Alessandra Lugo

Pricing Policies And Control of Tobacco in Europe (PPACTE) project: cross-national comparison of smoking prevalence in 18 European countries

Limited data on smoking prevalence allowing valid between-country comparison are available in Europe. The aim of this study is to provide data on smoking prevalence and its determinants in 18 European countries. In 2010, within the Pricing Policies And Control of Tobacco in Europe (PPACTE) project, we conducted a face-to-face survey on smoking in 18 European countries (Albania, Austria, Bulgaria, Czech Republic, Croatia, England, Finland, France, Greece, Hungary, Ireland, Italy, Latvia, Poland, Portugal, Romania, Spain and Sweden) on a total of 18 056 participants, representative for each country of the population aged 15 years or older. Overall, 27.2% of the participants were current smokers (30.6% of men and 24.1% of women). Smoking prevalence was highest in Bulgaria (40.9%) and Greece (38.9%) and lowest in Italy (22.0%) and Sweden (16.3%). Smoking prevalence ranged between 15.7% (Sweden) and 44.3% (Bulgaria) for men and between 11.6% (Albania) and 38.1% (Ireland) for women. Multivariate analysis showed a significant inverse trend between smoking prevalence and the level of education in both sexes. Male-to-female smoking prevalence ratios ranged from 0.85 in Spain to 3.47 in Albania and current-to-ex prevalence ratios ranged from 0.68 in Sweden to 4.28 in Albania. There are considerable differences across Europe in smoking prevalence, and male-to-female and current-to-ex smoking prevalence ratios. Eastern European countries, lower income countries and those with less advanced tobacco control policies have less favourable smoking patterns and are at an earlier stage of the tobacco epidemic.

Illicit cigarettes and hand-rolled tobacco in 18 European countries: a cross-sectional survey

Objective Little evidence, other than that commissioned by the tobacco industry, exists on the size of the illicit tobacco trade. This study addresses this gap by examining the level and nature of illicit cigarettes and hand-rolled tobacco in 18 European countries. Design Face-to-face cross-sectional survey on smoking. Setting 18 European countries. Participants For each country, around 1000 subjects representative of the population aged 15 and over were enrolled. Current cigarette smokers were asked to show their latest purchased pack of cigarettes or hand-rolled tobacco. Main outcome measure A comprehensive measure called an Identification of an Illicit Pack (IIP) was used to study the extent of illicit trade, defining a pack as illicit if it had at least one of the following tax evasion indicators: (1) it was bought from illicit sources, as reported by smokers, (2) it had an inappropriate tax stamp, (3) it had an inappropriate health warning or (4) its price was substantially below the known price in their market. Results Overall, the proportion of illicit packs was 6.5%. The highest prevalence of IIP was observed in Latvia (37.8%). Illicit packs were more frequent among less educated smokers and among those living in a country which shared a land or sea border with Ukraine, Russia, Moldova or Belarus. No significant association was found with price of cigarettes. Conclusions This study indicates that IIP is less than 7% in Europe and suggests that the supply of illicit tobacco, rather than its price, is a key factor contributing to tax evasion.

Towards a greater understanding of the illicit tobacco trade in Europe: a review of the PMI funded ‘Project Star’ report

Background Following a legal agreement with the European Union (EU), Philip Morris International (PMI) commissions a yearly report (‘Project Star’, PS) on the European illicit cigarette trade from KPMG, the global accountancy firm. Methods Review of PS 2010 report. Comparison with data from independent sources including a 2010 pan-European survey (N=18 056). Findings Within PS, data covering all 27 EU countries are entered into a model. While the model itself seems appropriate, concerns are identified with the methodologies underlying the data inputs and thus their quality: there is little transparency over methodologies; interview data underestimate legal non-domestic product partly by failing to account for legal cross-border sales; illicit cigarette estimates rely on tobacco industry empty pack surveys which may overestimate illicit; and there is an over-reliance on data supplied by PMI with inadequate external validation. Thus, PMI sales data are validated using PMI smoking prevalence estimates, yet PMI is unable to provide sales (shipment) data for the Greek islands and its prevalence estimates differ grossly from independent data. Consequently, comparisons with independent data suggest PS will tend to overestimate illicit cigarette levels particularly where cross-border shopping is frequent (Austria, Finland, France) and in Western compared with Eastern European countries. The model also provides data on the nature of the illicit cigarette market independent of seizure data suggesting that almost a quarter of the illicit cigarette market in 2010 comprised PMIs own brands compared with just 5% counterfeited PMI brands; a finding hidden in PMIs public representation of the data. Conclusions PS overestimates illicit cigarette levels in some European countries and suggests PMIs supply chain control is inadequate. Its publication serves the interests of PMI over those of the EU and its member states. PS requires greater transparency, external scrutiny and use of independent data.

E-cigarette awareness, use, and harm perceptions in Italy: a national representative survey.

INTRODUCTION Only a few studies have provided information on awareness, use, and harm perceptions of e-cigarettes in Europe. We fill the knowledge gap in Italy. METHODS We used data from a face-to-face survey conducted in 2013 of a sample of 3,000 individuals, representative of the Italian population aged ≥15 years (51.1 million inhabitants). RESULTS Awareness of e-cigarettes was 91.1%; it was lowest among women (87.8%), the elderly (78.4%), those with less education (84.1%), and never-smokers (89.0%). Ever e-cigarette use was 6.8% overall and was inversely related to age, whereas no significant difference was observed according to sex. With regard to smoking status, 2.6% of never-smokers, 7.0% of ex-smokers, and 20.4% of current smokers tried the e-cigarette at least once. Regular e-cigarette use was 1.2% overall, 1.5% among men, and 0.9% among women, and it was highest among young (2.4%) and current smokers (3.7%). Among 36 e-cigarette regular users, 22.0% did not change their smoking habit, 67.7% reduced traditional cigarette consumption, and 10.4% quit smoking. CONCLUSIONS After fewer than 3 years from the opening of the first Italian e-cigarette shop, more than 45 million Italians have heard about e-cigarettes, 3.5 million have tried e-cigaretts, and more than 600,000 Italians regularly use e-cigarettes. Three out of 4 e-cigarette users reported to have favorably modified their smoking habit; however, 90% of users did not quit smoking as a consequence of starting vaping e-cigarettes. Almost 900,000 Italian never-smokers, particularly young never-smokers, have tried this new and potentially addictive product at least once.

Prevalence and Determinants of Tinnitus in the Italian Adult Population

Background: Limited, outdated, and poor quality data are available on the prevalence of tinnitus, particularly in Italy. Methods: A face-to-face survey was conducted in 2014 on 2,952 individuals, who represented the Italian population aged 18 or more (50.6 million). Any tinnitus was defined as the presence of ringing or buzzing in the ears lasting for at least 5 min in the previous 12 months. Results: Any tinnitus was reported by 6.2% of Italian adults, chronic tinnitus (i.e. for more than 3 months) by 4.8%, and severe tinnitus (i.e. which constitutes a big or very big problem) by 1.2%. The corresponding estimates for the population aged ≥45 years were 8.7, 7.4 and 2.0%, respectively. Multivariable analysis on population aged ≥45 years revealed that old age (odds ratio (OR) = 4.49 for ≥75 vs. 45-54 years) and obesity (OR = 2.14 compared to normal weight) were directly related to any tinnitus, and high monthly family income (OR = 0.50) and moderate alcohol consumption (OR = 0.59 for <7 drinks/week vs. non-drinking) were inversely related. Conclusions: This is the first study on tinnitus prevalence among the general Italian adult population. It indicates that in Italy tinnitus affects more than 3 million adults and is felt as a major problem by more than 600,000 Italians, mostly aged 45 years or more.

Smoking prevalence in Italy 2011 and 2012, with a focus on hand-rolled cigarettes

OBJECTIVE To provide updated information on smoking prevalence in Italy, with a focus on type of tobacco product, including hand-rolled (HR) cigarettes. METHOD Two nationally representative surveys were conducted in 2011 and 2012 in Italy on a total sample of 6167 adults. Information on type of tobacco most frequently smoked was collected. RESULTS Current smokers were 21.7% (22.7% in 2011 and 20.8% in 2012) overall, 25.3% among men and 18.4% among women. Among smokers, 94.6% most frequently consumed manufactured cigarettes, 4.6% HR cigarettes, 0.5% cigars, 0.2% cigarillos, and 0.2% pipe and none smokeless tobacco. HR cigarette use was more frequent in men (6.9%) than in women (1.7%), in 2012 (5.9%) than in 2011 (3.4%), and among the young (15-24 years; 9.1%). The average estimated price of one HR cigarette was 0.09€ and that of a manufactured cigarette was 0.18€. CONCLUSION In 2012 we observed the lowest reported overall smoking prevalence in Italy, though change since 2008 has been limited. The proportion of HR cigarettes on total tobacco trade has appreciably increased, particularly among young male smokers, who appear to switch to affordable cigarettes in a period of economic crisis. Fiscal policies aiming to equalise the cost of different cigarette types are needed in Italy.

Body mass index trend in haemodialysis patients: The shift of nutritional disorders in two Italian regions

BACKGROUND In the USA, the increase in the prevalence of obesity in the general population has been accompanied by a marked increase in the prevalence and incidence of obesity in the dialysis population. However, secular trends of body mass index (BMI) have not been investigated in European renal registries. METHODS We investigated the secular trend of BMI across 18 years (1994-2011) in two haemodialysis (HD) registries (Calabria in southern Italy and Emilia in northern Italy) on a total of 16 201 prevalent HD patients and in a series of 3559 incident HD patients. We compared trends in BMI for HD patients with those in the background general population of the same regions. RESULTS The average BMI rose from 23.5 kg/m(2) in 1994 to 25.5 (+8.5%) in 2011 in the Calabria registry and from 23.7 in 1998 to 25.4 (+7.1%) in 2011 in the Emilia registry (P < 0.001). The proportion of obese patients (i.e. with BMI >30 kg/m(2)) rose from 6 to 14% in Calabria and from 6 to 16% in Emilia (P < 0.001). These patterns were fully confirmed in incident patients and were mirrored by a substantial decline in the prevalence of underweight-normal and underweight (P < 0.001) patients. Of note, the steepness of the increase in BMI in haemodialysis patients was 3.7 times more pronounced than that in the coeval, age- and sex-matched general population of Calabria and Emilia. CONCLUSIONS In two regional haemodialysis registries in Italy a steady increase in overweight and obese patients is observed. These patterns are more pronounced than those found in the general population. If further confirmed in other European haemodialysis cohorts, these findings may have relevant public health implications.

Relation between national-level tobacco control policies and individual-level voluntary home smoking bans in Europe

Background Little is known about the relationship between national tobacco control policies and implementation of private home smoking bans. Objective To determine the relationship between the Tobacco Control Scale (TCS), a score measuring national-level strength of tobacco control policies, and the prevalence of in-home smoking bans and beliefs on other tobacco control policies, among the Member States (MS) of the European Union (EU) that participated in the Pricing Policy And Control of Tobacco in Europe (PPACTE) project. Methods A face-to-face representative survey, based on 18 056 individuals aged ≥15 years, from 18 European countries—including 16 EU MS—was conducted in 2010. Multilevel logistic regression models were fit to examine the relationship between the TCS score and in-home smoking ban prevalence and beliefs that other policy approaches are useful. Results In 2010, the TCS scores ranged from 32 in Austria and Greece to 77 in England. The TCS score correlated with the prevalence of in-home smoking bans (rsp=0.65). A 10-unit increase in the TCS score significantly increased the odds of in-home smoking ban (OR=1.33; 95% CI 1.01 to 1.76). The odds of believing that providing cessation services (OR=1.21), raising prices (OR=1.01) and extending bans is useful (OR=0.93) were not significant. Conclusions Government tobacco control policies are positively related to the individual-level tobacco policy of having an in-home smoking ban.

Patterns of Smoking Prevalence among the Elderly in Europe

Scant information is available on determinants of smoking prevalence in the vulnerable population of the elderly, particularly in Europe. Therefore, we analyzed smoking patterns among older adults (≥65 years old), using data from a representative survey based on 3,071 elderly, conducted in 17 European countries in 2010, within the Pricing Policies And Control of Tobacco in Europe (PPACTE) project. Overall smoking prevalence in 17 European countries was 11.5% (15.3% in men and 8.6% in women). An inverse relation with level of education was observed among men, while no specific pattern was evident among women. Smoking prevalence was highest in eastern/central Europe for men (20.3%) and northern Europe for women (13.1%). In both sexes combined, smokers were more frequent in countries with low implementation of tobacco control activities (14.9%). Anti-tobacco campaigns and smoking cessation interventions specifically targeted to the elderly are urgently needed in Europe.

ROLL-YOUR-OWN CIGARETTES IN EUROPE: USE, WEIGHT AND IMPLICATIONS FOR FISCAL POLICIES

Excise duties on roll-your-own (RYO) tobacco, which are generally based on RYO cigarettes containing 1 g of tobacco, are lower than duties on factory-made (FM) cigarettes. This provides a price incentive for smokers to switch to RYO, the use of which is increasing across Europe. To effectively approximate duties on the two types of products, accurate data on the weight of RYO cigarettes are required. We provide updated information on RYO use and RYO cigarette weight across Europe. From a representative face-to-face survey conducted in 2010 in 18 European countries (Albania, Austria, Bulgaria, Czech Republic, Croatia, England, Finland, France, Greece, Hungary, Ireland, Italy, Latvia, Poland, Portugal, Romania, Spain and Sweden), we considered data from 5158 current smokers aged 15 years or above, with available information on daily consumption of FM and RYO cigarettes separately. In Europe, 10.4% of current smokers (12.9% of men and 7.5% of women) were ‘predominant’ RYO users (i.e. >50% of cigarettes smoked). This proportion was highest in England (27.3%), France (16.5%) and Finland (13.6%). The median weight of one RYO cigarette is 0.75 g (based on 192 smokers consuming exclusively RYO cigarettes). The proportion of RYO smokers is substantial in several European countries. Our finding on the weight of RYO cigarettes is consistent with the scientific literature and industry documents showing that the weight of RYO cigarettes is substantially lower than that of FM ones. Basing excise duties on RYO on an average cigarette weight of 0.75 g rather than 1 g would help increase the excise levels to those on FM cigarettes.