
==== Front
Nicotine Tob Res
Nicotine Tob Res
nictob
Nicotine & Tobacco Research
1462-2203
1469-994X
Oxford University Press US

38635413
10.1093/ntr/ntae083
ntae083
Original Investigations
AcademicSubjects/MED00010
AcademicSubjects/SOC02541
Tobacco Control in Denmark: How the Ugly Duckling Turned into a Swan
https://orcid.org/0000-0002-7970-3168
Pisinger Charlotta MD, PhD, MPH Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg University Hospital, Frederiksberg, Denmark
Faculty of Health Sciences, University of Southern Denmark, Copenhagen, Denmark

Rasmussen Sofie Bergman MA Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg University Hospital, Frederiksberg, Denmark

Corresponding Author: Charlotta Pisinger, MD, PhD, MPH, Professor, Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg University Hospital, Hovedvejen, indgang 5, 2. sal, Nordre Fasanvej 57, 2000 Frederiksberg, Denmark. Telephone: 45-38163017; E-mail: charlotta.pisinger@regionh.dk
10 2024
18 4 2024
18 4 2024
26 10 13391346
11 7 2023
19 3 2024
10 4 2024
20 5 2024
© The Author(s) 2024. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.

Abstract

Introduction

The implementation of tobacco control policies has been a neglected topic in tobacco research. A comprehensive Tobacco Action Plan including plain packaging, a point-of-sale display ban, a ban on characterizing flavors (in products other than cigarettes), a strengthening of the promotion and marketing ban, a ban on the sale of novel nicotine products to minors, smoke-and nicotine-free-school hours in all-schools with minors, and a significant increase in tobacco tax, was adopted in Denmark in 2019.

Aims and Methods

Eleven people involved or very close to the advocacy process were invited, two did not respond and nine attended our research center. We used the nominal group technique, a consensus method, to identify the most important driving factors for passing the Tobacco Action Plan.

Results

The round-robin identified 39 driving factors merged into 13 in the clarification phase. In the ranking phase, participants agreed on seven factors that they perceived have strongly influenced the political will to strengthen national tobacco control comprehensively. The most important factors were national data and evidence, a nationwide alliance with broad partnerships, a strict focus on young people, continuous media coverage, intensive lobbying by many different advocates, making it a community agenda—not a political one, and effective professional campaigns.

Conclusions

Our findings agree with experiences from other countries that significantly improved tobacco control. The Danish strategy, including a nationwide alliance with broad partnerships, had a high influence on the political agenda.

Implications

In this study, there was a consensus that seven factors strongly influenced the political will to comprehensively strengthen the national tobacco control in Denmark in a short time: national data and evidence; a nationwide alliance with broad partnerships; a strict focus on children and young people; continuous media coverage; intensive lobbying by many different advocates; making it a community agenda—not a political one, and effective professional campaigns. This is consistent with findings from other countries.

The Danish Heart Foundation Tryg Foundation 10.13039/501100007437
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pmcIntroduction

Denmark has recently experienced a fast and very comprehensive improvement in tobacco control, which is also unique from a global perspective. It did not happen accidentally or by luck—several years of targeted advocacy laid the foundation for this achievement.

The Tobacco Control Scale monitors the implementation of tobacco control policies across Europe. Every three years, a report is published by the Smoke-Free Partnership, a large European coalition of NGOs that works on EU policy analysis and advocacy. In 2013, Denmark ranked 15th out of 35 European countries concerning the implementation of efficient tobacco control policies. Six years later, Denmark was at the bottom of the scale and ranked 29th out of 36 European countries.1 When compared with other countries in Europe from 1998 to 2019, tobacco prices increased the least in Denmark,2 and no major legislative actions had been taken for many years.3 As a result of this, the previous yearly decline in adult smoking prevalence stagnated from 2012 to 2018 (approximately 17% daily smokers), and in 2017, a national survey found a significant increase (from 13% in 2013 to 16% in 2017) in daily smoking prevalence among adolescents and young adults.4

In 2016, as part of a new Cancer Plan for 2017–2020, smoking was identified as the main cause of cancer in Denmark, and it was recommended to give smoking the highest priority in cancer prevention. Consequently, the Danish government adopted the goal of a smoke-free generation, which aims to have no children or adolescents smoking by 2030.5 However, no formal strategy, sub-goals, or milestones were set for reaching the goal.

In May 2019, the prevention of smoking in children and young people became one of the hottest topics during the election campaigns. In June 2019, a new government was elected, and in December 2019, a broad political coalition agreed on a comprehensive Tobacco Action Plan aimed at children and young people. This was adopted by law 1 year later.6 A significant strengthening of the tobacco legislation took place including the adoption of plain packaging, a point-of-sale display ban, a flavor ban on e-cigarettes, heated tobacco, chewing tobacco, and waterpipe, a strengthening of the promotion and marketing ban, a ban on the sale of novel nicotine products to minors, health warnings on nicotine pouch packages and smoke- and nicotine-free-school hours in all-schools with minors (Table 1). Further, there was a major tobacco tax increase. The price of a 20-piece cigarette pack increased in April 2020 from approximately 40 DKK (approximately 5.3 euro/6 USD) to approximately 55 DKK (approximately 7.3 euro/8.2 USD), and in January 2022 the tax was further increased to approximately 60 DKK (approximately 8.1 euro/8.8 USD) per pack.

Table 1. The Tobacco Action Plan Adopted by Law, Denmark (December 2020)

	Conventional tobacco products	Emerging tobacco and nicotine products	
FCTC-based tobacco control policies	Cigarettes and RYO tobacco	Chewing tobacco	Pipes, pipe tobacco, and cigars	Waterpipe tobacco	e-Cigarettes and refill containers without nicotine	e-Cigarettes and refill containers with nicotine	Nicotine products a (eg nicotine pouches)	New tobacco categories (eg heated tobacco products)	
Article 8
Smoke- and nicotine-free school hours ¤	NEW	NEW	NEW	NEW	NEW	NEW	NEW	NEW	
Article 9
Ban on characterizing flavorsb	X	NEW	–	NEW	NEW	NEW	–	NEW	
Article 11
Health warnings	X	X	X	X	–	X	NEW	X	
Article 11 + 13
Plain packaging	NEW	NEW		NEW	NEW	NEW		NEW	
Article 13
Point-of-sale display ban	NEW	NEW	NEW	NEW	NEW	NEW	NEW	NEW	
Article 13
Ban on hidden marketing, both in shops and online	NEW	NEW	NEW	NEW	X	X	NEW	NEW	
Article 16
Ban on sale to minors below 18 years	STRONGER ENFORCEMENT	STRONGER ENFORCEMENT	STRONGER ENFORCEMENT	STRONGER ENFORCEMENT	X	STRONGER ENFORCEMENT	NEW	STRONGER ENFORCEMENT	
The table shows the NEW legislation according to the Tobacco Action Plan and the already existing legislation (shown as X) before implementation of the Tobacco Action Plan. In all-schools with students below 18 years. There was an existing ban on smoking on school premises. This new legislation also bans nicotine products and covers the whole day, also when the students leave the school premises, eg during a long break.

aNicotine products except pharmaceutical nicotine products approved for smoking cessation.

bExcept menthol.

In the latest edition of the Tobacco Control Scale in 2021, Denmark ranked number 13 out of 37 European countries. It was the country (together with the Netherlands) with the greatest improvements in tobacco control in the last three years.7 Subsequently, daily smoking prevalence in Denmark among 16 to 24-year-olds decreased from 17% in 2017 to 9% in 2021 among boys and young men and from 14% to 9% among girls and young women.8 A detailed overview of the Danish tobacco control legislation can be found in the Tobacco Control Laws, a database developed by the Campaign for Tobacco-Free Kids,9 and in the recent MPOWER report published by the World Health Organization (WHO).10

The passing and implementation of tobacco control policies have been neglected in tobacco research. A study found that less than 0.5% of tobacco or nicotine research papers had policies or politics as their main focus.11 This paper aims to explore which driving factors were perceived as the most important in adopting the comprehensive Danish Tobacco Action Plan.

Materials and Methods

Three people who had been close to the advocacy process in the years up to 2019 identified ten people (key informants) who they believed had been important actors and/or publicly significant voices advocating for a strengthening of tobacco control in Denmark in recent years and thereby had played a major role in the adoption of the new Tobacco Action Plan: two people from major NGOs; the former head of the Danish Medical Association; three politicians; the head of a scientific counsel; a newspaper journalist; a tobacco researcher; and a director of the association of Danish Merchants. Further, we invited a high-ranking person from the Danish Health Authority, a central observant. In total 11 persons were invited. Two of the invited politicians did not respond. The remaining nine persons attended a face-to-face meeting on 14 November 2022 at the Research Center for Prevention and Health, Capital Region of Denmark.

We used the Nominal Group Technique (NGT), a consensus method for idea generation, problem-solving, and priority determination.12 The NGT ensures that all-participants’ ideas are heard and that all-participants’ priorities have equal weight. Two tobacco researchers facilitated the process (CP assisted by SBR (authors of this paper)). In advance, we sent two questions regarding adopting the Tobacco Action Plan (Supplement 1). After a brief introduction, the participants were prompted to first think only about important drivers that could not be influenced by advocates (10 min of brainstorming). This was not a part of the NGT process. This was done, so the actors in the next step could fully concentrate on identifying drivers that could be influenced by advocates in the NGT process.

The NGT process consists of five phases: silent generation; a round robin; a clarification phase; confidential voting; and a discussion. For details, see Supplement 1.

The whole process took about 2 h.

Results

In a brainstorm (before the NGT process), eight factors were identified as important facilitating drivers, even though the researchers, health advocates, and other antismoking actors (referred to as “tobacco control advocates” in the rest of the paper) had no or little influence on them (Supplement 2).

The round-robin identified 39 drivers on which the tobacco control advocates had influence and which they perceived had facilitated the political process (Supplement 3). In the clarification phase, the participants agreed on slightly reformulating several of these and merging the 39 drivers into 13 (Supplement 4). After the ranking of drivers, the participants discussed further. They reformulated and merged some of the drivers, ending up with the seven most important drivers that influenced the adoption of the Tobacco Action Plan and could be defined as recommendations to tobacco control advocates in other countries (Table 2). The results are presented as ranked by the participants (most important first).

Table 2. Consensus on the Seven Most Important Factors that Facilitated the Adoption of the Tobacco Action Plan in Denmark.

1. National data on the target group, solid evidence, reviews, and reports	
2. A nation-wide alliance with very broad partnerships (harmonized strategies, speaking with one voice)	
 • Presenting successful initiatives at many levels of the society	
 • United in the rejection of the tobacco industry	
3. Focus on children and youth	
4. Continuous media coverage and pressure on the politicians	
5. Intensive lobbying by many different advocates	
 • Continuously reminding politicians that smoking is the most important risk factor for disease	
6. Make it a community agenda not a political agenda	
7. Effective professional campaigns and positive, good manners	

National Data on the Target Group, Solid Evidence, Reviews, and Reports

To drive progress in Danish tobacco control, the Smoke-free Future Partnership (for detailed information, please see below in Recommendation 2), in cooperation with the National Institute of Public Health, continuously presented new national data on children’s and young people’s smoking. Data were continuously communicated both to the public (in campaigns, media, etc.), to politicians (in reports, media, and face-to-face meetings), and to NGOs (via the Network for Tobacco Prevention, for detailed information, please see below in Recommendation 2) and the partners in the Smoke-free Future Partnership, who then repeated them.

For example, it was estimated that 40 children and adolescents started smoking every day in Denmark, a country with approximately 6 million inhabitants. This number was used systematically by all-tobacco control advocates and, later, quoted by the prime minister and other politicians in debates and in many other situations where the smoke-free generation agenda was promoted. Data on the general population’s position on tobacco legislation were also presented. In 2017, 89% of 14 to 19-year-olds supported the government’s goal of a smoke-free generation, and 82% supported the implementation of smoke-free school hours or actions preventing adolescents from smoking initiation.13 A survey of the adult general population supported these findings.14

Several Evidence Reports,15,16 simulation models of consequences of different legislative actions,17 and a Capacity Assessment Report (in cooperation with the WHO Regional Office for Europe and the European Network for Smoking and Tobacco Prevention)18 were published, and launched at national conferences where the Danish Health Authority, all-important stakeholders, and several politicians took part. The reports received a lot of media coverage.

A Nationwide Alliance with Very Broad Partnerships

The Danish Cancer Society and a large Danish non-profit foundation, TrygFonden (the Tryg Foundation), launched an endgame partnership, “Røgfri Fremtid” (Smoke-free Future), in 2017. The partnership has a steering committee, an advisory board, and seven full-time employees and it is placed in the Danish Cancer Society. In 2018, the Smoke-free Future Partnership consisted of 53 partners; in April 2023, there were 285. The partnership not only consists of the “usual suspects” but also includes trade unions, supermarket chains, private companies, actors, municipalities, and regions. The partnership had a proactive approach to the inclusion of partners who were not typically working with health promotion to make a Smoke-Free Future a society agenda. Please see Table 3 for examples of actions taken. The partnership continuously presented successful initiatives at many levels of society to the partners, the public, and the politicians to motivate them to further actions. There was consensus among the participants that the Smoke-free Future Partnership has been an essential driver for the adoption of the Tobacco Action Plan and that the partnership would not have succeeded without sufficient funding (Table 3).

Table 3. Examples of Actions Taken by the Smoke-free Future, Their Partners, and the Civil Society

The Smoke-free Future partnership
(Røgfri Fremtid)	The partnership works in four fields: (1) legislation, (2) partnerships (including local actions and projects), (3) evidence (national evidence generation, collection of successful cases, and focus on the World Health Organization recommendations), and (4) information (campaigns and broad information). All-partners are invited to a yearly conference where, among others, best-practice cases from the whole country are presented for inspiration. Partners can also find inspiration from other successful initiatives online and receive help and counseling on an ongoing basis, eg to implement stricter local smoke-free policies or arrange events focusing on smoke-free children and young people. Further, partners can download signs, posters, flyers, brochures, and other complimentary materials. A partnership is free of charge. The partnership is funded by the Danish Cancer Society and the non-profit organization, the Tryg Foundation.	
Regions	According to the Health Act, the five regions in Denmark are responsible for patient-oriented prevention at hospitals and from general practitioners, as well as for providing advice to municipalities.34 In 2018, the Regions established a “Prevention-laboratory” that should assist NGOs and civil society to find new prevention strategies in collaboration with researchers and through partnerships. The steering committee chose primary smoking prevention as the major focus area. The leadership of the Regions of Denmark and the Local Government of Denmark declared a strong commitment to preventing smoking in children and young people. The head of the Regions was very active and had a strong voice in national and local political discussions. She published large articles in major newspapers, arguing for a higher price on tobacco and a national tobacco action plan, and took part in workshops with, eg schools to promote smoke-free school hours. Further, the Regions of Denmark implemented smoke-free work hours.	
Municipalities	In Denmark, the municipalities are responsible for citizen-based health promotion and prevention.35 The term “smoke-free work hours” covers a strict smoking ban in workplaces and means that smoking is not only prohibited inside and outside a workplace, but it is also prohibited to smoke when an employee leaves the premises during work hours, eg when working at home, driving, or working out-door. Further, many municipalities have implemented smoke-free playgrounds, parks, and other outdoor areas. Copenhagen, the capital of Denmark, committed to becoming a Smoke-free City in 2025. This should be achieved through, eg smoke-free playgrounds, schools with smoke-free school hours, smoke-free work hours in public workplaces, an increase in smokers getting assistance to quit, campaigns, and partnerships with private workplaces and other stakeholders.	
Schools	The term “smoke-free school hours” covers a strict smoking ban in schools and means that smoking is not only prohibited inside and outside a school but pupils are also prohibited from smoking when they leave the premises during school hours (typically between 8 am and 3 pm) when having a long break at home or going on a field trip. (School-free school hours have been implemented successfully nationally in Norway in 2014.36) Many primary schools, several vocational schools, and high schools voluntarily implemented smoke-free school hours and reported that it was both feasible and successful. They took part in, eg workshops to inspire other schools and meetings with politicians.	
Festivals	The electronic music festival Strøm was the first to refuse complimentary cigarettes from the tobacco industry and the first festival to stop selling tobacco. Further, no smoking persons are depicted on marketing materials for the festival, and the staff has been made aware that they are role models to young people and should avoid smoking during the festival. Several festivals have followed in their footsteps by stopping the sale of cigarettes, and the largest of them, the Roskilde festival, attended by more than 130 000 mostly young people, has also joined the Smoke-free Future partnership.	
Traders and retailers	In 2018, one of the most famous malls in Denmark, Magasin du Nord, stopped the sale of cigarettes. Later the same year, a large national supermarket chain, Salling, introduced a voluntary point-of-sale-display ban. Some months later, they published full-page ads in major newspapers informing that the display ban had worked and that the sale of cigarettes had decreased substantially, especially in shops close to schools. Shortly after, several supermarket chains followed their example. A motivation for becoming a partner (according to the director of the Danish Merchants’ Association) and for introducing a voluntary point-of-sale-display ban was to show the politicians that there were other alternative legislative actions that could be taken than to increase the tobacco tax. Some supermarket chains run campaigns stating that they strictly enforced the ban on the sale of tobacco to minors. Further, several private companies voluntarily implemented smoke-free work hours. The Danish Heart Foundation worked with the implementation of stricter smoking bans and smoke-free work hours in private workplaces, and the youth agenda was also used here, as many minors work part-time in Denmark and are introduced to smoking at their workplace.	
Media and theater	In the summer of 2019, a very popular TV celebrity launched a podcast series called “Denmark’s Killer #1” that became the most listened-to podcast series in Denmark. The podcast was based on conversations with his father, who has a smoking-related disease, and with public health professionals, eg the Danish Cancer Society and the professor in tobacco control. The tobacco industry strategies and deception were some of the central elements, as well as the environmental impacts of smoking. Several journalists supported the Smoke-free Future agenda and published much news on the topic, pushing for political action. An actor toured in schools with an antismoking theater show, “Act on IIt—Don’t Smoke.”	
Sport	Many sports associations and sports facilities have become smoke-free. Several football stadiums implemented smoking bans or smoke-free football stands.	

Further, there is a national Network for Tobacco Prevention in Denmark. It was established in 1997 and includes 17 organizations of patient or health and scientific organizations and municipal networks active in tobacco control. The network has biannual meetings where members are updated on ie new national data, new tobacco and nicotine products and ongoing initiatives.

The network harmonized their strategies, and they spoke with one voice. For example, the members of the network agreed on emphasizing that higher tobacco taxes were the most important action (a pack of cigarettes should cost at least 80 DKK; approximately 10.7 euro/11.7 USD), but that many simultaneous actions were necessary. The partners and the network took every opportunity to speak with politicians. All the above-mentioned networks and partners were united in rejecting any collaboration with the tobacco industry.

Focusing on Children and Young People

Partners in the Smoke-free Future Partnership and the Danish Network for Tobacco Prevention agreed on a very narrow focus on children and young people. This was partly because other countries had good experience with this strategy and partly because it was the perception that focusing on children only would make it easier to get public and political support. Some participants also mentioned that the “No children should start smoking” focus made it difficult for the tobacco industry to argue against, as this is the tobacco industry’s own official opinion. Many of the typical heated public discussions (such as: “smoking is a free choice made by adults”) were avoided by strictly keeping focus on the prevention of smoking initiation in children and adolescents.

A sub-strategy was, based on the existing evidence, to give higher taxes on tobacco the maximum priority to prevent smoking initiation in children and young people. So, suppose one of the partners wrote a newspaper article, was interviewed on TV or radio, or took part in a political debate. In that case, he or she would say, “No children should start smoking,” and “A higher price on tobacco is the most effective way to achieve this goal.” There was not a cacophony of voices with different agendas pulling in different directions.

However, some organizations had an additional agenda. For example, the head of the Danish Medical Association also warned politicians about adolescents’ e-cigarette use.

The target group, children and young people, were actively involved. They were asked in surveys about their position on stronger legislation, they were interviewed in focus groups and took part in radio interviews, public meetings, the launch of reports, etc. For example, they stated that it would motivate them to quit if the price of cigarettes increased dramatically or the positive aspects of the implementation of smoke-free school hours in their high school were explained.

Continuous Media Coverage and Pressure on Politician

National and local media, independent of political orientation, supported the smoke-free generation agenda, gave column space to the topic, and called for political action. The tobacco control advocates identified journalists with high interest in the topic and regularly sent their news stories and new data, etc., directly to them. The newspaper journalist who participated in the NGT process expressed that it always had been easy to find new angles and new stories to write about, as the tobacco control advocates had been very efficient in providing interesting topics and materials to the media. The news articles, TV, and radio broadcasts always focused on children and included a call for political action.

A supermarket chain that voluntarily implemented a point-of-sale display ban paid for whole-page advertisements in national newspapers to inform the public about how markedly the sale of cigarettes had decreased in their supermarkets,19 especially in those near large education institutions, and called for legislation at the national level. The Danish Heart Foundation funded the first professorship in tobacco control in Denmark (author C.P.). The professor received a lot of media inquiries after getting this title.

Intensive Lobbying by Many Different Advocates

The Smoke-free Future, including the NGOs and the other different partners with very different connections, used their influence to lobby politicians at the local, regional, and national levels. In 2018, the leadership of the Regions of Denmark and the Local Government of Denmark declared a strong commitment to preventing smoking among children and young people and put pressure on politicians at the national level. The participants in the NGT process also noted that even though the main focus was not on the risks of smoking, it had been useful to continuously remind the politicians that smoking is the most important risk factor of disease in Denmark. Therefore, stronger tobacco legislation should have priority.

Make It a Community Agenda, Not a Political Agenda

The nationwide alliance with broad partnerships and many voluntary antismoking actions combined with the growing antismoking norm in the general population created a united call for political action. Examples of voluntary actions are presented in Table 3. It was a bottom-up approach to prevention. The strategy was not to assume that a few influential politicians would promote the agenda. Both left-wing and right-wing politicians took an active part in promoting the community agenda of “protecting the future of our children.” A popular TV campaign showed many small everyday things people disagree about but concluded that nine out of ten Danes agree that the next generations should not use tobacco. The campaign was voiced by two former Danish prime ministers from the Social Democratic Party and the Liberal Party.

Effective Professional Campaigns and Positive, Good Manners

The Smoke-free Future Partnership launched very professional and popular TV- and social-media yearly campaigns focusing on the prevention of children’s smoking. The themes would mostly provoke feelings and/or be humorous. As an example, a little boy gave an emotional speech to an adult audience, asking them to protect him and his little sister from becoming smokers. Again, the participants stressed that this would not have been possible without sufficient funding. The “tone of voice” in the campaigns and the public discussions strived not to be shrill or aggressive but polite and respectful, especially toward smokers. The campaigns typically build on data. For example, “40 children and young people start smoking every day.”

Discussion

Nine people whom we believed had a major influence on or inside knowledge about the adoption of the comprehensive Tobacco Action Plan in Denmark were invited and attended our research center. By using the nominal group technique, they jointly identified seven factors or strategies that they believed had been the most important drivers of the adoption of the Tobacco Action Plan. The three most important drivers—and recommendations to other tobacco control advocates were: (1) national data on the target group, solid evidence, reviews, and reports; (2) a nationwide alliance with very broad partnerships; and (3) focusing on children and young people.

Many countries in the world are making progress in tobacco control, but for the most part, only the results of many years of negotiation and advocacy—and not the process of how it was achieved—are presented.11 Thanks to the WHO’s Framework Convention on Tobacco Control (FCTC), decision makers have guidance on what should be adopted and implemented,20 but the political will to act is often lagging. One of the few papers that have studied the implementation of tobacco control policies concluded, based on findings from France, that the slow implementation of the WHO’s FCTC was due to a “lack of clear and consistent political will.”21 Policymaking is not a rational, linear process based on evidence; it is often unpredictable and complex and depends on multiple interacting actors. Also, the context (eg the social and cultural values) in which policies are implemented is constantly evolving. The question is how tobacco control advocates can fuel the passing of tobacco control policies.

Several of the “most important drivers” identified in this Danish study have been described before in other countries. The Netherlands was the only other country with as impressive improvements on the European Tobacco Control Scale in 2021 as Denmark. Researchers have explored how this was achieved in the Netherlands and have pointed out that adherence to Article 5.3 in the FCTC was one of the two most important drivers for passing the National Prevention Agreement (aiming at an endgame scenario with less than 5% of smokers in 2040).22 In 2016, in the Netherlands, the tobacco industry was reported to the police for attempted murder, and the Youth Smoking Prevention Foundation took the State to court for violating Article 5.3. The Dutch government gave in and began to adhere to its obligations not to consult the industry. The participants in our NGT process did not directly point to Article 5.3 adherence as one of the most important factors to achieve the passing of the Tobacco Action Plan, maybe because the industry during the advocacy years was busy promoting new nicotine products in Denmark instead of opposing stronger tobacco legislation. However, there had been some focus on tobacco industry interference during the intensive years of advocacy.23,24

Both the Dutch researchers and the Danish participants in the NGT process agreed that the nationwide advocacy coalition and the professional campaigns were extremely important drivers. The Dutch “Smoke-free Generation” movement in the wider society seems to be very much in line with the Danish nationwide alliance, the “Smoke-free Future,” with very broad partnerships and involvement at the grassroots level, continuous media coverage, and a community agenda. Other countries (Philippines, Ukraine, Nepal, and Vietnam) have also achieved improvements in tobacco control by using coordination of civil society, partnerships, and networks.25–28 Based on experiences from the European Union, Nepal, and Colombia it also seems that international cooperation (eg involvement of international health groups and technical and financial support from international agencies) can be helpful.28–30 A study investigated the implementation of the European Council Recommendation on smoke-free environments; the policy was adopted in 2009 after almost three years of negotiations. Interviews with stakeholders also pointed to the importance of an alliance.29 Tobacco control advocates, scientific institutions, public health organizations, and other actors worked together and were supported by a core group of national and European actors with experience in tobacco control. The European smoke-free alliance jointly promoted three key messages only in the political debates; in Denmark, the Smoke-free Future Alliance and the Network for Tobacco Prevention jointly promoted one key message only, a high tax on tobacco, as the most important policy action. Speaking with one voice and keeping the messages simple seems to be important. Willemsen introduced in 2018 the “Flywheel Model of Tobacco Control,” which predicts, in agreement with our findings, that policy makers are more willing to introduce tobacco control measures when the civil society is very supportive and the public has an antismoking social norm.11

The Smoke-free Future Partnership searched for inspiration in other successful countries. The Irish colleagues had a good experience with keeping the focus on children31; it paved the way in politics. In Denmark, “Focusing on children and young people” was identified as the third most important driver, as this strict focus created broad sympathy among smokers and pacified the tobacco industry. The Irish colleagues also pointed out the importance of national data. In our study, “‘National data”’ was identified to be the most important driver of the adoption of the Tobacco Action Plan in Denmark.

Even though several countries (Vietnam, Ukraine, and Philippines) found local data and scientific evidence to be important drivers,25–27 the fact that the implementation of tobacco control policies was attributed to evidence has been challenged.32 Values and coalitions seem to play a major role, as well as how arguments and evidence were constructed and framed.32 We agree that even the most convincing data would not have been effective without a strong and united nationwide network, the mobilization of civil society, professional campaigns, and massive media coverage to spread data.

Limitations

One weakness of the study is that the three people who chose the key informants did not establish a list of potential key informants independently. This would have strengthened our study design. It can be discussed whether we have identified the people that had played the most important role in the adoption of the Tobacco Action Plan and whether all-perspectives were represented in the sample of participants. Denmark is a small country, and actors working with tobacco control know each other well and share what they hear and observe, so we believe that the participants were representative. However, we probably should have contacted more politicians, as two out of three did not respond, and they have an insight into the political passing process that the other participants do not have. Many participants knew each other, which potentially might influence the dynamics of data collection, but this should have been avoided by the use of the NGT. The drivers identified were those who personally perceived to have played important roles, but there is no proof that they were the most important. It is our impression that there was little disagreement, but we cannot rule out that important drivers might have been overlooked.

Our NGT group consisted of nine participants. The optimal size of an NGT group is approximately seven participants, but groups of up to fourteen participants have been used.12 We would have preferred to spend more time on the NGT process, but this was not feasible. Other researchers have also conducted an NGT process in two hours.33

Strength

The diversity of participants is a strength. A key strength of the NGT is the balanced participation by group members, unlike focus groups, where there is a high risk of one or several dominant participants influencing the discussion, either by taking up a large part of the speaking time or by having a position that makes her or his words carry more weight. This is avoided by the structured format of the NGT. It might be either a strength or weakness that this study was performed three years after the Tobacco Action Plan was adopted. We believe that we often see the big lines more clearly when we see them from a (temporal) distance.

Convincing politicians to strengthen the tobacco control legislation is very challenging, and for many years, our experience in Denmark was that it was more or less impossible. The Danish experience is that we had more influence on the political agenda than we ever believed we might have. Our study and similar other studies indicate that a combination of national data, a united nationwide network, mobilization of civil society, focus on children and young people, intensive lobbying, professional campaigns, and massive media coverage can achieve major improvements in tobacco control legislation.

Supplementary material

Supplementary material is available at Nicotine and Tobacco Research online.

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Acknowledgments

We thank Niels Them Kjær from the Danish Cancer Foundation and Mads Lind from the Danish Heart Foundation for sparring and valuable review of the manuscript.

Funding

The Danish Heart Foundation and the Danish non-profit foundation, the Tryg Foundation, funded C.P.’s professorship during work on this paper.

Declaration of Interests

The authors declare no conflict of interest.

Author contributions

Charlotta Pisinger (Conceptualization [lead], Data curation [equal], Formal analysis [equal], Methodology [equal], Project administration [equal], Writing—original draft [lead], Writing—review & editing [lead]), and Sofie Rasmussen (Conceptualization [supporting], Data curation [equal], Formal analysis [equal], Methodology [equal], Project administration [equal], Writing—original draft [supporting], Writing—review & editing [supporting])

Data availability

Original data are available for researchers without a conflict of interest.
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