Q&A: Global Bridges grantee discusses tobacco dependence treatment and advocacy efforts in Macedonia

The Global Bridges team connected with Marija Zdraveska, M.D., MMsci, primary investigator of the Collaborative Development of a Continuing Education Program to Train Healthcare Providers on Tobacco Cessation Counseling in the Republic of Macedonia and president of the Macedonian Respiratory Society, to learn more about her team’s Global Bridges-funded project.

Global Bridges: Tell us about your project in collaboration with Henry Ford Health System. What are you working to accomplish and how is the project progressing?

Dr. Zdraveska: The situation in Macedonia concerning tobacco abuse is typical for all the surrounding Balkan countries, but specific issues in Macedonia have led to more problems. The prevalence of smoking in Macedonia is very high – 37 percent of adults on average (46.5 percent for men and 26.7 percent for women) smoke. In the country, tobacco products are cheap and easily available in all markets such as newspaper stands and grocery stores. They are even accessible within proximity of health institutions and educational facilities. Smoking is incorporated in everyday life and is socially and culturally accepted as “normal behavior”. Furthermore, growing and processing tobacco is a tradition that has lasted for centuries. It is the only means of living for a great number of families. The tobacco industry was reinforced several years ago by infiltration of Philip Morris into the tobacco economy of the country. Although banned by legislation, subtle marketing of tobacco products is still present, cigarettes are available to children under 18 years of age, which contributes to the high prevalence of smoking among adolescents (up to 27 percent). However, the support that the Government provides for smoking cessation programs, tobacco abuse treatment and education of health providers is minimal. Comprehensive and structured educational programs are not present and tobacco treatment education is not included in the formal education of health professionals. Currently, there are no supportive medications, nor nicotine replacement treatments available in Macedonia.

Considering these facts and comprehending the vast experience in tobacco cessation of the service within Henry Ford Health System, we decided to start a collaborative development of an educational program to train healthcare providers for the basic skills of tobacco control and cessation.

This project, generously funded by Pfizer/Global Bridges, encompassed training of five physician champions by certified tobacco cessation specialists, who further on, shared their knowledge on a two-day workshop organized in Macedonia, attended by 97 medical doctors from diverse regions of the country. Currently, the trained doctors are implementing their knowledge, advising their patients about smoking cessation.

GB: Alongside this project, we understand you are also involved in an advocacy initiative to protect the smoke-free law strengthened in 2010. Can you please talk about this challenge and how you’re working to address it?

Dr. Zdraveska: After a series of attempts and upgrades started in 1995, a moderately restrictive smoke-free law was introduced in Macedonia in 2010. Since then, smoking is prohibited indoors in public facilities and on public transportation. The marketing of tobacco products and selling cigarettes to children under 18 is also banned. Smoking is still allowed in private settings as well as outdoors public spaces, on terraces and the balconies of café bars and restaurants, but only if their walls are open from at least three sides. The practical implementation of this law has suffered pitfalls throughout the past years, but the population has started accepting this policy, getting used to the recommendations, and public behavior has slowly and gradually changed. Unfortunately, the newly elected Government, started lobbying with a group ofrestaurant, café-bar and casino owners, which resulted in an official proposal for introducing changes to the existing smoke-free law. This proposal allows smoking on terraces and balconies of their facilities, even if they are completely closed off and without ventilation. Though the proposal is still under consideration in the Parliament, suddenly, tobacco is freely consumed in all of the restaurants and cafés in the country, without any restrictions or punishments.

Foreseeing the negative consequences of such a liberalization of the smoking ban, the Macedonian Respiratory Society prepared an Open letter addressed to the public, Government institutions, Parliament and the media, in which we summarized our opinion about this action and the consequences of liberalization of the law. We proposed and demanded reconsidering and focusing the efforts of the officials to smoking cessation, education and tobacco dependence treatment, instead. This initiative was supported by the Association of Pulmologists of Macedonia and the Macedonian Society of Family Doctors. Representatives from these societies and other medical institutions were present at the dedicated public dispute at Parliament, protecting the arguments against liberalization of the smoking policy in the country and appealing for a bigger engagement of the officials in smoking cessation and treatment of tobacco dependence. We also addressed the public through numerous media to raise the awareness and influence the public opinion. We are now waiting for the final decision of the Parliament on this matter, hoping that this regressive initiative will be rejected.

GB: How has your work on a Global Bridges grant influenced your advocacy activities?

Dr. Zdraveska: As I have previously mentioned, tobacco control was very poorly addressed in the formal education of doctors and smoking cessation initiatives were not strongly supported by public officials. Most of the health providers had limited or vague knowledge on the negative effects of smoking and the possibilities and methods for treatment of tobacco dependence.  Only a few really believed that making a difference was possible in the setting where tobacco consumption is protected and almost encouraged by the public and institutions.

The educational reinforcement of the trained physicians, conducted within our ongoing program and the multicenter project targeting family doctors in Macedonia, who is also supported by Global Bridges, provided the necessary capacity to stand in protection of the positive smoke-free laws. The possibility to join the family of the European Network for Smoking and Tobacco Prevention, also enabled by Global Bridges, the access to the documents the ENSP issued, and the information about their positive experience, provided us with the strength and support as well as the courage to fight for the smoke-free policies, even against the highest institutions of our country.