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- Smoking and Health
Passive exposure to smoke is a major global public health issue. It has led to the formation of the WHO Framework Convention for Tobacco Control (FCTC)2 in order to protect the public. As the FCTC was ratified in 2009 in Greece, there is a great need to enforce the implemented legislation.
Passive smoking can be argued as a violation of human rights especially among vulnerable populations such as pregnant women and children but also in the broader sense of Healthcare and Workplace Health and Safety sectors.
What is Passive smoking? Passive smoking is the inhalation of side-stream tobacco smoke produced by other people who actively smoke near us.1 This includes but is not limited to, cigarettes, rolled cigarettes, cigars, pipes and water-pipe smoking but also from novel products such as electronic cigarettes.
Exposure to second-hand smoke occurs mainly:1
- At home (smoking parent, spouse, brother, etc.)
- In workplaces (offices, shops, public services, etc.)
- In entertainment venues (cafes, bars, restaurants, nightclubs, etc.)
- In vehicles (public transport, private cars, etc.)
Smoke pollution in an enclosed space is produced by:
- The smoke exhaled by the smoker (also known as mainstream smoke)
- Smoke released by the burning cigarette itself (side-stream smoke)
- Both mainstream and/or side-stream smoke are considered “second-hand smoke”*
- The invisible residue from the smoke that has settled onto surfaces such as furniture, carpets and curtains but also on clothes and hair (termed third-hand smoke). This toxic mixture contains heavy metals, carcinogens and radioactive elements, exposing bystanders for example a toddler who unsuspectingly crawls on the floor and then puts his hands in his mouth. Third-hand smoke remains on surfaces even if this space has good air circulation.
*In the case of e-cigarettes, they also produce environmental pollution in the form of an aerosol termed, “second-hand aerosol”.3
Health Effects from Passive Smoking
The strong link between passive smoking and disease has been known since 1981, when research conducted by Professor D. Trichopoulos at the Medical School of the University of Athens was amongst the first to report the dangers associated with passive smoking.7 Today, it is considered the third-most preventable cause of death and disease. Lung cancer, the 4th cause of all deaths globally,8 has been firmly established as a health effect causally related not only to active smoking but also to second-hand smoke exposure.9,10
According to a World Health Organization in 2018, passive smoking (being exposed to second-hand smoke of others) causes 890 000 premature deaths of non-smokers every year. 11
Among adults who have never smoked, passive smoking causes heart disease, stroke and lung cancer.1 According to the US CDC, second-hand smoke among children causes ear infections, asthma attacks and respiratory symptoms and infections (such as bronchitis and pneumonia).1 In 2004, 28% of deaths from passive smoking were children.11
Also seriously affected from the effects of exposure to passive smoke are pregnant women and their unborn babies. Pregnant women repeatedly exposed to passive smoke are at risk to have abnormal fetal development, increased incidence of placental abruption, bleeding, or premature rupture of membranes.10 Passive smoking has also been shown to be associated with low birth weight newborns, sudden infant death syndrome11 and childhood behavioural disorders such as hyperactivity and attention deficit disorder.12
Passive Smoking at home
According to the Eurobarometer 332 on the attitudes towards tobacco in 2009, the reported rate of second-hand smoke exposure in Greek homes was 45% and 47% in Cyprus, the highest rates in all of the EU.4 This is especially important as children are most likely to be exposed at home as opposed to workplaces or entertainment venues. Children are considered a vulnerable population as they are not able to control or avoid the home/environment where second-hand exposure occurs. Current research is being conducted in Greece on the levels of environmental pollution produced in homes that have at children who reside in the home and one parent who smokes.
Passive Smoking at Work
In terms of second-hand smoke exposure in the workplace, the Eurobarometer 332 reported only 42% of respondents were not exposed to passive smoking in their workplace, while 18% who were employed, said they were exposed to passive smoke more than five hours per day at work. By gender, men were more likely than women to be exposed to cigarette smoke while at work. Furthermore, the younger than the respondents were, the more likely they were to be exposed in the workplace. Specifically, 33% of respondents aged 18-24 stated they were exposed to cigarette smoke at work.4 Furthermore, it should be considered that blue-collar workers and service workers and construction workers are more at risk than other groups.1
Passive Smoking in Restaurants and Bars
According to the Eurobarometer 332, Greece had the highest rate of exposure to second-hand smoke in the EU in establishments such as restaurants and bars (72% and 78%, respectively).4 However, in as recent as 2017, the exposure to passive smoke in restaurants and bars in Greece was 78% and 87%, respectively,5 while generally, 96.6% of Greeks reported that they were exposed to SHS in the past year.6 The rate of passive smoke exposure is very high in Greece and is increasing, regardless of a national smoking ban law that was implemented in Greece in 2010 for all public places as it has never been enforced since.
Passive Smoking in Cars
In 2009, 62% of smokers in Greece allowed smoking in their cars. In Greece a law that prohibits smoking in cars that have children under the age of 18 years old is in place. The cost of infarction is 1,500 euros. This is one way in which the use of smoking bans can reduce the amount of second-hand smoking in children.
Declaration by Greek Students
Greece’s Innovative Proposition to Europe:
The Declaration of 10,329 Greek Students to treat Passive Smoking as a Human Rights Issue
In less than a week, from May 25 to 30, 10,329 students of Greek Universities and Technological Educational Institutions completed the “National Committee for Tobacco Control” questionnaire and in collaboration with the National Network of Research and Technology signed a petition demanding that passive smoking be treated as a human rights issue.
Greek students together with the then President of the European Network for Tobacco Control, President of the National Committee for Tobacco Control and Associate Professor at the Harvard University School of Public Health, Dr. Panagiotis Behrakis presented the results of an opinion survey conducted at the same time as the petition. There, they advocated for passive smoking to be treated by the European Commission as a human rights violation in the sectors of Healthcare and Workplace Health and Safety. It was also demanded that passive smoking in enclosed public places also be treated as a form of violence against children and vulnerable populations. In addition, pregnant women and the working population who are subject to mandatory passive smoking at work are also at higher risk for harmful effects of passive smoking.
This innovative Greek proposal to Europe was the central topic at the annual European Tobacco Control Network conference which was attended by the chairpersons of Smoking Prevention Committees of all European countries in Athens on 5 -7 June 2013.
Passive smoking as a human rights violation has also been raised as a topic of discussion at European Parliament at the “European Smoke free Environment from the Human Rights Perspective” event on November 5th, 2013. Speakers included Sylla Sideris, a student from the Athens University of Economics and Business, a representative of the Greek students who signed the passive smoking petition and Prof. Panagiotis Behrakis, the then President of the European Network for Tobacco Control, President of the National Commission Tobacco Control and Associate Professor at Harvard University School of Public Health. This event was held by Members of European Parliament Elena Oana Antonesku and Satu Hassi.
This issue was also presented at the CHEST World Congress held in Madrid on 21- 24 March 2014 in a speech by Professor Panagiotis Behrakis, Pulmonologist-Intensivist, previous President of the European Network on Tobacco Control, President of the National Committee for Tobacco Control and Associate Professor at the Harvard School of Public Health. His speech was entitled “Passive Smoking from the Human Rights Perspective” and contained the report on passive smoking in Europe, the implications of passive smoking, as well as international conventions which supported this perspective, for example the Lisbon Treaty and Framework for the World Health Organization’s Tobacco Control. It was then taken and discussed at the 6th European Conference on Tobacco and Health (ECTH) held on 26-29 March 2014 in Istanbul, Turkey.
Pan-Hellenic Survey on the implementation of the law protecting the public against passive smoking
KAPA Research 2013
A nationwide survey was conducted by KAPA Research on behalf of the Academy of Biomedical Research of the Academy of Athens in September 2012 on the opinions on implementation of the smoking ban law in Greece. The sample was representative and evenly distributed across 13 regions in Greece that included 2,038 adults over the age of 18 years. Data was collected using computer-assisted personal interviewing (CAPI) methods.
The results of the survey reported,
- The current prevalence of smoking in Greece was 36.7%
- 30.5% daily smokers
- 6.2% occasional smokers
- Almost 60% of smokers reported they want to quit smoking
- As a result of an increase of 2 euros/pack, 32% of smokers reduced their consumption of smoking
- When asked about the increase of another 2 euros in order to deter youth from being able to purchase cigarettes, a majority among both smokers and non-smokers reported they agreed with the tax hike
- These results imply that the Greek people are positive toward a smoke-free community in the future
KAPA Research 20177,13
A second follow-up survey by KAPA Research was conducted in June 2017 on the attitudes of the Greek public towards the non-implementation of the smoking ban law. A nationally representative sample of 2,054 adults from 13 regions in Greece, were interviewed through CAPI.
The results showed that,6,13
- A total of 28.5% reduction of prevalence of smoking was observed from 2009 to 2017
- Ages 16-24 years exhibited a 33% reduction from 2009 to 2014
- The total number of legally taxed cigarettes in Greece showed a parallel trend, showing an overall 49% total reduction
- 88.1%, a majority of Greek citizens consider the national aim for smoking reduction as important or very important
- 96.6% reported that they were exposed to SHS in the past year
- 74.2% reported being upset whenever they visited an indoor public space where the smoking ban law was violated
- 76.1% of the Greek public reported being upset that Greece is the only European Union Member State that has not comprehensively enforced the smoking ban law
- 93% of Greek people did not believe that the State has done everything in its power to enforce the smoking ban law in hospitality venues
- 83.8% of Greek citizens consider the smoking ban violation as a sign of cultural decline in Greece
The World Health Organization definition of health is as follows:
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”14
Το Smoking has been identified by the World Health Organization as the biggest epidemic of our time, and the international community has taken actions to address the problem. However, the situation in Greece remains uncontrolled, as our own state laws are not enforced and International Agreements (Framework Convention on Tobacco Control, Treaty of Lisbon, etc.) are abused in order to protect economic interests.
The Framework Convention on Tobacco Control is the first international treaty of the World Health Organization that guides the Global Community in addressing and resolving the tobacco problem worldwide. The implementation procedure of this Convention was launched at the 52nd World Health Assembly in 1999 and currently has 167 signatories.2 In May 2003, it was signed in Geneva under the Greek Presidency. The European Community and all Member States signed the Convention on 16 June 2003 which entered into force in February 2005.
Greece ratified the FCTC on November 8th 2005 and entering into force April 2006 and has since been obliged under Law.3420 to fulfill terms outlined in the Convention.
Our country actively participates in Biennial Conferences, playing a leading role in the Working Group for the implementation of FCTC articles on tobacco and regularly updates the World Health Organization of the progress on implementation of the Convention at the national level.
The Lisbon Treaty (1997)
The Lisbon Treaty, known as the “Reform Treaty”, is an international treaty that provides the European Union with the legal framework and tools needed to meet future challenges and respond to citizens’ demands. It was signed on December 13th 2007 at the Lisbon Summit, attended by political leaders and foreign ministers of the Member States of the European Union, and entered into force on December 1st 2009, ending multi-annual negotiations on institutional issues.
Article 2: Right to life.
Everyone has the right to life.
“Article 2. The Union is founded on the values of respect for human dignity, freedom, democracy, equality, the rule of law and respect for human rights, including the rights of persons belonging to minorities. These values are common to the Member States in a society in which pluralism, non-discrimination, tolerance, justice, solidarity and equality between women and men prevail.”
Article 24. Children’s rights.
Children have the right to be protected from harm. In all actions that involve children, whether undertaken by public authorities or private organizations, interest of the child should be the primary consideration.
“Article 24. 1. The Union’s competence in matters of common foreign and security policy shall cover all areas of foreign policy and all questions relating to the Union’s security, including the progressive framing of a common defence policy that might lead to a common defence.”
Article 26. Integration of people with disabilities.
The Union recognizes and respects the rights of people with disabilities and their right to measures that ensure their autonomy and inclusion in the community, workplace and their ability to participate in community activities.
“Article 26 (ex Article 13 TEU) 1. The European Council shall identify the Union’s strategic interests, determine the objectives of and define general guidelines for the common foreign and security policy, including for matters with defence implications. It shall adopt the necessary decisions. ”
Article 31. Fair and appropriate working conditions.
Every worker has the right to working conditions in relation to his / her health, safety and dignity.
“Article 31 (ex Article 23 TEU) 1. Decisions under this Chapter shall be taken by the European Council and the Council acting unanimously, except where this Chapter provides otherwise. The adoption of legislative acts shall be excluded”
Article 35. Healthcare.
Everyone has the right to access health prevention services and receive medical treatment in accordance with the conditions laid down in national laws and practices. A high level of protection of human health should be ensured in the definition and implementation of all Union policies and activities.
“Article 35 (ex Article 20 TEU) The diplomatic and consular missions of the Member States and the Union delegations in third countries and international conferences, and their representations to international organisations, shall cooperate in ensuring that decisions defining Union positions and actions adopted pursuant to this Chapter are complied with and implemented.”
The Universal Declaration of Human Rights (UDHR) adopted by the United Nations General Assembly on December 10th 1948 in Paris, France outlines the fundamental human rights to be universally protected for all. Articles of the UDHR that refer to the exposure of passive smoking include:
Articles 2 και 7, the right of all people to equal protection under the law without discrimination.
Article 2. “Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status. Furthermore, no distinction shall be made on the basis of the political, jurisdictional or international status of the country or territory to which a person belongs, whether it be independent, trust, non-self-governing or under any other limitation of sovereignty.”
Article 7. “All are equal before the law and are entitled without any discrimination to equal protection of the law. All are entitled to equal protection against any discrimination in violation of this Declaration and against any incitement to such discrimination.”
Article 3 of the UDHR recognizes that everyone has the right to life, liberty and security of person.
Article 3. “Everyone has the right to life, liberty and security of person.”
Article 5 stipulates that everyone is entitled to humane treatment.
Article 5. “No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment.”
Article 22 the right to a standard of living.
Article 22. “Everyone, as a member of society, has the right to social security and is entitled to realization, through national effort and international co-operation and in accordance with the organization and resources of each State, of the economic, social and cultural rights indispensable for his dignity and the free development of his personality.”
Article 23 (1) guarantees the right to safe and healthy working conditions.
Article 23 (1) Everyone has the right to work, to free choice of employment, to just and favourable conditions of work and to protection against unemployment.
Universal Declaration of Human Rights
The Universal Declaration of Human Rights (1948) was the basis for the Human Rights Commission to draft two other legal treaties, the International Covenant on Civil and Political Rights
- International Covenant on Civil and Political Rights
- International Covenant on Economic, Social and Cultural Rights
The International Covenant on Civil and Political Rights (ICCPR) and the International Covenant on Economic, Social and Cultural Rights (ICESCR) (19 December 1966, New York) two International Treaties, along with the Universal Declaration of Human Rights, constitute the “Universal Declaration of Human Rights”.
The International Covenant on Civil and Political Rights focuses on issues such as the right to life, freedom of speech, religious freedom and the right to vote. More specifically,
Articles 2 και 26 follow the right of non-discrimination and equal protection.
Article 2. “1. Each State Party to the present Covenant undertakes to respect and to ensure to all individuals within its territory and subject to its jurisdiction the rights recognized in the present Covenant, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status….”
Article 26. “All persons are equal before the law and are entitled without any discrimination to the equal protection of the law. In this respect, the law shall prohibit any discrimination and guarantee to all persons equal and effective protection against discrimination on any ground such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status.”
Article 6 of the ICCPR imposes an obligation on the state to “ensure the right to life, including measures to protect the environment”.
Article 6 “1. The States Parties to the present Covenant recognize the right to work, which includes the right of everyone to the opportunity to gain his living by work which he freely chooses or accepts, and will take appropriate steps to safeguard this right…”
Article 7 stipulates that no one shall be subjected to inhuman treatment.
Article 7 “No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment. In particular, no one shall be subjected without his free consent to medical or scientific experimentation.”
The International Covenant on Economic, Social and Cultural Rights focuses on food, education, health and housing. In particular, the following are mentioned related to passive smoking.
Article 2 guarantees that the Rights will be exercised without discrimination of any kind.
Article 7 “The States Parties to the present Covenant recognize the right of everyone to the enjoyment of just and favourable conditions of work which ensure, in particular:
(a) Remuneration which provides all workers, as a minimum, with:
(i) Fair wages and equal remuneration for work of equal value without distinction of any kind, in particular women being guaranteed conditions of work not inferior to those enjoyed by men, with equal pay for equal work;
(ii) A decent living for themselves and their families in accordance with the provisions of the present Covenant;
(b) Safe and healthy working conditions;
(c) Equal opportunity for everyone to be promoted in his employment to an appropriate higher level, subject to no considerations other than those of seniority and competence;
(d ) Rest, leisure and reasonable limitation of working hours and periodic holidays with pay, as well as remuneration for public holidays”
Article 10 provides for the rights of the child.
Article 10 “The States Parties to the present Covenant recognize that:
1. The widest possible protection and assistance should be accorded to the family, which is the natural and fundamental group unit of society, particularly for its establishment and while it is responsible for the care and education of dependent children. Marriage must be entered into with the free consent of the intending spouses.
2. Special protection should be accorded to mothers during a reasonable period before and after childbirth. During such period working mothers should be accorded paid leave or leave with adequate social security benefits.
3. Special measures of protection and assistance should be taken on behalf of all children and young persons without any discrimination for reasons of parentage or other conditions. Children and young persons should be protected from economic and social exploitation. Their employment in work harmful to their morals or health or dangerous to life or likely to hamper their normal development should be punishable by law. States should also set age limits below which the paid employment of child labour should be prohibited and punishable by law.”
Article 12 of the ICESC deals with the right to health.
Article 12.1 of ICESC includes “the right of everyone to enjoy the highest possible level of physical and mental health”.
Article 15 recognizes the right of everyone to participate in cultural life and to enjoy the benefits of scientific progress and its applications.
“1. The States Parties to the present Covenant recognize the right of everyone:
(a) To take part in cultural life;
(b) To enjoy the benefits of scientific progress and its applications;
(c) To benefit from the protection of the moral and material interests resulting from any scientific, literary or artistic production of which he is the author.
2. The steps to be taken by the States Parties to the present Covenant to achieve the full realization of this right shall include those necessary for the conservation, the development and the diffusion of science and culture.
3. The States Parties to the present Covenant undertake to respect the freedom indispensable for scientific research and creative activity.
4. The States Parties to the present Covenant recognize the benefits to be derived from the encouragement and development of international contacts and co-operation in the scientific and cultural fields.”
In addition to the International Declaration of Human Rights, the United Nations has adopted other major agreements, more than twenty. These include agreements detailing the human rights of particularly vulnerable populations, such as the Treaty on the Elimination of All Forms of Discrimination Against Women (1979), the Convention on the Rights of the Child (1989).
Convention on the Elimination of All Forms of Discrimination against Women (CEDAW)
Adopted and opened for signature, ratification and accession by General Assembly resolution 34/180 of 18 December 1979 entry into force 3 September 1981, in accordance with article 27(1)
“Article 12 1. States Parties shall take all appropriate measures to eliminate discrimination against women in the field of health care in order to ensure, on a basis of equality of men and women, access to health care services, including those related to family planning…”15
The Convention on the Rights of the Child (Convention on the Rights of the Child) Convention on the Rights of the Child20
Adopted and opened for signature, ratification and accession by General Assembly resolution 44/25 of 20 November 1989 entry into force 2 September 1990, in accordance with article 49.
- States Parties recognize that every child has the inherent right to life.
- States Parties shall ensure to the maximum extent possible the survival and development of the child.
Article 24: “States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services.”
Article 24 (2) (d): To ensure appropriate pre-natal and post-natal health care for mothers.
- US Centers for Disease Control and Prevention. Smoking and Tobacco Use Fact Sheet, Secondhand Smoke. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/general_facts/index.htm. Published 2018.
- World Health Organization. WHO Framework Convention on Tobacco Control. Geneva; 2007. http://www.who.int/tobacco/framework/WHO_FCTC_english.pdf.
- Fernándes E, Fu M, Martinez-Sanchez J. Exposure to Aerosol from Smoking-Proxy Electronic Inhaling Systems: A Systematic Review. Barcelona; 2016. http://www.who.int/tobacco/industry/product_regulation/BackgroundPapersENDS1_4november.pdf.
- Eurobarometer 72.3: Special Eurobarometer 332: Tobacco. Brussels ; 2010. https://ec.europa.eu/health/sites/health/files/tobacco/docs/ebs332_en.pdf.
- European Union. Special Eurobarometer 458: Attitudes of Europeans towards Tobacco and Electronic Cigarettes.; 2017. https://data.europa.eu/euodp/data/dataset/S2146_87_1_458_ENG.
- Demi M, Vyzikidou V-K, Teloniatis S, et al. Attitudes of the Greek Public towards the implementation of the smoking ban law. Tob Prev Cessat. 2018;4(Supplement). doi:10.18332/tpc/90472.
- Trichopoulos D, Kalandidi A, Sparros L MB. Lung cancer and passive smoking. Int J Cancer. 1981;27(1):1-4.
- World Health Organization. The top 10 causes of death. http://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death. Published 2018.
- Centers for Disease Control and Prevention (US), U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General.; 2006.
- U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress.A Report of the Surgeon General. Atlanta, GA; 2014. https://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf.
- World Health Organization. Tobacco: Fact Sheet. http://www.who.int/news-room/fact-sheets/detail/tobacco. Published 2018.
- US Centers for Disease Control and Prevention. Smoking in Pregnancy: A Possible Risk for ADHD | Features | CDC. https://www.cdc.gov/features/smoking-adhd/index.html. Published 2017.
- Demi M, Teloniatis S, Vyzikidou V-K, et al. Smoking Prevalence in Greece. Tob Prev Cessat. 2018;4(Supplement). doi:10.18332/tpc/90109.
- WHO | Constitution of WHO: principles. WHO. 2016. http://www.who.int/about/mission/en/.
- Convention on the Elimination of All Forms of Discrimination against Women. https://www.ohchr.org/documents/professionalinterest/cedaw.pdf.