Question

What significance does the case of The Prohibition of Smoking in Public Places in Bulgaria have regarding chronic disease prevention and health promotion? Explain your answer

Answer 1

Introduction

Chronic noncommunicable diseases , including cardiovascular diseases, malignant
neoplasms, and noninfectious pulmonary diseases, are a major cause of the global
burden of disease in the European Region 3
(86 % of the 9.6 million deaths and 77 %
of the 150.3 million disability-adjusted life years (DALYs) (Vassilevsky et al. 2009 ).

Commonly associated risk factors include smoking , alcohol consumption, unhealthy
diet, and low physical activity.

Tobacco smoking alone produces 12 % of the global disease burden in the
European Region (ranges from 3 to 27 % for the individual countries) and it causes
2–21 % of all deaths. For Bulgaria, these rates are 13.5 % and 12.4 %, respectively
(Vassilevsky et al. 2009 ). Annually, more than four billion people die worldwide
from diseases related to tobacco products. By 2030, this number is expected to
reach ten million, which will turn tobacco smoking into the biggest single cause of
death (World Bank 1999 ).

Bulgaria is among the countries with the highest level of morbidity and mortality
from cardiovascular diseases, especially cerebrovascular disease. Standardized
death rates of all smoking-related causes of death for 2011 were estimated to be 318 per 100,000 people, whereas the average for the European Union (EU) 4
was 195 per
100,000 people. Standardized death rates of stroke in Bulgaria were about three
times higher than the average level for the EU. Only Ukraine, Moldova, Kyrgyzstan,
and Russia had higher rates (World Health Organization [WHO] 2012 ).

At the same time, Bulgaria is a leading country in cigarette use among Central
and Eastern European countries (Ministry of Health, Bulgaria 2008 ). About 40 % of
the population are smokers: 47 % of men and 33 % of women (Vassilevsky et al.
2010 ). Cigarettes smoked per person per year in Bulgaria (2793 cigarettes) is sig-
nifi cantly higher than the average for the European Region (1681 cigarettes) (WHO
2012 ). Smoking among teenagers in Bulgaria is also among the highest in
Europe—40 % of teenagers smoke (36 % of boys and 44 % of girls) (Tsolova et al.
2010 ). A 2011 survey found that Bulgaria was fourth out of 36 countries in teenage
smokers (Hibell et al. 2012 ).

These data are alarming. But additional concern for public health is the effect of
secondhand smoking. The risk of death from coronary heart disease increases 30 %
from exposure to secondhand smoke (American Heart Association 2013 ).
Secondhand smoke—“passive” smoking—increases a child’s risk of developing
pneumonia, asthma, and other allergic conditions (Naydenov et al. 2007 ). A survey
of countrywide integrated noncommunicable disease intervention (CINDI)
programme- Bulgaria found more than 80 % of teenagers were exposed to passive
smoking daily (20 % of teenagers were exposed for 1–2 h per day; 50 % were
exposed for more than 2 h per day). Exposure was higher among girls than boys
(43.1 % of boys and 56.7 % of girls were exposed to secondhand smoke for more
than 2 h per day) (Tsolova et al. 2010 ).
As a member of the EU , Bulgaria has had to harmonize its legislation with
European legislation. The fi rst smoke free legislation in Europe was adopted in
March 2004 in Ireland (Howell 2004 ). Currently, all EU member countries have
some form of regulation aimed at limiting exposure to secondhand smoke. However,
the scope of these regulations differs widely within the EU (European Public Health
Alliance 2012 ). First attempts to prohibit smoking in public places in Bulgaria date
back to January 2005. Restaurants and other food and drink places were separated
into zones for smokers and nonsmokers. The Bulgarian society also split into groups
of supporters of the changes and opponents of smoking restrictions.

On November 7, 2005, Bulgaria ratifi ed the World Health Organization
Framework Convention on Tobacco Control . Article 8 of the Convention stipulates
that “effective legislative, executive, administrative and other measures, providing
for protection from exposure to tobacco smoke in indoor workplaces, public trans-
port, indoor public places and, as appropriate, other public places should be taken”
(WHO 2003 ).

On May 17, 2012, the parliament voted to amend the Bulgarian Health Act pro-
hibiting smoking in public places (Republic of Bulgaria Council of Ministers 2012 ).
According to the new regulation , which took effect June 1, 2012, smoking was prohibited in all indoor public places and workplaces including stadiums, children
playgrounds, kindergartens, and other schools . Still, Bulgarian society remained
confl icted about the issue.
In November 2012, two independent members of the Bulgarian parliament raised
the issue of business losses from the smoking ban . They claimed that 10,000 people
lost jobs due to fewer patrons of food and drink establishments and pleaded for revi-
sion of the law (Todorova 2012 ). Offi cial data about business losses were not pro-
vided, and such surveys have not been done. Nevertheless, these claims increased
public debate about the smoking bans . On December 10, 2012, the Bulgarian Hotel
and Restaurant Association offi cially protested the law and insisted it be revised.

The prime minister initially agreed that some revision could be possible but later
supported the minister of health, who opposed changing the law. The minister of
health pointed out that pitting business against health was unacceptable and, instead
of discussing business losses, the government should be discussing the cost of treat-
ing oncological and cardiovascular diseases (Dimitrova 2012 ). The minister of
economy, energy, and tourism favored a more fl exible application of the law .
Eventually, decision making was transferred to parliament’s Economic Committee
with the idea that the ban on smoking could be abolished through the Law of
Tourism, particularly if certain amendments were adopted to allow smoking in spe-
cifi c areas of bars and restaurants. On December 18, 2012, the Economic Committee
rejected any amendment to the law. Thus, despite the controversy and public
debates, the law prohibiting smoking in public places has survived without change
as of May 2013.

In Bulgaria, Croatia, Romania and Turkey, there are complete smoking bans in healthcare, education and government facilities. Theatres and cinemas also ban smoking in these nations. The most permissive smoking facilities include pubs and bars. There are no restrictions in Romania and Turkey while Bulgaria and Croatia have partial restrictions. After 6 months of experimentation, Croatia partially eased their smoking ban in cafes in response to complaints from smokers and business owners. There are complete bans in indoor workplaces and offices in Bulgaria and Croatia, but only a partial restriction in Turkey and virtually no restrictions in Romania.2 Despite these legal restrictions, compliance and enforcement have oftentimes been lax.6

# Chronic disease prevention and management

Integrated chronic disease prevention and management aims to reduce overall risk in high-risk individuals and provide appropriate care by facilitating early case finding through affordable strategies and technologies, and equitable and good quality health care for major chronic diseases.

Prevention of disease means forsaking the bad habits which many people enjoy—[but the] cost of sloth, gluttony, alcoholic intemperance, reckless driving, sexual frenzy, and smoking is now a national, and not an individual, responsibility. This is justified as individual freedom—but one man’s freedom is another man’s shackle in taxes and insurance premiums. I believe the idea of a ‘right’ to health should be replaced by the idea of an individual moral obligation to preserve one’s own health—a public duty if you will. The individual then has the ‘right’ to expect help with information, accessible services of good quality, and minimal financial barriers (Knowles 1977).

How You Can Prevent Chronic Diseases

* Eat Healthy. Eating healthy helps prevent, delay, and manage heart disease, type 2 diabetes, and other chronic diseases. ...

* Get Regular Physical Activity. Regular physical activity can help you prevent, delay, or manage chronic diseases. ...

* Avoid Drinking Too Much Alcohol. ...

* Get Screened. ...

* Get Enough Sleep.

* avoid smoking