The tax earmarked for tobacco control in Iceland dates to 1972. It was implemented by the Government at a time when the prevalence of smoking was increasing rapidly and the harmfulness of smoking was becoming known. Subsequent to the findings of Sir Richard Doll[1] in 1950, the Professor of Medicine at the University of Iceland, Dr Níels Dungal, published a paper on the harmful effects of smoking on health[2]. Tobacco consumption in Iceland was similar to that in neighbouring countries, tobacco being advertised even in medical journals; there was a high smoking prevalence, and wholesale distribution of tobacco throughout the country was monopolized by the State Alcohol and Tobacco Company by law. Both professional and political interest in tobacco control began to be expressed.

The first formal proposals to ban advertising of tobacco in Iceland were brought before the Parliament in December 1964 and again in 1967, but neither was passed into law because of lack of political support[3],[4]. In 1969, an independent law was passed regarding the organization of the State Alcohol and Tobacco Company[5], which included an article requiring health warning messages on cigarette packages. This was the first formal legislative provision in Iceland aimed to reduce smoking and one of the first examples of warning labels worldwide[6]. The text to be put on packages was: “Viðvörun: Vindlingareykingar geta valdið krabbameini í lungum og hjartasjúkdómum”, which can be translated as: Warning: Cigarette smoking can cause cancer of the lungs and heart disease. Use of an earmarked tobacco tax for tobacco control was first proposed in Parliament, and, in 1970, Parliament Member Jón Ármann Héðinsson proposed changes to laws on alcohol and tobacco to ban all advertising of tobacco in newspapers, radio and television and on outdoor billboards, on the basis of professional advice from the Chief Medical Officer at that time, Dr Bjarni Bjarnason. Mr Héðinsson found no support from his colleagues in Parliament, but, with support from society, public discussions and petitions, the proposal was passed. An additional proposal led to replacement of the warning labels on tobacco products by an earmarked tobacco tax amounting to 0.2% of gross nationwide tobacco sales[7]. The rationale was that warning labels were not effectively reaching young people and children, the target population for prevention. The funds were to be allocated directly to tobacco control organized by a newly appointed national tobacco control committee. The law entered into force on 1 January 1972. One member of the committee was appointed by the State Alcohol and Tobacco Company, one by the Icelandic Cancer Society and one by the Icelandic Heart Association. An office for tobacco control was established at the Reykjavik Cancer Society. The focus of preventive activities from the beginning was educating children and students about the harmful effects of smoking on health, sending the same message through the mass media and newspaper advertisements. The funding available at that time for tobacco control was similar to that for labelling cigarette packages, and this was used as the rationale for the tax in discussions in Parliament. These events marked the beginning of nationwide organized tobacco control in Iceland.

The borgarlæknir, the district medical officer in Reykjavik, surveyed the prevalence of smoking among adolescents aged 14–16 years old in 1975[8] and found that about half of this age group smoked. Extensive education in Reykjavik elementary schools about the harmfulness of smoking on health and prevention measures were initiated by the Reykjavik Cancer Society, with rapid effects. At the same time, Þorvarður Örnólfsson, the Managing Director of the Reykjavik Cancer Society, was employed to manage all tobacco control projects and funding[9].Over the next few years, several legislative changes were made, and the earmarked tobacco tax was dropped in 1977[10]. Nevertheless, changes were made to laws related to tobacco control, and the stated political aim was to preserve or increase funding for tobacco control, although this was not documented in the State budget. The changes included a ban on advertising of tobacco in the media, cinemas and outdoors and giving the Minister of Health the authority to publish regulations on smoke-free areas in public buildings and to appoint the Tobacco Control Committee. Thus, the State Alcohol and Tobacco Company no longer had a representative on the Committee and its role was broadened to conduct more extensive tobacco control programmes. Funding for tobacco control was not earmarked between 1977 and 1984, and both funding and activities decreased during this period[11]. The Committee organized the first smoke-free day in Iceland on 23 January 1979.

The Icelandic Parliament passed the first comprehensive tobacco control law in 1984, which entered into force on 1 January 1985[12]. The law banned sale of tobacco to minors under 16 years of age and banned smoking in public places, schools, health care facilities, public transport, domestic flights and workplaces. The ban on advertising was more explicit than before, and a regulation called for graphic health warnings on cigarette packages. The Government, guided by the work of a committee at the Ministry of Health, made a political decision to restore the earmarked tax of 0.2% on tobacco sales, to be used to support implementation of projects proposed by the Tobacco Control Committee. There was no political support for a regular budget for tobacco control.

In 1991, Parliament adopted the National Health Policy 1991–2000[13]. Continuing support for tobacco prevention in Parliament was shown by revision of the tobacco control law passed in 1996[14] to double the earmarked tax from 0.2% to 0.4%; however, during discussions, the tax was raised to 0.7% based not on a formal assessment of budget needs but on political support in Parliament for greater tobacco control. Several other changes were introduced when European Union regulations on tobacco were adopted, banning snuff and snus and sales to minors under 18 years. The Tobacco Control Committee was still appointed by the Minister of Health, with nominations from the Icelandic Cancer Society and the Icelandic Heart Association. An increase in the budget for tobacco control in 1996 made a huge difference. Two full-time staff were hired to work on tobacco control nationwide, a “train the trainer” programme was set up, and new educational material was published. During the next few years, “outreach” projects were introduced, such as “Quit and win – don ́t start”[15] and a “Smoke-free class” competition[16], which has been a nationwide project held annually since 1998. A quit-line for smoking cessation[17] was established in 2000 in collaboration with the Thingeyjarsyslur Health Centre and with specialist training from the Swedish quit-line. A considerable increase in mass media campaigns was seen, and public and professional discussions on tobacco control were sup- ported, in collaboration with various organizations in sports, schools and municipalities and with health professionals.

In 2001, the Parliament adopted the second National Health Policy, for 2001–2010[18], and the tobacco control law was revised for the third time[19], with a memorandum that unconventional methods of tobacco control would be required to achieve the goals for tobacco use in the National Health Policy. The major changes were a ban on displays of tobacco at points of sale, a ban on media coverage of tobacco other than warnings of its harmful effects, mandatory licensing of all tobacco sales and an increase in the earmarked tobacco tax to 0.9% of gross sales. The Office of Tobacco Control was still jointly run by the Icelandic Cancer Society and the Reykjavik Cancer Society, and the Tobacco Control Committee was still appointed by the Minister of Health every 4 years to allocate funds to projects. By this time, all indoor public places, transport, schools and sporting events were smoke-free, and it was time to seek new frontiers. The ban on displays at points of sale was met by legal action from the tobacco industry[20]. A media campaign was released, and licensing of sales of tobacco led to a reduction in the number of retail outlets for tobacco.

The next major change in the legal framework of tobacco control in Iceland was the founding of the Public Health Institute in 2003, which brought together several Government health promotion and prevention units[21], including nutrition, alcohol, drugs and tobacco. Prevention of both alcohol and tobacco use was funded by earmarked taxes, which were included in the budget of the new institute, which financed tobacco control projects. When the Office of Tobacco Control was transferred to the Public Health Institute, the projects continued, and new programmes were started for general health promotion, in collaboration with schools[22]. Between 1970 and 1975, the national tobacco committee was responsible for allocating the budget; when the State Alcohol and Tobacco Company was responsible, their projects were mainly mass media campaigns on the harm caused by smoking; between 1976 and 2003, the Tobacco Control Committee was responsible for the budget and allocated it to the Icelandic Cancer Society and the Reykjavik Cancer Society.

In May 2011, the Public Health Institute was merged with the Directorate of Health[23], and committees on prevention in specific areas, such as tobacco and alcohol, appointed by the Directorate, replaced the independent Tobacco Control Committee. All earmarked funding for prevention of tobacco and alcohol use was subsumed in a new Public Health Fund, managed by the Directorate of Health in accordance with a regulation of the Ministry of Health[24]. The board members include participants from the Directorate committees. In the current regulation, 65% of the funds are allocated to programmes run by or in conjunction with the Directorate and 35% to specific projects by application (see Table 1). The Office of Tobacco Control was also transferred and continued the annual projects such as World No Tobacco day and the Smoke-free Class Competition. In response to increasing use of smokeless tobacco by young Icelandic men, the latter was changed to the Tobacco-free Class Competition in 2011. Health promotion projects were extended, with formal implementation in elementary and secondary schools; they are now also beginning at community level, with participation from the pioneer community, Mosfellsbær[25] and Reykjavík City[26].

Table 1. Total annual earmarked tobacco tax (million ISK), 2004–2014

The goal of the National Health Policy for 2010 to reduce daily smoking among adults to less than 15% was met. On ratification of the WHO FCTC, the national authorities assumed the obligation to integrate tobacco control into various policies, laws and regulations. The Government legislated a policy direction in 2010, called “Iceland 2020”[27], which included health promotion for the prevention of alcohol and drug use and to improve nutrition, physical activity, sexual health and mental well-being. In 2012, a new National Health Policy to 2020 was introduced in Parliament but was not passed[28]. On the following World No Tobacco Day, in 2013, the Minister of Health launched work on a public policy for national tobacco control in Iceland to 2020, in response to changes in tobacco and nicotine consumption and based on collaborative work on the National Health Policy by the Ministry of Welfare, the Ministry of Finance and Economic Affairs, the Ministry of Education, Science and Culture, the Directorate of Health, the National Association of Municipalities and others[29].Iceland ratified the WHO FCTC in June 2004[30]. It had already implemented the Tobacco Products Directive of the European Union when it entered into the European Economic Area agreement in 1993. Recently, there has been increased formal and informal collaboration among the Nordic countries to become tobacco free by 2040, in accordance with the public health agenda of the Nordic Council of Ministers[31].

  1. Statistics of earmarked funds

Earmarked taxes have been the main source of financing for tobacco control from the beginning. The revenue flow of earmarked tax has been delivered annually on the basis of an estimate and reviewed against actual sales figures. There is no separate analysis of the amounts budgeted and used for specific projects before 2004, and, in view of intermittent inflation in the Icelandic economy, they would not be comparable over time. The Minister of Health provided a formal report for 2004–2007 in response to a question in Parliament on how the funds were spent[32]. In 2004–2007, 84% of earmarked funding was used specifically for tobacco use prevention and health promotion and 16% for the overheads of the Public Health Institute. After its transfer to the Directorate of Health, 65% of the earmarked tax went to the Directorate, which continues to finance national tobacco control programmes, and 35% to the Public Health Fund. The board of the Public Health Fund requires regular reporting and monitoring of the effectiveness of the projects funded. The Public Health Fund has financed various health promotion projects in schools and the community, including tobacco control activities. A rough estimate indicates that 20% of its funds go to specific tobacco control projects and 80% to more general health promotion projects.

The Icelandic health care system is a centralized, publicly financed system with universal coverage, based on residence in the country. The primary care health centres throughout the country are the main points of care, although access to specialist care in Reykjavik is also widely available. The health care system is financed mainly by general taxation, and the health expenditure as a share of gross domestic product was similar to that of Denmark and Norway until 2008; subsequently, it dipped below that of the other countries, mainly due to increases in other countries[33]. The health budget for NCDs is not available.

The trends in the prevalence of daily smoking by adults in Iceland over the past 30 years is shown in Fig. 1. The prevalence decreased over time, with minor differences between men and women. A national survey in 2007–2012, “Well-being of Icelanders”, showed a decreasing trend in smoking by both sexes and in all socioeconomic groups in all parts of the country[34]. Iceland can be considered to be in stages III–IV of the tobacco epidemic[35]; the prevalence of daily smoking is up to three times higher in people with lower education than those with university education, but the difference between rural and urban areas is smaller. As shown in Fig. 1, the increases in earmarked tax were followed by slightly steeper decreases in prevalence than before; however, other changes were made to the tobacco control law each time.

Fig. 1. Prevalence of daily smoking by Icelanders aged 18–69 years, 1985–2015, with major milestones of earmarked tax for tobacco control[36]

The smoking prevalence among Icelanders aged 14–16 years has changed considerably since the first survey in 1975, when half of them smoked, to the situation in the new millennium, when only 15–21% smoked daily (Fig. 2). The decrease in smoking in this age group is very promising. The nationwide study of the Directorate of Health, “Well-being of Icelanders” in 2012 found for the first time that more than half the population of Iceland had never smoked or had quit smoking34. There is reason for concern, however, with regard to the youngest age groups, as young men are increasingly using smokeless tobacco; furthermore, this appears to be additional to smoking and not a substitute.

Fig. 2. Prevalence of daily smoking among Icelanders aged 15–20 years in primary and secondary school, 2000–2014[37],[38]

The effectiveness of tobacco control over time can be seen in research on the trends in mortality from diseases caused by smoking, such as in ischaemic heart disease. The death rates from coronary heart disease decreased between 1981 and 2006 among people aged 25–74 years, by 79% for men and 82% for women. According to Aspelund et al.[39], over 70% of the decrease was attributable to reductions in population risk factors; reduced smoking prevalence contributed 22% of the decrease. The death rate from lung cancer increased between 1980 and 2009, by 50% for men and 20% for women, although the rate appears to have reached a plateau in the past 5 years[40]. The combined number of deaths due to smoking in Iceland is estimated to have decreased by about a third in the past 20 years.

  1. Summary and conclusions

Organized tobacco control in Iceland began in 1970 and received strong support for interventions in schools 5 years later as a reaction to the high prevalence of smoking among adolescents. At first, the work was led by doctors and lawyers collaborating with politicians, supported by many, diverse nongovernmental organizations (NGOs), which brought about changes to the tobacco control laws. The contributions of the Reykjavik Cancer Society, the Icelandic Cancer Society and the Icelandic Heart Association were important and resulted in a more multi-disciplinary approach to tobacco control over time.

The earmarked tax on tobacco products in Iceland has supported independent tobacco control projects for decades, mainly to support the legal framework, tobacco control at community level and regulatory actions for primary prevention. Changes to the tobacco control law often took years, including targeted actions supported by the goals of the National Health Policy. Iceland was among the first countries to ratify the WHO FCTC and had been planning tobacco control legislation that met the official WHO recommendations long before that time[41]. This was important for a small country with limited resources. Additional support was provided by collaboration at European level and among the Nordic countries.

The most highly prized asset for tobacco control in Iceland is the support of the people, who want to protect children and young adults from the use of tobacco; awareness of the effect of smoking on bystanders has also increased. Discussion of legislative action in the public arena has been made visible in the media, with petitions to support the suggested changes. Tobacco control legislation in Iceland scores high on the European Tobacco Control Scale. It provides its people with an almost smoke-free society for those who do not smoke and has also affected the private space; many people have declared their homes smoke-free as well. One limitation is that people in Iceland who still smoke or use tobacco do not have as good access to cessation support as people in many other European countries. The earmarked tax has been used to only a small extent to support such activities.

The earmarked tobacco tax in Iceland has made an important contribution to tobacco control. When it was withdrawn, organized activity decreased, despite political support for increased funding. Reintroduction of a higher tax changed the situation markedly. As tobacco sales decrease when consumption decreases, the earmarked tax must be increased to secure revenue for tobacco control.


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Related report

World Health Organization. (2016). Earmarked tobacco taxes: lessons learnt from nine countries. Geneva, World Health Organization.

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