Tobacco Control in Europe. Excerpt from the Tobacco Atlas Germany 2020 1 the Tobacco Control Scale in Europe

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Tobacco Control in Europe

Excerpt from the Tobacco Atlas Germany 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 Contents

Tobacco Control in Europe. Excerpt from the Tobacco Atlas Germany 2020 1 The Tobacco Control Scale in Europe...... 2

Responsible for the Content 3 Smoking Prevalence in Children and Adolescents in Europe...... 6 German Cancer Research Center Unit Cancer Prevention and 4 Taxation in Europe...... 8 WHO Collaborating Centre for Tobacco Control 5 Smoke-Free Legislation in Europe...... 10 Dr. Katrin Schaller (head, comm.) 6 Health Warnings and Plain Packaging in Europe...... 12 Im Neuenheimer Feld 280 69120 Heidelberg 7 Tobacco and E-Cigarette Advertising in Europe...... 14 Germany 8 Smoking Cessation in Europe...... 16 www.dkfz.de www.tabakkontrolle.de 9 Use and Regulation of E-Cigarettes in Europe...... 18 [email protected] 10 Use and Regulation of Heated Tobacco Products in Europe...... 20 Layout, Illustration, Typesetting Dipl.-Biol. Sarah Kahnert References and List of Figures...... 22 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

Norway Iceland 5 66 Since 2004, the Tobacco Control Scale (TCS) has been used to The United Kingdom and Ireland have always been at the top 4 70 Finland Sweden compare tobacco control activities in many European countries | of the scale and Germany has always been at the bottom | 6 62 Developed by international tobacco control experts, the scale Hungary has intensified its tobacco control measures since 2010, 15 52 United Estonia assigns a score (number of points) to each tobacco control mea rising from 27th place in 2010 to 8th place in 2019. In contrast, Kingdom 23 49 Russian sure, with a higher score for measures that are highly effective Germany has been continuously downgraded since 2007 as it 1 80 Denmark Latvia Federation 29 47 (e. g. high cigarette prices) and a lower score for those that are has not implemented significant tobacco control measures since 29 47 Poland 23 49 Ireland Netherlands Lithuania less effective. When a country implements a measure in full, it then, and came last in 2019. In a European comparison, Ger- Netherlands 23 49 3 73 14 53 29 47 receives the full score. When it partially implements a measure, many is one of the countries with the greatest need for action in Germany Czechia Belgium 36 40 23 49 Slovakia Ukraine it receives only part of the maximum score. tobacco control. 10 58 Luxembourg Austria 32 46 20 50 34 44 France 20 50 Hungary Romania 8 59 2 74 Switzerland Slovenia 12 57 8 59 Croatia Measures to restrict tobacco industry interference (2)new since 2019 Not ratifying the FCTC (-1) 35 41 Serbia Bulgaria 3 2 new since 2019 17 51 33 45 Spain 27 48 Portugal Italy Measures to combat illicit tobacco trade (3)new since 2019 10 10 58 Turkey ■ ratication of the FCTC Illicit Trade Protocol (1)■ track and trace system (2) Price of cigarettes (30) 20 50 15 52 Greece 17 51 30 maximum score for 13 54 10 €/pack in 2018* Malta Smoking cessation support (10) ■ quitline (2) Cyprus 10 17 51 ■ medical smoking status recording (1)■ network of support (4) total 27 48 ■ brief advice in primary care (1) ■ medication reimbursement (2) maximum Smoke-free public places (22) TCS ranking of the European countries in 2019 Israel 100 points ■ workplaces (10) rank | points: 7 61 Health warning labels (10) ■ bars and restaurants (8) ■ plain packaging (4) ■ size (3) ■ pictorial health warnings (3) 13 ■ public transport (4) 40 45 50 55 60 65 70 75 80

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** 93 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 81 80 77 Points 2005 2007 2010 2013 2016 2019 73 74 74 Price of cigarettes 20 19 17 14 13 14 64 Smoke-free public places 2 2 11 11 11 11 59 56 57 Spending on campaigns 0 0 0 0 0 0 55 53 52 53 Bans on advertising 4 5 4 4 4 4 50 47 50 46 Health warning labels 6 6 1 1 5 5 40 Smoking cessation support 4 5 4 2 4 4 37 37 36 37 35 32 36 Illicit tobacco trade – – – – – 2 31 32 31 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 2005 2007 2010 2013 2016 2019

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

2 Tobacco Control in Europe Excerpt from the Tobacco Atlas Germany 2020 3 United Kingdom Hungary Germany

Tobacco Control Scale (TCS) Tobacco Control Scale (TCS) Tobacco Control Scale (TCS) Smoking Prevalence and 2005 2007 2010 2013 2016 2019 2005 2007 2010 2013 2016 2019 2005 2007 2010 2013 2016 2019 Tobacco Control Measures in Europe 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 % The proportion of smokers in the member states of the Euro- The better evidence-based tobacco control measures are imple- 33 % 32 % 33 % 30 % 30 % pean Union, including the United Kingdom, fell by an average mented in a country, the lower the proportion of smokers in the 28 % 36 % 27 % 27 % 26 % 27 % of 18.8 percent between 2006 and 2017 | However, according population and the higher the proportion of those who stop 22 % 25 % 28 % to a European-wide representative survey, there are very large smoking | In Germany, effective tobacco control measures were 17 % 25 % 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 2006 2008 2010 2012 2014 2016 2018 2006 2008 2010 2012 2014 2016 2018 2006 2008 2010 2012 2014 2016 2018 proportion of smokers has not changed between 2006 and 2017 between 2008 and 2009 and there has been hardly any change 2005 2007 2009 2011 2013 2015 2017 2019 2005 2007 2009 2011 2013 2015 2017 2019 2005 2007 2009 2011 2013 2015 2017 2019 and in five countries (Slovakia, Croatia, Portugal, France, Slovenia) since then. it has even increased. In 17 countries, the proportion of smokers Trends in smoking rates from 2006 to 2017 in selected EU countries and their ranking in the Tobacco Control Scale (TCS) has decreased more among men than among women, and in from 2005 to 2019 | data: Eurobarometer and Tobacco Control Scale nine countries more among women than among men.

EU 28 EU 28 30 -7 22 -5

Finland Finland Sweden Sweden 24 -5 16 -7 5 -10 9 -13 Estonia Estonia 33 -12 15 -9 Denmark Denmark United Latvia United Latvia Kingdom 19 -16 47 -5 Kingdom 18 -11 21 0 Ireland 17 -16 Netherlands Lithuania Ireland 17 -15 Netherlands Lithuania 20 -8 22 -9 Poland 42 -8 18 -11 17 -10 Poland 19 -1 Belgium Germany 34 -6 Belgium Germany 26 -4 21 -9 28 -8 17 -5 23 -2 Czechia Slovakia Czechia Slovakia Luxembourg 38 3 34 2 Luxembourg 21 -2 19 0 25 -4 Austria Hungary 17 -6 Austria Hungary 34 -4 23 -1 31 -13 Romania 23 -6 Romania France France Slovenia 38 -4 Slovenia 19 -1 40 1 Croatia 32 5 Croatia 32 7 24 3 40 -2 31 6 Bulgaria Bulgaria Italy Italy 45 3 28 -2 Proportion of male smokers aged Spain 34 -5 Proportion of female smokers aged Spain 17 -7 Portugal 30 -10 Portugal 25 -3 15 years and over in the European 33 -2 Greece 15 years and over in the European 19 5 Greece Union (including the United King- 41 -7 Union (including the United King- 32 -5 dom) in 2017 dom) in 2017 Malta Malta 5 % 26 % 47 % 30 1 Cyprus 9 % 20.5 % 32 % 18 -4 Cyprus 39 -9 17 1 and change from 2006 to 2017 in percentage and change from 2006 to 2017 in percentage points: increase/no change, decrease | points: increase/no change, decrease | data: Eurobarometer 2007 and 2017 data: Eurobarometer 2007 and 2017

4 Tobacco Control in Europe Excerpt from the Tobacco Atlas Germany 2020 5 1 % 0 % United Ireland 1 % 0 % Kingdom* 4 % 3 % Smoking Prevalence in Children 4 % 2 %

1 % 2 % and Adolescents in Europe Finland Hungary 1 % 2 % 8 % 5 % 6 % 6 %

In 2018, an average of around 17 percent of 15-year-old boys. In three countries each there were no changes for boys or 2 % 1 % Czechia Austria adolescents have smoked at least one cigarette within the last girls. In four countries (Bulgaria, Italy, Wales, Lithuania) the pro- 0 % 0 % 30 days in the countries of the European Union including the portion of smoking girls has increased, while for boys this is the 5 % 3 % United Kingdom | This is shown by an international represen case in five countries (Bulgaria, Lithuania, England, Spain, Ireland). 7 % 3 % tative survey on the health behaviour of school children. There 1 % 0 % is no significant difference in smoking behaviour between boys The proportion of young people who smoke increases sig- Luxembourg Germany 2 % 1 % (16.7 percent) and girls (17.9 percent). nificantly with age | In the countries of the European Union 4 % 5 % including the United Kingdom, in 2018, one percent of 11-year- 5 % 5 % 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. 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 EU 28 17 -3 19 -4

Finland Finland Sweden Sweden 18 -7 17 -4 11 0 12 -4 Estonia Estonia 19 -2 17 -3 Denmark Denmark United Latvia United Latvia Kingdom* 18 -1 21 -1 Kingdom* 16 -6 24 0 Ireland 11 0 Netherlands Lithuania Ireland 13 -2 Netherlands Lithuania 10 2 13 -5 Poland 31 2 10 -1 13 -8 Poland 27 5 Belgium* Germany 16 -7 Belgium* Germany 19 -5 13 -5 15 -2 11 -8 15 -6 Czechia Slovakia Czechia Slovakia Luxembourg 16 -2 20 -4 Luxembourg 21 -7 22 -3 12 -6 Austria Hungary 14 -10 Austria Hungary 16 -6 18 -5 21 -7 Romania 25 -7 Romania France France Proportion of 15-year-old boys who Slovenia 23 0 Proportion of 15-year-old girls who Slovenia 22 -1 16 -8 Croatia 19 -9 Croatia have smoked at least one cigarette 14 -8 have smoked at least one cigarette 17 -5 25 -5 24 -3 Bulgaria Bulgaria in the last 30 days in the European Italy in the last 30 days in the European Italy 26 1 38 2 Union (including the United King- Spain 24 -3 Union (including the United King- Spain 33 2 Portugal 15 2 Portugal 17 0 dom, excluding Cyprus) in 2018 12 -4 Greece dom, excluding Cyprus) in 2018 9 -6 Greece 16 -4 19 0 10 % 20.5 % 31 % 8 % 23 % 38 % Malta Malta 14 -2 Cyprus 8 -11 Cyprus and change from 2014 to 2018 in percentage and change from 2014 to 2018 in percentage points: increase/no change, decrease | points: increase/no change, decrease | *unweighted average (Belgium: Flemish, French; *unweighted average (Belgium: Flemish, French; United Kingdom: England, Scotland, Wales) | United Kingdom: England, Scotland, Wales) | n/a | data: HBSC 2013/2014 and 2017/2018 n/a | data: HBSC 2013/2014 and 2017/2018

6 Tobacco Control in Europe Excerpt from the Tobacco Atlas Germany 2020 7 The WHO recommends tobacco taxes should account Taxation in Europe 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 Tobacco tax increases are the most effective measure to curb A specific tax on electronic cigarettes can contribute to pre- 4.38 3.55 Denmark tobacco use | In high-income countries, a ten percent increase in venting young people from using e-cigarettes, because young United Latvia prices reduces tobacco consumption by about four percent. All people are particularly sensitive to price | An estimate for Europe Kingdom 4.28 5.39 4.54 3.18 tobacco products should be taxed at a similar level, as large dif- suggests that a ten percent increase in e-cigarette prices is asso- Ireland 8.43 8.77 Netherlands Lithuania 6.08 11.37 4.69 6.19 Poland ferences in the taxation of different tobacco products encourage ciated with a decrease of e-cigarette sales by about eight percent. 3.91 2.77 Belgium Germany 4.59 3.26 smokers to switch to cheaper products rather than quit. The Conference of the Parties to the FCTC and the World Bank rec- 5.30 6.10 4.59 5.64 Czechia Slovakia ommend taxation of e-cigarettes at a level that makes them less Luxembourg 3.87 3.48 3.92 3.06 In 2018, 18 EU member states have reached the highest affordable to minors. At the same time, taxes on all other tobacco 1.83 4.64 Austria Hungary 3.75 4.76 level of implementation of tobacco taxation according to the products should be increased to prevent use of tobacco products. 4.94 3.46 Romania France Slovenia 5.31 3.40 WHO definition | Despite the targets set by the EU Directive To facilitate taxation, all e-cigarettes and liquids should be taxed, 7.48 7.78 Croatia 4.03 3.51 2011/64/EU for tobacco taxes, there is wide variation in taxes regardless of nicotine content, including nicotine-free products. 5.32 3.35 Bulgaria Italy on the most commonly sold brand of cigarettes. There are also 5.14 2.57 Spain 5.16 4.90 large price differences between cigarettes and roll-your-own There is no harmonized EU regulation for electronic cigarettes | Portugal 4.97 4.52 tobacco. Currently, 14 EU member states levy a specific tax on e-cigarettes. 5.90 4.49 Greece 6.15 4.18

Malta 5.36 5.25 Cyprus 4.98 4.33 Country 2008 2010 2012 2014 2016 2018 Cigarette prices in the European Union Austria 1.02 1.13 1.19 1.26 1.24 1.26 (including the United Kingdom) | price of a pack Belgium 1.25 1.44 1.50 1.62 1.69 1.67 in Euros taking into account Purchasing Power Bulgaria 3.03 4.14 4.08 4.05 3.70 3.47 Standards (PPS) per capita 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 1.50 2.50 3.50 4.50 5.50 6.50 7.50 8.50 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 weighted average price of a package in Euro | as of: 2018 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 United Kingdom Hungary Germany Greece 1.37 1.57 2.15 2.45 2.48 2.70 38 % 33 % Hungary 2.10 2.25 2.62 3.03 3.20 2.98 33 % Ireland 1.94 2.33 2.39 2.30 1.89 1.92 36 % 36 % 30 % Italy 1.30 1.38 1.86 1.87 1.88 1.90 28 % 27 % 27 % 32 % 30 % 26 % Latvia 1.88 2.54 2.37 2.54 2.37 2.35 28 % 22 % Lithuania 1.42 2.43 2.21 2.18 2.30 2.36 27 % 25 % 25 % 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 17 % Netherlands 1.20 1.31 1.46 1.59 1.59 1.57 11.44 11.15 Poland 1.70 2.09 2.71 3.03 3.00 2.79 8.83 Portugal 1.95 2.06 2.62 2.70 2.67 2.56 9.86 6.60 Romania 2.49 3.79 4.56 4.33 4.12 3.66 9.29 5.90 Slovakia 1.65 1.93 2.03 2.02 2.07 1.99 7.45 3.87 6.77 2.72 3.00 3.69 5.81 5.86 6.01 Slovenia 1.17 1.41 1.65 1.89 1.79 1.65 2.52 4.09 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 2007 2009 2011 2013 2015 2017 2007 2009 2011 2013 2015 2017 2007 2009 2011 2013 2015 2017 United Kingdom 2.22 2.49 2.48 2.63 2.77 2.98 2006 2008 2010 2012 2014 2016 2018 2006 2008 2010 2012 2014 2016 2018 2006 2008 2010 2012 2014 2016 2018

Affordability of cigarettes in the European Union (including the United Kingdom)| percentage of the gross domestic product Prices in Euro of a pack of 20 cigarettes of the most sold brand and smoking prevalence rates in three member states of the per capita needed to buy 2,000 cigarettes of most sold brand European Union from 2006 to 2018 | data on smoking prevalence rates: Eurobarometer 2017

8 Tobacco Control in Europe Excerpt from the Tobacco Atlas Germany 2020 9 The WHO recommends to make all public places com- Smoke-Free Legislation in Europe pletely smoke-free. EU 28 20 8

Finland Sweden 7 2 2 1 Estonia Smoke-free legislation protects health | Smoke-free legislation level of implementation as defined by the World Health Organi- 11 4 Denmark reduces exposure to toxicants from secondhand smoke and sation. Cyprus and Hungary only lack a ban on smoking in public United Latvia reduces the incidence of cardiovascular as well as respiratory dis- transport to achieve the highest level of implementation. Kingdom 39 3 22 7 eases. It also contributes to the reduction of smoking prevalence. Ireland 5 2 Netherlands Lithuania 6 3 20 5 Poland Smoking is still prevalent especially in bars, despite existing 11 5 Belgium Germany 14 6 To be effective, smoke-free legislation must be comprehensive laws | In 2017, 20 percent of people in Europe who had visited a 18 4 22 4 Czechia Slovakia and be well enforced | Smoking rooms, designated smoking areas bar in the last six months saw people smoking inside on their last Luxembourg 73 44 50 16 or ventilation do not effectively protect from secondhand smoke. visit. 11 2 Austria Hungary 57 30 7 4 Romania France Slovenia 11 5 Protection from secondhand smoke varies widely between the The majority of people in the European Union support smoke- 16 7 Croatia 6 2 countries of the European Union | Only seven EU member states free legislation | Approval of the laws increases after their 77 14 Bulgaria Italy and seven other countries in the WHO European Region have implementation – even among smokers. The majority (63 per- 42 18 Spain 15 8 implemented comprehensive smoke-free legislation without cent) is also in favour of a ban on e-cigarette use in smoke-free Portugal 12 3 exemptions or smoking rooms, and have achieved the highest public places. 38 10 Greece 87 70

Malta 39 13 Cyprus 65 47 Educational Healthcare Government Pubs Public facilities Universities Indoor oﬃces Restaurants Country facilities facilities and bars transport Smoking in bars and restaurants in the European except universities Union (including the United Kingdom) Austria Belgium 0 % 20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 % Bulgaria (2012) 10 % Croatia Cyprus Czechia of respondents have visited a bar and seen people smoking inside in the last six months | percentages of respondents who have Denmark visited a restaurant and seen people smoking inside in the last six months | data: Eurobarometer 2017 Estonia Finland France Germany Greece (2010) 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 % Hungary Ireland (2004) Italy 12 % 13 % 17 % 17 % 18 % 32 % Latvia 20 % 21 % 22 % 24 % 26 % 13 % 20 % 25 % 29 % Lithuania 79 % 21 % 26 % 28 % 31 % 28 % 30 % 78 % 22 % 29 % 26 % 33 % 41 % Luxembourg 75 % 73 % 73 % 37 % 40 % Malta (2010) 71 % 70 % 70 % 69 % 69 % 67 % 66 % 66 % 65 % 65 % 24 % Netherlands 63 % 62 % 62 % 62 % Poland 60 % 60 % 59 % 59 % 58 % 56 % Portugal 53 % Romania (2015) 50 % 50 % 50 % Slovakia Slovenia Spain (2010) Sweden United Kingdom (2006)

Smoke-free legislation in the European Union (including the United Kingdom) | comprehensive ban, ban with exemptions 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 (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 Attitudes towards a ban on the use of e-cigarettes in smoke-free environments in the European Union (including the United King- purpose, blue country name: maximum level of implementation (since year) | as of: 2018 dom) | in favour, against, don’t know | EU 28: weighted average of the 28 countries | data: Eurobarometer 2017

10 Tobacco Control in Europe Excerpt from the Tobacco Atlas Germany 2020 11 Health Warnings and Plain Packaging Norway in Europe 1 July 2018

United Kingdom 20 May 2017 Health warnings on tobacco products are an effective and low- promotional information. It only allows a standard colour for the Countries with plain packaging cost tobacco prevention intervention, as the tobacco industry packaging and a standard font for the brand name. It motivates outside Europe bears the costs | Large pictorial warnings can prevent young smokers to think about quitting smoking, increases calls to NetherlandsNetherlanes Australia 1 December 2012 people from taking up smoking, motivate smokers to quit smok- quitlines and enhances the effectiveness of health warnings. The 1 October 2020 ing and prevent relapse in former smokers. Providing the national sparse available evidence suggests that plain packaging may New Zealand 6 June 2018 quitline number on cigarette packs increases the number of calls reduce smoking prevalence. Ireland Hungary Belgium from smokers looking for help to quit. 20 September 2018 1 January 2022 Thailand 8 December 2019 1 January 2021 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 Uruguay 21 December 2019 France rial and textual warnings on cigarette packs | By implementing packaging is under consideration. 1 January 2017 the EU Directive 2014/40/EU all EU countries have reached the Slovenia Saudi Arabia 1 January 2020 1 January 2020 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 Turkey 5 January 2020 against the introduction of plain packaging. Plain packaging improves the effectiveness of health warn- Israel 8 January 2020 ings | Plain packaging prohibits the use of logos, colours and 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 introduction 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 % Cigarette packs in Germany in compliance with the EU Directive and plain packaging for cigarettes in France 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

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

12 Tobacco Control in Europe Excerpt from the Tobacco Atlas Germany 2020 13 The WHO recommends ban- Tobacco and E-Cigarette Advertising ning all forms of direct and indirect advertising. EU 28 in Europe 44 7

Finland Sweden 32 3 35 1 Estonia Advertising is powerful | Advertising for tobacco products gener- Advertising for tobacco products and e-cigarettes is still present 46 7 Denmark ates a positive opinion of tobacco products and creates a favourable in the European Union despite existing advertising bans | Several United Latvia attitude towards smoking. Tobacco advertising increases smoking EU directives prohibit the advertising for tobacco products and Kingdom 52 11 36 6 initiation and tobacco consumption. The few studies available so nicotine-containing e-cigarettes on television, radio, print and Ireland 65 23 Netherlands Lithuania 63 18 54 4 Poland far on the effect of e-cigarette advertising suggest that e-cigarette internet as well as cross-border sponsorship – but several adver- 39 7 Belgium Germany 41 3 advertising is associated with a positive attitude towards e-ciga- tising channels remain unrestricted. 55 9 39 6 Czechia Slovakia rettes and with a greater intention to use the products. Luxembourg 37 3 29 2 Only Slovenia and Spain reach the highest level in implementing 45 7 Austria Hungary 43 2 Advertising bans reduce the demand for tobacco | They reduce advertising bans, as defined by the World Health Organization. 17 1 Romania France Slovenia 37 3 awareness of advertising and increase the intention to stop 52 9 Croatia 32 4 smoking; they reduce tobacco consumption and smoking preva- Advertising bans are widely supported by the public | The 38 2 Bulgaria Italy lence. To be effective, advertising bans must be comprehensive, majority of the EU population is in favour of a ban on displaying 22 1 Spain 41 2 covering all forms of advertising and promotion. tobacco products at the point of sale (display ban). 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) 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 15 % 25 % 35 % 45 % 55 % 65 % Austria Belgium Bulgaria of respondents have seen advertising for e-cigarettes in the last 12 months (often, from time to time or rarely) | Croatia percentages of respondents who have often seen advertising for e-cigarettes in the last 12 months | data: Eurobarometer 2017 Cyprus Czechia Denmark 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 % Estonia Finland France 12 % 15 % 22 % Germany 14 % 18 % 24 % Greece 33 % 37 % 80 % 29 % 33 % 32 % 29 % Hungary 76 % 23 % 29 % 30 % 33 % 33 % 34 % 37 % 33 % 39 % 39 % 73 % 73 % 72 % 33 % 39 % Ireland 70 % 40 % 52 % Italy 35 % 39 % 47 % Latvia 63 % 61 % 60 % 60 % 59 % 59 % 59 % Lithuania 58 % 57 % 56 % 55 % 55 % 54 % 54 % 53 % Luxembourg 52 % 51 % 50 % Malta 46 % 46 % 45 % Netherlands 40 % 39 % Poland Portugal Romania Slovakia Slovenia Spain Sweden 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 United Kingdom Attitudes towards a ban on displaying tobacco products at the point of sale (display ban) in the European Union (including the United Advertising bans for tobacco products and e-cigarettes in the European Union (including the United Kingdom) | Kingdom) | in favour, against, don’t know, countries with display ban for tobacco products | EU 28: weighted average of the yes (including nicotine-free e-cigarettes), yes (tobacco products and nicotine-containing e-cigarettes), no | as of: 2018 28 countries | data: Eurobarometer 2017

14 Tobacco Control in Europe Excerpt from the Tobacco Atlas Germany 2020 15 The WHO recommends all countries to provide a quitline, stop Smoking Cessation in Europe 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 More than half of smokers in the European Union want to quit smokers use nicotine replacement products or other medical sup- 67 28 Denmark smoking | More than half of current smokers in the European port to quit smoking, and ten percent use e-cigarettes. Only five United Latvia Union have tried to quit smoking at least once, with large differ- percent try to quit smoking with the help of cessation services Kingdom 80 27 80 23 ences between countries. However, the proportion of smokers such as telephone quitlines. With regard to the use of smoking Ireland 69 26 Netherlands Lithuania 62 29 77 33 Poland who have tried to quit smoking within the last year dropped from cessation support, there are large differences at national level. 64 19 Belgium Germany 48 14 19 to 15 percent between 2014 and 2017. Most smokers attempt 64 22 58 17 Czechia Slovakia to quit or succeed in quitting at a young or middle age. Most member states of the European Union provide telephone Luxembourg 46 9 48 14 quitlines as well as nicotine replacement therapy to support 67 25 Austria Hungary 36 8 Smoking cessation support increases quit rates, but is rarely smoking cessation | However, in only ten countries the costs of 40 8 Romania France Slovenia 35 8 used | Most smokers (75 percent) quit smoking or try to quit nicotine replacement therapy are covered at least partially by 66 17 Croatia 60 11 without any method of assistance. Only eleven percent of health insurance schemes. 40 9 Bulgaria Italy 23 5 Spain 24 3 Portugal 52 15 36 6 Greece 44 12

Malta 65 24 Cyprus National Nicotine Smoking cessation support Smoking cessation support Smoking cessation support Smoking cessation support 56 17 toll-free replacement in primary care facilities in hospitals in oﬃces of in the community quitline therapy health professionals cost-covered Quit attempts in the European Union (including the United Kingdom) available cost-covered available cost-covered available cost-covered available cost-covered Country 20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 % Austria Belgium Bulgaria of smokers have ever tried to quit smoking | proportion of smokers who have tried to quit smoking within the last 12 months | Croatia data: Eurobarometer 2017 Cyprus Czechia Denmark Estonia 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 % Finland France 12 % 14 % 13 % 13 % 17 % 18 % 18 % 20 % Germany 20 % 18 % 20 % 21 % 22 % 23 % 24 % 27 % Greece 88 % 24 % 27 % 27 % 27 % 31 % 86 % 85 % 32 % 35 % 36 % 39 % Hungary 84 % 82 % 36 % 40 % 41 % 82 % 81 % 79 % 41 % Ireland 79 % 78 % 78 % 78 % 76 % 77 % 75 % Italy 73 % 72 % 72 % 72 % 72 % 69 % Latvia 66 % 65 % 63 % Lithuania 62 % 61 % 60 % Luxembourg 58 % 57 % Malta Netherlands Poland Portugal Romania Slovakia Slovenia Spain Sweden United Kingdom 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

Smoking cessation support in the European Union (including the United Kingdom) | yes, no, fully, partial, Use of assistance for smoking cessation in the European Union (including the United Kingdom) | stopped or tried to stop without yes, in most, yes, in some, data not reported/not available, data not required/not applicable | as of: 2018 assistance, used at least one aid, don’t know | EU 28: weighted average of the 28 countries | data: Eurobarometer 2017

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

EU 28 in Europe 15 2

Finland Sweden 17 1 10 Estonia 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 21 1 Denmark arettes once or twice or use them for a certain period of time in 2017, with large differences between countries. United Latvia and then stop again | Especially young people and smokers try Kingdom 16 2 24 1 out e-cigarettes. In the EU, regular use of e-cigarettes (daily or Directive 2014/40/EU sets quality and safety requirements as Ireland 18 5 Netherlands Lithuania 13 2 15 2 Poland well as rules on packaging, labelling and advertising in the EU | 15 1 Belgium Germany 13 1 In the WHO European region that goes beyond the EU, Turkey and 16 4 12 2 Czechia Slovakia Turkmenistan ban the sale of e-cigarettes and Israel bans the sale 33 % Luxembourg 20 1 10 of e-cigarettes containing more than 20 mg/ml nicotine. Several 12 2 Austria Hungary 21 3 countries prohibit the sale of e-cigarettes to minors and most 9 1 Romania France Slovenia 9 12 % countries restrict the use of e-cigarettes in smoke-free environ- 24 4 Croatia 11 1 ments. Some countries apply a specific tax on e-cigarettes. 11 4 % 4 % Bulgaria 3 % Italy 0 % 9 Spain 9 smokers former smokers never-smokers Portugal 12 1 8 1 Greece E-cigarette use ( ever, currently) in the European Union 15 3 (including the United Kingdom) by smoking status | data: Eurobarometer 2017 Malta 12 2 Cyprus Ban on use 21 3 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 Use of e-cigarettes in the European Union Austria (including the United Kingdom) | Belgium Bulgaria 8 % 10 % 12 % 14 % 16 % 18 % 20 % 22 % 24 % Croatia Cyprus Czechia of respondents are currently using e-cigarettes, previously used e-cigarettes or have tried them once or twice (ever use), Denmark percentages of respondents currently using e-cigarettes, n/a | data: Eurobarometer 2017 Estonia Finland France 25 % Germany Greece 22 % 6 % Hungary 7 % Ireland 17 % Italy only in schools 16 % Latvia Lithuania 12 % 20 % Luxembourg only on new products Malta 67 % Netherlands from 1 January 2022 Poland 5 % Portugal 3 % 3 % 3 % 2 % 2 % 2 % Romania 1 % Slovakia 0 % Slovenia 15–24 25–34 35–44 45–54 55–64 65–74 75 years Spain years years years years years years and over Sweden Frequency of e-cigarette use among current users in the United Kingdom only in Scotland E-cigarette use ( ever, currently) in the European Union European Union (including the United Kingdom) | Regulation of e-cigarettes in the European Union (including the United Kingdom) | yes (including nicotine-free e-cigarettes), (including the United Kingdom) by age group | data: daily, weekly, monthly, less than monthly | yes (nicotine-containing e-cigarettes), no, general ban on the sale of nicotine-free e-cigarettes | as of: 2020 Eurobarometer 2017 data: Eurobarometer 2017

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

Finland Sweden

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. Denmark ucts first appeared on test markets in Italy and Japan at the end United of 2014. As of August 2020, heated tobacco products from three All provisions of the WHO Framework Convention on Tobacco Kingdom Netherlands different manufacturers are available in the majority of countries Control (FCTC) apply to heated tobacco products | The Confer- Ireland Poland in the WHO European Region. ence of the Parties to the FCTC decided at its eighth session in Belgium Germany 2018 that heated tobacco products are tobacco products, thus Luxembourg 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 Switzerland France Romania ucts suggests that smokers, rather than former smokers and in some European countries. Slovenia never-smokers, seem to be interested in heated tobacco products. Italy Spain Portugal

Malta Cyprus

Sweden Regulation of heated tobacco products in Europe | ban, tobacco product, novel tobacco product/ tobacco-like product, regulation unclear/multiple options Russian United Latvia Denmark Federation for regulation, no regulation, n/a | as of: 2020 Kingdom Lithuania

Netherlands Belarus Poland Germany Czechia Ukraine 3.1 % Slovakia France Austria Switzerland Hungary Moldova Slovenia Romania Croatia 2.4 % Italy Bosnia- Serbia Herzegovina Montenegro Bulgaria North Macedonia Spain Albania Portugal Greece

1.0 % 1.0 % 1.0 % 0.9 % 0.8 % Cyprus

Number of manufacturers from which heated tobacco 15–24 years 25–44 years 45–64 years 65 years and over smokers former smokers never-smokers products are available in European countries | 1 manufacturer, 2 manufacturers, 3 manufacturers, Ever use of the heated tobacco product “Iqos” in Italy Ever use of the heated tobacco product “Iqos” in Italy no heated tobacco product available | as of: 2020 by age groups | data: 2017 by smoking status | data: 2017

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22 Tobacco Control in Europe Excerpt from the Tobacco Atlas Germany 2020 23 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) References and List of Figures 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. 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24 Tobacco Control in Europe Excerpt from the Tobacco Atlas Germany 2020 25 Figures: E-cigarette use (ever, currently) in the European Union Japan Tobacco Inc. (2019) Annual Report 2018 (including the United Kingdom) by smoking status | Use of e-cigarettes in the European Union (including the United Kingdom) | Kotz D & Kastaun S (2018) E-cigarettes and heat-not-burn prod- References and List of Figures 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 World Health Organization (2019) WHO report on the global World Health Organization (2019) WHO report on the global and electronic cigarettes. Special Eurobarometer 458 – Wave EB87.1 products: concerns from the Italian experience. Tob Control 28: tobacco epidemic, 2019. Offer help to quit tobacco use. Appen- tobacco epidemic, 2019. Offer help to quit tobacco use. World 113–114 dix VI. Table 6.11 – Bans on indirect advertising Health Organization, Geneva, Switzerland Figure: Regulation of e-cigarettes in the European Union (including the United Kingdom) Philip Morris International (2020) Investor Information. July 2020 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) Institute for Global Tobacco Control (2020) Country laws regu- Sutanto E, Miller C, Smith DM, et al. (2019) Prevalence, use behav- dix VI. Table 6.12 – Additional bans on indirect advertising lating e-cigarettes: a policy scan. Baltimore, MD: Johns Hopkins iors, and preferences among users of heated tobacco products: World Health Organization (2019) WHO report on the global Bloomberg School of Public Health. https://www.globaltobacco- findings from the 2018 ITC Japan Survey. Int J Environ Res Public Figures: Awareness of e-cigarette advertising in the European tobacco epidemic, 2019. Offer help to quit tobacco use. 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26 Tobacco Control in Europe Excerpt from the Tobacco Atlas Germany 2020 27