Introduction
Around 700,000 people die annually in the European Union (EU) due to tobacco use1. Despite recent efforts undertaken to reduce misperceptions of tobacco products, implementation of tobacco control policies is still needed2.
Within the EU countries, around half of smokers use cigarettes with special characteristics such as additive-free or organic, light, menthol flavor, slim, etc. Slim cigarettes are consumed by around 5% of EU smokers1. Slim cigarettes have a diameter of 5 or 6 millimeters and a length that varies from 68–121 mm according to the category (from regular to extra-long)3. Tobacco companies have historically targeted women by promoting slim cigarettes as stylish and feminine3. A qualitative study among young women concluded that slim cigarettes are perceived to be correlated with glamour, cleanliness, and safety4. Similarly, in a Scottish study, slim cigarettes were considered as lovely, pretty, fun, cool, and cute by teenage girls and young women5. A Polish study among young population aged 13–19 years (secondary and high school students) found that that slim cigarettes were perceived to be less harmful6. In light of such misperceptions, supporters (both smokers and non-smokers) of a ban on slim cigarettes argued that slim cigarettes are as harmful as normal cigarettes but that their promotion and design features reinforce smoker’s misconceptions on these products to be less harmful and, therefore, make quitting smoking more difficult. The study of Siu et al. concluded that is a misconception to consider less harmful the super slim cigarette7. Authors report that this kind of tobacco can emission higher levels of toxicants such as phenol, ammonia etc. while the amount of nicotine is similar to other regular cigarettes7. Another study found that levels of cadmium were found 20% and 27% higher on women smoking long and ultra-long cigarette in comparison to normal cigaretts8. From all the above it is clear that the slim cigarette consumption could improve the health status of the population. Exposure to some toxicants such as formaldehyde, ammonia and the phenols increases in super slim cigarettes according to a study conducted in Canada9. Tobacco is a multicomplex problem that is not depending just on the nicotine dependence but also on social and psychological factors. A study in San Francisco shows that banning of flavored tobacco use can decrease the prevalence but not in high rates10. This clearly states that banning is not the only measure possible but comprehensive polices are needed for tobacco control.
The revised EU Tobacco Products Directive (TPD) came into force in May 2016. The TPD aims to improve protection of the health of EU citizens from the harms of tobacco11. The main objective of the TPD provisions was to reduce misperceptions around reduced harm often associated with special characteristics of tobacco products. Such features of cigarettes and roll-your-own tobacco banned under the TPD include characterizing flavors, misleading labels, packs resembling a food or cosmetic product and pack sizes less than 20 cigarettes or 30g of tobacco, but did not include information on banning slim cigarettes. Population support for tobacco control policies is an important determinant of successful policy implementation. However, there is a lack of data on the factors that are associated with harm perceptions and support for a slim cigarettes ban in the EU. Given that the TPD implementation report is being prepared in 2021, it is important to understand support for banning slim cigarettes. The main goal of this study was to examine support for a ban on slim cigarettes among a representative sample of smokers in six EU countries.
Methods
The survey protocols and all materials, including the survey questionnaires, information letter and consent, were cleared for ethics by the ethics research committee at the University of Waterloo (Ontario, Canada, REB#21262), and ethics committees in Germany (Ethikkommission der Medizinischen Fakultät Heidelberg, No. DV-097-160401), Greece (Medical School, University of Athens - Research and Ethics Committee, No. 156023993), Hungary (Medical Research Council – Scientific and Research Committee, No. 46344-2/2017/EKY), Poland (State College of Higher Vocational Education - Committee and Dean of the Department of Health Care and Life Sciences, No. dnia 22.09.2017 r), Romania (Iuliu Hatieganu University of Medicine and Pharmacy, No. 155), and Spain (Clinical Research Ethics Committee of Bellvitge, Hospital Universitari de Bellvitge, Catalonia, PR100/16). Eligible respondents were male or female adult (aged 18+) cigarette smokers who reported smoking at least once a month. After a respondent was selected, an information letter was provided and consent was taken. Informed written consent for participation and publication of data was obtained at the time of data collection, in which participants were informed that, “All personal information you provide is treated as strictly confidential, subject to legal requirements and limitations. It will be held in secure storage and password protected at the University of Waterloo, Canada and only be accessed by this research team. Any identifying information about you will be removed before the data are securely stored, so that your answers cannot be linked back to you. After two years, the survey data, but not your name or other identifying information, will be shared with authorized researchers in other countries, as it will be used to make comparisons of smoking behaviour and attitudes across countries.”
Data came from the 2018 (Wave 2) International Tobacco Control Evaluation Project 6 European Country (ITC 6E) Survey, a cohort study of 6,027 adult smokers (aged 18+ years) who reported having smoked at least 100 cigarettes in their lifetime and smoked at least monthly from Germany, Greece, Hungary, Poland, Romania, and Spain. Respondents were recruited via multi-stage stratified random sampling. Sampling was based on geographic strata created according to Nomenclature of Territorial Units for Statistics (NUTS) regions and degree of urbanization. Respondents consisted of two sample types: (1) re-contacted (cohort) respondents (n=3,195) from Wave 1 of the ITC 6E Survey and (2) new respondents (current smokers) to replenish those who were lost to attrition. Re-contact respondents were followed up regardless of their current smoking status (retention rates ranged from 36% in Hungary to 71% in Germany and Spain, with an average of 53% for the full sample). The replenishment sample (n=2,832) was recruited from newly selected households, and approached in the same manner as Wave 1, with the random-walk procedure beginning at a new (random) starting point. Smokers followed from Wave 1 who had quit smoking by Wave 2 were excluded (n=415) leaving 5,612 current smokers eligible for analysis, the group directly affected by regulations banning the sale of slim cigarettes.
Face-to-face interviews were conducted from February to May 2018. After providing written consent, respondents completed the survey via a computer-assisted personal interview conducted in each country's official language. The ITC 6E Survey is part of the European Commission Horizon-2020 funded study European Regulatory Science on Tobacco: Policy Implementation to Reduce Lung Diseases (EUREST_PLUS-HCO-06-2015), which aimed to evaluate the impact of the EU TPD12. Further details about the study methodology are provided elsewhere13–16.
The primary outcome of this study, support for a ban on slim cigarettes, was assessed with the question: “Would you support or oppose a law that banned all slim cigarettes, that is, those cigarettes that are slimmer in size than regular cigarettes?” (strongly support, support, oppose, strongly oppose, don’t know). The ‘support for a slim ban’ variable was transformed into a binary variable (supports or strongly supports vs. otherwise = oppose/strongly oppose/ don’t know). Demographic measures were sex (male, female), age group (18–24, 25–39, 40–54, 55+), degree of urbanisation (low, intermediate, high)13,14, education (low, moderate, high), and income (low, moderate, high, not reported). In all countries, low education was defined as pre-primary/no education, primary, and lower secondary. Moderate education was defined as upper secondary, post-secondary non-tertiary, and short-cycle tertiary. High education was defined as bachelor or equivalent, master or equivalent, and doctoral or equivalent. Country-specific income thresholds were used to classify household income into low, moderate, or high17. Respondents who refused to provide income information were classified as income not reported. Additional independent measures were smoking behaviours, as defined in Table 1. Smoking status was classified as daily or non-daily (at least once a week or at least once a month). Respondents also reported beliefs about the harm of their own cigarette brand vs other brands and whether they believed that slim cigarettes are less harmful than regular cigarettes (agree/strongly agree that slims are less harmful vs. neither agree nor disagree/disagree/strongly disagree/don’t know). Unless otherwise indicated, respondents who provided “refused” or “don’t know” responses for any of the measures were excluded from the analysis.
Table 1. Support for a ban on slim cigarettes among smokers from six European countries, International Tobacco Control Evaluation Project Six European Country Survey Wave 2 (2018) (N=5577).
| % Supporting Slim Ban* | Odds of Support† | Test |
|---|
| Covariate | (Unwtd Freq) | % | (95% CI) | aOR | (95% CI) | ChiSq | DF | p |
|---|
| Country |
| Germany | (182 / 939) | 19.2 | (14.6, 24.9) | 0.99 | (0.64, 1.52) | 23.95 | 5 | <.001 |
| Greece | (174 / 944) | 18.0 | (13.7, 23.3) | 0.91 | (0.61, 1.37) | | | |
| Hungary | (188 / 942) | 21.7 | (16.7, 27.8) | 1.12 | (0.77, 1.64) | | | |
| Poland | (177 / 947) | 20.0 | (15.5, 25.4) | 1.00 | (0.68, 1.47) | | | |
| Romania | (291 / 916) | 33.8 | (29.2, 38.8) | 2.00 | (1.41, 2.82) | | | |
| Spain | (193 / 889) | 20.2 | (16.9, 24.1) | 1.00 | | | | |
| Urban/rural residence |
| Urban | (389 / 1932) | 21.8 | (18.5, 25.5) | 1.14 | (0.82, 1.57) | 1.19 | 2 | 0.550 |
| Intermediate | (487 / 2134) | 22.7 | (20.0, 25.8) | 1.18 | (0.88, 1.57) | | | |
| Rural | (329 / 1511) | 21.8 | (18.1, 26.1) | 1.00 | | | | |
| Sex |
| Female | (536 / 2715) | 19.5 | (17.4, 21.9) | 0.78 | (0.67, 0.91) | 10.03 | 1 | 0.002 |
| Male | (669 / 2862) | 24.2 | (21.9, 26.6) | 1.00 | | | | |
| Age group |
| 18–24 | (96 / 432) | 24.1 | (19.1, 30.0) | 1.22 | (0.88, 1.71) | 1.94 | 3 | 0.586 |
| 25–39 | (351 / 1533) | 22.9 | (20.2, 25.8) | 1.12 | (0.90, 1.39) | | | |
| 40–54 | (416 / 1940) | 21.7 | (19.2, 24.4) | 1.10 | (0.89, 1.35) | | | |
| 55+ | (342 / 1672) | 21.1 | (18.3, 24.1) | 1.00 | | | | |
| Income |
| Not stated | (260 / 1543) | 17.7 | (14.9, 20.9) | 0.88 | (0.65, 1.19) | 12.23 | 3 | 0.007 |
| Low | (226 / 993) | 22.3 | (18.7, 26.3) | 1.14 | (0.84, 1.54) | | | |
| Moderate | (452 / 1800) | 25.8 | (22.8, 29.1) | 1.34 | (1.05, 1.71) | | | |
| High | (267 / 1241) | 22.4 | (18.9, 26.3) | 1.00 | | | | |
| Education |
| Low | (379 / 1790) | 21.5 | (18.6, 24.8) | 1.08 | (0.79, 1.49) | 0.47 | 2 | 0.790 |
| Moderate | (698 / 3126) | 22.8 | (20.5, 25.3) | 1.10 | (0.83, 1.46) | | | |
| High | (121 / 640) | 19.9 | (16.3, 24.1) | 1.00 | | | | |
| Smoking status |
| Daily smoker | (1135 / 5343) | 21.8 | (19.8, 23.9) | 0.68 | (0.47, 0.97) | 4.46 | 1 | 0.035 |
| Non-daily smoker | (70 / 234) | 29.3 | (23.4, 35.9) | 1.00 | | | | |
| Cigarettes smoked/day |
| ≤ 10 | (485 / 2072) | 23.1 | (20.7, 25.7) | 0.98 | (0.62, 1.54) | 1.60 | 3 | 0.659 |
| 11–20 | (577 / 2796) | 21.4 | (19.1, 23.9) | 0.92 | (0.61, 1.41) | | | |
| 21–30 | (91 / 475) | 22.2 | (17.4, 27.9) | 1.11 | (0.69, 1.80) | | | |
| 31+ | (46 / 214) | 21.7 | (14.8, 29.9) | 1.00 | | | | |
| Flavour smoked |
| Menthol | (44 / 277) | 15.2 | (10.8, 20.5) | 0.55 | (0.36, 0.86) | 8.44 | 3 | 0.038 |
| Other flavour | (20 / 115) | 19.8 | (11.0, 31.6) | 0.79 | (0.40, 1.59) | | | |
| Unflavoured | (974 / 4545) | 22.0 | (20.0, 24.2) | 0.95 | (0.73, 1.23) | | | |
| No usual brand | (167 / 640) | 25.9 | (21.5, 30.9) | 1.00 | | | | |
| Smokes factory-made(FM)/roll-your-own(RYO) |
| FM | (919 / 4165) | 22.7 | (20.6, 24.8) | 1.00 | (0.73, 1.37) | 0.24 | 2 | 0.885 |
| RYO | (204 / 1027) | 20.5 | (16.9, 24.6) | 1.06 | (0.73, 1.52) | | | |
| Both | (79 / 382) | 20.2 | (15.6, 25.9) | 1.00 | | | | |
| Attempts to quit in past year |
Has not tried to quit in
last 12 months | (989 / 4773) | 21.2 | (19.2, 23.3) | 0.91 | (0.72, 1.15) | 0.57 | 1 | 0.452 |
Tried to quit last 12
months | (215 / 798) | 27.8 | (23.9, 32.1) | 1.00 | | | | |
| Plans to quit smoking |
| No plans to quit | (983 / 4966) | 20.1 | (18.2, 22.2) | 0.45 | (0.36, 0.56) | 48.35 | 1 | <.001 |
Plans to quit in next 6
months | (222 / 611) | 38.8 | (34.1, 43.7) | 1.00 | | | | |
| Harm of own cigarette brand vs. other brands |
| Don't know | (14 / 129) | 12.7 | (6.1, 22.4) | 0.58 | (0.29, 1.19) | 2.99 | 3 | 0.394 |
| A little less harmful | (191 / 803) | 25.2 | (21.6, 29.3) | 1.04 | (0.82, 1.30) | | | |
| A little more harmful | (66 / 199) | 31.8 | (24.9, 39.8) | 1.17 | (0.80, 1.72) | | | |
| No different | (932 / 4444) | 21.4 | (19.3, 23.7) | 1.00 | | | | |
| Slim cigarettes are less harmful than regular cigarettes |
| Don't know | (80 / 532) | 16.5 | (12.9, 20.9) | 0.79 | (0.58, 1.08) | 50.06 | 3 | <.001 |
| Strongly agree/Agree | (402 / 1190) | 33.4 | (29.3, 37.6) | 2.14 | (1.69, 2.71) | | | |
| Neither | (264 / 1249) | 22.2 | (18.8, 25.9) | 1.26 | (0.99, 1.60) | | | |
| Strongly disagree/disagree | (457 / 2589) | 18.3 | (16.0, 20.9) | 1.00 | | | | |
Descriptive statistics were used to estimate support for a ban on slim cigarettes by sociodemographic characteristics and smoking behaviors. Wald χ2 tests were used to test for an association between independent variables and support for a ban on slim cigarettes. Multivariable logistic regression was used to estimate adjusted odds ratios (OR) and the corresponding 95% confidence intervals (CI). All statistical analyses were conducted using SAS-callable SUDAAN (Version 11.0.3) to account for the complex sampling design and cross-sectional sampling weights. In addition to standard sociodemographic measures, covariates for regression models were selected because they were used in the construction of sampling weights13,16 or because they were used in previous empirical research on slim cigarettes18,19 or perceptions of the harmfulness of different tobacco products20. “Harm of own cigarette brand vs other brands” was included as a covariate in the model examining support for a slim ban because respondents were not directly asked whether they smoked a slim brand. However, previous research found that people who smoked slim cigarettes were more likely to believe their own brand was less harmful than other brands18,21. Therefore, perceptions about the harm of one’s one brand might be related to support for a ban on slim cigarettes.
Results
Sample characteristics
Of 5592 respondents who smoked on a daily (96%) or non-daily basis (4%), 51% were male, 28% were 25–39 years of age, 35% were 40–54 years of age, and 30% were 55 or older. About 35% of respondents from Germany, Hungary, Poland, and Romania lived in urban areas, 53% of respondents from Spain lived in urban areas, while only 17% of respondents from Greece lived in urban areas. Across all countries, more than half of all respondents (56%) had a moderate education and 12% had a high education; 32% had a moderate household income, 22% had a high income, and 28% chose not to report their income.
Support for a ban on slim cigarettes
Support for a ban on slims varied across the six European countries, with highest support in Romania (33.8%; 95%CI=29.2-38.8), and lowest in Greece (18.0%; 95%CI=13.7-23.3). Smokers from Romana had significantly higher odds (aOR=2.00; 95%CI =1.41-2.82) of supporting a ban on slim cigarettes than smokers from Spain. Those who had a moderate income in comparison to those with high income (aOR=1.34; 95%CI =1.05-1.71) were more likely to support a ban on slim cigarettes. Female smokers (aOR=0.78; 95%CI=0.67-0.91; ref=males), daily smokers (aOR=0.68; 95%CI=0.47-0.97; ref=non-daily smokers), menthol smokers (aOR=0.55; 95%CI=0.36-0.86; ref=no usual brand), and smokers who did not have plans to quit within next six months (aOR=0.45; 95%CI=0.36-0.56; ref=smokers with plans to quit in the next six months) had significantly lower odds of supporting a ban on slim cigarettes. Smokers who agreed or strongly agreed that slim cigarettes are less harmful than regular cigarettes were more likely to support a ban on slim cigarettes compared to those who disagreed or strongly disagreed (OR=2.14, 95%CI=1.69-2.71) (Table 1).
Perceptions that slim cigarettes are less harmful
Perceptions that slim cigarettes are less harmful than regular cigarettes also varied significantly across the six countries, ranging from 8.1% (95%CI=5.8-11.3) among German smokers to over one-quarter among Hungarian (29.1%; 95%CI=24.0-34.8), Polish (28.9%, 95%CI=24.3-33.9), and Romanian (26.8%, 95%CI=23.0-31.1) smokers. Smokers who reported not having plans to quit within the next six months were less likely to report that slim cigarettes are less harmful compared to those with plans to quit (aOR=0.70; 95%CI=0.54-0.91). Lastly, smokers who believed that their own cigarette brand is less harmful than other brands were more likely to report that slims are less harmful compared to those who perceived no difference in harm between their own and others’ brand (aOR=1.84; 95%CI=1.45-2.33) (Table 2).
Table 2. Perceptions that slim cigarettes are less harmful among smokers from six European countries, International Tobacco Control Evaluation Project Six European Country Survey Wave 2 (2018) (N=5592).
| % Slims Less Harmful | Odds Slims Less
Harmful† | Test |
|---|
| Covariate | (Unwtd
Freq) | %* | (95%CI) | aOR | (95%CI) | ChiSq | DF | p |
|---|
| Country |
| Germany | (75 / 939) | 8.1 | (5.8, 11.3) | 0.34 | (0.21, 0.53) | 71.32 | 5 | <.001 |
| Greece | (132 / 951) | 13.1 | (10.0, 17.0) | 0.63 | (0.42, 0.94) | | | |
| Hungary | (263 / 949) | 29.1 | (24.0, 34.8) | 1.77 | (1.22, 2.56) | | | |
| Poland | (290 / 947) | 28.9 | (24.3, 33.9) | 1.48 | (1.04, 2.11) | | | |
| Romania | (252 / 918) | 26.8 | (23.0, 31.1) | 1.23 | (0.86, 1.78) | | | |
| Spain | (180 / 888) | 19.5 | (15.7, 24.0) | 1.00 | | | | |
| Urban/rural residence |
| Urban | (405 / 1943) | 19.6 | (17.1, 22.3) | 0.80 | (0.60, 1.06) | 2.78 | 2 | 0.249 |
| Intermediate | (433 / 2137) | 20.1 | (17.6, 23.0) | 0.92 | (0.69, 1.24) | | | |
| Rural | (354 / 1512) | 24.0 | (20.3, 28.1) | 1.00 | | | | |
| Sex |
| Female | (624 / 2724) | 22.3 | (20.3, 24.5) | 1.17 | (1.00, 1.37) | 4.02 | 1 | 0.045 |
| Male | (568 / 2868) | 19.8 | (17.8, 22.0) | 1.00 | | | | |
| Age group |
| 18–24 | (95 / 432) | 20.5 | (16.2, 25.6) | 0.83 | (0.60, 1.15) | 2.67 | 3 | 0.445 |
| 25–39 | (324 / 1538) | 20.7 | (18.2, 23.4) | 0.87 | (0.71, 1.08) | | | |
| 40–54 | (390 / 1948) | 20.1 | (17.7, 22.7) | 0.86 | (0.70, 1.06) | | | |
| 55+ | (383 / 1674) | 22.4 | (19.9, 25.2) | 1.00 | | | | |
| Income |
| Not stated | (353 / 1555) | 21.5 | (18.5, 24.8) | 0.91 | (0.69, 1.18) | 2.14 | 3 | 0.544 |
| Low | (189 / 995) | 18.8 | (15.6, 22.4) | 1.00 | (0.73, 1.36) | | | |
| Moderate | (389 / 1801) | 21.1 | (18.5, 23.9) | 1.08 | (0.86, 1.36) | | | |
| High | (261 / 1241) | 21.6 | (18.6, 25.0) | 1.00 | | | | |
| Education |
| Low | (358 / 1799) | 20.1 | (17.3, 23.2) | 1.03 | (0.75, 1.42) | 0.69 | 2 | 0.708 |
| Moderate | (703 / 3129) | 21.8 | (19.9, 23.9) | 1.10 | (0.82, 1.46) | | | |
| High | (125 / 645) | 18.8 | (15.1, 23.1) | 1.00 | | | | |
| Smoking status |
| Daily smoker | (1153 / 5356) | 21.1 | (19.4, 23.0) | 1.38 | (0.86, 2.21) | 1.76 | 1 | 0.185 |
| Non-daily smoker | (39 / 236) | 16.4 | (11.2, 22.8) | 1.00 | | | | |
| Cigarettes smoked/day |
| ≤ 10 | (456 / 2085) | 21.9 | (19.7, 24.4) | 1.14 | (0.71, 1.82) | 5.88 | 3 | 0.118 |
| 11–20 | (614 / 2795) | 21.8 | (19.5, 24.2) | 1.14 | (0.72, 1.79) | | | |
| 21–30 | (79 / 477) | 13.0 | (10.0, 16.8) | 0.77 | (0.47, 1.26) | | | |
| 31+ | (34 / 215) | 17.0 | (11.6, 23.8) | 1.00 | | | | |
| Flavour smoked |
| Menthol | (84 / 278) | 26.5 | (20.4, 33.7) | 0.79 | (0.52, 1.18) | 7.17 | 3 | 0.067 |
| Other flavour | (33 / 114) | 28.0 | (15.2, 44.1) | 1.41 | (0.70, 2.82) | | | |
| Unflavoured | (900 / 4562) | 19.7 | (17.9, 21.6) | 0.75 | (0.58, 0.98) | | | |
| No usual brand | (175 / 638) | 25.8 | (21.5, 30.7) | 1.00 | | | | |
| Smokes factory-made/roll-your-own |
| FM | (942 / 4175) | 21.8 | (20.1, 23.7) | 1.25 | (0.85, 1.83) | 7.86 | 2 | 0.020 |
| RYO | (180 / 1032) | 18.2 | (14.8, 22.2) | 0.90 | (0.58, 1.41) | | | |
| Both | (68 / 382) | 18.1 | (13.5, 23.9) | 1.00 | | | | |
| Attempts to quit in past year |
Has not tried to quit in
last 12 months | (1013 / 4782) | 21.0 | (19.2, 23.0) | 1.13 | (0.89, 1.44) | 1.03 | 1 | 0.310 |
Tried to quit last 12
months | (178 / 804) | 20.6 | (17.6, 23.9) | 1.00 | | | | |
| Plans to quit smoking |
| No plans to quit | (1012 / 4974) | 20.0 | (18.2, 21.9) | 0.70 | (0.54, 0.91) | 7.23 | 1 | 0.007 |
Plans to quit in next 6
months | (180 / 615) | 28.8 | (24.5, 33.5) | 1.00 | | | | |
| Harm of own cigarette brand vs. other brands |
| Don't know | (30 / 133) | 21.8 | (13.8, 31.9) | 0.86 | (0.50, 1.48) | 27.57 | 3 | <.001 |
| A little less harmful | (240 / 804) | 30.6 | (26.3, 35.2) | 1.84 | (1.45, 2.33) | | | |
| A little more harmful | (63 / 199) | 28.9 | (22.0, 36.9) | 1.37 | (0.92, 2.04) | | | |
| No different | (858 / 4454) | 18.9 | (17.1, 20.8) | 1.00 | | | | |
Discussion
This study has found that approximately 20% of smokers supported a ban on slim cigarettes. Country, gender, daily/non-daily smoking status, and quitting plans were key correlates of supporting a ban on slim cigarettes. Women were less likely to support a ban on slims than men, which is not surprising given that slim cigarettes have historically been specifically marketed to females by the tobacco industry22. The fact that slim cigarettes are associated with perceptions of glamour, cleanliness, and safety4, which are mainly characteristics of femininity, may be the reason5,23. According to the 2017 Special Eurobarometer 458, women in the EU are more likely than men to smoke slim cigarettes (10% vs 2%) and find slim cigarettes attractive (e.g., feminine, elegant) (20% vs. 15%)1. Non-daily smokers and those smokers planning to quit were more likely to support a ban of slim cigarettes. This is similar to a study that found that menthol smokers who had plans to quit were more likely to support a menthol ban in comparison to those with no plans to quit24.
We found considerable country differences in reporting that slim cigarettes are less harmful, with misperceptions significantly higher in Hungary, Poland, and Romania (>25%) than in Germany (8%). Variation may be partly explained by differences in popularity of slim cigarettes. According to the 2017 Eurobarometer, use of slim cigarettes among the observed countries also varied (1% in Spain, 2% in Germany, 5% in Hungary, 6% in Greece, 6% in Romania, and 16% in Poland). Given that slim cigarettes are as harmful as other cigarettes, the high levels of misperceptions that slim cigarettes are less harmful in our sample of EU smokers is concerning. However, we found some counter-intuitive results that smokers who agreed (rather than disagreed) that slim cigarettes are less harmful were more likely to a support a ban on slim cigarettes. While the existing literature is limited, other studies have found harm perceptions and social norms to be associated with support for tobacco control policies and related to the choice of tobacco product used25–27.
While the initial draft TPD included a ban on slim cigarettes, the final version lacked such a ban. This was proposed to be due to the strong tobacco industry lobbying to dilute the regulation28. As previous research has shown that smokers perceptions are impacted by cigarette pack and stick design, and as other provisions included in the TPD were aimed at reducing misperceptions about reduced harm, results from this study further illustrate how banning slim cigarettes would support this goal29,30. While this study uses data from large representative samples of smokers from six EU Member States, there are some limitations to be considered. First, the survey did not directly ask respondents if they smoke slim cigarettes, which precluded analysis of this variable as a possible covariate. Second, the cross-sectional nature of the analysis does not allow for any causal conclusions. Moreover, due to the nature of the study some possible bias can be such as social desirability bias and/or societal impact. Lastly, our study relies on self-report data, which might be subject to information bias, leading to misclassification31. The statistical approach used for analysis of the ITC 6 European Country (ITC 6E) Survey data is considered standard for the analysis of population health survey data employing complex sampling designs using unequal weighting and clustering. Statistical approaches that ignore the complex design will produce variances and probability levels of hypothesis tests that are too small, potentially leading to erroneous conclusions31. Therefore, it was essential to account for the sampling design and sampling weights in the analysis of the ITC 6E data. The statistical procedures implemented in SUDAAN provide the ability to correctly compute variances and hypothesis tests under complex sampling when only minimal design information is employed31. However, the approximations used are generally considered to be conservative, so that estimated variances will be slightly larger31; thus, p-values reported here may be somewhat conservative.
In conclusion, our results indicate that among a sample of smokers from six EU Member States, the percentage of smokers who support a slims ban is low, while misperceptions that slim cigarettes are less harmful is high, particularly among countries where slim cigarette use is more prevalent. Findings of the current study provide evidence that can be used when discussing a ban on slim cigarette in order to further mitigate misperceptions that certain tobacco products are less harmful than others. The European Commission should consider this evidence in the next revision of the TPD. Future activities should focus on the strategies for addressing misperceptions about the harm of slim cigarette. Moreover, it is important policy makers to assess the effectiveness of different tobacco control policies and to better implement them in different EU settings. Policymakers should focus also on prevention activities and health promotion campaigns regarding slim cigarettes.
Funding
The ITC EUREST-PLUS Project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 681109 (CIV) and the University of Waterloo (GTF). Additional support was provided to the University of Waterloo by the Canadian Institutes of Health Research (FDN-148477). GTF was supported by a Senior Investigator Grant from the Ontario Institute for Cancer Research. EF is partly supported by the Ministry of Universities and Research, Government of Catalonia (2017SGR319). UM is supported by the Marga and Walter Boll Foundation (Kerpen, Germany).
Data availability
In each country participating in the international Tobacco Control Policy Evaluation (ITC) Project, the data are jointly owned by the lead researcher(s) in that country and the ITC Project at the University of Waterloo. Data from the ITC Project are available to approved researchers 2 years after the date of issuance of cleaned data sets by the ITC Data Management Centre. Researchers interested in using ITC data are required to apply for approval by submitting an International Tobacco Control Data Repository (ITCDR) request application and subsequently to sign an ITCDR Data Usage Agreement. The criteria for data usage approval and the contents of the Data Usage Agreement are described online (http://www.itcproject.org).
Acknowledgements
*EUREST-PLUS CONSORTIUM MEMBERS:
European Network on Smoking and Tobacco Prevention (ENSP), Belgium: Constantine I. Vardavas, Andrea Glahn, Christina N. Kyriakos, Dominick Nguyen, Katerina Nikitara, Cornel Radu-Loghin, Polina Starchenko, Enkeleint A. Mechili. University of Crete (UOC), Greece: Aristidis Tsatsakis, Charis Girvalaki, Chryssi Igoumenaki, Sophia Papadakis, Aikaterini Papathanasaki, Manolis Tzatzarakis, Alexander I. Vardavas. Kantar Public, Belgium: Nicolas Bécuwe, Lavinia Deaconu, Sophie Goudet, Christopher Hanley, Oscar Rivière. Smoking or Health Hungarian Foundation (SHHF), Hungary: Tibor Demjén, Judit Kiss, Anna Piroska Kovacs. Catalan Institute of Oncology (ICO) and Bellvitge Biomedical Research Institute (IDIBELL), Spain: Esteve Fernández, Yolanda Castellano, Marcela Fu, Sarah O. Nogueira, Olena Tigova. Kings College London (KCL), United Kingdom: Ann McNeill, Katherine East, Sara C. Hitchman, Máirtín McDermott, Sarah Aleyan. German Cancer Research Center (DKFZ), Germany: Ute Mons, Sarah Kahnert. National and Kapodistrian University of Athens (UoA), Greece: Yannis Tountas, Panagiotis Behrakis, Filippos T. Filippidis, Christina Gratziou, Paraskevi Katsaounou, Theodosia Peleki, Ioanna Petroulia, Chara Tzavara. AerPur Romania, Romania: Antigona C. Trofor, Marius Eremia, Lucia Lotrean, Florin Mihaltan. European Respiratory Society (ERS), Switzerland: Gernot Rohde, Tamaki Asano, Claudia Cichon, Amy Far, Céline Genton, Melanie Jessner, LinneaHedman, ChristerJanson, Ann Lindberg, Beth Maguire, Sofia Ravara, Valérie Vaccaro, Brian Ward. Maastricht University, the Netherlands: Marc Willemsen, Hein de Vries, Karin Hummel, Gera E. Nagelhout. Health Promotion Foundation (HPF), Poland: Witold A. Zatoński, Aleksandra Herbeć, Kinga Janik - Koncewicz, Krzysztof Przewoźniak, Mateusz Zatoński. University of Waterloo (UW), Canada: Geoffrey T. Fong, Thomas K. Agar, Pete Driezen, Shannon Gravely, Anne C. K. Quah, Mary E. Thompson.
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