Epidémiologie du tabagisme et Epidémiologie du tabagisme et stratégie de lutte italiennestratégie de lutte italienne

Lorenzo Spizzichino

Ministry of Health – ITALYRome, 24/09/2010

Ministero della Salute

Tobacco Control StrategyTobacco Control Strategy

Monitoring of the law’s implementation is still ongoing and focuses on six aspects

1. Surveillance (prevalence, behaviours)2. Sales of tobacco products3. Effects on Health4. Compliance with the Law5. Smoking cessation 6. Prevention and communication

activities

Tobacco Control StrategyTobacco Control Strategy

Monitoring of the law’s implementation is still ongoing and focuses on six aspects

1. Surveillance (prevalence, behaviours)2. Sales of tobacco products3. Effects on Health4. Compliance with the Law5. Smoking cessation 6. Prevention and communication

activities

Surveillance systems

Prevalence of smokersPrevalence of smokers

The survey is conducted yearly with more than 60,000 face-to-face interview’ to person with age more than 14 years old

Surveillance of prevalenceSurveillance of prevalence

Prevalence of smokers by sex

31,0%28,3% 29,5%

17,4% 16,2% 17,0%

23,8% 22,0% 23,0%

15%

20%

25%

30%

35%

40%

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2005 2006 2007 2008 2009

Male Female Tot

In 1986-1993 there was a 2% of yearly decrease in both sexes. During 1993-99 there was a 1,3% of yearly decrease in men but a 0,7% increase among women. During 2000-2009 prevalence still decreased among men (0,9%) while it is stable among women around 17%

Prevalence of smokersPrevalence of smokers

Regions with higher prevalence are Lazio, Emilia Romagna and Umbria (24,6%).Regions with lower prevalence are Valle d’Aosta (18,9%) and Trentino A.A (19,4%).

ISTAT 2009Italy = 23%

Range: 18,9% V.D’Aosta – 24,6% Lazio, E-R, Umbria

MINIMAL EFFECT IN REDUCING YOUNG SMOKERS MINIMAL EFFECT IN REDUCING YOUNG SMOKERS PREVALENCEPREVALENCE

Prevalenza di fumatori per sesso nei giovani (15-24yrs)

21,7%22,2% 21,8%

26,1%26,4% 27,1%

16,9%17,8% 16,4%10%

15%

20%

25%

30%

35%

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2005 2006 2007 2008 2009

tot M F

Surveillance of prevalenceSurveillance of prevalenceIn YouthIn Youth

During the last school year (2009-2010) Italy performed the GYTS an international survey, coordinated by the WHO and Centre for Disease Control (CDC), its goal is to monitor, through a highly detailed questionnaire, the habits and attitudes of young people with regards to smoking, including, where applicable, at what age they took up smoking More than 1800 questionnaires have been gathered in around 100 classes all over Italy

Surveillance in youthSurveillance in youth

3,4% 2,6%

14,0%

10,0%

32,6%

26,6%

2001 2006

11 anni 13 anni 15 anni

Last year Italy performed the HBSC survey.More than 3.700 classes have been observed with around 75,000 questionnaires gathered.

Tobacco Control StrategyTobacco Control Strategy

Monitoring of the law’s implementation is still ongoing and focuses on six aspects

1. Surveillance (prevalence, behaviours)2. Sales of tobacco products3. Effects on Health4. Compliance with the Law5. Smoking cessation 6. Prevention and communication

activities

TOBACCO PRODUCT S CONSUMPTIONTOBACCO PRODUCT S CONSUMPTION

DATADATA

A special Agency for tobacco sales (AAMS) monthly send data on sales of tobacco products to ministry of health. Data in Kg represent the gross sales from fiscal wharehouses to the 57,000 tobacco’s shops and 16,000 authorized dealershipsData are partitioned by regions

• cigarettes; • cigars • cigarillos; • Roll your own tobacco; • Snuff tobacco;

Increase of sales of other tobacco products (cigars and cigarillos) and, especially, of

RYO cigarettes (less expensive and only 1.7%

of the market)  

2004-2009: - 10%

2010: - 3,9% (about 5 packs less for each smoker)

REDUCTION IN TOBACCO CONSUMPTION REDUCTION IN TOBACCO CONSUMPTION CIGARETTES SALES 2004- 2009CIGARETTES SALES 2004- 2009

Vendite di sigarette 2004-2009

89

91

93

95

97

99

2004 2005 2006 2007 2008 2009

KG

(M

ilio

ni)

-6,1%

-9,8%

-1.1%

-0.9%

-3.1%

+1.1%

Other tobacco products sales 2004-2009

0,20

0,60

1,00

1,40

2004 2005 2006 2007 2008 2009

KG

(M

illio

ns)

RYO Cigars Cigarillos

+139%

+42%

+15,5%

CIGARETTES SALES 1993-2009CIGARETTES SALES 1993-2009

- 142,450,000 packs- 2,849 tons- 3.1%

        

2008/2009

91.005

95.886

100.354

101.595

102.932

101.582

98.846

91.979

89.130,0088.669

89.454

89.852

89.361

89.230

92.822

93.807

92.821

85.000

90.000

95.000

100.000

105.000

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

ton

ne

llate

More than one pack of cigarettes not smoked by each smoker every month!

Tobacco Control StrategyTobacco Control Strategy

Monitoring of the law’s implementation is still ongoing and focuses on six aspects

1. Surveillance (prevalence, behaviours)2. Sales of tobacco products3. Effects on Health4. Compliance with the Law5. Smoking cessation 6. Prevention and communication

activities

LOWER MORBIDITY FOR HEART DISEASELOWER MORBIDITY FOR HEART DISEASE

HOSPITAL ADMISSIONS FOR ACUTE HEART ATTACKHOSPITAL ADMISSIONS FOR ACUTE HEART ATTACK

Descriptive study on trend of first admissions in hospital (Jan.- Mar. 2004 vs. Jan.- Mar. 2005)

Population in study:• All people (M, F) admitted in hospital Jan. 10–Mar.10 • age 40-64• 4 Regions: 28.3% of Italian population (in the age class) ~5

million people

Source: Ministry of Health – Italian Regions

24,7

26,4

28,229,5

27,2

22,0

24,0

26,0

28,0

30,0

32,0

2000 2001 2002 2003 2004 2005 2006

Expected

31,3

-7,8% of AMI in 2005 respect to same period of 2004

Acute Miocardial Infarction & SmokeAcute Miocardial Infarction & Smoke

Decrease (%) of admissions one year after the ban

0

5

10

15

20

Piemonte(<60 yrs)

Roma(<65 yrs)

4Regions

(<65 yrs)

Italy(<70 yrs)

Ireland New YorkState

Scotland(M<55,F<65yrs)

Numerous studies have now consolidated the evidence of the efficacy of smoking ban on the rate of Hospitalization for acute myocardial infarction (before and after the law came in force) with values between -5% (age< 70 yrs whole Italy) to -13% (age 40-64 yrs, four Regions), with a reduction of 11% both for Piemonte (<60 yrs) and Rome population (35-64 yrs). Data are consistent with other international studies such as Ireland (-14%), State of New York (-8%) and Scotland (-8%)

IMPACT ON THE HOSPITAL ADMISSIONS IMPACT ON THE HOSPITAL ADMISSIONS FOR HEART ATTACK: ANOTHER STUDYFOR HEART ATTACK: ANOTHER STUDY

Barone Adesi et al: “Effects of Italian smoking regulation on rates of hospital admission for

acute coronary events” In press, 2010

After the Italian ban, hospital admissions for AMI decreased around 5% among people under the age of 70 all over Italy.

IMPACT ON THE HOSPITAL ADMISSIONS IMPACT ON THE HOSPITAL ADMISSIONS what’s next?what’s next?

After the ban in Scotland hospital admissions for Asthma decreased around 18% among children (<15 yrs)

Tobacco Control StrategyTobacco Control Strategy

Monitoring of the law’s implementation is still ongoing and focuses on six aspects

1. Surveillance (prevalence, behaviours)2. Sales of tobacco products3. Effects on Health4. Compliance with the Law5. Smoking cessation 6. Prevention and communication

activities

2. LAW ENFORCEMENT2. LAW ENFORCEMENT

Controls by Special Corps of Controls by Special Corps of “Carabinieri” for Health“Carabinieri” for HealthJanuary - November 2005January - November 2005

6,076 inspections6,076 inspections 327 fines (5.4%):327 fines (5.4%):• 112 for currently smoking clients (1.8%)• 215 for inappropriate law enforcement (3.5%)

(public and private workplaces, schools, (public and private workplaces, schools, Universities, hospitals, restaurants, Universities, hospitals, restaurants,

train stations, airports, libraries, train stations, airports, libraries, museums, postal offices, etc.)museums, postal offices, etc.)

Since 2005 around 17,000 controlsSince 2005 around 17,000 controls

% of fines total and to smokers

1,4%

3,4% 3,7%

6,7% 7,3% 7,6% 8,1%

10,2%11,3%

15,2%

0,3%1,9%

0,9%

3,1%

0,9% 1,4%2,6%

6,5%5,3%

2,8%

Postal Off ices Train Stations Airports Schools andUniversities

Libraries andMuseums

Outpatientdepartments

Restaurants,Pubs and

Discos

Hospitals Bets' Shopsand Arcades

CoveredMarkets

The law seems to be respected, even if the fines doubled, from 2005 to 2010

The most of the fines for currently smoking clients in Hospitals

Fines

4,1%

5,3%

3,6%

2,2%2,8%

1,8%

5,6%

3,6%

5,2%

3,5%

2005 2007 2008 2009 2010

Currently smoking clients Inappropriate law enforcement

2. LAW ENFORCEMENT2. LAW ENFORCEMENT

2007: National project led by Veneto Region: control of 2007: National project led by Veneto Region: control of private private workplacesworkplaces

Roma

Regions involved

Health Local Unit involved

N° of Companies visited

N° of rooms visited

10

33

863

3,828

Opinion of safety responsibles Observational componentWho respect the law

All71%

Majority21%

Few5%

Nobody3%

Presence of Signs Smokers Ashtrays Butts Smell

Rooms % % % % %Adm. Office 56,0 1,4 9,5 1,2 5,7Production 63,7 4,4 3,4 9,3 4,5Bathroom 30,9 0,4 0,7 2,6 5,6Lockers 39,4 0,8 3,2 1,1 5,9Canteen 59,2 1,0 3,1 1,6 1,6Rest rooms 54,7 1,6 8,1 3,1 7,1Others 54,2 2,9 5,8 8,4 4,9Total 49,9 1,9 4,7 3,9 5,3

2007: National project led by Veneto Region: control of 2007: National project led by Veneto Region: control of public public workplacesworkplaces

Regions involved

Health Local Unit involved

N° of Companies visited

N° of rooms visited

9

13

308

2,431

Opinion of safety responsibles Who is respecting the law? Observational component

Roma

Few3%

Nobody1%

Unknown4%

Majority5%

All87%

Presence of Signs Smokers SmellRooms % % %Closed to public 67,3 1,8 7,0Empoyees only 62,2 1,2 5,1Customer only 67,6 0,5 5,7Both 69,9 1,3 4,6Total 69,6 1,5 5,2

2. LAW ENFORCEMENT2. LAW ENFORCEMENT

From 2005 different survey found values between 69% and 92% on the respect of the law in working places (favorable + very favorable)

Values between 81,5% and 92% for the respect in public places (favorable + very favorable)

Opinions on the utility of the law have been always very positive too, with values between 76% and 95,2%.

COMPLIANCE WITH THE LAWCOMPLIANCE WITH THE LAWthe opinions of populationthe opinions of population

Survey 2005 2006 2009DOXA/ISS 90,40% 93,60% 95,20%Enfasi Study 76%

Survey 2005 2006 2009DOXA/ISS 86,80% 91,00% 93,20%

Favorable to the law in public places

Favorable to the law in working places

Survey 2005 2006 2007 2008 2009DOXA/ISS 69,15 70,60% 71,80% 69,45Veneto region project 92%PASSI 69% 85% 88% 88%

Respect in working places

Survey 2005 2006 2007 2008 2009DOXA/ISS 87,30% 88,20% 83,90% 81,50%Veneto region project 92%PASSI 87% 84% 88% 86%

Respect in public places

Tobacco Control StrategyTobacco Control Strategy

Monitoring of the law’s implementation is still ongoing and focuses on six aspects

1. Surveillance (prevalence, behaviours)2. Sales of tobacco products3. Effects on Health4. Compliance with the Law5. Smoking cessation 6. Prevention and communication

activities

SMOKING CESSATIONSMOKING CESSATION

Attempts to quit smoking

40,6%41,6%

36,0% 36,3%

30,5% 29,8%

27,5%

2003 2004 2005 2006 2007 2008 2009

905.709

37.260

438.665

41.042

178.250

106.788 +103.704

2008*

1.260.935

51.126

532.969

32.165

635.276

9.399

2005

+20%636.269837.859752.797Total

-24%39.73041.33449.201Nicotine inhaler

+1%468.001416.159433.601Nicotine gum and candy

+111%34.01437.71619.446Nicotine tablet

-25%184.233335.241237.900Nicotine patches

+744%5.937

+ 47.3077.40912.649Bupropion +

varenicline

Variation200720062004Products (units)

905.709

37.260

438.665

41.042

178.250

106.788 +103.704

2008*

1.260.935

51.126

532.969

32.165

635.276

9.399

2005

+20%636.269837.859752.797Total

-24%39.73041.33449.201Nicotine inhaler

+1%468.001416.159433.601Nicotine gum and candy

+111%34.01437.71619.446Nicotine tablet

-25%184.233335.241237.900Nicotine patches

+744%5.937

+ 47.3077.40912.649Bupropion +

varenicline

Variation200720062004Products (units)

Data from the annual DOXA/ISS-OFAD surveys show that over time, the percentage of smokers making at least one attempt to quit during the previous year dropped from 36% in 2005 to 27.5% in 2009

Bupropion and Varenicline need a medical prescription; in charge of patientsNRTs are drugs “Over the Counter” (don’t need medical prescription)

Drugs for cessation and NRTs: sales 2004 – 2008Drugs for cessation and NRTs: sales 2004 – 2008

Number of Buproprion and Varenicline packs rocketed in the last two years

NRTs increase until 2005 then are decreasing

Bupropion + Varenicline

12.649 9.399 7.409

53.244

210.492

2004 2005 2006 2007 2008

Nicotine Replacement treatments

740.148

1.251.536

830.450725.978 695.217

2004 2005 2006 2007 2008

Centres for quit smoking and national Centres for quit smoking and national toll-free numberstoll-free numbers

SOS LILT 800 998877

SMOKING CESSATIONSMOKING CESSATION

1. Shiffman S, et al.Annual Review of Public Health 1998; 19: 335–358.

Estimated efficacy and utilization ofapproaches to smoking cessation

counselling

treatment

Efficacy% quit at 6

months

Utilization number using

method annuallyin USA

Impacttotal number of

quitters

No intervention 3 22,800,000 684,000

Prescription NRT 14 2,500,000 280,000

OTC NRT 14 6,300,000 560,000

Behavioural 24 395,000 94,800

Inpatient 32 500 160

Tobacco Control StrategyTobacco Control Strategy

Monitoring of the law’s implementation is still ongoing and focuses on six aspects

1. Surveillance (prevalence, behaviours)2. Sales of tobacco products3. Effects on Health4. Compliance with the Law5. Smoking cessation 6. Prevention and communication

activities

Prevention activities targeting the youngsPrevention activities targeting the youngsProjects selected as “best practices”Projects selected as “best practices”

A pass to the city of the Sun (for kindergartens - 5 years)

Childood in living volour/Winners’club (9-10 years) elementary schools

“Free to choose” and “Towards an unexplored planet” (middle schools 11-12 years)

Smoke Free Class Competition (13-16 years) middle and high schools

Smoke Free Schools high schools

Prevention and advocacyPrevention and advocacy

Training on anti-tobacco counselling for Midwives Training on anti-tobacco counselling for Midwives

Smoke-free MumsSmoke-free Mums

Educational Campaign for parentsEducational Campaign for parents

Don’t smoke!Don’t smoke!

Network of social and health operatorsNetwork of social and health operators

Training of five operators each region in order to:• cohordinate projecting and planning of interventions in

the region; • prevention and health promotion;• counselling to quit smoking from General Practitioner;• Quit smoking center activities; • Second hand smoke protection in public and working

places.

Shared documents on tobacco control

• In 2004 only few Regions with local legislation on tobacco control

• In 2009 ALL Regions included tobacco control programs in their local prevention plans

Prevention and AdvocacyPrevention and AdvocacyEducational Campaign 2009/2010 Educational Campaign 2009/2010

“ “Smoke kills: protect yourself!”Smoke kills: protect yourself!”

Legislative activitiesLegislative activities

• Ratification of the WHO-FCTC

(Law 18.3.2008)

• Participation in the COP 3 (Durban 2008) and COP4 (Montevideo 2010)

• Participation in the process of review of the Directive 2001/37/CE (new health warnings and pictorial warnings)

LESSONS LEARNED / 1LESSONS LEARNED / 1

• Media campaigns have been a critical component for law success

• Information about law also important (hot line)• Law more effective than voluntary agreements• Law effective in: - reducing exposure to passive smoke

- decreasing prevalence of smokers- encouraging smokers to quit - reducing cigarettes consumption

- decreasing incidence of heart attacks

• Scientific approach to evaluation (law enforcement; policy) feasible and helpful to strategy improvement

LESSONS LEARNED / 2LESSONS LEARNED / 2We need:• to continue law-enforcement activity• to evaluate the outcomes of specific

policies• to implement new prevention strategies • to improve knowledge about tobacco

consumption among young people• to develop ad-hoc strategies for young

people• to implement quitting strategies

THE “NO SMOKING MINISTRY” THE “NO SMOKING MINISTRY” EXPERIENCEEXPERIENCE

OBJECTIVESOBJECTIVES 1. MAKE A PICTURE OF THE SITUATION IN THE MINISTRY OF HEALTH• How many employees smoke? • Whic is the level of SHS exposure? • Smokers would quit?  

Ministero della Salute

OBJECTIVESOBJECTIVES  2. CREATE A SMOKE FREE ENVIRONMENTS FOR EMPLOYEES • eliminate (reduce) the numbers of non smokers exposed to SHS• improve the cohabitation between smokers and non smokers• protect smokers and non smokers’health 3. GIVE AN OPPORTUNITY TO QUIT SMOKING TO THE EMPLOYEES • Courses to quit smoking free of charge, during the working hours and in the workplace 

ACTIVITIES INCLUDED:

-An information seminar for employees on the risks of smoking and on the proposed tobacco cessation programme;

- A questionnaire-based survey on the smoking habits of employees working in the Via Giorgio Ribotta offices of the Ministry of Health;

- The launch of “Groups to discourage smoking” run by personnel from the Italian anti-cancer league.

Mean age 47,5 (range 23 – 73)

RESULTS

13.3 cigarettes smoked every day

43% are heavy smokers

25,0%

50,4%

24,5%

Smokers

Non smokers

Ex smokers

1,244 questionnaires sent – 1,030 returned – 994 analysed (participation rate 82.8%)

2% AFFIRMED of smoking in their room

CARACHTERISTICS OF EMPLOYEESCARACHTERISTICS OF EMPLOYEES

The ex and non smoker that consider a serious nuisance Second-hand smoke

61,2%

Ex and non smokers who declares to be exposed to SHS in other place of the Ministry’s building 

Ex and non smokers who declares to be exposed to SHS in other’s rooms6,4%

24,4%

Ex and non smokers who declares to be exposed to SHS in their room1,8%

Smokers whom his GP suggested to quit smoking39,4%

2% Of smokers AFFIRMED of smoking in their room

THE OPPORTUNITY TO QUITFour tobacco cessation courses were activated

between may and june 2009

ProcedureProcedure  - Individual interview to test the motivationIndividual interview to test the motivation- Groups of max 20 personGroups of max 20 person- 9 meetings one hour and half long9 meetings one hour and half long- 1 meeting after 3 months1 meeting after 3 months- 1 meetings after 1 year1 meetings after 1 year

  

THE OPPORTUNITY TO QUITFour tobacco cessation courses were activated

between may and june 2009

74 enrolled16 members of the NAS health and safety unit

58 Ministry employee

25 smoke fewercigarettes (44%)

32 smokers quit after completing the 9 courses (56%)

57 participants(77%)

74 enrolled16 members of the NAS health and safety unit

58 Ministry employee

25 smoke fewercigarettes (44%)

32 smokers quit after completing the 9 courses (56%)

57 participants(77%)

“No smoking Companies”

Ministry of health n.1250 dipendentiACEAElectrabel   n. 500 dipendenti Cassa Italiana Geometri  n. 150 dipendenti Ford                                    n. 170 dipendenti INAIL                                     n. 800 dipendenti  ISPESL                                  n. 800 dipendenti

THANKS!THANKS!

Ministry of Health

Prevention Department

Lorenzo Spizzichino

Daniela Galeone