General introduction 11 1 of the first reports to draw attention to the lethal consequences of tobacco use. However, it quickly became evident that in itself a desire to quit smoking often proved insufficient to enable successful cessation. Smoking appeared to be not only highly addictive but also profoundly influenced by social and environmental factors; it made cessation a formidable challenge.3 Nowadays, the negative effects of smoking extend well beyond the adverse health effects among individuals, with large losses in productivity and excess health care costs each year.4 On top of that, tobacco production has been estimated to have contributed up to 20% of annual greenhouse gas increases and cigarette butts and other waste forms contaminate beaches and waterways.5 As a response to the wide range of negative effects of tobacco use, many governments implemented tobacco control policies. Tobacco control In 2003, the World Health Organization (WHO) launched the Framework Convention on Tobacco Control (FCTC) in which 168 countries committed themselves “to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke”. Within the FCTC framework, the WHO introduced a concise set of essential tobacco control policies under the acronym MPOWER, comprising six key components: (1) Monitor tobacco use and prevention policies, (2) Protect people from tobacco smoke, (3) Offer help to quit smoking, (4) Warn about the dangers of tobacco, (5) Enforce bans on tobacco advertising, promotion and sponsorship, and (6) Raise taxes on tobacco. Nowadays, 5.6 billion people, or 70% of the world population, are protected by at least one MPOWER measure at the highest level, meaning that all recommended measures are implemented. In the past 15 years the number of countries with comprehensive smoke-free legislation (i.e. the ‘P’ in MPOWER) increased from 10 (i.e. 5% of countries worldwide) to 74 (38%).6 Policies such as an increased tobacco taxation, smoke-free air regulations and cessation support have significantly reduced the prevalence of smoking and its associated mortality.7
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