Sarah Kahnert1,2, Pete Driezen3,4, James Balmford5, Christina N Kyriakos6,7, Sarah Aleyan4,8, Sara C Hitchman8, Sarah Nogueira9,10,11,12, Tibor Demjén13, Esteve Fernández9,10,11,12, Paraskevi A Katsaounou14,15, Antigona C Trofor16,17, Krzysztof Przewoźniak18,19,20, Witold A Zatoński18,21, Geoffrey T Fong3,4,22, Constantine I Vardavas6,7,15, Ute Mons1. 1. Cancer Prevention Unit and WHO Collaborating Centre for Tobacco Control, German Cancer Research Center (DKFZ), Heidelberg, Germany. 2. Medical Faculty, Heidelberg University, Heidelberg, Germany. 3. Department of Psychology, University of Waterloo, Waterloo, Canada. 4. School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada. 5. Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany. 6. European Network for Smoking and Tobacco Prevention (ENSP), Brussels, Belgium. 7. School of Medicine, University of Crete, Heraklion, Greece. 8. Department of Addictions, Institute of Psychiatry, Psychology & Neuroscience, King's College London. 9. Cancer Epidemiology and Prevention Department, Catalan Institute of Oncology (ICO), L'Hospitalet de Llobregat, Spain. 10. Tobacco Control Unit, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Spain. 11. School of Medicine and Health Sciences, University of Barcelona (UB), Barcelona, Spain. 12. Consortium for Biomedical Research in Respiratory Diseases (CIBER en Enfermedades Respiratorias, CIBERES), Madrid, Spain. 13. Smoking or Health Hungarian Foundation, Budapest, Hungary. 14. First ICU Evaggelismos Hospital Athens, National and Kapodistrian University of Athens, Athens, Greece. 15. European Respiratory Society, Lausanne, Switzerland. 16. University of Medicine and Pharmacy 'Grigore T. Popa' Iasi, Iasi, Romania. 17. Aer Pur Romania, Bucharest, Romania. 18. Health Promotion Foundation, Warsaw, Poland. 19. Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland. 20. Collegium Civitas, Warsaw, Poland. 21. European Observatory of Health Inequalities, President Stanisław Wojciechowski State University of Applied Sciences, Kalisz, Poland. 22. Ontario Institute for Cancer Research, Toronto, Canada.
Abstract
BACKGROUND: Tobacco product packaging is a key part of marketing efforts to make tobacco use appealing. In contrast, large, prominent health warnings are intended to inform individuals about the risks of smoking. In the European Union, since May 2016, the Tobacco Products Directive 2014/40/EU (TPD2) requires tobacco product packages to carry combined health warnings consisting of a picture, a text warning and information on stop smoking services, covering 65% of the front and back of the packages. METHODS: Key measures of warning label effectiveness (salience, cognitive reactions and behavioural reaction) before and after implementation of the TPD2, determinants of warning labels' effectiveness and country differences were examined in a longitudinal sample of 6011 adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (EUREST-PLUS Project) using longitudinal Generalized Estimating Equations (GEE) models. RESULTS: In the pooled sample, the warning labels' effectiveness increased significantly over time in terms of salience (adjusted OR = 1.18; 95% CI: 1.03-1.35), while cognitive and behavioural reactions did not show clear increases. Generally, among women, more highly educated smokers and less addicted smokers, the effectiveness of warning labels tended to be higher. CONCLUSION: We found an increase in salience, but no clear increases for cognitive and behavioural reactions to the new warning labels as required by the TPD2. While it is likely that our study underestimated the impact of the new pictorial warning labels, it provides evidence that health messages on tobacco packaging are more salient when supported by large pictures.
BACKGROUND:Tobacco product packaging is a key part of marketing efforts to make tobacco use appealing. In contrast, large, prominent health warnings are intended to inform individuals about the risks of smoking. In the European Union, since May 2016, the Tobacco Products Directive 2014/40/EU (TPD2) requires tobacco product packages to carry combined health warnings consisting of a picture, a text warning and information on stop smoking services, covering 65% of the front and back of the packages. METHODS: Key measures of warning label effectiveness (salience, cognitive reactions and behavioural reaction) before and after implementation of the TPD2, determinants of warning labels' effectiveness and country differences were examined in a longitudinal sample of 6011 adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (EUREST-PLUS Project) using longitudinal Generalized Estimating Equations (GEE) models. RESULTS: In the pooled sample, the warning labels' effectiveness increased significantly over time in terms of salience (adjusted OR = 1.18; 95% CI: 1.03-1.35), while cognitive and behavioural reactions did not show clear increases. Generally, among women, more highly educated smokers and less addicted smokers, the effectiveness of warning labels tended to be higher. CONCLUSION: We found an increase in salience, but no clear increases for cognitive and behavioural reactions to the new warning labels as required by the TPD2. While it is likely that our study underestimated the impact of the new pictorial warning labels, it provides evidence that health messages on tobacco packaging are more salient when supported by large pictures.
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