Campaigners fight to bring down Russia's tobacco toll

Abstract

With more than 40 million smokers, Russia has one of the highest rates of tobacco use in the world. But while calls are growing for a nationwide service to help smokers quit, doctors' own predilection for cigarettes is proving a stumbling block. Tom Parfitt reports from Moscow.It was not teenage bravado that drove Vladimir Levshin to start smoking at medical college. He and his friends had a more practical reason. “We just couldn't stand the smell during autopsy class”, he chuckles. “Cigarettes helped kill the stink.”Now, 30 years on and a non-smoker—he gave up after starting work with patients with throat cancer and emphysema—Levshin is Russia's leading advocate of tobacco control.As head of the prevention measures department of the Russian Academy of Science's Cancer Research Centre, he is one of the lone voices calling for adoption of a nationwide smoking cessation service. “Our statistics show that about 60% of current smokers want to quit”, says Levshin in an interview at the centre, a crumbling brick building on the edge of Moscow. “The problem is that the state is giving no money to help them do it. Not a kopeck.”Russia is one of the few countries worldwide that has not signed or ratified the WHO Framework Convention on Tobacco Control, and there is no coordinated national effort to cut tobacco use.Smokers who approach state clinics for help are often greeted by ill-informed or disinterested doctors, many of them tobacco users themselves. Meanwhile, big tobacco companies have muscled in on the market since the fall of the Soviet Union in 1991 and allegedly stifled campaigners' attempts to force tobacco control on to the agenda.A shocking 63% of Russian men (more than twice the proportion in the UK or the USA) and 15% of women are smokers, and the number is rising by 1·5–2% every year.The Ministry of Health's State Research Centre for Preventive Medicine estimates that 220 000 people a year die from illnesses related to tobacco.Prevalence of cardiovascular disease in Russia is one of the highest in the world with a death rate of 994 per 100 000 people in 2002. About 40% of deaths from coronary heart disease among men are linked to smoking.Last year, in a report on premature mortality called Dying Too Young, the World Bank concluded smoking is the “single most preventable cause of disease and death in Russia”, associated as it is with cardiovascular disease, many cancers, and chronic lung diseases. The report estimated that reducing cardiovascular disease in Russia by 20% would add 5 years to male life expectancy, which hovers just above age 58 years.Research by the Cancer Research Centre shows that one of the greatest hurdles to cutting smoking is the fact that health professionals themselves cannot kick the habit. “It stands to reason”, says Levshin. “If you go to your doctor and see him puffing away himself then you're hardly going to heed his advice to stop.”Smoking prevalence among doctors—and ignorance about its health effects—were found to mirror that of the general population in a recent survey by Levshin and his colleagues. Only 38% of doctors who smoke said they always advised their patients to quit, compared with 58% of doctors who had never smoked. The survey also showed that less than 10% of doctors interviewed were aware of all tobacco's harmful health effects.Olga Vikhireva, communications coordinator at the Society of Cardiology and a senior researcher at the Centre for Preventive Medicine, says the ignorance and apathy among doctors is a disaster. “Only with a change in the position and professional conduct of doctors toward smoking—albeit, within a framework of political, economic, and legislative support—can we expect real success in the battle with smoking in our country”, she says.In a first step, the Cancer Research Centre has teamed up with Moscow Health Education Centre and the Russian Public Health Association to organise seminars to motivate doctors in providing “smoking cessation assistance”.The 1-h lectures are offered free and are usually attended by about 30 doctors at each institution. At the end of the lecture, atendees can seek further advice on how to quit themselves or sign up for a week-long course on treating patients with tobacco dependence and nicotine addiction.In 4 years, about 3000 doctors in Moscow have attended the lecture, but it is still only a tiny proportion of the capital's health professionals.For the general public, Levshin and colleagues have devised a smoking cessation session that focuses on group counselling, complemented by nicotine replacement therapy for those who can afford it.He says the session could be adopted as a model nationwide, but the Ministry of Health has twice rejected it. “This reflects the fact that even health professionals regard smoking as a low priority”, he adds. “Drugs and alcohol are seen as much greater problems, although smoking is more of a killer. And there's just no net of assistance for patients.”Campaigners for tobacco control say lack of will among health chiefs, bureaucratic barriers, and aggressive lobbying from the tobacco industry have conspired to keep the convention off the agenda. Excise taxes remain low and cigarettes without filters called “papirosy” can be bought for as little as 8 roubles (15 pence) per packet.Tobacco-control legislation introduced in 2001 prohibited sale of tobacco products to people younger than 18 years, banned tobacco advertisements on television and radio, and made smoking in some public places illegal. New measures that come into force in 2007 will restrict all outdoor advertising of cigarettes. However, enforcement is lax and campaigners say leadership from the government is critically lacking.Smoking is deeply embedded in Russian culture and British soldiers are thought to have brought back the habit from the Crimean War in the 19th century. After the Soviet break-up, multinational tobacco companies were quick to move in to Russia, snapping up local producers and ramping production. About 400 billion cigarettes are now made every year, although a quarter of them are thought to be smuggled to the EU and former Soviet states.Although the Russian delegation approved the Framework Convention on Tobacco Control at the 56th World Health Assembly in 2003, Russia has neither signed nor ratified it. Administrative shake-ups in the Ministry of Health have hindered progress on signing the agreement and politicians, mindful of the public outcry during the cigarette shortage of the Perestroika era, are wary of backing attempts to cut smoking.Andre Demin, president of the Russian Public Health Association and coordinator of the National Coalition for Tobacco Free Russia, says big tobacco companies have developed a collaboration with government officials “which does not favour public health”.Demin presented a paper on smoking in Russia at the 13th World Conference on Tobacco or Health in Washington last month. His study focused on material from the Guildford Depository—a collection of internal documents that British American Tobacco was obliged to make publicly accessible after a US court ruling in 1998.“A good example of how officials here work with tobacco companies is the record of a promise given by a deputy chairperson of the parliamentary public health committee to BAT representatives to ‘kill’ tobacco control legislation”, he says.While there is no explicit evidence of corruption, Demin says transnational companies have worked hard to stifle tobacco-control measures. “They are funding education programmes aimed at adolescents but often their material has a subtext, such as ‘if you don't smoke, you're boring’,” he says. “Effectively this is a sophisticated kind of advertising.”BAT has consistently denied such accusations, saying the company is “socially responsible” and works hard to cut sales to minors.Demin says what is needed most is political will and leadership. “President Vladimir Putin must give a clear message that smoking is a public health hazard”, he says. “Then comes deeper spending, earmarking of excise taxes for tobacco control, services to help smokers quit, and all the rest.”Anna Gilmore, a clinical lecturer in public health at the London School of Hygiene and Tropical Medicine who has studied smoking trends in Russia, believes stemming the increase in female smokers is a key task.“It's very clear that the transnational companies are targeting young women, especially in cities”, she says. “What's critical now is to introduce a full advertising and sponsorship ban, to make sure taxes on cigarettes are high and to get a ban on smoking in public places—to get those key measures in place because they are cheap to do.” With more than 40 million smokers, Russia has one of the highest rates of tobacco use in the world. But while calls are growing for a nationwide service to help smokers quit, doctors' own predilection for cigarettes is proving a stumbling block. Tom Parfitt reports from Moscow. It was not teenage bravado that drove Vladimir Levshin to start smoking at medical college. He and his friends had a more practical reason. “We just couldn't stand the smell during autopsy class”, he chuckles. “Cigarettes helped kill the stink.” Now, 30 years on and a non-smoker—he gave up after starting work with patients with throat cancer and emphysema—Levshin is Russia's leading advocate of tobacco control. As head of the prevention measures department of the Russian Academy of Science's Cancer Research Centre, he is one of the lone voices calling for adoption of a nationwide smoking cessation service. “Our statistics show that about 60% of current smokers want to quit”, says Levshin in an interview at the centre, a crumbling brick building on the edge of Moscow. “The problem is that the state is giving no money to help them do it. Not a kopeck.” Russia is one of the few countries worldwide that has not signed or ratified the WHO Framework Convention on Tobacco Control, and there is no coordinated national effort to cut tobacco use. Smokers who approach state clinics for help are often greeted by ill-informed or disinterested doctors, many of them tobacco users themselves. Meanwhile, big tobacco companies have muscled in on the market since the fall of the Soviet Union in 1991 and allegedly stifled campaigners' attempts to force tobacco control on to the agenda. A shocking 63% of Russian men (more than twice the proportion in the UK or the USA) and 15% of women are smokers, and the number is rising by 1·5–2% every year. The Ministry of Health's State Research Centre for Preventive Medicine estimates that 220 000 people a year die from illnesses related to tobacco. Prevalence of cardiovascular disease in Russia is one of the highest in the world with a death rate of 994 per 100 000 people in 2002. About 40% of deaths from coronary heart disease among men are linked to smoking. Last year, in a report on premature mortality called Dying Too Young, the World Bank concluded smoking is the “single most preventable cause of disease and death in Russia”, associated as it is with cardiovascular disease, many cancers, and chronic lung diseases. The report estimated that reducing cardiovascular disease in Russia by 20% would add 5 years to male life expectancy, which hovers just above age 58 years. Research by the Cancer Research Centre shows that one of the greatest hurdles to cutting smoking is the fact that health professionals themselves cannot kick the habit. “It stands to reason”, says Levshin. “If you go to your doctor and see him puffing away himself then you're hardly going to heed his advice to stop.” Smoking prevalence among doctors—and ignorance about its health effects—were found to mirror that of the general population in a recent survey by Levshin and his colleagues. Only 38% of doctors who smoke said they always advised their patients to quit, compared with 58% of doctors who had never smoked. The survey also showed that less than 10% of doctors interviewed were aware of all tobacco's harmful health effects. Olga Vikhireva, communications coordinator at the Society of Cardiology and a senior researcher at the Centre for Preventive Medicine, says the ignorance and apathy among doctors is a disaster. “Only with a change in the position and professional conduct of doctors toward smoking—albeit, within a framework of political, economic, and legislative support—can we expect real success in the battle with smoking in our country”, she says. In a first step, the Cancer Research Centre has teamed up with Moscow Health Education Centre and the Russian Public Health Association to organise seminars to motivate doctors in providing “smoking cessation assistance”. The 1-h lectures are offered free and are usually attended by about 30 doctors at each institution. At the end of the lecture, atendees can seek further advice on how to quit themselves or sign up for a week-long course on treating patients with tobacco dependence and nicotine addiction. In 4 years, about 3000 doctors in Moscow have attended the lecture, but it is still only a tiny proportion of the capital's health professionals. For the general public, Levshin and colleagues have devised a smoking cessation session that focuses on group counselling, complemented by nicotine replacement therapy for those who can afford it. He says the session could be adopted as a model nationwide, but the Ministry of Health has twice rejected it. “This reflects the fact that even health professionals regard smoking as a low priority”, he adds. “Drugs and alcohol are seen as much greater problems, although smoking is more of a killer. And there's just no net of assistance for patients.” Campaigners for tobacco control say lack of will among health chiefs, bureaucratic barriers, and aggressive lobbying from the tobacco industry have conspired to keep the convention off the agenda. Excise taxes remain low and cigarettes without filters called “papirosy” can be bought for as little as 8 roubles (15 pence) per packet. Tobacco-control legislation introduced in 2001 prohibited sale of tobacco products to people younger than 18 years, banned tobacco advertisements on television and radio, and made smoking in some public places illegal. New measures that come into force in 2007 will restrict all outdoor advertising of cigarettes. However, enforcement is lax and campaigners say leadership from the government is critically lacking. Smoking is deeply embedded in Russian culture and British soldiers are thought to have brought back the habit from the Crimean War in the 19th century. After the Soviet break-up, multinational tobacco companies were quick to move in to Russia, snapping up local producers and ramping production. About 400 billion cigarettes are now made every year, although a quarter of them are thought to be smuggled to the EU and former Soviet states. Although the Russian delegation approved the Framework Convention on Tobacco Control at the 56th World Health Assembly in 2003, Russia has neither signed nor ratified it. Administrative shake-ups in the Ministry of Health have hindered progress on signing the agreement and politicians, mindful of the public outcry during the cigarette shortage of the Perestroika era, are wary of backing attempts to cut smoking. Andre Demin, president of the Russian Public Health Association and coordinator of the National Coalition for Tobacco Free Russia, says big tobacco companies have developed a collaboration with government officials “which does not favour public health”. Demin presented a paper on smoking in Russia at the 13th World Conference on Tobacco or Health in Washington last month. His study focused on material from the Guildford Depository—a collection of internal documents that British American Tobacco was obliged to make publicly accessible after a US court ruling in 1998. “A good example of how officials here work with tobacco companies is the record of a promise given by a deputy chairperson of the parliamentary public health committee to BAT representatives to ‘kill’ tobacco control legislation”, he says. While there is no explicit evidence of corruption, Demin says transnational companies have worked hard to stifle tobacco-control measures. “They are funding education programmes aimed at adolescents but often their material has a subtext, such as ‘if you don't smoke, you're boring’,” he says. “Effectively this is a sophisticated kind of advertising.” BAT has consistently denied such accusations, saying the company is “socially responsible” and works hard to cut sales to minors. Demin says what is needed most is political will and leadership. “President Vladimir Putin must give a clear message that smoking is a public health hazard”, he says. “Then comes deeper spending, earmarking of excise taxes for tobacco control, services to help smokers quit, and all the rest.” Anna Gilmore, a clinical lecturer in public health at the London School of Hygiene and Tropical Medicine who has studied smoking trends in Russia, believes stemming the increase in female smokers is a key task. “It's very clear that the transnational companies are targeting young women, especially in cities”, she says. “What's critical now is to introduce a full advertising and sponsorship ban, to make sure taxes on cigarettes are high and to get a ban on smoking in public places—to get those key measures in place because they are cheap to do.”