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Smoking in Russia: will old habits die hard?

2011; Elsevier BV; Volume: 378; Issue: 9795 Linguagem: Inglês

10.1016/s0140-6736(11)61434-7

1474-547X

David Holmes,

Cardiovascular Health and Risk Factors

Smoking is a leading cause of death and disease, and Russia leads the world in smoking. David Holmes reports on emerging efforts to rein in the country's tobacco epidemic. Addictions to alcohol and tobacco have taken a greater and greater toll on Russia's health ever since the collapse of the Soviet Union. Now, fresh from renewed efforts to tackle Russia's drinking problem (beer was finally officially classed as an alcoholic drink in late July), the Russian Ministry of Health has announced a range of new measures aimed at tackling the country's need for tobacco. The scale of the task is huge. WHO puts the number of adult smokers in Russia at 44 million, with male prevalence rates just over 60%—the highest in Europe. Female smoking is much lower at just over 20%, but tobacco companies have targeted women with intense marketing campaigns touting slim and ultra slim brands, and the proportion of women smoking is already high and still rising in big cities such as Moscow and St Petersburg compared with rural areas. “If nothing changes, female smoking rates will soon be at 35% plus”, says Fiona Godfrey, of the International Union Against Tuberculosis and Lung disease. “Smoking prevalence rates this high can't be addressed without a coordinated, evidence-led policy response by the whole of government.” About 400 000 Russians die each year from diseases related to smoking. Last summer the Russian Ministry of Health and Social Development required all packets of cigarettes to carry an anti-smoking message as “one of the steps in the path to restrict the use and spread of tobacco production in Russia”. Then, in September, 2010, Prime Minister Vladimir Putin signed the national tobacco control concept paper. “The concept is based on the WHO Framework Convention (FCTC) on Tobacco Control, which was ratified by Russia in 2008”, says Nataliia Toropova, Tobacco Control Program Coordinator for WHO Russia. The concept paper called for a 10–15% reduction in smoking by 2015, and although “not a legal document”, Toropova says the concept paper is “a strategic platform for future legislative steps”. This August, the Ministry of Health announced the form that some of that future legislation might take. The proposed measures would radically rewrite the current law that governs the protection of public health from tobacco consumption, and are similar to proposals put forward by the Moscow State Duma earlier this year. Among the additions to the legislation are a ban on small tobacco shops and all tobacco display cases in large stores from summer 2013, and a ban on smoking in areas open to the public such as restaurants, bars, and clubs from 2015. A smoking ban will also take effect on public transport from 2014, including waiting rooms and anywhere within 10 m of airports and train stations. Rebecca Perl, Associate Director at the World Lung Foundation, told The Lancet that she is “cautiously optimistic that the new tobacco legislation proposed by the Ministry of Health is a real and large step for tobacco control”. But, she warns, “if they let the tobacco industry weigh in, that will be disastrous”. WHO's Toropova acknowledges that the “tobacco lobby is very intense in Russia”, and with the country providing manufacturers with their third biggest market in the world, it is unthinkable that they will loosen their grip without a fight. It is a grip that goes back decades. A year before the failed coup d’état in 1991 by members of the Soviet Government, the then Soviet President Mikhail Gorbachev had to face down another potential revolt. By then, the Soviet Union's economic crisis had reached a point at which the production of cigarettes had ground to a halt, and the protests staged by armies of desperate smokers in Moscow, St Petersburg (what was then known as Leningrad), and other big cities was dubbed the tobacco rebellion. Gorbachev was forced to turn to the west for help, and in return for access to the vast Soviet market, the manufacturers Philip Morris and R J Reynolds duly obliged. The Russian market is now unique in that all four of the major transnational tobacco suppliers (Japan Tobacco, Philip Morris International, British American Tobacco, and Imperial Tobacco Group) ply their trade there, with the competition between them giving rise to ever more inventive and aggressive marketing. In terms of influence, says Godfrey, the tobacco companies “are probably being helped by a resurgence in tobacco industry lobbying in the wider European region”. Vasiliy Vlassov is president of the Russian Society for Evidence Based Medicine, which is a co-founder of the Russian anti-tobacco coalition. He explains that even though the Ministry of Health might be insulated from lobbyist influence, the lobbyists can still exert influence through other channels. For example, he says, “the Ministry of Agriculture is interested in the legislation; tobacco lobbyists are very influential there. In the field of negotiations inside the tax-free space (Russia, Belorussia, and Kazakhstan), the Ministry of Agriculture is taking the lead”. But, says Godfrey, although “a lot of the time industry lobbying is hidden in Russia, the industry certainly doesn't have everything its own way, and several politicians have spoken out against its influence and its damaging impact on Russian society”. Persuading Russian society of the need for what many will label draconian anti-smoking legislation will be absolutely crucial if new legislation is to stand any chance of being enforced. Currently, only flights are smoke free, and according to Toropova this is explained “only by such will of the airlines”—it is not a legal obligation. There is nowhere else that is 100% smoke free, including hospitals. “The only penalty existing today for smoking in the forbidden places is RUB100 (about US$3)”, says Toropova—“that is for smoking on a train, in a non-smoking compartment”. One popular saying, Vlassov recounts, is that “the draconian nature of Russian law is softened by the non-obligatory nature of its implementation”. The implementation of the legislation banning the drinking of alcohol in public places is a case in point. “Still people drink beer in public places, in subway cars”, he says. Nonetheless, Vlassov is still positive, and there are reasons to believe that attitudes towards smoking, as has been the case elsewhere, might be different. “In my opinion the [public] perspective is better than in relation to beer drinking: a drinker is not smelling, and Russian people are often neutral to beer drinking”, he says. “Smoking is different: even before this forthcoming legislation many times I saw people attacking the smokers in public places.” Godfrey agrees that there is an appetite for change among the public. “There is a growing awareness in Russia of the harm caused by tobacco. Compared with 4 or 5 years ago we are also seeing a lot more coverage of the tobacco epidemic in newspapers and on television”, she says. “Opinion polls over the last 18 months have regularly found that over 60% of the population would support a 100% workplace smoking ban: this is higher than in many countries that actually did go smoke free—and higher than in some of the poorer performing EU countries”. Moreover, says Godfrey, this awareness is not confined to cosmopolitan Moscow, whose State Duma has taken the lead on anti-tobacco legislation. “There is a lot of interest in tobacco control in the regions, and several regional governments would like to implement stronger smoke-free legislation and other tobacco-control policies.” Historically, the reduction that Russia is aiming for has few parallels. In the UK, over 60% of the male population were smokers in the 1950s and 1960s, and although those rates have been slashed, it took the UK 40 years to do so. Russia does not have the luxury of time. It could look across the Black Sea, to Turkey, for an example of what can be achieved in a short timeframe. In the 1990s, Turkey had smoking prevalence rates similar to Russia, but “over the last few years it has introduced a raft of evidence-based policies and is now an acknowledged leader in tobacco control in the WHO European region”, says Godfrey. “Russia—and many European Union member states—could benefit a lot from adopting the same approach as Turkey.” One thing that everyone agrees on is a need for a new regime of taxation on tobacco. “Very low tobacco tax is a key factor of high smoke prevalence in the Russian Federation”, says Toporova, while Godfrey puts it more bluntly: “raise taxes, raise taxes, raise taxes”. Vlassov fears that, possibly mindful of the difficulties that befell Gorbachev, “Putin is afraid to increase the taxes because of the coming elections (even taxes with good promise in the end)”. However, the Ministry of Finance is keen to increase excise duty from its current point of about RUB7 ($0·22) for a pack of filtered cigarettes usually costing no more than $1—the lowest tax on tobacco in Europe. This is roughly half the duty imposed on a pack of cigarettes in neighbouring Ukraine, which has ramped up its taxation in a bid to cut its own numbers of smokers, “and 30 times less than in New York City”, says Toporova. “A series of Ukrainian-style tax increases over the next 4 or 5 years would have a massive impact on prevalence rates in Russia”, says Godfrey, who concludes on a note of cautious optimism: “so far, the signs are that the Russian Government understands the scale of the problem and accepts the need for something to be done in the context of the wider demographic catastrophe that the country is facing. The devil is now in the detail.”