Study design

This study was conducted within the context of the European Commission Horizon 2020 funded study entitled European Regulatory Science on Tobacco: Policy implementation to reduce lung diseases (EUREST-PLUS-HCO-06-2015). The EURESTPLUS Project^14,15, which involves the creation of a cohort of adult smokers in six EU Member States (Germany, Greece, Hungary, Poland, Romania, Spain; n=6011) aims to assess the implementation of the Tobacco Products Directive (2014/40/EU)¹⁶ and the WHO FCTC at the European level. The conceptual model of EUREST-PLUS is based on the theory-driven framework of the International Tobacco Control Policy Evaluation Project (ITC), which hypothesizes the pathways of tobacco control polices on tobacco use behaviours¹⁷. Data from the first wave of this ITC 6 European Country (ITC 6E) Survey were used for this study. Because all ITC surveys are based on the same methodology and use standardized survey questionnaires¹⁸, it was possible to additionally use cross-sectional data from the first wave of the ITC Four Country Tobacco and E-Cigarette (ITC 4CE1) Survey in England, and from the ITC Netherlands (ITC NL) Survey.

Data collection

The ITC 6E sample, collected between 18 June and 12 September 2016, comprised 6011 nationally representative smokers (i.e. adult cigarette smokers) aged 18 years or older (about 1000 in each of the project six countries). The geographic strata were regions according to the Classification of Territorial Units for Statistics (NUTS) crossed with degree of urbanization (urban, intermediate, rural). Approximately 100 area clusters were sampled in each country, with the aim of obtaining 10 smokers per cluster. Clusters were allocated to strata proportionally to an 18 years and older population size. Within each cluster, household addresses were sampled using a random walk design. One randomly selected male smoker and one randomly selected female smoker were chosen for interview from a sampled household, where possible. Screening of households continued until the required number of smokers from the cluster had been interviewed. All interviews were conducted face-to-face by interviewers using tablets (Computer Assisted Personal Interview, CAPI). For further details, see the ITC 6E Wave 1 Technical Report¹⁹.

Data for Wave 1 of ITC 4CE1 Survey were collected in England between 7 July and 16 November 2016. The sample comprised the following cohorts: 1) recontacted smokers and quitters living in England who participated in Wave 10 of the earlier ITC 4C Project in the UK, regardless of e-cigarette use; 2) newly recruited current smokers and recent quitters (quit smoking in the past 24 months) from a commercial online panel, regardless of e-cigarette use; and 3) newly recruited current e-cigarette users (use at least weekly) from a commercial online panel. In sampling, quotas obtained from national survey data for region crossed with male/female were applied to cohorts 2) and 3). For further details on methods and data collection, see the ITC 4CE Wave 1 Technical Report²⁰. Only data from current adult cigarette smokers were used for this study.

Data for Wave 10 of the ITC NL Survey were collected in the Netherlands between 15 November and 31 December 2016. Respondents were 1696 adults aged 15 years or older recruited as cigarette smokers, who were members of a commercial online panel. The nationally representative sample included 1318 subjects who had also responded in Wave 9, and 378 new respondents recruited to replenish dropouts. Again, only current adult smokers were included. For further details on methods of data collection, see the ITC NL Wave 10 Technical Report²¹.

Ethics procedures

The study was approved by the Research Ethics Board of the University of Waterloo, Ontario, Canada and by local ethics boards within the study countries. Participation in the study was contingent on provision of individual informed consent, which was obtained either in written or verbal form according to local ethical requirements. The EUREST-PLUS Project is registered in Clinicaltrials.gov with trial registration number NCT02773836.

Measures

The questionnaires included relevant sociodemographic variables, such as sex, age, marital status, education, and degree of urbanization. Age was categorized into four age groups (18–24, 25– 39, 40–54, 55 years and older). Marital status was classified into two groups (not married, widowed, divorced or separated; and not married but living together, married or registered partners). In each country, education was reclassified to match International Standard Classification of Education (ISCED) coding, which was, in turn, categorized into low (pre-Primary, Primary, lower Secondary), moderate (upper Secondary, post-Secondary non-Tertiary, short-cycle Tertiary), and high (Bachelor or equivalent, Master or equivalent, Doctoral or equivalent). The degree of urbanization comprised the three categories rural, intermediate and urban.

The number of cigarettes smoked per day (CPD) and self-reported time to the first cigarette of the day (TTF) were used to create the Heaviness of Smoking Index (HSI)²². CPD was categorized into less than 10, 11–20, 21–30, and 31 and more cigarettes, while the categories of TTF were more than 60 minutes, 31–60 minutes, 6–30 minutes, and 5 minutes or less. The HSI was calculated by summing the value of the categorical CPD and categorical TTF, both having category values from 0 to 3, which translates to the HSI having values ranging from 0 to 6. If either value was missing or coded as a non-response, then HSI was also classified as missing or non-response. According to the index, value smokers were subsequently categorized into three HSI groups (low 0–1: moderate 2–4: high 5–6).

To gather information on self-reported exposure to TAPS, respondents were asked ‘Thinking about everything that happens around you, in the last 6 months how often have you noticed things that promote smoking?… It doesn’t have to be advertising — anything that promotes smoking’. Response options were ‘never’, ‘rarely’, ‘sometimes’, ‘often’, ‘very often’ and ‘don’t know’, which were categorized into ‘yes’ (‘rarely’, ‘sometimes’, ‘often’, ‘very often’), ‘no’ (‘never’) and ‘don’t know’. Respondents who answered this question affirmatively were asked the following questions, with response options ‘yes’, ‘no’ and ‘don’t know’, about whether they had noticed, in the last 6 months, things that promote smoking in various media and localities, such as: a) television, b) radio, c) newspapers or magazines, d) social media sites, like Facebook, Twitter, YouTube, Instagram or Snapchat, e) the internet, f) posters or billboards, g) bars or pubs, h) outside shops or stores that sell tobacco, i) inside shops or stores that sell tobacco, and j) fairs, markets, festivals, sporting events, or music concerts. While all places were prompted in ITC 6E Survey, a)–c), f) and j) were not captured in ITC 4CE1 Survey, and f)–j) were not captured in ITC NL Survey. Additionally, in ITC 4CE1 Survey, there was a single question regarding ‘websites or social media sites’. Therefore, d) and e) were combined to one variable for comparative analysis. Exposure to things that promote smoking varies across countries and thus, even though site-specific exposure to TAPS was only asked amongst those who had noticed things that promote smoking, site-specific prevalence of exposure to TAPS was calculated with the whole sample as the denominator to allow for a more straightforward interpretation and better comparability of exposure prevalence.

Furthermore, in all surveys, respondents were asked if they had seen in the last 30 days tobacco packages (ITC 6E and ITC 4CE1 Surveys: ‘cigarette or roll-your-own tobacco packages’; ITC NL Survey: ‘cigarette packages’) ‘being displayed inside shops or stores where people can buy tobacco products, including on shelves or on the counter’ (ITC NL Survey does not refer to shops and stores).

To measure awareness of anti-smoking campaigns, respondents of ITC 6E and ITC NL Surveys, were asked: ‘Now I would like you to think about advertising or information that talks about the dangers of smoking or encourages quitting. In the last 6 months, how often have you noticed such advertising or information?’.

Moreover, in ITC 6E and ITC NL Surveys, but not in ITC 4CE1 Survey, support of complete bans ‘on tobacco advertisements inside shops and stores’ and ‘on displays of cigarettes inside shops and stores’ was inquired with the response options ‘not at all’, ‘somewhat’ and ‘a lot’ , which were categorized into ‘yes’ (‘somewhat’, ‘a lot’) and ‘no’ (‘not at all’).

Statistical analysis

Percentages of exposure to TAPS in various media (TV, radio, print, online, billboards) and localities (bars/pubs, points of sale, events) were reported for each country. Exposure to things that promote smoking was additionally reported by sex, age group, education, marital status, level of urbanization (except for England and the Netherlands, as it was not captured in the surveys), and Heaviness of Smoking Index, while associations were tested for statistical significance using logistic regression models. All analyses incorporated weights derived from the complex sampling design. All statistical tests were two-sided, with an alpha level of 0.05. SAS v9.4 was used throughout.

Results in context

The analyses showed a wide variety of awareness of both TAPS and anti-smoking information across countries. When comparing country-specific regulations regarding TAPS and through the Tobacco Control Scale¹² domain ‘bans of tobacco advertising’ (Table 4), TAPS tended to be noticed more often in countries with less restrictive regulation (e.g. Germany and Greece). In Germany, the only country within the EU where outdoor tobacco advertising is still allowed, the percentage of smokers having noticed tobacco advertising on billboards was also markedly higher compared to other media and countries.

While exposure to individual TAPS channels was also reported in countries with more comprehensive advertising bans (e.g. Hungary and England), this was generally at lower levels compared to countries with less comprehensive bans. These findings are consistent with a previous study using data from the EU-wide 2014 Eurobarometer survey among the general population, which showed that those living in countries with more comprehensive advertising bans were less likely to report exposure to tobacco advertising in the last twelve months²³. This supports the conclusion that TAPS bans are effective in reducing exposure to marketing activities for tobacco products.

Although tobacco advertising is banned on TV and radio, in print media, and on the internet, in all countries included in this analysis, substantial proportions of the surveyed smokers (up to 19.1 %) have nevertheless noticed advertising in these media. Also, tobacco advertising exposure was quite common outside and inside of points of sale, even in countries where bans on this kind of advertising have been implemented (Hungary, Romania, England). The same applies to the display of tobacco products inside shops and stores in England, which quite a few respondents reported to have noticed even though it is banned in this country. While some misreporting cannot be ruled out due to inaccurate recall or other causes, and some of the exposure could be due to non-TAPS sources that are also captured by asking for ‘things that promote smoking’, the prevalence of self-reported exposure, despite bans being in place, could possibly point to the exploitation of loopholes or to problems with enforcement.

The multivariate analysis revealed some variation of self-reported exposure to tobacco promotion with sociodemographic factors, of which the age pattern showed the largest consistence across countries with younger smokers being more likely to notice tobacco promotion than older smokers. This is in line with the recently published study using data from the EU-wide Eurobarometer Survey, which showed a clear age gradient and noted the highest self-reported TAPS exposure among 15- to 24-yearolds²³.

It is noteworthy that support for complete bans on tobacco advertising and on display of tobacco products inside points of sale was moderate to high and tended to be higher in countries where advertising bans at the point of sale were in place. It has been found for smoke-free legislation that comprehensive policies attract more support from smokers than partial policies²⁴, and it is possible that this applies to advertising bans as well.

Limitations and strengths

Some limitations need to be considered when interpreting the results of this study. First, this study is based on self-reported recall of exposure to TAPS. This measure can be subject to recall bias and in some cases might reflect awareness to TAPS rather than actual exposure. However, self-reported exposure is widely used as a standard method in surveys on TAPS, which makes our results comparable with other studies.

Second, our TAPS exposure measurement captured ‘things that promote smoking’, which does not necessarily include TAPS alone, but could also include other ways of favourable depiction of smoking, such as through news articles or movies.

Third, the media-specific exposure variable used in this study was based on a simple yes/no question and does not capture frequency of exposure. This needs to be considered when interpreting country differences, as self-reported exposure to TAPS in a country with stronger regulations might reflect a much less frequent actual exposure to TAPS than self-reported exposure in a country with less regulations. The country differences in terms of actual exposure to TAPS might therefore even be larger than found in this study.

Finally, this study is based on cross-sectional samples and thus can only show associations while not allowing any conclusions to be made on the direction of these associations.

On the other hand, the major strength of this study is that the surveys were based on large national probability samples of smokers from eight European countries, using standardized survey questions that assure comparisons across countries.