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

Introduction The European Union (EU) Tobacco Product Directive (TPD), which went into effect in 2016, regulates tobacco product content and packaging design, aimed at decreasing misperceptions around reduced harmfulness and addiction potential. The aim of the current study was to examine the extent to which smokers noticed TPD-related changes to tobacco product design and correlates associated with noticing these changes. Methods Data came from Wave 2 of the ITC 6 European Country Survey as part of the EUREST-PLUS project, among a nationally representative sample of adult smokers from six EU countries in 2018 (n=6037). Bivariate and logistic regression analyses of weighted data were conducted using SAS-callable SUDAAN. Results 56.3% of smokers noticed any TPD-related design change to cigarettes or roll-your-own tobacco. Over one-quarter of smokers noticed changes to health warnings (30.0%), standardized opening (27.7%), minimum unit size (27.9%), and the removal of tar, nicotine, and carbon monoxide (TNCO) information (26.7%) on packaging. Fewer smokers noticed packages no longer resembling food/cosmetic products (18.7%) and the removal of characterising flavours (12.8%). Noticing any change was significantly associated with older age (compared to ages 18-24), higher education, higher income, being a daily smoker, and usually smoking a menthol or other flavoured tobacco product. Awareness of changes varied significantly across countries for all measures. Compared to Spanish smokers, Greek smokers had 14.8 greater odds of noticing the removal of TNCO information (28.8% vs 4.9%, OR=14.8, p<0.001). Romanian smokers had greater odds of noticing packages no longer resembling food/cosmetic products (28.8%) as compared to respondents from Spain (4.1%, OR=10.71, p<0.001). Noticing the removal of characterising flavours was more likely among respondents from Hungary (17.2%, OR=5.25), Romania (18.1%, OR=4.66), and Poland (16.1%, OR=4.08) as compared to smokers from Spain (4.2%, p<0.001). Conclusions Findings indicate that TPD regulatory changes to tobacco product content and packaging design are being noticed by over half of smokers, but this varied across countries and populations.