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The European Tobacco Control Report
2007
EUR/06/5062780 15 January 2007 E89842 ORIGINAL: ENGLISH
The E uropean Tobacco C
ontrol R eport 2007
THE EUROPEAN TOBACCO CONTROL REPORT
2007
ABSTRACT
The European tobacco control report describes the tobacco control situation and the status of tobacco control policies in the WHO European Region as at late 2006; reviews progress following the adoption of the European Strategy for Tobacco Control (ESTC) in 2002; and establishes a baseline for monitoring implementation of the WHO Framework Convention on Tobacco Control (FCTC) in the Region. The document presents an overview of the situation regarding tobacco use and related harm in the WHO European Region during the period 2002–2006 and of Member States' policy responses and implementation of national tobacco control measures in line with the recommendations of the ESTC. Reference is also made to the status of policies in countries in the light of the specific requirements of the
WHO FCTC. Lessons learned and challenges faced during the policy-making process are illustrated by several short national, regional and subregional case studies attached to the Report.
Keywords
SMOKING – adverse effects – prevention and control HEALTH POLICY HEALTH PROMOTION TOBACCO – legislation TOBACCO INDUSTRY – legislation INTERNATIONAL COOPERATION INTERSECTORAL COOPERATION TREATIES EUROPE ISBN 978-92-890-2193-7
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ACKNOWLEDGEMENTS This report was prepared by the WHO Regional Office for Europe in collaboration with the network of national counterparts for the European Strategy for Tobacco Control whose contributions of data, comments, suggestions and overall guidance were invaluable. The network of national counterparts/alternates included: Roland Shuperka, Albania; Joan Martinez-Benazet, Andorra; Alexander Bazarchyan, Armenia; Alice Schogger, Cornelia Franta, Austria; Nadir Eyvazov, Azad Gajiev, Azerbaijan; Paul van den Meerssche, Belgium; Aida Ramic-Catak, Zivana Gavric, Bosnia and Herzegovina; Andrei Sekach, Belarus; Masha Gavrailova, Bulgaria; Vlasta Hrabak-Zerjavic, Croatia; Charitini Komodiki, Cyprus; Hana Sovinova, Czech Republic; Ulla Skovgaard Danielsen, Denmark; Gaby Kirschbaum, Germany; Andrus Lipand, Estonia; Olli Simonen, Finland; Pascal Melihan-Cheinin, France; Akaki Gamkrelidze, Levan Baramidze, Georgia; Maroulio Lekka, Greece; Tibor Demjen, Hungary; Solveig Gudmundsdottir, Iceland; Marie Killeen, Ireland; Yair Amikam, Israel; Daniela Galeone, Italy; Aigul Tastanova, Kazakhstan; Chinara Bekbasarova, Kyrgyzstan; Gelena Kriveliene, Lithuania; Simone Steil, Luxembourg; Janis Caunitis, Latvia; Mario Spiteri, Anne Buttigieg, Malta; Denis Ravera, Monaco; Agima Ljaljevic, Montenegro; Pieter de Coninck, Netherlands; Rita Lindbak, Norway; Witold Zatonski, Poland; Emilia Nunes, Portugal; Tudor Vasiliev, Liubova Andreeva, Republic of Moldova; Magdalena Ciobanu, Romania; Galina Sakharova, Russian Federation; Davide Rosa, San Marino; Isabel Saiz, Spain; Natasa Lazarevic-Petrovic, Serbia; Elena Kavcova, Slovakia; Tomaz Caks, Slovenia; Margaretha Haglund, Sweden; Patrick Vuillème, Switzerland; Ziyovuddin Avgonov, Tajikistan; Mome Spasovski, The former Yugoslav Republic of Macedonia; Rejep Geldiev, Turkmenistan; Toker Erguder, Turkey; Alla Grygorenko, Ukraine; Nick Adkin, Andrew Black and Tim Roberts, United Kingdom; Shukrat Khashimov, Uzbekistan. Special thanks go to Claude Vilain for data collection and preparing the first draft and Patsy Harrington for cross-checking the data and technical editing. The contributions of Luk Joossens, Stella Bialous, Kerstin Schotte and Rifat Atun in drafting, respectively, the sections on illicit trade, industry tactics, smoking prevalence and the case studies are much appreciated. Kari Paaso and Shubhada Watson provided valuable support in the technical review and Gail Denner in the publishing process. Haik Nikogosian provided overall coordination, review and guidance in the development of the report. Acknowledgements are extended to the committee of experts (Carolyn Dresler, Anna Gilmore, Luk Joossens, Martina Pötschke-Langer and Tibor Szilagyi) for their valuable comments and suggestions during the drafting process. Kathleen Strong and Regina Guthold in WHO headquarters gave important support in the cross-country analysis of smoking prevalence. Valuable comments, data and suggestions on different aspects of the report were received from the Tobacco Free Initiative in WHO headquarters, various WHO Regional Office programmes, the European Commission, the European Network of Quitlines, the WHO collaborating centre in Heidelberg and other colleagues and institutions to whom we extend our sincere thanks and appreciation. Contributions received from the European Commission, national counterparts, experts and institutions and WHO colleagues for the respective case studies deserve special appreciation. Acknowledgements are also extended to Rosemary Bohr for overall editing and layout and Gill Paludan- Müller for preparing the graphic material. The Regional Office is especially grateful to the governments of France and Ireland for hosting the meetings of national counterparts in the process leading to the preparation of the report.
CONTENTS
Page
Summary ........................................................................................................................ 3
Introduction....................................................................................................................... 6
Background ............................................................................................................... 6
Process and data sources ........................................................................................... 8
PART 1 Tobacco consumption and tobacco-related harm................................................ 11
Summary ...................................................................................................................... 12
Prevalence of tobacco use................................................................................................. 12
Smoking prevalence among adults ............................................................................ 12
Smoking prevalence among young people.................................................................. 18
Socioeconomic differences ........................................................................................ 21
Tobacco-related harm....................................................................................................... 22
Summary ................................................................................................................ 22
Burden of disease attributable to tobacco use ............................................................ 23
Tobacco-related mortality ......................................................................................... 24
Tobacco-related costs .............................................................................................. 28
PART 2 Tobacco Control Policies................................................................................... 29
Measures to reduce the demand for tobacco products ......................................................... 30
Price and taxation policies ........................................................................................ 30
Exposure to tobacco smoke (passive smoking, environmental tobacco smoke) ............. 36
Advertising, promotion and sponsorship..................................................................... 44
Education, information and public awareness ............................................................. 48
Smoking cessation ................................................................................................... 53
Product control and consumer information ................................................................. 58
Measures to reduce the supply of tobacco products............................................................. 61
Illicit trade............................................................................................................... 61
Availability of tobacco to young people ...................................................................... 63
Tobacco subsidies .................................................................................................... 67
The WHO FCTC................................................................................................................ 68
The negotiation process and the European coordination mechanism ............................ 68
Status of the WHO FCTC .......................................................................................... 69
The Conference of the Parties ................................................................................... 70
Region-wide action........................................................................................................... 70
Facilitating Region-wide political commitment............................................................. 71
International support for building national capacity ..................................................... 71
Strengthening international coordination.................................................................... 73
Information exchange, technical cooperation and monitoring....................................... 74
Other policy issues ........................................................................................................... 76
Intersectoral coordination, funding, plans and programmes of action ........................... 76
Developments in EU tobacco control policy ................................................................ 77
The tactics of the tobacco industry ............................................................................ 78
Litigation................................................................................................................. 82
Conclusions ..................................................................................................................... 83
References ...................................................................................................................... 86
Annex 1 Case studies.................................................................................................... 93
Annex 2 Comparable estimates of adult daily smoking prevalence in the WHO European Region ........................................................................................... 143
Annex 3 Methodology for assessing tobacco smoking prevalence ................................... 144
Annex 4 Adult smoking prevalence in the WHO European Region ................................... 147
Annex 5 World No Tobacco Day Award winners, 2002–2006 .......................................... 155
The European tobacco control report 2007 page 3
Summary
The WHO Regional Committee for Europe adopted the European Strategy for Tobacco Control (ESTC) in 2002 (1). The ESTC followed three consecutive regional action plans spanning the period from 1987 to 2002 and was developed at the request of the WHO European Ministerial Conference, Warsaw, in February 2002. Since 2002 there have been substantial developments in international tobacco control. In May 2003, the Member States of WHO adopted the Framework Convention on Tobacco Control (WHO FCTC) – the first global public health treaty (2). The WHO FCTC entered into force in February 2005 and the first Conference of the Parties was convened from 6 to 17 February 2006 to outline and promote its implementation. Simultaneously, several Member States updated their policies and legislation, commissioned new surveys and strengthened their national capacity in tobacco control. The European tobacco control report 2007 reflects on the above developments. The report was prepared by the WHO Regional Office for Europe in collaboration with the WHO European network of national counterparts and experts, with valuable input from WHO Headquarters, the European Commission and international partners such as the European Network of Smoking Prevention. The purpose of the report is threefold: to describe the tobacco control situation and tobacco control policies in the WHO European Region as at late 2006; to review progress with the implementation of the ESTC since its adoption in 2002; and to establish a baseline for monitoring progress with the implementation of the WHO FCTC in the Region. The document presents an overview of the situation regarding tobacco use and related harm in the Region during the period 2002–2006, and of Member States’ policy responses and implementation of national tobacco control measures in line with the recommendations of the ESTC. The lessons learned and challenges faced during the policy process are also illustrated by 15 short national, regional and sub-regional case studies which are attached to the Report. Smoking prevalence data are derived from information provided by WHO national counterparts and international sources, together with comparable prevalence estimates provided by the WHO Headquarters Infobase database (3). Data confirm recent observations that the tobacco epidemic is being generally curbed in the Region, but not in all countries and at different rates. According to available data, at the end of 2005 smoking prevalence (current daily cigarette smokers, population weighted, age and year standardized) was estimated at around 28.6% (40.0% among males and 18.2% among females) as compared with 28.8% (40.9% among males and 17.8% among females) in 2002. In most western European countries, smoking prevalence among men and women has in general stabilized or is decreasing. Overall prevalence has, however, reached a level from which it will be difficult for it to show a further decrease unless substantially stronger measures are implemented. Smoking prevalence has also started to decrease in some countries in the eastern part of Europe, although generally it is only stabilizing among men, with no clear overall trends, and in some cases, a slight rise in prevalence among women is being recorded. Among young people aged 15 years, the prevalence of weekly smoking is on average 24% (24% in boys and 23.5% in girls). In many western European countries the prevalence of smoking
among 15-year-old girls exceeds that of 15-year-old boys. In eastern Europe, smoking among 15-year-old boys tends to be higher than among girls. The overall positive trends in male smoking prevalence are now reflected in a Region-wide fall in the standardized death rates for lung cancer among men, whereas lung cancer among women is still increasing. Tobacco remains the leading contributor to the disease burden in more than half of the European Member States, and one of the three leading contributors in the absolute majority. Tobacco also poses considerable economic costs. According to World Bank estimates, tobacco-related health care costs range from between 0.1% to 1.1% of gross domestic product (GDP) in different countries. Of particular concern is the growing concentration of smoking in the lower socioeconomic groups observed throughout the Region. This is leading to a widening gap in current and future health outcomes. Smoking remains a major contributory factor to the gap in mortality and healthy life expectancy between the most and least advantaged. Between 2002 and 2006, most Member States made significant progress in relation to banning advertising, increasing the size of health warnings, strengthening product regulation and, to a certain extent, raising taxes on tobacco. The price of tobacco products rose by an average annual rate of 6.8% above inflation between 2001 and 2005 in the European Union (EU) countries – good progress when compared to the previous annual rate of increase of 2.7%. The data are less encouraging in the countries in the eastern part of the Region where, in some cases, tobacco became cheaper over this period. Most countries still do not earmark tobacco taxes for tobacco control. Since 2002, major developments have also occurred in the area of smoke-free policies. Several countries have introduced bans on smoking in public places which for the first time extended to bars and restaurants. These restrictions were led by the example of Ireland and Norway (2004). Nearly 20 countries have passed stricter laws covering smoking in bars and restaurants, and currently, nearly two thirds of countries have bans or restrictions on smoking in most indoor public places – a substantial improvement since 2001. Recent years have also been characterized by significant and increasing public support for strong tobacco control policies and action at both national and international levels. Smokers as well as nonsmokers are now in favour of tougher controls. Since 2002, 24 Member States have reinforced legislation on direct advertising by either passing new laws or implementing existing provisions. EU Directive 2003/33/EC (4) totally banned advertising in the press, on the radio and in the sponsorship of sporting or cultural events with cross-border effect from 31 July 2005. Advertising remains less regulated in the Commonwealth of Independent States (CIS), although there has been notable progress in most countries since 2002. There have also been significant developments in the regulation of tobacco products. Since December 2002, EU Directive 2001/37/EC (5) has required EU tobacco manufacturers to disclose the nature and quantities of all the ingredients used in tobacco products. In 2006, 32 countries and, in particular, the EU are regulating the levels of tar at 10 mg per cigarette, nicotine at 1 mg and carbon monoxide at 10 mg in cigarettes, a decrease compared with the 2001–2002 levels of 12 mg of tar and carbon monoxide per cigarette and 1.2 mg of nicotine per cigarette. The CIS countries and those in south-eastern Europe (SEE) in the main still set higher levels: 1.2–1.4 mg for nicotine and 12–16 mg for tar per cigarette.
The European tobacco control report 2007 page 5
In 2002 the average size of warning labels was less than 10% of each large surface of the pack. This has now been increased more than threefold in the 32 countries that have transposed or adopted EU Directive 2001/37/EC (5). In the 14 other Member States (mainly CIS and SEE countries), health warnings are still usually less than 10% of the largest surface. Misleading descriptions on tobacco packs are prohibited in EU countries and in some SEE and CIS countries. There has been marked progress in restricting the sale of tobacco products to minors. Currently 34 countries ban the sale of tobacco products to young people aged under 18 years and 10 countries to young people aged under 16 years. Despite these bans, tobacco is still widely available to young people throughout the Region. Forty Member States ban the sale of single or unpacked cigarettes and 32 ban the distribution of free samples. Compliance with laws on age restrictions appears to need improvement in the majority of countries. Most countries provide information and education on the harm caused by tobacco. Information is generally disseminated through public awareness campaigns or school programmes. There are still some major weaknesses in policy in many countries, particularly concerning restrictions on indirect advertising, the introduction of smoking cessation in the national health care system and, above all, in combating smuggling. In the western part of the Region the fight against smuggling has had some success, especially in reducing the supply of illegal tobacco products. Progress has also been reported by some SEE countries. The Region, in general, has made a significant contribution to the negotiation and entry into force of the WHO FCTC. By 15 December 2006, 40 countries in the WHO European Region and the European Community had become Parties to it. All this has been carried out against the backdrop of strong resistance by the tobacco industry to control or regulation justified by public health concerns. In parts of the European Region where smoking prevalence is stabilizing, attempts to maintain the rates of tobacco use and to increase profits have become a major preoccupation of the industry. The Regional Office has supported Member States and international partners in strengthening and coordinating policies throughout the Region through surveillance, capacity-building, review and update of legislation, the promotion of intersectoral links, and so on. Particular highlights have included support with the development of national action plans, updating of legislation, implementation of internationally standardized surveys, capacity-building projects focusing on CIS and SEE countries, information campaigns such as World No Tobacco Day, organization of the work of the national counterparts network, and updating and extending the European tobacco control database (6). In conclusion, although smoking prevalence has in general stabilized in the WHO European Region and is decreasing in some countries, it does not yet present a clear diminishing trend. WHO Member States need to continue and in many cases accelerate their implementation of the baseline recommendations outlined in the ESTC. Governments and society need to use the current momentum to create a turning-point in combating the tobacco epidemic in the Region. The European tobacco control report outlines a number of additional areas where, by strengthening controls, European Member States could make a considerable contribution to reducing the significant health burden associated with tobacco consumption.
Introduction
The European Strategy for Tobacco Control (ESTC) was adopted by the Regional Committee for Europe in 2002 (1). The first progress report on the ESTC was due in 2006. In May 2003, the Member States of WHO adopted the Framework Convention on Tobacco Control (WHO FCTC) – the first global public health treaty (2). There have been many developments since the adoption of the treaty at global, regional and national level. The WHO FCTC entered into force in February 2005, and the first Conference of the Parties was convened from 6 to 17 February 2006 to outline and promote its implementation. In recent years several Member States have updated their policies and legislation, undertaken new surveys and strengthened their national capacity in tobacco control. The purpose of this review is threefold:
• to describe the tobacco control situation and tobacco control policies in the WHO European Region as at late 2006;
• to review progress on the implementation of the ESTC since its adoption in 2002; and
• to establish a baseline for monitoring progress on the implementation of the WHO FCTC in the Region.
The report provides a general overview of tobacco use and tobacco-related harm in the Region from 2002 to 2006, and outlines Member States’ policy responses in the form of national tobacco control measures in line with the recommendations contained in the ESTC. Reference is also made to the status of policies in countries in the light of the specific requirements of the WHO FCTC. Part 1 contains an analysis of tobacco use and its health consequences in the Region, followed by an analysis of tobacco control policies at the national and international levels in Part 2. The report concludes with some observations on the progress made, the remaining challenges and the next steps in this important of area of public health in the Region. The lessons learned and challenges faced during the policy process are illustrated by several short national, regional and sub-regional case studies in Annex 1. This report is of particular importance in ensuring that, as stipulated by the Regional Committee, the ESTC is a continuing process subject to regular review and strategic modification, as necessary.
Background
Europe was the first WHO Region to launch a regional action plan on tobacco. In 1987 the First European Action Plan on Tobacco 1987–1992 called for a comprehensive approach, including restrictions on the production, distribution and promotion of tobacco; pricing policies; protection for nonsmokers; health promotion and health education programmes; smoking cessation training for professionals, and practical help with giving up smoking (7). It also urged countries to monitor and evaluate these measures. In 1988, the First European Conference on Tobacco Policy (held in Madrid) set out directions in a Charter for a Tobacco-free Life, supported by 10 detailed strategies for achieving a tobacco-free Europe. In 1992, 37 proposals designed to strengthen Member States’ commitment and capacities were incorporated in the Second Action Plan for a Tobacco-free Europe 1992–1996 (8). This new strategy document emphasized the importance of building alliances to support tobacco control
The European tobacco control report 2007 page 7
policies. It set out priorities for the promotion of a smoke-free environment, nonsmoking behaviour among young people and cessation activities. The Action Plan recommended that Member States allocate more human and financial resources to these priorities and that there should be intensive cooperation among the countries of central, eastern and southern Europe. It recognized that tobacco-related problems were not only a European concern but very much also a global one, and that international safeguards were needed to ensure that they were not exported to other parts of the world. To ensure that more effective action was taken than had been the case in previous years, the Regional Committee at its forty-seventh session adopted the Third Action Plan for a Tobacco- free Europe for the period 1997–2001 (9). This new Action Plan set specific targets to be achieved in Member States in the areas of pricing, availability and advertising of tobacco, control of smuggling, product regulation, smoke-free environments, support for smoking cessation, and public education and information. It outlined the specific role that Member States should play by establishing adequately funded national intersectoral committees, drawing up country-based action plans, and carrying out effective monitoring of tobacco control measures. The Plan highlighted the role of integrational, intergovernmental and nongovernmental organizations, as well as of health professions, in forging effective partnerships for strengthening tobacco control in Europe. At the end of 2001, according to the previous European tobacco control report (10), approximately 30% of the adult population of the Region were regular smokers. The overall trend was relatively stable, with a slight decline after the mid-1990s. Almost no Member State showed a decrease in smoking prevalence among young people during the latter part of the 1990s. Among lower socioeconomic groups the trend was not encouraging, and there was no indication that the socioeconomic gradient in tobacco use was falling. The standardized death rate for lung cancer among males had stabilized or was slightly decreasing in the central and western parts of the Region. The death rate among women was still increasing as they were in general exposed to tobacco later than men. The ESTC was based on the lessons learnt from the assessment of the three consecutive Action Plans (1987–2001) (10) and from the evidence underpinning policy development and implementation at national, regional and global levels. It also took into account the guiding principles set out in the Warsaw Declaration for a Tobacco-free Europe (2002) (11). The ESTC established strategic directions for action in the Region, to be carried out through national policies, legislation and international cooperation within the means and capacities of each Member State. It also identified the specific international tools and mechanisms that could be used and suggested a time-frame for implementation and monitoring. The structure and content were consistent with the strategic approach of the WHO FCTC, in whose negotiation European Member States were simultaneously actively involved. The ESTC aimed to promote and facilitate the adoption at country level of comprehensive and multisectoral evidence-based policies to reduce the demand for and supply of tobacco products and to cut down the prevalence of tobacco use in all population groups. The principal target was to obtain a significant and realistic increase in the rates of people not taking up and of those stopping smoking, in order to at least double the average annual reduction of smoking prevalence in the Region which was standing at nearly 1%. The reduction in smoking rates was expected to vary from a significant fall in countries with a high smoking prevalence to a more moderate decrease in countries which had already achieved lower prevalence. The ESTC also aimed to assure the citizens’ right to a smoke-free environment.
Process and data sources
This report has developed from a process of consultation, drafting and reviewing, involving the network of WHO European national counterparts, international experts, the WHO Regional Office for Europe, WHO headquarters and collaborating centres, and international partners such as the European Commission and the European Network for Smoking Prevention. The approach is based on the use of factual information followed by crosschecking that information against various additional sources to clarify different data or possible misinterpretations. Standard templates and questionnaires were developed to gather information on specific topics. An external expert group was established to provide guidance and assistance in the preparation and drafting of the report. The process for writing and the structure of the Report were presented, commented on and reviewed during the First Expert Meeting held in Copenhagen on 24 January 2005. A questionnaire addressing issues not covered by existing survey instruments (for example, the level of enforcement of current regulations and legislation) was drafted at the Second Expert Meeting held in Paris on 11 May 2005. The outline of the process for reviewing the ESTC was agreed during a meeting of national counterparts for the ESTC held in Paris from 12 to 14 May 2005. A drafting committee comprising national counterparts from seven countries (Armenia, France, Ireland, Serbia and Montenegro,1 Spain, Sweden and Switzerland) was designated at that meeting to work in close collaboration with the Regional Office. The initial draft was reviewed during a meeting of the drafting committee held in Dublin on 3 and 4 November 2005 at the invitation of the Irish Office for Tobacco Control. This first draft was then reviewed and amended by experts and drafting committee members, in anticipation of further review by the meeting of national counterparts held in Dublin on 10 and 11 April 2006, kindly hosted by the Irish Ministry of Health and the Children and the Irish Tobacco Control Office. The cross-checking of data, incorporation of comments and reflection of new policy developments continued until November 2006. The data used in this document were drawn extensively from the WHO European Database on Tobacco Control established in 2001, as part of the development of a global tobacco control surveillance system (6). The database is based on information provided by the WHO national counterparts in the Regional Survey for Country-specific Data and on other internationally recognized sources. The information was made available in the first edition of the WHO European country profiles on tobacco control (12) and in an electronic database. It has been updated on a continuing basis and the data have been cross-checked with different sources and with the national counterparts for tobacco control. The questionnaire drawn up by the expert group for the WHO European Report on Tobacco Control Policy and reviewed by the national counterparts for the ESTC was designed to check the accuracy of existing information and to provide additional information on national tobacco control policies and facilitate comparisons with the measures recommended by the ESTC. The questionnaire was sent to the national counterparts for the ESTC in June 2005, and by April 2006, 40 of the 52 Member States had responded (Andorra, Armenia, Austria, Belarus, Belgium, Bulgaria, Bosnia and Herzegovina, Croatia, the Czech Republic, Cyprus, Denmark, Estonia, Finland, France, Georgia, Germany, Hungary, Iceland, Ireland, Italy, Kazakhstan, Kyrgyzstan,
1 Serbia and Montenegro became two separate Member States of WHO in September 2006. Throughout this report they are referred to as either one country or two countries according to the dates of the references or data. Where, prior to September 2006, separate data are available for either or both of the entities, they are shown as Serbia and Montenegro (Serbia) or Serbia and Montenegro (Montenegro).
The European tobacco control report 2007 page 9
Latvia, Lithuania, Malta, the Republic of Moldova, Netherlands, Norway, Poland, Portugal, Russian Federation, Sweden, Serbia and Montenegro, Slovakia, Slovenia, Spain, The former Yugoslav Republic of Macedonia, Ukraine, the United Kingdom and Uzbekistan).
This report also draws on presentations of national practices made during two Meetings of National Counterparts for the ESTC in Helsinki, Finland (1–2 August 2003) and in Paris, France (12–14 May 2005). Other important sources of data include the WHO Global InfoBase (3), WHO Regional Office for Europe programmes and networks, including its Health for All (HFA) database (13) and the WHO Health Behaviour in School-aged Children study (14,15), the European Commission (16) (in particular the ASPECT Report on Tobacco or Health in the European Union (17) ), the World Bank (18) and other international and nongovernmental organizations, especially the European Network for Smoking Prevention (ENSP) (19). To facilitate analysis, countries were grouped according to the Regional Office’s usage:
• the European Union (EU) countries: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden and the United Kingdom prior to 1 May 2004, plus Cyprus, the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovakia and Slovenia since 1 May 2004;
• the south-east European (SEE) countries: Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Republic of Moldova,2 Romania, Serbia and Montenegro, The former Yugoslav Republic of Macedonia;
• the Commonwealth of Independent States (CIS): Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Republic of Moldova, Russian Federation, Tajikistan, Turkmenistan, Ukraine, Uzbekistan.
In a comprehensive exercise such as this, some of the information gathered could be inconsistent or conflicting. Whenever this happened, alternative sources were used to compare the data and decisions as to the most appropriate data to use were made on a case-by-case basis in cooperation with national counterparts for the ESTC.
2 The Republic of Moldova is included with both the SEE and the CIS countries in order to maintain the integrity of the data relating to the SEE grouping.
The European tobacco control report 2007 page 11
PART 1
TOBACCO CONSUMPTION AND TOBACCO-RELATED HARM
Summary
In the WHO European Region smoking prevalence is estimated at around 28.6% (40% among males and 18.2% among females). There are, however, wide disparities in different parts of the region. In most western European countries, the smoking prevalence in men and women has in general stabilized or is decreasing, but the picture is not so homogenous in the eastern part of the region. In some eastern European countries, the smoking prevalence is starting to fall, although in general it shows a slight upward trend in women and is stabilizing among men. Among young people aged 15 years, the prevalence of weekly smoking is on average 24% (24% in boys and 23.5% in girls). In many western European countries, the prevalence of weekly smoking in 15- year-old girls exceeds that of boys of the same age. In eastern European countries the prevalence of weekly smoking in boys tends to be higher than that of girls. The new data confirm the observations of the 2002 European report on tobacco control policy that the tobacco epidemic is being curbed in some parts of the Region. However, many countries, particularly in the CIS, need to do more to achieve an annual 2% reduction in smoking prevalence as suggested by the ESTC. Since the last European report on tobacco control policy was published in 2002, the standardized death rate for lung cancer among men across the European Region has fallen but those for women have increased. Smoking remains a major contributory factor to the gap in mortality and healthy life expectancy between the most and least advantaged. The growing concentration of smoking in the lower socioeconomic groups observed throughout the Region is leading to a widening gap in current and future health outcomes. Although the absolute number of socioeconomically disadvantaged people may be diminishing in some countries, the persisting relative gap emphasizes the need to address the social and economic factors which have an impact on smoking.
Prevalence of tobacco use
One of the principal objectives of the ESTC was to obtain a significant and realistic reduction in smoking prevalence in the Region and to at least double the average annual reduction rate, which was standing at nearly 1%.
Smoking prevalence among adults
The smoking prevalence data in this report derive from the information provided by national counterparts together with comparable estimates provided by the WHO Global InfoBase (3). Infobase estimates for the prevalence of tobacco consumption are based on a standardization of survey data in the different Member States, sometimes a composite of several different surveys in one country, with the aim of obtaining a global picture of current and future smoking prevalence patterns. The InfoBase draws on a wide variety of sources. Adjustments are made to the initial estimates to take account of urban/rural criteria, survey year and age (the InfoBase methodology is presented in Annex 3). At the time of this report it was possible to derive estimates for 41 of the 52 countries in the WHO European Region.3 As these are estimates there may be differences between the figures shown in Fig. 1 and 2 (and in Annex 2) and the best available national prevalence data as confirmed through the network of national counterparts (Annex 4).
3 In some cases further clarification is required of data and for this reason Infobase estimates for some countries have not been included in this report.
The European tobacco control report 2007 page 13
The definition of smoking status for the reported data is “current daily cigarette smoker” in the group aged 15 years and over. Data are adjusted for 2002 and 2005. Aggregated data from the InfoBase were used to estimate comparable smoking prevalence data for the male, female and overall population of each country. Data provided by countries and verified through the network of national counterparts for the ESTC are presented in Annex 4. The limitations on the InfoBase are similar to those with any database, namely the availability and quality of data and common definitions. The InfoBase nevertheless serves as an important tool for encouraging investment in the collection of reliable national data on which to base intercountry comparisons.
Current status
The overall adult daily estimated smoking prevalence (population-weighted) has stabilized at around 28.6% in the Region. The estimated average smoking prevalence among males is 40%: in 14 (mostly eastern European) countries there is a higher prevalence rate of male smoking, while in 12 (mostly western European) countries the male smoking prevalence is below 30% (Fig. 1). The estimated average female smoking prevalence in the Region is 18.2%: in 24 (mostly western European) countries the prevalence rate is higher, while in 8 eastern European countries it is below 10% (Fig. 2).
Gender differences
Fig. 3 depicts the percentage differences between male and female smoking prevalence estimates in the Region in 2005. In all but two countries (Iceland and Sweden), smoking prevalence is higher among men than among women. Data from Georgia show the widest gender gap – 46.9%, followed by five eastern European countries with a gender difference of more than 40% (Armenia, Belarus, Kyrgyzstan, Republic of Moldova and Russian Federation). A small difference between male and female smoking prevalence of less than 10% can be found in 18 (mostly western European) countries (Fig. 3).
Changes in smoking prevalence
Estimates for male and female smoking prevalence for 2002 and 2005 are available for 41 countries. Only relative differences of more than +/-10% have been taken into account as noteworthy changes when comparing data for these two years. Since the 2002 European report on tobacco control policy, smoking prevalence among the male population has in general stabilized across the Region. A notable decrease has been reported for Sweden (16.3% to 14.4%), Iceland (22.8% to 19.4%) and Israel (31.5% to 27.4%), but in most countries in the Region male smoking prevalence did not show a significant change between 2002 and 2005. Female smoking prevalence has notably decreased in Iceland (22.8% to 19.7%) and increased in Ukraine (15.5% to 18.7%). In all other countries, there was no significant change in female smoking prevalence although slight increases were observed in many CIS and SEE countries. Fig. 4 shows the average population-weighted smoking prevalence estimates in the Region in 2002 and 2005. Total smoking prevalence did not change notably (28.8% in 2002 as compared to 28.6% in 2005). Smoking prevalence among males and females has also not changed notably during the period although there was a slight downward trend among men (40.9% in 2002 as compared to 40% in 2005) and a slight upward trend among women (17.8% in 2002 as compared to 18.2% in 2005).
Fig. 1. Male daily smoking prevalence estimates, 2005
0 10 20 30 40 50 60 70
Sweden
Uzbekistan
Iceland
Switzerland
Finland
Norway
Israel
Slovenia
Denmark
United Kingdom
Italy
Malta
Czech Republic
France
Netherlands
Germany
Spain
Andorra
Luxembourg
Slovakia
Croatia
Kazakhstan
Portugal
Lithuania
Poland
Hungary
Romania
Bulgaria
Austria
Estonia
Turkey
Bosnia and Herzegovina
Latvia
Armenia
Serbia and Montenegro
Republic of Moldova
Kyrgyzstan
Georgia
Ukraine
Belarus
Russian Federation
Prevalence of daily cigarette smokers (%)
Male, population-weighted
average: 40%
Note. Fig. 1 does not reflect the use of smokeless tobacco. Source: WHO Global InfoBase (3).
This overall regional pattern does, however, hide varying sub-regional trends. In the EU plus the three European Economic Area countries (Iceland, Norway and Switzerland), there was no notable change in the average smoking prevalence among the overall, male and female populations (Fig. 5). A slight downward trend could be observed in the total (26.1% in 2002 as compared to 25.4% in 2005) and in the male (31.7% in 2002 as compared to 30.3% in 2005) populations.
The European tobacco control report 2007 page 15
Fig. 2. Female daily smoking prevalence estimates, 2005
0 5 10 15 20 25 30 35 40 45
Azerbaijan
Uzbekistan
Albania
Armenia
Georgia
Kyrgyzstan
Republic of Moldova
Kazakhstan
Lithuania
Turkey
Israel
Slovakia
Italy
Belarus
Latvia
Switzerland
Sweden
Slovenia
Romania
Finland
Ukraine
Iceland
Malta
Estonia
Czech Republic
Russian Federation
Germany
Poland
Bulgaria
France
Norway
Denmark
Andorra
Croatia
Spain
Netherlands
United Kingdom
Luxembourg
Hungary
Bosnia and Herzegovina
Austria
Prevalence of daily cigarette smokers (%)
Female, population-weighted
average: 18.2%
Source: WHO Global InfoBase (3).
In the CIS, a slight increase in smoking prevalence among females can be observed (13.7% in 2002 as compared to 14.7% in 2005) but no notable changes among males (56.8% in 2002 as compared to 56.7% in 2005) or in the total adult population (33.2% in 2002 as compared to 33.7% in 2005) (Fig. 6). In the SEE countries, there was no notable change in the estimated average smoking prevalence in the overall, male and female populations. A slight downward trend could be observed among males (44.5% in 2002 as compared to 44.1% in 2005) and a slight upward trend among females (15.4% in 2002 as compared to 16.1% in 2005) (Fig. 7).
Fig. 3. Difference between male and female daily smoking prevalence estimates, 2005 (%)
-5 0 5 10 15 20 25 30 35 40 45 50
Sweden
Iceland
United Kingdom
Austria
Norway
Netherlands
Denmark
Spain
Luxembourg
Switzerland
Finland
France
Andorra
Malta
Hungary
Germany
Czech Republic
Croatia
Slovenia
Israel
Italy
Poland
Bosnia and Herzegovina
Bulgaria
Uzbekistan
Slovakia
Romania
Estonia
Lithuania
Latvia
Kazakhstan
Turkey
Ukraine
Belarus
Russian Federation
Republic of Moldova
Armenia
Kyrgyzstan
Georgia
Source: WHO Global InfoBase (3).
Prevalence of “smokeless” tobacco products
The consumption of oral non-combustible products, which are highly addictive and can cause cancer of the head, neck, throat and oesophagus as well as many serious oral and dental conditions, remains widespread in Scandinavian countries (20). In 2004, the daily snus (oral smokeless tobacco) prevalence rate reached 23.4% (+3.4% since 1997) among Swedish men and 2.8% (+1.9% since 1997) among women. In Norway the use of snuff increased significantly during the same period, reaching 8% among men in 2004 (+3% since 1997), although fewer than 1% of Norwegian woman use snuff daily (21). Meanwhile, Nasvay (another form of smokeless tobacco product) is widely used in CIS countries such as Kyrgyzstan and Uzbekistan: in 2005 over 40% of the rural male population was using it.
The European tobacco control report 2007 page 17
Fig. 4. WHO European Region: average population-weighted smoking prevalence estimates, 2002 and 2005
40.9 40
17.8 18.2
28.8 28.6
0
10
20
30
40
50
S m
o ki
n g
p re
v a le
n c e
Males Females Both sexes
2002
2005
Source: WHO Global InfoBase (3).
Fig. 5. EU plus European Economic Area countries: average population-weighted smoking prevalence estimates, 2002 and 2005
31.7 30.3
20.8 20.8
26.1 25.4
0
10
20
30
40
S m
o k in
g p
r e v a
le n c e
Males Females Both sexes
2002
2005
Source: WHO Global InfoBase (3).
Fig. 6. CIS: average population-weighted smoking prevalence estimates, 2002 and 2005
56.8 56.7
13.7 14.7
33.2 33.7
0
10
20
30
40
50
60
S m
o k in
g p
re v a le
n c e
Males Females Both sexes
2002
2005
Source: WHO Global InfoBase (3).
Fig. 7. SEE countries: average population-weighted smoking prevalence estimates, 2002 and 2005
44.5 44.1
15.4 16.1
30.2 30.4
0
10
20
30
40
50
S m
o k in
g p
e rc
e n ta
g e
Males Females Both sexes
2002
2005
Source: WHO Global InfoBase (3).
Smoking prevalence among young people
The analysis of smoking prevalence among young people is based on the WHO Health Behaviour in School-aged Children (HBSC) study, a unique cross-national research study conducted every four years: 1993/1994, 1997/1998 (14) and 2001/2002 (15). The 2005/2006 survey has recently been launched in 41 countries and regions and no comparable data are yet available. Information based on a second survey instrument, the Global Youth Tobacco Survey (GYTS) (22), was also used in the preparation of this report. The GYTS was developed by the US Centers for Disease Prevention and Control (CDC) and WHO and has been carried out in a large number of countries in the European Region (Table 1). With more and more countries carrying out and repeating the GYTS, comparisons should be possible in the next two to three years (Annex 3 provides more technical information on both instruments).
Current status
According to the HBSC study, weekly smoking prevalence rates were on average 2% among 11- year-olds, 8% among 13-year-olds, and 24% among 15-year-olds. In general, smoking prevalence rates increased more steeply between the ages of 11 and 13 years than between 13 and 15 years. The results of the HBSC and GYTS studies show that weekly smoking prevalence rates in 15-year-old boys were especially high (>30%) in some eastern European countries (Belarus, Estonia, Georgia, Latvia, the Russian Federation, Slovakia and Ukraine). The highest smoking prevalence rates (>30%) among 15-year-old girls were found mostly in western European countries such as Austria, the Czech Republic, Finland and Spain. The lowest smoking prevalence rates among 15-year-old boys (<15%) were in Albania, Bosnia and Herzegovina, Greece, Kazakhstan, Kyrgyzstan, Serbia and Montenegro, Sweden and Turkey. Smoking prevalence rates among girls were especially low in Armenia (0.5%) and below 10% in a number of other countries, particularly in the east of the Region (Albania, Bosnia and Herzegovina, Georgia, Greece, Kazakhstan, Kyrgyzstan, Republic of Moldova and Turkey). An overview of smoking prevalence rates among young people in the WHO European Region obtained by the HBSC and GYTS is provided in Table 1.
The European tobacco control report 2007 page 19
Table 1. Smoking prevalence (at least one cigarette per week) in 15-year-old boys and girls (%), 1997/1998, 2001/2002 and 2001/2004
HBSC
1997–1998 2001–2002
GYTS
2001/2004
Country
Boys Girls Boys Girls Year Boys Girls
Albania 2004 10.6 5.4
Armenia 2004 15.8 0.5
Austria 30 36 26.1 37.1
Belarus 2004 33.2 23.8
Belgium 28 28 21.3 23.5
Bosnia and Herzegovina 2003 10.8 7.5
Bulgaria 2002 28.7 26.4
Croatia 23.2 24.9 2002 18.6 16.7
Czech Republic 22 18 28.7 30.6 2002 29.9 32.8
Denmark 20 28 16.7 21.0
Estonia 24 12 30.4 18.2 2002–2003 31.8 23.0
Finland 25 29 28.3 32.2
France 28 31 26.0 26.7
Georgia 2003 31.8 6.3
Greece 18 19 13.5 14.1 2003 16.3 9.5
Hungary 36 28 28.2 25.8 2003 24.1 27.4
Ireland 25 25 19.5 20.5
Israel 24 13 16.9 11.6
Italy 21.8 24.9
Kazakhstan 2004 14.5 9.0
Kyrgyzstan 2004 10.2 2.9
Latvia 37 19 28.9 21.1 2002 30.2 22.1
Lithuania 24 10 34.9 17.9 2001 29.0 20.5
Malta 16.9 17.4
Netherlands 22.5 24.3
Norway 23 28 20.1 26.6
Poland 27 20 26.3 17.0 2003 20.8 14.3
Portugal 19 14 17.6 26.2
Republic of Moldova 2004 21.7 4.9
Romania 2004 16.8 12.8
Russian Federation 24 22 27.4 18.5 2003 39.9 28.8
Serbia and Montenegro 2003 12.4 15.7
Slovakia 28 18 2003 31.3 28.8
Slovenia 29.5 29.7 2003 24.2 28.8
Spain 23.6 32.3
Sweden 18 24 11.1 19.0
Switzerland 25 25 25.4 24.1
The former Yugoslav Republic of Macedonia
14.6 12.7 2003 15.2 7.3
Turkey 2003 12.9 5.0
Ukraine 44.6 22.8 2004 41.0 22.2
United Kingdom 25 33 21.1 27.9 Note. Dark grey fields signify a relative increase of more than 10% in smoking prevalence; light grey fields signify a decrease of more than 10% in smoking prevalence between the survey periods 1997/1998 and 2001/2002.
Source: HBSC 1997/1998 (14), HBSC 2001/2002 (15) and GYTS 2001–2004 (21).
Gender differences
The prevalence of weekly smoking among 15-year-old girls was higher than that of 15-year-old boys in 18 mainly western European countries of the 28 that implemented the HBSC study in 2001/2002 (Austria, Belgium, Croatia, the Czech Republic, Denmark, Finland, France, Greece,
Ireland, Italy, Malta, the Netherlands, Norway, Portugal, Slovenia, Spain, Sweden and the United Kingdom). In Austria, Belgium, Norway, Sweden and the United Kingdom, this difference was even greater than in the late 1990s. In the remaining 10 (mainly eastern European) countries (Estonia, Hungary, Israel, Latvia, Lithuania, Poland, the Russian Federation, Switzerland, The former Yugoslav Republic of Macedonia and Ukraine), smoking prevalence in girls was lower, but in at least half of these 10 countries, it was catching up and, in two countries (Czech Republic and Hungary), even overtaking smoking prevalence in boys. The GYTS data in general confirmed the pattern of higher rates of smoking prevalence among boys than girls in eastern Europe (except in Serbia and Montenegro). Countries for which there were GYTS data include Albania, Armenia, Belarus, Bosnia and Herzegovina, Bulgaria, Estonia, Georgia, Greece, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Poland, Republic of Moldova, Romania, the Russian Federation, Slovakia, The former Yugoslav Republic of Macedonia, Turkey and Ukraine. The differences in prevalence rates between boys and girls were highest in Armenia, where the prevalence among girls was the lowest (0.5%) whereas among boys it had reached 15.8%. The gender gap is also wide in Georgia, where boys smoked five times more often than girls, the Republic of Moldova (four times), Kyrgyzstan and Turkey (three times) and Albania, Lithuania and Ukraine (twice as often).
Changes in smoking prevalence
Twenty-one countries implemented the HBSC both in 1997/1998 and 2001/2002. A comparison of the results from those two surveys shows that weekly smoking prevalence rates in 15-year-old boys decreased in 11 (mostly western European) countries of the 21, increased in 5 countries and remained stable in 4. The picture among 15-year-old girls is quite similar: weekly smoking prevalence rates decreased in 10 out of the 21 countries, increased in 6 and remained stable in 5. A calculation of the averages from these two HBSC surveys shows that the average weekly smoking prevalence among 15-year-old boys (25.4% and 24.0%) and girls (23.3% and 23.5%) did not change significantly between the two periods (Fig. 8), although a slight downward trend in boys and a slight upward trend in girls can be noticed.
Fig. 8. Weekly smoking prevalence in boys and girls aged 15 years 1997/1998 and 2001/2002
25.4 24 23.3 23.5
0
10
20
30
W e e k ly
s m
o k in
g p
re v a le
n c e (
% )
Boys Girls
1997/1998
2001/2002
Source: HBSC 1997/1998 (22 countries) (14) and 2001/2002 (19 countries) (15).
The European tobacco control report 2007 page 21
Age of starting to smoke
The 2001/2002 HBSC showed the average age at which 15-year-old weekly smokers reported smoking their first cigarette, cigar or pipe. Among boys in this age group, the figures ranged from an average age of 10.8 years in Lithuania and 10.9 years in the Czech Republic and Estonia, to an average of 13 years in Greece and 13.2 years in Israel. The corresponding figures for girls ranged from 11.7 years in Austria to 13.6 years in Italy and 13.7 years in Israel and Greece. In most countries, boys generally started to smoke earlier than girls. The largest gender gaps in age of starting to smoke were found in Estonia, Lithuania and Ukraine, where girls started to smoke on average almost two years later than boys.
Socioeconomic differences
Differences between countries
There is growing evidence of strong links between poverty, sustainable development and tobacco use (23). The countries with the lowest gross national product (GNP) per capita, mostly in the eastern part of the European Region, had male smoking prevalence rates of over 50% compared with an average of 34% in wealthier countries. The death rate as a result of smoking among males aged 35–69 years is higher in the countries with the lowest GNP.
Differences within countries
In most European countries, and certainly those where the epidemic has been long established, poor and less educated people are more likely to smoke than the rich and/or better educated. Moreover, smokers are becoming more and more concentrated among the lower socioeconomic groups. This concentration is particularly significant in high-income countries but it is also observed in middle-income countries, notably among men. For example, in 2002, in the EU member states the top two groups in terms of smoking (daily and occasional smokers) were unemployed people (54%) and manual workers (51%) compared with an overall population average of 35% (24). In the United Kingdom in 1998, smoking prevalence among manual workers was in relative terms 49% higher than among non-manual workers; there was no significant change by 2003, when the gap was 48% (25). In the mid-1970s, approximately 35–40% of male smokers were concentrated in the lower socioeconomic groups. This proportion has now increased to 60–65% in the western countries for which data are available. A similar rising trend is observed for women but at a slower speed. In 2003, in Ireland 60.4% of male and 59.0% of female smokers were classified as manual workers, unemployed or dependent on the state (together representing around one third of the adult population). By 2005 there had been a slight decrease but the prevalence picture remained almost unchanged: 57.8% among men and 56.2% among women. In France in 2003, the smoking prevalence gap between those with a university degree and those with only a primary education was as high as 60%, while the difference in prevalence between those with the highest and lowest incomes was around 30%. Wider differences were observed in the Nordic countries: in Iceland in 2004, smoking prevalence among those with a university degree was half (10.1%) that of those who had not completed secondary school (21.6%). In Spain in 2003, the difference in smoking prevalence according to professional status was around 44.4% for men and 10.1% for women between the highest and lowest professional groups. Similar trends have been noted in Denmark and Sweden (21) and Finland (26).
In the eastern part of the Region, the impact of socioeconomic determinants, particularly the effect of income, is more varied. In the former Soviet Union, higher education was not a guarantee of a higher income and income distribution was substantially more equal than in the west. However, education was important for people’s perception of their own social status and commanded high prestige (27). For instance in Armenia, Belarus, Bulgaria, Georgia, Kazakhstan, Kyrgyzstan, the Republic of Moldova, the Russian Federation and Ukraine, smoking prevalence is generally lower among men with a higher education and (very recently) to a certain extent among those economically better off and with stronger social support. For women, with the exception of place of residence, no major factor to explain smoking has been clearly identified. Smoking prevalence among women living in rural areas tends to be lower than among those living in urban areas, which is thought to reflect the stronger marketing and easier availability of cigarettes in urban areas. In the Russian Federation, where smoking prevalence among women is the highest in the CIS, educational achievements also tend to be inversely associated with smoking, although this is not as significant as for men (28).
Cumulative exposure to socioeconomic disadvantages is a known factor for increasing the risk of smoking among men. Recent studies in the western part of the Region suggest that the risk is also important for women, especially young single mothers. For example, studies in the United Kingdom have shown that 46% of women in the group aged 18–49 years who leave school without qualifications are smokers (24). Within this group, of those whose current or last job was semi-skilled or unskilled, 50% are smokers. When the group is further narrowed down to those who are also reliant on social housing, prevalence rises to 67%. When the additional disadvantage of living on means-tested benefits is included, prevalence rises to 73%. In the United Kingdom, single mothers with dependent children who receive income support have a smoking prevalence of 57% compared with the average of 26%. In Sweden, a similar pattern can be observed among single mothers. Patterns of smoking and inequalities persist among women in pregnancy across Ireland, the Nordic countries and the United Kingdom (countries where data are available). In these countries, cessation rates during pregnancy fall from 70% among women in the most advantaged circumstances to around 40% among women in the poorest circumstances. Children from less-advantaged families are more exposed to the risks of environmental tobacco smoke than those from more affluent backgrounds because of their parents’ smoking habits. In the United Kingdom, for instance, 54% of the children in the lower socioeconomic groups were exposed to tobacco smoke in the home compared with 18% in professional households (24).
Tobacco-related harm
Summary
Since the last European report on tobacco control policy was published, the standardized death rate for lung cancer among men in the whole European Region has decreased while there has been a slight increase among the female population. Smoking has been identified as a major contributor to the gap in mortality and healthy life expectancy between those most in need and those most advantaged. Tobacco is the leading contributor to the disease burden in more than half of the European Member States and is among the three leading contributors in the absolute majority of countries.
The European tobacco control report 2007 page 23
Burden of disease attributable to tobacco use
The World health report 2002 (29) estimated that in the WHO European Region smoking is the second most important risk factor, accounting in 2000 for 12.3% of the total years of life lost due to premature mortality and years lived in disability (DALYs), which equates to about 18.6 million years of life lost (Table 2).
Table 2. Proportion of seven leading risk factors in the burden of DALYs in the WHO European Region, 2000
Risk factor Total DALYs (%)
1. High blood pressure 12.8
2. Tobacco 12.3
3. Alcohol 10.1
4. High blood cholesterol 8.7
5. Overweight 7.8
6. Low fruit and vegetable intake 4.4
7. Physical inactivity 3.5
Total 59.6
In 2002, tobacco was the leading contributor to the burden of disease in 31 Member States of the European Region (particularly in the western part of the Region), the second in 8 and the third in 6 (Table 3) (30).
Table 3. Rank and proportion of the burden of DALYs attributable to tobacco by country, 2002
Country Rank DALYs (%)
Country Rank DALYs (%)
Albania 1 9.2 Latvia 3 12.0
Andorra 1 11.2 Lithuania 3 11.5
Armenia 1 12.3 Luxembourg 1 11.3
Austria 1 11.0 Malta 3 9.7
Azerbaijan 2 6.9 Monaco 1 10.4
Belarus 4 11.6 Netherlands 1 16.7
Belgium 1 15.8 Norway 1 11.8
Bosnia and Herzegovina 1 14.7 Poland 1 16.6
Bulgaria 2 12.4 Portugal 2 10.4
Croatia 1 15.8 Republic of Moldova 4 9.7
Cyprus 2 5.6 Romania 2 13.1
Czech Republic 1 15.5 Russian Federation 3 13.4
Denmark 1 17.7 San Marino 1 11.0
Estonia 3 11.9 Serbia and Montenegro 2 15.3
Finland 3 7.7 Slovakia 2 12.2
France 1 12.4 Slovenia 1 13.7
Georgia 4 9.2 Spain 1 12.3
Germany 1 13.7 Sweden 2 8.0
Greece 1 12.9 Switzerland 1 10.7
Hungary 1 20.9 Tajikistan 8 2.3
Iceland 1 12.6 The former Yugoslav Republic of Macedonia 1 11.1
Ireland 1 11.8 Turkey 1 7.0
Israel 1 6.1 Turkmenistan 5 5.1
Italy 1 12.0 Ukraine 3 12.8
Kazakhstan 1 13.4 United Kingdom 1 14.2
Kyrgyzstan 1 6.6 Uzbekistan 7 3.1
Tobacco-related mortality
The World health report 2002 estimated that throughout the European Region tobacco was the leading risk factor for premature mortality, causing about 1.6 million deaths (29).
Current status
Changes in mortality from cancer of the trachea, bronchus and lung may be used as a marker of past trends in a population’s exposure to tobacco smoke. Standardized death rates for all ages per 100 000 have been used to illustrate trends across the Region as well as trends for the male and female populations (13). After a peak in mortality in the late 1980s and early 1990s, death rates have been falling throughout the Region although to a different extent in the various areas. According to the most recent available data (2004), the average mortality rate for the whole Region was 35.2 per 100 000 inhabitants (13).
Gender differences
In the Region, overall mortality rates from cancer of the trachea, bronchus and lung are generally much lower among women than among men. For example in 2004, the female standardized death rate was 13.8 per 100 000, as compared to 65 per 100 000 in the male population (13). The Region has been experiencing a favourable trend of falling death rates from these cancers in the male population since the early 1990s (Fig. 9).
Fig. 9. Standardized death rates (SDRs) per 100 000 inhabitants, cancer of the trachea, bronchus and lung, all ages, males and females, from 1980
Source: WHO European HFA database, 2006 (13).
10
20
30
40
60
70
80
90
1980 1985 1990 1995 2000 2005 2010
1540 SDR, malignant neoplasm of trachea, bronchus and lung, per 100 000
1560 SDR, males, malignant neoplasm of trachea, bronchus and lung, per 100 000
1580 SDR, females, malignant neoplasm of trachea, bronchus and lung, per 100 000
50
The European tobacco control report 2007 page 25
Considering the time lag between smoking behaviour and manifestation of disease and the relatively recent development of the tobacco epidemic among women, it is of grave concern that mortality from cancer of the trachea, bronchus and lung in the female population is steadily rising in the Region (Fig. 9).
Falling death rates due to trachea, bronchus and lung cancer in the male population of the WHO European Region since the mid-1990s imply that trends in smoking prevalence among men have been curbed in many countries since at least the early 1980s. Female mortality trends, although rising at different rates in the Region, in general reflect increasing smoking prevalence rates among women since at least the early 1980s. Four countries (the Czech Republic, Finland, the Netherlands and the United Kingdom) have been selected to demonstrate the different male and female mortality trends (Fig. 10–13).
Fig. 10. Standardized death rates (SDRs) per 100 000 inhabitants, cancer of the trachea, bronchus and lung, all ages, male and female, Czech Republic, 2005
Source: WHO European HFA database, 2005 (13).
Fig. 11. Standardized death rates (SDRs) per 100 000 inhabitants, cancer of the trachea, bronchus and lung, all ages, male and female, Finland, 2005
Source: WHO European HFA database, 2005 (13).
0
20
40
60
80
100
120
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2002
S D
R a
ll a
g e
s p
e r
1 0 0 0
0 0
Female
Male
2004 2000
0
20
40
60
80
100
120
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
S D
R a
ll a g e s p
e r
1 0
0 0
0 0
Female
Male
Fig. 12. Standardized death rates (SDRs) per 100 000 inhabitants, cancer of the trachea, bronchus and lung, all ages, male and female, Netherlands, 2005
Source: WHO European HFA database, 2005 (13).
Fig. 13. Standardized death rates (SDRs) per 100 000 inhabitants, cancer of the trachea, bronchus and lung, all ages, male and female, United Kingdom, 2005
Source: WHO European HFA database, 2005 (13).
In other European countries, for example Portugal and Romania, both male and female death rates from cancer of the trachea, bronchus and lung per 100 000 are rising. In these countries, the population’s exposure to smoking is either still rising among women as well as men, or has merely fallen very recently, and because of the time lag between smoking and morbidity and mortality rates, lower mortality rates (Fig. 14,15) which reflect smoking behaviour have not yet become apparent.
0
20
40
60
80
100
120
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002
S D
R a
ll a
g e
s p
e r
1 0 0 0
0 0
Male
Female
0
20
40
60
80
100
120
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002
Male
Female
S D
R a
ll a
g e
s p
e r
1 0 0 0
0 0
2004
2004
The European tobacco control report 2007 page 27
Fig. 14. Standardized death rates (SDRs) per 100 000 inhabitants, cancer of the trachea, bronchus and lung, all ages, male and female, Portugal, 2005
Source: WHO European HFA database, 2005 (13).
Fig. 15. Standardized death rates (SDRs) per 100 000 inhabitants, cancer of the trachea, bronchus and lung, all ages, male and female, Romania, 2005
Source: WHO European HFA database, 2005 (13).
Socioeconomic differences in mortality
In all countries with available data, the rates of premature mortality, particularly among men, are higher among those with lower levels of education or income. Smoking has been identified as a major contributory factor to the gap in mortality and also in healthy life expectancy between those most in need and those most advantaged. Data from France, Poland and the United Kingdom show that smoking is responsible for more than half of the difference in adult male mortality between those with the highest and lowest socioeconomic status. In the United Kingdom, premature deaths from lung cancer are five times higher among men in unskilled manual work compared with those in professional work (24). Comparable figures are available in France and Poland (for males aged 20–44 years). Similar gaps according to education level
0
20
40
60
80
100
120
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
Male
Female
S D
R a
ll a
g e
s p
e r
1 0 0 0
0 0
S
D R
a ll
a g e s p
e r
1 0
0 0
0 0
1984 1996 0
20
40
60
80
100
120
1980 1986 1992 1994 2000 2002
Male
Female
1988 1982 1990 1998 2004
have recently been reported in Finland (Helsinki), Norway (Oslo) and the Russian Federation (Moscow and St Petersburg), with the differences widening noticeably after about 1990 in the two Russian cities (31). Among men, the concentration of smoking in the lower socioeconomic groups observed throughout the Region is leading to a widening gap in future health outcomes. As underlined during the EU Presidency Summit on Tackling Health Inequalities (London 17–18 October 2005), no significant reduction in the socioeconomic gradient has been observed in countries where the prevalence has been reduced. Although the absolute number of people exposed to socioeconomic disadvantages could be diminishing in some countries, the persisting relative gap emphasizes the need for the Region to move beyond general tobacco control policies to tackle the different social and economic factors related to smoking (32).
Tobacco-related costs
The estimates of health care costs related to smoking cited in World Bank publications range from 0.1% to 1.1% of the gross domestic product (GDP) (33). Studies recently conducted in the WHO European Region suggest that these costs could be even higher. The direct and indirect costs of smoking in the EU were estimated to range from €97.7 to 130.3 billion in 2000, corresponding to between 1.04% and 1.39% of the EU GDP (17). Available data show that the costs are more substantial in the new EU member states, where the burden of disease and the death rates related to smoking are higher. For example, studies in Hungary concluded that the cost of smoking represented 2.7% to 3.2% of GDP in 1996 and 1998, respectively, while in Finland and France the estimated costs were between 1.1% and 1.3% of GDP (30). In Sweden it was estimated that the total costs arising from health care and productivity losses for smoking were SKr 26 billion in 2001 – compared with the national contribution to international aid (21 billion) or to the functioning of the judicial institutions (23 billion) (34).
The European tobacco control report 2007 page 29
PART 2
TOBACCO CONTROL POLICIES
Measures to reduce the demand for tobacco products
Price and taxation policies
Summary
On average, the price of tobacco products rose by an annual 6.8% above inflation between 2001 and 2005 in the EU countries – good progress when compared to the previous annual rate of increase of 2.7%. The trend is not promising in the CIS and SEE countries, however, as in many countries tobacco products became cheaper over this period. According to the information available for 35 countries,4 tobacco products became less affordable in 13 countries but more affordable in 20 countries. No major convergence of the price and tax burden on cigarettes, fine-cut tobacco, pipe tobacco and cigars has been achieved in the Region. In the EU, hand-rolled cigarettes are still half the price or less than manufactured products, despite tax increases. There is no major initiative to harmonize taxation of tobacco products in the other WHO European Member States, although a recent trend towards harmonization with the EU framework has been observed in some SEE countries, and some coordination (albeit limited to the taxation of imported tobacco products) is due to be introduced in the CIS. Most countries still do not earmark tobacco taxes for tobacco control or for public health in general.
Background
Raising taxes on tobacco products is considered to be one of the most effective components of a comprehensive tobacco control strategy (35,36). The ESTC recommended that strategic national action should include:
• maintaining high prices and taxes for tobacco products;
• raising taxes in order to bring the price of tobacco products above the average rates of inflation and income growth, to ensure their constantly decreasing affordability;
• prohibiting all tax-free and duty-free sales of tobacco products;
• allocating and sustaining a significant part of government revenues, including those from tobacco taxes, to funding national tobacco control programmes;
• harmonizing taxation and prices of all tobacco products to discourage the substitution of one tobacco product by another.
Different objectives were suggested for Member States in 2002 according to their progress with tobacco control:
• countries that had relied mainly on the impact of legislation and information should make public health concerns the explicit cornerstone for sustained and regular increases in tobacco taxes;
4 Armenia, Azerbaijan, Austria, Belgium, Bulgaria, Croatia, Cyprus, the Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Kyrgyzstan, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Norway, Poland, Portugal, Romania, the Russian Federation, Slovakia, Slovenia, Spain, Sweden and the United Kingdom.
The European tobacco control report 2007 page 31
• countries that had developed a set of comprehensive measures and multisectoral strategies should above all sustain the progress made in terms of tax increases, and to engage in internal cooperation in particular for coordinating taxation policies and combating counterfeiting, smuggling and cross-border sales.
Price and tax variations
The price variation indicator is expected to reflect tax variations, since an increase in the price of tobacco products mainly results from an increase in taxes. In order to take into account the impact of inflation, a real annual price variation was calculated by taking the annual percentage difference of the tobacco products price index and discounting inflation measured by the annual percentage difference of the general consumer price index (excluding tobacco products, when possible). Table 4 presents the data for the countries where information was available.
Table 4. Annual price variation of tobacco products in real terms (%), 1997–2005
Country 31.12.1997– 31.12.2001
31.12.2001– 31.12.2005
Countries 31.12.1997– 31.12.2001
31.12.2001– 31.12.2005
Albania -2.1 -0.4 Italy +0.9 +6.1
Armenia +14 -5.4 a Kyrgyzstan - 0.2 - 2.6
a
Austria +1.5 +2.4 Latvia +1.9 +5.3
Azerbaijan -8.9 -2.4 a Lithuania – +7.9
Belgium +1.6 +3.5 Luxembourg +1.6 +1.8
Bulgaria -2.1 +21 Malta – +7.9
Croatia – +1.4 Netherlands +2.6 +6.3
Cyprus +5.8 +14.8 Norway +7.3 +7.6
Czech Republic 0 0 Poland +4.3 +1.9
Denmark -1.1 -3.2 Portugal +1.8 +2.8
Estonia +5.3 +5.5 Republic of Moldova +3.5 -3.8
Finland +0.7 -1.1 Romania – + 2.9
France +3.8 +13.1 Russian Federation – - 6.2 a
Germany +1.6 +11 Slovakia +1.6 +10.7
Greece +3.1 +1.5 Slovenia 0 +9.3
Hungary +0.5 +11.8 Spain +4.7 +2.3
Iceland +4.8 +5.7 Sweden +2.9 +0.7
Ireland +3.2 +4.1 United Kingdom +7.2 +0.3
Israel +4.1 +5.2
a Until June 2005 instead of December 2005.
Source: Data provided by national counterparts.
On average, from 2001 to 2005 the price of tobacco products rose by an annual rate of 6.8% above inflation in the EU countries (37), which was good progress when compared to the previous annual rate of increase of 2.7% observed in the same group of countries during the period 1997–2001. Cyprus, France,5 Germany, Hungary, Lithuania and Slovakia managed a greater increase. However, real prices increased by less than 3% annually in Austria, Greece, Luxembourg, Poland, Spain and the United Kingdom over the same period. Prices were almost stable in Sweden and even fell in Denmark and Finland. The prices of cigarettes and rolling tobacco followed similar trends. In the CIS and SEE countries (apart from Bulgaria) there was an unpromising trend towards cheaper tobacco products (Table 4) (38).
5 At the end of 2003 the French Government signed an agreement with licensed tobacconists freezing the taxation of tobacco products until late 2007.
In the EU countries where excise duties are over 57% of the retail price and total taxes often exceed 75% when value-added tax (VAT) is included (Table 5), taxes and prices have followed parallel trends. With prices and taxes being in general proportional to each other, the increases/decreases in the retail price of tobacco were higher when the tax increases/decreases were the highest.
Table 5. Structure of taxation for tobacco products (%), 2005 a
Country Specific excise
Ad valorem excise
Total excise VAT Total tax
Albania 41.70 – 41.70 16.7 58.3
Austria 15.70 43 58.70 16.67 75.37
Belgium 3.87 53.76 57.63 17.36 74.99
Bosnia and Herzegovina 49.0 – 49.0 16.7 67.7
Bulgaria (filtered cigarettes) 15.93 31.80 47.73 16.67 64.4
Croatia (2003) n.a n.a 49.1 18.0 67.1
Cyprus 14.55 44.50 59.05 13.04 72.09
Czech Republic 27.27 24.00 51.27 15.97 67.24
Denmark 41.07 13.61 54.68 20.00 74.68
Estonia 28.05 26.00 54.05 15.25 69.30
Finland 7.38 50.00 57.38 18.03 75.41
France 6.03 57.97 64.00 16.39 80.39
Germany 37.00 25.29 62.29 13.79 76.08
Greece 3.67 53.83 57.5 15.97 73.47
Hungary 31.27 27.00 58.27 16.67 74.94
Ireland 42.01 18.32 60.33 17.36 77.69
Italy 3.75 54.74 58.49 16.67 75.16
Latvia 34.50 14.80 49.35 15.25 64.60
Lithuania 25.33 15.00 40.33 15.25 55.59
Luxembourg 9.88 47.14 57.02 13.04 70.06
Malta 9.42 51.40 60.82 15.25 76.07
Netherlands 36.53 20.56 57.09 15.97 73.06
Norway 56.1 – 56.1 20.0 76.10
Poland 25.68 31.30 56.98 18.03 75.01
Portugal 38.04 23.00 61.04 17.36 78.40
Republic of Moldova 7.7 – 7.7 16.7 24.4
Romania 22.72 30.00 52.72 19.00 71.72
Russian Federation n.a n.a 8 to 20 n.a
Serbia and Montenegro (Montenegro)
10.0 26.0 36.0 20.0 56.0
Slovakia 31.43 23. 00 54.43 15.97 70.39
Slovenia 14.84 42.71 57.55 16.67 74.22
Spain 7.29 57.00 64.29 13.79 78.08
Sweden 10.00 39.20 49.20 20 69.20
Switzerlandb 29.7 25.0 54.7 7.06 62.6
United Kingdom 40.89 22 62.89 14.89 77.79
Uzbekistan (2003) – 45.0 45.0 17.0 62.0 a The tax structure is presented as a percentage of the retail selling price, all taxes included. For the EU countries the structure has
been updated as at 1 January 2006 (39). b Includes 0.87% for the Growers’ Prevention Fund.
The relationship between tax and price is more variable in the CIS and south-eastern Europe. In countries where the total amount of taxes was below 50%, significant increases in excise duty observed since 2002 have often been counterbalanced by a cut in price by the tobacco industry. For example, in the Russian Federation, despite tax increases of 70% in 2003–2004 and 75% more recently, cigarettes are actually cheaper than in 2002. According to the Ministry of
The European tobacco control report 2007 page 33
Finance, since the excise is tied to the release price rather than to the retail price, cigarette manufacturers have been lowering their release prices from between 5% and 35%.
Affordability 6
Real price increases do not necessarily mean that tobacco products are becoming less affordable. Variations in income also have to be taken into account. Fig. 16 presents information on the affordability of tobacco products. In order to take account of variations in income level, the real price index of tobacco products has been discounted by the changes in income estimated according to variations in gross domestic product per capita calculated at a constant price by the United Nations Development Programme (40). In general, in countries where annual price increases were above 5% the domestic affordability of tobacco products has declined. Information available for 35 countries shows that although affordability declined in 13 (particularly in Cyprus, France, Israel, Kyrgyzstan, Malta, Norway Slovakia and Slovenia) it increased in 20 countries: Armenia, Azerbaijan, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, Greece, Hungary, Ireland, Latvia, Lithuania, Luxembourg, Poland, Portugal, Romania, Russian Federation, Spain and the United Kingdom (Fig. 16). The level of affordability has important implications for governments who should adjust their taxation policies on tobacco products according to inflation but also in accordance with increases in income.
Tax-free and duty-free sales of tobacco products, movement of duty-paid products
Since 2002, no countries have prohibited all tax-free and duty-free sales of tobacco products. In the EU private individuals are still free to purchase tobacco products for their own use in any EU country of their choice and to transport them personally to another EU member state without paying duty again and with almost no limit on quantity. Although all the original 15 EU member states that share borders with the new member states do restrict quantities, cross-border shopping has not diminished as the new member states still have low levels of taxation. Between the new EU member states and some bordering countries such as Belarus, the Russian Federation (Kaliningrad) and Ukraine, cross-border shopping has increased. In order to reduce this shopping, most EU member states have been granted a derogation to apply the same quantitative limits on tobacco products brought into their territories from the new EU member states as those applied to imports from third countries.
6 Since data are not consistently available, the changes in tobacco affordability are limited to 2001–2003. Some new EU member states substantially increased their duties on tobacco in 2004 and 2005, so conclusions drawn on the basis of data from 2001 and 2003 should be treated with caution.
Fig. 16. Affordability: average annual change in relative income price of tobacco products, 2001–2003
-14 -12 -10 -8 -6 -4 -2 0 2 4 6 8 10 12 14
Cyprus
France
Kyrgyzstan
Malta
Norway
Israel
Slovenia
Slovakia
Netherlands
Italy
Iceland
Belgium
Sweden
Germany
Austria
Portugal
Spain
Romania
United Kingdom
Finland
Poland
Greece
Hungary
Estonia
Denmark
Russian Federation
Czech Republic
Ireland
Luxembourg
Bulgaria
Latvia
Azerbaijan
Croatia
Lithuania
Armenia
Source: WHO Tobacco Free Initiative.
Earmarking of tobacco tax revenues for funding national tobacco control programmes
According to the available data, 12 countries (Austria, Estonia, Finland, France, Greece, Iceland, Poland, the United Kingdom and, since 2002, Belarus, Romania and Switzerland) have introduced an earmarking tobacco tax mechanism. Serbia and Montenegro (Serbia) introduced an earmarking mechanism in 2005. Bulgaria was expected to do so in 2006. The countries that use such funds for tobacco control and health promotion are Poland, Finland and Iceland (which earmark 0.5%, 0.75% and 0.9% of tobacco taxes, respectively), Serbia and Montenegro (Serbia) (which earmarks 1 csd per pack of cigarettes to preventive action) and Switzerland (which earmarks 2.6 Swiss cents per pack of cigarettes). Romania uses the funds to finance health promotion activities, including those in tobacco control areas such as awareness-raising campaigns, the Quitline, and training in and treatment for smoking cessation.
The European tobacco control report 2007 page 35
Harmonization of taxation and prices of tobacco products
In the EU since 2002, the regime for cigarette taxation established in 1972 has been modified in accordance with Directive 2002/10/EC (41). In addition to the 57% minimum excise incidence rule, which failed to achieve significant convergence in tax levels, new rules were established requiring a minimum excise burden of €95 per 1000 cigarettes, which meant either applying a specific regime or the former regime of 57% rate plus a specific excise of €60 per 1000 cigarettes (€64 from July 2006 onwards). At present almost all EU countries comply with this new regime. The Czech Republic, Greece, Slovenia and Spain have, however, negotiated a transition period up to 31 December 2007; Hungary, Poland and Slovakia until 31 December 2008, and Estonia, Latvia and Lithuania until 31 December 2009. Italy, Luxembourg, the Netherlands and Portugal are temporarily operating below the minimum burden. In order to increase convergence between the minimum rates of tax on cigarettes and other tobacco products, Directive 2002/10/EC has also gradually increased the minimum percentage rates for rolling tobacco from 30% to 39.36% and the minimum specific amount from €25 to €32 per kg as from1 July 2004. A minimum excise rate for cigars of 5% of the retail selling price inclusive of all taxes or €11 per 1000 items or per kg was also introduced. The minimum excise rate for pipe tobacco was adjusted for inflation to 20% of the retail selling price or €20 per kg (the Czech Republic and Estonia have derogations). Despite these increases, hand-rolled cigarettes are still half or less than half the price of manufactured products. This is far from the 33.33% difference envisaged in 2002 by most member states. On average, the total tax yield on hand-rolling tobacco is actually approximately 44% of the average total tax yield on cigarettes. Such a difference has been used by the German tobacco industry when introducing, in response to the 2003 tax increases, new cheap cigarettes presented as “tobacco sticks” (roll “make your own” tobacco) in order to benefit from the lower tax on loose tobacco (tobacco sticks cost on average 20% less than usual cigarettes). Between 2003 and the end of 2005, sales of singles or sticks accounted for almost one fifth of the cigarette market with a consequent reduction in the impact of tax increases on smoking prevalence. On 10 November 2005 the European Court of Justice ruled that this initiative by the German tobacco industry was illegal and classified tobacco sticks as cigarettes (42). Although Directive 2002/10/EC has had a visible impact on increases in excise taxes on cigarettes, fine-cut tobacco, pipe tobacco and cigars in the 10 acceding countries (which had the lowest rates in 2002), it has not resulted in a major convergence in the price and tax burden between the 25 EU member states. In terms of purchasing power parity (PPP), the difference between the most popular price cigarette in the United Kingdom and Lithuania is 4 : 1, greater than the difference observed between the United Kingdom and Spain (3 : 1) before the 2004 enlargement (Fig. 17). The difference in the tax burden expressed in PPP is even higher, €230 per 1000 cigarettes in the United Kingdom compared to less than €25 in Latvia and Lithuania (Fig. 18). As stipulated by Directive 2002/10/EC, a review of the structure and rates of excise duty on tobacco products is under way and a proposal for revision will be put forward no later than 31 December 2006. The proposal should reflect the wider objectives of the Treaty related to public health considerations (Art. 152) and the provisions following the ratification of the WHO FCTC. Unfortunately, owing to the length of the negotiated transition periods, no major convergence and price increases could realistically be expected before 31 December 2009.
Fig. 17. Retail sale price of the most popular price cigarettes (pack of 20) in the European Union, January 2005
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0
Latvia
Lithuania
Estonia
Poland
Slovakia
Czech Republic
Hungary
Spain
Slovenia
Greece
Portugal
Malta
Luxembourg
Austria
Italy
Cyprus
Netherlands
Belgium
Switzerland
Finland
Denmark
Sweden
Germany
France
Ireland
United Kingdom
Price in € per packet of 20 cigarettes
Source: Confédération des Débitants de Tabac de France, 2006 (www.lelosange.fr/confe/article.php?id_article=7, accessed 11 September 2006).
In the other WHO European Member States (apart from Bulgaria and Romania, which have tax regimes similar to the EU) no major initiative has been developed to harmonize the taxation of tobacco products. A study of the price level indices carried out in some SEE countries (Albania, Bosnia and Herzegovina, Croatia, Serbia and Montenegro and The former Yugoslav Republic of Macedonia) during 2003 showed that tobacco products were relatively cheaper in these countries than they were in the EU taken as a whole (43). There has recently been a trend towards harmonization with the EU framework observed in those countries, and the CIS countries are due to start coordinating the taxation of imported tobacco products.
Exposure to tobacco smoke (passive smoking, environmental tobacco smoke)
Summary
The regulation of smoking in public places has become more restrictive in the WHO European Region. On 29 March 2004 a major development occurred in Ireland when smoking bans in public places were extended for the first time in the Region to pubs, bars and restaurants as well as all workplaces. Since then, legislation banning smoking in all indoor premises, including bars and restaurants, has been passed in Italy, Malta, Norway, Spain, Sweden and the United Kingdom.
The European tobacco control report 2007 page 37
Fig. 18. Tax burden on cigarettes in € per 1000 cigarettes, 3 October 2005
0 25 50 75 100 125 150 175 200 225 250
Latvia
Lithuania
Romania
Estonia
Bulgaria
Czech Republic
Poland
Slovakia
Hungary
Slovenia
Spain
Greece
Luxembourg
Portugal
Cyprus
Italy
Austria
Malta
Belgium
Netherlands
Sweden
Malta
Denmark
Finland
Germany
France
Ireland
United Kingdom
Values in €
Note. Malta appears twice in Fig. 18 because the excise tax structure is 51.4% of the retail price + Lm 7.30 per 1000 cigarettes but not less than Lm 43.30 (or €100.84) per 1000 cigarettes. Source: Excise duty tables. Part III – Manufactured tobacco. Brussels, European Commission, 2006 (ref 1.022) (www//europe.eu.int/comm./taxation_customs/, accessed 2 December 2006).
Since 2002, a number of Member States (mainly in the EU) have introduced bans on smoking in health care, educational and government facilities and in indoor workplaces and offices. A smaller number of Member States, mainly in the eastern part of the Region, have introduced or reinforced restrictions in the same settings. In particular, a large majority of countries (70%) have enforced bans – complete or with completely separated rooms – on smoking in health care and educational facilities. Smoking in government facilities, workplaces and cultural institutions is also banned in a smaller number of countries (60%). Since 2002, 14 Member States have passed complete bans on smoking in taxis, 13 in trains and 12 in buses. Five Member States, mostly in the eastern part of the Region, have introduced partial restrictions in some settings, particularly on trains. By the end of 2005, 80% of the countries had enforced a ban on smoking in buses, 70% in taxis but fewer than 50% on trains.
Background
The accumulation of evidence on the risks and health consequences of involuntary exposure to environmental tobacco smoke emphasizes the need for stronger regulation to protect nonsmokers, particularly children. There is also evidence that smoke-free legislation will help current smokers to stop smoking and reduce the average consumption of tobacco by those that continue to smoke (44). The ESTC recommended that strategic national action should include:
• introducing or strengthening legislation to make all public places smoke-free, including public transport and workplaces;
• banning smoking indoors and outdoors in all educational institutions and their premises for children up to the age of 18 years, and indoors in all other educational institutions;
• banning smoking in all places of health care delivery and their indoor and outdoor premises;
• banning smoking at all public events arranged indoors and outdoors;
• banning or severely restricting smoking in restaurants and bars, to protect owners, employees and clients from serious damage to their health;
• classifying environmental tobacco smoke as a carcinogen to protect the rights of workers (nonsmokers and smokers), particularly those working in smoking environments, and to speed up the banning of smoking in all workplaces.
It was also suggested that Member States review and strengthen the mechanisms for enforcing their legislation and increase compliance through comprehensive information campaigns and litigation.
Restrictions on smoking in public places
Smoking is increasingly being regulated in public places in the WHO European Region. This trend has moved from restrictions on smoking in specific institutions, such as schools and hospitals, to separating smokers and nonsmokers in a larger number of places and finally to legislation banning or restricting smoking in public places, including workplaces. The main reasons for these developments are the increasing evidence about the risks of environmental tobacco smoke and growing public support among both smokers and nonsmokers for regulation (45). In general, public support increases after such bans. In Norway, for instance, public support increased from 54% before the introduction of new legislation banning smoking in bars and restaurants to 76% 16 months after it entered into force (46). The first session of the Conference of the Parties to the WHO FCTC that was held in Geneva from 6 to 17 February 2006 decided, among other things, to start developing guidelines for protection from exposure to tobacco smoke (Article 8 of the WHO FCTC). These guidelines, or at least a progress report, should be presented to the second Conference of the Parties planned for the first half of 2007. A large majority (70%) of countries in the WHO European Region had enforced bans (absolute or in physically separated rooms) on smoking in health care and educational facilities. Smoking in government facili