Smoking and other forms of tobacco consumption are considered the single most important cause of preventable morbidity and premature mortality worldwide. Efforts to reduce the devastation of tobacco-related deaths and illness in the EU consist of the Tobacco Products Directive (TPD), and the ongoing implementation of the WHO Framework Convention on Tobacco Control (FCTC).
Over a period of three years, the research team which includes experts from different scientific disciplines based in 10 European countries and in Canada will work together to address 4 specific objectives which are all intimately linked to tackling tobacco use, which is fundamental to reducing the impact of chronic non-communicable diseases.
The main objective of EUREST-PLUS is to monitor and evaluate the impact of the TPD within the context of FCTC ratification at a European level. These articles in the TPD address issues of tobacco product ingredients, additives, reporting, packaging, labelling, illicit trade, cross border sales, and e-cigarettes.
Furthermore, the FCTC articles also indicate aspects of avoidance of secondhand smoke (SHS) exposure, tobacco taxation, advertising and issues of tobacco dependence and cessation. To address the areas covered by these articles we will perform four central tasks:
Create and follow up a cohort study of smokers in 6 EU MS;
1. Perform cross-country analyses:
- across the 6 participating countries;
- incorporating the other 3 International Tobacco Control (ITC) countries within the EU; and
- across the broader set of 16 other countries of the ITC Project outside the EU;
2. Monitor progress in FCTC implementation through secondary analyses of Eurobarometer surveys;
3. Evaluate changes in e-cigarette product design and its linkages with population use indexes.
Thus our main objective is addressed through five integrated research-oriented work packages in EUREST-PLUS.
Our 4 specific objectives hence are as follows:
- To evaluate the psychosocial and behavioral impact of TPD implementation and FCTC implementation, through the creation of a cohort of adult smokers in 6 EU MS (Germany, Greece, Hungary, Poland, Romania, Spain; total n=6000) in a pre- vs. post-TPD study design (WP2-WP3), Moreover, these evaluation studies of the impact of the TPD and FCTC will be conducted with respect to vulnerable populations, including low-income/socio-economic status (SES) groups and those smokers with respiratory co-morbidities (and/or those with pre-morbid symptomatology). Another important topic that will be addressed include e-cigarettes, addressing basic issues of transition rates from cigarettes to e-cigarettes vs. dual use vs. reversion back to cigarettes vs. quitting all nicotine products. Studies that examine e-cigarettes will be linked to WP6, which focuses on product testing of various design features of e-cigarettes systematically procured in those same 6 countries where the cohort study will be conducted.
- To assess support for TPD implementation through secondary dataset analyses of the 2015 Special Eurobarometer on Tobacco Survey (SETS), a cross-sectional survey performed among 27,000 adults in all 28 EU MS, before the TPD is implemented (WP5) and to monitor progress in FCTC implementation in the EU over the past years through trend analyses on the merged datasets of the 2009, 2012 and 2015 SETS datasets (n=80,000), and other SETS that may become available during the duration of the project with a special focus on vulnerable populations (youth, minorities, unemployed, etc.) (WP5)
- To document changes in e-cigarette product parameters (technical design, labelling/packaging and chemical composition) following TPD implementation of Article 20 of the TPD. (WP6)
- To enhance innovative joint research collaborations on chronic, non-communicable diseases (NCDs) in low- and middle-income countries (LMICs) and in vulnerable populations in high-income countries (HICs), a key priority of the Global Alliance for Chronic Disease (GACD) outlined in the call. We will specifically address these cross-country analyses through the pooling and comparisons across both other EU countries of the ITC Project (UK, France, Netherlands), and other non-EU countries from LMICs and HICs from the global ITC Project (including key countries of comparison such as Australia, Canada, New Zealand, United States, China). (WP4)
The activities of the five research-oriented work packages in fulfilling these objectives will be facilitated by an administrative work package (WP1), and by a specific work package dedicated to planning and implementing targeted dissemination activities to maximize the impact of research findings of the EUREST-PLUS Project (WP7).
New knowledge produced will be disseminated through multiple avenues targeted at the general public, the media, researchers, patient networks and policy makers.
EUREST PLUS project is registered at clinicaltrials.gov (identifier: NCT02773836).
EUREST-PLUS Project Structure
EUREST-PLUS Work Packages
EUREST-PLUS is a 36-month project that consists of an integrated sequence of seven (7) work packages presented below:
This work package coordinates the overall management of the project including its financial management. It supports communication activities including reporting to the European Commission, and provides scientific support to the work of individual work packages.
Work package 2 conducts the first wave of a prospective longitudinal cohort study as part of the International Tobacco Control (ITC) Policy Evaluation Project. The primary objective of WP2 is to evaluate the psychosocial and behavioral impact of the pre-implementation phase of the TPD and other tobacco control measures of the FCTC. A cohort of 1,000 adult (≥18 years) smokers will be recruited by multistage cluster sampling in each of 6 EU countries: Germany, Greece, Hungary, Poland, Romania and Spain. These Wave 1 analyses will result in a detailed picture of the current status of the TPD and FCTC policy domains, which in some countries will represent the first such data on the impact (or lack of impact) of current policy domains.
This work package conducts the Wave 2 ITC 6-European Country Survey, which is the follow-up survey to WP2. The survey is part of the International Tobacco Control (ITC) Policy Evaluation Project, and similarly aims to evaluate the psychosocial and behavioural impacts of post-implementation phase of the TPD and other tobacco control measures of the FCTC. The survey will be conducted approximately 18 months from the directive’s official implementation at national level (22 May 2016). Wave 2 will be conducted in each of 6 the participating EU Member States, i.e., Germany, Greece, Hungary, Poland, Romania and Spain.
Work package 4 conducts a cross-sectional and longitudinal cross-country comparisons, examining differences and similarities between before the implementation of the EU TPD and longitudinal comparisons of any differences in changes after the implementation of the EU TPD. The Wave 1 and Wave 2 cross-sectional and longitudinal data will also be compared with (1) data collected from the 6 countries on this project (Germany, Greece, Hungary, Poland, Romania, and Spain), (2) data collected from other EU countries involved in the International Tobacco Control Policy Evaluation Project (France, The Netherlands, and the United Kingdom) and (3) data collected from selected non-EU counties from the ITC Project (e.g., Australia, Canada, Kenya, Thailand, United States, Uruguay, Zambia). It focuses on whether there are differences or commonalities in the impact of the EU TPD and the FCTC policies amongst European States, as well as states not beholden to the TPD. It measures whether there are any differences in implementation and enforcement of the EU TPD and FCTC policies across all 28 ITC Project countries that may explain any differences in impact.
This work package assesses the support for TPD implementation and FCTC policies across 28 EU Member States in 2015 through a secondary analysis of the 2015-Special Eurobarometer Tobacco Survey which aims to evaluate the associations between socio-demographic and personal parameters and specific policy determinants e.g. price and tax measures, protection from exposure to SHS (second hand smoke); tobacco advertising; tobacco dependence and cessation; tobacco packaging and labelling; tobacco product design characteristics; e-cigarettes.
Work package 6 assesses e-cigarette product compliance to the TPD. This is done by investigating e-cigarette labelling/packaging practices, the technical design/safety features and chemical composition in 9 MS before the implementation of Article 20 of the TPD, and compares and re-evaluates these parameters after the adoption of the TPD and thus assesses their compliance.
This last work package maximizes the impact of the project by widely disseminating policy recommendations and project outcomes via the project website, scientific manuscripts, conference abstracts, policy reports and at stakeholder meetings, with the ultimate aim to create sustainable partnerships beyond the project lifetime.