Health beliefs, smoking behaviours and attitudes towards the tobacco flavor ban among smokers of menthol, other flavored and unflavored cigarettes: Findings from the EUREST-PLUS ITC Europe Surveys
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Health Promotion Foundation, Warsaw, Poland
National Research Institute of Oncology, Warsaw, Poland
Tobacco Control Research Group, University of Bath, Bath, United Kingdom
President Stanisław Wojciechowski State University of Applied Sciences, Kalisz, Poland
UK Centre for Tobacco and Alcohol Studies, London, United Kingdom
University College London, London, United Kingdom
German Cancer Research Center, Heidelberg, Germany
University of Waterloo, Waterloo, Canada
Ontario Institute for Cancer Research, Toronto, Canada
Smoking or Health Hungarian Foundation, Budapest, Hungary
University of Athens, Athens, Greece
University of Medicine and Pharmacy, Iasi, Romania
Aer Pur Romania, Bucharest, Romania
Catalan Institute of Oncology, L'Hospitalet de Llobregat, Spain
Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Spain
University of Barcelona, Barcelona, Spain
King's College London, London, United Kingdom
Maastricht University, Maastricht, the Netherlands
Imperial College London, London, United Kingdom
European Network for Smoking and Tobacco Prevention, Brussels, Belgium
University of Crete, Heraklion, Greece
Publication date: 2021-12-10
Tob. Prev. Cessation 2021;7(Supplement):45
Pre-Conference Event- 10 June 2021: ENSP Scientific Webinar “Effects and Challenges in Enforcing Ban on Flavoured Tobacco Products”.

Since May 2017, the tobacco flavour ban came into force in the European Union as an effect of the 2014 EU Tobacco Product Directive (TPD), however menthol cigarettes could be sold until May 2020. The tobacco control measure was aimed to change health beliefs and smoking behaviors of millions of menthol cigarette smokers.

Aim and objective:
To assess patterns and changes in health beliefs, smoking behaviors and attitudes towards the tobacco flavor ban among smokers of menthol, other flavoured and unflavoured cigarettes.

Social and behavioral patterns of smoking behaviours and cessation as well as health beliefs and attitudes towards the tobacco flavour ban were analysed on the basis of cross-sectional dataset from the 2016 EUREST-PLUS ITC Europe Surveys (Wave 1) that have been conducted on a total sample of 10,760 adult current smokers from eight European Union Member States (Germany, Greece, Hungary, Poland, Romania, Spain, England and the Netherlands). The analysis of changes in health beliefs, prevalence of cigarette smoking by tobacco flavour and cessation behaviors following the implementation was based on longitudinal data from Wave 1 (2016; pre-TPD) and Wave 2 (2018; post-TPD) of the EUREST-PLUS ITC Europe Surveys from above eight EU countries (N=19,691). All analyses were conducted among smokers of menthol and other flavoured cigarttes (or combined group) when compared with smokers of unflavoured cigarettes. Cross-sectional data were analysed in SPSS Complex Samples Package using univariate, bivariate and multivariate regression models adjusted for few selected confounding factors. Longitudinal analyses of health beliefs, smoking and cessation behviours were based on descriptive statistics and used the SAS-callable SUDAAN (Version 11.0.1).

When compared to smokers of unflavoured cigarettes (Wave 1), menthol cigarette smokers were less likely smoke daily and less addicted from tobacco when analysed by the Heavy Smoking Index. Results of Wave 1 also shows that health smokers of flavoured cigarettes were also more likely believe than unflavored cigarette smokers that menthol cigarettes are less harmful (32% vs. 13%) and smoother (57% vs. 20%). They are more convinced that smoking causes lung and throat cancer, lung cancer and heart attacks among non-smokers, bronchitis, impotence and asthma in children. The study findings also show that smokers of menthol cigarettes were much less likely (25%) to support the tobacco flavour ban than other cigarette smokers (48 to 50%), including smokers of other flavoured cigarettes. 16% of menthol cigarette smokers and 10% of other flavored cigarette smokers intended to quit smoking after the flavour ban enforcement although quit intention rates varied substantially between countries. Furthermore, 27% said they will find a way to get menthol tobacco product banned. After the tobacco flavour ban enactment significant but small decline in the prevalence of menthol and other flavoured cigarette use between survey waves has been found in the pooled sample of all countries. This decline was primarily driven by flavour smoker's switching to unflavoured tobacco (23% among menthol and 62% among other flavoured cigarette smokers), rather than quitting smoking (14% and 9%, respectively). Almost 52% of menthol and 11% of other flavoured cigarette smokers continued to smoke their flavoured cigarette brands. It could be partly caused by positive changes in health beliefs of flavoured cigarette smokers between 1st and 2nd wave of the survey, for example in the increase of smokers of flavoured cigarettes who believe that smoking causes mouth cancer, COPD and blindness.

Smokers of different cigarette flavours in Europe differ on smoking behaviours, cessation characteristics, health beliefs and their attitudes towards the tobacco flavour ban. The lower dependence of menthol cigarette smokers could lead to greater success rates if quit attempts are made, however cross-country differences in smoking behaviours, quitting intention and health beliefs could lead to the TPD ban on cigarette flavours having differential impact if not accompanied by implementing additional measures such as target-tailored smoking cessation support or public awareness campaigns.

G. T. Fong has served as an expert witness on behalf of governments in litigation involving the tobacco industry. A. McNeil is a UK National Institute for Health Research (NIHR) Senior Investigator. The views expressed in this article are those of the author and not necessarily those of the NIHR, or the UK Department of Health and Social Care.
The EUREST-PLUS project has received funding from the EU's Horizon2020 research and innovation programme under grant agreement No. 681109 (CIV) and the University of Waterloo (G.T.F.). Additional support was provided to the University of Waterloo by a foundation grant from the Canadian Institutes of Health Research (FDN-148477). G.T.F. was supported by a Senior Investigator Grant from the Ontario Institute for Cancer Research. E.F. is partly supported by Ministry of Universities and Research, Government of Catalonia (2017SGR319) and by the Instituto Carlos III and co-funded by the European Regional Development Fund (FEDER; INT16/00211 and INT17/00103), Government of Spain. E.F. thanks CERCA Programme Generalitat de Catalunya for the institutional support to IDIBELL. The England arm of the ITC 4 Country Smoking and Vaping Survey was supported by grants from the US National Cancer Institute (P01 CA200512) and the Canadian Institutes of Health Research (FDN-148477). The ITC Netherlands Surveys were supported by the Dutch Cancer Foundation (KWF) (UM 2014-7210).
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