Effective protection from exposure to environmental tobacco smoke in Poland: The World Health Organization perspective.

IJOMEH 2010;23(2) 123
R E V I E W P A P E R S
International Journal of Occupational Medicine and Environmental Health 2010;23(2):123 – 131
DOI 10.2478/v10001-010-0014-7
EFFECTIVE PROTECTION FROM EXPOSURE
TO ENVIRONMENTAL TOBACCO SMOKE IN POLAND:
THE WORLD HEALTH ORGANIZATION PERSPECTIVE
DOROTA KALETA1,2, KINGA POLAŃSKA3, PIOTR WOJTYSIAK4, ANNA KOZIEŁ2,
MAGDALENA KWAŚNIEWSKA1, PAULINA MIŚKIEWICZ2, and WOJCIECH DRYGAS1
1 Medical University of Łódź, Łódź, Poland
Department of Preventive Medicine
2 The World Health Organization (WHO) Country Office for Poland, Warszawa, Poland
3 Nofer Institute of Occupational Medicine, Łódź, Poland
Department of Environmental Epidemiology
4 The Secretary of Piotrkowski District, Piotrków Trybunalski, Poland
Abstract
Tobacco is the single greatest preventable cause of death in the world today, killing approximately half of the people who
use it. Several strategies have been proved to reduce tobacco use. However, more than 50 years after the health effects of
smoking were scientifically proven, and more than 20 years after evidence confirmed the hazards from exposure to second-
hand smoke, few countries have implemented effective and recognized strategies to control the tobacco epidemic. This pa-
per summarizes the World Health Organization recommendations for effective protection from exposure to environmental
tobacco smoke along with the existing tobacco control programs and legislation in force in Poland.
Key words:
Environmental tobacco smoke exposure, Legislation, World Health Organization
Received: Jan 8, 2010. Accepted: May 23, 2010.
Address reprint requests to D. Kaleta, Department of Preventive Medicine, Medical University of Łódź, Żeligowskiego 7/9, 90-752 Łódź, Poland (e-mail: dkaleta@op.pl).
INTRODUCTION
According to the World Health Organization (WHO)
data, tobacco use causes 1 in 10 deaths among adults
worldwide, which makes up more than 5 million peo-
ple every year [1]. By 2030, unless urgent action is tak-
en, tobacco-related annual death toll will rise to more
than eight million. Data for the year 2000 indicate
that in Poland, tobacco smoking caused approximate-
ly 69 000 deaths, of which ca. 43 000 were premature
deaths of individuals aged 35–69 years [2].
Smokers are not the only group facing tobacco-related
hazards. Involuntary exposure to environmental tobacco
smoke (ETS) also has serious, and often fatal, health con-
sequences.
Involuntary smoking refers to exposure to secondhand
tobacco smoke, which is a mixture of exhaled mainstream
smoke and sidestream smoke released from the smolder-
ing cigarette or other smoking device (cigar, pipe, bidis,
etc.) and diluted with ambient air [3]. ETS is an air pol-
lutant made up of a complex mixture of around 4000 vari-
ous chemicals including 50 carcinogens, such as benzene,
1,3-butadiene, benzo[a]pyrene, 4-(methylnitrosamino)-
1-(3-pyridyl)-1-buta none, and many others [4]. It has
been estimated that the total number of smoke constitu-
ents may actually be 10–20 times the number of those
identified, meaning that tobacco smoke may contain as
many as 100 000 different chemicals. Nicotine is one of
the ETS components. Ambient nicotine concentrations

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IJOMEH 2010;23(2)124
Environmental tobacco smoke exposure
in the Polish population
According to the most recent report on “The current
status of the tobacco epidemic in Poland”, 29% of non-
smoking women and 20% of men smoke involuntarily at
home, and 19% of adults are exposed to tobacco smoke
in the workplace (24% of men and 14% of women) [2].
The most frequently indicated sites of ETS exposure
were bars and pubs (32%), discothèques and music
clubs (25%), cafés (22%) and restaurants (17%). Less
frequently indicated were health care units, cultural
venues (2%), schools (8%), and shopping centers (5%).
Moreover, current data indicate that 48% of parents do
smoke in the presence of their children, and 27% in the
presence of pregnant women.
The existing international legislation provides regulato-
ry measures and relevant tools for protection from ETS
exposure.
This paper summarizes the WHO recommendations for
effective protection from exposure to environmental
tobacco smoke, along with the existing tobacco control
programs and legal regulations in Poland.
Regulations on tobacco control
and smoking cessation activities in Poland
The Polish “Act on the Protection of Health against the
Consequences of the Use of Tobacco and Tobacco Prod-
ucts” and the “Act on Excise Duty Tax”, with executive
provisions promulgated by relevant ministers, are com-
pliant with the provisions of the WHO Framework Con-
vention for Tobacco Control, signed by Poland in 2006,
and with the relevant EU Directives [7–9].
At the time of its introduction (1995), the Tobacco Con-
trol Act passed in Poland was among the most compre-
hensive regulations of its kind in Europe. The regula-
tions specified in the Act, which include measures for
a total ban on tobacco advertising, promotion and spon-
sorship, and at least a 30% area of health warnings on
cigarette packs, are generally respected in Poland.
The Polish law also regulates the obligation of the gov-
ernment to implement actions leading to a reduction
of tobacco consumption. There have already been two
in smokers’ homes and in workplaces where smoking is
permitted typically range from 2 to 10 μg/m3 [5]. Fur-
thermore, tobacco smoke includes large quantities of
carbon monoxide, a gas that inhibits the capacity of the
blood to carry oxygen to different body tissues including
vital organs, such as the heart and brain. It also contains
a number of other substances that contribute to heart
diseases and stroke [6]. The concentrations of respirable
particles may be substantially elevated in closed spaces
where ETS exposure occurs. The composition of to-
bacco smoke inhaled involuntarily varies in quantity and
depends on the intensity of smoking as well as on the
composition of cigarettes or other smoking devices.
Exposure assessment can be carried out by measuring
relevant ETS indicators in the air, by using exposure
biomarkers as well as through epidemiological studies
employing questionnaire surveys [3]. The marker com-
pounds that are widely used for assessing the presence
and concentration of ETS in indoor air are vapour-phase
nicotine and respirable suspended particle (RSP) mass.
Airborne nicotine and 3-ethenylpyridine are specific to
tobacco combustion, while respirable suspended par-
ticles are present in large quantities, but are not unique
to ETS [3]. Nicotine exposure is also measured by test-
ing the saliva, urine, blood or hair for the presence of co-
tinine. Cotinine is a bioproduct of nicotine metabolism,
and tobacco is the only source of this biomarker [6].
It is important to notice that no level of ETS exposure
is safe. Scientific evidence has established that this ex-
posure is associated with several adverse health effects,
including lung cancer and heart disease in adults, and
asthma exacerbation, lower respiratory tract infections,
ear infections, and other diseases in infants and chil-
dren. ETS exposure increases the risk of lung cancer
by 20% in women and 30% in men [3]. Moreover, it
is linked with an increased risk of coronary heart dis-
ease [3]. It has been shown that passive smoking increas-
es the risk of acute cardiovascular event by 25–30% [3].
It has also been estimated that in the European
Union, ETS exposure is associated with about 50 000
to 100 000 deaths, and 200 000 to 400 000 nonfatal car-
diovascular events [4].

PROTECTION FROM ETS EXPOSURE: THE WHO PERSPECTIVE R E V I E W P A P E R S
IJOMEH 2010;23(2) 125
coffee shops, and more than 40% in the streets. Among
those who have never smoked cigarettes, those who have
quitted smoking and those who smoke occasionally, the
percentage of people who think that smoking should be
banned in restaurants amounted to 82%, 77% and 62%
respectively. It should be noted that half of the smok-
ers also accept that restriction. The same pattern was
observed with respect to the smoking ban in pubs, bars
and cafes but the percentages were slightly lower (never-
smokers 77%, quitters 67%, occasional smokers 54%,
active smokers 39%). More than 50% of respondents
thought that introducing the total ban to restaurants,
bars and pubs would make most of the occasional smok-
ers give up the habit. However, about 80% expected that
the active smokers would start smoking in the streets.
A recent Euro barometer opinion poll launched by the
European Commission in March 2009 shows that 73%
of EU citizens on average approve introducing smoke
free restrictions in offices and other workplaces. As for
the restaurants, 63% would definitely accept the smoking
ban (in Poland, 47% of the population would be strongly
in favor, and 28% partially in favor of the ban). As much
as 65% of EU citizens approve the smoking ban in bars,
compared to a 66% approval rate in Poland.
Taking into consideration the public expectations as well
as the actions taken in other countries in the latter half
of 2008, the Polish Parliament has intensified work on
amending the Act on the Protection of Health against
the Consequences of the Consumption of Tobacco and
Tobacco Products. It aims mainly at creating a more
restrictive environment to fight the tobacco epidemic
and includes the following activities: elimination of
the possibility of tobacco smoking in designated facili-
ties (smoking rooms) on such premises as the schools
and healthcare units; introduction of a complete ban on
tobacco smoking in eating establishments, with an op-
tion of making available separate facilities for smoking
(smoking rooms); introduction of a complete ban on to-
bacco smoking in all other public venues, e.g. at public
transport stops/stations. The legislation is also designed
to develop a more precise regulation on advertising and
promoting tobacco products, in order to prevent the
such programs. The National Health Program (NHP)
for 2007–2015 calls for a reduction in the rate of tobacco
smoking. The tasks associated with the reduction of ETS
exposure in NHP are dedicated mostly to the protection
of children from ETS exposure as well as ensure that
workplaces are free from tobacco smoke. The other ac-
tion is the “Program for Reducing Health Consequences
of Tobacco Smoking in Poland”, which also addresses
the problem of ETS exposure. The Chief Sanitary In-
spectorate is preparing yet another program for the pe-
riod of 2009–2013. Task 8 of this program is focused on
eliminating exposure to cigarette smoke in public places,
selected protected areas and workplaces.
The smoking ban in healthcare settings, educational
buildings as well as public facilities is, quoting after the
Act, a key tool to reduce ETS exposure, although the
exception of areas designated for the smokers has not
fully protected the general population from involuntary
exposure.
According to the Tobacco Act, the Ministers of Defense,
Interior and Administration, and Justice are to deter-
mine the rules of consuming tobacco products in their
respective facilities. The Act also makes it possible for
the local councils to establish, by way of a resolution, ad-
ditional smoke-free areas to those indicated in the legis-
lation (such as bus stops, parks, beaches, etc.).
Despite numerous cases of violation of the statutory
norms, substantial improvement in the protection of
non-smokers and in workplace smoking reduction have
been achieved. Limiting smoking in public places, in-
cluding bars or restaurants, proved to be an effec-
tive tool.
The survey conducted in February 2008 on a randomly
selected sample of 1137 Polish adults indicated a general
approval for a total ban of tobacco smoking in public fa-
cilities [10]. Moreover, 92% of the population accepted
the total ban on tobacco smoking in theaters and cin-
emas, as well as in public transport. More than 70% ac-
cepted smoking ban at bus stops, railway stations and
airports. The same percentage of people thought that
smoking should be banned at workplaces and restau-
rants, more than 60% accepted the ban at bars, pubs and

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IJOMEH 2010;23(2)126
smoking prevention activities: 1) tobacco cessation advice
incorporated into primary health care services; 2) easily
accessible and toll-free telephone help lines known as
‘quitlines’ and 3) access to low-cost pharmacological ther-
apy. The treatment methods vary with respect to their cost
effectiveness ratio, and may not have a similar impact on
individual tobacco users. The treatment should be adapted
to local conditions and cultures and tailored to individual
preferences and needs. Cessation counseling is most effec-
tive when it includes clear, strong and personalized advice
from health care practitioners as a part of general medical
care. Physician advice can be especially powerful when it
is related to the issues of special interest to the patient.
Warnings from health care professionals about the risks
from tobacco use are usually well received as this profes-
sional group is generally well respected. The quitting rates
also increase when the counseling is delivered by a variety
of health care workers. Well-staffed quitlines should be ac-
cessible to a country’s entire population through toll-free
numbers and waivers of access charge for mobile phone
users. Telephone quitlines are inexpensive to operate,
easily accessible, confidential and can be staffed for long
hours. They can help introduce users to tobacco depen-
dence treatment such as counseling or nicotine replace-
ment therapy. In addition to medical advice and quitlines,
effective treatment can also include pharmacological treat-
ment such as nicotine replacement therapy (NRT) in the
form of patches, gum and nasal sprays, and prescription
medicines such as bupropion or varenicline. NRT is usu-
ally available over-the-counter, whereas for other medica-
tions, a doctor’s prescription is required. Pharmacological
therapy is generally more expensive and considered to be
less cost effective than the physician advice or quitlines,
but it has been shown to double or triple the quitting rates.
The retail cost of a course of treatment with NRT may be
less than the cost of smoking over that same time period.
NRT and other medications can be covered or reimbursed
by public health services to reduce out-of-pocket expenses
for the smokers trying to quit. Pharmacological treatment
of nicotine addiction should ideally be used in conjunction
with advice and counseling, although it is also effective
when provided separately.
illicit marketing practices. As most parties are in favor
of this legislation, some of them also tend to agree that
it may even be more restrictive. The current progress as
of September 2009 indicates that it might be possible to
establish a new law by the spring of 2010.
In parallel to the Polish regulations, the public aware-
ness campaigns and smoking cessation programs were
implemented to persuade young people not to smoke,
to protect non-smokers from second-hand smoke, and
to support smokers in quitting the habit. Since 1997, the
tobacco control activities in Poland have been conducted
along the lines set forth by the National Tobacco Control
Strategy and Action Plan. Under this Action Plan, moni-
toring and evaluation of tobacco-attributable incidence
and mortality, trends and patterns in tobacco use, public
attitudes towards smoking and tobacco control policy,
and its enforcement at the national and community lev-
els are considered to be the major tasks of the strategy
which is a part of the WHO European Strategy for To-
bacco Control and the National Health Program for the
coming years.
According to the International Classification of Diseases
and Related Health Problems, 10th Revision, nicotine
addiction is classified under Chapter V “Mental and Be-
havioral Disorders” F17 “Mental and behavioral disorders
due to use of tobacco” [11]. Many tobacco users need sup-
port to quit smoking due to the high addictivity of tobacco
products. Article 14, paragraph 2(d) of the WHO FCTC
states that “each Party shall endeavour to collaborate with
other Parties to facilitate accessibility and affordability for
the treatment of tobacco dependence including pharma-
ceutical products pursuant to Article 22. Such products
and their constituents may include medicines, products
used to administer medicines and diagnostics when appro-
priate” [9]. To date, over 160 WHO Member States are
bound by international law to implement the measures
specified in Article 14 of the WHO FCTC. In other words,
increased access to tobacco dependence treatment is man-
dated by the force of international legislation.
The health care systems in particular Member States take
the primary responsibility for the treatment of tobacco ad-
diction. Three types of treatment should be included in any

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IJOMEH 2010;23(2) 127
It is also known that the funds provided by NHF do not
cover the total expenses related to that service. This could
be one of the reasons why the numbers quoted above are
not very high. In April 2009, the College of General Prac-
titioners released a report on the number of patients who
received counseling on smoking cessation from the fam-
ily doctors since the onset of contracting the service. The
report showed that 20 000 patients in total had been pro-
vided with anti-smoking counseling [2].
Another way to help the smokers who want to quit is
a telephone quitline service. The Maria Sklodowska-Curie
Memorial Cancer Centre and Institute of Oncology is the
body responsible for implementing this task. No public
data are available regarding the number of calls or the ef-
fectiveness of the service.
These smokers support tools seem not to be enough for
around 9 million smokers in Poland in terms of the popu-
lation coverage.
WHO policies for protection
from exposure to environmental tobacco smoke
In 2003, the World Health Assembly unanimously adopt-
ed the WHO Framework Convention on Tobacco Con-
trol (FCTC) in order to initiate action at the global and
country level against the tobacco epidemic [9]. According
to Article 8 of the WHO FCTC, “each Party shall adopt
and implement in areas of existing national jurisdiction
as determined by national law and actively promote at
other jurisdictional levels the adoption and implementa-
tion of effective legislative, executive, administrative and/
or other measures, providing for protection from exposure
to tobacco smoke in indoor workplaces, public transport,
indoor public places and, as appropriate, other public
places”.
To expand the combat against the tobacco epidemic, WHO
has introduced the MPOWER package of six proven
policies [1]. These policies are focused on active and pas-
sive smokers and intended to reduce the ETS exposure.
The objectives can be reached in two ways: firstly, by pro-
tecting non-smokers from ETS exposure, and secondly, by
decreasing the number of smokers and consequently the
number of people exposed to ETS.
In Poland, the Chief Sanitary Inspectorate is a coordi-
nating body for the implementation of the National
Program to Reduce the Burden of Tobacco Use. One
of the objectives of the National Program is to increase
the percentage of young people who quit smoking and to
decrease the percentage of daily tobacco smokers who
are over 20 years of age. In order to achieve these ob-
jectives, some actions are being proposed, like smoking
prevention and tobacco addiction treatment in health
care centers. These include a brief advice from the pri-
mary physicians and nurses, the treatment for tobacco
dependence offered through “cessation centers”, as well
as anti-smoking education and cessation training. Some
of these centers are funded by local governments. The
activities for tobacco control, prevention of tobacco-
related diseases and treatment of dependencies are car-
ried out under the contract with the National Health
Fund (NHF) [2]. NHF secures the funds for cessation by
contracting health care professionals who provide them
(It has been found that not all available funds are being
contracted). Support is also offered in addiction manage-
ment at the addiction treatment and mental health cen-
ters. The total expenditure on the treatment provided by
anti-smoking clinics exceeded 86 000 PLN (21 000 EUR)
in 2005, through almost 50 000 PLN (13 000 EUR)
in 2006 to over 50 000 PLN (13 500 EUR) in 2007 [2].
The rules for contracting health programs were established
in 2008. The basic stages of the prophylactic activities have
been designated to primary health care physicians. Every
provider who meets the mandatory criteria of the National
Health Fund can carry out such a program.
Over the years, the contracting of services for the preven-
tion of tobacco-related diseases has increased at various
levels. Expenditure on the basic activities which reached
the level of 9000 PLN (2250 EUR) in 2005 increased to
the level exceeding 2 300 000 PLN (575 000 EUR) in 2006.
The health programs provided care to over 6000 individu-
als in 2005 and over 58 000 individuals in 2006. Expendi-
ture on the specialist activities amounted to 230 000 PLN
(57 500 EUR) in 2005, approximated 600 000 PLN
(150 000 EUR) in 2006 and exceeded 560 000 PLN
(140 000 EUR) in 2007 [2].