Report from the witness seminar on tobacco control policy in Poland, Chief Sanitary Inspectorate, Warsaw, Poland, 31 May 2016

The witness seminar, organised by the Health Promotion Foundation (Fundacja “Promocja Zdrowia”) and hosted by the Chief Sanitary Inspectorate, brought together leading politicians, public health activists, and senior bureaucrats, some of whom have been historically involved in Poland’s anti-tobacco advocacy and policy­making, and others who continue their involvement. The format of the meeting was modelled after the witness seminar programme organised by the Wellcome Trust Centre for the History of Medicine at University College London. It has been characterised as “a particularly specialised form of oral history, where several people associated with a particular set of circumstances or events are invited to come together to discuss, debate, and agree or disagree about their memories” [1]. The seminar provided an opportunity for an in-depth, moderated discussion on the past, present, and future of tobacco control in Poland, with a particular focus on the introduction and impact of the Polish Anti-Tobacco Law of 1995 and its amendment of 1999 [2].

Background and introduction

The discussion opened with an outline of the history of anti-tobacco advocacy in Poland, a version of which has been published in the previous issue of the Journal of Health Inequalities [3]. Jan Bondar then opened the first section of the seminar, launching a discussion on the origins of Polish anti-tobacco legislation. When did the question of tobacco control policy first appear on the radar of Polish policymakers? Why were no legislative solutions introduced in the 1980s, despite several attempts of the anti-tobacco advocates? Why were the major advances made in the 1990s, in the period of post-communist transformation?

Smoking epidemiology in Poland

Witold Zatoński laid out the epidemiological picture that fueled the rising concern over smoking in Poland in the 1980s. After the Second World War, Poland experienced a rapid increase in the sale of cigarettes, which peaked in the 1980s. At the time, Poles were among the top smokers in the world with a smoking prevalence of about 80% in men and 50% in women. In the 1990s, the sale of cigarettes began to decrease. Between 1990 and 2015, it fell from 100 billion to 40 billion. These changes were followed by improving health indicators – lung cancer rates, which in the early 1990s in Poland were at one of the highest levels in the world, halved between 1990 and 2015 (Fig. 2). The most important effect of these changes was rapidly growing life expectancy, which since 1991 increased by 5 years in Polish males (Fig. 3). Between 1991 and 2002 Poland experienced one of the fastest health gains in the world. Unfortunately, this was cut short in 2002, as the price of vodka was lowered by 30% [4].

Health advocacy in communist Poland – focus on alcohol, neglect of tobacco

Józef Kozioł recalled that in the 1980s he was the chairman of the gathering of legally functioning anti- nicotine and anti-alcohol coalitions. Their members were representatives of numerous social organisations, including religious groups. Some demands for legislative anti-tobacco measures were heard but these were much less resonant than the calls for anti-alcohol legislation. The understanding of the health and social consequences of alcohol at the time was much more complete in Poland than of smoking harm. The behaviour of public figures reflected this – while smoking in public was becoming frowned upon, alcoholism was judged much more harshly. For example, Andrzej Wojtyła remembered that the medical community in the 1980s exhibited a carefree attitude towards tobacco. As a young doctor, he himself picked up smoking from other doctors during his shifts at the hospital. In this period, almost 80% of male doctors smoked, and while the awareness of harm was developing, it was offset by the fashion for smoking.
Nonetheless, the situation was slowly changing as scientists such as Professor Zatoński began to forcefully disseminate the knowledge about tobacco harm and about available cessation aids. The social awareness of smoking harm was growing. Krzysztof Kuszewski reminisced about how anti-tobacco advocates tried to exploit the political conditions to their advantage. As the declaration of martial law sparked a boycott of the state media by journalists, suddenly a lot of free airtime became available. Kuszewski and Zatoński decided to use this opportunity and developed a 13-hour health education television programme called “Your health in your hands”, which informed the viewers about the dangers of smoking. In addition, despite the lack of other tobacco control laws, some increases in tobacco prices were introduced in the 1980s. According to Józef Kozioł, these were primarily motivated by health rather than economic reasons. By the final years of the communist regime, in the years 1988-1989, the calls for anti-tobacco legislation were growing stronger.

Health policy during the early years of political transformation

In the years after the Solidarity revolution and during the overhaul of the system, the picture of tobacco control in Poland began to change. In the early 1990s, through efforts of parliamentarians including Andrzej Wojtyła, the goal to reduce by 30% the number of smokers in comparison to the 1980 rate was introduced into the National Health Programme (Narodowy Program Zdrowia). According to Wojtyła, this gave a clear direction to the changes in tobacco policy. A key figure for developing the first versions of the anti-tobacco bill at the time was the later Speaker of the Senate (the upper house of the Polish parliament), and a medical doctor, Adam Struzik. He introduced the first draft of the Anti-Tobacco Law under deliberation of the Senate in 1992. However, because the term of parliament was cut short in 1993, the bill never left the chamber and had to wait until after the next election to be re-introduced.
Jan Kopczyk recalled that as he began work in the Health Commission of the newly elected Sejm (the lower house of the Polish parliament) in 1993, there was a multitude of healthcare issues that required new legislation. The parliamentarians did not consider the question of tobacco as more important than other matters. The medical profession was governed by archaic laws from the 1950s. There was no law regulating mental health provisions or the work of nurses and obstetricians. The Ministry of Health and the whole spectrum of political parties were pushing towards fundamental changes in the health system. However, the amount of work was not an insurmountable obstacle for good policymaking. Beginning in 1993, Poland experienced a period of relative political stability, which led to the first full parliamentary term since the collapse of communism. Jan Kopczyk emphasised just how important this period of “calm, systematic work” was. The parliamentarians on the Health Commission had many months, sometimes even years, to work on the bills. They spent a year and a half introducing the final version of the Anti-Tobacco Law under deliberation, making sure it was the most comprehensive, but also politically viable, bill possible.

Importance of committed individuals

Another deciding factor behind the success of tobacco control in the mid-1990s, according to Jan Kopczyk, was the quality of policymakers in the parliament and in the Ministry of Health in this period. A significant number of deputies and senators were medical professionals, physicians, and nurses. Many of them were very experienced, not just in medical practice, but also in broader public health activity, including people like Seweryn Jurgielaniec, Krystyna Sienkiewicz, Marek Balicki, Roman Kurzbauer. They decided to divide the work up: Jan Kopczyk was put in charge of the medical profession sub-committee, Krystyna Sienkiewicz, a nurse, entrusted with the nursing sub-committee, etc. The tobacco sub-committee became the responsibility of Seweryn Jurgielaniec. However, the deputies were collaborating, working on all pieces of legislation together. Even where there was disagreement, they were willing to work towards a consensus across political divides. While there were arguments over the science, there was no opposition just for the sake of political gain, or just because the project originated from a different political grouping. The same applied to the collaboration with the Ministry of Health, between 1993 and 1997 led by Minister Jacek Żochowski. According to Krzysztof Kuszewski, Minister Żochowski was one of the most important advocates of the anti-tobacco legislation. Due to his political clout, he could lend a helping hand whenever a potentially controversial decision on the anti-tobacco bill had to be pushed through the leading political circles.
More broadly, what drove Polish policymakers at the time, in the opinion of Włodzimierz Cimoszewicz, was that they were playing the role of someone who wants to be the top of their class. As Krzysztof Kuszewski put it: “we had a common goal, we were ambitious, and we wanted to achieve something”. The politicians were eager to import what they considered “golden standards” of policy from other countries. The general feeling was that freedom and democracy shouldn’t be constrained by anything. This applied to various issues. For instance, when electoral reform was carried out, the law was amended to make it possible to start a political party with just fifteen signatures. As a result, a year later, Poland had 400 political parties registered, and in the next election 27 parties fielded candidates. The same applied to economic reforms. Politicians were keen to choose the most extreme routes, tried to formulate their policies based on ideal models and solutions. According to Cimoszewicz, this also applied to health policymaking. Krzysztof Kuszewski confirms this, remembering that in the years of transition, 14 new pieces of health legislation were passed in just four years, effectively remaking the entire fundament of the Polish healthcare system. The Polish Anti-Tobacco Law was a beneficiary of this revolutionary approach.

Access to expert knowledge

As Grzegorz Hudzik pointed out, the Polish success in reducing tobacco harm in the 1990s was rooted in the fact that the political decision-makers were willing to listen to experts and to representatives of the medical profession. Jan Kopczyk remembered that public health experts and scientists were involved in every stage of work on the tobacco bill. This meant that the members of the Health Commission in their negotiations with other politicians were always equipped with factual and scientific knowledge. Each of the members of the Commission would take these arguments back to their parliamentary club – Jurgielaniec to the left-wing Sojusz Lewicy Demokratycznej, Balicki to the centrist Unia Wolności, Kopczyk to the Polish People’s Party (PSL). This worked, and by the third reading, there were very few dissenting voices in the parliament opposing the anti-tobacco legislation. Włodzimierz Cimoszewicz added that the competency and authentic passion for tobacco control of experts such as Professor Zatoński was particularly persuasive for him during his term as Prime Minister. Facing challenging political decisions every day, and often presented with competing issues, he needed someone like Zatoński to clearly lay out where the essence of the problem was, how Poland compared to other countries, why this was the case, and how could the situation be improved.

Opposition to the legislation

Nonetheless, despite the broad consensus that an anti-tobacco law is needed, there was much disagreement on what form it should take. Andrzej Wojtyła and Jan Kopczyk recall that the bill was encountering a lot of resistance within the Council of Ministers. In addition, the representatives of the liberal opposition believed that the market will solve everything, and that tobacco should not be strongly regulated. Meanwhile, the far-right wing politicians wanted the law to be much stricter. Politically, a center ground had to be sought by health advocates, and certain compromises needed to be made to allow the passage of large health warnings on cigarette packaging, such as delaying a total ban on advertising. In addition, as soon as the Law was passed, its supporters had to fight off proposals for amendments that would limit the size of the text warnings on cigarette packaging.
There was also a strong opposition from tobacco planters. Collective farms, relics of the communist system, were collapsing and the agricultural sector was being restructured. The income of many farmers, especially in the east of the country, was largely tied to tobacco. As the Minister of Health at the time, Andrzej Wojtyła had several stormy meetings with tobacco planters. He understood that the Minister of Agriculture had to be under huge pressure not to accept the anti-tobacco legislation proposed by the Ministry of Health. However, Artur Balazs, the Minister of Agriculture at the time, chose not to oppose the anti-tobacco measures, although officially he did not support them either. His tacit agreement was instrumental in passing the 1999 amendment to the Polish Anti-Tobacco Law, which banned tobacco advertisement. The amendment did not just introduce a complete ban on tobacco advertising, but also a ban on the sponsorship of political parties by the tobacco industry. It also mandated that 0.5% of the excise tax from tobacco products must be devoted to tobacco control efforts every year. Andrzej Wojtyła remembers that to overcome the opposition on this, a political compromise had to be reached. In order to get the support of the strong and influential representation of Kashubians in the parliament, a proposal that would ban snuff, a form of tobacco consumption particularly popular among this ethnic group, had to be dropped. A ban on smoking in cars was also proposed, but was unsuccessful.

Role of the State Sanitary Inspectorate

As Andrzej Wojtyła recalled, from 1993, most of the operational tasks of state anti-tobacco activity were handed over to the State Sanitary Inspectorate (SSI). Elżbieta Łata explored the role of the SSI in depth. She recalled that the anti-tobacco effort of the SSI really started as the collaboration with Professor Zatoński was launched, first on regional, and then on a country-wide scale. The SSI became involved in organisation of the annual Great Polish Smoke-out campaign (Rzuć palenie razem z nami), and its health education and promotion specialists received training relevant to tobacco control [5]. These activities were centrally organised, which assured the campaign’s cohesiveness. The SSI ran educational programmes and pedagogical materials for children in kindergartens, primary and middle-schools, but also involved parents and caregivers. Education about the perils of smoking was conducted in most schools on the World No Smoking Day. Due to its institutional capacity and its 314 regional stations, the 650 health promotion specialists working for the SSI could reach even the most remote towns.
The SSI also collaborated closely with other major institutions in its anti-tobacco efforts. A regular cooperation with the Catholic Church, led by Cardinal Józef Glemp, was initiated. In some smaller towns and villages without the involvement of the dominant religious organisation, the SSI simply would not have the infrastructural capability of carrying out its educational activities. The SSI also collaborated with the local and provincial governments, the military, and the police, all of which proved crucial in assuring logistical support for some of the early large mass social campaigns and outdoor anti-tobacco actions.

Social and cultural change

A crucial development that allowed the success of anti-tobacco measures in Poland in the 1990s was the change in the level of awareness of smoking harm in the Polish society. Krzysztof Przewoźniak suggested that the model of three distinct phases of policy can help account for the developments in Poland. The first phase is policy formation. In the Polish case, this was when policy leaders, such as Professor Franciszek Venulet, Alfred Jaroszewicz, Professor Bogusław Kożusznik or Professor Kornel Gibiński [3], were becoming increasingly interested in the harmful effect of smoking on the human body. The phase of policy formation laying the fundaments of anti-tobacco policy in Poland, lasted from 1960s – when the knowledge of tobacco harm was beginning to take root, until the final formulation of the anti-tobacco legislation in the 1990s. The level of awareness in the elites is decisive for the formulation of a regulatory and policy framework. Włodzimierz Cimoszewicz remembered that in the early 1990s the lobby of the plenary chamber of the Polish Sejm was always filled with smoking parliamentarians and lined with a carpet that had millions of cigarette holes in it. As soon as the bell announcing a vote rang, the deputies would throw their cigarettes in the general direction of the tin ashtrays and run into the chamber of the Sejm. However, it was those same politicians who decided to implement a ban on smoking in the corridors of the Sejm much earlier than any bans on smoking in public places were introduced. Many parliamentarians voted in favor of the ban, despite being smokers themselves. This was due to the realisation that standards need to be raised and that it is the duty of politicians to perform that gesture before they attempt to regulate smoking. Cimoszewicz suspected that many of the smoking deputies themselves ignored the risk but understood that it is a question of social responsibility and that those who create legislation for the society need to go even further in their personal choices.
The second phase was that of policy implementation. The first draft of anti-tobacco legislation, which surfaced in 1983, was met with very doubtful attitudes – a state tobacco monopoly was in place and the law could cause damage to it. There was no social acceptance for such a law or understanding why it was needed. This understanding was only emerging in the medical community and among social leaders. The broader social awareness was to be decisive for how people will react to the regulatory stimulants proposed by the parliament. In Poland, for a long time, it was clear to scientists that smoking is a major cause of lung cancer and a host of deadly diseases, but the general understanding in the population was that it’s a question of probability. Each individual smoker trying to rationalise their addiction, hoped that maybe they can escape the health consequences. These destructive thinking patterns were exacerbated by anecdotal examples of public figures who smoked for many decades, yet remained healthy.
The combined effort of individuals, NGOs, and media helped to change this attitude during the third and final phase – social identification. According to Krzysztof Przewoźniak, this was the most challenging phase for anti-tobacco policy in Poland. An opinion polling institute, OBOP [6], in 1974 conducted a survey, which showed that most Poles did not believe that there is a link between smoking and negative health effects [7]. Today, this figure is down to around 20%. Social identification with the anti-tobacco policy came in the 1990s, and this was partly thanks to the Great Polish Smoke-out campaign. It was first organised in the times of fledgling democracy, when everyone believed that with a common effort everything was possible. The breath and legacy of Solidarity was still palpable and the Great Polish Smoke-out embodied the ideals of health solidarity. Later, this idealism quietened down and such radical change became more difficult. But in these times the Poles were learning how to build a civil society and the health movement formed part of those efforts.
The involvement of the dominant religious denomination – the Catholic Church – and of leading cultural figures in the tobacco control campaigns strengthened the movement. Krzysztof Przewoźniak mentioned that anti-tobacco posters, songs, caricatures, films, comedy sketches, articles, reports, radio and television programmes, were created by some of the most prominent artists and journalists of the time. An example was the song “Tylko nie pal”, written by Agnieszka Osiecka, composed by Jerzy Woy-Wojciechowski and recorded in 1997 by one of the most famous Polish singers, Maryla Rodowicz. Jan Bondar remembered that one of the icons of this involvement of the cultural world was Andrzej Pągowski, a well-known poster artist and graphic designer. His poster entitled “Papierosy są do dupy” [in free translation – “Cigarettes are shit”] proved a PR bullseye for the anti-tobacco campaign. As it stirred much controversy, and some parliamentarians were criticising the spending of public money on such ‘obscene’ campaigns, the Minister of Health Jacek Żochowski publicly defended the poster using the strong wording contained in its title . Witold Zatoński pointed out that it was precisely this brand of political and civic courage represented by Minister Żochowski that allowed to create the conditions, in which awareness of tobacco harm could grow exponentially in Poland.

Legacy of Poland’s anti-tobacco legislation

Włodzimierz Cimoszewicz pointed out that if one measures success by the number of lives saved, the Polish Anti-Tobacco Law was probably one of the most significant developments in Poland and a reason for satisfaction and pride. Its success was also widely appreciated in scientific and public health circles in western countries. Andrzej Wojtyła recalled that he only realised the true importance of the ban on tobacco advertising that he himself fought for in the parliament when he visited the USA for an American Public Health Association conference in the early 2000s. After his lecture about health system reform, a professor in the audience stood up and told him that everything he was talking about was of marginal importance, and that the greatest public health achievement in Poland after the collapse of communism was the ban on cigarette advertising and the Polish Anti-Tobacco Law.
As Krzysztof Przewoźniak pointed out, Poland in the 1990s became a very interesting place for leading western scientists. It still had the status of the country with the poorest tobacco and health indicators but at the same time, after the collapse of communism, it became more accessible for western researchers. Between the 1980s and 1990s they played an important role in helping the Polish scientific community to realise the threat posed by smoking. Witold Zatoński underlined the role of the International Agency for Research on Cancer and the American Cancer Society, which in November 1990 co-organised in Poland the conference on A Tobacco Free New Europe. It was at this conference that Poland’s anti-tobacco roadmap was designed, in the form of the Kazimierz Declaration. Some of the people who participated in the conference went on to form the core of public health advocacy in Poland.
Once Poland achieved its tobacco control success of the 1990s, the international medical and scientific circles responded with great esteem to those achievements, in the view of Krzysztof Przewoźniak. The World Health Organisation (WHO) called the Polish Anti-Tobacco Law an “example to the rest of the world” [8]. Poland became the leader of public health in Central and Eastern Europe, fulfilling most of the WHO recommendations on tobacco control. Poland implemented one of the first modern bans on the advertisement and promotion of tobacco, and of the sponsorship of media and political parties by the tobacco industry. The first quitline in the region was created in Poland. The Law contained provisions for the financing of further tobacco control efforts from the excise tax, and assuring free treatment of tobacco dependence for smokers. Poland also introduced the largest health warning labels on cigarette packs. This was particularly important, as the European Union was just starting to work on its own warnings, and the Polish example became the golden standard to be followed by other European countries. The WHO was very keen to promote the Polish example in other countries of the region. Professor Zatoński, alongside Przewoźniak and other WHO experts travelled all the countries of Central and Eastern Europe, from Uzbekistan to Bulgaria, sharing their experiences. Today, all of these countries have their own anti-tobacco legislations, many of which were modelled on the Polish Anti-Tobacco Law. Przewoźniak concluded by pointing out that unfortunately in the last decade some of these countries have overtaken Poland in the strength of their tobacco regulations.

The present and future of tobacco control in Poland

The speakers have voiced some concern about the future of tobacco control and public health more broadly in Poland. They were particularly critical of the current public health bill in Poland, as well as the decision to side-line the SSI. Andrzej Wojtyła expressed the hope that the vast network of sanitary stations, which are a unique asset of public health in Poland and have a level of operational capacity that far surpasses any NGO, will not go to waste. He remembered Andrzej Pągowski’s comment that the SSI was the only institution, which was able to disseminate his posters in a month and a half – the same task took the Ministry of Education three years. The fact that Poland is no longer at the forefront of the fight against smoking is partly because the SSI is not adequately used. Finally, criticism has been also directed at the current version of the National Cancer Programme, which placed too much stress on curative medicine and buying costly diagnostic equipment, instead of focusing on prevention and health promotion.
Aleksandra Lusawa presented some of the findings of SSI research among 15 and 19-year-old students on their perception and knowledge on smoking. Their main declared motivation to smoke was curiosity, the desire to be an adult, peer pressure, fear of exclusion, and the example given by their smoking parents. In addition, according to other research conducted by the SSI, since 2011, a decrease in the proportion of regular smokers is noticeable, from 31% in 2011 to 24% in 2015. A piece of particularly optimistic data was that 58% of Poles declared that they have never smoked. As to the perception of what are effective policies to limit smoking, respondents indicated the increase of prices, bans on smoking in public places, and mass social campaigns.
Włodzimierz Cimoszewicz praised the SSI’s focus on smoking prevention among the youth. However, he also suggested that bolder plans for future anti-tobacco activities should be drawn than just preventing new people from picking up smoking. The examples of anti-tobacco legislation in European countries with the lowest rates of smoking prevalence, such as Sweden, Belgium, or the UK, should be followed. An ambitious goal for the next decades should be formulated, for example that of lowering the smoking prevalence to 12% in the next 20 years.
Witold Zatoński concurred with this sentiment, adding that in the last decade many opportunities in tobacco control were wasted. The National Cancer Programme has been destroyed, and the proposal for the new National Health Programme is not of the best quality. He suggested that a return to the old Cancer Programme would be more beneficial. Professor Zatoński expressed his hope that the new governing body of the Ministry of Health is heading in the right direction, and that their thinking about public health and tobacco control seems to be modern and progressive – but that only time will show.
Krzysztof Przewoźniak added that proper financing of the tobacco control programme needs to be restored. As billions of złoty come into the state budget from the VAT and excise taxes on tobacco products, the 0.5% that is in theory legislated for tobacco control efforts could be a major boost for helping Poles to quit smoking. Unfortunately, very little of this money actually goes towards tobacco control. This stands in contrast with the late 1990s, when under the premiership of Jerzy Buzek, the anti-tobacco programme was well financed and as a result became one of the best public health programmes in Poland and Central and Eastern Europe, with 250 projects conducted by almost 20,000 people. The return of good financing to the tobacco control programme should be one of the main political goals of health-oriented policymakers in the near future. Andrzej Wojtyła underlined that this must form a part of a comprehensive approach to public health, not limited to smoking, regulated by strong public health legislation, and with a major involvement of the SSI. Witold Zatoński concluded by underlining that there seems to be a good atmosphere in the Ministry of Health that should be conducive towards more effective tobacco control and public health efforts. He also emphasised that it is the role of public health experts and practitioners, including the participants of the witness seminar, to help the Ministry achieve this goal.

Acknowledgments

The author would like to acknowledge the invaluable input of Prof. Martin McKee and Dr. Martin Gorsky, who have provided the counsel and training necessary to successfully conduct and analyse the witness seminar. Acknowledgements are also due to the ESRC Bloomsbury DTC for the Social Sciences, which is the funder of the author’s PhD research project on tobacco control history in Poland. Sole responsibility for this research lies with the author.

Disclosure

Author reports no conflict of interest.

References

1. Crowther SM, Reynolds LA, Tansey EM (eds.). The Medicalization of Cannabis. The transcript of a Witness Seminar held by the Wellcome Trust Centre for the History of Medicine at UCL, London, on 24 March 2009. The Trustee of the Wellcome Trust, London, 2010.
2. Zatoński M, Zatoński WA, Przewoźniak K, et al. The significance and impact of the Polish Anti-Tobacco Law. J Health Inequal 2016; 2: 32-35.
3. Zatoński M. Poland’s anti-tobacco advocacy – a historical outline. J Health Inequal 2016; 2: 26-31.
4. Zatoński WA, Sulkowska U, Zatoński MZ, et al. Alcohol taxation and premature mortality in Europe. Lancet 2015; 385: 1181.
5. Zatoński W. Droga do zdrowia. Historia przeciwdziałania epidemii chorób odtytoniowych w Polsce [The path to health. History of fighting tobacco-related diseases in Poland]. Health Promotion Foundation, Warsaw 2004.
6. Geer JG (ed.). Public opinion and polling around the world: A historical encyclopedia. ABC Clio, Oxford 2004.
7. Zatoński W, Przewoźniak K (eds.). Health consequences from smoking tobacco in Poland. Ariel, Warsaw 1992.
8. 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.