Chapter eight
he great health hazards of smoking were convincingly demonstrated
in the 1950's and 1960's. At that time smoking was a wide-spread
phenomena in most of the industrialized world, particularly among
the male population, but since then has increased steadily among
the female population.
Smoking is a major epidemic in the modern world; infact tobacco and AIDS are the two leading global scourges. It is estimated that tobacco kills about 3 million people annually, and the figure is expected to increase to as much as 10 million in the next 25 years.
For a person who smokes the habit is usually the most important single changeable factor harming his or her health. Roughly every second a smoker dies of the tobacco habit. Although stopping smoking is often difficult due to addiction, millions of people have succeeded to permanently get rid of the habit. At the same time efforts are being intensified to prevent this disastrous habit from spreading among children and youth.
The big change also altered the health picture and the tobacco situation. Western tobacco industry aggressively moved in to these countries. Local tobacco factories were bought and western type of advertising and sales promotion was brought in. The popular atmosphere was favourable to these western advertisements and western type of cigarettes such as Marlboro and West were associated with western freedom and lifestyle. At the same time economic transition made many economic problems and great constraints occurred for all kind of health work.
In many CEE countries the burden of chronic diseases increased, and the East-West health gap in Europe widened. In 1993-94 the life-expectancy of Russian men dropped to 58 years, in Estonia the average was 63 years and in Hungary 64 years. At the same time, in Finland the average was 73 years, in France and Britain 74 years and in Iceland 76 years.
Table 1 shows the high premature mortality (age groups 35-69) rates of cancer, CVD and all causes in Central and Eastern Europe ("former socialist countries") according to estimates by Peto et al. (1994). The rates, especially among men, are high and in general rose until 1985. Thereafter cancer rates have continued to increase but CVD rates have apparently declined.
On the other hand the proportion of mortality attributed to smoking has increased continuously. For the male population as much as 40% is estimated to be due to smoking--this means about 600,000 smoking-related male deaths each year (Table 2). The nearly three quarters of these people who die below 70 years lose on average 20 years of their life.
| Year | All | % smoking | Cancer | % smoking | CVD | % smoking |
| Men | ||||||
| 1965 | 1511 | 390 | 535 | |||
| 1975 | 1716 | 400 | 657 | |||
| 1985 | 1895 | 39 | 449 | 54 | 841 | 40 |
| 1990 | 1879 | 39 | 483 | 56 | 825 | 40 |
| 1995 (proj.) | 1835 | 41 | 512 | 58 | 752 | 42 |
Women | ||||||
| 1965 | 788 | 235 | 332 | |||
| 1975 | 816 | 223 | 378 | |||
| 1985 | 848 | 6 | 220 | 5 | 420 | 6 |
| 1990 | 805 | 7 | 225 | 6 | 387 | 7 |
| 1995 (proj.) | 762 | 7 | 229 | 6 | 350 | 8 |
| Year | 35--69 | 70 - | All ages | ||||||
| All | Cancer | CVD | All | Cancer | CVD | All | Cancer | CVD | |
| Men | |||||||||
| 1975 | 256 | 80 | 97 | 94 | 23 | 29 | 350 | 103 | 126 |
| 1985 | 379 | 121 | 159 | 138 | 36 | 52 | 517 | 157 | 211 |
| 1990 | 441 | 157 | 189 | 126 | 36 | 48 | 567 | 193 | 237 |
| 1995 (proj.) | 463 | 179 | 198 | 135 | 44 | 51 | 598 | 223 | 249 |
Women | |||||||||
| 1975 | 28 | 6 | 11 | 18 | 2 | 6 | 46 | 8 | 17 |
| 1985 | 36 | 8 | 17 | 37 | 5 | 16 | 73 | 13 | 32 |
| 1990 | 42 | 10 | 20 | 44 | 7 | 20 | 87 | 17 | 40 |
| 1995 (proj.) | 44 | 12 | 21 | 56 | 10 | 26 | 101 | 22 | 47 |
Female mortality rates are lower and the proportion attributed to smoking is also much lower, though steadily increasing.
Generally the national smoking rates among male population vary between 40% and 60%. But in some regions and in some population groups even higher smoking rates can be found. Also the cigarettes smoked are usually strong and contain more harmful substances than cigarettes in the western markets.
It is more difficult to discern the trends in smoking in the CEE countries. Alongside aggressive tobacco advertising many efforts by health professionals are taking place to fight the killer habit. Anti-smoking campaigns have been accompanied by at least some initial policy measures by governments. Countries such as Poland, Lithuania and Slovenia have already passed regulatory legislation to curtail tobacco, and legislative issues are under discussion in most other CEE countries. Anti-smoking health education campaigns have often been associated or supported by international efforts, including from the World Bank, WHO, and the International Union Against Canser.
There are signs from many CEE countries that smoking among the male population may have started to decline. Table 3 shows findings from Estonia, where comparable health behaviour surveys as part of Finnish-Baltic co-operation have taken place since 1990 (Kasmel et al. 1997).
| Year | Men | Women |
| 1990 | 46% | 20% |
| 1992 | 49% | 20% |
| 1994 | 52% | 23% |
| 1996 | 48% | 22% |
Similar indications are available from Hungary, Poland and some parts of Russia. In the Russian Karelian district of Pitkäranta where a joint Russian-Finnish health programme has taken place, the repeated cross-sectional surveys show the following prevalence rates for smoking among adult men: 1992: 65%, 1994: 63% and 1996: 57%. It seems that Poland, with its long tradition of anti-smoking activity, has witnessed a levelling off and reduction in smoking already since mid 1980's. However, the proportion of daily smokers is still as high as nearly 50% (Zatonski 1996).
It is more difficult to say about trends in female smoking. The general feeling is that an increase is still taking place although there is also a levelling off in many countries. The surveys, however, seem to reflect more uncertainty about the reliability of smoking prevalence figures among females.
The surveys also give an interesting insight into changes in the course of smoking in these countries. Tables 4 and 5 present this kind of information for two countries--Estonia and Hungary. The figures concerning Estonia are drawn from the above-mentioned report (Kasmel et al. 1996). Because of the good comparability with the respective Finnish report of the same year (Helakorpi et al. 1996), the comparative figures for Finland are also given. The information concerning Hungary is taken from a National Survey sponsored by the World Bank programme in Hungary (Szonda Ipsos 1996).
| Men | Women | |||
| Est | Fi | Est | Fi | |
| Total population | ||||
| Daily smokers | 48 | 27 | 22 | 18 |
| Ex smokers (stopped
>1 year ago) | 10 | 21 | 4 | 12 |
| Daily smokers | ||||
| Worried about the health
consequences of their smoking | 72 | 71 | 73 | 77 |
| Would like to stop smoking during previous year | 60 | 56 | 62 | 52 |
| Smokers | |
| Think smoking is dangerous to health | 93% |
| Smoking restricted at home | 62% |
| Doctor advised to stop smoking | 31% |
Surprisingly, the tables show that in many CEE countries there is plenty of recent interest by smokers about the health consequences of the habit and the possibilities to quit. In these surveys the people usually give health reasons (both treatment and prevention) as the main reason to quit, followed by economic reasons, pressure from family, advice by others.
In spite of the interest, the actual stopping is not easy because of addiction. Also, social norms are still weighted in favour of smoking--reducing the chances of successful quitting. The Estonian survey shows that about more than 75% of men and more than 50% of women working outside of their home are daily exposed to cigarette smoke at their work site. And in more than 50% of homes somebody smokes indoors.
After the political and social upheaval the western tobacco industry came marching in with aggressive marketing strategies and the aim to buy up the local tobacco factories. The industry represented a new western style of the marketing, and the cigarette brands themselves represented fashionable western lifestyles. Eastern governments often welcomed these model western business investments.
At the same time the economic transition caused many problems. The social security provided by the communist system broke down and great economic constraints followed for many people. Health services suffered from public funding problems. The general comment was that all this insecurity "causes so much stress" and that stopping smoking in this situation is not easy.
At the same time, however, support for healthy change is growing. The great burden of chronic diseases and the unquestionable role of smoking and some other unhealthy lifestyles is recognized by health experts, and, due to campaigns, increasingly by the public. Although the health administration understandably strive at modernization of hospitals and health clinics, many realize that the east-west health gap can only marginally be closed by improvements in clinical medicine. Instead population lifestyles and risk factors are in key position. Improving population lifestyles is an affordable and effective way to improve the health status of the population.
Accordingly non-smoking and other healthier lifestyle approaches have started to appear as new innovations, and especially appreciated by more educated people. Pressure on politicians and the government to pass antismoking legislative measures is increasing. Tobacco advertising is being restricted and smoke-free areas are expanding.
International collaboration has been important in this development. Scientific collaboration has strengthened the evidence. Western health experts have been seen as credible sources. And international collaboration has also brought some, albeit limited, funds for new forms of public health work. The World Bank has supported activities in many countries, and the WHO, the International Union Against Cancer and others have also contributed.
Some of these international antismoking campaigns have been strikingly successful, at least when judged by the extent of participation and interest. During a Finnish-Estonian anti-smoking TV programme as many as some 20,000 smokers in Estonia signed up for the Quit & Win contest--about 5% of the country's smokers.
When the first international Quit & Win campaign was organized, in 1994, about 26,000 smokers in Russia registered, even though the campaign was held only in Moscow and a few other large cities. It was noted that for the first time anti-smoking efforts were "something more than dull propaganda". It was a positive message, involved broad coalitions, commercial sponsors and modern media messages.
The road to a smoke-free central and eastern Europe is long and difficult, though most of the countries of the region have started along it. Because of the high peak of the tobacco problem there is practically only one sustainable course for this route; and without any doubt the progress achieved will be met by respective improvements in public health.
International collaboration is of great importance both for western and CEE countries. Smoking is a global problem, the industry is multinational, lifestyles are international, and therefore the fight for smokefree future must be global. n
Peto R, Lopez A, Boreham J, Thun M, Heath C Jr. Mortality from smoking in developed countries 1950-2000. Oxford University Press 1994.
Kasmel A, Lipand A, Kasmel K, Traat U, Markina A, Uutela A, Helakorpi S, Puska P. Health behaviour among Estonian adult population, Spring 1996. Publications of the National Public Health Institute B2/1997.
Smoking and passive smoking. Szonda Ipsos, Budapest 1996.
Zatonski W. Evaluation of health in Poland since 1988. Warsaw 1996.