SUU, Alm.del - 2017-18 - Endeligt svar på spørgsmål 1350: Spm. om ministeren er enig i, at det er et selvstændigt mål at begrænse interaktionen mellem embedsmændene i danske ministerier og styrelser og repræsentanter fra tobaksindustrien til det strengt nødvendige, sådan som Verdenssundhedsorganisationen WHO anbefaler, til skatteministeren

Sundheds- og Ældreudvalget 2017-18
SUU Alm.del
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TABLE OF CONTENTS

Resumé og anbefalinger

Executive summary and recommendations

1. Introduction

2. Policy coordination and implementation

3. Countering tobacco industry interference

4. Increasing price through taxation

5. Protection from exposure to tobacco smoke

6. Warning people of the dangers of tobacco

7. Public awareness and mass media campaigns

8. Banning advertising, promotion and sponsorship

9. Helping smokers quit

Annex 1: Overview of recommendations

Annex 2: List of capacity assessment team members

Annex 3: Country focal point representatives

Annex 4: List of key stakeholders

References

RESUMÉ OG ANBEFALINGER

Andelen af rygere i Danmark er faldet konstant i flere årtier, men de seneste seks år er tallet stagneret. Hvert år

er der mange, der lykkes med at holde op med at ryge. Men der er ligeså mange, der begynder eller genoptager

rygningen. Rygning er derfor det væsentligste forebyggelige folkesundhedsproblem og medfører ca. 13.600 år-

lige dødsfald i Danmark. Udviklingen er særligt alarmerende på grund af især børn og unges udbredte rygning.

Det er både nødvendigt og muligt at styrke tobaksforebyggelsen i Danmark og få vendt udviklingen, så færre

børn og unge begynder at ryge, og flere bliver røgfri.

Danmark har indført forskellige forebyggelsesinitiativer på tobaksområdet i løbet af de seneste årtier, og i

2004 ratificerede Danmark WHO´s rammekonvention om tobak, FCTC, der er juridisk bindende, og som for-

pligter Danmark til at beskytte nuværende og kommende generationer mod konsekvenserne af tobaksbrug.

For at styrke og kvalificere den danske tobaksforebyggelse indledte partnerskabet Røgfri Fremtid i 2017 et sam-

arbejde med WHO Regional Office for Europe (WHO Europe) og det europæiske netværk for tobaksforebyggel-

se (ENSP). Formålet var at vurdere, hvordan implementeringen af effektive og evidensbaserede tiltag i WHO

FCTC kan forbedre den fremtidige danske tobaksforebyggelse. Et hold bestående af danske, internationale og

WHO eksperter gennemførte i efteråret 2017 interviews med 40 centrale aktører i dansk tobaksforebyggelse.

De væsentligste udfordringer og anbefalinger til en styrket tobaksforebyggelse blev identificeret med baggrund

i interviewene og vurderinger af, i hvilket omfang centrale dele af WHO FCTC er implementeret i Danmark.

De væsentligste udfordringer i dansk tobaksforebyggelse

Følgende faktorer blev identificeret som de væsentligste udfordringer:

•

Der er ingen overordnet strategi eller plan for at beskytte børn, unge og voksne mod tobak på trods af den

nationale vision om, at ingen børn og unge skal ryge i 2030.

Børn og unge er især udsatte for:

• let adgang til cigaretter grundet lave priser

• tobaksprodukternes attraktive indpakning

• promovering af cigaretter ved salgssteder

• eksponering for passiv rygning både på offentlige og private steder

Tobaksindustrien har mulighed for at påvirke dansk sundhedspolitik og er ikke tilstrækkeligt reguleret

med hensyn til gennemsigtighed, donationer eller virksomhedernes sociale ansvar (CSR).

Danmark overholder ikke fuldt ud de vigtigste forpligtelser i WHO FCTC og anbefalingerne i de tilhørende

guidelines.

•

De væsentligste anbefalinger

På baggrund af de udfordringer, der blev fremhævet af danske aktører, og anbefalingerne i WHO FCTC,

anbefales de følgende prioriterede tiltag:

National handleplan.

Der bør udvikles en overordnet strategi i form af en national handleplan til at be-

skytte børn, unge og voksne mod de skadelige effekter af tobak. For at nå visionen om en røgfri generation

i 2030, er det nødvendigt med en koordineret indsats mellem bl.a. myndigheder, kommuner, regioner,

organisationer og civilsamfund.

Højere priser på tobak.

Højere afgifter på tobak er et af de mest effektive tiltag til at mindske rygning, især

blandt børn og unge.

Neutrale cigaretpakker og tobak under disken.

Indfør neutral indpakning af tobaksprodukter og forbud

mod eksponering af tobak ved salgssteder. Det vil gøre cigaretter mindre attraktive især for børn og unge.

Tilstrækkelig beskyttelse mod tobaksrøg.

Lov om røgfri miljøer bør omfatte alle uddannelsesfaciliteter,

privat dagpleje, arbejdspladser (inklusive små værtshuse) og andre steder, der i dag er undtaget fra loven.

Transparens og beskyttelse mod tobaksindustriens indflydelse.

Beskyt sundhedspolitik og anden politik

relateret til tobaksforebyggelse mod indflydelse fra tobaksindustrien:

• Begræns interaktioner mellem offentlige embedsmænd fra alle ministerier og styrelser, med repræsen-

tanter for tobaksindustrien til de strengt nødvendige. Der skal være transparens omkring alle interakti-

oner med tobaksindustrien.

• Beskyt børn og unge mod eksponering for tobaksindustriens markedsføring ved at sikre, at det nuvæ-

rende reklameforbud omfatter alle former for tobaksreklame, promovering og sponsorater f.eks. i for-

bindelse med musikfestivaler.

• Ratificér WHO FCTC Protokollen til eliminering af ulovlig handel med tobaksvarer for at sikre uafhæn-

gig kontrol af illegal handel med tobaksvarer. Undlad at indgå partnerskaber mellem myndigheder og

tobaksindustrien.

EXECUTIVE SUMMARY AND

RECOMMENDATIONS

Denmark has a relatively short history of tobacco control compared to other Nordic countries. A wide range of

Danish tobacco control measures led to a continuous decline in the prevalence of smoking in the past decades.

In 2004, Denmark ratified the legally binding treaty, the World Health Organization Framework Convention

on Tobacco Control (WHO FCTC). However, smoking still presents a major public health problem in Denmark,

and is responsible for an estimated 13,600 deaths every year. In recent years, progress in Danish tobacco con-

trol has come to a halt and there has been no decline in smoking prevalence since 2011. This development is

especially alarming due to widespread tobacco use among children and adolescents.

Further progress in Danish tobacco control is both necessary and possible. To drive progress in Danish tobac-

co control, in 2017 the Danish partnership Smokefree Future (Røgfri Fremtid) initiated a collaboration with

the WHO Regional Office for Europe (WHO Europe) and the European Network for Smoking and Tobacco

Prevention (ENSP) with the aim of assessing the capacity for advancing implementation of central measures

of the WHO FCTC and developing recommendations for future Danish tobacco control. A team of national,

international and WHO experts conducted interviews with key stakeholders from 40 Danish institutions and

organisations involved with tobacco control. Through the interviews and assessment of the implementation of

WHO FCTC provisions in Denmark, key challenges and recommendations for tobacco prevention in Denmark

were identified.

Key challenges in Danish tobacco control

The following factors were found to be the most significant challenges to continued progress in tobacco con-

trol in Denmark:

• There is no overall strategy or plan to protect children, adolescents and adults from the harms of tobacco,

despite the national vision of no children and adolescents smoking by 2030.

• Children and adolescents remain especially unprotected from:

• the excessive affordability of cigarettes

• the attractiveness of tobacco products in stylish packaging

• the promotion of cigarettes at point of sale

• exposure to second-hand smoke in public and private places

• The tobacco industry is influential in Danish policy-making and not properly regulated with respect to

transparency, donations or corporate social responsibility (CSR) efforts.

• Denmark does not fully comply with key obligations of the WHO FCTC and recommendations of its imple-

mentation guidelines.

Key recommendations

Based on the challenges highlighted by stakeholders and on the provisions of the WHO FCTC, the following

recommendations have been made to ensure the sustainability of current initiatives and further progress in

Danish tobacco control. These five recommendations should be considered as priorities:

1. Develop an overall, comprehensive strategy and implement a well-designed plan for the protection of chil-

dren, adolescents and adults from the harms of tobacco on the road to a smoke-free generation by 2030.

Reducing the prevalence of tobacco use will need the coordinated efforts and resources of both govern-

mental and non-governmental organisations.

2. Decrease the affordability of cigarettes and other tobacco products by increasing tobacco taxes.

3. Adopt plain packaging and a point-of-sale display ban to diminish the attractiveness of tobacco products

and to reduce the exposure to tobacco marketing in shops and supermarkets, especially among children

and adolescents.

4. Ensure protection from exposure to second-hand smoke by creating a complete smoke-free environment

in all educational facilities, private day care facilities, at workplaces (including bars) and all other public

places.

5. Protect public health policy from the influence of the tobacco industry

• Limit interactions of public officials of all branches of government and agencies with tobacco industry

representatives to those that are strictly necessary for appropriate regulation. All interactions with the

tobacco industry should be conducted transparently.

• Protect children and adolescents from exposure to tobacco marketing by introducing a comprehensive

ban on all forms of tobacco advertising, promotion and sponsorships.

• Ratify the WHO FCTC Protocol to Eliminate Illicit Trade in Tobacco Products to ensure independent

control with illegal tobacco products. Do not form partnerships with the tobacco industry.

Chapter 1

INTRODUCTION

In Denmark, the proportion of smokers peaked in the early 1950’s with 78 % of men smoking daily. Smoking

among women peaked around 1970 with almost 50 % of women smoking on a daily basis. As a result of both

regulatory measures in tobacco control (Table 1) and increasing awareness of smoking-related health risks, the

proportion of daily smoking continuously declined in the following decades in line with global trends. Howev-

er, in recent years, the decline in smoking prevalence has levelled off (Figure 1).

Denmark is now ranked 23 out

of 35 European countries with respect to implementation of efficient tobacco control policies.

Table 1 - Timeline of key policy measures in tobacco control 1995-2017

2016

Law on tobacco

products. Adopted fol-

lowing the EU Tobacco

Products Directive

2014/40/EU.

Executive orders

adopted on the

reporting system for

tobacco products, limit

values, health alerts and

age control systems,

additives, labelling and

packaging, and electro-

nic cigarettes.

2004

(amended 2008)

Law prohibiting the sale

of tobacco to persons

under the age of 16

2004

2001

(amended 2008)

Law on the prohibition

of tobacco advertising

Ratification of the WHO

Framework Convention

on Tobacco Control

Executive Order on the

issuance of ID cards to

persons aged 16 and

over

2008

(amended 2010)

Notice of the ban on

tobacco sales to persons

under the age of 18 and

the sale of alcohol to

persons under the age

of 16

1995

(repealed 2007)

Departmental note on

smoke-free environ-

ments

2017

2002

(amended 2008)

Act on the manufactu-

ring, marketing and sale

of tobacco products

2007

(amended 2010

and 2012)

Law on smoke-free

environments

2012

(amended 2017)

Executive Order on the

limitation of the right

of inmates to smoke in

their own accommodati-

on and visiting areas

Smoking remains an important public health challenge in Denmark

Tobacco causes 13,600 deaths per year or 25 % of the total number of deaths in Denmark (Figure 2).

Smokers

and ex-smokers account for an additional cost of DKK 10 billion in treatment and care and extra costs of DKK

34 billion in lost productivity, compared to non-smokers.

Cigarettes are the most consumed tobacco product in Denmark and 79 % of current smokers started smoking

with cigarettes.

The latest smoking survey indicates that after decades of decline in smoking prevalence rates,

the proportion of daily smokers in Denmark has remained stagnant for the last six years at around 22 %.

Figure 1 - Daily smoking among men and women 15 years or older, 1953-2017

100

Men

All

Women

1950

1960

1970

1980

1990

2000

2010

2020

High smoking prevalence among young people

80 % of Danish smokers in the age group 16-25 years were younger than 18 when they started smoking on a

weekly basis.

In 2014, 46 % of Danish boys and 45 % of girls attending senior high

school (gymnasier) smoked daily or occasionally. The proportion of boys

and girls attending vocational schools (erhvervsskoler) who smoked dai-

ly or occasionally reached an even more significant magnitude with 57

% of boys and 49 % of girls smoking.

The National Institute of Public

Health estimates that 40 children and adolescents start smoking every

day in Denmark.

Young people are thus at the centre of the tobacco ep-

idemic in Denmark.

Young people are

at the centre of the

tobacco epidemic in

Denmark

Assessing national capacity to reverse the tobacco epidemic

Denmark has been a Party to the World Health Organization Framework Convention on Tobacco Control

(WHO FCTC)

since 16 December 2004.

As such, Denmark has committed to implementing all provisions of

the treaty, which are binding under international law. The Parties have adopted guidelines for the implemen-

tation of several WHO FCTC provisions. The guidelines are “intended

to help Parties meet their obligations

under… the Convention,” and they “reflect the consolidated view of Parties.”

Despite the achievements in tobacco control, tobacco remains a severe threat to public health in Denmark.

In 2016, a number of Danish organisations therefore launched the Danish Endgame Partnership, Smokefree

Future (Røgfri Fremtid) with the aim of reaching a maximum of 5 % adult smokers and no children and ado-

lescent smokers in Denmark by 2030. The Danish government adopted the goal of a smoke-free generation,

aiming to have no children or young people smoke by 2030.

As a step towards the vision of a smoke-free future, TrygFonden and the Danish Cancer Society initiated a

collaboration with the World Health Organization Regional Office of Europe (WHO Europe) and the European

Network for Smoking and Tobacco Prevention (ENSP) in 2017. The aim was to assess the capacity for imple-

menting effective tobacco control measures in Denmark and to make practical recommendations to counter

the tobacco epidemic based on the evidence-based measures and obligations of the WHO FCTC.

The capacity assessment on the implementation of effective tobacco control policies in Denmark (the capacity

assessment) is carried out according to the WHO Operational Manual on planning, conduct and follow up of

joint national capacity assessments.

The assessment is realised with inspiration from the Joint National Ca-

pacity Assessment on the Implementation of Effective Tobacco Control Policies in Norway carried out in 2010

at the request of the Norwegian Ministry of Health

and from a corresponding capacity assessment in Estonia

carried out in 2011.

The Danish capacity assessment is administered by the Country Focal Point, which consists of the Danish

Cancer Society and ENSP, and supported by WHO Europe (Annex 3).

Between 28 September and 3 October 2017, a group of national, international and WHO experts in tobacco

control (Annex 2) reviewed the status and present development efforts of key tobacco control policies by con-

ducting interviews with 40 key stakeholders in Denmark (Annex 4). Through the stakeholder interviews and

assessment of the implementation of WHO FCTC provisions in Denmark, a number of factors were highlighted

as the most significant challenges to continued progress in tobacco control in Denmark. On this basis, recom-

mendations were made for ensuring the sustainability of current initiatives and further progress in Danish

tobacco control.

The WHO Framework Convention on Tobacco Control (WHO FCTC)

is the first and only global public

health treaty. The WHO FCTC was developed by countries in response to the globalization of the tobacco

epidemic. Its objective is to “protect

present and future generations from the devastating health, social,

environmental and economic consequences of tobacco consumption and exposure to tobacco smoke by

providing a framework for tobacco control measures to be implemented by the Parties at the national, re-

gional and international levels in order to reduce continually and substantially the prevalence of tobacco

use and exposure to tobacco smoke.”

The Convention entered into force in 2005. There are currently 181 Parties to the Convention.

WHO Framework Convention on Tobacco Control

Structure of the report

The report first examines the status of the tobacco epidemic in Denmark and characterises its main features. It

then analyses the following policies, which are key evidence-based measures of the WHO FCTC:

•

Coordination and implementation of comprehensive tobacco control interventions (WHO FCTC Art. 5.1

and 5.2)

Countering the tobacco industry interference (WHO FCTC Art. 5.3 and guidelines)

Increasing the real price of tobacco products through taxation (WHO FCTC Art. 6 and guidelines)

Protection from the exposure to tobacco smoke (WHO FCTC Art. 8 and guidelines)

Warning people of the dangers of tobacco (WHO FCTC Art. 11 and 12 and guidelines)

Banning tobacco advertising, promotion and sponsorship (WHO FCTC Art. 13 and guidelines)

Helping smokers quit (WHO FCTC Art. 14 and guidelines)

For the analysis of each policy, the report includes the following sections:

• Policy status and development.

The section provides a summary of the present status and planned devel-

opment of the policy in question, based on a thorough review of documents made available by the Country

Focal Point before the country visit (e.g. the Tobacco Control Country Profile and the WHO report on the

global tobacco epidemic 2017) and on the stakeholder interviews.

•

Key findings.

The section provides a summary of the most critical aspects discovered through stakeholder

interviews and other Danish tobacco control sources. Where applicable, the report describes the essential

factors for the success in implementing present policies and developing future ones.

• Recommendations.

The section specifies actions required to improve the design, implementation and en-

forcement of the policy in question.

Figure 2 - Consequences of smoking in Denmark

Hospitalisations

150,000

Somatic hospitalisations

Extra costs

DKK 34 Billion

In lost productivity

500,000

Somatic outpatient

hospital visits

DKK 10 Billion

On treatment and care

Mortality and

morbidity

13,600 deaths

3 years

of life ecpenctancy lost in

the population as a whole

Emergency visits

59,000 somatic emergency

visits

Sick leave days

2,7 million sick leave days

short term

2,8 million sick leave days

long-term

Chapter 2

POLICY COORDINATION AND

IMPLEMENTATION

WHO FCTC Articles 5.1 and 5.2

Each Party shall develop, implement, periodically update and review comprehensive mul-

tisectoral national tobacco control strategies, plans and programmes... a) establish or rein-

force and finance a national coordinating mechanism or focal points for tobacco control;

and b) adopt and implement effective legislative, executive, administrative and/or other

measures and cooperate, as appropriate, with other Parties in developing appropriate poli-

cies for preventing and reducing tobacco consumption, nicotine addiction and exposure to

tobacco smoke.

Policy status and development

Governmental coordination and implementation agencies at national level

The Ministry of Health

(Sundheds- og Ældreministeriet) is responsible for the implementation of the policies

and laws passed in Parliament. The Ministry of Health has an estimated 1.5 full-time employees working on

tobacco control supported by other staff members as needed.

The Danish Health Authority

(Sundhedsstyrelsen), under the Ministry of Health, provides evidence-based

recommendations concerning measures such as smoking cessation, smoke-free environments and prevention

of smoking initiation to the Ministry of Health and municipalities etc.

The Danish Health Authority has a

Health Promotion unit that consists of approximately 25 full-time employees, of which an estimated 1.5 full-

time employees are dedicated to tobacco control.

The Danish Safety Technology Authority

(Sikkerhedsstyrelsen) under the Ministry of Industry, Business and

Financial Affairs (Erhvervsministeriet), and the Danish Health Authority carry out the implementation of the

Danish regulations on tobacco, including regulation resulting from the implementation of the EU Tobacco

Products Directive (2014/40/EU) (EU TPD). The Danish Safety Technology Authority carries out inspection of

tobacco products in retail. In 2017, the Authority monitored the implementation of the EU TPD with 6.7 full-

time employees working on tobacco and 5.7 full-time employees working on e-cigarettes, herbal cigarettes and

new tobacco products.

The Ministry of Justice

(Justitsministeriet) has the main responsibility for the regulation of illegal sales to

minors and the primary control of the illegal sale of snus. The police are responsible for the enforcement of

regulations related to the illegal sale of these products.

The Ministry of Taxation

(Skatteministeriet) is responsible for implementation of regulation on tobacco taxa-

tion. The customs department (SKAT) is responsible for border control.

The Danish Working Environment Authority

(Arbejdstilsynet) is the main enforcement agency of the law on

smoke-free environments. The Working Environment Authority performs routine inspections at workplaces

and targeted inspections in response to complaints.

The Consumer Ombudsman

(Forbrugerombudsmanden) supervises compliance with legislation on advertis-

ing, promotion and sponsorship of tobacco products and Electronic Nicotine Delivery Systems (ENDS). The

Consumer Ombudsman has a team of 16 case investigators for all topics under its purview. In 2016, the agency

finalised four cases related to tobacco.

Municipalities and regions

Denmark has five regions and 98 municipalities. According to the Health Act,

the municipalities are respon-

sible for citizen-based health promotion and prevention. In Denmark, publically funded smoking cessation

counselling is primarily the responsibility of individual municipalities. The regions are responsible for patient

oriented prevention at hospitals and from general practitioners and consultants as well as for providing advice

to municipalities.

In tobacco control, the Danish Health Authority recommends that municipalities implement measures that

involve smoking cessation, more smoke-free environments and prevention of smoking initiation.

Civil society

The Danish Network for Tobacco Prevention was established in 1997 and includes 17 organisations of health

care professionals, NGOs, patient organisations, researchers and municipal networks active in tobacco control,

including the Danish Health Authority.

Out of the main NGOs working on tobacco control, the Danish Cancer Society has one unit dedicated to tobac-

co control with an estimated 17 full-time employees, while the Danish Heart Foundation has three full-time

employees and the Danish Lung Foundation has one full-time employee working on tobacco control. Other

NGOs have employees working on tobacco control along with other prevention subjects. Furthermore, the

Danish partnership Smokefree Future currently includes 53 organisations, institutions, municipalities and pri-

vate companies working towards the aim of a smoke-free Denmark by 2030.

National tobacco control coordination bodies

The Danish Health Authority takes on a coordinating function between both governmental and non-govern-

mental players involved in tobacco control. However, this is not an official task assigned to the Danish Health

Authority.

National strategies and plans of action

In 2016, the Danish government adopted the goal of a smoke-free

generation, which aims to have no children or adolescents smoke by

2030. The existing Cancer Plan IV for 2017-2020 sets the following ob-

jectives to achieve the smoke-free generation goal:

•

Support smoke-free school hours at all schools and educational es-

tablishments, which are attended by young people under 18 years of

age. No separate funding is allocated to this objective.

Set up a voluntary partnership with the business community to en-

sure a more effective enforcement of the ban on underage sales of

tobacco and alcohol.

Initiate a campaign targeting smoking among children and young

people. DKK 14 million has been allocated to this objective for 2017-

2020.

Fund nicotine replacement therapy and prescription cessation medication for participants in municipal

smoking cessation courses.

DKK 26.5 million has been allocated to this objective for 2017-2019 through

the grant “Satspuljemidler,

19, 20

The allocation was based on the findings from the national grant “Storry-

gerpuljen”.

Provide smoking cessation services for cancer patients.

In 2016, the Danish

government adopted

the goal of a smoke-

free generation,

which aims to have

no children or

adolescents smoke

by 2030

No formal strategy, sub goals or milestones have been set for reaching the goal of a smoke-free generation

by 2030.

Key findings

There is no comprehensive national action plan or strategy to reach the goal of a smoke-free

generation by 2030

Denmark has no comprehensive national tobacco control plan aimed at achieving the goal of a smoke-free

generation by 2030. The current tobacco control activities funded under Cancer Plan IV are insufficient to

have an impact on tobacco prevalence to a degree that will lead to the realization of the goal. They do not live

up to the WHO FCTC Article 5.1 obligation to “develop,

implement, periodically update and review comprehen-

sive multisectoral national tobacco control strategies, plans and programmes.”

There is a strong local political will to work on tobacco control

Several stakeholders noted that there seems to be more political interest in advancing the tobacco control

agenda in the regions and municipalities than there is at national level, although the means and political reach

at local level are more limited. Both the Local Government Denmark (Kommunernes Landsforening) and the

Regions of Denmark (Danske Regioner) have recently launched prevention initiatives, which emphasise the

need for efficient and well coordinated tobacco control within regions and municipalities and call for further

national action in tobacco control.

21, 22

There is no sufficiently funded coordinating mechanism for tobacco control

The Danish Health Authority along with the Ministry of Health are currently the main actors responsible for

coordinating tobacco control activities in Denmark. However, with an estimated total of three full-time em-

ployees dedicated to tobacco control, their resources are inadequate for the task as a coordinating mechanism

with an overview of tobacco control in Denmark.

Activities of organised civil society have not yet reached their full potential

Civil society organisations have great potential to influence national tobacco control policy and express both

the will and determination for united action to decrease the prevalence of tobacco. In the stakeholder inter-

views, many organisations noted a sense of momentum for creating change in the field of tobacco control and

were inspired by new voices and a renewed focus on the potential for reducing the massive negative conse-

quences of tobacco on health, the economy and social equality.

More research in tobacco control is needed

The stakeholder interviews demonstrated a need for further coordination in tobacco control research and for

more studies on tobacco control interventions, policies and advocacy possibilities, adapted to the Danish context.

Denmark has not fully implemented the WHO FCTC

The WHO FCTC is an evidence-based treaty to which Denmark is legally bound. However, Denmark has not

fully implemented the treaty, and both governmental and non-governmental actors in tobacco control seem to

have a low awareness of the WHO FCTC obligations and its implementation guidelines.

This concerns the WHO FCTC provisions on general obligations (Article 5), price and tax measures to reduce

the demand for tobacco (Article 6), protection from exposure to tobacco-smoke (Article 8), packaging and

labelling of tobacco products (Article 11), education, communication, training and public awareness (Article

12), tobacco advertisement, promotion and sponsorship (Article 13), demand reduction measures concerning

tobacco dependence and cessation (Article 14) and illicit trade in tobacco products (Article 15). In stakeholder

interviews it was furthermore noted that the ban on tobacco sales to minors (Article 16) is currently not prop-

erly enforced.

Recommendations

Adopt a comprehensive national action plan or strategy for tobacco control

In order to reduce the prevalence of smoking, the government and parliament, in consultation with relevant

ministerial departments and civil society, should set up a comprehensive national action plan for tobacco con-

trol. According to WHO FCTC Article 5 “Each

Party shall develop, implement, periodically update and review

comprehensive national tobacco control strategies, plans and programme in accordance with this Convention

and the protocols to which it is a Party.”

Reducing the prevalence of tobacco will need the coordinated efforts and ressources of all governmental or-

ganisations under a well-designed national plan. The national plan should set specific targets and strategies

for short and long-term action. As well as programs directed at the overall community, special attention should

be paid to reducing smoking among children and adolescents, as well as among high-risk groups including

socially disadvantaged citizens and pregnant women. The action plan should outline recommendations, re-

sponsibilities, necessary actions, monitoring and timeframe. Key measures of the plan should be the full im-

plementation of the FCTC including the prioritized measures recommended in this assessment.

The government should set up a stronger national coordinating mechanism

Establishing mechanisms to coordinate a multisectoral approach based on the treaty’s provisions, guidelines

and protocol with the involvement of the different stakeholders and the strong leadership of the Ministry of

Health would improve and strengthen the current tobacco control. The government needs to pay special atten-

tion to the coordination of interministerial efforts as tobacco control not only applies to the health ministry

and agencies, but also to other relevant government programmes and agencies, including those that deal with

taxation and commerce. As mandated by WHO FCTC Article 5.2.a, Denmark should “reinforce

and finance a

national coordinating mechanism or focal points for tobacco control.”

Denmark should provide more human and financial resources for tobacco control

The current levels of government funding to tobacco control do not allow a sufficient workforce to monitor

current tobacco control activities, propose new efforts and liaise with relevant partners in tobacco control, all

of which are necessary to reach the goal of a smoke-free generation by 2030. The budget allocation to tobacco

control from the government should reflect the magnitude and urgency of the problem – the country’s larg-

est preventable cause of death and disease – and should be adjusted to the current goal and future strategies

adopted to reach a smoke-free generation by 2030.

It is further recommended that additional resources are allocated to improve funding and coordination of the

national research environment in tobacco control.

Reducing the

prevalence of

tobacco will need the

coordinated efforts

and resources of all

governmental and

non-governmental

organisations under

a well-designed plan

Civil society should participate more actively in tobacco control

activities

Civil society in Denmark can play a much more active role in promoting

tobacco control activities and can be a strong partner for the government

by working towards common goals. This role may include promoting new

legislative initiatives and their enforcement or helping to build public sup-

port for new policy proposals. While civil society organisations are already

quite numerous and involved in the tobacco agenda, NGOs and health pro-

fessional associations should look to strengthen their coordination through

joint action and by speaking with one voice in support of the common goal.

The Smokefree Future partnership is a potential platform for this, and

the partnership should be strengthened through the participation of new

stakeholders and common activities.

To achieve the goal of a smoke-free generation by 2030, Denmark should strengthen the protection

of children and adolescents from tobacco and fully implement the WHO FCTC

The WHO FCTC and its guidelines provide a roadmap of cost-effective, evidence-based and intersectoral to-

bacco control measures. The Danish government should take a stronger leadership role in implementing all

the provisions of the WHO FCTC as soon as possible, particularly in order to address the interministerial and

intersectoral issues arising from the implementation of the WHO FCTC.

Chapter 3

COUNTERING TOBACCO

INDUSTRY INTERFERENCE

WHO FCTC Article 5.3

In setting and implementing their public health policies with respect to tobacco control,

Parties shall act to protect these policies from commercial and other vested interests of the

tobacco industry in accordance with national law.

Policy status and development

British American Tobacco, Philip Morris and Japan Tobacco are the major tobacco companies in Denmark, that

dominate the cigarette market.

British American Tobacco is the owner of leading local brands like Prince,

LA, Kings, Look and Cecil, which were acquired in the takeover of the Danish tobacco manufacturer House of

Prince in 2008. Cigarette production by British American Tobacco in Denmark ended in 2011.

According to WHO FCTC Article 5.3, Denmark is obliged to protect the setting and implementation of public

health policies from the commercial and other vested interests of the tobacco industry. Its guidelines

and

later the United Nations General Assembly has clearly indicated that there is a fundamental conflict between

the interests of the tobacco industry have and the interests of public health policy.

In Denmark, no explicit measures exist to avoid the interference of the tobacco industry in public health poli-

cies, or the possibility to influence policy-makers or the public. Only general rules and codes of conduct have

been identified, which solely concern public employees and which are not specific to tobacco.

Key findings

The tobacco industry is actively working to influence policymakers and the public. However, only a

small part of their activities are known

Representatives from the tobacco industry have advanced their own propositions in response to proposals for

tobacco control legislation and have sought to influence policy in direct contravention of Article 5.3, including

through media statements on various topics e.g. promotion of smoking in TV-series

and of unproven harm

reduction products.

However, the stakeholders interviewed indicated that only a small part of the tobacco

industry marketing strategies and how they try to influence tobacco control policy are known.

Interactions between the government and the tobacco industry lack transparency

No formal rules or adopted guidelines requiring transparency of meetings and activities held between govern-

ment or parliamentary representatives and the tobacco industry were identified.

The government works with the tobacco industry on illicit trade,

but has not ratified the WHO FCTC Protocol to Eliminate Illicit

Trade in Tobacco Products

The Danish government has not ratified the WHO FCTC Protocol to

Eliminate Illicit Trade in Tobacco Products (the Protocol). It has engaged

in a partnership with the tobacco industry with the proclaimed objective

“to

fight contraband and counterfeiting of tobacco products.”

The tobacco

industry is actively

working to influence

policymakers and the

public

Article 8 of the Protocol indicates that the responsibility for the tracking

and tracing of tobacco products cannot be assigned or delegated to the

tobacco industry because their operations are the subject of control under these provisions. Therefore, each

Party must limit its interaction with the tobacco companies to the minimum that is strictly necessary.

A WHO report shows evidence indicating that tobacco industry representatives have developed joint and indi-

vidual strategies to interfere with the implementation of Protocol policies.

The same report highlights the fact

that tobacco companies have been accused of direct and indirect involvement with cigarette smuggling.

31, 32, 33

The tobacco industry strategically works to appear socially responsible

According to the Article 5.3 guidelines, “the

tobacco industry conducts activities described as socially respon-

sible to distance its image from the lethal nature of the product it produces and sells or to interfere with the

setting and implementation of public health policies.”

In Denmark, one example of this approach is demonstrated through the proclaimed wish of Philip Morris to

help people go smoke-free. The company has actively targeted the parliamentary health committee and was

granted a meeting to present the committee with their novel heated tobacco products and their vision of a

smoke-free world.

35, 36

Recommendations

Raise awareness of the methods and tactics of the tobacco industry

Both NGOs and the government need to increase awareness among the public and all branches of the gov-

ernment about the need to protect public health policies related to tobacco from the interests of the tobacco

industry. The strategies and tactics used by the tobacco industry to interfere with public health policies related

to tobacco need to be denounced and monitored as specified in the Article 5.3 guidelines.

Establish immediate measures to limit interactions of public officials and civil servants with the to-

bacco industry and ensure the transparency of any interactions that occur

The Article 5.3 guidelines recommend that Parties “interact

with the tobacco industry only when and to the

extent strictly necessary to enable them to effectively regulate the tobacco industry and tobacco products.”

interactions with the tobacco industry are necessary, governments should ensure that such interactions are

limited to the role set out in Article 5.3, conducted transparently and in public and that records of such interac-

tions are disclosed to the public. All the propositions of the Article 5.3 guidelines should be fully implemented

in Denmark.

The government should prohibit, or at least mandate the disclosure

of, the tobacco industry’s donations of funds and in-kind contri-

butions to political parties, trade unions or their foundations, and

think tanks

The Article 5.3 guidelines recommend that governments should have ef-

fective measures to prohibit contributions from the tobacco industry or

any entity working to further its interests to political parties, candidates

or campaigns, or it should require full disclosure of such contributions.

The Danish government should therefore prohibit donations from the

tobacco industry or, as a minimum, disclose to the public all details of

such contributions.

Governments should

have effective

measures to prohibit

contributions from

the tobacco industry

Do not invest in the tobacco industry

According to the guidelines of Article 5.3, Parties should not invest in the tobacco industry or related ventures.

Monitor the activities of the tobacco industry

Monitoring the implementation of WHO FCTC Article 5.3 and the activities of the tobacco industry is essential

to ensure efficient tobacco control policies. It is crucial to keep up to date with changes in the country’s tobac-

co market in order to anticipate opposition to new tobacco control policies. Governmental organisations and

members of civil society not affiliated with the tobacco industry must monitor the market development, mar-

keting strategies and public affairs activities of the tobacco industry, including for instance the development of

new and flavoured products with special appeal to young people. Existing guidelines for industry monitoring

are available.

37, 38, 39, 40

The activities of the

tobacco industry

to appear socially

responsible fall

under the scope

of advertising,

promotion and

sponsorship within

the WHO FCTC

Ratify the WHO FCTC Protocol on illicit trade and cease the part-

nership with the tobacco industry

Following the Protocol, Denmark should establish a track and trace sys-

tem that is independent of the tobacco industry, and it should cease all

agreements with the tobacco industry in the fight against illicit trade.

The CSR strategies of the tobacco industry should be denormalised

and if possible regulated

According to Article 5.3 guidelines, the activities of the tobacco industry

to appear socially responsible fall under the scope of advertising, promo-

tion and sponsorship within the WHO FCTC. In line with the guidelines,

it is recommended that the Danish government ensure that all branches

of government and the public are well informed of the true purpose of

such activities. In addition, it is recommended that the Danish govern-

ment does not endorse, support or form partnerships with or participate

in such CSR activities.

Chapter 4

INCREASING PRICE THROUGH

TAXATION

WHO FCTC Article 6

The Parties recognize that price and tax measures are an effective and important means of

reducing tobacco consumption by various segments of the population, in particular young

persons ... each Party should ... adopt or maintain ... tax policies and, where appropriate,

price policies, on tobacco products so as to contribute to the health objectives aimed at re-

ducing tobacco consumption.

Policy status and development

Cigarettes are subject to a specific excise tax of DKK 1.18 (EUR 0.16) per stick and 1 % of the retail price (excise

rate). Tobacco products are also subject to a value added tax rate of 20 % on the retail price. The total tax rate

is 79.7 % of the Weighted Average Price of the tobacco product. Fine cut smoking tobacco, used for rolling ciga-

rettes, is subject to a specific excise duty of DKK 788.50 (EUR 105.9) per kg.

The average price for a pack of 20

cigarettes is DKK 40.35 (EUR 5.42) (December 2017).

In January 2014, the Danish government increased tobacco taxes to the current level, which represented an

increase of DKK 0.40 (EUR 0.05) per average pack of 20 cigarettes.

Since the 1980s, prices of tobacco products

have followed a price development similar to other consumer goods, and when corrected for the development

in disposable household income they have become more affordable.

Key findings

Denmark is the EU member state with the second most

affordable cigarettes

The most popular brand of cigarettes in Denmark is 3.4 times more af-

fordable than in the EU country with most expensive cigarettes.

A vast

amount of research shows that higher taxes and prices on tobacco leads

to reductions in overall tobacco use, especially among young people and

people with low incomes.

46, 47

Although the affordability of cigarettes has

Higher taxes and

prices on tobacco

leads to reductions

in overall tobacco

use, especially

among young people

decreased since 2008 in Denmark (but not since 2014), 18 EU member states have decreased affordability at a

faster rate than Denmark.

The price difference between the cheapest and the

premium cigarette brand is too broad in Denmark

The price difference between the cheapest and the premium brand of

cigarettes

indicates the scope that smokers have to move to cheaper

brands when price increases occur. In Denmark, the price of the cheap-

est cigarette brand is 79 % of the price of the premium cigarette brand.

Compared to the other EU member states, Denmark is placed 16th out

of 28 in terms of price dispersion between the cheapest and premium

cigarette brands.

Denmark is the EU

member state with

the second most

affordable cigarettes

The guidelines for the implementation of Article 6 (Article 6 guidelines) note, “Parties

should ensure that tax

systems are designed in a way that minimizes the incentive for users to shift to cheaper products in the same

product category or to cheaper tobacco product categories as a response to tax or retail price increases or other

related market effects.”

There is a general concern that the increase of tobacco taxes leads to cross-border and illicit trade

In the public debate on increasing tobacco taxes and prices there is a general concern that higher prices will

lead to increased cross-border trade and illicit trade.

49, 50, 51

However, illicit trade does not increase as a result of

tobacco taxation. Article 6 guidelines note that many Parties have raised tobacco taxes effectively and experi-

enced revenue increases without increases in illicit trade. A WHO review further finds no association between

high tobacco taxes and high levels of illicit trade. Illicit trade is more common in countries where governance

is poor, whether taxes are high or low.

Cross-border trade is particularly an issue when great disparities in

prices exist in neighbouring countries. The WHO therefore recommends: “Raising

tobacco taxes and prices

should be a coordinated effort with neighbouring countries; this is a key point within the WHO FCTC. The new

Protocol to Eliminate Illicit Trade in Tobacco Products, currently open for ratification, facilitates cross-border

cooperation for effective control.”

The public is supportive of price increases for tobacco

A majority of the

Danish population

supports higher

prices on tobacco

products

A majority of the Danish population supports higher prices on tobacco

products: 64 % are positive towards increasing the price to 60 DKK per 20

cigarettes, corresponding to a 50 % price increase.

Expressed as the share of cheapest brand price in premium brand price in international dollars at purchasing power parity.

Recommendations

Decrease the affordability of cigarettes by increasing tobacco taxes at regular intervals

As mandated by the WHO FCTC, tax policies and price policies on tobacco products should be set in order to

contribute to the reduction of tobacco consumption. This is particularly important to protect young people

and low-income groups from the dangers of tobacco, as these groups are generally more responsive to changes

in the price of tobacco products.

As recommended by Article 6 guidelines, “Parties

should establish coherent long-term policies on their tobacco

taxation structure and monitor (these policies) on a regular basis including targets for their tax rates, in order

to achieve their public health and fiscal objectives within a certain period of time.”

Adopt similar tax burdens for different tobacco products

All tobacco products should be taxed in a comparable way to avoid the risk of smokers shifting to cheaper

brands or to cheaper tobacco products following a tax increase on one product (i.e. shifting from cigarettes to

roll-your-own tobacco) (Article 6 guidelines).

Ratify the WHO FCTC Protocol on illicit trade to curb illicit trade and cross-border trade

According to the Protocol to Eliminate Illicit Trade in Tobacco Products, tobacco tax increases should be ac-

companied by “stronger,

cooperative systems to curb illicit tobacco trade. This includes measures such as licens-

ing, regulations on international transit, and sanctions applicable to those complicit in illicit tobacco trade.”

Chapter 5

PROTECTION FROM EXPOSURE

TO TOBACCO SMOKE

WHO FCTC Article 8

Each Party shall adopt and implement ... measures, providing for protection from exposure

to tobacco smoke in indoor workplaces, public transport, indoor public places and, as ap-

propriate, other public places.

Policy status and development

The smoke-free environments Act of 2007

as amended in 2012

mandates protection of people from ex-

posure to second-hand smoke. Smoking is prohibited in workplaces and public places and since 1 April 2017,

smoking is banned in prisons.

The smoking ban is, however, subject to several exemptions. Smoking is al-

lowed in designated smoking rooms and smoking cabins in workplaces and in bars and pubs of less than 40

. Smoking is not prohibited in workplaces that function as the private home of residents e.g. nursing homes.

Other exemptions to the smoking ban include schools in which the majority of students are over 18 years old,

such as the majority of vocational schools. Smoking is allowed in private day care homes outside of day care

hours and in rooms other than those, which the children primarily use. Smoking is also allowed in homeless

shelters.

The smoke-free environments law sets out minimum standards for

smoke-free environments and workplaces are free to introduce rules that

ensure better protection from tobacco smoke. Private workplaces can

choose to establish smoking rooms, but many work places, especially

public ones, choose to be completely smoke-free indoors.

60 % of health care

workers report being

exposed to second-

hand smoke at work

Although the law on smoke-free environments allows smoking rooms or

cabins in workplaces, three out of five Danish regions and 21 of the 98

Danish municipalities have implemented a “smoke-free work hours” policy. This means that employees in the

regional or municipal workplaces in question are not allowed to smoke during work hours. Three out of the 21

municipalities have implemented a complete “smoke-free work hours” policy and 18 have adopted a weaker

policy where smoking is allowed for employees who have self-paid breaks.

The agencies in charge of enforcing the legislation to protect Danes from second-hand smoke are the Danish

Working Environment Authority under the Law on the Working Environment as well as the Danish Maritime

Authority and the Ministry of Transport, Building and Housing.

The work of the Danish Working Environment Authority in supervising enforcement of the smoke-free envi-

ronments law takes place in association with the Authority’s routine visits to companies, and they can be part

of a risk-based supervision or a sample check.

In 2017, the Working Environment Authority made 319 orders

relating to the smoke-free environments law.

Key findings

Exposure to second-hand smoke is still a challenge and some groups are heavily exposed to

second-hand smoke

Smoking in small bars and pubs presents a significant source of exposure to second-hand smoke for patrons

and workers. About a third (34%) of Danes who visited a bar in 2016 reported seeing smoking.

Exposure to second-hand smoke in other workplaces is seemingly less frequent than exposure to second-hand

smoke in bars. In 2017, 9 % of Danish employees reported that indoor smoking took place at their workplace

and 6 % reported that there were designated smoking rooms or cabins at their workplace.

Some groups are

particularly exposed to second-hand smoke in their work environment. Among health care workers, 60 %

report being exposed to second-hand smoke at work.

Children in private spaces such as homes and cars are not protected against exposure to second-hand smoke.

In 2017, 80 % of the general population had smoke-free homes and 54 % of smokers never allowed smoking in-

side their home. 4 % of smokers reported that they had smoked inside cars when children were present.

Dan-

ish research has found that there is a significantly higher likelihood for a child to be exposed to second-hand

smoke at home if the parent has a low level of education compared to a higher level of education.

The Danish population is generally in favour of more comprehensive smoking restrictions

In Denmark, 73 % of the population supports the current smoke-free environments law and 14 % does not

support it.

There is also support for a complete ban on smoking in private day care homes (69 % support) and

for banning smoking in private cars when children are present (71 % support).

Interviewed stakeholders were

very interested in seeing national legislation on smoke-free school hours with a ban on tobacco use – both

indoors and outdoors for students and teachers.

Legal smoke-free provisions do not comply with WHO FCTC Article 8 guidelines

Denmark does not comply with the international standards set forth by the WHO FCTC in the guidelines for

the implementation of WHO FCTC Article 8 (Article 8 guidelines).

The guidelines state that “all

indoor work-

places and indoor public places should be smoke free,”

and that “legislation

is necessary to protect people from

exposure to tobacco smoke. Voluntary smoke free policies have repeatedly been shown to be ineffective and do

not provide adequate protection.”

Recommendations

Improve legislation to protect children and adults from exposure to second-hand smoke

The objective of WHO FCTC Article 8 is to protect non-smokers fully and without exceptions. To this end, the

scientific evidence shows that only well enforced legislation in all workplaces and public places can protect

non-smokers fully from the harmful effects of second hand smoke. A comprehensive smoking ban would en-

sure better compliance and understanding among government agencies and the general population.

To be comprehensive the ban must eliminate the option of creating smoking rooms in workplaces, whether

ventilated or not, and it must eliminate exemptions to the smoking ban in small bars, at vocational schools, in

private day care homes, as well as in other public places. This should be supplemented with the introduction of

smoke-free school hours, including assistance to schools with implementation and appropriate enforcement

strategies.

Protect minors from second-hand smoke in private homes and cars

through evidence-based mass media campaigns and by legislation

as appropriate

The level of protection of minors from second-hand smoke needs to be

improved. As children and adolescents are less likely to have the choice

to avoid exposure in private spaces such as homes and cars, protecting

their health becomes a matter of human rights.

69, 70

Parents and caregivers of children should be informed of the health risks

of children exposed to second-hand smoke. They should be advised that

only completely smoke-free homes and cars offer adequate protection

for children and they should be advised not to smoke near children –

even when outside. Denmark should consider adopting legislation to

further protect children in indoor private spaces such as Norwegian and Icelandic legislation, which obliges

parents and caregivers to protect children against exposure to second-hand smoke.

71, 72

... only well enforced

legislation in all

workplaces and

public places can

protect non-smokers

fully from the

harmful effects of

second hand smoke

Inform the public about the dangers of exposure to second-hand smoke and of necessary actions to

reduce exposure to second-hand smoke in private and public spaces

Independent of a possible improvement to the smoke-free legislation, there is a need for regular campaigns

that enhance information to the public about the dangers of exposure to second-hand smoke and the neces-

sary actions needed to reduce exposure to second-hand smoke in private and public spaces.

The government should, along with NGOs and relevant stakeholders,

1. develop and implement an evidence-based communications strategy in order to improve protection of

children from exposure to second-hand smoke in private spaces;

2. raise awareness and mobilise support among key stakeholders and the public for eliminating the exemp-

tions to the smoking ban; and

3. protect employees and citizens against the dangers of second-hand smoke.

Chapter 6

WARNING PEOPLE OF THE

DANGERS OF TOBACCO

WHO FCTC Article 11

Each Party shall … ensure that tobacco product packaging and labelling do not promote a

tobacco product by any means that are false, misleading [or] deceptive … Each Party shall

… ensure that … tobacco products … carry health warnings describing the harmful effects

of tobacco use.

Policy status and development

Following provisions of the EU Tobacco Products Directive, since 2016 Danish law has mandated 15 rotating

pictorial health warnings that appear on cigarette packaging covering 65 % of the principal display areas on

the front and rear of the pack, as well as the display of the telephone number and website of the national quit

line on tobacco packaging. Denmark uses warnings from the EU picture library.

However, the EU Tobacco Products Directive allows Member States to go beyond the obligatory measures on

packaging

and implement plain packaging of tobacco products.

Key findings

Denmark has not implemented plain packaging

Plain packaging is recommended in the guidelines for the implementation of the WHO FCTC articles 11 and

13.

76, 77

Article 11 guidelines state, “Parties

should consider adopting measures to restrict or prohibit the use of

logos, colours, brand images or promotional information on packaging other than brand names and product

names displayed in a standard colour and font style (plain packaging). This may increase the noticeability and

effectiveness of health warnings and messages, prevent the package from detracting attention from them, and

address industry package design techniques that may suggest that some products are less harmful than others.”

Independent comprehensive reviews of experimental evidence prior to introducing legislative proposals from

the United Kingdom and Ireland, as well as the 2016 post implementation review of Australian plain packaging,

conclude that plain packaging is effective for reaching its objectives as part of a comprehensive approach.

78, 79, 80

Field experiments with adult smokers in the United Kingdom and France have found that plain packaging is

associated with less positive perceptions of the pack and product, lower brand attachment and less positive

feelings about smoking.

81,82

The Danish Health Authority estimates that the 2016 smoking prevalence in Denmark would have been 20.5 %

and that there would have been 26,313 fewer smokers in the age group 15+ years if plain packaging of tobacco

products had been introduced in Denmark 34 months prior to 2016 (subject to model uncertainty). This com-

pares to a smoking prevalence of 21.1 % in the fourth quarter of 2016.

Recommendations

Implement plain packaging

Denmark should introduce plain packaging. To prepare the implemen-

tation of plain packaging it is recommended to carry out independent

reviews of the effects of plain packaging in a national context and closely

follow international development in the area.

Plain packaging

would lead to 26,313

fewer smokers per

year in Denmark

Chapter 7

PUBLIC AWARENESS AND MASS

MEDIA CAMPAIGNS

WHO FCTC Article 12

Each Party shall promote and strengthen public awareness of tobacco control issues, using

all available communication tools, as appropriate.

Policy status and development

As a part of Cancer Plan IV, the Danish government has allocated DKK 14 million to a media campaign targeted

towards children and adolescents and run on social media channels used by the target group. The campaign is

administered by the Danish Health Authority and runs throughout 2017-2020.

Government funded national campaigns since 2009:

Year

2009/2010,

2011, 2012

2012-2013

2015, 2016

Name

“Every cigarette is doing you damage”

(Hver eneste cigaret skader dig)

“Smoking – Quit now”

(Rygning - Skod det nu)

“Help to stop smoking” (Hjælp til Rygestop):

Smoking cessation campaign launched

within the Grant ”Forstærket indsats over

for storrygere”

“BUT WHY”

Purpose

Smoking cessation campaign.

The campaign was targeted at preventing smoking among

young people.

The campaign addressed adult heavy smokers (≥ 15 cigarettes

per day) of lower education and pregnant women who smoke.

The purpose was to enhance their motivation to quit, to seek

help from their municipality and via the National quit line, and

to raise awareness of available cessation support.

The campaign aimed to change attitudes towards smoking and

hereby prevent young people from taking up smoking. The first

campaign wave has appeared in social media.

2017 (-2020)

The external evaluation of “Every cigarette is doing you damage” shows that the campaign had a significant

impact on the population. The campaign was in particular seen by smokers. 40 % of smokers stated that the

campaign gave them new knowledge about the health impact of smoking. The campaign caused 40 % of smok-

ers to consider quitting smoking and more than 10 % of smokers to make an attempt to quit.

The internal evaluation of the campaign “Help to stop smoking” (3rd boost), showed that awareness of the

campaign and of the national quit line increased during the campaign period. However, the evaluation found

that the reference to the national quit line on cigarette packs was particularly instrumental in achieving this.

While more than half of evaluation respondents found the campaign good or very good, 38 % found the cam-

paign to be relevant and 23 % had adjusted their behaviour accordingly.

Examples of tobacco control campaigns administered by NGOs include “Cool without Smoke” (Cool uden Røg)

(2015-2016) and “Say No” (Sig Nej) (2017) (part of Smokefree Future).

Year

2015, 2016

Name

“Cool without Smoke” (Cool uden Røg)

Purpose

The campaign aimed to prevent smoking initiation and

promote smoking cessation among young people by

focusing on smoking without blame. A secondary tar-

get was to increase knowledge and use of the smoking

cessation programme XHALE.

The campaign aimed to address smoking among

young people and was targeted young people (15-17

years) and their parents.

2017

”No” (Nej) (part of Smokefree Future

partnership)

The evaluation of “Cool without Smoke” showed that 50 % of 16-25 year olds had seen the campaign in 2015-

2016, and after seeing it 17 % of them had thought about whether smoking is cool or not. 15 % knew of the

youth smoking cessation programme XHALE after seeing the campaign. The campaign “No” was evaluated

exclusively with regards to social media response.

Key findings

Government-funded campaigns focus on high-risk groups

The mass media campaigns administered by the Danish Health Authority since 2009 have focused on high-

risk groups.

Recommendations

Ensure a current and evidence-based background for development

and evaluation of future campaigns

To increase the potential impact of future campaigns in tobacco control,

campaign administrators should ensure that education, communication

and training programmes “undergo

rigorous pre-testing, monitoring and

evaluation at local, national/federal, regional and/or international lev-

el.”

Evaluation of campaigns should be as current and evidence-based as

possible (Article 12 guidelines). Campaigns should be based on research

that is up to date with the current media landscape including dissemina-

tion in various social media channels.

Campaigns should

be based on research

that is up to date

with the current

media landscape

There is very strong

evidence that media

campaigns directed

specifically towards

children have limited

impact

Mass media campaigns with strong graphic images demonstrating

the harms of tobacco are shown to be effective with mass

audiences, including subgroups, and targeted campaigns for

different socioeconomic groups are not required

Creative media strategies and good media planning can reach smokers in

all socioeconomic groups, and are particularly effective in reaching those

in lower socioeconomic groups. There is also very strong evidence that

while media campaigns directed specifically towards children have limit-

ed impact, sustained, hard-hitting, adequately funded media campaigns

directed at adults also reach young people and are effective in reducing

smoking among this group.

85, 86

Campaign administrators should note the recommendation of the Ar-

ticle 12 guidelines to disseminate the message “as widely as possible”,

and run hard-hitting, sustained, community-wide media campaigns. It

is essential that funding for such campaigns is adequate both to ensure

appropriate reach and to be consistent with the urgency and magnitude

of the problem.

Additional evidence-based information campaigns are needed in

support of some of the new policies proposed in this report

NGOs and the Danish Health Authority need to consider increasing

awareness and public support for a number of the specific tobacco con-

trol policies proposed in this report, including information on tobacco

industry tactics.

Campaign

administrators

should disseminate

the message “as

widely as possible”,

and run hard-

hitting, sustained,

community-wide

media campaigns

Chapter 8

BANNING ADVERTISING,

PROMOTION AND SPONSORSHIP

WHO FCTC Article 13

Each Party shall ... undertake a comprehensive ban of all tobacco advertising, promotion

and sponsorship.

Policy status and development

Direct tobacco advertising is banned in Denmark except at retailer point of sales, e.g. shops and supermarkets.

However, the following forms of promotion of tobacco are allowed:

•

Branding of tobacco packaging

Display of products at point of sale

Appearance of tobacco products in TV and/or films and when they do, anti-tobacco advertisements are not

required

Vending machines (no complete ban)

Internet sales of tobacco products

In addition, tobacco companies are allowed to fund or make contributions (including in-kind contributions) to

smoking prevention media campaigns, including those directed at young people. Tobacco companies are not

prohibited from conducting CSR activities. According to Article 5.3 guidelines, these activities fall under the

scope of advertising, promotion and sponsorship within the WHO FCTC.

Key findings

The existing legislation on tobacco advertising, promotion and sponsorship is well-intentioned

however not comprehensive enough

The existing legislation on tobacco advertising, promotion and sponsorship does not cover certain forms of

promotion to which children and young people are most susceptible. These include branding of tobacco pack-

aging and display of products at point of sale. As a result of the tight rules against tobacco advertising, the

point-of-sale display of tobacco in retail establishments remains a way for the tobacco industry to advertise its

products by ensuring high visibility of tobacco products and using the pack as an advertising tool.

The tobacco industry uses legislation gaps to promote their products

There is clear evidence both from within Denmark and from other countries that tobacco companies seek out

and exploit any possible legislative loopholes in their efforts to promote their products.

The Office of the Dan-

ish Consumer Ombudsman has prosecuted possible cases of illegal promotion of tobacco products. However,

the Ombudsman has been unsuccessful in convicting flagrant cases of promotion due to the limitations of the

Danish legislation in regulating advertising, promotion and sponsorship of tobacco. These cases have involved

the promotion of tobacco at cultural events and the display of tobacco products in illuminated power walls in

convenience stores.

Young people more

frequently exposed to

point-of-sale tobacco

displays are around

1.6 times more likely

to experiment with

smoking

The tobacco industry promotes their products at music festivals

and other cultural events

The tobacco industry pays music festivals large sums through undis-

closed agreements in exchange for exclusive rights and activities.

89, 90

The

industry uses music festivals to promote new products, which seem to

specifically target adolescents. A study of Roskilde Festival in 2009 con-

cluded that 9 % of people who had never smoked started smoking at the

festival. An additional 24 % of ex-smokers that had not smoked for more

than a year relapsed into smoking while attending the festival.

There is increasing concern and lack of monitoring of online pro-

motion of tobacco products

There is an increasing concern among stakeholders in Danish tobacco control about the promotion of tobacco

products via the internet and social media. However, no data from these tobacco industry marketing strategies

have been published in Denmark. It has been documented globally that tobacco companies often promote

their products on online sites with a large number of children and adolescent users, such as Facebook and

YouTube and as product placement in gaming videos.

92, 93

Recommendations

Ban the display of tobacco products at point-of-sale

As recommended by the guidelines for the implementation of WHO

FCTC Article 13 (Article 13 guidelines), Denmark needs to ensure that

there are no promotional elements at the point of sale for tobacco prod-

ucts. Therefore, Denmark should introduce a total ban on any display

and on the visibility of tobacco products at points of sale, including

fixed retail outlets and street vendors.

Only the textual listing of products and their prices, without any pro-

motional elements, and in a form strictly regulated by the government

should be allowed.

A recent meta-analysis found that young people more frequently exposed

to point-of-sale tobacco displays are around 1.6 times more likely to ex-

Tobacco companies

promote their

products on online

sites with a large

number of children

and adolescent users,

such as Facebook

and YouTube and as

product placement in

gaming videos

periment with smoking and around 1.3 times more likely to be susceptible to smoking in the future, compared

with those less frequently exposed.

Banning point-of-sale tobacco displays reduces the exposure of tobacco

marketing among children and adolescents, and is likely to reduce impulse purchases and provide a supportive

environment for smokers wanting to quit. Countries that have implemented bans have seen large reductions in

smokers’ reported exposure to advertising, with impulse purchases also reduced.

Implement a comprehensive ban on advertising, promotion and sponsorships

According to the definitions in Article 1 of the WHO FCTC, a comprehensive ban on all tobacco advertising,

promotion and sponsorship applies to all forms of commercial communication, recommendation or action

and all forms of contribution to any event, activity or individual with the aim, effect or likely effect of promot-

ing a tobacco product or tobacco use either directly or indirectly. This includes, but is not limited to, a ban on

contributions from the tobacco industry to music festivals or other events, activities and individuals, a com-

plete ban on vending machines and a ban on internet sales of tobacco.

Chapter 9

HELPING SMOKERS QUIT

WHO FCTC Article 14

Each Party ... shall take effective measures to promote cessation of tobacco use and adequ-

ate treatment for tobacco dependence.

Policy status and development

Denmark has a national toll-free telephone quit line (Stoplinien) providing counselling and/or referral to mu-

nicipal cessation services. The service is operated by trained smoking cessation professionals using motiva-

tional interviewing. Internet based, tailored smoking cessation programmes are available for adult and young

smokers free of charge. The effects of the smoking cessation services offered by the municipalities are moni-

tored by the WHO Collaborating Centre “Rygestopbasen”.

Most municipalities offer one or more free smoking cessation services, primarily in municipal settings, but

some also at pharmacies, hospitals or in agreement with private providers. In 2016, there were 10,272 partic-

ipants on all national smoking cessation courses, and 1.1 % of smokers in Denmark received quality assured

smoking cessation treatment.

The Danish Health Authority recommends that municipal smoking cessation

services reach 5 % of the smokers in each municipality per year.

The Danish Health Authority published the

national smoking cessation guidelines in 2011

and further recommendations for smoking cessation in 2016.

A recent study in Denmark found that 33 % of smokers who attended smoking cessation courses, succeeded in

quitting and were continuously abstinent after 6 months.

100

There are considerable differences in attendance at smoking cessation courses and in success rates across the

municipalities.

101

In 2017, the self assessed status of smoking cessation services across all municipalities found that the most

commonly offered service was referral to national cessation services (92 % of the municipalities) and group-

based smoking cessation courses (86 % of the municipalities). 51 % of the municipalities offered smoking

cessation specifically targeting pregnant women. 68 % of the municipalities offered cessation services, where

the municipality actively contacted citizens and informed about the possibility of smoking cessation services,

mainly in educational facilities with a high number of smokers (i.e. vocational schools).

102

Key findings

The majority of Danish smokers want to stop smoking

61 % of the daily smokers in Denmark would like to stop smoking.

103

Denmark has a comprehensive smoking cessation approach

Compared to other EU countries, Denmark offers a comprehensive

package of smoking cessation services.

104

61 % of the daily

smokers in Denmark

would like to stop

smoking

Recommendations

Ensure a minimum of effective smoking cessation services to all citizens and strengthen national

coordination across municipalities

Smoking cessation services offered across municipalities should be standardised based on lessons learnt from

most effective municipal services. All health care workers should be “trained

to record tobacco use, give brief

advice, encourage a quit attempt, and refer tobacco users to specialised tobacco dependence treatment services

where appropriate.”

(Article 14 guidelines). Article 14 guidelines highlights that “Parties

should … ensure that

all tobacco users are identified and provided with at least brief advice.”

Coordination should be improved between actors involved with smoking cessation services to further im-

prove the common standard of services and the referral system. Article 14 guidelines note that Parties should

“Ensure

that the national coordinating mechanism or focal point facilitates the strengthening or creation of a

programme to promote tobacco cessation and provide tobacco dependence treatment.”

Take a proactive approach to smoking cessation as social inequality in smoking is increasing and find

new ways to reach smokers from lower social economic groups

As social inequality in smoking is increasing,

105

smoking cessation services should prioritise reaching citizens

with a lower social economic status, vulnerable groups such as pregnant women and those with pre-existing

conditions. Proactive rather than passive services should be strengthened and standardised across municipal-

ities. Over the past 25 years, multiple large randomised trials conducted in various settings demonstrate that

telephone-based counselling, especially when proactive call back to quitters was included, increased cessation

rates in the long-term.

106

Annex 1 : Overview of the recommendations

Chapter 2

Policy coordination and implementation

•

Adopt a comprehensive national action plan or strategy for tobacco control

The government should set up a stronger national coordinating mechanism

Denmark should provide more human and financial resources for tobacco control

Civil society should participate more actively in tobacco control activities

To achieve the goal of a smoke-free generation by 2030, Denmark should strengthen the protection of

children and adolescents from tobacco and fully implement the WHO FCTC

Chapter 3

Countering tobacco industry interference

•

Raise awareness of the methods and tactics of the tobacco industry

Establish immediate measures to limit interactions of public officials and civil servants with the tobacco

industry and ensure the transparency of any interactions that occur

The government should prohibit, or at least mandate the disclosure of the tobacco industry’s donations of

funds and in-kind contributions to political parties, trade unions or their foundations, and think tanks

Do not invest in the tobacco industry

Monitor the activities of the tobacco industry

Ratify the WHO FCTC protocol on illicit trade and cease the partnership with the tobacco industry

The CSR strategies of the tobacco industry should be denormalised and if possible regulated

Chapter 4

Increasing price through taxation

•

Decrease the affordability of cigarettes by increasing tobacco taxes at regular intervals

Adopt similar tax burdens for different tobacco products

Ratify the “Protocol to eliminate illicit trade” to curb illicit trade and cross-border trade

Chapter 5

Protection from exposure to tobacco smoke

•

Improve legislation to protect children and adults from exposure to second-hand smoke

Protect minors from second-hand smoke in private homes and cars through evidence-based mass media

campaigns and by legislation as appropriate

Inform the public about the dangers of exposure to second-hand smoke and of necessary actions to reduce

exposure to second-hand smoke in private and public spaces

Chapter 6

Warning people of the dangers of tobacco

•

Implement plain packaging

Chapter 7

Public awareness and mass media campaigns

•

Ensure a current and evidence-based background for development and evaluation of future campaigns

Mass media campaigns with strong graphic images demonstrating the harms of tobacco are shown to be

effective with mass audiences, including subgroups, and targeted campaigns for different socioeconomic

groups are not required

Additional evidence-based information campaigns are needed in support of some of the new policies pro-

posed in this report

•

Chapter 8

Banning advertising, promotion and sponsorship

•

Ban the display of tobacco products at point-of-sale

Implement a comprehensive ban on advertising, promotion and sponsorships

Chapter 9

Helping smokers quit

•

Ensure a minimum of effective smoking cessation services to all citizens and strengthen national coordi-

nation across municipalities

Take a proactive approach to smoking cessation as social inequality in smoking is increasing and find new

ways to reach smokers from lower social economic groups

Annex 2: List of capacity assessment team members

•

Armando Peruga,

World Health Organization consultant on tobacco control and researcher at the Centre for Epidemiology and Health

Policy of the University of El Desarrollo, Santiago, Chile

Kristina Mauer-Stender,

Programme Manager, Tobacco Control, World Health Organization Regional Office for Europe, Copenhagen,

Denmark

Mike Daube,

Professor, Curtin University, Perth, Australia

Mervi Hara,

Executive Director, ASH Finland, Helsinki, Finland

Knud Juel,

Professor Emeritus, National Institute of Public Health, Copenhagen, Denmark

Charlotta Pisinger,

Associate Professor, Senior Researcher, Centre for Prevention and Health, Capital Region Denmark, Glostrup, Denm

Hanne Vibjerg,

Head of Section, Danish Health Authority, Copenhagen, Denmark

Jørgen Falk,

Independent consultant on tobacco control, Copenhagen, Denmark

Céline Brassart Olsen,

PhD Fellow, University of Copenhagen, Copenhagen, Denmark

Annex 3: Country focal point representatives

•

Astrid Knudsen,

Analysis and development consultant, Danish Cancer Society, Copenhagen, Denmark

Andrea Glahn,

Project leader, Danish Cancer Society, Copenhagen, Denmark

Annex 4: List of key stakeholders

Name

Peter Hamborg Faarbæk

Jacob Buch

Christine Højer Eriksen

Per Larsen

Lisbeth Holm Olsen

Ole Hilberg

Maja Bertram

Dina Schrøder

Bodil Hoier

Inge Ibsen

Karen Stæhr

Christina Toftegaard Nielsen

Arne Høst

Simon Rask

Dorthe Crüger

Niels Them Kjær

Else Smith

Position

Health policy advisor

Director of Supervision

Advisor, nurse

Chair

Advisor

Chair

Advisor

Educational consultant

Chief Physician

Chair of sector

Consumer Ombudsman

Chief physician and clinical

lecturer

Chief consultant

Chair

Head of project

Chair

Arbejdstilsynet

Astma-Allergi Danmark

Børnerådet

Center for forebyggelse I Praksis

Dansk Lungemedicinsk Selskab

Dansk Selskab for Folkesundhed

Dansk Sygeplejeråd

Danske Erhvervsskoler og

gymnasier

Familieambulatoriet Region

Syddanmark

FOA

Forbrugerombudsmanden

H.C. Andersens Børnehospital

Odense Universitetshospital

Hjerteforeningen

Kræftens Bekæmpelse

Kræftens Bekæmpelse,

Tobaksforebyggelse

Kræftens Bekæmpelses

Forebyggelsesudvalg

Institution/Organisation

Trade Union 3F

Danish Working Environment

Agency

Danish Asthma and Allergy Associati-

Children’s Council

Center for Prevention in Practice

Danish Society of Respiratory

Medicine

Danish Association for Public Health

Danish Nurses Council

Association of Danish Vocational and

High Schools

Family Clinic, South Denmark Region

Trade Union FOA

Danish Consumer Ombudsman

Children’s Hospital Odense Univer-

sity Hospital

Danish Heart Foundation

Danish Cancer Society

Danish Cancer Society, Tobacco

Prevention Unit

Prevention Council Danish Cancer

Society

Name

Camilla Kjærager

Anne Brandt

Andreas Rudkjøbing

Flemming Møller Mortensen

Position

Consultant

CEO

Chair

Member of Parliament, Health

spokesperson for the Danish

Social Democratic Party

Member of Parliament, Health

spokesperson for Venstre

Health coordinator

Chair

Vice-chair

Senior reseacher, midwife and

PhD

Legal principal

CEO

Project lead

CEO

Director of secretariat

Board member

Chair

Head of department

Professor of gynecology and

obstetrical nursing

Odontological advisor

Chair of the health committee

School leader

Head of research

Project manager

Head of the secretariat

Københavns Kommune

Lungeforeningen

Lægeforeningen

Folketinget

Institution/Organisation

Municipality of Copenhagen

Danish Lung Foundation

Danish Medical Association

Danish Parliament

Jane Heitmann

Anders Linde Seekjær

Lisbeth Søbæk Hansen

Niels Ulrich Holm

Hanne Heegaard

Sascha Maria Löwenstein

Morten Grønbæk

Henrik Wiben Pihlmann

Frederik Birket Smith

Maja Kring Schjørring

Uffe Nymark Breum

Ninna Thomsen

Jakob Krogh

Jette Jul Bruun

Ellen Nøhr

Dorte Jeppe Jensen

Charlotte Groule

Bo Danielsen

Anders Hede

Helle Stuart

Pernille Bendtsen

Folketinget

Odense Kommune

Patientforeningen Lungekræft

Praktiserende Lægers Organisa-

tion (PLO)

Rigshospitalet

Sikkerhedsstyrelsen

Statens Institut for Folkesundhed

Stoplinien

Strøm Musikfestival

Sund By Netværket

Sundheds- og Omsorgsborgme-

ster Københavns Kommune

Sundheds- og Ældreministeriet

Sundhedsstyrelsen

Syddansk Universitet

Tandlægeforeningen

Tandplejeruddannelsen

TrygFonden

Vallensbæk Kommune

Vidensråd for Forebyggelse

Danish Parliament

Municipality of Odense

Association of Lung Cancer Patients

Danish Union of General Practice

Rigshospitalet

Danish Safety Technology Authority

National Institute of Public health

National quit line

Strøm Music Festival

Healthy Cities Network

Mayor of Health and Care Muni-

cipality

Ministry of Health

Danish Health Authority

South Denmark University

Dental Association

School of Dental Hygienists

TrygFonden

Municipality Vallensbæk

Council on Health and Disease

Prevention

References

Danskernes rygevaner: Daily smoking among men and women 15 years or older, 1953-2017.

Raw, Martin & Luk Joossens. 2016. The Tobacco Control Scale 2016 in Europe. Associations of European Cancer Leagues Brussels.

Eriksen L, Davidsen M, Jensen H et al. Sygdomsbyrden i Danmark - risikofaktorer. 2nd ed. Statens Institut for Folkesundhed, Syddansk Universitet for

Sundhedsstyrelsen. 2016.

Directorate-General for Health and Food safety, Directorate-General for Communication. Special Eurobarometer 458: Attitudes of Europeans towards

tobacco and electronic cigarettes. 2017.

For mange danskere ryger stadig. Sst.dk. 2018.https://www.sst.dk/da/nyheder/2018/for-mange-danskere-ryger-stadig (accessed 11 Jan 2018).

16-25-åriges rygevaner. Epinion for Kræftens Bekæmpelse 2016.

Bendtsen P, Schou Mikkelsen S, S. Tolstrup J. Ungdomsprofilen 2014. Statens Institut for Folkesundhed, Syddansk Universitet. 2015

Bendtsen P, Schou Mikkelsen S, S. Tolstrup J. Ungdomsprofilen 2014. Statens Institut for Folkesundhed, Syddansk Universitet. 2015 samt Statens

Institut for Fokesundhed. Ugens tal for folkesundhed, uge 36, 2016.

WHO Framework Convention on Tobacco Control. Apps.who.int. 2003.

BKI no 43 of 08/12/2005.

WHO Framework Convention on Tobacco Control: guidelines for implementation Article 5.3; Article 8; Articles 9 and 10; Article 11; Article 12; Article

13; Article 14. 2011 edition.

World Health Organization. Assessing national capacity to implement effective tobacco control policies: operational manual on planning, conduct

and follow-up of joint national capacity assessments.

World Health Organization. Joint National Capacity Assessment on the Implementation of effective Tobacco Control Policies in Norway. 2010.

Danish Health Authority. Forebyggelsespakke – Tobak. 2012 updated 2016.

Law No. 546 of 24 June 2005.

Danish Health Authority. Forebyggelse og sundhedsfremme i kommunen – en vejledning til Sundhedslovens §119 stk. 1 og 2.

Danish Health Authority. Forebyggelsespakke – Tobak. 2012 updated 2016.

Danish Health Authority. Udmøntningsaftale om Kræftplan IV (2017-2020).

Government of Denmark. Patienternes Kræftplan, Kræftplan IV. August 2016.

Ministry of Health. Status på udmøntning af Kræftplan IV-2017.

KL. Forebyggelse for fremtiden. 2018.

Danske Regioner. Sundhed for livet, forebyggelse er en nødvendig investering. 2nd edition. 2017.

Euromonitor International 2013. SMOKING TOBACCO IN DENMARK. www.euromonitor.com.

Conference of the Parties of the WHO FCTC. Guidelines for implementation of Article 5.3: Guidelines on the protection of public health policies with

respect to tobacco control from commercial and other vested interests. Who.int. 2008.

United Nations General Assembly. Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of

Non-Communicable Diseases (A/66/L.1). New York: UN 2011.

Moderniseringsstyrelsen, KL, Danske Regioner. God adfærd i det offentlige. 2017.

Feilberg L. Rita fra TV2-serien ryger - men derfor kan hun godt være rollemodel. Politiken. 1 July 2015

Jepsen T. Tobaksfirmaet Philip Morris: Vi vil gerne hjælpe danskerne med at blive røgfri. Politiken. 15 January 2018.

Joint press release from The Danish Tax Authority and the Tobacco Manufactures, 7/1/2016. http://www.skat.dk/skat.aspx?oid=2186015 (accessed 3

Jan 2018).

Bialous S, da Costa e Silva V, Kummer-Peiry K et al. The Tobacco Industry and the Illicit Trade in Tobacco Products. 1st ed. Geneva: WHO FCTC Secreta-

riat 2015.

Collin J, Legresley E, MacKenzie R et al. Complicity in contraband: British American Tobacco and cigarette smuggling in Asia. Tobacco Control

2004;13:ii104-ii111. doi:10.1136/tc.2004.009357

Nakkash R, Lee K. Smuggling as the ”key to a combined market”: British American Tobacco in Lebanon. Tobacco Control 2008;17:324-331. doi:10.1136/

tc.2008.025254

Clarke K. Dilemma of a cigarette exporter. The Guardian. 2000.

World Health Organization: Guidelines for implementation of the article 5.3 of the Framework Convention of Tobacco Control.

Danish Parliament. Sundheds- og Ældreudvalget. SUU alm. del - bilag 178.

Danish Parliament. Sundheds- og Ældreudvalget. Dagsorden for møde tirsdag den 23. januar 2018. 2. udgave.

World Health Organization. Technical resource on the protection of public health policies with respect to tobacco control from commercial and other

vested interests of the tobacco industry for country implementation of the WHO FCTC article 5.3. 1st ed. Geneva: WHO 2012.

International Union Against Tuberculosis and Lung Disease. FCTC Article 5.3 Toolkit: Guidance for Governments on Preventing Tobacco Industry

Interference. 1st ed. Paris: The Union 2012.

Southeast Asia Tobacco Control Alliance. Surveillance of Tobacco Industry Activities Toolkit. 1st ed. Bangkok: SEATCA 2009.

THE WHO FCTC Secretariat. Good country practices in the implementation of WHO FCTC Article 5.3 and its guidelines. 2018.

Ministry of Taxation. E.A.10.1.5 Afgiftens størrelse og beregning. http://skat.dk/skat.aspx?oid=2084870&vid=214580 (accessed 24 Jan 2018).

Ministry of Taxation. Sundheds- og Ældreudvalget 2017-18 SUU Alm.del endeligt svar på spørgsmål 159 Offentligt.

Ministry of Taxation. Status over grænsehandelen 2016.

Ministry of Taxation. Notice on tobacco. 2009.

World Health Organization. WHO Report on the Global Tobacco Epidemic, 2017: monitoring tobacco use and prevention policies. 2017.

U.S. National Cancer Institute and World Health Organization. The Economics of Tobacco and Tobacco Control. National Cancer Institute Tobacco

Control Monograph 21. NIH Publication No. 16-CA-8029A. 1st ed. Bethesda, MD and Geneva, CH: Human Services, National Institutes of Health,

National Cancer Institute and World Health Organization. 2016.

Irwin A, Márquez P, Jha P et al. Tobacco Tax Reform at the crossroads of health and development: A Multisectoral Perspective. 1st ed. Washington,

D.C. World Bank Group. 2017.

World Health Organization. WHO Report on the Global Tobacco Epidemic, 2017: monitoring tobacco use and prevention policies. 2017. Table 9.5.4

Ministry of Taxation. Sundheds- og Ældreudvalget 2017-18 SUU Alm.del endeligt svar på spørgsmål 159 Offentligt

Mandag Morgen. Danskerne vil have højere afgifter på tobak. 28. april 2017.

Schmidt A L. “Direkte: Vi skal ikke være en omklamrende curlingstat.” Politiken. 14. Januar 2018.

World Health Organization. Illicit trade in tobacco. A summary of the evidence and country responses.

World Health Organization Regional Office for Europe. Factsheet on tobacco taxation.

Kantar Gallup for Kræftens Bekæmpelse og Hjerteforeningen. Danskernes holdning til tobak 2017.

100

101

102

103

104

105

106

Conference of the Parties of the WHO FCTC. Guidelines for implementation of Article 6: Price and tax measures to reduce the demand for tobacco.

Who.int. 2014.

Law No. 512 of 06/06/2007

Law No. 607 of 18/06/2012

Law No. 1726 of 27/12/2016

Danish Working Environment Authority. Spørgsmål og svar om kontrol med reglerne – rygning på arbejdspladsen.

Danish Working Environment Authority. Tilsyn i Tal.

Directorate-General for Health and Food safety, Directorate-General for Communication. Special Eurobarometer 458: Attitudes of Europeans towards

tobacco and electronic cigarettes. 2017.

TNS Gallup for Sundhedsstyrelsen, Kræftens Bekæmpelse, Hjerteforeningen og Lungeforeningen. Danskernes Rygevaner, 2017.

FOA. Notat om rygning på arbejdspladserne. Internetsurvey, november 2016

TNS Gallup for Sundhedsstyrelsen, Kræftens Bekæmpelse, Hjerteforeningen og Lungeforeningen. Danskernes Rygevaner,2017.

Pisinger C, Hammer-Helmich L, Andreasen AH, Jørgensen T, Glümer C. Social disparities in children’s exposure to second hand smoke at home: a

repeated cross-sectional survey. Environ Health. 2012 Sep 17;11:65. doi: 10.1186/1476-069X-11-65.

TrygFonden og Mandag Morgen. Forebyggelse ifølge danskerne, 2017

Conference of the Parties of the WHO FCTC. Guidelines for implementation of Article 8: Guidelines on the protection from exposure to tobacco

smoke. Who.int. 2007.

Toebes B, Gispen M, Been J et al. A missing voice: the human rights of children to a tobacco-free environment. Tobacco Control 2017;27:3-5.

doi:10.1136/tobaccocontrol-2017-053657

Dresler C, Lando H, Schneider N et al. Human rights-based approach to tobacco control. Tobacco Control 2012;21:208-211. doi:10.1136/tobaccocon-

trol-2011-050206

Norway. LOV-2017-06-21-89 from 01.01.2018. Lov om vern mot tobakksskader (tobakksskadeloven).

Iceland. 148a. Lov om tobaksvarer. 2002 nr. 6. 31 January.

DG Health and Food Safety. DELEGIERTE RICHTLINIE 2014/109/EU DER KOMMISSION. Eur-lex.europa.eu. 2014.

EU Tobacco Products Directive (2014/40/EU) Article 24.2.

Conference of the Parties of the WHO FCTC. Guidelines for implementation of Article 11: Guidelines on packaging and labelling of tobacco products.

World Health Organization. 2008.

Conference of the Parties of the WHO FCTC. Guidelines for implementation of Article 11: Guidelines on packaging and labelling of tobacco products.

World Health Organization. 2008.

Conference of the Parties of the WHO FCTC. Guidelines for implementation of Article 13: Guidelines on tobacco advertising, promotion and sponsors-

hip. Who.int. 2008.

Report of the independent review undertaken by Sir Cyril Chantler. Standardised packaging of tobacco. April 2014.

Hammond D. Standardized packaging of tobacco products: Evidence review. Prepared on behalf of the Irish Department of Health; March 2014.

Australian Government, Department of Health. Post-Implementation Review: Tobacco Plain Packaging 2016.

Gallopel-Morvan K, Moodie C, Eker F, et al. Perceptions of plain packaging among young adult roll-your-own smokers in France: a naturalistic appro-

ach. Tob Control Published Online First: 11 June 2014 doi:10.1136/tobaccocontrol-2013-051513

Moodie CS, Mackintosh AM. Young adult women smokers’ response to using plain cigarette packaging: a naturalistic approach. BMJ Open

2013;3:e002402. doi:10.1136/bmjopen-2012-002402

Ministry of Health. Sundheds- og Ældreudvalget 2016-17. SUU Alm.del endeligt svar på spørgsmål 1022 Offentligt.

“Hver eneste cigaret skader dig” – Evaluering af Sundhedsstyrelsens rygestopkampagne oktober 2009 - januar 2010 https://www.sst.dk/da/udgivel-

ser/2011/~/media/7998CE02F2D14089B4DBD5CBB9DF4694.ashx

HHS, Preventing Tobacco Use Among Youth and Young Adults, A Report of the Surgeon General, 2012. http://www.cdc.gov/Features/YouthTobaccoUse/.

Australian National Preventive Health Agency. Promoting a Healthy Australia. Tobacco Control and Mass Media Campaigns. 2013

WHO Tobacco Control Playbook. Tobacco marketing is targeted at children and young people.

The Danish Consumer Ombudsman filed police report against 7-Eleven and House of Prince. Bird & Bird. 2017.

Hansen J, Rasmussen L. Musikfestivaler tjener millioner på at levere nye rygere. Politiken 2016.

Rasmussen L, Hansen J. S til festivaler: Overvej jeres samarbejde med tobaksfirmaer. Politiken 2016.

Hesse M, Tutenges S, Schliewe S. The Use of Tobacco and Cannabis at an International Music Festival. European Addiction Research 2010;16:208-212.

doi:10.1159/000317250

World Health Organization. WHO Tobacco Control Playbook.

Depue JB, Southwell BG, Betzner AE, Walsh BM. Encoded exposure to tobacco use in social media predicts subsequent smoking behavior. Am J Health

Promot. 2015 Mar-Apr;29(4):259-61. doi: 10.4278/ajhp.130214-ARB-69. Epub 2014 Mar 26.

Robertson L, Cameron C, McGee R et al. Point-of-sale tobacco promotion and youth smoking: a meta-analysis. Tobacco Control 2016;25:e83-e89.

doi:10.1136/tobaccocontrol-2015-052586

WHO Regional Office for Europe. Evidence brief Tobacco point-of-sale display bans. 1st ed. Copenhagen: WHO EURO 2017.

Clinical Health Promotion Centre. WHO-CC. Bispebjerg & Frederiksberg Hospital. Rygestopbasens årsrapport 2017.

Danish Health Authority. Behandling af tobaksafhængighed – Anbefalinger til en styrket klinisk praksis. 2011.

Danish Health Authority. Anbefalinger for forebyggelsestilbud til borgere med kronisk sygdom. 2016.

Rasmussen M, Fernández E, Tønnesen H. Effectiveness of the Gold Standard Programme compared with other smoking cessation interventions in

Denmark: a cohort study. BMJ Open 2017;7:e013553. doi:10.1136/bmjopen-2016-013553

Clinical Health Promotion Centre. WHO-CC. Bispebjerg & Frederiksberg Hospital. Rygestopbasens årsrapport 2017.

Center for Interventionsforskning, Statens Institut for Folkesundhed, SDU. Monitorering af kommunernes forebyggelsesindsats 2017. Arbejdet med

Sundhedsstyrelsens forebyggelsespakker siden 2013 og anbefalinger til borgere med kronisk sygdom. Center for Interventionsforskning, Statens

Institut for Folkesundhed, SDU. København. 2017.

TNS Gallup for Sundhedsstyrelsen, Kræftens Bekæmpelse, Hjerteforeningen og Lungeforeningen. Danskernes Rygevaner, 2017.

World Health Organization. WHO Report on the Global Tobacco Epidemic, 2017: monitoring tobacco use and prevention policies. 2017.

Koch MB, Diderichsen F, Grønbæk M, Juel K. What is the association of smoking and alcohol use with the increase in social inequality in mortality in

Denmark? A nationwide register-based study. BMJ Open. 2015 May 11;5(5).

World Health Organization. Developing and improving national toll-free tobacco quit line services. 2011.

SUU, Alm.del - 2017-18 - Endeligt svar på spørgsmål 1350: Spm. om ministeren er enig i, at det er et selvstændigt mål at begrænse interaktionen mellem embedsmændene i danske ministerier og styrelser og repræsentanter fra tobaksindustrien til det strengt nødvendige, sådan som Verdenssundhedsorganisationen WHO anbefaler, til skatteministeren SUU, Alm.del - 2017-18 - Endeligt svar på spørgsmål 1350: Spm. om ministeren er enig i, at det er et selvstændigt mål at begrænse interaktionen mellem embedsmændene i danske ministerier og styrelser og repræsentanter fra tobaksindustrien til det strengt nødvendige, sådan som Verdenssundhedsorganisationen WHO anbefaler, til skatteministeren