Tobacco control in Finland

Although the GNP in Finland recovered after World War II, public health in the 1960s was quite bad in comparison with other industrialized countries. Finland was faced with an exceptionally stormy epidemic of cardiovascular diseases and high rates of lung cancer, particularly among males. Faced with this grave problem, a number of preventive measures and policies were started, developed and pursued.

When the situation was examined in the early 1970s, it was obvious that smoking was a major factor causing poor health among Finnish men, contributing much to both cardiovascular and cancer rates. Smoking had, for long, been common among Finnish men: Of the male generation at the time of World War II, about 75 % smoked in the mid-1940s (1). There was some decline already in the 1960s but in the early 1970s more than half of Finnish males smoked.

Some of the early measures to combat smoking involved informing people about the health hazards, training of health personnel and early attempts to involve legislation. In 1972 a new Primary Health Care Act was passed which put emphasis on primary health care and prevention, and put in place the infrastructure which is necessary for systematic common based disease control programmes. In the same year the North Karelia Project was initiated to act as a national pilot and demonstration project intended to reduce the high rates of cardiovascular morbidity and mortality. Smoking was one of the three main target risk factors of the project (2).

The aim of this paper is to describe the main elements of the Finnish national antismoking efforts during the last three decades. We emphasise the value of gradual implementation of legislation and the major health promotion activities.

MAIN ELEMENTS OF THE FINNISH TOBACCO CONTROL STRATEGY

Tobacco Control: Policy and Legislation

National tobacco control in Finland has been based on a policy of decisive, long term development (3). Early efforts to pass tobacco control legislation succeeded in 1977 when the Finnish Act to reduce the harmful consequences of smoking (Tobacco Act for short) was passed. This comprehensive piece of legislation was, at that time, clearly an international pioneer (4,5). In 1994 the legislation was amended to include especially worksite tobacco policies. In 1999 Parliament further amended the legislation to encompass especially restaurant tobacco policies. A particular aim of that legislation has been occupational health protection of restaurant and bar employees. The contents of the legislations will be explained below.

In 1978 a special health education office was established with the National Board of Health. This office was active and constituted a focal point for the national tobacco control policy. In 1992 the National Board of Health ceased to exist and its tasks were moved to the Ministry of Social Affairs and Health where the work continued. The role of the Finnish Centre for Health Education and that of the NPHI was strengthened. The Ministry is concerned with the implementation and reinforcement of the legislation, with allocation of the tobacco control funds for smoking prevention and research and with tobacco price policy. Several agencies residing in the Ministry contribute to implement the policy and monitor the development.

The main points of the 1977 Tobacco Act were:

- 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

- A sum corresponding to 0,5 % of estimated tobacco tax revenue shall be put aside in the state budget for tobacco control activities.

The main points of the 1994 amendment included the following measures:

- Prohibition of smoking at all (indoor) work sites, except office rooms with only one person working or in a designated smoking room (with special ventilation)

- Prohibition of sale of tobacco to persons under 18 years

- Prohibition of sale of smokeless tobacco

- Prohibition of all forms of sale promotion of tobacco

- Prohibition of smoking in schoolyards.

The main points of the 1999 amendment included the following:

- Gradual introduction of smokefree areas in bars and restaurants so that by 2003 at least 50 % of the area must be completely free of environmental tobacco smoke.

- Prohibition of smoking at bar service counters.

Finland joined the EU in 1995. The directive concerning the manufacture, presentation and sale of tobacco products (2001/37/EC) is an example of an important step regarding tobacco policies on the EU level.

Health Services

Tobacco control measures have been gradually undertaken in various sectors of the health services. The primary health care (health centres) and occupational health care, general practitioners and public health nurses have been central. Guidelines published by health authorities and many forms of training have supported this activity. The Finnish Medical Association and organizations of other health professionals have been active to curb tobacco usage for many years. In 2002 national consensus guidelines for smoking cessation services were issued (6).

Health Promotion and Smoking Cessation Programmes

A great number of health education activities have taken place to reduce smoking. Leadership, co-ordination and funding of organized action was provided by the office for health education at the central health authority, The National Board of Health, and a network of local focal politics was organized in the 1970s. Major programmes have been carried out by many NGOs (non-government organisations) particularly and especially by the Cancer Society, Finnish Heart Association, Finnish Lung Disease Association and Folkhälsan. In addition to health services, several NGOs have carried out various smoking cessation programmes. These activities have largely relied on funds made available through legislation, according to which a sum corresponding to a certain percentage of tobacco tax revenues must be put aside by the state for tobacco control activities.

The North Karelia Project carried out in collaboration with the national TV channel 2 a number of major national smoking cessation TV programmes in 1977-1989. (7). Inspired by these programmes major national smoking cessation contests have been organized since 1986. These Quit & Win campaigns developed later on to the International Quit & Win campaigns coordinated by the National Public Health Institute (KTL) in Finland, in collaboration with the World Health Organization (8).

In 1993 a major national collaborative campaign Smokefree Finland was launched as a long-term antismoking effort involving a great number of voluntary organizations. This campaign which lasted for several years was coordinated by the Finnish Centre for Health Promotion. It consisted of major national media activities and active work of field groups in a great number of localities.

Several NGOs have also been active in promoting smokefree environments in worksites, restaurants and hotels, other public facilities and homes.

The North Karelia Project was started in 1972, as explained earlier, to stand out as a major national demonstration programme intended to reduce cardiovascular diseases. Initially, the project involved only North Karelia and spanned the period 1972-1977 (2). Thereafter the preventive work in North Karelia was continued, with many new innovative methods tested, but the project after 1977 has actively and in many ways contributed to the national development, much also for tobacco control.

Citizens' Action and Litigation

The voluntary organizations already mentioned (The Finnish Heart Association, Lung Disease Association, Cancer Society and Folkhälsan) have been forerunners in organized civic and pressure group action.

Later, in 1989 ASH (Action for Smoking and Health) in Finland was founded following international examples to fight the economic, political, legal and other issues supporting tobacco use. The Finnish ASH has carefully followed the work of the tobacco industry and made public many of the industry activities to undermine tobacco control. Litigation was started and some court cases have drawn much publicity. In 2002 a report was published on tobacco industry tactics concerning Finland (9). It showed how the international tobacco industry has seen Finland as a dangerous example of success of a tobacco control policy.

Research

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

School and Youth

Schools have been actively involved in the efforts to control tobacco consumption. The tobacco legislation in 1977 prohibited smoking in schools. Tobacco and health issues were taken up as subjects in the curriculum. Special smoking prevention studies and demonstration programmes were carried out in connection with the North Karelia Project. National Healthy School and SMOKEFREE Class programmes were started. This work was a background when the European Commission started to support KTL as a coordinating centre for the European Network on Young People and Tobacco (ENYPAT). This network launched the SMOKEFREE class programme on the European level. An important tool for approaching young people's behaviour is a repetitive school health survey, which provides direct feedback to the schools involved.

A governmental plan on smoking prevention among youth was developed in 1996, renewed later and many of the recommendations have been implemented. In 2001 a law was passed that made health knowledge a compulsory subject of its own for school children on the 7th grade.

Monitoring

A comprehensive national information system is in place in Finland to monitor smoking, its determinants and consequences. The national health behaviour monitor is the major system to monitor smoking and its determinants among adults, as described below. Other systems monitor smoking among children and adolescents. Statistics Finland follows the tobacco sales trends. To monitor smoking related diseases, the National Cancer Registry and the national Hospital Discharge Registry provide valuable information - in addition to mortality statistics.

Since 1978 the National Public Health Institute (KTL) has carried out a national adult health behaviour monitoring system. Annually a random sample of some 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, preventive health practices and on some background variables. In addition to actual health behaviour, there are questions related to determinants and change process and to health promotion campaigns. Since smoking is a major target area, there are a number of questions on how to deal with smoking.

A systematic series of nation-wide biannual surveys of health habits of young people (aged 12 to 18) has provided valuable tools for monitoring levels and trends of smoking over time and in cohorts of young people (10).

Trends Related To Smoking

Figure 1 shows how the long term trends of smoking rates (men and women) and tobacco consumption has greatly declined among the male population in Finland, while a slight increase took place until late 80s, thereafter levelling off, among women. The details of the tobacco-consumption related trends is discussed in another article (11). A dramatic reduction in CVD mortality among both genders and cancer mortality in men has taken place in association with the great reduction in male smoking and levels of diet related risk factors (12). These changes have led to a great improvement in public health in Finland.

The latest report of the Adult Health Behaviour Monitoring concerns the year 2002 (13). In 2002 approximately 27 % of men and 18 % of women were daily smokers. During the years of observation some 80 % of smokers have been concerned about the consequences of smoking to their health. At the same time some 60 % of both male and female smokers have indicated that they would like to stop smoking. The proportion of daily smokers who had tried to stop smoking during the past year has gradually increased and is close to 40 % (in 2002 approximately 33 % among men and 44 % among women).

In 2002 some 25 % of the smokers reported that they had received advice from a physician to stop smoking during the preceding year. This proportion has remained stable since 1978-1980 among the male smokers but increased from 19 % to 25 % among the female smokers.

The surveys have shown that the population has generally been well aware of the tobacco control measures. For example, in the 1995 national health behavior survey 97 % of the respondents indicated that they were aware of the new law (passed in the previous year). Currently some 94 % of people working outside of home say that they are satisfied with the smoking arrangements at their work site. The corresponding proportion is nearly the same among smokers. Surveys have also shown that the legislation for smokefree restaurant areas is widely supported, both by non-smokers and by smokers.

After 1995 about half of the respondents reported that changes in smoking policy had been made at their work places as a result of the new legislation. Currently about 33 % of the respondents reported that they work in completely smokefree work sites. About 54 % report that they work in a place where smoking is permitted only in special designated smoking facilities. Some 6 % indicate that smoking is permitted also in individual offices (with a single employee), and approximately 7 % indicate that smoking is allowed also elsewhere. Although the legislation does not concern private homes, smoking in homes has declined - currently nobody smokes at home in 74 % of the households.

DISCUSSION

The proportion of smokers in Finland is presumably among the lowest compared with other European countries and actual tobacco consumption (including smokefree tobacco) is the lowest in Finland. In 2002 approximately 27 % of men and 18 % of women, aged 15-64 years, were daily smokers; these rates are considerably lower among older people. Among men the smoking rates in the European Union countries vary from more than 40 % in Greece, Germany and Spain to less than 20 % in Finland and Sweden where, however, there is in addition a high consumption of rate of smokeless tobacco. Among women, Portugal has had a clearly lower smoking rate (below 10 %) than Finland, while Austria, Italy, Sweden and Finland all have about the same rate and in other EU countries the rates among females are higher (14). The development in Finland has been particularly favourable among men: from the early 1960s the percentage of regular smokers has dropped from 60 % to below 30 %. At the same time the proportion of female smokers has increased, but this increase - which mainly concerns women with a low level of education - has levelled off to below 20 % many years ago.

Finnish teenagers still do not stand well in the European comparisons: the prevalence rates of smoking among 15-16 year old boys and girls are relatively high (15). However, since smoking in Finland in the age group 20 to 24 years, when at least 90 % of smokers have already started (16), stands among the lowest in Europe, the main problem seems to be that smoking is initiated exceptionally early. Recent public discussion has highlighted some possible reasons and needed actions.

There have been two major steps in developing the tobacco control legislation in Finland: the original comprehensive law in 1977 and the amendments in 1994 and in 1999. The legislative actions have been preceded by much public discussion. This discussion has probably acted as a stimulus for smoking cessation and tobacco control.

A key issue in the law amendments in 1994 and in 1999 was the restriction of smoking at work sites and restaurants to ensure and promote smokefree environments. The new regulations, although heavily debated, were accepted by the vast majority of Finns, including the majority of smokers. Data and experience show that the national worksite and restaurant tobacco policies have been feasible, well accepted and well implemented.

About one third of ever-smokers have quitted smoking. In the oldest age groups this proportion 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 widespread desire to stop the habit. A great number of smoking cessation activities have also taken place, including large TV smoking cessation programmes, visible Quit & Win campaigns and also emphasis on pharmacological therapies (nicotine replacement).

Overall, the Finnish experience described in this review has been and is a remarkable process emerging from new medical knowledge and subsequently being transformed into comprehensive action and public policy. The process has met with major success, especially among adults, and with greatly reduced smoking rates among men. The rates of death due to tobacco related chronic diseases have fallen dramatically and tens of thousands of lives have been saved (12).

In spite of the good results achieved to control tobacco consumption in Finland, many challenges lie ahead. The generally positive atmosphere towards non-smoking and a generally supportive public opinion favouring tobacco control measures is deeply rooted. Finland has also been quite active in pursuing international collaboration with tobacco control research and programmes. This has certainly contributed to the national development. At this point the consumption of tobacco in Finland, including smoking and the use of smokeless tobacco, is obviously the lowest in Europe.

An important international aspect and cause for concern is that in the neighbouring states (Russia and the Baltic states) smoking is very common, and that the Western tobacco industry is targeting those populations heavily. Surveys show that the prevalence of smoking among men in Russian Karelia is about 65 % and in Estonia around 50 % (17). Thus, a change in the situation behind the borders lies also in interest of Finland.

Future development is, indeed, increasingly dependent on international development. With continuously increasing international influences and the Finnish membership in the European Union, the evolution in Finland will be even more linked with the general development in Europe and globally. This is why Finland wants to contribute actively to a positive tobacco control development within the Union.

At the same time Finland is strongly supporting global development, based on successful and wide implementation of the WHO Framework Convention on Tobacco Control. Successful tobacco control is in increasingly dependent on favourable international development in each individual country as a consequence of increasing, strong global influences. The 12th World Conference on Tobacco or Health in Helsinki, Finland in August 2003 is a major forum to assess and to foster this development.