This study aims to determine the relationship between chewing ability and the nutritional status of the elderly in Korea. This study utilized the data from the Korea National Health and Nutrition Examination Survey (KNHANES) conducted from 2013–2018 for persons who were ≥65 years of age. Of the 7835 subjects, 43.2% had chewing difficulty. Compared to the normal group, the chewing difficulty group had more stress, lower exercise frequency, less snack intake, a lower frequency of eating out, and a higher proportion of food insecurity. The chewing difficulty group had significantly lower food intake compared to the normal group, including various food groups such as cereals and grain, potatoes, fruits, meat, and milks and dairy products. The intake of fresh fruits was 24.5% lower and the intake of plant food (fresh fruits and nonstarchy vegetables) was 17.8% lower in the chewing difficulty group compared to the normal group. In addition, the intake of most nutrients  was significantly lower in the chewing difficulty group than in the normal group. The chewing difficulty was significantly associated with undernutrition (OR = 1.63). In conclusion, chewing ability is closely related to food and nutrient intake among the elderly, which can decrease the quantity and quality of diet and is also related to undernutrition. Therefore, it is necessary to develop customized nutrition programs and aging-friendly food products that consider the chewing ability of the elderly. The improvement in living conditions and the development of medical technology have led to a rapid increase in the elderly population worldwide. The UN’s World Population Prospects 2022 predicts the proportion of the global population aged ≥65 years is expected to increase from 10% in 2022 to 16% by 2050 . This study showed that the chewing difficulty group had a higher smoking rate and lower alcohol consumption frequency. This result is not congruent with Park et al. , which sThere was no difference in the frequency of breakfast between the two groups, but the snack intake and frequency of eating out were lower in the chewing difficulty group. It is thought that chewing difficulty can reduce the variety of food intake in the elderly, thereby reducing the quality of their meals. In previous studies, the elderly with chewing difficulty consumed fewer side dishes  and had The results of food intake analysis according to chewing ability in the present study are similar to previous studies that analyzed KNHANES ,8 and a In previous studies, the intake of difficult-to-chew food such as vegetables and fruits was significantly lower in the elderly, especially those with chewing difficulty ,8,9. HowThe intake of fresh fruits, excluding fruits preserved in sugar, jam, and fruit juice was 24.5% lower in the chewing difficulty group than in the normal group, and the combined intake of fresh fruits and nonstarchy vegetables was also significantly lower in the chewing difficulty group. Elderly people with many missing teeth had a low preference for vegetables and fruits . Poor chIn this study, nutrient intake tended to be similar to the food group intake, and the intake of most nutrients was significantly lower in the elderly with chewing difficulty than in the normal group. In the chewing-difficulty group, the intake of several micronutrients and macronutrients such as carbohydrates and fats was low. It is thought that insufficient intake of animal-based foods such as meat and eggs and fruits resulted in decreased vitamin and mineral intake. This result is consistent with previous studies: in the KNHANES 2015, the elderly with difficulty in mastication had lower energy and intake of protein, carbohydrate, potassium, thiamin, and vitamin C . In KNHAAging increases the possibility of malnutrition as food intake and the efficiencies of digestion and absorption decrease. This study also showed that the quality of meals can further deteriorate in the elderly with chewing difficulties. Although there are differences in some food groups and nutrient intake between the two groups, the nutrient intake insufficiency of the elderly has been further aggravated by chewing difficulty. In particular, the intake of calcium, vitamin A, and vitamin C was found to be far below the dietary reference intake. When comparing average nutrient intake with KDRI , calcium intake was 57.4% and 64.8%, vitamin A intake was 70.3% and 79.9%, and vitamin C intake was 67.8% and 81.8% in the chewing difficulty and normal groups, respectively. This result shows that chewing difficulty exacerbated the deficiency of nutrients important to the health of the elderly such as skeletal health, connective tissue formation, and antioxidant activity. The low intake of plant foods, such as fruits, was related to the insufficient intake of vitamin C, and the low intake of milk and dairy products was related to the insufficient intake of calcium in the chewing difficulty group. Cho  reportedThe Japanese elderly with chewing difficulty also had a significantly lower intake of most nutrients such as protein, fat, vitamins, and minerals except carbohydrates than the elderly with no chewing problem , and IsrIn this study, poor diet and insufficient food intake caused by chewing difficulty resulted in imbalanced nutrient intake, which is thought to affect the nutritional status of the elderly.It was found that the undernutrition of the elderly with chewing difficulty was about 1.5 times higher. Moreover, in chewing difficulty, the odds ratio of undernutrition was 1.33–1.63, which suggests that chewing ability is an important factor in the nutritional status of the elderly. Similar to these results, previous studies also reported that the chewing ability of the elderly affects nutritional status. The nutritional status score of subjects with good chewing ability was high ,34 and tBy negatively affecting the nutritional status, chewing difficulty can also affect the health-related quality of life among the elderly. As chewing ability is known to be associated with general health and wellbeing , it has As observed in this study, elderly people with chewing difficulty are likely to have an unbalanced diet and, as a result, have a nutritional imbalance which could contribute to a reduced quality of life, possibly leading to degenerative disease. Therefore, it is necessary to develop food and nutrition management strategies to overcome the changes in food intake caused by chewing discomfort and to improve the quality of meals.Intervention studies have been reported on providing a modified diet for chewing difficulties. One study prepared meals by blending and mincing to obtain a similar appearance to an ordinary meal and provided this softly cooked meal to patients with chewing problems. As a result, their intake of energy and protein increased, and patient satisfaction was high . MeanwhiIn Japan, where the proportion of the elderly population is high, various processed foods, such as universal design food (UDF) and the smile care diet are provided to the elderly with poor mastication and swallowing ability. The UDF was developed with a consideration of texture and nutrition and the smile care diet was designed for supplying nutrients, and those with chewing and swallowing difficulties are provided food tailored to their needs . In the Furthermore, Suzuki et al.  showed tIn conclusion, chewing difficulty aggravates nutritional imbalance in the elderly by reducing the variety and quality of diet and was found to be significantly associated with undernutrition among the elderly. As a rapidly aging society, Korean society needs customized and institutional programs that consider the oral health and chewing ability of the elderly. This development will contribute to securing the health and quality of life of the elderly by improving the quality of diet and nutritional status.This study has certain limitations. First, since it is a cross-sectional study that analyzed KNHANES data, there is a limitation in proving causal relationships. Second, the chewing ability of each subject was judged based on their subjective response, not a medical diagnosis by dental experts. Finally, since the dietary intake was surveyed with a 24-h recall method, there is a limit to reflecting the subjects’ usual intake. Despite these limitations, however, this study is meaningful in that it provides a scientific basis for the improvement of nutritional problems caused by the elderly’s chewing difficulty and the development of health improvement programs. It is considered necessary to identify the dynamic causal relationship between the chewing ability and nutritional status of the elderly and chronic diseases in further studies. Additional research should investigate the development of senior-friendly food tailored to the needs of the elderly with chewing difficulty.The purpose of this study was to investigate the relationship between chewing ability and nutritional status in the elderly in Korea. This study used data from Korean elderly aged 65 years or older who participated in the Korea National Health and Nutrition Examination Survey (KNHANES) conducted from 2013 to 2018. Of the total 7835 subjects, 43.2% had difficulty chewing. Compared to the normal group, the chewing difficulty group had more stress, less exercise frequency, less snack intake, less frequency of eating out, and a higher rate of food anxiety. It was found that the chewing difficulty group consumed significantly less food than the normal group, including various food groups such as grains, grains, potatoes, fruits, meat, milk, and dairy products. Compared to the normal group, the chewing difficulties group consumed 24.5% less fresh fruit and 17.8% less plant food (fresh fruit and nonstarchy vegetables) than the normal group. In addition, intake of most nutrients  was found to be significantly lower in the chewing difficulty group than in the normal group. Finally, the result of a logistic regression analysis showed that the chewing difficulty group was significantly associated with undernutrition (OR = 1.63). In conclusion, chewing ability is closely related to food and nutrient intake in the elderly, which can reduce the quantity and quality of meals and is also related to nutritional deficiencies. Therefore, it is thought that it is necessary to develop a customized nutrition program and aging-friendly food considering the chewing ability of the elderly.


General practices have adapted the practice organisation to the circumstances of the COVID-19 pandemic. In this article we describe several adjustments in general practices in the field of patient flow management, appointments, triage, referral and infection prevention. We also examined how practices relate to the policy of the government and of the professional organisations during the pandemic.A cross-sectional online survey was conducted among a sample of 893 general practitioners (GPs) during February and March 2021. The response rate was 17%. Because the questionnaire concerns practices and not individual GPs, one practice owner per practice received an invitation with a link to the online questionnaire. One reminder has been sent.General practices adapted their organisation during the corona pandemic, partly based on information and advice from their professional organisations. The adjustments were necessary to ensure that patient care continued as much and as safely as possible, often remotely. The use of video consultations quickly increased from 6% to 65% of the practices. The cooperation with neighbouring practices improved and practices felt supported by the professional organisations.The pandemic itself, remote care and stricter patient flow management have put pressure on the quality of care and patient safety. The accessibility of the practices was sometimes limited. In the perception of patients, this was stronger than in reality. The corona pandemic has (had) major consequences for general practitioners (GPs). Due to the limited care capacity in hospitals, they received the majority of patients with possible COVID-19 complaints . The enoBecause the role of primary care differs between European countries, the corona pandemic offers opportunities for cross-country learning . This waThe Dutch health care system is based on social insurance funding, in traditionally corporatist governance, with a relatively distant role for the central government . The insIn 2021, 13,492 GPs were actively employed the Netherlands, working in 4,999 general practices. Taking part-time working into account, the provider-population ratio was 5.3 full-time equivalents (fte) GP per 10,000 inhabitants. General practices in the Netherlands are relatively small:35% of the practices are single-handed (i.e. staffed by one GP);42% of the practices are staffed by two GPs, and.23% of the practices are staffed by more than two GPs.The largest category of GPs is self-employed, 51%; 28% works as an employee in a health centre or practice, and 21% works as a locum in different practices [All practices employ practice assistants . Nearly all employ practice nurses for patients with a chronic disease, elderly care, and mental health care.Nearly all Dutch citizens are on the list of a specific practice they can choose freely. Access to specialist care is only after a referral (gatekeeping). Consultations are relatively short; standard booking time is still ten minutes but increasing.GPs are paid in a mixed system:Capitation with differentiation by patient age and patients living in deprived areas;Pay per consultation, also telephone, email and teleconsultations;Performance payment for some services to be negotiated with the insurance company in the area of referrals, prescribing, and service and accessibility, and for disease management for a number of chronic diseases.GP care is covered by the basic health care insurance. All insured pay a mandatory deductible, but GP care is exempted from this; however, the deductible applies to drugs prescribed by a GP, laboratory work, and to follow-up care by specialists after a referral.There are two large professional organisations, the National College of GPs (NHG) and the National Association of GPs (LHV). The first is the scientific association which focuses on the quality and evidence base of GP care, amongst others, through developing guidelines. The second represents the professional and material interests of general practice.Overall, the Dutch primary care system is seen as a strong system in international perspective. An important problem, however, is fragmentation and coordination, because other primary care providers, such as physiotherapists and occupational therapists, work in their own practices and have their own insurance coverage and payment modalities .At the height of the first wave, May 2020, the number of confirmed COVID-19 cases in the Netherlands was 2,548 per million inhabitants. A relative moderate number, as twelve of the participating countries in the PRICOV-19 study had more confirmed cases. It should be noted that access to testing for the general population was restricted then. As of June 2020, testing was available for all citizens with symptoms . During Testing and tracing were done by the local public health authorities that act in groups of municipalities. GPs were (and are) the first contact point for patients with health complaints (possibly) related to COVID-19, usually with special consultation hours. GPs had no role in testing and tracing. Vaccination was the responsibility of the local public health authorities, but GPs were responsible for the vaccination of community dwelling patients who were unable to visit the vaccination sites (e.g. because of age-related frailty). GPs were not responsible for writing sickness absence certificates. Tariffs for telephone and teleconsultations by GPs existed before the pandemic and were open to be used. There was extra compensation for GPs for COVID-19 care, set at EUR 10 for each registered patient in their practice and additionally EUR 15 per hour for extra out-of-hours care provided. The insurance companies also stepped in for costs of personal protective equipment .The health insurance companies did not play a role in decision-making around COVID-19 measures, although they were represented in the Regional Committees of the Organisation of Acute Care .The COVID-19 pandemic has had a strong impact on health care and society in general. GP practices had to adapt their day-to-day organisation to be as much as possible accessible to their patients, while at the same protecting their staff and patients against infections, e.g. by changing the routing of patients or referral to special COVID centres. In this article, we address the question: How have GPs adapted their practice organisation during the pandemic regarding patient flow management, appointments, triage, referral and infection prevention?The results will provide GPs with mirror information about how their own measures and experiences relate to those in other GP practices, which is both relevant to Dutch GPs to see how their direct colleagues act as well as for foreign GPs to see how their Dutch colleagues on average work during this difficult period.PRICOV-19 is an international questionnaire survey in general practices, set up in 2020 by the Quality and Safety Ghent expertise centre of the Department of Public Health and Primary Care of Ghent University, in collaboration with two networks of the World Organisation of Family Doctors (WONCA), namely the European Society for Quality and Patient Safety in General Practice/Family Medicine (EQuiP) and the European General Practice Research Network (EGPRN), and the European Forum for Primary Care (EFPC) . The Duthttps://www.nivel.nl/en/beroepenregistraties-de-gezondheidszorg/healthcare-professionals-registries). The first sample consisted of practices that had previously indicated their willingness to participate in research (n = 282); the second was randomly drawn from all other practices (n = 611). Because the questionnaire concerns practices and not individual GPs, one practice owner per practice received an invitation with a link to the online questionnaire. The PRICOV-19 study used the Research Electronic Data Capture (REDCap) platform to host the survey, send out invitations to the national samples of general/family practices, and securely store the answers from the participants [In the Netherlands, two samples were taken from the practices within the Nivel GP registry  and subsequently adapted to the Dutch situation. The questions mainly refer to the situation in the practice at the time of filling out the questionnaire, unless specified differently  answering categories and Likert type answering categories . Descriptive analyses were performed with Stata 16.1.The questionnaire was returned by 208 practices; 155 questionnaires were  fully completed  fully completed questionnaires is 17%). The responding practices were somewhat larger on average, both in terms of number of patients (average 4300 in our sample against 3940 in the GP registry) and in number of GPs . Characteristics of the responding practices are given in Table During the corona pandemic, GP practices could take various measures to reduce the risk of infection: reducing the risk of personal contact, adjusting the appointment system and triage, and conducting as many remote consultations as possible Table .Table 2In the Netherlands, 81% of the practices used an adapted protocol for telephone consultations and 75% used that protocol regularly or all the time. For more than 70%, the most recent information about how a patient can be referred to a COVID-19 triage post  was immediately available in every consultation room. An important change was video consultations: 6% indicated that they sometimes did this before the pandemic (at most once a week); in our study period 65% used video consultations. Telephone triage also seems to play a more important role, as evidenced by the answers to a question about changes in the tasks of practice staff (not in table).In addition to these organisational measures, many practical measures have been taken to prevent infections, such as hand gel in all consultation rooms and cleaning protocols see Fig. .Fig. 1PBefore the pandemic, 19% of responding practices reserved fixed times in the agenda for reviewing new guidelines or literature; at the time of the survey, this was 32%. Comparing the situation before and during the pandemic, a similar difference was also found for discussions on existing, new or amended guidelines – 27% before the pandemic and 68% during the pandemic.Although attention to new guidelines and collaboration increased, the participants had the impression that the new organisational measures put pressure on patient safety. For example, almost two out of five GPs had the impression that care was sometimes delayed, mainly because patients came late to the practice: 79% had experienced that a patient with a serious condition was seen late . About half of these cases involved five or more staff members. In nearly a quarter of cases, absenteeism was coped with internally and in nearly one third with the help of neighbouring practices  and from the professional organisations. We have distinguished between the perceived quality of the support and the speed with which these organisations supported GP practices Fig. During the pandemic, digital and remote GP care in the Netherlands was often used, especially through video consultations. Although we do not have information on the use of video consultations before the pandemic, the use at the time of our questionnaire is surprisingly high, which may indicate a rapid increase. Furthermore, the appointment system, triage and patient flow to the practice have been adjusted. The absence of practice staff could often be accommodated internally or with the help of a neighbouring practice; two in five practices found that cooperation with other practices had improved.The first waves of the pandemic have put pressure on patient safety, among other things, because patients have been reluctant to visit the practice. Reasons may have been that patients did not consider it safe or they did not want to burden the GP unnecessarily . Due to The reported patient safety incidents are another point of interest. These will to some extent reflect the GPs’ perceptions, and perhaps also the safety culture and the extent to which they reflect on and recognise incidents. However, the lack of direct contact with patients in certain phases of the pandemic suggests that many incidents have not (yet) been traced. In this respect it is useful to quote the National College of GPs (NHG) definition of patient safety incidents: ‘Any unintended event  that has reached the patient and that has led to, could have caused or (still) could lead to damage to the patient’ , 16. WhiThe response of 17% achieved in the Dutch part of the PROCOV-19 project is reasonable by Dutch standards, but large practices are somewhat overrepresented in the response group. Therefore, the results cannot be generalized to all GP practices in the Netherlands.Our sample was taken partly from GP practices that had indicated their willingness to participate in research and partly from a random sample of all other practices. The reason to this is that we wanted to keep the number of practices that we approached as low as possible. Dutch GP practices are under high survey pressure, also in a European comparative perspective . The point of departure may have influenced the necessary adjustments. The answering categories used in the questionnaire were global and subjective assessment and not exact frequencies. The latter would have required a different research design.The COVID-19 pandemic has demonstrated worldwide the importance of GP care, but has also shown where improvements can be made –22. HealTriage in GP practices has been introduced on a larger scale for safety and infection prevention reasons. No comparable pre-pandemic figures are available, but triage was likely deployed more thoroughly during the pandemic. No patient came to the practice without the reason and the urgency of each visit was discussed with the practice assistant, the practice nurse or the GP. Patients did not always appreciate that. Stronger triage can create extra barriers for people who have difficulty expressing themselves – due to language difficulties or low health literacy. This may have contributed to delays in seeking care for some categories of patients. Also, video consultations do not work well for all patients or is appreciated by them. If patients cannot withdraw during the video consultation, this can lead to privacy issues. Moreover, for video consultations, just as with triage, not all patients are equally skilled with the technology and articulating their care needs over this medium.Many GPs indicated they sometimes saw patients late, because they did not come to the practice or contacted them earlier. That will certainly be experienced as a problem, but the question is whether practices could have influenced this and how. Half of the practices used their knowledge of their own patient population to approach certain patients actively. The corona files on the website of NHG have also responded to this, providing regularly updated information and recommendations, based on advancing insight and experiences in the field. This went together with the mutually coordinated information from the National Association of GPs (LHV) and the umbrella organisation for health centres, GP out-of-hours organisations, and GP care groups (InEen).The collaboration within practices and with neighbouring practices to deal with problems of absenteeism, reflects one of the recently reassessed core values of the profession: mutual cooperation in primary care . The timThe results of this descriptive study lead to several suggestions for similar situations in the future.GP organisations have an important role in the providing information; it is useful to monitor the experiences of GPs so that recommendations and guidelines can be adapted quickly if circumstances require.It is important to give practice staff the feeling that they are supported in providing good and safe care, and similarly to give patients the feeling that they can visit the practice safely and on time. This requires risk assessments based on knowledge about the practice population and the specific context of the patients (by using a person-oriented approach) .Patients must be actively informed about the accessibility of care in understandable language . It is iThe specific GP system of the Netherlands may have helped Dutch practices to adapt during the pandemic. Tariffs for e-consultations were already existing. This saved much time that otherwise would have been taken by setting tariffs and rules. The list system with (nearly) all inhabitants registered to a practice of their choice, provided GPs with a well-defined patient population and, through their electronic files, with knowledge about patients. This has facilitated an outreaching approach. Also, support by the strong national college of GPs has supported practices in practical matters of, e.g., guidelines for infection prevention. Regular updates and intensive communication are a must.These are all features of the Dutch GP care organisation that may not easily be translated to other health care systems, at least in the short run. However, evaluation of the response of primary care and general practice to the pandemic may provide arguments for changes in weaker primary care systems .Finally, it is interesting to notice the small scale of Dutch GP practices that may have posed problems in coping with absenteeism. Good relations with neighbouring practices may have attenuated this and GPs in this study reported improved cooperation with neighbouring practices as an unintended side effect. Health care systems with larger practices, in terms of the number of GPs and other staff, may be more flexible in adapting to a crisis such as the COVID-19 pandemic. Also, the fragmentation of the Dutch health and social care system may have hampered a coordinated response. Countries with a more integrated system of primary care, public health, home care and long-term care may be better able to provide a coordinated response. Payment per consultation and home visit, which is one part of the payment system in Dutch general practice, appeared to be a problem when the numbers of consultations decreased during the pandemic. Due to the restraint among patients to consult the practice, less accessibility became a result of practice level safety measures, although financial support was available to compensate at least partly for this . CountriDutch general practices have responded to the COVID-19 pandemic with an adapted organisation of their practice, safety regulations and use of video consultations. Despite the absence of staff due to illness or quarantine, GP care was able to continue. Still, triage, remote care and lack of clarity about the accessibility of care may have led to incidents in patient safety, according to the GPs surveyed.


The Netherlands plans to ban tobacco sales in supermarkets in 2024. In a comprehensive policy evaluation, we aim to examine: 1) the impact of the policy on the number and types of tobacco outlets, 2) the impact on attitudes and behaviors of smoking adults and non-smoking youth, and 3) the influence of the tobacco industry on the policy process and the retail environment. In addition, our study focusses on differential effects in disadvantaged neighborhoods, where both smoking rates and tobacco outlet density are typically highest. This study brings together economic, psychological, and journalistic research methods. We investigate the impact of the new legislation on the number and type of tobacco outlets, and on the number of smokers by using routinely collected population monitoring data. We examine the impact of the legislation on smoking susceptibility of non-smoking youth and on impulse tobacco purchases by smoking adults with yearly quantitative surveys and with qualitative interviews and discussion sessions. We describe whether these impacts differ for disadvantaged versus non-disadvantaged neighborhoods. We investigate what strategies the tobacco industry uses to influence the new legislation, policy processes, and the tobacco retail environment by performing a journalistic investigation, by means of documents obtained by Freedom of Information Act (FOIA) requests, (possibly) leaked documents from insider meetings, and interviews with insiders. The methods of our evaluation can be used as a model for other comprehensive public policy evaluations.Clinical Trials ID NCT05554120, Protocol ID KWF140282021-2.FOIA: Freedom of Information Act. SES-WOA: socioeconomic scores of private households. MCID: minimal clinically important difference. Most governments try to discourage the use of tobacco with, for example, warning labels on tobacco packages and high tobacco taxes, while some governments have also implemented plain packaging and tobacco display bans at the point of sale2. However, few countries have legislation in place to reduce the number and types of tobacco retail outlets4.Although smoking tobacco is highly addictive and detrimental to health3. The introduction of licensing systems has seen a 28% reduction in the number of tobacco outlets in Finland, 31% in California, and 83% in Hungary, which has the most restrictive licensing system in Europe5. In Pennsylvania (USA), tobacco outlet density decreased by 20% three years after implementing a licensing system intended to reduce the number of outlets6. In New York (USA), tobacco outlet density decreased by 7% after their tobacco-free pharmacy law, especially in areas with a higher socioeconomic background7. New Zealand plans to decrease the number of retailers that can sell tobacco by 90% by the end of 20238.An important element of any policy to reduce the number of tobacco sale outlets is a tobacco sale licensing system. In Europe, tobacco licensing for retail outlets has been adopted in Finland, France, Hungary, Italy, and Spain, but not always with the goal of diminishing the number of tobacco outlets9 and adults10. Based on these results, we can expect that policies that reduce the number of tobacco outlets will likely diminish the visibility and availability of tobacco products, may further denormalize smoking among non-smoking youth, and thereby may contribute to the reduction of smoking in society. However, few studies have investigated the impacts of such policies on smoking behavior or prevalence. The state-monopoly licensing systems of France, Italy and Spain have not contributed to a decline in smoking prevalence3; but these licensing systems were introduced without the explicit goal of reducing the number of tobacco outlets and did not lead to large reductions in the number of tobacco outlets. A local ban on the sales of tobacco by pharmacies in the US did not lead to a significant reduction in smoking rates11, but the decision to stop the sales of tobacco by a large pharmacy chain in the US was related to a decline in household- and population-level cigarette purchasing12, a decline in cigarette consumption among non-daily smokers13, and a decline in maternal smoking during pregnancy14.Recent meta-analyses have shown that lower levels of tobacco outlet density are associated with a lower likelihood of smoking among adolescents15. One of the main goals of this Agreement is a reduction in the number of smokers to ≤5% of the adult population by the year 2040 and to create a ‘smoke-free generation’. Reducing the number of tobacco outlets is mentioned in the Agreement as one of the policy measures that the government will implement. The Netherlands does not currently have a licensing or registration system for all tobacco retailers. It is estimated that there were about 15700 tobacco retail outlets in the Netherlands in 2019, or 5.8 retail outlets per 10000 inhabitants, excluding cigarette vending machines16. Differences in tobacco outlet density between disadvantaged and non-disadvantaged neighborhoods have not been examined in the Netherlands, but a recent study showed that lower educated adolescents in the Netherlands are about 50% more exposed to tobacco outlets than higher educated adolescents17. Smoking prevalence in 2021 was 21% among Dutch adults and 17% among Dutch adolescents (aged 12–16 years), with large socioeconomic differences in smoking19.The Dutch government released a National Prevention Agreement in 201816  the impact of the policy on the number and types of tobacco outlets; 2) the impact on attitudes, smoking, and purchase behaviors of smoking adults and non-smoking youth; and 3) the influence of the tobacco industry on the policy process and the retail environment. In addition, our study focusses on differential effects in disadvantaged neighborhoods, where both smoking rates and tobacco outlet density are typically highestOur study consists of three parts. See Research questionsPart 1 of our study answers the following research questions:What is the impact of the new legislation on the number and type of tobacco outlets?What is the impact of the new legislation for supermarkets on the number of smokers?Does this impact differ for disadvantaged versus non-disadvantaged neighborhoods?DataTo assess the impact of the sales ban, a time series of the number of tobacco outlets is used, distinguished by type of outlet, from Locatus. Locatus is a company which collects information about retail locations on a daily basis by a professional field service. They distinguish the following points of sale of tobaccoSupermarkets;Mini supermarkets;Petrol stations (staffed);Convenience stores: they sell tobacco and convenience articles like journals, lottery tickets, office supplies, greeting cards, telephone accessories and candies;Tobacco specialty shops ; andNight shops.We use data from Locatus for the period 2018–2025 at the level of postal codes.Smoking prevalence data is used at the individual level. Data at the individual level can more accurately control for differences in the characteristics of the individual. Moreover, using individual-level data enables us to evaluate heterogeneous effects between subgroups of smokers. We use existing data from the lifestyle monitor of Statistics Netherlands  and the polling station survey among students (8000 observations every four years). For each individual we link the area in which they live.28. The livability measure is a monitoring instrument for quality of life at the level of 100×100 m, measuring the following sub-dimensions: physical environment, housing stock, services, social cohesion and nuisance, and insecurity. The measure consists of a resident judgement assessment model and a housing market behavioral model. The former is a residents’ assessment of how pleasant they find it to live in their neighborhood, the latter an analysis of transactions on the housing market to determine to what extent people are willing to live in a specific place. We use the classification ‘vulnerable neighborhoods’ to identify disadvantaged neighborhoods.Data is used from a study which classifies neighborhoods according to the quality of living: the ‘livability measure’AnalysesWe will describe the trends in the number of tobacco outlets from 2018 forwards, distinguished by type of retail outlet. In 2024, the number of supermarkets selling tobacco will decline to zero because of the ban on tobacco sales in supermarkets. From 2024, the number of other types of tobacco outlets might increase. In anticipation of the sales ban for supermarkets, this might even occur before 2024. Observation of the trends gives us an indication of the extent of substitution of supermarkets by other types of tobacco outlets. We also describe the development of the number of tobacco outlets in postal codes with and without supermarkets. New tobacco outlets in areas with supermarkets are likely to be replacements of supermarkets. We also investigate the development of the number of supermarkets in disadvantaged neighborhoods and non-disadvantaged neighborhoods to see whether access to supermarkets remains in all neighborhoods.The impact of the supermarket tobacco sales ban is determined with a regression analysis. To assess the causal effect of the sales ban in supermarkets, we explain the change in the density of tobacco outlets per area by the density of supermarkets. Due to the policy, the number of supermarkets where tobacco is sold will decrease to zero in 2024. Districts with a relatively large number of supermarkets are therefore expected to experience a greater decline in the number of tobacco outlets.We describe trends in smoking behavior in the Dutch population. These trends are described separately by type of region (more versus less densely populated or disadvantaged versus non-disadvantaged) and by individual characteristics .The effect of the change in the density of tobacco outlets on the number of smokers is estimated using an instrumental variable (IV) regression. This is necessary because the change in density of tobacco retail outlets is also determined by changes in the local demand for tobacco products. Hence, simply regressing changes in smoking behavior on changes in the number of tobacco retail outlets produces biased results.29. The IV-technique has gained popularity in medicine, and is used for example to correct for non-compliance in randomized controlled trials31. An IV analysis offers a non-experimental alternative based on many of the same principles as a randomized controlled trial. IV analysis relies on finding a naturally varying phenomenon, related to treatment but not to the outcome, except through the effect of treatment itself, and then using this phenomenon as a proxy for the confounded treatment variable. One can then estimate how much the variation in the treatment variable that is induced by the instrument – and only that induced variation – affects the outcome measure.The IV-technique is widely used in economics because of the difficulty of doing controlled experiments in economicsOur IV-strategy relies on the change in density of tobacco retail outlets that is driven by the ban on sales of tobacco in supermarkets, which is a shock in supply that is independent from changes in demand. The density of supermarkets per area prior to the introduction of the policy is used as an instrument. If it is established in the first step that the change in tobacco outlet density is strongly related to the density of supermarkets prior to the policy change, the supermarket density can be used as an instrument. The supermarket density is then a suitable instrument as it is related to treatment (the change in the density of tobacco outlets) but is not related directly to the outcome measure (the change in smoking behavior).Causal effects are estimated in two steps. In the first step, we predict the development of tobacco outlet density in each area by the number of supermarkets in 2018 in that area and the nationwide growth in the area. In the second step, we use this predicted number as an explanatory variable. As this predicted number is independent of the number of smokers in the area, our estimate can be interpreted as a causal effect of the change in the density of tobacco outlets.Research questionsPart 2 of our study answers the following primary research questions:What is the impact of the new legislation on smoking susceptibility of non-smoking youth?What is the impact of the new legislation on impulse tobacco purchases by smoking adults?Does this impact differ for smoking adults living in disadvantaged versus non-disadvantaged neighborhoods?Secondary research questions are:How do non-smoking youth and smoking adults experience the new legislation?To what extent does the new legislation lead to more illegal (online) sales of tobacco?What is the impact of the new legislation on use of ‘reduced risk’ products such as electronic cigarettes and heated tobacco?Data32. Three samples are obtained from NIPObase with quotas on gender, age, geographical region, and household size determined by information from Statistics Netherlands.Our aim is to conduct yearly quantitative surveys in the autumn of 2022, 2023, 2024, and 2025. Respondents are recruited from NIPObase, a large probability-based access database that mirrors the Dutch population. NIPObase includes over 103000 respondents who regularly participate in surveys from Kantar. With NIPObase we are able to draw samples that are representative of the Dutch population according to known characteristics such as gender, age, geographical region, and household size. Respondents receive points for questions they answer, which can be exchanged for a gift certificate for themselves or a donation to a charity of choice. This procedure results in high response rates and high-quality data. Surveys are completed online. Once a respondent is included in the sample, every effort is made to track and recontact them at subsequent waves. Respondents who cannot be recontacted at a subsequent wave are replenished with a new sample of respondents, using the same inclusion criteria. These replenishment samples compensate for both the decrease in sample size, aging of the samples, and bias in demographic characteristics caused by attrition33, averaging responses to: ‘Would you try smoking a cigarette if one of your best friends offered it to you?’, ‘Do you think you would smoke in the next 6 months?’, and ‘Are you curious about smoking?’. The youth questionnaire (translated from Dutch to English) can be found in the Supplementary file.The first sample consists of 250 non-smoking youth aged 12–17 years. Youth are excluded from this survey if they have smoked (part of) a cigarette at least once a month during the last six months. For youth aged <16 years, their parents give online informed consent before the youth are asked to give online informed consent, as is according to Dutch regulations. The primary outcome measure among the sample of non-smoking youth is smoking susceptibility. This is measured with a three-item index34. We distinguish between disadvantaged and non-disadvantaged neighborhoods by socioeconomic status. We use two measures as a proxy for neighborhood socioeconomic status: the ‘livability measure’28 and the socioeconomic scores of private households (SES-WOA)35. The SES-WOA from Statistics Netherlands is a composite measure based on the financial prosperity, the level of education and the recent employment history of households, each dimension informed by pre-existing datasets from Statistics Netherlands at the national level. Scores from both measures are available at the neighborhood level. The adult questionnaire can be found in the Supplementary file.The second and third samples consist of 600 smoking adults aged ≥18 years from disadvantaged neighborhoods and 600 smoking adults aged ≥18 years from non-disadvantaged neighborhoods. Inclusion criteria are smoking at least monthly and having smoked at least 100 cigarettes in their lifetime. Respondents fill in an online informed consent before taking part in the survey. The primary outcome measure is impulse purchases of tobacco. This is measured with the question: ‘When you are shopping in a store in your neighborhood for something other than cigarettes, how often do you decide to buy cigarettes?’After the implementation of the ban in supermarkets, qualitative interviews will be carried out to provide more in-depth supplementary information to the quantitative surveys. Individual semi-structured interviews are carried out with 10 to 15 non-smoking youth aged 12–17 years, 10 to 15 smoking adults aged ≥18 years from disadvantaged neighborhoods, and 10 to 15 smoking adults aged ≥18 years from non-disadvantaged neighborhoods. Within each group variation is ensured in gender, age, education level, and cultural background. All participants receive an incentive for participation in the interview.AnalysesThe primary analyses will be Generalized Estimating Equations models for the youth and adult samples, separately. For the primary analyses, the second and third survey waves are compared, i.e. before and after the ban on tobacco sales in supermarkets. In secondary analyses, changes across the four survey waves are examined. With the two waves before the planned policy implementation, we can catch anticipatory actions of tobacco retailers. With the two waves after the planned policy implementation, we can still measure policy effects if policy implementation will be delayed by a year or if a transition period will be applied. If the policy is implemented as planned in 2024 (between the second and third survey wave), the fourth survey wave can be used to identify whether effects are temporary or lasting. It should be noted that with a longitudinal cohort study without a control group, we cannot be certain that changes in responses between the survey waves before the policy implementation and the survey waves after the policy implementation can be attributed to the policy change.For the sample of non-smoking youth, the primary outcome measure is smoking susceptibility, measured on a 4-point scale. Mean scores on smoking susceptibility between survey waves 2 and 3 are compared, while adjusting for gender, age, education level, and time in sample. With an alpha of 0.05, power of 0.90, and an expected dropout of 70%, we can detect a minimal clinically important difference (MCID) of 0.25 with n=250 respondents in total.For the sample of smoking adults, the primary outcome measure is impulse purchases of tobacco, measured on a 5-point scale. Mean scores on impulse tobacco purchases between survey waves 2 and 3 are compared and the interaction between living in a disadvantaged neighborhood or not and survey wave (change in impulse tobacco purchases) is tested, while adjusting for gender, age, education level, heaviness of smoking, living in a disadvantaged neighborhood or not, and time in sample. With an alpha of 0.025, power of 0.90, and an expected dropout of 70%, an MCID of 0.25 can be detected with n=600 respondents from disadvantaged neighborhoods and 600 from non-disadvantaged neighborhoods.36. Analyses will start during the interviewing phase, and new participants are interviewed until we have 15 interviews per group or until saturation is reached. Participants can choose to participate only in the interviews or to stay involved throughout the remainder of our study. Participants who want to stay involved will first meet in a discussion session with 5 to 10 participants per session. In these sessions, we discuss the results of the interviews and ask for feedback about our interpretations. This is a form of ‘member checking’ that is often useful to better understand and interpret qualitative findings. Transcripts of the discussion sessions are added to the thematic analyses of the interviews.Qualitative interviews are analyzed thematically using the Framework MethodResearch questionsPart 3 of our study answers the following primary research questions:What strategies does the tobacco industry use to influence the new legislation and policy processes?What strategies does the tobacco industry use to influence the tobacco retail environment?Secondary research questions are:To what extent does the new legislation lead to more illegal (online) sales of tobacco and what is the role of the tobacco industry in this?What is the impact of the new legislation on marketing of ‘reduced risk’ products such as electronic cigarettes and heated tobacco?DataA journalistic investigation is performed of the tobacco industry’s responses to government policies concerning tobacco outlets and the retail environment. We investigate the interrelatedness of these responses with reactions to other tobacco control policies and the industry’s successes in reducing their impact. We also look into the industry’s use of proxy lobbies and on its lobbying efforts via the European Union, the coordination of lobbying efforts with other sectors, trade associations, retailers’ unions, and employers’ organizations. In this investigation, documents obtained by FOIA-requests, (possibly) leaked documents from insider meetings, and numerous (background) interviews with insiders are used.Financial data and marketing data about the key developments in the Dutch tobacco retail environment are collected and analyzed. OSINT (open source intelligence) is used to collect financial data and marketing data. This includes annual reports, chamber of commerce data, and market reports. We collect information about industry strategies from annual reports, shareholders’ meetings, and meetings of CFOs with financial analysts (recordings of which are often publicly available). Sometimes we may acquire leaked internal strategy documents and other information may come from background interviews with former staff. This will be complemented with observations ‘on the ground’ by regularly (at least quarterly) visiting tobacco outlets, photographing new marketing features and talking to the people behind the counters.37. This technique involves systematically gathering and arranging data from a large number of websites and provides insight into the development of the number of (online) sales sites, of product pricing, of changes in product availability and of the overall ‘traffic’ (visitor number) of these websites, indicating  shopping activities. The scraping software that we use was custom-made by the Dutch firm Trollrensics.Observations are done on the Internet, for mapping the developments in (online) sales, possibly also via ‘scraping’Social media campaigns are analyzed and how these influence the political debate. We investigate whether, and if so, to what extent, grassroots movements are infiltrated by industry and how (possibly fake) bottom-up campaigns are covertly started by commercial actors, such as manufacturers themselves or their affiliated PR-firms. An initial probing search using our custom-made scraping software has already led to some ‘red flags’ for orchestrated/commercially steered social media campaigns focused on EU policy documents on measures regarding ‘reduced risk’ products.Tobacco industry activity cannot be viewed in isolation but needs to be put in a wider context. Our already running large-scale investigative research program offers such a context. In this large-scale research program, we investigate the implementation and consequences of the main policies of the National Prevention Agreement, including those concerning tobacco outlets but also those related to excise duties, plain packaging, and the display ban. In addition, major investigations into the tobacco industry’s involvement in the development of new versions of the main European tobacco directives (Tobacco Product Directive and Tobacco Tax Directive) are set up. These policy measures will have a direct impact on the tobacco retail environment, since prices, packaging and advertisement regulations affect the sales and therefore profitability of tobacco. This impacts the entire retail chain, from industry to shopkeeper.38. The industry has begun to roll out this strategy in western countries and may gradually introduce it in non-western parts of the world as well. For our comprehensive evaluation, a wide definition of ‘tobacco outlets’ is adopted and includes the so-called ‘reduced risk’ products.It is also important to address the fact that in the last decade, the tobacco industry has changed its marketing strategies and is moving away from ‘burned’ tobacco to e-cigarettes and heated tobacco products, using the ‘harm reduction’ concept as a new sloganAnalysesFor part 3 of our study, an investigative journalism approach is used to analyze our data and answer our research questions. We have developed a structured, process-oriented investigative journalism approach over the past ten years by integrating existing journalistic techniques, recently developed datajournalistic techniques, and elements from qualitative  research methodology. This has resulted in a step-by-step, structured but iterative approach which involves orientation research, the development of research plans based on central research questions, periodic internal research updates, reappraisals (if necessary) of research questions, and structured, analysis-based reporting.In the next four years, we will conduct this comprehensive mixed-methods policy evaluation in which we evaluate the implementation of new legislation to reduce the number and types of tobacco outlets in the Netherlands. We believe that the methods of our evaluation described above can be used as a model for other comprehensive public policy evaluations. Major strengths of our approach are the combination of economic, psychological, and journalistic research methods, the combination of quantitative and qualitative data collection and analyses, the combination of a population perspective and a focus on disadvantaged neighborhoods, and examining both smoking adults and non-smoking youth.A challenge that we foresee in this evaluation is the integration of all evidence into a coherent narrative about our core findings with resulting policy recommendations for the Netherlands and other countries. We will start the integration process by creating an overview of complementary and contradicting findings from the three parts of our study. In the last project year, we will organize meetings with the project team, interested study participants from the qualitative discussion sessions, and relevant national experts and stakeholders. During these meetings, the attendees discuss study results and work towards formulating policy recommendations based on these results. These meetings are expected to help considerably with the integration process.Another possible challenge is that many elements of the new tobacco outlets policy are still unknown, including the exact timing of policy implementation. A study design with multiple measurements before and after the planned policy implementation is chosen to take this into account. With the multiple measurements before the planned policy implementation, anticipatory actions of tobacco retailers can be caught. With the two measurements after the planned policy implementation, policy effects can still be measured if policy implementation will be delayed by a year or if a transition period will be applied. If the worst-case scenario happens and no policy is implemented at all, the investigative journalism part of our research will uncover how this happened, which can lead to important recommendations on how to prevent significant policy delay or policy failure in other countries and in the Netherlands in the future.42. This makes us confident about a successful collaboration in the current evaluation that will likely lead to a high scientific and journalistic output.The four research organizations that collaborate in this comprehensive policy evaluation have already worked and published together in several previous research projectsWe aim to publish at least four scientific articles in open-access international peer-reviewed journals, multiple journalistic publications per year, and short accessible research updates in the form of news flashes, factsheets, and blogs. During the project, we will present our work at national and international scientific conferences. We will close our project with a final webinar in which we present the core findings of our evaluation and the resulting policy recommendations to an international audience. With these dissemination activities, we aim to inform the general public, national health funds, policy makers and scientists about the progress and findings of our comprehensive evaluation.Click here for additional data file.


We implement a method from computer sciences to address a challenge in Paleolithic archaeology: how to infer cognition differences from material culture. Archaeological material culture is linked to cognition, and more complex ancient technologies are assumed to have required complex cognition. We present an application of Petri net analysis to compare Neanderthal tar production technologies and tie the results to cognitive requirements. We applied three complexity metrics, each relying on their own unique definitions of complexity, to the modeled production processes. Based on the results, we propose that Neanderthal technical cognition may have been analogous to that of contemporary modern humans. This method also enables us to distinguish the high-order cognitive functions combining traits like planning, inhibitory control, and learning that were likely required by different ancient technological processes. The Petri net approach can contribute to our understanding of technology and cognitive evolution as it can be used on different materials and technologies, across time and species. The development of complex technologies over the last 3.3 million years provides a mirror to the cognitive developments that underpin behavioral changes. Generally, the processes of production and use of archaeological objects are first  reconstructed and then interpreted using concepts such as cognitive load, learning, reflectiveness, working memory, extended thought, and action sequences10. Oversimplifying one of the main hypotheses, it could be said that a more complex mind can give rise to more complex technologies and thus that we can reverse engineer cognition from technology and material culture. However, the link between the complexity of technologies and cognition remains qualitative, restricting systematic comparisons of different technological processes and their cognitive requirements.Human origins and the evolution of cognition are intricately tied to the use of technology13. However, the exact complexity of birch tar technology is debated, as there are multiple ways to make tar without fireproof containers16. Recent experiments show that birch tar can be produced with simple methods15. However, none of the reconstructed methods have been systematically studied for their complexity with definitions for what is considered simple or complex that can contribute to the current technology and cognition debates. The simplest method, does require fewer materials and the production process consists of fewer unique steps than other techniques, but the implications of these criteria on complexity/cognition are unspecified. In this paper we take a step back in the debate and we explore a method to overcome these two problems of a) measuring technological complexity, and b) linking technology to cognition. We use Petri net modeling17 to compare the complexity of Neanderthal birch tar production methods in terms of the cognitive requirements of each method. This analysis is based on the examination of the events and conditions involved in the processes and the relationships between them. We utilize Petri nets as a method for modeling and quantifying system complexity for ancient tar production methods. By doing so, we establish a proxy for measuring the cognitive demands associated with these methods and other ancient technological processes.Tar production, an example of complex technology, often features in discussions about Neanderthal and modern human technological and cognitive capabilities22. These measurements are generally unique for specific tools and materials. In this paper we use Petri nets as a tool for expanding measurements of technological processes. Petri nets can model and study the causality and execution of events, including sequential, concurrent, and parallel execution17. This allows the identification of differences in the way information is processed to obtain or use a product. Additionally, we argue that with Petri nets, different definitions for complexity can be applied and compared for the same production process, exposing related behavioral and cognitive implications. Our approach moves away from focusing solely on verifying one particular dimension (definition) of technological complexity. Instead, we consider the differences between production methods in light of the type of solution a method represents.The measurement and comparison of different ancient technological processes is often challenging due to the uniqueness of interrelations between cognitive processes and production events, and the sparse nature of the archaeological record. Various measures have been used in the past, such as counting techno-units in tool kits, steps in behavioral sequences, procedural units in the production of a specific tool, number of and/or decisions, and distance between a need and the satisfaction of that need23, and causal reasoning is required to infer forces that are not directly perceived25. Similarly, previous studies suggest that the production of Paleolithic or Stone Age adhesives requires the maker to be able to: a) accessing multiple pieces of information at the same time while executing the process; b) avoid errors and correct problems throughout the production process; c) understand and abstract information about the materials, product templates, and the process itself before starting to make adhesives26. We measured these requirements using Petri nets and discuss the implications of the results in light of the technical cognition models. Our aim is to gain a deeper understanding of the cognitive implications of current knowledge about the tar technologies employed in the Paleolithic.The skilled technical cognition model implies that technologies, such as birch tar production, demand the retrieval and integration of a wide range of cognitive structures. Active attention is required to combine these structures during tar production28. Moreover, such instances in a process involve the use of cognitive functions to focus attention29 and to reach the end goal of a task in the face of interference-rich contexts30. This becomes particularly relevant when conducting a technological process in an environment without permanent craft specialization.Processing information at the same time (a) is a fundamental requirement in technological production. Production systems have different demands regarding the amount of information and the timing of information processing to execute the tasks and obtain the final product. The level of information processing needed at a given time is influenced by the number of interactions among elements involved in the tasks. Higher levels of interaction often imply a larger volume of information that needs to be processed simultaneously31. Complexity is also increased with more choices, because individuals may be unaware of all available choices, or what the best choices are to obtain the desired product. For these reasons, a sequential production process is also easier to execute than one with several paths to reach the end of the workflow32. Implementing strategic planning33 and inhibitory control34 may reduce the likelihood of errors produced by different permutations and choices and help to solve complex problems.Multiple permutations of events increase the likelihood of errors (b) and complexity. In a production process, different permutations create more possible paths to obtain the final product and increase the probability of deadlocks, wasting time and resources35. Previous studies have identified that understanding how to produce a technology was an important aspect in the acquisition, transmission, and production of Paleolithic technologies .Process structures with more elements and relations are harder to understand (c) because more information needs to be processed. Since information presented in a simple arrangement is easier to understand than if the same information is presented in an elaborate structure, both the amount of information and the types of structures affect the structural complexity of a process. This in turn affects process understandability, which provides an indication of how much information is embedded in the process39. To do this, we used Petri nets to model Paleolithic tar production processes. Petri nets are a modeling language with underlying mathematical semantics40. These nets are used to study systems that may show concurrent agents or events and components that operate independently with occasional resource sharing or synchronization. We used workflow nets41, a class of Petri net, to model and measure the complexity of resulting models using three pre-existing metrics: (a) the density metric that takes into account the interconnectedness between events and resources42, and can be related to requirements of simultaneous information processing; (b) the extended cyclomatic metric43, that concerns the likelihood of errors throughout the process, and the potential need for planning and inhibition control; and c) the structuredness metric, which relates to the effort to understand abstract information about the materials, product templates and the process itself, and thus to learning43.The complexity of the production of prehistoric artifacts can be measured using the requirements introduced above in combination with computational modelscondensation15, pit roll, and raised structure18. Currently, the condensation method is interpreted to be the simplest of the three, and the raised structure the most complex. These methods cover the widest range of potential tar making techniques and represent our current knowledge about aceramic tar production, both in terms of yield, time invested, number of production steps, and materials required. Our focus lies in assessing the structure and state space of each tar production process. We are not primarily concerned with comparing mental models of tar makers. The Petri net models of these production processes and the results of the complexity metrics allow us to present a multidimensional comparison of the complexity of an ancient technology. With the metrics, we also aim to show that simultaneous information processing, inhibitory control, and planning are all cognitive requirements involved in the aceramic production of tar. This approach enhances our understanding of technological processes through modeling. It reveals often overlooked attributes like concurrency, thereby enriching technological analyses in archaeology.We model and measure three experimental techniques of birch bark tar production known from the literature: condensation method a piece of bark is burnt next to a cobble, tar fumes condense against the rock, and tar can be periodically scraped off15. This process is repeated again until a small lump of tar is collected. For the pit roll method, a roll of bark is fit into a small hole in the ground and embers are used to burn the bark from the top. As tar is formed inside the roll, it drips into a container at the bottom of the hole18. In the raised structure, a birch bark vessel is placed in a hole in the ground. A screen of small twigs is placed over the hole, and a large roll of birch bark is placed over the screen. This is covered with muddy soil to form a dome or oven-like structure. A fire is lit around the structure for several hours. Any holes in the dome are fixed before or during heating as needed. The tar that forms drips through the twigs and into the underground container18.We modeled the tar production processes based on existing literature, observations of experimental executions, and knowledge from experts in Paleolithic tar production. In the 44. S.F. observed and recorded the experiments and the actions of P.R.B.K and G.H.J.L with a video camera, and time stamped all events during the coding phase. After the experiments, P.R.B.K was asked to describe the workflow of the experiments from the executant’s perspective.We recreated the tar production processes in field experiments. Non-participant observation was implemented to record the process of each experiment45.These different sources were integrated to produce comprehensive models of the actions, events, conditions, and sequences that could occur during the workflow. These models may be used to generate system description files that are essential for analyzing the cognitive complexity of actual task-solving process descriptions translated into log files40. Places represent states, conditions, or resources that need to be met or available before an event can be carried out. They also represent the result of an event, i.e., a condition or resource. Places cannot be directly connected with one another. Places are depicted as circles in the Petri net graphic representation. Transitions represent events. A transition may occur when all the required conditions or resources of its input places are available. Two transitions cannot be directly connected. The firing of a transition is instantaneous and the choice of which transition to fire when several transitions may occur concurrently is random. Transitions are shown as black rectangles in the graphic representation. Arcs represent the flow of the system and connect places and transitions. They indicate which places  are required for enabling a transition and to which places the resources or conditions resulting from a transition are directed. In the graphic representation arcs are shown as arrows. By combining these three elements, Petri nets provide a formal, graphical, and executable model of the system.Petri nets have three basic elements: places, transitions, and arcs . In the simulations, an event represented the execution of one of the transitions within each tar production model. Each trace represented a sequence of events (transitions) executed to obtain the tar product. These sequences were restricted to a maximum of 10,000 events per trace. All synthetic sequences can be found as Supplementary Table Based on the nature of the processes being modeled, there may be some variation in the resolution of the transitions. To evaluate this potential bias in transition complexity, we computed the proportion of transitions that represented embedded components (composite transitions) relative to the total number of transitions within the Petri nets folded as state machine constructs. These folded nets resulted from the final iteration of the structuredness algorithm (see below), before folding all net transitions into a single transition. These nets showed composite transitions signifying embedded sequences, 'while' loops, and marked graphs. Additionally, there were other transitions that could not be simplified further into distinct components. We interpreted a high percentage of composite transitions as an indicator of high resolution, whereas a lower percentage suggested low resolution in the transition complexity of the models. Differences in the percentages of composite transitions between the models were taken as indication of the magnitude of the differences in the complexity of the modeled transitions.50. The analysis of individual usage behavior from human subjects could be effectively conducted through the use of the Automatic Mental Model Evaluation method (AMME)45. However, such an investigation lay beyond the scope of our present study. To analyze structural properties and control flow patterns, we used three metrics commonly applied in the literature to measure the complexity and comprehensibility of process models.Our analysis is centred on comprehending the structure and state space using the potential states and transitions of each tar production method. This direction was chosen because grasping the inherent comprehensibility of a process holds significant relevance for studying the process's invention, discovery, or execution. Similar approaches implement modeling and identification of common control flow patterns to evaluate the comprehensibility and cognitive complexity of process modelsDensity metric. The density metric measures the degree of connection between events (transitions) and conditions/resources (places) in the process42. It can be used as a proxy for how much information a maker has to access when several actions can be executed at the same time or when several conditions are needed to execute a given action in the process. The density metric in a workflow net calculates the ratio of existing arcs to the maximum number of possible arcs. The maximum number or arcs is calculated by multiplying the total number of places and transitions and then multiplying the result by two. A high ratio of existing arcs means that conditions/resources and actions are more interconnected, and therefore the amount of information required to change states of the process is higher. For instance, in Fig. Extended Cyclomatic metric. The extended cyclomatic metric measures the number of possible paths through which the final product can be obtained given the structure of the modeled system43. This metric is an extension of the cyclomatic metric51 which has previously been validated to measure cognitive complexity of human individuals52 We use it as a proxy for the likelihood of errors and reassessments throughout the process. The extended cyclomatic metric is calculated using the reachability graph of a Petri net model. This graph identifies all the possible moments (reachable states) at which a production system can be observed before obtaining the product17. In the reachability graph, reachable states can be represented as ovals (vertices), and the events that change the system’s states are represented as arrows (edges) connecting the ovals. The number of strongly connected components of each reachability graph is considered in the calculation. These components are subsets of reachable states of the reachability graph, where each state can be reached from any other state in the component. The minimal strongly connected component is represented by a single reachable state. The extended cyclomatic metric is calculated by subtracting the total number of vertices (reachable states) from the total number of directed edges and adding the number of strongly connected components to the result43. Practically, this means that low values in the extended cyclomatic metric imply fewer possible paths to reach the product, and lower chances of producing errors. High values mean that several different paths exist which translates to more possible errors during the process which may generate higher system complexity. In Fig. Structuredness metric. The structuredness metric measures the effort required to understand the information behind the process43 by deconstructing the Petri net models into components similar to programming constructs such as sequences, selections, and iterations53. These constructs are given a weight based on their structural complexity, which is a reported factor that reduces the comprehension of conceptual models54. In Petri nets, these constructs are sets of places, transitions, and arcs. Constructs with a smaller number of elements allow the information about the process to be transmitted easier and more accurately. This makes it easier to store information about components for future use, meaning the process is easier to learn. The algorithm to calculate the metric searches for seven types of components: (1) sequence, (2) choice, (3) while, (4) marked graph, (5) state machine, (6) well-structured, and (7) unstructured53. The metric is calculated using a function that weighs each component following the order above. First, the algorithm searches for sequences; the less complex components which receive the lowest weight, and it finishes with unstructured components, which receive the highest weight. Next, a weight is calculated for the identified component which is folded into a single transition. Then, the algorithm continues to search, weight, and fold components in the Petri net using the same priority function. This procedure continues until only a single transition remains, which is connected to both an input place and an output place. The weight of the last transition represents all the weights of the identified components. The metric gives higher weights to components containing embedded components, based on the assumption that components made of other nested components are more complicated and therefore harder to understand. A low metric score means a process has low complexity because the amount of information embedded in its structure is small. A high value indicates that the amount of information is large and it will require more effort to understand the structure of the process. For instance, when we use the algorithm to calculate the structuredness metric of the Petri net in Fig. diff function, which measures how evenly split and merge points are matched within the component. A higher diff value indicates unevenness in a workflow net. The marked graph in Fig. diff value of one, making the structuredness metric value equal to eight. Please refer to Lassen and van der Aalst43 for further details on the weight functions and algorithm.ponents:  sequenceponents:  sequencecondensation and pit roll methods have fewer conditions (places), events (transitions) and relations (arcs) than the raised structure method. The condensation model has the smallest number for all elements , followed by the condensation , and finally the raised structure . The differences in the mean number of events between the three models remain statistically significant even when considering a 99% confidence interval , followed by the pit roll model , and then the raised structure model . When compared with the condensation model, this value results from a larger number of conditions to be fulfilled without a strong increment in the arc density. The pit roll model included only two more arcs and two more places than the condensation model. Three transitions and three places are connected each with more than two arcs . There are four places and three transitions in the Petri net connected with more than two arcs with other elements , followed by the pit roll model , and then the raised structure model , and the low number of reachable states are explained by the number of transitions that can be executed concurrently and the small number of sequential actions. Thirty eight percent (N=5) of the total reachable states occur during the preparations before the use of fire. The only two transitions (‘Tear bark’ and ‘Place rock’) that may occur concurrently at any given marking are part of the preparations. The potential for concurrent actions in the condensation model is the lowest of the three models. The largest strongly connected components in the condensation model has four reachable states representing 30% of the total. This is the highest percentage for any strongly connected component in the three models. The largest strongly connected component in the condensation model occurs after the transition ‘Light bark’ . Compared with the condensation model, the reachability graph of the pit roll model has almost double the number of reachable states, and twice the number of edges and strongly connected components  occurs as a self-loop during the use of fire.The c value=3. Comparents Fig. b. The maraised structure model scored the highest for the extended cyclomatic metric . The raised structure model is the longest of the three models and also shows the largest number of sequences  are repeated as self-loops, separated by sequences of actions during the use of fire.The ces Fig. . This moces Fig. c. The lacondensation model scored the lowest in the structuredness metric , followed by the pit roll , and then the raised structure  and the pit roll model the lowest (N = 3).The  value = 8, follow value = 02, and tThe while components appear in the second tier of the deconstructed nets, embedded within the state machine components. Each model contained one while component.condensation model is the smallest, collapsing four places and four transitions. The marked graph of the pit roll model collapses eight places and seven transitions, and has one embedded sequence. The raised structure model has a marked graph that collapses nine places and has two embedded sequences.The marked graph components were found with different sizes in the second tier of the deconstructed nets. The marked graphs relate to the preparations before the use of fire. The marked graph of the condensation model had a total of four places, three composite transitions, and two transitions. The pit roll model showed four places, one composite transition, and three transitions. Finally, the raised structure model showed five places, four composite transitions, and three transitions.The top tier of the hierarchical structure of the decomposed nets is a state machine component. The sequences, whiles and marked graphs are embedded in this tier. The top tier shows different sizes for each model with composite transitions representing the embedded sequences, whiles, and marked graphs described above. At the top tier of the folded net Table condensation method primarily requires a mechanism to process information at the same time. The complexity metrics also show that the raised structure method relies on cognitive functions that combine the use of different cognitive processes, such as information processing, planning, and learning. The simulations showed longer sequences of events for the raised structure and the condensation model, indicating a higher expected behavioral complexity in real-world scenarios. However, it is also worth noting that as expertise of the maker is developed over time, it may reduce the length of the observable behavior duration during product production55.The experiments, the Petri net models, and the metrics show that the condensation method imposes the most interconnection between elements of the process of all three methods . This is observed in similarities regarding the amount of information and the number of conditions needed to execute each of the three methods. The capacity of working memory for contemporary humans is estimated at around four items65, but recent studies show that working memory usage maintains two to three features simultaneously66. In the condensation method, the peak of conditions that need to be dealt with at the same time has three components: the positioning of the bark against the rock, the condition of the ignited bark, and the initiation of condensation. The attention required to monitor these three conditions creates the relations between resources and activities that gives the condensation method its high-density metric value. Moreover, a maximum of two concurrent activities in the condensation method, and three activities in the pit roll and raised structure methods need to be taking into account at the same time to avoid repetition. This is also required for components of composite tools that are produced asynchronously67. These results suggest the need for systematic testing of cognitive requirements and the differences in how Neanderthals and early modern humans developed their technologies. The method presented here, which involves analyzing three different aspects of a production process, facilitates such comparisons for future studies.Recent studies show evidence of production processes by Neanderthals like plant cookingraised structure without giving enough time to reach high temperatures increases the possibility of not obtaining tar, even if all the steps in the process are executed. Therefore, self-control is required in tar production. This type of self-control in the production of material culture is argued to date back to the Early Stone Age and is a prerequisite for any tool-making and extended problem solution distance behaviors68. For example, in stone-tool making69 and specifically in the production of symmetrical Acheulean handaxes70 self-control is required to invest time to acquire the required stone knapping skills. The modeling approach and the metrics presented here can be helpful to test such hypotheses in the future.The three production processes all contain choices that require inhibitory control. To ensure that the process will produce tar when its execution terminates, makers are required to control their need of obtaining tar. All the models ensure termination of the production processes and the cyclomatic metric evaluates every possible combination of actions in modeled production processes. However, in real world situations, we cannot ensure that a production process will yield the desired product if it terminates because not all events will occur successfully every time. Interference, random events, or urgency in obtaining the product may prevent makers from fetching tar, even if all steps in the process are executed. For example, opening the dome of the 72 73, processes with low understandability , such as the raised structure, are likely to emerge later in the development of a technology. Conversely, processes with high understandability are likely to be more prevalent during the emergence of a technology. In this light, the condensation method could have been discovered first15. It relies on materials directly available in the environment and the process of tar formation can be directly observed in an open fire. This technique may even qualify as a latent solution75; presented under the right circumstances to an individual and not requiring teaching. For Neanderthal tar making via condensation, these circumstances must have included the ability to synchronize information from distinct parts of the process, access to birch bark, a suitable rock, a tool for scraping, and fire. The other production methods have more embedded information, making them more difficult to learn. They are, therefore, unlikely to be latent solutions. It is more likely that, if used, the technological know-how of the pit roll and raised structure techniques were transmitted culturally76. These two production methods also rely on a greater planning depth and inhibition ability, and the integration of these with other cognitive processes.If the information required to produce a technology is acquired cumulatively78. The results are by no means a complete representation of the complexity of the Neanderthal technological world; this would require modeling of the production of bone, wood, and stone tools, as well as other technologies like fire84. Moreover, for a comprehensive model of early technological complexity and its relation with cognitive evolution, comparisons require the inclusion of early modern human ancient technology.Our study and method are not without limitations. Here we studied a single technology using three possible production methods.In reality, Neanderthals may have used more or different methods85. Instead, our approach centered on assessing the structure and state space within each tar production process. This method, based on the examination of possible states and transitions, was the most dependable proxy for our analysis.In addition, with Petri nets we model a reconstructed version of the past; missing details in this reconstruction may influence measured outcomes. We were unable to incorporate additional factors of cognitive complexity, such as task complexity, understood as the minimum required problem-solving knowledge for a given task, and behavior complexity, referring to the observed behaviors employed to accomplish a taskThe metrics used are designed for modern human processes and their relevance to ancient cognition may be questioned. In this study we work from the assumption that both Neanderthals and modern humans share similar evolutionary traits, and we therefore considered the metrics suitable. Basic metrics, such as counts of places, arcs, and transitions, can be influenced by the modeling language and process length. Also, composite complexity metrics such as the ones presented in our study, encounter difficulties when dealing with highly unstructured process models, a prevalent occurrence in ancient contexts. To reduce the impact of these biases, we employed multiple metrics in our analysis of the aceramic tar production process formalizations. We believe this methodological approach reduces any possible bias in the systematic analysis of technological production using process modeling within archaeology.17, language development in the production process, or the effects of resource availability in the process complexity. Other classes of Petri nets such as place/transitions nets are more adequate to explore these problems17.In future works, all known production methods of multiple technologies from ancient technological systems should be compared to illuminate the trends in technological and cognitive solutions available in the past. For some technological processes, like lithic where refits exist, much data may be present, whereas for others, like basketwork, there is heavy reliance on experimental archaeology. In addition, some of the tar production techniques are scalable and we did not model for that here. The models and metrics have limitations to study the role of division of tasks, cooperation45 is a valuable source to facilitate such comparison, particularly when it comes to understanding the cognitive complexity inherent in actual usage through the application of the Petri net formalism.Our focus was directed towards discerning the differences between methods based on possible states and transitions, rather than emphasizing actual usage by human participants. Testing the use of cognitive resources in real life scenarios could be approximated for the middle Paleolithic with a large experimental setting. However, that is outside of the scope of this study. Future research may use task sequential data from empirical scenarios involving participants with varying degrees of expertise in tar production. These records may be compared with the results for the top-down models presented in this study. The AMME toolkit87. Evidence from various Neanderthal technologies and other behaviors such as deep cave activity88, cave painting89, use of jewelry and body painting90, and deliberate burial91 have identified over the last decades. In our study, we have demonstrated the possibility of approximating the cognitive requirements of these technologies and behaviors. The use of Petri nets and their derived measures is particularly valuable, as they allow for comparisons of complexity across different materials and technologies. Furthermore, Petri nets hold promise as a tool for investigating older technologies, where making inferences is more challenging compared to the Middle Paleolithic period. This approach can shed light on the cognitive abilities of our earliest tool-making ancestors.There is an increasing argument that Neanderthals possessed technological and cognitive capabilities comparable with modern humanscondensation method requires more simultaneous processing of information than the other two methods. However, the two other methods are more demanding in terms of knowledge density, and require cultural learning, self-control, and planning. The Petri net approach to measure complexity presented here has proven to be useful for the systematic analysis and comparison of ancient technologies and their production systems. Independent of which proposed tar production methods were used in the past, the Petri net models and complexity metrics suggest that Neanderthals probably relied on several cognitive traits that archaeologists often associate with modern behavior. Our multi-angled approach to the embedded information in technological processes does justice to the different and idiosyncratic forms of technological complexity and cognitive traits hominins may have had. Future studies can extend this implementation to other technological processes to improve our understanding of human and technological evolution.The method presented here links process complexity of ancient technologies to cognitive processes. At face value the Supplementary Information 1.Supplementary Information 2.