Abstract
Background
The prevalence of roll-your-own tobacco (RYO) in Europe has been increasing. The aim of this study was to investigate transitions between factory-made (FM) cigarettes and RYO in a longitudinal sample of European smokers, and their perceptions of relative harmfulness and knowledge of health effects.
Methods
We used data collected from the EUREST-PLUS ITC 6 European Country (6E) Surveys in 2016 (n = 6011 smokers) and in 2018 (n = 6027) in Germany, Greece, Hungary, Poland, Romania and Spain. A total of 3195 cohort respondents were interviewed in both years. Use of RYO and FM, knowledge of health effects of smoking as well as perceptions about RYO were assessed. We used logistic regression models to explore sociodemographic correlates of transitions from one product to the other, of perceptions and knowledge related to smoking health effects.
Results
Approximately 7.4% of exclusive FM smokers transitioned to RYO and 29.5% of exclusive RYO smokers transitioned to FM cigarettes from 2016 to 2018. RYO use in 2018 was more frequent among smokers of low education and income, but none of these factors were associated with transitions. Most RYO smokers perceived RYO as cheaper than FM and 21.7% of them considered RYO to be less harmful than FM. Knowledge of the health effects of smoking was not associated with type of product smoked.
Conclusions
RYO is popular among European smokers; its lower cost seems to be a major factor for RYO users; reasons for transitions to and from RYO are less clear and need to be further investigated.
Introduction
Combustible tobacco is the main form of tobacco used globally,1 with its health consequences well-established and well-known even among smokers, at least in Europe.2 Factory-made (FM) cigarettes has been the dominant product in European and global tobacco markets with a market share of more than 90%.1 In recent years, European tobacco markets have changed with the introduction of novel tobacco products, such as electronic cigarettes and heated tobacco products and the rise in consumption of more traditional tobacco products, such as waterpipes and roll-your-own tobacco (RYO) whose popularity has increased.3–8 This has led to an increase in dual and polytobacco use in Europe, which may complicate attempts to quit and undermine the effectiveness of tobacco control measures.9
The case of RYO is particularly interesting; its rise in popularity is neither the result of a technological innovation nor a component of a harm reduction approach, although RYO is often falsely perceived as less harmful compared with FM by those who use it.10–12 Despite the fact that no one in the health community recommends use of RYO, such beliefs and perceptions may be associated with RYO use,12 especially in Europe where FM cigarettes have been the main target of tobacco control policies and information campaigns for decades. RYO has been subject to lower taxation in Europe compared with FM5,10,13 and, only since the implementation of the recent Tobacco Products Directive (TPD) across the European Union (EU) in 2016,14 RYO products have to comply to the same regulations as FM regarding packaging, labeling and compulsory health warnings, which might impact RYO users’ knowledge and perceptions.
The most common explanation for the increasing prevalence of RYO use is the price differential between FM and RYO; RYO are generally cheaper and deemed more affordable, which may be important for price-sensitive smokers. In almost all EU member states, the cost of RYO is lower than the cheapest FM.15 However, studies investigating the role of price, affordability and price differential in switching from FM to RYO are few and have produced conflicting results, with some suggesting that price differences between FM and RYO may drive increases in RYO use with others failing to find evidence of such an effect.7,16,17 Other factors, such as potential differences in knowledge of the health effects of smoking and perceptions of RYO may also influence decisions to switch. RYO users also cite efforts to reduce the number of cigarettes smoked or social and cultural factors as reasons for using this form of tobacco rather than FM, although these perceptions may not be backed by evidence.7,18–20 Another potential factor in the choice of tobacco products is taste21 which may vary between FM and RYO.22 However, these elements have not been researched much in Europe. The picture is complicated further by the fact that concurrent use of FM and RYO is frequent;23 most studies use cross-sectional study designs, which limits the researchers’ ability to investigate switching from FM to RYO and vice versa, as well as the factors that may be associated with such changes in smoking behavior.
The main aim of this study was to investigate switching from FM to RYO and vice versa in a longitudinal sample of smokers in six European countries. We also explored perceptions about RYO and beliefs regarding the health consequences of smoking and whether these were associated with the type of combustible tobacco product used.
Methods
Data source
Data were collected as part of the International Tobacco Control Policy Evaluation Six European Country (ITC 6E) Project. The ITC 6E is a two-wave European-focused cohort study aiming to measure the direct and indirect impacts of the EU TPD and policies of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) and was part of the ‘European Regulatory Science on Tobacco: Policy Implementation to Reduce Lung Disease (EUREST PLUS)’ project. Data were collected from June to September 2016 (wave 1) and February to May 2018 (wave 2) in Germany, Greece, Hungary, Poland, Romania and Spain.
Sampling was based on geographic strata created according to Nomenclature of Territorial Units for Statistics (NUTS) regions and degree of urbanization. Clusters proportional to population size were then selected by stratified random sampling. Within each cluster, up to two smokers (one female and one male) were interviewed face-to-face in each dwelling selected with the random walk method. At wave 2, we attempted to re-contact and interview all of the wave 1 respondents who had agreed to be re-contacted. Dropouts (ranging from 30 to 64%) were replaced by adult smokers recruited wherever possible by the same method as in wave 1 and in the same cluster, from dwellings not approached in wave 1. Among the 6011 individuals interviewed across the six countries in wave 1, 3195 responded in wave 2. Including respondents recruited in wave 2 for the first time, a total of 6027 individuals were interviewed in 2018. Cross-sectional survey weights have been constructed for each of the survey waves, and longitudinal survey weights have been constructed for the two waves of data being examined in each country. More details regarding the sampling methodology and data collection have been described elsewhere.23,24
Measures
By design, wave 1 included only smokers, defined as individuals who responded that they smoke FM or RYO cigarettes at least monthly. However, wave 2 also included a number of individuals who were smokers in wave 1 but had quit by the time they were re-interviewed in wave 2. In both waves, participants were asked ‘Do you smoke factory-made cigarettes, roll-your-own cigarettes, or both?’. Responses included FM cigarettes only; RYO only and both. Those who responded ‘RYO only’ or ‘both’ were classified as RYO users. Smokers who used FM cigarettes only in wave 1 but reported use of RYO in wave 2, either exclusively or with FM cigarettes, were considered to have made a transition to RYO between the two waves. Similarly, exclusive RYO users in wave 1 who reported some or exclusive use of FM cigarettes in wave 2 were considered to have transitioned to FM cigarettes. Those who reported concurrent use of RYO and FM are referred to as dual users.
In wave 2, RYO users were asked ‘Which of the following are important reasons for your smoking roll-your-own cigarettes?’. Participants could give one or more of the responses ‘they are less expensive’; ‘they taste better’; ‘they are not as bad for your health’ and ‘they reduce the amount you smoke’. The abovementioned question was not asked to respondents who were not using RYO at the time. All smokers were asked to respond either ‘Yes’ or ‘No’ to whether they believed that smoking (any type of tobacco product) causes (in smokers) heart disease, heart attack, stroke, impotence in male smokers, blindness, lung cancer, mouth cancer, throat cancer, chronic obstructive pulmonary disease (COPD), bronchitis and tuberculosis.
Data were also collected on degree of urbanization (urban, intermediate, rural), sex (female, male), age group (18–24, 25–39, 40–54, 55+ years), marital status (not married, married/common-law, widowed, divorced), income (income not reported, low income, moderate income, high income), education [low education (primary, lower pre-vocational secondary, middle pre-vocational secondary); moderate education (secondary vocational, senior general secondary and pre-university); high education (higher professional and university bachelor, university master)] and the number of FM or RYO cigarettes smoked every day (≤10; 11–20; 21–30; ≥31).23
Statistical analysis
The statistical analysis was conducted using SAS-callable SUDAAN (Version 11.0.1) to account for the complex sampling design and longitudinal sampling weights. Descriptive statistics are shown as weighted percentages with 95% confidence intervals (CI). The longitudinal sample was analyzed to describe transitions from FM cigarettes to RYO and vice versa. A logistic regression model was estimated among participants who were exclusive FM cigarette users in wave 1 and were re-interviewed in wave 2 to explore correlates of the transition from FM cigarettes to RYO. Independent variables were country, age, sex, degree of urbanization, marital status, income, education and number of cigarettes smoked per day. A similar model was estimated among exclusive RYO users of wave 1 to assess correlates of transition to FM cigarettes. Logistic regression results are presented as odds ratios (OR) with 95% CI.
A logistic regression model was fitted among participants of the most recent wave (wave 2) to assess the association between using RYO tobacco (dependent variable) and various independent variables including country, age, sex, degree of urbanization, marital status, income, education and number of cigarettes smoked per day.
We also analyzed data on smokers’ perceptions about RYO tobacco and on knowledge of the health effects of smoking by country and product used in wave 2 only. Proportions within countries were compared with chi-square tests. The Cochran–Mantel–Haenszel test was used to test the association between product used and perception/health belief controlling for country. Additional cross-sectional multivariable logistic regression models were fitted to assess potential associations of type of tobacco product used (FM only, RYO only or dual use) with each of the perceptions about RYO (only among RYO users in wave 2) and health beliefs (among all smokers in wave 2). Models controlled for socio-demographic factors such as age, sex, degree of urbanization, marital status, income, education, country of residence and number of cigarettes smoked per day.
Ethics review
For the ITC 6E Survey, study procedures and material including the survey questionnaire were approved by the ethics research committee at the University of Waterloo (Ontario, Canada), and ethics committees in Germany (Ethikkommission der Medizinischen Fakultät Heidelberg), in Greece (Medical School, University of Athens—Research and Ethics Committee), in Hungary (Medical Research Council—Scientific and Research Committee), in Poland (State College of Higher Vocational Education—Committee and Dean of the Department of Health Care and Life Sciences), in Romania (Iuliu Hatieganu University of Medicine and Pharmacy) and in Spain (Clinical Research Ethics Committee of Bellvitge, Hospital Universitari de Bellvitge, Catalonia).
Results
Sample characteristics
Sample characteristics of the cross-sectional and longitudinal samples, as well as their smoking behaviors are shown in Supplementary tables S1–S4.
Transitions in type of cigarettes smoked
In the total longitudinal sample across all six countries, 13.9% of exclusive FM cigarettes users, 10.3% of exclusive RYO users and 7.2% of dual users quit between wave 1 and wave 2. Among exclusive FM cigarette users in wave 1, 4.4% (95% CI: 3.5%, 5.5%) reported exclusive RYO use and 3.0% (2.2%, 4.1%) dual use in wave 2. Among exclusive RYO users in wave 1, 18.2% (13.7%, 23.8%) reported exclusive FM cigarette use and 11.3% (7.7%, 16.5%) dual use in wave 2, although there was considerable variation between countries (table 1). In total, 5.6% of the total longitudinal sample transitioned from exclusive FM use to RYO or dual use between the two waves, while 3.2% of the total longitudinal sample transitioned from exclusive RYO use to FM or dual use in the same period.
Table 1.
Transitions between tobacco products from wave 1 to wave 2
| FM/RYO status in wave 2 |
||||||||
|---|---|---|---|---|---|---|---|---|
| FM only |
RYO only |
Dual use |
Quit smoking |
|||||
| FM/RYO status in wave 1 | n | % (95% CI) | n | % (95% CI) | n | % (95% CI) | n | % (95% CI) |
| Overall | ||||||||
| FM only | 1872 | 78.8 (76.2, 81.1) | 101 | 4.4 (3.5, 5.5) | 70 | 3.0 (2.2, 4.1) | 330 | 13.9 (11.9, 16.2) |
| RYO only | 90 | 18.2 (13.7, 23.8) | 333 | 60.1 (54.4, 65.5) | 52 | 11.3 (7.7, 16.5) | 59 | 10.3 (7.8, 13.5) |
| Dual use | 103 | 39.2 (32.0, 46.9) | 50 | 18.3 (13.3, 24.6) | 108 | 35.3 (27.6, 43.8) | 26 | 7.2 (4.4, 11.5) |
| Germany | ||||||||
| FM only | 445 | 84 (78.1, 88.6) | 10 | 1.4 (0.6, 3.0) | 29 | 5.1 (2.9, 8.6) | 51 | 9.5 (6.2, 14.2) |
| RYO only | 15 | 26.7 (13.4, 46.2) | 42 | 48 (32.7, 63.7) | 14 | 20.1 (10.2, 35.9) | 5 | 5.2 (1.9, 13.7) |
| Dual use | 30 | 31.2 (20.0, 45.3) | 11 | 11.2 (5.6, 21.0) | 49 | 52.5 (38.4, 66.2) | 6 | 5.1 (1.5, 16.0) |
| Greece | ||||||||
| FM only | 219 | 80.5 (74.5, 85.3) | 20 | 6.1 (3.7, 9.8) | 3 | 0.9 (0.3, 3.0) | 39 | 12.5 (8.4, 18.2) |
| RYO only | 15 | 14.1 (6.3, 28.6) | 84 | 65.8 (54.9, 75.2) | 6 | 3.3 (1.4, 7.9) | 19 | 16.8 (10.4, 25.9) |
| Dual use | 1 | 8.2 (1.2, 40.0) | 5 | 79.8 (47.6, 94.5) | 1 | 5.9 (0.7, 37.0) | 1 | 6.1 (0.7, 37.8) |
| Hungary | ||||||||
| FM only | 103 | 63.4 (51.7, 73.7) | 22 | 17.2 (10.8, 26.5) | 6 | 3.4 (1.3, 8.5) | 22 | 15.9 (9.1, 26.4) |
| RYO only | 24 | 17.8 (10.7, 28.2) | 113 | 67.1 (56.3, 76.4) | 11 | 5.4 (1.9, 14.7) | 22 | 9.6 (6.4, 14.3) |
| Dual use | 13 | 42.6 (25.3, 62.0) | 6 | 28.8 (11.7, 55.2) | 10 | 19 (8.1, 38.6) | 4 | 9.5 (3.5, 23.2) |
| Poland | ||||||||
| FM only | 300 | 81 (74.9, 86.0) | 7 | 1.7 (0.6, 4.4) | 13 | 4.2 (2.2, 8.1) | 42 | 13 (9.4, 17.8) |
| RYO only | 6 | 9.4 (3.6, 22.4) | 16 | 39.5 (23.8, 57.7) | 15 | 51.1 (31.7, 70.2) | 0 | 0 |
| Dual use | 13 | 21.5 (10.6, 38.9) | 12 | 19 (10.7, 31.5) | 31 | 55.3 (36.8, 72.5) | 4 | 4.1 (1.3, 12.7) |
| Romania | ||||||||
| FM only | 428 | 83.5 (78.3, 87.7) | 3 | 0.5 (0.2, 1.2) | 4 | 0.6 (0.2, 1.8) | 79 | 15.4 (11.4, 20.6) |
| RYO only | 3 | 54.9 (20.1, 85.5) | 1 | 17.6 (2.2, 67.3) | 1 | 10.0 (1.3, 48.8) | 1 | 17.6 (2.2, 67.3) |
| Dual use | 16 | 77.2 (58.5, 89.1) | 2 | 8.6 (2.3, 27.6) | 5 | 9.8 (2.7, 29.8) | 2 | 4.4 (1.0, 17.6) |
| Spain | ||||||||
| FM only | 377 | 70.6 (64.7, 75.9) | 39 | 8.4 (6.1, 11.6) | 15 | 3.4 (1.8, 6.3) | 97 | 17.5 (12.6, 23.8) |
| RYO only | 27 | 20 (13.1, 29.3) | 77 | 61.5 (51.8, 70.4) | 5 | 6.9 (2.8, 16.1) | 12 | 11.6 (6.5, 19.9) |
| Dual use | 30 | 54.5 (42.0, 66.4) | 14 | 18.1 (9.7, 31.2) | 12 | 13.6 (7.6, 23.1) | 9 | 13.8 (6.5, 27.2) |
FM cigarette users in Hungary were the most likely to have made the transition to RYO (OR = 2.27; 1.21, 4.26 compared with Spain) and users in Romania the least likely to have done so (OR = 0.06, 0.03, 0.15 compared with Spain). Compared with Spain, RYO users were more likely to have transitioned to FM cigarettes in Poland (OR = 3.19; 1.17, 8.71) and Germany (OR = 2.86; 1.12, 7.28). Given the small longitudinal sample size of exclusive RYO users in Romania (n = 6), the estimated OR had a very wide 95% CI. None of the other factors were statistically significantly associated with transitions to FM cigarettes or RYO (table 2).
Table 2.
Factors associated with use of roll-your-own tobacco in wave 2 and with transition from FM to roll-your-own tobacco and from roll-your-own tobacco to FM between wave 1 and wave 2
| Covariate | RYO user in wave 2 (yes vs. no) n = 5555 |
Transition from FM to RYO from wave 1 to wave 2 n = 2028 |
Transition from RYO to FM from wave 1 to wave 2 n = 472 |
|||
|---|---|---|---|---|---|---|
| OR | (95% CI) | OR | (95% CI) | OR | (95% CI) | |
| Country | ||||||
| Germany | 0.62 | (0.43, 0.89) | 0.42 | (0.22, 0.79) | 2.86 | (1.12, 7.28) |
| Greece | 1.10 | (0.81, 1.49) | 0.49 | (0.27, 0.89) | 0.69 | (0.27, 1.78) |
| Hungary | 2.67 | (2.01, 3.56) | 2.27 | (1.21, 4.26) | 1.49 | (0.61, 3.66) |
| Poland | 0.88 | (0.63, 1.24) | 0.41 | (0.19, 0.88) | 3.19 | (1.17, 8.71) |
| Romania | 0.13 | (0.07, 0.23) | 0.06 | (0.03, 0.15) | 9.30 | (0.59, 147.56) |
| Spain | 1.00 | 1.00 | 1.00 | |||
| Degree of urbanization | ||||||
| Urban | 0.88 | (0.67, 1.15) | 0.86 | (0.46, 1.58) | 1.56 | (0.67, 3.66) |
| Intermediate | 1.01 | (0.78, 1.30) | 1.26 | (0.78, 2.03) | 1.23 | (0.54, 2.82) |
| Rural | 1.00 | 1.00 | 1.00 | |||
| Sex | ||||||
| Female | 0.95 | (0.82, 1.10) | 1.06 | (0.74, 1.53) | 0.94 | (0.59, 1.50) |
| Male | 1.00 | 1.00 | 1.00 | |||
| Age group | ||||||
| 18–24 | 1.33 | (0.91, 1.96) | 1.90 | (0.77, 4.67) | 0.75 | (0.26, 2.18) |
| 25–39 | 1.38 | (1.08, 1.74) | 1.29 | (0.75, 2.23) | 0.73 | (0.37, 1.42) |
| 40–54 | 1.06 | (0.85, 1.32) | 0.91 | (0.54, 1.54) | 0.82 | (0.42, 1.60) |
| 55+ | 1.00 | 1.00 | 1.00 | |||
| Marital status | ||||||
| Not married | 0.96 | (0.69, 1.35) | 0.69 | (0.34, 1.42) | 1.82 | (0.52, 6.39) |
| Married/common-law | 0.80 | (0.60, 1.06) | 0.82 | (0.43, 1.56) | 1.76 | (0.56, 5.58) |
| Widowed | 0.55 | (0.36, 0.86) | 0.38 | (0.12, 1.18) | 0.99 | (0.21, 4.65) |
| Divorced | 1.00 | 1.00 | 1.00 | |||
| Income | ||||||
| Income not reported | 1.38 | (1.06, 1.80) | 0.71 | (0.34, 1.49) | 1.90 | (0.77, 4.68) |
| Low income | 2.08 | (1.53, 2.84) | 1.22 | (0.62, 2.40) | 1.99 | (0.76, 5.24) |
| Moderate income | 1.85 | (1.47, 2.32) | 0.83 | (0.42, 1.61) | 1.27 | (0.48, 3.39) |
| High income | 1.00 | 1.00 | 1.00 | |||
| Education | ||||||
| Low education | 1.59 | (1.18, 2.13) | 1.30 | (0.66, 2.59) | 0.83 | (0.26, 2.69) |
| Moderate education | 1.31 | (0.97, 1.75) | 1.66 | (0.83, 3.32) | 1.99 | (0.66, 5.96) |
| High education | 1.00 | 1.00 | 1.00 | |||
| Cigarettes smoked/day | ||||||
| ≤10 | 0.69 | (0.44, 1.06) | 1.08 | (0.39, 2.96) | 1.19 | (0.34, 4.22) |
| 11–20 | 1.12 | (0.74, 1.71) | 1.49 | (0.56, 3.95) | 1.02 | (0.33, 3.20) |
| 21–30 | 1.91 | (1.18, 3.10) | 2.43 | (0.85, 6.92) | 1.17 | (0.32, 4.36) |
| 31+ | 1.00 | 1.00 | 1.00 | |||
FM, factory-made cigarettes; RYO, roll-your-own tobacco. Transition from FM to RYO (exclusive or with FM) from wave 1 to wave 2 is based only on those respondents who smoked FM exclusively in wave 1 (1 = yes vs. 0 = no transition). Transition from RYO to FM (exclusive or with RYO) from wave 1 to wave 2 is based only on those respondents who smoked RYO exclusively in wave 1 (1 = yes vs. 0 = no transition).
Correlates of RYO use
Among smokers in wave 2, RYO use (exclusive or dual) was more likely in those aged 25–39 years compared with those aged ≥55 (OR= 1.38), in individuals of moderate (OR = 1.85) and low income (OR = 2.08) compared with those of high income, as well as in those with low education compared with high education level (OR = 1.59) and in those who smoked 21–30 cigs/day compared with those who smoked >30 cigs/day (OR = 1.91) (table 2).
Perceptions and knowledge
Across all six countries, 81.7% of respondents who reported exclusive use of RYO in wave 2 and 91.2% of those who reported dual use agreed with the statement that RYO is cheaper than FM cigarettes (P = 0.043). Almost 22% of exclusive RYO users and 15.6% of dual users thought that RYO is not as bad for health as FM cigarettes and less than half in both groups reported that RYO may reduce tobacco consumption (table 3). Greece had the highest proportion of RYO users who thought that RYO tastes better and that it helps reduce consumption, whereas half of Romanian exclusive RYO users (51.2%) thought that it is not as bad for one’s health as FM cigarettes. Controlling for sociodemographic factors and cigarette consumption, RYO users in Hungary, Poland and Germany were the most likely to say that RYO is cheaper (OR = 4.10, OR = 3.88 and OR = 2.62 compared with Spain, respectively) and those in Greece that it tastes better (OR = 3.32) and that it helps reduce consumption (OR = 6.26). With the exception of Romania, RYO users in all other countries were less likely to believe that RYO is not as bad for health as FM cigarettes compared with Spain (results not shown in tables). There was a positive association between exclusive RYO use and thinking that RYO tastes better (OR = 3.41; 2.36, 4.92) and is not as bad for health (OR = 1.68; 1.04, 2.74) compared with dual use (table 4).
Table 3.
Perceptions and health beliefs by type of product used and by country in wave 2
| Perceptions | Germany a | Greece a | Hungary a | Poland a | Romaniaa | Spain a | Overall b | CMH Test c |
|---|---|---|---|---|---|---|---|---|
| % | % | % | % | % | % | % | P | |
| RYO are cheaperd | ||||||||
| RYO only | 90.7 | 68.5* | 91.0 | 89.5 | 84.7 | 74.3 | 81.7*** | 0.043 |
| Dual use | 91.1 | 89.6 | 93.9 | 94.6 | 87.9 | 83.2 | 91.2 | |
| RYO taste betterd | ||||||||
| RYO only | 70.2*** | 84.6 | 49.8 | 45.9*** | 55.4 | 60.5*** | 62.4*** | <.001 |
| Dual use | 37.8*** | 72.2 | 37.5 | 17.3 | 21.0 | 20.4 | 28.9 | |
| RYO are not as bad for healthd | ||||||||
| RYO only | 12.7 | 15.5 | 15.9 | 30.0 | 51.2 | 40.1 | 21.7* | 0.027 |
| Dual use | 5.9 | 12.1 | 22.0 | 14.4 | 34.3 | 25.3 | 15.6 | |
| RYO help reduce amount smokedd | ||||||||
| RYO only | 30.4 | 83.4 | 25.4 | 25.4 | 71.2 | 45.7 | 45.9 | 0.161 |
| Dual use | 39.9 | 76.4 | 36.5 | 23.0 | 69.1 | 55.3 | 39.2 | |
| Smoking causes heart disease | ||||||||
| FM only | 79.7 | 95.3 | 70.3 | 78.8 | 87.0 | 88.2 | 83.8 | 0.852 |
| RYO only | 86.1 | 93.9 | 68.8 | 79.4 | 82.5 | 83.0 | 80.6 | |
| Dual use | 82.6 | 95.0 | 59.9 | 81.3 | 92.6 | 88.5 | 80.9 | |
| Smoking causes heart attacks | ||||||||
| FM only | 45.0 | 60.6* | 49.5 | 59.4 | 73.0 | 75.6* | 61.3** | 0.098 |
| RYO only | 51.8 | 55.5 | 48.7 | 51.9 | 74.7 | 58.5 | 53.3 | |
| Dual use | 45.3 | 84.2 | 38.6 | 67.2 | 74.6 | 65.3 | 57.6 | |
| Smoking causes stroke | ||||||||
| FM only | 77.4 | 80.2 | 68.4* | 63.3 | 75.0 | 76.9 | 73.7* | 0.096 |
| RYO only | 81.4 | 75.0 | 59.4 | 65.7 | 79.1 | 70.3 | 68.2 | |
| Dual use | 76.7 | 68.8 | 56.9 | 62.3 | 85.7 | 71.5 | 68.7 | |
| Smoking causes impotence | ||||||||
| FM only | 58.9 | 55.1 | 57.9 | 56.9 | 68.0 | 64.2 | 60.6* | 0.312 |
| RYO only | 64.6 | 55.2 | 51.5 | 48.9 | 57.1 | 55.1 | 54.1 | |
| Dual use | 67.4 | 53.6 | 45.2 | 52.0 | 70.5 | 52.0 | 56.6 | |
| Smoking causes blindness | ||||||||
| FM only | 35.7 | 40.9 | 42.7 | 42.8 | 66.0 | 56.7 | 48.3* | 0.496 |
| RYO only | 39.6 | 41.5 | 38.2 | 34.8 | 79.3 | 48.2 | 41.5 | |
| Dual use | 31.4 | 42.3 | 33.6 | 41.7 | 83.9 | 48.4 | 40.9 | |
| Smoking causes mouth cancer | ||||||||
| FM only | 90.0 | 94.7* | 84.0 | 83.5 | 86.4 | 93.6* | 88.7 | 0.077 |
| RYO only | 94.3 | 97.4 | 78.9 | 84.6 | 88.5 | 90.6 | 87.8 | |
| Dual use | 93.1 | 95.0 | 81.1 | 91.2 | 88.6 | 98.7 | 91.5 | |
| Smoking causes lung cancer | ||||||||
| FM only | 78.9 | 88.1 | 74.8 | 80.2 | 79.9 | 84.9 | 81.2 | 0.297 |
| RYO only | 86.4 | 82.4 | 72.5 | 83.1 | 82.5 | 78.0 | 78.3 | |
| Dual use | 83.8 | 89.9 | 76.4 | 81.8 | 93.9 | 78.9 | 82.2 | |
| Smoking causes throat cancer | ||||||||
| FM only | 83.7 | 91.3 | 80.7 | 82.8 | 85.6 | 85.4 | 85.1 | 0.342 |
| RYO only | 89.4 | 86.8 | 76.1 | 85.4 | 88.5 | 81.7 | 82.0 | |
| Dual use | 85.5 | 79.6 | 79.3 | 86.3 | 93.9 | 84.7 | 85.0 | |
| Smoking causes COPD | ||||||||
| FM only | 69.9 | 87.5 | 68.4 | 75.2 | 71.1 | 84.0 | 75.9 | 0.197 |
| RYO only | 77.4 | 91.3 | 69.9 | 80.8 | 85.1 | 83.4 | 79.9 | |
| Dual use | 63.0 | 79.6 | 74.3 | 85.6 | 90.7 | 85.0 | 77.4 | |
| Smoking causes bronchitis | ||||||||
| FM only | 74.8 | 88.4 | 76.7 | 70.6 | 78.3 | 94.6 | 80.3 | 0.769 |
| RYO only | 81.9 | 91.8 | 75.4 | 74.7 | 82.5 | 89.0 | 82.9 | |
| Dual use | 66.4 | 84.6 | 76.5 | 70.9 | 83.9 | 96.7 | 75.5 | |
| Smoking causes tuberculosis | ||||||||
| FM only | 44.4 | 47.6 | 54.8 | 64.7 | 77.4 | 61.7 | 59.5** | 0.177 |
| RYO only | 48.6 | 44.4 | 51.2 | 68.7 | 88.3 | 53.3 | 51.8 | |
| Dual use | 36.6 | 25.2 | 42.2 | 65.5 | 86.4 | 44.3 | 50.1 | |
χ2 test within country.
Overall χ2 test between RYO status and perceptions ignoring country.
CMH, Cochran–Mantel–Haenszel test controlling for country (tests association between RYO status and perception controlling for country).
Perceptions of RYO cigarettes were only asked of RYO smokers, not those who smoke FM exclusively.
P < 0.001,
P < 0.01,
P < 0.05.
Table 4.
Factors associated with perceptions about RYO tobacco among RYO users and with health beliefs about smoking among FM and RYO tobacco users in wave 2
| RYO cheaper (n = 1407) |
RYO tastes better (n = 1405) |
RYO not as bad for health (n = 1405) |
RYO to reduce amount smoked (n = 1407) |
|||||
|---|---|---|---|---|---|---|---|---|
| Covariate | OR | (95% CI) | OR | (95% CI) | OR | (95% CI) | OR | (95% CI) |
| Smokes FM/RYO | ||||||||
| RYO only | 0.65 | (0.37, 1.13) | 3.41 | (2.36, 4.92) | 1.68 | (1.04, 2.74) | 0.73 | (0.50, 1.07) |
| Dual use | 1.00 | 1.00 | 1.00 | 1.00 | ||||
| Heart disease (n = 5545) |
Heart attacks (n = 5533) |
Stroke (n = 5531) |
Impotence (n = 5534) |
Blindness (n = 5531) |
||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Covariate | OR | (95%CI) | OR | (95%CI) | OR | (95%CI) | OR | (95%CI) | OR | (95%CI) |
| Smokes FM/RYO | ||||||||||
| FM only | 0.91 | (0.66, 1.25) | 0.94 | (0.71, 1.24) | 1.06 | (0.78, 1.44) | 1.05 | (0.81, 1.38) | 1.11 | (0.81, 1.53) |
| RYO only | 0.92 | (0.63, 1.35) | 0.77 | (0.58, 1.03) | 0.89 | (0.64, 1.23) | 0.93 | (0.70, 1.24) | 0.99 | (0.71, 1.37) |
| Dual use | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | |||||
| Lung cancer (n = 5537) |
Mouth cancer (n = 5532) |
Throat cancer (n = 5533) |
COPD (n = 5527) |
Bronchitis (n = 5539) |
Tuberculosis (n = 5523) |
|||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Covariate | OR | (95%CI) | OR | (95%CI) | OR | (95%CI) | OR | (95%CI) | OR | (95%CI) | OR | (95%CI) |
| Smokes FM/RYO | ||||||||||||
| FM only | 0.61 | (0.38, 0.97) | 0.83 | (0.57, 1.22) | 0.85 | (0.59, 1.23) | 0.80 | (0.58, 1.10) | 1.04 | (0.74, 1.48) | 1.34 | (0.98, 1.82) |
| RYO only | 0.61 | (0.37, 1.00) | 0.75 | (0.52, 1.09) | 0.76 | (0.52, 1.11) | 0.99 | (0.68, 1.45) | 1.14 | (0.77, 1.68) | 1.20 | (0.88, 1.64) |
| Dual use | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | ||||||
ORs further adjusted for country, age, sex, degree of urbanization, marital status, wave of recruitment, income, education and number of cigarettes smoked per day.
Knowledge of the health effects of smoking was generally high in wave 2, although approximately 20% of smokers did not know that smoking causes lung cancer or heart diseases. The percentages of smokers who knew about the association between smoking and blindness, tuberculosis and impotence were below 50% in several countries and subgroups (table 3). Controlling for sociodemographic factors and country, there was no statistically significant difference in the odds of knowing about any of the health effects of smoking by product use (RYO only, FM only or dual use) (table 4).
Discussion
Our analysis confirmed that use of RYO is quite popular among smokers in European countries, albeit less so than FM cigarettes, although there were variations among the six countries assessed. Overall, those of low income and education were more likely to be RYO users, but no such associations were significant in switching from and to RYO between 2016 and 2018. We also found that overall knowledge of the health effects of smoking was not associated with RYO use, but perceptions that RYO is less harmful than FM were widespread among RYO smokers. The majority of RYO users also reported that RYO is cheaper than FM.
A significant proportion of smokers in our sample used RYO either exclusively or in combination with FM cigarettes, especially in some of the countries assessed. This confirms the penetration of RYO in European markets which has been observed in previous, country-specific studies.5,25,26 In the longitudinal sample, only 7.4% of exclusive FM smokers in 2016 switched—partly or exclusively—to RYO by 2018, whereas 29.5% of exclusive RYO smokers switched to FM during the same period. However, there were many more exclusive FM smokers in the sample; therefore overall, more smokers switched from FM to RYO (5.6%) than from RYO to FM (3.2%), which is consistent with the increasing prevalence and sales of RYO in Europe in recent years.10
RYO use was more likely among those with low education and income. The majority of RYO users also reported that RYO is cheaper than FM, which is true in the majority of EU Member States, as it still is subject to lower taxation,27 although direct comparisons of cost are undermined by the variable quantity of tobacco used in each RYO cigarette.25 These findings highlight the fact that RYO may be attractive to those with limited financial capacity to buy cigarettes.2,6,7,10,28 Therefore, it could serve as an alternative to FM cigarette when taxation and prices increase. When we looked at switching between RYO and FM cigarettes, no sociodemographic factors were associated with transitions from one to another so we were unable to resolve the debate regarding the importance of financial capacity and price differences in this context.16,17 A potential reason for this is that we did not have data on the balance between FM and RYO in dual users. For instance, dual users with lower income may indeed consume more RYO than FM as a strategy to avoid increasing costs. Overall, dual users were the most likely to change smoking behaviors and had the lowest proportion of quitting between the two waves, so they likely play a key role in transitions and switching which should be investigated in future research.
Overall, there were major differences between countries. Some of these may be linked to taxation and price differentials.27 A recent study on pricing and taxation of FM and RYO in European countries found that, among the countries we studied, price differences between the cheaper brands of FM and RYO were highest in Germany and Hungary, while RYO was almost as costly as cheap cigarettes in Greece.15 However, these differences are not necessarily reflected in the findings of our study regarding perceptions that RYO is cheaper or/and transitions from one product to the other. Other factors, such as cultural, other tobacco control policies and market characteristics may better explain the variation. For instance, in Germany, where RYO is much cheaper than FM,15 tobacco control measures are rather weak,29 so the strong financial incentive to switch to RYO may be attenuated by the lack of strict tobacco control measures which usually target FM. Similarly, the availability, promotion and pricing of electronic cigarettes and heated tobacco products also differ among the six countries; some smokers who may wish to switch away from FM and/or RYO could have opted for these novel products.
Although Romania had a high percentage of RYO users who thought it is less harmful than FM cigarettes, this does not seem to be a major reason for using RYO in most countries. Other than price, taste seems to be an important factor and, in Greece and Romania, the perception that it helps reduce consumption. This is not necessarily true. Those smoking 21–30 cigarettes per day were more likely to smoke RYO compared with those smoking 30+ per day, so it might be partly true for heavy smokers, but there was no difference among those smoking less than 20 cigarettes per day.
We found no link between product used and knowledge of the health effects of smoking. However, exclusive RYO users were more likely to think that RYO is less harmful than dual users. This may imply that, although RYO users are not less likely to recognize the health consequences of smoking in general, they might think that these are relevant to FM smoking and not so much to RYO. Unfortunately, these questions were asked in general and not for specific types of tobacco. Years of different approaches in health warnings on packs of RYO compared with FM could partly explain this. Current TPD provisions14 are likely to narrow this gap in coming years. Some health effects were known to more smokers than others and there were stark differences between countries. Local information campaigns and varying efforts to raise awareness about specific diseases may explain this.29 Following decades of campaigns and programs to educate the public, a substantial proportion of smokers still did not know that smoking causes cancer, respiratory and cardiovascular diseases, which highlights the need for continued effort to communicate the negative health effects of smoking.
Strengths and limitations
Our analysis is the first to investigate transitions between RYO and FM in multiple European countries before and after the implementation of the TPD. Sampling methods and questionnaires were consistent across survey waves and countries, allowing us to make direct comparisons between countries and over time. The longitudinal design of the study lends itself to adequately examining changes of smoking behaviors within individuals. However, the attrition rate varied among countries and was high, which may have introduced selection bias. We attempted to account for this by using longitudinal sampling weights in the analysis that account for attrition at a high level. Sources of RYO may vary, with some users obtaining tobacco directly from tobacco producers or other informal sources; however, we did not make such a distinction in our study. Another limitation was the relatively small number of smokers who switched products during the study period, which reduced the power of our statistical analyses. In some countries in particular RYO use was rare; these small sample sizes preclude any firm conclusion in those countries where the prevalence of RYO use was low. The assessment of perceptions and knowledge was based on binary yes/no responses, which may fail to fully capture the extent of someone’s knowledge and perceptions; however, this applied to both FM and RYO users, hence comparisons can still highlight differences between the these group of smokers. Finally, perceptions about RYO were assessed among RYO users only, which precluded more insightful investigation of the role of such perceptions in the transition between FM and RYO.
Conclusions
This study revealed a complex picture in the relationship between RYO and FM among smokers in six European countries. Switching between RYO and FM, as well as dual use was frequent despite the short follow-up period. We also found gaps in the knowledge of the health effects of smoking and concerning perceptions about RYO among its users. These findings highlight the increasing role of RYO in the tobacco market in Europe and underline the need for stricter regulatory approaches, some of which have already been legislated through the revised TPD. Future tobacco-related studies in Europe should routinely include RYO, with particular attention to dual use.
Supplementary Material
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 and Polina Starchenko. University of Crete (UOC), Greece: Aristidis Tsatsakis, Charis Girvalaki, Chryssi Igoumenaki, Sophia Papadakis, Aikaterini Papathanasaki, Manolis Tzatzarakis and Alexander I. Vardavas. Kantar Public, Belgium: Nicolas Bécuwe, Lavinia Deaconu, Sophie Goudet, Christopher Hanley and Oscar Rivière. Smoking or Health Hungarian Foundation (SHHF), Hungary: Tibor Demjén, Judit Kiss and Anna Piroska Kovacs. Tobacco Control Unit, Catalan Institute of Oncology (ICO) and Bellvitge Biomedical Research Institute (IDIBELL), Catalonia: Esteve Fernández, Yolanda Castellano, Marcela Fu, Sarah O. Nogueira and Olena Tigova. Kings College London (KCL), United Kingdom: Ann McNeill, Katherine East and Sara C. Hitchman. Cancer Prevention Unit and WHO Collaborating Centre for Tobacco Control, German Cancer Research Center (DKFZ), Germany: Ute Mons and 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 and Chara Tzavara. Aer Pur Romania, Romania: Antigona Carmen Trofor, Marius Eremia, Lucia Lotrean and Florin Mihaltan. European Respiratory Society (ERS), Switzerland: Gernot Rohde, Tamaki Asano, Claudia Cichon, Amy Far, Céline Genton, Melanie Jessner, Linnea Hedman, Christer Janson, Ann Lindberg, Beth Maguire, Sofia Ravara, Valérie Vaccaro and Brian Ward. Maastricht University, the Netherlands: Marc Willemsen, Hein de Vries, Karin Hummel and Gera E. Nagelhout. Health Promotion Foundation (HPF), Poland: Witold A. Zatoński, Aleksandra Herbeć, Kinga Janik-Koncewicz, Krzysztof Przewoźniak and Mateusz Zatoński. University of Waterloo (UW), Canada: Geoffrey T. Fong, Thomas K. Agar, Pete Driezen, Shannon Gravely, Anne C. K. Quah and Mary E. Thompson.
Funding
The EUREST-PLUS project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 681109 (C.I.V.) and the University of Waterloo (G.T.F.). Additional support was provided to the University of Waterloo by a foundation grant from the Canadian Institutes of Health Research (FDN-148477). G.T.F. was supported by a Senior Investigator Grant from the Ontario Institute for Cancer Research. E.F. and M.F. are partly supported by Ministry of Universities and Research, Government of Catalonia (2017SGR319) and by the Instituto Carlos III and co-funded by the European Regional Development Fund (FEDER) (INT16/00211 and INT17/00103), Government of Spain. E.F. and M.F. thank CERCA Programme Generalitat de Catalunya for the institutional support to IDIBELL.
Conflicts of interest: The funders had no role in the design of the study; in the collection, analyses or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. G.T.F. has served as an expert witness on behalf of governments in litigation involving the tobacco industry. K.P. reports grants and personal fees from the Polish League Against Cancer, outside the submitted work.
Contributor Information
the EUREST-PLUS Consortium:
Constantine I Vardavas, Andrea Glahn, Christina N Kyriakos, Dominick Nguyen, Katerina Nikitara, Cornel Radu-Loghin, Polina Starchenko, Aristidis Tsatsakis, Charis Girvalaki, Chryssi Igoumenaki, Sophia Papadakis, Aikaterini Papathanasaki, Manolis Tzatzarakis, Alexander I Vardavas, Nicolas Bécuwe, Lavinia Deaconu, Sophie Goudet, Christopher Hanley, Oscar Rivière, Tibor Demjén, Judit Kiss, Anna Piroska Kovacs, Esteve Fernández,, Yolanda Castellano, Marcela Fu, Sarah O Nogueira, Olena Tigova, Ann McNeill, Katherine East, Sara C Hitchman, Ute Mons, Sarah Kahnert, Yannis Tountas, Panagiotis Behrakis, Filippos T Filippidis, Christina Gratziou, Paraskevi Katsaounou, Theodosia Peleki, Ioanna Petroulia, Chara Tzavara, Antigona Carmen Trofor, Marius Eremia, Lucia Lotrean, Florin Mihaltan, Gernot Rohde, Tamaki Asano, Claudia Cichon, Amy Far, Céline Genton, Melanie Jessner, Linnea Hedman, Christer Janson, Ann Lindberg, Beth Maguire, Sofia Ravara, Valérie Vaccaro, Brian Ward, Marc Willemsen, Hein de Vries, Karin Hummel, Gera E Nagelhout, Witold A Zatoński, Aleksandra Herbeć, Kinga Janik-Koncewicz, Krzysztof Przewoźniak, Mateusz Zatoński, Geoffrey T Fong, Thomas K Agar, Pete Driezen, Shannon Gravely, Anne C K Quah, and Mary E Thompson
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