Health Professionals against Tobacco: the Swedish experience

WHO encourages health professionals to be proactive in minimizing the adverse effects on health caused by the addiction to and consumption of tobacco and exposure to tobacco smoke. In particular, the WHO FCTC emphasizes the role of health professional bodies in efforts to incorporate tobacco control into public health agendas and actively contribute to reducing tobacco consumption.

Sweden has a long tradition of fighting against tobacco going back over 40 years. It was the first country in Europe to achieve WHO’s goal of reducing the population prevalence of smokers to below 20%. Progress made over the years can be attributed to various factors including, in particular, the accomplishments of nongovernmental organizations of health professionals. This case study describes the role of such organizations and their contribution to the successful anti-tobacco work.

Situation prior to the involvement of health professionals

Sweden was one of the first countries in the world to fund tobacco control efforts. Since the early 1960s a comprehensive programme has been developed, including public information and

education activities (1963); publication of scientific reports on the risks of smoking (first published in 1957); explicit commitments by politicians to responsibility in the fight against tobacco (1974);

restrictions (1975) and subsequently a ban (1994) on tobacco advertising and promotion; the regulation and labelling of tobacco products (first warnings introduced in 1977); legislation favouring smoke-free environments, and development of smoking cessation facilities. As a result of this continuous and comprehensive anti-tobacco effort, Sweden now enjoys the lowest

prevalence of smokers in Europe.

Health professionals in Sweden have significantly contributed to anti-tobacco activities since the tobacco control efforts began. However, it was only in the last 15 years that this action took a more structured and coordinated form. Prior to this, health professionals’ activities were rather fragmented and participation in broad tobacco control efforts was widely acknowledged to be sub-optimal. There were a number of concerns in relation to these activities, in particular:

• greater involvement of health professionals in preventive, advocacy and health-promoting activities was seen as one of the greatest challenges to be accomplished in the area of tobacco prevention efforts;

• training in issues related to tobacco control, an essential precondition for more active involvement of health professionals in the fight against tobacco, was inadequately incorporated into the basic education and training curricula of health professionals;

• coordination of efforts to combat tobacco at regional and national levels was not satisfactory as regards individual activities by health professionals and by their professional associations.

Enabling context and development of the initiative

Various groups of health professionals are ideally positioned to lead tobacco control activities as they are respected by politicians, policy-makers, the public and other health professionals, and through individual and collective action (through their professional associations) they can have a substantial impact on the battle against tobacco. Acknowledgement of this potential and the hitherto sub-optimal participation of this group created an impetus for action.

In 1992, the establishment of the National Institute of Public Health, whose responsibilities included the improvement of coordination of activities against tobacco, helped to catalyse the activities of health professionals and provided them with financial support. In the same year, the establishment of Doctors against Tobacco created the first anti-tobacco front by health

professionals. This group focused on promoting health through reducing tobacco use and encouraged the medical profession to focus on tobacco issues. Subsequently, other professional groups espousing the same vision were established, including Dentists and Nurses against Tobacco (1992), Pharmacists against Tobacco (1996) and Psychologists against Tobacco (2000).

Teachers against Tobacco joined in 1994. These nongovernmental organizations subsequently formed the umbrella organization, Health Professionals against Tobacco, an informal network which shares information and plans to improve the coordination of activities. Health

Professionals against Tobacco aims to promote a tobacco-free culture in Sweden by:

• monitoring and influencing the political processes regarding tobacco control issues;

• increasing the awareness, knowledge and tobacco-free behaviour of members of their professional group;

• creating health education and information materials;

• supporting local tobacco control initiatives;

• engaging in international cooperation.

This network has further expanded with the addition of other nongovernmental organizations such as the Swedish Cancer Society, the Swedish Heart-Lung Foundation, the VISIR (an organization formed in 1974 to promote smoke-free environments) and the National Institute of Public Health.

The success of this collaboration has been greatly facilitated by a number of factors, including:

• the establishment of regional representatives throughout the country to improve communication and coordination of activities, thus encouraging the involvement of professionals in local communities and increasing their engagement and support;

• advocacy aimed at tightening tobacco control legislation to complement other tobacco control efforts (such as tobacco cessation and prevention) and raising the profile and influence of the professional associations in policy-making circles;

• financial autonomy of the organizations achieved through funding provided by the Institute of Public Health, donations and (importantly) by membership fees, which has protected the independence of the organizations in part and provided short-term sustainability.

Impact of the initiative

The efforts of the tobacco control movement have contributed to the adoption of advanced tobacco control legislation which has further helped to reduce tobacco use in the country, so that:

• in 2005 the prevalence of daily smoking was 17% in women and 13% in men, among the lowest in the world;

• in 2005 the rate of daily oral smokeless tobacco use was 4% in women and 22% in men;

• in 2003, among pregnant women, the prevalence of smoking was 10% and the prevalence of oral smokeless tobacco use was 1.4%.

Since 1992, Health Professionals against Tobacco in Sweden have been continuously engaged in multilateral action to advance tobacco control. This has included:

• demonstrations for a comprehensive Tobacco Act;

• advocacy and staging of media events with awards to Saab Automobiles for their decision to produce vehicles without ashtrays and the Swedish Tourist Association for refusing to take sponsorship money from the tobacco industry; attending Swedish Match’s annual shareholders’ meeting to distribute an alternative company report containing mortality and morbidity statistics which led to two insurance companies immediately selling their shares in the company;

• developing international networks and initiating European conferences.

Between 2003 and 2005, political lobbying and information campaigns were carried out aimed at the media and the public in order to build broad-based support for a review of the tobacco control legislation. There were two objectives: to expand the ban on smoking in all public places to include the hospitality sector, and to encourage ratification by Sweden of the WHO FCTC.

These activities were critical to the enactment of the law which came into force in June 2005 banning smoking in all public places. Sweden became a signatory of the WHO FCTC in 2003 and ratified it in 2005.

Lessons and conclusions

Health professionals are important role models as they are regarded by the public as credible sources of health information.

Comprehensive tobacco control programmes should consider a mix of measures, such as legislation and pricing interventions, prevention (through health education and information campaigns that raise awareness of the adverse effects of tobacco on health) and other demand reduction measures that focus on reducing dependence on tobacco and encouraging smokers to stop. Health professionals can play an important role in every facet of these interventions.

Health professional associations can use a number of strategies to enhance tobacco control, including:

• educating members as to their valuable roles in tobacco control;

• influencing health institutions and educational centres to include tobacco control in their professional training curricula;

• collaborating with the wider scientific community and communicating research evidence on effective tobacco control and cessation strategies to their members and to the general public;

• building partnerships with the community to deliver cessation, prevention and protection messages to the public and encouraging members to participate in public education activities;

• advocating to governments on the effective role of health professionals in tobacco control;

• lobbying governments for continuous funding to sustain a national tobacco control coordinating centre;

• lobbying governments at various levels to provide funding support for smoking cessation services;

• lobbying governments and politicians to support anti-tobacco legislation;

• promoting smoke-free environments and encouraging members not to use tobacco in any form and to set an example as role models.

Through their professional activities and networks, health professionals can help people by giving advice, guidance and answers to questions related to tobacco use and its health effects, and serve as a reference for the media to educate the public and policy-makers.

Autonomy of the professional organizations is a key precondition for their successful intervention in the fight against tobacco and its future sustainability.

For more information, visit www.tobaccoorhealthsweden.org (accessed 22 August 2006) or e-mail professionals@globalink.org.