Tobacco control in Europe: A deadly lack of progress

Cigarettes are uniquely dangerous, killing half of all those who regularly use them and damaging the health of those who breathe in users’ smoke, particularly children. Just under a third of European adults currently smoke, and smoking has become increasingly associated with poverty, contributing significantly to widening health inequalities across the EU. In 2004, the ASPECT report, a comprehensive review of tobacco use and tobacco control policies in the EU, found that tobacco use caused well over half a million deaths in Europe annually and on top of that constituted a huge economic burden, estimated conservatively at €98-130 billion a year.1 This review also identified that whilst some European countries were observing declines in tobacco use and mortality, in other countries tobacco use was still increasing, particularly among women. The ASPECT report identified 43 recommendations to combat the epidemic, covering tobacco control policy, interventions and research. Yet to date, few of these recommendations have been implemented, and as a result, future prospects for curbing the smoking epidemic across Europe are currently very bleak. On the optimistic side, in 2003, the world's first public health treaty, the World Health Organisation's Framework Convention on Tobacco Control (FCTC) came into force in recognition of the smoking pandemic and the power of the major transnational tobacco companies to push their deadly products.2 The FCTC sets out supply and demand strategies to reduce tobacco use and has since been ratified by all EU countries (except the Czech Republic) and the European Union. The FCTC represents a unique and historic opportunity to fight the pandemic and collectively reduce the public health burden caused by tobacco and should therefore herald the way to faster progress in reducing smoking. However, the FCTC will only fulfil its potential if it is implemented in the most effective way and there is strong evidence that this is currently not the case. The Tobacco Control Scale (TCS) was developed by Joossens and Raw3 to monitor the implementation of tobacco control policies across Europe. Findings from the TCS for 2005, 2007 and 2010 demonstrate that progress in European tobacco control is painfully slow. Two-thirds of the countries spent less than 10 euro cents per capita on tobacco control; in several countries, in fact, funding was even decreasing over time. Some countries such as Hungary, Czech Republic, Bulgaria, Romania, and Greece still have virtually no protection against ‘tobacco smoke pollution’ (the term we use throughout this supplement to more aptly capture the substance that has been traditionally termed “secondhand smoke” or “environmental tobacco smoke”)4; some have poor controls on tobacco advertising (e.g. Switzerland, Germany, and Greece); only a minority of countries have pictorial health warnings (e.g. UK, Turkey, Belgium, and Switzerland), point of sale tobacco display bans (e.g. Ireland, Norway), reimbursement of tobacco dependence treatment (e.g. UK, France), or well-funded mass media tobacco education campaigns (e.g. Iceland and Switzerland). Importantly, Europe lacks a uniform and coherent strategy for surveillance of the smoking epidemic and measuring the impact of the FCTC. There is no consistent system for surveillance and monitoring of tobacco use,5,6 no framework for evaluating the impact of tobacco control policies, and there is no identifiable budget for such research within the European Commission's funding streams. In addition, recent research has shown that the tobacco industry has been heavily involved in the ‘Better Regulation’ agenda: whilst the EC has been endeavouring to increase the transparency of the European policy-making process, tobacco companies have been using this agenda to increase their involvement and influence in policy development (e.g. through the impact assessment process). The tobacco industry employs a wide range of individuals and organisations to lobby on its behalf and there is no legal obligation to disclose benefactors, which means that within the complex machinery of the EC, it is extremely difficult to expose tobacco industry influence. Article 5.3 of the FCTC states that consultation with the tobacco industry should be restricted to the strictly necessary and should be transparent. Article 5.3 Guidelines specify that they are applicable to government officials, representatives and employees of any national, state, provincial, municipal, local or other public or semi/quasi-public institution or body within the jurisdiction of a Party, and to any person acting on their behalf and that government branches (executive, legislative and judiciary) responsible for setting and implementing tobacco control policies and for protecting those policies against tobacco industry interests should be accountable. This includes EU officials as the EU is a Party. This important principle of the FCTC is clearly being violated within Europe7,8. The International Tobacco Control Policy Evaluation Project (the ITC Project) was created in 2002 to strengthen the evidence base for the FCTC by evaluating the impact of new tobacco control policies, identifying cross-country differences, understanding the reasons for policy successes and failures, and disseminating evidence-based guidance on how to implement strong policies. The ITC Project thus fills an important gap in guiding what needs to be done to combat tobacco use within Europe. Given that it is not possible to conduct randomised controlled studies to evaluate the effects of national tobacco control policies, the ITC Project employs a quasi-experimental design involving longitudinal adult smoker (and non-smoker in some countries) cohorts who are regularly surveyed using the same key policy-specific and other explanatory variables, across 20 countries throughout the world (soon to be 23 countries with the addition of Kenya, Nigeria, and Zambia in 2012). This design enables data collection before and after implementation of policies and enables inferences to be made about the causal, psychosocial, and behavioural effects of FCTC tobacco control policies. The ITC Project is now active in countries covering 70% of the world's tobacco users and five European countries have been involved over recent years (UK, Ireland, France, Germany and the Netherlands). The papers in this issue discuss key areas of ITC research in Europe. Several of the papers assess issues in relation to Article 8 of the FCTC which covers the implementation of smoke-free policies. Decades of research have concluded that exposure to tobacco smoke pollution adversely affects the health of children and adults causing an estimated 19,000 premature deaths per year across Europe.9 Protecting children's health is paramount and one of the key tenets of European health policy10 and we therefore believe that implementing and enforcing strong smoke-free laws in accordance with Article 8 of the FCTC should be straightforward for policy makers and a public health priority for Europe. Survey data collected from smokers before and after the implementation of these laws and published documentation of the implementation of smoke-free laws from our collaborators demonstrate that this is not happening in all ITC Europe countries. The ultimate impact of smoke-free legislation depends on compliance by both smokers and proprietors. An important determinant of compliance is level of support for the law.11 Although we already know that support generally tends to increase after the implementation of smoke-free legislation,12,13 this support cannot be taken for granted. This hard lesson can be learned from the study by Mons and colleagues14 who present evidence, comparing Germany and Netherlands (where partial smoke-free laws were implemented) to France (total smoke-free law), which demonstrated that level of support depends on the comprehensiveness of the policy. The idea of a partial ban, where smoking is still allowed in certain venues, for example in small bars, might appeal to policy makers, but is a recipe for disaster: low levels of support which will then lead to non-compliance and enforcement issues further undermining implementation of a weak policy. This paper builds on previous ITC Europe research that highlighted the need to accompany smoke-free legislation with well-funded media campaigns in order to educate smokers properly about why smoke-free legislation is important: it is about real health concerns for non-smokers, not about bullying smokers.15 ITC data have shown that Dutch smokers are currently very poorly informed about the harms of smoking compared with smokers in other countries and there is great concern that the tobacco control infrastructure in the Netherlands, once one of the best, is currently being systematically dismantled.16,17 Making worksites and public places smoke-free might affect smokers’ ability to quit smoking as well4,18 thus increasing the net health benefit of such a policy. Nagelhout et al.19 analyzed data before/during and after the comprehensive smoking ban from Ireland and England and compared the findings to data from Dutch smokers who experienced a partial (hospitality industry only) ban. They concluded that, in contrast to Ireland and England, the stand-alone partial hospitality ban did little to increase quitting behaviour among Dutch smokers, providing another argument why it is unwise to treat bars and pubs differently from other workplaces. Kennedy and colleagues20 also assess the impact of smoke-free policies on quitting behaviour in France, but indirectly via smokers’ recall of healthcare professional smoking interventions before and after implementation of the French smoke-free bars and restaurants policy. Their research shows a missed opportunity – there was no indication of any increase in interventions around the time of smoke-free policy implementation which might have helped to enhance the impact of smoke-free laws on quitting behaviour. The conclusion of these research studies is that smoke-free policies are being implemented inconsistently across Europe and that opportunities to maximise their impact are being lost. Sadly, despite strong evidence of the deadly effect of tobacco smoke pollution and the benefits of comprehensive smoke-free policies, today, only in some European countries is the health of citizens being adequately protected. Other studies look at the next frontiers for smoke-free policies: smoke-free cars and outdoor policies. Hitchman and colleagues21 examine the prevalence of smoking in cars across three ITC Europe countries and look at modifiable characteristics of this behaviour. This work built on their previous research from the ITC Four Country Project examining predictors of smoking in cars among smokers in Australia, Canada, the UK, and the United States.22 The study shows that significant proportions of smokers across the European countries allow smoking in their cars. Smokers with smoke-free homes were less likely to allow smoking in cars across all three European countries. The findings highlight the potential for tobacco control initiatives that promote long-term denormalisation of smoking such as strong smoke-free laws and mass media campaigns to achieve reductions in tobacco smoke pollution not only in public places, but also in private homes and vehicles. The second paper by Kennedy et al.23 assesses smoking outside pubs, bars and restaurants in France. Whilst the smoke-free policy moved smoking outdoors, it was also associated with increasing non-smoking behaviour in these environments. The majority of respondents after implementation of the smoke-free policy legislation supported outdoor smoking restrictions in areas just outside of these establishments. Two other papers in this supplement examine different areas of tobacco policy research. The first, by Brown and colleagues,24 assesses misperceptions of the relative harmfulness of cigarettes. It is now accepted that efforts to reduce the harmfulness of cigarettes by reducing machine-measured tar and nicotine yields of cigarettes were unsuccessful and undermined by the tobacco industry, who introduced health-reassuring tobacco brands named ‘light’ and ‘mild’. Eight years after the introduction of the EU Tobacco Products Directive, which banned misleading terms such as ‘light’ and ‘mild’, it is now apparent that, at least in three European countries, the legislation has not had the desired effect. Brown et al.'s research shows that a significant minority of European smokers still believe that there are differences in the harmfulness of cigarettes and that their own cigarettes are less harmful and most smokers believed that tar and nicotine yields printed on packs were indicative of harmfulness. This paper underlines the limitations of European directives. In 2001, when the European directive was enacted, there was a consensus from experts that yields on packs were misleading, yet the Directive maintained them. The revision of the Tobacco Product Directive began in 2010 and is still ongoing. We believe that the failure to remove yields on packs has cost lives and a better system for surveillance, feedback and corrective action within European tobacco control policy needs yet to be found. In addition, this study illustrates the need for the revised Tobacco Products Directive to include stronger measures to decrease misperceptions of relative harms, such as introducing generic packaging following Australia's lead. Finally, Caleyachetty and colleagues25 explore a current key conundrum in tobacco control: why should smokers who are under financial stress be less successful at stopping smoking?26 Caleyachetty's study using data from the ITC Four Country study (UK, US, Canada and Australia) substantiated other research which shows that smokers with financial difficulties were significantly less likely to stop smoking, but went on to explore the mediators of this relationship. Anticipated factors such as use of treatment did not appear to play a role, whereas cognition of health-related and quality of life related consequences of smoking were associated with a significant decrease in quit success, although this mediated effect was small. In these times of austerity across Europe, we need to support smokers to quit and research like this is important in ensuring we concentrate our efforts on helping the more disadvantaged to stop. The current studies indicate the importance of cross-county tobacco control research of this nature in Europe in improving our understanding of the epidemic and combating its inexorable progress across Europe. We hope that it stimulates much greater related research within Europe. The EC are to be commended for their important role in negotiating some guidelines for FCTC Articles on the international stage, but stronger leadership by the EC is required closer to home. Article 20 of the FCTC states that ‘parties should coordinate research at regional and internal level’ and the EU, as a party to the FCTC should fulfil this role in Europe. There is an urgent need for identified funding streams for European tobacco research and better cooperation between policy makers, scientists and civil society is required both to combat the invidious and widespread lobbying by the tobacco industry and to ensure that effective tobacco control policies are speedily enacted, implemented, monitored and improved. The UK Centre for Tobacco Control Studies receives core funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council and the Department of Health under the auspices of the UK Clinical Research Collaboration. Geoffrey Fong was supported by a Senior Investigator Award from the Ontario Institute for Cancer Research and a Prevention Scientist Award from the Canadian Cancer Society Research Institute. Conflicts of interest: None declared. We are very grateful to Florence Berteletti-Kemp for her comments on an earlier draft of this manuscript.

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