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One  possible  approach  to  assess  the  impact  of  the  introduction  of  the  display  ban  in
Iceland in August 2001 is to compare the evolution of smoking prevalence in that country
before and after the introduction of the display ban.
Smoking  prevalence has  been  declining  in  Iceland  since  the  mid  1980s,  as  in  most
Western countries. For example, the percentage of individuals aged 15 to 79 years who
smoke declined from 33% in 1987 to 19% in 2007.22 This declining trend is also observed
for other age groups. Smoking rates of individuals aged 15 to 24
years  fell  from  28%  in  1989  to  19%  in  2007,  and  also  followed  a  negative  trend  for
individuals aged 15 to 19 years and 20 to 29 years.

The decline in smoking prevalence is driven  by many factors, some that can be clearly
identified and quantified, such as price increases, and others that are difficult to measure
such  as  changes  in  the  level  of  press  coverage  of  smoking  related  health  issues.  So
while  the  display ban may have  been responsible  for part  of the observed decline,  it  is
clearly not the only explanation for this negative trend. This is for several reasons.
First,  the  display ban  cannot  explain  the  decline  in smoking  prevalence  prior  to  its
introduction, in August 2001.
Second, the display ban regulation was preceded by  various other regulatory measures
including advertising bans on all media and mandatory health warnings in 1984, bans on
smoking in public areas in 1999 and brand sharing prohibition in 2001. (Table 2 reports a
complete  summary  of  these  tobacco  control  measures  and  the  date  of  their
implementation in Iceland.) These regulations are likely to be responsible for part of the
observed reduction in smoking prevalence in Iceland before and after August 2001.

Third,  cigarette  prices  in  Iceland  have  been  increasing  since  the  mid  1980s,  both  in
absolute and relative terms, driven primarily by tax increases. The Consumer Price Index
(CPI) for  the whole  economy increased  by 115% from  1989  to  2007.  During  the  same
period  the  CPI  for  tobacco  increased  by  256%.  In  other  words,  the  relative  price  of
tobacco  (i.e.,  the  tobacco  CPI  divided  by  the  overall  CPI)  increased  by  66%  over this
period.
One would expect that this increase in tobacco prices would have had a negative impact
on smoking prevalence. The data suggests that this is indeed the case. Figure 7 shows a
clear  negative  relationship  between  smoking  prevalence  and  cigarette  prices: cigarette
prices increased by 66% from 1989 to 2007, while smoking prevalence declined by 41%.
A  simple  correlation  analysis  confirms  the  strength  of  this  relationship.  The  estimated
correlation  between  smoking  rates  and  the  relative  price  of  cigarettes is  negative,  very
near one (-0.96) and statistically significant. This means that variations of smoking rates
are closely related to changes in cigarette prices

VA has long been engaged in efforts to promote tobacco cessation in veterans. VA
researchers have been at the forefront of advances in tobacco-cessation treatments. Nevertheless,
veterans served by the VA health-care system continue to have higher rates of tobacco use than
their general-population counterparts, although not as high as those of military personnel. That
suggests that many veterans quit using tobacco, but with tobacco use increasing in the military, it
is likely that many new veterans accessing the VA health-care system will also be tobacco users,
especially those who have been deployed in Iraq and Afghanistan.
Like DoD, VA has many components of a comprehensive tobacco-control plan already in
place, including effective and enforceable policies, communication mechanisms, surveillance
activities in the form of performance measures, and periodic evaluation of tobacco-control
practices. VA has developed a National Smoking and Tobacco Use Cessation Program, and it
has recently strengthened its Smoke-Free Policy for VA Health Care Facilities. But in its efforts
to become entirely tobacco-free, the department has been thwarted by congressional legislation
that requires VA medical facilities to have designated smoking areas for veterans and employees.
The committee finds that such a requirement prevents VA from protecting its patients, employees, and visitors from possible exposure to secondhand smoke and prevents it from
promoting the health of its more vulnerable patients, those who smoke.
Virtually all the VA medical centers (VAMCs) have some form of tobacco-control
program, although the programs are not standardized or uniform. Each VAMC must designate a
smoking and tobacco-use cessation lead clinician to be the point of contact for all clinical and
other communications on tobacco cessation. However, the committee finds that that position is
typically not full-time, and the lead clinicians may have other responsibilities that take
precedence. The committee also finds that the availability of tobacco-cessation services in VA
community-based outpatient clinics (CBOCs), other than the required access to medications and
brief counseling, is highly variable: some CBOCs have trained staff who offer group or
individual counseling, and others only refer patients to outside community services.
Use of the VA/DoD Clinical Practice Guideline for the Management of Tobacco Use has
been encouraged by the VA Office of Public Health Policy and Prevention, and it has been
included in the National Smoking and Tobacco Use Cessation Program. The guideline highlights
the effectiveness of using the 5 A’s for each patient. VA has been successful in ensuring that all
patients are asked about their tobacco status, are advised to quit, and are referred to a tobaccocessation
program; these prompts are included in patients’ electronic medical records and are
performance metrics for evaluating VA health-care providers. But adherence to the guidelines
beyond the minimal effort required by the prompts in the medical records is variable.
VA appears to offer a broad array of tobacco-cessation counseling interventions to
patients, but there is little information on the effectiveness of these interventions for veterans.
The guidelines do not specify particular tobacco-cessation programs to be used, and VA uses
several standard programs, including those of the American Cancer Society and the American
Lung Association. The committee does not know whether VA tailors the programs to address
special needs of veterans.
The VA/DoD clinical-practice guideline and the PHS guideline provide
recommendations for evidence-based treatment of special populations that seek medical care at
the VA. Those populations include older patients, hospitalized patients, and patients who have
mental-health disorders. The committee believes that the guidelines provide a good treatment
framework.
The committee believes that veterans would benefit from a national VA quitline for
tobacco, possibly supplemented by a computer-based cessation campaign similar to the DoD
“Quit Tobacco. Make Everyone Proud” Web site. A national quitline has the advantage of
consistency of service regardless of where veterans are. Quitline counselors should be trained to
deal with veteran-specific issues, such as PTSD. Evidence shows that people who have mentalhealth
disorders are willing and able to engage in tobacco cessation and should be encouraged to
do so. The committee believes that VA should assess whether quitline counselors can provide
tobacco-cessation medications to veterans as in the private sector without the need for veterans to
obtain prescriptions from their health-care providers, particularly for over-the-counter
medications, such as nicotine-replacement therapy.
Performance measures that assess health-care providers are a good start for improving
care, but the effect of that care on patient outcomes might be even more important. The
committee believes that VA should evaluate the long-term effect of its tobacco-cessation
programs on abstinence rates. Such information would help to show where programs could be
improved or replaced.

Be prepared for a small spike in crave episodes on day seven, as you celebrate your first full
week of freedom from nicotine. Yes, for most of us, nicotine use was part of every celebration. Also
stay alert for subtle differences between crave-triggers. For example, the Sunday newspaper is much
thicker and may have required three cigarettes to read instead of just one.
Understanding the Big Crave – The “average” quitter will be experiencing just 1.4 crave episodes
per day within ten days. After that you may soon begin to experience entire days without encountering
a single un-reconditioned subconscious trigger. If a later crave episode ever feels more intense, it is
likely that it has been some time since your last significant challenge and you’ve dropped your guard
and defenses a bit. It can feel as though you have been sucker-punched. If one does occur, see the
distance between challenges as the wonderful sign of healing the incident reflects.
Crave Coping Techniques - One crave coping method is to practice slow deep breathing while briefly
clearing your mind of all needless chatter by focusing on your favorite person, place or thing. Another
popular three minute coping exercise is to say your ABCs while associating each letter with your
favorite food, person or place. For example, the letter “A” is for grandmother’s hot apple pie. “B” is for
warm buttered biscuits. You may never reach the challenging letter “Q.”
Embracing Craves - Another coping technique is to mentally reach out and embrace your craves.
A crave cannot cut you, burn you, kill you, or make you bleed. Try to be brave just once. In your mind,
wrap your arms around the crave’s anxiety energy and then sense as it slowly fizzles while within your
embrace. Yes, another trigger bites the dust and victory is once again yours, as you reclaim yet
another aspect of life!
Confront Your Crave Triggers - Within two weeks, you should begin to realize that everything
you once did while nicotine’s slave can again be comfortably done without it, and often better.
Meet, greet and defeat your triggers. Don’t hide from them. You need not give up anything during
recovery except nicotine.