Just What the Doctor Ordered?

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CMAJ News

A pack a day: Just what the doctor ordered?

mokers in Iceland may soon need a doctor’s note to light up. SMember of Parliament and for - mer health minister Siv Fridleifsdottir, backed by the country’s medical asso - ciation, will table a private member’s bill in the fall to make cigarettes a pre - scription-only product. Only pharma - cies would be allowed to dispense tobacco products — at first to anyone over 20 and finally only to people with medical certificates. The pitch is part of an ambitious 10- year plan articulated in the bill to ban smoking in all public places, including sidewalks, parks and cars when driving or with children, in a bid to reduce the

k visibility and harmful second-hand c o t s k

effects of smoking. Under the legisla - n i h T tion, doctors would be compelled to 1 1 0 2

prescribe cigarettes to smokers unwill - ing or unable to quit using cessation © Iceland may soon confine smoking to people’s residences as part of a 10-year plan that programs. would ban smoking in all public places, including sidewalks, parks and cars when dri - “The idea is not to penalize those ving or with children, in a bid to reduce the visibility and harmful second-hand effects of who already smoke, but prevent others, smoking. particularly young people, from mak - ing uninformed choices to pick up the where. But once the prescription sys - hand smoke is not harmful, arguments habit,” explains Fridleifsdottir. tem was in place, prices would be cut I thought we had put behind us for Iceland has one of the lowest rates to the cost of importing the products, as many years.” of smoking in Europe at about 15%, it would be unfair to tax people unable But as with prior antismoking initia - largely because of antismoking policies to quit, Fridleifsdottir says. “We’d clas - tives, what’s considered radical is only adopted in the past, but the rate is sify smokers as being addicted to a matter of time and perspective, she higher among young Icelanders at 20%. tobacco, and look at tobacco as medi - counters. “Today we wouldn’t think of “Every year 700 young people start cine for that addiction.” lighting up on a plane, and yet it once smoking in Iceland, and about half The prescription system would also was radical to propose such a ban. Even will die prematurely from diseases serve as an entry point for smokers to our most recent ban in 2007 stirred all related to that addiction,” Fridleifsdot - receive regular medical care to mitigate kinds of debate, but we’ve since done tir says. “With all that we know today and manage the long-term health opinion polls and it’s overwhelmingly about how harmful it is to smoke, it is effects of their habit. supported. It’s just a matter of time for ethical and right to take radical steps But few smokers are eager to be the steps we’re suggesting to become a to try and prevent children from start - diagnosed as addicts and public debate reality.” ing to smoke.” surrounding the proposal has already But strong antismoking measures The proposed legislation would see resurrected some “old ghost” contro - and sales bans are only effective if tobacco and nicotine designated as versies, Fridleifsdottir says. “All the enforced, says Armando Peruga, pro - addictive drugs, while second-hand arguments we heard in 2006 and 2007 gram manager of the World Health smoke would be controlled like other when we banned smoking in restau - Organization’s Tobacco Free Initiative. carcinogenic substances. rants, bars and discotheques have “That includes ensuring no alternative The price of tobacco products would come back around. They say now, like markets are created by the measure.” increase by 10% annually so long as then, that the proposal is too radical, The success of Iceland’s proposed they’re available over the counter — a that it goes too far against personal prescription system is anyone’s guess, strategy that’s been proven to reduce freedoms. I’ve even heard some really he adds. Only Bhutan has ever imposed smoking rates by as much as 6% else - old-fashioned arguments that second- a total ban on tobacco products, and

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treating cigarettes as prescription drugs tions for such a prescription, based on criticized us for destroying their free - is an entirely novel approach. consensus between Iceland’s medical dom of expression so perhaps we’ll Yet Iceland, by virtue of its isolated association and the government.” agree to support those films if the geography, may be in the perfect posi - In response to criticisms of the ini - artists can prove the tobacco industry tion to impose such strictures as there tiative, Fridleifsdottir plans to make is not sponsoring them.” are few points of access by air or sea some modifications to the private Even if Parliament were to neuter for tobacco products to be smuggled member’s bill before tabling it in Par - the proposal, as some have suggested, into the country, Peruga says. liament in October. “We were going to by making tobacco products only Moreover, imported tobacco sold at propose the public smoking ban be available from licensed stores, as alco - premium prices on the black market extended to balconies, but we see the hol now is, it would be incremental could hardly compete if the physician- argument that if you’re a smoker with progress, Fridleifsdottir adds. “The prescribed stuff was sold wholesale, children and don’t want to smoke value of linking it to a prescription says Fridleifsdottir. inside there’s really nowhere else to go system would be lost, but any step to If anything, the ethical implications without leaving home,” she explains. reduce the availability and visibility of of involving physicians in dispensing “We were also suggesting that taxpay - tobacco is one in the right direction.” tobacco is a greater concern, argues ers’ money not be used to pay [subsi - — Lauren Vogel, CMAJ Peruga. “If it goes ahead, there should dies] for films produced in Iceland if be firm guidelines to define the indica - they show people smoking, but artists CMAJ 2011. DOI:10.1503/cmaj.109-3969

E1046 CMAJ, October 4, 2011, 183(14)