Tobacco Induced Diseases

Research Paper

Tobacco endgame in the WHO European Region: Feasibility

in light of current tobacco control status
Adrián González-Marrón1,2, Helena Koprivnikar3, Judit Tisza4, Zsuzsa Cselkó4, Angeliki Lambrou5, Armando Peruga6,7,8,
Biljana Kilibarda9, Cristina Lidón-Moyano1, Dolors Carnicer-Pont6,7,10, Efstathios Papachristou5, Emilia Nunes11,
Giulia Carreras12, Giuseppe Gorini12, Hipólito Pérez-Martín1, Jose M. Martínez-Sánchez1, Lorenzo Spizzichino13, Maria
Karekla14, Maurice Mulcahy15, Milena Vasic9,16, Otto Ruokolainen17, Romain Guignard18, Sotiria Schoretsaniti5, Tiina
Laatikainen17,19, Viêt Nguyen-Thanh18, Hanna Ollila17

ABSTRACT
INTRODUCTION To assess the feasibility of developing World Health Organization AFFILIATION
1 Group of Evaluation of
(WHO) European Region countries’ goals and measures in line with tobacco Health Determinants and
endgame objectives, information on the current tobacco control context and Health Policies, Department
of Basic Sciences, Universitat
capacity is needed. The aim of this study was to assess the implementation of Internacional de Catalunya,
the Framework Convention on Tobacco Control (WHO FCTC) and MPOWER Sant Cugat del Vallès, Spain
measures in the region. 2 Department of Health
Technology Assessment and
METHODS In this cross-sectional study we used data from the WHO FCTC Health Economics, Institute
implementation reports and MPOWER from 2020 in 53 WHO European Region for Clinical Effectiveness and
Health Policy (IECS), Buenos
countries. Six domains (i.e. capacity, taxation and price policies, other national key Aires, Argentina
regulations, public awareness raising and communication, tobacco use cessation, 3 National Institute of Public
Health, Slovenia
and monitoring) were formed. Subsequently, available indicators under these 4 National Korányi Institute
domains were scored and the level of implementation was computed for each of Pulmonology, Budapest,
Hungary
country. Mann-Whitney tests were carried out to compare the scores between 5 Directorate of Epidemiology
the group of countries with and without official endgame goals. and Prevention of Non-
RESULTS Overall, implementation of the WHO FCTC with the selected indicators at Communicable Diseases and
Injuries, National Public
the country level ranged from 28% to 86%, and of MPOWER from 31% to 96%. Health Organization (NPHO),
Full implementation was achieved by 28% of WHO FCTC Parties in the region in Athens, Greece
6 Grupo de Investigación en
taxation and price policies, 12% in public awareness raising and communication, Control del Tabaco, Institut
and 42% in monitoring. In capacity, tobacco use cessation and other national key d'Investigació Biomèdica
de Bellvitge (IDIBELL),
regulations, none of the Parties in the region reached full implementation. Overall L'Hospitalet de Llobregat,
median WHO FCTC scores were significantly higher in countries with official Barcelona, España
endgame goals than in those without (p<0.001). 7 Centro de Investigación
Biomédica en Red de
CONCLUSIONS There is unequal implementation of both WHO FCTC and MPOWER Enfermedades Respiratorias,
measures among WHO European Region countries. MPOWER and WHO FCTC (CIBERES), Madrid, España
8 Centro de Epidemiología y
provide all the measures for the necessary first steps, followed by innovative Políticas de Salud, Facultad
measures, to accomplish tobacco endgame goals. de Medicina Clínica Alemana,
Universidad del Desarrollo,
Santiago, Chile
9 Institute of Public Health
Tob. Induc. Dis. 2023;21(November):151 https://doi.org/10.18332/tid/174360 of Serbia “Dr Milan Jovanovic
Batut”, Belgrade, Serbia
10 Programa de Prevenció
i Control del Càncer,
INTRODUCTION Institut Català d'Oncologia,
Tobacco smoking is still one of the leading preventable causes of morbidity L'Hospitalet de Llobregat,
Barcelona, España
and mortality worldwide. In the European Union (EU), around 24% of adult 11 General Directorate of
population smoked tobacco products in 20191, and around 0.74 million people Health, Ministry of Health,
die every year due to tobacco smoking2. In the World Health Organization (WHO) Lisbon, Portugal
12 Clinical Epidemiology

Published by European Publishing. © 2023 González-Marrón A. et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0
International License. (https://creativecommons.org/licenses/by/4.0/)

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Research Paper

European Region, the estimated tobacco smoking the tobacco epidemic to Unit, Oncologic network,
prevalence in 2015 was 27%3 and smoking accounts ending it. For example, in prevention and research
institute (ISPRO), Florence,
for 25%, 41% and 63% of cardiovascular disease, December 2022, New Zea- Italy
cancer and respiratory disease deaths in men, and land adopted a bill which 13 Ministry of Health, Rome,
Italy
6%, 10% and 37% of deaths in women, respectively4. included the ban on the 14 University of Cyprus,
To end the tobacco epidemic, the concept of endgame commercial sales of com- Nicosia, Cyprus
has been put forward. Endgame does not have one bustible tobacco products 15 National Environmental
Health Service, Health Service
definition, but it commonly refers to the situation to anyone born on or after Executive (HSE), Galway
where the tobacco epidemic is to be ended rather than 1 January 2009, a drastic Business Park, Dangan, Ireland
16 Faculty of Dentistry,
controlled5. Proposed endgame goals and strategies reduction of around 95% Pancevo, Serbia
by some countries across the world include reducing in the number of retailers, 17 Finnish Institute for Health
and Welfare, Helsinki, Finland
the prevalence of tobacco use to a minimal level in and the reduction of nico- 18 Santé Publique France, the
the population (<5%) or achieving tobacco-free tine content in cigarettes25. French National Public Health
generations within a specified time frame. In the EU, Over the years, the rati- Agency, Saint-Maurice, France
19 Institute of Public Health
seven member states already have official endgame fication of the WHO FCTC and Clinical Nutrition,
goals with differing definitions. These are Belgium, has led to the implementa- University of Eastern Finland,
Kuopio, Finland
Finland, France, Ireland, the Netherlands, Slovenia, tion of key tobacco control
and Sweden. While Ireland6 and Sweden7 plan to measures across several CORRESPONDENCE TO
Adrián González-Marrón.
achieve their endgame goal by 2025, Finland8, France9 policy domains, which Group of Evaluation of Health
and the Netherlands10 endgame goals are planned for have also resulted in sig- Determinants and Health
Policies, Department of Basic
between 2030 and 2040, and Belgium11 and Slovenia12 nificant reductions of to- Sciences, Universitat
by 2040. Also, in Denmark, an action plan was bacco use . Yet, there is a
26
Internacional de Catalunya,
introduced with a goal on a smoke-free generation large variation in the im- Josep Trueta Street, 08195
Sant Cugat del Vallès,
by 203013. The EU has also set its overall goal, with plementation of different Barcelona, Spain.
the Europe’s Beating Cancer Plan goal to reduce the WHO FCTC articles and E-mail: agonzalezm@uic.es
ORCID ID: https://orcid.
prevalence of tobacco use in Europe under 5% by the comprehensiveness org/0000-0003-1087-1769
204014. In non-EU countries endgame goals have also and effectiveness of the
KEYWORDS
been set. Norway aims for a tobacco-free society15 and measures implemented advertising and promotion,
in the UK, England and Scotland aim to be smoke- under different articles .27
cessation, end game,
free by 203016 and 2034, respectively17. Importantly, In order to inform about packaging and labelling,
public policy
endgame strategies have also been proposed by other the feasibility of achieving
organizations (e.g. non-profit organizations)18. tobacco endgame goals and Received: 8 August 2023
Revised: 20 October 2023
To achieve these ultimate tobacco endgame goals, strategies, this study aimed Accepted: 23 October 2023
different facilitators have been considered. These in- to assess the current status
clude public support for tobacco control in the pop- of implementation of key
ulation, strong political leadership19, or going beyond tobacco control measures in WHO European Region
the FCTC mandates implementing innovative mea- countries. Specifically, the aim was to identify poten-
sures. However, the first step would be to fully imple- tial strengths and deficiencies among countries in the
ment the ‘best buys’ defined as part of the MPOWER implementation of measures overall and within six do-
measures20, the WHO Framework Convention on To- mains derived from the WHO FCTC and MPOWER:
bacco Control (FCTC)21, and the recommendations in tobacco control capacity, taxation and price policies,
its implementation guidelines22. These contain sev- national key regulations, public awareness raising and
eral evidence-based measures, and encourage even communication, tobacco use cessation, and monitoring.
going beyond the requirements and recommendations
to protect the health of the population23,24. In recent METHODS
years, several innovative measures, such as different Design
market/supply and product-focused measures have The present study uses cross-sectional data from the
been proposed for countries to shift from controlling WHO FCTC implementation reports and the WHO

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MPOWER assessments. WHO MPOWER data for recommended in the treaty or in its implementation
the year 2020 were available from the WHO Global guidelines) were included in the current analysis.
Health Observatory 20. The officially submitted Implementation was assessed as full if ‘yes’ was
implementation reports of the Parties to the WHO reported for ‘yes/no’ questions or ‘complete’ for
FCTC are publicly available in the WHO FCTC ‘complete/partial/no’ questions. For indicators with
Implementation Database28. In the present study, the possible answers ‘complete/partial/no’, partial
through participation of the WHO FCTC Knowledge implementation was determined if ‘partial’ was
Hub on Surveillance, full datasets for the 2020 reported. Non-implementation was determined if
reporting cycle deriving from the reporting platform ‘no’ was reported for ‘yes/no’ and ‘complete/partial/
of the WHO FCTC, including updated information no’ questions. A score was assigned to each of the
provided by the Parties, were also utilized. For the indicators, giving two/one point for full, one/half
countries for which the WHO FCTC implementation point for partial, and none for no implementation of
report was not available due to recent acceptance advanced/core measures, respectively, to weigh for
of the treaty (i.e. Andorra) or not being part of the the implementation of advanced measures over core
Convention (i.e. Monaco and Switzerland), only data measures in the context of accomplishing an endgame
from MPOWER were extracted. Hence, WHO FCTC scenario. Details on the grouping and the score of the
data were utilized for 50 countries while MPOWER indicators can be found in the Supplementary file.
data were utilized for 53 countries in the region. The overall maximum score was 146 points for all
This study was carried out under the project Joint Articles and relevant guidelines.
Action on Tobacco Control 2 (JATC2)29 Work Package To provide a better picture of the strengths and
9 (WP9), which is focused on the best practices to challenges in the region, the indicators were further
develop an effective and comprehensive tobacco grouped under the following six domains: capacity
endgame strategy. The WP9 partners representing (i.e. ‘infrastructure’ for tobacco control, strategies,
15 countries also reviewed their country data and resources, enforcement mechanisms, measures
had the possibility to provide recent updates. The to prevent industry influence and act on industry
updates were minor and did not substantially change through liability measures); taxation and price policies
the general information gathered from the existing (including measures to prevent illicit trade); other
databases. national key regulations (i.e. smoking bans applied in
indoor settings; testing, measuring and regulation of
Procedure and measures contents and emissions of tobacco products; packaging
Indicators assessing the implementation of both and labelling of tobacco products; advertising,
WHO FCTC and MPOWER measures were initially promotion and sponsorship; and retail measures
identified and extracted by two JATC2 partners from to prevent youth access); public awareness raising
the abovementioned sources of data. These were and communications (i.e. publication of industry
reviewed and refined by the rest of the partners, and data, campaigns, trainings); tobacco use cessation,
a set of indicators were selected to be included in (i.e. resources directed to cessation of tobacco), and
the current status assessment. The selection process monitoring (i.e. availability of different key data and
is described in detail in the indicator compendium promoting research). The maximum score for each of
available on the JATC2 website (www.jaotc.eu) . the domains was 23 for capacity, 15 for taxation and
Given the focus on tobacco endgame, only the price policies, 54 for other national key regulations,
strongest level of requirements or recommendations 13 for public awareness raising and communications,
without exemptions were considered from the WHO 34 for tobacco use cessation, and 7 for monitoring.
FCTC and its implementation guidelines. This Regarding the MPOWER measures, 10 indicators
means that, for example, only advertising bans, not were used: smoking bans and compliance with
advertising restrictions, were included. For MPOWER, smoking bans; health warnings and anti-tobacco mass
the focus was on established ‘best buys’. Eventually, campaigns; bans in advertising and compliance; offer
106 core indicators (for measures required in the help to quit smoking; share of total taxes in the retail
treaty) and 20 advanced indicators (for measures price, affordability trend (since 2010), % of gross

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Table 1. Level of implementation of WHO FCTC and MPOWER measures and age-standardized prevalence of
tobacco smoking in WHO European Region countries, 2020

Country WHO FCTC MPOWER Age-standardized estimates

of current tobacco smoking
(2020)
% % %
Albania 66.4 50.0 22.4
Andorra NA 48.1 31.8
Armenia 61.3 76.9 25.5
Austria 72.9 86.5 26.4
Azerbaijan 47.3 37.5 20.5
Belarus 74.3 75.0 25.8
Belgium* 75.3 78.8 22.2
Bosnia and Herzegovina 60.3 59.6 35.0
Bulgaria 69.5 73.1 39.0
Croatia 75.0 47.1 36.9
Cyprus 67.5 82.7 35.1
Czech Republic 65.1 89.4 30.7
Denmark 61.3 65.4 17.5
Estonia 60.6 86.5 26.7
Finland* 78.1 89.4 18.2
France* 73.3 87.5 33.4
Georgia 68.2 84.6 31.7
Germany 57.5 67.3 22.0
Greece 63.4 51.0 33.5
Hungary 68.2 48.1 31.8
Iceland 56.8 76.9 12.0
Ireland* 86.3 92.3 20.8
Israel 69.9 41.3 21.2
Italy 65.8 60.6 23.1
Kazakhstan 54.1 67.3 21.1
Kyrgyzstan 76.4 65.4 27.0
Latvia 76.4 87.5 35.0
Lithuania 59.2 68.3 27.4
Luxembourg 63.7 44.2 21.1
Malta 76.7 47.1 24.0
Monaco NA 30.8 -
Montenegro 62.0 44.2 32.8
The Netherlands* 81.5 65.4 22.2
Norway* 75.3 84.6 16.2
Poland 42.8 77.9 24.0
Portugal 73.3 62.5 25.4
Republic of Moldova 72.6 63.5 25.4
Romania 52.1 78.8 28.0
Russian Federation 67.8 74.0 26.8
San Marino 28.4 42.3 -
Continued

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Table 1. Continued

Country WHO FCTC MPOWER Age-standardized estimates

of current tobacco smoking
(2020)
% % %
Serbia 68.5 69.2 39.8
Slovakia 63.7 68.3 31.5
Slovenia* 80.5 61.5 22.0
Spain 86.0 89.4 27.7
Sweden* 73.6 48.1 15.6
Switzerland NA 55.8 25.5
Tajikistan 42.1 48.1 -
Republic of North Macedonia 80.8 66.3 -
Turkey 84.6 88.5 30.7
Turkmenistan 85.6 90.4 5.5
Ukraine 39.4 84.6 25.8
United Kingdom* 83.9 96.2 15.4
Uzbekistan 51.0 38.5 10.6
FCTC: Framework Convention on Tobacco Control. NA: not applicable. *Countries/areas with planned and implemented official tobacco endgame strategies.

domestic product (GDP) per capita to purchase 2000 goals. Excel version 16.26 and R version 4.2.2, with
cigarettes of the most sold brand. Implementation the package ggplot2 for graphs, were used for the
was assessed using the score reported in the WHO analyses. The significance level was set at 0.05.
Global Health Observatory30. Also, an ad hoc score
was computed for the indicators ‘affordability trend RESULTS
since 2010 to 2020’, giving 1 point if less affordable There were substantial differences in the overall
in 2020 than in 2010, 0 for no change, and -1 if more implementation of both WHO FCTC and MPOWER
affordable in 2020 than in 2010; and ‘% GDP per measures among countries, with ranges of 57.6% for
capita to purchase 2000 cigarettes of the most sold WHO FCTC (minimum: 28.4%, maximum: 86.0%) and
brand’, giving 0 points to countries in the lowest 65.4% for MPOWER (minimum: 30.8%, maximum:
tertile; 0.5 points to countries in the second tertile; 96.2%), respectively (Table 1).
and 1 point to countries in the third tertile. These Concerning FCTC measures, the lowest percentage
were incorporated into this analysis to provide a of implementation was found in the capacity domain.
better description of the affordability of tobacco at In the capacity domain, none of the countries reached
the national level. The overall maximum score was full implementation. Only 5 out of 50 WHO FCTC
52 points for MPOWER measures. parties achieved at least 80% of the maximum score
and 33 at least 50% of the maximum score. The
Data analysis percentage of implementation ranged from 17% in
For each country, we estimated the percentage of Ukraine to 91% in the Netherlands (Figure 1a).
implementation of the overall WHO FCTC and Within the taxation and price policies domain,
MPOWER measures, dividing the estimated score 30 out of 50 WHO European Region FCTC parties
by the corresponding maximum. We also computed achieved at least 80% of the maximum score, and 47 at
the percentage of implementation of each WHO least 50% of the maximum score. Altogether 14 WHO
FCTC domain per country. Mann-Whitney tests FCTC parties reported full implementation. Lowest
were carried out to compare the scores between the percentage of implementation was 21% (San Marino)
group of countries with and without official endgame (Figure 1b).

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 Tobacco Induced Diseases
Research Paper1a. Level of implementation of the domain capacity for WHO FCTC measures
Figure
in WHO European Region countries (2020)
Figure 1a. Level of implementation of the domain capacity for WHO FCTC measures in WHO European
Region countries (2020)

*Countries with planned or implemented official

*Countries with tobacco
planned endgame official
or implemented strategies.
tobacco endgame strategies.

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Research Paper
Figure 1b. Level of implementation of the domain taxation and price policies for
WHO FCTC measures in WHO European Region countries (2020)
Figure 1b. Level of implementation of the domain taxation and price policies for WHO FCTC measures in
WHO European Region countries (2020)

*Countries with planned or implemented official

*Countries with tobacco
planned endgameofficial
or implemented strategies.
tobacco endgame strategies.

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Research Paper
Figure 1c. Level of implementation of the domain other national key regulations for
WHO FCTC measures in WHO European Region countries (2020)
Figure 1c. Level of implementation of the domain other national key regulations for WHO FCTC measures in
WHO European Region countries (2020)

*Countries with planned or implemented official tobacco endgame strategies.

*Countries with planned or implemented official tobacco endgame strategies.

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Figure
Research 1d. Level of implementation of the domain public awareness raising and
Paper
communication for WHO FCTC measures in WHO European Region countries
(2020)
Figure 1d. Level of implementation of the domain public awareness raising and communication for WHO
FCTC measures in WHO European Region countries (2020)

*Countries with planned or implemented official tobacco endgame strategies.

*Countries with planned or implemented official tobacco endgame strategies.

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Figure 1e. Level of implementation of the domain tobacco use cessation for WHO
FCTC measures in WHO European Region countries (2020)
Figure 1e. Level of implementation of the domain tobacco use cessation for WHO FCTC measures in WHO
European Region countries (2020)

*Countries with planned or implemented official tobacco endgame strategies. Lithuania is not included due to not reporting.

*Countries with planned or implemented official tobacco endgame strategies. Lithuania is not included due to not reporting.

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Figure 1f. Level of implementation of the domain monitoring for WHO FCTC
measures in WHO European Region countries (2020)
Figure 1f. Level of implementation of the domain monitoring for WHO FCTC measures in WHO European
Region countries (2020)

*Countries with planned or implemented official tobacco endgame strategies.

*Countries with planned or implemented official tobacco endgame strategies.

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Table 2. Median (and interquartile range) MPOWER and WHO FCTC scores, overall and according to
domains, 2020

Countries without official Countries with official

endgame goals endgame goals
(N=41) (N=9)
Median (IQR) Median (IQR) p*
Overall WHO FCTC 65.8 (59.2–72.9) 78.1 (75.3–81.5) <0.001
WHO FCTC domains
Capacity 52.2 (41.3–65.2) 69.6 (65.2–69.6) 0.017
Taxation and price policies 85.7 (57.1–92.9) 85.7 (85.7–100.0) 0.062
Other national key regulations 79.6 (62.0–85.2) 82.4 (80.6–84.3) 0.136
Public awareness raising and communication 69.2 (53.8–84.6) 69.2 (61.5–84.6) 0.889
Tobacco use cessation 50.8 (33.5–62.2) 69.1 (63.2–79.4) 0.002
Monitoring 87.5 (50.0–100) 100.0 (100.0–100.0) 0.003
MPOWER 66.8 (48.1–78.1) 84.6 (65.4–89.4) 0.037
IQR: interquartile range. WHO FCTC: World Health Organization Framework Convention on Tobacco Control. *Mann-Whitney test.

The second domain with the highest implementation (IQR: 75.3–81.5)] and without [65.8 (IQR: 59.2–
was other national key regulations. Among 50 WHO 72.9)] official endgame goals (p<0.001). Significant
European Region FCTC parties, 27 achieved 80% or differences were also found in the capacity, tobacco
more of the maximum score, while almost all, that is use cessation, and monitoring domains (Table 2).
47, achieved at least 50% of the maximum score. The
percentage of implementation ranged from 25% in DISCUSSION
Poland to 99% in Slovenia (Figure 1c). Still, none of We have observed wide differences between WHO
the Parties in the region reported full implementation. European Region countries in the implementation of
In the public awareness raising and communications both WHO FCTC and MPOWER measures, meaning
domain, 19 out of 50 WHO European Region FCTC there is plenty of room for improvement in maximizing
parties achieved at least 80% of the maximum score the implementation of measures of WHO FCTC and
and 39 at least 50% of the maximum score. Altogether its implementation guidelines. Importantly, although
6 Parties reported full implementation. The lowest the implementation of different tobacco control
percentage of implementation was 15% (Denmark) policies has been assessed already through diverse
(Figure 1d). tools31 and in different reports32, this is, as far as we
In the tobacco use cessation domain, only 3 out of know, the first study assessing the implementation
50 WHO FCTC parties achieved at least 80% of the of tobacco control measures at their strongest level,
maximum score and 31 at least 50% of the maximum which would be required to achieve tobacco endgame
score. The percentage of implementation ranged from goals.
6% in San Marino to 91% in the United Kingdom In all six domains (i.e. capacity, monitoring,
(Figure 1e). None of the Parties in the region reached other national key regulations, public awareness
full implementation. raising and communication, taxation and prices, and
The highest percentage of implementation was tobacco use cessation), notable differences between
found in the monitoring domain, where among the countries were also observed. Considering each of
50 WHO European Region FCTC parties, 21 achieved the domains, the highest level of implementation of
full implementation, 32 achieved 80% or more of the measures of WHO FCTC and associated guidelines
maximum score, and 44 achieved at least 50% of the is in the monitoring domain, for which many parties
maximum score (Figure 1f). achieve full implementation. This means that
There were significant differences in the median monitoring systems are well established in a great
overall WHO FCTC scores in countries with [78.1 part of the countries, including data availability on

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smoking prevalence and other relevant indicators a higher ranking in these 5 countries is not necessarily
for argumentation of new measures or evaluation of reflected in lower smoking prevalence, a fact which
implemented ones. Secondly, an estimated 54% of is also true for countries with the highest achieved
parties have implemented at least 80% of measures percentage of the overall implementation of WHO
in the other national key regulations domain. FCTC measures or MPOWER measures, showing
However, the WHO FCTC implementation database there is still plenty of room to reduce the prevalence
does not include indicators describing the level of of tobacco smoking in Europe34. This is also supported
compliance with the measures, which would show the by the WHO projections on reaching the 30% relative
actual implementation of those measures in practice. reduction in tobacco use prevalence between 2010
Thirdly, and surprisingly, 60% of the parties have and 2025, as set in the Global Action Plan on non-
implemented at least 80% of the measures within communicable diseases (NCD). Based on the 2021
the taxation and prices domain, which also included assessment, the WHO European Region was seeing
measures to control illicit trade in the current a relatively slow rate of decline, currently tracking
assessment. Based on the WHO data on prices of towards a 19% relative reduction between 2010
cigarettes in international dollars at purchasing power and 20253. Reaching this NCD goal is the interim
parity30, we would assume that a lower percentage of target of the Tobacco-Free Generation goal in the
countries would show high implementation. In this EU Cancer Plan14, making it even more important to
case, we believe that some other indicators would strengthen the implementation of key tobacco control
benefit the analysis to show the actual differences measures. Given this, and since there is evidence
in the taxation and pricing of tobacco products. In that the prevalence of tobacco use is mainly reduced
Europe, the EU-wide tracking and tracing regime may when national tobacco policies are comprehensively
also explain some of the higher scores in the current implemented, and also that synergistic effects are
analysis. Regarding the public awareness raising and observed when different policies are implemented
communications domain, 38% of the parties achieved simultaneously 35, further simultaneous tobacco
at least 80% implementation. Here we assume that control efforts should be taken in individual countries.
the most extensive differences among WHO FCTC It is also important to point out that discrepancies
parties reporting are present fundamentally on between ranks and prevalence of smoking might be
awareness and training programs in different settings, due to variations in the level of compliance (which
due to no validation of reported data in the WHO is not assessed in our analysis), higher impact of
FCTC Implementation Database. Finally, the lowest some measures depending on the country context,
percentages of implementation were found in the sociocultural differences among countries and also due
capacity and smoking cessation domains, with only to the differences in methodologies used for obtaining
10% and 6% of parties having implemented at least data on tobacco use prevalence, that are further used
80% of the measures, respectively. Public funding by WHO for producing estimates and standardized
or reimbursement schemes are essential in order smoking rates. Simulation modelling studies, as
to achieve a higher rate of implementation of WHO carried out elsewhere36, should be realized at the
FCTC Article 14 measures. WHO European Region level to fully understand the
Importantly, there are relevant within-country association between the different endgame facilitators
variations in the implementation of measures included put forward (e.g. public support for tobacco control
in different domains. As a result, no country at the in the population, strong political leadership)19 and
moment is among the top ten in the implementation the probability of achieving tobacco endgame goals.
of measures across all six domains. Ireland is in the Significant differences were found in the
top ten in 5 out of the 6 domains, and Latvia, Finland, implementation of WHO FCTC measures between
Turkey and Spain top ten in 3 of the 6 domains. countries with and without official endgame
These results, except for Latvia, are similar to those strategies regarding, capacity, tobacco use cessation,
observed in the Tobacco Control Scale 202133, in and monitoring. Still, the countries that established
which Ireland is in the top and Finland, Turkey and official tobacco endgame goals have not implemented
Spain within the first tertile of the scale. Nevertheless, all the key requirements and recommendations

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from the WHO FCTC or MPOWER. These results purchase 2000 cigarettes of the most sold brand’
warrant attention and action in these countries, as the were estimated ad hoc and may not correctly estimate
effectiveness of innovative tobacco endgame measures the implementation of these measures. Besides,
can be undermined by the lack of implementation of implementation of the indicators was assessed using
key evidence-based measures. a semi-quantitative scoring (i.e. scores were assigned
Overall, and according to our results, the feasibility to the categories of implementation), which lack the
of accomplishing supranational endgame goals in discrimination capacity of continuous scales.
Europe, such as the one proposed in the Europe’s The update of the status of implementation of the
Beating Cancer Plan of reducing the prevalence of WHO FCTC indicators at the national level performed
tobacco use in Europe under 5% by 204014, may be by JATC2 WP9 partners, resulted in only a few
hampered by the low implementation of WHO FCTC updates which requested only minor corrections of
and MPOWER measures in a number of countries. the data gathered from WHO FCTC reports. This
However, at the same time, establishing national indicated the data gathered are complete and updated.
tobacco endgame goals can provide the opportunity Finally, our study is the first carried out to
to bring the need for strengthened implementation of estimate the implementation of both WHO FCTC
the WHO FCTC and MPOWER to the political agenda and MPOWER measures in WHO European Region
as part of the national measures for achieving the goal. countries in the context of tobacco endgame, a
relatively new field in tobacco control. For this reason,
Strengths and limitations this study may be considered a road map to identify
Our study should be interpreted considering some the gaps to achieve the objective in the Europe’s
limitations. Firstly, the WHO FCTC implementation Beating Cancer Plan of reducing the prevalence of
reports are completed by national focal points and tobacco smoking under 5% by 2040.
did not go through a validation process. In this sense,
inter-reporter validity may be low, which may bias CONCLUSIONS
comparisons between countries and between WHO There are wide differences in the implementation
FCTC and MPOWER assessment. For example, WHO of both WHO FCTC and MPOWER measures
FCTC party reporting on smoking bans may indicate among WHO European Region countries. Further
complete protection, even though smoking cabins tobacco control regulations in order to achieve full
are allowed in certain enclosed places. However, in implementation of core and advanced WHO FCTC
MPOWER, such a situation is assessed as incomplete measures are needed, especially in the capacity
protection. and smoking cessation domains, to accomplish the
Also, the lack of available evidence in the WHO Europe’s Beating Cancer Plan goal of Tobacco-free
FCTC indicators on compliance with tobacco control Generation.
measures, missing data in MPOWER indicators
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Bill. 2023. Accessed October 20, 2023. https:// CONFLICTS OF INTEREST

legislation.govt.nz/bill/government/2022/0143/ The authors have each completed and submitted an ICMJE form for
latest/096be8ed81cddfbb.pdf Disclosure of Potential Conflicts of Interest. The authors declare that
26 Chung-Hall J, Craig L, Gravely S, Sansone N, Fong GT. they have no competing interests, financial or otherwise, related to the
current work. A. González Marrón, C. Lidón-Moyano, H. Pérez-Martín,
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Expert Group. Tob Control 2019;28:s119–s128. Health Program (2014-2020) under grant agreement N°101035968. H.
doi:10.1136/tobaccocontrol-2018-054389 Koprivnikar, J. Tisza, Z. Cselkó, A. Lambrou, E. Papachristou, M. Vasic,
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Convention on Tobacco Control. WHO; 2022. Accessed 2). In addition, M. Mulcahy reports that since the initial planning of the
October 20, 2023. https://iris.who.int/bitstream/hand work he received support from the Health Service Executive, Ireland
and the Joint action on tobacco control 2 (JATC 2). He also reports that
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28 World Health Organization. WHO FCTC Implementation attending meetings and travels and receipt of equipment/ materials
Database. Accessed December 21, 2022. https://fctc.who. from the Health Service Executive, Ireland and the Joint action on
int/who-fctc/reporting/implementation-database tobacco control 2 (JATC 2). H. Koprivnikar reports that in the past 36
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for strengthening tobacco control in Europe. Tob Prev the initial planing of the work she received support from European
Cessat. 2022;8:26. doi:10.18332/tpc/151050 Commission and from General Directorate of Health, Ministry of Health,
Portugal. M. Karekla reports that since the initial planning of the work
30 World Health Organization. WHO report on the she received support from Horizon Europe (no payments made to her
global tobacco epidemic, 2021. WHO; 2021. Accessed or her institution). She also reports that in the past 36 months she
October 20, 2023. https://iris.who.int/bitstream/hand received support from Horizon Europe for attending meetings of this
le/10665/343287/9789240032095-eng.pdf?sequence=1 group and that she is the immediate past president of the Association
for Contextual Behavior Science. R. Guignard and V. Nguyen-Thanh
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32 Directorate-General for Health and Food Safety, European
FUNDING
Commission. Study on smoke-free environments and This work was supported by the European Union’s Health Program
advertising of tobacco and related products : executive (2014-2020) under grant agreement N°101035968. The content of
summary. Publications Office of the European Union. this document represents the views of the authors only and is their
2021. doi:10.2875/316884 sole responsibility; it cannot be considered to reflect the views of the
European Commission and/or the European Health and Digital Executive
33 Tobacco Control Scale. Results 2021: The Tobacco Agency (HaDEA) or any other body of the European Union. The
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34 Levy DT, Huang AT, Currie LM, Clancy L. The benefits
ETHICAL APPROVAL AND INFORMED CONSENT
from complying with the framework convention on Ethical approval and informed consent were not required for this study.
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effects of tobacco control policies on global smoking AUTHORS’ CONTRIBUTIONS
prevalence. Nat Med. 2021;27(2):239-243. doi:10.1038/ HK, HO, JT, ZC and AGM conceptualized the manuscript and wrote the
s41591-020-01210-8 initial draft. All the authors interpreted data for the work, drafted the
work and reviewed it critically for important intellectual content and
36 Levy DT, Bauer JE, Lee HR. Simulation modeling and approved the final version to be published.
tobacco control: creating more robust public health
policies. Am J Public Health. 2006;96(3):494-498. PROVENANCE AND PEER REVIEW
doi:10.2105/AJPH.2005.063974 Not commissioned; externally peer reviewed.

DISCLAIMER
ACKNOWLEDGEMENTS G. Gorini, Editorial Board member of the journal, had no involvement
The authors thank all JATC2 WP9 partners for their contributions in in the peer-review or acceptance of this article and had no access
developing the method for the current status assessment. Further, the to information regarding its peer-review. Full responsibility for the
authors are grateful for the support from the WHO FCTC Knowledge editorial process for this article was delegated to a handling editor of
Hub on Surveillance and the Secretariat of the WHO FCTC in accessing the journal.
the most recent implementation data from the 2020 reporting cycle.

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