Effectiveness of tobacco warning labels before and after implementation of the European Tobacco Products Directive-findings from the longitudinal EUREST-PLUS ITC Europe surveys

Examining the Effectiveness of the 2012 Canadian Graphic Warning Label Policy Change by Sex, Income, and Education

INTRODUCTION

We examined the differential impact of the 2012 Canadian GWL policy changes on key indicators of warning label impact and quit intentions using national cohorts of Canadian and U.S. adults who smoke.

AIMS AND METHODS

We used data from all waves of the International Tobacco Control surveys (2002-2020) in Canada and the United States. Our key measures were quit intentions and an index of warning label effectiveness (salience, cognitive and behavioral reactions). We estimated overall policy impact by comparing Canada (treatment group) with the United States (control group) using controlled interrupted time series (CITS) regression models, with interactions to examine whether policy impact varied by sex, education, and income.

RESULTS

The CITS model showed a statistically significant increase in the warning label effectiveness in Canada post-policy, compared to the United States (β = 0.84, 95% CI 0.35,1.33). Similarly, the odds of quit intentions were relatively higher among adults who smoked in Canada compared to the United States (OR = 1.89, 95% CI 1.51,2.36) post-policy. The three-way interaction model showed that these associations were greater among adults from low socioeconomic status (SES) groups than in high SES groups.

CONCLUSIONS

The 2012 change in the Canadian GWL policy was associated with stronger cognitive and behavioral responses to GWLs and higher odds of quit intentions among adults who smoked in Canada when compared to the United States, specifically among individuals from low SES groups, suggesting a positive equity impact. Our findings affirm the need for countries to implement or enhance GWLs, in line with the WHO Framework Convention on Tobacco Control (FCTC).

IMPLICATIONS

The evidence on the potential health equity benefit of GWL policies is mixed. To further understand the influence of GWL policies on tobacco use disparities, more systematic research using pre/post-policy designs with control groups is needed. Using a CITS model, we aimed to strengthen the available evidence on the causal influence of this tobacco control approach. Our findings show that the 2012 GWL policy change had a greater impact on adults who smoked from low SES groups than it did on adults who smoked from high SES groups, indicating a potentially positive equity impact and confirming the need for countries to implement or maximize the size of GWLs, as recommended by the WHO FCTC.

Price Policy and Taxation as Effective Strategies for Tobacco Control

Objective

Only 13% of the world's population are living in countries imposing appropriate tobacco tax-rates. This study aims to promote the implementation of price policy measures as a striking tobacco control strategy in Austria and to encourage other countries to further increase their taxes to WHO best-practice levels.

Method

This study used the yearly economic data from Austria from 1997 to 2015. Applying a model for regression analysis, the price elasticity of total tobacco consumption was estimated.

Results

Between 1997 and 2015 the price elasticity of demand for tobacco products (including cigarettes, cigars, and other tobaccos) was -0.661, however, the result is statistically insignificant. When excluding 2 anomalous years and removing a variable of the regression model the elasticity was -0.691 and statistically significant, indicating that a 1% increase in tobacco prices will result in a 0.691% decrease of tobacco consumption.

Conclusion

The responsiveness of Austrian smokers to price changes has increased during the last decades. Because other activities showed no significance in the analysis, this study should encourage countries world-wide to use price policy and taxation more intensively in order to reduce smoking rates effectively.

European Tobacco Products Directive (TPD): current impact and future steps

Efforts to reduce the toll of tobacco-related morbidity and mortality in the European Union are spearheaded by the Tobacco Products Directive (TPD), a legal act implemented during 2016-2021, with the overall aim to reduce tobacco consumption by 2% in Europe. Within this time frame, several core tobacco control measures were implemented, the impact of which is outlined within this manuscript. Key successful legislative actions implemented in this time frame led to greater availability of information and further regulation of additives, the banning of mentholated cigarettes, enhanced pictorial package warnings and a regulatory framework for e-cigarettes. While repeated cross-sectional data indicated a 12.5% relative reduction in smoking prevalence after implementation of the TPD, the differential regulation of cigarettes and roll-your-own tobacco compared with other products, such as cigarillos, e-cigarettes and heated tobacco products, may have also led to product displacement. Moreover, as the TPD could not keep up with the ever-changing nicotine product landscape, further adaptations may be needed.

Perceived efficacy of existing waterpipe tobacco warning labels versus novel enhanced generic and waterpipe-specific sets

INTRODUCTION

Since 2008, Egypt has four existing generic bi-annually rotating warning labels (WLs) on 50% of the waterpipe tobacco packs (WTPs). The Ministry of Health Tobacco Control Unit proposed increasing WL size to 80%, removing colours and flavour imagery from WTPs, and plain packaging to help curb the rising epidemic of waterpipe tobacco smoking. Therefore, we measured the perceived efficacy of existing against novel enhanced (generic and waterpipe-specific) WTP WLs and the associated factors among Egyptian waterpipe smokers and nonsmokers.

METHODS

A purposive quota sample of 2014 adults was surveyed in two rounds using face interviews. At each round, participants were randomly shown one of four existing WLs, then one of four novel WLs. Participants rated the perceived efficacy of existing and novel WLs regarding the salience, depth of processing, affective reactions, credibility, relevance, perceived harm and perceived behavioural control. Data were analysed using Generalized Estimating Equations.

RESULTS

Participants rated novel WTP WLs with higher mean perceived efficacy scores than existing WLs for all measures, although both sets collectively scored modestly (59.7; 95% CI: 58.9-60.5 vs 53.0; 95% CI: 52.1-54.0, respectively; p<0.001). Relative to the existing WTP WLs, novel WLs were particularly able to induce higher salience, affective reactions, and depth of processing. Relative to the generic novel WTP WLs, waterpipe-specific WLs induced higher relevance, perceived harm, and affective reactions. Nonsmokers scored higher than waterpipe tobacco smokers, specifically for perceived behavioral control (65.0±32.5 vs 43.6±19.8, respectively; p<0.001). WTP WLs featuring proximal risks, such as dental effects (β = 9.70; 95% CI: 7.00-12.40), fetal harm (β = 9.42; 95% CI: 6.75-12.10), or toxic contents (β = 9.14; 95% CI: 6.58-11.70) were strongly associated with participants' perceived efficacy scores. Among other independent factors, rural residence (β = 24.09; 95% CI: 22.21-25.97), being a nonsmoker (β = 10.51; 95% CI: 8.92-12.10), survey round 2 (β = 6.96, 95% CI: 5.73-8.19), the novel WTP WL set (β = 6.68; 95% CI: 6.19-7.17), and having higher education (β = 6.31; 95% CI: 4.34-8.27) were highly associated with participants' perceived efficacy scores.

CONCLUSIONS

Waterpipe-specific WLs on plain WTPs that feature proximal risks and address different population subgroups need to be developed in conjunction with awareness raising campaigns on WTS harms to reinforce the credibility of WTP WLs. Our findings suggest the proposed WTP WL enhancements by the Tobacco Control Unit may support a more effective WTP labelling policy within a comprehensive waterpipe-specific tobacco control framework.