Norway's tobacco control strategy
The Ministry of Health and Care Services launched its strategy in 2013 «A tobacco-free future. National strategy for tobacco control 2013–2016» (regjeringen.no).
The vision is a tobacco-free future – a future in which individuals and communities are no longer affected by tobacco's many harmful effects on health and where children and adults live healthier and longer lives.
Goals of tobacco strategy
1. Prevent young people from taking up smoking and snus use
- Children and young people born after the year 2000 shall not take up smoking or snus use
- Daily smoking prevalence among children and young people (ages 16-24) should be below six per cent (2011: 11 per cent)
- The sharp increase in daily snus use among children and adolescents (ages 16-24) should be halted (2011: men 25 per cent, women 11 per cent)
2. Motivate and provide assistance for snus and smoking cessation
- Daily smoking prevalence in the population (ages 16-74) should be below ten per cent (2011: 17 per cent)
- Daily prevalence of snus use in the population (ages 16-74) should not exceed eight per cent (2011: eight per cent)
3. Protecting the population and society against the harmful effects of tobacco
- No children should be exposed to second hand smoke
- Smoking prevalence among pregnant women in late pregnancy should be below four per cent (2011: seven per cent)
The correlation between tobacco use and the harmful effects on health is well documented. There is also broad knowledge of the measures that have proven effective when it comes to limiting and preventing tobacco-related damage. The broad approaches have the greatest long-term effect on tobacco consumption in a population. That is, the use of regulatory and economic policy instruments along with campaigns and initiatives in the health sector. The WHO FCTC emphasizes precisely the need for broad efforts across sectors.
Mass media campaigns, in addition to high taxes and restrictive legislation, shall prevent more people from taking up smoking and snus use. Those who currently smoke or use snus shall be offered professional cessation services.
Evaluation of Norwegian tobacco control
The Ministry of Health and Care Services invited the World Health Organization (WHO) to make an assessment of the Norwegian tobacco control efforts in 2010. WHO made several important findings, where some required swift action, while others needed a more long term strategy.
The April 2010 WHO report
«Joint National Capacity Assessment on the Implementation of Effective Tobacco Control Policies in Norway» (regjeringen.no, PDF) is part of the basis for the new Norwegian strategy that was introduced in 2013.
Tobacco control policies and measures
A comprehensive approach to tobacco control is often stressed as the most important way of reducing tobacco use.
Norwegian tobacco control policy has three main objectives: to prevent the onset of tobacco use by young people, to provide tobacco users with help and motivation to quit, and to protect third parties from exposure to tobacco smoke and tobacco use.
Norwegian tobacco control legislation is restrictive, and has been so since the tobacco Act was enacted in 1975. When the Act was introduced, it was strongly underlined that legislation was only part of the plan and that other steps such as information, education and cessation activities were vital components of a comprehensive program. The policy makers at the time believed that a lack of balance between these components would impair the effectiveness of the tobacco control program. This has remained official policy to date.
Restrictive measures – legislation and taxation
The tobacco Act contains a total ban on advertising, compulsory pictorial health warnings on packages, as well as a tobacco display ban and ban on smoking in public transportation and public indoor environments. The act also prohibits the sale of tobacco products to minors (under 18s).
Additionally, price increases and relatively high tobacco taxes are instrumental for supporting these health policies.
Norwegian tobacco control policy has a strong focus on cessation. There is a public phone Quit-line (free of charge), as well as web-based and smartphone quitting services. There are community based smoking cessation courses. GPs assist smokers who would like to quit. These measures notwithstanding, there is still a substantial need for improved cessation activities.
Mass media campaigns
A new mass media campaigning strategy was launched in 2012, with fresh money and a five year perspective. Repeated and intensive mass media campaigns are effective measures to reduce tobacco consumption, as an integrated part of an otherwise comprehensive tobacco control strategy. Also from 2003 to 2007 mass media campaigns were successful and important parts of Norway's tobacco control efforts.
A central component in the youth prevention strategy is a three-year school-based program for youth between 13 and 15 years. The basic idea is to show pupils what it means to be a free and independent person responsible for own choices. The long-term health damages caused by tobacco control are only moderately focused on.
40 years with tobacco legislation
A variety of legislative measures have been implemented during the tobacco control legislations' 40 years' history in Norway. The Norwegian Tobacco Act entered into force in 1975, requiring health warnings on tobacco packagings, a 16 year age limit and a ban on advertising of tobacco products. Today Norway is still considered a country with restrictive tobacco legislation.
EU directive implemented in Norway
The EU Directive 2001/37/EC concerning the manufacture, sale and presentation of tobacco products is implemented in national legislation, and the 2014 Directive will be integrated into the Norwegian legislation in 2016/17. Like Sweden, Norway has an exception from the EC ban on the sale of tobacco for oral use (moist snuff).
The age limit for buying tobacco is 18 years. Since 1988, there has been legal protection from exposure to tobacco smoke in workplaces, and since 2004, even a complete ban on smoking in bars and restaurants. Designated smoking rooms were banned in 2014.
To enhance the effect of the advertising ban, a ban on retail display of tobacco products was introduced in 2010. Norway's tobacco display ban was challenged in court by Philip Morris Norway, claiming it was incompatible with EEA law (freedom of trade). The case was tried in the Oslo District court in 2012, and the law was upheld by the court.
Since 2011 all cigarette packages have been required to be equipped with pictorial warnings, as well as reduced ignition propensity standards.
WHO tobacco convention
Norway was the first country to ratify the
WHO Framework Convention on Tobacco Control (who.int), which entered into force in 2005. Norway has yet to ratify the Protocol to eliminate illicit trade in tobacco products.
Norway's implementation reports are available at the FCTC website (who.int).
Milestones in Norwegian tobacco control
Norwegian tobacco control policy has developed through several decades, and the tobacco Act has been revised numerous times since its adoption in 1973.
|1965 ||The Norwegian Parliament (Storting) appoints an interdisciplinary committee to investigate what measures could be implemented to combat the health problems caused by tobacco use.|
|1967||The committee's report is submitted: «Influencing Smoking Behaviour». Among the many suggestions were a ban on tobacco advertising and compulsory health warnings on all tobacco products.|
| 1969||The government presents a White Paper to the Parliament supporting the committee's proposals.|
|1971||A governmental office for tobacco control is established; The National Council on Tobacco and Health.|
|1973 ||The Act relating to Restrictive Measures for the Marketing of Tobacco Products etc. (the Tobacco Act) is sanctioned. Monitoring of smoking prevalence is started.|
|1975||The Tobacco Act comes into force (advertising ban, 16 years age limit, labelling). Media campaign (large ads) in support of the new act.|
|1985 ||The National Council on Tobacco and Health presents the report «Clean Air for Everyone – The Right to Breathe Smokefree Air». It contains a proposal for provisions for a «clean air act».|
|1988||The Clean Air Act is adopted. It provides for smokefree air in public locations and means of transportation. However, restaurants and bars were exempted.|
|1989||Regulation banning new nicotine and tobacco products is adopted.|
|1993||Restrictions on smoking in public restaurants and other hospitality places (bars, cafes, pubs, diskoteques etc). Smoking allowed in 2/3 of the establishment.|
|1996 ||More restrictive measures in the Tobacco Act are enacted. These include a ban on smoking in open restaurants, provisions for smoke free schools, and an age limit of 18 for both sale and purchase of tobacco products. A free phone "quit-line" is established.|
|1997||Regulation is adopted which prohibits indirect advertising for tobacco products: «Regulation on prohibition of tobacco advertising, etc.»|
|1998||Further restriction on smoking in public restaurants and other hospitality places (bars, cafes, pubs, diskoteques etc). Smoking only allowed in 50% of the establishment (as opposed to the previous 2/3).|
|1999 ||A long term strategy plan for tobacco control (1999–2003) is adopted by the Ministry of Health and Social Affairs and the National Council on Tobacco and Health. A National Cancer Plan allocates funds to provide several counties with personnel devoted to promote public health.|
|2002 ||The EU Directive 2001/37/EC concerning the manufacturing, sale and presentation of tobacco products is implemented in national legislation: ban on misleading descriptors such as «light» and «mild», larger health warnings, and a legal basis for demanding disclosure of ingredients in tobacco products. The National Council on Tobacco and Health becomes a department under the new Norwegian Directorate for Health and Social Affairs.|
|2003||A bill concerning a total ban on smoking in bars, restaurants, cafes etc is passed by Parliament. The first national comprehensive mass media campaign on tobacco and health for many years is run in Norway, adapted from the Australian campaign «Every cigarette is doing you damage», followed by a campaign targeting the tobacco industry. Norway ratifies the Framework Convention on Tobacco Control (FCTC).|
|2004||A total ban on smoking in restaurants and bars takes effect 1 June. Mass media campaign on the right to a smoke free workplace.|
|2005||The Framework Convention on Tobacco Control (FCTC) enters into force.|
|2006||«National strategy for tobacco control 2006–2010» and «National strategy on COPD 2006–2011» is launched by the Ministry of Health. Large scale mass media campaign focusing on COPD.|
|2007||The Ministry of Health wins a Supreme Court case concerning the smoking ban in restaurants and bars (smoking clubs).|
|2009||Regulations on pictorial warnings on tobacco products are adopted by the Government (in effect from 1 January 2010, with a transitional period until June 2011 for cigarettes and January 2012 for other tobacco products, except for smokeless tobacco).|
|2010||A ban on the visible display of tobacco products at points of sale enters into force.|
|2011||The Ministry of Health wins a Supreme Court case concerning the smoking ban on restaurants and bars (smoking outside). Pictorial warnings are required on cigarette packages. To reduce the risks of fire, reduced ignition propensity cigarettes are required.|
|2012||New mass media efforts in January and August with focus on health risks and passive smoking respectively. The Ministry of Health wins a case in Oslo District court, after being sued by Phillip Morris Norway, claiming that the tobacco display ban violates the EEA agreement. The law is upheld by the court and the ruling is not appealed.|
|2013||Mass media campaign in January directed towards occasional smokers. Several legislation amendments enters into force, including a ban on packages smaller than 20 cigarettes, and a normative provision on children's right to a smoke-free environment.|
|2014||Several legislation amendments enters into force, including a prohibition for students to use tobacco during school hours, a ban on designated smoking rooms, smoke free entrance areas outside health care institutions and government agencies.|
Health and smoking prevalence – the situation in Norway
Thirteen per cent of people aged 16–74 smoked daily in 2015. Smoking prevalence has dropped steadily in Norway since 1998, and young people are leading the way.
Prevalence rates are published by Statistics Norway (ssb.no).
In the early 1970s, 51 per cent of men and 32 per cent of women (aged 16-74) smoked daily. In 2015 there was practically no difference between men and women.
Apparently there was a shift in smoking prevalence around 1998. Since then, smoking prevalence has decreased among both men and women. The latest figures are found at Statistics Norway.
In 2015, about 4 per cent of young people aged 16–24 reported to be daily smokers. Five per cent of young men and 3 per cent of young women smoked daily. The prevalence of young daily smokers was reduced from 23 to 4 percent in the last ten years.
Low education is the number one explanatory factor for prediction of smoking prevalence. The difference in smoking prevalence between the none- or low-educated and the well educated, elucidates the importance of considering social inequality as a health issue.
For several years, the use of smokeless tobacco has been strongly increasing in Norway. In the population aged 16 to 74, 10 per cent were daily users and 4 per cent were occasional users in 2015.
The use of smokeless tobacco is mainly a male phenomenon. Among men, 15 per cent report using smokeless tobacco daily and among women, approximately 4 per cent use smokeless tobacco daily.
In the younger population, however, the prevalence is higher. Among people aged 16–24 years, 20 per cent of the men are daily users and 13 per cent of the women.
Hence, among men aged 16–24, smokeless tobacco is four times more common than smoking. Given the sharp decline in smoking over the last years, a relation can not be ruled out. However, smoking has declined also among women, where the increase of smokeless tobacco did not show the same opposite pattern to the decrease in smoking.
Deaths related to smoking
In Norway, about 5 100 persons die each year because of tobacco related diseases (2009). Cardiovascular diseases are the greatest cause of increased mortality among smokers. More than 250 000 people in Norway suffer from chronic obstructive pulmonary disease (COPD).
25 years ago, the number of men contracting lung cancer was four times that of women. Today, only twice as many men contract lung cancer. Among those under 50 years of age, there has actually been registered more lung cancer incidents among women than among men. This tendency is closely related to the development of smoking prevalence in Norway during the last decades.
The Norwegian Institute of Public Health presents their research in smoking and the use of snus and e-cigarettes (fhi.no).