Slovakia: Death, Sex & Lifestyles in Latvia - 2005 and Beyond

On my visit to the Forum Cinema in Riga recently to see the much-acclaimed, "Mr & Mrs Smith", the advertisements were still rolling. They ended with the Camel cigarette advertisement (permitted in Latvia!). A slick production which would make anyone think that the promotion was for a really great health food, or fashion apparel. The ad. ended with a fade-out logo with the caption ‘..Camel, since 1913’. Whilst waiting for the film to start, I tried to do the math as according the World Health Organisation smoking kills 4 million people yearly. I worked out that between 1913 and 2005 around 400 million deaths were caused by smoking! Not bad for a legalised product, but sad to note that in 1995, in Latvia, according to the World Health Organisation, 5300 people died from the results of smoking. In 2005, deaths are projected to around 10, 000. Tobacco is responsible for more than 16% of all deaths in Latvia. In 2005, passive smoking will have killed over 1000 people in Latvia.

According to the World Health Organisation, tobacco consumption is a leading cause of death in the world. Every year, 4 million people die directly from the results of smoking and this figure is rising from year to year. The world has around 1.25 billion smokers. Women and young persons smoking is on the increase and the average age of smokers is falling year by year. 70% of tobacco-linked deaths projected over the next few years will occur in the developing countries – seen by cigarette manufactures as ripe targets for this kind of exploitation by reason of ignorant masses and irresponsible governments.

In Central Europe twice as many Northern/ Central European as Western European men at ages 35 - 69 die of tobacco-related diseases and those killed by tobacco in middle age lose an average of 20 - 25 years of life! In that regard, life expectancy for men in Northern/Central Europe has been decreasing since 1975, and the cancer rate has been increasing. Rates of lung cancer in the region are now the highest in the world with tobacco being the main cause.

In Northern/ Central Europe, of every 10 men aged 35, 5 will die before age 70 and 40% of these deaths will be from tobacco. In contrast, in Western Europe of 10 men aged 35, 3 will die before age 70, and only a third of these deaths will be from tobacco. Here is the problem, cigarette smoke contains nicotine, which is addictive, but also contains about 4000 other known chemicals, which collectively cause an extraordinarily wide-range of diseases - cancer of the mouth, throat, lung, oesophagus, stomach, pancreas and bladder; heart attacks, strokes, stomach ulcers, and arterial destruction, plus emphysema and other respiratory diseases.

A few conditions such as Parkinsonism, and possibly endomental cancer, may be made less likely by smoking, but tobacco causes 100 times as many deaths as it may possibly prevent. Also, tobacco exacerbates the dangers from other factors such as diabetes, radon exposure, environmental pollutants, high blood pressure or cholesterol. Furthermore, tobacco has now been proved to harm, or kill the non-smoker.

According to Professor Peto, an Oxford University Medical Statistics specialist, smoking is not often seen as a direct and fatal threat to health due to the long delay between cause and fatal effect. For example, the risk of lung cancer - the main cause of death from tobacco - is higher among those who started before 20 than among those who started later on. Therefore a large and persistent increase in cigarette use of young people tends to have its full fatal effects in their middle age. For example, Professor Peto points out, in the United States, the large increase in cigarette use in men between 1915 and 1945 led to a fivefold increase in lung cancer deaths in men between 1945 and 1985. This pattern of tobacco consumption followed after a delay of several decades, by a significant increase in lung cancer deaths has already been seen in the developing countries of Northern and Central Europe. However, there are lessons to be learned from the US experience – there the Surgeon General has estimated that in 1985 tobacco caused around 20% of all US deaths. Smoking is now the number 2 killer of all people in the USA.

Still in 2005, cigarettes and tobacco are big business in the developing economies of the new EU countries as Western and more enlightened governments realise the true and unpalatable cost of smoking and create adverse environments for the tobacco trade. However, the tobacco products manufacturer Philip Morris were keen to point out to the Czech government recently in a report to justify the relaxation of smoking restrictions there, smoking is economically beneficial to a country's finances. That is because the Czech government saved about US $147 million in 1997 through the deaths of smokers who did not live to use healthcare or housing for the elderly. That and revenues from tobacco tax make it clear that smoking is good for government finances and it is not surprising that the relatively poorer countries of the European Union, like Latvia, are not falling over themselves to tighten up the tobacco trade.

That smoking is extremely good economics for governments is borne out by its reliability to dramatically reduce life expectancy – so as to enable a natural culling of the elderly and a great saving on health care for them as well as retirement housing cost. This could well balance out the cost of medical care for smoking-related illnesses for the younger population. However, there is even better news for governments, who in addition to wanting to keep old people off their books, are keen to reverse populations growth trends. This news is provided in the form of the report of the British Medical Association (BMA) in February 2004 which confirms that both passive and active smoking have a serious impact on sexual, reproductive and child health.

The BMA report finds that smoking not only harms sexual and reproductive health in both men and women, but it damages them seriously from puberty, through young adulthood and into middle age. Smoking compromises the ability to have a family and parents who smoke inflict great harm in respect of the health of their born and foetal-stage children. The report notes the findings of some leading world-wide authorities in respect of the effects of smoking on sexual and reproductive health as follows:-

• US Surgeon General’s findings are that men who smoke have altered levels of male sex hormones and also, smoking is a cause of infertility and early menopause in women.

• UK Royal College of Physicians: smoking during pregnancy increases the risk of miscarriage, low birth-weight and perinatal death;

• The UK Scientific Committee on Tobacco and Health: passive smoking causes childhood respiratory disease and is causally associated with cot death;

• World Health Organisation: passive smoking causes respiratory disease and middle-ear infection, and reduces lung growth and function in children. Furthermore, the WHO International Agency for Research on Cancer (IARC) concludes that smoking is a cause of invasive cervical cancer;

• British Medical Association’s findings are that smoking is a cause of male sexual impotence;

• UK Confidential Enquiry into Stillbirths and Deaths in Infancy identifies exposure to second-hand smoke during infancy as a cause of cot death.

The inability to have an erection affects one in ten men aged 21–70 years and smokers (passive as well as active) are particularly affected – about 2.3 million men in the UK suffer from impotence. Smokers are at least 50 per cent more likely to suffer from an inability to have an erection as in the UK an estimated 120,000 men aged 30–50 years are impotent because of tobacco smoke. Men of all ages are affected. Tobacco smoke affects a man’s inability to have an erection through the damage caused to the circulatory system by smoking and impotence can be an indicator of more serious underlying health problems which include a heart attack.

The reason that both passive and active smoking causes impotence is due to circulatory and vascular problems being the most common cause of impotence. In that regard, the achievement and keeping of an erection depends on the balance between blood flow to and from the penis.

However, the many toxins that include carbon monoxide that are found in tobacco smoke cause the arteries in the area to be narrowed by fatty deposits which decrease the blood flow to the penis. Secondly there is the aspect that the same toxins damage the valve mechanism in the penis that traps blood so that the erection is maintained; thirdly the toxins act to constrict the arteries in the penis which create a limited blood flow and poor ability to have and maintain an erection.

For women, smoking creates a rich and interesting cocktail of illnesses (some potentially deadly). For example, women who smoke with combined oral contraceptive pill have an increased risk of coronary heart disease and also an increased risk of stroke and contraceptive failure. They tend to suffer from painful periods, missed periods and irregular periods.

In respect of female fertility, smoking causes delayed conception; primary infertility; secondary infertility; reduced response to fertility treatment and other reproductive health effects. These include early menopause, pre-cancerous changes of the cervix and invasive cervical cancer. Other effects include the drying of the skin (premature ageing); shrinking of the gums and urinary tract illnesses (these affect both men and women).

The BMA report acknowledges cervical cancer as the leading cause of cancer death in women worldwide. Over half a million new cases are diagnosed each year. The infection with certain types of human papilloma virus (HPV) is the major cause of cancer of the cervix (neck of the womb). However, only some women with infection with HPV go on to the precancerous changes progressing to cervical cancer. But, studies among women who are infected with HPV have found that women who smoke are at higher risk of developing preinvasive and invasive cervical cancer. Smoking increases the risk of invasive cervical cancer some two-to-three times.

Women who smoke develop male body shapes in time and more and more severe menopausal symptoms. Pregnant smokers tend to have placental complications; premature rupture of the membranes; premature baby; low birth–weight baby; perinatal death; ectopic pregnancy; miscarriage and foetal malformation. For women (in pregnancy) smoking causes reduced foetal growth; low-weight baby; premature birth. A study of almost 11,000 women in Denmark found that women who smoked between five and nine cigarettes a day were 1.8 times more likely than non-smokers to wait longer than 12 months to conceive.

Children who are passive smokers have suffered from cot death; middle ear disease and respiratory illnesses. They tend to develop asthma and for those children (and others) who have asthma, passive smoking makes them prone to asthma attack. In addition, children exposed to passive smoking develop behavioural problems and impaired growth.

In respect of both men and women exposed to second-hand smoke, for men there is the risk of sexual impotence as there is good evidence to suggest that passive smoking is associated with an increased risk of impotence. One study presented in the report found that non-smoking men exposed to second-hand smoke were significantly more likely to become impotent.

Smoking and male/ female fertility

Smoking damages fertility in both men and women as the toxins in tobacco smoke cause alterations in sex hormone metabolisms and harm both testes and ovaries. The reports finds that animal studies been conclusive of this kind of damage to reproductive systems. In particular, men who smoke have a lower sperm count than non-smokers. Also their semen contains a relatively fairly high proportion of malformed sperm. That is because, the nicotine present in the semen of smokers reduce the motility of sperm and damage their genetic material. Benzo [a] pyrene is one of the cancer-causing components of tobacco smoke and has been found to distort the DNA in sperm to induce mutations and ultimately damage embryos.

The BMA report points to studies which find that women smokers are at particular risk of tubal infertility. Here, the underlying underlying problem involves the failure of the function of the fallopian tubes which is about 3 times more likely for smokers.

Cot death (SIDS) – is the sudden unexplained death of an infant in the first year of life. It is the leading cause of death among infants aged one to 12 months in the UK. Smoking during pregnancy has been definitely identified as a cause of cot death. The risk of cot death is approximately three times more in infants whose mothers smoke both during and after pregnancy.

The legal issues facing the Latvian government from non-smokers and environmental tobacco contamination concerns the right of non-smokers enshrined in the constitution of Latvia (in particular by Article 93 ‘the right to life of everyone shall be protected by law’) to:-

1. the enjoyment of public places without having to endure inhaling other’s smoke and thus risking death, or alternatively a seriously impairment of their health

2. not have their clothes and bodies contaminated with tobacco smoke from a visit to a restaurant, or bar have the law adequately enforced so that there is effective segregation of smokers from non-smokers in bars and restaurants so that non-smokers are not contaminated by environmental tobacco;

3. babies yet to be born to enjoy protection from deadly environmental tobacco smoke

4. be able to win significant damages against those who cause them harm, or death through environmental tobacco contamination

5. to be protected from such harm, or death in accordance with the constitution and human rights law per the European Convention of Human Rights which has been incorporated into the Latvian constitution, in particular Art.93.

With respect to the criminal liability of those who cause, or permit damage to non-smokers by environmental tobacco smoke contamination, non-smokers will take comfort from a landmark case. In 2002, in Milan, two bank managers of a leading bank were convicted of criminal manslaughter for causing the death of a 35-year-old female bank worker who suffered a fatal asthmatic attack from exposure to second-hand tobacco smoke on the job. They were sentenced to spend three months in jail, and to pay a fine of 50,000 Euros. The decision also opened the door for a civil wrongful death lawsuit by her heirs to recover damages for causing her death by smoke.

Furthermore, in addition to the civil redress possible, failure by the Latvian government to implement effective protection laws for non-smokers may create a serious risk of a winnable case against it in ECtHR for violations of the relevant provisions of the ECHR.

Passive, involuntary or second-hand smoking occurs when a non-smoker breathes "sidestream" smoke from the burning tip of the cigarette and "mainstream" smoke that has been inhaled and then exhaled by the smoker. This kind of smoke (environmental tobacco smoke - ETS) is now recognised as a major source of indoor air pollution. The Environmental Protection Agency (EPA) in the USA has classified environmental tobacco smoke (the smoke which passive smokers breathe in) as a class A (known human) carcinogen in the family of asbestos, arsenic, benzene and radon gas.

My recent experience in Latvia (as in Slovakia) is that there is a widespread feeling that smoking protection laws are not being enforced. Active smokers are allowed a free rein in proliferating environmental tobacco contamination in public places and objecting non-smokers are treated as cranks and busybodies by active smokers and facility owners as well. Many non-smokers avoid bars, restaurants and other such places, which permit an abundance of tobacco environmental pollution. Slovak and Latvian smokers of all ages appear ignorant of the serious risk to their health posed by smoking and overt and discreet advertising promotes the image of smokers as trendy, or ‘macho’. Teenagers can be seen in bars, smoking one cigarette after another, hopelessly and proudly addicted to the one of the most toxic, addictive and damaging drugs we as human beings have ever inflicted on each other.

It is fair to say that there is a feeling of helplessness and despair among non-smokers in both countries. Many complain that whilst they do not wish to interfere with the rights of smokers to smoke as much tobacco as they wish, if it only fair that non-smokers should not have to endure the same consequences to their health (or worse) as smokers by way of non-smokers’ involuntary inhalation of the potentially deadly tobacco smoke pollution in their environment caused by smokers in bars, restaurants and other public places.

The US Health Department concedes that second-hand tobacco smoke (passive smoking) kills more than 60,000 Americans each year — more than those killed in by motor vehicle accidents yearly. Tobacco smoke pollution at work is responsible for a large number of these deaths. In the UK a recent government study concludes that over 11,000 people die annually from the effects of passive smoking and about 600 lung cancer deaths and up to 12,000 cases of heart disease in non-smokers can be attributed to passive smoking.

In addition, the recent report of the UK government's Scientific Committee on Tobacco and Health (SCOTH) is conclusive that passive smoking is a cause of lung cancer. Long-term exposure carries an increased risk of 20-30%. The report confirms that passive smoking is a cause of deadly heart disease, serious lung damage, asthmatic attacks, middle-ear disease in children and sudden infant death syndrome. The study found that tobacco specific carcinogens are found in the blood and urine of non-smokers contaminated by environmental tobacco smoke.

Further, the effect of passive smoking with respect to cardiac disease was studied by Ichiro Kawachi of the Harvard School of Public Health, who followed 32046 healthy, non-smoking women enrolled in the nurse’s health study for a period of 10 years (Circulation 1997; 95:2374-9). Healthy, non-smoking women who were regularly exposed to passive smoke at home or in the workplace had a 91% greater relative risk of heart attack than those who had low passive smoke exposure. Those with occasional exposure had a 58% greater relative risk.

The potentially lethal effect of environmental tobacco smoke pollution can be worked out from its constituents: generally, tobacco smoke has over 4000 chemicals comprising particles and gases. Research findings show that toxic gases are greater in side stream smoke than in mainstream smoke. Around 85% of the smoke in a room is from side stream smoke. Particulates in the smoke include tar, nicotine, benzene and benzo(a)pyrene. Gaseous substances comprise: carbon monoxide, ammonia, dimethylnitrosamine, formaldehyde, hydrogen cyanide and acrolein. Most of these are known irritants and the majority are known, or suspected cancer-causing substances (carcinogens).

These include: eye irritation, headache, cough, sore throat, dizziness, nausea and now impotence. Those suffering from asthma experience a worsening of their condition when exposed, while new cases of asthma may be caused in children whose parents smoke.

Even short-term contamination by tobacco smoke has the effect of reducing heart blood flow – this is measurable after about only 30 minutes. Over a longer term, passive smokers suffer a wide range of smoking-related diseases. In addition, passive smokers in the home have a 25% increased chance of heart disease and lung cancer. This is supported by the recent review by the UK Government-appointed Scientific Committee on Tobacco and Health (SCOTH) (quoted above), which concluded that passive smoking is a cause of lung cancer and serious heart disease in adult non-smokers and a cause of respiratory disease, cot death, middle ear disease and asthmatic attacks in children.

The International Agency for Research on Cancer (IARC) noted that "the evidence is sufficient to conclude that involuntary smoking is a cause of lung cancer in never smokers". As such there is enough reputable scientific evidence worldwide to support a view that passive smoking kills.

Again, the UK is a good reference point. Almost half of all children in the UK are exposed to tobacco smoke at home. The position is increased in Latvia (as well as Slovakia). In children this kind of contamination increases the risk of lower respiratory tract infections such as bronchitis, pneumonia and bronchiolitis. In that regard researches have shown that in homes where both parents smoke, children have a 72 per cent increased risk of lung diseases. In addition, passive smoking causes a deterioration of lung function and the increased severity of asthma symptoms in children. In that regard, it is a principal risk factor for all new cases of asthma in children. Passive smoking is associated with middle ear infection in children, heart impairment and behavioural problems. Young children of smoking parents tend to be admitted to hospital for bronchitis and pneumonia in the first year of life. In the UK, more than 17,000 children under the age of five are admitted to hospital every year because of the effects of passive smoking. There are no statistics available for Latvia, or Slovakia. Passive smoking during childhood has been found to be a major contributing factor in children developing chronic obstructive airway disease, mental defects, eye and ear impairment and cancer.

Someone once said that the road to hell was paved with good intentions! Well, in that case, I am well on my way to hell as from this paper, it is my intention to mobilise the Latvian government to accelerate its positive health program in respect of smoking laws for the good of not only those who smoke, but also those who do not smoke. Secondly, the paper is aimed at educating and encouraging legal action (as necessary in the ECtHR) and lobbying from those who care about the innocent children and affected non-smokers in Latvia whose lives are permitted and legalised by the government to be interfered with seriously through delay in taking action to offer adequate protection to their lives and well-being from the deadly effects of environmental tobacco smoke pollution.

• The Right to Life and the Protection of Non-Smokers in Slovakia. WWW.MONDAQ.COM Author: Edward Lestrade for Slovkonsult s.r.o. July 23 2003.

• Smoking and Reproductive Life – the impact of smoking on sexual, reproductive and child health. British Medical Association Board of Science and Education & Tobacco Resource Control Centre. WWW.BMA.ORG.UK . February 2004.

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