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BACKGROUND: As of May 2016, pictorial health warnings (PHWs) showing the harms of smoking were implemented in the European Union. After one year they had to be fully implemented. We studied changes in awareness of the health risks of smoking after implementation of PHWs among smokers from the Netherlands, whether the trend before the implementation changed after the implementation, and whether there were differences between subgroups. METHODS: We used survey data from six yearly waves of the International Tobacco Control (ITC) Netherlands Survey from 2012 to 2017. The number of participating smokers ranged between 1236 and 1604 per wave. Data were analyzed using Generalized Estimating Equations (GEE) analyses. RESULTS: Indicators of awareness of the health risks of smoking that did not change between 2015 and 2017 were perceived susceptibility (β = 0.043, p = 0.059) and perceived severity (β = − 0.006, p = 0.679) regarding lung problems. Perceived susceptibility, however, was more pronounced between 2015 and 2017 than between 2012 and 2015(p value of interaction: p = 0.044). Noticing information about the dangers of smoking (β = 0.119, p < 0.001) and knowledge about the health risks of smoking (β = 0.184, p < 0.001) increased between 2015 and 2017. These increases were both more pronounced when compared to 2012–2015 (p values of interactions: p = 0.002 and p < 0.001 respectively). Compared to high educated smokers, low educated smokers (β = − 1.137, p < 0.001) and moderate educated smokers (β = − 0.894, p < 0.001) were less knowledgeable about the health risks of smoking in 2016 and 2017. CONCLUSIONS: Introducing PHWs coincided with an increase in smokers' knowledge about the health risks of smoking. Dutch tobacco control policy and campaigns should focus on improving Dutch smokers' awareness of the health risks of smoking even more, especially among low educated smokers.

Background As of May 2016, pictorial health warnings (PHWs) showing the harms of smoking were implemented in the European Union. After one year they had to be fully implemented. We studied changes in awareness of the health risks of smoking after implementation of PHWs among smokers from the Netherlands, whether the trend before the implementation changed after the implementation, and whether there were differences between subgroups. Methods We used survey data from six yearly waves of the International Tobacco Control (ITC) Netherlands Survey from 2012 to 2017. The number of participating smokers ranged between 1236 and 1604 per wave. Data were analyzed using Generalized Estimating Equations (GEE) analyses. Results Indicators of awareness of the health risks of smoking that did not change between 2015 and 2017 were perceived susceptibility (beta = 0.043, p = 0.059) and perceived severity (beta = - 0.006, p = 0.679) regarding lung problems. Perceived susceptibility, however, was more pronounced between 2015 and 2017 than between 2012 and 2015(p value of interaction: p = 0.044). Noticing information about the dangers of smoking (beta = 0.119, p <0.001) and knowledge about the health risks of smoking (beta = 0.184, p <0.001) increased between 2015 and 2017. These increases were both more pronounced when compared to 2012-2015 (p values of interactions: p = 0.002 and p <0.001 respectively). Compared to high educated smokers, low educated smokers (beta = - 1.137, p <0.001) and moderate educated smokers (beta = - 0.894, p <0.001) were less knowledgeable about the health risks of smoking in 2016 and 2017. Conclusions Introducing PHWs coincided with an increase in smokers' knowledge about the health risks of smoking. Dutch tobacco control policy and campaigns should focus on improving Dutch smokers' awareness of the health risks of smoking even more, especially among low educated smokers.

This study examined to what extent e-cigarette users noticed the European Union's new legislation regarding e-cigarettes, and whether this may have influenced perceptions regarding addictiveness and toxicity. Data were obtained from yearly surveys (2015-2017) of the International Tobacco Control (ITC) Netherlands Survey. Descriptive statistics and Generalized Estimating Equations were applied. About a third of the e-cigarette users noticed the text warning (28%) and the leaflet (32%). When compared to tobacco-only smokers, e-cigarette users showed greater increases in perceptions regarding addictiveness (beta = 0.457, p = 0.045 vs. beta = 0.135, p <0.001) and toxicity (beta = 0.246, p = 0.055 vs. beta = 0.071, p = 0.010). In conclusion, the new legislation's noticeability should be increased.

This study examined to what extent e-cigarette users noticed the European Union's new legislation regarding e-cigarettes, and whether this may have influenced perceptions regarding addictiveness and toxicity. Data were obtained from yearly surveys (2015–2017) of the International Tobacco Control (ITC) Netherlands Survey. Descriptive statistics and Generalized Estimating Equations were applied. About a third of the e-cigarette users noticed the text warning (28%) and the leaflet (32%). When compared to tobacco-only smokers, e-cigarette users showed greater increases in perceptions regarding addictiveness (β = 0.457, p = 0.045 vs. β = 0.135, p < 0.001) and toxicity (β = 0.246, p = 0.055 vs. β = 0.071, p = 0.010). In conclusion, the new legislation's noticeability should be increased.

BACKGROUND: Our study evaluated the short-term impact of introducing European Union's tobacco pictorial health warnings (PHWs). METHODS: Longitudinal data were collected at two time-points from adult smokers, participating in the International Tobacco Control (ITC) surveys, conducted in the Netherlands, Australia, Canada, the United Kingdom and the United States. In the Netherlands, textual health warnings (THWs) were replaced by PHWs between both time-points. Health warning policies did not change in the other countries. Data from continuing smokers were used (N=3,487) and analyzed using Generalized Estimating Equations. RESULTS: Between both time-points, only Dutch smokers showed increases in noticing health warnings (β=0.712, p<0.001), self-reports of health warnings leading to a cognitive response such as thinking about smoking health-risks (SHRs) (OR = 1.834, p<0.001), knowledge about SHRs (β=0.369, p<0.001), and avoiding health warnings (OR=9.869, p<0.001). However, Dutch smokers showed no changes in attitude towards smoking (β=0.035, p=0.518), intention to quit smoking (OR=0.791, p=0.157), self-efficacy to quit smoking (β=−0.072, p=0.286), or reporting that health warnings helped them to resist having a cigarette (OR=1.091, p=0.714). CONCLUSIONS: Results suggest that introducing the European PHWs was effective in provoking changes closely related to health warnings, but there was no direct impact on variables more closely related to smoking cessation.