Tobacco taxes and tobacco control in Norway Bjørn-Inge Larsen, Secretary General, Norwegian Ministry of Health and Care Services 2017 World Bank Group/International Monetary Fund Spring Meeting

Quick glance at Norway 5,2 million people One of the first countries to adopt a Tobacco Control Act in 1973, with health warnings, age limits and advertising ban First country to ratify the WHO Framework Convention on Tobacco Control A comprehensive tobacco control strategy has been in place for decades Still, over 6000 people die every year due to tobacco-related illnesses Norway is a small country, with its 5,2 mill inhabitants. Despite progress, tobacco use continues to be a major public health problem in Norway. At present more than one in eight (12 %) of Norwegians still smoke on a daily basis. Each year, 6000 Norwegians die of diseases caused by smoking. We see the same smoking pattern in Norway as in several other countries; i.e that smoking prevalence is closely linked to social status. It has recently been estimated that 100,000 children from 0-12 are daily exposed to second hand smoke.

National tobacco control strategy Strict tobacco control legislation 2. Hard-hitting media campaigns 3. Tobacco cessation programme 4. High tobacco taxes

Strict tobacco control legislation Total smoking ban at public places and transport, and workplaces, including bars and resturants Age limits (18 years to buy tobacco) Total advertising ban Display ban at points of sale Health warnings on packages From July 2017; plain packaging

Smoke free bars and restaurants Introduced 1 June 2004 Massive media debate Health of employees was main argument Extensive evaluations 5 yrs later - a big success Up until 2004, bar and restaurant workers were the only employees without protection against second hand smoking in the workplace. The process of amending the legislation started in 1999 and was based on the evaluation of the current legislation, increasing scientific evidence concerning second hand smoke and pressure from the trade unions. The media debate was massive. The industry was afraid of reduced turnover and job loss, some argued that the evidence on second hand smoke was not enough to warrant such restrictive legislation, and others saw the ban as an intrusion of the right to privacy. The authorities maintained that the main reason for the ban was the health of the employees and despite the resistance, the proposal was passed by an overwhelming majority of the parliament members. It entered into force on June 1 2004. The ban has been evaluated by several research institutions.

Public support for smoke-free bars and restaurants Several surveys were carried out to monitor public support of the ban. The first graph shows support among smokers and non-smokers. The second graph shows overall support, and they both show how support has increased after the introduction of the ban. Today, over 90 % of the population support the ban.

Plain packaging in Norway From 1 July 2017, all cigarette and snus packages must look the same Plain packaging will remove advertising effect of tobacco packaging design enhance health warnings and reduce packages' ability to mislead consumers regarding health risks (Not accurate illustrations)

Mass media campaigns Important to educate new generations about health risks, and motivate tobacco users to quit Hard-hitting campaigns most effective Norway runs 2-3 campaigns per year

Tobacco Cessation Programme Work in progress to harmonize smoking cessation activites to ensure evidence-based methods “Minimal intervention” a key tool New digital platforms; Facebook and mobile apps No financial aid for cessation medicines Tittel på presentasjon 16. november 2018

Rankings of smoking as a risk factor for all-cause, all-age attributable DALYs for both sexes combined in 2015 Norway is one of 24 countries (in red) where tobacco smoking is the number 1 risk factor for the total burden of disease measured in DALYs. The map also illustrates the epidemic of tobacco. Tobacco smoking first increased in the developed countries, hence the larger burden of desease now. As developing countries take on smoking, the desease burden will increase. Within each country, there is also a relatively systematic epidemic movement of tobacco smoking inn the population: starting in high education / high income groups and then spreading to other groups. The epidemic then leaves the country in the same pattern. Today, smoking is a habit for low education / low income groups in many developed countries. Source: Global Burden of Disease Study 2015; Lancet 2017

Tobacco tax revenue Norway, 1995–2016 Non price adjusted.

Tobacco tax revenue Norway

Price index for tobacco compared to consumer price index, 1995–2015

Minutes of work needed for an industrial worker to afford a 20-pack of cigarettes, 1948–2015

Societal costs associated with tobacco smoking The Norwegian cost estimates vary: NOK 8 billion per year (includes healthcare costs and production losses associated with morbidity and premature mortality) NOK 80 billion per year (includes an economic valuation of the welfare loss – lost life years and health related life quality – due to tobacco smoking) What is the magnitude of the societal costs associated with tobacco smoking in Norway? This report addresses this question by transferring cost estimates from Denmark and Sweden to a Norwegian context. The Norwegian cost estimates vary from NOK 8 billion to NOK 80 billion per year. The lower part of the interval includes healthcare costs and production losses associated with morbidity and premature mortality. The upper part of the interval includes an economic valuation of the welfare loss (lost life years and health related life quality) due to tobacco smoking. The economic value of the welfare loss is one of the parameters that affect the cost estimates the most. But the magnitude of welfare loss associated with smoking also depends on assumptions related to the existence of market failures. Are consumers acting as fully informed individuals in a perfect market or are they not? Cost estimates that include the valuation of welfare loss would generally assume some level of market failure (consumers not taking into account the full consequences of their behaviour in a long-term perspective). The cost estimates do indicate that interventions with the potential to reduce the number of daily and occational smokers can result in substantial benefits to society. But in order to guide decision makers towards identifying which interventions are cost-effective or not, interventions need to be systematically compared in terms of their potential costs and consequences. This report argues that welfare effects are important to include in such analyses. This report also briefly addresses the question of the societal costs related to passive smoking. Based on an assumption that passive smoking contributes to about 5 percent of smoking related deaths and a welfare loss, the societal costs related to passive smoking are estimated to be about NOK 4 billion per year. Without an economic valuation of welfare loss the estimate is between NOK 400 million and NOK 1 billion per year. Health care costs related to passive smoking affecting children are assumed to be about NOK 21,5 million per year. In addition, there will be relatives’ production loss and welfare effects. Such costs could easily reach a magnitude of hundreds of millions NOK per year.

The ad was placed at our international airport to welcome visitors and inform about the new smoke-free legislation.