Ten-year Results of a Community-based Anti-smoking Program (as Part of the North Karelia Project in Finland)

This report details a study of the 10-year results of North Karelia Project, a community-based anti-smoking programme launched in 1972 in North Karelia, Finland. Among the main intermediate objectives was the reduction of smoking rates, especially among the male population, which had much higher cardiovascular disease (CVD) and smoking rates than the female population of the area. Created by the government of Finland in cooperation with the World Health Organization (WHO), the intervention was based on the application of behavioural and social theories in a community setting, including Bandura's social learning theory, the classical communication-persuasion model, and the belief-attitude-intentional model.

Specifically, the health education activities of the project consisted of increased health information, persuasive messages, provision of social support, and certain environmental modifications. The project activities were implemented mainly through existing community structures, and emphasised community participation. For instance, local authorities and civic organisations were asked to promote no-smoking areas in their facilities. Local physicians and nurses were asked to inquire about smoking and to give advice to their patients about cessation. Specific smoking cessation courses were organised. Printed information on smoking was included in patient cards and files. During the initial 5-year period, 39 seminars were arranged for the training of local health personnel in various education skills.

At the same time, both mass and interpersonal communication via various community leaders was used to influence smoking behaviour in the community. The major theoretical background here was innovation-diffusion theory, which treats smoking cessation and non-smoking as a new innovation that spreads through the community. People are classified into the categories of innovators, early adopters, early majority, late majority, and laggards; the innovators and early adopters are understood to have the greatest social influence in the community. Based on the classical idea of the two-step flow of new ideas and attitudes through opinion leaders, the project worked in close co-operation with different kinds of official and unofficial leaders in the community. A network of lay leaders was established and trained to support the community activities.

During the first 5 years of the programme, local newspapers published about 250 articles on smoking. The local radio station broadcast the project's specific non-smoking messages. During the same period, 45,000 anti-smoking leaflets were distributed in addition to other anti-smoking materials, including 150,000 copies of signs and stickers with the message, "Do not smoke here - we are in the North Karelia Project." During the second 5-year period, 1977-1982, most of the activities continued in the local area. At the same time the project, as a national pilot programme, launched nationwide activities. Thereafter, the use of the reference area in the evaluation was limited. Comprehensive smoking cessation programmes were broadcast on national television in 1978, 1979, 1980, and 1982. These were supported in North Karelia by extensive field activities, a primary feature of which was the training of lay leaders to provide social reinforcement in imitating television models who stopped smoking.

Cigarette advertising was voluntarily restricted by retailers in North Karelia in 1973, and was prohibited in the country as a whole in 1978. Other restrictions on marketing, e.g., the raising of the age of legal right to purchase, were also implemented at that time.

The programme was evaluated by standardised examination of large representative cross-sectional population samples in 1972, 1977, and 1982, in North Karelia and in a matched reference area. The proportion of current smokers among 30- to 59-year-old men in North Karelia decreased from 52% in 1972 to 44% in 1977, and to 38% in 1982. In the reference area the respective smoking rates were 50, 45 and 45%. About 27% of male smokers in North Karelia stopped smoking during the project period, while in the reference area the proportion was 10% (P<0.001). Among women the initially low smoking rates increased in both areas by 7% - due to new birth cohorts with higher smoking rates entering the age group of the study. At the same time, the prevalence of ex-smokers among women increased markedly, especially among the younger females. The net reduction in North Karelia in the mean amount of daily smoking (per inhabitant) among men was 28% (P<0.001) and in women 14% (not significant, or n.s.). Serum Thiocyanate was used to validate the self-reports of smoking. In 1982 the mean was among men 71 µmol/L in North Karelia and 81 µmol/L in the reference area (:<0.001) and among women 55 and 58 (n.s.), respectively.

It is concluded that a well-conceived community-based programme can have a favourable long-term effect on smoking rates in the community, and that in North Karelia the effect was demonstrated among the male population, which had much higher smoking rates than were observed among women, at the outset.

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