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Twenty years ago I worked on an advisory report on the effectiveness of various tobacco control policy measures, commissioned by the Dutch Ministry of Health as part of the process of presenting a revised tobacco act to the parliament (Willemsen, De Zwart, & Mooy, 1998). Soon after the report was finished I attended the World Conference on Tobacco or Health in Beijing, where I spoke with a civil servant from the Dutch Ministry of Health. I asked him what would happen with the report and was shocked when he told me that many of the conclusions were “not politically feasible” and could not be taken up.

Tobacco control policy is a long step from the neat theoretical path of identifying a problem, selecting the most effective strategy to tackle it, and then just implementing it. This chapter describes the many steps that were taken by the Dutch government to shape tobacco control policy. The description covers more than half a century and stays close to the timeline of events. The reader will learn how the government chose to combat smoking from the early years when it first became clear that smoking is not an innocent pleasure. At first the government was hesitant to react, but in the 1970s it became more active, culminating in a with far-reaching policy proposals, many of which were killed or toned down over subsequent years. The fight over tobacco policy then concentrated on two major national pieces of legislation: the 1988 Tobacco Act and its 2002 revision. These were not definitive laws but “framework” laws—meaning that they offered the basis for more specific decisions to be taken by the Council of Ministers (so-called orders-in-council) or by a minister (Ministerial Regulations) at a later stage. This opened up long periods of bargaining between interest groups, politicians, and the government about interpretations during the implementation phase.

This chapter considers the tempo at which the Dutch government took steps to control smoking by comparing the moment of adoption of policy measures in the Netherlands with the United Kingdom and with the rest of Europe. Before we embark on comparisons, it will be useful to define what 'tobacco control policy' is. It is not straightforward, since it refers to various actions that governments may take. Scholars (e.g., Birkland, 2011) distinguish between “types” of policy: , , (spending, grants, reimbursement), , and (education, campaigns). These differ in effectiveness, timelines (a quick or a slow effect), cost, efficiency, flexibility, visibility, accountability, and degree of citizen choice (Levine, Peters, & Thompson, 1990). Effective tobacco control is comprehensive in that it is a combination of many policy instruments. At its core are laws that restrict the availability of and exposure to tobacco products. Such regulations tend to become increasingly restrictive over time and are supported by various degrees of education, cessation support, incentives, and taxation.

Policy is not made in a vacuum. Disputes over tobacco control are fought within changing policy environments. This chapter explores key population-level factors that influence a national government’s decision to adopt tobacco control policy measures. These factors include social norms about smoking, the proportion of smokers in the population, societal support for tobacco control, and cultural values. These factors are interrelated in a specific way and to understand this, we will take a short detour into what is sometimes called “system thinking in tobacco control.” Ten years ago, the US National Cancer Institute (NCI) published a monograph on this topic (Best, Clark, Leichow, & Trochim, 2007), which acknowledged the complexity of tobacco control at the national level, involving as it does the interplay of factors over long periods of time, including feedback loops. According to experts from the NCI, a government’s willingness to acknowledge and address the smoking problem follows from its level of awareness that tobacco is a problem, and from the balance of lobbying forces that propose or hold back policy solutions. A government’s awareness of the problems associated with tobacco is further affected by specific population factors that are amenable to change. A country’s smoking rate is one of these: as long as the proportion of smokers is high, the government is more likely to be aware that there is a public health risk that needs to be addressed. Changes in the number of smokers also affect public support for tobacco control, which increases when adult smoking rates go down—a process which was believed to be mediated by social norms. Reduced smoking (people quitting or fewer people starting) shifts the balance between smokers and non-smokers, increasing the level of anti-smoking norms and altering public opinion. There is also evidence for the reverse effect, in that people quit smoking when social norms become less accommodating. Together, these population factors determine the context within which national tobacco control policymaking takes place. I have put the main factors together in a simplistic model, which I have called the flywheel model of tobacco control (Willemsen, 2011).

Tobacco policy is made by actors who operate in an institutional environment with specific characteristics (Scharpf, 1997), and differences in these characteristics can explain much of the variation in tobacco control between countries. Governments and parliaments, and their bureaucracies, have formal and informal “rules of the game.” Informal rules include conventions, unwritten procedures, and expectations. Formal rules are official and legal procedures. While the contextual factors discussed in Chap. 4 are relatively dynamic and amenable to change by tobacco control interest groups, the rules of the game that are the subject of the current chapter are more static. In terms of the Advocacy Coalition Framework, they are the constitutional structural factors (Breton, Richard, Gagnon, Jacques, & Bergeron, 2008; Sabatier, 2007) which determine how countries differ from each other—less about how countries change over time, although institutional factors and conditions can gradually change. Knowledge of these factors is not only key to understanding why tobacco policymaking is most of the time a tedious and slow process; it also helps to understand how tobacco interest groups may influence policymaking and why some groups are more successful at this than others.

Since the 1960s, governments around the world have been developing policies to control tobacco. Countries have employed different combinations of measures (World Bank, 1999), taking national circumstances into account. For example, the United Kingdom attached importance to building a national infrastructure of smoking cessation support in combination with having the highest cigarette prices in Europe, while Australia invested in mass media campaigns and was at the forefront of pictorial health warnings and plain packaging, in addition to high tobacco taxes. In contrast, the United States combined strong smoking bans to protect non-smokers, with restrictions on the sale of tobacco to youth and a long history of litigation against the tobacco industry, but has relatively low cigarette taxes, modest health warnings on cigarette packs, and weak advertising restrictions (Kagan & Nelson, 2001). Despite such differences, there is an increasing convergence of strategies across countries (Studlar, 2006). There are two aspects to this. The first is the process of governments and tobacco control coalitions becoming inspired by countries that lead the way, facilitated by increased levels of corporation and coordination of tobacco control advocacy at the international level. The second is the emergence of “hard” international law to which national governments need to abide. This is facilitated by supranational legislation from the EU and WHO forcing countries to adopt similar policies. In Europe these processes add two extra layers of governance above the national and sub-national levels, and as a result tobacco control policymaking has become the outcome of a continuous negotiation among nested governments at several tiers, a process which has been described as multi-level governance (Asare, Cairney, & Studlar, 2009; Marks & Hooghe, 2003).

Scientific evidence plays an important role in the policymaking process. Facts about the seriousness of a problem need to be accepted before a problem will be fully addressed, and evidence needs to be available for policymakers to decide about solutions. The Netherlands is among those countries where an evidence-based public health policy is best developed (CHRODIS, 2015; Smith, 2013, p. 4). When the evidence-based movement in public policy reached its apotheosis in the United Kingdom in 1997, with the new Labour government declaring “what matters is what works” (Davies, Nutley, & Smith, 2000), this was already common in the Netherlands. However, sometimes the call for more evidence may paralyse the policy process. There are also limits to the power of evidence. While a prerequisite for current policymaking in the field of public health is that important policy choices are “evidence based,” in practice this often means that policy is at best “evidence informed” (Slob & Staman, 2012).

The origins of the tobacco market can be traced back to the seventeenth century. The famous Dutch golden age was an era of prosperity for tobacco merchants. They traded not only in spices and slaves but also in tobacco, and made Dutch towns extremely wealthy and financed the famous grand houses lining the canals of Amsterdam today. The habit of smoking tobacco spread from the New World and from England to the Dutch harbours. The act of smoking can be seen on many Dutch paintings from the seventeenth century. According to historian Schama (1987, p. 189), in the Golden Age “the smell of the Dutch Republic was the smell of tobacco.” He referred to accounts by visitors to the Netherlands who were struck by the omnipresence of tobacco smoke in inns and towing barges, and the common sight of men and women smoking in public. Dutch clay pipes became an important export product. In the first half of the seventeenth century, tobacco was imported from the Americas, processed in Amsterdam, and exported to Russia and the Baltic. Amsterdam was the biggest staple market for Virginia and Maryland tobacco. The Dutch tobacco trade received a further boost when merchants set up tobacco plantations on Dutch soil, especially in the middle of the country, around the city of Amersfoort, and in the province of Gelderland. Around the year 1700 the total volume of exported mixed tobacco to Denmark, Sweden, Russia, and the Baltic states was about 10–15 million pounds per year, much larger than the 1.2 million that England exported to the Nordic countries (Roessingh, 1976).

Tobacco is the main contributor to three groups of disease: cancer, lung disease, and heart disease. Everywhere in the world, health charities fighting these illnesses became natural leaders in the field of tobacco control. The Netherlands is no exception. The Dutch Cancer Society, the Dutch Heart Foundation, and the Lung Foundation Netherlands have been fighting tobacco from the start of the Dutch tobacco control advocacy movement. The Dutch Cancer Society holds the oldest track record in tobacco control advocacy and has the largest financial resources.

Tobacco is a highly contested topic. Lobbyists present their policy solutions to politicians and government officials who weigh the evidence against what they believe is feasible or desirable, much like solving a complex puzzle (Kingdon, 2003). Such puzzles take considerable time. In the meantime, the many other concerns that a government is confronted with compete with tobacco control for a place on the policy agenda. The public policy literature distinguishes different stages of agenda setting: issues move from the public agenda to the political agenda, move again to the formal (sometimes called institutional or governmental) agenda, and finally reach the decision agenda. The public agenda consists of issues that have achieved a high level of public interest and visibility, while the formal agenda lists the topics that decision makers formally give serious consideration to (Cobb, Ross, & Ross, 1976). For an issue to reach the formal agenda, decision makers must be aware of the underlying problem, and consensus must be reached that acting upon the problem is possible and necessary and that the solution falls within the government’s responsibility.