http://hdl.handle.net/10143/30058 Search the Channel search http://hera.helsebiblioteket.no/hera/simple-search http://hdl.handle.net/10143/97664 Title: Alkoholpolitikken og opinionen. Endringer i befolkningens holdninger til alkoholpolitikken og oppfatninger om effekten av ulike virkemidler i perioden 2005-2009<br/><br/>Authors: Storvoll, Elisabet Esbjerg; Rossow, Ingeborg; Rise, Jostein<br/><br/>Abstract: NORSK SAMMENDRAG: SIRUS har laget rapporten på oppdrag av Helsedirektoratet. Den bygger på data fra seks befolkningsundersøkelser av personer over 20 år som Synovate har utført for direktoratet fra 2005 til 2009. Studien tyder på at oppslutningen om en restriktiv alkoholpolitikk har økt de siste årene. Tidligere studier har vist samme tendens siden tusenårsskiftet.Endrete holdningerDet er færre som ønsker en mer liberal alkoholpolitikk i 2009 enn i 2005, selv om det fortsatt er et flertall som mener at vin bør selges i butikk (61 % mot 71 % i 2005) og at alkohol er for dyrt (59 % mot 75 % i 2005).På den annen side er det ikke lenger et flertall som mener at det er greit å smugle til eget forbruk (46 % mot 57 % i 2005). Bare 1 av 5 mener at det er for vanskelig å få kjøpt alkohol. Det er svært få som er enig at aldersgrensene er for høye (4 %) eller at dagens promillegrenser er for strenge (14 %).Oppfatninger om effektFra 2005 til 2009 har det vært en økning i andelen som tror at høye priser (fra 25 til 33 %), vinmonopolordningen (fra 31 til 40 %) og begrenset tilgjengelighet på utesteder (fra 35 til 46 %) i stor grad kan bidra til å begrense skadevirkningene av alkohol. Men det har vært en nedgang i andelen som tror at aldergrenser og promillegrenser er effektivt i så måte. Andelen som tror at foreldres grensesetting og informasjons- og holdningsskapende tiltak har slik effekt har vært stabil høyt.Gap mellom forskning og folks oppfatningerDet er fortsatt et stort gap mellom forskningen og folks oppfatninger om hva som har mest effekt for å begrense konsumet og skadevirkninger av alkohol. Forskning viser at høy pris og begrenset tilgjengelighet inkludert aldersgrenser og monopolordningen har god effekt, mens det er lite som tyder på at informasjons- og holdningsskapende arbeid har det.Kvinner og eldre mest restriktiveOppslutningen om en restriktiv alkoholpolitikk er størst blant kvinner, eldre, de med høyest utdanning og de som aldri eller sjelden drikker alkohol. De samme gruppene har også størst tro på at de alkoholpolitiske virkemidlene de ble spurt om, er effektive for å begrense skadevirkningene.Politikken allerede liberalisertRapporten peker på noen mulige forklaringer på at færre ønsker en mer liberal alkoholpolitikk. De siste tiårene har politikken allerede blitt liberalisert med langt flere vinmonopol og utesteder og utvidete salgs- og skjenketider. Økt kjøpekraft har gjort at alkohol relativt sett er billigere enn tidligere, og det kan ha redusert motstanden mot prisreguleringer.Alkoholforbruket har også økt betydelig de siste femten årene, og flere har kanskje opplevd alkoholens skyggesider. Det er også mulig at Helsedirektoratets alkoholkampanjer siden 2004 har bidratt til økt oppslutning om restriktive alkoholpolitiske virkemidler de siste årene. http://hdl.handle.net/10143/97618 Title: Fylkeskommunenes tannhelsetilbud til rusmiddelmisbrukere : en kartlegging<br/><br/>Authors: Edland-Gryt, Marit; Skretting, Astrid<br/><br/>Abstract: NORSK SAMMENDRAG: BakgrunnFylkeskommunene fikk i 2005 ansvar for å gi tilbud om tannhelsetjenester til rusmiddelmisbrukere som oppholdt seg i døgninstitusjon ut over tre måneder. I 2006 ble dette utvidet til å gjelde rusmiddelmisbrukere som mottok tjenester etter sosialtjenesteloven § 4-2 bokstav a-d, jf. § 4-3, og i 2008 til å gjelde pasienter i legemiddelassistert rehabilitering (LAR). SIRUS fikk i oppdrag av Helse- og omsorgsdepartementet (HOD) å kartlegge tilbudet. Datagrunnlaget er intervju med alle de 19 fylkestannlegene og aktuelle dokumenter gitt oss av fylkestannlegene.Fylkeskommunene hadde jevnt over problemer med å gi fyllestgjørende svar på mange av spørsmålene departementet ønsket besvart. Dette må sees i sammenheng med at det ikke var lagt opp til spesielle rapporteringsrutiner utover det som generelt gjelder for rammetilskudd. Det kan derfor være hensiktsmessig å gi fylkestannlegene informasjon om hva en i framtida ønsker at det skal rapporteres på.Godt i gangKartleggingen viser at fylkeskommunene har fulgt opp ansvaret de er gitt, selv om det varierer noe ”hvor langt en har kommet”. Det rapporteres om engasjerte medarbeidere, og at etablering av tilbudet stort sett har gått greit. Fylkestannlegene rapporterer også at målgruppa jevnt over har vært enklere å behandle enn en på forhånd hadde antatt.Når tilbudet alle?Det er naturlig nok vanskelig å si i hvilken grad alle de aktuelle rusmiddelmisbrukerne har fått tilbudet. Dette har dels sammenheng med at fylkeskommunene ikke har den nødvendige oversikt over antall rusmiddelmisbrukere som omfattes av rettigheten, dels at ikke alle fylkeskommunene har lagt opp til et rapporteringssystem som kan gi informasjon om hvor mange i de aktuelle pasientgruppene som har mottatt tannbehandling. Fylkestannlegene rapporterer imidlertid om flere grupper de mener faller utenfor tilbudet slik det i dag er definert. Dette gjelder blant annet personer som har vedtak etter sosialtjenestelovens kapittel 6 og personer i medikamentfri poliklinisk behandling utover tre måneder.OrganiseringNoen fylkeskommuner har valgt å gi de aktuelle pasientgruppene behandling innen den offentlige tannhelsetjenesten, mens andre har gjort bruk av private tjenesteytere. Det er ulike erfaringer med hensyn til hvor lett eller vanskelig det har vært å rekruttere private tjenesteytere til denne pasientgruppa, noe som på den ene siden kan ha sammenheng med hvilke økonomiske betingelser som tilbys og på den andre siden hvor mange private tannleger som holder til i fylkeskommunen. For å få tilbudet på plass, har flere av fylkeskommunene opprettet ulike bonusordninger til tannleger som behandler rusmiddelmisbrukere. Samarbeidet med den kommunale sosialtjenesten/NAV, behandlingsinstitusjoner og de regionale LAR-sentrene ser ut til å ha gått uten store problemer.ØkonomiDet uttrykkes en viss bekymring med hensyn til kostnader. Vi ser en økning i enhetskostnadene for tannbehandling for de aktuelle pasientgruppene i enkelte fylkeskommuner, samtidig som det også er en økning i antall pasienter. LAR-pasienter vil stå for en stor del av denne økningen ettersom denne gruppa i de fleste fylkeskommunene først ble inkludert i 2008.Oppgjør mellom fylkeskommunene i tilfeller der en pasient får tannbehandling i annen fylkeskommune enn der hvor vedkommende hører hjemme, har i en del tilfeller ført til problemer. Det er her ulik praksis, ved at noen fylkeskommuner har etablert rutiner for slike oppgjør seg i mellom, mens andre ikke har.BrukerundersøkelserDet var bare to av 19 fylkeskommuner som har gjennomført brukerundersøkelse i forbindelse med tannhelsetilbudet til rusmiddelmisbrukere; ENGLISH SUMMARY: BackgroundIn 2005 the county councils were given responsibility for the provision of dental healthcare for drug-users living in institutions for periods of more than three months. This responsibility was widened in 2006 to include drug users in receipt of social welfare provisions pursuant to section 4?2, letters a?d, cf. section 4?3 of the Social Services Act, and in 2008 to patients undergoing drug substitution treatment (LAR ? legemiddelassistert rehabilitering). The Ministry of Health and Care Services (HOD) asked SIRUS to investigate and specify service delivery. The data on which the study is based include interviews with the directors of dental health in all nineteen county councils and relevant records submitted by the directors.Overall, the county councils found it difficult to respond in full to many of the questions the Ministry wanted answered. This should be seen in connection with the absence of special reporting routines beyond what generally applies for block grants. It might therefore make sense to inform the directors of dental health what exactly one would prefer them to include in their reports in future.Well under wayThe investigation shows that the county councils have followed through on the responsibilities given them despite certain variation in “how far one has got”. They speak of enthusiastic employees and a mostly problem-free introduction of the service. The directors of dental health also state that the target group overall has been easier to treat than anticipated beforehand.Does the service reach all?It is naturally difficult to say exactly how far the service has been able to reach the drug users in question. This is partly because the county councils lack the necessary information on the number of eligible drug users, partly because some county councils have not organised a reporting system which includes information on how many individuals in the patient group in question have received dental care. The directors of dental health do mention several groups who, they believe, fall outside the service’s eligibility criteria, as they are defined today. They include people subject to intervention under the Social Services Act, chapter 6 and people undergoing drug-free out-patient treatment of more than three months’ duration.OrganisationSome county councils have chosen to give the patient groups in question treatment in the public dental service, while others have made use of private dentists. Experiences are varied with regard to how easy or difficult it has been to recruit private dentists for this group of patients. This may on the one hand have something to do with the financial incentives offered and, on the other, how many private dentists are actually practising in the county. To set up an operating service, several county councils introduced different bonus schemes for dentists treating drug users. Collaboration with the municipal social services/NAV (Norwegian Labour and Welfare Organisation), treatment institutions and the regional LAR centres appears to have proceeded without major incident.EconomyA certain worry is expressed with regard to costs. We see a rise in costs per unit for dental treatment for the patient groups in question in some counties, while the number of patients has grown at the same time. LAR patients will comprise a significant share of this rise since this group in most counties were not eligible until 2008.Settlement between counties in cases in which a patient is given dental treatment in another county than the county of residence has, in some cases, resulted in problems. Procedures vary, in that some county councils have instituted routines for settlements between counties, while others have not.User surveyOnly two of the nineteen county councils had conducted user surveys in connection with the dental service for drug users. http://hdl.handle.net/10143/90234 Title: Nære pårørende av alkoholmisbrukere. Hvor mange er de og hvordan berøres de?<br/><br/>Authors: Rossow, Ingeborg; Moan, Inger Synnøve; Natvig, Henrik<br/><br/>Abstract: NORSK SAMMENDRAG: Mellom 50 000 og 150 000 barn og mellom 50 000 og 100 000 ektefeller/partnere bor sammen med personer med et risikofylt alkoholkonsum i Norge. Mer enn 130 000 har i løpet av livet opplevd ulike negative konsekvenser av foreldres eller partners alkoholproblemer.Da det ikke er noen klare skiller mellom alkoholmisbrukere og andre alkoholbrukere, ville det være misvisende å lage et enkelt anslag over antall barn og partnere som berøres. Det er derfor angitt intervaller som antyder i hvilket størrelsesområde antallet trolig befinner seg.For første gangBeregningene i rapporten er gjort på grunnlag av en intervjuundersøkelse blant vel 2000 voksne og en spørreskjemaundersøkelse blant vel 20 000 ungdommer. Det er første gang det er gjort beregninger i Norge av hvor mange nære pårørende det er til alkoholmisbrukere og hvilke negative konsekvenser de opplever.Negative konsekvenserDe negative konsekvensene varierer både i type, varighet og alvorlighetsgrad. Blant de mulige konsekvensene som er undersøkt i denne studien, er sjikane, vold og trusler om vold, seksuelle overgrep og uønsket seksuell tilnærming og hærverk.Psykososiale problemerBlant ungdom øker andelen med ulike psykososiale problemer som å bli utsatt for vold, dårlig mental helse og dårlige foreldrerelasjoner, med hyppigheten av å se foreldrene beruset. Ungdom som så foreldrene beruset flere ganger i uka, hadde 3 – 5 ganger høyere risiko for å få slike problemer sammenlignet med annen ungdom. Likevel er det et flertall som ikke rapporterer denne typen problemer, selv blant dem som ofte opplever at foreldrene er beruset.Forsømt forskningsområdeAlkoholbrukets konsekvenser for nære pårørende er et forsømt forskningsområde. Gjennomgangen av forskningslitteraturen viser at det åpenbart er behov for mer forskning om norske forhold. Det er også viktig å bidra til den internasjonale kunnskapen om dette feltet.; ENGLISH SUMMARY: Alcohol accounts for the largest fraction of substance related problems, both with respect to the number substance abusers and with respect to the extent of health and social consequences of substance use. The aim of the report was twofold: (i) to estimate the number of children and partners who live with an alcohol abuser, and (ii) to examine negative consequences that they experience. This is the first attempt to examine these issues using Norwegian data.We used two available data sets for the analyses; one interview survey conducted among more than 2000 adults and a school based survey conducted among more than 20 000 adolescents. An important concern of this report has been to show that there are no clear distinctions between those who abuse alcohol or people with a hazardous drinking pattern and other alcohol consumers. Moreover, children and partners of heavy drinkers may experience negative consequences that will probably vary with respect to type of consequences as well as degree of severity. Such consequences can probably be attributed to a larger group of alcohol consumers than the small group of the most heavy drinkers.Our estimates showed that we may assume that there are some 50 000 – 150 000 children and some 50 000 – 100 000 partners living with persons who have a hazardous alcohol consumption. There are more than 130 000 persons who, during their adulthood, have experienced certain types of consequences (harassment, violent threats, unwanted sexual contact, vandalism, and sexual abuse) due to parents’ or partners’ heavy drinking. Among adolescents, psychosocial problems such as violence, mental health problems and poor parental relations, were found to increase with frequency of exposure to parental alcohol intoxication. However, even among those who often have seen their parents intoxicated, the majority did not report having experienced any of these problems.A review of the research literature showed that this is a neglected area of research. It is clearly a need not only for further research on Norwegian conditions in this area, but also important to contribute to the international scientific literature on this topic. http://hdl.handle.net/10143/84935 Title: Ungdom og rusmidler. Resultater fra spørreskjemaundersøkelser 1968-2008<br/><br/>Authors: Vedøy, Tord Finne; Skretting, Astrid<br/><br/>Abstract: NORSK SAMMENDRAG: Rapporten gir en oversikt over bruk av rusmidler blant ungdom i alderen 15 til 20 år basert på to parallelle tverrsnittsundersøkelser utført av SIFA/SIRUS. Den ene undersøkelsen omfatter ungdom registrert bosatt i Oslo og er gjennomført årlig fra 1968 til og med 2008. Den andre omfatter hele landet, inkludert Oslo, og ble første gang foretatt i 1986. Fra og med 1990 er også denne gjennomført som en årlig undersøkelseAlkoholDet store flertall (omkring 80 prosent) av 15-20-åringer svarte at de hadde drukket alkohol noen gang. I de senere år har det vært en større andel jenter enn gutter som oppgir at de noen gang har drukket alkohol. For årene 2006-2008 sett under ett, var den gjennomsnittlige debutalder i aldersgruppa 15-20 år i underkant av 15 år for øl, omkring 15 år for ”rusbrus”, og omkring 15,5 år for vin og brennevin. Den gjennomsnittlige debutalder har gått noe opp i de senere år.Ser vi på de siste årene, oppga omkring 60 prosent av 15-20-åringene å ha drukket alkohol i løpet av de siste fire ukene. Øl var den drikkesorten flest oppga å ha drukket. Dette gjaldt både guttene og jentene. Beregnet årlig alkoholforbruk i aldersgruppen 15-20 år økte i siste halvdel av 1990-tallet, men har stort sett stabilisert seg etter årtusenskiftet. Ser vi på årene 2006-2008, var det beregnete årlige alkoholforbruket 4,9 liter ren alkohol for ungdom på landsbasis (4,1 liter for jenter og 5,6 liter for gutter), mens det var 5,4 liter i Oslo-utvalget (4,5 liter for jenter og 6,2 liter for gutter).I de senere år har omkring to av tre oppgitt at de har kjent seg tydelig beruset. For årene 2006-2008 sett under ett, oppga noe under 20 prosent i Oslo og noe over 20 prosent på landsbasis at de hadde kjent seg tydelig beruset mer enn 50 ganger i livet. Denne andelen økte i siste halvdel av 1990-tallet, mens det var en jevn nedgang etter årtusenskiftet. Forskjellen mellom gutter og jenter har imidlertid vært langt mindre i de senere år, enn hva tilfellet var på begynnelsen av 1990-tallet. Omkring 10 prosent oppga å ha vært beruset mer enn 25 ganger i løpet av de siste seks månedene.For årene 2006-2008 sett under ett, oppga noe over ¼ av alle ungdommer at de hadde opplevd krangel, noe over 10 prosent at de hadde opplevd slagsmål og noe over 10 prosent at de hadde vært utsatt for ulykke i forbindelse med alkoholkonsum.CannabisI siste halvdel av 1990-tallet var det en økning i andelen som oppga at de hadde brukt cannabis noen gang. Ved årtusenskiftet oppga i underkant av 20 prosent på landsbasis og i underkant av 30 prosent i Oslo at de noen gang hadde brukt hasj eller marihuana. I den senere tid har det imidlertid vært en klar nedgang og i årene 2006-2008 svarte i overkant av 10 prosent på landsbasis og i underkant av 20 prosent i Oslo at de hadde brukt cannabis.Andelen som oppga bruk av cannabis i løpet av de siste seks månedene har vist en tilsvarende utvikling. Mens det ved årtusenskiftet var i underkant av 10 prosent på landsbasis og omkring 17 prosent i Oslo som oppga å ha brukt cannabis i løpet av de siste seks månedene, var denne andelen sunket til omkring seks prosent på landsbasis og 10 prosent i Oslo for årene 2006-2008 samlet. Det er lite eller ingen forskjell mellom gutter og jenter når det gjelder bruk av cannabis.I de senere år har omkring én av tre i landet som helhet oppgitt at de har blitt tilbudt cannabis og litt over halvparten at de tror de ville kunne klare å skaffe seg cannabis i løpet av to-tre dager. De tilsvarende resultatene hvis vi bare ser på Oslo, var at oppimot halvparten oppga at de hadde blitt tilbudt hasj eller marihuana og omkring to av tre trodde de ville kunne klare å skaffe stoffet.Det overveiende flertallet var av den oppfatning at cannabis ikke burde kunne selges fritt her i landet. Det var også bare et mindretall som sa at de kunne tenke seg å prøve cannabis hvis det ikke var fare for å bli arrestert.TobakkAndelen 15-20-åringer som røyker sigaretter har gått jevnt ned i de senere år. For årene 2006-2008 samlet, oppga omkring 10 prosent at de røykte daglig, og omkring 10 prosent at de røykte av og til. I det samme tidsrommet oppga omkring 15 prosent av guttene og fem prosent av jentene at de brukte snus daglig, mens 25 prosent sa at de brukte snus av og til.Andre narkotiske stofferVed siden av cannabis var amfetamin det stoffet flest unge rapporterte å ha brukt. Andelen i aldersgruppen 15-20 år i landet som helhet som oppga at de noen gang hadde brukt amfetamin, økte til omkring fire prosent fram mot årtusenskiftet, for deretter å falle til rundt to prosent. Hvis vi bare ser på Oslo, var det ved årtusenskiftet omkring syv prosent som oppga at de noen gang hadde brukt amfetamin. Deretter var det en nedgang fram mot 2008, hvor omkring tre prosent oppga å ha brukt amfetamin. Hva angår andre narkotiske stoffer lå andelen som oppga å ha brukt disse stort sett på en halv til tre prosent i undersøkelsesperioden.Sniffing av løsemidler og bruk av psykofarmakaVed de siste målingene var det i underkant av seks prosent som oppga at de noen gang hadde sniffet løsemidler og omkring to prosent som oppga at de hadde gjort dette i løpet av de siste seks månedene i begge utvalgene. Omkring fire prosent oppga at de noen gang hadde brukt psykofarmaka uten at det var foreskrevet av lege.Sammenheng mellom cannabis, alkohol og andre rusmidlerDet var en tydelig sammenheng mellom bruk av cannabis og andre rusmidler i begge utvalgene. Andelen som hadde prøvd amfetamin, heroin eller sniffing av lim var klart mye høyere blant de som også hadde brukt cannabis enn blant dem som aldri hadde brukt dette stoffet. Vi ser en tilsvarende sammenheng når vi undersøker bruk av rusmidler etter hvor ofte respondentene hadde drukket seg beruset i løpet av de siste seks månedene.; ENGLISH SUMMARY: This report presents an overview over the use of drugs among youth in the ages 15 to 20 years in Norway, based on data from two parallel cross sectional surveys conducted by SIFA/SIRUS. One survey was conducted among youth in Oslo from 1968 to 2008, another among youth nationwide in 1986 and from 1990 to 2008.AlcoholThe majority of youth aged 15 to 20 years had used alcohol at some time. In the last few years (2006-2008) the percentage of ever use of alcohol has been greater among girls than among boys. The average age of onset for drinking was 15 years for beer and “alcopops” and around 15,5 years for wine and liquor. The onset age has increased slightly in the last few years.In the period 2006-2008, 60 percent of youth aged 15 to 20 years had drunk alcohol during the last four weeks. Beer was the beverage most respondents had drunk, both among girls and boys. The estimated annual consumption of pure alcohol increased during the 1990s and has been stable since 2000. During the period 2006-2008 the estimated annual consumption of alcohol was 4,9 liter for youth in Norway as a whole (4,1 for girls and 5,6 for boys) and 5,4 liters in Oslo (4,5 liters for girls and 6,2 for boys).During the last few years around two out of three responded that they had been drunk once or more during their lifetime. During the period 2006-2008, around 20 percent of youth aged 15 to 20 years in both Oslo and Norway as a whole said that they had been drunk more than 50 times during their lifetime. The percentage increased during the 1990s but fell somewhat after 2000. The difference between girls and boys were less pronounced during the last few years than in the beginning of the 1990s. Around 10 percent of boys and seven percent of girls in both groups reported that they had been drunk more than 25 times during the last six months.During the period 2006-2008, more than 25 percent in both groups reported having experienced quarrels and more than 10 percent reported that they had experienced fighting or accidents as a result of alcohol consumption CannabisIn the second half of the 1990s there was an increase in the percentage that reported having used cannabis at some time. In 2000, 20 percent of youth in Norway and around 30 percent of youth in Oslo had used marihuana or hashish at some time. In the last few years this percentage decreased to above 10 percent in Norway as a whole and fewer than 20 percent in Oslo.In the last few years about one in three aged 15 to 20 years in Norway as a whole reported that they had been offered to buy cannabis and over 50 percent said that they thought they would be able to acquire cannabis in two to three days. In Oslo, one out of two said they had been offered cannabis and two out if three said that they would be able to acquire cannabis in two to three days.The majority of youth, over 90 percent, reported that they thought that cannabis should not be legalized. Only a small percentage, fewer than 20 percent in both groups, said that they would try cannabis if they knew that they would not be arrested.TobaccoThe percentage of youth aged 15 to 20 years that smoke tobacco has decreased during the last four decades. In the period 2006-2008, 10 percent reported smoking daily and 10 percent said they smoked from time to time. In the same period, 15 percent among boys and five percent among girls said they used snus on a daily basis while 25 percent among both sexes said they used snus from time to time.Other narcotic substancesBesides cannabis, amphetamine was the narcotic substance that most young people reported having used. In Norway, about four percent of youth aged 15 to 20 years reported having used amphetamine in the year 2000. In the following years this percentage decreased to around two percent. In Oslo the corresponding percentages in Oslo was seven and three. The use of other narcotic substances was limited to around a half to three percent in both groups over time.Solvent abuse and the use of tranquilizers/sedatives/prescription drugsIn the last few years, less than six percent reported having used solvents and around two percent said that they had done this during the last six months. Around four percent reported having used tranquilizers/sedatives/prescription drugs that had not been prescribed by a doctor.The association between cannabis, alcohol and other drugsThere was a clear association between the use of cannabis and other drugs in both Oslo and Norway. The percentage that had used amphetamine, heroin or solvents was many times higher among youth that had used cannabis many times than among youth that had not or rarely used cannabis. There was a similar, but less pronounced trend when we examined the association between having used hard drugs and the number of times the respondents had been drunk during the last six months http://hdl.handle.net/10143/84934 Title: Heroinforbruk og heroinbeslag i Norge<br/><br/>Authors: Bretteville-Jensen, Anne Line; Amundsen, Ellen J.<br/><br/>Abstract: NORSK SAMMENDRAG: I perioden 2000-2008 ble det i gjennomsnitt beslaglagt 61 kilo heroin i Norge pr. år. Mengden som beslaglegges varierer mye fra år til år, fra 8 kilo heroin i 2007 til 129 kilo i 2004. Politiet stod for 98 prosent av alle beslag, mens Tollvesenet beslagla ca. 55 prosent av total mengde. Tollvesenets andel av total beslagsmengde har økt de siste tre årene.Forbruk av heroinSIRUS har beregnet hvor stort forbruket av heroin er i Norge i løpet av et år på oppdrag av Toll- og avgiftsdirektoratet. Det er første gang en slik beregning er gjort i Norge.For å kunne beregne det samlete forbruket av heroin må man beregne antall brukere og mengde heroin de bruker i løpet av et år. Heroinbrukerne er delt inn i tre grupper: problembrukere, sporadiske brukere og eksperimentbrukere. Problembrukerne står for det meste av heroinforbruket i Norge.Forskerne anslår at forbruket i perioden 2006-2008 var i underkant av 1500 kilo. Forbruket har gått ned fra 2000-2002 da det estimerte anslaget var i overkant av 2000 kilo. Nedgangen skyldes i all hovedsak en reduksjon i antall problembrukere i Norge i dette tidsrommet.Beslag i forhold til beregnet heroinforbrukBeslaglagt mengde utgjorde i gjennomsnitt fire prosent av beregnet heroinforbruk i perioden 2000-2008. Politi og Tollvesenets beslag sto hver for ca to prosent.I forhold til beregnet forbruk og antall problembrukere skiller ikke norske beslag seg fra andre land der det finnes tilsvarende beregninger. I Norge beslaglegges 4,8 kg heroin pr tusen problembrukere mens tilsvarende tall for Storbritannia er 4,5 kg, Australia 4,9 kg, Italia 6,2 kg og Spania 3,9 kg.; ENGLISH SUMMARY: • Each year between 2000 and 2008, 61 kilos of heroin were seized in Norway on average. In terms of the number of seizures, the customs authorities took a mere 2 per cent, but in terms of quantities seized, they took about 55 per cent. To estimate how much heroin is consumed in Norway, we estimated the number of persons using heroin in the course of a year and multiplied that number by an estimate of the amount consumed. We adopted as a working assumption a threefold division of heroin users: experimental users; occasional users; and problem users. We subdivided the latter group by route of administration: administration route is considered to impact the amount of heroin taken. We estimated the annual quantities taken by users who only inject, users who only smoke the drug and users who do both. Because of insufficient data subdivision of occasional and experimental users by route of administration proved unfeasible.• We used a multiplier method to estimate the number of problem users injecting heroin. The method uses the annual number of drug-related deaths, an estimate of mortality in the group, and the percentage of all causes of death comprised by overdose deaths. We were then able to calculate how many heroin injecting users there would have to be for that number of recorded drug-related deaths to be valid. The numbers of heroin users who ingest only by smoking or by smoking and injecting were estimated as a percentage of this figure. Estimates of the numbers of experimental and occasional users respectively were made on the basis of survey data.• Dosage was mainly estimated from information on heroin users obtained by special surveys, including frequency of use and dosage on each occasion. There is wide variation in the quantities taken, both within the group of problem users and, not least, between problem, occasional and experimental users. Our estimates suggest that injecting problem users consume annually about 160 grams, heroin smokers about 118 grams, while combined smokers and injectors consume an annual average of 140 grams. We assume that the occasional users take heroin twice per month, giving an annual consumption rate of 6.6 grams. The smallest share of overall consumption is, naturally enough, down to the experimental users, whom we assume try heroin on average twice, resulting in 0.3 grams for each of them.• In 2006, the amount of heroin consumed in Norway was estimated to be around 1,445 kg. 2006 is the last year for which we have reliable data for calculating the number of problem users. It shows a drop from the years 2000?2002, when the estimated figure exceeded 2,000 kg. The main cause of the reduction was a fall in the number of problem users.• According to our calculations, problem users are the principal consumers of heroin in Norway. If we change the number of occasional users, for instance, or estimated dosage by 20 per cent, the total quantity changes only by plus/minus 5 kg (1,440?1,450 kg). If we change the number of experimental users or the amount used by them, the effect is minimal. But a 20 per cent change in the number of problem users changes the estimated consumption figures by 15?17 per cent (1,205?1,730 kg), and changing annual consumption figures changes the estimated figure by 16?20 per cent (1,160?1,730 kg).• For the years 2000?2008, seizures made by the police and customs authorities amounted, we found, on average to 4 per cent of the total amount of heroin consumed in Norway. Overall average seized by the customs was 2 percent. In per cent of estimated overall consumption, seizures by the customs authorities in 2006 came out on top at 6 per cent, with the lowest rate in the following year, 2007, when less than 1 per cent of the total amount consumed was taken. http://hdl.handle.net/10143/84913 Title: A tobacco-free society or tobacco harm reduction? Which objective is best for the remaining smokers in Scandinavia?<br/><br/>Authors: Lund, Karl Erik<br/><br/>Abstract: ENGLISH SUMMARY: Harm reduction means that cigarette smokers who are either unable or unwillingto stop using nicotine products are encouraged to switch to nicotine products withmuch lower health risk.Harm reduction has previously been debated in various forms in the area oftobacco when filter cigarettes were introduced in the 1960s, and when so-called«light cigarettes» with reduced tar and carbon monoxide content were introducedin the 1980s. However, epidemiological research has shown that the health benefitsassociated with switching to such products have been small – perhaps even nonexistent.The result of such previous negative experience is that the healthauthorities in most countries have shown very little enthusiasm for new preventivestrategies that include switching to tobacco and nicotine products that are lessdamaging.However, the current debate about harm reduction is different from the previousdebates in that this time real risk-reducing products (snus, medicinal nicotineproducts and other non-medicinal nicotine products) are being discussed. There isconsensus that a switch from cigarettes to such products would involve a significantreduction in risk for individual smokers. The reason for current scepticism isprimarily uncertainty about what a harm reduction strategy could lead to at thepopulation level. In addition, the established measures that the authorities inScandinavia have introduced to reduce smoking have been very effective, and whynot just intensify their use? If snus were added to the arsenal of harm-reducingproducts, for example, this would go against the stated aim of the authorities toachieve a totally tobacco-free society.Some of the important areas that are discussed in this report:• Despite the fact that measures to prevent smoking have been effective, and theproportion of smokers is decreasing in Scandinavia, the need for harm reductionmeasures has become greater because: – There is an imbalance between the motive to stop smoking that theauthorities have created with campaigns, duties, restrictions etc, and the helpthat is offered to people who are trying to stop smoking. Nicotinereplacement products are used to a small extent. The amount of assistanceprovided by health care personnel is moderate. In addition, the effect ofnicotine replacement products and the effect of interventions provided bydoctors is very limited.– The remaining group of smokers increasingly contains a higher proportionof people with social, mental and demographic characteristics associatedwith reduced ability to stop smoking.– For twenty years there has been a social gradient in smoking pattern inScandinavia. The search for measures that are tailor-made for smokers withspecific characteristics, for example short education, has been going on for a longtime. Literature reviews have not identified measures that the authorities couldimplement in order make the social gradient in smoking pattern less steep.– In Scandinavia, nearly all the political measures recommended by WHO forreducing smoking have already been implemented. There is probably littlepotential for further reduction by using publically-regulated control of tobacco.Despite the fact that tobacco control measures are utilized to such a degree,the proportion of deaths due to smoking among adults is still very high.– Intensifying the existing measures against smoking that have been effectiveup to now would probably give only a moderate return (diminishingmarginal returns).– Cigarette smoking is ideal for a harm reduction strategy, because thesubstance that causes addiction – nicotine – is not the cause of the healthrisk. People smoke because of nicotine, but die from tobacco smoke. Muchless hazardous nicotine products are available.• Harm reduction is an obvious strategy for a many other areas of risk. The reasonwhy the debate about harm reduction in the area of tobacco has come later, isprobably related to the widespread belief that it is possible to achieve a tobaccofreesociety.• If the authorities in the Scandinavian countries wish to even out future socialdifferences in health in the population, a harm reduction strategy in the field oftobacco may be appropriate.• In order for harm reduction to be successful, consumers must receive correctinformation about the relative health risks of different types of nicotineproducts. Today, both smokers and general practitioners are misinformed. The ban that exists in several Scandinavian • countries against «new types oftobacco and nicotine products» can function today as a barrier to effective harmreduction in the remaining segment of smokers, and should be replaced withregulations that control «new» nicotine products.• Production of nicotine products that have higher potential for use thancurrently available medicinal nicotine products, and that is more effective instopping smoking, should be stimulated.• Harm reduction policy must be made legitimate by the authorities. It is clearly adisadvantage and a hindrance for harm reduction if the snus industry is themost visible proponents of harm reduction.Snus as a harm-reducing alternative:• The health authorities in Norway and Sweden – where sale of snus is allowed –provide information about the health risks associated with the use of snus, butdo not inform smokers about the health benefits that can be achieved byswitching from cigarettes to snus. At worst, this can mean that nicotine-addictsremain smokers with no motive to try a harm-reducing alternative.• The cigarette industry are in the process of buying themselves into the snusindustry, and wish to sell snus in addition to – and not instead of – cigarettes.They regard snus as a so-called «bridging product» that can be used in socialarenas where there are smoking restrictions in order to keep smokers dependenton nicotine (nicotine maintenance policy). In addition, there are severalexamples from Scandinavia that the snus industry are carrying out innovativeproduct development with a view to recruiting young people of both sexes.• Reviews of the scientific literature show that snus is substantially less hazardousthan cigarettes. The magnitude of the overall reduction in hazard has beenestimated to at least 90 %.• Much research remains to be done before we know the precise effects of snusfrom a public health perspective. Several issues are not possible to research, butthe pattern of use of snus in Sweden and Norway suggests that availability ofsnus must have a positive net effect on public health. This can be an argumentfor withdrawing the ban on snus in the EU, but it can also be argued that thepattern of use observed in Scandinavia not necessarily will occur in othercountries.• There is little empirical data from Scandinavia to support the hypothesis thatsnus increases the risk of starting to smoke. There is some empirical data tosupport the hypothesis that snus reduces the risk of starting to smoke. • There are no randomized controlled studies in which the effect of snus onsmoking cessation has been measured. Observational data from Scandinaviaare consistent in demonstrating that snus leads to an increase in the quit rate forsmoking. Self-reports from Norwegian quitters indicates that the effect is greaterthan the effect of nicotine replacement products.• An argument for including snus in the arsenal of harm-reducing products isthat it has great potential for use in marginalized smoking populations, whichinclude people who have high immunity for traditional preventive measures forsmoking.The structure of the reportThe report starts with a discussion of what should be the overall aim of futuretobacco policy in countries with an advanced tobacco epidemic: a tobacco-freesociety or reduction in tobacco-related diseases? Does striving towards a tobaccofreesociety hinder harm-reducing measures that could save lives?In the report, the harm reduction debate is presented. The difficult climate fordiscussion, resulting from harm reduction being an ethical issue, is discussed. In asociety where tobacco has become «our worst enemy», that everyone can be unitedin fighting against, it is easy to regard harm reduction as an untimely course ofaction, and to dismiss it by labelling it as tobacco liberalism.I then show how harm reduction will become increasingly relevant and appropriatein Scandinavia, among other things because political measures can have attainedtheir full effect, while levels of harm remain high. Harm reduction may also becomeappropriate because the group of remaining smokers in Scandinavia will consist ofmore and more people with the psycho-social characteristics of people who aredifficult to influence just by more intensive use of the traditional preventivemeasures against tobacco. I argue that harm reduction will be an appropriatemeasure for achieving the aim of the authorities to reduce inequalities in healthbetween different social groups.Harm reduction may also become appropriate because there is an imbalancebetween the strong desire for smokers to stop smoking that the authorities havecreated (with campaigns, restrictions and duties), and the moderate supply andmediocre effect of the help that is offered to people who are trying to stop smoking.We also discuss how biased information about the relative health risks associatedwith the use of different tobacco products has created misinformed consumers whoare unable to make optimal choices. http://hdl.handle.net/10143/84842 Title: Nye lokaler – andre resultater? Videreført evaluering av sprøyteromsordningen i Oslo<br/><br/>Authors: Skretting, Astrid; Olsen, Hilgunn<br/><br/>Abstract: NORSK SAMMENDRAG: På oppdrag av Helse- og omsorgsdepartementet foretok SIRUS en evaluering av prøveordningen med sprøyterom basert på de første to driftsårene (SIRUS-rapport 7/2007). Vinteren 2009 ba Rusmiddeletaten/Oslo kommune om en oppfølgende evaluering. Evalueringen er utført av Astrid Skretting og Hilgunn Olsen ved SIRUS.Nye lokalerOslo kommune åpnet sprøyterom i Tollbugata 3 i januar 2005. Etter en tids drift ble det tydelig at lokalene var lite egnet til formålet, og 1. juli 2007 flyttet sprøyterommet til en brakkerigg i Prindsenkvartalet i Storgata 36.Ny evalueringDen oppfølgende evalueringen er gjort på samme måte som den som ble levert i 2007 og gir en vurdering av om sprøyterommet, slik det fungerer i dag, innfrir formålene som ble satt i lov og forskrift. Oslo kommune ba også om en ”kost-nytte” vurdering av tilbudet.ForbedringerDe ansattes situasjon er blitt langt bedre i nye lokaler, og brukerne gir også uttrykk for at de synes tilbudet har blitt bedre. Dette har ført til bedre trivsel for både ansatte og brukere. Det har vært en økning i helse- og sosialfaglig oppfølging av brukerne. Sårbehandling og samtaler er det som oftest går igjen.DilemmaerFlere av dilemmaene som ble vurdert i den foregående evalueringen, er imidlertid fortsatt aktuelle. Ordningen omfatter fremdeles bare injisering av heroin, selv om røyking av stoffet er langt mindre helseskadelig. Omfanget av injisering i hals og lyske har økt, da dette medfører økt risiko for helseskade er det et dilemma hvorvidt sprøyterommet skal tillate slik injisering.Når det gjelder de ansattes meldeplikt til barnevern og sosialtjeneste, ser det nå ut til å være avklart at denne skal overholdes slik det fremkommer i helsepersonelloven. Tidligere ble det også opplevd som et dilemma at psykisk syke brukere ikke alltid kunne bruke sprøyterommet fordi de ikke greide å innordne seg reglene. Dette problemet er langt på vei løst med nye og større lokaler som bedre ivaretar de ansattes sikkerhet, samtidig som det gir brukerne mer armslag.”Kost-nytte”Kost-nyttevurderingen av sprøyteromstilbudet blir i evalueringen vurdert ut fra om de oppsatte formålene med ordningen kan sies å være nådd, selv om disse ikke alltid er målbare. Det må kunne sies at tilbudet bidrar til økt verdighet for den aktuelle målgruppen, både på et individuelt og på et overordnet nivå. Sprøyterommet har også bidratt til økt mulighet for helse- og sosialfaglig oppfølging, og trolig også til bedre sprøytehygiene.Det finnes imidlertid ikke grunnlag for å si at ordningen har redusert omfanget av overdoser og overdosedødsfall. Ordningen har også en såpass begrenset kapasitet at selv om antall registrerte brukere nå totalt har oversteget 1000 personer, er det bare en brøkdel av injeksjonene som daglig foretas i Oslo som settes i sprøyterommet.; ENGLISH SUMMARY: The new premises are satisfactory. Staff security is well attended to. Operating costs have virtually doubled since the injecting room moved to a new home, however. Higher outlays must be seen in light of the depreciation of the new premises.Consistent with the findings of the former evaluation, frequency of use by registered clients varies widely. The ‘frequently’ percentage (on average 6 or more visits per month) rose slightly, but so did the ‘rarely’ category (0?2 visits per month on average). A detailed examination of the ten clients with the highest visiting frequency reveals, all the same, large fluctuations from month to month.The amount of heroin the users report to inject shows more or less the same distribution as at the former evaluation. Percentage of injections in the groin was slightly higher compared the first two years of operations.Again compared with that period, the move to new premises has not caused problems in the sense of the police “chasing” injecting room clients away or making it difficult to run the Oslo-injecting facility in any way.As was said in connection with the last evaluation, the supervised drug injection scheme can be said to have promoted the dignity of the group in question, both generally and for the individual. Although it is impossible to operationalise dignity as a concept in a measurable way, one can say that the injecting room communicates an acknowledgement of injecting drug users’ basic human value and need of help. For the clients, the services and contact with staff doubtless go some way to underpinning a sense of dignity. Working conditions at the new premises are better, increasing staff and client satisfaction, which again can be said to help clients feel more valued than was the case in the old facility.After the move to the new premises, somatic and psycho-social health matters were raised in 14 per cent of all visits, while the corresponding percentage during the first two operating years was 8 per cent. Treatment of wounds and consultations with staff are the most frequent forms of assistance. Although the rise can be put down to an improved registration procedure, there is reason to believe that increased focus and better staffing have played a not inconsiderable role.There was a rise in the number of visits during which the clients receive advice about injecting the drug, from 13 per cent in the first two years to 17 per cent in the new injecting room. At the same time, advice was given to a smaller percentage of clients, from 81 to 76 per cent.Following the move, 0.68 per cent of injections have resulted in overdose incidents, compared with 0.61 per cent during the first two years. There was, however, a fall in the percentage of clients suffering from an overdose, from 18 per cent in the first two years to 11 per cent after the move.Staff sick leave fell significantly and reports attest to a good working environment. Staff express great satisfaction with their immediate superior, but feel dogged by the senior management at the Alcohol and Drug Addiction Service. Training of new staff and support meetings appear to work in a satisfactory way. While staff are generally happy with the working environment, they would like more space, longer opening hours and more staff. http://hdl.handle.net/10143/84873 Title: Bruk av alkohol blant kvinner. Data fra ulike surveyundersøkelser<br/><br/>Authors: Vedøy, Tord Finne; Skretting, Astrid<br/><br/>Abstract: NORSK SAMMENDRAG: Rapporten tar sikte på å gi en oversikt over kvinners alkoholbruk, på bakgrunn av fire datasett fra SIRUS. De fire datasettene bygger på fire spørreundersøkelser om bruk av rusmidler i ulike grupper av befolkningen: Ungdoms¬undersøkelsen blant 15 til 20-åringer, Undersøkelsen blant unge voksne i alderen 21 til 30 år, Studentundersøkelsen ved Universitetet i Oslo og undersøkelsen om bruk av rusmidler i den voksne befolkningen (15 år+).Et fellestrekk for alle undersøkelsene er at forbruket av alkohol har økt. Blant jentene i ungdomsundersøkelsen fant vi en svak nedgang i andelen som hadde drukket alkohol noen gang, men samtidig hadde det gjennomsnittlige alkoholforbruket, andelen som oppga å ha vært beruset og andelen som hadde opplevd problemer som følge av egen drikking økt i undersøkelsesperioden (1973 – 2007 i Oslo og 1986 – 2007 i landet som helhet).Undersøkelsen blant unge voksne opererer med et kortere tidsperspektiv (1998, 2002 og 2006), men også her fant vi at så vel det gjennomsnittlige alkoholforbruket og problemer som følge av egen drikking, økte i undersøkelsesperioden. Andelen som hadde vært beruset i løpet av de siste seks månedene var rundt 80 prosent ved alle de tre undersøkelsestidspunktene. Vi fant òg at unge kvinner i Oslo drikker mer alkohol enn unge kvinner på landsbasis og at forbruket av alkohol avtok mindre med økende alder i Oslo sammenliknet med landet sett under ett.Blant de kvinnelige studentene ved Universitetet i Oslo fant vi at så godt som alle hadde drukket alkohol noen gang, og i underkant av 90 prosent hadde drukket i løpet av de siste fire uker. Vi fant en økning i alkoholforbruket fra 1997 til 2006. Rundt 50 prosent av de kvinnelige studentene hadde opplevd problemer med studiene som følge av egen drikking, men vi fant ingen økning i selvrapporterte problemer fra 1997 til 2006.I voksenbefolkningen økte det gjennomsnittlige alkoholforbruket blant kvinner fra én til to liter ren alkohol i perioden 1973 til 2004 og vin utgjorde en stadig større andel av det som ble drukket i denne perioden. Både andelen som svarte at de hadde vært beruset siste 12 måneder og andelen som drakk mye siste gang de drakk steg i fra 1979 til 2004.Det er nærliggende å tro at det økte konsumet har negative konsekvenser for kvinnehelsen. Våre funn viser at andelen som rapporterte om problemer som følge av egen bruk av alkohol økte i takt med økende alkoholkonsum, særlig blant jentene i alderen 15-20 år. Kunnskap om hvilke følger bruk av alkohol har for kvinnehelsen er mangelfull. Tall fra Norsk pasientregister (NPR) viser imidlertid at antall kvinner som registreres med alkoholrelaterte diagnoser ved somatiske sykehus, har steget over det siste tiåret. ; ENGLISH SUMMARY: The aim of this report is to provide a broad overview over alcohol use among women in Norway. The data used are four population surveys conducted by the Norwegian Institute for Alcohol and Drug Research (SIRUS) among different age groups: adolescents aged 15 to 20; young adults aged 21 to 30, student in the ages 20 to 35 years at the University of Oslo and a survey of the general population, 15 years old and above. The report focuses mainly on the use of alcohol among women, but includes data on men’s alcohol use for comparison.A common trait of these different age groups is that women’s estimated consumption of alcohol has increased over time. Results from the survey among adolescent women show a small decrease in the percentage that had ever used alcohol. However, the estimated annual alcohol consumption, the percentage that reported having been drunk and the percentage that had experienced problems caused by own drinking increased in the survey period (1973-2007 in Oslo and 1986-2007 in Norway generally).The survey among young adults has a shorter time span, interviews were conducted in 1998, 2002 and 2006, but also here the estimated annual consumption of alcohol and experience of problems caused by own alcohol consumption had increased. About 80 percent of the young women at all three time points had been drunk during the last 6 months. The estimated annual consumption of alcohol was greater in Oslo than in Norway generally, and the effect of aging on alcohol consumption, in this case a decrease, was less pronounced among women in Oslo than in Norway.Surveys were conducted among students at the University of Oslo in 1997 and 2006. Almost all female students had drunk alcohol at some time and around 90 percent had drunk alcohol during the last four weeks. The estimated alcohol consumption increased between 1997 and 2006. About 50 percent of the female students had experienced school related problems caused by own alcohol consumption, but there was no increase in self reported problems due to alcohol from 1997 to 2006.In the adult population the estimated annual alcohol consumption among women doubled from one liter pure alcohol to two liters in the period 1973 to 2004 and over time wine constituted a greater percentage of the total amount consumed. Both the percentage of women that reported being drunk in the past 12 months and the percentage that reported drinking a lot the last time they drank increased in the period 1973 to 2004.We can assume that the increase in alcohol consumption have negative consequences for women’s health. Our results show that both alcohol consumption and the percentage that experienced problems due to own alcohol consumption increased with time, especially among women aged 15 to 20 years old. Knowledge about the harmful effects of alcohol on women’s health is inadequate. However, data from the Norwegian patient register show that the number of women that are registered with alcohol related diseases has increased during the last ten years. http://hdl.handle.net/10143/84840 Title: Evaluering av myndighetenes samlede innsats for å forebygge tobakksrelaterte sykdommer i perioden 2003 til 2007<br/><br/>Authors: Aarø, Leif Edvard; Lund, Karl Erik; Vedøy, Tord Finne; Øverland, Simon<br/><br/>Abstract: NORSK SAMMENDRAG: SIRUS har i samarbeid med HEMIL-senteret ved Universitetet i Bergen evaluert den statlige innsatsen mot tobakksskadene fra 2003 til 2007, på oppdrag fra Helsedirektoratet. I denne perioden intensiverte myndighetene sitt arbeid mot tobakkskader. For det første satset man mer på massemediakampanjer med sterkere virkemidler enn tidligere. For det andre ble røykeloven med et totalforbud mot røyking på spisesteder og puber innført fra 1. juni 2004. For det tredje videreutviklet og forbedret man allerede pågående tiltak som Røyketelefonen og programmet for røykfrihet i ungdomsskolen (”FRI”-programmet). Et fjerde tiltak var utvidelsen av helseadvarselen på tobakksemballasjen.Evalueringen av myndighetenes tiltak viser at nedgangen i røyking har blitt kraftigere etter at arbeidet mot tobakkskader ble intensivert. Samlet sett har tiltakene hatt en klar effekt på nordmenns røykevaner.Nedgang i røykingI denne perioden har både røyke- og snusvaner endret seg markant. Nedgangen i røyking i den voksne befolkningen – som hadde begynt før 2002 – har fortsatt, og andelen dagligrøykere var i 2007 nede i 24 prosent blant kvinner og 22 prosent blant menn. Blant elever i ungdomsskolen ble røykingen halvert i løpet av årene 2000-2005 (fra 10 til 5 prosent dagligrøyking alle klassetrinn sett under ett).Økning i snusbrukSamtidig har andelen som bruker snus økt kraftig, særlig blant unge menn. Men man ser også en tendens til at det eksperimenteres mer med snus blant unge kvinner. Ut fra undersøkelsene kan man ikke si sikkert om økningen i bruk av snus har bidratt til nedgangen i røyking, men dette er sannsynlig.MassemediakampanjerEvalueringer av to av massemediakampanjene som ble gjennomført i perioden viser at de ble positivt mottatt. Dette er spesielt interessant med tanke på at kampanjen i 2003 tok i bruk sterkere visuelle effekter enn det som har vært vanlig tidligere her i landet. Grensene for hva som er akseptable virkemidler endrer seg sannsynligvis i takt med at stadig færre røyker og i takt med at grensene for hva som kan presenteres i media generelt er utvidet i forhold til tidligere.RøykelovenDet ble også gjennomført egne undersøkelser for å vurdere innføringen av totalforbud mot røyking på spisesteder og puber. De ansattes holdninger til forbudet endret seg i positiv retning etter at det ble innført. De ansatte opplever at luften er blitt renere, helseplagene er redusert, og de fleste opplever større trivsel på arbeidsplassen. Blant publikum fortsatte tilslutningen til røykfrie serveringssteder å øke etter innføringen – også blant røykere.Hva nå?Spørsmålet nå er hvordan man skal få ned røykingen blant de som fortsatt røyker. De som røyker skiller seg fra ikke-røykerne på ved at de har kortere utdanning og er mer negative til tiltakene mot røyking. Et mulig tiltak kan være skadereduksjon, altså en overgang til langt mindre farlige nikotinprodukter (f.eks. snus) for røykere som ikke kan eller vil slutte med nikotin. Dette er et kontroversielt spørsmål som diskuteres i Karl Erik Lunds rapport Tobakksfritt samfunn eller skadereduksjon? Hvilken målsetting tjener de gjenstående røykerne (SIRUS-rapport 2/2009).; ENGLISH SUMMARY: This report was written by researchers from The Norwegian institute for Alcohol and Drug research (SIRUS) and The Research Centre for Health Promotion (HEMIL-senteret), University of Bergen, for the Norwegian Directorate of Health. The main aim was to evaluate the government’s tobacco control program for the period 2003 – 2007. This report summarizes research findings from studies and publications.Part 1 of this report3 starts with an overview of different factors and mechanisms that influence tobacco behavior (smoking and use of snus). Tobacco behavior is modified by a range of factors and processes beyond the control of any tobacco control program. The links between a specific intervention and changes in behavior seen at the population level are often indirect and complex. However, it is still interesting to examine changes which take place in the population as a whole as well as in specific segments and subgroups. These changes can, at least to some extent, shed light on the effects of the combined tobacco control measures.The changes that were observed in the period 2003–2007 can best be understood if we are familiar with previous tobacco control policies in Norway and statistics that shows changes in tobacco behavior in the period before 2003. For this reason the report presents a brief overview of tobacco control measures in the following three periods: 1970 to mid 1990, 1996–2002 and 2003–2007. Towards the end of the first period the government’s tobacco control policies were given less priority. In a 14- year period, from 1980 to 1995, there were no mass media campaigns, and during the same period the decline in smoking prevalence was brought to a standstill. In the 1990s the tobacco control policies were intensified and a new reduction in smoking was observed. In the period 2003–2007 a series of control measures were instigated. Firstly, new mass media campaigns were launched and more dramatic 3 In part 2 of this report we present summaries of the articles and reports which were published as part of the evaluation project. visual measures were adopted. Secondly, from the June 1st 2004, a total ban on smoking in bars and restaurants entered into force. Thirdly, already ongoing tobacco control activities, such as the smoking quit line and the program aimed at creating smoke free schools (the «Free»-program), were improved. Fourthly, health warning labels on cigarette packs were enlarged. In addition, a new control measure, a ban of visual displays of tobacco products in shops, was suggested.Smoking behavior has changed significantly in the evaluation period, both with regards to smoking and snus. The reduction in smoking among adults, which was noticeable already in 2002, continued, and in 2007 the prevalence of daily smoking had fallen to 24 percent among women and 22 percent among men4. Among students in secondary school the prevalence of smoking was halved in the period 2000–2005 (from 10 to 5 percent daily smoking all grades combined). Meanwhile, the prevalence of snus-use has increased considerably, especially among young men. However, an increase is also found among young women. On the basis of the research summarized in this report we cannot conclude firmly that the increase in snus is linked to the reduction in smoking, but we see this as a reasonable assumption. Both adults and adolescents seem to overestimate the dangers associated with snus, compared to smoking.The Norwegian tobacco advertising ban has reduced tobacco advertising to a minimum. However, it has been shown that among adolescents who are exposed to the limited amount of advertising that still exist a higher proportion intend to start smoking. Results summarized in this report also show that branding and specific packet designs contribute to increasing sales.Evaluation of two of the mass media campaigns that were conducted in the evaluation period showed that the campaigns were well received by the public. This is interesting as the campaign from 2003 adopted strong visual measures that had not previously been used in Norway. One reason for this could be an increasing acceptance of strong tobacco control measures as fewer people smoke, but increasing tolerance for strong visual means could also stem from a development where media generally are using more dramatic pictures, language and other strong measures.Tailored surveys were conducted to evaluate the total ban on smoking in bars and restaurants, including a prospective panel study with three data collection occasions (shortly before the ban entered into force as well as 3–4 months and one year later). Results show that the prevalence of daily smokers and the number of cigarettes smoked daily (among continuing smokers) decreased slightly. The rather small decrease in prevalence of smokers and the attrition from the first to the second survey made it difficult to conclude that the ban had any effect on smoking prevalence among employees in bars and restaurants. However, it was quite clear that attitudes among employees towards the ban changed towards being more positive after the ban was introduced. Furthermore, enforcement of a total ban on smoking proved to be much easier than enforcement of a partial ban (with zones for smokers and other zones for non-smokers). Employees also reported an improvement of air quality, and the frequency of respiratory problems and health problems more generally decreased. Both smokers and non-smokers that were positive to the introduction of the ban reported an increase in job satisfaction. Smokers that were negative to the ban reported a decrease in job satisfaction.Among customers, support for the smoking ban increased after the ban was introduced, even among smoking customers. The expected decrease in well-being among smoking customers proved to be marginal. Customers reported better air quality and few problems with enforcement. Self reported patronage (proportion who reported that they had visited restaurants) was the same before and after the ban.The total ban on smoking in bars and restaurants was accompanied by a small and short lived reduction in turnover for bars. The restaurant sector, the larger of the two, was unaffected by the smoking ban. Reported sales from breweries to bars declined. This was not accompanied by an increase in retail sales, which indicates that the consumption of beer did not move from public to private settings. The number of employees in the bar and restaurant industry varies considerably for a number of reasons. We can therefore not conclude that the small and temporary decrease in employees observed after the smoking ban entered into force actually was linked to the smoking ban.There is an overrepresentation of people with short education among the 23 percent daily smokers in Norway. For many of these smokers, stopping smoking may be perceived as really hard. Stopping smoking may have been easier for the average smoker in the 1970s and the 1980s than among today’s population of smokers. The social gradient in smoking observed today has been evident during the last 20 years in countries where the tobacco epidemic is in its advanced stages, like Norway. Throughout this period there has been a search for effective measures for smokers with short education. With the exception of tax increases, researchers have not been able to identify measures which would effectively contribute to reducing the social inequality gap in smoking.Smokers are different from non-smokers in many respects. In addition to generally having shorter education, they are more negative to policies aimed at reducing smoking. One main challenge in the years to come is to do research which will increase our knowledge of what are the most effective policies to reduce smoking among those who continue to smoke. One possibility is to adopt harm reduction strategies, in other words to make it easier for smokers to stop smoking by encouraging them to switch to less harmful nicotine products (for example snus). This is a controversial issue as it involves giving up the ideal of a tobacco free society.Since fewer and fewer start to smoke in secondary school (covering the age groups 13–16), it is increasingly important to monitor and prevent smoking in high school (age groups 16–19). http://hdl.handle.net/10143/84816 Title: Tobakksfritt samfunn eller skadereduksjon? Hvilken målsetting tjener de gjenstående røykerne?<br/><br/>Authors: Lund, Karl Erik<br/><br/>Abstract: Hvis målet er å utjevne sosiale forskjeller i helsestatus, bør framtidens tobakksforebyggende politikk ta i bruk skadereduksjon som en strategi. Visjonen om et tobakksfritt samfunn bør ikke stå i veien for å redusere tobakksrelaterte sykdommer med en pragmatisk innstilling til skadereduserende nikotinprodukter som f.eks. snus, konkluderer forskningsleder Karl Erik Lund i denne rapporten.Lund diskuterer hvordan man skal unngå at røykere som ikke kan eller vil slutte med nikotin fratas overlevelsesmuligheter fordi de ikke oppfordres til bruk av mindre farlige tobakksprodukter. Derfor ønsker han en debatt om skadereduksjon på tobakksområdet. Som ett av flere tiltak mener han at man bør vurdere å oppheve loven som setter forbud mot nye nikotinprodukter som for eksempel elektroniske sigaretter.Lund utfordrer i rapporten myndighetenes tobakkspolitiske framtidsstrategier. Han ønsker å stimulere til en debatt om overgang til mindre farlige nikotinprodukter bør vurderes som en tilleggsstrategi i tobakkspolitikken. Han løfter i rapporten fram en rekke forhold som taler for dette.Røykerne får stadig dårligere evne til å slutteDe gjenstående røykerne er overrepresentert av personer med kort utdanning, de er oftere enn før involvert i annen risikoatferd og har høyere frekvens av psykiske sykdomstilstander. Etter hvert som andel røykere minker er det sannsynlig at det snart vil stå igjen en hard kjerne med mindre evne til å mestre et slutteforsøk. For disse kan overgang til snus eller e-sigaretten være et livreddende alternativ.Fortsatt høye tapstallNorge har tatt i bruk så å si alle virkemidlene som Verdens helseorganisasjon anbefaler, men fortsatt dør 6700 personer hvert år av røyking. Det blir stadig vanskeligere å identifisere nye tiltak som kan forventes å få samme effekt som de som allerede er innført. Intensivering av de eksisterende virkemidlene er både politisk vanskelig og vil trolig ha redusert nytteverdi på sikt.Nikotinlegemidlene er ineffektiveBruk av nikotintyggegummi eller nikotinplaster dobler sannsynligheten for å lykkes ved et slutteforsøk. Til tross for at de har vært tilgjenglig på markedet i 25 år, blir legemidlene kun brukt av 10-12 prosent av røykeslutterne. Den lave bruksfrekvensen kombinert med den moderate effekten gjør at legemidlene ikke har hatt noen vesentlig betydning for nedgangen i røyking.En hard kjerne av nikotinavhengige røykere vil kunne trenge tilgang til produkter med høyere nikotininnhold og større bruksverdi, selv om det kan innebære risiko for fortsatt avhengighet. Nikotin i ren form er imidlertid ikke spesielt farlig. Dessuten intervenerer helsepersonell kun i begrenset grad overfor røykere, og effekten av slike intervensjoner er moderat.Misforhold mellom motivasjon og hjelpetilbud75 prosent av de gjenstående røykerne har et ønske om å slutte, og svært mange av disse har utført gjentatte mislykkede slutteforsøk. Lund drøfter i rapporten om det er et etisk dilemma at røykerne i så stor grad eksponeres for røykenegative impulser samtidig som hjelpen som tilbys fra helsepersonell og legemidler er så lite effektiv.Skadereduserende alternativerSigarettrøyking innbyr til en skadereduksjonsstrategi fordi det finnes mindre farlige alternativer på markedet. Våre om lag 800 000 røykere inhalerer for nikotinen, mens den halvpart som kommer til å dø vil gjøre det som følge av giftstoffene i tobakksrøyken. Dette bør være unødvendig, konkluderer Lund i rapporten.; ENGLISH SUMMARY: Harm reduction means that cigarette smokers who are either unable or unwillingto stop using nicotine products are encouraged to switch to nicotine products withmuch lower health risk.Harm reduction has previously been debated in various forms in the area oftobacco when filter cigarettes were introduced in the 1960s, and when so-called«light cigarettes» with reduced tar and carbon monoxide content were introducedin the 1980s. However, epidemiological research has shown that the health benefitsassociated with switching to such products have been small – perhaps even nonexistent.The result of such previous negative experience is that the healthauthorities in most countries have shown very little enthusiasm for new preventivestrategies that include switching to tobacco and nicotine products that are lessdamaging.However, the current debate about harm reduction is different from the previousdebates in that this time real risk-reducing products (snus, medicinal nicotineproducts and other non-medicinal nicotine products) are being discussed. There isconsensus that a switch from cigarettes to such products would involve a significantreduction in risk for individual smokers. The reason for current scepticism isprimarily uncertainty about what a harm reduction strategy could lead to at thepopulation level. In addition, the established measures that the authorities inScandinavia have introduced to reduce smoking have been very effective, and whynot just intensify their use? If snus were added to the arsenal of harm-reducingproducts, for example, this would go against the stated aim of the authorities toachieve a totally tobacco-free society.Some of the important areas that are discussed in this report:• Despite the fact that measures to prevent smoking have been effective, and theproportion of smokers is decreasing in Scandinavia, the need for harm reductionmeasures has become greater because:– There is an imbalance between the motive to stop smoking that theauthorities have created with campaigns, duties, restrictions etc, and the helpthat is offered to people who are trying to stop smoking. Nicotinereplacement products are used to a small extent. The amount of assistanceprovided by health care personnel is moderate. In addition, the effect ofnicotine replacement products and the effect of interventions provided bydoctors is very limited.– The remaining group of smokers increasingly contains a higher proportionof people with social, mental and demographic characteristics associatedwith reduced ability to stop smoking.– For twenty years there has been a social gradient in smoking pattern inScandinavia. The search for measures that are tailor-made for smokers withspecific characteristics, for example short education, has been going on for a longtime. Literature reviews have not identified measures that the authorities couldimplement in order make the social gradient in smoking pattern less steep.– In Scandinavia, nearly all the political measures recommended by WHO forreducing smoking have already been implemented. There is probably littlepotential for further reduction by using publically-regulated control of tobacco.Despite the fact that tobacco control measures are utilized to such a degree,the proportion of deaths due to smoking among adults is still very high.– Intensifying the existing measures against smoking that have been effectiveup to now would probably give only a moderate return (diminishingmarginal returns).– Cigarette smoking is ideal for a harm reduction strategy, because thesubstance that causes addiction – nicotine – is not the cause of the healthrisk. People smoke because of nicotine, but die from tobacco smoke. Muchless hazardous nicotine products are available.• Harm reduction is an obvious strategy for a many other areas of risk. The reasonwhy the debate about harm reduction in the area of tobacco has come later, isprobably related to the widespread belief that it is possible to achieve a tobaccofreesociety.• If the authorities in the Scandinavian countries wish to even out future socialdifferences in health in the population, a harm reduction strategy in the field oftobacco may be appropriate.• In order for harm reduction to be successful, consumers must receive correctinformation about the relative health risks of different types of nicotineproducts. Today, both smokers and general practitioners are misinformed.The ban that exists in several Scandinavian • countries against «new types oftobacco and nicotine products» can function today as a barrier to effective harmreduction in the remaining segment of smokers, and should be replaced withregulations that control «new» nicotine products.• Production of nicotine products that have higher potential for use thancurrently available medicinal nicotine products, and that is more effective instopping smoking, should be stimulated.• Harm reduction policy must be made legitimate by the authorities. It is clearly adisadvantage and a hindrance for harm reduction if the snus industry is themost visible proponents of harm reduction.Snus as a harm-reducing alternative:• The health authorities in Norway and Sweden – where sale of snus is allowed –provide information about the health risks associated with the use of snus, butdo not inform smokers about the health benefits that can be achieved byswitching from cigarettes to snus. At worst, this can mean that nicotine-addictsremain smokers with no motive to try a harm-reducing alternative.• The cigarette industry are in the process of buying themselves into the snusindustry, and wish to sell snus in addition to – and not instead of – cigarettes.They regard snus as a so-called «bridging product» that can be used in socialarenas where there are smoking restrictions in order to keep smokers dependenton nicotine (nicotine maintenance policy). In addition, there are severalexamples from Scandinavia that the snus industry are carrying out innovativeproduct development with a view to recruiting young people of both sexes.• Reviews of the scientific literature show that snus is substantially less hazardousthan cigarettes. The magnitude of the overall reduction in hazard has beenestimated to at least 90 %.• Much research remains to be done before we know the precise effects of snusfrom a public health perspective. Several issues are not possible to research, butthe pattern of use of snus in Sweden and Norway suggests that availability ofsnus must have a positive net effect on public health. This can be an argumentfor withdrawing the ban on snus in the EU, but it can also be argued that thepattern of use observed in Scandinavia not necessarily will occur in othercountries.• There is little empirical data from Scandinavia to support the hypothesis thatsnus increases the risk of starting to smoke. There is some empirical data tosupport the hypothesis that snus reduces the risk of starting to smoke.• There are no randomized controlled studies in which the effect of snus onsmoking cessation has been measured. Observational data from Scandinaviaare consistent in demonstrating that snus leads to an increase in the quit rate forsmoking. Self-reports from Norwegian quitters indicates that the effect is greaterthan the effect of nicotine replacement products.• An argument for including snus in the arsenal of harm-reducing products isthat it has great potential for use in marginalized smoking populations, whichinclude people who have high immunity for traditional preventive measures forsmoking.The structure of the reportThe report starts with a discussion of what should be the overall aim of futuretobacco policy in countries with an advanced tobacco epidemic: a tobacco-freesociety or reduction in tobacco-related diseases? Does striving towards a tobaccofreesociety hinder harm-reducing measures that could save lives?In the report, the harm reduction debate is presented. The difficult climate fordiscussion, resulting from harm reduction being an ethical issue, is discussed. In asociety where tobacco has become «our worst enemy», that everyone can be unitedin fighting against, it is easy to regard harm reduction as an untimely course ofaction, and to dismiss it by labelling it as tobacco liberalism.I then show how harm reduction will become increasingly relevant and appropriatein Scandinavia, among other things because political measures can have attainedtheir full effect, while levels of harm remain high. Harm reduction may also becomeappropriate because the group of remaining smokers in Scandinavia will consist ofmore and more people with the psycho-social characteristics of people who aredifficult to influence just by more intensive use of the traditional preventivemeasures against tobacco. I argue that harm reduction will be an appropriatemeasure for achieving the aim of the authorities to reduce inequalities in healthbetween different social groups.Harm reduction may also become appropriate because there is an imbalancebetween the strong desire for smokers to stop smoking that the authorities havecreated (with campaigns, restrictions and duties), and the moderate supply andmediocre effect of the help that is offered to people who are trying to stop smoking.We also discuss how biased information about the relative health risks associatedwith the use of different tobacco products has created misinformed consumers whoare unable to make optimal choices.