Perceived strengths and case for a conventional strategy

The most consistent message conveyed in the interviews was the strong consensus and cooperation among members of the tobacco control community, legislators from various political parties and administrators in government ministries (table 1). The stakeholders’ consensus is best illustrated by the almost unanimous support for a nicotine- versus smoke-free Finland, which can be traced to the country’s experience with Swedish snus. The origins of the nicotine-free goal could be political and cultural, dating back to the time Finland joined the European Union. One participant stated “…the EU was against snus and the (Finnish) authorities didn’t want to make a special issue around snus. We were more concerned about alcohol monopoly.” The same participant proceeded to describe how snus was unpopular at this time (“a Swedish thing”), but has since gained favour among young Finnish males.28 Several participants expressed dismay at the growing popularity of snus and its use for reasons other than harm reduction. Others mentioned the challenge of conveying coherent messages on the relative risks of snus and other products, such as electronic cigarettes. The strong views against a harm reduction strategy were frequently expressed in terms of the problematical relationship with Swedish Match. In the words of one stakeholder, “The policy that Sweden has is really challenging for us (because) they should not be marketing the product to Finland….yet, they are still doing it.” Another stakeholder stated that the main reason for not instituting a harm reduction strategy is that “…we already started seeing results (smoking reduction) with the current policy”. A minority of participants challenged the overwhelming support for a nicotine-free Finland. One said “…consensus discussion has not always been academically logical, (and has been) driven by strong personalities over the years”. Expressing a similar sentiment, another participant said that the tobacco control community in Finland does not have the “manpower to ask the hard questions”.

Study participants repeatedly referred to the strategical and legislative successes that contributed to the reduction in Finland’s smoking prevalence. They often alluded to Finland’s pioneering initiatives in tobacco control policy, ranging from advertising restrictions in the 1970s to the more recent tobacco endgame in 2010. Stakeholders discussed Finland’s successes in tobacco control in terms of demand-side policies (table 1). One stakeholder, for example, alluded to the comprehensiveness of the original Tobacco Act, whose restrictions on tobacco advertising were easily revised to include electronic cigarettes and accessories. The Finnish government’s exemplary record of passing effective legislation could be viewed as a strength of Tobacco–Free Finland 2030; but, some indicated that the success could stymie innovation. One participant said “I think the problem is that Finland has such a long history of being successful in developing legislation. So it’s sort of blind.” The same participant aptly used the phrase “trapped by our former success” in describing the challenges of developing innovative policy.

Barriers to achieving the 2030 goal

The lack of designated funds for Tobacco-Free Finland 2030 was perceived to contribute to the continued dependency on NGOs for tobacco control (table 2). Some participants expressed concern that the NGOs, which handle tobacco control functions at provincial and national levels, will not have sufficient resources to reach the 2030 goal. With limited funding and lack of public health services designated by the government, one participant felt that “…the (NGOs) can’t do it by themselves”. Representatives from various NGOs conveyed the challenges of accomplishing their objectives with short-term government grants, donations and other sources. The discontinuity in funding has created challenges for large-scale implementation of innovative programme, such as smoking cessation coaches. In the words of one participant, “…we are lucky if (our project) will be adopted by the public sector”. Another stakeholder expressed frustration at having to seek funding for the nation’s quitline on an annual basis. An even greater challenge is the lack of coordination between NGOs and the healthcare system, which, for example, hinders systematical referrals to smoking cessation services.

Despite policymakers’ support for a conventional strategy, some acknowledged the barriers and limitations of not implementing a bold, innovative measure. The most common response was that such an intervention (eg, “sinking lid”), implemented without the public’s support, could be detrimental to the tobacco endgame. One stakeholder said that “…if we proposed measures not accepted by the general public, then it could have a backlash on other areas of tobacco control”. Others referred to legal barriers, such as free trade established by the European Union, and political barriers of the opposing views held by representatives of Finland’s coalition government (table 2). The current trend in liberalising Finnish alcohol policy was one participant’s explanation for why the government is not contemplating government-controlled tobacco outlets. Several participants mentioned the constitutional constraint of instituting the tobacco–free generation, which could be perceived, according to one stakeholder, as being inequitable.

Disparities in tobacco use were largely attributed to the socioeconomical gradient that is common in other high–income countries. In the case of vocational schools, institutional practices may also play a role in students’ high prevalence of smoking. Stakeholders mentioned the low quality of health education, variability in compliance with the smoke–free policy due to autonomy of unit leaders and poor leadership exemplified by personnel smoking in the vocational schools. But, others provided a more nuanced explanation for the disparity based on the concept of equity in Nordic countries. One participant said “… living in a Nordic welfare state, we think that one spoon is enough for everybody. So positive discrimination is really difficult for countries like Finland”. Providing extra programme for specific groups could pose a challenge for tobacco-control professionals.

Among all of the topics discussed, the issue of whether Finland should institute a large media campaign to change social norms about tobacco use had the least consensus. One participant stated that the current media strategy was not very coherent in the sense that “(we) have this year a pregnancy campaign and we forget that next year somebody might get pregnant”. As expected, the professionals who developed media campaigns targeted to high-risk groups (eg, vocational students) were less focused on changing social norms of the general population. Some felt that a campaign directed to the masses would have little impact because of the segmentation of tobacco users. As conveyed by senior stakeholders, younger policymakers were not exposed to the successful campaigns that aired decades ago in Finland. Some key informants who had experienced the mass campaigns in the 1980s felt passionately about the need for a nationwide anti-smoking campaign. These individuals argued that mobilising the public was necessary in order to change social norms and combat “generational forgetting”. Some participants perceived mass media campaigns as being incompatible with the Finnish culture, particularly the ones modelled after American-style campaigns. Others expressed that a large-scale campaign would be unnecessary because of public support for tobacco control and mandatory health education in Finnish schools.

Deficiencies in smoking cessation services were regarded by many as the greatest challenge to Tobacco–Free Finland 2030. Most of the problem was attributed to the lack of an organised system of cessation services in healthcare, leading to variability in the availability and quality of services across hospitals and municipalities. Stakeholders also noted the limited awareness of existing services among patients and physicians, the perception that smoking is not treated in the health centre because it is a private matter, healthcare professionals’ insufficient training in smoking cessation and other barriers to the delivery of cessation treatment, such as nurses’ excessive workload.

Potential solutions for achieving the 2030 goal

New policy initiatives in tobacco control were not uniformly viewed as the top priority for achieving the 2030 goal. In fact, one leading advisor expressed that tobacco policy has reached its limit via the statement “…when I say those traditional tobacco products, like cigarettes, it’s already more or less case closed; I mean politically and legally.” The same individual then suggested that policymakers direct their attention to more pressing problems such as alcohol, drugs and domestic violence.

Participants frequently mentioned the need for improving services and promoting initiatives aimed at tobacco cessation, including smoke-free surgeries; support for smoking cessation specialists; role of former smokers as cessation coaches; incentives for general practitioners to specialise in primary healthcare; more health promotion in medical curriculum; an app for smoking cessation and a website cataloguing the various cessation services throughout Finland. Limiting the sales of nicotine replacement therapy to pharmacies, an initiative currently being debated, was supported by some participants. But, not all supported the paradigm of treating smoking behaviour with medication and behavioural therapy. In lieu of improving cessation services, one participant promoted tobacco taxation as a means of incentivising smokers to quit.

Modelling Finnish municipalities after the Smoke-Free Helsinki Programme was perceived as another means of improving cessation services. The Programme’s organised system was praised for facilitating the referral of smokers to a tobacco clinic. One stakeholder was impressed by the fact that “…the city of Helsinki has done a lot for tobacco control that is not in any legislation”. Others noted that Helsinki’s success was attributed to its educated populace and a strong political commitment from its city officials.

Impact of external factors on 2030 goal

Factors that extend beyond Finland’s own tobacco policy were perceived by most stakeholders as neither impeding nor facilitating Tobacco-Free Finland 2030 (table 3). Regarding the EU’s 2014 TPD, participants expressed confidence that the Finnish government was capable of enacting effective policy independent of the European Union. Many felt that Finland was autonomous and more progressive than the EU in tobacco control policy. Some participants noted that the EU’s TPD has aided Finland’s own initiative through a common framework, which, for example, reduces the smuggling of products across European countries. Others expressed concern that the TPD has opened the door to electronic cigarettes, which were previously unavailable in Finnish markets. The second factor, the tobacco industry, was seldom discussed by participants because the industry was viewed as a non-entity in Finland. One participant, however, noted that Philip Morris International has been working with former political advisors employed by public relations firms.

The third factor, the proposed SOTE, plans to transfer services from small municipalities to larger districts in Finland. SOTE was viewed by participants as having great potential for standardising the delivery of smoking cessation services. But, many acknowledged that the fate of SOTE was unclear due to political debate and protracted negotiations. Some raised the spectre that even if SOTE were approved, it would have minimal impact on smoking cessation services because health promotion is secondary in priority to provider choice. One participant expressed concern that the bifurcation of services into medical care (districts) and health promotion (municipalities) could lead to fewer physician interventions for smoking cessation.