Why culture makes smoking a hard habit for the Western Balkans to kick

Smoking in the Western Balkans is bucking the European trend, with the number people consuming tobacco on the rise. Entrenched cultural norms, a lack of coherent government policy, and lax laws are to blame.

For most western Europeans, the days (and nights) of smoke-filled restaurants, bars and clubs have long gone. Furthermore, the number of people who smoke has fallen considerably over the past two decades, the result of a series of public health measures aimed at gently nudging smokers to kick the habit.

In the Balkans, the fall has been much less pronounced, for both legal and cultural reasons. Indeed, according to some sources, there are countries in the Balkans where the number of people smoking has actually been increasing, such as Montenegro.

Experts across the region agree that governments and other stakeholders must do more to increase awareness about the dangers of smoking and bring laws in the region in line with EU standards.

“The smoking problem in Macedonia, as in the whole Balkan region, is affected by many variables and therefore very difficult to address. There is a tradition of growing, processing, consuming and manufacturing tobacco, as well as high social acceptance of tobacco consumption. On the other hand, there is a low level of health education, a lack of active and aggressive educational and prevention programmes, and a lack of supportive medication,” Dr Deska Dimitrievska, from the Skopje Faculty of Medicine, tells Emerging Europe.

New products, poorly-enforced bans

As if the situation wasn’t bad enough already, new forms of tobacco products have appeared – such as heated tobacco and electronic cigarettes – which are often excluded from lax and poorly-enforced smoking bans.

While it can be hard to establish just which country in the Balkans has the most smokers, available statistics make it clear that smoking is still an important public health concern, and the number of those who consume tobacco is just not going down fast enough. Serbia, Bulgaria, North Macedonia, Bosnia and Herzegovina, and Montenegro, lead not just in Europe but also in the world when it comes to the number of people who are still smoking.

In Serbia, according to data from the World Health Organisation’s Tobacco Monitor, 40.6 per cent of those over the age of 15 of both sexes consume some form of tobacco. However, comparing numbers is hard, because not all countries report data on tobacco every year, and some data only includes those over 18.

Still, the numbers don’t lie: Southeastern Europe has a serious smoking problem. In the WHO data, 38.9 per cent of Bulgarians are smokers, just ahead of Bosnia and Herzegovina’s 38.3 per cent. Sound data for North Macedonia and Montenegro is not yet available, but estimates place the percentage of smokers at around the same value.

For instance, according to 2018 data from the Tobacco Atlas, North Macedonia consumes 2,784.9 cigarettes per capita, placing it fourth in the world by cigarette consumption. In Montenegro, according to a general population survey by the country’s Institute of Public Health, among those aged 15-64, 35.4 per cent are now smokers, a marked increase from 2011 when just 31 per cent smoked.

Two important issues are key to understanding the problem. The first is that some countries in the region have yet to ban indoor smoking, while the second is that even when laws try to address the issue they fall well short of doing so.

Consider the case of Serbia, which has tried to curb indoor smoking in bars and restaurants. However, owing to pressure from hospitality operators, the ban wasn’t total. Venues smaller than 80 square meters can choose whether to declare themselves smoking, or non-smoking. Unsurprisingly, the vast majority chose to allow it. Venues that are bigger must have separate smoking sections if they choose to allow smoking.

Yet, exactly what counts as a separate smoking section is left to the discretion of the proprietors, leading to bizarre situations where two tables right next to each other belong to separate smoking and non-smoking sections.

In Bosnia, there is no ban at all

The situation is even more dire in Bosnia and Herzegovina, which hasn’t enacted any laws to ban indoor smoking. Over the last few years, attempts were made by various NGOs and other stakeholders to get the ball rolling, and in 2018 it seemed like a solution was just around the corner. However, two years later, the proposal has yet to become law, leaving the NGOs who participated in its drafting as to wonder why.

“We can only speculate theoretically as to why because we don’t have an exact response from anyone [in the government],” says Uliana Bakh, a member of PROI, one of the NGOs that helped draft the law.

She also points out two additional problems in Bosnia and Herzegovina when it comes to smoking. One is that according to the WHO’s Global Youth Tobacco Survey (GYTS), the number of children who smoke has been increasing.

“I think we are among the four or five top countries [in the world] when it comes to children smoking. It’s a real catastrophe that shows that not only is the state not doing anything to make the situation better, but it’s actually getting worse,” Ms Bakh says.

The second problem in Bosnia and Herzegovina is the rise in popularity of hookah (also known as nargile) bars, where young people under the age of 18 are often allowed to consume tobacco because of a lack of control and inspections.

She adds that dangerous myths persist in the country about the hookah, with many believing that the pipes are less harmful than cigarettes or even not harmful at all. This is, of course, false. All forms of tobacco are addictive and cause health problems.

No indoor smoking bans, hookahs, and heated tobacco products are not the end of the issue in Bosnia and Herzegovina and the region. While all countries have banned outright advertisements of cigarettes and other tobacco products, there are loopholes that tobacco companies exploit.

For instance, in supermarkets, cigarettes are sold at the cash register and the shelves all sport glossy promotion pictures of new products. In Bosnia and Herzegovina, tobacco companies are actually allowed to advertise only when they introduce a new product, leading many of them to constantly redesign packaging.

In Serbia, it’s common to see these promotional pictures at street kiosks. Because they are not free-standing billboards, these de facto ads get a free pass under the current laws. Promotion of heated tobacco products is another gap in the law which lets tobacco companies skirt around the regulations.

While hostesses in bars are not allowed to offer free samples of conventional cigarettes, no such ban exists for the likes of IQOS and Glo, the two most popular heated tobacco products available on the Balkan markets.

Easy availability

Jovan Dašić, public health and policy advisor at the Juventas NGO, notes many of the same problems exist in Montenegro as well. He especially stresses the availability of tobacco and how easily it can be purchased almost anywhere.

“Tobacco products are easily available. You can see them at markets, supermarkets, kiosks, and gas stations, while in some places there is a grey market for cigarettes, usually without the [excise] stamp,” he explains.

All this goes to show that tobacco companies are far from just passively offering their wares and letting consumers make their own choices, the oft-repeated canard of an industry that, since the wave of bans and regulations started in the 1990s across the world, has been struggling to maintain an image of a responsible corporate citizen.

Mr Dašić tells Emerging Europe that excise taxes are the most effective measure in the prevention of tobacco consumption, but interference from tobacco companies frustrates these efforts. Across the entirety of the Balkan region, cigarettes are much less expensive than in the rest of Europe. On average, a Montenegrin smoker will pay around three euros for a pack of 20 cigarettes. In France, on the other hand, the average price is 10 euros.

“Until 2018, the government in Montenegro organised traditional summits which were essentially meetings of tobacco industry representatives and high state officials that made decisions on tax policies. These summits were a direct and inadmissible violation of the WHO Framework Convention on Tobacco Control (WHO FCTC) of which Montenegro is a signatory,” Mr Dašić points out.

Montenegro is not the only regional signatory of the convention however. All regional countries have signed it, but so far none has actually fulfilled all or even most of its provisions.

Yet another issue for Montenegro is the lack of of preventative services as well as smoking cessation programmes.

“In Montenegro, there are no smoking cessation services, while prevention programmes are conducted by youth counsellors that function within state healthcare clinics. The reach of this prevention programme is very small,” Mr Dašić says.

The only good news to come out of Montenegro about smoking is the enactment of a law that finally bans smoking in restaurants and bars. Mr Dašić remains cautiously optimistic. According to him, while it is good start, issues like enforcement and the fact that the law does not ban heated tobacco products will affect just how effective the law will be in curbing smoking.

Besides, merely enacting a law isn’t enough, and enforcement is key, as the Bulgarian experience shows. The country, which banned indoor smoking totally in 2012, registered very good results at first.

“In the first year after the introduction of the ban, with its strict observance, the prevalence of smoking decreased by three per cent. After that, controls weakened, violations of the ban became more frequent, and the state did not take measures to improve the effectiveness of controls despite constant proposals by NGOs. Now, eight years after the introduction of the ban, no effect can be established,” explains Dr Masha Gavrailova, senior policy expert at Bulgaria Without Smoke, a citizen’s tobacco control initiative.

No political will

Like other experts Emerging Europe has spoken to, she too notes the lack of smoking cessation services, low prices on tobacco products, and the allowance for outdoor and point-of-sale advertising of cigarettes. Additionally, in Bulgaria, drugs that help with smoking withdrawals are not covered by state health insurance.

Yet it seems that the issue of indoor smoking remains of the most crucial one. The hospitality industry and public health are often at odds with one another, something that has been exacerbated by the Covid-19 pandemic.

North Macedonia illustrates this point well, as the country’s somewhat stringent 2013 anti-smoking law, which banned smoking in all indoor and public spaces was amended in 2017 to allow smoking in outdoor hospitality areas, even if these supposedly outdoor areas were actually enclosed on all sides.

Dr Dimitrievska adds that in North Macedonia tobacco is listed among “strategic cultures”, and subsidies are given for its cultivation, which furthers complicates an already challenging landscape for those interested in tobacco cessation and prevention.

“As to my knowledge there are no recent studies for the prevalence of smoking in Macedonia,” she says.

Dr Dimitrievska is part of the Macedonian Respiratory Society, an NGO involved in providing and organising educational programmes for healthcare workers, and an organisation which is part of the European Network for Smoking Prevention (ENSP). Currently, they are working to distribute their adapted translation of the ENSP guide for smoking cessation to healthcare workers in North Macedonia.

“We are also organising numerous educational lectures and workshops. Unfortunately, I am not aware of any comprehensive activities supported or organised by the government,” she says.

In the end, it seems that this is the main problem in the region. While NGOs and even some state actors such as hospitals and health ministries do run regular anti-smoking campaigns across most of the region, a lack of concerted effort by governments prevents meaningful change.

There are some who would say that smoking is simply far too ingrained in Balkan culture, and passing by any outdoor (and in some places indoor) cafe or bar certainly seems to support that conclusion.

But, Ms Bakh from the Bosnian organisation PROI takes a different position. According to her, other European countries such as Italy and France also have a strong smoking culture, but managed to at least somewhat change it through legal and regulatory action.

“[Anti-smoking] campaigns are necessary, but without laws, campaigns can’t be effective. So, campaigns on their own can’t solve the problem,” Ms Bakh says.

It’s clear that there is no panacea for smoking in the Balkans. Owing to the complexity of smoking as an addiction, and myriad social and legal factors, it’s not realistic to expect things to change quickly.

But, the experts are clear on one point: governments need to lay down the law before anything meaningful can even begin to happen.

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