Smoking policies

Tobacco control policies aim at improvement of population health

Tobacco control policies are defined by the WHO as ‘supply, demand and harm reduction strategies that aim to improve the health of a population by eliminating or reducing their consumption of tobacco products and exposure to tobacco smoke’ (WHO, 2005g). This EUphact presents information on the range and effectiveness of such strategies and the extent to which they are developed and implemented at EU and (sub-)national level.

Curbing tobacco use a longstanding EU health priority

Curbing the use of tobacco is a clear policy priority for the EU. Building on its changing competencies and instruments the EU has developed a comprehensive approach. This has resulted in the current four-tiered strategy based on legal measures, preventive action, mainstreaming across Community policies, and involvement in global efforts.

Efforts to reduce tobacco use evolved over twenty years

The initial legal efforts, tackling smoking in public places, television broadcasting, and supporting healthy workplaces, were also taken in the late 1980s. Since then, many more legal measures have been taken and the reduction of tobacco use and dependence has featured prominently in all consecutive Community public health action programmes.

EU smoking strategy consists of four key elements

The EU's efforts consist of four key elements:

• legislative measures, based on the Community Treaties as well as more specific, secondary legislation;
• support for Europe-wide and cross-national smoking prevention and cessation activities, financed via action programmes and the Community Tobacco Fund;
• mainstreaming of tobacco control into a range of other Community policies;
• ensuring the Community’s achievements also have an impact outside the EU region, by fostering international co-operation and taking on a major role in tobacco control at a global level.

Treaty provides primary legal base

EU competencies in health and safety, and taxation have also provided legal ground for tobacco control measures.

Secondary legislation: specific measures to support tobacco control

The provisions in the Treaty have been given force through a range of secondary legal measures to support tobacco control. Together, they underpin and complement the Community’s action, including a range of smoking prevention and cessation activities.

Binding legal measures include Directives on:

• the advertising and sponsorship of tobacco products;
• the structure and rates of excise duty applied on manufactured tobacco;
• the manufacture, presentation and sale of tobacco products;
• television broadcasting, banning the advertising of tobacco products; and
• minimum safety and health requirements for the workplace.

Non-binding legal measures include:

• a Council Recommendation on the prevention of smoking and on initiatives to improve tobacco control. This recommendation pays particular attention to measures restricting youth access to tobacco; and
• a Resolution on banning smoking in public places. Since the adoption of the resolution in 1989, Member States’ governments have developed their own specific action to implement this resolution, and have done so at their own pace.

A complete overview of EU legal documents related to tobacco control can be found on the DG SANCO website.

Broad consultation process on reduction of second-hand smoke

Early in 2007 the Commission published a Green Paper (COM (2007) 27 final) launching a broad consultation process on the best way forward to tackle second-hand smoke. Exposure to second-hand smoke is also known as ‘passive smoking’, and is increasingly recognized as a major threat to health, throughout the EU. The Commission had already committed itself in its Environment and Health Action Plan (2004-2010) to improve indoor air quality by encouraging the restriction of smoking in all workplaces (COM (2004) 416 final).

Community Tobacco Fund: increasing public awareness

The Community Tobacco Fund was created in 1992 from a 2% levy on the subsidies given to the growing of tobacco in the EU. It was initially known as the ‘Fund for Research and Information on Tobacco’. Through this fund, money is made available for public information projects to increase awareness on the harmful effects of tobacco consumption. The fund is scheduled to finish in 2008.

Thus far, the Fund has supported two public anti-smoking campaigns managed by the European Commission:

• the Feel Free To Say No campaign, which ran between 2002 and 2004;
• the HELP – For a life without tobacco campaign, which was launched in 2005 and will run until 2008 with a total budget of € 72 million.

In addition, the fund finances projects that support tobacco growers to switch to other crops or activities.

Supportive action: prevention, networking and building knowledge base

Two important tobacco control networks set up via the EU public health action programmes are ENSP (European Network for Smoking Prevention) and ENYPAT (European Network for Young People and Tobacco). For more detailed information on these two networks, please see: ENSP and ENYPAT: two major networks against smoking in the EU.

The EU’s Framework Programmes on Research and Development have also supported the knowledge base for tobacco control across the EU. Developing a better understanding of the effectiveness of fiscal policies for tobacco control in Europe is among the priority areas of the 7th Framework Programme running from 2007 to 2013.

WHO Framework Convention on Tobacco Control

WHO treaty supports measures to reduce demand for tobacco

Significant measures to reduce the demand for tobacco, that are supported by the FCTC include:

• price and tax measures;
• protection from exposure to tobacco smoke, particularly in workplaces, public transport and indoor public places;
• regulation of the contents of tobacco products;
• regulation of tobacco product disclosures;
• packaging and labelling of tobacco products, requiring large health warning labels and prohibiting the use of deceptive labels such as "light", "low tar", and "mild";
• education, communication, training and public awareness;
• tobacco advertising, promotion and sponsorship. Countries are to undertake a comprehensive ban on tobacco advertising, promotion and sponsorship within five years of ratifying the treaty if their constitutions allow this. If there are constitutional constraints, countries are required to put restrictions in place; and
• demand reduction measures concerning tobacco dependence and cessation.

WHO treaty also supports measures to reduce the supply of tobacco

The FCTC also supports measures to reduce the supply of tobacco. These include:

• illicit trade in tobacco products (smuggling);
• sales to and by minors, and
• provision of support for economically viable alternative activities.

Supportive measures must be taken at national level as well

By signing the treaty, countries also commit themselves to take supportive measures at national level. Key examples of these measures are:

• the establishment of a national coordinating mechanism or focal point for tobacco control;
• the inclusion of tobacco cessation services in national health programmes, and
• promoting the participation of NGOs in the development of national tobacco control programmes.

Economic and Social Council calls for tobacco control measure

Under the UN Charter, identifying solutions to international social and health problems falls within the remit of the Economic and Social Council (ECOSOC). Their Resolution 2004/62 on Tobacco Control supports the WHO Framework Convention on Tobacco Control (ECOSOC, 2004). It urges UN Member States to strengthen tobacco control measures and programmes.

Six cost-effective policy interventions at (sub-)national level

Tobacco-control interventions are among the most cost-effective investments in health (ASPECT, 2004). There is strong consensus among international experts and researchers as to what policy measures are cost-effective and should be included in (sub)national tobacco-control programmes. WHO’s Health Evidence Network (HEN), the World Bank and the ASPECT research consortium all point towards six policy interventions (WHO, 2003a; World Bank, 2003; ASPECT, 2004):

• permanent price increases (scaled to inflation), notably through higher taxes on cigarettes and other tobacco products;
• comprehensive bans on advertising and promotion of tobacco products, logos and brand names;
• bans or strong restrictions on smoking in work places and public spaces;
• good consumer information, education and counter-advertising campaigns;
• large, direct warning labels on cigarette boxes and other tobacco products, and
• treatment and help for smokers who wish to quit. This should include good access to counselling, nicotine replacement therapy (NRT) and other cessation therapies.

All these measures are included in WHO’s Framework Convention on Tobacco Control (WHO, 2005g).

Most impact attributed to price and taxation policies

Based on an analysis of effective tobacco control policies in 28 European countries – the EU-25, Switzerland, Norway and Iceland – A ‘tobacco control scale’ has been drawn up (Joossens & Raw, 2006) to allocate a relative weighting to the impact of the six policy measures. Most impact was attributed to price and taxation policies. Smoking bans in workplaces and public places were judged to have the second largest impact. An overall tobacco control budget, advertising bans, health warning labels, and tobacco dependence treatment followed in decreasing order of importance.

Comprehensive policy packages are important

While each policy measure can be expected to have an impact in its own right, both the WHO and the World Bank stress the importance of a comprehensive package of policy measures. Different measures are likely to complement each other. Tobacco control programmes should, therefore, be of a comprehensive nature in order to maximize the reduction of smoking (WHO, 2003a; World Bank, 2003).

New developments give rise to new policy challenges

EU policy can have added value

While the EU can support Member States’ national policy, it’s competence also allows for specific policy measures to be developed and implemented at EU level. Not surprisingly, therefore, regulatory measures feature relatively prominently in the EU’s potential package for action.

Aiming to inform policy making at Member State as well as EU-level, the ASPECT Consortium pointed out that the European Commission could act on all previously mentioned evidence-based pillars for intervention (ASPECT, 2004) by:

• creating a European tobacco and nicotine products regulatory agency;
• creating a nicotine and tobacco product regulation advisory committee;
• developing a co-ordinated EU research strategy;
• proposing an FCTC protocol on illicit trade;
• implementing a new and comprehensive regulatory framework for all tobacco and nicotine products;
• introducing a requirement for the reduction and removal of specific harmful ingredients of tobacco and tobacco smoke;
• rescinding the requirement for tar, nicotine and carbon monoxide yields to be displayed on cigarette packs.

Also see National policies and strategies and Policies tackling socio-economic inequalities in smoking.

Existing socio-economic differences can be reduced through policy

Smoking is more prevalent among lower socio-economic groups, as is the burden of ill health caused by smoking (see also: EUphocus Health inequalities). Indeed, smoking-related disorders contribute substantially to European social inequalities in health. Also, lower educated smokers are less likely to quit smoking than higher educated smokers (Eurothine, 2007). Both opportunities for specific tobacco control measures aimed at these groups and possible government measures to increase their effectiveness have been identified.

Five types of policy interventions especially effective

Mackenbach et al. looked at specific opportunities for tackling socio-economic inequalities in smoking in the European Union. The authors identified five types of tobacco control measures that may be especially effective among lower socio-economic groups (Mackenbach et al., 2004):

• increasing tobacco taxation;
• banning of promotion of tobacco products;
• smoking restrictions in indoor workplaces;
• availability of smoking cessation therapies; and
• telephone help lines.

There is considerable overlap between this list and the six interventions advocated by WHO and the World Bank as highly effective measures for the broader population (also see: Effective policy measures).

Effectiveness of tobacco control measures could be increased

There is great potential to develop tobacco control strategies that are maximally effective among lower socio-economic groups. The effectiveness of specific tobacco control measures among these groups could be increased by (Mackenbach et al., 2004):

• strict enforcement of laws and agreements;
• removal of financial and other barriers;
• geographic or social targeting of services; and
• tailoring of communication approaches.

Increasing the price of tobacco products is a very effective measure

Increasing the price of tobacco products has been identified as an extremely effective measure in reducing cigarette smoking (WHO, 2003a; Joossens, 2004). Concerns that price increases may put a disproportionate burden on smokers from lower income groups have been shown by the WHO to be ‘either false or overestimated’. The resulting reduction in consumption compensates for the price rise. Evidence has been found that increasing tobacco prices reduces consumption among lower educational groups in England and Wales (Mackenbach et al., 2004). However, little comparable research has been undertaken in other European countries.

Universal health treaty to discourage smoking

In 2003 the WHO adopted the Framework Convention on Tobacco Control (WHO, 2003). The purpose of this treaty was to reduce the percentage of smokers and the exposure to smoke. The agreement entered into force on 25 February 2005 (WHO, 2005b). More than 150 contracting parties have committed themselves to:

• placing restrictions on tobacco advertising, sponsorship and promotion;
• establishing new packaging and labelling for tobacco products;
• establishing clean indoor air controls; and
• strengthening legislation to tackle tobacco smuggling.

The national implementation of the guidelines of the treaty is monitored by the European Network on Smoking Prevention (ENSP).

Tobacco Control Scale shows increasing commitment to tobacco control

The Tobacco Control Scale (TCS) quantifies the implementation of tobacco control policies at country level (Joossens & Raw, 2006), by allocating each tobacco control policy a particular number of points out of 100 (see the TCS for more details). Using this scale, it can be shown that most European countries have increased their commitment to the reduction of tobacco smoking since the implementation of the Framework Convention on Tobacco Control. In 2007 the UK, Iceland and Ireland ranked the highest, achieving 93, 74 and 74 points respectively. For an overview of the progress made see Progress in Tobacco Control between the years 2005 to 2007.

Health warnings are present on tobacco-products in most EU-countries.

In most EU countries smoking hazards are outlined in large, direct health warning labels on cigarette boxes and other tobacco products. Since 2004 it has been possible to accompany such warnings with a picture. Belgium was the first country to make use of this option.

Price increases decreases the number of smokers

According to the World Bank the price rise of tobacco products is the most cost effective deterrent - especially for young people and others with low incomes. A price rise of 10% decreases consumption by about 4% in high-income countries (Joossens & Raw, 2006). The effect depends on the size of the tax hike and the initial price. However, since the price of tobacco products varies greatly from country to country in Europe, the overall effect may be weakened by cross-border shopping.

Most EU-countries do not have indirect-advertising bans.

Denmark, Finland, France, Iceland, Norway and Portugal are the only countries in Europe that have total bans over all forms of tobacco advertisements including indirect-advertising (e.g., events sponsored by tobacco-brands, or 'brand stretching', in which trade names of tobacco-brands are starched to another line of products such as clothing). No EU countries allow direct television advertising for tobacco, and in most EU countries there are limitations on tobacco sellers, such as not selling to teenagers younger than 16. In Finland, Iceland, Ireland, Norway, Sweden and Switzerland the minimal age is 18 (Byrne, 2004).

Increasing numbers of EU countries are prohibiting smoking in cafes and restaurants

So far Ireland, Italy, Malta, Norway, Sweden, Belgium, England, Scotland, Iceland, Lithuania, Estonia and Germany prohibit smoking in cafés and restaurants. On 1 July 2008 a law to this effect will also enter into force in the Netherlands.

Intensive smoking discouragement policies lower percentage of smokers

Particular countries outside of Europe have had anti smoking policy in place for many years (Van der Wilk et al., 2007). Among these countries are Australia, USA and Canada, in which the percentages of smokers are 17.4% (2004), 21.6% (2003) and 20% (2004), respectively. In 1988 California raised tobacco tax by 25 US cents and directed 20% of the profits from this raise toward the prevention of smoking. The percentage of smokers accordingly decreased from around 23% in 1988 to 14% in 2005. For comparison of smoking prevalence see also Percentage of daily smokers aged 15 in the EU-27.

Areas for improvement

Joossens & Raw recognized several areas for improvement in reducing tobacco smoking (Joossens & Raw, 2007) . They recommend that:

• Tobacco control programmes should be comprehensive and should include at least the six measures described by the World Bank.
• Countries should spend a minimum of € 3 per capita per year on tobacco control.
• Countries should introduce comprehensive smoke-free legislation. This should include a total ban on smoking in work and public places, including bars, restaurants, health and educational facilities, and public transport.
• Regular increases in tobacco taxes should be policy at EU and Member State levels. The number of cigarettes that can be imported for personal consumption between EU countries should be reduced to 200 per person.
• Pictorial health warnings on the two main sides of tobacco product packages should be mandatory for all EU countries.

Also see Policies tackling socio-economic inequalities in smoking and the EUphact Smoking.

Article 152: protect and improve health across all EU policy areas

The public health competence as laid down in article 152 EC allows for incentive measures to protect and improve human health. These measures should complement national policies. Consequently, the harmonisation of national Member States’ tobacco control laws is not within the scope of article 152, nor is any binding EU tobacco control legislation.

Article 152 does require health to be protected in all Community policies. Thus, tobacco control objectives can - or indeed should - be mainstreamed into EU policy areas other than public health. Agriculture, Taxation and the Internal Market are examples of policy areas where actions to this effect could be taken.

Article 95: internal market competence scope for binding measures

In contrast to the limitations of Article 152, the EU’s competence to regulate the internal market does enable the development of binding measures, such as regulations, directives and decisions. This explains why the current binding EU legal measures on tobacco control are not based on the EU’s public health competency. Instead, they are predominantly founded on the EU's jurisdiction in the field of the internal market, as laid down in Article 95 EC. It is important to note that the EU’s competence here is limited to those aspects of tobacco control that involve cross-border activities.

The European Network for Smoking Prevention (ENSP)

The European Network for Smoking Prevention (ENSP) is a prominent example of a network that evolved into an organisation. It aims to create greater coherence among smoking prevention activities and to promote comprehensive tobacco control policies at both national and European level.

ENSP functions as the base for a range of EU-funded networks, including the European Network of Quitlines and the European Network for Smoke Free Hospitals. It has hosted projects focusing on smoking cessation in pregnancy, on the development of a measurement tool for tobacco control activities at national level, and on tackling socioeconomic inequalities in smoking in the EU. Since 2005, DG SANCO has funded ENSP to lead European-coordinated action to reduce smoking prevalence and tobacco related harm.

European Network for Young People and Tobacco (ENYPAT)

Another important EU-funded network was the European Network for Young People and Tobacco (ENYPAT). Activities of this network ceased in 2006. ENYPAT aimed to contribute to the reduction of tobacco use among young people in Europe by promoting collaboration between health educators, experts and researchers. It also acted as a centre of information for smoking experiences, smoking prevention programmes and smoking policy questions. Like ENSP, ENYPAT coordinated wide-scale European smoking prevention programmes, particularly those targeting young people. It also organised an annual one-week training course for European health professionals on how to prevent smoking among young people: the Spring School.

The WHO adopted the Framework Convention on Tobacco Control aiming to reduce the percentage of smokers and the exposure to smoke by

• placing restrictions on tobacco advertising, sponsorship and promotion;
• establishing new packaging and labelling for tobacco products;
• establishing clean indoor air controls; and
• strengthening legislation to tackle tobacco smuggling.

The rank and TCS score presented in the table were obtained in 2007; the change in TCS score reflects the increase or decrease in score from 2005 to 2007.

Also see the TCS.