Swedish

Progress & Challenge – both are greater than ever 2006

CONTENTS The Minister’s View The Voice of NGOs is Harmful A Focus on Youth 1 June 2005 – Smoke-free Sweden Innovative Tobacco Cessation The Cost-Effective Quitline International Challenges Margaretha – Luther Terry Award Winner Meet the Swedish Network Photo: Åsa Till Swedish Beware of the Trojan horse… MORGAN JOHANSSON, SWEDEN’S MINISTER OF PUBLIC HEALTH: “The statistics on our behaviours in Sweden are looking better and better every year, and I “We will be following believe that the new is contributing to the continued decline.” Morgan Johansson, Minister of Public Health

developments closely” Photo: Pawel Flato » Public Health Goals for the year 2014 “The ban on smoking in dining and drinking establishments that went into risks of smoking are much greater,” tobacco activity in their public health effect on 1 June 2005 is probably one of our most popular reforms,” says says Mr. Johansson. “However, there programmes. Reducing tobacco use is one of the primary are also health risks with snus and it is “We will be following develop- Morgan Johansson, Sweden’s Minister of Public Health, when he summarizes goals for public health set by the Swedish » best to stop using tobacco entirely. ments closely to make sure that there Parliament. It includes the following interim the current state of tobacco prevention in Sweden. “We are also striving to bring about are no cutbacks in that regard,” says targets: a reduction in the use of snus. For that Mr. Johansson. “In addition, the state purpose, it is necessary to provide in- must also provide fairly substantial • A tobacco-free start in life, effective by He states that, after nearly one year formation in the schools and other long-term resources for the work of the year 2014. This refers, first and with the ban on smoking in cafés, settings, and to make sure that sup- prevention. We are therefore allocat- foremost, to influencing the tobacco restaurants, bars and other facilities port is available to those who want ing funds to the municipal drug coun- behaviours of pregnant women and where food and drink are served, there to quit. That is how we succeeded in cils throughout the country, for exam- parents in general, so that children can is great popular support for the new turning the smoking trend downward, ple. They work primarily with alco- grow up in a tobacco-free environment. law. That is indicated by, among other and that is how we have to work with hol- and narcotics-related issues, but • Halving, by the year 2014, the number things, the results of opinion surveys the snus problem, as well.” also with tobacco use.” of young people under age 18 who (more on that subject on p. 14-15). begin smoking or using oral smokeless During 2002–2005, Morgan Johansson believes “When my predecessor introduced the Swed- that tobacco. the idea of smoke-free pubs in 2000, ish government invested a total of 90 it is entirely possible to fulfil the sub- there was strong opposition, especial- million SEK (approx 962,000€) to goals of public health policy in the area • Halving, by the year 2014, the pro- ly from the restaurant branch and the strengthen the work of tobacco pre- of tobacco use that has been set for the portion of smokers among those who affected labour union,” notes Mr. Jo- vention. The emphasis was on increas- year 2014 (see “Public Health Goals”). currently smoke the most. Health gaps hansson. “Today, smoke-free dining ing the availability of cessation sup- “To some extent, the decline in related to social class shall be nar- and drinking facilities are regarded as port and influencing the tobacco be- smoking is a development which, I rowed. Among the unemployed and perfectly natural. There is nothing to haviours of young people. The Na- believe, is bound to continue in the poorly educated, for example, the rate indicate that the new law has resulted tional Institute of Public Health was western world,” says Mr. Johansson. of smoking is significantly higher than Morgan Johansson is pleased by the decline in smoking but wants to promote the same trend for the use of that of the general population. in problems of any kind.” oral , snus. given the task to design and imple- ”But in order to reach our objectives, ment a programme to stimulate the it is important that people can get The primary reason for the smoking that the new smoking ban is contribut- the health effects of this product in- development of tobacco prevention help to stop smoking. The work of the • No one shall be involuntarily exposed to ban was to provide service personnel ing to the continued decline,” says the dicates that the oral smokeless tobac- efforts by municipal, county and re- municipalities and county councils is environmental tobacco smoke. The ban on smoking in dining and drinking facili- with a healthier work environment. Public Health Minister. “There was a co sold in Sweden increases the risk of gional governments. very important in this regard. Anoth- ties was an important step toward the But the Public Health Minister is con- worrying increase in smoking among fatal heart disease and certain forms of Morgan Johansson believes that er important resource is the National fulfilment of this objective. But there vinced that, by influencing general at- young women a few years ago, but that cancer, among other health effects (see many useful activities have been ini- Quitline.” (see article on p. 17). are still occupations in Sweden in which titudes toward smoking, the ban has trend has now been reversed.” p. 6-7). tiated during the past three years at “We also need to work with young it is difficult to avoid . also produced other positive effects. “The low rate of smoking among both the local and regional levels, and people, so that they don’t begin to use Among those affected are homecare However, there has “The statistics on our smoking be- been an increase men in Sweden can in no doubt be stresses that it is important for munici- tobacco. The schools, and especially providers and prison personnel. haviours in Sweden are looking bet- in the use of oral smokeless tobacco, explained in part by the use of oral palities and county councils to con- school health services, have an impor- ter and better every year, and I believe snus. A recent review of research on smokeless tobacco instead; yet the tinue placing a high priority on anti- tant role to play.” Government Bill: 2002/03:35

TIMELINE IN 1957 The Swedish tobacco 1958 The Swedish Medical 1960 the state-owned tobac- 1960 The state tobacco monopoly is dissolved and replaced by the 1963 The first major survey monopoly, in effect since 1915, Research Council evaluates the co monopoly distributes a bro- Swedish Tobacco Company (“Tobaksbolaget“). Although the new compa- of smoking behaviours is conduct- SWEDISH expresses concern after the first health effects of tobacco use and chure which warned that “heavy ny was still owned by the state during its first decades of existence, the ed. The results indicate that half of TOBACCO scientific reports on the risks of warns smokers about the risk of consumption of cigarettes can change led to a more distinct commercial profile and an increase in ad- Swedish men smoke. A delegation smoking are published. cancer. contribute to the development of vertising for tobacco products. Those trends were more apparent by the of prominent scientists visit Prime CONTROL lung cancer” based on the conclu- introduction of U.S. cigarette brands in Sweden. Minister Tage Erlander to warn sion from the 1958 report. about the risks of tobacco use, In 1963 half following which, the government of Swedish men makes the first allocation for pub- were smokers. lic information on the harmful ef- 2 Swedish Tobacco Control 2006 fects of tobacco. Swedish Tobacco Control 2006 3 “It’s true that at a first glance today’s situation looks satisfactory. Smoking in Sweden continues to decline, and the smoking ban in dining and drinking establishments is being successfully implemented. Yet it would be unfortunate if such positive developments were » to give decision-makers the impression that the work of tobacco prevention is complete.” So says Dr. Göran Boëthius, pulmonary specialist and chairman of Doctors against Tobacco, one of the non-governmental organizations in the Swedish Network for Tobacco Prevention. The battle is not over

Göran Boëthius’ assessment of the to- The move will, at least in a 2-3 years’ per- a majority of county councils and their bacco situation in Sweden in the near fu- spective, result in a loss of competence in hospitals and health centres. ture differs in several respects from the the area of tobacco prevention, since few “This will prove to be an important more optimistic view of the Minister of of the Institute’s most experienced person- move, supporting many smokers’ efforts Public Health, Morgan Johansson. nel are making the move to Östersund. to get control over their smoking and “Efforts to bring about a decline in “Article 5 of the WHO Framework promote their willingness to quit. That smoking and its damaging effects in Swe- Convention on Tobacco Control (FCTC), will result also in more smoke-free role den have been successful during the past which Sweden has ratified, emphasizes the models in the community”, states Göran 10-15 years,” concedes Göran Boëthius. importance of a strategic national agen- Boëthius. “But again, it will not be done “But we cannot rest on our heels and be cy which co-ordinates the work of tobac- without continued opinion building and satisfied so long as one million people con- co prevention. Additionally, this agency is leadership at national and local levels”. tinue to smoke, a quar- to be supported with adequate and long- ter of which risk short- term funding. But the government does The national public health goals set for use snus. If we consider the total extent of A popular accusation by snus advocates difference. Medical associations should ening their lives by 20- not seem willing to meet these obligations the year 2014 are described on p. 3. nicotine dependence – that is, daily smok- is that the patient, without a snus option, speak out to the government about in- 25 years. We can do of the Convention.” says Göran Boëthius. “Those goals to further reduce tobac- ing and/or daily use of snus – Sweden rates is left with no real choice – ‘quit smok- vesting in tobacco control as well as to all better.” co use particularly among specified sub- poorly,” says Göran Boëthius. “Every third ing or die’. health professionals to be more aware of Efforts in recent years populations will be unattainable unless male and every fifth woman in Sweden are “This is what has been going on all the and skilled in handling all aspects of the to develop tobacco pre- strategic investments are made,” Göran hooked on nicotine.” time before the harm reduction debate tobacco issue. And the individual doctor “We must never forget vention programmes at Boëthius says, ”We need an action plan Göran Boëthius believes that snus was even started – we have to a very small should stop blaming a lack of time – reali- how powerful and skilled both the local and region- running until 2014 and a continued ade- and other smokeless products containing extent offered the smoking patient pro- zing that a brief intervention is the most the commercial forces al levels of government quate funding scheme to have a chance of nicotine pose a great challenge to tobac- fessional cessation support at all!” argues cost-effective measure that can be under- have produced good re- fulfilling these goals”. co prevention in Sweden. “We all want to Göran Boëthius. “In the individual medi- taken in everyday health care. I wish we are that we struggle sults, he believes. “We must never forget how powerful reduce harm – and to reduce smoking be- cal case if a truly professional support in- as a group could be better opinion-build- against. The tobacco “There exists increas- and skilled the commercial forces are that haviours is our main focus. But there are cluding the recommendation for pharma- ers in the future”. industry does not rest.” ing awareness of these is- we struggle against. The numerous reasons why smokeless tobacco ceutical therapy is not successful, then the “The bottom line is Dr. Göran Boëthius sues in the municipalities does not rest: it has adapted to the wide- can not and should not be part of the so- doctor may very well respect the patient’s that the Swedish to- and county councils, and spread current awareness of the health lution to the smoking problem (see Argu- wish to use smokeless tobacco – with a bacco control movement is challenged by One of the things that worries him at excellent initiatives have been launched. risks associated with smoking. Under the ments against snus, p. 9) long term aim to support him or her to several aspects. The most fundamental of present is that the resources allocated to But to keep this positive momentum from mask of doing public health good by pro- What the effect would be on smoking also quit that form of tobacco use”. them all is to make the government aware the National Institute of Public Health for slowing down there is a need for support moting snus as a cessa- behaviour in the European Union if the “For the sake of credibility we must as that the national public health goals for tobacco control have been cut back by at and co-ordination at the national level.” tion tool, the industry ban on snus sales would be lifted is hard to health professionals draw the conclusions 2014 and the FCTC constitute the very least 50%. In addition, the Institute is be- A slowly increasing number of munici- simultaneously targets predict. One of the basic principles in the of all the knowledge we possess about best arguments for investing considerably ing moved out of the capital to the city of palities are introducing smoke-free work- young people with an Framework Convention is that health as- the tobacco issue and take advantage of and continuously in tobacco control”, Östersund for domestic political reasons. ing hours, a policy previously adopted by ever-increasing variety pects should dominate economical aspects the great possibilities we have to make a Göran Boëthius concludes. of smokeless tobac- when conflicting interests are apparent. co and other nicotine- “Again, the Swedish government is vio- 28 per cent of Swedes are nicotine dependent containing products.” lating the Convention when it, for market- Few men replace smoking with snus » ing reasons, is recommending the Com- » According to a nationwide survey conducted by the National Institute of Public A mere five per cent of all adult men in Sweden have “The truth is that mission to lift the ban. At the same time Health, 13 per cent of adult males and 17 per cent of adult females in Sweden the quit smoking with the use of snus. If snus was not avai- the government does not spend a penny to smoked daily in 2005. The rate of smoking for all persons aged 18-84 was 15 use of snus is increas- lable, it is estimated that a maximum of 18 per cent of per cent. The highest rate was among those aged 45-64. ing in Sweden, most- investigate the longterm health effects of men would be daily smokers; in reality the prevalence Thirty-three per cent of men and 22 per cent of woman in Sweden is nicotine ly among young wom- the products that it wants to impose on the is 13 per cent. dependent – they smoke and/or use snus on a daily basis. en. In fact, more than Union... Such a position does not increase

one million Swedes Photo: Ingvor Farinotte the credibility of the government”.

4 Swedish Tobacco Control 2006 Swedish Tobacco Control 2006 5 Chances of surviving a heart attack are » Pregnant women’s use of snus for heart attacks. lower among those who use oral smokeless The use of snus is increasing among Swedish wo- The Karolinska Institute report states that snus increases blood pressure and pulse rate, but that the research findings do not per- tobacco, snus, than among those who do men, including expectant mothers and this trend is most evident in parts of northern Sweden. In mit a definite conclusion regarding the question of whether or not. That conclusion has been drawn by a 2003, snus was used by 1.4 per cent of women not snus contributes to dangerously high blood pressure in the » Karolinska Institute research group which in the early stages of pregnancy. Yet, in some long run. recently published an assessment of health counties of the Norrland region, however, Some research indicates that snus increases the risk of both the figure was significantly higher – among stroke and diabetes; but the evidence is not sufficient for any def- risks associated with use of snus. pregnant women, 9.0 per cent in Jämtland inite conclusions, according to the Karolinska group. Regarding County, 7.1 per cent in Västerbotten County, the effects in the oral cavity, the report notes that snus damages and 3.6 per cent in Västernorrland County the mucus membrane of the mouth, sometimes exposes the necks use snus during pregnancy. of teeth where the snus plug is kept, and that some research sug- gests a connection between the use of snus and loosening of the The Inequality Aspect teeth in general, especially among those who also smoke tobac- Snus is » co. The largest proportion of daily smokers among women are those that have left the workplace A crucial question is how the foetus is affected if a pregnant early, are on long-term sick leave and are unemployed. Among men, those that study, are woman uses snus. One Swedish study indicates that such use harmful unemployed and on long-term sick leaves. can result in foetal poisoning, premature birth and reduced birth The shorter the amount of time in school, weight. Other research indicates that nicotine may adversely ef- the more snus is used among men. A little over fect the development of the brain and nervous system. The assessment was based on a review of available research a quarter of men with less education were daily “There is a need for more research on the health risks of snus, on that issue. snus users compared to one in ten men with higher especially those relating to foetal development,” says Göran Pers- “For me, the most surprising result was that there is such education. hagen. “It is also a serious problem that we still have too little strong evidence regarding the harmful effects of snus on the car- knowledge to permit a quantitative assessment of the snus-related diovascular system,” says Professor Göran Pershagen, leader of risks of cancer and cardiovas- the research group. cular disease. The available knowledge on the health effects of snus were are often lower in Swedish snus products, which may explain “Sweden has an interna- analysed by researchers from the departments of environmental why the increased risk of cancer appears to be less in Sweden

Produced by KING for 2005 NSG, tional responsibility to ensure medicine (IMM) and of medical epidemiology and biostatistics than in the United States. that more research on snus are at Karolinska Institute, on a commission from the National In- The review of research in the area of cardiovascular illness carried out,” argues Professor stitute of Public Health. The resulting report, Hälsorisker med Social Marketing campaign launched by A Non Smoking Generation in 2005 to deter yielded results that were more surprising to Göran Pershagen. Pershagen. “Since the use of svenskt snus (Health Risks of Swedish Snus), was published at youth from using snus. “In that area, there is stronger evidence for certain health snus has been so widespread the end of 2005. risks than I had expected,” he says. in this country for such a long He notes that IARC, the International Agency for Research on The conclusions of the analysis were based on both epidemi- While snus does not appear to increase the risk of experienc- time, we have better oppor- Cancer based in Lyon, France, has arrived at the same conclu- ological and experimental studies. Receiving greatest attention ing a heart attack, the rate of recovery is lower among those who tunities for studying the risks sion— that snus is carcinogenic— on two previous occasions. in the media was the conclusion that Swedish snus is carcinoge- use snus than among those who do not. Thus, the use of snus ap- here than in other countries Both IARC and the Karolinska Institute group base their conclu- nic. Especially with regard to pancreatic cancer, the evidence is pears to increase the risk of dying from heart attack. where the use of snus is more sions on research conducted in Sweden and in other countries, felt to be so strong that it can be stated with certainty that snus “Animal studies indicate that nicotine can contribute to recent or limited.” increases the risk of cancer. There primarily the United States. heart rhythm disturbances and increased severity of heart at- are also research findings which “We cannot detect any fun- tacks,” notes Professor Pershagen. “This can help to explain the indicate an increased risk for other Increasing use of snus damental qualitative differences increased risk of death.” » which indicate that Swedish snus types of cancer, but the evidence is Consumption of oral smokeless tobacco is increa- An English summary of the report should be treated as a different not as strong. sing in Sweden. According to a nationwide public Cardiovascular disease is the most common cause of death will be available at the 13th World smokeless tobacco product,” says “Actually, there is nothing new health survey, 22 per cent of adult males and 4 per among both women and men in Sweden. It accounts for rough- Conference on Tobacco or Health, Göran Pershagen. in our position on cancer risks,” cent of adult females were daily users of snus in ly half of all deaths in the western world with a large propor- or electronically at www.fhi.se or says Göran Pershagen, who is pro- 2005. The highest use rates were among men and The report of the Karolinska tion due to acute coronary disease, for example unstable vascular by request: [email protected]. The full fessor of environmental medicine women aged 30-44 – the parent generation. group states, however, that levels spasms and heart attacks. Every year in Sweden, with its popu- report in English is scheduled to at IMM. of the carcinogenic nitrosamines lation of nine million, about 27,000 individuals are hospitalized be launched in October 2006.

TIMELINE IN 1970 Tobaksbolaget agreed 1971 A second delegation of 1974 The findings of the Na- 1975 Following an increase in 1977 As a result of the 1974 1979 A Non Smoking Genera- to certain advertising restric- prominent scientists visit the gov- tional Board of Health and Wel- advertising since the state mo- report of the National Board of tion, a non-governmental organi- SWEDISH tions in hopes of avoiding compul- ernment to warn about the dan- fare’s study are presented to the nopoly ended in the 1960s, the Health and Welfare, an obligato- zation is founded. TOBACCO sory legislation. One restriction gers of tobacco. The National government. It marks the begin- tobacco industry is compelled to ry warning text is included on all includes tobacco advertising in Board of Health and Welfare is ning of a new policy, based on the accept an agreement on advertis- cigarette packaging. CONTROL connection with sporting events given the task of studying possible insight that it is the responsibili- ing restrictions. Henceforth, only which never has been permitted. measures against tobacco use. ty of politicians, not surgeons, to the product may be depicted and solve the tobacco problem. the use of human images in ad- Since 1977 an obligatory warning text vertising is prohibited. is included on all cigarette packaging. 6 Swedish Tobacco Control 2006 Swedish Tobacco Control 2006 7 i “Stop comparing snus with smoking” Photo: Ingvor Farinotte Dr Gunilla Bolinder is critical of the picture spread about snus as an almost harmless product good arguments 4 against snus use The report on the health effects of snus has aroused a heated debate in the Swedish media. Critics argue that it is wrong to discuss the health risks of using snus without How would Göran Boëthius, Chair of Doctors comparing them with the even greater risks of smoking tobacco. Those that oppose this against Tobacco, summarize the arguments for » view argue that the use of snus should be compared with abstinence from all forms of curbing the use of snus in Sweden? tobacco. They also point out that approved medications are available for those who want Firstly, the recent Karolinska Institute report (see p. 6-7) rein- to quit smoking without abruptly ending their nicotine intake. forces our belief that snus use indeed has serious health effects and that much more research is needed. Advocates for a liber- al use of oral smokeless tobacco are taking a great responsibility “I am surprised that even some phy- dependency feel that the addiction has a anti-snus education campaign during the upon themselves when neglecting an increasing number of indi- sicians strongly defend the use of snus,” very negative impact on their quality of spring of 2005 to deter youth from using cations of health effects that still have to be proven or refuted. says Gunilla Bolinder, snus researcher and life. They feel trapped – that their brains snus. The social marketing campaign did chief physician of the Clinical Informa- not mention any of the harmful effects Secondly, effective measures to reduce smoking, included in tion Centre at Karolinska University Hos- that snus can have, it concentrated instead the comprehensive tobacco control strategy, have been neglect- pital. “Often, they are doctors who work on portraying snus users as unclean and ed. California recently reported lower smoking prevalence figures with the elderly or with patients suffer- unattractive. than Sweden – without the use of snus... So let’s do our home- ing from severe cancer, lung or cardiovas- “It was a new approach which, I be- work first, investing in the strategy, before taking shortcuts. cular disease. Such doctors see only that lieve, can be effective in getting young it would be better for the smokers among people to reflect on the issue,” says Gu- Thirdly, a number of “side effects” of snus promotion can be an- their patients to use snus instead; but they nilla Bolinder. “We ticipated or at least not ruled out: a repeated “light cigarette-les- ignore the broader perspective for society intend to discuss son”; an overall increased nicotine dependence in the population; as a whole.” “We intend to discuss and inform the pub- more adult snus users yielding more young users, half of which Gunilla Bolinder, who serves on the and inform the pub- lic about snus with- will become pregnant young women. Not least, the interaction Board of Doctors against Tobacco, be- lic about snus with- out comparing it between alcohol and nicotine should be remembered by every- lieves that the key issue is the picture of with smoking all one who is concerned with the generous drinking habits in the snus use which young people receive. ”If out comparing it with the time.” young generation.

the message is conveyed that snus is a Photo: Lasse Skog, Nyköpings Bildtjänst smoking all the time.” She also feels harmless product, there is a risk that even Dr. Gunilla Bolinder that it is very impor- Lastly, the Swedish snus manufacturer has made people believe more young people will fasten in the ni- tant to continue re- that snus is a prerequisite for the reduction of smoking. Avail- cotine dependence that in fact results from have been kidnapped by the drug,” says search on the health effects of snus. “The able statistics do not prove that this is the case. Most probably the use of snus.” Dr. Bolinder. new report on the current state of know- the inexpensive and widely available snus products may have in- Accordingly, she feels that using snus as a ledge is an important step, not least be- fluenced smoking behaviour in a number of men, but historical- She believes that the development of means to quit smoking is wrong. “There cause it indicates how much research re- ly not in women. Seven out of ten men have quit smoking with- dependence is a factor that is discussed are medications containing some nicotine mains to be done.” out help of any sort. And 40 per cent of today’s male snus users entirely too little in the snus debate. which can be used until new and more ef- do also smoke. “Many snus users expose their bodies to fective alternatives without nicotine are high nicotine levels for 13-15 hours per developed,” she maintains. Dr. Gunilla Bolinder will be presenting day. They feel that they cannot live with- on the topic of oral smokeless tobacco Gunilla Bolinder believes that the key issue is the picture of snus use which young people receive. Dr Göran Boëthius will present a paper entitled “Snus is not out the drug. Is that healthy? The Swedish organization A Non in a Plenary session at the 13th World “If the message is conveyed that snus is a harmless product, there is a risk that even more young the Magic Pill – a broad perspective on harm reduction” at the “Many who have developed a heavy Smoking Generation conducted a public Conference on Tobacco or Health. people will fasten in the nicotine dependence that in fact results from the use of snus.” 13th World Conference on Tobacco or Health.

TIMELINE IN 1983 Restrictions for indoor 1990 Sweden’s National To- 1990 A national enquiry on to- 1992 The National Institute of 1992 Doctors, Dentistry and 1992 The Swedish Cancer So- 1993 A new Tobacco Act re- smoking started with guidelines bacco Control Committee is es- bacco recommends a new law in- Public Health is established, with Nurses against Tobacco are ciety, the Swedish Heart and Lung places all other previous laws and SWEDISH for smoke-free environments that tablished. The committee includes cluding provisions for smoke-free responsibilities that include coor- founded. Other health profession- Foundation and the National In- consists primarily of regulations TOBACCO were developed by the National members from nongovernmental environments, prohibitions on ad- dination of national efforts to com- al groups formed thereafter in- stitute of Public Health launch a for the restriction of smoking in Board of Health and Welfare and and governmental organizations. vertising, and other measures. bat tobacco use. clude Teachers against Tobac- comprehensive counselling train- public places with the exclusion CONTROL the National Board of Occupation- co (1994), Pharmacy against To- ing program named “the Smoke- of hospitality establishments such al Safety and Health. bacco (1996) and Psychologists free pregnancy/Smoke-free chil- as restaurants and bars. against Tobacco (2000). dren counselling method” specifi- cally for midwives and peadiatric 8 Swedish Tobacco Control 2006 nurses. Swedish Tobacco Control 2006 9 INSPIRING PROJECTS

“I would like to say how much I regret that I smoke and how difficult, how unpleasant it is to be a smoker, and how Brief intervention made little money it leaves for other things. I would also like to tell them how it feels when you start smoking and you teenagers tobacco-free are so terribly insecure, and most of all how you just want » perimental or to appear more self-assured than you actually are. And I A brief motivational interview with a dental hygienist combi- control group. would also tell them that many others feel the same way, During a re- but that they are good enough just as they are.” ned with a magazine contain- gular visit, pa- ing tips on how to stop using tients aged 16- tobacco can be enough to help 17 were asked if young people stop smoking they would like to participate in Teenagers want and snus use. This has been the study. Those demonstrated by an Uppsala who chose to County Council project entitled The “Butt out now!” magazine do so comple- ted a question- “Brief Motivational Interview naire about their tobacco behaviours and parents to say no with Young People”. measured their carbon monoxide level with a More young people, compared to previous studies, want their parents to make an attempt to influence their tobacco behaviours. breathalyzer test. Young patients at the clin- ics in the experimental group were invited This is how one The important role The project was conducted in two phases. 15-year-old girl re- The survey was conducted in 2003 of parents is under- ponding figure among the boys was 32 per to return for a special visit to meet a hy- sponded to the question of what she, as by Maria Nilsson, Doctoral student in lined by the survey’s confirmation that cent. In the first, a basic structure for a short mo- tivational conversation with young tobac- gienist and discuss the oral health effects an adult smoker, would tell her children Epidemiology at Umeå University, on a parents who smoke or use oral smokeless of tobacco use, among other things. They One worrisome result co users was developed, along with a maga- about smoking. The question was includ- commission from the National Institute tobacco (snus) more often have children of the survey were also given a copy of “Butt out now!”. ed in a survey that documented the tobac- of Public Health. A questionnaire was who do likewise. related to smoking on Swedish school zine hand-out directed to young people ti- tled “Butt out now!”. In addition to oth- The dental hygienists involved atten- co behaviours of Swedish teenagers, along sent by post to a sample of grounds which, according to a law passed ded a two-day training in the motivation- with their attitudes toward and knowledge 4500 youths aged 13, 15, in 1994, are supposed to be smoke-free er useful information, the hand-out includ- “The survey results also indicate al interviewing technique prior to inter- of tobacco. and 17, selected random- throughout the day and night. It is the ed practical advice on how to stop smoking that teachers and other adults at the and using oral smokeless tobacco (snus). vention phase. ly from the national pop- responsibility of the school administra- A total of 1225 youths aged 16-17 par- Parents are important role In the second phase, a study was con- ulation. Nearly 3000 re- schools often do not intervene when tion to ensure that the law is followed. Of ticipated in the study. Of these, 636 were models. Parents who smoke sponded, and the results the teenagers who responded to the ques- ducted within the public dental service of or use snus more often have someone smokes on school grounds. Uppsala County. Half of the dental clin- in the experimental group and 589 to the children who were published in a report tionnaire, 83 per cent stated that smoking control group. All were followed up two do likewise. which also included com- As one 15-year-old boy put it: ‘It seems takes place on their school grounds. Near- ics distributed the “Butt out now!” mag- azine and offered a special visit for a mo- months later with a questionnaire sent to parisons with similar sur- sort of odd that they don’t care’. ” ly 40 per cent reported that many pu- their homes by regular mail. veys conducted in 1987 pils did so. Among teenagers who smoke, tivational interview session to young peo- ple aged 16-17 who smoked or were us- and 1994. the proportion who frequently smoke on The results indicate that the number of Attitudes toward the tobacco indus- ing snus. The remaining half comprised Among other things, the results of the school grounds has increased during the those who quit using snus or smoking was try are not very favourable among Swed- the control group that conducted regular latest survey indicate that more young past ten years. greater among those in the experimental ish teenagers. The survey included a ques- dental visits. people compared to previous studies want The survey results also indicate that group compared to those in the control tion about which branches of the economy The results showed a significant differ- their parents to make an attempt to in- teachers and other adults at the schools group. For boys, the difference was signifi- they would like to work in when they be- ence between the experimental and con- fluence their tobacco behaviours. Of the often do not intervene when someone cant only for snus. For girls, the effect was come adults. Working for a tobacco com- trol groups which indicated that the met- teenagers surveyed, nine of ten wrote that smokes on school grounds. As one 15- significant for both snus and smoking. pany was by far the least popular alterna- hod was effective in motivating tobacco- they wanted their parents to persuade year-old boy put it: “It seems sort of odd Margareta Pantzar hopes that this kind tive. Among the girls, 44 per cent respond- using young people to attempt to quit. them not to smoke. Nearly as many felt that they don’t care. It makes me think of health-related conversation, supported ed that they absolutely could not imag- “It was very satisfying to demonstrate that their parents should themselves re- that they don’t give a damn about any- by training in how to motivate young peo- ine themselves in such a job. The corres- how such a small effort can be effective,” frain from smoking. thing else either.” ple to stop using tobacco, will eventually says the project leader, Margareta Pantzar be included in the normal routines of the of the Primary Health Care Department public dental service, school health servic- at Uppsala County es and youth counselling centres. Council. » Smoking and snus use among teenagers “Research has shown that many young Smoking among teenagers in Sweden continues to decline. Figures from the people want help to stop using snus or The second phase Swedish Council for Information on Alcohol and other Drugs (CAN) indicate that smoking.” concludes Margareta Pantzar. of the project began in 19 per cent of boys and 30 per cent of girls in grade nine smoked cigarettes in August of 2004, and 2005. Oral smokeless tobacco consumption has declined among teenage boys Margareta Pantzar will be presenting the in recent years, but has increased among teenage girls. The rate of oral smoke- all seventeen public less tobacco use is 20 per cent among boys and 6 per cent among girls. dental clinics partici- results of this study at the 13th World Con- pated in either the ex- Margareta Pantzar ference on Tobacco or Health.

10 Swedish Tobacco Control 2006 Swedish Tobacco Control 2006 11 INSPIRING PROJECTS Collaborative effort Photo: Mats Lundqvist prevented “Considering the total range and availability of The project, ”Tobacco prevention in the Twenty-six schools with a total of 5500 schools and the local community”, was a students from grades 6 through 9 partici- support currently, I would not think that anyone in collaborative effort of A Non Smoking Ge- pated in the project. Roughly half of the stu- Sweden who wants to stop smoking needs to search neration, the municipalities of Gotland and dents attended schools where the project in vain. But this is still the case as only half of all Järfälla, and the Kronoberg County Council. was implemented, and the remainder made It resulted in a measurable reduction of to- up the control group. Use and knowledge » primary health care centres offer such support, bacco use among youth. of tobacco, along with attitudes toward it, which is too few. County councils also need to deve- The purpose was to establish a collabo- were surveyed by administering question- rative responsibility for tobacco behaviours naires before and after the comprehensive lop methods to actively encourage people to utilize of young people. This project set out to de- project. the resources that are available.” velop a comprehensive programme with The experimental and control groups the participation of schools, parents, the were compared, and the most evident ef- local community and mass media. Impor- fect was a shift in tobacco use behaviours tant components of the project included a during the transition from grade 7 to 8. Be- letter to tobacco retailers, an information fore the project started, the rate of tobacco WANTED: Active cessation support campaign and a competition for students. In use among seventh-year students was the addition, parent meetings and a media stra- same in both the experimental and control tegy were planned. groups. But in grade 8, after the project So reasons Barbro Holm Ivarsson at Holm Ivarsson. “That is why a compila- sions were also conducted, so that the MI sation support person. Nevertheless, the The project started with special training was implemented, the use rate was 44 per the National Institute of Public Health tion of existing knowledge was put to- method could be further conveyed. resource persons reported that the total on tobacco use and its consequences for cent higher among students in the control who co-ordinated a recent effort to in- gether in a report entitled Tobacco and number of such personnel has doubled. teachers and school administrators. Two group thereby concluding that the compre- crease the availability of tobacco cessation Quitting,” she explains. “It contains many Another attempt to stimulate greater “There are clear indications that both booklets were developed to support teach- hensive effort influenced smoking rates in support for adults. The effort was made important arguments directed at decision- investment in support awareness and availability of cessation ers and parents. these communities. because it had long been known that the makers and other interested parties.” included a major project involving county support have increased,” says Barbro level of support provided by the county The National Institute of Public resource persons. Each county council re- Holm Ivarsson. “But it is very important councils did not meet the demand. Health also wanted to improve the prac- ceived funding to hire a resource person to that this development continue, and that “One thing we tried to do was to in- tical conditions for providing support develop tobacco cessation programmes in the county councils also make an effort to Athletic associations adopt crease awareness among political leaders, throughout Sweden to those that want the county during a contractual period. actively encourage people to stop smoking other decision-makers, and health care to stop using tobacco. One approach was “These individuals made great contri- and use snus.” tobacco control policies professionals in the county councils about to arrange 24 training sessions on to- butions!” says Barbro Holm Ivarsson. the importance of ensuring a sufficient ca- bacco cessation and Motivational Inter- A survey conducted following this A project based on co-operation between use including those organizations serving pacity to help people who want to become viewing (MI) where some 3000 individ- project indicates that still only half of all Barbro Holm Ivarsson will be presenting a poster at county councils and the athletic sector handicapped youth. The idea is that such a uals participated. “Train the trainer” ses- local health centres employ a tobacco-ces- the 13th World Conference on Tobacco or Health. has been carried out in seven policy will lead to a more conscious attitude free of their tobacco dependence,” relates Swedish counties – Dalarna, toward tobacco control policy, and ultimate- Gävleborg, Södermanland, ly to reduced tobacco use rates. Uppsala, Värmland, Väst- During the course of the project, 502 manland and Örebro of the 2285 athletic associations and 39 » Pregnant women » Children and second-hand smoke – between 2003 and of 179 of those for handicapped youth, At the start of the 1980s, roughly The strategy to reduce tobacco use among expectant parents and those with 2004. adopted tobacco control policies. As the every third pregnant woman in Sweden young children via maternity and paediatric clinics has been successful in Swe- The county councils policy development process continued, by smoked cigarettes. In 2003, 9.5 per den. Yet roughly five per cent of Swedish children under the age of seven years worked with SISU, an December 2005, an additional 300 athletic cent of women registered at maternity are still exposed to tobacco smoke in the home. organization devoted to associations and 21 for handicapped youth centres were smokers, and nearly 1.5 Every year, around 500 cases of childhood asthma, and as many cases of athletics education, to en- adopted a policy. At the national level, the per cent were using oral smokeless ear infections, are caused by second-hand smoke as stated the National Board courage as many youth-orien- Swedish Sports Confederation has establis- tobacco at the time of registration. of Health and Welfare in its report on environmental health, 2005. ted athletic associations as pos- hed a working committee on drug issues, sible to adopt tight policies on tobacco including tobacco.

TIMELINE IN 1994 The National Tobacco 1995 Sweden joins the EU and 1997 An age restriction of 18 1997 Tobaksfakta known to- 1998 The National Quit Smok- 2002 A mandatory registra- Act is strengthened with, among is exempt from the oral smoke- years of age to buy tobacco be- day as www.tobaksfakta.org is ing Telephone Line is launched. tion system is introduced for to- Since 1997 it´s forbidden SWEDISH other measures, a complete ban less tobacco sales ban. comes law on January 1. launched as a national commu- Phone number: 020-84 00 00 bacco sales outlets where retail- by law to on advertising. nications system for those work- ers are required to provide local TOBACCO sale tobacco ing in tobacco control and for the authorities with information on to people CONTROL public at large. where tobacco is sold, thereby fa- under 18 cilitating the monitoring of the ban years of age. on the sale of tobacco to people under 18 years of age. 12 Swedish Tobacco Control 2006 Swedish Tobacco Control 2006 13 » Improved health in hospitality workers Swedes like smoke-free Respiratory and sensory symptoms among hospitality workers have declined sharply since the new law went into effect, according to the initial results of a study on that issue. “The frequency of symptoms has been halv- pubs and restaurants ed,” says Dr. Göran Boëthius, who is leading the research. The study involves 91 service personnel asked if it had been their experience that other patrons respect the On the first of June, 2005, all restaurants in nine Swedish municipalities who answe- and other public places in Sweden where smoking ban, ninety percent responded “yes”. red a questionnaire before the start of the Supervising the new law is the responsibility of Sweden’s mu- food and drink are served became smoke- smoking ban. Tobacco smoke exposure was nicipalities. During 2005, many have reported their observa- monitored using nicotine samplers worn free. Nine of ten Swedes approve of the tions to the National Institute of Public Health, and very few vi- during 2-4 working days and by urine coti- » new law, according to the results of a sur- olations of the smoking ban were noted. nine measurements. The same procedure vey conducted for the National Institute of was repeated four months after the new law “It is our impression that compliance with the smoking ban is went into effect, and again in May of 2006 Public Health by the TEMO Institute. very good,” says Gunnar Ågren, Director-General of the Nation- after nearly one year with the smoking ban. al Institute of Public Health. “Smokers in Sweden deserve praise Self-reported reduction of smoke expo- The survey also found that most of the Swedes interviewed had for their contribution to improving the work environment of ser- sure was supported by a substantial drop in not changed their dining-out habits as a result of the smoking ban; vice personnel.” the level of nicotine contained in the samp- eight of ten had not changed their behaviour at all, one of ten had lers. Among the symptoms that have been significantly reduced are wheezing, short- started to go out more often, and one of twenty more seldom. Ola Assarsson will make a presentation on what has happened in Swe- ness of breath, coughing, excess mucus, Even among smokers, eight of ten continued to visit dining den since the ban at the 13th World Conference on Smoking or Health. and drinking establishments as frequently as before the ban, and irritation of the eyes, nose and throat. but for another one-tenth, the frequency of visits had declined. The reduction of symptoms were far less Swedes have become even more positive to the idea of smoke- » Few have set up smoking rooms pronounced in workers that were smokers free establishments than they were before the new law went into themselves. The new law permits owners of dining and drinking establish- effect. After the first six months, over ninety per cent approved; ments to set up separately ventilated designated smoking among smokers, the approval rate was seventy per cent. rooms. Such a room may take up only a small portion of the Matz Larsson will present a poster on the health of establishment’s total area, and shall be located in an area workers and Göran Boëthius will make a presenta- Smokers were also asked if they usually comply to the smok- where others need not pass through and may not allow food ing ban when they dine out. At restaurants, nearly all smokers tion on the general aspects of such a study at the nor drink. According to Swedish municipality reports, very few 13th World Conference on Tobacco or Health. (98 per cent) said that they always respect the ban, while one per owners have set up smoking rooms in their establishments. cent responded, ”Most of the time.” When all respondents were Photo: Photos.com

» No loss of business “A golden opportunity for greater impact was missed” After the first half year smoke-free, there was no measurable loss of The smoking ban in Swedish res- The National Institute of Public Health ence of other countries, including Ireland ished tobacco use, among other things. arranged 18 educational sessions in which business among Swedish dining taurants was the result of a long was assigned to study the necessary condi- and Norway, a broad strategy of prepara- “As it turned out, the smoking ban re- over 600 officials participated. Among and drinking establishments. That tions for introducing a smoking ban at din- tory information and opinion-making is ceived a great deal of attention, anyway, them were representatives from more than is the conclusion of a process. Debate on the issue ing and drinking establishments, and did important to ensure the greatest possible due to the strong interest of the news me- 200 of Sweden’s 290 mu- survey conducted by had gone on for years before this in consultation with diverse groups in- effect of such a law; yet, the Institute did dia on the issue. But if we had been given a nicipalities. The superviso- the Swedish Hotel & cluding representatives of both the labour not receive any additional funding for that chance to exploit this opportunity for pub- ry personnel were then able Restaurant Associa- the Parliament decided in 2002 union and the employers’ association of the purpose. lic information and opinion-making, the to inform the local commu- tion. Sixteen per cent that all such establishments Swedish hotel and restaurant branch. effect of the new law would have been even nity and the owners of din- of the interviewed were to become smoke-free. “It’s a pity that we did not use that gold- greater. It is not very often that one has a ing and drinking establish- business operators The outcome of the study resulted ina en opportunity to provide the general pub- chance to operate in such a favourable cli- ments. The National In- reported that the recommendation by the Institute to legislate lic with additional information and try to mate,” notes Margaretha Haglund. stitute of Public Health ban had increased The primary motivation was to ensure that the smoking ban, as the voluntary approach their turnover, while service personnel would have the same right was considered to be unfeasible. In 2004, the further influence its attitudes toward to- “Instead, most of our limited resourc- produced three brochures six per cent repor- as employees in other occupations to avoid Parliament adopted the new law that would bacco,” observes Margaretha Haglund, es were used to prepare the supervision au- about the new law which ted a decline. The involuntary exposure to second-hand smoke. go into effect 2005. who is head of the tobacco prevention pro- thorities for the new law – which is also a were sent to the municipal- great majority had The Parliament set 2004 as the target date for In its final report, the National Institute gramme at the National Institute of Public critical task, of course.” ities’ supervisory person- not experienced any the proposed smoking ban. Voluntary com- of Public Health noted that substantial re- Health. “If we had been able to do so, the nel who distributed them to change at all. pliance was preferred, with compulsory legis- sources would be required for implement- effect of the new law would probably have Together with the municipal administra- owners and other interested lation as a less desirable alternative. ing of the smoking ban. Based on the experi- been even more effective due to dimin- tive boards, the Institute of Public Health parties.

14 Swedish Tobacco Control 2006 Swedish Tobacco Control 2006 15 INSPIRING PROJECTS

Questionnare in the waiting Sluta-röka-linjen or “the Quitline” was launched in line boasts a 1-year quit rate of 25 per cent. The 1998 and has branded itself as a well-known re- majority of callers are women over the age of 40. room – an effective method source to help people to quit smoking or to stop The Quitline continues to evolve to reach distinct using oral smokeless tobacco in Sweden. target groups and adapt to new technology. Staffed 51 hours a week, counsellors re- The yearly costs of running the Quitline is The Quitlines logo is well-known in Sweden. spond to around 10 000 calls per year. The Quit- 5 million SEK (540,000€). Quitline – a cost effective resource The Quitline has made By asking patients much progress since the last world con- lors press on gaining new knowledge to complete a simple ference. Most recently, the Quitline’s first PhD thesis was pub- and advising one another on treatment questionnaire about lished by Tanja Tomson. The report not only concludes that the regimens. their tobacco use, Quitline is effective in assisting people to quit smoking, it is also while waiting to see The Future Opportunities a health professional, cost effective and thus worth investing in. the interest in In 2004, one of the Quitline counsellors, Teresa Hoikkani- Because tobacco use across the Swed- cessation activities emi, was invited by the Swedish Cancer Foundation to partici- ish population is changing, the Quitline strongly increased. pate in a 5-part TV reality show on quitting smoking. has new priorities for reaching addition- al groups based on research and need. With a systematic working procedure at primary health Another innovative example from the Quitline was to engage As well, effectiveness is continually eval- care centres, it is possible to persuade many more tobacco us- many people to attempt to quit tobacco use before the launch of uated. In addition, since the smoke-free ing patients to visit cessation counsellors. The results of the the smoking ban on 1 June 2005. Two newspapers ran quit cam- bylaw started, media attention and pub- project, ”Prescription for Quitting”, which was carried out paigns before the implementation of the smoking ban. An out- lic attention has turned away from to- in three Swedish counties indicates that surveys in the wait- standing 30 000 people logged on to the newspapers’ websites bacco to hotter issues such as alcohol ing room do work. pledging to quit using tobacco and some individuals were fea- consumption and obesity. “It should be easy to extend the procedure we developed tured in newspaper testimonials. “Engaging immigrant populations, to the other county councils,” says project leader Ulla Lind- The Ever-Changing Quitline the 10 per cent of women that still ström, public health planner at Jönköping County Council. smoke during pregnancy and younger “But it requires the allocation of adequate resources for The Quitline is evolving over time due to technology, new re- tobacco uses are the next priorities for tobacco cessation, and training of all personnel in the tech- search and changes in smokers’ profiles. It started as a simple tele- the Quitline,” says Hans Gilljam, Di- nique of discussing tobacco use with their patients.” phone line with two employees. Today there is a sophisticated shared database where all counsellors can confidentially access rector of the Centre for Public Health’s Tobacco Prevention Program and the In a study conducted at the nine health care centres between callers’ information and history to accurately diagnose and fol- Quitline. “Strategies for reaching out October 2004 to March 2005, all patients aged 20–75 were low-up. Prompt email support and of course old-fashioned post Åsa Forsgårdh is one of the Quitline’s counsellors. Every year they respond to around 10 000 calls. to immigrant populations include de- asked to complete a simple questionnaire while waiting to see is available for clients. veloping the Quitline so there are coun- a doctor, nurse or another health care provider. Patients were New research indicates that oral smokeless tobacco is in fact sellors that speak specially common second languages. For preg- asked if they currently use tobacco, in that case the amount, harmful. This knowledge definitively concluded in an expert re- “The client profile has changed over time,” says Maria Rankka, nant women it is a little more complex because the majority of and to rate their motivation to quit. port on oral smokeless tobacco not only decreased the stock val- Manager of the Quitline, “In the early days it was mainly wom- these 10 per cent that continue to smoke during pregnancy are The completed questionnaire was then taken to the schedu- ue of Swedish Match shares, it also drove people to the Quitline en over 40 that called the Quitline. Although this same group very young between the ages of 16-20. Finally, the young adult led appointment and used as the basis for a brief discussion on to seek help to stop using oral smokeless tobacco. Although not still calls today, new callers with very complicated problems on population, although with a low smoking prevalence by Europe- tobacco use behaviours. The patient was offered a referral to a formally promoted as a “Quit-oral-smokeless-tobacco-phone- top of their nicotine addiction are calling for support.” There are an standards, has been hard to reach.” tobacco-cessation therapist. If accepted, the offer was followed line” counsellors are trained to advise against using this product challenges in treating these patients for tobacco addiction with by a written invitation from the therapist. in both harm-reduction and smoking cessation strategies. so many lingering additional issues. Yet, the Quitline counsel- For more information visit www.slutarokalinjen.org

The questionnaire was completed by a total of 8722 pa- tients, of which 19 per cent were smokers. Nearly one-third » Faster recovery by quitting tobacco use before surgical treatment? (571) of the smokers accepted the offer to visit a cessation When smoking orthopaedic patients recei- reduced by two days. These are among the performed surgery. The other project is be- therapist, and 62 per cent kept their appointments. By com- ved help to quit smoking 6–8 weeks before results of a Danish study that has received ing conducted in the Jämtland County Coun- parison, the health care centres that served as controls issued their operations, the rate of post-operative much attention. cil and is unique as it also includes help in a total of 101 referrals demonstrating that the waiting room complications fell from 52 to 18 per cent. There are two projects under way in quitting the use of oral smokeless tobacco. questionnaire led to a six-fold increase in the referral rate. Sores and related complications decreased Sweden, based on the Danish experience. “This was a simple and effective method for engaging from 31 to 5 per cent, and cardiovascular One study in several hospitals in the Stock- smokers, and it strongly increased the pace of cessation ac- complications from 10 to 0 per cent. The holm area is investigating various effects of A poster of the latter study will be tivities,” notes Ulla Lindström. need for re-operation dropped from 15 to 4 smoking cessation, either before elective presented at the 13th World Confer- A follow-up study is planned after one-year of the project. per cent, and average time in hospital was operations or in connection with acutely ence on Tobacco or Health.

16 Swedish Tobacco Control 2006 Swedish Tobacco Control 2006 17 Margaretha Haglund Global problems demand global solutions. One important guiding principle » Swedish International Develop- – a worthy Award winner of Swedish Tobacco Control work is that progress made should ment Cooperation Association Margaretha Haglund won a Luther L. Terry extend beyond the country’s boarder. Similar to other countries, SIDA and other developing aid organi- Award for her “Distinguished Career” as se- sations including its sister organisation Sweden has a role to play in strengthening tobacco control at the lected by a prestigious team of international » in Canada have contributed significant- global level in order to combat the well-organized transnational tobacco control experts. The 2006 Awards ly to international efforts by providing fi- will be presented at a ceremony on 14 July tobacco industry. nancial support to tobacco-related initia- 2006 in Washington, DC, during the World tives. Conference on Tobacco or Health, where “Tobacco is an important challenge Margaretha will be honoured with a com- to society and a major public health is- memorative medal. sue with increasing importance also for Margaretha has dedicated her profes- Tobacco Control low-income countries”, says Anders Mo- sional career, spanning over 25 years, to lin, Head of the Health Division within tobacco control and has made many ad- the Department for Democracy and So- vances in Sweden and internationally. She cial Development at SIDA. is the Director of Tobacco Prevention for In 2006 SIDA donated funds in the the National Institute of Public Health and beyond the border tune of 9 million SEK (approx. 962,000€) also serves on many tobacco control work- over a three-year period to the Framework groups and committees. Her third term as Convention Alliance. President of the International Network of Sweden has partnered with a variety of to launch this report which is a key piece Women Against Tobacco (INWAT) ends at governments and networks to share expe- of research not only for the Network but » Health Professionals against this World Conference. riences and gain knowledge in the collec- the tobacco control and women’s health Tobacco Margaretha Haglund serves today as one of the strongest advocates for tobacco tive global effort to tighten tobacco con- movements.” says Margaretha, “INWAT – Carrying the WHO’s World No Tobacco control in Sweden and internationally. trol. Below are selected examples of inter- is now a well recognized watchdog that Day Theme Beyond 2005 national work that members in Sweden ensures women’s issues are as visible as Six organizations make up Health Profes- are involved with. men’s”. Many women and tobacco ex- sionals against Tobacco (see p. 20). The perts from around the world have con- non-governmental organizations were The International Network of tributed to the production of this unique » founded at different points in time and Women Against Tobacco (INWAT) publication. collectively have a strong voice. Margaretha Haglund, a Swede that has Tobacco, Nurses against » European Activities The 2005 theme for World No Tobac- South Africa and Sweden Health been in the business of tobacco control for » Tobacco and the National Coun- Two members from the Swedish co (WNTD) raised awareness of the cri- Forum Cooperation over 25 years, has served as the President cil Against . Network for Tobacco Prevention (SNTP) tical role that Health Professionals play of INWAT for the last nine years. Her fi- The South Africa and Sweden Health In 2004 and 2006 tobacco control actively partake in the European Network in advancing tobacco control. Activities nal term ends at the 13th World Confer- Forum Cooperation which was official- teams from South Africa and Sweden for Smoking Prevention (ENSP). Addi- from counselling patients to raising pub- ence where she will leave the job having ly launched in March 2003, aims to fa- joined together to implement workshops tional members work in specialized sub- lic opinion are all important in reducing dedicated a significant portion of her ca- cilitate: the policy dialogue in the area of for participants from many organizations networks including the European Net- tobacco use rates. reer to the issue of women and tobacco by public health at the national level; expe- and authorities. They left the training work of Smoke-free Hospitals; the Euro- For the 2005 leading INWAT to achieve many accomp- rience and information sharing; human with the expectation that they could im- pean Network of Quitlines; and INWAT- Theme the NGOs built www.TobaccoOr- lishments. resource development; and transfer and plement the techniques and start tobacco Europe. HealthSweden.org, published advocacy At this World Conference, INWAT sharing of know-how. control work at community-based levels In the past two years, there has been a articles in high-profile health profession- will continue to raise its profile by launch- One of the areas is Health Promotion in South Africa. specially financed European Commission al journals and newspapers and supported ing a report named Turning a New Leaf: and within that, Tobacco Control. The In addition, the partners shared know- Project named HELP For a Life without health professional organizations in oth- Women, Tobacco and the Future. This re- National Institute of Public Health and ledge about tobacco control laws, differ- Tobacco. This mass media campaign tar- er countries. Moreover, Göran Boëthius, port is co-led by the British Columbia the Department of Health in South Afri- ent political and social environments and gets a young audience in the 25 Europe- Chair of Doctors against Tobacco and Photo: Ingvor Farinotte Centre of Excellence for Women’s Health ca are the main partners in this project on challenges faced in advancing legislation an member states. In Sweden, members a 2004 WNTD Award recipient contri- and INWAT. “It is nice to leave the job tobacco control which engages other civ- such as the Framework Convention on Margaretha Haglund has dedicated 25 years to tobacco of SNTP worked together to promote the buted to the WHO Background report control. as President of INWAT having been able il society groups such as Doctors against Tobacco Control. campaign at the country level. launched that year.

TIMELINE IN 2003 A ban on indirect ad- 22 May 2003 Sweden 1 June, 2005 The 2 June 2005 the 2005 An expert report on 2006 Sale of cigarettes in vertising such as using trade- becomes a Signatory to the WHO smoke-free restaurants and bars Swedish Government ratifies the the health effects of oral smoke- packages less that twenty is pro- SWEDISH marks (e.g. pictures or names) of Framework Convention on Tobac- legislation comes into force. This WHO Framework Convention on less tobacco is released. hibited. TOBACCO a tobacco product when market- co Control which was made offi- law allows a proprietor to build a Tobacco Control which became ing products other than tobacco cial at the UN 16 June 2003. separately ventilated designated official at the UN 7 July 2005. CONTROL such as watches, shoes and cloth- smoking room where eating and ing is applied to commercial ad- drinking is prohibited. 2004 Parliament passes legislation vertisements in newspapers, on on smoke-free serving establishments. radio and TV. 18 Swedish Tobacco Control 2006 Swedish Tobacco Control 2006 19 The Network for Tobacco Prevention A Non-Smoking Generation was founded Swedish Cancer Society is a non-profit or- Dentistry against Tobacco is made up of in 1979 and focuses its efforts on young ganization whose main task is to fund can- more than 400 dentists, dental hygienists people between the ages of 11 and 16. We cer research within Sweden in addition to and dental assistants across Sweden. Our visit school classes and talk about health, focussing on information about cancer and work includes raising awareness within attitudes and peer pressure. We also work prevention. Within prevention, smoking is our professions on how tobacco users can to shape public opinion by producing mass our focus as it is the single most important be treated within dental care. media campaigns and lobbying against the factor in causing cancer. www.dentistryagainsttobacco.org tobacco industry. www.nonsmoking.se www.cancerfonden.se Nurses against Tobacco was founded in Non-smokers’ Rights Association (VISIR) Swedish Chiropodist Association. The 1992 in order to increase awareness with- is a grassroots anti-tobacco movement foot’s health is our focus. Chiropodists ha- in the profession of the dangers associated that started in 1974. A major objective of ve a unique opportunity to meet and treat with tobacco use. Our objectives are to serve the Association is that every child should patients in a relaxed and private atmos- as role models by refraining from tobacco, be able to grow up in a tobacco-free envi- phere. If the patient use tobacco, the Chi- to support tobacco-free pregnancies and to ronment. www.visir.a.se ropodist should inform the patient on how counsel patients we encounter. healing is influenced and assist the patient www.nursesagainsttobacco.org Swedish Asthma and Allergy Foundation in quitting. serves the interests of those who suffer Teachers against Tobacco was established from asthma, allergies and other forms The National Institute of Public Health is a in 1994, in order to promote healthy lifesty- of hypersensitivity. The Foundation works governmental authority under the Ministry les by preventing the use of tobacco among actively to influence public opinion and deci- of Health and Social Affairs. Established in children and youth. The overarching goal is sion-making on smoke-free environments. 1992, the Institute has eleven general ob- to actively engage school personnel to sup- www.astmaoallergiforbundet.se jectives to create social conditions that will port tobacco-free school environments. ensure good health for the entire population www.teachersagainsttobacco.org Swedish Heart and Lung Association including reducing the use of tobacco. www. aims to make certain that those affected fhi.se Pharmacy against Tobacco joined other by heart or lung disease can live the best health professional groups in 1996 to influ- life possible. An important issue is that all The National Quitline provides telephone ence tobacco control issues and promote people with heart or lung disease should support to tobacco users that wish to quit. tobacco cessation by way of our broad net- have the right to a qualified care and reha- www.slutarokalinjen.org work of contacts with the public. bilitation regardless of gender, age or com- www.pharmacyagainsttobacco.org munity where they live. www.hjart-lung.se Doctors against Tobacco was established in 1992, primarily to influence decision-ma- Psychologists against Tobacco is a pro- Swedish Heart and Lung Foundation aims kers to adopt a comprehensive tobacco fessional association which seeks to alert to combat cardiovascular and lung di- prevention policy. An important task for psychologists and other behavioural scien- seases, mainly through funding of research the organization is to increase the medi- tists to the important role they can play in projects. www.hjart-lungfonden.se cal profession’s awareness of and skills in preventing the use of tobacco. handling tobacco-related problems. www.psychologistsagainsttobacco.org www.doctorsagainsttobacco.org

Swedish Tobacco Control 2006 Progress & Challenge – both are greater than ever was published by the Swedish Network for Tobacco Prevention for the 13th World Conference on Tobacco or Health in Washington, DC, USA, 12-15 July 2006, with financial support from the National Institute of Public Health. Articles by: Helene Wallskär and Sara Sanchez Translation: Al Burke Editors: Göran Boëthius, Margaretha Haglund and Sara Sanchez Graphic design: Ordagrant i Laholm Printing: Pressgrannar AB For more information: www.tobaksfakta.org or www.tobaccoorhealthsweden.org 20 Swedish Tobacco Control 2006 © Swedish Network for Tobacco Prevention 2006