Melissa Nondorf
Poland vs. Tobacco: The Fight for a Nation’s Health
Tobacco use is one of the most preventable causes of morbidity and mortality worldwide2. Implementing a successful anti-tobacco campaign is often extremely problematic, though. Aside from the obvious difficulty of persuading people to give up an addictive habit that they frequently enjoy, tobacco companies and their lobbyists always staunchly oppose such measures and do everything in their power to prevent governments from getting involved and passing tobacco use reduction legislation.
Poland has been an unusual success story in the fight against tobacco use. While in the late 1980′s it held the dubious title of most cigarette-addicted nation7, now the country’s legislation for tobacco control is considered one of the world’s most progressive1. Poland is in many ways a good case study for any nation looking to formulate its own tobacco control program. The country’s history, struggles and achievements are all worth investigating to discover common threads that might work elsewhere.
Poland could be considered something of a Phoenix that has risen from the ashes of Communism. Behind the Iron Curtain, the government “effectively brib[ed] and sedat[ed] its citizens with cheap tobacco, vodka, and red meat. Keeping proportionately low prices… was a means of keeping people happy7.” Such policies also caused Poles’ health to deteriorate. Smoking though, seems to have had the largest impact, especially on men. By the end of the 1980s, over half of the non-communicable disease burden among Polish men was due to smoking. Additionally, lung cancer – a direct effect of smoking – in Polish men was among the world’s highest10. Communism was overthrown in 1989 and Poles immediately went to work transforming their society into a freer and healthier one.
Under Communism, tobacco-related health information was heavily censored10. Many people smoked without any idea of the damage they were causing themselves and others. As democracy took hold in Poland and a market economy flourished, foreign tobacco companies descended upon the country. They mounted aggressive advertising campaigns, banking on the fact that Western-brand cigarettes had been a precious and revered commodity under the old regime7. Surprisingly, national smoking levels began to decline instead of increase. The percentage of adult males who smoked dropped from an all-time high of 64% in the mid 1970s to around 60% in 1985 and then 40% by 1998. The percentages for women fluctuated from 21% in the 1970s to 34% in 1985 and 20% in 19981.
There were several reasons for this unusual result. First, Polish scientists had taken notice of the plummeting health of middle-aged men back in the 1970s and began studying its relationship to smoking. Papers were published, but the information was withheld from the public. As soon as the country began to liberalize in the 1980s though, the scientific community acted. In 1990, the year after Communism fell in Poland, the country hosted a conference at Kazimierz titled “A Tobacco-free New Europe.” This was the first time health advocates from both sides of the Iron Curtain were able to come together and formulate plans of action to lessen disparities in health and address the damage being caused by cigarettes in Eastern Europe10. Then, in 1991, Poland’s Center of Oncology initiated what has become an annual event; the ‘Great Polish Smoke-Out.’ Every year prizes are offered to people who have quit smoking6.
Secondly, the newly democratic Polish legislature was very open to taking proactive measures on health reform. In 1996, the parliament passed the Tobacco Control and Health Protection Act. This Act had several important functions; it prohibited most forms of tobacco advertising and sponsorship, required that health warnings constitute 30% of available space on cigarette packs, banned the sale and production of smokeless tobacco, and prohibited sales to minors or the use of cigarette vending machines. It also placed a total smoking ban in most hospitals and on public transport6.
In fact, by 1998, Poland was considered to have the most developed anti-smoking attitude of all European countries8.
Clearly, Poland was ready to fight for its people’s health. The question was how effective these measures would be. Many countries have enacted public health legislation but have not being willing or able to enforce it. Even Poland had experience with this back in the 1970s, when the Communist government passed smoking regulations known as “paper tigers – they looked strong on paper but were ineffective because of lack of enforcement10.” This time though, the results were real.
A survey conducted on the prevalence of tobacco use in Polish primary care settings from 1998-1999 found that 44% of participants reported any cigarette use in the last three months, with results split by sex being 54% for males and 37.3% for females6. By 2004, the numbers of daily smokers had fallen to 38% in men and 25.6% in women4 and 2006 data show percentages inching downward even more, to 37% and 23% for men and women, respectively5.
These drops in cigarette consumption have had rapid and noticeable effects on the nation’s health. Even as early as the end of the 1990s, lung cancer mortality – that strongly correlated health indicator of cigarette consumption – dropped by up to 30% in certain male age groups. Cardiovascular disease has also diminished by 20% since 1991 and even the reduction in infant death risk during the 1990s has been attributed to a decline in smoking among pregnant women10. Life expectancy increased by 3 years for men and by 2 years for women between 1991 and 1998, a trend largely due to the reduction in cardiovascular deaths and one that represents the greatest decline in cardiovascular disease-related mortality in the world1.
Approximately 30% of the adult Polish population continues to smoke, though5, 9. The challenge now is to determine what steps should be taken to lower this number even further. Additional legislation has been enacted, including the 2002 Declaration on Counteracting Nicotine Dependence, which includes a detailed health promotion policy1 and the 2004 Framework Convention on Tobacco Control, a multi-nation agreement that includes an article specifically about the need to promote cessation and treatment activities for current smokers4. But, as the data above indicate, success has been more pronounced in some areas than in others. For instance, smoking rates in men have plunged, but rates in women have remained more stubborn. Also, data indicate that smoking among adolescents is increasing and should be an area in which to focus prevention measures. The Global Youth Tobacco Survey in 2003 found that over 20% of Polish youth between 13 and 15 had been offered free cigarettes and 19.6% of boys and 17.1% of girls were current smokers2.
Increased emphasis on the role of health care staff in promoting smoking abatement seems to be a plausible option. Currently, most smokers who are considering quitting do not anticipate seeking any sort of counseling from a health care provider4. “Cold turkey” is the most common method of quitting and smokers generally make 2-10 attempts before gaining success8. Hospitals, doctors, and pharmacists, though, all have positive roles to play in helping their patients quit. A combination of professional medical advice and nicotine replacement therapy has been shown to be the most cost-effective method for encouraging smoking cessation3. Pharmacists can also play an integral role; they were ranked most likely to be consulted for pharmacological smoking cessation treatment of all health professionals in a 2007-2008 Polish survey4.
Great strides have been made in decreasing cigarette usage among the world’s formerly most nicotine addicted country. There are still significant improvements that need to be made, though, especially regarding nicotine-related education of both the general Polish population8 and even of Polish medical professionals3. Nevertheless, Poland’s experiences and it’s achievements in the face of a veritable health catastrophe are worth considering for other countries looking to protect or salvage the health and lives of their own people.
Works Cited
1. Bałczewska E. Smoking and Tobacco Control in Poland. European Journal of Dental Education. 2004 Feb;8 Suppl 4:42-5.
2. Baska T, Warren CW, Basková M, Jones NR. Prevalence of youth cigarette smoking and selected social factors in 25 European countries: findings from the Global Youth Tobacco Survey. International Journal of Public Health. 2009;54(6):439-45.
3. Cofta S, Staszewski R. Hospital staff and smoking habits: do we need modification of smoking behavior in Polish hospitals? Journal of Physiology and Pharmacology. 2008 Dec;59 Suppl 6:191-9.
4. Goniewicz ML, Lingas E, Czogala J, Koszowski B, Zielinska-Danch W, Sobczak A. The role of pharmacists in smoking cessation in Poland. Evaluation & the Health Profession. 2010 Mar;33(1):81-95. Epub 2009 Dec 29.
5. Kawecka-Jaszcz K, Jankowski P, Podolec P, et. al. Polish Forum for Prevention Guidelines on Smoking. Kardiologia Polska. 2008 Jan;66(1):125-6.
6. Manwell LB, Ignaczak M, Czabala JC. Prevalence of tobacco and alcohol use disorders in Polish primary care settings. European Journal of Public Health. 2002 Jun;12(2):139-44.
7. Neroth P. Stubbing out Communist Habits. The Lancet. 2005 Jul 9-15;366(9480):109-110.
8. Sieminska A, Buczkowski K, Jassem E, Lewandowska K, Ucinska R, Chelminska M. Patterns of motivations and ways of quitting smoking among Polish smokers: a questionnaire study. BMC Public Health. 2008 Aug 4;8:274.
9. Thyrian JR, Panagiotakos D, Polychronopoulos E, West R, Zatonski W, John U. The relationship between smokers’ motivation to quit and intensity of tobacco control at the population level: a comparison of five European countries. BMC Public Health. 2008 Jan 3;8:2.
10. Zatonski W. Democracy and Health: Tobacco Control in Poland. In: De Beyer, J., Brigden, L., eds. Tobacco control policy: strategies, successes, and setbacks. Washington, DC: The International Bank for Reconstruction and Development/The World Bank. 2003. siteresources.worldbank.org/INTETC/Resources/375990…/2850-Ch05.pdf
