This study analyzed tobacco smoking among different age groups in Sofia, Bulgaria. It found high smoking rates, especially among teenagers (44% of 13-19 year olds) and younger men (51.7% of men aged 20-40). Smoking places a large economic burden on both individuals and Bulgaria as a whole. The authors call for stronger tobacco control policies to reduce smoking rates and protect public health, especially among youth. Effective programs are needed to curb the tobacco epidemic and its social and economic costs in Bulgaria.

1. Title:
COMPARATIVE SOCIAL AND ECONOMIC ANALYSIS OF TOBACCO SMOKING
AMONG THE POPULATION OF SOFIA CITY
Authors:
Jasmine B. Pavlova – Faculty of Public Health, Medical University - Sofia, jpavlova@abv.bg
Dobriana A. Sidjimova – Faculty of Public Health, Medical University - Sofia, dobrianka@mail.bg
Lora A. Afanasieva - Medical University - Sofia, lora_the_blade@yahoo.com
Momchil A. Sidjimov – Ministry of Health, Bulgaria, M.SIDJIMOV@ncphp.government.bg

2. Abstract:
Background: Smoking is a behavioural factor with significant adverse health consequences.
Bulgaria occupies one of the leading places in the world by tobacco consumption per capita. As to
diseases caused by smoking, the list of WHO is very long, treatment is costly and ends with
disability or death. Passive smoking is particularly important for children and adolescents. This is
an open door to the next level of dependency - drugs. Methods: Study of five age groups (100
persons each) in Sofia to establish the extent of smoking. Used methods: Questionnaire method;
Methods of economic analysis; Statistical methods for determining the relationships and
dependencies among the parameters studied. Results: Among 3-6 years old children, we found:
smoking parents–58%; high rate of families with all adult members smoking–23%; 61% of children
do not estimate smoking as dangerous. The volunteers in the second group are teenagers 13-19
years, 44% of them are smoking. Tobacco appears strongly linked to all other lines say risk, a
concept that includes drinks, violent or criminal and risky sexual behaviors. The analysis of active
age groups shows: men are more addicted to smoking in the younger age group and women - in the
age category 40-65; cigarettes expenditure ie rather high. Conclusions: The current economic crisis
makes it even more imperative that states, in our case Bulgaria, ensure funding for effective tobacco
control programmes. Tobacco control requires political commitment at all governmental levels, of
municipal authorities, public health institutions, families and individuals.
Keywords: tobacco smoking, social and economic analysis, expenditure, behavioural factors.

3. Introduction
Bulgaria is on first place in Europe and second in the world, after Cuba, of smokers per
capita. It is estimated that over three million Bulgarians are active smokers. Negative trend is the
fact, that since 1990 there is an increasing proportion of smoking women (from 17% in 1986,
women who smoke have reached 30% in 2001). Age of smokers also decreases progressively, but
tobacco smoking remains a widespread habit among people aged 25-45 years, of which 59 percent
are smokers. [1, 2, 3]
Scientific data confirm that globally in 1990 smoking was the main cause of death of three
million people, and in 1998 – up to 4,023,000, and projected data for 2020 are that smoking will
take 8 400,000 human lives. [4, 5]
As a result of active tobacco smoking, the smokers are exposed to the following risk factors
- a list in excess of 25 diseases, reduced speed of memory and memory capacity. Smoking kills
more people than alcohol, traffic accidents and AIDS combined. [4, 6] In Bulgaria, smoking causes
the deaths of at least 12,000 people annually. [1, 7]
Furthermore, besides the significant health problems that are caused by smoking, as a result
from it there is an economic loss, such as costs of sick leave, health insurances, absence from work
and output. Smoking is a major expense for the family budget - money spent on cigarettes could be
utilized for other needs. [8, 9, 10]
The need to develop active policies to control smoking derives from a number of reasons,
most important of which are:
the aggressive policy of advertising, promotion and sponsorship from companies producing
tobacco products;
the difficulties in overcoming this social disaster;
The inadequate policies of many countries, producing tobacco and tobacco products [11,
12].

4. It should be noted the fact, that mass campaigns and initiatives that promote healthy
lifestyles and restrictive measures against aggressive tobacco nowadays mark a significant success,
and this is reflected in the attempts of long-term smokers to quit this harmful to themselves and
others habit. Studies of the European Commission show, that every third smoker in Europe has
attempted in the recent years to stop smoking. [13]
Methods
This study aims, based on a questionnaire survey of five age groups (each of 100 persons) of
the population of Sofia, to identify and analyze the extent of smoking, and suggest approaches to
prevention.
To achieve this target the following tasks have to be carried out: Preparation of a
questionnaire adapted to each target group; fieldwork; data processing and analysis.
Time frame of the study - August 2010 - June 2011.
The project used the following economic and statistical methods:
- Inquiry method (questionnaires are tailored to the specific age groups surveyed: children 3-6
years (6 questions), growing up teenagers 13-19 years (10 questions), adults - 2 groups: 20-
40 and 40-65 years, elderly 65 + years (12 questions);
- Methods of economic analysis;
- Statistical methods to determine the relationships and dependencies among the studied
parameters.
Results and discussion
Smoking is a behavioral factor with significant adverse health consequences. The
accumulated scientific evidence suggests that smoking and passive smoking are direct or indirect
factor for morbidity and mortality in more than 25 types of diseases. Smoking reduces life

5. expectancy, and only 54% of heavy smokers reach the age of 65, against 78% of nonsmokers
exposed to tobacco smoke. [4, 14]
It is necessary to analyze why people become addicted to cigarettes, in order to be found a
solution to the problem and accordingly to facilitate the process of quitting cigarettes. The majority
(33%) of smokers indicate stress as the main reason for starting to smoke. Youth (34%) determine
friends and their environment as a factor that is influencing them to smoke. [15, 16]
Bulgaria occupies one of the leading places in the world in tobacco consumption per capita.
Average consumption of cigarettes is up to 3200-3300 pieces per person per year. (2009) Assuming
an average price of 2 Euro per pack of cigarettes, it makes about 2.5 billion Euro cost for the
Bulgarian population for cigarettes per year. According to WHO, world scale is observed the
opposite trend in the number of smokers by region. In Western Europe and the U.S., their number
decreases, while in Eastern Europe, Asia, South America and Africa increases. Established is an
inverse relationship between level of economic development and consumption of cigarettes.
Alarming are the data that about 30% of those aged 15-18 are smoking in Europe and for Bulgaria
this percentage is 38% (2005). Regarding the distribution by sex, noteworthy is that at average, in
Europe the boys smoke more than the girls, while in Bulgaria it is the opposite. Of course, we must
stipulate that the statistical data, although obtained in anonymous surveys may differ from reality
due to the possibility that some respondents may not have provided correct answers. When
comparing the number of smokers at age aspect in Bulgaria, noticed is a larger share of smokers
among men (51.7%) than boys (31.3%), while with women (29.8%) the proportion of smokers is
lower than with the girls (42.7%) [2, 17].
In Bulgaria, according to the official statistics are allocated about 4% of the gross domestic
product on healthcare. The population spends on cigarettes about 4.5% of GDP (2009). Next to
these expenses have to be added the costs of treating illnesses directly related to smoking; costs and
damages caused by fire due to smoking [1, 9, 17].

6. Tobacco production is traditional for the Balkans. Bulgaria is the biggest producer of this
crop in Southeast Europe. Tobacco is planted at about 53,000 hectares mainly in the region of
Kardjali, less along the Struma River in northeastern Bulgaria [1, 10]. Production of tobacco and
cigarettes is a profitable business. The interested in those profits outline, that tobacco creates
livelihood for almost the entire population of those regions. On the other hand, thus is developed the
production of the tobacco culture, proven harmful to human health, and which the whole
community of economically developed countries restricts by law, persuasion, and all possible
mesures. Experience shows that people engaged in tobacco production, live poor and is with low
educational level. Tobacco growing is labour intensive and hazardous. It aims to engage the whole
families (from elderly to children). Often children are absent from school or leave it completely, in
order to work. Therefore, they remain with the low level of education. This turns on a vicious circle,
from which exit is almost impossible. On lands, that for decades have been sown with tobacco
should be grown other crops (eg herbs, berries) according to soil and climatic conditions. This
would ensure the livelihood of the population and meet the requirements of the European Strategy
for Tobacco Control. [18]
We would like to emphasize that the economic impacts of smoking on children can be
grouped, namely: direct economic loss of use of cigarettes, economic costs of treating illnesses
directly related to active and passive smoking and the economic consequences of engaging children
in tobacco production. Taking in account the decreased number of children in Bulgaria, the growing
number of smoking children and adolescents, the reduced age of starting smoking, then the parents,
the community and the responsible institutions urgently need to identify effective measures to
address the tobacco epidemic in children. We believe that effective measures could be increased
prices of cigarettes, banning of smoking in public places, provision of sport facilities and
involvement of young people in active occupations where smoking is contraindicated. [19]
Passive smoking is the inhalation of the combination of sidestream smoke of smoldering
cigarette and the exhaled smoke from a cigarette smoker. The smaller the space and more smokers

7. into it, the more dangerous is the environment of passive smoking - 89% of it is a result of side
stream smoke and 11% - a result of smoke exhaled by the smokers. [2, 20]
The problem with passive smoking is particularly important with adolescents. Children
raised in a family of smokers, in many cases follow the bad example of their parents. Also, children
exposed to passive smoking, are with increased incidence of upper and lower respiratory tract
infections. Some studies show the direct relationship between passive smoking and asthma in
childhood. The phrase "where parents smoke, children cough" confirms the findings of numerous
epidemiological studies. [2, 21]
The object of the study are 100 children aged 3-6 years who attend kindergarten in Sofia -
46 boys and 54 girls. Basis for selection of the respondents - children in this age group, served two
main arguments: 1) significant medical and social risk to those children from passive smoking and
2) the ability to increase their awareness of the dangers of cigarette smoke through educational
campaigns conducted from childcare educators. Our goal was to determine the attitude of children
towards smoking and their level of awareness about the risks of this habit.
From the questionnaired children was found, that in 58 cases in the family is smoked, and in
42 – it is not. According to the results obtained, women are greater victims of the smoking habit. In
the smoking families, the mothers are more active smokers (38 mothers vs 34 fathers). Extremely
worrying to note is that in the 23% of the surveyed families, where is smoked, smoke all the
relatives (mother, father, grandparents). In terms of places where is smoked in the presence of the
child, respondents indicate, that most parents smoke at home but also in the car. This trend is
particularly alarming, because the indoor damage from passive smoking is the most significant.
Among children in families who smoke, the majority (61%) determined that tobacco smoke does
not disturb them. To a large extent the fact that the children are not feeling irritated from the smoke,
explaines also the high percentage of those who have not asked their parents to quit smoking (26%).

8. The results of the survey show that 48% of respondents aged 3-6 years do not know what
dangers are connected to smoking. 34% of children recognize the harm to health from cigarette
smoke and 18% of children literally interpreted cigarette smoking as a cause of fires.
Early adolescence is the age when a large percentage of young people begin experimenting
with tobacco. Smoking is a serious problem in many new Member States of the European Union:
Bulgaria, Lithuania, Latvia, Estonia, Czech Republic, Poland, Romania and Hungary are among the
12 countries with the biggest number of smokers among young people. These results are
particularly troubling, given that the very early onset of smoking is a major factor not only for
further consumption of tobacco, but also doing it more intensively. [15, 22, 23]
The proportion of young smokers is currently increasing in many countries and regions, and
we find significant differences in the distribution by sex:
- in Eastern Europe, smoke more boys than girls;
- gender differences are minimal in Central and Southern Europe;
- more girls than boys smoke in many countries in Western and Northern Europe;
- the greater is the probability that boys start smoking younger than girls. [22, 24, 25]
The first symptoms of dependence may occur several weeks after the accidental use of
tobacco among teenagers. There are indications that girls develop faster symptoms of nicotine
addiction than boys. [24, 25]
The reasons why a person starts or stops smoking are numerous: friends, parents, family.
Tobacco use often begins as a social activity, first with offered cigarettes from friends. Approval or
disapproval of the parents of tobacco use in general is crucial, as well as the influence of friends,
brothers and sisters. Young people who have smokers among friends and family members, are more
likely to start smoking in turn. [22, 26]
Smoking is also a symbolic act of rebellion, an attempt to convey the message that the
individual is already old enough and experienced. Children, attracted by the perception of adulthood
and the spirit of rebellion, usually come from communities with high rates of smoking among

9. parents, brothers and sisters, and attend schools where smoking is common. Children, prone to
smoking, have low self-esteem, low grades and experience lack of social care. [15, 16, 27, 28]
The easy access to tobacco advertising and to the weak efforts to control tobacco are the
factors that encourage young people to start smoking. The tobacco dependence disorder has been
recognized by the International Classification of Diseases (ICD-10) - WHO. Tobacco is an open
door to the next level of addiction - drugs. Children are particularly vulnerable age group. And in
this respect we follow the inseparable link between health, economic and social consequences. The
use and abuse of various drugs have a high cost for addicts, their families and the society: severe
somatic and mental diseases, whose treatment is expensive; in overdose – death; execution of theft,
murder to find the money for drugs etc. Efforts should be aimed at preventing drug abuse and to a
lesser extent, to treat the consequences. [27, 29]
In the 100 persons aged 13 - 19 years we applied two types of surveys: interviewers in work
active age and teenagers interviewers - each group of 50 teenagers interviewed. Volunteers in our
survey were aged between 13 and 19 years, mean age 15.86 years (boys - 16.04; girls - 15.67). No
significant statistical differences in gender distribution in smokers/nonsmokers has been
established. But the fact that only 44 of 100 state thay smoke, is alarming. Fig. 1 presents the
distribution of respondents by age, sex and smoking. In the 20-40 age category, the more active
smokers are men (54:46), while in the older group - 40-65 years, women are those, that more
practice the habit (53:47). There is an interesting trend related to smokers aged 40-65. While with
men, the increasing of age decreases the addiction to smoking, with women there is a peak in the
period 51-55, which, with the consequent increase of age, declines.

10. Figure 1
DISTRIBUTION BY GENDER, AGE GROUP AND SMOKING
(%)
40
35
30
25
20
15
10
5
0
13 - 19 20 - 40 40 - 65 65+
MALE SMOKERS 24 31 24 17
MALE NON-SMOKERS 28 23 23 29
FEMALE SMOKERS 20 24 23 15
FEMALE NON-SMOKERS 28 22 30 39
We studied the reasons for starting to smoke among the different age groups (Fig. 2). With
persons 13-19, 20-40 and 65 + years, major reason is the friendly environment, while with 40-65
years old - the example of the family. We found statistically significant differences in the causes
between groups 20-40 and 40-65 (t=7.18, p<0.001).
Figure 2
REASONS FOR SMOKING (%)
80
70
60
50
40
30
20
10
0
13 - 19 20 - 40 40 - 65 65+
FRIENDLY ENVIRONMENT 72 78 33 72
FAMILY 14 9 62 4
BOTH 14 13 5 22
CURIOSITY 0 0 0 2

11. The number of smoked cigarettes varies widely, as illustrated at Fig. 3. With teenagers, the
smoked cigarettes daily ranges between 3 and 10, with no statistically significant differences by
gender. The majority of respondents smoke an average of 5 cigarettes a day. This makes 150
cigarettes per month. Without evaluating the damage to health, let make a simple account of the
costs for these young people: around 30 euros a month - for a student who has no personal income.
This means that parents provide cash to them to smoke. Or maybe there is another source of
funding? With smokers over 20 years of age, the results are profoundly disturbing: those who
smoked over 10 cigarettes a day are 57, 76 and 70% in the three age groups correspondingly.
Figure 3
NUMBER OF SMOKED CIGARETTES PER DAY (%)
80
70
60
50
40
30
20
10
0
13 - 19 20 - 40 40 - 65 65+
till 5 59 17 5 6
from 6 to 10 41 26 19 24
more than 10 0 57 76 70
Data analysis shows that most young smokers do not want to quit smoking - 26 of 44. These
results give us reason to believe, that the emphasis has to be put on prevention of smoking, because
giving up this disastrous habit is painful, difficult and costly.
Extremely interesting results we received in the distribution of smokers according to the age
of the interwier (adult and peer of the respondents). Established were statistically significant
differences in the distribution smoker/ nonsmoker. Young people, interviewed by the peer, may be

12. more sincere in their answers - 34 say they smoke. In the group of respondents from an adult
interviewer, only 10 are identified as smokers.
In both age categories - 20-40 and 40-65, the majority of respondents note as a leading
reason for their attempts to quit smoking, the concern for personal health damage. Not to be ignored
also the reason for saving money, which for the group of older is more important than for the
young. With the age group over 65 years, the main reason for giving up smoking is referred to
damage to health (49%).
Perhaps to a more active non-tobacco campaigns and the promotion of healthy lifestyles, is
due the significant number of those interviewed in work active age (45%), who tried to quit
smoking. Significant also is the share of respondents, who have successfully overcome their
addiction to smoking (14%). In persons over 65 years, 17% were former smokers. [30]
We studied the places where the participants in our survey smoke. Teenagers say they
smoke in the gardens near schools, restaurants. In connection to the establishment of the preferred
places for smoking is documented an adverse fact, characteristic for the both two working age
categories, that the respondents do not limit themselves and smoke everywhere. The logical
dependence is the stronger markedness of young smokers aged 20-40 years (64%), who smoke
without regard to the specific location, to 41% for older smokers. They lead a more dynamic life,
socially and professionally active and in this context use every opportunity to light a cigarette,
regardless of where they are. Respectively, the percentage of people who smoke more at home,
among the age category 40-65 years, was higher (25%), mainly because they spend their free time
at home. From the total number of 65 + years old, who said they are active smokers (38 people), 12
persons indicated that they do not restrict themselves to smoking at specific places and smoke
everywhere. 11 of the respondents prefer to smoke only at home, and 9 persons smoke only
outdoors.

13. Figure 4
FRIENDLY ENVIRONMENT (%)
70
60
50
40
30
20
10
0
13 - 19 20 - 40 40 - 65 65+
SMOKERS 48 63 42 37
NON-SMOKERS 52 37 58 63
When asked who prevail among friends - smokers or nonsmokers, in the teenagers group
and the persons 20-40 years, the smokers are over the half of the groups, within the 40-65 and 65 +
groups is increased the nonsmoking environment (Fig. 4). There are significant differences in the
environment as smoking criterion in the aged 40 and over (t=2.82, p<0.01).
Conclusions
The earlier starts the smoking, the stronger is the nicotine dependence. Most young people
who smoke regularly continue to do so also as adults. Smoking damages a significant degree of the
physical fitness of young people.
Factors that predispose young people to smoking are complex, interrelated and vary among
individuals and groups. Long-term studies in many countries still identify some common factors
that contribute to smoking initiation. Among them are high levels of social acceptability of tobacco
products; aggressive supply and vulnerability to marketing; easy delivery and facilitated purchase of

14. these products; the example, set by parents and other adults; and the consumption of these products
with a friendly environment.
Smoking is closely linked to all other habits, known to be behaviourally risky, alcohol
consumption and drug abuse, violent or criminal behavior (escape, theft, extortion, fighting), risky
sexual behaviour.
The main factor that influences the decision to quit smoking in this group of respondents, is
the possible injury to health (49%). The propostion of those, who indicated other possible motives
is almost equal: health and finance, the influence of relatives and complex reasons.
High risk factor are the smoking parents of children (3-6 years) at home and in the car,
which adversely affects the health of the exposed to passive smoking. For both adult age groups is
typical the behavioural characteristics, that they smoke on any places. One third of the respondents
who are active smokers in the elderly group indicate, that they smoke everywhere. Another 30%
prefer to smoke only at home.
A significant proportion of the respondents from Sofia city support the introduction of a ban
on smoking at public places.
The average monthly cost of cigarettes among different age groups of respondents ranges
from 30 euros in adolescents up to 100-125 euros for those over 20 years of age.
Increasingly popular worldwide is the desire of modern man to a healthy lifestyle, but by
numerous historical, cultural and national mentality circumstances, smoking in Bulgaria still ranks
the country at the forefront in this nonprestigeous rating.
Within the frame of this research project are prepared presentations and brochures with
materials, revealing the bad consequences of smoking, which are distributed and presented to
kindergartens, schools, community centers, diagnostic-consultative centers for public awareness.
The idea of our team is to study the same age after a period of 1.5 - 2 years, possibly to report the
results after the preventive actions are taken.

15. Acknoledgements: This paper is part of a research project funded by the Council of
Medical Science of the Medical University – Sofia.
Conflicts of interests: None declared.
Endnotes
Smoking is widespread within the Bulgarian society. Strongly necessary are immediate,
adequate and proactive measures to control and reduce this harmful habit.
Prevention should begin in kindergarten and primary school.
The basic guidelines to fight smoking are: education programs, higher prices of cigarettes and
fines for smoking in public places, higher health insurance for smokers.
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18. Corresponding author:
Jasmine Pavlova,
Associate professor, MD
Vice dean of the Faculty of Public Health,
Medical University - Sofia
Bialo more str. 8, fl. 5
Sofia 1527
Bulgaria
Tel: +359887161580
E-mail: jpavlova@abv.bg