Even Health Ministry doesn’t understand best ways to combat smoking, says Dr. Eva Králíková

Eva Králíková, photo: Matěj Pálka

Eva Králíková was one of the first Czech doctors to specialise in tobacco dependency and for many years has been the country’s best-known anti-smoking campaigner. In the wake of last week’s defeat of the latest attempt to ban smoking in Czech pubs and restaurants, I wanted to ask Dr. Králíková why the county seems to be lagging so much of Europe in this regard. But I was first curious to know what had drawn her to that particular field of medicine.

Eva Králíková,  photo: Matěj Pálka
“It was a fascination with how important tobacco dependency is, how important it is to treat tobacco dependency in patients and what a big impact it has, and, by contrast, how low the interest of health professionals – doctors, nurses and others – is.

“This fascinates me until today.”

Why is interest so low, do you think?

“I don’t know [laughs]. Ask those who don’t have an interest in it. Maybe it’s too simple. It’s not bloody medicine.

“If, in the framework of medicine, you would now like to invent some new method, very probably it will be very complicated, very specific, and colleagues of yours may not be able to understand what it is and how to do it, because medicine now has very specific regions.

“But this is something that can be done by doctors, psychologists, nurses, pharmacists – it’s quite simple.

“It’s very cost-effective – probably the most cost-effective intervention in the whole of medicine.”

As somebody who works with addiction to tobacco, generally what do you find to be the best, most effective method of treatment?

“It’s a combination of intensive intervention and support with pharmacotherapy. It’s really simple [laughs].”

But does that also involve a lot of will power on the part of your patients?

“Oh, definitely. The patient has to wish and decide to stop.

“In clinical medicine the first step is motivation of the patient. Seven out of 10 smokers would prefer not to smoke, so mostly they are not very happy that they smoke.

“Mostly they have tried to stop and did not succeed. So there are something like almost two million people in the Czech Republic who are unhappy with the fact they smoke.

“It makes you sad. Your confidence goes down and you may feel depression.

“So it’s not a very good feeling and when our patients finally stop smoking they are very happy.”

Have you ever smoked?

Photo: Kristýna Maková
“Unfortunately, yes. From 16 to about 23 I was an occasional smoker, with my classmates and colleagues at university.

“It took me several months to stop. I would like to erase it from my life, but it’s not possible. The only ones who are happy about it are my patients.

“But I don’t see any positive aspect of it, because for example a doctor doesn’t need to undergo myocardial infarction to be able to treat it.

“So I guess the understanding would be enough – without the personal experience.”

When you entered the field of addiction to tobacco, was there much interest in the subject in the Czech Republic, or Czechoslovakia then, compared to in the West?

“There was a huge difference. Nobody was interested. About 25 years ago there were only two of us doctors [in the field].

“So now I feel really big changes, because doctors, nurses and pharmacists have become interested and involved.”

My country, Ireland, was the first country to bring in a ban on smoking [in workplaces]. Not long after that when friends or family would visit some of them thought it was great that they could still smoke here. Now, however, they tend to say it’s a bit primitive and ask why the Czech Republic is so backward in this respect. What reason would you give them – why is the Czech Republic behind so much of the rest of Europe when it comes to tackling smoking?

“I don’t know. Probably we have a very strong lobby of the tobacco industry. That’s the only explanation.

“Concerning Ireland, I had the privilege to be there in March 2004 when your minister of health announced this law. It was a moving moment.

“As to why the Czech Republic is so behind, he mentioned on that occasion that the Ministry of Health in Ireland had hired some PR persons for two years, to explain to Irish people why this law was good for them.

“When I counted the number of inhabitants in Ireland and the Czech Republic, I came up with the number of 70 PR persons that should be hired by the Czech Ministry of Health to explain why this legislation should be accepted.

Photo: archive of Radio Prague
“Of course the Ministry of Health doesn’t have one PR person for this purpose. And in the whole of the Czech Republic I don’t know of any single person who would be paid full-time for tobacco control.

“So maybe that’s the explanation.”

So there’s no government-funded campaign against smoking at all in the Czech Republic?

“I don’t know of any such campaign.

“Also what is common in the Czech Republic is the idea that it’s very important to ban the sale of tobacco to the under 18s.

“In principle this is of course correct, but not in a country where cigarettes are cheap, available everywhere with food, you can see smoking everywhere, you can see the sale of cigarettes everywhere and we don’t even have pictorial warnings.

“Still in the Czech Republic, even at the Ministry of Health, you can hear that effective prevention of smoking is to ask children to paint some anti-smoking posters and so on.

“Nobody understands that the best high price given by tax is the most effective prevention. Or completely smoke-free public places.

“That would not only be free of charge, because it costs nothing, but for fewer sold cigarettes with higher tax the state would collect more money into the state income.

“So it’s crazy that we don’t want to do effective prevention.”

You mentioned the tobacco lobby. I know you obviously don’t have access to the back rooms of the Chamber of Deputies, but still, what’s your sense of how that influence works? How does the tobacco lobby actually influence Czech politicians, in your view?

“You are right that I have absolutely no idea. But if I were the tobacco industry, I would use the fact that nobody can understand everything, so MPs and senators need assistants to analyse laws and everything that comes to Parliament.

“They have some extra budget for [these assistants], which is quite high, so they can pay some person to do this work for them. So I would offer them this service for free.

Czech Parliament,  photo: Filip Jandourek
“I would offer them a free legal service to analyse suggested legislation. They can then spend the money [allocated for this purpose] on some other person.

“I would also have access to all documents coming to Parliament, so I would immediately know if there is something that could touch the tobacco industry and I could prepare a position that fits with my interests.

“I would also have access to the Parliament and Senate 24 hours a day, so I can lobby other MPs and Senators.”

You say the tobacco lobby is the only reason. But what about the Czech love of freedom. I think a lot of people here, after the experience of communism, regard regulation as simply a bad thing.

“Yes, this is the argument raised mainly by the tobacco lobby for many years in many countries. So this is nothing new.”

On Wednesday the latest attempt to ban smoking in Czech pubs and restaurants failed. It’s a little bit hard to talk about this right now, as the prime minister says he’s going to take the issue back to the cabinet again. But are you optimistic that there could in future be a ban on smoking in Czech pubs and restaurants?

“I really don’t know. The easiest way would be to accept the one sentence that is now in Parliament as the second option of this law, which just says that in indoor public spaces smoking is banned.

“But what I would like to see is one complex law concerning tobacco control according to the [WHO’s] Framework Convention on Tobacco Control.

“Currently legislation concerning smoking is spread across several tens of laws and amendments and is absolutely unclear. Maybe that was on purpose – they wanted to do it like this.

“So I would like to see one complex law on tobacco control: on graphic warnings, a ban on sale together with food, specific shops with licenses, taxes, smuggling control, offer of treatment and, of course, protection from passive smoking. And other points.

“This could be done by according to the Framework Convention on Tobacco Control, which was ratified in the Czech Republic, which means that MPs and senators and the president agreed.

“It includes, for example, a request to have smoke-free spaces in August this year. This is a legally binding treaty and we should take care about it and direct attention to it.”

Some people might say that the trend is already positive in this respect. I was reading that according to the latest figures, 24 percent of Czech adults smoke, down from 29 percent in the previous figures. Also, you see more and more restaurants themselves opting to go smoke-free, regardless of the law.

Photo: Filip Jandourek

But isn’t that enough, that this is happening already?

“No, it’s absolutely not enough. Because you need a complete ban on smoking in all restaurants; in some villages, for example, there is just one restaurant.

“An argument often mentioned – another one raised by the tobacco industry – is that the hospitality industry will lose money. This is not true. It’s just coming from the tobacco industry.

“The majority of the population is non-smoking, even in the Czech Republic. Seventy-six percent do not smoke and they don’t visit those pubs, because they are smoky.

“After a smoking ban they may start to go there and the hospitality industry may make more money.

“The problem is that it will mean a decrease in the sale of cigarettes. Because smokers will either stop smoking or reduce their consumption; it’s not possible to smoke in restaurants and they have to go out, so they will reduce consumption.

“And of course fewer young people will start, so it would be powerful prevention.”