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Background: One of the factors influencing variation in tobacco control policies across European countries is the relative policy dominance of pro and anti-tobacco control interest groups. Scholars investigating this power balance have predominantly conducted single country case studies. This study aims to explore and describe the relative dominance of pro and anti-tobacco control interest groups across six European countries by using a tobacco display ban as a case study. We examined whether there are patterns and similarities with regards to two components of policy monopolies: framing of tobacco and institutional arrangements., Methods: Thirty-two semi-structured interviews with 36 key stakeholders were conducted in Belgium, Finland, Germany, Ireland, Italy, and the Netherlands. These interviews were coded using the Framework Method., Results: In countries where health Non-Governmental Organizations (NGOs) have a relative policy dominance, tobacco consumption was predominantly framed as a health issue, NGO communities were well developed, the industry was largely absent in terms of production and manufacture, the health ministries played central roles in the policymaking process, and FCTC article 5.3 was strictly interpreted. In countries where the tobacco industry has a relative policy dominance, tobacco was framed as a private problem, NGO communities were absent or weak, the industry was well represented, the health ministries played subordinate roles in the policymaking process, and FCTC article 5.3. was only interpreted in terms of transparency., Conclusion: The ways in which tobacco consumption is framed in a country and the ways in which institutions are arranged correspond to the policy monopoly in place, with strong similarities across countries with the same policy monopoly.

Introduction: The Dutch implementation of the black border provision in the 2001 European Union Tobacco Products Directive (TPD) is studied to examine the implications of tobacco industry involvement in the implementation phase of the policy process., Methods: A qualitative analysis was conducted of Dutch government documents obtained through Freedom of Information Act requests, triangulated with in-depth interviews with key informants and secondary data sources (publicly available government documents, scientific literature, and news articles)., Results: Tobacco manufacturers' associations were given the opportunity to set implementation specifications via a fast-track deal with the government. The offer of early implementation of the labelling section of the TPD was used as political leverage by the industry, and underpinned by threats of litigation and arguments highlighting the risks of additional public costs and the benefits to the government of expediency and speed. Ultimately, the government agreed to the industry's interpretation, against the advice of the European Commission., Conclusions: The findings highlight the policy risks associated with corporate actors' ability to use interactions over technical product specifications to influence the implementation of health policy and illustrate the difficulties in limiting industry interference in accordance with Article 5.3 of the Framework Convention on Tobacco Control (FCTC). The implementation phase is particularly vulnerable to industry influence, where negotiation with industry actors may be unavoidable and the practical implications of relatively technical considerations are not always apparent to policymakers. During the implementation of the new TPD 2014/40/EU, government officials are advised to take a proactive role in stipulating technical specifications., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Introduction: The aim of the current study is to investigate trends and socioeconomic differences in policy triggers for thinking about quitting in six European countries., Methods: Data were derived from all available survey waves of the International Tobacco Control (ITC) Europe Surveys (2003-2013). France conducted three survey waves (n=1420-1735), Germany three waves (n=515-1515), The Netherlands seven waves (n=1420-1668), Ireland three waves (n=582-1071), Scotland two waves (n=461-507), and the rest of the United Kingdom conducted seven survey waves (n=861-1737). Smokers were asked whether four different policies (cigarette price, smoking restrictions in public places, free or lower cost medication, and warning labels on cigarette packs) influenced them to think about quitting. Generalized Estimating Equation (GEE) models were estimated for each country., Results: Cigarette price was mentioned most often in all countries and across all waves as trigger for thinking about quitting. Mentioning cigarette price and warning labels increased after the implementation of price increases and warning labels in some countries, while mentioning smoking restrictions decreased after their implementation in four countries. All studied policy triggers were mentioned more often by smokers with low and/or moderate education and income than smokers with high education and income. The education and income differences did not change significantly over time for most policies and in most countries., Conclusions: Tobacco control policies work as a trigger to increase thoughts about quitting, particularly in smokers with low education and low income and therefore have the potential to reduce health inequalities in smoking., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: There has been much variation between European countries in the development of tobacco control policy. Not much is known about the factors that shape this variation. This study aimed to assess the role of political factors in tobacco control policy development., Methods: We used data from 11 European countries from 1996 to 2010. Multilevel regression modelling was used to investigate associations between the Tobacco Control Scale (TCS) and indicators of left-wing government and government effectiveness (policy formulation, implementation and enforcement), with control for confounders., Results: An association was found between left-wing government and TCS over the period 1996-2003, but not over the whole period. The association between government effectiveness and TCS was significant and negative over the whole period, but positive between 2001 and 2005. Residual analysis showed that TCS scores from 2002 onwards were higher than expected based on the political factors. Associations varied among the five subscales of the TCS., Conclusions: The results suggest that, on the whole, national political factors have had only a minor influence on the large variations in tobacco control policy development in Europe over the last 15 years. However, there are indications that left-wing governments were important for early adoption of tobacco control policy, and high government effectiveness was important in the phase of adopting innovative policies. However, since 2002, with the advent of international treaties, the influence of national politics has diminished., (© The Author 2014. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

This study examined whether awareness of tobacco control policies was associated with social unacceptability of smoking and whether social unacceptability had an effect on smoking cessation in three European countries. Representative samples (n = 3865) of adult smokers in France, the Netherlands and Germany were used from two survey waves of the longitudinal International Tobacco Control Europe Surveys. Associations were examined of aspects of social unacceptability of smoking (i.e. feeling uncomfortable, important people disapproval and societal disapproval) with tobacco policy awareness (i.e. awareness of warning labels, anti-tobacco information and smoking restrictions at work) and smoking cessation. Only the positive association of awareness of anti-tobacco information with feeling uncomfortable about smoking was significant in each of the three countries. Important people disapproval predicted whether smokers attempted to quit, although this did not reach significance in the French and German samples in multivariate analyses. Our findings suggest that anti-tobacco information campaigns about the dangers of second-hand smoke in France and about smoking cessation in the Netherlands and Germany might have reduced the social acceptability of smoking in these countries. However, campaigns that influence the perceived disapproval of smoking by important people may be needed to ultimately increase attempts to quit smoking.

Background: Because of the magnitude of the global tobacco epidemic, the World Health Organisation developed the Framework Convention on Tobacco Control (FCTC), an international legally binding treaty to control tobacco use. Adoption and implementation of specific tobacco control measures within FCTC is an outcome of a political process, where social norms and public opinion play important roles. The objective of our study was to examine how a country's level of tobacco control is associated with smoking prevalence, two markers of denormalisation of smoking (social disapproval of smoking and concern about passive smoking), and societal support for tobacco control., Methods: An ecological study was conducted, using data from two sources. The first source was the Tobacco Control Scale (TCS) from 2011, which quantifies the implementation of tobacco control policies in European Union (EU) countries. Data on smoking prevalence, societal disapproval of smoking, concern about passive smoking, and societal support for policy measures were taken from the Eurobarometer survey of 2009. Data from Eurobarometer surveys were aggregated to country level. Data from the 27 European Union member states were used., Results: Smoking prevalence rates in 2009 were negatively associated with a country's TCS 2011 score, although not statistically significant (r = -.25; p = .21). Experience of societal disapproval was positively associated with higher TCS scores, though not significantly (r = .14; p = .48). The same was true for societal support for tobacco control (r = .27; p = .18). The TCS score in 2011 was significantly correlated with concern about passive smoking (r = .42; p =.03). Support for tobacco control measures was also strongly correlated with concern about passive smoking (r = .52, p = .006)., Conclusions: Smokers in countries with a higher TCS score were more concerned about whether their smoke harms others. Further, support for tobacco control measures is higher in countries that have more of these concerned smokers. Concerns about passive smoking seem central in the implementation of tobacco control measures, stressing the importance of continuing to educate the public about the harm from passive smoking.

Aim: To develop a simulation model projecting the effect of tobacco control policies in the Netherlands on smoking prevalence and smoking-attributable deaths., Design, Setting and Participants: Netherlands SimSmoke-an adapted version of the SimSmoke simulation model of tobacco control policy-uses population, smoking rates and tobacco control policy data for the Netherlands to predict the effect of seven types of policies: taxes, smoke-free legislation, mass media, advertising bans, health warnings, cessation treatment and youth access policies., Measurements: Outcome measures were smoking prevalence and smoking-attributable deaths., Findings: With a comprehensive set of policies, as recommended by MPOWER, smoking prevalence can be decreased by as much as 21% in the first year, increasing to a 35% reduction in the next 20 years and almost 40% by 30 years. By 2040, 7706 deaths can be averted in that year alone with the stronger set of policies. Without effective tobacco control policies, almost a million lives will be lost to tobacco-related diseases between 2011 and 2040. Of those, 145,000 can be saved with a comprehensive tobacco control package., Conclusions: Smoking prevalence and smoking-attributable deaths in the Netherlands can be reduced substantially through tax increases, smoke-free legislation, high-intensity media campaigns, stronger advertising bans and health warnings, comprehensive cessation treatment and youth access laws. The implementation of these FCTC/MPOWER recommended policies could be expected to show similar or even larger relative reductions in smoking prevalence in other countries which currently have weak policies., (© 2011 The Authors, Addiction © 2011 Society for the Study of Addiction.)

Objectives: (a) to examine exposure to ETS in 5 European countries that differ in their tobacco control (TC) activity, (b) to examine attitudes towards TC measures and (c) to relate these results to sociodemographic and smoking related variables., Methods: population-based, representative sample of n = 3,500 participants age 16-59, in Germany, Greece, Poland, Sweden, UK., Results: most never smokers are exposed to ETS in leisure time (55.74%); chances of being exposed to ETS at home or outside of the home are dependent on sex, smoking status, country, whether there are smokers in the households, what the status of the relationship is (single vs. not single); results differ significantly between countries., Conclusion: smoking restrictions are associated with lower levels of actual exposure to ETS. non-smokers want governmental regulation.

INTRODUCTION Due to a continuing international trend of decentralization of public health policies, local governments are given an increasingly important role in tobacco control. The process of developing local-level tobacco control policies is an underexplored topic. This study uses grant applications as a data source to gain insight into the planning, development and proposed implementation of local tobacco control policies by regional public health departments in the Netherlands. METHODS Grant applications of 24 regional public health departments were analyzed using the second stage of the rational policy cycle, a four-stages policy model about the decisions made by local policy makers during the policy process. We coded the applications with open and axial coding. RESULTS Public health departments formulated four main goals for tobacco control: adding tobacco control policies to existing local policy documents, creating smokefree (child) environments, developing and improving access to smoking cessation care, and participating in media campaigns. Public health departments often specify tobacco control aims and involve partners in reaching these aims. However, the grant applications lacked information about implementing these tobacco control policies. CONCLUSIONS The information on implementation strategies and process evaluation, as well as the (evidence-based) legitimation for the policy choices, needs improvement. Under the current conditions, which include the brief explanation the departments received, an unclear mandate, insufficient funding, and local restricting factors such as time and knowledge, significant contributions to tobacco control policy cannot be expected from local governments. [ABSTRACT FROM AUTHOR]

Background: When health promotion interventions are implemented, the gains are often short-lived, as interventions are seldom successfully sustained. The current study explores how and under what conditions community-level smoking cessation interventions for people with a lower socioeconomic position can be sustained, drawing upon interventions delivered in Dutch neighbourhoods with a predominantly low socioeconomic position. Methods: We conducted 15 semi-structured interviews with key stakeholders from three Dutch community-level smoking cessation interventions implemented at least three years prior. The topic guide was developed based on the Determinants of Innovation framework and transcripts were analysed thematically. Results: We identified several factors that promote the sustainment of smoking cessation community-level interventions: 1) structural, long-term funding through the commitment of health insurers and policy makers; 2) continued stakeholder enthusiasm and involvement; 3) training and time for professionals to discuss smoking cessation, thereby also increasing the visibility of the intervention for professionals and residents; 4) integrating the intervention with existing initiatives and adapting it to be compatible with current working practices of executive staff; and 5) planning for sustainment as a team from the outset. Conclusions: The current study highlights challenges and successes in intervention sustainment for people with a lower socioeconomic position. Lack of structural funding was one of the most challenging aspects for intervention sustainment in which health insurers and policy makers can play an important role. Planning for sustainment from the outset would enable intervention coordinators to consider the abovementioned factors early on. This need not be done alone but can best be discussed within a team of stakeholders. [ABSTRACT FROM AUTHOR]

Background Effectiveness of tobacco taxation can be undermined through smokers applying price-minimizing behaviours rather than quitting or reducing consumption. Common price-minimizing strategies are buying cheaper tobacco [discount brands or roll-your-own (RYO) tobacco], bulk buying and cross-border purchasing. This study analyses trends in and factors associated with such behaviours in four European countries from 2006 to 2020. Methods Data came from adult smokers participating in the International Tobacco Control (ITC) Surveys conducted between 2006 and 2020 in England (9 waves, n  =   768–4149), France (4 waves, n  = 1415–1735), Germany (5 waves, n  =   513–1515) and the Netherlands (10 waves, n  =   1191–2177). Country-specific generalized estimating equation regression models were fit to assess trends in smoking RYO tobacco, discount brands, bulk buying and cross-border purchasing within the European Union. Results Buying discount brands or RYO tobacco was the most common strategy in all countries, except France. Except for buying discount brands, estimates of price-minimizing behaviours were highest in France (2019: RYO = 27.2%, discount brands = 17.3%, bulk buying = 34.1%, cross-border purchasing = 34.2%), and lowest in Germany (2018: RYO = 18.6%, discount brands = 43.7%, bulk buying = 8.0%, cross-border purchasing = 9.8%). Direction and magnitude of trends differed by country, and behaviour. Young smokers were less likely to buy in bulk. Low-income and low-education smokers were more likely to purchase RYO tobacco or discount brands. The association with discount brands was not found for French low-income smokers. Conclusions Smoking cheaper tobacco is the most prevalent price-minimizing strategy in three countries (England, Germany and Netherlands), and more prevalent among low-income individuals. Harmonizing prices across products and countries would reduce switching to cheaper tobacco. [ABSTRACT FROM AUTHOR]

Background: Higher Tobacco Control Scale (TCS) scores, in the early 2000s were associated with higher smoking cessation rates across Europe, both among lower and higher educated people. We aimed to assess if this association held in recent years.Methods: Repeated cross-sectional Eurobarometer surveys were used, in 27 European countries from 2006 to 2012 (study sample=73,617 adults). We used multilevel regression to model associations between the TCS (ranging from 0 to 100, quantifying: tobacco price, smoke-free laws, mass-media campaigns, advertising bans, warning labels, and cessation support) and both smoking cessation and cigarettes smoked per day. We modelled associations according to respondents' education and occupation, with adjustment for age, sex, and survey-wave.Results: We found no association between the TCS and smoking cessation for lower or middle educated respondents, but we did find an association for higher educated respondents (OR: 1.13, 95%CI: 1.08 to 1.19). For smoking intensity, we observed no associations with the TCS for lower educated respondents (beta: 0.04, 95%CI: -0.33 to 0.41) but we did observe significant associations for middle (beta: -0.25, 95%CI: -0.47 to -0.03) and higher educated respondents (beta: -0.27, 95%CI: -0.55 to -0.01). Associations were observed for both manual and non-manual classes, but not for those not working for pay. Of the TCS domains, none were associated with smoking cessation for lower educated respondents, but five were for higher educated respondents.Conclusions: Associations between tobacco control policies and smoking cessation were found mostly among higher socioeconomic groups. This underlines the need for specific tobacco control policies that explicitly focus on reaching low socio-economic groups. [ABSTRACT FROM AUTHOR]

In 2011, the Dutch government reimbursed smoking cessation pharmacotherapy with behavioral therapy for quitting smokers. We investigate whether inequalities in the use of pharmacotherapy change and, if not, whether this is due to a relatively positive injunctive norm in lower socioeconomic status (SES) groups. A total of 75,415 participants aged ≥15 years from the Dutch Continuous Survey of Smoking Habits, 2009-2012, were considered with the following measures: SES (education/income), injunctive norm (mostly acceptable/neutral/mostly unacceptable), period (2011/all other years), and pharmacotherapy use (yes/no). The proportion of low SES smokers compared with high SES smokers making quit attempts with pharmacotherapy did not differ significantly. The injunctive norm of low SES smokers differed significantly from high SES smokers and nonsmokers of all SES levels. Low income smokers with mostly acceptable injunctive norms were significantly less likely to make quit attempts using pharmacotherapy than those with a neutral or less accepting injunctive norm. The significantly lower use of pharmacotherapy in quit attempts in low income smokers with a positive injunctive norm toward smoking may partly underlie the lack of uptake of reimbursed pharmacotherapy in low SES smokers. [ABSTRACT FROM AUTHOR]

Background During the 1990s, inequalities in smoking prevalence by socioeconomic status (SES) have widened in Europe. Since then, many tobacco control policies have been implemented. Yet, European overviews of recent trends in smoking inequalities are lacking. This paper aims to provide an overview of longterm trends of socioeconomic inequalities in smoking cessation in Europe. Methods We used data for 11 countries taken from Eurobarometer surveys from 1987 to 1995 and 2002- 2012, with a total study sample of 63 737 respondents. We performed multilevel logistic regression to model associations of the quit ratio (proportion former smokers of ever smokers) with SES, measured by education and occupation separately, with adjustments for age, sex and time. Results We found a significant, positive association for education and occupation with the quit ratio. The strength of the association decreased slightly from 1987 to 1995 and increased again from 2002 to 2012. Inequalities increased between the two periods in most countries and decreased in only one country. While in 1987-1995, the quit ratio increased among all SES groups and most strongly among the low SES group, in 2002-2012 it increased only among the high-education group (OR=1.38, 95% CI 1.02 to 1.87), and nonmanual occupation group (OR=1.59, 95% CI 1.19 to 2.12). Conclusions Socioeconomic inequalities in smoking cessation rates have strongly increased since the 1990s and during the 2000s. This suggests that the tobacco control policies implemented during the 2000s have not been able to counter the trend in increasing inequalities. [ABSTRACT FROM AUTHOR]

The aim of the study was to understand, from the perspective of youth, how and under which circumstances a ban on tobacco sales to minors can be effective in influencing youth smoking behaviour. We searched Medline, Embase, and PsychINFO in February 2016. A systematic search for studies about a ban on sales to minors and smoking behaviour was performed. Only studies that addressed potential mechanisms were included, resulting in thirty-three studies. We extracted evidence from 26 quantitative, 5 qualitative, and 2 mixed-methods studies, explaining how the ban may be effective in reducing smoking behaviour, and contextual factors that may influence these mechanisms. We identified two mechanisms and three contra-mechanisms. First, when direct access to commercial sources is limited, cigarette consumption may be reduced because minors have restricted access to commercial cigarettes. Minors' access to social sources and the various ways in which they continue to buy cigarettes by circumventing the ban, are two contra-mechanisms that undermine this effect. Second, when the ban is strongly enforced, an anti-smoking norm may be created and adolescents may smoke less as a result. One contra-mechanism may possibly undermine this effect: the 'forbidden fruit' effect. Whether these (contra-)mechanisms occur depends on contextual and individual factors such as level of enforcement, the minors' social network, and their dependence on smoking. The ban can be effective if well enforced. However, minors' access to social sources and their ways to circumvent the ban should be addressed to achieve its full potential. [ABSTRACT FROM AUTHOR]