Despite equal levels of quit attempts and heaviness of smoking, gender minority smokers make more use of smoking assistance, and respond stronger to triggers for thinking about quitting smoking. IMPLICATIONS: Smoking cessation counselors should be sensitive to the stressors that individuals from any minority population face, such as stigmatization, discrimination, and loneliness, and should educate their smoking clients on effective coping mechanisms to prevent relapse into smoking after they experience these stressors. Developing tailored smoking cessation programs or campaigns specifically for gender minority populations can also be useful. Based on the results of our subgroup analyses, programs or campaigns for younger gender minority smokers could focus on the availability of telephone helplines and on how friends and family think about their smoking behavior.

Trends in Individualized Affordability of Factory-Made Cigarettes: Findings of the 2008-2020 International Tobacco Control Netherlands Surveys.

INTRODUCTION: Cigarette affordability, the price of tobacco relative to consumer income, is a key determinant of tobacco consumption. AIMS AND METHODS: This study examined trends over 12 years in individualized factory-made cigarette affordability in the Netherlands, and whether these trends differed by sex, age, and education. Data from 10 waves (2008-2020) of the International Tobacco Control Netherlands Surveys were used to estimate individualized affordability, measured as the percentage of income required to buy 100 cigarette packs (Relative Income Price [RIP]), using self-reported prices and income. The higher the RIP, the less affordable cigarettes are. Generalized estimating equation regression models assessed trends in individualized affordability over time and by sex, age, and education. RESULTS: Affordability decreased significantly between 2008 and 2020, with RIP increasing from 1.89% (2008) to 2.64% (2020) (p ≤ .001), except for 2008-2010, no significant year-on-year changes in affordability were found. Lower affordability was found among subgroups who have a lower income level: Females (vs. males), 18-24 and 25-39-year-olds (vs. 55 years and over) and low or moderate-educated individuals (vs. highly educated). Interactions between wave and education (p = .007) were found, but not with sex (p = .653) or age (p = .295). A decreasing linear trend in affordability was found for moderately (p = .041) and high-educated (p = .025), but not for low-educated individuals (p = .149). CONCLUSIONS: Cigarettes in the Netherlands have become less affordable between 2008 and 2020, yet this was mostly because of the decrease in affordability between 2008 and 2010. There is a need for more significant increases in tax to further decrease affordability. IMPLICATIONS: Our findings suggest that cigarettes have become less affordable in the Netherlands between 2008 and 2020. But, this appears to be the result of a steep decrease in affordability between 2008 and 2010. Affordability was lower among groups who have on average lower incomes (females, young adults, and low- and moderate-educated individuals), and differences in trends across education levels could be explained by per capita income changes. Our individualized measure indicated lower affordability than published aggregate affordability estimations. Future tax increases should be large enough to result in a lower affordability.

Proactive Referral to Behavioral Smoking Cessation Programs by Healthcare Staff: A Systematic Review.

INTRODUCTION: Behavioral smoking cessation programs are an effective tool for quitting smoking, yet remain underused by smokers. Proactive referral may be a promising strategy for healthcare staff to connect smokers to such programs. AIMS AND METHODS: The aim of this study was to gain insight into the effectiveness and implementability of proactive referral of smokers to behavioral smoking cessation programs by healthcare staff. A systematic review was conducted using five databases. Effectiveness of proactive referral was defined as the proportion of referred smokers who enrolled in a behavioral smoking cessation program. To determine the implementability of proactive referral, measures of feasibility, acceptability, adoption, and referral rates were included as variables of interest. Out of 6686 screened records, 34 articles were eligible for review. A narrative synthesis approach was used. RESULTS: The majority of the included studies investigated proactive referral within an e-referral system, combined with one or more intervention components that enhance implementation. Overall, proactive referral resulted in higher enrollment rates, especially among low-income smokers, and was found to be feasible, adoptable, and acceptable to healthcare staff. E-referral systems performed better in terms of implementability compared to fax referral systems. About half of the studies were of good quality. Many studies lacked information which resulted in lower-quality scores. CONCLUSIONS: The literature provides evidence that the proactive referral of smokers to behavioral smoking cessation programs by healthcare staff is effective and implementable across different settings. Based on the results, e-referral systems may be preferable to fax referral systems in terms of implementability. IMPLICATIONS: This systematic review demonstrated that proactive referral has the potential to increase the reach of smoking cessation programs and reduce inequalities in access to such programs. In the selection and implementation of behavioral smoking cessation programs with a proactive referral component, stakeholders (eg, policymakers, healthcare funders, and healthcare professionals) may benefit from taking different aspects of proactive referral systems into account, such as the type of proactive referral system used and additional strategies which can enhance the implementability of the system.

Accelerating tobacco control at the national level with the Smoke-free Generation movement in the Netherlands.

The Netherlands has moved towards the forefront of tobacco control in Europe, after having implemented important tobacco control measures in 2020 and 2021, which included higher tobacco taxation, plain packaging of tobacco products, a partial point of sale tobacco display ban, smoking ban on school grounds, and other smoking restrictions. We examined the factors contributing to these successes, focussing on the network of tobacco control advocacy organisations and the process of agenda-setting. Crucial determining factors were stricter adherence to Article 5.3 FCTC, which prevents government to consult tobacco industry, and the genesis of a 'Smoke-free Generation' movement in the wider society, initiated by the three main national charities (Lung Foundation Netherlands, Dutch Heart Foundation, Dutch Cancer Society). The Smoke-free Generation concept proved to be a highly attractive unifying strategy for national en local policy makers and Dutch society. As a result, the Dutch government was able to start a process of strengthening tobacco control policy through drafting and implementing a National Prevention Agreement, which aims at a tobacco control endgame goal of less than 5% smokers in 2040. Between 2019 and 2020 smoking rates dropped from 21.7% to 20.2%. The Dutch experience can provide inspiration for countries where tobacco control is still lagging behind. It also illustrates that continued vigilance is needed, since the most recent government change was associated with a hampering of further reduction of the proportion of smokers and a temporary drop in attention to tobacco control from the central government.

Price minimizing behaviours by smokers in Europe (2006-20): evidence from the International Tobacco Control Project.

BACKGROUND: Effectiveness of tobacco taxation can be undermined through smokers applying price-minimizing behaviours rather than quitting or reducing consumption. Common price-minimizing strategies are buying cheaper tobacco [discount brands or roll-your-own (RYO) tobacco], bulk buying and cross-border purchasing. This study analyses trends in and factors associated with such behaviours in four European countries from 2006 to 2020. METHODS: Data came from adult smokers participating in the International Tobacco Control (ITC) Surveys conducted between 2006 and 2020 in England (9 waves, n = 768-4149), France (4 waves, n = 1415-1735), Germany (5 waves, n = 513-1515) and the Netherlands (10 waves, n = 1191-2177). Country-specific generalized estimating equation regression models were fit to assess trends in smoking RYO tobacco, discount brands, bulk buying and cross-border purchasing within the European Union. RESULTS: Buying discount brands or RYO tobacco was the most common strategy in all countries, except France. Except for buying discount brands, estimates of price-minimizing behaviours were highest in France (2019: RYO = 27.2%, discount brands = 17.3%, bulk buying = 34.1%, cross-border purchasing = 34.2%), and lowest in Germany (2018: RYO = 18.6%, discount brands = 43.7%, bulk buying = 8.0%, cross-border purchasing = 9.8%). Direction and magnitude of trends differed by country, and behaviour. Young smokers were less likely to buy in bulk. Low-income and low-education smokers were more likely to purchase RYO tobacco or discount brands. The association with discount brands was not found for French low-income smokers. CONCLUSIONS: Smoking cheaper tobacco is the most prevalent price-minimizing strategy in three countries (England, Germany and Netherlands), and more prevalent among low-income individuals. Harmonizing prices across products and countries would reduce switching to cheaper tobacco.

Impact of the European Union's menthol cigarette ban on smoking cessation outcomes: longitudinal findings from the 2020-2021 ITC Netherlands Surveys.

INTRODUCTION: To reduce the appeal of tobacco, the European Union (EU) banned menthol as a characterising flavour in cigarettes in May 2020. This pre/post-study evaluated the impact of the menthol ban on smoking cessation outcomes among a representative cohort of Dutch smokers. METHODS: Adult (18+ years) smokers were recruited at wave 1 (pre-ban) of the International Tobacco Control Netherlands Surveys (February-March 2020) and followed post-ban at wave 2 (September-November 2020) and wave 3 (June-July 2021) (N=1326 participated in all three waves). Weighted bivariate, logistic regression and generalised estimating equation model analyses were conducted. RESULTS: Usual menthol use decreased from pre-ban (7.8%) to post-ban (4.0% at wave 2 and 4.4% at wave 3) (p<0.001). Pre-ban menthol smokers had greater odds of making a post-ban quit attempt than non-menthol smokers (66.9% vs 49.6%, adjusted OR (aOR)=1.89, 95% CI: 1.13 to 3.16). Compared with pre-ban non-menthol smokers, a higher proportion of menthol smokers quit by wave 2 (17.8% vs 10.2%, p=0.025) and by wave 3 (26.1% vs 14.1%, p=0.002), although this was not significant after adjusting for other factors. Female pre-ban menthol smokers had greater odds of quitting by wave 3 than female non-menthol smokers (aOR=2.23, 95% CI: 1.10 to 4.51). Most pre-ban menthol smokers (n=99) switched to non-menthol cigarettes (40.0%) or reported that they continued to smoke menthol cigarettes (33.0%) at wave 3. CONCLUSIONS: The EU menthol ban was effective in reducing menthol use and in increasing quit attempts and quitting among pre-ban menthol smokers. Impact could be maximised by closing gaps that allow post-ban menthol cigarette use.

"If the social circle is engaged, more pregnant women will successfully quit smoking": a qualitative study of the experiences of midwives in the Netherlands with smoking cessation care.

BACKGROUND: If smoking is common within a pregnant woman's social circle, she is more likely to smoke and her chances of succeeding in quitting smoking are reduced. It is therefore important to encourage smoking cessation in a pregnant woman's social circle. Midwives are ideally positioned to help pregnant women and members of their social circle quit smoking but there is currently little knowledge about if and how midwives approach smoking cessation with pregnant women's social circles. METHODS: In 2017 and 2018, semi-structured interviews were conducted with 14 birth care providers in the Netherlands. Interviews were inductively coded; data were analyzed thematically. RESULTS: In the interviews, midwives reported that they don't commonly provide smoking cessation support to members of pregnant women's social circles. The respondents noted that they primarily focused on mothers and weren't always convinced that advising the partners, family, and friends of pregnant women to quit smoking was their responsibility. Data from the interviews revealed that barriers to giving advice to the social circle included a lack of a trusting relationship with the social circle, concerns about raising the topic and giving unwanted advice on cessation to members of the social circle and a lack of opportunity to discuss smoking. CONCLUSIONS: Midwives in the Netherlands were reluctant to actively provide smoking cessation advice to the social circle of pregnant women. To overcome barriers to addressing cessation to the social circle, educational programs or new modules for existing programs could be used to improve skills related to discussing smoking. Clear guidelines and protocols on the role of midwives in providing cessation support to the social circle could help midwives overcome ambivalence that they might have.

Mentioning smoking cessation assistance during healthcare consultations matters: findings from Dutch survey research.

BACKGROUND: Smoking cessation assistance (SCA) can help smokers to successfully quit smoking. It is unclear to what extent hearing about SCA from a healthcare professional is associated with using SCA during a quit attempt. METHODS: We used pooled survey data from the 2016, 2018 and 2020 'Module Substance Use' survey in the Netherlands (N = 5928). Multivariate logistic regression analyses were used to determine the association between having heard about SCA from one or more healthcare professionals in the last year and the use of SCA during the most recent quit attempt in the last year. We used two models: model 1 included any type of assistance; model 2 included assistance typically recommended by treatment guidelines (i.e. counselling and pharmacotherapy). RESULTS: Hearing about any type of SCA from a healthcare professional in the last year was significantly associated with using any type of SCA during the most recent quit attempt [odds ratio (OR) = 2.96; 95% confidence interval (CI) 2.16-4.06; P < 0.001]. We found the strongest association between hearing about counselling and/or pharmacotherapy and using counselling and/or pharmacotherapy (OR = 5.40; 95% CI 4.11-11.60; P < 0.001). The odds of using SCA was not significantly higher for smokers who had heard about it from two or more healthcare professionals compared to one healthcare professional (OR = 1.38; 95% CI 0.79-2.42; P = 0.26). CONCLUSIONS: Healthcare professionals can play a greater role in stimulating the use of SCA, especially counselling and pharmacotherapy, by mentioning it to smokers during consultations.

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.

Outdoor smoking as a nuisance to non-smokers: The case for smoke-free outdoor public spaces in dense urban areas.

INTRODUCTION: Despite the growing number of smoke-free spaces, many non-smokers continue to be involuntarily exposed to secondhand smoke outdoors and on public streets. Both theory and research suggest that people living in densely populated urban areas are more likely to smoke than those living in less densely populated areas. Consequently, non-smokers in densely populated urban areas might be more likely to be exposed and feel annoyed by secondhand smoke outdoors. We investigated whether the extent to which non-smokers feel annoyed by secondhand smoke exposure in outdoor public spaces is related to urban population density. METHODS: We used cross-sectional survey data from the Netherlands 'Module Substance Use' survey (2020 data, n=9375). This is a nationally representative sample of the adult population in the Netherlands. Using logistic regression models, we investigated whether urban population density predicts both smoking and non-smokers' annoyance to secondhand smoke exposure outdoors. RESULTS: We found that smoking rates were associated with urban population density. In the Netherlands, people living in extremely population-dense urban areas were more likely to smoke than those living in non-urban areas (AOR=1.59; 95% CI: 1.25-2.02, p<0.001). Feeling annoyed by secondhand smoke outdoors was also associated with urban population density: non-smokers living in extremely population-dense urban areas were more likely to be annoyed than respondents living in non-urban areas (AOR=1.65; 95% CI: 1.34-2.02, p<0.001). CONCLUSIONS: These cross-sectional data highlight the importance of comprehensive local tobacco control policy programs that include creating smoke-free outdoor public spaces. This need for such smoke-free outdoor public spaces might be particularly strong in densely populated areas.