Since the Netherlands had implemented a
comprehensive Tobacco Act, an important political question became whether this is sufficient for the time being or is more needed? In December 2004 Health Minister Hoogervorst started
a round of consultations.Footnote 87 A total of 47 organisations from the tobacco industry network and the health network received invitations to comment on the way the government had tackled the tobacco problem so far, and to give suggestions for future steps. On 17 June 2005, Hoogervorst sent an evaluation of the government’s tobacco control policy to parliament.Footnote 88 It presented data showing that about 70% of businesses had implemented measures to protect workers from tobacco smoke, and that most employers were positive about the new law and had had little trouble implementing the new rules (VWA, 2005). The ministry concluded that the new regulations in the revised Tobacco Act, in combination with the price increase and intensive campaigns, had been successful, and that smoking rates were finally going down after a long period of stagnation.Footnote 89 However, various breaches of the advertising and promotion ban had occurred as the tobacco industry continued to find loopholes. The report ended with the remark that other countries had much lower smoking rates and such results should be attainable in the Netherlands as well. However, instead of presenting a new governmental tobacco policy agenda, Hoogervorst made new policy intentions contingent on the tobacco control efforts of civil society and in particular the efforts of the three charities: Cancer Society, Lung Foundation, and Heart Foundation.
On 15 June 2005, the directors of the three charities and Hoogervorst signed a statement that they would join forces to intensify tobacco control: the
Nationaal Programma Tabaksontmoediging (National Program of Tobacco Control) (NPT
) (VWS, 2006).Footnote 90 STIVORO was
appointed as the central coordinating organisation, responsible for implementing the programme. The government and the charities committed to a policy goal of 20% smokers in the population by 2010, even more ambitious than the goal of 25% in 2007, formulated in Hoogervorst’s prevention paper. The ambitious goal was taken over from the Nationaal Programma Kankerbestrijding (National Program to Combat Cancer) (NPK), a collaboration between the Ministry of Health and Dutch cancer control organisations that had also started in 2005 (Jongejan, Hummel, Roelants, Lugtenberg, & Hoekstra, 2003). With the NPK programme, the government answered to calls from WHO and the European parliament to establish a national “comprehensive cancer control programme” geared towards optimisation of cancer control in the Netherlands.
Hoogervorst’s decision to share responsibility for national tobacco control with non-governmental organisations must be seen against the backdrop of the cabinet’s desire to reduce the role of the state, in line with the Balkenende II cabinet’s intent to reinforce personal responsibility and sovereignty in civil society. Hoogervorst formally justified this by referring to a section in the text of WHO’s 2003 Framework Convention on Tobacco Control (FCTC), in which the role of civil society is mentioned brieflyFootnote 91:
The special contribution of non-governmental organisations and other members of civil society … to tobacco control efforts nationally and internationally and the vital importance of their participation in national and international tobacco control efforts. (WHO, 2003)
The Dutch government hoped that the cancer, lung, and heart charities would contribute financially to the NPT programme. A five-year plan was to be developed “that contained collective and reinforcing efforts that would optimise the current tobacco control policy.” Its main focus was smoking cessation, through how-to-quit campaigns and support for smokers, including patients and smokers from low socioeconomic groups.Footnote 92 While the 20% goal was taken from the NPK programme, the list of concrete policy actions for the government was not.Footnote 93 Instead, a number of optional measures were listed that were “possible” or “conceivable,” including increasing the price of tobacco, having pictorial health warnings on packs, developing mass media smoking cessation campaigns, increasing the age for tobacco sale to 18, enforcing smoking bans in the Horeca (the hotel, restaurant and café industry), and restricting tobacco sales to specialty shops (STIVORO, 2005).
In 2006, Hoogervorst announced an intention to put graphic health warnings on
cigarette packs through an adaptation of the Tobacco Act.Footnote 94 In addition, the old idea to
restrict the sale of tobacco to specialty shops (Socialist Party member Jan Marijnissen’s motion from 1996) was raised again. As a first step, Hoogervorst announced an increase in the legal age at which tobacco might be sold, from 16 to 18, and the ending of mobile tobacco sales at festivals.Footnote 95 These were policy intentions that required parliamentary approval. Parliament was informed on 18 May 2006Footnote 96 and a first debate followed a few weeks later.Footnote 97 The political reality was clear: the proposals had no chance. VVD, CDA, and LPF had a majority of 80 seats in parliament and were against. In June 2006, VVD parliamentarian Edith Schippers
Christian Democrat Siem Buijs
a motion condemning the government’s prevention policy.Footnote 98 In it they wrote that current disease prevention policy was mainly based on “more control and repression, such as bans, commandments, reduction of selling points, increases in taxation on specific drugs and other matters that threaten the health of the people in the eyes of the government.” They demanded that the government base its policy on “positive proposals and less on repressive measures that increasingly affect people’s private life.” Their bill received support from a majority of the Parliament,Footnote 99 signalling that there was no political support for tougher tobacco control.
From that moment the NPT programme was doomed. It was clear that the government had no political support for new policy measures, while the programme lacked a clear strategic plan and offered no ideas about how the ambitions and strengths of the four partners could best be accommodated and combined. The grim prospect of failing ambitions was confirmed when experts from the Rijksinstituut voor Volksgezondheid en Milieu (National Institute for Public Health and the Environment) (RIVM) calculated the likely impact of the NPT measures and concluded that even with very optimistic estimates, the 20% target could not be reached without new policy measures (Vijgen et al., 2007). The target would only be obtainable when the government imposed yearly tobacco tax hikes (between 10% and 20%) and substantially increased the reach of efficacious smoking cessation support, and when both government and charities allocated substantial sums of money to mass media campaigns. It was clear that this would not happen. Around the same time, another report by the RIVM concluded that the Netherlands did not have a strict tobacco policy compared to other countries, and that smoking rates would not go down without further measures (Van der Wilk, Melse, Den Broeder, & Achterberg, 2007). Policy steps that had been successful in other countries were recommended, such as a smoking ban in the hospitality sector, higher tobacco taxes, and better availability of smoking cessation services.
Parallel Interests and the Fight Over Smoking in Bars
In 2007 the fourth and last
Balkenende cabinet was installed. This was a coalition of Christian Democrats, the Labour Party and the small Christian Union Party. The Minister of Health was Ab Klink
liberal Christian Democrat pur sang and an influential party ideologist, having worked for many years at the scientific bureau of the CDA (between 1984 and 1992 as scientific staff member and from 1999 to 2007 as director). He re-introduced the idea of parallel interests as
the leading concept for a prevention policy
(Klink, 2007; VWS, 2007). This meant that such a policy was to be developed in concordance with the interests of societal organisations, including businesses and manufacturers, seeing “health as a justified interest in close connection with other justified interests,” including those that were economic and social (VWS, 2007). The downside of this principle was that Klink de facto opened the door for tobacco industry lobbyists—and was far more receptive to industry contacts than previous ministers (see Chap. 8 for a detailed account of industry influence).
In 2007, the Netherlands was falling more and more behind other countries in Europe, as far as a policy to restrict smoking in pubs and bars was concerned. Seventeen countries had some kind of ban installed, including Germany (three states) and Belgium (albeit restricted to bars that serve food).Footnote 100 In February 2007, at his first public appearance a few days before the first cabinet meeting, Minister
Ab Klink (CDA) surprised everyone by proclaiming that the hospitality sector must become smoke free within a year. This was not in line with the coalition agreement, which had 2011 as the final date (the end of the cabinet period), while former Minister Hoogervorst had agreed with the sector that the period of
self-regulation would last until 2009. Klink saw injustice in the fact that workers in this particular sector were not yet protected against tobacco smoke while workers in others sectors were. His proclamation was headline news, framed in newspapers as revealing his “true nature.” Klink was depicted in the media as a patronising Christian moral crusader, an image he detested since he regarded himself as a dyed-in-the-wool liberal. He was also an occasional smoker of cigars himself. However, he kept his promise under pressure from a strong health lobby, and in June 2007 the cabinet announced that it wished to make the sector smoke-free within 12 months.Footnote 101 The sports canteens and coffee shops, which also were still self-regulated, would be covered by the ban.
In the following months Klink set out to get approval from parliament. Between March and July the ministry organised consultation talks with representatives from the tobacco industry network, the hospitality sector, employer and employee organisations, the sports sector, and health organisations.Footnote 102 Parliament further requested a written consultation round, which was organised in September. While the health organisations unanimously applauded the ban, the industry-related network of organisations raised concerns, most of which were rebutted by the ministry; however, some resulted in a weakening of the ban, such as a more lenient definition of a smoking section as a room “specifically” dedicated to smoking instead of “exclusively” dedicated to smoking. This opened the possibility of having attractive smoking sections in pubs, receiving the same services as non-smoking sections. The only difference was that personnel could not serve drinks and food at a table.Footnote 103
Parliamentarians from different parties attempted to soften the ban. For example, VVD parliamentarian Edith Schippers
(unsuccessful) motions to allow bar owners to eliminate tobacco smoke through ventilation techniques, and to exempt small pubs and bars with no personnel.Footnote 104 D66 and the Green–Left party drafted unsuccessful motions to exempt coffee shops from the ban.Footnote 105 In July 2008, the smoking ban was implemented in the hospitality sector, accompanied by a tax increase of €0.29 per pack of cigarettes, which translated to a consumer price increase of €0.35 per pack (including a price increase by the industry).
The Dutch bar smoking ban was
one of the friendliest for smokers in Europe. Smoking was still allowed in designated areas with closed doors where personnel did not serve, and on covered terraces as long as one side was open. Smokers were not fined for non-compliance, only the bar owner. The ban was accompanied by a government-run mass media campaign that failed to explain the rationale for the ban. The campaign merely reinforced the image of pitiful smokers who were no longer welcome in cafés, and fanned the flames of discontent among bar owners and smokers’ right groups. When the campaign was evaluated, it turned out that the proportion of people who were positive about a
smoking ban in bars and restaurants (only 51% of the public) had not increased.Footnote 106 Despite its inept implementation, compliance to the ban was high at first, despite the low level of fines: first a warning, then €300 for the first violation, which was doubled for each repeated offence up to €2400. In the first three months, the Netherlands Food and Consumer Product Safety Authority (NVWA
) undertook 7264 inspections and found that 94% of the hospitality sector complied.Footnote 107 This proportion was lower in pubs and bars, but was still 74%, with 15% having a smoking section.
With support and legal advice from the tobacco industry, small pubs began to deliberately provoke the government by openly showing disobedience (Baltesen & Rosenberg, 2009; Gonzalez & Glantz, 2013). The NVWA started to impose fines from October 2008 onwards and the public prosecutor began criminal prosecution for obstinate offenders. In two months 821 fines were imposed.Footnote 108 Tougher inspections, often accompanied by police officers, resulted in emotional responses from the smoking clientele of a small number of pubs. Some collected money from regular consumers to help pay fines. Newspapers ran headlines such as “Klink declares war on smokers pubs.” The hospitality industry was quick to generate reports suggesting that the smoking ban had damaged the food and drink sector, which, it claimed, had suffered serious revenue declines and bankruptcies, leading to a series of parliamentary questions.Footnote 109
In response to the pressure, parliamentarians from all parties declared themselves willing to explore pragmatic solutions to accommodate pub owners’ concerns
. Fleur Agema
from the populist Partij voor de Vrijheid (Freedom Party) (PVV), the daughter of pub owners, called for several urgent debates on the matter, in which she attacked Minister Klink vehemently, demanding an end to the smoking ban for small pubs. Klink gave
in to a request from the CDA to explore the possibility of using innovative air systems (such as curtains of air that prevented tobacco smoke from drifting from a smoking section to a non-smoking section) in bars, as an alternative to a full smoking ban.Footnote 110 VVD and CDA, with support from most other parties, convinced Minister Klink to attempt to define exact norms for air quality in pubs that would be acceptable for public health.Footnote 111 Until that moment, the government’s stance was that there is no safe limit for exposure to second-hand smoke, in line with recommendations from the WHO and the RIVM. Chapter 8 discusses the industrial lobby for
ventilation as an alternative to a smoking ban in more detail.
In the spring of 2009, successful legal procedures against the state by two small cafés (Victoria in Breda and De Kachel in Groningen) led to legal vagueness and uncertainty about whether the ban applied to small bars without personnel. Dutch courts considered the law discriminatory towards small bars without personnel on the grounds that the legislation was intended to protect employees from passive smoking, not visitors. This led to a new storm of media attention on the issue, and an escalation of the problem. Many pub owners reacted by replacing ashtrays on tables. In July 2009 Minister
Klink responded by promising to rephrase the text of the Tobacco Act so that both employers and visitors would be protected.Footnote 112 Pending these alterations, smoking in bars without personnel was condoned and no fines were imposed, and existing penalties were put on hold. In November 2009 the industry organised a public protest in The Hague to put more pressure on the government to withdraw the ban; VVD and PVV added fuel to the flames by calling for an urgency debate on the issue.Footnote 113
In December 2009, Klink
presented the results of an assessment of the remaining issues and problems with the smoking ban.Footnote 114 The conclusion was reassuring: the ban was not responsible for reduced revenue for pubs and bars or for bankruptcies, as such effects could be explained by the long-term downward trend caused by the 2007–2008 global financial crisis, and financial compensation was therefore out of the question. Other potential problems, such as that small bars faced more technical obstacles in constructing smoking sections than did larger bars, and street disturbances when smokers went outside, remained within reasonable boundaries. About one-third of pubs had some sort of smoking section.Footnote 115 In the same month, further results of studies commissioned by the Ministry of Health and sent to parliamentFootnote 116 showed that the
smoking ban in bars and restaurants had improved the air quality (the concentration of fine dust particles), reduced exposure to second-hand smoke, had a beneficial effect on smoking cessation, and did not lead to more smoking in private homes (Dekker, Soethout, & Tijsmans, 2009). The government appealed the court decision and in March 2010 the Dutch Supreme Court ruled that the legislation was not discriminatory and applied to all bars, including those without personnel. By that time, however, compliance had dropped to the point where a little over half of all bars and cafés had replaced their ashtrays (Intraval, 2010).
In line with his policy focus of approaching the tobacco problem in a positive manner, and his wish to not be accused of
paternalism, Klink approved the introduction of financial reimbursement for
smokers who need smoking cessation counselling.Footnote 117 This would become available to smokers through the mandatory health-care insurance in the beginning of the next year (2011). This was a positive outcome, after a period of no less than 10 years of political hassle and many studies and advisory reports on this issue. The process had started in May 2001 with a motion by Labour and Socialist Parties
) which requested the government to provide smokers with cessation support free of charge.Footnote 118
Failure of the NPT Programme
Minister of Health Ab Klink
most of the NPT
policy intentions initiated by Hoogervorst on ice.Footnote 119 He ignored the directors of the three health charities, who asked him to consider necessary measures such as pictorial health warnings on cigarette packs, increasing the age of sale to 18 years, and reducing the number of selling points (Rutgers, Hanselaar, Stam, & Van Gennip, 2007). Klink formulated his tobacco control strategy in 2009 as follows: “if it comes to tobacco control, I want to focus mainly on positive incentives.”Footnote 120 He distanced himself from the previous government’s intent to implement graphic health warnings on cigarette packs (unattractive warnings were “bad taste”),Footnote 121 said he did not want further regulation of tobacco sale outlets such as reducing their numbers or banning mobile sales of tobacco, and did not wish to pursue national regulations banning tobacco additives that increased attractiveness or addictiveness.Footnote 122 There was hardly a protest from parliament, which was too preoccupied with the issue of smoking bans in small pubs.
In 2010, by the end of the five-year NPT period, smoking prevalence was still high (27%) and had hardly decreased from when the
NPT programme had started (28% in 2006). Smoking among women had gone up, and youth smoking had not gone down. Despite clear messages from experts that the NPT goals were unrealistic without new tobacco control measures, the government under the leadership of Klink remained unwilling to take the necessary steps. The charities were disappointed and were, in turn, not prepared to contribute sufficient sums to campaigns, leading to a complete failure of the NPT programme and tremendous feelings of disappointment among the health organisations (Zeeman & De Beer, 2012). STIVORO, which
was responsible for execution of the programme, was scapegoated, and the three charities started to withdraw their financial support (further discussed in Chap. 9). Meanwhile, there was brief discussion within the government bureaucracy about starting a new five-year
NPT programme, from 2011 to 2015 (Ministerie van Economische Zaken, 2010), but this was abruptly discarded when the Rutte cabinet came to power.