Chapter eight
lthough western consumers are reducing their use of tobacco, the
situation in the countries of central and east Europe (CEE) looks
very different. Smoking prevalence figures are high and in general
are not decreasing. In addition, the per capita consumption of
cigarettes exceeds that of almost any other area in the world.
As the result, smoking is estimated to be the most significant
single factor behind the health gap that now divides Europe.
Tobacco control advocates in the CEE countries are facing an enormous task in persuading people to quit smoking or, even better, not to start. To begin with they need to tackle their politicians and parliaments. After the initial confusion of privatization of state-owned tobacco factories and the successive invasion of local markets by the transnational tobacco companies with their money, modern technology and flamboyant advertising, health activists have closed ranks and are fighting back. And despite the powerful lobby of the adversary, new legislation has been passed or initiated in most CEE countries.
Professors Witold Zatonski from Poland and Endre Morava from Hungary raised the voice of the Central and East Europe at the Helsinki Smokefree Europe conference. In analysing the developments in their own countries both of them stress the need for all-European cooperation in devising tobacco control policies and strategies.
rofessor Witold Zatonski finds it fitting that he participated in a tobacco
control conference in Finland. "I was impressed to see that Finnish lung cancer rates
went down following the decline of smoking in the 1970's. That
was the beginning of my anti-smoking career. I thought it would
be a real achievement to see the cancer rates decrease in Poland
too."
Witold Zatonski characterises the health situation in central and eastern Europe as a demographic catastrophe. "Such a rise of premature mortality among middle-aged men has never been seen anywhere else. The chances of a 15-year boy living to the age of 60 is half that of his western European counterpart and worse than in China or in Latin America. And all this has happened despite free medical services for everyone for over forty years!"
Zatonski lists the main reasons for premature death as tobacco, lack of safety, alcohol and a diet high in animal fat. "Information about the risks is a necessary start, but attitudes and beliefs need adjusting too. For instance, if you ask people about health risks, they usually mention the ones they can't influence directly: the pollution of the environment, the economic situation, stress and so on. But in fact the premature death rate is neither the result of economic growth nor development."
"If higher salaries means more animal fat, alcohol and tobacco in take, their effect on life expectancy is negative: man-made diseases that kill. Of course at a certain age the mortality rate is everywhere 100 percent, but the distribution of mortality is interesting and differs from country to country.
"By the 1970's CEE countries had become the heaviest consumers of tobacco in the world. At that time women also took up the habit. Of my mother's generation maybe 10% smoked, of my wife's some 25%, and of the generation of my daughter (if I had one--I have five sons) already 40% are smokers. Nowadays women in big cities like Warzaw and Krakow smoke more than men.
"Smoking is no longer increasing among Polish young women, but remains at a stable level--a very high level unfortunately. We know for example that 30% of pregnant women smoke."
"This has started to change, especially among educated groups, but only slowly. The new law makes it possible to demand a smoke-free environment at work. The employer has the obligation to protect you from environmental tobacco smoke. Some public places have gone smoke-free and many local communities have taken steps to protect non-smokers from ETS by passing stronger regulations than the law requires. The changes are generating a new thinking. When people are not allowed to smoke everywhere, they become aware of their behaviour in a different way than before. For the first time people start to feel that they should do something about their smoking."
"As long as we are advertising cigarettes and allow the building of a good image of smoking, we are sending out the message that smoking is not that dangerous, that it is just one habit among others. We proposed a total ban on advertising tobacco in Poland, but the tobacco industry prevented it by a wide alliance they called 'mass media without censorship'--which goes to show how they use the history of our country for profit."
Pricing is one of the most powerful tools for reducing smoking. "If you count how long you have to work to buy a pack of cigarettes, the cheapest brands still allow you to smoke very inexpensively in eastern Europe. Governments have had a policy of keeping prices low. It is not easy to understand the reasons for that."
Zatonski believes that both private and public changes in attitudes are making way for a reduction of smoking in the CEE countries. He reckons that governments can and must choose if they want to speed things up. But even if they side with the tobacco industry, the process cannot be stopped. Smoking is going out of fashion in the east as well as the west.
Sometimes the experiences are gained the hard way. Zatonski says that many politicians and businessmen made their first trip abroad to the USA. "They often chose an American plane instead of a Polish one, Delta for example. And then they were suddenly enclosed in a space where smoking was not allowed at all. This kind of possibility had not even occurred to them before. And when they arrived in New York after an eight-hour flight only to realize that the whole airport was smoke-free, they really got a shock.
"Some reacted simply by saying that the Americans are crazy. But for plenty of others it was a discovery to realize that they are a minority and have not the right to ignore other people. From our point of view it was important that politicians see an example where smoking restrictions are asked for and heeded by the public."
But there are also problems coming from the west. Many CEE countries look to the European Union as a model for tobacco policy. The Poles are also keeping a close eye on their big neighbour Germany. Both the EU and Germany leave much to be desired in terms of tobacco control, as the EU has not been able to ban tobacco advertising and German tobacco policy is not well developed.
"Our politicians use the situation as an excuse for doing nothing. We try to explain that it is even more important for us to make progress than for countries where consumption is already going down and where smoking prevalence are lower to start with."
Health promoters faced a new challenge with the change. "The tobacco lobby used not to be strong, it never had any prestige in East Europe. That has changed and now the industry is powerful and well organized, they do their lobbying professionally and they have established wide alliances."
Zatonski thinks that the health sector should know more about the economics of tobacco. "The industry claims that it is good business and provides stable jobs and generates taxes which they pay loyally. But look at employment. The modernization of production is diminishing the need for labour. And because the factories import more of the raw material, the farming of tobacco has declined by 50 percent in five years.
"Of course, Poland is still a big market with a consumption of about 100 billion cigarettes a year. So at the same time the industry makes profits for the owners, it generates a lot of money and supporting the state budget by taxes. Our problem is that we don't have good data on the costs. Health care expenditure statistics would be very important especially in our countries where we are used to free medical care."
"As the economy becomes stronger and the markets grow and diversify, any one industry will lose its special status. "There will be other tax payers and sponsors of rock concerts and clients for advertising agencies and advertisers for the media in addition to the tobacco companies. I think that we are now slowly moving in that direction in Poland."
"If we believe that soon there will be no more borders between European countries, we have even more reason for cooperation. We should not be xenophobic or patronizing but work together to achieve our goals." n
ungarians are the heaviest smokers in the world. Over a third
of adults smoke, and they consume twice as many cigarettes as
the western smokers. Every third death is due to the combination
of tobacco and alcohol and Hungary has become the lead country
in the heart disease mortality. It is no wonder that Professor
Endre Morava sees smoking reduction as one of the main areas of
health promotion.
"The mortality and morbidity of middle aged male Hungarians has fallen to the level of 1920's. Until 1960's the health situation improved and the life expectancy increased. From the late 1960's there has been an increase in premature mortality caused by heart attacks, strokes, liver diseases and other non-infectious diseases."
Endre Morava says that not all the reasons for the changes are known. "The increase in life expectancy was probably due to the control of infectious diseases--especially tuberculosis--after the war. At the same time, because of the low level of income, we did not yet have the so called 'civilisation' diseases. Little by little unhealthy lifestyles--high fat food, little exercise, increasing consumption of alcohol and cigarettes--became common, with the result that mortality rates increased. This is only an hypothesis; it is supported by facts."
"Trying to alter peoples' smoking habits is difficult but compared to changing nutritional customs there are some advantages. With smoking we have a clear message: tobacco is dangerous, so either don't start, or try to stop.
"Diet is a more complex issue. You have to address questions of the amount of fat and salt in your food, the quality of fat, obesity, the importance of vegetables and fruits and so on. So it is a multifaceted problem, while smoking is more of a single factor phenomenon."
Money is also involved in life style decisions. "I am simplifying a little but in principle quitting smoking leaves you more money for other purposes while a healthy diet increases your expenses. Vegetables and fruit are expensive in Hungary and the fat calory is still the cheapest available calorie. People with financial problems can't really afford to pay more for their food."
"If one does not consider the value of health, but take into account only direct expenses and income, it is quite easy to draw conclusions that go against health objectives. The taxation of tobacco and alcohol gives the government such an enormous income that it almost keeps the state budget in balance. And if you have a deficient budget, losing this income is an unattractive prospect. The pressure to secure taxes is very strong," says Morava.
"Of course, if you don't look only at this year but look further ahead, the picture changes. You are spending the future health of the people. But the governments take today's money because they need it most."
"During previous decades an attitude developed that if you are an intellectual, if you are thinking hard or have problems to solve, you are supposed to smoke. As a consequence almost all the teachers and politicians and doctors used to be smokers and a fairly high proportion of them still are," says Morava. "Now a slight decrease in smoking frequency has happened among university students, at least in the medical faculty and teachers' college."
"Some politicians also have direct or indirect links with the tobacco industry. In that case it is very easy to see different issues from their point of view."
Depending on these or other factors it has been difficult to pass new tobacco control legislation in Hungary. A comprehensive law has been prepared by the Ministry of Health but it has been suspended by other ministries.
"The main opposition comes from the Ministry of Commerce and the Ministry of Justice. They have made suggestions that would make the law worthless. The wording may sound good but their kind of regulation would be completely inefficient," says Morava.
The traditional conference structure is sometimes criticized for being too heavy for dealing with a wide variety of issues, but Morava thinks it would be difficult find other ways to obtain the same advantages. "Nothing can replace personal discussions in exchanging experiences. If you only follow the literature you miss a lot of the everyday practical experiences of others.
"Another reason is encouragement. Anti-tobacco work can be very frustrating and there are so many failures that you need to hear about successes and you need the support of your colleagues to be able to continue. The third important factor is planning. Because our problems are interrelated, our plans should be too. You can do all these in a wider meeting"
Endre Morava would like to bring to the next conference politicians both from countries where effective anti-tobacco measures exist and from where they don't. "Politicians find it easy to say to us that some regulations are impossible. If they were to be confronted by their colleagues from countries where the same laws already exist they might get some new ideas. And tobacco control activists could add to the pressure to initiate new legislation by showing that there is a demand for such policy." n