Why do 48.4% of adults in North Macedonia smoke?
– The paradox of a nation economically dependent on a crop that is its leading cause of preventable death.
– How a history of tobacco farming traps generations in a cycle of poverty and illness.
– The shocking reality for farmers: earning as little as $477 a year while facing acute nicotine poisoning.
– The alarming trend of children starting to smoke as young as 10 years old.
– The future: 39,000 preventable deaths projected in the next 40 years.
I thought I understood smoking cultures. I really did. I mean, I’d navigated the cafe scenes in southern France, Italy, places where having a cigarette with your coffee is, oh, it’s practically a given. So, when I started working with Macedonians and the first like cultural warning I got was about smoking, I figured, okay, I can handle this. I was not prepared. Not at all. It’s not just that nearly half the entire adult population smokes. That’s staggering enough. It’s the sheer unreachable wall of it. Yeah, like being in a small restaurant where the air is literally so thick with smoke you can barely see the person across the table. It’s noticing that stale smell clinging to your clothes, your hair, even I swear the food sometimes. But the real shocker, the thing that truly sets it apart is this unspoken rule. You do not under any circumstances ask someone not to smoke. It’s considered the absolute height of rudeness. Just unthinkable. And then right next to these smoke filled cafes, you’ll see these like really antiquated posters. Sort of like something from a ’90s health class back home. Just a simple almost naive message. Smoking kills. The contrast is so jarring, it just stops you in your tracks. This profound paradox, isn’t it? How can a country be so aware of a problem on paper yet so completely surrendered to it in reality? That opening really isn’t just an anecdote. It uh it captures the core of this paradox we’re diving into today. Exactly. How can you have those stark messages smoking kills side by side with being one of the highest smoking rates globally? It’s baffling and we need to unpack that duality starting with just the sheer scale of the habit itself. Right. We’re talking about North Macedonia, a place that Yeah. despite its size, it really ranks up there. Absolutely. The numbers are uh striking when you put them in context. What? Well, North Macedonia has a smoking prevalence of 48.4%. Wow. Almost half. almost half the adult population. And just to put that into perspective, the European Union average is uh around 18.4%. That’s a massive difference. Huge. It really is. It shows a societal norm that’s just miles away from say Western Europe. And it’s not just that nearly half the adults smoke. It’s the intensity. What do you mean intensity? Well, a significant portion, over 44% of those smokers consume more than 20 cigarettes daily. 20 a day. That’s heavy smoking. Exactly. This isn’t just a casual habit, you know, something they pick up now and then. It’s deeply ingrained. It’s part of their daily lives, almost like a ritual woven into social interactions, daily routines. So, it’s omnipresent pretty much. That’s the daily reality we’re talking about. And I understand it starts alarmingly young, doesn’t it? Which I mean, that just locks people in for life, right? Compounding the risks. It does. And that’s perhaps one of the most concerning aspects. It really sets the stage for lifelong addiction, chronic health issues down the line. How young are we talking? Most smokers in North Macedonia start before they’re 25. About 81.4% of them. In fact, 80% starting before 25. Yeah. And if you dig deeper, the average starting age is incredibly low. Around 13 and 1/2 years old. 13. That’s kids. Kids. And what’s really striking is there’s very little difference between boys and girls at that initiation age. So, it’s not just a boy thing. Not at all. It suggests the societal pressures, the accessibility. It’s equally powerful for both genders right from that young age. And are there reports of even younger kids? In some areas, yes. Children as young as 10 are reported to start smoking regularly. And once they start, the addiction kicks in fast. So, by the time they’re teenagers, by the time they’re 14 or 15, many are already regular smokers. It sets them on this lifelong path of nicotine dependence and well, all the severe health consequences that come with it. decades of exposure then for a huge chunk of the population. Exactly. Given how long people are smoking and starting so young, the health consequences must be just devastating. Can you paint a clearer picture of that impact? Tragically so. I mean, tobacco use is universally the leading cause of preventable deaths globally. That’s not news. But in North Macedonia, the impact is severe. It’s farreaching. It puts immense strain on an already, frankly, overburdened healthare system. What are the numbers like? Smoking contributed to, get this, 170.17 deaths per 100,000 people back in 2019. Wow. 170 per 100,000. Yeah. A figure that just dwarfs many other causes of preventable death. And if the current trends continue, which is the worrying part, what’s the projection? The country could face an estimated 39,000 entirely preventable tobacco related deaths over the next four decades. 39,000 preventable deaths. That’s it’s hard to wrap your head around. It really is. And it isn’t just a number. It represents thousands of lives cut short, families losing loved ones prematurely, and the economic cost. Yeah, the strain on the health system must be huge. Immense, unsustainable, really. It diverts resources that could be used for other critical things, maternal care, screenings, infrastructure, you name it. And the diseases themselves, right? More importantly, it leads to widespread premature mortality, particularly from non-communicable diseases, cardiovascular illnesses, COPD, which is that chronic lung disease, and various forms of cancer, lung, oral, esophageal. The list goes on. The human cost is just staggering. It impacts families, communities, productivity, quality of life for everyone involved. It really underscores the urgency, doesn’t it? Absolutely. This is a full-blown public health crisis. So, with all that devastating health information laid out, it’s hard to reconcile those numbers with just individual choice. It feels like there has to be more going on, like bigger systemic forces keeping this habit so prevalent despite the dangers. You’re absolutely right. This isn’t just millions of people individually deciding to smoke against all evidence. There are deep-seated systemic forces at play here, like what? Economics. Yeah. History. Both. There’s a profound economic and historical layer that really explains this persistence. You have to remember North Macedonia gained independence in the early 90s from Yugoslavia, right? A tough transition period. Very. And they leaned heavily on their ability to grow oriental leaf tobacco. It was seen as a key strategy to well to kickstart their new economy. Oriental leaf tobacco. Is that specific to the region? Yes. It’s known for its small leaves, distinct aroma. It thrives there in that climate, that soil. And how big a crop is it for them? Well, it’s a small country, right? Roughly the size of Vermont, but about 3.2% of its total land area is used for tobacco cultivation. 3%. That sounds like a lot for one crop in a small country. It is. And globally, they’re second only to Turkey in producing this type of tobacco. Second only to Turkey. Wow. So, that really highlights how central this crop is. It’s not just another commodity. It’s core to their agricultural identity and uh the economy. So, it’s more than just a cash crap. It sounds like it’s woven into the fabric of rural life. Yeah. Tradition, livelihood. Exactly. For generations. I was thinking about a specific story that kind of brings this complexity home. I heard about this man, Stojan, a tobacco farmer from the PLP region. Mhm. Pleup is a major tobacco area, right? And his hands stained yellow brown from the resin. You know, those same hands fed his family for three decades. This land, this crop, it’s in his blood. part of his identity, a sense of pride, I imagine definitely looking over his feels, that sense of continuity. But lately, apparently, a different feeling started creeping in. His cough getting deeper, and then seeing his 18-year-old son, Marco, smoking with friends. Ah, the cycle repeating. Just like Stoan probably started himself. He hears talk about diversifying crops, maybe subsidies for peppers or grapes. Sure, the alternatives, but tobacco is the known quantity. It’s the guarantee. It’s the life he understands. So he’s caught in this quiet impossible bind. The very thing providing for his family is poisoning the next generation. That anecdote perfectly captures the reality for so many. It really underscores this profound trap they’re in. A trap. Yeah. Because while tobacco farming is seen as relatively stable, especially if you don’t have higher education or specialized training because the government subsidizes it. Partly, yes, the government does provide subsidies. But here’s the kicker. The actual profitability for the average farmer is shockingly low. How low? Some earn as little as $477 US annually. Annually, that’s barely anything. It’s a subsistence struggle, barely above the poverty line, often propped up by state pensions. A survey in 2023 found nearly half of them aren’t even turning a profit. They rely on pensions just to get by. So, they’re trapped financially, too. Completely. So, when you talk about diversifying crops, it’s not just about economic models. It’s about fundamentally reshaping the survival strategy for thousands of families who literally cannot afford to fail. They don’t have the capital or training to just switch. Exactly. They’ve done this their whole lives, inherited the land, the knowledge. So, yeah, exploring sustainable agricultural diversification, alternative livelihoods, things like high-v value herbs, medicinal plants, specialized fruits. That’s crucial. But it needs massive support. Massive sustained support, financial incentives, yes, but also expertise, market connections, risk mitigation. That’s the scale of the challenge for policy makers trying to shift away from tobacco dependence. And on top of the economic hardship, the physical cost for the farmers themselves must be a mess, even before anyone lights up. Exactly. That’s often overlooked. Beyond the economics, there are significant health risks for the farmers. Like what? Pesticides. Yes. Tobacco requires more pesticides than many other crops. So, there’s exposure to harmful chemicals, respiratory issues, skin problems, maybe long-term neurological damage, and handling the leaves themselves, right? Handling the leaves, especially when they’re wet, often leads to something called green tobacco sickness. Green tobacco sickness. What’s that? It’s acute nicotine poisoning absorbed directly through the skin. Seriously, just from touching the leaves? Yes. Symptoms can range from headaches, nausea, up to severe things like seizures, even comas in extreme cases. And it can sometimes result in lifelong health problems. That’s awful. And are kids involved in this work, too? Disturbingly, yes. Children of tobacco growers are 2.3 times more likely to be involved in the farming activities than kids of non-tobacco farmers. So, they’re exposed to these risks from a young age directly, perpetuating a cycle of illness within these farming communities. And like you said, all of this is before anyone even lights up a cigarette. It just shows how pervasive the impact is. So it seems like the national government is maybe less influenced by the purely economic arguments against tobacco, especially when they compare it to bigger industries like oil or mining. That feels counterintuitive given the health burden. Why is that? It is curious and it’s a really critical nuance for understanding the policy challenges there. Unlike in many other countries where the huge economic costs of tobacco-reated illness, the healthc care burden lost productivity are a powerful advocacy tool. Right? You’d think that would sway them. In North Macedonia, national officials seem less swayed by those specific arguments. The revenue directly from tobacco itself is considered well pretty insignificant at the national level compared to income from oil, minerals, other larger resources. Okay, so it’s not a huge national revenue stream. Not compared to the big stuff. What’s more, most of the tax revenues from tobacco production and sales actually go to regional governments. Ah, so it’s localized money. Exactly. And those regional governments are heavily influenced by the big tobacco companies and the jobs their factories create in those specific areas. So the industry has a lot of local clout, considerable local power. Yeah. Because of employment numbers, investment. This effectively shifts the advocacy argument. It has to focus almost entirely on the direct health burden rather than the economic one. at the national level which makes it a harder fight. A more challenging fate definitely because the national level economic incentive just isn’t as compelling as it might be elsewhere. Okay. So if the economic arguments are often sidelined nationally, the fight really hinges on the health burden. But even that faces this other huge force, something I felt immediately, the sheer social wall of smoke. It’s not just accepted, it feels expected. That’s a critical point because it speaks to this deep cultural entrenchment, maybe even more pervasive than the economics for the average person on the street. How so? Smoking in North Macedonia is just it’s truly ingrained in the social fabric. It’s a social lubricant, a common ritual. Many business owners, especially in cafes, bars, restaurants, they genuinely believe their businesses will suffer if they enforce no smoking rules. They think they’ll lose customers. Yes. You often hear them say things like, “Look, 80% of people who go out here are smokers, so it makes sense to give them a place to smoke. It’s a perceived economic threat at the local level, quite separate from the national picture we just talked about.” And socially, offering a cigarette. It’s often seen as a gesture of welcome, of friendship. To refuse one, or worse, to ask someone not to smoke near you can be seen as rude, as an insult, almost a rejection of that social bond. It definitely creates an incredibly challenging environment for non-smokers. Makes everyday things feel like a battle. I remember imagining the scene. A young mother, let’s call her Elina, wanting to meet her sister for coffee in Bata. It’s cold outside. Okay. Inside the cafe, it’s warm, inviting, but thick with smoke. You can see the haze. She finds a table, bounces her 2-year-old daughter on her knee, trying to find the least smoky spot. Within minutes, the little girl starts coughing. that wet struggling sound. The Alina looks around and sees smoke just wafting right into their space from everywhere. Every instinct screams, “Protect your child. Say something.” But the cultural norm is just overwhelming. It’s palpable. Complaining would be disruptive. Seen as attacking a social ritual. She’d cause a scene. So, she feels defeated, powerless. A guest in her own city’s public spaces. She cuts the visit short, just leaves feeling frustrated. That story resonates so much because it highlights exactly how personal choice, especially the choice not to smoke or to breathe clean air gets completely overshadowed by these powerful societal pressures and habits. Even if there are laws, even when laws exist on paper, if the cultural understanding and crucially the enforcement are weak, individuals like Alina feel totally powerless. And the smell, yeah, non-smokers notice it everywhere, right? The fact that non-smokers notice it clinging to everything, but many smokers either don’t notice it anymore or just don’t care, that speaks volumes about how normalized it’s become. It’s like a sensory blind spot. So creating smoke-free spaces isn’t just about loss. No, it requires a profound cultural shift, redefining what’s socially acceptable, what hospitality means, what freedom means in public spaces. It’s about challenging those deeprooted norms. So, we have this intense cultural and economic entrenchment, but like I said at the start, you still see those smoking kills posters. So, there is some awareness, some policy on the books. Where’s the disconnect? Why aren’t these policies working? As you’d expect, it’s a it’s a long and winding road for tobacco policy in North Macedonia. Lots of starts and stops, twists and turns, often influenced by politics and industry pressure. Okay. The country has ratified the Framework Convention on Tobacco Control, the FCTC. That’s the WHO’s global treaty, the roadmap for tackling tobacco. So on paper, there’s commitment, right? They’re signed up to the international standard. Exactly. And they have implemented various measures over the years. Back in 2003, there were partial restrictions. By 2008, smoking was prohibited in most public places, schools, places with kids. Then in 2010, they brought in a general ban in restaurants and bars. Okay, that sounds like real progress. Like they were getting serious. It looked like it. On the surface, significant progress moving towards protecting citizens aligning with global recommendations. So then what happened? Why didn’t that stick? Did the momentum just die? Well, the momentum wasn’t sustained. And this is where that paradox really deepens. In 2018, there was a significant step backward backward. Amendments were made to the law on protection from smoking. And these amendments partially weakened the ban. They allowed smoking again in specially designated areas and on open air terraces. Ah, loopholes. big loopholes. And this wasn’t just a random decision. It really illustrates that constant struggle between public health goals and well vested interests. Business associations implicitly the tobacco industry lobbied hard. Doing it hurt business tourism. Exactly. That a full ban was economically damaging, infringed on personal freedoms, even if those freedoms impacted others health. These loopholes, the designated areas, the terraces, they essentially nullified the spirit of the original ban in many, many places. So the smoking kills posters just hang there while the policy got watered down. Precisely. They represent this older, maybe less effective messaging existing side by side with this complex shifting reality of policy and social norms. It creates that jarring disconnect you felt. The policy on paper ended up much weaker than the initial intent. Okay, so a complex policy landscape, this push and pull, but maybe one of the most glaring issues undermining everything else is just how cheap cigarettes are. It feels like they’re practically giving them away. That’s a huge part of the problem. And it directly undermines so many other efforts, especially preventing kids from starting. Cigarette prices in North Macedonia are remarkably low. How low compared to say the EU? The current excise size tax level is €54 per 1,000 cigarettes. The EU minimum standard is €9. 90. So they’d need a massive increase to even meet the minimum. A huge increase. They’d need to raise their tobacco excise rate by 66%. A substantial jump that would definitely make cigarettes far less affordable. And this low cost makes them super accessible, especially for young people. Exactly. Kids are very price sensitive. Imagine this. A pack of the cheapest domestic cigarettes, can cost just 10 to 12 US cents. 12 cents. While a loaf of bread, a basic necessity, is three times as expensive. Wow. Cheaper than bread. This stark affordability is a massive factor in smoking initiation and prevalence. It makes it incredibly hard for young people to avoid it when it’s cheaper than food. It sends this message, intentional or not, that smoking isn’t just tolerated, it’s almost economically encouraged. It really feels like the country is unintentionally making it easier to smoke despite any stated goals. What about enforcement then? Even for the laws still in the books, the weakened ones. Is it a lack of laws or just a lack of follow through? Enforcement is a continuous pervasive challenge. And it often renders even well-intentioned laws completely ineffective. Creates a sense of impunity. Like the laws are just suggestions. pretty much many regulations and national programs, especially in uh less developed countries, aren’t effectively enforced. They have loopholes that get exploited all the time. Can you give an example? Sure. Look at Moldova nearby. They have laws banning smoking indoors in public places, but enforcement is reportedly lax. People still smoke openly in offices, clearly breaking the law. And nobody does anything. Often, no. And what’s truly shocking, you can see smoking even in medical institutions, including places treating lung cancer patients. You’re kidding. In hospitals, staff, visitors. It completely undermines the public health message. Imagine health leaders themselves smoking during interviews about tobacco control. It sends such a confusing, contradictory signal. Yeah, that’s unbelievable. And on top of that, the tobacco industry is very strong, very influential in the region, actively opposing stricter measures, sometimes even benefiting from cigarette smuggling, which is a huge problem in that area, further complicating taxation and control. So, weak enforcement, industry influence. It creates this environment where the laws exist, but nobody really expects them to be followed. Makes fostering a truly smoke-free culture incredibly difficult. Which brings us right back to those blunt, almost naive smoking kills posters. They’re everywhere, but clearly they aren’t doing much good. They’ve just become background noise. They really don’t work, and that’s precisely the issue. These traditional scare tactics, however well-intentioned, they just fall flat. They lack personal resonance. They lack empathy. Yeah. Just showing a diseased lung doesn’t seem to connect. Exactly. I heard this incredibly powerful story from a young woman in Scupji. Her grandfather died from emphyma, smoked since he was a teenager. Okay. She described his slow, agonizing struggle just to breathe, his frustration with the addiction, and the emptiness of his chair at the dinner table after he was gone. That visual, the empty chair. Mhm. Then she saw one of those government antismoking billboards, just a generic black lung blunt warning, and she said it made her angry. Angry? Why? Because that cold impersonal image didn’t capture an ounce of her family’s slow, painful goodbye, the daily suffering, the emotional void. Her grandfather wasn’t a statistic on a poster. He was the man who taught her to ride her bike. Right. He was a person. She ended by saying something like, “They don’t need to show us dying lungs. They need to show us the empty chair at the dinner table.” Wow. That’s that’s incredibly powerful. It really hits the difference between a clinical fact and an emotional reality, between data and lived experience. Precisely. It speaks to the heart of what actually moves people, what makes them think differently. It makes you wonder though, these smoking kills campaigns have been around forever. Why has it taken public health so long to shift towards these more emotional narrative approaches? Is it just easier to put up a scary picture? That’s a crucial question. I think the answer involves understanding psychology, addiction, traditional scare tactics or slogans like be smart, don’t start. They often fail because they lack that empathy. For someone addicted, it feels like an accusation. Like you’re calling them stupid. Exactly. Implying they’re stupid or suicidal for continuing a habit they often desperately want to quit. And that’s why these campaigns in North Macedonia have been largely ineffective. The numbers prove it. What numbers? Only 43 people contacted smoking sessation centers in 2023. 43 in the whole country with that smoking rate. Shockingly low. And surveys show these generic ads barely affect heavy smokers. They just don’t connect with the reality of addiction or the true personal cost. Plus, there’s often a lag between knowing what works in communication and governments actually adopting it. They can be riskaverse, have limited budgets. So, if smoking kills doesn’t work, what does? What kind of communication actually breaks through that noise and creates real change? How do you connect? truly effective campaigns, the ones that get real results, they do two critical things. One, they connect with smokers personally, emotionally. Two, they saturate every available platform with ads, making the message unavoidable. Okay. Personal connection and saturation. Exactly. Look at the CDC’s tips from former smokers campaign in the US. It’s a prime example of success. How did that work? It used authentic stories, real people, former smokers, their families, talking about the brutal real life consequences, not abstract stats. And did it work hugely? In its first 6 years, it encouraged an estimated 16.4 million smokers to try to quit and an estimated 1 million actually quit entirely. 1 million quitters from one campaign. That’s impressive. It is. There’s one recent ad featuring Tammy, a 45-year-old Native American runner. She had severe cardiac events from smoking menthols. Okay. Her ad doesn’t just show a sick person. It digs into her background, her family’s history with smoking. She says, “It’s something my father did, my grandfather did. It’s just something we did. It’s the one thing we could afford. It makes her relatable human, right? It gives context. And then she talks about promising her mom right before open heart surgery, I won’t make you bury me if I have a choice.” That kind of narrative. It taps into love, family, survival. It’s visceral, unforgettable. So, it’s about culturally tailored, evidence-based communication using stories. Yes. Prioritizing emotional connection and authenticity. That’s what works and that’s where modern communication strategies really come in, right? Using digital platforms, meeting people where they actually are online. Absolutely. Social media is incredibly pervasive. 72% of adults globally use at least one platform. And these platforms profoundly influence health behaviors, perceptions, norms. Public health has to leverage this. How specifically? Okay. First, tailoring messages and targeting specific populations. Move beyond generic billboards. Send messages based on demographics, age, sex, language, interests, like smoking sessation or motherhood. Even geo targeting specific cities like hyper localal campaigns. Exactly. Look at Germany’s social media ads and migrants languages significantly boosted COVID vaccine appointments. It allows for precision public health, reaching communities that need it most, cutting through the noise. Okay. What else? Second, include members of the target population in developing the message. Design it with them, not just for them. Use community advisory boards, native speakers for translations to ensure cultural sensitivity. Build trust. Co-creation is key. Makes sense. Avoids missteps. Third, identify and actively address misinformation. Social media is an infomic battleground. False news spreads fast because it’s novel, provokes emotion. Public health needs to counter it directly. Mythbusting messages. State the false claim. Explain why it’s false. Reiterate the accurate info and actively moderate comments. We did it. Fight the fakes. Fourth, leverage information sharing. Messages need to be sharable. Partnering with trusted social media influencers within specific communities can extend reach dramatically. Think Magic Johnson and HIV awareness. When the message comes from a credible, relatable source, it carries far more weight. Right? Crusted messengers. And finally, fifth, evaluate real world impact. Don’t just count clicks or views. Those are vanity metrics. Measure actual changes in health behavior. Did fewer people use tanning salons after a campaign? Did smoking sessation rates rise? Did public perception shift? Focus on tangible outcomes. That makes a lot of sense. Measurable results. And it sounds like civil society groups, the NOS’s, they’re often the ones really pushing these more innovative approaches, right? Often without big budgets, but with a lot of creativity. They are. Their role is absolutely crucial, especially driving change from the ground up when government action is slow or maybe compromised by other interests. They’re closer to the communities. Exactly. Civil society organizations, local NOS’s, they’re often the first advocates. They operate at the grassroots, understand the nuances. They’ve been key in devising policies, demanding enforcement even when governments hesitate. You have a good example of that. A great one is the form smokefree Kazakhstan coalition. They didn’t just write reports. They got creative. Wow. They armed parliamentarians, police, health inspectors with video cameras, invited journalists along, and went on walking tours of Almati, documenting blatant, widespread violations of anti-tobacco laws in public spaces. Wow. Direct action. Yes. The media coverage was powerful, generated huge public pressure, and it spurred local officials to allocate $315,000, an unprecedented amount, for a smoke-free Elmati initiative. first specific tobacco control funding like that in the entire region. So using media strategically made a real difference, a huge difference. It shows how media can be a powerful ally for advocates to create pressure and drive actual policy change pushing towards that smoke-free environment. Okay. So despite all these massive challenges, the economic dependence, the cultural acceptance, the policy loopholes, the weak communication, the industry lobbying, there are efforts to change things, where do we see a path forward? Are there glimmers of hope for North Macedonia and places facing similar struggles? There are definite glimmers of hope, mostly driven by these persistent local initiatives and I think a growing global recognition of what truly effective tobacco control actually looks like. So learning from what works elsewhere. Exactly. And seeing local successes proving change is possible. Like the Kazakhstan example. Yes. And Ukraine provides another one. The Parody Foundation Intricacy, a city that even has a tobacco factory, successfully pushed for a local law banning smoking in public places way back in 2004, before national laws, way before they were the first Ukrainian municipality to do it. And they didn’t use huge budgets. They used simple lowcost community focused activities like what? organizing roundts with local authorities to build agreement, sending letters to the president from city officials showing local support, distributing brochures about smoke-free rules, even holding youth soccer tournaments with the motto champions do not smoke. Engaging the community directly. Yes. And these actions had a huge impact on policy reform locally. It shows what’s possible with dedication and creativity at the grassroots. Okay. So, local successes are key. What else offers hope? a comprehensive approach. Lessons learned globally, like in Poland, really emphasize you need multi-pronged strategies. You can’t just do one thing. So, laws and campaigns and coalitions. Exactly. Strong laws, yes. But also extensive, emotionally resonant media campaigns, building broad coalitions, civil society, healthcare pros, government partners, directly challenging policy makers and industry influence, and constantly collecting and sharing robust health and economic data to show the true cost. It’s a coordinated, relentless effort on many fronts. Makes sense. What about helping people who already smoke? Absolutely vital. That’s the third point. Quitting support restrictions work much better when coupled with accessible, affordable quit smoking services and health promotion. So, not just banning, but helping. Yes, punitive measures alone rarely work for addiction. People need pathways out, compassionate support, counseling, nicotine replacement therapy, follow-up programs. Without that support, bands can feel oppressive, not helpful. Okay. And you mentioned learning from other countries, right? That’s the fourth glimmer. Expanded regional learning and cooperation. Strategies that work in one place can often be adapted elsewhere, respecting cultural differences, but leveraging shared challenges, sharing best practices. Exactly. Initiatives like Poland’s Health Promotion Foundation have been training advocates across Central and Eastern Europe and Central Asia for years. Building Combat City and establishing things like a regional tobacco control network helps formalize this information sharing, collaboration, resource sharing, collective advocacy. It creates a stronger front. So there are positive signs strategies that work. But what are the biggest hurdles still standing in the way for North Macedonia and similar countries? What needs to be cleared to really turn the tide? Despite the positives, significant obstacles absolutely remain. It’s a complex web. Like what? Well, one is public perception. In places like Kazakhstan and likely North Macedonia, too, the public often doesn’t see smoking as a major immediate threat to them. That it won’t happen to me attitude. Complacency, deeply ingrained complacency. It requires persistent, personally relevant education that changes fundamental attitudes, not just presents stats. Then there’s often a lack of civil society expertise and training in effective advocacy. The core groups can be small, underresourced, limited in their reach. While the tobacco industry is strong, very strong. They continue to strengthen relationships in political circles, often successfully opposing reforms through various means, funding events, donations, leveraging their economic power and health officials. Sometimes there’s a lack of clear vision, maybe a reluctance to directly confront those powerful protobacs that also hampers progress. At the end of the day, it’s a long-term fight against deeply embedded economics, pervasive cultural norms, and really influential industry lobbying. It needs sustained political will and a united front. It really is this situation where the desire for public health seems locked in this constant dance with ingrained habits, economic realities, the smoke in the cafes, those smoking kills posters. There really are a powerful symbol, aren’t they? A country caught between what it knows on paper and what it actually lives every day. There’s just so much at play here. Individual choice, deep social rituals, national economies, global policies. It creates this incredibly complex mosaic of challenges. Yeah, but also you see the quiet persistence of those fighting for change, trying to improve health and wellbeing in their communities. It’s a truly compelling reminder of how complex public health issues become when they’re woven so tightly into the very fabric of a society. It impacts everything, health, economics, social life, even identity. The challenge really for North Macedonia and beyond is figuring out how to untangle those threads. How to genuinely prioritize human health and dignity above everything else. Not just for today but you know for the generations to