A Dutch Dilemma

IN MAY 2015, I sat outside Café Hoppe, a traditional “brown bar” established in 1670 in Amsterdam, the Netherlands, chatting with smokers who had been forced outside by a government-imposed smoking ban. Brown bars—popular gathering places with dark wood interiors and walls stained from years of patrons’ smoking—are a familiar sight in the Netherlands. They are also at the center of recent shifts in tobacco policy that have affected many Dutch citizens—smokers and nonsmokers alike. As I sat talking with locals, I discovered that even among smokers, there is disagreement about what kinds of tobacco regulation are appropriate in their country.

The Netherlands, a low-lying country of nearly 17 million people situated on the North Sea between Belgium and Germany, has a reputation as a progressive and technologically advanced nation. Yet, as I observed many innovative examples of environmental sustainability and healthy living during a two-week visit, I came to realize that the country has trailed many Western nations on one front that’s dear to many progressive thinkers and health advocates: comprehensive tobacco-control measures supported by long-standing research showing the dangers of smoking and exposure to secondhand smoke, particularly the risk of developing cancer.

Between 2010 and 2013, the Dutch government even took steps backward in tobacco control and public health, weakening an existing smoking ban on hospitality businesses and reducing funding for programs that educate the public about smoking and that help smokers to quit. The full ban was reinstated in late 2014, but anti-smoking organizations are still working to raise awareness of smoking’s health risks.

The Netherlands is not alone in failing to follow through with all the recommendations for reducing cancer risk in the World Health Organization (WHO) Framework Convention on Tobacco Control, which the country signed in 2003. But according to a report published in 2012 by the Dutch Cancer Society, Dutch Heart Foundation, and the Asthma Foundation (now the Lung Foundation Netherlands), the nation increasingly lagged behind others on implementing many articles of the convention, such as the addition of warning labels with pictures on tobacco products and the development of a comprehensive ban on tobacco advertising, promotion and sponsorship.

When I looked further into the national debate about smoking regulation, I discovered what seemed to me to be a tug-of-war more about political ideology than about the dangers of smoking: an emphasis on individual freedoms that is at odds with tobacco legislation aimed at improving public health—and with efforts to stop adolescents from becoming addicted to tobacco before they have the maturity to make an informed decision about using it.

As Tim Rombouts, the tobacco prevention officer at the Dutch Cancer Society, says, “In recent years, the Netherlands hasn’t been the most progressive nation” regarding tobacco policy.

Personal Freedom vs. Government Regulation

The Dutch have been long recognized as masters of technology and enterprise. Just over a quarter of all land in the Netherlands sits below sea level, and by the 15th century the Dutch had engineered windmills to pump water out of the lowlands, dikes to protect land they reclaimed from the sea, and other innovative methods for managing all that water. While they were at it, the Dutch built an impressive culture of trade, sailing and deal-making the world over and established their coastal cities as some of the world’s most influential ports by the 17th century.

The Dutch have also been known for their tolerance of diverse values and behaviors: Amsterdam is home to coffee shops where marijuana can be bought and consumed, even though pot remains technically illegal, and in the city’s Red Light District, legalized prostitution is on display.

This cultural backdrop supporting individual rights over government regulation perhaps plays one of the biggest roles in the Netherlands’ route through the murky waters of tobacco control. Many who chafe at tobacco restrictions believe that individual Dutch citizens should make up their own minds about their behaviors, including smoking. Meanwhile, owners of small drinking establishments have suggested that bans on smoking hurt their business, and the tobacco industry has argued that it has a right to produce, market and sell its products to adults as it sees fit.

According to Heleen Weyers, an assistant professor specializing in law and society at the University of Groningen, in the Netherlands, the “Dutch government will only design a law when society is not able to regulate the problem.”

In 1990, the government’s Tobacco Act went into force, banning smoking in limited locations, including government buildings and public buildings of government-funded organizations. More widespread concerns about smoking in the workplace led the government to amend the law so that in 2004 smoking bans went into effect in most workplaces and on public transportation. Businesses in the hospitality sector—including pubs, restaurants and brown bars like Café Hoppe—were exempt from this ban.

In 2006, when the Netherlands Food and Consumer Product Safety Authority (known by its Dutch abbreviation NVWA) surveyed about 1,400 businesses, the workplaces were close to 86 percent smoke-free, representing a large increase from previous years. According to a 2013 study in the journal Health Policy, which used telephone surveys, compliance increased to 96 percent overall in 2008 from about 83 percent in 2006 for workplaces covered by the ban.

Although the hospitality industry wasn’t subject to the ban, the government issued target compliance levels for smoke-free spaces that it encouraged the industry to self-police, says Gera Nagelhout, a health communications researcher at Maastricht University in the Netherlands. But starting July 1, 2008, the industry lost its exemption from the smoking ban. All hospitality businesses were required to go smoke-free indoors—separate smoking rooms without food and drink service were allowed—and about three months later, the NVWA reported that hotels, restaurants and fast-food joints complied at rates of 94 to 99 percent. But one group lagged behind: drinking establishments—just 79 percent of which were adhering to the ban.

Owners of small pubs argued that smoking bans were an “intrusion on their privacy” to run their businesses as they saw fit, explains Weyers, and that they would lose smoking customers and income. Additionally, she says, many barkeepers believed they should not impede their smoking patrons’ “free choice” to smoke.

The arguments presented by small pub owners found an audience. In 2010, Edith Schippers, of the People’s Party for Freedom and Democracy, was appointed the new health minister. One of her first actions was to modify the 2008 smoking ban on hospitality businesses, allowing smoking in small bars less than 70 square meters that had no employees other than the owner.

“If adults decide on Friday evening to smoke together with their glass of beer in a small pub, who am I to forbid this?” Schippers explained in an October 2011 documentary television program called Zembla, which highlighted Schippers’ contacts with the tobacco lobby, dubbing her the Minister of Tobacco. “I think that people should be given a choice,” she said, according to an English-language transcript of the show. “There are plenty of alternatives for all those people that do not want this.” (Despite my repeated attempts to speak with proponents of personal freedom in the tobacco debate, none of the people or organizations I contacted responded to my requests.)

Around the same time, the Ministry of Health decided to cease all smoking education mass-media campaigns, and it also ended direct funding to STIVORO, an expert center on tobacco control, for its smoking-cessation help line. STIVORO, founded in 1974 by the Dutch Cancer Society, the Lung Foundation Netherlands and the Dutch Heart Foundation, had coordinated large mass-media anti-smoking campaigns along with running the quit line and studying and monitoring Dutch tobacco use. Due to the lack of funding, the organization disbanded in January 2014.

In 2012, the Dutch government also ended a one-year-old program that offered smokers the opportunity to claim a financial reimbursement for smoking-cessation treatment. (The reimbursement was reinstated in 2013, after several studies showed that the program had been effective.)

Elco Brinkman, a member and leader of the Christian Democratic Appeal party in the Senate of the Dutch Parliament, explained in Vrij Nederland news magazine in November 2002 why he thinks smokers have the right to use tobacco as they see fit. Brinkman told the interviewer that he was brought up “with a way of thinking that emphasizes people’s individual responsibility. I believe that smoking is a personal decision. Moreover, tobacco is a legal product.”

In the interview, summarized in English for Cancer Today by TabakNee, which produces investigative journalism about the tobacco lobby, Brinkman, who was diagnosed with non-Hodgkin lymphoma and later salivary gland cancer, acknowledged that he was a director at the tobacco company Philip Morris. “I don’t smoke myself,” he said. However, he went on to ask, “What’s wrong with a cigarette now and again? Everything in life in moderation.”

Children at Risk

Dutch supporters of increased regulation of tobacco products are quick to challenge the model of free choice—at least when it comes to tobacco. In particular, they note that adolescents in the Netherlands often start smoking between ages 13 and 15, or even younger. Young teens, Rombouts argues, do not have the maturity to make an informed choice about starting to use tobacco, which legally cannot be bought before age 18, but in reality is readily available to them.

Children in their early teens are the “perfect target” for tobacco companies, adds Wanda de Kanter, a pulmonologist at the Netherlands Cancer Institute in Amsterdam and a co-founder of the national nonprofit Youth Smoking Prevention Foundation, because they get addicted to cigarettes before they can fully understand the long-term implications of a smoking habit. It’s an addiction that research shows increases their risk of heart disease and other medical conditions and can cause at least 14 types of cancer, including cancers of the lung, mouth, esophagus and stomach.

Lung cancer survivor and childhood smoker Bert van Herk worries that his son is following in his footsteps. Photo by Gon Buurman

Bert van Herk, 62, from Amsterdam, is a case in point: He started smoking around age 14 and was diagnosed with stage I or II non–small cell lung cancer in 2000, at 47. When van Herk was a child, “it was very common to smoke in the house, at parties, anywhere,” he says. “When my parents had people over, they would offer them cigarettes along with drinks.

“Even though I had lung problems as a child, I smoked,” he says, eventually quitting around 1988. “I finally saw myself as an ‘addict,’ which decreased my self-esteem. That feeling was the main push to quit.”

After his diagnosis, van Herk took medication to address a lung infection, and then underwent chemotherapy followed by surgery to remove the tumor. He is grateful that he currently shows no signs of cancer. But he is also distressed that his 26-year-old son, following in his footsteps, currently smokes.

“Like me, my son started smoking at a young age, just 14. Maybe he sees that I have survived and thinks lung cancer is not such a big concern, but that is not true,” he says.

The portrayal of smoking as an individual choice also contributes to the stigma that many former or current smokers experience after a lung cancer diagnosis, says de Kanter. It results in “blaming the victim,” which, she says, is inappropriate because tobacco is a highly addictive product that the government is lax in regulating.

Rombouts agrees. “Personal freedom does not exist when a person is addicted,” he says.

Promoting a Smoke-Free Culture

A combination of efforts could reduce the likelihood that a new generation of adolescents will begin smoking, suggests Rombouts.

His organization, the Dutch Cancer Society, and de Kanter’s group, the Youth Smoking Prevention Foundation, are both members of the Dutch Alliance for a Smokefree Society, a partnership of public and private organizations that aims to reduce the number of smokers in the Netherlands from its current 25 percent of adults to 18 percent by 2025, and to 0 percent by 2040. The WHO has set a goal of a 30 percent reduction in tobacco use globally by 2025.

The 2040 goal may be an unrealistic one. “We know that the last 5 to 10 percent of smokers will be the most addicted, hard-core smokers,” says Rombouts, and he acknowledges that it will be difficult, if not impossible, to get those holdouts to quit. But, he says, the alliance nonetheless hopes for a day when “no child born [in the Netherlands] will smoke or be exposed to smoke in his or her lifetime.”

To reach its goals, alliance members are seeking increased taxes on tobacco products; limits on the marketing of those products; increased education about the risks of tobacco use; more support to help smokers quit; and more smoke-free environments, particularly those that are easily accessible to children.

According to Nagelhout, the health communications researcher, the Netherlands needs politicians who will implement the policies outlined by the alliance. “Also, when a policy is implemented, government officials should explain in the media that they are doing this to protect people from the dangers of smoking,” she says. “For instance, smoking rooms in pubs and restaurants are places where smokers can [still] go,” and not only should these rooms be eliminated, she says, but the government should inform the public through mass-media campaigns about the dangers of secondhand smoke so that they can understand the rationale behind public-smoking bans.

That’s important, because while research shows that exposure to secondhand smoke greatly increases the risk of many types of cancer and other diseases, tobacco-control advocates including Rombouts and de Kanter say that many Dutch citizens are skeptical that secondhand smoke is a legitimate threat.

In what may be a sign of good news for the anti-tobacco proponents, in spring 2015, the NVWA issued a report showing that compliance with the reinstated smoking ban in small drinking establishments between fall 2014 and spring 2015 rose to 88 percent from 50 percent in small bars without employees and to 96 percent from 75 percent in other bars. While some small bars may be continuing to avoid the ban—by allowing smoking after midnight when inspectors are off-duty, for example—compliance rates “have increased considerably” since the ban returned, Weyers says.

According to Nagelhout, a government committed to regulating tobacco needs to persuade owners of small pubs who see a public-smoking ban as a detriment that adhering to smoking restrictions is the right thing to do for their customers and employees.

In fact, I discovered, sometimes support for increased tobacco regulation comes from the most unexpected places.

Back at Café Hoppe, a waiter confided to me that although he was a smoker himself, he appreciates the public-smoking ban. Many employees will not want to voice this opinion aloud, he admitted, because those who support an individual’s right to smoke might not appreciate hearing that even some smokers believe that legislation to restrict tobacco has a role in Dutch society.

“I used to go home feeling sick from so much smoke after I had been working,” he said. “I can control how much I smoke, but I couldn’t do anything about how much customers smoked when they came here.”

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