This week, we will examine a case study about smokers in Poland. As noted in the Center for Global Development and Jassem, Przewozniak, & Zatonski (2014), prior to 1989, Poland had the highest rate of

This week, we will examine a case study about smokers in Poland. As noted in the Center for Global Development and Jassem, Przewozniak, & Zatonski (2014), prior to 1989, Poland had the highest rate of
Curbing TobaCCo use in Poland O nly two major causes of death are growing worldwide: AIDS and tobacco. While the course of the AIDS epidemic is uncertain, one can be more sure that current smoking pat – terns will kill about 1 billion people this century, 10 times more than the deaths from tobacco in the 20th century. 1 Much of this burden will fall on poor countries and the poorest people living there. While smoking rates have fall – en in rich countries over the past two decades, smoking is on the rise in developing countries. 2 Currently, more than three quarters of the world’s 1.2 billion smokers live in low- and middle-income countries, and smoking-related deaths are estimated to double in number by 2030. As Poland’s story shows, there is reason to hope that concerted efforts to tackle the growing smoking prob – lem in low- and middle-income countries can succeed. In many instances, this will likely take a very high level of political commitment—enough to counter the sig – nificant economic influence of the tobacco industry—as well as state-of-the-art communication strategies to induce major shifts in attitudes toward smoking. Lighting Up: Dangers of Tobacco Smoking causes an astonishingly long list of diseases, leading to premature death in half of all smokers. To – bacco is implicated in numerous cancers including blad – der, kidney, larynx, mouth, pancreas, and stomach. Lung Case 14 Curbing Tobacco Use in Poland Geographic area: Poland Health condition: in the 980s, Poland had the highest rate of smoking in the world. nearly three quarters of Polish men aged 20 to 60 smoked every day. in 990, the probability that a 5-year-old boy born in Po – land would reach his 60th birthday was lower than in most countries, and middle-aged Polish men had one of the highest rates of lung cancer in the world. Global importance of the health condition today: Tobacco is the second deadliest threat to adult health in the world and causes in every 0 adult deaths. it is estimated that 500 million people alive today will die prematurely because of tobacco consumption. More than three qua rters of the world’s .2 billion smokers live in low- and middle-income countries, where smoking is on the rise. by 2030, it is estimated that smoking-related deaths will have doubled, accounting for the deaths of 6 in 0 people. Intervention or program: in 995, the Polish parliament passed groundbreaking tobacco-control legisla – tion, which included the requirement of the largest health warnings on cigarette packs in the world, a ban on smoking in health centers and enclosed workspaces, a ban on electronic media advertising, and a ban on tobacco sales to minors. Health education campaigns and the “great Polish smoke-out” have also raised awareness about the dangers of smoking and have encouraged Poles to quit. Impact: Cigarette consumption dropped 0 percent between 990 and 998, and the number of smokers declined from 4 million in the 980s to under 0 million at the end of the 990s. The reduction in smok – ing led to 0,000 fewer deaths each year, a 30 percent decline in lung cancer among men aged 20 to 44, a nearly 7 percent decline in cardiovascular disease, and a reduction in low birth weight. Case drafted by Molly Kinder. 2 Curbing Toba CCo use in Poland cancer is the most common disease caused by smoking, and overall, smoking is responsible for about one half of all cancer deaths. 3 Smoking is also a major cause of car – diovascular diseases, including strokes and heart attacks, and of respiratory diseases such as emphysema. Addi – tional health threats are emerging as research advances. A recent study in India found that smoking accounts for about half of the country’s tuberculosis deaths and may well be increasing the spread of infectious tuberculosis. 4 Cigarette smoking takes a heavy toll not only on smok – ers but also on those around them, particularly young children. Passive smoking (inhaling smoke in the sur – rounding air) contributes to respiratory illnesses among children including ear infections, asthma attacks, sinus infections, and throat inflammations. Tobacco use in and around pregnant women can contribute to sudden infant death syndrome, low birth weight, and intrauter – ine growth retardation. 5 Smoking places an economic burden on individuals, families, and societies chiefly because of its massive death and disability toll and also because of the high cost of treatment, the value of lost wages, and the diver – sion of income from other basic needs such as children’s food. 6 Because the poor are more likely to smoke than their rich neighbors, the economic and health impact of smoking disproportionately burdens the poor. In Poland, most of the gap in risk of dying early between uneducated and educated men is due to smoking. 7 Furthermore, because cigarettes claim the lives of half of their users, often during their prime years, smoking robs countries of valuable labor and strains health systems. Curbing Tobacco Use Compared with controlling other health scourges, stopping the deadly effects of smoking requires chang – ing personal behavior rather than undergoing complex medical procedures. Preventing smoking-related cancer and respiratory disease simply requires that smokers quit smoking and that fewer people light up their first cigarette. Because most tobacco deaths over the next few decades will occur among today’s smokers, getting adults to quit is a special priority. 2,8 However, despite the clear health and economic benefits, quitting is extremely difficult. In addition to having to combat the addictive nature of nicotine, those seeking to reduce cigarette consumption are stymied by the fact that smoking is an ingrained social norm whose popu – larity is sustained through billions of dollars worth of cigarette advertising (which in the United States alone totaled over $11 billion in 2001). 9 Moreover, many smokers in developing countries are unaware of the link between smoking and health—just as was the case in the United States and other industrialized countries before the mid-1960s. In China, for example, a survey discov – ered that more than half of Chinese smokers and non – smokers thought that smoking did “little or no harm.” 10 Although changing the behavior of smokers is daunt – ing, it can be done—and it has been done. Governments and civil society can implement proven and highly cost-effective interventions to control tobacco use. Governments have at their disposal a range of legislative measures that can limit the supply of cigarettes and pro – mote nonsmoking behavior, including increasing taxes on tobacco products; limiting tobacco advertising and promotion; limiting the harmful ingredients in tobacco products; requiring health warnings on products and advertisements; and establishing “nonsmoking” ar – eas. 2,8,10 Both the government and civil society can work to educate the public about the negative health effects of smoking. Implementation of such interventions requires high lev – els of political commitment, as well as the determination and energy of civil society and antitobacco advocates to counter commercial interests. Tobacco companies are well financed and have played a key role in thwarting progress in tobacco control internationally. 11 Poland: Highest Cigarette Consumption in the World Before the fall of the Berlin Wall in 1989, Poland had the highest cigarette consumption in the world. In the late 1970s, the average Pole smoked more than 3,500 cigarettes each year. Nearly three quarters of Polish men aged 20 to 60 smoked every day, and by 1982, 30 percent of adult women smoked regularly. 12,13 The impact on the health of Poles was staggering. In 1990, the probability that a 15-year-old boy born in Poland would reach his 60th birthday was lower than Curbing TobaCCo use in Poland 3 most countries in the world—even India and China. Half of these early deaths were attributable to tobacco consumption. 12 Middle-aged Polish men had one of the highest rates of lung cancer in the world—higher than every European country except for Hungary—and other smoking-related illnesses, such as laryngeal and oral cancer, were at all-time high levels. It is estimated that 42 percent of cardiovascular deaths and 71 percent of respiratory disease in middle-aged men were due to smoking. Few Poles were quitting, largely because of the politi – cal and social climate of the time. Because the state-run tobacco production was a significant source of revenue, the government—which controlled information—did not fully disclose the negative consequences of smoking. As a result, Polish smokers were less informed about the dangers of smoking than most of their European neighbors. In addition, tobacco-control laws were rarely enforced, and stronger tobacco-control legislation intro – duced in the early 1980s was rejected by the government because it was seen as a threat to government revenue during an economic downturn. The dramatic social, economic, and political changes ushered into Poland after the fall of communism ini – tially exacerbated Poland’s addiction to tobacco. When a market economy replaced the state-run system in 1988 and 1989, the tobacco industry was one of the first to be privatized—opening the country to the powerful influence of multinational corporations. In less than a decade, multinationals had taken over more than 90 percent of Poland’s lucrative tobacco industry. Suddenly, cigarettes in Poland were available in abundant sup – ply and in more tempting variety. International brands flooded the market, along with popular new domestic brands like Solidarnosc and Lady Di. Adding to their appeal, cigarettes were also cheap, less than the price of a loaf of bread—thanks to deals made between the corpo – rations and the Polish government that kept prices down during the first half of the 1990s. At the same time, democratic changes sweeping the country brought with them a potent force: savvy and state-of-the-art marketing. Tobacco companies poured more than $100 million into Poland, making the to – bacco industry the largest advertiser in the country. The industry aggressively set out to increase consumption by 10 percent a year. As a result, smoking rates in the early 1990s climbed steadily, particularly among children aged 11 to 15. 12 Roots of the Tobacco-Control Movement As the tobacco epidemic was escalating in the early 1990s, historic changes in Poland set in motion powerful influences that helped amplify antitobacco voices. Poland’s scientific community laid the foundation of the antitobacco movement when they first established the in-country scientific evidence illustrating the devastat – ing health impact of smoking. Research conducted in the 1980s by the Marie Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology contributed to the first Polish report on the health impact of smok – ing, highlighting in particular the link between smoking and the escalating cancer outbreak in Poland. The body of evidence about the harmful effects of smoking and the need for tobacco-control legislation were further strengthened through a series of international work – shops and scientific conferences held in Poland. With solid evidence now in hand, Poland’s budding civil society took up the call for tobacco-control measures. Health advocates in Poland were first brought together around the antismoking cause in the 1980s as civil society was experiencing a renewal. During this time, antitobacco groups such as the Polish Anti-Tobacco So – ciety formed and began to interact with the WHO, the International Union Against Cancer, and other interna – tional groups. Later in the new political milieu, when nongovernmen – tal organizations (NGOs) could freely form, Poland’s civil society had an even stronger voice. In 1990, Poland hosted “A Tobacco-Free New Europe” conference of western and eastern European health advocates, which resulted in a set of policy recommendations that would later prove instrumental in shaping Poland’s own anti – tobacco laws. Finally, the Health Promotion Foundation was established to lead health promotion and antito – bacco education efforts. The free media was essential to the success of the ad – vocates’ movement to control tobacco use. In the new 4 Curbing Toba CCo use in Poland democratic era, the Polish press could cover health issues, including the reporting of scientific studies illustrating the health consequences of smoking. The dissemination of this information raised awareness about the dangers of smoking and shaped public opin – ion about tobacco-control legislation. It also provided a venue for health advocates to broadcast special adver – tisements with health messages, such as how to take the steps to quit smoking. Finally, democracy provided a window for the most powerful tool in the fight against smoking: tobacco- control legislation. The Smoke Clears: Implementing Tobacco-Control Measures In 1991, legislation was brought to the Polish Senate, which introduced a comprehensive set of tobacco-con – trol measures based on the recommendations from the 1990 international conference and the WHO. The mo – tion faced intense opposition from tobacco companies, sparking a heated public debate that lasted several years. Advocates consistently defended the bill by reiterat – ing the scientific evidence of the public health threat of smoking, while the powerful tobacco lobbies countered by emphasizing their right to advertise freely and the potential threat to Poland’s economy. The tobacco lob – bies poured an unprecedented amount of money into fighting the legislation, wielding a force as a special interest never before seen in Poland. Media coverage of the debates helped shape public opinion, which eventu – ally swayed toward the health advocates—the “David” against the “Goliath” tobacco lobby. In November 1995, the Polish parliament passed the “Law for the Protection of Public Health Against the Ef – fects of Tobacco Use” with a huge majority of 90 percent of the votes. The groundbreaking legislation included: A ban on smoking and the sale of cigarettes in health care centers, schools, and enclosed workspaces A ban on the sale of tobacco products to minors under 18 years of age A ban on the production and marketing of smoke – less tobacco • • • A ban on electronic media advertising (includ – ing radio and television) and restrictions on other media The printing of health warnings on all cigarette packs to occupy 30 percent of at least two of the largest sides of the packs—the largest health warn – ings on cigarette packs in the world at that time Free provision of treatment for smoking dependence The sweeping legislation has served as a model for other countries. The European Union followed the Polish precedent in 2003 and required similar health warn – ings on all cigarette packs. In 1999 and 2000, the tax on cigarettes increased 30 percent each year, and a total ban on advertising was passed in 1999. a In just a few years, Poland had transformed from one of the least favorable climates in Europe for tobacco controls to one of the most favorable. According to legislation, Poland is required to dedicate 0.5 percent of all tobacco taxes to funding prevention programs. In practice, the tobacco-control movement has not received the full 0.5 percent allocation and con – tinues to lobby the government for increased funds for prevention programs. However, one recipient of tobacco tax revenue, the Health Promotion Foundation, has led health education and consumer awareness efforts with a profound impact on smoking patterns in Poland. Since the early 1990s, the foundation has launched an an – nual campaign each November called the “Great Polish Smoke-Out” to encourage smokers to quit. For a time, the smoke-out, the largest public health campaign in Poland, included a competition that invites Poles who have quit smoking in the past year to send a postcard for the chance to win a week-long stay in Rome and a private audience with the Polish-born Pope John Paul II. The campaign attracted extensive media attention and uses television, radio, and print media to spread the core messages of how and why to quit. Throughout the year, health education promoted by schools, the Catho – lic Church, and local civic groups has reinforced the campaign’s messages. a The impact of these additional measures is not captured in this chapter. • • • Curbing TobaCCo use in Poland 5 The campaign is popular, and 80 to 90 percent of Poles have heard of it. Each year, between 200,000 and 400,000 Poles credit the campaign with their successful quitting. Since the first smoke-out in 1991, more than 2.5 million Poles have permanently snuffed their cigarettes because of the campaign. Because raising tobacco taxes has long been recognized as one of the most effective tobacco-control policy interventions, health promotion foundations like the one in Poland are becoming more common around the globe. Increasing the price of cigarettes not only keeps many from starting to smoke, but tobacco taxes can also be a source of sustained funding for tobacco control and other health promotion activities. Health promo – tion foundations financed by these taxes are not limited to supporting tobacco control: funds can also be used to subsidize treatment for HIV/AIDS, tuberculosis, or malaria; to conduct wider disease prevention and in – formation campaigns; and to provide opportunities for training or other capacity building for health profession – als that are otherwise unavailable. Tobacco Consumption and Cancer Rates Plummet Because of the extensive tobacco controls and the health education efforts, far fewer Poles now smoke. Cigarette consumption dropped 10 percent between 1990 and 1998. In the 1970s and 1980s, Poland had an estimated 14 million smokers, including 62 percent of adult men and 30 percent of adult women. By the end of the 1990s, this figure had dropped to less than 10 million Polish smokers, with 40 percent of adult men and 20 percent of adult women smoking. The decline in tobacco use has led to a corresponding improvement of health in Poland. The total mortality rate in Poland, taking into account all causes of death, fell by 10 percent during the 1990s. The decline in smoking is credited for 30 percent of this reduction in deaths, translating into 10,000 fewer deaths each year. At the end of the 1990s, lung cancer rates in men aged 20 to 44 had dropped 30 percent from their peak levels just a decade earlier and fell 19 percent in middle-aged men between 45 and 64 years (see Figure 14–1). Decreased smoking rates have contributed to one third of the 20 percent decline in cardiovascular diseases since 1991. Infant mortality has fallen as well, and the percentage of babies born with low birth weight has dropped from over 8 percent in 1980 to less than 6 percent a decade later. About one third of this reduced risk stems from decreased smoking among pregnant women. In total, life expectancy during the 1990s in Poland increased by four years for men and more than three years for women. 13 Comparing the path of Poland with its neighbor Hun – gary, a country that did not implement tobacco-control measures, further illustrates the dramatic impact of Poland’s efforts. In the 1980s, before Poland initiated controls and health awareness campaigns, lung cancer rates in the two countries were roughly equivalent. Throughout the 1990s, lung cancer rates in Hungary continued to climb, at the same time that they were falling by one third in Poland; today rates in Hungary have peaked at their highest levels ever for young and middle-aged residents. Figure 14–1 Standardized mortality rates among Polish males, 1959–1999. Source : Zatonski W, personal communication, July 2, 2004. Aged 20 to 44 0 1 2 3 4 5 6 7 8 195919611963196519671969197119731975197719791981198319851987198919911993199519971999 Deaths per 10,000 Deaths per 10,00 0 Aged 45 to 64 0 50 100 150 200 250 195919611963196519671969197119731975197719791981198319851987198919911993199519971999 6 Curbing Toba CCo use in Poland Box 14–1 South Africa’s Story until the 990s, south africa’s tobacco industry—controlled almost entirely by one company—exerted im – mense power and operated virtually untouched by government restrictions or taxes. The tobacco industry was seen as a major source of government revenue, taxes, jobs, and advertising dollars. The dominant tobacco company, rembrandt, was established in 948, when the national Party came to power, and was seen as a symbol of afrikaaner success in business—and therefore beyond question in policy debates about tobacco. With strong ties to the media and the apartheid government, nothing stood in its way. When the african national Congress came to power in 994, the antismoking movement gained a valu – able ally in incoming President nelson Mandela. Mandela had made his strong antismoking stance known during World Tobacco day in 992 and through his call for a “world free of tobacco.” unlike the previous afrikaaner government, Mandela’s african national Congress party had no ties to the tobacco industry and placed a much higher priority on health care for all. The first health minister of the new government, nkosa – zana Zuma, was an ardent supporter of the tobacco-control cause and fearlessly pursued the tobacco con – trol that her predecessor rita Venter had begun, despite intense opposition from the industry. even before assuming office as the minister of health in 994, she committed the african national Congress to take a leadership role when she addressed the first all-africa Tobacco Control Conference in Harare in 993. despite the influence of the tobacco industry, public health researchers worked tirelessly to bring atten – tion to the dangers of smoking: Professor Harry sefterl’s work from the 970s stimulated many to recog – nize that unless action was taken, south africa faced pending chronic disease epidemics. derek Yach, a researcher who had established evidence on the economic and health impacts of smoking, collaborated in the mid-980s with local civic groups such as the Tobacco action group and international partners to promote tobacco-control efforts. The first major victory for the antitobacco movement occurred in 995 with the passage of the Tobacco Products Control act. The act introduced health warnings, banned smoking on public transportation, and established restrictions on youth under 6 purchasing cigarettes. although relatively mild in reach, the legislation was an important milestone because it was the first schism between the government and the tobacco industry. The tobacco-control policies implemented in the second half of the 990s were bolstered by research at the university of Cape Town, which established the rationale and evidence base for increased taxes on smoking, considered by the group’s researchers to be the most cost-effective and powerful way of rapidly reducing smoking. studies demonstrated that because of the sensitivity of demand for cigare ttes to changes in prices, an increase in prices would cause a decline in consumption and at the s ame time increase tax revenue. Health advocates argued that a tax increase of 50 percent—in t heir view necessary because the real value of taxes had fallen 70 percent between 970 and 990—would lead to 400,000 fewer smokers and an increase in tax revenue of approximately $92 million. 14,15 in 997, taxes on cigarettes were increased by 52 percent, to reach 50 percent of the value of the retail price of cigarettes. between 993 and 200, the real value of cigarette taxes increased by 25 percent. (continued on next page) Curbing TobaCCo use in Poland 7 Strengthening Tobacco Controls Worldwide Both South Africa (Box 14–1) and Poland share a com – mon lesson in battling tobacco. Once smoking is seen for what it is—the leading cause of preventable deaths among adults worldwide—then governments do act. They do so with a set of tools that are powerful, cost- effective, and save millions of lives. Importantly, the national experiences of Poland and South Africa have not remained confined to the two countries. The leadership created in South Africa about tobacco control was strengthened into global leader – ship during five years of negotiations, which led to the world’s first treaty for public health, the Framework Convention on Tobacco Control. The South African negotiating team played a decisive role in ensuring that the most effective text was accepted first by African countries—and that no watering down could be toler – ated—and later by all 192 governments that adopted it in May 2003. In May 2003, all of WHO’s member states unanimously adopted the convention, indicating their commitment to stronger efforts to reduce tobacco use through many of the same interventions that proved successful in Poland and South Africa: health education, tobacco-control legislation, cigarette taxes, warnings on cigarette packs, restrictions on smoking in public places, and bans on all cigarette advertising and promotion. By the end of 2006, more than 130 countries had ratified the treaty and were beginning to implement it. Although still in its early days, the treaty has played an important role in changing the way that most governments approach tobacco use. References Peto R, Lopez AD. The future worldwide health effects of current smoking patterns. In: Koop EC, Pearson CE, Schwarz RM, eds. Global Health in the 21st Century. New York, NY: Jossey-Bass; 2000. Jha P, Chaloupka F. The economics of global to – bacco control. BMJ. 2000;321:358–361. Peto R, Lopez A, Boreham J, Thun M, Heath C Jr. Mortality from tobacco in developed countries: in – direct estimates from national vital statistics. Lancet. 1992;339:1268–1278. Gajalakshmi V, Peto R, Kanaka TS, Jha P. Smok – ing mortality from tuberculosis and other diseases in India: retrospective study of 43,000 adult male deaths and 35,000 controls. Lancet. 2003;363:507– 515. 1. 2. 3. 4. in 999, the Tobacco Products Control amendment bill was passed, outlawing smoking in enclosed public places, banning tobacco advertising and sponsorship, and requiring explicit health warnings on all ciga – rette packs. The results of the price increases and control measures have been striking. Cigarette consumption fell from .9 billion packs in 99 to .3 billion in 2002—a decline of more than 30 percent, peaking after the 997 tax increases. The sharpest drops have been among youth and the poor, two groups that are most sensitive to changes in price. smoking prevalence among youth has dropped from 24 percent in 993 to 9 percent in 2000. at the same time that consumption dropped, tax revenues in south africa doubled since 994. Yach has credited the mix of basic science and political commitment with the passage of one of the world’s most far-reaching tobacco-control policies. “You need the right combination of science, evidence, and politics to succeed,” he explained. “if you have one without the other, you don’t see action.” 16 Box 14–1 South Africa’s Story (continued) 8 Curbing Toba CCo use in Poland Gajalakshmi CK, Jha P, Ranson L, Nguyen S. Global patterns of smoking and smoking-attributable mor – tality patterns. In: Jha P, Chaloupka FJ, eds. Tobacco Control in Developing Countries. Oxford, England: Oxford University Press; 2000. Bonu S, Rani M, Nguyen S, Jha P. Household to – bacco and alcohol consumption and child health in India. Health Policy. In press. Bobak M, Jha P, Nguyen S. Poverty and smoking. In: Jha P, Chaloupka FJ, eds. Tobacco Control in Devel – oping Countries. Oxford, England: Oxford Univer – sity Press; 2000. Jha P, Chaloupka F. Curbing the Epidemic: Govern – ments and the Economics of Tobacco Control. Wash – ington, DC: World Bank; 1999. Federal Trade Commission. Cigarette Report for 2001. Washington, DC: Federal Trade Commission; 2003. Jha P, Chaloupka F, eds. Tobacco Control in Develop – ing Countries. Oxford, England: Oxford University Press; 2000. Yach D, Hawkes C, Gould L, Hofman K. The global burden of chronic diseases: overcoming impediments to prevention and control. JAMA. 2004;291:2616–2622. 5. 6. 7. 8. 9. 10. 11. Zatonski W. Evolution of Health in Poland Since 1988. Warsaw, Poland: Marie Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Department of Epidemiology and Cancer Preven – tion; 1998. Zatonski W, Harville E. Tobacco control in Poland. Eurohealth. 2000;6(2):13–15. Abedian I, van der Merwe R, Wilkins N, Jha P, eds. The Economics of Tobacco Control: Towards an Op – timal Policy Mix. Cape Town, South Africa: Univer – sity of Cape Town; 1998. Van Walbeek C. The tobacco epidemic can be reversed: tobacco control in South Africa during the 1990s. Available at: http://archive.idrc.ca/ritc/ SA-finalreport.pdf. Accessed January 12, 2007. Malan M, Leaver R. Political change in South Af – rica: new tobacco control and public health policies. In: de Beyer J, Brigden LW, eds. Tobacco Control Policy: Strategy, Success, and Setbacks. Washington, DC: World Bank and International Development Research Center; 2003. 12. 13. 14. 15. 16.
This week, we will examine a case study about smokers in Poland. As noted in the Center for Global Development and Jassem, Przewozniak, & Zatonski (2014), prior to 1989, Poland had the highest rate of
Transl Lung Cancer Res 2014;3(5):280-285 In the 20 th century, tobacco smoking was the leading health burden and the major cause of death in the world. It is estimated that around 100 million people died from smoking-attributed diseases at that time (1). The epidemic of cigarette smoking in the past century was mostly continued in developed countries. Recent estimates show that currently 1.2 billion people use tobacco worldwide, mostly in developing countries. Based on current trends in tobacco exposure, 8 million people will die every year by 2030 from different forms of tobacco (2). Since the 1960s, smoking rates and its health consequences have gradually decreased in rich countries and have rapidly increased in developing countries, including the region of Central and Eastern Europe (3). Poland, being at the time part of the communist bloc, was among countries with particularly high tobacco consumption. In the mid-1970s and early 1980s, 65% to 75% of Polish men aged 20 to 60 smoked cigarettes every day (4). In consequence, Poland faced a catastrophically high level of premature mortality among young and middle-aged adults. By 1990, over 40% of Polish men died prematurely from smoking-attributed diseases (5). The health impact of smoking, including cancer, was particularly high in poor and uneducated groups of society (6). At that time, effective tobacco-control measures, such as increasing taxes on tobacco products, ban on tobacco advertising and promotion, health warnings on tobacco products and advertisements, as well as establishing “non-smoking” areas, were already well known in Europe and worldwide. However, Poland was one of the largest tobacco producers in Europe, and this state- run industry was a source of high revenues (7). Hence, in view of the difficult economic situation of the country, the government did not undertake any real tobacco-control legislative measures, and sparse tobacco-control regulations were ineffective because of a lack of their enforcement. After the fall of the communist system [1989-1990] and the introduction of a market economy, the tobacco industry in Poland was extensively privatized and in over 90% of cases became the property of multinational corporations. In view of the dramatic decline in the prevalence of smoking in North America, Poland, along with other Eastern European countries, became a fertile field for future growth and a strategic target of the international tobacco companies. In 1990, it was planned to increase cigarette sale in Poland by 10-20% by 2000 (8). In the first half of 1990, new attractive Review Article Tobacco control in Poland—successes and challenges Jacek Jassem 1, Krzysztof Przewo ź niak 2, Witold Zato ń ski 2 1Department of Oncology and Radiotherapy, Medical University of Gda ń sk, Gda ń sk, Poland; 2Department of Cancer Epidemiology and Prevention, Maria Skłodowska-Curie Cancer Center and Institute of Oncology, Warsaw, Poland Correspondence to: Jacek Jassem, MD, PhD. Department of Oncology and Radiotherapy, Medical University of Gda ń sk, 7 D ę binki St., 80-211 Gda ń sk, Poland. Email [email protected]. Abstract: For many years, tobacco smoking was the major single avoidable cause of premature mortality in Poland. In the 1970s and 1980s, Poland was a country with an extremel y high prevalence of smoking and lung cancer mortality among men in the world. By 1990, over 40% of Polis h men died prematurely from smoking-attributed diseases. However, the enforcement of comprehensive tobacco-control measures and programs based on the World Health Organization recommendations and the best practices from other countries, contributed to a spectacular decrease of smoking incidence, particularly in men. This led to dramatic decrease in lung cancer incidence and mortality, and to a substantial improvement in public health in Poland. This article reviews the achievements of tobacco-control in Poland over the past decades and points out current challenges in this field. Keywords: Tobacco control; Poland; successes and challenges Submitted Sep 12, 2014. Accepted for publication Sep 28, 2014. doi: 10.3978/j.issn.2218-6751.2014.09.12 View this article at: http://dx.doi.org/10.3978/j.issn.2218-6751.2014.09.12 Translational lung cancer research. All rights reserved. www.tlcr.org 281 Translational lung cancer research, Vol 3, No 5 October 2014 Transl Lung Cancer Res 2014;3(5):280-285 cigarette brands became easily available and were relatively cheap due to government concessions to multinational companies by keeping tobacco taxes low for several years. Tobacco companies introduced aggressive advertising of their products in the private media, especially on billboards and in the press (television advertising was already banned at that time). In consequence, smoking rates increased steadily, particularly among children and adolescents. According to data of the World Health Organization (WHO) and the Polish Central Statistical Office, Poland reached an average cigarette consumption of over 3,600 cigarettes per adult person per year, thus zooming from 11th place in 1972 to the first in the world in 1992 (9). Heavy smoking was taking a deadly toll in high rates of lung cancer and cardiovascular diseases. The estimated number of deaths in Poland caused by tobacco smoking in 2000 reached approximately 69,000, of which 43,000 occurred prematurely i.e., between the ages of 35 -69 (5). Around 43% of all deaths in males aged 35- 69 were caused by smoking; middle aged adult smokers lost nearly 22 years of life and smokers aged 70 and older lost an average of 8 years of life (5). Lung cancer killed half of all Polish men who died before reaching 65 (6). Fortunately, democratic changes in the 1980s resulted in a more open society and a movement towards the rapid development of civil society. This led to the creation of health-focused non-government organizations (NGOs), such as the Health Promotion Foundation and the Polish Anti-Tobacco Society, which emphasized the devastating effects of smoking and the need for comprehensive tobacco- control legislation. These organizations, supported by health professionals, the free media, and local communities, were very instrumental in large-scale counter-tobacco promotion and educational activities. Examples of such nationwide actions included an annual campaign entitled “Let’s Stop Smoking Together” that has been based on the Great American Smoke-Out and aimed at convincing as many smokers as possible to make a serious attempt to quit smoking. This population-based smoking cessation program included social and media campaigns, professional and community-based support for smokers, and a competition that motivated smokers to quit smoking and, as an award, to take part in a one-week trip to Rome, including a private audience with Pope John Paul II (8,10). Between 1992 and 2006, almost half a million Polish smokers took part in the contest. Nation-wide surveys estimated that over 4 million smokers decided to give up smoking between 1992 to 2008 as a result of the Great Smoke-Out campaign (11). Medical doctors and health institutes were particularly active in building capacity for tobacco-control in Poland. The first smoking cessation clinics were established in the 1980s. The Polish Quitline, that was based on the best practices taken from the UK Quit ® and Norwegian Quitline, was established in 1996 and was first in Central and Eastern Europe. In 2002, the Supreme Medical Council announced the “Declaration on Counteracting Nicotine Dependence” calling for the intensification of tobacco-control activities in the Polish medical community by creating health-conscious attitudes and rising health awareness in society (12). A few years later, several medical associations signed the Consensus on the Diagnostics and Treatment of Tobacco Dependence—a key guideline on smoking cessation addressed to all health professionals in Poland (13). In the meantime, separate guidelines have been published by general practitioners, cardiologists, oncologists and chest physicians, and over 10,000 physicians and nurses have been trained in methods of smoking cessation. Polish medical and scientific societies in cooperation with the WHO, the International Union Against Cancer (UICC), the American Cancer Society (ACS) and other international organizations and institutions launched several scientific studies on tobacco control in Poland and organized a series of large workshops and scientific conferences on tobacco and health. All these activities raised public awareness of tobacco-related dangers and proved to be truly effective. It has been estimated that the number of daily smokers diminished from 14 million in 1982 to 9 million in 2010 (11). The most successful tobacco-control activity undertaken in the past 25 years in Poland, however, was the enforcement of comprehensive legislative measures in this field (8). In November 1990, very soon after democracy came to Poland, a working group at the Institute of Oncology in Warsaw invited the WHO, UICC, ACS, public health leaders and tobacco-control advocates from Western and Eastern Europe to Kazimierz in Poland in order to discuss and prepare a long-term strategy for “A New Tobacco Free Europe”. The Kazimierz Declaration was a milestone for the enforcement of tobacco-control legislation in Central and Eastern Europe including Poland, and one of the few public health resolutions that have been fully implemented. A few years later, the same group of Polish tobacco-control advocates developed policy recommendations and prepared a draft of a tobacco control bill in Poland. The bill, based on the WHO gold standard, included a comprehensive set of provisions for reducing the tobacco epidemic in Poland. This initiative faced a furious counteraction from the powerful and well organized tobacco lobbies, who questioned the impact of Translational lung cancer research. All rights reserved. www.tlcr.org 282Jassem et al. Tobacco control in Poland Transl Lung Cancer Res 2014;3(5):280-285 an advertising ban, health warnings, economic regulations and public health education. They also emphasized the right to free advertising and the potential adverse impact on the Polish economy. Meanwhile, however, Polish public attitudes on this matter have turned to smoke-free solutions, and political parties took notice. The members of the Sejm (the lower house of the Polish Parliament), including around 40 medical doctors, were encouraged to vote for the Tobacco-Control Bill. As a result, in November 1995, the Polish Parliament with an overwhelming majority from all political parties, passed new tobacco-control legislation, the toughest in any of the former communist countries of Eastern Europe. Its main provisions and subsequent amendments in 1999 and 2002 included: • A ban on smoking and the sale of cigarettes in health care centers, schools and enclosed workplaces; • A ban on the sale of tobacco to minors (under 18) and by vending machines; • A ban on electronic media advertising, including radio and television (in 1999 extended to all media); • A ban of tobacco promotion and sponsorship; • 30% textual health warnings on cigarette packs (one of the largest in the world at that time); • Free provision of treatment for smoking dependence; • The gradual reduction of tar, nicotine and carbon monoxide according to the European Union (EU) standards; • Developing the government program aimed at reducing health and socio-economic consequences of smoking in Poland; • Establishing a tobacco-control fund comprising of a levy of 0.5% from the excise tobacco tax for the abovementioned program (however, actual funds transferred annually for tobacco-control were substantially lower). Furious attempts by the tobacco lobby to block the new legislation, in particular to thwart the introduction of the ban on tobacco advertising and promotion and the placement of large health warnings on cigarette packs, failed (8). These regulations made Poland a country with a most favorable climate for tobacco-control and a model for other countries. The WHO welcomed it as “an example for the rest of the world” (14) and the World Bank praised it as a “courageous” move (15). This Polish legislation became the best practice for new members of the EU, and the provision on large health warnings on cigarette packs were proposed to be enacted by the European Parliament for all EU countries. The next challenge for tobacco-control in Poland was to reduce exposure to tobacco smoke in public places and worksites. This issue was addressed in the Framework Convention on Tobacco Control (FCTC) developed in 2003 by WHO and ratified by Poland in 2006 (16). The FCTC (Poland was one of its initiators) was the first convention of the United Nations regarding public health. This document became a guidepost for global, regional, and national health policies and was ratified by the European Parliament in 2005. In 2007, the European Commission developed a strategy for reducing smoking in public places and workplaces (17) and, in 2009, the European Parliament issued a respective resolution. By that time, the ban on smoking in public places had already been introduced in some EU countries (for example, Ireland and England) and in Norway. Yet, the road to smoke-free Poland was again winding. The first draft of the legislation that banned smoking in public places was developed again by the medical community and first presented publicly in April 2006. A few months later, the new legislation was formally submitted to the Parliament as a project of the Parliamentary Health Commission. As expected, this sparked a vivid debate within the country, heated by the tobacco lobby. This time it was argued that the legislation was too strict and would limit civic freedom. Tobacco lobbyists and some parliamentarians warned that the new regulations would lower revenues from tobacco taxes, and cause bankruptcies and the scrapping of jobs on a large scale, especially in hospitality industry. Despite this, a Polish Radio survey conducted in 2006 showed that 77% of Poles supported the complete ban on smoking in all public places, and similar results were obtained in subsequent surveys performed in 2007 and 2008. Finally, after numerous discussions and modifications, the ban and other tobacco-control measures were enacted in April 2010 and came into effect six months later. With that, Poland joined ten other Europeans countries which enforced by that time a smoke-free policy in their countries. The new legislation foresaw a smoking ban in all workplaces, hospitals and other outpatient clinics and premises for patients, all educational premises, all means of public transport, bars and restaurants, public cultural and leisure venues, bus, tram, and train stops and children’s playgrounds. However, according to the obtained political compromise, owners of venues in the hospitality sector, retirement homes, airports and universities might build (but were not obliged) special tightly sealed and ventilated smoking rooms. These regulations contributed to substantial changes in smoking behaviors and exposure to tobacco smoke in Poland. In a public survey conducted by the Cancer Center and Institute in Warsaw, in collaboration Translational lung cancer research. All rights reserved. www.tlcr.org 283 Translational lung cancer research, Vol 3, No 5 October 2014 Transl Lung Cancer Res 2014;3(5):280-285 with TNS Poland one year after enacting the ban, over 1 million Polish smokers had made a serious attempt to quit smoking or had quit smoking for good. Results of nation- wide surveys, conducted by the Chief Sanitary Inspectorate and TNS Poland in 2009 and 2013, showed that exposure of smokers to tobacco smoke in workplaces dropped from 41% to 8% and that of non-smokers from 19% to 6%. Additionally, Poles declared a substantial decline in smoking tobacco in the presence of children (from 53% to 23%), pregnant women (25% to 11%) and non-smokers (83% to 54%). Surveys conducted before and after the enforcement of the ban on smoking in public places and worksites also showed an increase in public support for smoke-free policies, especially in bars and restaurants. Besides the enforcement of smoke-free policies in Poland, new tobacco-control regulations included a gradual increase of tobacco excise taxes. Since the beginning of the 1990s, excise tax for cigarettes sold in Poland has increased over four times and now constitutes around two-thirds of the weighted average price, following the EU’s excise tax rules. This led to a substantial increase in tobacco prices in Poland, especially for manufactured cigarettes (18). However, cigarette prices are still low when compared to other EU countries, especially in Western Europe. Additionally, Poland’s rapidly growing economy has resulted in higher affordability of tobacco products.. Hence, increases in excise duties and prices of cigarette and other tobacco products should be steadily continued. Lasting for over two decades, legislative and other efforts to combat tobacco in Poland has paid off. According to the year books of the Central Statistical Office of Poland, the number of sold cigarettes in Poland decreased from 101 billion per year in 1995 to 47 billion in 2013. Between 1980 and 2013, the proportion of smokers among men dropped from 65% to 28% and among women from 32% to 18%. If this trend continues, the consumption of cigarettes per capita in Poland in 2040 will fall to the level of the 1920s (Figure 1). Changes in cigarette consumption and smoking behavior have contributed to a substantial improvement in the health of the Polish population. According to the National Cancer Register, age- standardized mortality rates per 100,000 from lung cancer in men declined from 71.1 in 1990 to 56.2 in 2010. The patterns of changes in lung cancer mortality among Polish men became similar to those observed two decades earlier in the Unites States (Figure 2). Between 1991 and 2005, the death rate from coronary heart disease halved in Poland, and 15% of this decrease in men was attributable to reduced smoking (19). However, considerable progress in tobacco-control in Poland has been facing challenges. In the years 2003-2012, tobacco production in Poland increased by 90%, of which around two-thirds is now exported. This places Poland third in Europe, after Germany and the Netherlands in tobacco production and sale. In consequence, Poland ceased to support EU policy restricting smoking, and does not implement consecutive FCTC regulations, such as pictorial health warnings on tobacco packs. Recently, Poland also appealed against the EU ban on flavored tobacco products. A worrying phenomenon is the persistently high proportion of smoking women. In the 35-44 age bracket, there is almost a gender parity between smokers (34% of women and 32% of men) (11). Although a similar trend has been reported elsewhere, Poland is among the countries with a particularly high prevalence of smoking women (20). In consequence, whilst the mortality rates from lung cancer among men are rapidly decreasing, they are still on the rise among women ( Figure 3). The levels of premature mortality of young and middle-aged adults remain above those in Western Europe (21). The percentage of smokers is particularly 50 45 40 35 30 25 20 15 10 5 0 2000 2003 2005 2007 2009 2011 2013 Percentage (Years) Males Females Ratio (Years) 1963 1968 1973 1978 1983 1988 1993 1998 2003 2008 Poland USA 70 60 50 40 30 20 10 0 Figure 1 Percentage of daily smokers in Poland by gender, 2000- 2013. Source: Polish nation-wide survey “Social Diagnosis 2013”. Figure 2 Standardized lung cancer mortality (ratio/100,000) in Poland and USA, men aged 35-54, 1963-2010. Source: WHO health database. Translational lung cancer research. All rights reserved. www.tlcr.org 284Jassem et al. Tobacco control in Poland Transl Lung Cancer Res 2014;3(5):280-285 high among less educated and unemployed Poles, reaching even 50% in men. While smoking traditional cigarettes is decreasing, there is a rise (including children) in the use of much cheaper, manually rolled cigarettes, water pipes (shisha) and electronic cigarettes (22,23). There is certainly still room for improvement in tobacco- control in Poland (24). The government should consistently continue a tobacco-control policy according to the FCTC regulations and the 2012 EU directive (25). In the coming years, the following tobacco-control measures should be enforced in Poland: • Raising awareness of tobacco smoking dangers through the continuous nationwide education of children and adolescents, teachers and educators; • The introduction of large pictorial health warnings on all tobacco packs and information on the harmfulness of toxic substances in cigarettes; • The introduction of plain cigarette packages; • The placement of the Quitline number on all tobacco packs; • A complete ban of tobacco advertisement in points of sale and in Internet; • A complete ban of smoking in all public facilities; • A ban on the sale of aromatic (e.g., menthol) and ‘slim’ cigarettes • A ban on the sale of smokeless tobacco, including nasal snuff, electronic cigarettes and herbal smoking products; • Stricter regulation for roll-ups prepared from loose tobacco and smuggled tobacco products. The recently developed “Strategy for Cancer Control in Poland 2015-2024” (available at http://www.walkazrakiem.pl/) includes several long-term intervention measures to reduce the incidence and impact of recognized cancer risk factors, including tobacco smoking and passive exposure to tobacco smoke. This would vastly be facilitated by continued cooperation in this field between government institutions and NGOs. Finally, government programs to limit health and socio-economic consequences of smoking tobacco should receive adequate financial support. If all abovementioned tobacco control measures are successfully enforced, Poland will join again a group of leading countries in tobacco- control, and substantially improve its indicators in public health. Acknowledgements Disclosure: The authors declare no conflict of interest. References 1. Jha P. Avoidable global cancer deaths and total deaths from smoking. Nat Rev Cancer 2009;9:655-64. 2. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2008 The MPOWER package. World Health Organization, Geneva, 2008. 3. Jha P, Chaloupka FJ. The economics of global tobacco control. BMJ 2000;321:358-61. 4. Zato ń ski W, Przewo ź niak K. eds. The Health Consequences of Tobacco Smoking in Poland. Ariel, Warsaw, 1992. 5. Peto R, Lopez AD, Boreham J, et al. Mortality from smoking in developed countries 1950-2010. 2nd edition. Oxford University, Oxford, 2012. Figure 3 Mortality from lung cancer in Poland 1963-2010 (standardized mortality ratio/100,000), men (A) and women (B), age 0+. Source: Polish National Cancer Registry; Cancer Center and Institute, Warsaw. 1963 1968 1973 1978 1983 1988 1993 1998 2003 2008 1963 1968 1973 1978 1983 1988 1993 1998 2003 2008 80 70 60 50 40 30 20 10 0 18 16 14 12 10 8 6 4 2 0A B Ratio Ratio (Years) (Years) Translational lung cancer research. All rights reserved. www.tlcr.org 285 Translational lung cancer research, Vol 3, No 5 October 2014 Transl Lung Cancer Res 2014;3(5):280-285 6. Zato ń ski W, Becker N. Atlas of Cancer Mortality in Poland 1975-1979. Springer-Verlag, Berlin, 1988. 7. Zato ń ski W, Harville E. Tobacco control in Poland. Eurohealth 2000;6:13-5. 8. Zato ń ski W. Democracy and Health: Tobacco Control in Poland. In: de Beyer J, Brigden LW. eds. Tobacco Control Policy: Strategies, Successes and Setbacks. The World Bank and the International Development Research Center, Washington, 2003:97-120. 9. World Health Organization. The Current Status of the Tobacco Epidemic in Poland. WHO Regional Office for Europe, Copenhagen, 2009. 10. Jaworski J, Linke D, Przewozniak K, et al. Prevention of tobacco-related diseases – national health campaigns. In: Zatonski W, Przewozniak K. eds. Tobacco-smoking in Poland: attitudes, health consequences and prevention. Part III, Chapter 1. Cancer Center and Institute, Warsaw, 1999:275-88. 11. Ministry of Health of Poland: Global Adult Tobacco Survey. Poland 2009–2010. Warsaw: Ministry of Health, 2010. Available online: http://www.who.int/tobacco/ surveillance/en_tfi_gats_poland_report_2010.pdf 12. Radziwiłł K. Jak pomóc pa lą cemu pacjentowi? Gazeta Lek 2002;11:20-1. 13. Zatonski W. eds. Consensus on the diagnostics and treatment of tobacco dependence. Update 2008. Gazeta Lek 2008;12:1-16. 14. Blanke DD, de Costa e Silva V. Tools for advancing tobacco control in the 21st century. Tobacco control legislation: An introductory guide. World Health Organization, Geneva, 2004. 15. World Bank. Development in practice. Curbing the epidemic. Governments and the economics of tobacco control. World Bank, Washington, 1999. 16. World Health Organization. The Framework Convention on Tobacco Control. World Health Organization, Geneva, 2003. 17. European Commission. Green Paper. Towards a Europe free from tobacco smoke: policy options at EU levels. COM (2007) 27 final. Directorate-General Health and Consumer Protection, Brussels, 2007. 18. Czart-Ciecierski C, Cherukupalli R, Weresa MA. The Economics of Tobacco and Tobacco Taxation in Poland. International Union Against Tuberculosis and Lung Disease, Paris, 2011. 19. Bandosz P, O’Flaherty M, Drygas W, et al. Decline in mortality from coronary heart disease in Poland after socioeconomic transformation: modelling study. BMJ 2012;344:d8136. 20. Giovino GA, Mirza SA, Samet JM, et al. Tobacco use in 3 billion individuals from 16 countries: an analysis of nationally representative cross-sectional household surveys. Lancet 2012;380:668-79. 21. Zatonski WA, Bhala N. Changing trends of diseases in Eastern Europe: closing the gap. Public Health 2012;126:248-52. 22. Centers for Disease Control and Prevention. Global Youth Tobacco Surveillance, 2000-2007. Surveillance Summaries, January 25, 2008. MMWR 2008;57(No. SS-1). 23. GTSS Collaborative Group. A cross country comparison of exposure to secondhand smoke among youth. Tob Control 2006;15 Suppl 2:ii4-19. 24. Zato ń ski W, Zato ń ski M, Przewo ź niak K. Health improvement in Poland is contingent on continued extensive tobacco control measures. Ann Agric Environ Med 2013;20:405-11. 25. European Commission. Proposal for a Directive of the European Parliament and of the Council on the approximation of the laws, regulations and administrative provisions of the Member States concerning the manufacture, presentation and sale of tobacco and related products. COM (2012) 788 final. European Commission, Brussels, 19 December 2012. Cite this article as: Jassem J, Przewo ź niak K, Zato ń ski W. Tobacco control in Poland—successes and challenges. Transl Lung Cancer Res 2014;3(5):280-285. doi: 10.3978/ j.issn.2218-6751.2014.09.12 Translational lung cancer research. All rights reserved. www.tlcr.org

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