It is now one year since Yiayia first voiced her concerns on the alarming dimensions of the tobacco epidemic in Greece, and the Sunday edition of Kathimerini thoughtfully reported on the latest figures on smoking and “vaping” (“άτμισμα”, “atmisma”, i.e., electronic smoking) in Greece. This report was also well-timed, because the present Minister of Health, Andreas Xanthou has recently announced the planned introduction of legislation to forbid the use of electronic cigarettes in public places. Meanwhile, his Deputy Minister, Pavlos Polakis, a surgeon by profession, openly flouts the smoking ban in work places by lighting up in the canteen in Parliament and at press conferences in the Ministry – part of a lovingly cultivated “Cretan mountain man” persona which also includes composing threatening verse in the traditional mantináda style directed at his adversaries, and Berlusconi-style rants alleging corruption in the judiciary.
The debate over electronic cigarettes continues, with evidence to show that their use as a source of nicotine helps smokers to quit, and other evidence to suggest that new users will get addicted to nicotine and then graduate to smoking “the real thing”. Nicotine itself is harmful to the blood vessels and other elastic tissues, so “vapes” themselves are not entirely harmless to the user. Regardless of the debate, “vaping” has caught on in Greece, and the sales of electronic cigarette products is one of the few domains that has flourished during the crisis, with 300 registered specialty stores and over 1,000 sales points now operating throughout Greece. Kathemerini quotes current estimates of 200,000 systematic “vapers” among the Greek population.
Yiayia, being suspicious of what she reads in the newspapers (ever since being misquoted by the local rag at the tender age of 10), resorted to the primary source, in this case the Hellenic Statistical Authority ELSTAT, which publishes information on all aspects of life and death in Greece (no wisecracks about “Greek statistics” please; no doubt there is the inevitable conspiracy angle here too if you go looking for it, but in my professional experience I always found them reliable, professional and cooperative where population and health data were concerned). Every 5 years a Health Interview Survey (HIS) is conducted, and the findings of the most recent survey in 2014 were published this year (in English). The report shows that the percentage of regular smokers in Greece has fallen from 32% in 2009 to 27.3% in 2014, continuing a welcome trend that we noted in an earlier post. Is it possible that the Ministry of Health warnings on cigarette packets, the health education activities, the anti-smoking campaigns and the restriction on smoking in public places are actually producing results? Perhaps it is also the decreased spending power of smokers in the crisis. Although these findings are encouraging, the idea that more than one quarter of the population are still putting themselves, and the rest of us, at risk, is still alarming and is rightfully described as one of the biggest public health problems facing Greece today.
The rationale for restricting vaping is not clear. Second hand vape may be annoying to those at the next table, in the way that taking selfies or dowsing oneself in Poison are, but at least it is not loaded with the carcinogens of exhaled cigarette smoke. And arguably the government’s efforts would be better directed at enforcing existing laws, starting in their own back yard, rather than issuing new edicts. Although the existing smoking ban is largely observed in public offices and banks, it is acknowledged that its enforcement in bars, coffee shops and eating places has met with spectacular failure. This failure is confirmed by the report cited above, whose figures show that of the people who chose to eat or drink out, nine in ten had recently experienced passive smoking in coffee shops/bars, and eight in ten in restaurants/tavernas. If these numbers are anything to go by, the “vapers” have no more to fear than the traditional Greek smokers from the introduction of legislation to restrict their habit…
“The Greek Tobacco Epidemic” is the very apt title of a 162 page report prepared by the Faculty of the Harvard School of Public Health in collaboration with the Hellenic Ministries of Health and Education and the Hellenic Anti-Cancer Society and published in December 2011. It was funded by the George D Behrakis Foundation as part of the “Hellenic Action through research against Tobacco” (HEART) Project. I cite it in defence of what some followers thought were over-gloomy pronouncements in my earlier post on smoking.
Among the multiplicity of data presented in that report are the following numbers: Diseases caused by tobacco accounted for 14.4% of the total Greek health budget, with 53 deaths a day in Greece related to smoking. Bad News indeed. However there was also some Good News: Between 2006 and 2010 the prevalence of smoking dropped by 12% in the 18-24 year age-group. The Good News was confirmed in the European Journal of Public Health in October 2012 in a paper with a less catchy title, “Prevalence and determinants of tobacco use among adults in Greece: 4-year trends”. Based on the Hellas Health III survey in 2010 it was estimated that overall 41% of Greeks (45% of men and 38% of women) were smokers. Comparing the findings with the Hellas Health I survey in 2006, in the “young adult” group there was a fall from 48% in 2006 to 35% in 2010, with “a substantial reduction in the number of cigarettes smoked in all groups”.
Approaching the situation from the economic angle, a very recent publication in the British Medical Journal with another unsexy title, “Estimates of price and income elasticity in Greece. Greek debt crisis transforming cigarettes into a luxury good: an economic approach”, aimed to assess smokers’ sensitivity to cigarette price and consumer income changes, and to project health benefits of an additional tax increase. Using a statistical model the authors estimated that depending on the level of tax increase, revenue could rise while smoking could be reduced and smoking related deaths averted. Also Good News, if somewhat hypothetical. Along with increased taxation, the authors recommend that now is the time for “focused antismoking campaigns, law reinforcement (to ensure compliance with smoking bans)” but also “intensive control for smuggling”, thus keeping a one foot on either side of the fence.
Concerning focused antismoking campaigns, the HEART project, introduced above, remains ever active. It is sponsoring the 6th Three-day Conference “Education for a World without Smoking”, with scientific coverage of such topics as quitting smoking, passive smoking, the electronic cigarette and contraband tobacco. It was opened on 9th December with an event for schoolchildren at the Hellenic Ministry of Education, Research and Religion by the President of Greece Prokopis Pavlopoulos, who tossed back his white mane and presented awards to the children with winning entries in the contest “I learn not to smoke”, confessing that he himself started smoking at their age and has regretted it ever since. He was recently caught on camera cadging a light off the Mayor of Thessaloniki at an official event (above). The Minister of Education, Nikos Filis, looked on with a somewhat sheepish expression, as well he might, when his colleagues in the Ministries of Economy, Development and Tourism, Citizen Protection and Mercantile Marine and Island Policy were publicly supporting the other “Stop Smoking” movement – NO to contraband cigarettes (www.oxistaparanomatsigara.gr).
Yiayia was initially heartened when she opened the Sunday newspaper one weekend last month to find a full-page advertising spread dominated by a huge 100 euro note mutilated by a charred-edged cigarette burn. “At last” she thought “An antismoking campaign that will hit Greeks where it hurts – their pocket”. But she looked closer and found that the campaign was anti contraband smoking, and the hurting pockets were the state coffers. She looked even closer and found that she was being invited by 4 tobacco companies, 3 ministries, the municipalities of Athens and Thessaloniki, the Consumers’ Institute, and the Greek federations of tobacco processors, kiosk owners and agricultural cooperatives to join them in their fight against contraband cigarettes and loose tobacco. They even, helpfully, provided the telephone number for the hotline of the revenue office and its e-mail (firstname.lastname@example.org) for easy “κάρφωμα” (karfoma – nailing, i.e., snitching) of offenders one might happen to meet. So, in effect, the message was “DO smoke legal tobacco products and lower the country’s primary deficit”.
The full extent of import and sale of untaxed tobacco products is not known. A recent government estimate put the potential gains from a crackdown on contraband at €800 million annually.
Meanwhile, many Greeks are turning to alternative smoking experiences. The increase in the numbers of smokers rolling their own cigarettes is obvious to anybody who takes a walk around. One incentive is the price – it works out cheaper – particularly if your source is contraband. Another is the impression that you cut down on consumption, which may be true, as a lot of time is taken up with all the process of opening your kit, shaking out the shreds, licking the paper, etc.; or you cut down on risk, which is not true. Many smokers in Greece who wanted to reduce the risk have switched to “electronic cigarettes” – now one of the few growth sectors in the Greek “high street”. NOBACCO, one of the marketers of e-cigarettes in Greece, with 22 new shops in Athens, 15 throughout the rest of Greece and numerous other outlets, claims in its advertising that the “British Ministry of Health” says that e-cigarettes are 95% safer than cigarettes. Perhaps so – they don’t have the carcinogen content of cigarettes; however, their active ingredient is one ofthe constituents of cigarettes, nicotine, which contributes to cardiovascular damage. It is difficult to find data on legal sales figures for loose tobacco or e-cigarettes – an internet search just throws up advertising of the products.
It appears, then, that a combination of antismoking legislation, albeit loosely enforced in the case of bars, coffee shops and restaurants, antismoking campaigning and economic pressures, is resulting in a reduction in smoking in Greece, with fewer young people starting and seasoned smokers cutting down, switching to e-cigarettes or rolling their own. Less revenue, but less burden on health and health costs.
What is Good News for some is Bad News for others, and vice versa. Still, on the rare occasion that Yiayia decides to dine al fresco by the sea she inevitably ends up at the next table to the couple who light up between all the many dishes they order.
On the morning of Sunday 13 September 2015 yet another boat packed with refugees, mostly Syrian, entered European waters, battling heavy waves. It overturned near the rocky islet of Farmakonisi (pop. 10). The Greek coastguard rescued 68 from the sea and a further 34 managed to swim to shore, but 34 drowned, including 4 babies and 11 children. The bodies were taken to Rhodes, the administrative capital of the Dodecanese, and the survivors were taken to the island of Leros, where they were housed temporarily, pending identification procedures and issue of the documents required to continue their journey. Many of them will have to go first to Rhodes for their own, heart-rending identification procedures.
They are not the first refugees for whom Leros was the introduction into Europe. When Yiayia visited the island in 2000 there were already a few – including a young African woman whose baby, born in the excellent maternity department of the island’s general hospital, was provided with a full layette by the hospital staff. Although the larger islands, particularly Lesvos and Kos, have received greater numbers since the Syrian hostilities, Leros, with a population of less than 8,000, has been inundated. Like the other islands, it was unprepared for such numbers, and they have been camping in the hospital grounds, and in the surrounds of the island’s other hospital, the Κρατικό Θεραπευτήριο Λέρου (Leros Kratiko Therapeftirio – the Psychiatric Hospital) – in spite of protests by its board and some of the local community.
A bit of background on Leros. Leros is one of the many small beautiful islands in the Aegean, with its ruined temple, in this case dedicated to Artemis, its castle on a hilltop, its row of windmills along a ridge (now converted into studio holiday apartments), its scattered little white churches (perhaps the most picturesque is the Panaghia Kavouradena, in a cleft in the rock just above the sealine, like the crabs it takes its name from). It also has a well-tended British Military Cemetery by the sea – reminder of the World War II Battle of Leros in November 1943, when the German paratroopers took the island from the British, but not before the Aegean had claimed another victim – a downed Junkers was brought up from the bay in 2003.
Leros has all these, and more. It was under Italian administration for over 30 years, from 1912 to 1943, and because of its fine natural harbour at Lakki, extensive facilities were installed for the Italian fleet, including a whole art deco seafront and mass planting of eucalyptus trees. In 1948 Leros was united with Greece, its Italian legacy being a multiplicity of well-constructed buildings, and a scattering of Italian names. The buildings have been put to a variety of uses, including a Queen Frederiki’s craft school after the Greek civil war, and detention of political prisoners during the military Junta years. The general hospital is still housed in one complex, but the best known institution to take over the empty Italian naval buildings was the Leros “Colony of the Mentally Ill”.
The Leros Colony of the Mentally Ill opened its doors to its first 400 patients on 2/1/1958 according to Royal Decree 452/1957. Its purpose was to relieve pressure on the urban psychiatric hospitals by housing long-term patients and also to provide employment for the local population. Over the years, to the patients with chronic mental illness were added people with severe mental retardation, including children who grew up within the Colony. By the 1970s the patient population had reached 3,379. The care they received was mainly custodial. They were cut off from their families by the prohibitive cost of travelling from other parts of Greece, but well before tourism found Leros, a small industry had developed around providing for those relatives who persisted in visiting. In 1976, Presidential Decree 133/1976 renamed the institution “Leros Psychiatric Hospital”. The 1980s movement for psychiatric reform, with the EEC Regulation 815/1984, promoted deinstitutionalization of people in long-term mental health facilities. In the case of Leros this was hastened by prominent coverage in the British press and a widely broadcast investigation by Channel 4’s “Cutting Edge” documentary series.
The language of mental illness has never been famed for its political correctness, and perhaps it is a sign of progress that the word “asylum” is now associated with refugees rather than “lunatics”. The word “lunatic” has been replaced by supposedly less stigmatizing alternatives; but no euphemisms can hide the fact that Greece, while being called upon to respond to the waves of refugees being washed up on its shores, is in the midst of its own humanitarian crisis with the collapse of psychiatric reform. It is ironic that the victims of both crises find themselves cohabiting at close quarters on a tiny island out of the stream.
There will always be an unfortunate minority of people, by whatever label, whose mental capacity does not enable them to care for themselves. Many have other serious health problems which preclude care at home. Leros was called upon to provide custodial care to such people in the past, however outdated the conditions seem by today’s standards, and rose to the challenge of adapting this in line with the principles of psychiatric reform. The people of Leros are now responding to needs of its refugees, but where are the resources to support them, on either front?
Image: Alex Majoli, taken shortly after the closure of Wing 16 of the Leros Psychiatric Hospital, from thepressproject.gr. The grafitti reads “We’ve closed it and we’re leaving, 6/5/94, time 10:30, Goodbye.”
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.