The Norwegian Counties Public Health Survey (NCPHS): a design study.

BACKGROUND: Effective public health initiatives should be founded on a comprehensive and robust understanding of health-related factors including societal and community contexts. The Norwegian Counties Public Health Survey (NCPHS) aims for insights into the adult population on topics relevant for planning public health practices at county and municipality levels. METHODS: The NCPHS includes a core questionnaire on public health-related topics and demographics, including indicators of socio-economy, with additional optional questions and scales varying across data collections. Samples are drawn from the Norwegian National Population Register and 'washed' against the Common Contact Register to retrieve digital contact information and exclude those who cannot be contacted electronically. NCPHS was piloted in 2015 and 2018 (four counties). After some revision of instruments and sampling procedures, surveys have been carried out in most Norwegian counties since 2019. The total number of participants has now passed 400,000. RESULTS: Expedient data analysis has enabled the Norwegian Institute of Public Health to present comprehensive reports within 6 weeks of completed data collections. In these, outcome variables are analysed against district (within counties), gender, age, educational attainment and self-reported sufficiency of household income. Tables are also made available at the municipality level. CONCLUSIONS: The NCPHS represents a valuable addition to existing data sources, providing critical information for planning purposes for local and regional public health authorities, for assessing trends over time, comparisons across counties and regions and for evaluation of policies and interventions. The value of such a system during times of crisis was demonstrated during the COVID-19 pandemic.

Does who you live with matter for your health? The influence of partners' socioeconomic characteristics on self-rated health in Norway.

AIMS: Studies of the association between self-rated health and persons' income and education have almost invariably shown that people with higher education and incomes report better health. Less is known of the influence of household members' socioeconomic characteristics on individuals' health. This study thus aimed to assess the extent to which the socioeconomic characteristics of partners may contribute to explaining the variation in the respondents' self-rated health (SRH). METHODS: Using an observational design, we analysed cross-sectional Norwegian survey data on SRH (2015 and 2019), linked to register data on education and income for respondents (N = 7082) and their opposite-sex coresident spouse or partner. We employed logistic regression models to assess the associations between respondents' SRH and the relative income and education of their partner. Average marginal effects were calculated to enable cross-model comparisons. RESULTS: Net of individual characteristics, having a higher-educated partner was positively associated with SRH for both male (OR = 1.56) and female (OR = 1.36) respondents. Having a partner with an above median income (by age and sex) was positively associated with SRH for female (OR = 1.29) respondents only. For education, the positive SRH associations were roughly similar for respondents and partners. For income, the associations were more pronounced for respondents than partners. CONCLUSIONS: Our findings suggest that health is affected by the resources (or lack thereof) in one's immediate networks. To reduce social inequalities in health, health personnel might customise interactions to account for household resources. Such knowledge could also be used in health-promoting activities to enhance participation and health competency.

Factors associated with initiation and use of snus among adolescents.

AIM: We investigated factors associated with the initiation and continuation of snus use in adolescents in Norway. The associations with adolescents' own educational plans, the parents' educational level(s) and tobacco habits were estimated. METHODS: In this cross-sectional questionnaire-based study, 1465 patients aged 18-20 years participated. The questionnaire was administered at regular dental examinations in the public dental health service. To assess the association between individual factors and the initiation of tobacco habits, a generalised structural equation model with random effects at the clinic level was used. Binary responses were modelled using multilevel binary logistic regression, while the number of snus boxes used per month was modelled using a multilevel Poisson regression model. RESULTS: Of current (daily and occasional) tobacco users, 85% were snus users, including dual users of both snus and cigarettes. The median age of snus initiation was 16 years. Both parental snus use and smoking were associated with an increased risk of snus initiation, snus use and a higher amount of use. An increased risk of using snus was associated with male gender and with no educational plans or planning for further vocational education. The amount of snus used was higher among current snus users with a prior smoking history and among those planning for further vocational education. CONCLUSIONS: These findings may aid in developing and targeting tobacco prevention strategies aimed at young people. Tobacco prevention measures should start at the elementary school level. The strong association with parental tobacco habits underlines the importance of parents' influence on their children's tobacco use.

Evaluation of incomplete maternal smoking data using machine learning algorithms: a study from the Medical Birth Registry of Norway.

BACKGROUND: The Medical Birth Registry of Norway (MBRN) provides national coverage of all births. While retrieval of most of the information in the birth records is mandatory, mothers may refrain to provide information on her smoking status. The proportion of women with unknown smoking status varied greatly over time, between hospitals, and by demographic groups. We investigated if incomplete data on smoking in the MBRN may have contributed to a biased smoking prevalence. METHODS: In a study population of all 904,982 viable and singleton births during 1999-2014, we investigated main predictor variables influencing the unknown smoking status of the mothers' using linear multivariable regression. Thereafter, we applied machine learning to predict annual smoking prevalence (95% CI) in the same group of unknown smoking status, assuming missing-not-at-random. RESULTS: Overall, the proportion of women with unknown smoking status was 14.4%. Compared to the Nordic country region of origin, women from Europe outside the Nordic region had 15% (95% CI 12-17%) increased adjusted risk to have unknown smoking status. Correspondingly, the increased risks for women from Asia was 17% (95% CI 15-19%) and Africa 26% (95% CI 23-29%). The most important machine learning prediction variables regarding maternal smoking were education, ethnic background, marital status and birth weight. We estimated a change from the annual observed smoking prevalence among the women with known smoking status in the range of - 5.5 to 1.1% when combining observed and predicted smoking prevalence. CONCLUSION: The predicted total smoking prevalence was only marginally modified compared to the observed prevalence in the group with known smoking status. This implies that MBRN-data may be trusted for health surveillance and research.

Trends in maternal use of snus and smoking tobacco in pregnancy. A register study in southern Norway.

BACKGROUND: The use of tobacco products including Swedish snus (moist snuff) in pregnancy may cause adverse health outcomes. While smoking prevalence has decreased among fertile women in Norway, snus use has increased during the last years. We investigated whether these trends were reflected also during pregnancy in a population of women in Southern Norway. METHODS: Data on smoking tobacco and snus use at three time points before and during pregnancy for 20,844 women were retrieved from the electronic birth record for the years 2012-2017. The results for the three-year period 2015-2017 were compared with a previously studied period 2012-2014. Prevalence and quit rates of tobacco use within groups of age, parity and education were reported. Within the same groups adjusted quit rates were analyzed using logistic regression. Mean birthweight and Apgar score of offspring were calculated for tobacco-users and non-users. RESULTS: There was an increase of snus use before pregnancy from the period 2012-2014 to the period 2015-2017 from 5.1% (CI; 4.6 to 5.5) to 8.4% (CI; 7.8 to 8.9). Despite this, the use of snus during pregnancy did not increase from the first to the second period, but stabilized at 2.8% (CI; 2.5 to 3.2) in first trimester and 2.0% (CI; 1.7 to 2.2) in third trimester. Cigarette smoking decreased significantly both before and during pregnancy. Snus use and smoking during pregnancy were associated with a reduction in average birthweight, but no significant effects on Apgar scores. Odds ratios for quitting both snus and smoking tobacco during pregnancy were higher for women aged 25-34 years, for the primiparas and for those with a high level of education. Pregnant women were more likely to have quit tobacco use in the last time period compared to the first. CONCLUSIONS: While smoking during pregnancy was decreasing, the use of snus remained constant, levelling off to around 3% in first trimester and 2% in third trimester. Approximately 25% of those that used snus, and 40% that smoked before pregnancy, continued use to the third trimester. This calls for a continuous watch on the use of snus and other nicotine products during pregnancy.

Associations of tobacco smoking with body mass distribution; a population-based study of 65,875 men and women in midlife.

BACKGROUND: Studies indicate an effect of smoking toward abdominal obesity, but few assess hip and waist circumferences (HC and WC) independently. The present study aimed to assess the associations of smoking status and volume smoked with HC and WC and their ratio in a population with low prevalence of obesity together with high prevalence of smoking. METHODS: We used cross-sectional survey data from 11 of a total 19 Norwegian counties examined in 1997-99 including 65,875 men and women aged 39-44 years. Analysis of associations were adjusted for confounding by socioeconomic position, health indicators, and additionally for BMI. RESULTS: Compared with never-smokers, when adjusting for confounders and in addition for BMI, mean HC remained lower while mean WC and waist-hip-ratio (WHR) were higher in current smokers. The finding of a lower HC and higher WHR level among smokers was consistent by sex and in strata by levels of education and physical activity, while the finding of higher WC by smoking was less consistent. Among current smokers, BMI-adjusted mean HC decreased whereas WC and WHR increased by volume smoked. Compared with current smokers, former smokers had higher BMI-adjusted HC, lower WHR and among women WC was lower. CONCLUSIONS: The main finding in this study was the consistent negative associations of smoking with HC. In line with the hypothesis that lower percentage gluteofemoral fat is linked with higher cardiovascular risk, our results suggest that smoking impacts cardiovascular risk through mechanisms that reduce the capacity of fat storage in the lower body region.

Impact of snus use in teenage boys on tobacco use in young adulthood; a cohort from the HUNT Study Norway.

BACKGROUND: As smoking rates decreased, the use of Swedish snus (smokeless tobacco) concordantly increased in Norway. The role of snus as possible contributor to the reduction of smoking has been widely discussed. Our aim was to quantitate transitions in snus use, smoking and dual use of snus and cigarettes in a young male population. METHODS: This prospective cohort study includes 1346 boys participating in the Nord-Trøndelag Health Study in Young-HUNT1 1995-97, age 13-19 and in HUNT3 2006-08, age 23-30. Participants reported on tobacco use at both points of time. Models with binominal regression were applied to examine relative risks (RRs), of adolescent ever snus users, dual users or smokers (reference: never tobacco use), to be current snus only users, smokers (including dual users), or tobacco free in adulthood. RESULTS: Current tobacco use in this male cohort increased from 27% in adolescence to 49% in adulthood, increasing more for snus only use and dual use than for smoking only. The adjusted RR (95% CI) of becoming a smoker as young adult, was 2.2 (CI 1.7-2.7) for adolescent snus users, 3.6 (CI 3.0-4.3) for adolescent dual users, and 2.7 (CI 2.2-3.3) for adolescent smokers. RR to become snus only users as adults was 3.1 (2.5-3.9) for adolescent dual users, 2.8 (2.2-3.4) for adolescent snus users and 1.5 (1.0-2.2) for adolescent smokers. The adjusted RR for the transition from adolescent tobacco use to no tobacco use in adulthood was similar for snus users and smokers with RR 0.5 (CI 0.4-0.7), but considerably lower for dual users with RR 0.2 (CI 0.2-0.3). CONCLUSIONS: The use of snus, with or without concurrent smoking, carried a high risk of adult smoking as well as adult snus only use. Dual use seemed to promote the opportunity to become snus only users in adulthood, but made it also more difficult to quit. The benefit of snus use for harm reduction is not evident in our cohort, as the combination of smoking and dual use resulted in high smoking rates among the young adults.

Development of Social and Demographic Differences in Maternal Smoking Between 1999 and 2014 in Norway.

INTRODUCTION: The Medical Birth Registry of Norway provides national coverage of all births in Norway. In this study trends of smoking at the beginning of pregnancy and the variation of these trends across different sociodemographic groups are analyzed. This knowledge is important for planning interventions both in the general population and specifically among pregnant women. METHODS: All births registered in Medical Birth Registry of Norway 1999-2014 with information on mothers' smoking status were included in the overall analyses of the smoking trends (806 298). Records from 210 268 births in two time periods 1999-2000 and 2013-2014 were selected, and for the multivariate analyses we used general linear models to provide adjusted risk ratios. RESULTS: The prevalence of maternal smoking at the beginning of pregnancy decreased from 25% to 8% over the 15-year period. Mothers with low, medium, and high education, respectively, had a 46% (RR 0.54, CI 0.52-0.55), 62% (RR 0.38, CI 0.37-0.40), and 80% (RR 0.20, CI 0.19-0.22) reduction in maternal smoking between the two time periods. Similarly, the decline in smoking was greater for mothers who were married or living together (64%; RR 0.36, CI 0.35-0.37) than for single mothers (39%; RR 0.61, CI 0.58-0.64). Immigrants had a lower smoking prevalence than Norwegians in the entire period 1999-2014. CONCLUSION: The prevalence of smoking during pregnancy in Norway decreased in all population groups, but the relative differences between the educational groups increased from 1999-2000 to 2013-2014. This is a public health concern and a strong contributor to health disparities. IMPLICATIONS: Women with low and medium education level and single mothers had the highest smoking prevalence and the lowest decline over the two time periods. These groups constitute 45% of our study population, the relatively high maternal smoking in these groups continues to be of public health concern for maternal and child health.

Patterns of snus and cigarette use: a study of Norwegian men followed from age 16 to 19.

BACKGROUND: The use of moist snuff (snus) in young Norwegians is increasing, while smoking rates are declining. It is not clear whether snus facilitates smoking. OBJECTIVE: To assess whether 16-year-old men who were never-smokers, but snus users in 2001, had an increased risk of smoking 3 years later. METHODS: In a prospective school-based cohort study, 1440 men, who responded to questionnaires in 2001 and 2004, were included in the analyses. The participation rate was 89% in 2001 and 50% in 2004. Multinomial logistic regression models were used to assess the OR of snus users, smokers and dual users of cigarettes and snus, compared with non-tobacco users at baseline, to be smokers at follow-up. RESULTS: Snus use at baseline was associated with increased odds of dual use at follow-up when the outcome was (1) current dual use versus no tobacco (OR 3.49, 95% CI 1.8 to 6.8) and when the outcome was (2) current dual use versus no smoking but including snus-only use (OR 1.88, 95% CI 1.1 to 3.3). Baseline snus users who were dual users at follow-up seemed to prefer using snus daily and cigarettes occasionally. Use of snus only at baseline was not associated with increased odds of smoking only at follow-up, after adjusting for known risk factors. CONCLUSIONS: Young men who only used snus at baseline had an increased risk of being dual users at follow-up. Snus use may therefore facilitate smoking.

A study of socio-economic inequalities in self-reported oral and general health in South-East Norway.

This study assesses the association between socioeconomic determinants and self-reported health using data from a regional Norwegian health survey. We included 9,068 participants ≥ 25 years. Survey data were linked to registry data on education and income. Self-reported oral and general health were separately assessed and categorized into 'good'/'poor'. Exposures were educational level, personal income, and economic security. Prevalence ratios (PR) were computed to assess the associations between socioeconomic determinants and self-reported health using Poisson regression models. Participants with low education or income had poorer oral and general health than those with more education or higher income. Comparing the highest and lowest education levels, adjusted PRs for poor oral and general health were 1.27 (95%CI, 1.11-1.46) and 1.43 (95%CI, 1.29-1.59), respectively. Correspondingly, PRs for lowest income quintiles compared to highest quintile were 1.34 (95%CI, 1.17-1.55) and 2.10 (95%CI, 1.82-2.43). Low economic security was also significantly associated with poor oral and general health. There were socioeconomic gradients and positive linear trends between levels of education and income in relation to both outcomes (P-linear trends < 0.001). We found statistical evidence of effect modification by gender on the association between education and oral and general health, and by age group between income and oral health.

Prevention of snus use: Attitudes and activities in the Public Dental Service in the south-eastern part of Norway.

Dental health care professionals have the opportunity to play a key role in tobacco prevention and cessation among adolescents. Snus use has increased in Norway, especially in the age group 16-24, whereas there has been a decline in smoking. This study investigated attitudes and activities related to snus prevention among dental health care professionals working in the Public Dental Service (PDS) in south-eastern Norway. A web-based survey with a total of 557 dentists and dental hygienists in seven counties in Norway, with a response rate of 53.5%, was carried out in 2017. Dentists' and dental hygienists' activities regarding preventive snus use intervention were analysed using the chi-square test. Intervention was measured with a score (1-5) based on four questions. Bivariate and multivariate linear regression analyses were used to investigate the associations between the explanatory variables of attitudes/activities and the outcome intervention variable. Approximately 87% of the dentists and 58% of the dental hygienists were not familiar with the "minimum intervention method" for tobacco prevention and cessation. Dental hygienists were most active in informing and supporting their patients in prevention and cessation of snus use. The PDS is an underutilized arena for tobacco prevention and cessation among adolescents, and the intervention potential is particularly high among the dentists.

Social differences in smoking and snuff use among Norwegian adolescents: a population based survey.

BACKGROUND: A change in pattern of tobacco use has been observed in the last decade in Norway. Snuff use and occasional smoking have to some degree replaced daily smoking among adolescents and young adults. Daily smoking is known to be negatively associated with social background factors, but little is known about these associations for other types of tobacco use. Our aim was to study different types of tobacco use among adolescents according to gender, educational ambitions, family background factors, and urbanization. METHODS: Cross-sectional, school-based study with 15 931 participants and response-rate 87%, conducted among 15 and 16 year olds during 2000-2004. RESULTS: More girls (33.8%) than boys (26.4%) were daily or occasional smokers, while more boys (21.4%) than girls (3.5%) were daily or occasional snuff users. Daily smoking was more common among adolescents planning vocational education, with single parents or poor family economy. Occasional smoking and snuff use (daily or occasionally) showed a similar, but less pronounced pattern regarding education and single parent families. Adolescents with parents from foreign countries were less likely to use tobacco. One exception was boys with parents from Muslim majority countries who had an increased risk of daily smoking. A typical combination user of both tobacco types was a Norwegian boy with divorced parents and ambitions to complete vocational studies or only one year of upper secondary school. CONCLUSION: Tobacco use in adolescents is mainly associated with low educational ambitions and less affluent self-reported family economy. Adolescents with divorced parents use more tobacco than those living with both parents. Public health initiatives to avoid or reduce tobacco use should mainly target adolescents in vocational studies and those leaving school early.

[Risk factors for myocardial infarction, stroke and diabetes in Norway]. / Risikofaktorer for hjerteinfarkt, hjerneslag og diabetes i Norge.

BACKGROUND: Frequency of and mortality from coronary heart disease (CHD) have decreased,but type 2 diabetes is on the rise. Risk factors measured in health surveys 2000-2003 are presented and compared with recommended or ideal levels. MATERIAL AND METHODS: In five counties, all inhabitants aged 30, 40, 45, 60 or 75 years were invited to participate in the survey (participation rate 29-75%). RESULTS: In the age group 30-60 years, about 30% were daily smokers, 50% exercised < 3 hours per week, and 75-90% had total serum cholesterol > or = 5 mmol/L. By age 60 years 40-50% had elevated blood pressure and 23% were obese (body mass index (BMI) > or =30 kg/m2 ). Different measures of obesity, general and abdominal, produced somewhat different results. In younger men, BMI and waist circumference gave a higher obesity prevalence than waist-hip ratio. In contrast, for women aged 60 and 75 years BMI gave the lowest prevalence. INTERPRETATION: The burden of risk factors in the population is relatively high, and a further increase of overweight and diabetes may stem the decline of CHD. Establishment of a health monitoring system including risk factors is an important element of health promotion.

Association between age, gender and reasons for smoking cessation.

AIMS: To contribute to improved programs for smoking cessation, the authors wanted to assess the relationships between age, gender and ex-smokers' quitting reasons and examine predictors of the most commonly reported quitting reasons. METHODS: A questionnaire was mailed to 11,919 subjects in Akershus County, Norway. Among the 7,697 respondents (65%), self-reported reasons for smoking cessation in 1,715 ex-smokers were analysed. Using cross-tables and multivariate logistic regression, associations between age, gender, and reported quitting reasons were examined. RESULTS: Men were more likely to have stopped smoking to improve physical fitness, or out of consideration for other family members than the children, and less likely to have quit out of consideration for their own children, or in solidarity with a spouse that stopped smoking. In multivariate logistic regression analysis, age was a predictor of all seven most common reasons to quit smoking. Gender, education, and the physical component of health status each predicted three of the seven quitting reasons. CONCLUSIONS: In the study sample, differences in smoking cessation behavior and reported quitting reasons were found according to both age and gender. Smoking cessation programs should be tailored to the relevant target groups, including stratification according to age and gender.