Listen, the one about “weed” (text in last issue) was good, but I immediately lit up out of boredom. Weed is allowed, but smoking is not. It’s getting harder and harder for us smokers, I thought at least on the ship I would be free from terror, but I’m stuck on the “Norwegian” and they have smoke detectors in the bedrooms. I can’t even smoke on deck, except in the marked square at the stern – like a dog. Sailors have their own idea of freedom, of course, but this was a typical smoker’s frustration. And indeed, after thirty years of listening to their plight, one of the most striking changes is that smokers on board have virtually disappeared. Even when I ask the question, “Do you smoke?” the answer is usually yes. “Yes, unfortunately, or yes, and what am I going to do about it…” with a hint of embarrassment in the voice. So what has changed in the last 20 years: the ships are the same, the seafarers are the same, the work is no less stressful, but something has happened. Are people afraid – The World Health Organisation (WHO) estimates that tobacco use, smoking and smokeless tobacco are currently responsible for the deaths of around six million people worldwide each year, many of them premature, and that tobacco-related diseases kill more people than AIDS, malaria and tuberculosis combined. It has been established that active and passive smoking is associated with the development of many forms of cancer, cardiovascular disease, chronic obstructive pulmonary disease (COPD), pregnancy complications, sudden infant death syndrome, etc. These are all undeniable facts, but they have been published time and time again, and people have continued to smoke.
It is significant that the incidence of smoking is higher in populations of lower socio-economic status, and even in countries where smoking rates are falling, there is a visible disparity between the richer and poorer classes. Where there are sailors, the majority are certainly not from the poorer strata of our society. Smoking rates are particularly high in marginalised groups, such as people on extremely low incomes and people with mental health problems. There are no seafarers there either. The problem is that the aim of all public health programmes is to target these vulnerable groups, so it is clear that no public health system really cares about seafarers.
But who cares, and what is the real situation? Several good studies have been published and most have confirmed what we have known for a long time: populations living in stressful environments smoke more and have higher mortality from lung cancer and chronic obstructive pulmonary disease. Stress in general, and work-related stress in particular, has been identified as an important determinant of smoking. And here we are getting closer to the problem: seafarers = stress. Research on the relationship between working conditions and smoking has shown that smoking and the type of occupation are related, and that conflict at work or in the family can be associated with increased smoking rates. So, we have: seafarers, families on land, separation, bad situation on board…. Other studies have found a significant link between working hours and smoking. And here we are at sea – it is a well-known phenomenon that seafarers use alcohol and cigarettes as medication: they use alcohol to fall asleep and smoking to wake up when they have to go to sleep in the middle of the day or get up in the middle of the night because of the watchmen. The search for positive effects, such as stimulation to combat fatigue, or negative effects, such as escape from stressful situations, is therefore important for seafarers. Studies have shown that fishermen and merchant mariners are extremely susceptible to alcohol and cigarette consumption. Among fishermen, average time spent at sea is significantly associated with nicotine addiction. The number of days spent at sea in the last 12 months was also significantly associated with nicotine dependence. All of this is true and the association is real, which is why sailors are often portrayed in popular literature as heavy smokers and alcoholics. What we do know for sure is that seafarers live shorter lives than the population on land and that the main cause of death is cardiovascular disease. Cigarette smoking among seafarers is considered a significant risk factor for cardiovascular disease, which is higher in seafarers than in the general population.
In their study (Survey on smoking habits among seafarers), Iolanda Grappasonni and colleagues analysed the smoking problem among Spanish, Greek, Italian and Polish seafarers, with responses from around 1,700 respondents from 80 vessels. About half of the sample (55.07%) had never smoked, 28.96% were current smokers, while 15.97% of the respondents belonged to the category of ex-smokers. A large proportion of the sample (92.8%) is aware that smoking cigarettes or other tobacco products is a serious health hazard. So WHO is still reaching people. And they know a lot about the consequences: among the main risks associated with tobacco smoking, 92.02% of participants mentioned lung cancer, followed by cancer of the mouth, throat and oesophagus (53.45%), high blood pressure and heart problems (52.44%), addiction (42.96%), increased cholesterol and risk of cardiovascular disease (22.19%), nervousness, apathy, anxiety and headaches (16.31%). Smokers usually say “oh, I have to die of something” when the risk is pointed out to them, and they also say that when the problems start, because the study showed that 4.53% of respondents said they suffered from coughing fits (of which 32.84% were productive). Of the seafarers who reported ‘shortness of breath’ (35 people, representing 2.37% of the sample), 25.71% reported shortness of breath at rest and 42.86% after exertion. 6.97% of respondents reported coughing in the morning. 88.70% of the respondents who filled in the questionnaire stated that addiction to smoking cigarettes is caused by nicotine, 23.68% of them believe that addiction is also a consequence of tar and carbon monoxide, while 4.74% of the respondents do not know which ingredient in cigarettes they are talking about. In terms of awareness of the dangers of smoking, galley crew are six times less aware of the dangers of smoking than captains. In comparison with the engine room crew, no statistically significant correlation was found between this category and the captain.
Looking at the tested sample of seafarers by age, the majority of current seafarer smokers are in the 21-30 age group (33.88%), i.e. younger seafarers, while former smokers are in the 31-40 age group (31.36%). Among current smokers, most are deck crew (35.28%), followed by engine-room crew (26.40%) and deck officers (19.86%).
Regarding the number of cigarettes smoked per day, 11.69% of seafarers reported smoking between 21 and more than 30 cigarettes per day. Most respondents smoke 1-10 cigarettes (63.79%), followed by those who smoke 11-20 cigarettes (24.53%). Analysis of cigarettes smoked per day by rank shows that masters and officers smoke more cigarettes per day than other crew members, who smoke a maximum of 10 cigarettes per day. A less straightforward question is whether seafarers are also at increased risk of addiction if they are employed in higher ranks. In addition to a crude analysis of the number and frequency of cigarettes smoked for each rank and age group, the level of addiction was also analysed. Analysis of the results in different age groups showed that the 41-50 and 51-60 age groups had high levels of addiction (18.09% and 19.61% respectively). In terms of rank, captains and deck officers are groups characterised by high cigarette addiction (30.00% and 22.35%, respectively). If we compare the results for masters with those for deck, engine and galley crew, we see that masters are twice as likely to be medium/high addicts as other ranks. So how do we explain this? On land, higher levels of education are associated with lower smoking rates! The answer is clear: captains and deck officers have the most stressful job on board and the most responsibility, so they use cigarettes as a medicine the most.
Respondents included in the smoking group were also asked separately about their awareness of smoking, i.e. they were asked to estimate how much they smoke. 33.41% of the seafarers said they smoked a little, 40.89% a fair amount, 19.63% a lot and 6.1% a very lot. When cross-checking addiction and awareness, the highest percentage (44.68%) of ‘sufficient’ awareness of smoking was found among those in the high/very high group. The lowest percentage (6.38%) of awareness of smoking was found among those classified as highly/very highly addicted.
Regarding the desire to quit smoking, 68.09% of seafarers classified as highly/very highly addicted replied that they wanted to quit smoking. Of this group, 68.7% tried to quit and 95.4% started smoking again. Yes, smoking is one of the most difficult addictions to break, and anyone who manages to quit should be congratulated. The crew members were the ones with a higher number of respondents who had never smoked or who had quit smoking. This can be explained by the fact that masters and officers have more freedom to choose when and how much they smoke. Another worrying result is the positive and statistically significant correlation between smoking and alcohol consumption. It is likely that the co-occurrence of smoking and drinking habits indicates that individuals who feel the need to smoke also feel the need to consume alcohol in order to cope with stress or fatigue, or to fall asleep after a day’s work on board. These findings are consistent with other studies suggesting a possible link between increased smoking and alcohol consumption and work-related stress. Alcohol and cigarettes may also be used as anti-anxiety or antidepressant drugs to alleviate the impact of work stress and to self-medicate the physiological effects of stress (increased cortisol, suppressed release of serotonin and catecholamines).
Since the health risks of smoking have been well known for many years, many countries have introduced (apparently successfully) laws that impose strict controls on smoking, especially in enclosed public places, i.e. places where exposure to passive smoking is more pronounced than in open spaces. For example, in 1990, New Zealand adopted the Smoke-Free Environments Act, which aimed to completely eliminate the use of tobacco products. This law led to a significant reduction in smoking rates among the New Zealand population. From 27% in 1992, the incidence of smoking fell to 18% in twenty years and is now 10.9%, one of the lowest in the world. During this period, cigarette smoking has declined significantly, but new products, notably e-cigarettes, have come onto the market to replace traditional tobacco products. It took a generation for New Zealand to achieve this result and for the incidence of smoking to fall at an average rate of 1% per year over 30 years.
Similar attempts have been made in the maritime industry. A ban on smoking in enclosed public places on the coast came into force in Scotland in 2006, followed by similar bans in Wales, Northern Ireland and England in 2007. Scotland has legislation that also applies to vessels engaged in domestic passenger transport. However, it was not clear whether such legislation could apply to ships sailing only to and from UK ports. In addition, enforcement on non-UK vessels would be difficult and ineffective. A further problem arose from the fact that although employers were required to apply the law to their seafarers wherever the ship was, the smoking ban would only apply in a very limited area of the world in a legal sense. In the UK, the Merchant Shipping and Fishing Vessels Regulations 1997 require employers to ensure, so far as is reasonably practicable, the health and safety of employees and other persons on board. Their National Maritime Occupational Health and Safety Board is of the opinion that smoking control policies on board ships should, as far as possible, reflect those that apply in land-based workplaces and that passenger ship operators should consider applying these guidelines in relation to passengers and passenger space on board. In real life, it was up to employers and, as we saw at the beginning of this text, some took it quite seriously.
But bans are not the answer. Even if the sale of cigarettes were completely banned, the black market would surely revive, and stigmatising and penalising smokers has never led to a reduction in smoking.
One method that is supported by the professional community and can be applied on ships is the harm reduction approach. This is nothing new in the fight against drug addiction and includes a wide range of strategies including safer use, alternative treatment, abstinence and psychosocial support. This approach is based on the recognition that addiction as a disease cannot be completely eradicated in the world, and that it is necessary to find ways of reducing its harmful consequences as effectively as possible, rather than ignoring the problem and stigmatising the addict. Smokers are addicted to the nicotine in cigarettes, not to the tar and other carcinogens in cigarettes, so providing nicotine by other means rather than smoking cigarettes can prevent most of the harmful effects of smoking. The use of nicotine replacement therapy in the form of gum, patches, sprays or lozenges, combined with advice from a health professional and available psychosocial support, is an effective way to quit smoking. Well, these last two elements are not really available to you on board. In fact, doctors can be as smart as they like, they figured it out by smoking. After all, the aforementioned study showed that they know that smoking is dangerous and that they want to quit, but they can’t. Many smokers turn to new products such as e-cigarettes, heated tobacco or pouches to help them quit.
E-cigarettes are devices that use a liquid containing nicotine derived from tobacco. This liquid usually contains flavourings, propylene glycol, vegetable glycerine and other ingredients. The liquid is heated in the electronic device, creating an aerosol that the user – the “vaper” – inhales. An aerosol containing nicotine is also produced by heating tobacco in so-called heat-not-burn tobacco products or heated tobacco products [HTP]. These are electronic devices that heat the tobacco but do not burn it. The vapours produced have been shown to contain significantly fewer harmful and potentially harmful chemical compounds than the smoke from an ordinary cigarette. Among the newer variants of tobacco products are sublingual tobacco pouches, known as SNUS. This is a smokeless product that is particularly popular in Scandinavian countries. It is similar to the way people used to chew tobacco. It’s been on the Swedish market for several decades, and as many as a third of smokers who have quit have used SNUS as a “stopgap”. Sweden now has one of the lowest smoking rates in the EU. It is important to note that the proportion of SNUS users is significantly higher among men than among women, and that the reduction in smoking rates, lung cancer and heart attacks has been significantly greater in the male population than in the female population over the period observed. So “being a man”, ie chewing tobacco, still has some advantages in this crazy “woke” world.
Cigarette smoke contains more than 8,700 identified chemicals, many of which contribute to the development of disease, and at least 70 of which are carcinogenic. Compared to cigarette smoke, the aerosol produced by the use of e-cigarettes and HTPs contains significantly lower concentrations of harmful chemicals, or the presence of certain harmful substances in the aerosol cannot be determined. Reduced exposure to harmful chemicals, in some cases comparable to quitting smoking, has also been confirmed in clinical trials where smokers replaced cigarettes exclusively with e-cigarettes or HTPs.
E-cigarettes and HTPs appear to be significantly more popular than nicotine replacement therapies among people trying to quit smoking. This may also explain the significant decline in sales of regular cigarettes in certain markets. For example, in Japan, between 2011 and 2019, sales of traditional cigarettes decreased by 38% and total tobacco sales by 19%, with the largest decline in total sales of all tobacco products coinciding with the emergence of HTPs.
It has been shown that e-cigarettes and HTPs are effective tools for smokers to quit smoking and that the risks associated with their long-term use, according to the currently available evidence, do not exceed 5% of the risk associated with smoking conventional cigarettes. The results of toxicological and clinical tests showed that smokers who switched from conventional cigarettes to HTPs had 50-90% lower concentrations of carboxyhaemoglobin and other biomarkers of potential harm after 5 days. After 180 days of exclusive use of HTPs, lower levels of tobacco-specific aromatic amine metabolites, indicators of oxidative stress and a lower number of leukocytes were found in the study group, indicating a reduction in inflammation (yes, yes, if you smoke, you are in a constant state of inflammation). The levels of exhaled nitric oxide and carbon monoxide in HTP users were comparable to those found in smokers who quit smoking.
Although it cannot be said that e-cigarettes, HTPs and SNUS are not harmful, toxicological and clinical studies confirm that they are associated with a lower risk of developing smoking-related diseases, and this has been confirmed by the FDA as well as numerous European and international scientific organisations. But between two evils, one chooses the (in this case, much, much) lesser one.
All these studies confirm what can be observed in seafarers’ clinics – they show that the percentage of seafarers who smoke on merchant ships is actually low. The data processing also showed a good awareness of the possible health effects of smoking. In particular, they are aware of cancers (lung, mouth, larynx and oesophagus), cardiovascular diseases (high blood pressure, heart problems, high cholesterol, etc.), nervousness and anxiety. So the message got through. And it had to get through because we really do live in a society that no longer tolerates smoking, and as my friend from the beginning of the text says: “I can’t even smoke on deck, except in a marked square at the stern – like a dog”.
And if you want some motivation at the end: Nobody smokes on the “Jordanovac” in the ward for malignant lung diseases. Those who get lung cancer stop smoking overnight and never miss a cigarette.
Your Maritime Doc.