Results

Responses were obtained from 1550 individuals. The results of the analyses are summarised in table 2. The overall prevalence of smoking was 38.4% among men and 16.7% among women. Smoking was strongly associated with age. For men, the highest rate was in the age group 30–39 whereas for women it was among those under 30. Smoking was also more common in Sofia and, for women, in cities and towns than in villages. Among men, there was no significant association with education. Among women, although just short of statistical significance, smoking was most common among those with secondary or higher education (reaching significance if the two categories are combined). For both sexes, the probability of smoking was much higher if the respondent was widowed or divorced. There was no consistent relationship with household income but home ownership was strongly predictive of not smoking. Although not statistically significant, compared with orthodox Christians, male Muslims were more likely to smoke, whereas female Muslims were less likely.

Few women smoked more than 20 cigarettes per day whereas a significant minority of men did (figure).

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Distribution of number of cigarettes smoked per day (men and women).

Discussion

Before discussing the results, the limitations of the survey must be considered. Although the overall sample was relatively large, the small size of certain groups reduced the power to detect significant differences. Furthermore, although a quite close match, the sample was not entirely representative of the Bulgarian population. Ethnic minorities were likely to be under-represented, although this is complicated by what is believed to be under-registration in the census. Women and pensioners were over-represented as were, to a lesser extent, the divorced, although their numbers were likely to have risen since 1992 (table 1).

With these caveats, however, this survey provides information, for the first time, on the socioeconomic determinants of smoking among the Bulgarian population. As we note in the introduction, we have been able to find one other set of figures for smoking prevalence, which gives somewhat different results, but we have not been able to determine the nature of the sample used or its representativeness in that survey. For example, as our results indicate, a survey confined to major cities would have given results broadly similar to those in the earlier one.

There are three possible explanations for the observation that the prevalence of smoking is much higher among the young than the old, all of which are likely to have had some effect. It may be due to: (a) selective mortality among the old, with smokers dying younger; (b) smokers quitting as they grow older; or (c) a higher likelihood of those born in recent years taking up smoking. It is not possible, with the data available, to determine the relative importance of each. However, as the rate of lung cancer has, historically, been low in Bulgaria, and as the patterns of smoking are now similar for both sexes although it is known that female smoking was previously rare, an increase in smoking prevalence seems likely to be particularly important.

The picture is consistent with a scenario in which smoking is relatively infrequent in the more traditional sections of the population, such as older people living in villages, and most common in the cities, where there will have been most exposure to Western influences and, especially, tobacco advertising. Some of the other findings are consistent with what is seen in other countries, such as the higher smoking prevalence among those not owning their own homes or who are widowed or divorced; but the absence of a link with family income or, for men, education, is inconsistent with the current pattern in the West. In our study it was not possible to examine any differences in use of local or imported cigarettes between groups and this should be explored in any subsequent study.

Bulgaria has already enacted wide-ranging legislation against tobacco, including a ban on many forms of advertising, a prohibition on sales near schools, and restrictions on smoking in many public places; however, as in other parts of eastern Europe, the laws are inadequately enforced. On the basis of existing trends in mortality, it has been estimated that the death rate from lung cancer will almost double in Bulgaria in the next 20 years.8 The high rates of smoking among the young suggest that this is likely to increase further.

An effective and comprehensive anti-smoking policy is urgently needed. As a start, it is important to enforce the legislation that already exists but it will also be necessary to understand better why Bulgarians smoke. This survey has indicated the scale of the problem but, by itself, is insufficient. What is now needed is detailed qualitative research, using techniques such as focus groups, to understand why different groups smoke and which messages would be most effective in persuading them to stop or, preferably, preventing the onset of smoking.