Challenges in legitimizing further measures against smoking in jurisdictions with robust infrastructure for tobacco control: how far can the authorities allow themselves to go?

BACKGROUND: According to a recently published study, approximately half of those who currently smoke in Norway have little or no desire to quit despite a hostile regulatory and socio-cultural climate for smoking. On this background, we discuss some challenges that regulators will face in a further tightening of structural measures to curb smoking. MAIN BODY: Central to our discussion is the research literature concerned with the concept of state-paternalism in tobacco control-the line between an ethically justified interference with the freedom of those who smoke and an exaggerated infringement disproportionate to the same people's right to live as they choose. In countries with an already advanced infrastructure for tobacco control, this dilemma might become quite intrusive for regulators. We ask that if people, who smoke are aware of and have accepted the risks, are willing to pay the price, smoke exclusively in designated areas, and make decisions uninfluenced by persuasive messages from manufacturers-is a further tightening of anti-smoking measures still legitimate? Strengthening of the infrastructure for tobacco control can be seen as a "help" to people who-due to some sort of "decision failure"-continue to smoke against their own will. However, for those who want to continue smoking for reasons that for them appear rational, such measures may appear unwanted, punitive, and coercive. Is it within the rights of regulators to ignore peoples' self-determination for the sake of their own good? We problematize the "help" argument and discuss the authorities' right to elevate the zero-vision of smoking as universally applicable while at the same time setting up barriers to switching to alternative nicotine products with reduced risk. CONCLUSION: We recommend that a further intensification of smoking control in countries that already have a well-developed policy in this area requires that regulators start to exploit the opportunity that lies in the ongoing diversification of the recreational nicotine market.

Vaping among Norwegians who smoke or formerly smoked: reasons, patterns of use, and smoking cessation activity.

BACKGROUND: The majority of Norwegians who use e-cigarettes are adults who have smoked. Little is known about vaping reasons and -patterns in this group. The aim of this paper was to study vaping prevalence, patterns, and motivations among adults who smoke. Furthermore, to investigate smoking intensity and smoking cessation behaviour differences between those who vape and those who do not. METHODS: This study was based on two separate Norwegian samples: People who had ever smoked, from 2017 (N = 2099), and people who currently smoked and recent quitters, from 2018/2019 (N = 1336). Measures of vape frequencies, vape motives, and smoking cessation behaviours were utilised in descriptive analyses of relationships between vaping and smoking behaviour. RESULTS: Less than 1 in 10 in the ever-smoked group, 1 in 5 of the currently smoked or recently quit group, were currently vaping. Ever trial rates for vaping were much higher at 1 in 3 in the ever-smoked group, and 1 in 2 in the currently smoked or recently quit group. Dual use with combustible cigarettes was common, but people who smoked tended to use e-cigarettes less frequently while those who formerly smoked tended to use them more frequently. Both quitting attempts and smoking intensity reduction were positively associated with vaping, and the most common reasons for e-cigarette use were reported to be desires to reduce harm, to stop smoking, or to reduce smoking intensity. CONCLUSION: The results indicate that Norwegians who smoke tend to see e-cigarettes as a tool to reduce or completely stop smoking. The predominance of use-motivations related to reducing harm points at the importance of conveying correct information about relative harmfulness of tobacco- and nicotine products.

Accumulation of material and lifestyle problems among daily smokers in Norway 1999 to 2013 - a cross-sectional analysis.

BACKGROUND: International studies have found that smoking is increasingly concentrated among lesser-privileged individuals and marginalised groups, indicating a possible rise in daily smokers' accumulated problem burden. The study asks whether material shortages and occurrence of behaviours related to poor health are increasing among daily smokers in Norway, and whether the time trends differ between daily smokers on the one hand, and occasional and non-smokers on the other. METHOD: The study used data acquired by biennial cross-sectional surveys from 1999 to 2013 of the adult (i.e. over 15) Norwegian population. Time trends in individual and accumulated material and lifestyle problems among daily smokers and non-daily and non-smokers combined were assessed using logistic regression analyses for men and women separately. RESULTS: The accumulation of problems in any isolated survey is higher among daily smokers than other respondents. Over the longer term, however, there are few signs of decline in any group, except in regards to frequent alcohol drinking, which increased in all studied groups. The only problem factor differentiating daily smokers from occasional smokers/non-smokers that did change during the period was quality of diet. While problem accumulation declined in all but one group, i.e., male daily smokers, the difference between them and the group of occasional smokers and non-smokers was not significant. CONCLUSION: Daily smokers are generally worse off than occasional smokers and non-smokers combined. However, the accumulation of material problems and health-risk behaviours by daily smokers and occasional smokers/non-smokers did not change significantly and all groups had fewer problems in 2013 than in 1999.

Tobacco denormalisation and representations of different tobacco users in Norway: a cross-sectional study.

This study asks whether representations of different typical tobacco users vary in line with established stereotypes and by social group membership (especially tobacco user status). Social identity theory posits that representations differ due to varying identification with product users on the basis of personal use, while distinction theory suggests representations will be structured by proximity and distance to user groups. Using principal component analysis to identify representations and regression analysis to determine variances in representations, we find that four of five groups of typical tobacco users (snus users, pipe, cigarette, and cigar smokers) can be classified according to three similar representations: socially secure, culturally marginal and unappealing. Respondents who themselves use a certain tobacco product are more likely to consider a 'typical' user from their own group as more 'socially secure' and less 'culturally marginal' and 'unappealing' than non-users. Former smokers tend to side with non-smokers, which suggests their 'smoker identity' is on the wane. At the representational level, then, socio-historical distinctions between different tobacco products seem to have diminished in favour of a largely dual classification, with users expressing positive and non-users negative representations, of any typical user. This is a likely consequence of persistent tobacco denormalisation policies.

Perceptions of plain and branded cigarette packaging among Norwegian youth and adults: a focus group study.

INTRODUCTION: In Norway, packaging is one of the few remaining ways for tobacco companies to promote their products. Plain packaging of tobacco products could be a means to limit this promotion. METHODS: Eleven focus group interviews with daily, occasional, and former smokers and nonsmokers (N = 69) aged 16-50 were undertaken to explore perceptions of different cigarette brands, the role of package design in communicating brand images, and how participants perceived cigarette packages when important design elements such as colors, symbols, logos, and branded fonts were removed. RESULTS: Distinct images of brands and user identities associated with these were narrated. Elements of the package design such as colors, images, and fonts were described as configuring brand images. Compared with current, completely branded cigarette packages, packages that displayed progressively fewer branding design elements were perceived increasingly unfavorably and as detracting from the images that packages otherwise communicate. CONCLUSIONS: The findings indicate that packaging is vital to consumer identification with and differentiation between cigarette brands and that a policy of plain packaging could be useful in reducing the impact of packaging in promotion of tobacco products.

Is the perceived public stigma of smokers associated with value opposites? An exploratory cross-sectional analysis of Norwegian data 2011-2013.

Smoker stigma is a likely unintended consequence of tobacco polices aiming to denormalise smoking. Little is known about the dissemination of stigmatising attitudes toward smokers at the population level, including their associations with personal values. Applying a theoretical approach that conceptualises stigma as a cultural (moral and intersubjective) issue, we analyse the spread of perceived public stigma of smokers in Norway and factors predicting agreement with such a perception. Using merged data from the biennial national survey Norwegian Monitor 2011 and 2013 (N = 7,792), we tested whether the tendency to agree with a perceived public stigma of smokers differs by four indexes of value opposites ('puritanism/emancipation,' 'conformity/individuality,' 'tolerance/intolerance,' 'status/anti-status'), controlling for smoking status, SES, and demographics. Descriptive statistics and block-wise logistic regression models were applied. In the total sample, 59.1% agree with the statement that 'most people think less of a person who smokes.' Two of the four indexes of value opposites tested were associated with tendencies to agree with the perceived public stigma of smokers ('puritanism/emancipation' and 'status/anti-status'). Smokers with current plans to quit expressed the highest perceived public stigma, while ex-smokers expressed a higher perceived public stigma than never-smokers. Women, young people and respondents with high SES agree with a public stigma of smokers more than men, older people and respondents with low SES do. The perceived public stigma of smokers is high in Norway and varies to some extent with personal values, but also with socio-demographics and especially smoking status.

Indexing Quit-Smoking Interest among Norwegian Smokers 2019-2021.

Even if smoking prevalence is declining in several western countries, continued smoking cessation is required to reduce tobacco-related harms and to achieve future goals of smoke-free societies or the tobacco endgame. But how many of the current smokers want to quit? Estimates vary and depend on the type of question asked. We investigate how a pooled sample of Norwegian smokers (N = 1321) is distributed over four indicators of interest in quitting: (i) degree of desire to quit, (ii) prediction of future smoking status, (iii) reported plan for quitting smoking, and (iv) statements on previous attempts to quit. Based on these variables, we constructed an index. One-third of the smokers (32.6%) was categorized as having a high or very high interest in quitting. However, nearly half of the smokers (47.8%) had low or very low interest in quitting. Like several other countries, Norway has legislated a vision of a smoke-free society and, under the government's plans; this goal will be achieved by intensified use of structural measures such as tax hikes, tighter restrictions on outdoor smoking, and reduced availability of cigarettes. For the third who want to quit smoking, such constraints on their behaviour may help them to pursue their desire to quit. However, for the half who want to continue smoking, these measures may not be helpful but instead be experienced as a loss of welfare, less freedom to act, and increased social disqualification.

Public support for further regulating smoking, snus and e-cigarettes in Norway, and its associations with risk perceptions and tobacco use.

BACKGROUND: Public support is an indication of the legitimacy of governmental tobacco interventions. Little is known about what it is that shapes the support for various tobacco policy measures. We examine whether there are differences in public support for new measures against smoking, snus, and e-cigarettes in Norway, and whether public support is associated with user status and perceptions of the products' harm potential. DATA AND METHODS: In December 2017, 4,002 people aged between 16 and 89 answered a web-based questionnaire. The sample was randomly drawn from Norstat's web panel, and pre-stratified by gender, age, region, and education in order to obtain an approximate country-representative sample. Respondents were asked to indicate their support for eight possible future measures to further restrict accessibility of tobacco (asked separately with regard to smoking tobacco, snus and e-cigarettes respectively), on a five-point scale from 1 = 'no support' to 5 = 'full support'. We utilized means and t-tests to address differences in support between measures. We then constructed sum scores to assess the total support for regulating each tobacco product and subjected these indexes to linear regression analyses, controlling for background variables. RESULTS: For six of the eight proposed measures, public opinion is less supportive of e-cigarette regulations than of similar regulations for snus and, especially, smoking tobacco. In all three regression models, significant associations with risk perception, user status and gender were maintained after multiple controls. The associations with risk perceptions were stronger for support of snus and e-cigarette regulation than for smoking tobacco. CONCLUSION: Overall, these findings illustrate the key role of risk perceptions in forming public opinions regarding tobacco-preventive regulations and underline the importance of information to ensure that population risk perceptions are accurate.

Children's right to smoke-free air: Public support in Norway for banning smoking in vehicles with children present.

BACKGROUND: Children have a statutory right to a smoke-free environment, and tobacco control advocates are now considering regulation of smoking behavior in the private sphere. The Norwegian Institute of Public Health has investigated the support for a ban on smoking in cars with children compared to other possible extensions of the tobacco act among the Norwegian public. MATERIAL AND METHODS: A nationwide representative survey (CAWI) of 5543 participants was conducted in 2014-2015. Respondents were asked to consider several possible new tobacco control measures, through selfreported ranking on 5-point scales for each measure. Multiple logistic regression models were applied to control for confounders (i.a. smoking behavior) for the tendency to state full support. RESULTS: A majority (78 % of all respondents, 61.8% of daily smokers) supported a proposal prohibiting smoking in cars when children are present. This proposal received substantially more support than bans on private balconies, in parks and at public transport stops and work entrances. Full support for the latter proposals varied between 39.9% and 58.1% (between 2.7% and 16.8% among smokers). Differences by smoking status were maintained after multiple controls. INTERPRETATION: The strong endorsement of the proposal (also provided by the majority of current smokers) suggests high legitimacy and compliance, which means that an implementation could be introduced without serious enforcement problems.

Assessing notions of denormalization and renormalization of smoking in light of e-cigarette regulation.

The rationale for 'denormalization' of smoking in tobacco policies has been challenged by the emergence of e-cigarettes and the need to regulate e-cigarette use and promotion. Our aim is to assess the research status on e-cigarettes' contribution to 'renormalization' of smoking and to clarify how renormalization of smoking can be appraised at the conceptual and empirical level. Combining conceptual analysis and narrative review, the paper brings out three dimensions of denormalization/renormalization of smoking ('unacceptability/acceptability'; 'invisibility/visibility'; 'phasing out behaviour/maintaining behaviour') and an inherent duality of the e-cigarette as a smoking-like device and a smoking alternative. These analytical dimensions are applied qualitatively to consider the literature identified by searching the Web of Science database for 'e-cigarettes AND renormalization' (and variants thereof). Theoretically, normative changes in smoking acceptability, increased visibility of e-cigarettes and use, and observations of actual use (prevalence, dual use, gateway) can all be applied to illustrate processes of renormalization. However, only acceptability measures and user measures can be said to be empirical tests of renormalization effects. Visibility measures are only based on logical assumptions of a possible renormalization; they are not in themselves indicative of any "real" renormalization effects and can just as well be understood as possible consequences of normalization of e-cigarettes. Just as a downward trend in smoking prevalence is the litmus test of whether denormalization policy works, stagnating or rising smoking prevalence should be the main empirical indicator of renormalization.

"It looks kind of cool when cool people smoke, but " Norwegian adolescents' decoding of smoking scenes in films.

AIMS: Exposure to smoking scenes in films is seen as contributing to smoking initiation among young people. This has triggered calls to include depictions of smoking as a criterion in film ratings. All the same time, little is known about how adolescents interpret different smoking scenes. This study analyses how young people decode smoking scenes by contextualising identification with, and evaluation of, various characters who smoke, as well as the significance of film genres. DESIGN: In order to explore how adolescents conceptualize smoking scenes in different film genres, we conducted eight focus-group interviews with adolescents aged 13-17 years (n = 54), using purposive sampling. The discussions were semi-structured with a standard guide, and we used clips from eight films containing various positive and negative moods and character types as stimuli for the discussions. To analyse interpretations qualitatively, thematic coding was applied. RESULTS: The adolescents acknowledged that smoking is a narrative ingredient designed to illustrate and amplify character traits and situational moods. Characters who smoked were usually interpreted in terms of smoking stereotypes: stress relief, romantic seduction, social interaction between equals, habitual smoking, and as a symbol of "bad guys". The adolescents identified more strongly with elegant, positive, and self-assured smoking characters than with negative, anxious, or ambiguous characters. CONCLUSIONS: Adolescents interpret smoking scenes in accordance with encoded meanings: they tend to get the messages inscribed by the filmmakers. As positive and glamorous representations are more likely to stimulate smoking experimentation and initiation among adolescents than negative representations, future research should distinguish more clearly between exposure to positive and to negative representations.