A common enemy: half a century of US/Poland cooperation and tobacco control

INTRODUCTION

Both Poland and the US have made tremendous progress over the past several decades in reducing tobacco use and, in turn, tobacco related morbidity and mortality. For example, both countries have seen a decrease in lung cancer incidence since 2000, particularly among men, due to reductions in cigarette smoking (Figure 1). But this pattern of a rise and fall in cigarette smoking, followed by a similar trend in lung cancer, obscures the complexity of efforts to control tobacco use that were responsible for this dramatic reversal. The US and Poland have a lengthy history of bilateral cooperation in health, dating back to the 1960s when the US supported cancer research projects in Poland under the Foreign Assistance Act. The US government, particularly NCI, supported biomedical research in Poland beginning in the early 1960s. However, the bilateral relationship around tobacco control was more complex, with competing economic and foreign policy interests.
In the US, following publication of the 1964 report of the Surgeon General on Smoking and Health, a warning label was added to cigarette packages. However, this did not lead to an immediate drop in cigarette consumption. Indeed, it was not until 20 years later, in the 1980s, that we begin to see a sustained drop in cigarette consumption. This drop was largely due, not to specific government actions, but to the development of a strong anti-tobacco advocacy movement and non- smokers rights movement which began to push for poli­cies restricting smoking in public places and change public attitudes towards cigarettes. Poland, once among the highest smoking nations in the world, would follow a similar trajectory a few years later as a civil society tobacco control movement developed in the 1990s with support from the international community.

US FOREIGN POLICY AND POLAND

The 1960s saw a greatly expanded US role in health and development globally in the context of the Cold War. In 1958 President Eisenhower, in his State of the Union address, urged international campaign against diseases that are “a common enemy of all mortals,” including cancer. In 1960, the International Health Research Act authorized “cooperative endeavors with other countries in health research and research training,” which led to expanded support of international research grants. And the Foreign Assistance Act, signed into law by President Kennedy in 1961, led to an expansion of US foreign aid, including support of research projects using US-owned foreign currency accounts abroad (under P.L. 480). That year, the NCI Annual Report cited cancer projects in India, Egypt, and Poland, coordinated by the NCI using US-owned foreign currency overseas, which would continue into the 1970s.
Cold War tensions between the Soviet Union and the US eased during the 1970s, leading to an increase in US investment in the Soviet Bloc, including Poland. The US Export-Import Bank began underwriting loans to support American exports to Poland (which increased from $45 million in the first half of 1972 to $197 million in the first half of 1973). The press in Poland became less critical of the US and the US saw strategic advantage in a stronger alliance with Poland in the ongoing Cold War. As a 1973 New York Times article described: “The present happy relationship between Poland and the United States expresses itself in many ways” [1].
The Times noted another unusual trend – a dramatic increase in US government support for scientific research projects by Polish scientists. Most of the funds supported medical and agricultural research projects under the Department of Health, Education and Welfare and the Department of Agriculture. These projects were supported by local currency (Polish zloty) the US had accumulated in Poland through sale of grain and other agricultural products under the 1954 Agricultural Trade Development and Assistance Act (also know as PL W480 or the Food for Peace Act). The local currency could not be taken out of the country, but could be spent on local projects.
In August 1973, US Secretary of Health, Education and Welfare Caspar W. Weinberger visited Poland at the invitation of the Polish Health Minister, Marian Sliwinski, to discuss cooperation in health and medical research [2]. The following year, the US and Poland signed a bilateral agreement to collaborate on cancer research through the Poland’s Ministry of Health and the Institute of Oncology in Warsaw, then led by Professor Tadeusz Koszarowsky. This was one of the first such international agreements the US signed for cancer research (along with the USSR and Japan) following the 1971 National Cancer Act, which expanded the international work of the National Cancer Institute. At the time, NCI’s international program was growing, with several international agreements and grants and contracts in place, valued at over $8 million.
Cooperative work under the agreement was initially limited to the exchange of scientists. However, this was seen to be effective from the US perspective, as it enabled talented scientists in Poland to spend 3 to 4 months working in US laboratories on joint projects. Over time, collaborative projects developed around epidemiology and organization of cancer research activities [3]. For example, PL 480 funds were used to support epidemio­logic analyses of cancer trends comparing Poland and Polish Americans [4].
In July 1975, on the way to Helsinki for the Confe­rence on Security and Cooperation in Europe (Helsinki Accord), President Gerald Ford stopped in Poland. Ford and entourage met with Edward Gierek, First Secretary of the Polish United Workers Party, and other senior Polish leaders for formal bilateral talks in Krakow on July 28. Interestingly, the first statement recorded in the official transcript from that meeting is President Ford asking “Is it permissible to smoke?” Ford smoked a pipe. The answer was “yes”. Gierek went on to discuss Poland’s strong interest in expanding economic coope­ration with the US, particularly the continuing need for Poland to import grain and other agricultural products from the US [5].

A RISING BURDEN OF TOBACCO USE

During the 1970s and 1980s, Poland was among the highest smoking nations in the world. Smoking prevalence had risen to around 80% among men and 50% among women. Per capita consumption was around 3500 cigarettes per person per year. Smoking was increasingly popular among young adults, suggesting this pattern was unlikely to change in the future. At the same time, public awareness around the health effects of smoking was low and tobacco control measures almost non- existent. A 1974 ban on smoking in health facilities was largely ignored and cigarette smoking was widespread among health professionals [6]. The industry publication Tobacco Journal International, in a 1981 report on the tobacco market in Poland, noted that concern around health effects of smoking was “not of much concern to the general populace” [7].
At the same time, the US tobacco industry was making inroads into Poland. In December 1973, the Crackow Tobacco Industry Plant (ZPTK) began production of Marlboro cigarettes made under contract (licensing deal) with Philip Morris, purportedly using only American tobacco. The Marlboro cigarettes were expensive compared to domestic brands (7 times the cost of the most popular Sport brand) and were a luxury item, but sales in Poland grew rapidly. Tobacco manufacturing and sales remained controlled by the state monopoly. And cigarette regulations and pricing became a political issue. When in October 1981 the government proposed to double the price of cigarettes, along with a wave of price increases in other products, the Solidarity union threatened action. Leaders backed down on the price increase, and the stand off dampened interest in other tobacco control measures [8].
Meanwhile, population health indicators showed the worsening impact of the rise in cigarette smoking. American cardiologist Richard Cooper and colleagues analyzed mortality data from Poland, reporting a sharp increase since 1972 from lung cancer and cardiovascular disease, which they attributed largely to changes in tobacco and alcohol consumption [9]. Middle aged Polish men had higher rates of lung cancer than any other country in Europe, with the exception of Hungary. Half of all early deaths among Polish men were attributed to cigarette smoking [10]. In 1982, a joint US/Poland symposium was held at the National Institutes of Health in Bethesda on the rising impact of cardiovascular disease [11]. At the time, NCI was supporting studies in Poland around chemical exposure and cancer, as a new field of molecular epidemiology was emerging, moving beyond in vitro laboratory studies to directly measure genetic damage in human subjects under actual exposure conditions [12]. They found levels of pollution­ related DNA adducts (binding of chemical molecules to DNA) were two to three times higher among residents of Sile­sia compared with rural controls [13].
Some early tobacco control efforts began in the 1970s and 1980s, but their impact was limited and they faced many challenges [14]. In 1975, Kornel Gibinski, Director of the Institute of Internal Medicine at the Medical University of Silesia in Katowice, spoke at the Third World Conference on Smoking and Health and as part of a WHO expert committee on smoking, sharing experience from Poland [15], emphasizing the need to study obstacles to tobacco control efforts in Poland and to highlight the economic costs of smoking for Polish society [16]. The PTP Polish Antitobacco Society was established in 1979 and provided a focus for tobacco control efforts going forward. During the following decade, the Ministry of Health put forward two legislative proposals for tobacco control, in 1983 and 1988, which included prohibiting smoking in many indoor public spaces and adding health warning to cigarette packs, but both failed to pass [17].
In October 1984, a two-day conference was held in Warsaw on the health consequences of smoking in Polish society, sponsored by the International Union for Cancer Control (UICC), with an aim to increase attention to the public health problem and spur government action. Co-organizers included the Ministry of Health and Social Welfare, the Warsaw Institute of Onco­logy, the Polish Anti-Smoking Society, and the Polish Oncological Society, along with participation from WHO. While government representatives from the Mi­nistry of Health attended and participated in the workshop, they cautioned that it was better for tobacco control proposals to come from WHO, rather than from the Polish government, as government proposals would be viewed by the public as repressive measures. The following week, Poland also hosted the Second Antismoking Symposium of Socialist Countries on ‘Protection of children and adolescents from smoking’ was organized by Dr. Tadeusz Górski in Łódź, including 348 participants mostly from the Eastern bloc [15]. In 1988 Poland participated in the WHO World No Tobacco Day for the first time.
Despite these activities, the prospects for tobacco control in Poland seemed distant. While tobacco use was decreasing in the US and Europe, it continued to spread in Poland, particularly among youth and young adults. Meanwhile, the state’s continuing interest in tobacco as a source of revenue and the politics over cigarette price increases stood in the way of stronger tobacco control measures at the national level. Washington Post correspondent in Warsaw Jackson Diehl took an interest in health and tobacco use in Poland. His brother Andrew Diehl was an epidemiologist and specialist in gallbladder cancer who had traveled to Poland to collaborate on cancer research. But Diehl took a pessimistic view at the time, covering the issue in a 1987 article titled: “Poles refuse to put our their cigarettes.” He spoke with Witold Zatonski, then leader of the Polish Anti-Tobacco Society, who lamented that in the 20 years of the Society’s existence, “we haven’t had many successful days” [18].

OPENING THE FLOODGATES

The fall of communism, Poland’s transition to democracy during 1989 to 1991, and the move towards a capitalist market also had implications for the tobacco market, as multinational tobacco firms raced into Central and Eastern Europe [19]. When a 1990 economic crisis hit the Soviet Union and led to a shortage of Soviet produced cigarettes, RJ Reynolds and Philip Morris stepped in to fill the gap, promising to deliver 34 billion cigarettes [20]. RJ Reynolds built a state of the art factory outside Warsaw in the suburb of Piaseczno, giving it direct control over local manufacture of Camel, Winston, and other brands [21]. As multinational tobacco companies expanded in Poland, they worked to keep cigarette prices low and to lobby politicians against tobacco control measures. Philip Morris launched an aggressive marketing campaign, involving former Solidarity leader Lech Walesa and drawing a parallel between freedom of speech, the US Bill of Rights, and the freedom to smoke [22]. Cigarette manufacturers spent $100 million annually on advertising and, in the early 1990s, over half of all billboards in Polish cities were used to advertise cigarettes.
During the 1990s, US tobacco companies were rapidly expanding their markets abroad, particularly in Eastern Europe and in Asia. At the same time, the US government was actively promoting greater exports of US tobacco products and subsidizing sales of US tobacco to Poland. The US Commodity Credit Corporation provided financing to Poland to support purchase of US agricultural products, including tobacco, and also provided commercial risk protection to US firms selling to Poland [23]. Virginia Governor Douglas Wilder made a trip to Europe, including Poland, to promote sales of Virginia tobacco. The fact that Wilder had previously signed a clean air law restricting smoking in many public spaces in Virginia, but was now promoting tobacco products elsewhere, was seized on by critics as hypocrisy. Wilder defended his trip, noting “If people want to use our pro­ducts, we’d be proud to sell them” [24]. Cigarettes were actively marketed in Eastern Europe as representing the West, democracy, and American values. Billboards in Poland marketed L&M cigarettes as “Really American” [25]. The industry itself was rapidly changing as well; privatization of the state tobacco plants began in 1995 and by 1999 transnational companies controlled over 90% of the Polish cigarette market, a dramatic change from ten years earlier.
President Clinton came into office in 1993 with a promise that Washington would no longer support cigarette companies or get in the way of foreign go­vernments’ tobacco control actions. But this proved more difficult to put into practice. The 1997 Doggett Amendment, attached to appropriations bills, prohibited the Departments of Commerce, Justice and State from promoting tobacco products abroad, and a 2001 executive order further extended that prohibition to all agencies of the executive branch of government [26]. Yet US trade offices continued to challenge tobacco control measures on grounds that they violated free trade agreements [27].
Critics called attention to this double standard. Zatonski told reporters. “I feel strongly that the United States has only helped Philip Morris but has never really helped us.” He went on: “At the least, we would like to see President Clinton have the same policy for Polish children that he has for American children ”[28]. On a 1998 visit to Washington DC, Zatonski further elaborated on his response to US actions: “You want us to join NATO and fight for the free world. But how can our children fight for this if your tobacco companies target them as the replacement market for sales Philip Morris and others are loosing in the United States?” [29]. Zatonski was speaking alongside Mark Palmer, former ambassador to Hungary at the end of the Cold War, as part of a forum to raised awareness about the double standard in US foreign policy around tobacco as domestic tobacco control legislation was under debate in the US.

DEMOCRACY IS HEALTHIER

The tobacco industry expected to see an increase in cigarettes sales of 20% by the year 2000, as a result of their aggressive marketing efforts. Instead, however, the 1990s saw a 10% decline in cigarette consumption and a fall in the number of smokers [30]. While government support for tobacco control was lagging, a growing advocacy community US and Poland began working together. Help for advancing tobacco control in Poland came not from government but from journalists, voluntary organizations, and activists, part of a growing civil society movement in newly-democratic Poland. The movement was successful in advancing tobacco control legislation and turning Poland into a tobacco control success story.
In November 1990, the Institute of Oncology in Warsaw organized an international conference in Kazi­mierz titled ‘A New Tobacco Free Europe,’ with participation from the UICC, the World Health Organization, the American Cancer Society, and representatives from Central and Eastern European countries. Tom Glynn, head of the NCI tobacco control program, and Federico Welsch, NCI Associate Director for International Affairs, both attended the conference as well, having met with Zatonski during a visit to the US. The resulting Kazimierz Declaration called for a series of actions, including a tobacco advertising ban, a ban on smoking in public places, tar level reductions, cyclical health warnings, regular tax increases, and a major ongoing health campaign. The following year, Zatonski established the Health Promotion Foundation, which became a leading force for tobacco control advocacy in Poland, raising public awareness through the Great Polish Smokeout and other campaigns. The group drew on advocacy experience from the US. and other countries.
In 1995, a national tobacco control law was finally passed, following years of hard fought efforts and activity from civil society organizations. The new law banned smoking and the sale of cigarettes in healthcare centers, schools, and indoor workplaces, banned sales to minors under 18 years of age, banned radio and tv advertising for tobacco products, ordered health warnings to appear on 30 percent of at least two of the largest sides of the cigarette pack, and mandated free nicotine dependence treatment be offered. The new law put Poland in the forefront of tobacco control, with the largest pack warnings anywhere at the time. It also came about during a time of ambitious legislative activity, as a newly democratic Poland sought to import ideas from other countries. In 1999 the law was amended to ban all forms of tobacco advertising and sponsorship. Thus, by the end of the decade, the ubiquitous cigarette billboards were gone.
Now, more than 15 years after his first article, Jackson Diehl could write a very different story about tobacco and health in Poland, contrasting Poland’s progress, with rising life expectancy since the collapse of communism, with Russia’s rapidly declining health measures [15]. Diehl recalled first meeting Zatonski in 1986, describing him as a quixotic crusader with little resources to organize campaigns or influence policy at the time, but with the growth in democratic civil society and public awareness about health he can now look at the real, measurable impact his efforts have had on public health. Now surveys showed Poles to be more supportive of tobacco control laws than any other European country. And the state-of-the-art RJ Reynolds factory was now bankrupt. Zatonski, Glynn, and others who witnessed these dramatic changes have emphasized that international alliances were essential to Polish progress in tobacco control [31]. Yet it is important to note that US support for these efforts came not from US government policy, but from journalists, voluntary organizations, and activists.

CONCLUSIONS

The US and Poland share over 50 years of formal cooperation in health, with a continuous bilateral agreement in place since 1974. US government funds supported early cooperative medical and scientific research, which developed into long term collaborations between US and Polish scientists. NCI has continued to support cancer research in Poland through grants and collaborative projects, including on environmental risk factors and cancer prevention. Government-level bilateral agreements provided a framework to support exchange and collaboration between US and Polish scientists at a time when such connections were few.
Arguably the most impactful advance for health in Poland in recent decades has been the dramatic reduction in tobacco use. While the US and Poland cooperated on health in a variety of ways, the relationship around tobacco was complex, where economic and foreign policy goals sometimes weighed against public health. While tobacco control policies were being strengthened at the state and national level in the US during the 1990s, US trade representatives continued to clear the way for export of US tobacco products. Additionally, while US government support could provide technical assistance, building a civil society tobacco control movement in Poland and advocating for national policy fell to non-governmental voluntary organizations. US coope­ration had an important role here as well, but it came from organizations such as the American Cancer Society and the Advocacy Institute. The advocacy communities in both Poland and the US worked together and were critical to success in tobacco control.
Today, the tobacco landscape continues to evolve, with the marketing and uncertain regulation of electronic nicotine delivery devices, nicotine pouches, and other novel products. As use of novel products has risen rapidly among youth in both Poland and the US [32, 33], continued monitoring is critical to assess their potential impact on overall tobacco use patterns. As a changing tobacco product market continues to pose a threat to public health, and similar tactics are used by the alcohol industry, continued cooperation in research and health promotion is as important as ever.

DISCLOSURE

The authors report no conflict of interest.

References