Elsevier

The Lancet

Volume 381, Issue 9877, 4–10 May 2013, Pages 1588-1595
The Lancet

Series
Tobacco control efforts in Europe

https://doi.org/10.1016/S0140-6736(13)60814-4Get rights and content

Summary

Smoking is prevalent across Europe, but the severity and stage of the smoking epidemic, and policy responses to it, vary substantially between countries. Much progress is now being made in prohibition of paid-for advertising and in promotion of smoke-free policies, but mass media campaigns are widely underused, provision of services for smokers trying to quit is generally poor, and price policies are undermined by licit and illicit cheap supplies. Monitoring of prevalence is inadequate in many countries, as is investment in research and capacity to address this largest avoidable cause of death and disability across Europe. However, grounds for optimism are provided by progress in implementation of the WHO Framework Convention on Tobacco Control, and in the development of a new generation of nicotine-containing devices that could enable more widespread adoption of harm-reduction strategies. The effect of commercial vested interests has been and remains a major barrier to progress.

Introduction

Tobacco use in Europe began with a gift of tobacco leaves to Christopher Columbus on his arrival in the New World in 1492. Cigarettes, the most lethal method of tobacco consumption, were a 19th century innovation that made use of scraps of tobacco by hand-rolling them in paper. Philip Morris, like many familiar names in the modern tobacco industry, started out selling hand-made cigarettes in London in the 1840s. The onset of mass production of cigarettes in the late 19th century then transformed the industry, and fuelled the 20th century global epidemic of death and disability from smoking.

In Europe, the smoking epidemic has evolved at different rates and times in different countries. In the UK, one of the first countries affected, smoking prevalence reached around 65% in men in the mid-1940s and more than 40% in women in the late 1960s, and has been decreasing since.1 In Russia, where the epidemic was exacerbated by the entry of Western tobacco companies after the political and economic transitions of the 1990s,2, 3, 4 smoking prevalence was 53% in men (and 16% in women) in 2010.5 In the European Union (EU), smoking prevalence seems to have peaked only in the last decade in several countries (Greece, Austria, Spain, Bulgaria, Latvia), and could still be rising in some (Finland, Slovenia, Czech Republic).6 An estimated 28% of adults in the EU—nearly 120 million people—are smokers, and around 650 000 die from smoking every year.6, 7 In the wider WHO European region, smoking kills about 1·5 million people every year.8 All these deaths are preventable.

The wide variations in the extent to which smoking prevalence is decreasing in European countries is an indicator of the commitment of national governments to tobacco control policies, particularly those embodied in the Articles of the WHO Framework Convention on Tobacco Control (FCTC),9 a global treaty to which almost all countries are signatories. This review summarises progress in tobacco control in Europe, in broad relation to key policies summarised under the headings in the FCTC MPOWER policy package.10 We also discuss harm reduction, which offers a radical additional approach to prevention of death and disability from smoking.

Section snippets

Monitoring of tobacco use and prevention policies

Monitoring of the prevalence of tobacco use is crucial to understanding the progress of the tobacco epidemic, and assessment of the effect of prevention policies. However, although most EU countries undertake nationally representative surveys,10 most measure prevalence too infrequently to assess policy effects or short-term trends. European Commission surveys have provided near-annual data with use of standardised methods in all EU countries, but the national sample sizes of about 1000 people

Protection from tobacco smoke

Passive or second-hand smoking—the inhalation of smoke exhaled by smokers and the more toxic smoke from smouldering tobacco—causes substantial mortality and morbidity. In adults, the predominant risks are of the major diseases caused by active smoking, particularly lung cancer, chronic obstructive airways disease, coronary heart disease, and stroke, all of which are increased by about 25%.14, 15 Maternal smoking during pregnancy causes miscarriage and stillbirth; and passive smoking after birth

Provision of help to quit tobacco use

Interventions to help smokers to stop smoking are among the most cost effective in medicine. After roughly 35 years of age, every year of smoking reduces life expectancy by about 3 months, and stopping smoking avoids most of this loss.31 All smokers should be advised to stop smoking, or to adopt strategies to reduce harm,32 and be provided with information about the treatment choices available to help them to do so. Although mass media campaigns are by far the most effective means to achieve

Warnings on packs

Health warnings on packs, especially those combining written and pictorial components, communicate directly to smokers and potential smokers.36 Article 11 of the FCTC requires, among other things, that health warnings combine text and pictorial warnings, covering at least 30% and preferably 50% of the pack surface, at the top of the pack.37 In 2010, no European country fully met FCTC requirements.36 Written health warnings have been required in all EU countries since 2001,38 but the optional

Enforcement of bans on advertising, promotion, and sponsorship

Restrictions on tobacco advertising were first introduced in Italy in 1962, and television advertising prohibited throughout the EU in 1989. The 2003 Tobacco Advertising Directive44 progressively prohibited advertising through print media, radio broadcasting, the internet, and finally, in 2005, sponsorship of sports or events involving more than one EU Member State. Most EU countries have added national laws prohibiting billboard advertising, with the exception of Germany, although advertising

Raising of taxes

Increasing of tobacco prices through tax is one of the more effective tobacco control policies.51 WHO estimates that 10% increases in tobacco price in high-income countries reduce consumption by about 4%, and smoking prevalence by about 2%.36 Young people and other smokers with low incomes are particularly sensitive to price changes.51 However, the effects of price increases are substantially reduced by the availability of lower-price options including budget cigarettes, hand-rolling tobacco,

Harm reduction

Harm reduction is a controversial but potentially powerful tobacco control policy that has so far been omitted from the FCTC, and attracted scepticism from some leading tobacco control advocacy and public health organisations. The underlying principle of harm reduction is that smokers smoke mainly for nicotine, but are harmed primarily by other tobacco smoke constituents. The concept of substitution of smoked tobacco with medicinal nicotine (known as nicotine replacement therapy or NRT) has

Young people and tobacco

Young people are more likely to become smokers if they see others smoking. This tenet is particularly true if family members or friends smoke, which additionally creates opportunities to obtain tobacco products, but also applies to smoking imagery in the media and in remaining legal promotional options. The most effective way to prevent smoking uptake by young people is probably to reduce this exposure by driving down smoking prevalence in adults, and removing all advertising and unnecessary

Governments, public health, and the tobacco industry

Tobacco smoking is a commercially driven behaviour, and policies that prevent smoking have been identified for decades.71 As always in public health, the most effective of these policies operate at population level, and in this case cost almost nothing (price rises, promotion bans, smoke-free policy) or very little (media campaigns) to implement. However, implementation of these policies, as measured across Europe using the Joosens and Raw Tobacco Control Scale72 remains far from comprehensive (

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