Hungary, with about a third of its population smoking daily, has one of the highest rates of lung and oral cancer deaths in the European Union. But without detailed information on the health risks and financial costs caused by the habit, Hungary's government was reluctant to introduce and uphold strong policies to discourage tobacco use.
Into this void, Fogarty-funded researchers launched a multifaceted study generating evidence that helped bring about several tobacco tax increases and then comprehensive anti-smoking legislation in 2011.
"The result was unbelievable and in many ways unanticipated," said Dr. Kristie L. Foley, Fogarty grantee at Davidson College in North Carolina. "It was a remarkably productive study and emphasized the links between research and action."
Photo by Yosef Hadar/World Bank
Fogarty-supported research has
influenced anti-smoking policies
in several Eastern European
In 2007, Foley received a five-year Fogarty grant for tobacco research and capacity building in Hungary. Fogarty's International Tobacco and Health Research and Capacity Building Program encourages transdisciplinary research to tackle the international tobacco epidemic and reduce the global burden of morbidity and mortality caused by tobacco use in developing countries.
When the project began, Hungary's government lacked the will to enact comprehensive tobacco control legislation, the few scientists studying tobacco control were working in isolation and minority populations such as the Roma were ignored, Foley said. But she and her U.S. team forged a collaboration with Dr. Peter Balazs at Semmelweis University in Budapest, as well as with a diverse group of scientists, health care practitioners and others interested in the issue.
"Our project had a three-pronged intention: to influence science, practice and policy," Foley said. "We wanted our results to lead to health system changes, educational reforms and policies to reduce smoking."
The multidisciplinary team conducted 11 research projects, on topics that ranged from studying price increases as a tool to curb smoking; determining the benefits of including tobacco prevention information in dental school curricula; and quantifying the threat caused by mothers who smoke during pregnancy. The researchers also examined smoking-related health care costs and how the smuggling of inexpensive tobacco products from neighboring countries cut government revenue and caused a glut of cheap cigarettes.
From the start, Foley and her team placed a high priority on understanding local culture, politics and customs.
Communication with the health ministry began early and was bi-directional, and the researchers focused on science that would produce actionable results. The final outcome was an increase in scientific capacity and a sustainable effort to reduce tobacco consumption in Hungary. "The relationship between we American scientists and our Hungarian colleagues changed over time from funder/funded to one more horizontal and collaborative, an attitude of 'we are in this together,'" Foley said. "It was a very intentional breakdown."
The scientists documented the population's attitudes toward smoking. For instance, most public health workers favored steps such as higher tobacco taxation and smoking bans for indoor public spaces. In another study, members of the public indicated they favored fining retailers who sell tobacco products to minors, banning smoking in health care institutions and restricting tobacco advertisements.
To ensure their findings were available to inform government tobacco policies, Foley's U.S.-Hungarian team maintained communication with the health ministry and shared their research results directly with the minister. "He asked, 'What would you do with policy that would have the greatest health impact?'" The team picked higher taxes and steps to promote clean indoor air, better infrastructure to support pregnant women and resources to promote smoking prevention in schools, Foley said.
The government's new legislation, which took effect in 2012, bans smoking in all confined public places and many outdoor places. The Hungarian team has also leveraged the Fogarty support to secure funding from other sources, such as the European Union. Foley and her colleagues, including Hungarians, are using an additional grant from Fogarty and the National Cancer Institute to bring this research model to Romania, where smoking also poses a significant health problem.
Adapted from the March / April 2013 Global Health Matters article Smoking research influenced policy in Hungary.