European Journal of Cancer
Issue 10, 2009

By Helen Saul
 

PODIUM – The State of Denmark – with Dr. Hans Storm

Why do cancer patients fare so much worse in Denmark than in other Nordic countries?

For years, it has been impossible to disentangle the situation and establish whether patients, physicians or both were to blame. But recently, population-based research which links data on consumption with that from registries has come up with a simple explanation: tobacco and alcohol. Both men and women in Denmark smoke and drink too much. It explains most of the deficits in survival compared with other Nordic countries, and means that prevention is our best way forward.

Why is consumption so high in Denmark?

There is a liberal attitude towards alcohol and tobacco here. Cigarettes are cheap, the tax on them is low, and they are available in supermarkets and everywhere. Smoking is banned where food is served but is still allowed in bars which are less than 40m²; it is similar to the Spanish law which has been shown to be ineffective. In September 2008, it was made illegal to sell tobacco to anyone under 18, but the law is not enforced.

Danish people over 14 years of age drink, on average, 12 litres of alcohol per capita, per year. People are used to having wine with all meals and a lot of hard alcohol is drunk. Surveys have found that 10-15% exceed the recommended limit of 2 drinks per day for women, and 3 for men. Any reduction in heart disease associated with this level of drinking will be completely overtaken by increases in other diseases. The law states that people must be 16 years old to buy or import alcoholic beverages with more than 1.2% alcohol by volume – but beer is exempted from the import restriction! – and the law is not enforced.

What makes Denmark so different from neighbouring countries?

Danes put a high value on liberty and self-determination; they do not want to be regulated from top to bottom. It is not as easy to buy alcohol and tobacco in Norway or Sweden; in Sweden, even at my age, I’d have to show a driving licence as proof of age to be able to buy alcohol. The public impression of Sweden is of a country with legislation that controls people’s lives although in fact, Denmark has more laws that impinge on citizens. But there is a real difference in the willingness of Danes to take advice from professional groups and services. In the medical field, that means Danes take less notice of information advising them how to behave or when to see a doctor.

It is difficult to change a culture

It takes time but it is possible. One way is through strong legislation, another through changing the structure of society to promote healthy rather than unhealthy living.

Are there signs of impending change?

The Minister for Health had his title changed and is now the Minister for Health and Prevention. He set up the Danish Commission on Prevention Priorities, chaired by Professor Mette Wier who is head of a research organisation formed by the Danish communes (local governments). Several well-known epidemiologists sat on the committee whose task was, in 18 months, to decide on evidence-based preventive actions which could be introduced in Denmark to improve life expectancy by 3 years, over a 10 year period.

Our national institute for public health said this target was unambitious since it would have been achieved by doing nothing if current trends in life expectancy continue. One reason for this is, despite the lack of Government action, smoking prevalence has fallen by 1-1.5% per year over the past 15 years. But the decline seems to have levelled off over the past 2 years, so maybe the background increase in life expectancy will not continue.
 
What did the committee conclude?

The committee drew up a report including 52 recommendations for the Government. They were a little disappointing; there were few strong messages and those originally suggested were watered down by the Minister before the report went to print. So the committee originally recommended higher taxation of tobacco to bring prices in Denmark up to those in the UK, Ireland and Norway. But before the report came out, the Government increased the tax on a packet of cigarettes by 1/3 Danish kroner (= Euro 0.04), and said that they couldn’t increase the price again. But this increase is miniscule, it’s ridiculous. It means that the most effective tool we’ve got – the price – is something we’re not going to use. The Government says that increasing taxation will increase illicit cross-border trade in cigarettes; but cigarettes are more expensive in Germany than here, where you can get a packet of cigarettes for 3 Euros. Nobody is going to smuggle in cigarettes from Germany.

Different calculations on the direct and indirect costs have been done but one study, which considered sickness benefits, family support when a smoker contracts a disease, and so on, found that smoking costs 21 billion kroner per year. The Government receives about 7-8 billion kroner in tobacco tax revenue. There is no balance but this didn’t come into the report at all. The Government is not willing to use the most effective tool we’ve got. Cynics might say that smoking is beneficial for the economy if smokers die by the age of 65 when the health problems start.

What did the report suggest?

Factors that could increase life expectancy were arranged into: smoking; alcohol; physical exercise; diet; early detection; workplace; young people; knowledge; implementation.

On smoking, the suggested price hike is not going to happen. The committee also suggested that all smoking indoors is prohibited, except in ones’ own home. The public is in favour of a complete ban on smoking in public places along the lines of that in place in Ireland, but that doesn’t seem to influence the Government.

The report said that tobacco should be removed as a visible sales item in shops, and should be sold under the counter. The law banning sales to young people under 18 years should be enforced, and should become the shop’s responsibility. And there should be pictorial health warnings on cigarette packets. But this is all small stuff because most has already been decided at European level. Smoking cessation should be offered free of charge by all communes, and should be available in the workplace. These are recommendations for things that are already happening.

It called for information campaigns about smoking, but these have been done since the 1960s and we can’t really say they’re effective since they have never been linked to other interventions. They’re probably necessary but not sufficient to increase cessation.

What about on alcohol?

The committee recommended that the age limit for buying alcohol be increased from 16 to 18 years old, and said that all educational institutions should have an alcohol policy. They’ve asked for a ban on advertising and want to reduce access to alcohol in certain areas such as sports venues. Communes are to be asked to promote the existing proposed drinking limits, which are twice as high as they should be. The committee obviously considered the link between drinking and cardiovascular disease, but not the literature on breast cancer. It’s disappointing.

And physical exercise?

There are some interesting structural changes suggested here. The committee wants the communes to make local environments more conducive to increasing activity so that they promoting exercise and making it interesting as part of their normal services; targeting prevention without having it as a goal, which is good. There should also be more exercise in school for children. The government will probably support this as it will be paid for by the communes.

How involved are the communes in prevention?

Communes are responsible for primary prevention and under a new Health law last year, have to pay 20% of hospital costs; the rest is funded at regional and governmental level. But it is in the interests of communes to have a healthy population because of their contribution to hospital costs.

What did the report say about diet?

The committee called for an increase in tax on sugary and fatty foodstuffs, making fizzy drinks and chocolate much more expensive. They want to curb advertising of junk food and have proposed new labelling on foodstuffs, which manufacturers would have to do and which won’t be very effective. They want healthy food and free fruit in all schools.

Are there any other interesting ideas in the report?

They include campaigns which are not going to make much difference to life expectancy within a 10 year period. Educational campaigns on obstructive lung disease or diabetes, for instance; typically those diseases without strong non-governmental organisations (NGOs), unlike cancer. They don’t mention cancer at all, not even in the section on early diagnosis and screening. We really object to that: this is supposed to be an evidence-based activity and we have evidence for the effectiveness of screening for breast, cervical and colorectal cancer. But the provision of screening for these diseases is heterogeneous across the country. The committee could have made a difference here and it is disappointing that they didn’t.

Why did cancer play such a small part in the report?

They were looking for life expectancy gains over 10 years and it takes a long time for prevention to show a benefit in cancer. Lung cancer develops for 5 years before it can be diagnosed; other cancers are underway for 15-20 years. So the revenue generated by prevention won’t be seen for years after the current politicians have left office. In a way they have to be idealists to support prevention.

Is the Government obliged to implement the report’s recommendations?

No, the Government can put up a think tank and take whatever it wants from it. But the committee has influence and can target Government action. If experts are asked to work on a report like this for more than a year, it would be strange if the Government didn’t take any action proposed by their own advisors.

What has the reaction to the report been?

There has been a lively debate in the Danish press. Different committee members have been outspoken about the disappointing reaction of the minister to the report, especially in his lack of willingness to use taxation and regulation. That is where Government can make a difference in prevention and if it won’t, we have a problem.

How far will the Danish Cancer Society support the report?

It feels like a missed opportunity; and is disappointing. But the report has good parts and we will support all of them energetically. This is an opening for debate with politicians, even if it has delayed decisions. We think that our politicians have a genuine wish to be more involved in prevention, and so it is a positive step. But prevention remains an uphill battle in Denmark.