Who calls the shots in tobacco control policy? Policy monopolies of pro and anti-tobacco interest groups across six European countries

Background: One of the factors influencing variation in tobacco control policies across European countries is the relative policy dominance of pro and anti-tobacco control interest groups. Scholars investigating this power balance have predominantly conducted single country case studies. This study aims to explore and describe the relative dominance of pro and anti-tobacco control interest groups across six European countries by using a tobacco display ban as a case study. We examined whether there are patterns and similarities with regards to two components of policy monopolies: framing of tobacco and institutional arrangements. Methods: Thirty-two semi-structured interviews with 36 key stakeholders were conducted in Belgium, Finland, Germany, Ireland, Italy, and the Netherlands. These interviews were coded using the Framework Method. Results: In countries where health Non-Governmental Organizations (NGOs) have a relative policy dominance, tobacco consumption was predominantly framed as a health issue, NGO communities were well developed, the industry was largely absent in terms of production and manufacture, the health ministries played central roles in the policymaking process, and FCTC article 5.3 was strictly interpreted. In countries where the tobacco industry has a relative policy dominance, tobacco was framed as a private problem, NGO communities were absent or weak, the industry was well represented, the health ministries played subordinate roles in the policymaking process, and FCTC article 5.3. was only interpreted in terms of transparency. Conclusion: The ways in which tobacco consumption is framed in a country and the ways in which institutions are arranged correspond to the policy monopoly in place, with strong similarities across countries with the same policy monopoly.