Belgium is adopting 10 bold tobacco control measures

Presented by the Belgian Minister of Social Affairs and Public Health on Tuesday, 24 October 2023, after having been approved by the Council of Ministers, this set of new regulations marks an important step in putting an end to tobacco. The Belgian Alliance for a Tobacco-Free Society traces the process that led to these important decisions and details their content.

from

Pierre Bizel, Hainaut Health Observatory (OSH), Province of Hainaut, Belgium

Danielle van Kalmthout, The Belgian Alliance for a Smoke-Free Society, Brussels, Belgium

A sensational announcement

Frank Vandenbrouckem, Belgian Minister of Social Affairs and Public Health, announced a new national catalog of 10 measures on 24 October 2023, this having been approved the previous Friday by the Council of Ministers[1].The objective of this courageous plan, which places the health of the population at its centre, is simple: to take one more step toward a tobacco-free generation. The plan now places the country at the European forefront of tobacco prevention.

The measures include the removal of sales displays; the establishment of non-smoking outdoor areas such as amusement and animal parks, playgrounds, and sports fields; an increase in the price of a pack of cigarettes by €2, a ban on the sale of disposable electronic cigarettes and nicotine pouches from 2025; and better therapeutic reimbursement, etc.

But how did we get here?

The fight was clearly founded on Belgium's ratification in 2005 of the World Health Organization Framework Convention on Tobacco Control (FCTC)[2].

Indeed, tobacco is one of the main causes of death in Belgium. Every day, nearly 40 Belgians die from smoking – 15,000 per year. Not to mention 300,000 people who suffer from tobacco-related illnesses. 24% of the Belgian population smoke (including 19% daily) an average of 14 cigarettes per day[3]. 12% of young people ages 15 – 17 smoke daily[4].

As for vaping, 11% of Belgians say they vape. This practice is popular in the 15 – 34 age group and even more so in the 18 – 24 age group. 38% of young people ages 15 – 20 have already vaped at one time or another, 32% have done so in the past year, and 16% say they are still vaping. This is often a case of dual use (vaping and smoking)[5].

The Belgian Alliance for a Tobacco-Free Society was created in 2018 to revitalise anti-tobacco policy in Belgium, taking over from the Coalition Against Tobacco. The initiative was spearheaded by two organisations: Foundation against Cancer and Stand up against Cancer (Kom op tegen Kanker)[6]. Other organisations quickly joined in, such as the Belgian Cardiological League, the Respiratory Disease Fund (FARES), the Service for the Study and Prevention of Smoking (SEPT), Family Bond (Gezinsbond), Flemish Institute for Healthy Living (Vlaams Instituut Gezond Leven), the Flemish Association for Respiratory Healthcare and Tuberculosis Control (Vlaamse Vereniging voor Respiratoire Gezondheidszorg en Tuberculosebestrijding (VRGT), and of course the Hainaut Health Observatory.

The alliance's ambition is to create a society where no one suffers the consequences of smoking and second-hand smoking. Its objective is twofold: at the political level to advocate for a tobacco-free society with decision-makers, and on the level of support to civil society, to contribute to the creation of tobacco-free environments for young people and children through the “Generations without Tobacco" programme.

In the run-up to the 2019 elections, alliance members wanted to coordinate their actions by producing a memorandum addressed to the political parties in order to assert their wishes.

10 concrete measures to combat tobacco were then prioritised:

• The effective introduction of plain packs for tobacco products
• A legal ban on smoking in cars in the presence of underage passengers
• A total ban on tobacco advertising at points of sale and a ban on tobacco vending machines
• A ban on the visible display of tobacco products
• Investment in anti-smoking campaigns for the general public
• A raise of the minimum age for purchasing tobacco to 18
• A reduction in the number of points of sale of tobacco products
• Free or affordable smoking-cessation medications and pharmacological aids for vulnerable groups of smokers
• An excise tax policy that discourages the consumption of manufactured cigarettes and roll-your-own tobacco
• Measures to combat the positive image of smoking in films and series and to raise awareness among viewers

This memorandum served as the basis for active lobbying of political parties in the run-up to the elections, and in the crucial period of negotiating the federal intergovernment agreement. The result was that the final general government agreement literally included in its text the objective of a first tobacco-free generation[7].

However, prior to this September 2020 government agreement, a certain number of important measures had already been adopted at the last minute by the previous parliamentary majority (see figure): the adoption of the standardised neutral pack for cigarettes, roll-your-own tobacco, and shisha tobacco; the ban on advertising at sales outlets; the ban on smoking in cars in the presence of minors; and the increase from 16 to 18 years as the age limit for tobacco sales. The price, the most effective measure for reducing consumption, had also been increased following successive increases in excise duties.

Electronic cigarettes are now considered to be similar to tobacco products. Many general provisions now apply directly to them, such as the ban on sales to minors, the ban on advertising, and the prohibition of consumption in enclosed public places.

All these measures have led to significant progress in Belgium's tobacco control policy. The Tobacco Control Scale[8] measurement tool aims to quantify the implementation of tobacco control policies at the national level across 30 European countries. A ranking is then established. Belgium occupied 19th place in 2003 and progressed to 10th place in 2021.

The figure below traces its evolution in relation to Ireland and Switzerland (blue line for Belgium).

An Interministerial Conference

In March 2022, following the agreement of the federal government, the Interministerial Conference on Public Health announced a new intergovernmental tobacco control strategy. The federal, regional, and community ministers concerned then jointly committed to achieving a “tobacco-free generation”[9].

During the second half of 2022, an ad hoc working group made up of political decision-makers from each party and government administration developed an operational action plan. In December 2022, the Interministerial Public Health Conference announced the new Intergovernmental Strategy 2022 – 2028 for a Tobacco-Free Generation.

The alliance is delighter with the plan constituting a coherent set of mutually reinforcing measures. This new anti-smoking plan aligns with the European objective of reducing the number of daily smokers over age 15 to less than 5%, but Belgium has set the bar higher so that ultimately 0%, or almost 0%, of young people will start using tobacco products. The plan provides for concrete intermediate objectives, namely a maximum of 10% of daily smokers by 2028 and a maximum of 6% of daily smokers in the 15 – 24 age group. These intermediate milestones enable the strategy to be redirected if necessary.

The Belgian vision of achieving a tobacco-free generation also covers measures regulating protection from second-hand smoke, indoor/outdoor spaces, new tobacco products, the application of Article 5.3 of the WHO Framework Convention on Tobacco Control concerning interference by the tobacco industry[10], and others.

Here are the 10 decisions taken

1. Tobacco display ban

A display ban will come into force on 1 January 2025. From this date, it will be illegal for anyone to display cigarettes, vapes, etc. visibly in stores. Products will have to be placed in a separate room or stored in a drawer or cupboard so that they cannot be seen. This is a particularly important measure that has already been adopted by a number of countries (Ireland, the Netherlands, Denmark, Croatia, the United Kingdom, Finland, Canada...)

1. Ban on the sale of tobacco products in certain locations

Temporary sales outlets – such as festivals – will no longer be allowed to sell tobacco products from 2025. The ban on the sale of tobacco products in supermarkets of more than 400m² is being expedited. This ban will come into force on 7 January 2025 (instead of 1 January 2028).

Hotels, restaurants, and cafes (HoReCa) will be able to continue to sell tobacco. Smoking areas will also continue to be authorised, but access to them will be prohibited to minors. HoReCa establishments will be subject to strict control and if violations are noted, the establishment may be temporarily closed.

1. More no-smoking areas, especially where children and young people go

From 1 January 2025, a smoking ban will be enforced in many places across the country, especially where many children and young people go. In 2022, it was decided to ban smoking from amusement parks, animal parks, children's farms (during activities) and playgrounds, among others. The list has now been extended to include public places where smoking is prohibited. Therefore, smoking is also prohibited on and next to sports fields, with the exception of HoReCa terraces located near a sports field. However, a smoking area hidden from view can be set up in these places. No rules have as yet been established by the government.

The Generations without Tobacco project, however, has already set up a webshop with signage material for purchase by municipalities and organisations[11].

People often smoke when entering and leaving health care facilities and schools. From 1 January 2025, smoking will be prohibited within a radius of 10 metres at the entrance and exit of healthcare, hospitality, and educational establishments, as well as public libraries. The obligation to indicate this non-smoking area will also be introduced.

1. Smoking ban extended to all means of transport

Smoking was already prohibited on public transport (trains, trams, buses, etc.). This ban will now be extended to professional passenger transport: taxis, buses, etc. This ban will come into effect immediately upon publication of the law (in spring 2024).

1. Increase in tobacco taxes

The price of cigarettes, hand-rolled tobacco, and electronic cigarettes will increase sharply on 1 January 2024. The impact of a series of decisions that were taken at the time the government was formed and during the preparation of the 2024 budget results in an increase in total nominal excise duties of €52 per 1,000 cigarettes and €42.6 per kilo of smoking tobacco. For a pack of cigarettes, the price would therefore increase by around €2 (+- 25%, depending on the price set by the manufacturer, obviously) and will bring the price of a standard pack of 20 cigarettes to €10.79.

For electronic cigarettes, an excise duty of €0.15 per ml of liquid has been introduced. According to the alliance, increasing the price of tobacco is the most effective measure for reducing the number of smokers and preventing young people from smoking. The WHO also places this measure among its six best anti-tobacco actions.

1. Stricter controls, with the possibility of closure

From 2024, the inspection services of the General Directorate of Administration and Civil Service and the Federal Public Service for Public Health, Food Chain Safety, and Environment, responsible for monitoring tobacco legislation, will have additional powers in the area of public health protection. Thus, if they observe violations, they may proceed, in addition to fines which can go up to €12,500, to a possible closure of the controlled establishment (this can range from one hour to 30 days). The same extension of possibilities for action is also envisaged for the customs and excise authorities.

In the near future, “mystery shopping” as a control mechanism will be stepped up by hiring students to check whether stores are complying with the rules. Here, too, closure is possible. Options for this are currently being developed.

Finally, from 1 January 2025, the law will make it compulsory to ask the buyer for proof of age if they appear to be under 25. The age limit for tobacco sales remains 18.

1. Stricter policy on electronic cigarettes

A Royal Decree concerning electronic cigarettes already prohibits drawing attention to them, such as using lights[12]. Similarly, e-cigarette flavouring can only appear on the pack in a neutral way, without attractive colours or promotional claims (e.g. only “vanilla” and not “exotic vanilla”). This Royal Decree has been in force since July 2023, but a transitional phase remains in force for retailers until 11 January 2024[13].

Disposable electronic cigarettes will also be banned from 2025. From 2021, a regulation banning disposable electronic cigarettes has been introduced to the European Commission. The dossier has been recently supplemented with additional arguments, and a response is expected in spring 2024.

1. Ban on nicotine pouches

Nicotine pouches – like e-cigarettes and vapes – can be a springboard to smoking at an early age. Since 1 October 2023, the sale of nicotine pouches has been prohibited in our country. The health of children and young people is an absolute priority.

1. Nicotine Replacement Therapy

Reimbursement for Nicotine Replacement Therapy (NRT) could provide smokers with the help they need to quit smoking. The literature shows that these NRTs can be an aid to smoking cessation in the long term. A dossier on nicotine substitutes is currently being examined by the Drug Reimbursement Commission. A decision will be taken in spring 2024.

1. Extension of regulation to all tobacco and tobacco-like products

Certain rules already imposed on traditional cigarettes do not yet apply to other tobacco products. In 2024, existing regulations will be extended to these other products. Cigars and cigarillos will in particular be subject to a combined health warning and standardised packaging will be mandatory for all tobacco products and herbal smoking products. Online tobacco sales were already prohibited, but this ban will now be extended to devices for smoking tobacco or herbal products (vapes, water pipes, etc.) There is also already provision for the obligation to include a leaflet in each packaging unit of all tobacco products. The form that this notice should take is currently being developed.

The alliance’s satisfaction

For the Belgian Alliance for a Tobacco-Free Society, the 2022 – 2028 intergovernmental strategy had to be translated into concrete and effective measures. It is now an established fact.

The Belgian Alliance for a Tobacco-Free Society:

• welcomes this significant progress in the fight against tobacco and nicotine for recreational use
• expresses its satisfaction with this coherent plan based on almost all the action levers existing at the federal level and underlines that all of these measures stand out positively from the policies of previous legislatures
• notes that this series of measures constitutes a new step forward towards a tobacco-free generation and better protection of young people in particular, so that they have less contact with tobacco or other smoking products
• regrets, however, the lack of clarity regarding concrete support for cessation
• requests a contribution from the tobacco industry to encourage smoking cessation

The positive measures far outweigh the few concerns that the alliance wishes to highlight.

Building on this success in the approach and the soundness of the objectives pursued, the alliance has now launched a second memorandum for the 2024 elections[14].

Eight measures are prioritised and are already being actively lobbied:

• an annual substantial increase in excise duties
• the introduction of a tobacco industry financing scheme for anti-smoking measures
• a regular assessment of smoking in the country (monitoring)
• a focus on prevention and smoking cessation, with particular attention to vulnerable groups the introduction of a ban on cigarette filters
• a drastic reduction in the number of outlets selling tobacco products, and
• the concrete implementation of Article 5.3 of the Framework Convention on Tobacco Control

Thanks to the Intergovernmental Strategy for a Tobacco-Free Generation, and the measures adopted as a result, Belgian anti-smoking policy has reached an important milestone, although to achieve the ambition of a tobacco-free generation, we must undoubtedly go further[15]. The fight continues! The Belgian Alliance for a Tobacco-Free Society is more than ever mobilised to transform this objective into reality through its expertise and experience.

The Belgian Alliance for a Tobacco-Free Society

[1] https://vandenbroucke.belgium.be/fr/vers-une-g-n-ration-sans-tabac-10-mesures-pour-un-avenir-sain

[2] Convention cadre pour la lutte contre le tabac, OMS, https://fctc.who.int/fr/publications/i/item/9241591013

[3] Rapport 2022, Fondation contre le Cancer, https://www.cancer.be/la-fondation/rapport-annuel

[4] Fondation cancer – Ipsos - https://www.cancer.be/sites/default/files/22-037410-01_ipsos_rapport_rookenquete_2022_new_fr_final_pour_publication.pdf

[5] Krebsstiftung. Umfrage E-Zigarette 2023 https://www.cancer.be/sites/default/files/stichting_tegen_kanker_-_rapport_jongeren_en_vapen_2023_-_fr_pour_publication.pdf

[6] Allianz für eine rauchfreie Gesellschaft, https://alliancesocietesanstabac.be/propos-de-nous

[7] Regierungsabkommen 2020 https://www.belgium.be/sites/default/files/Accord_de_gouvernement_2020.pdf

[8] https://www.tobaccocontrolscale.org/

[9] Stratégie interfédérale 2022-2028 pour une génération sans tabac - Santé Publique (belgique.be)

[10] Richtlinien zur Umsetzung von Artikel 5.3 des WHO-Rahmenübereinkommens zur Eindämmung des Tabakgebrauchs: https://fctc.who.int/fr/publications/m/item/guidelines-for-implementation-of-article-5.3

[11] MicrosoftTeams-image (4).png (500×500) (generationssanstabac.be)

[12] https://www.ejustice.just.fgov.be/eli/arrete/2016/10/28/2016024250/moniteur

[13] https://www.health.belgium.be/fr/reglementation-specifique-aux-cigarettes-electroniques

[14] Allianz für eine rauchfreie Gesellschaft veröffentlicht ihr neues Memorandum, https://alliancesocietesanstabac.be/nouvelles