Snuffing Out Tobacco-Related Disease

Snuffing Out Tobacco-Related Disease

by Beryl Lieff Benderly

 

In a narrow street near the remains of the massive medieval wall that once embraced the ancient Gornji Grad section of Zagreb, Croatia’s capital city, a crowd of teenagers stands laughing in the sunshine outside their high school. The historic facades lining the district’s winding lanes and small squares recall the nation’s distant past, but these boys’ and girls’ actions bode ill for the future. As they hurry back inside their gimnazija for class, many of the students snuff out cigarettes on the paving stones.

“Smoking is one of the biggest public health problems in Croatia,” says Veljko Djordjevic, a psychiatrist at University Hospital-Zagreb and a leader in national anti-smoking efforts. Djordjevic's observation applies equally well to the rest of the Eastern Europe and Central Asia region, home to the world’s highest percentage of citizens who are regular smokers (35 percent in 2000), with the East Asia and Pacific region running a close second (34 percent in 2000).

These statistics portend problems because, along with HIV infection, smoking is one of just two causes of death now rising throughout the world, according to Disease Control Priorities in Developing Countries, 2nd edition (DCP2), one of three recent publications of the Disease Control Priorities Project. Tobacco kills between half and two-thirds of its long-term users; half of those victims die between ages 35 and 69 resulting in the loss of 20 to 25 years of life, DCP2 states. Tobacco deaths are heavily concentrated in middle-income countries, like Croatia, and in low-income countries, with over 80 percent of the world’s more than 1.1 billion smokers live in the developing world.

In Croatia, 30 percent of adults and a similar percentage of young people are regular smokers. Nearly equal numbers of male and female Croatians now smoke, a change from the mid-20th century and earlier, when male smokers far outnumbered females. Current rates represent a decline in smoking in recent years, according to Nevenka Cop-Blazic, a neuropsychiatrist at University Hospital-Sestre Milosrdnice, who co-founded the nation’s first smoking cessation program in the 1970s.

Still, with the second-highest lung cancer rate in Europe, Croatia annually suffers an estimated 14,000 tobacco-related deaths in a population of approximately 4.5 million. Its two leading causes of death, cancer and cardiovascular disease (CVD), are both closely linked to smoking. Despite the drop in the smoking rate, the number of tobacco-related deaths will continue to climb for some years to come, says Cop-Blazic, because of the large number of older Croatians who have smoked for many decades.

A Worldwide Problem

Tobacco’s toll is enormous not only in Croatia but in nearly all countries around the world. Smoking-related diseases now kill 5 million people a year worldwide and could cause a billion deaths during the 21st century from various cancers, CVD, and pulmonary diseases if current trends do not change, warns DCP2. Over the past several decades, developed countries like the United States and the United Kingdom have markedly cut their smoking rates and altered pro-smoking social norms, especially after the 1964 report of the U.S. Surgeon General officially recognized the causal connection between tobacco and lung cancer.

In Croatia, however—and in many other developing countries—campaigns to change traditional attitudes and practices and educate the public about tobacco’s dangers are much less advanced, despite the efforts of public health experts over more than three decades. Changing that situation will require “a national plan for eliminating smoking” according to the late Dr. Mijo Šimunic, a professor at the Andrija Štampar School of Public Health in Zagreb, in a book he wrote to educate his fellow physicians on their role in anti-smoking efforts.

The principles of such a program, as conceived by Šimunic, would include:

• -  Joint action by a wide range of governmental, educational, and private entities and institutions;
• -  Effective execution of a multisectoral policy that attacks the problem on multiple fronts;
• -  The necessity of creating a smoke-free environment and of raising a generation of nonsmokers;
• -  Effective support to smokers in quitting smoking;
• -  Commitment to international cooperation in attacking the problem; and
• -  Funding for planned, systematic action.

 

Pioneering Efforts

Anti-smoking efforts in Croatia got underway through the work of the late Vladimir Hudolin, an internationally known psychiatrist who for many years headed the department of psychiatry, alcoholism and other dependencies at Zagreb University. A smoker himself, Hudolin first began to learn about new evidence that linked smoking to health problems at a conference in the early 1970s. On his return from abroad, Hudolin announced that he intended not only to stop smoking himself but to start a program to help others quit as well.

In 1972, after examining the scientific literature, Hudolin and Cop-Blazic launched a five-day smoking cessation course based on the work of two Americans, Wayne McFarland, a physician, and Elman J. Folkenburg, a pastor and counselor. The program, which has been modified over the years has helped Croatians kick the habit ever since.

Smoking cessation is not an event but a process that requires a lifestyle change, says Cop-Blazic. Smokers must simultaneously battle a habit, a physical addiction, and a psychological addiction. Of these, she says, psychological addiction is most difficult, because people who start smoking young—as do the great majority of smokers—do not learn how to deal with everyday stresses without nicotine. Stress was an especially prominent factor for those who began or continued smoking to deal with wartime anxiety and fear during the fighting that engulfed Croatia and the other states of former Yugoslavia during the 1990s. “Successful techniques to avoid stress” are a vital element of overcoming tobacco addiction, Cop-Blazic says.

Since the inception of the program, about 65 percent of Non-Smoking School participants have successfully quit—some 3,000 to 4,000 individuals over the past 20 years—Djordjevic says. Crucial to their success, he notes, is that the program allows each individual to decide when he or she is ready to stop smoking. On the first day, psychiatric interviews determine whether participants have any psychiatric condition, such as depression, anxiety, or schizophrenia, that encourages smoking and needs specific treatment in its own right. Instruction also is tailored to the individual needs of various types of smokers. A number of other cities, including Split, Osijek, Rijeka, and Motovan also now offer Schools of Non-Smoking.

Cessation is hugely cost-effective, according to DCP2, and therefore needs to be a “dominant strategy,” said Prabhat Jha, physician and founding director of the Centre for Global Health Research of the University of Toronto. Stopping smoking by age 30 on average “gives back nearly 10 full years” of life, according to Sir Richard Peto, professor of medical statistics and epidemiology at Oxford University. Smokers who stop by their mid-30s can avoid 90 percent of lung cancer risk. Even stopping in one’s 50s and 60s substantially reduces the risk of disease.

In contrast to developed countries, where cessation programs are well-developed, however, “few smokers in the developing world quit,” said Jha. Thirty to forty percent of Britain’s population, for example, are ex-smokers, as compared to only 5 to 10 percent of India’s or China’s. Both are nations with high smoking rates. But unless large numbers of the developing world’s current smokers conquer their addiction, smoking-related death rates will rise for the next 50 years, predicts DCP2.

A Multi-Pronged Attack on Smoking

An effective anti-smoking strategy, as Šimunic pointed out, must also focus on the crucial issues of preventing those who have not yet started—especially youngsters—from becoming smokers and protecting non-smokers from environmental smoke. In 2002, a number of organizations in Croatia undertook a unified 2-year national anti-smoking campaign, spearheaded by the Andrija Štampar School of Public Health. Using the slogan “Say Yes to No Smoking,” the marketing and media campaign included “no smoking” postage stamps, daily anti-smoking announcements before the nation’s most popular TV news show, and a “stop smoking” day timed to coincide with Lent, which had considerable symbolic impact in the overwhelmingly Roman Catholic country.

Endorsements by celebrities, such as sports stars and politicians gave the campaign a high profile. Croatia’s president and other dignitaries attended the opening of a toll-free hotline that provided information and advice about smoking and quitting. TV personalities, singers, and other celebrities attended Non-Smoking School. A handbook was written for teachers to use in schools. Programs educated health care workers, with emphasis on persuading them to give up smoking themselves and on training doctors around the country to establish anti-smoking programs.

Subsequent research showed that the great majority of Croatians were aware of the campaign and its messages. “During this period we decreased the number of smokers by about 5 percent,” Djordjevic said. He believes strongly in the power of the media to shape attitudes. Outside his medical practice, he hosts both a radio show and a TV show. On both, he takes callers’ questions and shares information on health issues, including smoking.

In dealing with a behavior that is both addictive and deeply woven into daily life, however, knowledge does not necessarily equal action. Croatia has “a very good law” limiting smoking in workplaces, restricting smoking to specified areas of restaurants, and forbidding direct media advertising of tobacco, says Cop-Blazic. The country also participates in international tobacco control efforts. But it faces many difficulties in implementation. “There is no political will to enforce the rules strictly,” she adds.

Socializing with friends in cafés and other eating and drinking places is a central part of Croatian life, both for citizens and the millions of foreign tourists—10 million in 2005—who each summer pack the resort towns on the Dalmatian coast and its islands. Because of lax enforcement, smoke pervades restaurants, bars, cafés, hotel lobbies, airport and bus terminals, and other public places throughout the country, and even some office buildings and other worksites. Tobacco companies skirt the advertising restrictions with indirect messages widely recognized to refer to cigarette brands, such as posters that present striking nature photography and a pun on a brand name. The country lacks effective means for making cigarettes “less available to young people,” Cop-Blazic says.

In the long run, experts agree, persuasion and education work far better than prohibition in reducing smoking. Banning tobacco is “counter-productive,” says Jha. “Legislative measures are not against smokers,” says Cop-Blazic, “but against smoking, which is dangerous for both smokers and non-smokers.”

 

Beryl Lieff Benderly is a prize-winning Washington journalist and author specializing in health, behavior, and science policy. Her articles appear in major magazines and on the Internet, and she is a regular contributor to the Science magazine website. Her eight books include In Her Own Right: The IOM Guide to Women's Health Issues. She is working on a book about addiction (Oxford University Press, forthcoming).