Tobacco dependence treatment in Norway

38-GBAnders Ostrem
Gransdalen Legesenter
38-flag Norway
02 Aug 2013

What is the health care system in Norway?

Norway is a kingdom with 4.8 million inhabitants and is divided into 19 counties and 430 municipalities.  The municipalities are responsible for the provision of primary health care while the state run the hospital services.  Hospital care is free of charge and has a high standard, while patients pay a small sum for primary care services. Medication for chronic diseases are on a reimbursement scheme with a maximum payment per year of round € 220 which includes payment for primary care services. Gross national product is the second highest in Europe (mainly due to massive oil revenues) and the life expectancy is over 80 for both women and men.

What is the smoking prevalence?

Smoking prevalence varies from 27% daily smoking in the northern county of Finmark to 14% in the capital Oslo. As a whole the prevalence is now 16%.  There are however, a large social gradient with a substantial higher prevalence in lover social economic groups.

Do you have a national policy – and who takes responsibility for it?

The division of Public Health within the Directorate of Health prepares background material for policy formulation, implements the health policies that are adopted, and is the supervisory authority provisions in Norwegian tobacco control legislation.

Tobacco control legislation dates back to 1973 when the Tobacco control act was introduced, restricting the marketing of tobacco products. In 2004, Norway, as the second country in Europe, introduced a total smoking ban in bars and restaurants.

The Directorate of Health prepared the National strategy for Tobacco Control 2006 – 2010 to promote health in all parts of the population by reducing the use of tobacco. It has eight strategic areas;

  • Tobacco prevention among young people
  • Smoking cessation
  • Protection from exposure to tobacco smoke
  • The use of smokeless tobacco
  • Research, monitoring and evaluation
  • Information strategies and general communication
  • Tobacco control as a part of local public health activities

Even though the strategy for Tobacco Control is comprehensive it has not been followed by funding. As a result the aims of the strategy has not been met.  Focus has been on legislation to reduce exposure, advertising in addition to increase in taxes resulting in a high sales price (20 cigarettes retail round € 10).

What services or systems are available for smokers who want to stop?

  1. Quit line: The Norwegian quit line was established in 1996. It is nationwide and free to call. It offers both active and proactive counselling. About 10 000 persons have used the service since 2006.
  2. Group counselling – smoking cessation classes: In 2002 the Directorate of Health in collaboration with the counties developed a program for group counselling. However, only 200 courses with a total of 1700 participants (average 8,5 participants per course) has been held.  No systematic evaluation has been made.
  3.  The Norwegian health care system, including the education of health professionals, is mainly focused on diagnosis and treatment. Smoking cessation is not a mandatory service in any part of the health system. There has been performed several surveys among health professionals in Norway to assess their attitudes and involvement in the smoking cessation. The conclusions are similar among different groups; smoking cessation is not a prioritized task. Smoking cessation guidelines for primary care was published in 2004 but has not been implemented. In secondary care, smoking cessation activities that are offered are isolated and not implemented systematically. Under a handful of hospitals offer smoking cessation out-patients` clinics.
  4. Reimbursement: General practitioners get refunded when offering smoking cessation as part of treating an illness, but it this was only give round 50 000 times each year, a very modest number compared with the number of daily smokers in Norway (round 800 000).

None of the medications that enhance smoking cessation are reimbursed. NRT is offered over the counter while a prescription is needed for varenicline and bupropion.

What do you think should happen next?

There is a long way to go before smokers in Norway are able to benefit from the help the health care system can offer according to guidelines.  The lack of implementation of guidelines are evident also in Norway.  More than this, there is also a lack of legislation that would support increased smoking cessation assistance.  The fact that general practitioners, by law, are supposed only to offer smoking cessation in relation to treatment of disease is one barrier. Another is the lack of reimbursement of medication.  Despite the fact that there is consensus of the usefulness of reimbursement – political will seems to be lacking.

Primary care should be in the frontline in the fight against tobacco.  However, there is a need both to change the health care system to allow GPs to work within smoking cessation and guidelines that need to be implemented.