Some items are somehow always left off the political agenda, even if they are life and death. In the midst of the Greek political and public preoccupation with the “agreement” earlier this summer, the minister of health Panayiotis Kouroumplis generated a minor furore. He proposed compulsory medical checks for detecting four forms of adult cancer in the early stages, as a means of reducing the burden on the health system, even going so far as to suggest that individuals who failed to comply would be expected to contribute towards the cost of their treatment should they later develop cancer. I do not propose to analyse here either the ethical implications of such a programme or whether his proposal meets the well-defined criteria for medical screening (it was hastily retracted). The minister’s concern with the astronomical public expenditure on cancer treatment is justifiable; but how justifiable is his lack of enthusiasm, like that of many of his predecessors, for legislation to curtail exposure to cigarette smoke?
Smoking kills – the startling black words on every cigarette packet tell us so, except that they no longer startle. I shall not provide references, they are far too numerous, but they confirm that exposure to cigarette smoke is statistically associated with cancer of the lung and larynx, chronic obstructive pulmonary disease and other potentially fatal disorders of the lungs, heart and circulation; also with less lethal but nonetheless distressing conditions, such as wrinkling of the skin and erectile dysfunction. Even second-hand smoke is hazardous, particularly to family members, including unborn babies, whose body weight and immune system and even brain development are affected by their mothers’ – and probably even their fathers’ – smoking habit. Yes, smoking creates a burden on public and family expenditure, not only through direct health costs, but also because of loss of work-years to illness and premature death. Add this to the budget balance: Every year some home fires and more than a few forest and wayside fires are caused by unextinguished cigarettes, at inestimable cost to both state and citizens.
Why, then, does somebody not do something about it? Well, for one thing, cigarettes are mentally associated with a host of other images, some of them particularly Greek: accompaniment to the first morning καφεδάκι, the little Greek coffee to clear the head – or more recently the φραππέ (frappé), often enjoyed at the wheel of the car or even on the motor cycle on the way to work; as a symbol of “maturity”, “glamour”, “non-conformity” or “virility” (μαγκιά: maggiá), reinforced by the still prevalent advertising; an integral part of the “παρέα” experience (paréa: friendly company), and particularly the night-time and “ξεφάντωμα” (xefántoma: party); for post-coital relaxation; in response to yet another wage-cut, price-rise, political gaffe… the list goes on. In the Greek countryside distances to be traversed between places were measured by the time taken to smoke a cigarette (as in Melina Mercouri’s quote above, amazingly never used in an anti-smoking campaign)
Also, we must remember that Greece has traditionally been a tobacco-producing nation. Although there has been a reduction over the last few years in both numbers of tobacco growers and overall production, there are still 58,697 farmers whose primary crop is tobacco (some in the Muslim minority population in Thrace in NE Greece for whom tobacco is an essential cash crop). In the last 2 years domestic production, at 120,000-125,000 tons, was the second largest in the EU, after Italy. About 25 tobacco processing and trading enterprises are still active in Greece, far less than in the heyday of pre-war domestic cigarette manufacture, which has been eclipsed by the aggressive importing and marketing of the multinational companies. Some of the Greek companies have been taken over, and as recently as 2013 tobacco was being used as in incentive to “invest in Greece” as arrangements were being discussed for the creation of a Philip Morris “Logistics Hub” in Agrinion, the centre of the tobacco growing region in west central Greece. On that occasion the then Prime Minister Antonis Samaras said apparently without irony, “Greece does not stop here. We will develop all our comparative advantages to make our homeland a healthy investment destination with solid new job positions, particularly for our youth”. He is at present searching for his misplaced rose-tinted spectacles.
Cigarette sales represent a large slice of the turnover of the myriad περιπτερα (períptera: kiosks) and ψιλικατζίδικα (psilikantzídika: corner shops selling a bit of everything) that are a feature of every Greek neighbourhood. What is even more relevant here, is that taxation of tobacco sales, whether domestic or imported, has always provided a hefty source of revenue for the state, which at present is desperately in need of it. Increase in the tax on cigarettes has always been a controversial option for replenishing the coffers. Former New Democracy minister Kyriakos Mitsotakis recently suggested increasing the VAT on tobacco rather than private education (on Skai TV, 19th August 2015). We may never know if he would dare to make a similar proposal while in government; but even so, the success of such a measure cannot be taken for granted. According to Euromonitor International in its most recent report, “tobacco sales recorded negative growth in 2014 for the fifth consecutive year… not a reflection of decline in consumption, but a switch to illicit trade to reduce spending.” As we recently pointed out in this blog, at least €800 million a year is lost due to sale of contraband cigarettes. We are promised that this situation is to be rectified, with new legislation on the illegal import of tobacco.
So with this background it is hardly surprising that the Greek government has dragged its feet over legislation limiting the advertising, sales and consumption of tobacco products. Quite a few laws and ministerial decrees have, in fact, come into effect over the years – 22 to be precise, beginning in 1945 with a law to forbid cigarette sellers to give gifts coupons or lottery tickets. A law was actually passed in 1952 banning smoking in all forms of transport, but obviously was not put into practice at that time. Lack of enforcement of smoking laws is a popular Greek tradition. The first time a minister of health made concerted efforts to reduce exposure to tobacco smoke was during a New Democracy government, when Spyros Doxiadis, a paediatrician in civilian life, succeeded in passing legislation banning smoking in hospitals in 1979 (which was effected, although the doctors’ offices often seemed to be rather fogged up), and in closed public areas in 1980 (which had limited success, despite the ubiquitous appearance of the anti-smoking symbol). Doxiadis also tried to introduce a national health service based on primary health care, but was sabotaged by his own party. His successor, Georgios Gennimatas, riding the triumphant wave of PASOK, succeeded in founding a National Health Service, but failed to follow up on promotion of anti-smoking. He was a heavy smoker himself and died too young of lung cancer. His colleague Melina Mercouri, who became minister of culture after a career in acting characterized by a universally recognizable husky voice, was a legendary smoker who insisted on lighting up in hospital while receiving cancer treatment; she was also a casualty of her smoking habit.
Greece’s entry into the European Community in 1981 sped up legislative activity in line with European directives. This included recommendations on the content and “quality” of cigarettes. Ashtrays disappeared from public buildings and theoretically it is now forbidden to smoke indoors except in private quarters and designated areas. Some of the rules work – cigarette advertising has been restricted in content and venue, and the depiction of smoking in films banned; Greek buses and the enclosed spaces of ferries are smoke-free, and the first journey on a domestic flight without a fug over the back five rows was a red-letter day. Public service buildings and banks are slightly less unhygienic now that cigarettes have to be extinguished outside (though stress levels remain high); but when am I going to be able to enjoy my freddo without inhaling my neighbour’s fumes? The only noticeable effect of the smoking ban in cafes is that the ashtrays are kept under the bar. The French, equally fanatic smokers, have managed to conform, why not the Greeks? Once again, “the crisis” becomes an easy excuse for our perennial policy failures.
As a Yiayia (Γιαγιά, grandmother) my clubbing days are long past, so that is the problem of my children and grandchildren. How I wish that ministerial policy would extend to the enforcement of its own anti-smoking legislation, and to the promotion of health education measures (theoretically an integral part of primary health care) to help Greece’s young people to avoid poisoning themselves and each other.
Image of Melina Merkouri from ladylike.gr