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Chapter one

Anti-smoking policy in Finland

Pekka Puska M.D., Ph.D.

Heikki J. Korhonen, M.D.

Antti Uutela, Ph.D.

Satu Helakorpi, MLT[4]

Tapani Piha M.D.[5]

his paper describes the main elements of the national anti-smoking efforts in Finland during the past 20 years with emphasis on the most recent changes in legislation and some other recent activities. This article also describes the national system to monitor the trends in smoking and its determinants. Trends are prevailed since 1978, showing gradual reduction among men and a levelling off among women. In 1993-1996 some 27% of men and 18% of women were daily smokers in the age group 15-64 years, this level being among the lowest in Europe. Experience with the latest legislation restricting smoking at work sites is presented: 36% of Finns report to work at completely smokefree work sites and 45% at work sites where smoking is restricted to special smoking facilities. The Finnish experience is discussed and some future challenges brought up.

As the massive health hazards of smoking became convincingly demonstrated in the 1950's, attempts to reduce smoking started in many countries. The US Surgeon General's reports were international landmarks in these efforts. Today smoking is regarded as the most important single factor harming people's health. It is estimated that smoking is annually responsible for some three million deaths in the world, and the number is rapidly increasing (1).

At the beginning of the 1970's Finland was faced with exceptionally great epidemic of cardiovascular diseases (2). This concerned especially men. Also the cancer rates among men, lung cancer rates in particular, were high. Faced with this great problem, a number of preventive measures and policies were started and been developed and pursued ever since.

When examining the situation in the early 1970's, it was obvious that smoking would be a major factor behind the very bad health situation in Finnish men, contributing both to cardiovascular and to cancer rates. The available information indicated that more than half of men smoked. There had been a major decline in male smoking already in the 1960's. Of the male generation attending the World War II about 75% smoked in the mid 1940's (3).

Some of the early measures to combat smoking involved information to people about the health hazards, respective training of health personnel and early attempts to involve legislation. In 1972 the North Karelia Project was started in that eastern province of Finland to carry out an intensive national pilot and demonstration project to reduce the high cardiovascular rates. Smoking was one of the three main target risk factors of the project (4). In the same year also a new public health law was passed which put emphasis on primary health care and prevention.

The aim of this article is to describe briefly the main elements of the Finnish national anti-smoking efforts during the last 20 years, with emphasis on the most recent changes in legislation and some other recent activities. The article also describes the main national system to monitor smoking and some of its determinants in Finland, and presents the most recent smoking trends.

Research

Finnish researchers have been actively involved in research on smoking and health. The research has concerned health consequences of smoking, anti-smoking programmes and strategies, prevention of onset of smoking, smoking cessation methods, trends of smoking and its determinants, economic consequences of smoking etc. Different disciplines have been involved: clinical and biomedical, epidemiological, behavioural & social, economical, nursing etc. All this has greatly contributed to the basic credibility of the anti-smoking work in the country.

Health services

Anti-smoking measures have gradually been undertaken in various sectors of the health services. Primary health care (health centres) and occupational health care; general practitioners and public health nurses have been in most central position. This activity has been supported by various guidelines of health authorities and many forms of training. The Finnish Medical Association has been active in anti-smoking for many years.

Legislation and policy

Efforts to pass anti-smoking legislation succeeded in 1977 when the Finnish "Act to reduce the harmful consequences of smoking" was passed (5). Efforts to further improve and strengthen the legislation succeeded in 1994, when the Finnish parliament passed a number of amendments. The contents of the legislation will be explained later.

In 1978 a special health education office was established at the National Board of Health. This office was active and focal point for national anti-smoking policy. In 1992 the activities of the office were moved to the Ministry of Social Affairs and Health where the work continued. The unit has been concerned with the implementation and reinforcement of the legislation, with allocation the anti-smoking funds for the tobacco prevention and research, and with tobacco price policy.

In 1991 the Finnish parliament, contrary to the proposal of the government, decided that the new strict product liability law would apply also to tobacco products. Particularly after the altered legislation a lot of grass root citizens' activities have taken place to promote smoke-free environments. The Finnish Centre for Health Promotion has employed a lawyer who has given legal advice to a great number of people and organizations that have actively contacted him. At least partly related to these pressures Finnair declared a plan to become completely smoke-free.

Health education and campaigns

During the last 20 years a great number media based health education activities have taken place to reduce smoking. They have been carried out by many organizations, particularly by voluntary health organizations (especially Cancer Society of Finland, Finnish Heart Association, Finnish Lung Disease Association and Folkhälsan). Both the primary health care services and the voluntary organizations have carried out smoking cessation activities. The systematic work was initiated by the ETRA organization already in the 1960's with the Five Day Plan activity (6). All of these activities have to great extent been financed by the tobacco tax revenue money (see later).

The North Karelia Project carried out in collaboration with the national TV 2 a number a major national smoking cessation programmes in 1977, 1978, 1982, 1984, 1986, and 1989 (series with about seven sessions, appr. 30 min. each). In the last one also the Estonian TV was involved (7). Partly in connection with these programmes, four major national Quit & Win smoking cessation campaigns have been carried out: in 1986, in 1989, in 1994, and in 1996 (7,8). The last two were part of the large European Quit & Win campaign organized in the framework of WHO/CINDI and co-ordinated by the National Public Health Institute in Finland.

In 1993 a major national collaborative campaign "Smokefree Finland" was launched as a long-term anti-smoking effort of a great number of voluntary organizations. This campaign is co-ordinated by the Finnish Centre for Health Promotion. It consists of major national media activities and active work of "field groups" in great number of localities. A recent component is promotion of smokefree work sites and "smokefree municipalities". Several large voluntary health organizations started a supplementary campaign called "Smokefree Network" to strengthen the local cooperation in the municipalities.

Schools and youth

Schools have been actively involved in the anti-smoking work. Tobacco legislation in 1977 prohibited smoking at schools. Tobacco and health issues were handled in the curriculum. Special smoking prevention studies and demonstration programmes were carried out especially in connection with the North Karelia Project (8,9). A national Healthy School program was started in 1989 partly related to the experiences in North Karelia.

A special surveillance study (on health related habits of youth, aged 12 to 18) has been carried out every two years since 1977. It has given valuable information and feed-back on the smoking trends among children and youth (10).

The North Karelia Project

The North Karelia Project was started in 1972, as explained earlier, to carry out a major national demonstration programme to reduce cardiovascular diseases. The initial project period concerned 1972--1977 when only North Karelia was targeted (4). Thereafter, the work in North Karelia has continued, and many new innovative methods has been tested, but at the same time the project has actively and in many ways contributed to the national development.

The evaluation of the project has used carefully standardized surveys of large random population samples in North Karelia and in other areas of Finland. Actually the surveys, initially designed to evaluate the North Karelia Project have developed to a national risk factor monitoring system.

The 20 year results of the project have been published and show marked decline in male smoking rates in North Karelia: in the age group 30-59 years from 52% in 1972 to 32% in 1992. The decline in North Karelia has been significantly greater than in other areas, and has been associated with marked reduction in cardiovascular and cancer mortality rates (11).

Citizens' action

In 1989 ASH (Action for Smoking and Health) in Finland was founded following international examples. This organization has been active to fight the economic, political, legal and other issues supporting the smoking habits. ASH has carefully followed the work of tobacco industry and made public many of the questionable activities of the industry.

Several smoking-related court cases are pending. A cancer patient is suing two Finnish tobacco companies in a case that has drawn much attention. Parallel to this a Finnish professor of anatomy is sued for wrong action, because he--after receiving a sizable sum of money--gave testimony that the causal link between smoking and cancer has not been established.

Quite a comprehensive information system exists in Finland to monitor smoking and its consequences. The main system to monitor smoking among adults will be described later. The system to monitor smoking among children and adolescents was mentioned earlier. The central statistical office (Statistics Finland) follows the tobacco sales trends. To monitor smoking related diseases, national cancer register and national hospital discharge register give valuable information--in addition to the mortality statistics.

Legislation

The main points of the 1977 anti-smoking law were as follows:

• prohibition of all forms of tobacco advertising to the consumers

• obligatory warnings to the tobacco packages

• maximum limits of harmful substances

• prohibition of smoking at schools, public vehicles and public indoor places, except in specially designed places

• sale of tobacco to persons obviously below 16 years prohibited

• 0.5% of tobacco tax money for anti-smoking research and education

• The percentage was later reduced to 0.4%, and again increased to the present level of 0.45%.

The main new points of the 1994 amendment were as follows:

• prohibition of smoking at all work sites, except in individual offices (only one person working) or in a special smoking room

• sale of tobacco to persons under 18 years prohibited

• sale of smokeless tobacco prohibited

• prohibition of all forms of sale promotion of tobacco

• smoking prohibited also in school yards

It should be pointed out that the government proposed 16 years for the age limit, but the parliament finally decided the age limit to be 18 years.

National monitoring

In 1978 the National Public Health Institute (its newly established Department of Epidemiology) started the national adult health behaviour monitoring system.

Annually (in spring time) an independent sample of appr. 5 000 persons aged 15-64 years is surveyed by mail. The questionnaire has structured questions on main areas of health behaviour, on subjective health, on use of health services and on some background variables. In addition to actual health behaviour, there are questions related to several process factors and to health education campaigns. Since smoking is a major target area there are a number of questions concern smoking: In the 1994 questionnaire altogether 23 questions dealt with smoking.

The questions have been developed and validated in several international and domestic connections. Most of the core questions are repeated in the same form annually. Some questions rotate or are applied only in a particular year, to respond to a special need (eg. evaluation of a special campaign).

The questionnaire is mailed to the subjects who return it also by mail in the given return envelope. Two reminders are used. The results are published annually in form of a basic national report. The latest trends are also widely published.

The participation rate in the national samples have generally varied between 70% - 80%.

In addition to the national sample, each year an additional sample is surveyed from North Karelia to assess the trends in this demonstration area. Also some other local additional samples have been surveyed in certain years, and older age group (65-84 years) have been included in the national sample in 1985, 1987, 1989 and 1993.

Trends

Figures 1a and 1b show the trends in daily smokers in Finland since 1978 according to age and sex. Overall, among male population smoking has declined while among women a slight increase took place until late 1980's, thereafter levelling off. Among men, smoking has decreased among younger and older age groups, but among 35-44 year old men an increase took place until late 1980's, decreasing only thereafter. Among women smoking has during the last few years slightly reduced among the younger age groups. Among the older women some increase has taken place, obviously due to cohort effect.

Figure 2 shows the present smoking situation in Finland according to age and sex. Both among men and women the highest prevalence of daily smokers is in the 35-44 years age group. After this age the proportion of people who have stopped smoking equals or exceeds that of daily smokers.

Figure 3 indicates how reduction in male smoking has concerned both higher and lower educated groups of the population. Among women little change has taken place among higher educated, but some increase--especially in the 1980's--has taken place among the lower educated women.

Throughout the period of observation some 75% of both male and female smokers considered themselves to smoke "too much". At the same time some 60 percent of both male and female smokers indicated that they would like to stop smoking. This proportion changed very little during the time of observation. Nearly 30 per cent of daily smokers indicated that they would succeed if they tried to stop smoking. From 1978-80 to 1993-95 this proportion increased among men from 25.4 percent to 30.4 percent, while among women it varied, being 28.0 percent in 1993-95.

Figure 4 shows the proportion of daily smokers who had tried to stop smoking during the past six months. This percentage was at its highest in 1978-80 (after introduction of the anti-smoking legislation). Thereafter it has varied only a little. In 1993-95 the proportion of daily smokers who had tried to quit during past 12 months was 24.6 percent among men and 31.5 percent among women.

In 1993-95 some 25 percent of male smokers and 26 percent of female smokers reported that they had received during the preceding year advise form a physician to stop smoking. This proportion had remained on the same level since 1978-80 among male smokers but increased from 19 percent to 26 percent among female smokers.

New legislation

The 1995 national health behaviour survey was implemented some 2-4 months after the previously described changes in the anti-smoking legislation had become effective (12). In the survey 97% of people indicated that they were aware of the new law. Out of non-smoking men and women 99% stated that they agree with the work site smoking restriction rules of the law; the respective proportion was among smoking men 69% and among smoking women 83%.

Altogether 43% of people (48% of men and 38% of women) reported that changes in smoking policy had been made at the work site because of the new legislation. Table 2 shows how 36% of people indicated that they work at completely smokefree work sites. Some 45% report to work at a work site where smoking is permitted only at a specially designed smoking facilities. Some 12% indicated that smoking is permitted also in individual offices (with single employee), and some 7% indicated that smoking is allowed also elsewhere (either violation of the law or special work sites, like restaurants, bars etc.)

Figure 5 shows trends in the percentage of smokers and nonsmokers who indicate that they spend at their work site daily more than one hour in environment with tobacco smoke. These proportions have slowly reduced during the period of observation, but declined more sharply after the changes in the law in 1995.

Some 83% of smokers indicated in the 1995 survey that their smoking had not been influenced by the change in the legislation. Some 12% reported reduced smoking at work site, some 3% reported having stopped smoking at work site completely and some 2% reported complete smoking cessation.

Discussion

Compared with other European countries the proportion of smokers is among the lowest in Finland. In the European Union (12 countries) 42% of men and 28% of women were regular smokers in 1994 compared with 27% and 19% in Finland, respectively (13,14). Particularly favourable has been the development among men: from the early 1960's the percentage of regular smokers has dropped from 60% to below 30%. At the same time period the proportion of female smokers has increased to somewhat below 20%. Fortunately, this increase--that has concerned only low-educated women--seems to have stopped a few years ago.

Female smoking was relatively uncommon in Finland until young women started to adopt the behaviour in the 1960's and 1970's. The gradient between age groups (where younger women smoked considerably more frequently than the older ones) has diminished from the late 1970's. In fact the proportion of young female smokers has stayed very constant, and the overall increase in female smoking from late 1970's to early 1990's is explained by an increase in middle age smokers. The phenomena strongly indicates a cohort effect. Because of the steady prevalence levels among the youngest female age groups it can be assumed that a peak in the female smoking epidemic has been already faced in Finland.

Finnish adolescents stand poorly in the European comparisons: the prevalence rates of smoking for 15-16 year old boys and girls are among the highest (15). The most obvious reason for the discrepancy, adolescents figures among the worst and adult figures among the best, is exceptionally early onset of smoking in Finland. This assumption is supported by the fact that the smoking prevalence for even the age group 20 to 24 years is among the lowest in Europe. The difference in adolescent and early adulthood is particularly clear when comparing the situation with southern Europe. It may be that the social control and family coherence is stronger in southern Europe, and prevents early adoption of smoking behaviour. The overall acceptance of smoking, however, is probably much lower in Finland, and somewhat prevents young adults to start smoking. It has been shown that about 90% of smokers in Finland start before the age of 20 (16).

There have been two main steps in the tobacco control legislation in Finland: adoption of the national law in 1977 and amendment of the law in 1994. Both legislative actions were preceded by much public discussion. In both cases the discussion most probably acted as stimulus for smoking cessation: smoking prevalence and tobacco consumption figures decreased steeply. For example the tobacco consumption per capita decreased between the years 1990 and 1994 by 15%. In spite of the lively discussion in favour and against the legislation, the new regulations have been widely accepted.

A key issue in the discussion about the amendment in 1994 was the restriction of smoking of work sites. The new regulations were, however, accepted by vast majority, including 75% of smokers. The data presented here and the general experiences show that the new strict work site tobacco policies have been feasible, well accepted and implemented.

About one third of never smokers have stopped smoking. In the oldest age groups this share is more than half. The different activities to support cessation, including legislation, have obviously been quite successful. The high cessation rates reflect the general concern among smokers about the harmful consequences of their smoking and the common wish to stop the habit. A great number of smoking cessation activities have also taken place, including large TV smoking cessation programs, visible Quit & Win campaigns and also emphasis on modern nicotine replacement therapies. Several successful trials with nicotine replacement therapy have drawn attention to the usefulness of this model to support the overall cessation (17,18).

Concerning the prevention of onset the national experience has not been so encouraging. Teenage smoking rates declined in the 1970's but thereafter there has not been any major success (19). On the other hand the adolescent smoking trends have not differed much from the adult ones. Anyway, this means that most of the decline in adult male smoking has been due to cessation while the proportion of never smokers has changed only little.

Overall, the Finnish experience described here show a remarkable process from new medical knowledge to comprehensive action and public policy. Major success can be demonstrated, especially among adults and with introduction of smokefree environments. On the other hand still every fourth adult is a daily smoker and teenage onset is still common. Thus much work is still ahead. However, at present the feeling is optimistic, because of the general positive atmosphere and generally supportive public opinion. Finland has been quite active in international collaboration with antismoking research and programs. This has certainly contributed to the positive Finnish experience. At this point the Finnish tobacco use rates are obviously the lowest in Europe. With continuously increasing international influences and with the Finnish membership in the European Union, Finnish development in the future is even more linked with the European general development. This is why Finnish health representatives in the European Union want actively to contribute to a positive development on the EU level.

An additional international aspect and concern is that in the neighbouring Russia and Baltic states smoking is very common, and Western tobacco industry is heavily targeting to their populations. According to surveys where we have participated male smoking prevalence in Russian Karelia is 65% and in Estonia 52% (19,20). Thus the unfavourable trend and situation behind these borders is also in the Finnish interest.

Figures

Figure 1a. Proportion of daily smokers in Finland among men (15-64 years).

Figure 1b. Proportion of daily smokers in Finland among women (15-64 years).

Figure 2. Smoking status in Finland in 1995.

Figure 3. Proportion of daily smokers by education (age-adjusted).

Figure 4. Proportion of daily smokers who have tried to quit during the last six months.

Figure 5. Daily exposure to cigarette smoke at work for at least one hour in 1985-1995.

References

1. Peto R, Lopez AD, Boreham J, Thun M, Heath C Jr. Mortality from smoking in developed countries 1950-2000. Oxford University Press 1994.

2. Keys A. Coronary heart disease in seven countries. Circulation 1970;suppl 1:41-42.

3. Martelin T. Development of smoking habits in Finland. Publication of the National Board of Health, Finland. Series Original Reports 1/1984, Helsinki 1984.

4. Puska P, Tuomilehto J, Salonen J et al. Evaluation of a comprehensive community programme for control of cardiovascular diseases in North Karelia, Finland 1972-1977. World Health Organization, Regional office for Europe, Copenhagen 1981.

5. Hirvonen L. Smoking cessation by the Five-Day Plan in Finland. Acta Univ Oul D 1984;123:1-180.

6. Korhonen HJ, Puska P, Lipand A, Kasmel A. Combining mass media and contest in smoking cessation. An experience from a series of national activities in Finland. Hygie 1993;1:19-22.

7. Korhonen HJ, Niemensivu H, Piha T et al. National TV smoking cessation program and contest in Finland. Prev Med 1992;21:74-87.

8. Vartiainen E. Changes in cardiovascular risk factors during a two-year intervention programme among 13- to 15-year-old children and adolescents (The North Karelia Youth Project). Publications of the University of Kuopio. Series Original Reports 4/1982. Kuopio 1982.

9. Vartiainen E, Tossavainen K, Viri L et al. Itä-Suomen Nuorisoprojekti 1984-1988. Loppuraportti (in Finnish with English summary: East Finland Youth Project 1984-1988. Final Report). Publications of the National Board of Health, Finland. Series Original Reports 2/1990. Helsinki 1991.

10. Rimpelä A, Rimpelä M, Pohjanpää K, Karvonen S, Siivola M. Nuorten suojelu tupakkatuotteilta 1977-1993 (in Finnish, Preventing youth from tobacco products. A follow-up report 1977-1993). Publications of the Ministry of Social Affairs and Health 5/1993. Helsinki 1993.

11. Puska P, Tuomilehto J, Nissinen A, Vartiainen E (eds.). The North Karelia Project. 20 year results and experiences. Helsinki University Printing House, Helsinki 1995.

12. Helakorpi S, Berg M-A, Uutela A, Puska P. Health behaviour among Finnish adult population, Spring 1995. Publications of the National Public Health Institute B14/1995. Helsinki 1995.

13. Joossens L, Naett C, Howie C, Muldoon A. Tobacco and health in the European Union: An overview. European Bureau for Action on Smoking Prevention, Brussels 1994.

14. Helakorpi S, Berg M-A, Uutela A, Puska P. Health behaviour among Finnish adult population, Spring 1994. Publications of the National Public Health Institute B8/1994. Helsinki 1994.

15. King A, Wold B, Tudor-Smith C, Havel Y. Health Behaviour in school-aged children. A WHO Cross-National Survey. WHO Regional Publications. European series. No. 69, 1996.

16. Pulkkinen L, Kallio E. Young adults and smoking. Publications of the National Board of Health. Series statistics and reviews 7/1988. Helsinki 1988.

17. Korhonen HJ, Winell K, Virtala E. Lääkäreitä vieroitettiin tupakasta nikotiinilaastarilla: neljäsosa sinnitteli vuoden tupakoimatta (in Finnish, Nicotine patch smoking cessation of physicians). Suom Lääkäril (Finnish Journal of Medicine) 1995;50:1165-1167.

18. Puska P, Korhonen HJ, Vartiainen E, Urjanheimo E-L, Gustavsson G, Westin Å. Combined use of nicotine patch and gum compared with gum alone in smoking cessation: a clinical trial in North Karelia. Tobacco Control 1995;4:231-235.

19. Rimpelä M, Pohjanpää K. Myynti kielletty alle 18-vuotiaille (in Finnish, Prohibited sale for those under 18). Report 34/1995, National Research and Development Centre for Welfare and Health. Helsinki 1995.

20. Puska P, Matilainen T, Jousilahti P et al. Cardiovascular risk factors in the Republic of Karelia, Russia, and in North Karelia, Finland. Int J Epidemiol 1993;22:1048-1055.

21. Lipand A, Kasmel A, Tasa E et al. Health behaviour among Estonian adult population, spring 1994. Publications of the National Public Health Institute B5/1995. Helsinki 1995. n

Correspondence:

Professor Pekka Puska

National Public Health Institute

Department of Epidemiology and Health Promotion

Mannerheimintie 166

FIN-00300 Helsinki, Finland

Tel. +358-0-4744 336, Fax +358-0-4744 338

E-mail: PEKKA.PUSKA@KTL.FI

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