EU Tobacco Products Directive Research Articles

Innovations in Canada That May Inform the Next EU Tobacco Products Directive

Innovations in Canada That May Inform the Next EU Tobacco Products Directive

Correlates of e-cigarette use before and after comprehensive regulatory changes and e-liquid flavour ban among general population.

In 2016, the Finnish Tobacco Act was revised to harmonise e-cigarette regulations with the EU Tobacco Products Directive. Unlike before, the sale of nicotine-containing e-liquids was allowed while additional national regulations included, for example, a ban for other than unflavoured and tobacco-flavoured e-liquids. This study examines the correlates of e-cigarette use before and after the comprehensive regulatory change, and characteristics and correlates of flavoured e-cigarette use after the flavour ban in the general Finnish population. Repeated cross-sectional population-based drug surveys for 15-69-year-olds in 2014 (n=3485; 50% response rate) and in 2018 (n=3229; 46%). Correlates of e-cigarette use were studied with logistic regression models. Current e-cigarette use remained infrequent (approximately 2%) and the correlates of e-cigarette use varied only slightly between the study years. In 2018, of past-year e-cigarette users (n=316), 43% used unflavoured e-liquids, 24% used tobacco and 43% used other flavours, fruits being the most common. In univariate models, demographic variables, smoking and e-cigarette use-related factors were associated with flavoured e-cigarette use. In multivariable models, those who used e-cigarettes to experiment used unflavoured e-cigarettes more likely than other than tobacco flavours (odds ratio 3.00, 95% confidence interval 1.15-7.82). In Finland, the regulated entry of nicotine-containing e-liquids to retail sales has not led to increased e-cigarette use in the general population. After the flavour ban, other than tobacco-flavoured e-cigarette use still occurs. The use of flavoured e-cigarettes is associated with reasons for e-cigarette use. Flavoured e-cigarette use and its correlates warrant further monitoring.

Development and testing of relative risk-based health messages for electronic cigarette products

BackgroundHealth messages on e-cigarette packs emphasise nicotine addiction or harms using similar wording to warnings on cigarette packs. These may not be appropriate for e-cigarettes which constitute a reduced risk alternative for smokers. This research aimed to (1) develop and test a selection of relative risk messages for e-cigarette products; (2) compare these to the two current EU Tobacco Products Directive (TPD) nicotine addiction messages; and (3) explore differences between smokers, non-smokers and dual users.MethodTwenty-six messages focusing on either harm-reduction or cessation were developed and rated by multidisciplinary experts for accuracy, persuasiveness and clarity. The eight highest ranking messages were compared alongside the TPD messages in a sample of 983 European residents (316 smokers, 327 non-smokers, 340 dual users) on understandability, believability and convincingness.ResultsOn all three constructs combined, the two TPD messages rated the highest, closely followed by four relative risk messages “Completely switching to e-cigarettes lowers your risk of smoking related diseases”, “Use of this product is much less harmful than smoking”, “Completely switching to e-cigarettes is a healthier alternative to smoking”, and “This product presents substantially lower risks to health than cigarettes” which did not differ statistically from the TPD messages. Non-smokers rated TPD1 significantly higher overall than dual users. Dual users rated “This product is a safer alternative to smoking” significantly higher than non-smokers. Messages did not differ on understandability.ConclusionsThese alternative messages provide a useful resource for future research and for policy makers considering updating e-cigarette product labelling.

The Tobacco Endgame-Eradicating a Worsening Epidemic: A Joint Opinion From the American Heart Association, World Heart Federation, American College of Cardiology, and the European Society of Cardiology.

The Tobacco Endgame-Eradicating a Worsening Epidemic: A Joint Opinion From the American Heart Association, World Heart Federation, American College of Cardiology, and the European Society of Cardiology.

Implementation of e-cigarette regulation through the EU Tobacco Products Directive (2016) in Wales, Scotland and England from the perspectives of stakeholders involved in policy introduction and enforcement.

INTRODUCTIONFrom May 2016, the European Union introduced the Tobacco Products Directive (TPD) regulations, which included restrictions to advertising and new safety and labeling standards for e-cigarette products. This represented the first supranational policy regulating e-cigarette sales and marketing. This study explores perceptions of TPD and its implementation in Wales, Scotland and England, from perspectives of stakeholders involved in tobacco and e-cigarette policy and implementation in each nation.METHODSSemi-structured qualitative interviews were completed with 12 stakeholders from government and third sector organizations in the UK involved in tobacco control policy-making processes, and Trading Standards Officers from 13 UK local authorities. Data were analyzed thematically and a sub-sample double-coded.RESULTSStakeholders held varying views of e-cigarettes, recognizing potential benefits and harms of both the products and the new policy actions. Nevertheless, most perceived TPD to be a positive step in introducing regulation for e-cigarettes. Compliance was perceived as high across nations, although stakeholders highlighted product adaptations to circumvent restrictions, and absence of controls on non-nicotine products. Budgetary and staffing limitations also meant that capacity to communicate new measures, and enforce change, was limited. This led to a gap occupied by industry representatives, who played a substantial role in preparing retailers for adoption of new measures.CONCLUSIONSTPD policy roll-out was largely perceived positively and as having been effectively implemented. However, contribution of industry to communication of new measures and absence of resourcing for effective communication perhaps introduced widespread innovations within regulations. While largely viewed positively, some refinements to device regulations were proposed.

E-Cigarette Advertising in the UK: A Content Analysis of Traditional and Social Media Advertising to Observe Compliance with Current Regulations.

IntroductionThe advertising of e-cigarettes in the UK is regulated through the revised EU Tobacco Products Directive and the Tobacco and Related Products Regulations, with further rules set out in the Advertising Standards Authority (ASA) Committees of Advertising (CAP) Code. Focusing on the ASA CAP Code Rules, we examined e-cigarette advertising regulation compliance in traditional advertising channels and on social media.MethodsWe conducted a content analysis of UK e-cigarette and related product advertising using a randomly selected sample (n = 130) of advertising in traditional channels and on Instagram which appeared between January and December 2019. All ads were independently double-coded to assess compliance with each CAP Code Rule.ResultsIn traditional channels, our sample of advertising had largely good compliance. Only very small numbers of these ads appeared to be clearly in breach of any of the ASA rules (5% were in breach of Rule 22.7; 2% of Rule 22.9; and 1% of Rule 22.10). In contrast, we judged that all of the Instagram sample (n = 30) was in breach of Rule 22.12. For some rules, it was not possible to make definitive judgments about compliance, given uncertainty regarding how a rule should be interpreted and applied.ConclusionsWe found overall good compliance for advertising in traditional channels, but assessed all of our social media advertising samples was in breach of regulations. Current guidance on e-cigarette advertising could be improved to facilitate e-cigarette advertising assessment and regulation. It would be beneficial to bring consumer perspectives into the assessment of regulation compliance.ImplicationsThe regulation of e-cigarette advertising is a global concern. The UK Government has a statutory obligation to review the Tobacco and Related Products Regulations by May 2021. This study assessed compliance with current UK e-cigarette advertising regulations on placement and content. We identified areas where greater clarity is needed and outlined implications for future regulation.

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

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

Young people's use of e-cigarettes in Wales, England and Scotland before and after introduction of EU Tobacco Products Directive regulations: a mixed-method natural experimental evaluation

BackgroundYoung people's experimentation with e-cigarettes has increased in recent years, although regular use remains limited. EU Tobacco Products Directive (TPD) regulations introduced packet warnings, advertising restrictions, and regulated nicotine strength from 2016, in part due to concerns regarding use by young people. This paper examines e-cigarette use trajectories before and after TPD. MethodsE-cigarette use data were obtained from School Health Research Network/Health Behaviour in School-aged Children surveys in Wales and Smoking Drinking and Drug Use surveys in England. Data from Wales were analysed using segmented logistic regression, with before and after regression analyses of English data. Semi-structured group interviews included young people aged 14-16 years in Wales, England and Scotland in 2017 and 2018. ResultsIn Wales, ever use of e-cigarettes increased over time, but under a range of assumptions, growth did not appear to continue post-TPD. A small and non-significant change in trend was observed post-implementation (OR=0.96; 95%CI=0.91 to 1.01), which increased in size and significance after adjusting for ever smoking (OR=0.93; 95%CI=0.88 to 0.98). There was little increase in regular e-cigarette use from 2015 to 2017 in Wales. However, ever and regular use increased from 2014 to 2016 in England. Young people in all nations described limited interactions with components of TPD, while describing e-cigarette use as a ‘fad’, which had begun to run its course. ConclusionsThis study provides preliminary evidence that young people's e-cigarette experimentation may be plateauing in UK nations. The extent to which this arises from regulatory changes, or due to a fad having begun to lose its appeal among young people in the UK countries, remains unclear. These trends contrast to those observed in North America, where newer products whose EU market entry and marketing have been impacted by TPD, have gained traction among young people. Long-term monitoring of e-cigarette use trends and perceptions among young people remain vital.

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.

The European Tobacco Products Directive (TPD) introduced a ban on characterizing flavours in cigarettes (2016), including menthol (2020). The longitudinal data analysis of the EUREST-PLUS International Tobacco Control (ITC) Project Europe Surveys (n = 16 534; Wave 1 in 2016 and Wave 2 in 2018) found significant but small declines in the weighted prevalence of menthol (by 0.94%; P = 0.041) and other flavoured cigarette use (by 1.32%; P < 0.001) following the 2016 TPD. The declines tended to be driven primarily by the menthol and flavoured cigarette (MFC) smokers switching to unflavoured tobacco. Cigarette consumption declined between waves, but there were no statistically significant difference in decline between MFC and unflavoured tobacco smokers on smoking and cessation behaviours between the waves.

A Qualitative Exploration of Consumers' Perceived Impacts, Behavioural Reactions, and Future Reflections of the EU Tobacco Products Directive (2017) as Applied to Electronic Cigarettes.

Background:Electronic cigarette regulations included in the Tobacco Products Directive (TPD), Article 20, implemented in Europe by May 2017, aimed to improve safety for e-cigarette consumers, and prevent uptake among non-smokers, particularly young people. Before implementation, there were significant concerns from consumers, industry, and some in the scientific community about the potential negative impact of the TPD on people using e-cigarettes to remain abstinent from smoking. To date, there is limited evidence on how the TPD has affected consumers. This study aimed to add insight into how consumers perceived and experienced the regulations.Methods:Qualitative data, collected between March 2018 and March 2019, relating to participant views of the TPD were extracted from 160 interviews/extended surveys of e-cigarette consumers as part of a wider study into e-cigarette use trajectories (ECtra study). Data were thematically analysed.Results:Awareness of the TPD among consumers was not universal. Participants’ smoking behaviour did not appear to be influenced by the legislation. Participants were reassured by manufacturing regulations and requirements for ingredients labels. Participants responded negatively to changes perceived to cause inconvenience and extra plastic waste. The product restrictions prompted some participants to purchase non-compliant products illegally, potentially putting their safety at risk.Conclusions:E-cigarette regulation should focus on ensuring product safety. Raising awareness of the TPD among consumers and smokers could be beneficial.

A qualitative study of e-cigarette emergence and the potential for renormalisation of smoking in UK youth

BackgroundGrowth of e-cigarette use among smokers has raised concerns over uptake by non-smokers, particularly young people. Legislative changes aimed in part at reducing youth exposure to e-cigarettes include the EU Tobacco Products Directive (TPD). A core justification for such measures is the belief that e-cigarettes can lead to tobacco smoking through mechanisms of renormalisation including: mimicking and normalizing the act of smoking; increasing product acceptability via marketing; nicotine exposure. These mechanisms are here explored in relation to findings from qualitative research. MethodsThis paper reports results from twenty-one group interviews with 14–15 year olds in Wales, England and Scotland, conducted as part of an ongoing evaluation of the impact of the TPD on youth smoking and e-cigarette use. Interviews were conducted around the end of the transitional period for TPD implementation, and explored perceptions of e-cigarettes and tobacco, as well as similarities and differences between them. ResultsYoung people differentiated between tobacco and e-cigarettes, rejecting the term e-cigarette in favour of alternatives such as ‘vapes’. Experimental or occasional use was common and generally approved of where occurring within social activity with peers. However, regular use outside of this context was widely disapproved of, unless for the purpose of stopping smoking. Increased prevalence of e-cigarettes did not challenge strongly negative views of smoking or reduce perceived harms caused by it, with disapproval of smoking remaining high. Nicotine use was variable, with flavour a stronger driver for choice of e-liquid, and interest more generally. ConclusionThe extent to which participants differentiated between vaping and smoking, including styles and reasons for use in adults and young people; absence of marketing awareness; and continued strong disapproval of smoking provides limited support for some of the potential mechanisms through which e-cigarettes may renormalise smoking. However caution over nicotine exposure is still necessary.

Use of e-cigarettes by young people in Great Britain before and after Tobacco Products Directive

Abstract Background Young people’s experimentation with e-cigarettes has increased in recent years, although regular use remains rare. In May 2016, the EU Tobacco Products Directive (TPD) introduced regulations aimed in part at preventing use by young people. It imposed warnings on e-cigarette packets, banned many forms of advertising, and restricted nicotine strength. This paper examines change in young people’s e-cigarette use after TPD, as well as complementary and alternative causal explanations for change, from young people’s perspectives. Methods Quantitative data sources were 2013, 2015 and 2017 School Health Research Network/Health Behaviour in School-aged Children surveys in Wales and 2014 and 2016 Smoking Drinking and Drug Use surveys in England. Data were analysed using segmented binary logistic regression in Wales, with simpler before and after analyses in England. Results were considered alongside qualitative interview data from young people aged 14-15 years in England, Wales and Scotland, collected in 2017 and 2018. Results Ever-use of e-cigarettes almost doubled from 2013-15, though subsequent increases were smaller. In Wales, where pre-legislation time series data were available, under a range of assumptions, prior growth in e-cigarette ever-use did not continue post-TPD. Change in trend post-TPD did not reach significance (OR = 0.96; 95%CI=0.91 to 1.01), but became significant after adjusting for change in smoking rates across the time-series (OR = 0.93; 95%CI=0.88 to 0.98). Regular use did not increase significantly from 2015 to 2017 in Wales, although ever and regular use in England both increased from 2014 to 2016. Young people described limited interactions with core components of TPD, while commonly describing e-cigarette use as a fad which was beginning to run its course. Conclusions Growth in youth experimentation with e-cigarettes may be slowing. Qualitative data from young people provide a range of explanations which appear largely unrelated to TPD itself. Key messages Survey data provide preliminary evidence that use of e-cigarettes may be plateauing among young people in the UK after a rapid initial increase in experimentation. Explanations position e-cigarettes as a passing fad which is beginning to lose its appeal in UK youth. Longer term monitoring of trends and perceptions remain vital.

Awareness of changes to tobacco product content and packaging design after implementation of the EU Tobacco Products Directive among smokers: Findings from the EUREST-PLUS ITC Europe Surveys

Awareness of changes to tobacco product content and packaging design after implementation of the EU Tobacco Products Directive among smokers: Findings from the EUREST-PLUS ITC Europe Surveys

Assessment of priority tobacco additives per the requirements in the EU Tobacco Products Directive (2014/40/EU): Part 2: Smoke chemistry and in vitro toxicology

This publication is part of a series of three publications and describes the non-clinical assessment performed to fulfill the regulatory requirement per Art. 6 (2) of the EU Tobacco Products Directive 2014/40/EU under which Member States shall require manufacturers and importers of cigarettes and Roll Your Own tobacco containing an additive that is included in the priority list established by Commission Implementing Decision (EU) 2016/787 to carry out comprehensive studies (European Comission, 2016). This publication contains the results of a literature search, comprehensive smoke chemistry, additive transfer, and in vitro toxicity studies for the 13 priority additives (carob bean extract, cocoa powder, fenugreek extract, fig juice concentrate, geraniol, glycerol, guaiacol, guar gum, liquorice extract powder, maltol, l-menthol (synthetic), propylene glycol, and sorbitol) commissioned by the members of the Priority Additives Tobacco Consortium to independent Contract Research Organizations. Comparisons of the 39 World Health Organisation smoke emissions in smoke from cigarettes with and without priority additives identified some differences that, with few exceptions, were minor and well within the inherent variability of the analytical method observed for the 3R4F monitor cigarette. Most differences were not statistically significant and did not show consistent additive-related increases or decreases. However, test cigarettes with guar gum showed a statistically significant, additive-related increase in formaldehyde and cadmium; test cigarettes with sorbitol showed a statistically significant, additive-related increase in formaldehyde and acrolein; test cigarettes with glycerol showed a statistically significant, additive-related decrease in phenols, benzo[a]pyrene and N-nitrosoanabasine; and test cigarettes with propylene glycol showed a statistically significant, additive-related decrease in phenol and m + p-cresols. These changes were not observed when the additives were tested as a mixture. None of the increases or decreases in smoke chemistry translated into changes in the in vitro toxicity. Comparisons of the in vitro toxicity of smoke from cigarettes with and without priority additives gave some differences that were minor, well within the inherent variability of the assays, not statistically significant, and did not show consistent additive-related increases or decreases. Thus, it can be concluded that the addition of priority additives had no effect on the in vitro toxicity of the cigarette smoke. The results obtained in our studies are consistent with those in scientific literature.

Assessment of priority tobacco additives per the requirements of the EU Tobacco Products Directive (2014/40/EU): Part 3, Smoking behavior and plasma nicotine pharmacokinetics

This publication is part of a series of 3 publications and describes the clinical assessment performed to fulfill the regulatory requirement per Art. 6 (2) of the EU Tobacco Products Directive 2014/40/EU under which Member States require manufacturers and importers of cigarettes and Roll Your Own tobacco containing an additive that is included in the priority list established by Commission Implementing Decision (EU) 2016/787 to carry out comprehensive studies (European Union, 2016). In our clinical study, two distinct end points were investigated, namely measuring plasma nicotine pharmacokinetics as a measure of nicotine uptake, and analyses of changes in smoker puffing behavior as a measure of cigarette smoke inhalation. This clinical study indicated that the inclusion of none of the priority additives either as single additive or as part of a chemical mixture, facilitated nicotine uptake. Furthermore, the data did not suggest that differences in the inhalation pattern of cigarette smoke of any of the Priority Additives tested occurred when compared to the additive-free reference cigarette. Finally, it is concluded that neither the scientific literature nor our study gave circumstantial indications of increased addictiveness for cigarettes containing these priority additives.

Assessment of priority tobacco additives per the requirements of the EU Tobacco Products Directive (2014/40/EU): Part 1: Background, approach, and summary of findings

This paper is part of a series of 3 publications and describes the non-clinical and clinical assessment performed to fulfill the regulatory requirement per Art. 6 (2) of the EU Tobacco Products Directive 2014/40/EU; under which Member States shall require manufacturers and importers of cigarettes and roll-your-own tobacco containing an additive that is included in the priority list established by Commission Implementing Decision (EU) 2016/787 to carry out comprehensive studies. The Directive requires manufacturers and importers of cigarettes and Roll Your Own tobacco to examine for each additive whether it; contributes to and increases the toxicity or addictiveness of tobacco products to a significant or measurable degree; if it leads to a characterizing flavor of the product; if it facilitates inhalation or nicotine uptake, and if it results in the formation of CMR (carcinogenic, mutagenic and reprotoxic) constituents and if these substances increase the CMR properties of the respective tobacco product to a significant or measurable degree. This publication gives an overview on comprehensive smoke chemistry, in vitro toxicity, and human clinical studies commissioned by the members of the Priority Additives Tobacco Consortium to independent Contract Research Organizations (CROs) where the emissions of test cigarettes containing priority additives were compared to emissions emerging from an additive-free reference cigarette. Whilst minor changes in smoke chemistry parameters were observed when comparing emissions from test cigarettes with emissions from additive-free reference cigarettes, only two of the additives (sorbitol and guar gum) tested led to significant increases in a limited number of smoke constituents. These changes were not observed when sorbitol or guar gum were tested in a mixture with other priority additives. None of the priority additives resulted in increases in in vitro toxicity (Ames, Micronucleus, Neutral Red Uptake) or led to changes in smoking behavior or absorption (rate or amount) of nicotine measured during the human clinical study as compared to the additive-free reference cigarette.

Characterising smokers of menthol and flavoured cigarettes, their attitudes towards tobacco regulation, and the anticipated impact of the Tobacco Products Directive on their smoking and quitting behaviours: The EUREST-PLUS ITC Europe Surveys.

INTRODUCTIONLittle research exists on the sociodemographic characteristics of menthol and flavoured cigarette (MFC) smokers in Europe. This study assessed the proportion of MFC smokers in Europe, their sociodemographic characteristics, and their attitudes towards tobacco control measures.METHODSCross-sectional data were collected in 2016 among 10760 adult current smokers from 8 European countries (ITC Europe Project and EUREST-PLUS). Smokers of menthol, other flavoured, unflavoured tobacco, or no usual brand were compared on sociodemographic characteristics, attitudes towards a range of tobacco control measures (e.g. ban on flavouring), and on intentions regarding their smoking behaviour following the ban on flavoured tobacco. Data were analysed in SPSS Complex Samples Package using univariate analyses.RESULTSAmong the respondents, 7.4% smoked menthol cigarettes and 2.9% other flavoured tobacco, but large differences existed between countries (e.g. 0.4% smokers smoked menthol cigarettes in Spain vs 12.4% in England). Compared to other groups, menthol cigarette smokers were younger, more likely to be female, better educated, had higher household income, and smoked fewer cigarettes (all p<0.001). A quarter of menthol smokers supported a ban on additives, compared with almost half of all other smokers (p<0.001). In case of a ban on flavourings, around a fifth of all MFC smokers intended to switch to another brand, and a third to reduce the amount they smoked or to quit smoking, but there was no consistent pattern across MFC smokers among the countries.CONCLUSIONSThe ban on flavourings introduced by the EU Tobacco Products Directive (extended to 2020 for menthols) will affect one in ten smokers in the countries surveyed, which provides an opportunity for targeting these groups with cessation programmes. However, smokers of menthol and flavoured cigarettes in the different European countries are a heterogeneous group and may need different approaches.

An exploration into “do-it-yourself” (DIY) e-liquid mixing: Users' motivations, practices and product laboratory analysis

BackgroundE-liquids are commercially available and manufactured, however some users of e-cigarettes prefer to prepare them at home (Do-it-Yourself; DIY) using individual ingredients. To date there is a paucity of research on how and why users make their own e-liquids. MethodsForty-one European and US based exclusive users of e-cigarettes (ex-smokers) were individually interviewed. Structured interviews focused on motivations for home-mixing, practices, buying habits and broader themes around reasons for long-term vaping. We also measured nicotine and solvent concentrations and analysed 33 DIY e-liquids collected from 16 participants for nicotine, solvents, flavourings, and potentially harmful chemicals. ResultsThere were four main reasons for DIY: 1) economical (financial savings), 2) self-control over manufacturing process, 3) novelty, fun and 4) higher nicotine concentrations. Twelve out of 16 participants achieved nicotine concentration within 20% of their intended limit. Samples from five participants were above the EU Tobacco Products Directive's (TPD) 20 mg/ml nicotine concentration upper limit. Most samples contained more vegetable glycerine (VG) than propylene glycol (PG) and the most commonly used flavourings were dessert, e.g., vanilla and caramel. Chemical analysis also revealed presence of several potentially harmful chemicals and respiratory irritants, including cinnamaldehyde, benzaldehyde, and acetoin. ConclusionDIY may offer users of e-cigarettes a long-term affordable practical method of vaping. Recommended safety advice needs to reflect actual and fast moving user behaviour.

The effects of the European e-cigarette health warnings and comparative health messages on non-smokers\u2019 and smokers\u2019 risk perceptions and behavioural intentions

BackgroundArticle 20 of the EU Tobacco Products Directive [TPD] stipulates that e-cigarette packets and refill products must carry a nicotine addiction health warning. Although previous studies conducted in North America have found that perceived harm, addictiveness and intention to use declined following exposure to e-cigarette health warnings, possible effects of the TPD health warnings on smokers and non-smokers has not been studied. This study will investigate the effects of the EU TPD e-cigarette health warnings and a comparative harm message (COMP; developed specifically for this study) on smokers’ and non-smokers’ perceptions of harm, addictiveness and social acceptability of e-cigarettes. Additionally, the potential effects of the TPD warnings and the COMP on smokers’ intentions to purchase and use e-cigarettes will be explored.Methods/designA sample of 2400 UK residents will be recruited in this experimental, randomised design, with Smoking status (Smoker vs. Non-smoker), TPD presence (TPD1 vs. TPD2 vs. No-TPD) and COMP presence (Presence vs. Absence) as between subjects independent variables, and Time (pre-post exposure of images) as a within subjects factor. Dependent variables comprise self-reported perceived harm, addictiveness, social acceptability, e-cigarettes’ effectiveness, intentions to purchase and use e-cigarettes. Cigarette dependence, previous e-cigarette exposure, and baseline intentions to quit will be measured as covariates.DiscussionHealth warnings, such as those implemented by the TPD, may help to prevent non-smokers from e-cigarettes use, but it is possible that they may inadvertently deter smokers from initiating use and substituting their tobacco smoking for e-cigarettes use if their content is deemed too negative. It is hoped that this study will help identify the most effective message or combination of messages that encourage use among smokers without promoting use among non-smokers.Trial registrationISRCTN registry ISRCTN76967031; date of registration: 23/10/18.

Tobacco control achievements and priority areas in the WHO Europe Region: A review.

INTRODUCTIONTobacco control efforts have been advancing globally, including the adoption and entry into force of the World Health Organization (WHO) Framework Convention of Tobacco Control (FCTC), as well as the adoption of the European Union EU Tobacco Products Directive. With the present review, the European Network for Smoking and Tobacco Prevention (ENSP) and European Respiratory Society (ERS) aim to provide a comprehensive overview on the status of WHO FCTC implementation, policy achievements and priority areas across countries in the WHO Europe Region.METHODSThe review was conducted through a triangulation of data extracted from a survey administered to ENSP members, the WHO FCTC Implementation Database, Tobacco Control Laws and the Tobacco Control Scale 2016.RESULTSUsing the WHO MPOWER measures as a framework, we report on the implementation status of nine FCTC articles across 47 countries in the WHO Europe Region. The average number of articles fully implemented was 3.58. FCTC articles least fully implemented were: Article 5.3 on Tobacco Industry Interference (25.5%, n=12), Article 20 on Research (34.0%, n=16), and Article 15 on Illicit trade (40.4%, n=19). The most commonly fully implemented articles were: Article 8 on Smoke-free legislation (63.8%, n=30), Article 16 on Underage sales (57.4%, n=27), and Article 6 on Price and tax measures (51.2%, n=24). Policy achievements and recommended priority areas for future national tobacco control activities varied greatly among countries.CONCLUSIONSFindings highlight the multitude of successes in tobacco control efforts across the region in recent years, but point out the need to address gaps in FCTC implementation.