Despite two decades of tobacco control efforts, Europe still smokes more than any other World Health Organization (WHO) region — and the toll is stark. In the EU alone, tobacco is responsible for an estimated 700,000 deaths every year and a heavy, ongoing strain on health systems.

In 2000, tobacco use among people aged 15 years or older in the WHO European Region was 34.9%. By 2024, it had fallen to 24.1%. That’s progress, but not enough: It still falls short of the global target of a 30% reduction in tobacco use by 2025, and only seven EU countries are on track to meet that goal.

Against this backdrop, Europe has set an ambitious objective: a “tobacco-free generation” by 2040, defined as fewer than 5% of the population using tobacco. Whether that vision becomes reality may depend less on new laws than on what happens in ordinary consulting rooms — how often doctors ask about smoking, how confident they feel offering brief advice and pharmacotherapy, and how well health systems support them to refer and follow-up. Across the region, primary care is emerging as a critical — but still underused — lever for tobacco control.

Ambitious Policies, Shifting Products

In 2003, the WHO Framework Convention on Tobacco Control gave countries a roadmap for measures such as higher taxation, advertising bans, cessation support, packaging regulations, and protections against industry interference.

Yet implementation across Europe has been uneven. New and emerging nicotine products — including e-cigarettes and heated tobacco — have created regulatory headaches, even as the WHO European Region has become the world leader in adolescent e-cigarette use. Persistent industry interference continues to complicate policymaking and enforcement.

Within the EU, the Tobacco-Free Generation Initiative, part of Europe’s Beating Cancer Plan, has become the main vehicle for translating the 2040 vision into policy. The EU is revising its Tobacco Products Directive with stricter rules for novel products, flavor bans, updated taxation, and tighter controls on illicit trade. Some countries are also debating “generational” smoking bans that would phase out sales to people born after a certain year.

But laws alone cannot deliver cessation.

Frontline Doctors Under Pressure

Naomi van Westen-Lagerweij, PhD, from Netherlands Expertise Centre for Tobacco Control at the Trimbos Institute, Utrecht, Netherlands, told Medscape News Europe that primary care providers face multiple obstacles when trying to support patients to quit.

“They face challenges such as limited time, concerns about affecting the provider-patient relationship, and gaps in knowledge or training,” she said.

“However, smoking cessation is increasingly recognized as part of lifestyle prevention and many professional groups, including GPs [general practitioners], physiotherapists, and dental hygienists, are now addressing it.”

In Italy, Associate Professor of Hygiene and Epidemiology at Sapienza University, Rome, Italy, and President of the Alliance for a Tobacco-Free Italy, Maria Sofia Cattaruzza, MD, PhD, said smoking cessation is still largely absent from medical undergraduate and postgraduate curricula — despite national guidelines recommending that GPs provide brief advice and counselling on tobacco at every consultation with smokers.

“Less than 40% of doctors routinely ask the patient if he/she smokes and less than 50% give advice,” Cattaruzza told Medscape News Europe.

“Moreover, many GPs smoke themselves and many feel underprepared. More than 80% say they would like additional training in cessation strategies.”

Even highly motivated doctors work in conditions that make systematic cessation support difficult: short consultations, competing priorities, and high rates of burnout. Cattaruzza also cited lack of insurance reimbursement, operational constraints in busy practices, and confusion about new nicotine products, all of which can make conversations with patients more complex.

“GPs are crucial for tobacco control, [but] they need more time, support, and consistent policies to deliver cessation care systematically,” she said.

System Gaps and Mixed Messages

In Hungary, tobacco use has only slightly declined over the past 15 years, said Zsuzsa Cselkó, MD, head of the Department of Methodology at the National Korányi Institute of Pulmonology in Budapest, Hungary. She linked this in part to the rapid spread of e-cigarettes and heated tobacco products.

“Due to the widespread tobacco industry’s marketing tactics using ‘harm reduction’ as bait, many smokers have switched to these products or remain double users,” she said.

“Another reason is the [lack of] adequate and regular funding for counselling services and nicotine withdrawal treatment, which is essential to achieve progress in tobacco control.”

Cselkó said healthcare professionals play an important role in reducing the tobacco epidemic, and many have been trained in brief interventions and cognitive-behavioral techniques. But referral pathways to specialized services — such as behavioral counselling and toll-free telephone quit lines — are often weak or incomplete.

“[Smoking cessation support] must be embedded into the daily routine work. This requires prioritizing health awareness among healthcare professionals and the population … and a long-term funding system for cessation programs, including nicotine withdrawal treatment, is yet to be established.”

In Bosnia and Herzegovina, tobacco use prevalence remains among the highest in Europe, at 35.1%. Almost 1 in 3 health workers use tobacco themselves, said Anto Domić, MD, PhD, an independent researcher who works at a primary healthcare center in the northern city of Brčko, Bosnia and Herzegovina.

He said doctors face similar challenges to those elsewhere in Europe — including lack of education during training and competing priorities during consultations — but with an added obstacle: the high rate of smoking among healthcare professionals.

“Patients do not believe advice about the harmful effects of smoking if it’s advice given by a doctor who smokes,” Domić told Medscape News Europe.

He described a wider social context in which smoking remains widely accepted and where recent smoke-free legislation is poorly enforced. Funding to help smokers quit “is still not considered a priority,” he said.

Making Every Consultation Count

Despite these obstacles, experts stress that even brief interventions can make a measurable difference — especially when combined with clear referral pathways and funded treatment.

Van Westen-Lagerweij said it was vital to seize the opportunity whenever a smoker sees a GP, and that interventions do not need to be lengthy.

“Smoking is often linked to the reason patients seek care, and providers don’t need to deliver full cessation interventions themselves,” she said.

“Even very brief advice, which only takes a minute, can be effective, especially if the provider refers the patient to professional support. Our research shows patients are over five times more likely to access professional help if a provider mentions it.”

If doctors are equipped with the knowledge and confidence to mention counselling and pharmacotherapy — and if they have somewhere to refer patients — they could play a pivotal role in reducing tobacco use. Van Westen-Lagerweij noted that there are many free resources and training programs available to support providers in offering cessation care.

However, she and others emphasized that individual action must be backed by system-level changes: clear referral mechanisms, sustainable reimbursement, and policies that align incentives with cessation support. Cattaruzza said she would like to see more team-based models for smoking cessation, with nurses in primary care, psychologists, counsellors, and community pharmacists working alongside GPs under secure funding arrangements.

For now, many experts are pinning their hopes on two parallel tracks: stronger, better-enforced regulations on new and emerging nicotine and tobacco products, and clinical systems that make every consultation count. If governments follow through on ambitious policies — including, one day, generational smoking bans — and if healthcare systems invest in training, time, and infrastructure for cessation, the vision of a tobacco-free generation in Europe may yet be within reach.

Van Westen-Lagerweij, Cattaruzza,Cselkó, and Domić reported no relevant financial relationships.

Sophie Cousins, MIPH, is a global health journalist who has reported from more than 20 countries.