Missed opportunity: Denmark’s new prevention plan lacks needed policy changesAlcohol, Tobacco
Kristine Rømer Thomsen, Lotte Vallentin-Holbech & Janne Tolstrup Published 17 Jan 2024
In November 2023, the Danish Government and four political parties agreed on a new prevention plan aimed at reducing tobacco, nicotine, and alcohol use among adolescents in Denmark. The background stressed by the political parties is the new nicotine products which are popular among adolescents, the high alcohol use among adolescents compared to other European countries, and that age-restricted products are often illegally sold to underage adolescents.
The need for policy changes is clear. Danish adolescents continue to have the highest alcohol consumption in Europe. Among 15-16-year-olds, 40 per cent report past month intoxication, which is three times higher than the mean among European countries – and much higher than other Nordic countries (Norway 8.6 per cent, Sweden 9.4 per cent, Finland 13 per cent, and Iceland 16 per cent). While researchers in the Nordic countries are examining reasons for the reported decline in youth drinking in the (other) Nordic countries, adolescent drinking has increased in Denmark the past decade. For example, weekly drinking among 15-year-olds increased from 12 per cent (girls) and 21 per cent (boys) in 2014 to 22 per cent (girls) and 27 per cent (boys) in 2022.
Alcohol is a cause for concern
The widespread heavy episodic drinking at a young age is highly concerning due to the:
- negative impact on the brain that is still developing at this age,
- increased risk of alcohol-related accidents and death,
- increased risk of here-and-now negative consequences (e.g., doing things that are later regretted such as intimacy, fights, and drug use), and
- increased long-term risk of a wide range of diseases.
Furthermore, since heavy episodic drinking is the norm and closely intertwined with adolescents’ social life, there is a large pressure to drink to be part of the social life.
… and so are tobacco and nicotine products
Similarly, there is a clear need for policy changes regarding tobacco and nicotine products. The past decade, nicotine-containing products like e-cigarettes, vaping devices, and smokeless options (e.g., snuff, chewing tobacco, pouches) have entered the marked and surged in popularity.
Among 15-17-year-olds in Denmark, use of smokeless nicotine products increased from 8.7 per cent in 2020 to 12 per cent in 2022, and use of e-cigarettes more than doubled: from 4.5 per cent to 10.1 per cent. One might think that use of normal cigarettes would decrease, e.g. if adolescents replaced cigarettes with the new products. However, use of cigarettes also increased: among 15-17-year-olds, 11.9 per cent reported smoking cigarettes in 2020 which increased to 13.7 per cent in 2022.
This development is highly concerning due to the comprehensive health consequences of tobacco and nicotine use including increased risk of a long list of diseases. Similar to alcohol, the young developing brain is more sensitive to effects of nicotine, which can negatively impact cognitive functions (such as learning) and long-term mental health (such as symptoms of anxiety and depression).
The new agreement is a toothless tiger
The high rates of adolescent drinking in Denmark are rooted in a long-standing liberal alcohol policy with few restrictions on availability. For example, alcohol can be purchased 24/7 and at low prices; it can be consumed almost anywhere; it can be sold to adolescents 16 years and above; it can be advertised although not directed to adolescents; and policies are often not efficiently enforced.
The tobacco and nicotine policies in Denmark are also liberal, albeit not to the same extent. There are many places where smoking is not allowed (e.g., smoking is prohibited in all public indoor places) and there is an age limit of 18 for the sale of all tobacco and nicotine products.
Taken together, Danish politicians have many possibilities of reducing alcohol, tobacco, and nicotine use in adolescents (and adults and elderly) via policy changes – for example by limiting the availability of these substances.
The new plan includes 30 initiatives of which the following points are among the most noteworthy:
No sale of alcohol products with >6 per cent alcohol by volume to adolescents aged 16-17
(instead of previous 16.5 per cent by volume limit). This change is unlikely to have the desired effect of a decrease in consumption among minors. In fact, it contradicts recommendations from the Danish Health Authority of no alcohol use among adolescents below 18 years. By allowing 16-17-year-olds to continue to buy alcohol products already popular in this age group, the Government sends a clear message: that drinking in this age group is acceptable and fine.
The most obvious and effective step would be to prohibit sale of all alcohol products to adolescents below 18, in line with the vast majority of European countries and recommended by key stakeholders including the WHO. A higher age limit would also positively impact other important prevention initiatives e.g., by making it easier for parents to help postpone age of drinking debut, and by increasing efficacy of school alcohol policies. It would also change the longstanding tradition in Denmark of selling alcohol to students at parties hosted by and at high schools.
Relatedly, one of the initiatives in the new plan is to recommend all schools to adopt alcohol policies. It is our impression that many schools are already working with local alcohol policies and are taking part in the responsibility, however, this work is complicated and hampered by the fact that the Government approves and accepts (in Danish “blåstempler”) alcohol use among 16-17-year-olds by allowing them to buy popular alcohol products.
Increased prices on nicotine products and smoke-free tobacco, but not on cigarettes
The current excise tax on nicotine will be doubled. This corresponds to an increase in 12 DKK (1.6 EUR) for a typical box with 20 nicotine pouches and means that the price will be more or less the same as a packet of cigarettes. Although the increased price is a positive addition, the small volume of the increase means that it is unlikely to have a marked effect, at least on current users who may already be nicotine dependent.
Another, and potentially larger problem, is that these products are still sold at low prices in online shops (due to EU regulations). Importantly, the plan does not include increased pricing on cigarettes – despite the fact that use of cigarettes has increased the past decade among adolescents. The lack of increased pricing on cigarettes speaks for itself in terms of potential for reducing use.
Ban on use of alluring flavours and fragrances in tobacco substitutes (except menthol and tobacco)
This is positive and necessary to make the new products less attractive for adolescents, but would have been more powerful in terms of effects if also menthol was included. The current products on the marked allure adolescents into trying and continuing to use the new products e.g., via fruit flavors and fragrances that are appealing to adolescents and that they are unlikely to associate with harm.
Increased control and enforcement of policies
This includes several important and promising initiatives including (but not limited to) higher penalty for selling products to underage adolescents and the use of mystery shoppers i.e. underage adolescents who enter shops and test if they can buy the products, or if their ID is properly checked. There is a strong need for increased control and enforcement of policies and these initiatives are likely to have an effect. However, the success of some of these initiatives depend on another initiative regarding electronic age verification online.
Electronic age verification online
Currently, there are no requirements regarding how age is verified in online sale of tobacco, nicotine, and alcohol, which means it is typically done by ticking a box. The parties have agreed to set requirements regarding a digital age-control-system that effectively verifies the buyer’s age. This is likely to have an effect, but it has not been specified how it will be implemented. It is crucial, that the requirement will apply to both Danish and foreign websites that sell the products to Danish consumers, however this has not been finally decided.
Missed opportunity: The new plan is unlikely to have the desired effect
Overall, the plan is a small step in the right direction. However, for the reasons stated above, it is unlikely to lead to notable reductions, particularly in alcohol use among adolescents. The initiatives aimed at strengthened enforcement of policies are important and promising. In combination with a ban of sale of alcohol to adolescents below 18, the perspectives of markedly reducing alcohol use would have been very promising. Cultures are not changed overnight, but they can be changed. Such a change requires more political goodwill than the current prevention plan.
Needless to say, changes in policy should not be done in isolation. In order to succeed, we need to involve multiple actors and target prevention on several levels. For example, parents play an important role and similarly, the settings and contexts in which adolescents spend their everyday life and socialize (like schools) have an opportunity and responsibility to engage in decisions around substance use. Importantly, policies provide both the operational and value-based context for interventions and initiatives surrounding substance use. For example, a ban on all alcohol sale to adolescents below 18 years sends a clear signal to parents and schools, making it easier for them to navigate and help reduce adolescent substance use.
The article is written by
Kristine Rømer Thomsen, Professor, Centre for Alcohol and Drug Research, Aarhus University
Lotte Vallentin-Holbech, Assistant Professor, Centre for Alcohol and Drug Research, Aarhus University &
Janne Tolstrup, Professor, National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
on the request of PopNAD