Tobacco Control in

Excerpt from the Atlas 2020

Tobacco Control in Europe Excerpt from the Tobacco Atlas Germany 2020

Authors

Dr. Katrin Schaller | Dipl.-Biol. Sarah Kahnert | Laura Graen, M. A. | Prof. Dr. Ute Mons | Dr. Nobila Ouédraogo

This publication was funded by the Imprint

Tobacco Control in Europe. Excerpt from the Tobacco Atlas Germany 2020

© 2020 German Cancer Research Center (Deutsches Krebsforschungszentrum, DKFZ)

Responsible for the Content German Cancer Research Center Unit Cancer Prevention and WHO Collaborating Centre for Tobacco Control

Dr. Katrin Schaller (head, comm.)

Im Neuenheimer Feld 280 69120 Heidelberg Germany www.dkfz.de www.tabakkontrolle.de [email protected]

Layout, Illustration, Typesetting Dipl.-Biol. Sarah Kahnert

Cover Photo: © Alexander Marushin/Adobe Stock

Suggested Citation German Cancer Research Center (ed.) (2020) Tobacco Control in Europe. Excerpt from the Tobacco Atlas Germany 2020. Heidelberg, Germany

This publication is an English translation of chapter 8 of the “Tobacco Atlas Germany 2020” (Tabakatlas Deutschland 2020. Pabst Science Publishers, Lengerich, Germany, ISBN: 978-3-95853-638-8). To download the full publication (only available in German) go to https://www.dkfz.de/de/tabakkontrolle/Buecher_und_Berichte.html. Contents

1 The Tobacco Control Scale in Europe...... 2

2 Prevalence and Tobacco Control Measures in Europe...... 4

3 Smoking Prevalence in Children and Adolescents in Europe...... 6

4 Taxation in Europe...... 8

5 -Free Legislation in Europe...... 10

6 Health Warnings and Plain Packaging in Europe...... 12

7 Tobacco and E- Advertising in Europe...... 14

8 in Europe...... 16

9 Use and Regulation of E- in Europe...... 18

10 Use and Regulation of Heated Tobacco Products in Europe...... 20

References and List of Figures...... 22

Contents 1 The Tobacco Control Scale in Europe

Since 2004, the Tobacco Control Scale (TCS) has been used to The and Ireland have always been at the top compare tobacco control activities in many European countries | of the scale and Germany has always been at the bottom | Developed by international tobacco control experts, the scale Hungary has intensified its tobacco control measures since 2010, assigns a score (number of points) to each tobacco control mea­ rising from 27th place in 2010 to 8th place in 2019. In contrast, sure, with a higher score for measures that are highly effective Germany has been continuously downgraded since 2007 as it (e. g. high cigarette prices) and a lower score for those that are has not implemented significant tobacco control measures since less effective. When a country implements a measure in full, it then, and came last in 2019. In a European comparison, Ger- receives the full score. When it partially implements a measure, many is one of the countries with the greatest need for action in it receives only part of the maximum score. tobacco control.

Measures to restrict interference (2)new since 2019 Not ratifying the FCTC (-1) 3 2 new since 2019 Measures to combat illicit tobacco trade (3)new since 2019 10 ■ ratiƒcation of the FCTC Illicit Trade Protocol (1)■ track and trace system (2) Price of cigarettes (30) 30 maximum score for 10 €/pack in 2018* Smoking cessation support (10) ■ quitline (2) 10 ■ medical smoking status recording (1)■ network of support (4) total ■ brief advice in primary care (1) ■ medication reimbursement (2) maximum Smoke-free public places (22) 100 points ■ workplaces (10) Health warning labels (10) ■ bars and restaurants (8) ■ plain packaging (4) ■ size (3) ■ pictorial health warnings (3) 13 ■ public transport (4)

Comprehensive bans on advertising and promotion (13) 22 ■ TV and radio (2) ■ indirect advertising (1) ■ cinema (1) 10 Spending on campaigns (10) ■ outdoor advertising (2) ■ display ban (2) ■ sponsorship (1) maximum score for ■ print media (1.5) ■ point of sale (2) ■ internet (0.5) 2 €/capita in 2018**

Maximum achievable score on the Tobacco Control Scale in 2019 | *weighted average price taking into account EU Purchasing Power Standards (PPS), **based on the average EU gross domestic product per capita expressed in PPS

Points 2005 2007 2010 2013 2016 2019 Price of cigarettes 20 19 17 14 13 14 Smoke-free public places 2 2 11 11 11 11 Spending on campaigns 0 0 0 0 0 0 Bans on advertising 4 5 4 4 4 4 Health warning labels 6 6 1 1 5 5 Smoking cessation support 4 5 4 2 4 4 Illicit tobacco trade – – – – – 2 Tobacco industry interference – – – – – 0 total rank/of 36 22/30 37 27/30 37 26/30 32 33/34 37 33/35 40 36/36

Points and rank of Germany in the TCS ranking in 2005, 2007, 2010, 2013, 2016 and 2019

2 Tobacco Control in Europe Iceland 5 66 4 70 Finland 6 62 15 52 United Estonia Kingdom 23 49 Russian 1 80 Denmark Federation 29 47 23 49 29 47 Ireland 23 49 Lithuania 3 73 29 47 14 53 Germany Czechia 36 40 23 49 Slovakia 10 58 32 46 20 50 34 44 20 50 Hungary Romania 8 59 2 74 12 57 35 41 8 59 Croatia 17 51 33 45 27 48 10 58 20 50 15 52 Greece 17 51 13 54 Cyprus 17 51 27 48 TCS ranking of the European countries in 2019 Israel rank | points: 7 61

40 45 50 55 60 65 70 75 80

93

81 80 77 73 74 74

64 59 56 55 57 53 53 52 50 47 50 46 40 37 37 36 37 35 32 36 31 32 31

2005 2007 2010 2013 2016 2019

Points for selected countries in the TCS ranking in 2005, 2007, 2010, 2013, 2016 and 2019 | United Kingdom, France, Netherlands, Austria, Germany

Excerpt from the Tobacco Atlas Germany 2020 3 Smoking Prevalence and Tobacco Control Measures in Europe

The proportion of smokers in the member states of the Euro- The better evidence-based tobacco control measures are imple- pean Union, including the United Kingdom, fell by an average mented in a country, the lower the proportion of smokers in the of 18.8 percent between 2006 and 2017 | However, according population and the higher the proportion of those who stop to a European-wide representative survey, there are very large smoking | In Germany, effective tobacco control measures were differences: In Sweden and the United Kingdom, the proportion implemented mainly between 2000 and 2009. No significant of smokers has more than halved, in four countries (Denmark, tobacco control measures have been taken since 2010 – apart Ireland, the Netherlands, Estonia) it has dropped by almost a from the implementation of European regulation such as the third or more and in four countries (Belgium, Hungary, Finland, Tobacco Products Directive. According to the European survey, Italy) by around a quarter. In Bulgaria and the Czech Republic, the the proportion of smokers in Germany mainly decreased proportion of smokers has not changed between 2006 and 2017 between 2008 and 2009 and there has been hardly any change and in five countries (Slovakia, Croatia, Portugal, France, Slovenia) since then. it has even increased. In 17 countries, the proportion of smokers has decreased more among men than among women, and in nine countries more among women than among men.

EU 28 30 -7

Finland Sweden 24 -5 5 -10 Estonia 33 -12 Denmark United Latvia Kingdom 19 -16 47 -5 Ireland 17 -16 Netherlands Lithuania 20 -8 22 -9 Poland 42 -8 Belgium Germany 34 -6 21 -9 28 -8 Czechia Slovakia Luxembourg 38 3 34 2 25 -4 Austria Hungary 34 -4 31 -13 Romania France Slovenia 38 -4 40 1 Croatia 32 7 40 -2 Bulgaria Italy 45 3 Proportion of male smokers aged Spain 34 -5 Portugal 30 -10 15 years and over in the European 33 -2 Greece Union (including the United King- 41 -7 dom) in 2017 Malta 5 % 26 % 47 % 30 1 Cyprus 39 -9 and change from 2006 to 2017 in percentage points: increase/no change, decrease | data: Eurobarometer 2007 and 2017

4 Tobacco Control in Europe United Kingdom Hungary Germany

Tobacco Control Scale (TCS) Tobacco Control Scale (TCS) Tobacco Control Scale (TCS) 2005 2007 2010 2013 2016 2019 2005 2007 2010 2013 2016 2019 2005 2007 2010 2013 2016 2019 Rank (of) Rank (of) Rank (of)

2 1 1 1 1 1 15 22 27 11 9 8 22 27 26 33 33 36 (30) (30) (30) (34) (35) (36) (30) (30) (30) (34) (35) (36) (30) (30) (30) (34) (35) (36)

38 % 36 % 33 % 32 % 33 % 30 % 30 % 28 % 36 % 27 % 27 % 26 % 27 % 22 % 25 % 28 % 17 % 25 %

2006 2008 2010 2012 2014 2016 2018 2006 2008 2010 2012 2014 2016 2018 2006 2008 2010 2012 2014 2016 2018 2005 2007 2009 2011 2013 2015 2017 2019 2005 2007 2009 2011 2013 2015 2017 2019 2005 2007 2009 2011 2013 2015 2017 2019

Trends in smoking rates from 2006 to 2017 in selected EU countries and their ranking in the Tobacco Control Scale (TCS) from 2005 to 2019 | data: Eurobarometer and Tobacco Control Scale

EU 28 22 -5

Finland Sweden 16 -7 9 -13 Estonia 15 -9 Denmark United Latvia Kingdom 18 -11 21 0 Ireland 17 -15 Netherlands Lithuania 18 -11 17 -10 Poland 19 -1 Belgium Germany 26 -4 17 -5 23 -2 Czechia Slovakia Luxembourg 21 -2 19 0 17 -6 Austria Hungary 23 -1 23 -6 Romania France Slovenia 19 -1 32 5 Croatia 24 3 31 6 Bulgaria Italy 28 -2 Proportion of female smokers aged Spain 17 -7 Portugal 25 -3 15 years and over in the European 19 5 Greece Union (including the United King- 32 -5 dom) in 2017 Malta 9 % 20.5 % 32 % 18 -4 Cyprus 17 1 and change from 2006 to 2017 in percentage points: increase/no change, decrease | data: Eurobarometer 2007 and 2017

Excerpt from the Tobacco Atlas Germany 2020 5 Smoking Prevalence in Children and Adolescents in Europe

In 2018, an average of around 17 percent of 15-year-old boys. In three countries each there were no changes for boys or adolescents have smoked at least one cigarette within the last girls. In four countries (Bulgaria, Italy, Wales, Lithuania) the pro- 30 days in the countries of the including the portion of smoking girls has increased, while for boys this is the United Kingdom | This is shown by an international represen­ case in five countries (Bulgaria, Lithuania, England, Spain, Ireland). tative survey on the health behaviour of school children. There is no significant difference in smoking behaviour between boys The proportion of young people who smoke increases sig- (16.7 percent) and girls (17.9 percent). nificantly with age | In the countries of the European Union including the United Kingdom, in 2018, one percent of 11-year- The proportion of 15-year-olds who have smoked a cigarette old girls and two percent of 11-year-old boys have smoked a within the last 30 days has decreased in most countries since cigarette in the last 30 days. Among thirteen-year-old girls and 2014 | The decline is more significant among girls than among boys, five percent each did so.

EU 28 17 -3

Finland Sweden 18 -7 11 0 Estonia 19 -2 Denmark United Latvia Kingdom* 18 -1 21 -1 Ireland 11 0 Netherlands Lithuania 10 2 13 -5 Poland 31 2 Belgium* Germany 16 -7 13 -5 15 -2 Czechia Slovakia Luxembourg 16 -2 20 -4 12 -6 Austria Hungary 16 -6 21 -7 Romania France Proportion of 15-year-old boys who Slovenia 23 0 16 -8 Croatia have smoked at least one cigarette 14 -8 25 -5 Bulgaria in the last 30 days in the European Italy 26 1 Union (including the United King- Spain 24 -3 Portugal 15 2 dom, excluding Cyprus) in 2018 12 -4 Greece 16 -4 10 % 20.5 % 31 % Malta 14 -2 Cyprus and change from 2014 to 2018 in percent- age points: increase/no change, decrease | *unweighted average (Belgium: Flemish, French; United Kingdom: England, Scotland, Wales) | n/a | data: HBSC 2013/2014 and 2017/2018

6 Tobacco Control in Europe 1 % 0 % United Ireland 1 % 0 % Kingdom* 4 % 3 % 4 % 2 %

1 % 2 % Finland Hungary 1 % 2 % 8 % 5 % 6 % 6 %

2 % 1 % Czechia Austria 0 % 0 % 5 % 3 % 7 % 3 %

1 % 0 % Luxembourg Germany 2 % 1 % 4 % 5 % 5 % 5 %

Proportion of 11-year-old boys and girls and 13-year-old boys and girls who smoked at least one cigarette in the last 30 days in selected EU countries | *unweighted average (England, Scotland, Wales) | data: HBSC 2017/2018

EU 28 19 -4

Finland Sweden 17 -4 12 -4 Estonia 17 -3 Denmark United Latvia Kingdom* 16 -6 24 0 Ireland 13 -2 Netherlands Lithuania 10 -1 13 -8 Poland 27 5 Belgium* Germany 19 -5 11 -8 15 -6 Czechia Slovakia Luxembourg 21 -7 22 -3 14 -10 Austria Hungary 18 -5 25 -7 Romania France Proportion of 15-year-old girls who Slovenia 22 -1 19 -9 Croatia have smoked at least one cigarette 17 -5 24 -3 Bulgaria in the last 30 days in the European Italy 38 2 Union (including the United King- Spain 33 2 Portugal 17 0 dom, excluding Cyprus) in 2018 9 -6 Greece 19 0 8 % 23 % 38 % Malta 8 -11 Cyprus and change from 2014 to 2018 in percent- age points: increase/no change, decrease | *unweighted average (Belgium: Flemish, French; United Kingdom: England, Scotland, Wales) | n/a | data: HBSC 2013/2014 and 2017/2018

Excerpt from the Tobacco Atlas Germany 2020 7 Taxation in Europe

Tobacco tax increases are the most effective measure to curb A specific tax on electronic cigarettes can contribute to pre- tobacco use | In high-income countries, a ten percent increase in venting young people from using e-cigarettes, because young prices reduces tobacco consumption by about four percent. All people are particularly sensitive to price | An estimate for Europe tobacco products should be taxed at a similar level, as large dif- suggests that a ten percent increase in e-cigarette prices is asso- ferences in the taxation of different tobacco products encourage ciated with a decrease of e-cigarette sales by about eight percent. smokers to switch to cheaper products rather than quit. The Conference of the Parties to the FCTC and the World Bank rec- ommend taxation of e-cigarettes at a level that makes them less In 2018, 18 EU member states have reached the highest affordable to minors. At the same time, taxes on all other tobacco level of implementation of tobacco taxation according to the products should be increased to prevent use of tobacco products. WHO definition | Despite the targets set by the EU Directive To facilitate taxation, all e-cigarettes and liquids should be taxed, 2011/64/EU for tobacco taxes, there is wide variation in taxes regardless of content, including nicotine-free products. on the most commonly sold brand of cigarettes. There are also large price differences between cigarettes and roll-your-own There is no harmonized EU regulation for electronic cigarettes | tobacco. Currently, 14 EU member states levy a specific tax on e-cigarettes.

Country 2008 2010 2012 2014 2016 2018

Austria 1.02 1.13 1.19 1.26 1.24 1.26 Belgium 1.25 1.44 1.50 1.62 1.69 1.67 Bulgaria 3.03 4.14 4.08 4.05 3.70 3.47 Croatia 1.91 2.42 2.58 2.94 2.85 2.69 Cyprus 1.15 1.20 1.66 1.95 1.96 1.92 Czechia 1.36 1.66 1.76 1.75 1.86 1.90 Denmark 0.97 1.13 1.18 1.25 1.22 1.16 Estonia 1.66 1.85 2.29 2.33 2.37 2.26 Finland 1.11 1.24 1.32 1.45 1.55 1.71 France 1.65 1.76 1.88 2.08 2.03 2.21 Germany 1.48 1.54 1.53 1.51 1.56 1.56 Greece 1.37 1.57 2.15 2.45 2.48 2.70 Hungary 2.10 2.25 2.62 3.03 3.20 2.98 Ireland 1.94 2.33 2.39 2.30 1.89 1.92 Italy 1.30 1.38 1.86 1.87 1.88 1.90 Latvia 1.88 2.54 2.37 2.54 2.37 2.35 Lithuania 1.42 2.43 2.21 2.18 2.30 2.36 Luxembourg 0.41 0.46 0.55 0.55 0.57 0.55 Malta 2.39 2.51 2.45 2.43 2.34 2.13 Netherlands 1.20 1.31 1.46 1.59 1.59 1.57 Poland 1.70 2.09 2.71 3.03 3.00 2.79 Portugal 1.95 2.06 2.62 2.70 2.67 2.56 Romania 2.49 3.79 4.56 4.33 4.12 3.66 Slovakia 1.65 1.93 2.03 2.02 2.07 1.99 Slovenia 1.17 1.41 1.65 1.89 1.79 1.65 Spain 1.03 1.46 2.02 2.15 2.01 1.91 Sweden 1.34 1.34 1.37 1.46 1.44 1.40 United Kingdom 2.22 2.49 2.48 2.63 2.77 2.98

Affordability of cigarettes in the European Union (including the United Kingdom)| percentage of the gross domestic product per capita needed to buy 2,000 cigarettes of most sold brand

8 Tobacco Control in Europe The WHO recommends tobacco taxes should account for at least 70 percent of the retail price. EU 28 4.99 4.86

Finland Sweden 6.07 6.70 4.63 5.60 Estonia 4.38 3.55 Denmark United Latvia Kingdom 4.28 5.39 4.54 3.18 Ireland 8.43 8.77 Netherlands Lithuania 6.08 11.37 4.69 6.19 Poland 3.91 2.77 Belgium Germany 4.59 3.26 5.30 6.10 4.59 5.64 Czechia Slovakia Luxembourg 3.87 3.48 3.92 3.06 1.83 4.64 Austria Hungary 3.75 4.76 4.94 3.46 Romania France Slovenia 5.31 3.40 7.48 7.78 Croatia 4.03 3.51 5.32 3.35 Bulgaria Italy 5.14 2.57 Spain 5.16 4.90 Portugal 4.97 4.52 5.90 4.49 Greece 6.15 4.18

Malta 5.36 5.25 Cyprus 4.98 4.33 Cigarette prices in the European Union (including the United Kingdom) | price of a pack in Euros taking into account Purchasing Power Standards (PPS) per capita

1.50 2.50 3.50 4.50 5.50 6.50 7.50 8.50

weighted average price of a package in Euro | as of: 2018

United Kingdom Hungary Germany 38 % 33 % 33 % 36 % 36 % 30 % 28 % 27 % 27 % 32 % 30 % 26 % 28 % 22 % 27 % 25 % 25 % 17 % 11.44 11.15 8.83 9.86 9.29 5.90 6.60 7.45 3.87 3.69 6.77 2.72 2.52 3.00 5.81 5.86 6.01 4.09

2007 2009 2011 2013 2015 2017 2007 2009 2011 2013 2015 2017 2007 2009 2011 2013 2015 2017 2006 2008 2010 2012 2014 2016 2018 2006 2008 2010 2012 2014 2016 2018 2006 2008 2010 2012 2014 2016 2018

Prices in Euro of a pack of 20 cigarettes of the most sold brand and smoking prevalence rates in three member states of the European Union from 2006 to 2018 | data on smoking prevalence rates: Eurobarometer 2017

Excerpt from the Tobacco Atlas Germany 2020 9 Smoke-Free Legislation in Europe

Smoke-free legislation protects health | Smoke-free legislation level of implementation as defined by the World Health Organi- reduces exposure to from secondhand smoke and sation. Cyprus and Hungary only lack a ban on smoking in public reduces the incidence of cardiovascular as well as respiratory dis- transport to achieve the highest level of implementation. eases. It also contributes to the reduction of smoking prevalence. Smoking is still prevalent especially in bars, despite existing To be effective, smoke-free legislation must be comprehensive laws | In 2017, 20 percent of people in Europe who had visited a and be well enforced | Smoking rooms, designated smoking areas bar in the last six months saw people smoking inside on their last or ventilation do not effectively protect from secondhand smoke. visit.

Protection from secondhand smoke varies widely between the The majority of people in the European Union support smoke- countries of the European Union | Only seven EU member states free legislation | Approval of the laws increases after their and seven other countries in the WHO European Region have implementation – even among smokers. The majority (63 per- implemented comprehensive smoke-free legislation without cent) is also in favour of a ban on e-cigarette use in smoke-free exemptions or smoking rooms, and have achieved the highest public places.

Educational Healthcare Government Pubs Public facilities Universities Indoor offices Restaurants Country facilities facilities and bars transport except universities Austria Belgium Bulgaria (2012) Croatia Cyprus Czechia Denmark Estonia Finland France Germany Greece (2010) Hungary Ireland (2004) Italy Latvia Lithuania Luxembourg Malta (2010) Netherlands Poland Portugal Romania (2015) Slovakia Slovenia Spain (2010) Sweden United Kingdom (2006)

Smoke-free legislation in the European Union (including the United Kingdom) | comprehensive ban, ban with exemptions (separate, completely enclosed smoking rooms are allowed under very strict conditions), no ban, ban in all subnational jurisdictions, ban does not apply to water pipes, smoking is banned except in cigar or pipe clubs specially set out for this purpose, blue country name: maximum level of implementation (since year) | as of: 2018

10 Tobacco Control in Europe The WHO recommends to make all public places com- pletely smoke-free. EU 28 20 8

Finland Sweden 7 2 2 1 Estonia 11 4 Denmark United Latvia Kingdom 39 3 22 7 Ireland 5 2 Netherlands Lithuania 6 3 20 5 Poland 11 5 Belgium Germany 14 6 18 4 22 4 Czechia Slovakia Luxembourg 73 44 50 16 11 2 Austria Hungary 57 30 7 4 Romania France Slovenia 11 5 16 7 Croatia 6 2 77 14 Bulgaria Italy 42 18 Spain 15 8 Portugal 12 3 38 10 Greece 87 70

Malta 39 13 Cyprus 65 47

Smoking in bars and restaurants in the European Union (including the United Kingdom)

0 % 10 % 20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 % of respondents have visited a bar and seen people smoking inside in the last six months | percentages of respondents who have visited a restaurant and seen people smoking inside in the last six months | data: Eurobarometer 2017

9 % 9 % 8 % 10 % 9 % 9 % 17 % 9 % 9 % 7 % 13 % 2 % 8 % 10 % 14 % 11 % 9 % 10 % 16 % 9 % 12 % 11 % 12 % 16 % 11 % 6 % 26 % 13 % 10 %

12 % 13 % 17 % 17 % 18 % 32 % 20 % 21 % 22 % 24 % 26 % 13 % 20 % 25 % 29 % 79 % 21 % 26 % 28 % 31 % 28 % 30 % 78 % 22 % 29 % 26 % 33 % 41 % 75 % 73 % 73 % 37 % 40 % 71 % 70 % 70 % 69 % 69 % 67 % 66 % 66 % 65 % 65 % 24 % 63 % 62 % 62 % 62 % 60 % 60 % 59 % 59 % 58 % 56 % 53 % 50 % 50 % 50 % Finland Lithuania Cyprus Latvia Luxembourg Malta Estonia Sweden Ireland Netherlands United Kingdom Belgium Italy Germany Spain EU28 Poland Slovenia Slovakia France Portugal Denmark Romania Hungary Croatia Greece Bulgaria Czechia Austria

Attitudes towards a ban on the use of e-cigarettes in smoke-free environments in the European Union (including the United King- dom) | in favour, against, don’t know | EU 28: weighted average of the 28 countries | data: Eurobarometer 2017

Excerpt from the Tobacco Atlas Germany 2020 11 Health Warnings and Plain Packaging in Europe

Health warnings on tobacco products are an effective and low- promotional information. It only allows a standard colour for the cost tobacco prevention intervention, as the tobacco industry packaging and a standard font for the brand name. It motivates bears the costs | Large pictorial warnings can prevent young smokers to think about quitting smoking, increases calls to people from taking up smoking, motivate smokers to quit smok- quitlines and enhances the effectiveness of health warnings. The ing and prevent relapse in former smokers. Providing the national sparse available evidence suggests that plain packaging may quitline number on cigarette packs increases the number of calls reduce smoking prevalence. from smokers looking for help to quit. To date, seven countries in the WHO European region have All member states of the European Union have combined picto- introduced plain packaging | In several other countries plain rial and textual warnings on cigarette packs | By implementing packaging is under consideration. the EU Directive 2014/40/EU all EU countries have reached the highest level of implementation of health warnings as defined Plain packaging enjoys broad public support | In 23 member by the World Health Organization. states of the European Union, more people are in favour than against the introduction of plain packaging. Plain packaging improves the effectiveness of health warn- ings | Plain packaging prohibits the use of logos, colours and

Cigarette packs in Germany in compliance with the EU Directive and plain packaging for cigarettes in France

Packaging of liquid pods for an e-cigarette and of tobacco sticks for a heated tobacco product in accordance with the EU Directive as well as plain packaging of the same products in Israel

12 Tobacco Control in Europe Norway 1 July 2018

United Kingdom 20 May 2017 Countries with plain packaging outside Europe NetherlandsNetherlanes Australia 1 December 2012 1 October 2020

New Zealand 6 June 2018 Ireland Hungary Belgium 20 September 2018 1 January 2022 Thailand 8 December 2019 1 January 2021

Uruguay 21 December 2019 France 1 January 2017 Slovenia Saudi Arabia 1 January 2020 1 January 2020

Turkey 5 January 2020

Israel 8 January 2020

Canada 7 February 2020

Singapore 1 July 2020

Plain packaging in Europe and globally | The WHO recommends the use of plain packaging since/from large, regularly changing health warnings consisting of text and 2012 2014 2016 2018 2020 2022 pictures and to consider the intro- duction of plain packaging.

10 % 16 % 11 % 16 % 17 % 15 % 22 % 15 % 15 % 5 % 11 % 10 % 12 % 11 % 17 % 12 % 13 % 28 % 27 % 18 % 24 % 20 % 10 % 20 % 16 % 18 % 17 % 22 % 15 %

17 % 16 % 28 % 25 % 24 % 45 % 73 % 30 % 31 % 33 % 39 % 41 % 39 % 40 % 24 % 42 % 41 % 49 % 68 % 37 % 39 % 33 % 37 % 39 % 45 % 44 % 46 % 50 % 28 % 29 % 42 % 61 % 59 % 59 % 55 % 54 % 54 % 52 % 50 % 50 % 49 % 49 % 49 % 46 % 46 % 46 % 44 % 44 % 43 % 43 % 43 % 41 % 41 % 39 % 38 % 37 % 36 % 35 % Ireland United Kingdom Lithuania Finland Slovakia Malta Latvia Romania Hungary Belgium Sweden Greece Croatia Netherlands EU28 Poland Slovenia Bulgaria Estonia Cyprus Spain Italy Austria Portugal France Luxembourg Germany Denmark Czechia

Attitudes towards the introduction of plain packaging in the European Union (including the United Kingdom) | in favour, against, don’t know | EU 28: weighted average of the 28 countries | data: Eurobarometer 2017

Excerpt from the Tobacco Atlas Germany 2020 13 Tobacco and E-Cigarette Advertising in Europe

Advertising is powerful | Advertising for tobacco products gener- Advertising for tobacco products and e-cigarettes is still present ates a positive opinion of tobacco products and creates a favour­able in the European Union despite existing advertising bans | Several attitude towards smoking. Tobacco advertising increases smoking EU directives prohibit the advertising for tobacco products and initiation and tobacco consumption. The few studies available so nicotine-containing e-cigarettes on television, radio, print and far on the effect of e-cigarette advertising suggest that e-cigarette internet as well as cross-border sponsorship – but several adver- advertising is associated with a positive attitude towards e-ciga- tising channels remain unrestricted. rettes and with a greater intention to use the products. Only Slovenia and Spain reach the highest level in implementing Advertising bans reduce the demand for tobacco | They reduce advertising bans, as defined by the World Health Organization. awareness of advertising and increase the intention to stop smoking; they reduce tobacco consumption and smoking preva- Advertising bans are widely supported by the public | The lence. To be effective, advertising bans must be comprehensive, majority of the EU population is in favour of a ban on displaying covering all forms of advertising and promotion. tobacco products at the point of sale (display ban).

Country TV and radio and Magazines newspapers and Billboard advertising outdoor of sale Point Internet distribution in Free mail or other means Promotional discounts stretching Brand placement Product ban Complete on sponsorship ban Display Ban on machines vending Ban on sales internet

Austria Belgium Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Poland Portugal Romania Slovakia Slovenia Spain Sweden United Kingdom

Advertising bans for tobacco products and e-cigarettes in the European Union (including the United Kingdom) | yes (including nicotine-free e-cigarettes), yes (tobacco products and nicotine-containing e-cigarettes), no | as of: 2018

14 Tobacco Control in Europe The WHO recommends ban- ning all forms of direct and indirect advertising. EU 28 44 7

Finland Sweden 32 3 35 1 Estonia 46 7 Denmark United Latvia Kingdom 52 11 36 6 Ireland 65 23 Netherlands Lithuania 63 18 54 4 Poland 39 7 Belgium Germany 41 3 55 9 39 6 Czechia Slovakia Luxembourg 37 3 29 2 45 7 Austria Hungary 43 2 17 1 Romania France Slovenia 37 3 52 9 Croatia 32 4 38 2 Bulgaria Italy 22 1 Spain 41 2 Portugal 31 2 28 2 Greece 57 7

Malta 41 6 Cyprus 39 8

Awareness of e-cigarette advertising in the European Union (including the United Kingdom)

15 % 25 % 35 % 45 % 55 % 65 % of respondents have seen advertising for e-cigarettes in the last 12 months (often, from time to time or rarely) | percentages of respondents who have often seen advertising for e-cigarettes in the last 12 months | data: Eurobarometer 2017

8 % 9 % 5 % 13 % 10 % 6 % 4 % 10 % 3 % 17 % 8 % 9 % 12 % 13 % 13 % 11 % 12 % 11 % 9 % 13 % 14 % 9 % 10 % 11 % 19 % 14 % 16 % 13 % 9 %

12 % 22 % 15 % 18 % 24 % 14 % 33 % 37 % 80 % 29 % 33 % 32 % 29 % 76 % 23 % 29 % 30 % 33 % 33 % 34 % 37 % 33 % 39 % 39 % 73 % 73 % 72 % 33 % 39 % 70 % 35 % 40 % 39 % 47 % 52 % 63 % 61 % 60 % 60 % 59 % 59 % 59 % 58 % 57 % 56 % 55 % 55 % 54 % 54 % 53 % 52 % 51 % 50 % 46 % 46 % 45 % 40 % 39 % Ireland Finland Netherlands United Kingdom Latvia Sweden Greece Lithuania Belgium Estonia Croatia Italy Slovakia Spain Malta EU28 Denmark Cyprus Czechia Portugal Hungary Slovenia Poland Romania Bulgaria Germany Luxembourg France Austria

Attitudes towards a ban on displaying tobacco products at the point of sale (display ban) in the European Union (including the United Kingdom) | in favour, against, don’t know, countries with display ban for tobacco products | EU 28: weighted average of the 28 countries | data: Eurobarometer 2017

Excerpt from the Tobacco Atlas Germany 2020 15 Smoking Cessation in Europe

More than half of smokers in the European Union want to quit smokers use nicotine replacement products or other medical sup- smoking | More than half of current smokers in the European port to quit smoking, and ten percent use e-cigarettes. Only five Union have tried to quit smoking at least once, with large differ- percent try to quit smoking with the help of cessation services ences between countries. However, the proportion of smokers such as telephone quitlines. With regard to the use of smoking who have tried to quit smoking within the last year dropped from cessation support, there are large differences at national level. 19 to 15 percent between 2014 and 2017. Most smokers attempt to quit or succeed in quitting at a young or middle age. Most member states of the European Union provide telephone quitlines as well as nicotine replacement therapy to support Smoking cessation support increases quit rates, but is rarely smoking cessation | However, in only ten countries the costs of used | Most smokers (75 percent) quit smoking or try to quit nicotine replacement therapy are covered at least partially by without any method of assistance. Only eleven percent of health insurance schemes.

National Nicotine Smoking cessation support Smoking cessation support Smoking cessation support Smoking cessation support toll-free replacement in primary care facilities in hospitals in offices of in the community quitline therapy health professionals cost-covered

available cost-covered available cost-covered available cost-covered available cost-covered Country

Austria Belgium Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Poland Portugal Romania Slovakia Slovenia Spain Sweden United Kingdom

Smoking cessation support in the European Union (including the United Kingdom) | yes, no, fully, partial, yes, in most, yes, in some, data not reported/not available, data not required/not applicable | as of: 2018

16 Tobacco Control in Europe The WHO recommends all coun- tries to provide a quitline, stop smoking services and nicotine replacement therapy as well EU 28 as reimbursement of smoking 52 15 cessation support. Finland Sweden 76 30 82 43 Estonia 67 28 Denmark United Latvia Kingdom 80 27 80 23 Ireland 69 26 Netherlands Lithuania 62 29 77 33 Poland 64 19 Belgium Germany 48 14 64 22 58 17 Czechia Slovakia Luxembourg 46 9 48 14 67 25 Austria Hungary 36 8 40 8 Romania France Slovenia 35 8 66 17 Croatia 60 11 40 9 Bulgaria Italy 23 5 Spain 24 3 Portugal 52 15 36 6 Greece 44 12

Malta 65 24 Cyprus 56 17

Quit attempts in the European Union (including the United Kingdom)

20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 %

of smokers have ever tried to quit smoking | proportion of smokers who have tried to quit smoking within the last 12 months | data: Eurobarometer 2017

0 % 0 % 2 % 3 % 1 % 0 % 1 % 2 % 0 % 3 % 1 % 2 % 1 % 0 % 1 % 0 % 4 % 1 % 1 % 1 % 0 % 1 % 0 % 1 % 2 % 0 % 0 % 1 % 2 % 12 % 14 % 13 % 13 % 17 % 18 % 18 % 20 % 20 % 18 % 20 % 21 % 22 % 23 % 24 % 27 % 88 % 24 % 27 % 27 % 27 % 31 % 86 % 85 % 32 % 35 % 36 % 39 % 84 % 82 % 36 % 40 % 41 % 82 % 81 % 79 % 41 % 79 % 78 % 78 % 78 % 76 % 77 % 75 % 73 % 72 % 72 % 72 % 72 % 69 % 66 % 65 % 63 % 62 % 61 % 60 % 58 % 57 % Spain Slovenia Romania Croatia Germany Portugal Lithuania Hungary Greece Bulgaria Czechia Malta Latvia Estonia Luxembourg Netherlands Slovakia Poland Italy EU28 Cyprus Denmark Belgium Finland Ireland France Sweden Austria United Kingdom

Use of assistance for smoking cessation in the European Union (including the United Kingdom) | stopped or tried to stop without assistance, used at least one aid, don’t know | EU 28: weighted average of the 28 countries | data: Eurobarometer 2017

Excerpt from the Tobacco Atlas Germany 2020 17 Use and Regulation of E-Cigarettes in Europe

In the European Union, many people (15 percent) try out e-cig- weekly use) has increased from 1.5 percent in 2014 to 1.8 percent arettes once or twice or use them for a certain period of time in 2017, with large differences between countries. and then stop again | Especially young people and smokers try out e-cigarettes. In the EU, regular use of e-cigarettes (daily or Directive 2014/40/EU sets quality and safety requirements as well as rules on packaging, labelling and advertising in the EU | In the WHO European region that goes beyond the EU, Turkey and 33 % Turkmenistan ban the sale of e-cigarettes and Israel bans the sale of e-cigarettes containing more than 20 mg/ml nicotine. Several countries prohibit the sale of e-cigarettes to minors and most 12 % countries restrict the use of e-cigarettes in smoke-free environ- 4 % 4 % ments. Some countries apply a specific tax on e-cigarettes. 3 % 0 % smokers former smokers never-smokers

E-cigarette use ( ever, currently) in the European Union (including the United Kingdom) by smoking status | data: Eurobarometer 2017

Ban on use Ban on Ban on use Speci c Ban on in vehicles where Country sales to minors in public places taxation vending machines minors are present Austria Belgium Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Germany Greece Hungary Ireland Italy only in schools Latvia Lithuania Luxembourg only on new products Malta Netherlands from 1 January 2022 Poland Portugal Romania Slovakia Slovenia Spain Sweden United Kingdom only in Scotland

Regulation of e-cigarettes in the European Union (including the United Kingdom) | yes (including nicotine-free e-cigarettes), yes (nicotine-containing e-cigarettes), no, general ban on the sale of nicotine-free e-cigarettes | as of: 2020

18 Tobacco Control in Europe EU 28 15 2

Finland Sweden 17 1 10 Estonia 21 1 Denmark United Latvia Kingdom 16 2 24 1 Ireland 18 5 Netherlands Lithuania 13 2 15 2 Poland 15 1 Belgium Germany 13 1 16 4 12 2 Czechia Slovakia Luxembourg 20 1 10 12 2 Austria Hungary 21 3 9 1 Romania France Slovenia 9 24 4 Croatia 11 1 11 Bulgaria Italy 9 Spain 9 Portugal 12 1 8 1 Greece 15 3

Malta 12 2 Cyprus 21 3

Use of e-cigarettes in the European Union (including the United Kingdom) |

8 % 10 % 12 % 14 % 16 % 18 % 20 % 22 % 24 % of respondents are currently using e-cigarettes, previously used e-cigarettes or have tried them once or twice (ever use), percentages of respondents currently using e-cigarettes, n/a | data: Eurobarometer 2017

25 % 22 % 6 % 7 % 17 % 16 %

12 % 20 %

67 %

5 % 3 % 3 % 3 % 2 % 2 % 2 % 1 % 0 % 15–24 25–34 35–44 45–54 55–64 65–74 75 years years years years years years years and over Frequency of e-cigarette use among current users in the E-cigarette use ( ever, currently) in the European Union European Union (including the United Kingdom) | (including the United Kingdom) by age group | data: daily, weekly, monthly, less than monthly | Eurobarometer 2017 data: Eurobarometer 2017

Excerpt from the Tobacco Atlas Germany 2020 19 Use and Regulation of Heated Tobacco Products in Europe

Within a few years, tobacco manufacturers have introduced Although older adults seem to be the main users of the products, heated tobacco products throughout most of Europe | The prod- adolescents and young people also use heated tobacco products. ucts first appeared on test markets in Italy and Japan at the end of 2014. As of August 2020, heated tobacco products from three All provisions of the WHO Framework Convention on Tobacco different manufacturers are available in the majority of countries Control (FCTC) apply to heated tobacco products | The Confer- in the WHO European Region. ence of the Parties to the FCTC decided at its eighth session in 2018 that heated tobacco products are tobacco products, thus So far, few people use heated tobacco products | The scarce all provisions of FCTC apply to them. However, the regulation of prevalence data available on the use of heated tobacco prod- heated tobacco products differs between countries and is unclear ucts suggests that smokers, rather than former smokers and in some European countries. never-smokers, seem to be interested in heated tobacco products.

Sweden

Russian United Latvia Denmark Federation Kingdom Lithuania

Netherlands Belarus Poland Germany Czechia Ukraine Slovakia France Austria Switzerland Hungary Moldova Slovenia Croatia Romania Italy Bosnia- Serbia Herzegovina Montenegro Bulgaria Spain Albania Portugal Greece

Cyprus

Number of manufacturers from which heated tobacco products are available in European countries | 1 manufacturer, 2 manufacturers, 3 manufacturers, no heated tobacco product available | as of: 2020

20 Tobacco Control in Europe Norway

Finland Sweden

Denmark United Kingdom Netherlands Ireland Poland Belgium Germany

Luxembourg

Switzerland France Romania Slovenia

Italy Spain Portugal

Malta Cyprus

Regulation of heated tobacco products in Europe | ban, tobacco product, novel tobacco product/ tobacco-like product, regulation unclear/multiple options for regulation, no regulation, n/a | as of: 2020

3.1 %

2.4 %

1.0 % 1.0 % 1.0 % 0.9 % 0.8 %

15–24 years 25–44 years 45–64 years 65 years and over smokers former smokers never-smokers

Ever use of the heated tobacco product “Iqos” in Italy Ever use of the heated tobacco product “Iqos” in Italy by age groups | data: 2017 by smoking status | data: 2017

Excerpt from the Tobacco Atlas Germany 2020 21 References and List of Figures

1 The Tobacco Control Scale in Europe TNS opinion & social (2017) Attitudes of Europeans towards tobacco and electronic cigarettes. Special Eurobarometer 458 – Text and figures Wave EB87.1

Joossens L & Raw M (2006) The Tobacco Control Scale: a new Figure: Trends in smoking rates from 2006 to 2017 in selected scale to measure country activity. Tob Control 15: 247–253 EU countries and their ranking on the Tobacco Control Scale (TCS) from 2005 to 2019 Joossens L & Raw M (2007) Progress in tobacco control in 30 European countries, 2005 to 2007. Swiss Cancer League (ed.), Bern, Switzerland Joossens L, Feliu A & Fernandez E (2020) The Tobacco Control Scale 2019 in Europe. Association of the European Cancer Joossens L & Raw M (2011) The Tobacco Control Scale 2010 in Europe. Leagues, , Belgium, und Catalan Institute of Oncology, Association of the European Cancer Leagues (ed.), Brussels, Belgium , Spain

Joossens L & Raw M (2014) The Tobacco Control Scale . Joossens L & Raw M (2006) The Tobacco Control Scale: a new Association of the European Cancer Leagues (ed.) Brussels, Belgium scale to measure country activity. Tob Control 15: 247–253

Joossens L & Raw M (2017) The Tobacco Control Scale 2016 in Europe. Joossens L & Raw M (2007) Progress in tobacco control in 30 European Association of the European Cancer Leagues (ed.) Brussels, Belgium countries, 2005 to 2007. Swiss Cancer League (ed.), Bern, Switzerland

Joossens L, Feliu A & Fernandez, E (2020) The Tobacco Control Joossens L & Raw M (2011) The Tobacco Control Scale 2010 in Europe. Scale 2019 in Europe. Association of the European Cancer Association of the European Cancer Leagues (ed.), Brussels, Belgium Leagues, Catalan Institute of Oncology (eds.), Brussels, Belgium Joossens L & Raw M (2014) The Tobacco Control Scale 2013 in Europe. 2 Smoking Prevalence and Tobacco Control Measures Association of the European Cancer Leagues (ed.) Brussels, Belgium in Europe Joossens L & Raw M (2017) The Tobacco Control Scale 2016 in Europe. Text Association of the European Cancer Leagues (ed.) Brussels, Belgium

Feliu A, Filippidis FT, Joossens L, et al. (2019) Impact of tobacco con- The Gallup Organisation (2009) Survey on Tobacco. Analytical trol policies on smoking prevalence and quit ratios in 27 European report. Flash Eurobarometer 253 Union countries from 2006 to 2014. Tob Control 28: 101–109 TNS Opinion & Social (2007) Attitudes of Europeans towards TNS opinion & social (2017) Attitudes of Europeans towards Tobacco. Special Eurobarometer 272c/Wave 66.2 tobacco and electronic cigarettes. Special Eurobarometer 458 – Wave EB87.1 TNS Opinion & Social (2010) Tobacco. Special Eurobarometer 332/ Wave 72.3 Figures: Proportion of male smokers aged 15 years and over in the European Union (including the United Kingdom) in 2017 and TNS Opinion & Social (2012) Attitudes of Europeans towards change from 2006 to 2017 in percentage points: increase/no tobacco. Special Eurobarometer 385/Wave EB77.1 change, decrease | Proportion of female smokers aged 15 years and over in the European Union (including the United Kingdom) TNS Opinion & Social (2015) Attitudes of Europeans towards in 2017 and change from 2006 to 2017 in percentage points: tobacco and electronic cigarettes. Special Eurobarometer 429 increase/no change, decrease TNS opinion & social (2017) Attitudes of Europeans towards TNS Opinion & Social (2007) Attitudes of Europeans towards tobacco and electronic cigarettes. Special Eurobarometer 458 – Tobacco. Special Eurobarometer 272c/Wave 66.2 Wave EB87.1

22 Tobacco Control in Europe 3 Smoking Prevalence in Children and Adolescents in Europe Figure: Affordability of cigarettes in the European Union (including the United Kingdom) Text and figures World Health Organization (2019) WHO report on the global World Health Organization. Regional Office for Europe (2020) tobacco epidemic, 2019. Offer help to quit tobacco use. Appen- Spotlight on adolescent health and well-being. Findings from dix IX. Table 9.6 – Affordability the 2017/2018 Health Behaviour in School-aged Children (HBSC) survey in Europe and Canada. International Report. Volume 2. Figure: Cigarette prices in the European Union (including the Key Data. Copenhagen, Denmark United Kingdom)

4 Taxation in Europe World Bank (2019) E-cigarettes: use and taxation. WBG Global Tobacco Control Program, World Bank Group, Washington, D. C., USA Text World Health Organization (2019) WHO report on the global Chaloupka FJ, Straif K & Leon ME (2011) Effectiveness of tax and tobacco epidemic, 2019. Offer help to quit tobacco use. Appen- price policies in tobacco control. Tob Control 20: 235–238 dix IX. Table 9.1 – Taxes and retail price for a pack of 20 cigarette most sold brand. Conference of the Parties to the WHO Framework Convention on Tobacco Control (2016) Electronic nicotine delivery systems and World Health Organization (2019) WHO report on the global electronic non-nicotine delivery systems (ENDS/ENNDS). Seventh tobacco epidemic, 2019. Offer help to quit tobacco use. World session, Delhi, India, 7–12 November 2016. Provisional agenda Health Organization, Geneva, Switzerland item 5.5.2. FCTC/COP/7/11. August 2016 Figure: Prices in Euro of a pack of 20 cigarettes of the most sold Council of the European Union (2011) Council Directive 2011/64/ brand and smoking prevalence rates in three member states of the EU of 21 June 2011 on the structure and rates of excise duty European Union from 2006 to 2018 applied to manufactured tobacco. Official Journal of the Euro- pean Union L 176/124–L 176/136 TNS opinion & social (2017) Attitudes of Europeans towards tobacco and electronic cigarettes. Special Eurobarometer 458 – International Agency for Research on Cancer (2011) Effectiveness Wave EB87.1 of tax and price policies for tobacco control. IARC Handbooks of Cancer Prevention, Tobacco Control, Vol. 14. International Agency World Health Organization (2019) WHO report on the global for Research on Cancer, Lyon, France tobacco epidemic, 2019. Offer help to quit tobacco use. Appen- dix IX. Table 9.1 – Taxes and retail price for a pack of 20 cigarette Levy DT, Tam J, Kuo C, Fong GT & Chaloupka F (2018) The impact most sold brand of implementing tobacco control policies: the 2017 Tobacco Con- trol Policy Scorecard. J Public Health Manag Pract 24: 448–457 5 Smoke-Free Legislation in Europe

Lopez-Nicolas A & Stoklosa M (2019) Tax harmonisation and Text tobacco product prices in the European Union, 2004–2015. Tob Control 28: 434–439 Feliu A, Filippidis FT, Joossens L, et al. (2019) Impact of tobacco control policies on smoking prevalence and quit ratios in 27 Stoklosa M, Drope J & Chaloupka FJ (2016) Prices and e-cigarette European Union countries from 2006 to 2014. Tob Control 28: demand: evidence from the European Union. Nicotine Tob Res 18: 101–109 1973–1980 Frazer K, Callinan JE, McHugh J, et al. (2016) Legislative smoking World Bank (2019) E-cigarettes: use and taxation. WBG Global bans for reducing harms from secondhand smoke exposure, Tobacco Control Program, World Bank Group, Washington, D. C., USA smoking prevalence and tobacco consumption. Cochrane Data- base Syst Rev 2: CD005992 World Health Organization (2014) Guidelines for implementation of Article 6 of the WHO FCTC. Price and tax measures to reduce Gallup Organisation (2009) Survey on Tobacco. Analytical report. demand for tobacco. Flash Eurobarometer 253. European Commission

World Health Organization (2019) WHO report on the global Hoffman SJ & Tan C (2015) Overview of systematic reviews on tobacco epidemic, 2019. Offer help to quit tobacco use. World the health-related effects of government tobacco control policies. Health Organization, Geneva, Switzerland BMC Public Health 15: 744

Excerpt from the Tobacco Atlas Germany 2020 23 References and List of Figures

International Agency for Research on Cancer & World Health German Cancer Research Center (2011) Perspektiven für Organization (2009) Evaluating the Effectiveness of Smoke-free Deutschland: Das Rahmenübereinkommen der WHO zur Eindäm- Policies. Vol. 13, IARC Handbooks of Cancer Prevention, Tobacco mung des Tabakgebrauchs. WHO Framework Convention on Tobacco Control, International Agency for Research on Cancer, Lyon, Control (FCTC), Heidelberg, Germany France European Parliament & Council of the European Union (2014) Levy DT, Tam J, Kuo C, Fong GT & Chaloupka F (2018) The impact Directive 2014/40/EU of the European Parliament and of the Council of implementing tobacco control policies: the 2017 Tobacco Con- of 3 April 2014 on the approximation of the laws, regulations and trol Policy Scorecard. J Public Health Manag Pract 24: 448–457 administrative provisions of the Member States concerning the manufacture, presentation and sale of tobacco and related products Rando-Matos Y, Pons-Vigues M, Lopez MJ, et al. (2017) Smokefree and repealing Directive 2001/37/EC. Official Journal of the European legislation effects on respiratory and sensory disorders: a syste­ Union L 127/121–L 127/138 matic review and meta-analysis. PLoS One 12: e0181035 Feliu A, Filippidis FT, Joossens L, et al. (2019) Impact of tobacco con- TNS opinion & social (2017) Attitudes of Europeans towards trol policies on smoking prevalence and quit ratios in 27 European tobacco and electronic cigarettes. Special Eurobarometer 458 – Union countries from 2006 to 2014. Tob Control 28: 101–109 Wave EB87.1 Francis DB, Mason N, Ross JC & Noar SM (2019) Impact of tobacco- World Health Organization (2019) WHO Report on the Global pack pictorial warnings on youth and young adults: A systematic Tobacco Epidemic, 2019. Offer help to quit tobacco use. Licence: review of experimental studies. Tob Induc Dis 17: 41 CC BY-NC-SA 3.0 IGO. World Health Organization, Geneva, Switzerland McNeill A, Gravely S, Hitchman SC, Bauld L, Hammond D & Hartmann-Boyce J (2017) Tobacco packaging design for reducing Figure: Smoke-free legislation in the European Union (including tobacco use. Cochrane Database Syst Rev 4: CD011244 the United Kingdom) National Cancer Institute & World Health Organization (2016) The World Health Organization (2019) WHO Report on the Global economics of tobacco and tobacco control. Monograph 21. NIH Pub- Tobacco Epidemic, 2019. Offer help to quit tobacco use. Table 6.1 lication No. 16-CA-8029A. Department of Health and Human Ser- Public places with smoke-free legislation in Europe vices, National Institutes of Health, National Cancer Institute, World Health Organization, Bethesda, MD, U. S. und Geneva, Switzerland Figures: Smoking in bars and restaurants in the European Union (including the United Kingdom) | Attitudes towards a ban on the Noar SM, Hall MG, Francis DB, Ribisl KM, Pepper JK & Brewer use of e-cigarettes in smoke-free environments in the European NT (2016) Pictorial warnings: a meta-analysis of Union (including the United Kingdom experimental studies. Tob Control 25: 341–354

TNS opinion & social (2017) Attitudes of Europeans towards Stead M, Moodie C, Angus K, et al. (2013) Is consumer response tobacco and electronic cigarettes. Special Eurobarometer 458 – to plain/standardised tobacco packaging consistent with frame- Wave EB87.1 work convention on tobacco control guidelines? A systematic review of quantitative studies. PLoS One 8: e75919 6 Health Warnings and Plain Packaging in Europe TNS opinion & social (2017) Attitudes of Europeans towards tobacco Text and electronic cigarettes. Special Eurobarometer 458 – Wave EB87.1

Campaign for Tobacco-Free Kids (2020) Standardized or plain World Health Organization (2019) WHO report on the global tobacco packaging. International developments. Updated Febru- tobacco epidemic, 2019. Offer help to quit tobacco use. World ary 10, 2020. Factsheet Health Organization, Geneva, Switzerland

24 Tobacco Control in Europe Cigarette packs in Germany in compliance with the EU Directive Bloomberg School of Public Health. https://www.globaltobacco- and plain packaging for cigarettes in France control.org/e-cigarette_policyscan [Last Updated May 18, 2020] (accessed 7 August 2020) Photos: © German Cancer Research Center Levy DT, Tam J, Kuo C, Fong GT & Chaloupka F (2018) The impact Figure: Packaging of liquid pods for an e-cigarette and of tobacco of implementing tobacco control policies: the 2017 Tobacco Con- sticks for a heated tobacco product in accordance with the EU trol Policy Scorecard. J Public Health Manag Pract 24: 448–457 Directive as well as plain packaging of the same products in Israel National Cancer Institute (2008) The role of the media in pro- Photos: © German Cancer Research Center, Unit Cancer Prevention moting and reducing tobacco use. NIH Pub. No. 07-6242, Tobacco (European products) | © Shira Kislev (Israeli products) Control Monograph, U. S. Department of Health and Human Ser- vices, National Institutes of Health and National Cancer Institute, Plain packaging in Europe and globally Bethesda, MD, USA

Business.gov.nl (2020) Plain packaging for cigarettes and rolling Directive 2003/33/EC of the European Parliament and of the tobacco. https://business.gov.nl/amendment/plain-packag- Council of 26 May 2003 on the approximation of the laws, ing-cigarettes-and-rolling-tobacco/ (accessed 15 October 2020) regulations and administrative provisions of the Member States relating to the advertising and sponsorship of tobacco prod- Campaign for Tobacco-Free Kids (2020) Standardized or plain ucts. Official Journal of the European Union L 152, 20.06.2003, tobacco packaging. International developments. Updated Febru- p. 16–19 ary 10, 2020. Factsheet Directive 2010/13/EU of the European Parliament and of the European Parliament & Council of the European Union (2014) Council of 10 March 2010 on the coordination of certain provi- Directive 2014/40/EU of the European Parliament and of the sions laid down by law, regulation or administrative action in Council of 3 April 2014 on the approximation of the laws, Member States concerning the provision of audiovisual media regulations and administrative provisions of the Member States services (Audiovisual Media Services Directive). Official Journal of concerning the manufacture, presentation and sale of tobacco the European Union L 95, 15.4.2010, p. 1–24 and related products and repealing Directive 2001/37/EC. Official Journal of the European Union L 127/121–L 127/138 Directive 2014/40/EU of the European Parliament and of the Council of 3 April 2014 on the approximation of the laws, reg- Ministry of Health, Welfare and Sport (2019) The national Preven- ulations and administrative provisions of the Member States tion Agreement. A healthier Netherlands concerning the manufacture, presentation and sale of tobacco and related products and repealing Directive 2001/37/EC. Official Figure: Attitudes towards the introduction of plain packaging in Journal of the European Union L 127, 29.4.2014, p. 1–38 the European Union (including the United Kingdom) TNS opinion & social (2017) Attitudes of Europeans towards tobacco TNS opinion & social (2017) Attitudes of Europeans towards tobacco and electronic cigarettes. Special Eurobarometer 458 – Wave EB87.1 and electronic cigarettes. Special Eurobarometer 458 – Wave EB87.1 World Health Organization (2019) WHO report on the global 7 Tobacco and E-Cigarette Advertising in Europe tobacco epidemic, 2019. Offer help to quit tobacco use. World Health Organization, Geneva, Switzerland Text Figure: Advertising bans for tobacco products and e-cigarettes in Collins L, Glasser AM, Abudayyeh H, Pearson JL & Villanti AC the European Union (including the United Kingdom) (2019) E-cigarette marketing and communication: how e-ciga- rette companies market e-cigarettes and the public engages with Institute for Global Tobacco Control (2020) Country laws regu- e-cigarette information. Nicotine Tob Res 21: 14–24 lating e-cigarettes: a policy scan. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health. https://www.globaltobacco- Filippidis FT, Laverty AA, Fernandez E, Mons U, Tigova O & Varda- control.org/e-cigarette_policyscan [Last Updated May 18, 2020] vas CI (2017) Correlates of self-reported exposure to advertising (accessed 12 August 2020) of tobacco products and electronic cigarettes across 28 European Union member states. Tob Control 26: e130–e133 World Health Organization (2019) WHO report on the global tobacco epidemic, 2019. Offer help to quit tobacco use. Appen- Institute for Global Tobacco Control (2018) Country laws regu- dix VI. Table 6.10 – Bans on direct advertising lating e-cigarettes: a policy scan. Baltimore, MD: Johns Hopkins

Excerpt from the Tobacco Atlas Germany 2020 25 References and List of Figures

World Health Organization (2019) WHO report on the global World Health Organization (2019) WHO report on the global tobacco epidemic, 2019. Offer help to quit tobacco use. Appen- tobacco epidemic, 2019. Offer help to quit tobacco use. World dix VI. Table 6.11 – Bans on indirect advertising Health Organization, Geneva, Switzerland

World Health Organization (2019) WHO report on the global Figure: Support for the treatment of tobacco dependence in the tobacco epidemic, 2019. Offer help to quit tobacco use. Appen- European Union (including the United Kingdom) dix VI. Table 6.12 – Additional bans on indirect advertising World Health Organization (2019) WHO report on the global Figures: Awareness of e-cigarette advertising in the European tobacco epidemic, 2019. Offer help to quit tobacco use. World Union (including the United Kingdom) | Attitudes towards a ban Health Organization, Geneva, Switzerland on displaying tobacco products at the point of sale (display ban) in the European Union (including the United Kingdom) Figures: Quit attempts in the European Union (including the United Kingdom) | Use of assistance for smoking cessation in the TNS opinion & social (2017) Attitudes of Europeans towards European Union (including the United Kingdom) tobacco and electronic cigarettes. Special Eurobarometer 458 – Wave EB87.1 TNS opinion & social (2017) Attitudes of Europeans towards tobacco and electronic cigarettes. Special Eurobarometer 458 – 8 Smoking Cessation in Europe Wave EB87.1

Text 9 Use and Regulation of E-Cigarettes in Europe

Filippidis FT, Laverty AA, Mons U, Jimenez-Ruiz C & Vardavas CI Text (2019) Changes in smoking cessation assistance in the European Union between 2012 and 2017: pharmacotherapy versus coun- Institute for Global Tobacco Control (2020) Country laws regu- selling versus e-cigarettes. Tob Control 28: 95–100 lating e-cigarettes: a policy scan. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health. https://www.globaltobacco- Hartmann-Boyce J, Chepkin SC, Ye W, Bullen C & Lancaster T control.org/e-cigarette_policyscan [Last Updated May 18, 2020] (2018) Nicotine replacement therapy versus control for smoking (accessed 12 August 2020) cessation. Cochrane Database Syst Rev 5: CD000146 Laverty AA, Filippidis FT & Vardavas CI (2018) Patterns, trends and Hartmann-Boyce J, Hong B, Livingstone-Banks J, Wheat H & Fan­ determinants of e-cigarette use in 28 European Union Member shawe TR (2019) Additional behavioural support as an adjunct to States 2014–2017. Prev Med 116: 13–18 pharmacotherapy for smoking cessation. Cochrane Database Syst Rev 6: CD009670 TNS opinion & social (2017) Attitudes of Europeans towards tobacco and electronic cigarettes. Special Eurobarometer 458 – Wave EB87.1 Lancaster T & Stead LF (2017) Individual behavioural counselling for smoking cessation. Cochrane Database Syst Rev 3: CD001292 Directive 2014/40/EU of the European Parliament and of the Council of 3 April 2014 on the approximation of the laws, reg- Levy DT, Tam J, Kuo C, Fong GT & Chaloupka F (2018) The impact ulations and administrative provisions of the Member States of implementing tobacco control policies: the 2017 Tobacco Con- concerning the manufacture, presentation and sale of tobacco trol Policy Scorecard. J Public Health Manag Pract 24: 448–457 and related products and repealing Directive 2001/37/EC. Official Journal of the European Union L 127, 29.4.2014, p. 1–38 TNS opinion & social (2017) Attitudes of Europeans towards tobacco and electronic cigarettes. Special Eurobarometer 458 – World Bank (2019) E-cigarettes: use and taxation. WBG Global Wave EB87.1 Tobacco Control Program, World Bank Group, Washington, D. C., USA

26 Tobacco Control in Europe Figures: E-cigarette use (ever, currently) in the European Union Inc. (2019) Annual Report 2018 (including the United Kingdom) by smoking status | Use of e-cig- arettes in the European Union (including the United Kingdom) | Kotz D & Kastaun S (2018) E-cigarettes and heat-not-burn prod- E-cigarette use (ever, currently) in the European Union (including ucts: representative data on consumer behaviour and associated the United Kingdom) by age group | Frequency of e-cigarette use factors in the German population (the DEBRA study). Bundes- among current users in the European Union (including the United gesundheitsblatt Gesundheitsforschung Gesundheitsschutz 61: Kingdom) 1407–1414

TNS opinion & social (2017) Attitudes of Europeans towards tobacco Liu X, Lugo A, Spizzichino L, et al. (2018) Heat-not-burn tobacco and electronic cigarettes. Special Eurobarometer 458 – Wave EB87.1 products: concerns from the Italian experience. Tob Control 28: 113–114 Figure: Regulation of e-cigarettes in the European Union (including the United Kingdom) Philip Morris International (2020) Investor Information. July 2020

Institute for Global Tobacco Control (2020) Country laws regu- Sutanto E, Miller C, Smith DM, et al. (2019) Prevalence, use behav- lating e-cigarettes: a policy scan. Baltimore, MD: Johns Hopkins iors, and preferences among users of heated tobacco products: Bloomberg School of Public Health. https://www.globaltobacco- findings from the 2018 ITC Japan Survey. Int J Environ Res Public control.org/e-cigarette_policyscan [Last Updated May 18, 2020] Health 16: 4630 (accessed 12 August 2020) Figure: Number of manufacturers from which heated tobacco 10 Use and Regulation of Heated Tobacco Products in Europe products are available in European countries

Text Germany (2020) Weiterer wichtiger Meilenstein auf dem Weg zu einer besseren Zukunft, „A Better British American Tobacco Germany (2020) Weiterer wichtiger Tomorrow“. 17. Juni 2020. BAT Germany führt neuen glo™ Tabak­ Meilenstein auf dem Weg zu einer besseren Zukunft, „A Better erhitzer auf deutschem Markt ein. Pressemitteilung. http:// Tomorrow“. 17. Juni 2020. BAT Germany führt neuen glo™ Tabak­ www.bat.de/group/sites/BAT_AXBF4K.nsf/vwPagesWebLive/ erhitzer auf deutschem Markt ein. Pressemitteilung. http:// DOBQMGDT?opendocument (accessed 18 June 2020) www.bat.de/group/sites/BAT_AXBF4K.nsf/vwPagesWebLive/ DOBQMGDT?opendocument (accessed 18 June 2020) British American Tobacco p.l.c. (2020) Half year report to 30 June 2020. Multi-category strategy delivers growth in difficult times. British American Tobacco p.l.c. (2020) Half year report to 30 June News Release 2020. Multi-category strategy delivers growth in difficult times. News Release Japan Tobacco Inc. (2019) Annual Report 2018

Brose LS, Simonavicius E & Cheeseman H (2018) Awareness and Pfannschmidt C (2020) Verbreitung von Ploom. JT International use of ‘heat-not-burn’ tobacco products in Great Britain. Tob Germany GmbH Communications Manager, Corporate Affairs & Regul Sci 4: 44–50 Communications. Persönliche Mitteilung am 26. August 2020

Czoli CD, White CM, Reid JL, RJ OC & Hammond D (2019) Aware­ Philip Morris International (2020) Investor Information. July 2020 ness and interest in IQOS heated tobacco products among youth in Canada, England and the USA. Tob Control 9: 89–95 Figure: Regulation of heated tobacco products in Europe

Conference of the Parties to the WHO Framework Convention on Institute for Global Tobacco Control (2020) Countries that Tobacco Control (2018) Decision FCTC/COP8(22) Novel and emerging Regulate Heated Tobacco Products June, 2020. https://global­ tobacco products. Conference of the Parties to the WHO Framework tobaccocontrol.org/resources/countries-regulate-heated-tobacco Convention on Tobacco Control. Eighth session Geneva, Switzerland, (accessed 10 August 2020). John Hopkins Bloomberg School of 1−6 October 2018. https://www.who.int/fctc/cop/sessions/cop8/ Public Health and Institute for Global Tobacco Control FCTC__COP8(22).pdf (accessed 12 December 2019) Figure: Ever use of the tobacco heater “Iqos” in Italy by age groups | Institute for Global Tobacco Control (2020) Countries that Ever use of the tobacco heater “Iqos” in Italy by smoking status Regulate Heated Tobacco Products June, 2020. https://globalto- baccocontrol.org/resources/countries-regulate-heated-tobacco Liu X, Lugo A, Spizzichino L, et al. (2018) Heat-not-burn tobacco (accessed 10 August 2020). John Hopkins Bloomberg School of products: concerns from the Italian experience. Tob Control 28: Public Health and Institute for Global Tobacco Control 113–114

Excerpt from the Tobacco Atlas Germany 2020 27