Tobacco control fact sheet: Bulgaria

Bulgaria Health impact of tobacco control policies in line with the WHO Framework Convention on Tobacco Control (WHO FCTC) TABLE 1. Initial smoking prevalence and projected premature deaths a Premature deaths are based on relative risks from large-scale studies of high-income countries. b Premature deaths are based on relative risks from large-scale studies of low- and middle-income countries. Source: National Statistical Institute (1). Within 15 years, the effects of individual tobacco control policies when fully implemented in line with the WHO FCTC (2) are projected to reduce smoking prevalence by: • 11.9% by increasing excise cigarette taxes from its current level of 66% to 75% and prevent much youth smoking; • 6.3% by increasing from a low-level to a high-level mass media campaign; • 5.5% by banning just some forms of direct and indirect advertising to have a comprehensive ban on advertising, promotion and sponsorship that includes enforcement; • 4.5% by requiring strong, graphic health warnings added to tobacco products; • 4.3% by increasing from minimal provision to a well-publicized and comprehensive tobacco cessation policy; and • 1.8% with stronger enforcement of the comprehensive smoke-free laws already in place. Key findings BULGARIA Smoking prevalence (%) Smokers (n) Male Female Total 43.4 26.9 2 119 400 Projected premature deaths of current smokers (n) Malea Femalea Totala Maleb Femaleb Totalb 629 300 430 400 1 059 700 409 045 279 760 688 805 TOBACCO CONTROL FACT SHEET Ph ot o: ‘A le xa nd er N ev sk y C at he dr al ’ b y t eo do rp k. CC B Y 2. 0 Tobacco Control Fact Sheet Based on the current level of adult smoking in Bulgaria (1), premature deaths attributable to smoking are projected to be more than 1 million of the 2.1 million smokers alive today (Table 1) and may increase in the absence of stronger policies. © World Health Organization 2016. All rights reserved. TABLE 2. Effect of tobacco control policies (individual and combined) on initial smoking prevalence and smoking-attributable deaths TABLE 3. Complete smoke-free indoor public places With this stronger set of policies and consistent with the WHO FCTC (2), smoking prevalence can be reduced by 23% within 5 years, by 30% within 15 years and by 36% within 40 years. Almost 383 000 deaths could be averted in the long term (Table 2). The SimSmoke tobacco control model (3) incorporates synergies in implementing multiple policies (e.g., strong media campaign with smoke-free laws and tobacco cessation policies). Monitor tobacco use The prevalence of current adult smokers (15 years and older) was 34.7% in 2014 (men: 43.4%; women: 26.9%) (1). Relative change in smoking prevalence (%) Reduction in smokers in 40 years (n) Reduction in smoking-attributable deaths in 40 years (n) Tobacco control policy 5 years 40 years Total Male a Femalea Totala Maleb Femaleb Totalb Protect through smoke-free laws –1.6 –2.0 42 149 12 515 8 559 21 074 8 135 5 563 13 698 Offer tobacco cessation services –2.5 –6.1 129 831 38 550 26 366 64 916 25 057 17 138 42 195 Mass media campaigns –5.5 –6.6 139 880 41 534 28 406 69 940 26 997 18 464 45 461 Warnings on cigarette packages –3.0 –6.0 127 164 37 758 25 824 63 582 24 543 16 786 41 329 Enforce marketing restrictions –4.6 –6.0 126 740 37 632 25 738 63 370 24 461 16 730 41 191 Raise cigarette taxes –7.9 –15.9 336 648 99 959 68 365 168 324 64 973 44 437 109 410 Combined policies –22.7 –36.1 765 433 227 275 155 441 382 716 147 729 101 037 248 766 Protect people from tobacco smoke Almost all enclosed public places in Bulgaria are completely smoke free (Table 3). Smoking violations consist of fines on the patron but not on the establishment. Funds are dedicated for enforcement and a system is in place for citizen complaints and further investigations (4). a Smoking-attributable deaths are based on relative risks from large-scale studies of high-income countries. b Smoking-attributable deaths are based on relative risks from large-scale studies of low- and middle-income countries. Source: WHO (4). = completely smoke-free; = not completely smoke-free. Universities Government facilities Indoor offices & workplaces Restaurants Cafés, pubs & bars Public transport All other indoor public places Health care facilities Education facilities except universities 2 Tobacco Control Fact Sheet: BULGARIA TABLE 4. Bans on direct and indirect advertising Offer help to quit tobacco use Smoking cessation services are available of which some are cost-covered, but Bulgaria only provides cessation support in some health clinics or other primary care facilities. Nicotine replacement therapy can be purchased over the counter in a pharmacy but is not cost-covered, and a toll-free quit line is available (4). Warn about the dangers of tobacco Health warnings are legally mandated to cover 30% of the front and 40% of the rear of the principal display area, whereby 16 health warnings are approved by law. They appear on each package and any outside packaging and labelling used in the retail sale and describe the harmful effects of tobacco use on health. Moreover, health warnings rotate on packages and are written in the principal language(s) of the country. The law also mandates font style, font size and colour for package warnings. However, the warnings do not include a photograph or graphics. (4). Total tobacco control expenditures, which may include mass media campaign expenditures, amount to US$ 25 033 in Bulgaria, which is less than US$ 0.05 per capita and is, therefore, classified as a low level of funding (4). Enforce bans on tobacco advertising, promotion and sponsorship Bulgaria has a ban, through a law adopted in 1993 and amended many times since then (last amendment was in 2012) (5), on several forms of direct and indirect advertising (Table 4). The law requires fines for violations of these direct and indirect advertising bans (4). Raise taxes on tobacco In Bulgaria, a pack of cigarettes costs 4.70 BGN¹ (US$ 3.21), of which 82.65% is tax (16.67% is value added and 65.98% is excise taxes) (4). Bulgaria does not have: • bans on tobacco companies/tobacco industry publicizing their activities; • bans on entities other than tobacco companies/tobacco industry publicizing their activities; • bans on tobacco companies funding or making contributions (including in-kind contributions) to smoking prevention media campaigns including those directed at youth; and • a requirement to present prescribed anti-tobacco advertisements before, during or after the broadcasting or showing of any visual entertainment (4). Direct advertising Indirect advertising National television and radio Free distribution in mail or through other means International television and radio Promotional discounts Local magazines and newspapers Non-tobacco products identified with tobacco brand names International magazines and newspapers Appearance of tobacco brands in television and/or films (product placement) Billboards and outdoor advertising Appearance of tobacco products in television and/or films Advertising at point of sale Sponsored events Advertising on internet Tobacco products display at point of sale Source: WHO (4). ¹ The currency code is according to International Organization for Standardization, ISO 4217 currency names and code elements. = banned; = not banned. 3 Tobacco Control Fact Sheet: BULGARIA References2 1. European health interview survey, EHIS wave 2 – 2014: preliminary data. In: National Statistical Institute [website]. Sofia: National Statistical Institute; 2016 (http://www.nsi.bg/ en/content/13666/preliminary-data). 2. WHO Framework Convention on Tobacco Control [website]. Geneva: Convention Secretariat and World Health Organization; 2016 (http://www.who.int/fctc/en/). 3. Levy DT, Fouad H, Levy J, Dragomir AD, El Awa F. Application of the Abridged SimSmoke model to four Eastern Mediterranean countries. Tob Control. 2015. doi:10.1136/ tobaccocontrol-2015-052334 [Epub ahead of print]. 4. WHO report on the global tobacco epidemic, 2015: raising taxes on tobacco. Geneva: World Health Organization; 2015 (http://www.who.int/tobacco/global_report/2015/en/). 5. Tobacco Control Database for the WHO European Region [online database]. Copenhagen: WHO Regional Office for Europe; 2016 (http://data.euro.who.int/tobacco/). 6. Tobacco Free Initiative MPOWER [website]. Geneva: World Health Organization; 2016 (http://www.who.int/tobacco/ mpower/en/). Acknowledgements Data analysis: David Levy and Jeffrey Levy, Georgetown University, Washington DC, United States of America Report: Trudy Wijnhoven and Kristina Mauer-Stender, WHO Regional Office for Europe, Copenhagen, Denmark Editing: Nancy Gravesen, Irvine, California, United States of America Graphic design: Carli Hyland, Hill+Knowlton Strategies, Copenhagen, Denmark ² Websites accessed on 14 March 2016. About the SimSmoke model The abridged version of the SimSmoke tobacco control model, developed by David Levy of Georgetown University, United States of America, projects the reduction in smoking prevalence and smoking-attributable deaths as a result of implementing tobacco control policies (individually and in combination) (3). Specifically, the model projects the effects from: • protecting from secondhand smoke through stronger smoke-free air laws • offering greater access to smoking cessation services • placing warnings on tobacco packages and other media/educational programmes • enforcing bans on advertising, promotion and sponsorship • raising cigarette prices through higher cigarette taxes (6). For the SimSmoke model, data on smoking prevalence among adults were taken from the most recent nationally representative survey that covered a wide age range, and data on tobacco control policies were taken from the WHO report on the global tobacco epidemic, 2015 (4). Funding This was made possible by funding from the Government of Turkmenistan. 4 Tobacco Control Fact Sheet: BULGARIA WHO/EURO:2016-10473-50245-75736 © World Health Organization 2016. All rights reserved.