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Iceland: a pioneer's saga

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When people talk about the history of tobacco control, Norway and Finland are mentioned as the two western countries that pioneered tobacco advertising bans. During the 1980s, these nations' tobacco consumption data was endlessly analysed by other countries striving for a ban. It was also used, selectively of course, by the tobacco industry, desperate to show that the bans had no effect or that somehow they even increased smoking. In fact, another northern European country had got there first: Iceland.

With a population of under a third of a million, it is perhaps unsurprising, if unjust, that less is heard of Iceland than of the countries in other parts of Europe from which it is, geographically at least, relatively remote. In the first half of the twentieth century, few outside Iceland knew much about it. One factor for it beginning to be better known later may have been the award of the Nobel prize for literature in 1955 to its most famous modern writer, Halldór Laxness. He is probably best known for his novel Independent People, a compelling saga of a poor farmer's endurance through thick and often very thin times. That work's title in Icelandic, Sjálfstætt fólk–literally self-standing people–gives a clue to one of the most important characteristics of Iceland: standing on its own feet, as it were, and doing things in its own way. This is as true in tobacco control as in any other aspect of this unusual nation's achievements.

It is almost 40 years since Iceland placed health warning labels on cigarette packs by law–this was in 1969, when “leaders” such as the UK were still consulting tobacco companies about what texts they might be prepared to print on their packs by “voluntary agreement”, as the infamous system was known. In 1971, Iceland scored its world first when it banned tobacco advertising in mass media, cinemas and outdoors, with 0.2% of total tobacco sales revenue being set aside for tobacco control; but warning labels on packages were no longer mandatory.

After all remaining tobacco promotion was banned in 1977, a national tobacco control committee was established and new proposals were developed. In 1984, the first comprehensive tobacco control act was passed. Warning labels on packages were made mandatory again; sales to minors under 16 were banned; and smoking was restricted in service areas of public and private buildings, in schools, healthcare premises and in public transport and in other workplaces. The total ban on promotion was reaffirmed and made clearer.

Subsequent changes, many still well ahead of most other countries, included provision of help for smokers to quit through primary health care (when 40% of adults aged 18–69 were smoking), smoking bans and restrictions in Icelandic aircraft and ships, and an increase in the proportion of revenue allocated to tobacco control, to 0.7%. An unusual addition in a market economy in recent times was the introduction of tobacco sales licences in 2001. At the same time, all mass coverage of tobacco was banned, other than warnings about its harmful effects; point of sale displays were swept away, with the requirement that tobacco products must not even be visible at the point of sale.

Through all this, smoking prevalence has continued to decline to just under 20.7% for males and 17% for females aged 15–89, down from levels of nearly 30.9% and 28.8%, respectively in 1991.

In June, all bars and restaurants became smoke free, except for those with special, separately ventilated smoking areas. Reaction was highly favourable, to the extent that very few hospitality industry venues have implemented a smoking area. So Iceland now has among the world's most comprehensive tobacco control policies, showing what a small but progressive country can achieve.