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

Dirk-Jan A Van Mourik,Hein De Vries,Bas Van Den Putte,Hua-Hie Yong,Math J J M Candel,Marc C Willemsen,Gera E Nagelhout,Geoffrey T Fong

doi:10.3390/ijerph16214260

Abstract

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 (β = 0.301, p < 0.001) and a more positive attitude towards quitting (β = 0.180, p < 0.001), which, in turn, were associated with a stronger quit intention (health worries: β = 0.304, p < 0.001; attitude: β = 0.340, p < 0.001). Quit intention was a strong predictor of quit attempts (β = 0.336, p = 0.001). Health warning salience was also associated with stronger perceived social norms towards quitting (β = 0.166, p < 0.001), which directly predicted quit attempts (β = 0.141, p = 0.048). Quit attempts were positively associated with smoking cessation (β = 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.

Highlights

In the European Union (EU), pictorial health warnings (PHWs) on the packet of tobacco products [1]were introduced as of May 2016 with the new Tobacco Products Directive [2]
Previous studies have suggested that introducing PHWs leads to a greater likelihood of smokers quitting [4,5], but the health warnings evaluated in these studies differed from the EU PHWs in terms of accompanying textual health warning (THW) and graphic portrayals [1,6]
Respondents who were lost to attrition in Wave 11 were significantly younger (t = 2.908, p = 0.004), had higher self-efficacy (t = −2.515, p = 0.012), and reported higher levels of quit intention (t = −2.658, p = 0.008) than smokers who remained in the sample

Summary

Introduction

In the European Union (EU), pictorial health warnings (PHWs) on the packet of tobacco products [1]were introduced as of May 2016 with the new Tobacco Products Directive [2]. In the European Union (EU), pictorial health warnings (PHWs) on the packet of tobacco products [1]. The PHWs cover 65% of the front and back of the packet and are accompanied with a matching textual health warning (THW). Previous studies have suggested that introducing PHWs leads to a greater likelihood of smokers quitting [4,5], but the health warnings evaluated in these studies differed from the EU PHWs in terms of accompanying THWs and graphic portrayals [1,6]. This study aims to examine if, and through which pathways, the new EU tobacco health warnings affect quit attempts and smoking cessation. Our findings may result in a better understanding of the working mechanisms of current EU tobacco health warnings, leading to recommendations about its future use [7,8,9] and accompanying tobacco control policies

Objectives

Results

Discussion

Conclusion