POLICY CASE STUDY
doi:10.1111/add.12789
Understanding increases in smoking prevalence: case study from France in comparison with England 2000–10 Ann McNeill1, Romain Guignard2, François Beck3,4, Rosie Marteau5 & Theresa M. Marteau6 National Addiction Centre, Institute of Psychiatry, King’s College London, London, UK,1 National Institute for Health Promotion and Health Education (INPES), Saint-Denis, France,2 French Monitoring Center for Drugs and Drug Addiction (OFDT), Saint-Denis, France,3 Cermes 3, Cesames team (Research Centre Medicine, Sciences, Health, Mental Health, Health Policy), CNRS UMR 8211, Inserm U988, University of Paris Descartes, EHESS, Paris, France,4 18 St James’s Street, Shaftesbury, Dorset, UK5 and Behaviour and Health Research Unit, University of Cambridge, Institute of Public Health, Cambridge CB2 0SR, UK6
ABSTRACT Aim In France, following a long-term decline in smoking prevalence, an increase in smoking was observed between 2005 and 2010, an unusual occurrence in countries in the ‘mature’ stage of the smoking epidemic. By contrast, smoking prevalence in England, the neighbouring country, continued its long-term decline. Methods We identified and translated recent reports on smoking and tobacco control in France and using these assessed the main data sources on smoking and compared them with similar sources in England, in order to explore possible explanations. In France, national smoking prevalence data are collected 5-yearly, minimizing opportunities for fine-grained analysis; the comparable study in England is implemented annually. Results We identified several probable causes of the recent increased prevalence of smoking in France, the primary one being the absence of sufficient price rises between 2005 and 2010, due probably to the lack of a robust tobacco control strategy, which also appeared to have empowered tobacco industry influence. Funding to compensate tobacconists appears to incentivize tobacco sales and is significantly higher than tobacco control funding. Conclusions Mindful of the limitations of a case-study approach, the absence of sufficient price rises in the context of a weak tobacco control strategy seems the most likely explanation for the recent increase in smoking prevalence in France. A new cancer control plan and a national smoking reduction programme have been proposed by the French government in 2014 which, depending on implementation, may reverse the trend. In both countries, the higher levels of smoking among the more disadvantaged groups are of great concern and require greater political leadership for effective action. Keywords
England, France, inequalities, policy, smoking.
Correspondence to: Ann McNeill, Professor of Tobacco Addiction, National Addiction Centre, Institute of Psychiatry, King’s College London, London, UK. E-mail: [email protected] Submitted 8 May 2014; initial review completed 7 July 2014; final version accepted 24 October 2014
INTRODUCTION In France, following decades of a declining smoking prevalence, an increase in smoking was observed between 2005 and 2010, an unusual occurrence in countries in the ‘mature’ stage of the smoking epidemic [1]. By comparing smoking trends and patterns in France with those in England, where smoking prevalence has continued to decline since the mid-1970s, we explored some of the possible reasons for the upturn in France. Our objectives, therefore, were to: • Compare smoking patterns in France and England, particularly around the period of the increase in smoking in France
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• Compare tobacco control strategies and activities in France and England during this time • Identify possible explanations for the recent increase in smoking in France
METHODS We identified and translated a number of recent commentaries and reports on smoking and tobacco control policies in France, including the main governmental reports on tobacco control [2–5]. Using these reports, we assessed the main sources of data on smoking and compared them with data sources in England.
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The main source of smoking prevalence data in England is the General Household Survey/General Lifestyle Survey [6], which has been carried out annually since 1971, although smoking behaviour questions were only included from 1974, in alternate years until 1998 and then annually from 2000. In France, national smoking prevalence data have been collected, 5-yearly, since 2000, through the Health Barometer from the National Institute for Health Promotion and Health Education (INPES), based on telephone surveys using randomly generated telephone numbers [7]. The less frequent French data collection, compared with English data collection, reduces opportunities for fine-grained analysis. However, the sample sizes in both the English and French surveys are very large, between 13 K and 30 K in the French surveys and more than 18 K in the English surveys. RESULTS Trends in smoking prevalence Both France and England have observed a long-term decline in smoking prevalence since the mid-1970s. In France, among 18–75-year-olds, male smoking prevalence
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declined from 60% in 1976 to 38% in 2010, whereas rates of smoking among women changed very little, approximately 30% throughout [8]. In England, smoking prevalence among those aged 16 years and over decreased among both genders, from 51 to 22% for men and from 41 to 21% for women from 1974 to 2010 [9]. From 2005 to 2010, we were able to compare the same age group using a comparable measure of smoking prevalence. In France, among 16–75-year-olds, smoking prevalence increased from 32 to 34% (Table 1). This contrasts with a continuing decline observed in England in the same age group during that period from 25 to 22% in 2010.
Socio-economic patterns in smoking prevalence Smoking is socially patterned in both France and England, with the highest smoking prevalence among those most disadvantaged (Table 2). In France, the gap in smoking prevalence between the two extreme groups has increased since 2000 [11] whereas, in England, declines in smoking prevalence have been observed in all groups since 2000 and the gap between the highest and lowest disadvantaged groups has not increased [9]. The inequalities gap in
Table 1 Current smoking prevalencea in France and England. France (16–75 years)
Total • Men • Women
England (16–75 years)
2000 (n >13 K)
2005 (n >30 K)
2010 (n >27 K)
2000 (n ~20 K)
2005 (n ~20 K)
2010 (n ~18 K)
35 39 31
32b 36d 27b
34c 38e 30c
28 30 27
25b 27b 24b
22c 22c 21c
Currently defined: ‘any smoking, even if only from time to time’ in France; ‘any smoking nowadays’ in England. P27 K) 2001 (n ~20 K) 2005 (n ~20 K) 2010 (n ~18 K) High disadvantage • Men • Women Intermediate disadvantage • Men • Women Low disadvantage • Men • Women
35 39 31 36 40 32 34 36 31
36 41 33 31 35 26 30 34 25
40 45 36 34 38 30 29 31 26
33 34 31 27 29 26 19 21 17
31 33 29 23 24 22 17 18 16
28 28 28 20 20 20 17 18 16
a
No strictly comparable socio-economic data were available, so different indicators have been used: income per consumption unit in France and a socio-economic category based on occupation in England. France: high disadvantage reflects an income of or = €1800. England: high disadvantage reflects ‘routine and manual’ groups, an intermediate category, and low disadvantage e reflecting ‘management and professional’ categories. Comparable data were not available in 2000, only for 2001. Sources: England [9]; France [10]. © 2014 Society for the Study of Addiction
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smoking is now approximately the same in both countries, at 11 percentage points. Tobacco control policies and interventions France had an auspicious start to reducing tobacco use, being the first country to introduce tobacco control specific legislation and to ratify the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) in the European Union (Table 3). Between 2005 and 2010, however, although a comprehensive smoke-free policy was introduced, there was reduced tobacco control spend, in parallel with no sustained tobacco tax increases [2]. By contrast, England was initially very slow to legislate, relying upon ineffective ‘voluntary’ agreements between the industry and government, but since 1998 three laws and three government strategies specific to tobacco control have been instituted [12–14]. In 2007 and 2010, the United Kingdom was ranked the highest of the major European nations in a range of tobacco control measures [15,16].
beaches in 2008. Additionally, the French League against Cancer has commented that permissiveness around smoking in terraces (smoking is banned in ‘enclosed and covered’ terraces, but allowed in open terraces) has ‘reduced the impact of the ban in bars and restaurants, at times rendering it purely symbolic’ [2]. A recent survey of tobacconists’ outlets found that fewer than half displayed correct signage, 70% made no age checks on clients and 62% made sales to minors [2]. Strong implementation and enforcement of tobacco control interventions de-normalize the use of tobacco. Differences in the general acceptability of smoking are reflected in the rates of smoking among doctors in the two countries. In 2003, 29% of French doctors smoked [17] compared with 4% in England in 2000 (the latest available data) [12]. Given that stop smoking messages are more likely to be delivered by non-smoking healthcare professionals [18], it seems likely that this source of tobacco control has also been weaker in France than in England. Price
Potential explanatory factors for smoking increase in France From our analysis of French reports, several factors appear important in explaining the contrasting trends in smoking rates in France and England; these are described further below. Lack of a comprehensive tobacco control strategy and political leadership Countries with the best track records in tobacco control and smoking reduction are equipped with adequately resourced comprehensive tobacco control strategies usually enshrined in legislation and overseen by a dedicated tobacco control body [2]. The recent publication of national tobacco control strategies in England [12–14] is welcomed, and enforcement of laws implemented is generally high [15,16]. Several recent French reports, including one commissioned for the French National Assembly, have acknowledged the failure to develop a national tobacco control strategy, with clear ownership across government as a major failing of the French government since the 1990s [2–5]. We outline below some of the consequences of this ‘lack of clear and consistent political will’ [2]. There has been no coordinated monitoring, surveillance or enforcement plan for French laws, with most legal enforcement challenges being brought by antitobacco organizations, not governments [2]. There are several unacceptable exemptions and blatant violations of existing laws, one of the most notable being the distribution of British American Tobacco-labelled ashtrays on © 2014 Society for the Study of Addiction
Regulation of tobacco price is a key component of tobacco control [19,20]. The French government increased the price of cigarettes by 40% between January 2003 and January 2004 (approximately €1.1 per 20 cigarettes), resulting in a dramatic drop in cigarette sales of nearly one-third [2,4]. Tobacconists in France reacted very negatively to this, resulting in a moratorium on further tax increases implemented between 2004 and 2007, and all subsequent price increases (2007 and 2009) were less than 10% per annum, i.e. below the level effective for reducing consumption, but enough to be fiscally and commercially lucrative. The price increases since 2007 did not result from tax increases, instead being negotiated with the tobacco industry, and did not result in a decrease in tobacco sales [2]. Such negotiations between the tobacco industry and the government still take place today. In summary, the price of cigarettes increased markedly from 2001 to 2004, coinciding with the decrease in prevalence, but remained relatively stable from 2005 to 2010 when prevalence increased. In England, in 1998, the government committed to increasing tobacco tax by more than 5% annually in real terms. This commitment was dropped in 2001 and subsequently annual increases were generally at, or marginally above, inflation rates until 2010, when a new commitment was made to reintroduce a tobacco tax escalator, at 2% above inflation in the March 2010 budget. In England, therefore, the price of tobacco has been increasing steadily during this period. Addiction, 110, 392–400
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2003–07, 1st Cancer Pland
Banned sale of tobacco to minors aged < 16 years in 2003; sharp increases in tobacco taxes in 2003–04; ban of misleading terms, e.g. ‘light’/‘mild’; 2006 extension of public smoking ban planned
Banned remaining tobacco advertising except a restricted advertisement at point-of-sale and in specialized press. Introduced smoke-free law
1991, Evin Lawc
2000s
Banned tobacco advertising on television, radio, billboards and movies (allowed in the press) and tobacco sponsoring of sport events. Introduction of written warning labels on cigarette packs
1976, Veil Lawb
1960s 1970s–1990s
Comment
Law, date
Decade
France
Table 3 Key tobacco control actions in France and England: 1960s to present.
Increased size of health warnings on packs to be consistent with EU Directive 2001/37/EC; introduced new limits on yields and other product measures Banned tobacco advertising on billboards, print media, direct mail, internet advertising and new promotions; ban of misleading terms as ‘light’/‘mild’ Tobacco products (manufacture presentation and sale) Safety Regulations 2002 2003, Tobacco Advertising and Promotion Act
(Continues)
Banned sale of any tobacco product to minors aged < 16 years New targets to reduce smoking prevalence for adults, children and pregnant women; within the adult target, an objective was set ‘to see a rate of change in manual groups similar to or greater than in non-manual groups’ national NHS smoking cessation programme with national network of stop smoking services and reimbursable medications; ‘clean air’ charter for hospitality trade; plans to restrict smoking in the work-place further; introduced commitment to increase tobacco tax by >5% annually in real terms (dropped in 2001 and subsequently annual increases were generally at, or marginally above, inflation rates until 2010); high profile mass media campaigns to increase significantly (peaked in 2004/5 financial year, then declined, but expenditure rose again 2012/13) £200 m initiative to tackle tobacco smuggling. Illicit market share fell from 21% in 2000–01 to 15% by 2003–04
1986, Protection of Children (Tobacco) Act 1998, Publication of White Paper 12 on tobacco: Smoking Kills
Smuggling strategy introduced by government
Banned cigarette advertisements on television Series of voluntary agreements with the tobacco industry covering health warnings, advertising and sponsorship
Comment
1964, Television Act
Law, date
England a
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Decade
Table 3 (Continued)
1st country in EU to do so
2004, France ratifies WHO FCTC 2004, Public Health Lawe
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Smoke-free policy extended indoors in bars, restaurants, hotels, nightclubs and casinos, although smoking rooms were allowed under very strict conditions Introduced measures to protect young people from smoking: extension of ban on sales to minors to < 18 years; banned selling sugary flavoured cigarettes; banned opening tobacco shops close to youth education and leisure facilities Re-established targets set out in 2004 Public Health Law. Reimbursement of NRT for pregnant women was introduced from 2011 up to €150 per year. No measures were taken to ban point-of-sale advertising and TV motor sport broadcasting with tobacco sponsorship, although the need to do so was highlighted in the Plan
2008
2009–13, 2nd Cancer Planh
2009, Articles 98–100 of Hospital, Patients, Health and Territories Law no. 2009-879g
State Council decree introduced extension to smokefree policy in closed public places from February 2007 in work-places, shopping centres, airports, train stations, hospitals and schools Nicotine replacement therapies (NRT) can be reimbursed by €50 per person per year
2006, Bertrand Decreef
New targets to decrease tobacco daily smoking prevalence from 33 to 25% in males, from 26 to 20% in females by 2009, with a focus on young and underprivileged populations. Freeze in tobacco taxation from 2004 to 2007
Comment
Law, date
France
Commitment to review case for standardized packaging. Tax escalator—at 2% above inflation— re-introduced in March 2010 Budget. Mass media campaigns stopped in advance of general Election, reinstated 2011. Graphic warnings introduced on all tobacco products (first country to require this). Specific commitment to protect policy making in England from tobacco industry
2010, Publication of: A Smokefree Future—A Comprehensive Tobacco Control Strategy for England Publication of new public health 13 strategy
(Continues)
Paved way for ban on point-of-sale displays to be implemented in two phases
England implements comprehensive enforced smokefree policy and age of sale raised to < 18 years Graphic warnings introduced on manufactured cigarette packs. Extension of smoke-free policy to mental health buildings
Paved way for smoke-free implementation and rise in age of sale of tobacco to < 18 years Tobacco smuggling strategy extended with new targets
Comment
2009, Health Act
2007, main components of Health Act implemented 2008
2006
2005, Health Act
2005, England ratifies WHO FCTC
Law, date
England a
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Graphic warnings appear on roll-your-own packs
Announcement of plans to introduce standardized packaging, ban on smoking in cars with children, increase in the reimbursement of NRT for the most underprivileged population and young smokers aged 20–30 and patients with cancer, from €50 to €150 per year, and other measures
2012
2014–2019, 3rd Cancer Plan and National smoking reduction programme
2014
2013
2012
2011, Publication of New Tobacco Plan for England [14]
c
b
All English documents can be located at http://www.ash.org.uk/files/documents/ASH_741.pdf. Veil Law: République française. Loi no. 76-616 du 9 juillet 1976 relative à la lutte contre le tabagisme. Journal officiel, 10 juillet 1976. Evin Law: République française. Loi no. 91–32 du 10 janvier 1991 relative à la lutte contre le tabagisme et l’alcoolisme. Journal officiel, 10 janvier 199. d 1st Cancer Plan: Mission interministérielle pour la lutte contre le cancer (MILC). Plan cancer 2003–2007. Paris: MILC, 2003: 44p. e 2004 Public Health Law: République française. Loi no. 2004-806 du 9 août 2004 relative à la politique de santé publique. Journal officiel, 11 août 2004. f Bertrand decree: République française. Décret no. 2006-1386 du 15 novembre 2006 fixant les conditions d’application de l’interdiction de fumer dans les lieux affectés à un usage collectif. Journal officiel, 16 novembre 2006. g HPST law: République française. Loi no. 2009-879 du 21 juillet 2009 portant réforme de l’hôpital et relative aux patients, à la santé et aux territoires. Journal officiel, 22 juillet 2009. h 2nd Cancer plan: Institut national du cancer (INCa). Plan cancer 2009–13. Boulogne-Billancourt: INCa, 2009: 138 p. i Graphic warning labels: République française. Arrêté du 15 avril 2010 relatif aux modalités d’inscription des avertissements de caractère sanitaire sur les unités de conditionnement des produits du tabac. Journal officiel, 20 avril 2010. WHO = World Health Organization; FCTC = Framework Convention on Tobacco Control.
a
Tobacco information helpline number appears on all cigarette packs (previously just one of 14) Graphic warnings appear on manufactured cigarette packs
2011i
interference (WHO FCTC Article 5.3). One of the three 2020 aspirations set was ‘to reduce adult smoking rates to 10% or less, and halve smoking rates for routine and manual workers’. The other two aspirations were on reducing youth smoking and increasing smoke-free homes Set out national ambitions to reduce smoking rates among all adults from 21.2 to 18.5% by end 2015 and targets for pregnant women and 15-year-olds. No specific ambition set for inequalities. Committed to removing shop tobacco product displays, ban tobacco vending machine sales and to hold public consultation on plain packaging. Statement of commitment to protect policy development from tobacco industry interests Government consultation on standardized packaging; large shop removal of point-of-sale displays (small shops, 2015). Tobacco duty increased by 5% above inflation Government decided not to go ahead with standardized packaging. Tobacco duty escalator decreased from 5 to 2% Announcement of plans to introduce standardized packaging, ban on smoking in cars with children, and other measures
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Table 4 Manufactured cigarette prices 2000–10 in France and England.
Year
France: recommended retail price (RRP) of a typical pack of 20 manufactured cigarettes in the MPPCa on 1 January each year (Euro)
England: recommended retail price (RRP) of a typical pack of 20 manufactured cigarettes in the MPPCa on 1 January each year GBP (Euro)
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
2.96 2.96 3.60 3.90 5.00 5.00 5.00 5.00 5.30 5.30 5.60
3.36 (5.17) 4.33 (7.23) 4.33 (7.01) 4.51 (7.19) 4.65 (6.60) 4.98 (7.21) 5.23 (7.69) 5.44 (8.02) 5.66 (8.12) 5.85 (7.39) 6.29 (6.91)
a The Most Popular Price Category (MPPC) is a benchmark European Union (EU) price category reflecting the price of a popular brand(s) typically occupying about 35% of the national cigarette market. These data were not available for the same month each year; most proximal months utilized: for April 2000–03; May 2004; July 2005–10 [28].
Table 4 shows prices in England and France from 2000 to 2010 for cigarettes. Funding for tobacco control In both countries, funding for tobacco control is inadequate, according to recommended standards [21,22], not clearly identified or delineated, and has been diminishing due to competing priorities within a constrained budget. According to the Audit Court, the French National Institute for Health Prevention and Education, the main provider of tobacco control education campaigns and funder of regional projects, was allocated a budget of €8.4 m for tobacco control in 2011 (the latest year for which data are available), 44% less than the funds mobilized in 2003 [2]. In England, in 2012/13 it was estimated that just under €11 m was spent on mass media tobacco control campaigns, compared with €9 m in 2002/03 and €20 m in 2003/04 [23].
‘remobilization’ and the impact on tobacco control policy implementation having been raised by the French government in its report to the WHO FCTC Secretariat [2]. The High Council for Public Health (HCSP) has indicated ‘the tension between industry and financial interests and health priorities’ [2] with, for example, a report criticizing the involvement of the tobacco company Altria in funding a Brain and Spinal Cord institute in France [4]. Additionally, in contrast to England, tobacco is still grown in France, with 1800 farms remaining. Tobacco growers have been compensated by regional governments and the European Agricultural Fund for Rural Development by approximately €10 m from 2011 to 2013 for a projected reduction in tobacco consumption [2]. However, the resilience of the French industry is illustrated by its rise in profits, from €13 bn in 2002 to just under €17 bn in 2010 [2]. Role of tobacco retailers France is unusual—if not unique—in having tobacconists, an occupational group, dedicated to selling tobacco as part of a state-subsidized monopoly. This contrasts with England, where cigarettes are purchased from a variety of stores, including petrol stations and supermarkets (and until 2011 from vending machines). In France, three government contracts have been made since 2005 (‘Future Contracts’) to support tobacconists; these included various aids and grants, including exemption from licence duty below a certain profit threshold and additional and compensatory remuneration, designed to compensate for loss of profit from anticipated falls in sales. It has been estimated that tobacconists have benefited by an average of more than €300 million every year between 2004 and 2011, resulting in tobacconists’ revenue consistently rising in real terms, referred to as ‘exceptional in a prevailing context of most socio-economic categories experiencing stable or reduced purchasing power… evidence that state support has in fact provided a windfall to a very large number of tobacconists’ [2]. Stopping this state-subsidized provision of tobacco would be an important step towards an effective tobacco control strategy.
Influence of the tobacco industry
CONCLUSIONS
Any weaknesses in tobacco control risk being exploited by the tobacco industry, seeking to exert its influence [24]. In its 2011 Tobacco Control Plan, the English government made a specific commitment to protect policymaking from tobacco industry interference [14] in line with Article 5.3 in the WHO FCTC. This is an important statement of intent, although it remains to be seen whether it will be observed. In France, a lack of implementation of Article 5.3 has been noted with concerns about tobacco industry
France and England, two neighbouring European countries at a similar stage in the smoking epidemic, have recently shown diverging trends in tobacco use. The absence of meaningful price rises during the period 2005–10 seems to have played a significant part in this, stemming from the lack of a robust and coordinated tobacco control strategy in France which appears to have empowered the tobacco industry to undermine tobacco control further. It is particularly notable that funding to compensate
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tobacconists appears to incentivize the sale of tobacco and is significantly higher than tobacco control funding. During the last 2 years, this regrettable increase in prevalence has been acknowledged and analysed and, including the current paper, this has contributed to a new 5-year Cancer Plan [25] that accords tobacco control policies their rightful dominant position. As part of this, a national smoking reduction programme was released by the Health and Research Ministries in September 2014 [26]. This includes a plan to introduce standardized packaging of tobacco by January 2016, as well as making more transparent political lobbying by the tobacco industry. Of concern, however, is the absence of a plan to increase the price of tobacco. It remains to be seen how the 2014–19 Cancer Plan will be implemented and hence to determine any impact upon smoking prevalence. In addition, France would benefit from more frequent national smoking prevalence studies; the Smokers’ Toolkit in England allows for contemporaneous feedback on smoking trends [27] in addition to the annual national surveys [9]. In both countries, the higher levels of smoking among the more disadvantaged groups are of great concern and require concerted political leadership for effective action, including setting appropriate specific targets for reducing inequalities. We believe that this case study shows the benefits of cross-country comparative research. National strategies and policy environments cannot be studied using traditional research tools (e.g. randomized controlled studies), so quasi-experimental and other design methodologies are needed. In order to examine smoking prevalence, however, extremely large samples are needed, making many of them cost-prohibitive. We therefore encourage more case studies of this type, using nationally comparative data and reports, to provide useful insights to influence the implementation of evidence-based and enforced tobacco control policies. Declaration of interests None. Acknowledgements A.M. and T.M., psychologists and tobacco researchers, were commissioned to write the paper by the French National Cancer Institute (INCa); T.M. is a member of the Scientific Advisory Board for INCa. A.M./T.M. involved R.G. and F.B., who are statisticians and tobacco researchers, from the French Institute for Health Promotion and Health Education (INPES) and the French Monitoring Center for Drugs and Drug Addiction (OFDT) and R.M., a professional translator (English/Spanish/French), translated the French reports. A.M. is guarantor of the paper. We are grateful to Konstantin Krasovsky and other participants for their comments when this paper was presented © 2014 Society for the Study of Addiction
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at the 2014 European Conference on Tobacco or Health. The translation of French reports for the preparation of this paper was funded by the Institut National du Cancer (INCa). INCa had no role in the preparation of this manuscript. A.M. is part-funded by the UK Centre for Tobacco and Alcohol Studies, a UK Clinical Research Collaboration Public Health Research, Centre of Excellence. Funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council and the National Institute for Health Research under the auspices of the UK Clinical Research Collaboration is gratefully acknowledged. The Behaviour and Health Research Unit (BHRU) is part-funded by the UK Department of Health Policy Research Programme as the Policy Research Unit in Behaviour and Health (PR-UN-0409-10109). The Department of Health had no role in the preparation of this manuscript. The views expressed in this paper are those of the authors and not necessarily those of the funders. References 1. Lopez A. D., Collishaw N., Piha T. A descriptive model of the cigarette epidemic in developed countries. Tob Control 1994; 3: 242–7. 2. Audit Court [Cours des Comptes]. Report to the president of the National Assembly for the Committee for the Evaluation and Control of Public Policies. Article I 132–5 of the Public Accounts Code. Tobacco Control Policies. December 2012. 3. Jacquat D., Touraine J. L. Tobacco control: fifteen propositions to tackle a major public health issue. National Parliament Information Report n°764, 2013, p. 182. 4. Bur Y. Proposals for a new policy against tobacco. Report for the Minister of Work, Employment and Health. Paris, 2012. 5. Jacquat D., Touraine J. L. About the conclusions of the National Parliament Information Report n°764, 2013, National Parliament Information Report n°2099, 2014. 6. Guidance and methodology about the General Lifestyle Survey. Available at: http://www.ons.gov.uk/ons/guidemethod/method-quality/specific/social-and-welfare-methodology/general-lifestyle-survey/index.html (accessed 19 October 2014). 7. Health Barometer. 2010. Methods. Available at: http:// wwwinpessantefr/Barometres/barometre-sante-2010/pdf/HealthBarometer-2010-Methodspdf (accessed 19 October 2014). 8. Beck F., Guignard R., Richard J.-B., Wilquin J.-L., Peretti-Watel P. Recent increase in tobacco use in France: main results of the Health Barometer, France, 2010. Weekly Epidemiol Bull 2011; 21–22: 230–3. 9. Office for National Statistics. General Lifestyle Surveys. Available at: http://www.ons.gov.uk/ons/rel/ghs/general-lifestylesurvey/index.html (accessed 8 December 2014). 10. Health Barometers, 2000, 2005 and 2010; INPES, formerly CFES. (accessed 8 December 2014). 11. Peretti-Watel P., Constance J., Seror V., Beck F. Cigarettes and social inequalities in France: is tobacco use increasingly concentrated among the poor? Addiction 2009; 104: 1718–28. 12. HM Government. Smoking Kills. A White Paper on Tobacco. Presented to Parliament by the Secretary of State for Health and the Secretaries of State for Scotland, Wales and Northern Addiction, 110, 392–400
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doi:10.1111/add.12789
Understanding increases in smoking prevalence: case study from France in comparison with England 2000–10 Ann McNeill1, Romain Guignard2, François Beck3,4, Rosie Marteau5 & Theresa M. Marteau6 National Addiction Centre, Institute of Psychiatry, King’s College London, London, UK,1 National Institute for Health Promotion and Health Education (INPES), Saint-Denis, France,2 French Monitoring Center for Drugs and Drug Addiction (OFDT), Saint-Denis, France,3 Cermes 3, Cesames team (Research Centre Medicine, Sciences, Health, Mental Health, Health Policy), CNRS UMR 8211, Inserm U988, University of Paris Descartes, EHESS, Paris, France,4 18 St James’s Street, Shaftesbury, Dorset, UK5 and Behaviour and Health Research Unit, University of Cambridge, Institute of Public Health, Cambridge CB2 0SR, UK6
ABSTRACT Aim In France, following a long-term decline in smoking prevalence, an increase in smoking was observed between 2005 and 2010, an unusual occurrence in countries in the ‘mature’ stage of the smoking epidemic. By contrast, smoking prevalence in England, the neighbouring country, continued its long-term decline. Methods We identified and translated recent reports on smoking and tobacco control in France and using these assessed the main data sources on smoking and compared them with similar sources in England, in order to explore possible explanations. In France, national smoking prevalence data are collected 5-yearly, minimizing opportunities for fine-grained analysis; the comparable study in England is implemented annually. Results We identified several probable causes of the recent increased prevalence of smoking in France, the primary one being the absence of sufficient price rises between 2005 and 2010, due probably to the lack of a robust tobacco control strategy, which also appeared to have empowered tobacco industry influence. Funding to compensate tobacconists appears to incentivize tobacco sales and is significantly higher than tobacco control funding. Conclusions Mindful of the limitations of a case-study approach, the absence of sufficient price rises in the context of a weak tobacco control strategy seems the most likely explanation for the recent increase in smoking prevalence in France. A new cancer control plan and a national smoking reduction programme have been proposed by the French government in 2014 which, depending on implementation, may reverse the trend. In both countries, the higher levels of smoking among the more disadvantaged groups are of great concern and require greater political leadership for effective action. Keywords
England, France, inequalities, policy, smoking.
Correspondence to: Ann McNeill, Professor of Tobacco Addiction, National Addiction Centre, Institute of Psychiatry, King’s College London, London, UK. E-mail: [email protected] Submitted 8 May 2014; initial review completed 7 July 2014; final version accepted 24 October 2014
INTRODUCTION In France, following decades of a declining smoking prevalence, an increase in smoking was observed between 2005 and 2010, an unusual occurrence in countries in the ‘mature’ stage of the smoking epidemic [1]. By comparing smoking trends and patterns in France with those in England, where smoking prevalence has continued to decline since the mid-1970s, we explored some of the possible reasons for the upturn in France. Our objectives, therefore, were to: • Compare smoking patterns in France and England, particularly around the period of the increase in smoking in France
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• Compare tobacco control strategies and activities in France and England during this time • Identify possible explanations for the recent increase in smoking in France
METHODS We identified and translated a number of recent commentaries and reports on smoking and tobacco control policies in France, including the main governmental reports on tobacco control [2–5]. Using these reports, we assessed the main sources of data on smoking and compared them with data sources in England.
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The main source of smoking prevalence data in England is the General Household Survey/General Lifestyle Survey [6], which has been carried out annually since 1971, although smoking behaviour questions were only included from 1974, in alternate years until 1998 and then annually from 2000. In France, national smoking prevalence data have been collected, 5-yearly, since 2000, through the Health Barometer from the National Institute for Health Promotion and Health Education (INPES), based on telephone surveys using randomly generated telephone numbers [7]. The less frequent French data collection, compared with English data collection, reduces opportunities for fine-grained analysis. However, the sample sizes in both the English and French surveys are very large, between 13 K and 30 K in the French surveys and more than 18 K in the English surveys. RESULTS Trends in smoking prevalence Both France and England have observed a long-term decline in smoking prevalence since the mid-1970s. In France, among 18–75-year-olds, male smoking prevalence
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declined from 60% in 1976 to 38% in 2010, whereas rates of smoking among women changed very little, approximately 30% throughout [8]. In England, smoking prevalence among those aged 16 years and over decreased among both genders, from 51 to 22% for men and from 41 to 21% for women from 1974 to 2010 [9]. From 2005 to 2010, we were able to compare the same age group using a comparable measure of smoking prevalence. In France, among 16–75-year-olds, smoking prevalence increased from 32 to 34% (Table 1). This contrasts with a continuing decline observed in England in the same age group during that period from 25 to 22% in 2010.
Socio-economic patterns in smoking prevalence Smoking is socially patterned in both France and England, with the highest smoking prevalence among those most disadvantaged (Table 2). In France, the gap in smoking prevalence between the two extreme groups has increased since 2000 [11] whereas, in England, declines in smoking prevalence have been observed in all groups since 2000 and the gap between the highest and lowest disadvantaged groups has not increased [9]. The inequalities gap in
Table 1 Current smoking prevalencea in France and England. France (16–75 years)
Total • Men • Women
England (16–75 years)
2000 (n >13 K)
2005 (n >30 K)
2010 (n >27 K)
2000 (n ~20 K)
2005 (n ~20 K)
2010 (n ~18 K)
35 39 31
32b 36d 27b
34c 38e 30c
28 30 27
25b 27b 24b
22c 22c 21c
Currently defined: ‘any smoking, even if only from time to time’ in France; ‘any smoking nowadays’ in England. P27 K) 2001 (n ~20 K) 2005 (n ~20 K) 2010 (n ~18 K) High disadvantage • Men • Women Intermediate disadvantage • Men • Women Low disadvantage • Men • Women
35 39 31 36 40 32 34 36 31
36 41 33 31 35 26 30 34 25
40 45 36 34 38 30 29 31 26
33 34 31 27 29 26 19 21 17
31 33 29 23 24 22 17 18 16
28 28 28 20 20 20 17 18 16
a
No strictly comparable socio-economic data were available, so different indicators have been used: income per consumption unit in France and a socio-economic category based on occupation in England. France: high disadvantage reflects an income of or = €1800. England: high disadvantage reflects ‘routine and manual’ groups, an intermediate category, and low disadvantage e reflecting ‘management and professional’ categories. Comparable data were not available in 2000, only for 2001. Sources: England [9]; France [10]. © 2014 Society for the Study of Addiction
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smoking is now approximately the same in both countries, at 11 percentage points. Tobacco control policies and interventions France had an auspicious start to reducing tobacco use, being the first country to introduce tobacco control specific legislation and to ratify the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) in the European Union (Table 3). Between 2005 and 2010, however, although a comprehensive smoke-free policy was introduced, there was reduced tobacco control spend, in parallel with no sustained tobacco tax increases [2]. By contrast, England was initially very slow to legislate, relying upon ineffective ‘voluntary’ agreements between the industry and government, but since 1998 three laws and three government strategies specific to tobacco control have been instituted [12–14]. In 2007 and 2010, the United Kingdom was ranked the highest of the major European nations in a range of tobacco control measures [15,16].
beaches in 2008. Additionally, the French League against Cancer has commented that permissiveness around smoking in terraces (smoking is banned in ‘enclosed and covered’ terraces, but allowed in open terraces) has ‘reduced the impact of the ban in bars and restaurants, at times rendering it purely symbolic’ [2]. A recent survey of tobacconists’ outlets found that fewer than half displayed correct signage, 70% made no age checks on clients and 62% made sales to minors [2]. Strong implementation and enforcement of tobacco control interventions de-normalize the use of tobacco. Differences in the general acceptability of smoking are reflected in the rates of smoking among doctors in the two countries. In 2003, 29% of French doctors smoked [17] compared with 4% in England in 2000 (the latest available data) [12]. Given that stop smoking messages are more likely to be delivered by non-smoking healthcare professionals [18], it seems likely that this source of tobacco control has also been weaker in France than in England. Price
Potential explanatory factors for smoking increase in France From our analysis of French reports, several factors appear important in explaining the contrasting trends in smoking rates in France and England; these are described further below. Lack of a comprehensive tobacco control strategy and political leadership Countries with the best track records in tobacco control and smoking reduction are equipped with adequately resourced comprehensive tobacco control strategies usually enshrined in legislation and overseen by a dedicated tobacco control body [2]. The recent publication of national tobacco control strategies in England [12–14] is welcomed, and enforcement of laws implemented is generally high [15,16]. Several recent French reports, including one commissioned for the French National Assembly, have acknowledged the failure to develop a national tobacco control strategy, with clear ownership across government as a major failing of the French government since the 1990s [2–5]. We outline below some of the consequences of this ‘lack of clear and consistent political will’ [2]. There has been no coordinated monitoring, surveillance or enforcement plan for French laws, with most legal enforcement challenges being brought by antitobacco organizations, not governments [2]. There are several unacceptable exemptions and blatant violations of existing laws, one of the most notable being the distribution of British American Tobacco-labelled ashtrays on © 2014 Society for the Study of Addiction
Regulation of tobacco price is a key component of tobacco control [19,20]. The French government increased the price of cigarettes by 40% between January 2003 and January 2004 (approximately €1.1 per 20 cigarettes), resulting in a dramatic drop in cigarette sales of nearly one-third [2,4]. Tobacconists in France reacted very negatively to this, resulting in a moratorium on further tax increases implemented between 2004 and 2007, and all subsequent price increases (2007 and 2009) were less than 10% per annum, i.e. below the level effective for reducing consumption, but enough to be fiscally and commercially lucrative. The price increases since 2007 did not result from tax increases, instead being negotiated with the tobacco industry, and did not result in a decrease in tobacco sales [2]. Such negotiations between the tobacco industry and the government still take place today. In summary, the price of cigarettes increased markedly from 2001 to 2004, coinciding with the decrease in prevalence, but remained relatively stable from 2005 to 2010 when prevalence increased. In England, in 1998, the government committed to increasing tobacco tax by more than 5% annually in real terms. This commitment was dropped in 2001 and subsequently annual increases were generally at, or marginally above, inflation rates until 2010, when a new commitment was made to reintroduce a tobacco tax escalator, at 2% above inflation in the March 2010 budget. In England, therefore, the price of tobacco has been increasing steadily during this period. Addiction, 110, 392–400
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2003–07, 1st Cancer Pland
Banned sale of tobacco to minors aged < 16 years in 2003; sharp increases in tobacco taxes in 2003–04; ban of misleading terms, e.g. ‘light’/‘mild’; 2006 extension of public smoking ban planned
Banned remaining tobacco advertising except a restricted advertisement at point-of-sale and in specialized press. Introduced smoke-free law
1991, Evin Lawc
2000s
Banned tobacco advertising on television, radio, billboards and movies (allowed in the press) and tobacco sponsoring of sport events. Introduction of written warning labels on cigarette packs
1976, Veil Lawb
1960s 1970s–1990s
Comment
Law, date
Decade
France
Table 3 Key tobacco control actions in France and England: 1960s to present.
Increased size of health warnings on packs to be consistent with EU Directive 2001/37/EC; introduced new limits on yields and other product measures Banned tobacco advertising on billboards, print media, direct mail, internet advertising and new promotions; ban of misleading terms as ‘light’/‘mild’ Tobacco products (manufacture presentation and sale) Safety Regulations 2002 2003, Tobacco Advertising and Promotion Act
(Continues)
Banned sale of any tobacco product to minors aged < 16 years New targets to reduce smoking prevalence for adults, children and pregnant women; within the adult target, an objective was set ‘to see a rate of change in manual groups similar to or greater than in non-manual groups’ national NHS smoking cessation programme with national network of stop smoking services and reimbursable medications; ‘clean air’ charter for hospitality trade; plans to restrict smoking in the work-place further; introduced commitment to increase tobacco tax by >5% annually in real terms (dropped in 2001 and subsequently annual increases were generally at, or marginally above, inflation rates until 2010); high profile mass media campaigns to increase significantly (peaked in 2004/5 financial year, then declined, but expenditure rose again 2012/13) £200 m initiative to tackle tobacco smuggling. Illicit market share fell from 21% in 2000–01 to 15% by 2003–04
1986, Protection of Children (Tobacco) Act 1998, Publication of White Paper 12 on tobacco: Smoking Kills
Smuggling strategy introduced by government
Banned cigarette advertisements on television Series of voluntary agreements with the tobacco industry covering health warnings, advertising and sponsorship
Comment
1964, Television Act
Law, date
England a
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Decade
Table 3 (Continued)
1st country in EU to do so
2004, France ratifies WHO FCTC 2004, Public Health Lawe
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Smoke-free policy extended indoors in bars, restaurants, hotels, nightclubs and casinos, although smoking rooms were allowed under very strict conditions Introduced measures to protect young people from smoking: extension of ban on sales to minors to < 18 years; banned selling sugary flavoured cigarettes; banned opening tobacco shops close to youth education and leisure facilities Re-established targets set out in 2004 Public Health Law. Reimbursement of NRT for pregnant women was introduced from 2011 up to €150 per year. No measures were taken to ban point-of-sale advertising and TV motor sport broadcasting with tobacco sponsorship, although the need to do so was highlighted in the Plan
2008
2009–13, 2nd Cancer Planh
2009, Articles 98–100 of Hospital, Patients, Health and Territories Law no. 2009-879g
State Council decree introduced extension to smokefree policy in closed public places from February 2007 in work-places, shopping centres, airports, train stations, hospitals and schools Nicotine replacement therapies (NRT) can be reimbursed by €50 per person per year
2006, Bertrand Decreef
New targets to decrease tobacco daily smoking prevalence from 33 to 25% in males, from 26 to 20% in females by 2009, with a focus on young and underprivileged populations. Freeze in tobacco taxation from 2004 to 2007
Comment
Law, date
France
Commitment to review case for standardized packaging. Tax escalator—at 2% above inflation— re-introduced in March 2010 Budget. Mass media campaigns stopped in advance of general Election, reinstated 2011. Graphic warnings introduced on all tobacco products (first country to require this). Specific commitment to protect policy making in England from tobacco industry
2010, Publication of: A Smokefree Future—A Comprehensive Tobacco Control Strategy for England Publication of new public health 13 strategy
(Continues)
Paved way for ban on point-of-sale displays to be implemented in two phases
England implements comprehensive enforced smokefree policy and age of sale raised to < 18 years Graphic warnings introduced on manufactured cigarette packs. Extension of smoke-free policy to mental health buildings
Paved way for smoke-free implementation and rise in age of sale of tobacco to < 18 years Tobacco smuggling strategy extended with new targets
Comment
2009, Health Act
2007, main components of Health Act implemented 2008
2006
2005, Health Act
2005, England ratifies WHO FCTC
Law, date
England a
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Graphic warnings appear on roll-your-own packs
Announcement of plans to introduce standardized packaging, ban on smoking in cars with children, increase in the reimbursement of NRT for the most underprivileged population and young smokers aged 20–30 and patients with cancer, from €50 to €150 per year, and other measures
2012
2014–2019, 3rd Cancer Plan and National smoking reduction programme
2014
2013
2012
2011, Publication of New Tobacco Plan for England [14]
c
b
All English documents can be located at http://www.ash.org.uk/files/documents/ASH_741.pdf. Veil Law: République française. Loi no. 76-616 du 9 juillet 1976 relative à la lutte contre le tabagisme. Journal officiel, 10 juillet 1976. Evin Law: République française. Loi no. 91–32 du 10 janvier 1991 relative à la lutte contre le tabagisme et l’alcoolisme. Journal officiel, 10 janvier 199. d 1st Cancer Plan: Mission interministérielle pour la lutte contre le cancer (MILC). Plan cancer 2003–2007. Paris: MILC, 2003: 44p. e 2004 Public Health Law: République française. Loi no. 2004-806 du 9 août 2004 relative à la politique de santé publique. Journal officiel, 11 août 2004. f Bertrand decree: République française. Décret no. 2006-1386 du 15 novembre 2006 fixant les conditions d’application de l’interdiction de fumer dans les lieux affectés à un usage collectif. Journal officiel, 16 novembre 2006. g HPST law: République française. Loi no. 2009-879 du 21 juillet 2009 portant réforme de l’hôpital et relative aux patients, à la santé et aux territoires. Journal officiel, 22 juillet 2009. h 2nd Cancer plan: Institut national du cancer (INCa). Plan cancer 2009–13. Boulogne-Billancourt: INCa, 2009: 138 p. i Graphic warning labels: République française. Arrêté du 15 avril 2010 relatif aux modalités d’inscription des avertissements de caractère sanitaire sur les unités de conditionnement des produits du tabac. Journal officiel, 20 avril 2010. WHO = World Health Organization; FCTC = Framework Convention on Tobacco Control.
a
Tobacco information helpline number appears on all cigarette packs (previously just one of 14) Graphic warnings appear on manufactured cigarette packs
2011i
interference (WHO FCTC Article 5.3). One of the three 2020 aspirations set was ‘to reduce adult smoking rates to 10% or less, and halve smoking rates for routine and manual workers’. The other two aspirations were on reducing youth smoking and increasing smoke-free homes Set out national ambitions to reduce smoking rates among all adults from 21.2 to 18.5% by end 2015 and targets for pregnant women and 15-year-olds. No specific ambition set for inequalities. Committed to removing shop tobacco product displays, ban tobacco vending machine sales and to hold public consultation on plain packaging. Statement of commitment to protect policy development from tobacco industry interests Government consultation on standardized packaging; large shop removal of point-of-sale displays (small shops, 2015). Tobacco duty increased by 5% above inflation Government decided not to go ahead with standardized packaging. Tobacco duty escalator decreased from 5 to 2% Announcement of plans to introduce standardized packaging, ban on smoking in cars with children, and other measures
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Table 4 Manufactured cigarette prices 2000–10 in France and England.
Year
France: recommended retail price (RRP) of a typical pack of 20 manufactured cigarettes in the MPPCa on 1 January each year (Euro)
England: recommended retail price (RRP) of a typical pack of 20 manufactured cigarettes in the MPPCa on 1 January each year GBP (Euro)
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
2.96 2.96 3.60 3.90 5.00 5.00 5.00 5.00 5.30 5.30 5.60
3.36 (5.17) 4.33 (7.23) 4.33 (7.01) 4.51 (7.19) 4.65 (6.60) 4.98 (7.21) 5.23 (7.69) 5.44 (8.02) 5.66 (8.12) 5.85 (7.39) 6.29 (6.91)
a The Most Popular Price Category (MPPC) is a benchmark European Union (EU) price category reflecting the price of a popular brand(s) typically occupying about 35% of the national cigarette market. These data were not available for the same month each year; most proximal months utilized: for April 2000–03; May 2004; July 2005–10 [28].
Table 4 shows prices in England and France from 2000 to 2010 for cigarettes. Funding for tobacco control In both countries, funding for tobacco control is inadequate, according to recommended standards [21,22], not clearly identified or delineated, and has been diminishing due to competing priorities within a constrained budget. According to the Audit Court, the French National Institute for Health Prevention and Education, the main provider of tobacco control education campaigns and funder of regional projects, was allocated a budget of €8.4 m for tobacco control in 2011 (the latest year for which data are available), 44% less than the funds mobilized in 2003 [2]. In England, in 2012/13 it was estimated that just under €11 m was spent on mass media tobacco control campaigns, compared with €9 m in 2002/03 and €20 m in 2003/04 [23].
‘remobilization’ and the impact on tobacco control policy implementation having been raised by the French government in its report to the WHO FCTC Secretariat [2]. The High Council for Public Health (HCSP) has indicated ‘the tension between industry and financial interests and health priorities’ [2] with, for example, a report criticizing the involvement of the tobacco company Altria in funding a Brain and Spinal Cord institute in France [4]. Additionally, in contrast to England, tobacco is still grown in France, with 1800 farms remaining. Tobacco growers have been compensated by regional governments and the European Agricultural Fund for Rural Development by approximately €10 m from 2011 to 2013 for a projected reduction in tobacco consumption [2]. However, the resilience of the French industry is illustrated by its rise in profits, from €13 bn in 2002 to just under €17 bn in 2010 [2]. Role of tobacco retailers France is unusual—if not unique—in having tobacconists, an occupational group, dedicated to selling tobacco as part of a state-subsidized monopoly. This contrasts with England, where cigarettes are purchased from a variety of stores, including petrol stations and supermarkets (and until 2011 from vending machines). In France, three government contracts have been made since 2005 (‘Future Contracts’) to support tobacconists; these included various aids and grants, including exemption from licence duty below a certain profit threshold and additional and compensatory remuneration, designed to compensate for loss of profit from anticipated falls in sales. It has been estimated that tobacconists have benefited by an average of more than €300 million every year between 2004 and 2011, resulting in tobacconists’ revenue consistently rising in real terms, referred to as ‘exceptional in a prevailing context of most socio-economic categories experiencing stable or reduced purchasing power… evidence that state support has in fact provided a windfall to a very large number of tobacconists’ [2]. Stopping this state-subsidized provision of tobacco would be an important step towards an effective tobacco control strategy.
Influence of the tobacco industry
CONCLUSIONS
Any weaknesses in tobacco control risk being exploited by the tobacco industry, seeking to exert its influence [24]. In its 2011 Tobacco Control Plan, the English government made a specific commitment to protect policymaking from tobacco industry interference [14] in line with Article 5.3 in the WHO FCTC. This is an important statement of intent, although it remains to be seen whether it will be observed. In France, a lack of implementation of Article 5.3 has been noted with concerns about tobacco industry
France and England, two neighbouring European countries at a similar stage in the smoking epidemic, have recently shown diverging trends in tobacco use. The absence of meaningful price rises during the period 2005–10 seems to have played a significant part in this, stemming from the lack of a robust and coordinated tobacco control strategy in France which appears to have empowered the tobacco industry to undermine tobacco control further. It is particularly notable that funding to compensate
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tobacconists appears to incentivize the sale of tobacco and is significantly higher than tobacco control funding. During the last 2 years, this regrettable increase in prevalence has been acknowledged and analysed and, including the current paper, this has contributed to a new 5-year Cancer Plan [25] that accords tobacco control policies their rightful dominant position. As part of this, a national smoking reduction programme was released by the Health and Research Ministries in September 2014 [26]. This includes a plan to introduce standardized packaging of tobacco by January 2016, as well as making more transparent political lobbying by the tobacco industry. Of concern, however, is the absence of a plan to increase the price of tobacco. It remains to be seen how the 2014–19 Cancer Plan will be implemented and hence to determine any impact upon smoking prevalence. In addition, France would benefit from more frequent national smoking prevalence studies; the Smokers’ Toolkit in England allows for contemporaneous feedback on smoking trends [27] in addition to the annual national surveys [9]. In both countries, the higher levels of smoking among the more disadvantaged groups are of great concern and require concerted political leadership for effective action, including setting appropriate specific targets for reducing inequalities. We believe that this case study shows the benefits of cross-country comparative research. National strategies and policy environments cannot be studied using traditional research tools (e.g. randomized controlled studies), so quasi-experimental and other design methodologies are needed. In order to examine smoking prevalence, however, extremely large samples are needed, making many of them cost-prohibitive. We therefore encourage more case studies of this type, using nationally comparative data and reports, to provide useful insights to influence the implementation of evidence-based and enforced tobacco control policies. Declaration of interests None. Acknowledgements A.M. and T.M., psychologists and tobacco researchers, were commissioned to write the paper by the French National Cancer Institute (INCa); T.M. is a member of the Scientific Advisory Board for INCa. A.M./T.M. involved R.G. and F.B., who are statisticians and tobacco researchers, from the French Institute for Health Promotion and Health Education (INPES) and the French Monitoring Center for Drugs and Drug Addiction (OFDT) and R.M., a professional translator (English/Spanish/French), translated the French reports. A.M. is guarantor of the paper. We are grateful to Konstantin Krasovsky and other participants for their comments when this paper was presented © 2014 Society for the Study of Addiction
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at the 2014 European Conference on Tobacco or Health. The translation of French reports for the preparation of this paper was funded by the Institut National du Cancer (INCa). INCa had no role in the preparation of this manuscript. A.M. is part-funded by the UK Centre for Tobacco and Alcohol Studies, a UK Clinical Research Collaboration Public Health Research, Centre of Excellence. Funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council and the National Institute for Health Research under the auspices of the UK Clinical Research Collaboration is gratefully acknowledged. The Behaviour and Health Research Unit (BHRU) is part-funded by the UK Department of Health Policy Research Programme as the Policy Research Unit in Behaviour and Health (PR-UN-0409-10109). The Department of Health had no role in the preparation of this manuscript. The views expressed in this paper are those of the authors and not necessarily those of the funders. References 1. Lopez A. D., Collishaw N., Piha T. A descriptive model of the cigarette epidemic in developed countries. Tob Control 1994; 3: 242–7. 2. Audit Court [Cours des Comptes]. Report to the president of the National Assembly for the Committee for the Evaluation and Control of Public Policies. Article I 132–5 of the Public Accounts Code. Tobacco Control Policies. December 2012. 3. Jacquat D., Touraine J. L. Tobacco control: fifteen propositions to tackle a major public health issue. National Parliament Information Report n°764, 2013, p. 182. 4. Bur Y. Proposals for a new policy against tobacco. Report for the Minister of Work, Employment and Health. Paris, 2012. 5. Jacquat D., Touraine J. L. About the conclusions of the National Parliament Information Report n°764, 2013, National Parliament Information Report n°2099, 2014. 6. Guidance and methodology about the General Lifestyle Survey. Available at: http://www.ons.gov.uk/ons/guidemethod/method-quality/specific/social-and-welfare-methodology/general-lifestyle-survey/index.html (accessed 19 October 2014). 7. Health Barometer. 2010. Methods. Available at: http:// wwwinpessantefr/Barometres/barometre-sante-2010/pdf/HealthBarometer-2010-Methodspdf (accessed 19 October 2014). 8. Beck F., Guignard R., Richard J.-B., Wilquin J.-L., Peretti-Watel P. Recent increase in tobacco use in France: main results of the Health Barometer, France, 2010. Weekly Epidemiol Bull 2011; 21–22: 230–3. 9. Office for National Statistics. General Lifestyle Surveys. Available at: http://www.ons.gov.uk/ons/rel/ghs/general-lifestylesurvey/index.html (accessed 8 December 2014). 10. Health Barometers, 2000, 2005 and 2010; INPES, formerly CFES. (accessed 8 December 2014). 11. Peretti-Watel P., Constance J., Seror V., Beck F. Cigarettes and social inequalities in France: is tobacco use increasingly concentrated among the poor? Addiction 2009; 104: 1718–28. 12. HM Government. Smoking Kills. A White Paper on Tobacco. Presented to Parliament by the Secretary of State for Health and the Secretaries of State for Scotland, Wales and Northern Addiction, 110, 392–400
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