Introduction

The World Health Organization states that the tobacco smoking epidemic remains the largest international public health challenge killing more than 8 million people annually, including 1.2 million deaths from passive smoking [1].

In Poland, it is estimated that tobacco is used by 26% of adult Poles (32% of men and 20% of women) every day, and so Poland ranks 12th in the European Union. Most smokers are found in Greece - 42%, followed by Bulgaria - 38% and Croatia - 36%, while the least smokers are in Sweden - 7%, the Netherlands - 12%, and Finland - 15%. The anti-smoking activities in Poland in recent years may be considered effective since the number of people using tobacco products decreased by 9% compared to 2006 [2].

The current research suggests that exposure to tobacco smoke contributes to many disorders (including lung disorders and myocardial infarction, chronic pulmonary disease, cancer, and diabetes). At the same time, considering the COVID-19 epidemic which may exacerbate those diseases, promotion of smoking cessation seems even more important [3]. All the more so that the vast majority of smokers in Poland declare that knowing the negative impact of COVID-19 on the respiratory system did not lead to them reducing their nicotine consumption. The youngest smokers are particularly discernible here, who generally declare no limitations in that respect [4].

Taking all of this into account, it is important to implement educational programs aimed at raising awareness among Poles about the consequences of tobacco smoking. Since 1997, the activities carried out at the central level have been included in the Program for Prevention of Health Consequences of Smoking in Poland published by the Council of Ministers based on Article 4 of the Act on health prevention against consequences of tobacco and tobacco product use of November 9^th, 1995 (Journal of Laws of 2021, item 276) [5].  Since 2007, under the authority of the Minister of Health, the implementation, and coordination of this program was the responsibility of the Chief Health Officer. Due to the interpretation issues of Article 4 of the Act regarding the financing of the program, while working on the Public Health Act [6], it was decided to repeal Article 4 and to include actions to limit smoking of tobacco products in the National Health Program from 2018 onwards.

Recently, at the national level, actions have also been taken for primary prevention and detection of selected tobacco-related disorders (such as the Prevention of chronic obstructive pulmonary disease “Take a deep breath” program [7], the Polish national cerebrovascular disease prevention program (ICD10: I60-I69) [8], the Prevention and treatment of cardiovascular diseases program POLKARD [9] or the National Oncology Strategy [10]).

Due to a large number of anti-smoking programs implemented in Poland, it seems appropriate to carry out an analysis of whether the selected programs do not duplicate the same proposals for action and whether the proposed indicators for their implementation adequately assess their effectiveness.

Materials and Methods

This study is a retrospective analysis of data on national health prevention programs for tobacco-related disorders implemented in Poland between 2016 and 2022. We analyzed the national health prevention programs coordinated by the Ministry of Health between 2016 and 2022. Based on the data available on the official websites of the Ministry of Health and the National Health Fund, including the Public Information Bulletin of the Ministry of Health, twelve national health prevention programs were identified coordinated by the Ministry of Health relating to tobacco use reduction (Table 1). The objectives of each program were analyzed, emphasizing the type of intervention and the target group. The scope of the programs usually covered prevention and early diagnosis of selected tobacco-related disorders (cancer, COPD, stroke, heart disease, type 2 diabetes). For 9 out of the 12 programs, the anti-smoking measures were considered a secondary objective without any specific and targeted anti-smoking interventions. Three programs were included in the final analysis, which covered anti-smoking actions as one of their main objectives.

The following programs were analyzed in detail:

·       the Prevention of tobacco-related disorders program (including COPD);

·       the National Oncology Strategy;

·       the National Health Program.

The detailed analysis included the publications by the Ministry of Health and the subordinate agencies responsible for the implementation of each program. During the analysis, we compared the strategic objectives regarding tobacco, the proposed target groups, the planned actions, and the performance indicators.

A detailed analysis of those programs was conducted as they all include comprehensive preventive measures while identifying the precise tasks involved in reducing tobacco consumption. In addition, the prevention program for tobacco-related disorders (including COPD) is currently the only program dedicated entirely to smoking reduction. Moreover, on July 7^th, 2022, the National Oncology Strategy was significantly amended.

Since 1997, anti-smoking actions have been a part of the Program for the reduction of health consequences of tobacco smoking in Poland. This program was implemented in accordance with the provisions of Article 4 of the previously mentioned Act on health prevention against consequences of the use of tobacco and tobacco products, which states that the Council of Ministers establishes a program setting out health, social and economic policies aimed at reducing the use of tobacco products, which should be financed by the state budget at the level of 0.5% of the excise tax on tobacco products. Due to the interpretation issues regarding the financing of anti-smoking actions, while working on the Public Health Act of September 11^th, 2015 (Journal of Laws of 2015, item 1916), this Article has been repealed. Since January 1^st, 2018, the activities relating to reducing exposure to tobacco smoke have been included in the operational objective 2: Prevention of addiction, contained in the Regulation of the Council of Ministers of March 30^th, 2021 on the National Health Program for years 2021 - 2025 (Journal of Laws item 642).

Results

A comparative analysis of each national program for the prevention of tobacco-related disorders is presented in Table 2. The public administration responsible for the implementation of national anti-smoking prevention programs in Poland is the Ministry of Health. The coordination of a program is also transferred to agencies subordinate to the Ministry of Health (e.g. the Maria Skłodowska-Curie National Research Institute is responsible for the implementation of the National Oncology Strategy [11] ).

The legal basis for the operation of national campaigns is usually the regulations of the Council of Ministers, which describe the objectives, scope, and expected effects of a program in detail (e.g. the Regulation of the Council of Ministers of March 30th 2021on the National Health Program for years 2021 - 2025 [12], the Regulation of the Minister of Health of November 6^th, 2013 on guaranteed services of health programs (Journal of Laws of 2020, item 2209)[13]).

The current prevention programs implement comprehensive health-promoting activities, one of which is the reduction of tobacco consumption. This is directly reflected in the financing of such activities.

In the three studied programs, the proposed strategic objective of anti-smoking prevention can be considered the same, namely, it is supporting the reduction of tobacco product consumption, which is supposed to reduce the number of tobacco-related disorders (particularly the incidence of tobacco-related cancer).

The authors of the National Health Program and the Prevention of tobacco-related disorders program (including COPD) do not set a specific target for the reduction of tobacco-related disorders by using general performance indicators such as ‘reducing mortality in tobacco-related disorders’.  The performance indicators are clearly defined in the National Oncology Strategy, which sets specific targets, but the methodology of their estimation remains unclear.

The target groups of the three studied programs were defined as the general public over the age of 15. As part of the prevention of tobacco-related disorders program (including COPD), the Regulation of the Minister of Health of June 10^th, 2022 amending the Regulation on guaranteed services of health programs [14] was published on July 7^th, 2022; one of the most important elements of this program is that the specialty care level should be offered to patients over the age of 16 (until now the program has only been dedicated to adults).

The proposed anti-smoking prevention actions are primarily aimed at supporting the creation of the Clinics for Support of Smokers, as well as organizing training for medical staff, covering so-called ‘rapid anti-smoking interventions’.

The detailed comparative analysis is presented in Table 2.

Discussion

Currently, anti-smoking actions financed by the state budget are implemented as part of national health programs, such as the National Health Program or the National Oncology Strategy. The lack of one comprehensive anti-smoking program makes the proposed actions redundant and focused primarily on creating Clinics for Support of Smokers and training of medical staff to assist patients. Those actions are most often carried out because they have proven effective. Even a short intervention (< 3 minutes) given to a person addicted to tobacco affects the rate of smoking reduction (OR = 1.66; 95% CI, 1.42 – 1.94) and is highly cost-effective [15]. It is necessary to implement those actions because, according to the information in the commentary to the previously mentioned amendment to the Regulation on guaranteed services of health programs, there are currently ten anti-smoking clinics nationwide representing the specialty care level in the anti-smoking program. [16] Ensuring an adequate number of clinics is one of the most important elements in the update of the Prevention of tobacco-related disorders program (including COPD). The next step should be to ensure adequate funding for this program. Allocating financial resources is necessary for the implementation of Article 14 of the Framework Convention on Tobacco Control (FCTC) [17], to which Poland is also a party [18], indicating the need to develop and implement effective programs to encourage smoking cessation. Considering Article 26 of the FCTC, each Party should provide financial support for its own national efforts aimed at achieving the objective of the Convention, in accordance with its national plans, priorities and programs.

There are many possible ways to finance health programs by transferring the costs of their implementation to industry and retail outlets selling tobacco products, for example by developing appropriate taxation, licensing fees for tobacco production, import and sales, implementing registration fees or introducing annual fees for control of tobacco products [19].

The definition of a single comprehensive anti-smoking program could improve the effectiveness of anti-smoking actions by adapting their content to different target groups (e.g. appropriate for the consumer’s age). The development of such programs would make it possible to determine the amount of financial resources allocated to anti-smoking actions alone, because currently the overall funding for all actions is determined for each health program, which certainly makes it difficult to plan its implementation.

In addition, there is currently no institution that could fully coordinate anti-smoking activities carried out under a single program through e.g. adequate funding and quality control of the developed actions. According to the Polish experts in this field: a continued cooperation between governmental institutions and NGOs, as well as adequately funded health programs themselves, would make Poland one of the leading countries in terms of tobacco control, and would significantly improve public health indicators [20].

Another challenge is to establish verifiable performance indicators. Reducing the incidence of tobacco-related disorders is an interdisciplinary challenge. Smoking cessation support consists of a number of elements such as increasing tobacco prices, increasing excise tax, or implementing provisions of directives governing the tobacco market. With this in mind, it is difficult to identify the direct impact of a program on e.g. achieving reduction in the rate of tobacco-related disorders. It is, therefore, appropriate to keep the general performance indicators without providing any specific values. Moreover, continuation of the current anti-smoking intervention programs could reduce premature deaths (before age 65) by up to half [21], which would allow Poland to catch up with public health leaders such as Sweden.

Training of medical staff is an important element of anti-smoking prevention; however, young people who start using nicotine-based products acquire knowledge about the harmful effects of smoking in their school environment. Therefore, educational activities should be taken to promote anti-smoking attitudes among children and adolescents. Young people are keen to participate in such education programs, however, it is important to regularly update materials and adapt to the new public health challenges such as electronic cigarettes and heated tobacco products. It is estimated that about 28% of boys and 18.6% of girls aged 13 - 15 use e-cigarettes in Poland. Poland has one of the highest rates of e-cigarette use among teenagers [22].

Moreover, since 2019, we have seen an increase in the percentage of users of heated tobacco products (from 0.4% to 4%); interestingly, the rate of daily heated tobacco consumption almost tripled in the economically active population [23].

As smoking initiation starts at school age, promoting the reduction of tobacco use, including heated tobacco products and electronic cigarettes, should be prioritized in this target group, accompanied by adapting education campaigns to specific disorders caused by tobacco smoking.

Gender, age, and smoking are indeed correlated with the level of awareness of smoking-related disorders, and it is, therefore, also important to implement educational campaigns that clearly point out the health effects of tobacco use (especially non-respiratory diseases), adapted to different disease groups [24]. The available data suggest that up to 50% of patients who smoked before the diagnosis of cancer still smoke during treatment, unaware of the harm associated with continued tobacco use, and the underestimated benefits of smoking cessation after the diagnosis of cancer; such benefits include reduced risk of death by 30% up to 40% [25].

Our study has practical implications for actions undertaken as part of health programs aimed at reducing tobacco smoking. First of all, it pointed out the need to establish a single comprehensive anti-smoking program, which is guaranteed to limit double funding of the same activities carried out in different preventive programs. Furthermore, it was pointed out that there is currently no single coordinating institution in Poland for anti-smoking prevention and that there is no education on tobacco-related disorders adapted to different target groups.

The limitations of our study should also be mentioned. Only three national programs have been selected for the analysis; at the same time, the role of local authorities should be emphasized, which have their own public funds dedicated to the implementation of local prevention activities. It is the local authorities that are largely responsible for developing appropriate health programs for disease prevention and health promotion, including activities aimed at reducing tobacco smoking.

Conclusions

At the national level, there is currently no single comprehensive program to limit the use of nicotine products. Such activities are currently one of the elements of many health programs targeted toward the general public. Therefore, some actions are the same in different programs (including the promotion of anti-smoking counseling and medical staff training).

To effectively reduce smoking, it is necessary to develop a single comprehensive program with adequate funding. It should take into account different target groups and it should be coordinated by one of the agencies subordinate to the Minister of Health.

It is also important that the developed performance indicators are achievable; also, it is important to be aware that reducing the incidence of tobacco-related disorders is an activity that is influenced by various components, which indicates its interdisciplinary nature. 

Charts and Figures

Table I. National health prevention programs were identified coordinated by the Ministry of Health relating to tobacco use reduction.

Table II. Comparative analysis of programs which covered anti-smoking actions as one of their main objectives.

Authors disclose no conflict of interest.