A multifactorial approach to explaining the stagnation in national smoking rates


INTRODUCTION: The aim of this paper was to investigate if a multifactorial approach may be used to explain why national smoking rates have levelled off in Denmark after 60 years of decline. 
Methods: Seven hypothetical explanations for stagnation in smoking rate were explored. A period of five years with a declining smoking prevalence (2007-2011) was compared with four years of stalled smoking prevalence (2012-2015). We used individual and national level information sources, mostly cross-sectional data that were collected repeatedly, including large nationally representative surveys, sales stat-istics, nation-wide news and smoking cessation databases and legal information, among others. 
Results: Most theories were rejected, leaving some that might have contributed to the stagnation: substantially 
fewer smokers had tried to quit in the stagnation period. Furthermore, the price of tobacco had remained almost unchanged, tobacco control legislation and anti-smoking campaigns had not been very intensive, assistance to quit and the Health Authority's manpower allocated to tobacco control had decreased temporarily while the use of e-cigarettes had increased in the stagnation period.
 Conclusions: Important components to focus on in future tobacco control in Denmark were identified. The study suggests that, in future, we need to focus on exploring why Danish smokers have an increasing wish to quit while fewer and fewer, nevertheless, actually attempt to quit. Neither the authors nor the Danish Health Authority were aware of this paradox. 
Funding: We would like to express our gratitude to the Danish Health Foundation for financial support. The researchers are independent of the founders.
 Trial registration: not relevant.