SMOKING BEHAVIORS IN KOSOVA: RESULTS OF STEPS SURVEY
Sanije GASHI1,2, Merita BERISHA1,2*, Naser RAMADANI1,2, Musli GASHI2,3, Josipa KERN4, 
Aleksandar DZAKULA4, Silvije VULETIC4
1National Institute of Public Health of Kosova, Rrethi i spitalit, p.n., 10000 Prishtina, Kosova  
2University of Prishtina, Faculty of Medicine, Social Medicine, Mother Theresa n.n., 10000 Prishtina, Kosova  
3University Clinical Center of Kosova, Emergency Center, 10000 Prishtina, Kosova  
4University of Zagreb, School of Medicine, Šalata 3, 10000 Zagreb, Croatia  
Received: Oct 31, 2016
Accepted: Mar 13, 2017
Original scientific article
Introduction. Tobacco use continues to be the leading global cause of preventable death. Most of these deaths 
occur in low and middle-income countries, and this trend is expected to widen further over the next several 
decades. The overall objective of the study is to describe and analyse the smoking behaviours of adults in 
Kosova. 
Methods. According to the STEPs methodology, 6,400 respondents, aged 15 - 64 years, are selected randomly 
within each sex and 10-year age-group. Out of 6,400 participants, 6,117 were selected, which is approximately 
95.6%. 
Results. The prevalence of smoking was higher among males (37.4%) compared with females (19.7%). In all age 
groups, the prevalence of smoking was higher among males compared with females. Regarding the age group 
of 15 - 24 years, the prevalence of smoking was 16.0%, but in the age group of 25 - 34 years, it nearly doubled 
to the rate of 31.9%. We have a smaller increase in the age group of 35 - 44 years, and after the age of 45, it 
falls gradually.
Conclusions. The prevalence of smoking in Kosova is high compared with other countries in Eastern Europe. In 
future decades, Kosova will face a high probability of an increased burden of smoking-related diseases.
Uvod. Uživanje tobaka je še vedno eden izmed glavnih vzrokov smrti, ki bi jih lahko preprečili. Večina teh 
smrti se zgodi v državah z nižjim in srednjim prihodkom, po pričakovanjih pa se bo ta trend v naslednjih nekaj 
desetletjih še povečal. Cilj te študije je opis in analiza kadilskega vedenja odraslih na Kosovu.
Metode. Glede na metodologijo STEPS je bilo naključno izbranih 6.400 anketirancev obeh spolov, starih med 
15 in 64 let; razdeljeni so bili v starostne skupine po10 let. Izmed 6.400 anketirancev jih je bilo v študijo 
vključenih 6.117, kar je približno 95,6%.
Rezultati. Prevalenca kajenja je bila večja med odraslimi moškimi (37,4%) v primerjavi z ženskami (19,7%). V 
vseh starostnih skupinah je bila prevalenca kajenja višja med moškimi kot med ženskami. V starostni skupini 
med 15 in 24 let je bila prevalenca kajenja 16,9%, v starostni skupini med 25 in 34 let pa se je skoraj podvojila 
(31,9%). Prav tako je prisotno manjše povišanje v starostni skupini med 35 in 44 let, po 45. letu pa odstotek 
postopno pada.
Zaključki. Prevalenca kajenja na Kosovu je v primerjavi z ostalimi državami v Vzhodni Evropi visoka. 
V prihodnosti se bo Kosovo soočalo z visoko verjetnostjo povišanega bremena zaradi bolezni, povezanih s 
kajenjem.
ABSTRACT
Keywords: 
prevalence, 
smoking, Kosova, 
adults
IZVLEČEK
Ključne besede: 
prevalenca, 
kajenje, Kosovo, 
odrasli
*Corresponding author: Tel: ++ 377 4 423 8136; E-mail: merita.berisha@uni-pr.edu
10.1515/sjph-2017-0021 Zdr Varst 2017; 56(3): 158-165
158
KADILSKO VEDENJE NA KOSOVU: REZULTATI ANKETE STEPS 
Gashi S, Berisha M, Ramadani N, Gashi M, Kern J, Dzakula A, Vuletic S. Smoking behaviors in Kosova: results of STEPS survey. Zdr Varst 2017; 56(3): 158-165.
© Nacionalni inštitut za javno zdravje, Slovenija. 
1 INTRODUCTION
Tobacco use continues to be the leading global cause 
of preventable death. It kills nearly 6 million people 
annually, and it causes hundreds of billions of dollars in 
economic damage worldwide. Most of these deaths occur 
in low and middle-income countries, and this trend is 
expected to widen further over the next several decades. 
If current trends continue, by 2030, tobacco will kill more 
than 8 million people worldwide each year (1). Smoking 
increases the risk of heart disease, cancer, stroke, and 
chronic lung disease. Environmental tobacco smoke has 
been demonstrated to increase the risk of heart disease 
and cancer among non-smokers. It has also been shown 
that non-smokers exposed to second hand smoke have 
a 25% to 35% increased risk of suffering acute coronary 
diseases, and increased frequency of chronic respiratory 
conditions (2). Cessations of smoking by current smokers 
reduce their risk of heart disease, cancer, stroke, and 
respiratory disease (3).
Tobacco use prevalence in Europe is characterized by large 
disparities, with Western nations reporting smoking rates 
generally below 25%, while Eastern nations have smoking 
rates usually above 30% (4). In total, in the European 
region, 45% of males and 24% females over 15 years old 
are smokers (5). Kosova is a country with some specifics, 
for example, Kosova’s economic performance at the last 
assessment was evaluated as relatively weak as compared 
to Southeastern Europe. Kosova’s economy would need to 
grow 10% to 12% per annum respectively for the next ten 
years to reach Albania’s and Montenegro’s income level 
(6). The total population in Kosova according to the census 
of 2011 is 1,739,825 inhabitants (7), Birth rate 15.7‰ 
and Total Mortality 3.2‰. The mean age of population is 
estimated to be 30.2 years and life expectancy at birth is 
76.7 years: 79.4 years for females and 74.1 for males. In 
the years 2012 and 2013 the number one cause of death in 
Kosova were circulatory system diseases and the number 
two cause were neoplasm’s (8). Due to lack of law on 
statistics and weak implementation of the health law as 
well as relevant existing by laws, health information flow 
remains fragmented and weak. Until recently, no reliable 
epidemiological data were available on the prevalence of 
smoking in  Kosova adults. A study with school children (9) 
and first year medical students was available (10). In 2011 
Kosova conducted the European School Survey Project 
on Alcohol and Other Drugs (ESPAD) on 15-16 years old 
school children (11).  As  this is the first representative 
population survey conducted in Kosova findings from 
this survey will help policymakers to develop future 
public health programmes and interventions. The overall 
objective of the study is to describe and analyze the 
smoking behaviors of adults in Kosova. 
2 METHODS
A population-based survey for non-communicable diseases 
risk factors started in September 2010 by adopting the 
World Health Organization (WHO) STEPs Instrument (12), 
and the data collection was completed in March 2011. 
At that time the census of population in Kosova wasn’t 
conducted, therefore the data for households according to 
the settlements from Statistical Agency of Kosova for 2008 
were used (13), in total seven regions, 30 municipalities 
and 1464 settlements. The two-stage cluster random 
sampling was designed. Firstly, 120 enumeration areas 
were selected using probability proportional to size as the 
primary sampling units, followed by randomly selecting 
households from them as the secondary sampling units, 
using the proportion of households in urban and rural 
areas. Respondents aged 15-64 years old were selected 
randomly within each gender and 10-year age-group. One 
resident aged 15 to 64 years within each of the households 
was recruited for the survey using the Kish method, which 
provides tool for random selection of one individual from 
a household (12).  The total sample size consisted of 6,400 
men and women. The following assumptions for this cross-
sectional study were used for sample size calculation: 
level of confidence 95%, margin of error 5%, baseline level 
of risk factors 50%, expected response rate 90% and the 
design effect of 1.5. 
The WHO STEPs module is recommended for use on adults 
in the age group 25-64 years (12). The age group of 15-
24 years, which is the optional age group in STEPs, were 
included in this study because according to the existing 
data, Kosova has a high percentage of young people in 
it’s population (around 19.3% of population are in this age 
group) (7) .
2.1 Measurements
STEPs is a sequential process with three steps. Step 
1 includes assessment of smoking behaviors, alcohol 
consumption, physical activity, and fruit and vegetable 
intake using a structured questionnaire. Step 2 includes 
physical measurements, i.e. weight, height, waist 
circumference, hip circumference, blood pressure and 
heart rate measurements. Step 3 includes blood sampling 
and blood sugar and cholesterol examination. In this study 
we present only data of smoking behavior from Step 1 
and answers on the core questions: Do you currently 
smoke any tobacco products, such as cigarettes, cigars 
or pipes?  Do you currently smoke tobacco products daily? 
How old were you when you first started smoking daily? 
On average, how many of the following (manufactured 
cigarettes; Hand-rolled cigarettes; Pipes full of tobacco; 
Cigars, cheroots, cigarillos) do you smoke each day? 
10.1515/sjph-2017-0021 Zdr Varst 2017; 56(3): 158-165
159
10.1515/sjph-2017-0021 Zdr Varst 2017; 56(3): 158-165
160
Current smokers were defined as persons who reported 
smoking any tobacco products, such as cigarettes, cigars, 
or pipes daily or non-daily irrespective of the quantity 
and current daily smokers if they smoked ≥1 cigarette per 
day (12). 
2.2 Statistical Analysis
Statistical analysis was undertaken using SPSS version 
22.0. As age and sex are strong determinants of smoking, 
descriptive results were presented for men and women 
separately and stratified by age group. Data are presented 
as percentage and 95% confidence interval. Chi-square test 
or Fisher exact test was performed to test the differences 
in proportions of qualitative variables between groups, 
Mann Whitney U test for testing the difference between 
quantitative variables when distribution was not normal 
and Student t-test when distribution was normal. The 
level P<0.05 was considered as statistically significant.
Out of 6,400 persons planned for research, 6,117 were 
included, which is approximately 95.6%. The response 
rate was slightly higher among females 96.5% compared 
with males 94.6%. The response rate has been higher 
among 15-24-year-old participants with 99.2% (Table 1). 
Of the total respondents, 49.5 % were men. Four in ten of 
them had primary or lower education (from one to eight 
years of education). 64.7% were currently married. The 
mean number of family members more than 18 years old, 
excluding a responder, was 4.7 (Table 2).
3 RESULTS
In the age group 15-64 years old the prevalence of smoking 
was 28.4%. Prevalence of smoking was higher among men 
37.4% compared with women 19.7%, with significant 
difference (P<0.001). In all age groups, the prevalence 
of smoking was higher among men compared to women. 
Table 1.
Table 2.
Response proportions by gender.
Distribution of the sample by gender, age, education, 
marital status and number of family members - 
Kosova STEPS survey 2011.
15-24
25-34
35-44
45-54
55-64
15-64
25-64
Gender
Male
Female
Age - group (year)
15-24
25-34
35-44
45-54
55-64
Education
Primary or less
Secondary
Tertiary
Marital status
Never married
Currently married
Separated
Divorced
Widowed
Cohabitating
No answer
Nr. of family member more than 18 years except you
Mean±SD
640
640
640
640
640
3200
2560
640
640
640
640
640
3200
2560
1280
1280
1280
1280
1280
6400
5120
633
603
594
624
594
3028
2415
637
607
610
607
608
3089
2432
1270
1210
1204
1231
1202
6117
4847
98.9
94.2
92.8
97.5
92.8
94.6
94.3
99.5
94.8
95.3
94.8
95.0
96.5
95.0
99.2
94.5
94.1
96.2
93.9
95.6
94.7
3028
3089
1270
1210
1204
1231
1202
2438
2345
1334
1912
3960
14
19
163
19
30
4.7±2.4
49.5
50.5
20.8
19.8
19.7
20.1
19.7
39.9
38.3
21.8
31.3
64.7
0.2
0.3
2.7
0.3
0.5
Age Group
(Year)
Men
Eligible
n N Nn n n% % %
Eligible EligibleResponded Responded Responded
Women Both Sexes
N %
Prevalence of smoking increases with age. After the age 
of 45 it falls gradually, probably due to starting quitting 
smoking for health reasons, and this trend of prevalence is 
noticed in both sexes (Table 3). 
Table 3.
Table 4.
Percentage of current smokers by gender - Kosova STEPS survey 2011.
Current daily smokers among current smokers - Kosova STEPS survey 2011.
15-24
25-34
35-44
45-54
55-64
15-64
25-64
15-24
25-34
35-44
45-54
55-64
15-64
25-64
*Chi-square test or Fisher exact test
*Chi-square test or Fisher exact test
633
603
594
624
594
3028
2415
127
255
290
254
205
1131
1004
637
607
610
607
608
3089
2432
76
131
154
139
109
609
533
1270
1210
1204
1231
1202
6117
4847
203
386
444
393
314
1740
1537
127
255
290
254
205
1131
1004
114
243
273
240
195
1065
951
76
131
154
139
109
609
533
54
115
130
113
90
502
448
203
386
444
393
314
1740
1537
168
358
403
353
285
1567
1399
20.7
(17.7 - 24.1)
42.3
(38.4 - 46.3)
48.8
(44.8 - 52.8)
40.7
(36.8 - 44.6)
34.5
(30.7 - 38.3)
37.4
(35.6 - 39.1)
41.6
(39.6 - 43.6%)
89.8 
(83.3 - 93.9)
95.3 
(92.0 - 97.3)
94.1 
(90.8 - 96.3)
94.5 
(91.0 - 96.7)
95.1 
(91.3 - 97.3)
94.2 
(92.6 - 95.4)
94.7 
(93.2 - 95.9)
11.6
(9.3 - 14.6)
21.6
(18.5 - 20.5)
25.2
(22.0 - 28.8)
22.9
(19.7 - 26.1)
17.9
(15.1 - 21.2)
19.7
(18.4 - 21.2)
21.9
(20.3 - 23.6%)
71.1 
(60.0 - 80.0)
87.8 
(81.1 - 92.3)
84.4 
(77.9 -89.3)
81.3 
(74.0 - 86.9)
82.6 
(74.4 - 88.5)
82.4 
(79.2 - 85.2)
84.1 
(80.7 - 86.9)
16.0
(14.1 -18.1)
31.9
(29.3 -34.6
36.9
(34.2 - 39.6)
31.9
(29.4 - 34.6)
26.1
(23.7 - 28.7)
28.4
(27.3 - 29.6)
31.7
(30.4 - 33.0%)
82.8 
(77.0 - 87.3)
92.7 
(89.7 - 94.9)
90.8 
(87.7 - 93.1)
89.8 
(86.4 - 92.4)
90.8 
(87.1 - 93.5)
90.1 
(88.6 - 91.4)
91.0 
(89.5 -92.4)
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.001
0.013
0.001
0.000
0.001
0.000
0.000
Age Group
(years)
Age Group
(years)
P-value*
P-value*
Percentage of current smokers
Percentage of current smokers
Men
Men
Women
Women
Both Sexes
Both Sexes
% (95% CI)
% (95% CI)
% (95% CI)
% (95% CI)
% (95% CI)
% (95% CI)
Current smoker
Current daily smokers
Current smoker
Current daily smokers
Current smoker
Current daily smokers
n
Current 
smoker 
(n)
Current 
smoker 
(n)
Current 
smoker 
(n)
n nn
n
n
n
n
n
10.1515/sjph-2017-0021 Zdr Varst 2017; 56(3): 158-165
161
Among the current smokers of ages 15 – 64, current daily 
smokers were 90.1%. The rate of current daily smokers 
among men was 94.2% compared to women 82.4%. The 
lowest prevalence of daily smoking is recorded in the age-
group 15-24 years with 82.8%.  In all age-groups the daily 
smoking prevalence was higher among men compared 
with women (Table 4).
10.1515/sjph-2017-0021 Zdr Varst 2017; 56(3): 158-165
162
The mean age of starting smoking was 20.9 years. Among 
men the mean was 19.7 years, while among women 
the mean was 23.4 years, with significant difference 
(P<0.001), (Table 5).
Among the daily smokers aged 15-64 years, 93.6% smoke 
manufactured cigarettes, men 92.7% and women 95.6% 
(Table 6). 
Table 5. Mean age of starting smoking by gender – Kosova STEPS survey 2011.
15-24
25-34
35-44
45-54
55-64
15-64
25-64
*Mann Whitney U test or Student t-test
114
243
273
240
195
1065
951
54
115
130
113
90
502
448
168
358
403
353
285
1567
1399
0.003
0.002
0.000
0.000
0.000
0.000
0.000
16.2 
(15.7 - 16.7)
18.2 
(17.7 - 18.7)
19.6 
(19.0 - 20.3)
21.0 
(20.0 - 21.9)
22.1 
(20.9 - 23.4)
19.7 
(19.3 - 20.1)
20.1 
(19.7 - 20.5)
17.4 
(16.8 - 18.0)
19.4 
(18.5 - 20.3)
22.3 
(21.1 - 23.5)
25.5 
(23.8 - 27.1)
31.2 
(28.8 - 33.6)
23.4 
(22.6 - 24.2)
24.1 
(23.3 - 24.9)
16.6 
(16.2 - 17.0)
18.6 
(18.1 - 19.0)
20.5 
(19.9 - 21.1)
22.4 
(21.5 - 23.3)
25.0 
(23.8 - 26.2)
20.9 
(20.5 - 21.3)
21.4 
(21.0 - 21.8)
Age Group
(years)
Percentage of current smokers
Men Women Both Sexes
Mean age (95% CI) Mean age (95% CI) Mean age (95% CI) P-valuen n n
Table 6. Manufactured cigarette smokers among daily smokers by gender - Kosova STEPS survey 2011.
15-24
25-34
35-44
45-54
55-64
15-64
25-64
*Chi-square test or Fisher exact test 
114
243
273
240
195
1065
951
54
115
130
113
90
502
448
168
358
403
353
285
1567
1399
108
224
255
222
178
987
879
53
107
124
110
86
480
427
161
331
379
332
264
1467
1306
94.7 
(89.0 -97.6)
92.2 
(88.1 - 94.9)
93.4 
(89.8 - 95.8)
92.5 
(88.5 - 95.2)
91.3 
(86.5 - 94.5)
92.7 
(91.0 -94.1)
92.4 
(90.6 - 93.9)
98.1 
(90.2 - 98.1)
93.0 
(86.9 - 96.4)
95.4 
(90.3 - 97.9)
97.3 
(92.5 - 99.1)
95.6 
(89.1 - 98.3)
95.6 
(93.5 - 97.1)
95.3 
(92.9 -96.9)
95.8 
(91.7 - 98.0)
92.5 
(89.2 - 94.8)
94.0 
(91.3 - 96.0)
94.1 
(91.1 - 96.1)
92.5 
(89.0 - 95.1)
93.6 
(92.3 - 94.7)
93.4 
(91.9 - 94.5)
0.431
0.833
0.506
0.090
0.232
0.026
0.050
Age Group
(years) P-value*
Manufactured cigarette smokers among daily smokers
Men Women Both Sexes
% (95% CI) % (95% CI) % (95% CI)
Manufactured cigarette 
smokers
Manufactured cigarette 
smokers
Manufactured cigarette 
smokers
Daily 
smokers 
(n)
Daily 
smokers 
(n)
Daily 
smokers 
(n)n n n
10.1515/sjph-2017-0021 Zdr Varst 2017; 56(3): 158-165
163
The mean amount of manufactured cigarettes smoked 
during the day by smokers aged 15-64 years was 20.9 
cigarettes, in men 23.9 cigarettes and in women 14.7 
cigarettes.  In all age groups men smoke more than 
women (P<0.0001), (Table 7). 
4 DISCUSSION
This is the first comprehensive population-based survey on 
risk factors of Non communicable diseases (NCDs) among 
adults in Kosova. Our study shows that Kosova is among 
the countries with high prevalence of smoking. 31.7% 
of respondents aged 25-64 years are current smokers. 
Findings of this survey confirmed that cigarette smoking 
was more prevalent among men than women in Kosova 
(41.6% vs. 21.9%: P<0.001). 
The prevalence is similar with the prevalence of smoking 
among school children in Kosova (9). Students aged 
between 13 and 15 years reported smoking cigarettes 
with 37%. In Kosova, from the ESPAD survey on 15-16-year-
old school children in 2011, the frequency of lifetime 
cigarette use was reported in 35.0 % (boys 48.0% vs. girls 
25.0%), (11).
Another study (24) with 261 students from 4 secondary 
schools in Guilin, a town in south-east Kosova, found that 
36% reported to have smoked cigarettes every day. Girls 
consumed more cigarettes, and the incidence of smoking 
was higher among students in their last year of high school 
studies. 
In the study with the first year medical students, 
University of Prishtina, Kosova, (14) the prevalence of 
Table 7. Mean amount of manufactured cigarettes used by daily smokers by gender - Kosova STEPS survey 2011.
15-24
25-34
35-44
45-54
55-64
15-64
25-64
*Mann Whitney U test or Student t-test
108
224
255
222
178
987
879
53
107
124
110
86
480
427
161
331
379
332
264
1467
1306
0.000
0.000
0.000
0.000
0.000
0.000
0.000
18.4 
(16.9 - 19.9)
21.6 
(20.3 - 22.8)
24.2 
(22.9 - 25.4)
26.8 
(25.0 - 28.5)
26.0 
(24.3 - 27.8)
23.9 
(23.2 - 24.6)
24.5 
(23.8 - 25.2)
12.9 
(10.8 - 14.9)
11.9 
(10.6 - 13.2)
14.0 
(12.6 - 15.3)
16.1 
(14.2 - 18.0)
18.5 
(16.6 - 20.5)
14.7 
(13.9 - 15.5)
14.9 
(14.1 - 15.7)
16.6 
(15.3 - 17.8)
18.4 
(17.4 - 19.5)
20.8 
(19.8 - 21.9)
23.2 
(21.8 - 24.7)
23.6 
(22.2 - 25.0)
20.9 
(20.3 - 21.4)
21.4 
(20.8 - 22.0)
Age Group
(years)
Mean amount of manufactures cigaretes used by daily smokers
Men Women Both Sexes
Mean age (95% CI) Mean age (95% CI) Mean age (95% CI) P-value*n n n
daily smokers was 8.9% (9.1% men vs. 8.7% women) for 
general medicine students and 5.8% (4.8% men vs. 6.5% 
women) for dentistry students. This shows that the 
medical students in Kosova smoke less compared with the 
general population. 
The prevalence of smoking among Kosova adults is similar 
to the prevalence of smoking in most of Balkan countries 
(15). Compared to other studies from Balkan countries, 
Kosova has lower prevalence than Bosnia and Herzegovina 
(16, 17) and Albania (18, 19), but higher prevalence than 
Croatia (20, 21) and Slovenia (22, 23). In 2010, a face-to-
face survey on smoking in 18 European countries of the 
population aged 15 years or older was conducted. Overall, 
27.2% of the participants were current smokers (30.6% of 
men and 24.1% of women) (4). Our results show that the 
prevalence of current smokers in Kosova is higher than 
the European average, but lower than the prevalence in 
Bulgaria and Greece. 
Similar studies (24) with adults aged over 18 years from 
48 states which have reported their data, current daily 
smokers in the Middle-income country group among men 
was 34.1% and among women 10.8%. A current daily 
smoker in the Low-income country group was reported 
among men in 25.2%, and among women in 6%. In most 
countries, the prevalence of smoking is higher among 
10.1515/sjph-2017-0021 Zdr Varst 2017; 56(3): 158-165
164
men, except in Sweden, where smoking prevalence is 
higher among women (25). The prevalence of smoking in 
Kosova adults is higher among men compared to women. 
According to the age group, the highest prevalence of 
smoking in Kosova was among 25-34yearolds (31.9%) and 
35-44yearolds (36.9%) and 45-54yearolds (31.9%).
In the United States of America (USA), in 2014, nearly 17 
of every 100 USA adults aged 18 years or older (16.8%) 
currently smoked cigarettes (men 18.8% vs. women 
14.8%). Current cigarette smoking was higher among 
persons aged 25–44 years (20.0%), (26, 27). 
In our study, among the smokers aged 15-64 years, 90.1% 
were daily smokers. The average number of cigarettes 
smoked during the day was 20.9 cigarettes, for men 23.9 
cigarettes and for women 14.7 cigarettes. It is higher 
than in Germany (28), where the average number of 
cigarettes smoked per day is 10, and Greece (29) where 
the average number of cigarettes smoked per day is 19.8. 
Among the daily smokers aged 15-64 years, 93.6% smoked 
manufactured cigarettes. In 2012, in a study done in 187 
countries (30), there were 75 countries where the average 
number of cigarettes per daily smoker was higher than 20 
cigarettes per day. 
There is evidence that comprehensive tobacco control 
programmes reduce smoking prevalence (31), and the 
implementation of those policies has decreased the 
prevalence of smoking,for example, in the USA, Canada, 
Ireland, Norway, The Great Britain and Iceland (32-37).
At the time when the research was being conducted, 
there was no legislation on tobacco control in Kosova; 
there were only health education activities for quitting 
tobacco consumption and a few health warnings on boxes 
of tobacco. The law for tobacco control in Kosova came 
into force in May 2013. Therefore, these kind of studies 
(STEPs) need to be repeated in order to measure the 
effect of such actions to smoking prevalence, especially 
in places where the implementation of those measures is 
not satisfactory.
The limitation of the study is that, as the data were from 
a cross-sectional survey, a structured questionnaire was 
used to assess tobacco use by face-to-face interviews; 
this could have resulted in over-reporting or under-
reporting of smoking. The age of smoking initiation may 
also be subject to recall bias. Although these limitations 
exist, our study offers valuable data for tobacco control 
and prevention in Kosova.
5 CONCLUSIONS
The prevalence of smoking in Kosova is high compared 
with other countries in Eastern Europe. In future decades, 
Kosova will face a high probability of an increased burden 
of smoking-related diseases. A special attention should be 
paid to coordinated government- and community-based 
interventions, using the guidelines to implement and 
manage tobacco control, ratified by the WHO Framework 
Convention on Tobacco Control and proven measures 
to strengthen country level interventions in reducing 
cigarette smoking and smoking-related diseases and 
deaths among Kosova adults.
ACKNOWLEDGEMENTS
Authors would like to thank the French Embassy in Kosova 
for its financial and technical support, and particularly Dr 
My Maï Cao as the technical assistant. Authors would also 
like to thank the WHO in Geneva and the WHO office in 
Prishtina for their technical support.
CONFLICTS OF INTEREST
No conflicts of interest are declared.
FUNDING
The STEPs in Kosova was financed by the French Embassy 
in Kosova.
ETHICAL APPROVAL
Received from the Ethical Committee of the Medical 
Faculty, University of Prishtina, number 4483.
AUTHOR’S CONTRIBUTION
MB, SV, ADz and NR participated in design of the study, 
sample size, methodology and corrections of the 
manuscript. SG contributed to the design of the study, 
field work and statistical analysis. JK contributed in all 
phases and the correction of manuscript. MG compared 
the results with other studies. All authors have read and 
approved the final manuscript.
REFERENCES
1. World Health Organization.  WHO report on tobacco epidemic, 
2011. Warning about the dangers of tobacco. Geneva: World Health 
Organization, 2011. Available Sept 2016 from: http://www.who.int/
tobacco/global_report/2011/en/.
2. He J, Vupputuri S, Allen K, Prerost MR, Hughes J, Whelton PK. Passive 
smoking and the risk of coronary heart disease--a meta-analysis of 
epidemiologic studies. N Engl J Med 1999; 340: 920-6.
3. Fenelon A, Preston SH. Estimating smoking–attributable mortality in 
the United States. Demography 2012; 49: 10.
10.1515/sjph-2017-0021 Zdr Varst 2017; 56(3): 158-165
165
4. Gallus S, Lugo A, La Vecchia C, Boffetta P, Chaloupka FJ, Colombo 
P et al. Pricing policies and control of tobacco in Europe (PPACTE) 
project: cross-national comparison of smoking prevalence in 18 
European countries. Eur J Cancer Prev 2014; 23: 177-85. 
5. World Health Organization. WHO report on the global tobacco 
epidemic, 2013. Geneva: World Health Organization, 2013. Available 
Sept 2016 from: http://www.who.int/tobacco/global_report/2013/
en/.
6. The World Bank. The World Bank annual report 2009. The World 
Bank, 2009.
7. Kosovo Agency of Statistics. Kosovo population and housing census 
2011. Final results. Main data. Prishtina, 2012. Available Sept 2016 
from: https://ask.rks-gov.net/ENG/census-2011.
8. Kosovo Agency of Statistics. Yearly statistics of Republic of Kosova, 
2016. Prishtina, 2016.
9. Ramadani N, Berisha M, Thaçi A, Gashi-Luci L, Koçinaj D, Jerliu N. 
Tobacco use among Kosovar schoolchildren: a cross-sectional study. 
Med Arh 2009; 63: 44-7.
10. Çuperjani F, Elezi S, Lila A, Daka Q, Dakaj Q, Gashi S. Tobacco 
smoking habits among first year medical students, University of 
Prishtina, Kosovo: cross-sectional study. Mater Sociomed 2015; 27: 
176. 
11. Hibell B, Guttormsson U. A supplement to the 2011 ESPAD report – 
additional data from Bosnia and Herzegovina (Federation of Bosnia 
and Herzegovina), Kosovo (under UNSCR 1244) and the Netherlands. 
Stockholm, Sweden: The Swedish Council for Information on Alcohol 
and Other Drugs (CAN), 2013. Available Sept 2016 from: http://www.
can.se/contentassets/6cd00040d70444749606d8e6adedc50a/full-
report---supplement-to-the-2011-espad-report.pdf.
12. World Health Organization. WHO STEPs surveillance manual: the 
WHO STEPwise approach to chronic disease risk factor surveillance. 
Geneva: World Health Organization, 2008. Available Sept 2016 from: 
http://www.who.int/chp/STEPs/manual/en/index1.html.
13. Statistical Office of Kosovo. Population, households according 
to settlements and territorial organization of Kosovo until 2008. 
Prishtina, 2009.
14. Carkaxhiu L, Huseyin K, Berisha M, Botica MV. Problem of substance 
misuse and lack of national strategy in Kosovo. Cent Eur J Public 
Health 2011; 19: 108-14. 
15. Seniori Costantini A, Gallo F, Pega F, Saracci R, Veerus P, West R. 
Population health and status of epidemiology in Western European, 
Balkan and Baltic countries. Int J Epidemiol 2015; 44: 300-23. 
16. Vasilj I, Pilav A, Maslov B, Polasek  O. Cardiovascular risk factors 
research in Bosnia and Herzegovina. Coll Antropol 2009; 33(Suppl 
2): 185-8. 
17. Pilav A, Nissinen A, Haukkala A, Niksic D, Laatikainen T. Cardiovascular 
risk factors in the Federation of Bosnia and Herzegovina. Eur J Public 
Health 2007; 17: 75-9.
18. Ross H, Zaloshnja E, Levy DT, Tole D. Results from the Albanian adult 
tobacco survey. Cent Eur J Public Health 2008; 16: 182-8.
19. Shapo L, Gilmore AB, Coker R, McKee M, Shapo E. Prevalence and 
determinants of smoking in Tirana city, Albania: a population-based 
survey. Public Health 2003; 117: 228-36.
20. Samardzić S, Vuletić G, Tadijan D. Five-year cumulative incidence 
of smoking in adult Croatian population: the CroHort study. Coll 
Antropol 2012; 36(Suppl 1): 99-103.
21. Poljicanin T, Dzakula A, Milanović SM, Sekerija M, Ivanković D, Vuletić 
S. The changing pattern of cardiovascular risk factors: the CroHort 
study. Coll Antropol 2012; 36(Suppl 1): 9-13.
22. Koprivnikar H, Korošec A. Age at smoking initiation in Slovenia. Zdr 
Varst 2015; 54: 274-81. 
23. Martínez-Sánchez JM, Fernández E, Fu M, Gallus S, Martínez C, 
Sureda X et al. Smoking behaviour, involuntary smoking, attitudes 
towards smoke-free legislations, and tobacco control activities in 
the European Union. PLoS One. 2010; 5: e13881.
24. Hosseinpoor RA, Bergen N, Kunst A, Harper S, Guthold R, Rekve D et 
al. Socioeconomic inequalities in risk factors for non communicable 
diseases in low-income and middle-income countries. BMC Public 
Health 2012; 12: 912. 
25. Lindstrom M. Social capital, economic conditions, marital status and 
daily smoking: A population-based study. Public Health 2010; 124: 
71-7.
26. Centers for Disease Control and Prevention. Current cigarette 
smoking among adults—United States, 2005–2014. MMWR Morb Mortal 
Wkly Rep 2015; 64: 1233–40.
27. U.S. Department of Health and Human Services. The health 
consequences of smoking—50 years of progress: a report of the 
Surgeon General. Atlanta: US, Department of Health and Human 
Services, Centers for Disease Control and Prevention, National 
Center for Chronic Disease Prevention and Health Promotion, Office 
on Smoking and Health, 2014.
28. Haenle MM, Brockmann SO, Kron M, Bertling U, Mason RA, Steinbach 
G et al. Overweight, physical activity, tobacco and alcohol 
consumption in a cross-sectional random sample of German adults. 
BMC Public Health 2006; 6: 233.
29. Rachiotis G, Barbouni A, Katsioulis A, Antoniadou E, Kostikas K, 
Merakou K et al. Prevalence and determinants of current and 
secondhand smoking in Greece: results from the Global Adult 
Tobacco Survey (GATS) study. BMJ Open 2017; 7: e013150. 
30. Ng M, Freeman MK, Fleming TD, Robinson M, Dwyer-Lindgren L, 
Thomson B et al. Smoking prevalence and cigarette consumption in 
187 countries, 1980-2012. JAMA 2014; 311: 183-192. 
31. World Bank. Tobacco control at a glance, Washington DC, 2003. 
Available Sept 2016 from: www.worldbank.org/tobacco.
32. US Department of Health and Human Services. The health 
consequences of smoking—50 years of progress: a report of the 
Surgeon General. Atlanta, GA: US Department of Health and 
Human Services, CDC, 2014. Available Sept 2016 from: http://
www.surgeongeneral.gov/library/reports/50-years-of-progress/full-
report.pdf. 
33. Lee DS, Chiu M, Manuel DG, Tu K, Wang X, Austin P et al. Trends in 
risk factors for cardiovascular disease in Canada: temporal, socio-
demographic and geographic factors. CMAJ 2009; 181: E55-66.
34. Joossens L, Raw M. The Tobacco Control Scale: a new scale to 
measure country activity. Tob Control 2006; 15: 247–53. 
35. Gartner CE, Lund KE, Barendregt JJ, Nor NM, Hassan H, Vedoy TF et 
al. Projecting the future smoking prevalence in Norway. Eur J Public 
Health 2017; 27: 139-44. 
36. Office of National Statistics. Adult smoking habist in Great Britaion: 
2014. Stat Bull 2014.
37. OECD Health Statistics. How does Iceland compare?  2014. Available 
Sept 2016 from: http://www.oecd.org/els/health-systems/Briefing-
Note-ICELAND-2014.pdf.