Tobacco use continues to cause death, disease, and disability worldwide . Rates of smoking have levelled off or declined in the developed world, while they are increasing in the developing world . Because of the magnitude of the tobacco epidemic, the WHO developed the first legally binding international treaty on public health, the Framework Convention on Tobacco Control (FCTC) . When this treaty went into force in February 2005, governments throughout the world committed to implement a minimum set of tobacco control measures, but were also expected to go beyond that, following additional FCTC Guidelines. Governments now have a wide range of interventions at their disposal to reduce tobacco use, such as adopting high cigarette taxes, banning tobacco advertising and promotion, creating smoke-free public places and worksites, introducing health warnings on cigarette packs, and implementing mass media campaigns to educate about the harm from tobacco. However, more than five years after FCTC came into effect, large differences in implementation levels exist among FCTC ratifying countries .
A large and still growing body of literature exists within public health and related disciplines, describing the effectiveness and impact of tobacco control interventions on smoking and health [5–8]. There also is a growing body of literature, predominantly from political sciences, examining how these tobacco control interventions come about in diverse social and political contexts. Adoption and implementation of specific tobacco control interventions is thought to be primarily the outcome of a political process [9–11], where social norms and public opinion may play an important role. Jacobson and Zapawa argue that changes towards more restrictive civil norms regarding smoking facilitate the enactment of legislation, while laws institutionalize nascent civil norms and contribute to a social climate that discourages smoking . Kagan and Nelson, in a discussion of the politics of tobacco regulation in the United States, conclude that, on balance, US tobacco policy reflects shifts in public opinion . A central factor in explaining both the effect of policies on smoking and explaining how these policies originate in society is the concept of denormalisation. Chapman recently argued that “there is a dynamic, synergistic relationship between formal tobacco control interventions and policies, falling smoking prevalence and the increasing range and growth of markers [of denormalisation of tobacco]” .
An important aspect besides denormalisation is level of support for policies in the general population. Support for smoke-free legislation is an important determinant of compliance with the legislation [15, 16]. Studies found that support for tobacco policies, particularly smoke-free legislation, further increases after implementation [16, 17]. However, few studies looked at the association between level of societal support for tobacco control and countries’ tobacco control policy level.
The objective of our study was to examine how a country’s level of tobacco control is associated with markers of denormalisation of smoking, smoking prevalence, and societal support for tobacco control. We conducted an ecological study, using country as the unit of analysis. The European Union provides a good setting for such a study, because tobacco control implementation data are available from the Tobacco Control Scale (TCS) , while Eurobarometer surveys  provide data on denormalisation, smoking prevalence, and support for tobacco control. A recent study reported on the association between the 2007 TCS score and 2009 Eurobarometer data on smoking prevalence, self-reported exposure to passive smoking, and support for smoking bans . They found that TCS scores were negatively (although not statistically significant) associated with smoking prevalence and positively (and significantly) associated with public support for smoking bans in workplaces. However, they did not examine support for other policies nor markers of denormalisation. We investigated the associations between the more recent 2011 TCS score with Eurobarometer data on societal support for tobacco control measures, smoking prevalence, and markers of denormalisation of smoking.