The road to establishing a national tobacco endgame goal or adopting forward-looking measures differs in each country as well as enablers and challenges. In Work Package 9 of the JATC-2, perceptions and experiences on the tobacco endgame enablers and challenges have been gathered with a questionnaire and interviews among regulators, tobacco control experts and civil society organizations in several European countries.
Further, case studies from some of the JATC-2 partner countries presented here give practical examples of the different contexts, methods, types of stakeholder involvement, and implementation and evaluation practices. These may serve as references for other countries considering or preparing for tobacco endgame.
Stakeholder perceptions of enablers and barriers in the European context
Based on the opinions of regulators, tobacco control experts and civil society organizations in several European countries the perceptions of factors that could help or hinder national endgame strategies appear relatively consistent.
The most important perceived enablers are:
- established a binding endgame goal
- existence of active and effective civil society organizations engaged in tobacco control in the country
- having a structural organization that ensures well-functioning coordination of key individuals and organizations
- Committed individuals, such as politicians in key roles
- International tobacco regulation
- Previous governmental prevalence reduction goals, established in a cross-cutting way.
The most important perceived concerns and challenges in all countries are:
- the lack of political will
- tobacco industry interference (the most important barrier especially in countries with domestic production and presence of major tobacco companies in the country)
- issues with the current tobacco control processes
- shifting focus from tobacco control to other urgent issues such as COVID-19
- current high prevalence of use of tobacco and related products.
In addition, in countries that already have official tobacco endgame goals, concerns relate to:
- non-combustible and new tobacco and nicotine products
- differences between population groups
- cross-border marketing and sales
- sustaining the political will
- challenges in estimating the impact of the measures.
Road to tobacco endgame – European practices
In December 2022, Belgium's "Interfederal Strategy 2022-2028 for a Smoke-Free Generation" was signed. This political agreement was realised by extensive consultations between 24 different cabinets of the governing parties, both at the regional and federal levels. Behind this vision of a smoke-free generation is the concrete goal of drastically reducing tobacco use by 2040. This means reducing the number of daily tobacco users to 5% among the population aged 15 years and older; and reducing the number of people who start using tobacco products to 0% or close to 0%. By 2028, the target is to reduce daily tobacco consumption to 10% and daily consumption of tobacco products to 6% in the 15-24 year-olds age group. The strategy acts on different levels: product regulation, taxation, youth and education, prevention, help to quit, healthcare, and scientific research. Therefore, the strategy to be implemented must inevitably be transversal and multidisciplinary.
In Finland, ending the use of tobacco products that cause addiction and are toxic to humans has been the objective of the Tobacco Act since 2010. In 2016, the objective was broadened to cover nicotineproducts regulated under the Act. In practice, the objective has been defined as aiming for less than 5% of daily tobacco and non-pharmaceutical nicotine use in the adult (working age) population by the year 2030. The shift from merely controlling and reducing tobacco-related harms to actively pursuing the eradication of the tobacco epidemic was driven by the formation of the "Smoke-free Finland 2040" coalition in 2008. This coalition, comprising of civil society organizations, research institutes, and government agencies, later evolved into the "Tobacco-Free Finland 2030" network, expanding its scope to include nicotine. Another key driver has been the multisectoral ministerial working groups established regularly by the Ministry of Social Affairs and Health. These monitor the progress with tobacco control policies and propose a set of new measures to meet the objective of the Tobacco Act.
The National Prevention Agreement "A healthier Netherlands" launched in 2018 addresses the three largest causes of the burden of the disease in the country: smoking, problematic alcohol consumption and overweight. It was agreed with a broad representation of different stakeholders, including patient organisations, care providers, health insurers, municipalities, sports associations, businesses, funds, educational institutions, civil society organisations and central government. As part of this agreement an ambition for a smoke-free generation in 2040 was set. Specifically, this means that no child will take up smoking in 2040 and only 5% of adults will still smoke, and there will be no more women who smoke during pregnancy. The measures focus on creating a tobacco and smoke-free environment, helping people to quit smoking, and making buying cigarettes or tobacco as unappealing as possible. The National Institute for Public Health and the Environment (RIVM) monitors progress to see whether the measures taken are sufficient, whichwill allow to adjust or introduce new measures.
Read more: JATC-2 WP9 Case study on The Netherlands (Julkari)
In Slovenia, the official endgame goal is included in the Strategy for reducing harmful consequences of tobacco use –For Tobacco-Free Slovenia –2022 to 2030 with its first action plan for implementation for the period of 2022-2024. Many stakeholders in tobacco control, joined in the tobacco control stakeholder group called Anti-Tobacco Working Group coordinated by National Institute of Public Health, have been jointly working to achieve the adoption of the endgame goal for more than 5 years. In 2022, the government adopted the strategy including endgame objective that states that in 2040, there will be less than 5% users of tobacco, related and other nicotine products (not registered as nicotine replacement therapy) among inhabitants of Slovenia, aged 15 or more. The Strategy for reducing harmful consequences of tobacco use – For Tobacco-Free Slovenia – 2022 to 2030 includes the measures necessary to set the path towards tobacco and nicotine free Slovenia. The important player in proposing new measures is also the Coordination group of the Ministry of Health, including a broad group of stakeholders.
The Norwegian Tobacco Control Act has since 2013 had a "tobacco-free society" as its long-term objective. In 2018, the Norwegian Parliament requested the Government to pursue and facilitate a tobacco-free youth generation and, in 2023, a goal of achieving a tobacco and nicotine free generation was stipulated in the Government's national tobacco control strategy. According to this goal, children born 2010 and later should not use any tobacco or nicotine products.
Concurrently, the general tobacco-free objective for the population as a whole was broadened to be understood as aiming for less than 5% of daily use of tobacco and non-pharmaceutical nicotine products in all socio-demographic (age and educational) groups. The shift from controlling and reducing tobacco-related harms, to more actively pursuing the eradication of the tobacco epidemic, was initiated by the "Tobacco-free" coalition, comprising of civil society organizations, research institutes, and government agencies. The Norwegian Cancer Society was a particularly important driver, with another key actor being the multisectoral working groups at the Authorities level, led by the Ministry of Health and Care services.
To strengthen its anti-smoking policy, France has introduced since 2014 a package of measures aimed at preventing people from starting to smoke and encouraging them to quit. The policy has been formalised through 3 national tobacco control plans. First, the 2014-2019 National Smoking Reduction Program created a legal basis and a national and regional Tobacco control governance system. Then, the 2018- 2022 National Tobacco Control Program (PNLT) was fully in line with the National Health Strategy’s goals, mainly the following ones: “prevent addictive behaviours” and “reduce the prevalence of addictive practices and high-risk behaviour”. As a result of the Inter-ministerial work and the cooperation with numerous institutions and representatives of civil society, and by expanding the range of public actions against tobacco use in France, PNLT is the first strategy which combines action levers in economic,social and health fields.
The last 2023-2027 National Tobacco Control Program (PNLT) includes several actions to continue denormalising tobacco. Reducing the accessibility and attractiveness of tobacco products will require new legislation: the creation of new smoke-free areas, the extension of plain packaging to all tobacco and vaping products, the use of price leverage to move towards a €13 packet of cigarettes by 2027, and efforts to convert tobacco shops into other types of retail outlets. There is also a need to systematically identify smokers and refer them to appropriate treatment, and to improve access to nicotine replacement therapy, especially for groups with a high prevalence of smoking: people with low socioeconomic status, people with mental health problems, people with chronic illnesses, people who work in sectors where smoking prevalence is high and people in prison. The top priority aims of the PNLT are to protect young people and help our children become the first “tobacco-free generation” by 2032, to tackle social inequalities by supporting the most vulnerable members of our society, such as the unemployed and the least well-off, who are particularly impacted by tobacco, and to lend support to women, especially during pregnancy.