Greece: Crisis, smoking and tobacco conflicts in social media

Greece has undergone a distressing crisis that has taken a heavy toll, devaluing lives of individuals and functions of society at large. Besides the economic meltdown, there has been an even worse crisis of values. The country currently occupies a low rank in the WHO Happiness Index1 (99th in 2016 and 87th in 2017), not so much because of worsening ranking in healthy life expectancy (still ranked 24th in the world in 2017) or even wealth (still ranked 44th in GDP per capita), but because of mediocre ranking in social support (ranked 80th) and extremely low rankings in freedom to make life choices (ranked 150th among 155 countries), generosity (ranked 155th, ie last) and trust (protection from corruption) (ranked 128th). There has been an estimated 3% excess of deaths during the economic crisis,2 a dwindling population with one of the lowest fertility rates worldwide (1.3), a gross increase in use of psychoactive medications as demonstrated by measurements of drugs in the wastewater of Athens (11-fold increase in detected antidepressants, 19-fold increase in detected benzodiazepines, 35-fold increase in detected antipsychotics)3 and major shortages in public hospitals and social welfare. The superimposed refugee crisis is only partially under control. Finally, there is a massive exodus of highly educated citizens seeking a better future abroad. The demise of a country with a very high Human Development Index (HDI) (still ranked within the top 25 countries in the world in inequality-adjusted HDI despite the crisis, better than the USA that is ranked 28th) is not an incident of just local interest. It is pertinent for all nations dealing with high debts, instability of values and political and societal soul searching, including the USA and many other European countries.4 For over 2 years, I had maintained a column in The Blog section of the Greek edition of Huffington Post trying to contribute to the public debate on how to revert this sad situation. The contributed op-eds were not aligned with any particular political party, and thus, they attracted considerable attention—one of them had actually received the highest number of visits than any op-ed ever in the lifetime of this particular social media brand. The covered themes focused on the irrationality of the crisis and of the response to it. Proposed solutions focused on bolstering meritocracy, transparency, accountability and healthy democracy, seeking a new vision of excellence based on strong science, technology, innovation and catharsis from corruption. It is essential to capitalize on the major local strengths, especially the large mass of highly qualified, well-educated professionals. For example, Greeks represent about 3% of the world's most highly cited scientists, about 20 times more than expected given the relative small size of the Greek population—but most work abroad.5 An early op-ed in this series proposed that the economic crisis can be reverted by preventive medicine efforts. Taking smoking alone, a decrease from the current 40% smoking rates (among the highest in the world) to 25% would result in so many lives saved and major diseases averted that would amount within 50 years to a benefit exceeding the entire current public debt. However, in the middle of the crisis, a few years ago, the prime minister celebrated that the tobacco industry is heavily investing in Greece to make it a major epicentre of its global activities. Greece has been thirsty for investments. However, not all investment will help equally, and some investments may be highly harmful. Clearly investment by the tobacco industry cannot be celebrated, in my opinion. The current prime minister, coming from a diametrically opposite party than the previous one, visited recently the facilities of a local Philip Morris subsidiary. The specific facilities specialize in the production of a heat-not-burn tobacco product (IQOS) with a 300 million Euro investment and with plans to sell product in 30 countries. Heavy campaigning in the local media has promoted that IQOS offers major health advantages because tobacco is heated without burning. The prime minister was accompanied by three top ministers of the cabinet, and he warmly congratulated the industry. Yet, another leader congratulating the tobacco industry when tobacco has been responsible for 29.5% of the deaths of men and 11.2% of the deaths of women in Greece6 is unacceptable. I therefore wrote an op-ed where (among other things commented on) two long paragraphs were devoted to this event, clarifying that there is no scientific evidence that adoption of this IQOS technology will eventually reduce the tobacco-related public health burden. Conversely, it may become a way to promote nicotine and make more people dependent on it (and eventually other types of harmful tobacco products). The submitted op-ed also noted that the tobacco industry has a notorious track record of fooling public opinion with its powerful marketing/advertising arm.7 The editor of the column replied requesting key changes in the text if it were to be considered for publication. It was requested to remove the mention of the name of Philip Morris and to tone down the language. In our two years of collaboration, this was the first and only time where censorship intruded, despite the fact that many previous texts had used aggressive (but still honest, and evidence-based to my knowledge) language and had attracted vicious comments and counter op-eds at times from various disagreeing entities and people. The message of the editor demonstrated that he was under major pressure. He explained that they had some "trade collaboration" with the specific tobacco industry and they "did not want to cause problems to them." I replied that the wording of the op-ed was accurate and even lenient and declined to change it. If the text were censored, it should not be published at all. A week later, the editor replied that they would not publish the op-ed and that he had resigned. I thanked him for his stance, adding that I consider him a hero through his resignation and would not submit any further contributions there. The tremendous harm caused by the tobacco industry worldwide is well known: roughly for each 1 million cigarettes smoked, one death is caused. The tremendous influence of the tobacco industry worldwide is also well known.7 In some countries such as China, operations are run by the state. In Western democracies where the tobacco industry operates in the private sector, its ability to penetrate with its interests into government circles needs to be carefully watched and averted. This is likely to be a more major threat in countries going through economic crisis and where governments thus are weak and vulnerable to being exploited for promotion of the interests of Big Tobacco. It would be pitiful if a highly developed country indeed becomes an epicentre for promoting tobacco worldwide. Article 5.3 of the World Health Organization Framework Convention on Tobacco Control which has been signed by 180 countries (including Greece) explicitly seeks to protect policymaking from tobacco industry influence. Prime ministers embracing tobacco industry investments and congratulating the tobacco industry obviously violate this article. Of interest, all Greek governments, regardless of which are the governing political parties, have failed miserably to implement the antismoking law of 2008 that prohibited smoking in all workplaces, taxis, ferries and enclosed public places (including bars and restaurants). Current smoking continues largely unhindered even in hospitals. The penetration of the tobacco industry influence in mass and social media is also worrisome. The apparent ability to directly or indirectly censor information and opinions about its products is alarming. Europe (including Greece) has developed strict legislation about restricting and even banning tobacco advertisement. However, indirect ways of influencing the profile of tobacco products in highly visible and widely visited social media can still exist. Popular social media may be a prime way for effective promotion and support of the industry agenda. Several studies have demonstrated this both in the Western world and in China,8-11 but the exact depth and dynamics of this marketing approach are not well known. Young populations may be particularly vulnerable.12 Social media may shape or distort public knowledge, awareness and expectations. Therefore, measures should be taken to eventually prohibit trade agreements between the tobacco industry and all media, including major social media. In the meanwhile, for those media that do continue to trade with the tobacco industry, the type of trade and potential conflict of interests should be disclosed in public in full detail. I am grateful to Robert N. Proctor, PhD, and to Lisa Henriksen, PhD, for helpful insights.