epidémiologie du tabagisme et stratégie de lutte italienne lorenzo spizzichino
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Ministero della Salute. Epidémiologie du tabagisme et stratégie de lutte italienne Lorenzo Spizzichino Ministry of Health – ITALY Rome, 24/09/2010. Tobacco Control Strategy. Monitoring of the law’s implementation is still ongoing and focuses on six aspects - PowerPoint PPT PresentationTRANSCRIPT
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