Background: Smoking is one of the largest public heath problems and a cause of major concern not only among European members such as Greece but also worldwide. Greece over the past years has been suffering from a smoking epidemic with dramatic consequences on the economy and the cost of health services. Therefore, the purpose of this study is to describe the extent of tobacco usage, the methods used to control tobacco consumption, and the main reasons of anti-tobacco legislation failure over the past decades in Greece. Methods: Data were collected from the international PubMed database and from the Greek database, Iatrotek, during January 2006 and the tobacco legislation was discussed with other counterparts in Greece and was rechecked with the Greek ministry of Health and Social Welfare. Results: Currently Greece has the highest smoking prevalence not only among members of the European Union but also among all members of the OECD. Recent epidemiological studies estimate that 40% of the adult population are daily smokers, with one in two adolescents in certain areas also current smokers. Although anti-smoking policies do exist, and have been enforced over the years, many factors have contributed to their failure with a pro-tobacco culture and an increasing number of adolescent smokers exacerbating the problem. Conclusions: It is obvious that the strict enforcement of a nationwide anti-tobacco policy must be a priority on the national health agenda, if we are to ever effectively combat the high prevalence of smoking in Greece.
Smoking is one of the largest public heath problems and a cause of major concern not only among European members such as Greece, but also worldwide. Although Greece is suffering from a smoking epidemic, there is insufficient international scientific literature on the health hazard that dramatically affects the economy and welfare of the Greek population. Therefore, the purpose of this study is to describe the extent of tobacco usage, the methods used to control tobacco consumption, and the main reasons of anti-tobacco legislation failure over the past decades in Greece.
Data were collected from the international Pubmed database and from the Greek database, Iatrotek, during January 2006. Only population-based epidemiological studies were included. Iatrotek articles are written in Greek (with an English abstract) and are not easily available to researchers in other countries, resulting in the fact that their findings on smoking prevalence in Greece are most often left out of international literature. The current tobacco legislation was discussed with other counterparts in Greece and was rechecked by visiting the web page of the Greek ministry of Health and Social Welfare.1
Greece has one of the highest percentages of adult tobacco use worldwide, and the highest adult percentage of current tobacco use among OECD countries.2 Recent epidemiological studies estimate different prevalences, according to the age group and place of residence. City areas, such as Athens, have higher smoking rates among men and women (51% of men and 39% of women3) than rural areas. The difference is more noticeable between Greek women in cities and rural areas. Those of higher socioeconomic position are more likely to smoke than the less educated or those of lower income.4 Women in rural areas also smoke less, possibly owing to the existing traditional culture that regards female smoking a taboo.
Adolescents in Greece have a major smoking problem. According to recent studies on the usage of tobacco among high-school students, smoking prevalence ranged from 10 to 32% for 15 year olds (again depending on the location),5,6 to a maximum of 50% in 16–19 year olds.7 Smoking prevalence among university students ranged between 28 and 30% for medical students8,9 and between 42 and 44% for other university students.10 An alarming factor is the similar smoking habits between males and females,10 especially in the age group of 16–24. A summary of all relevant publications in Pubmed and the Greek medical database, IATROTEK, published between 2000 and 2005, on smoking prevalence in Greece, is shown in Table 1.
studies on smoking prevalence in Greece (Published 2000-2005)
Huisman et al.12
High School students
Labiris et al.7
High School students
Northern Greek cities
Sichletidis L et al.11
Mammas et al.8
Avlonitou et al.9
Pitsavos et al.3
Linardakis et al.5
University Students (Non health studies)
Steptoe et al.10
High School students
Kokkevi et al.6
i Year published
ii Only population based epidemiological studies included found in Pubmed and the Greek medical database Iatrotek
iii Based on the European Community Household Panel Survey
Regarding adolescent tobacco use, no nationwide smoking research has been done and there are no data that is representative of the entire Greek population. Only separate studies exist for different locations and since demographically the population is spread out with a substantial percentage living on the islands or in rural areas, adolescent smoking prevalence most probably differs within the population.
Passive smoking and the effects of environmental tobacco smoke also affect the total population, but Greek children and adolescents are the most vulnerable; it is likely that they are already predisposed to start smoking, not only from growing up with the familiarity of cigarettes but also owing to environmental tobacco smoke addiction, which has been suggested as being an independent predictor of adolescent smoking.11
The price of tobacco products is one of the main causes of the problem. Tobacco products, mainly cigarettes, are still relatively cheap compared with the price of cigarettes in other country members of the European Union14 and, therefore, easily accessible to adolescents, even those with limited spending power. Suggestions have been made to enforce higher taxes and to raise the price of tobacco products. Such actions would probably lead, as shown in other countries, to a decrease in tobacco consumption and to an increase in the population's health status.15 On the other hand, since Greece has been classified as a medium tobacco smuggling country16 (with a contraband market share of 8%), and keeping in mind its geographical location and large number of islands, one can deduce that efforts to raise prices and taxes would possibly be counterbalanced by an increase in tobacco smuggling.
Taking into account the low price of cigarettes and the non-existence of any law forbidding the sale of tobacco products to minors, children are susceptible to tobacco advertising and are targeted by tobacco companies. Anti-tobacco education is not incorporated into the school curriculum, and although school smoking prevention legislation does exist, it is not always enforced. Smoking by students and teachers in school grounds does take place, thus, demonstrating the inadequate enforcement of such legislation.
Many factors are responsible for Greece's current anti-tobacco policy failure.17 Smoking is a socially accepted habit and is embraced by a large part of the culture in which tolerance and freewill play an important role. Greece is also a tobacco producing country where the agricultural produce in some regions is largely tobacco, thus, creating a pro tobacco norm. As shown above, with such a high smoking prevalence and with a culture and economy that supports in certain areas tobacco use, there is insufficient basis for the efficient implementation of anti-smoking campaigns. During 1978–1980, Greece attempted and, for a limited time, efficiently conducted its only ever nationwide anti-smoking campaign. The national ban on tobacco advertising on broadcasting media enforced in 1979 gave rather unimpressive results. However, when the campaign became rather aggressive with repeated anti-smoking messages and the circulation of posters and booklets the annual increase in tobacco consumption dropped to nearly 0%. When the campaign stopped 2 years later tobacco consumption returned to prior rates.18
Television and radio advertisements of tobacco products have been banned since then, but only recently (August, 2005) did Greece comply with the European directive 2003/3/EC on the advertising and sponsorship of tobacco products, forbidding their free distribution, promotion, sponsorship, or advertising. The newly passed Greek law forbids advertisement of such products in magazines and the press but allows tobacco companies to freely advertise using posters and billboards.
Introducing tobacco-free zones in public transport, and in private-sector and public-sector workplaces, and creating smoking cessation clinics have been at the forefront of suggested measures by many ministries. Although some measures have been brought into action, most ministries seem afraid to face the tobacco companies' pressure and keep such ideas on the drawing board. As for laws on tobacco control, many loopholes exist; for example, a ban on smoking in the private-sector workplace although passed by law, depends on the employer who has the final decision whether or not smoking is to be permitted in the workplace. In certain cases smokers, especially in the public-sector workplace, bluntly ignore such rules since most directing bodies turn a blind eye or do not risk confronting smokers over such matters.
Greece complied with the EU Directive on Tobacco Product Regulation (EU Directive 2001/37/EC) and introduced large warning labels on tobacco-product packages, and although generally they were thought to have produced some positive results, they do not always affect Greek smokers, in particular they do not seem to affect Greek male smokers who regard the labelling as pointless and invasive.19 European guidelines do exist for adopting colour photographs and illustrations as health warnings on tobacco packages (EU Directive 2001/37/EC), a method that could be introduced in Greece. Such labels expose current (and/or candidate) smokers many times daily to a tobacco control intervention measure every time they reach for the packet.20 The effects though of such graphic labels on smoking habits are controversial. Although they are said to reduce tobacco consumption and increase the tendency to quit, they can also induce defensive reactions in smokers, who in turn might tend to get rid of the fear or disgust instead of facing the threat itself.20,21 The public health benefits of such an intervention though would outweigh any negative reactions by some Greek adults and adolescents. A pilot study to observe the possible reactions and asses the results of graphic labels on tobacco products would be valuable.
Obviously, since Greece's smoking epidemic mostly seems to affect adolescents and students, (male and female) one can see the need for anti-tobacco intervention programmes aimed at the younger people. High smoking rates in these populations will inevitably lead to higher adult smoking rates in the future, continuing the tobacco epidemic. School-based health intervention programmes have been implemented in certain areas in Greece leading to a decrease in smoking among children in the targeted group, even though, and as stated in numerous reviews, there are relatively no long-term effects from such intervention programmes on their own.5,7,22 Combinations of social influence interventions and school-based interventions have never been enforced but would probably produce more positive results, even though the population's pro tobacco norm might make the implementation of such measures difficult. A national anti-smoking movement, such as the one mentioned above, in combination with continuous school and socially based intervention programmes would probably give the best results, since it has been shown to be effective on the Greek population in the past.
In summary, tobacco policies that exist in Greece have been ineffective in combating a habit that affects the population so widely. Since tobacco-related diseases have a high health and economical cost, it is obvious that the strict enforcement of a nationwide anti-tobacco policy must be a priority on the national health agenda, if we are to ever effectively combat the high prevalence of smoking in Greece.
Conflict of interest
This short report was presented orally at the 4th Annual Conference of the International Society for the Prevention of Tobacco Induced Diseases in Athens, Greece, 30 September –2 October 2005 (2005 PTID Conference) with the title ‘Tobacco policy in Greece and the necessity for future intervention’.
Recent smoking prevalence data as reviewed in this paper:
States the extent of Greece's smoking problem.
Questions the effectiveness of existing anti-tobacco regulations.
Stresses the need for more effective nationwide actions to be taken.