Tobacco active and passive

smoking in Italy

Data Monitoring System PASSI (Progressi delle Aziende Sanitarie per la Salute in Italia)

www.epicentro.iss.it/passi/english.asp

Valentina MinardiPASSI Coordinating Group

National Centre for Epidemiology, Surveillance and Health Promotion

Italian Health Institute

Workshop Italo-Tunisien sur le TabagismeRome, 23-24 Septembre 2010

Public Health SurveillanceOngoing, systematic collection, analysis, and interpretation of health-related data essential to the planning, implementation, and evaluation of public health practices, closely integrated with the timely dissemination of these data to those responsible for prevention and control.

WHO

Purposes• Assess public health status• Define public health priorities• Evaluate programs• Stimulate research

Core Public Health Functions• Assessment• Policy development• Assurance• Advocacy• Empowerment

Information Action

What is surveillance and why do it?

Background

• 57 million inhabitants

• 21 regions

• Universal health care and preventive services

– Local Health Units (LHU) 1 unit per 300,000 residents

(100,000 – 1,000,000)

– Stewardship interpretation of national

guidelines (national health plans) by regional health authorities

Emilia-Romagna

LHU of Bologna

Example:

Data collection, analyses and dissemination of results are based at LHU level (and at regional level as well)

Data on health behaviors

• Collected by National Institute of Statistics (ISTAT) with several limitations:

– Surveys made every 5 years– national and regional level– delay in dissemination of data– items included not always useful for public health

planning and evaluation

Lack of data on health behavior at LHU level, where many health interventions are

planned and (sometimes) evaluated

PASSI(Progressi delle Aziende Sanitarie per la Salute in Italia)

• 2005 and 2006:– Two pilot cross-sectional studies testing materials and

methods for the future implementation of a surveillance system

– Knowledge shared by CDC/BRFSS and other international experts was very useful in setting up the system

• In 2006 the Ministry of Health funded the National Centre for Epidemiology, Surveillance and Health Promotion (CNESPS) to develop ongoing surveillance of behavioral risk factors and preventive measures included in the National Prevention Plan

A system able to:

– Collect useful and representative data on behaviors connected to health at LHU level

– Provide timely feedback planning and evaluation of programs/interventions

– Facilitate comparisons between LHU/regions identify best practices

– Permit comparisons with international data– Evaluate trend on time– Last but not least:

• Promote the professional development of local and regional staff

• Increase the use of epidemiological data at local level

Method

• Since 2007 ongoing (monthly) data collection in each participating LHU: – telephone interviews of at least 275 persons/year/LHU

– Interviewers: LHU personnel using a standardized questionnaire (questions adapted from BRFSS, ISTAT comparisons)

• Participants selected from LHU population registers using stratified random sampling

• Inclusion criteria: age 18-69, residence in catchment area, availability of telephone number (mobile or land-line, obtained through various sources)

The technological infrastructure of PASSI: an innovative system using free and open-source software

• e-Passi: a web-based infrastructure to collect, centralize and analyze data

• The infrastructure is flexible, user-friendly, and independent of local hardware and software installations

• A smart client application that uses a readily-available internet browser for:– stand-alone functions for data entry and real-time record

saving on interviewers’ computers– interview tracking (assignment, current status)– CATI-like data entry– automatic and secure upload of completed interviews

Source: P. Brunetti, G. Dallago, S. Fontanari, S. Menegon

Topics included are priorities of the National and Regional Health Plan

• quality of life

• smoking habits

• physical activity

• diet

• alcohol consumption

• driving behavior

• cardiovascular risk factors

• cancer screening

• vaccinations

• mental health

• domestic accidents

• socio-demographic aspects

The questionnaire114 questions, many administered to specific subpopulations (e.g. cancer screening) or categories (e.g. present smokers)

Not only behaviors…• Public health interventions

– Screening programs

– Counselling by general practitioners

– Optional modules on:• Police interventions for drunk drivers

• Evaluation of special health promotions programs implemented at regional level

• Diabetes

• Work place safety

• H1N1 Influenza

• Importance of social determinants of health:– All risk factors/compliance with public health programs are

broken down by• Income

• Education

Compliance to smoking band

Data collection (2007-2009)

• 21/21 Regions have begun data collection since April 2007, though not all at the same time

• Health personnel involved and trained: ~ 1.000

• Complete interviews: ~ 115,000– 21,498 in 2007

– 37,560 in 2008

– 39,230 in 2009

– 18,958 in gen-sept 2010 (delayed upload of interviews by LHU)

• 2009:– Response rate: 88%

– Substitution rate 12%• Refusal rate 9%

• Not found 3%

Smoking habits

Smoking habits

%

Never Smokers1 51,6

Former smokers2 19,7

Smokers 28,7

Smokers in abstention3 1,2

Occasional smokers4 0,5

Daily smokers 27,0

Mean of cigarettes 13

1 never smoked at all or smoked less than 100 cigarettes in lifetime2 smoked at least 100 cigarettes during their lifetime and stopped smoking since more than 6 months3 smoked at least 100 cigarettes during their lifetime and stopped smoking since less than 6 months4 smokers of less than one cigarette a day

• Higher (statistically significant):– in younger age groups– among men– in people with intermediate level of education (lower and upper secondary)– more economic difficulties

• Statistically significant differences comparing the Regions (range: 25% Veneto - 32% Abruzzi)

Smoke in Italy

Smokers (%)Pool HLU PASSI 2009

Trends over time• The ongoing (monthly) data collection offers the

possibility to compare annual/semestral/monthly prevalence

28.729.830.7

0

5

10

15

20

25

30

35

40

2007 2008 2009

%

Smokers (%) Pool LHU PASSI 2007-2009

Smokers in Piedmont (%) – 2007-2009

Smoking cessation

• 41% of smokers* declared at least one attempt to quit smoking in the last 12 months

• Nearly 1 in 5 of these came out:

– 8% reported not smoking during the past 6 months (successful cessation)

– 9% were in abstention for less than 6 months

• 96% of former smokers quit smoking alone without any additional help or support

* Among respondents who were smoker 12 months before the interview

Italian smoking ban

– Went into effect in jan/2005– Covers all enclosed public and work places

ENFASI Project 2004-05• Before and after law enforcement owners opinion evaluation• Source: National Health Institute 2004-2005• 50 public places in 33 auto-selected HLUs• Respondents were owners of public places (pub, restaurant,

etc.)• 1 pre and 3 post evaluations of smoking ban compliance

0

10

20

30

40

50

%

pre post 1 post 2 post 3

Presence of smokers in the public place (%)

Studio ENFASI 2005

Compliance to the smoking ban in the public places (%)

Studio ENFASI 2005

0

20

40

60

80

100

%

post 1 post 2 post 3

From ENFASI project…• Questionnaire section on smoking ban:Q12: How do you think your customers will

respond to the smoking ban? Everyone will comply Most customers will comply Some customers will comply and others will notMost

customers will not comply Everyone will not comply

…to PASSI• Questionnaire section on smoking ban:Q 3.11 In public places (as pubs, restaurants,...) you visited during

the last 30 days, in your view people comply to the smoking ban: Always Nearly always Sometime Never I haven’t been in public places in the last month Don’t know/ Don’t remember

Respect of the smoking ban Pooled data – 2009 (n=39,230)

• In Italy compliance with the law is good

• 87% of the interviewed reported that the ban is always or nearly always respected in public places and 88% think the same for work places

Respect of the smoking ban in public places

Pooled data – 2009

• Comparing results from Regions a geographical gradient is noticed from north to south

• The region with the highest compliance rates are Valle D'Aosta and Friuli-Venezia Giulia (96%) and the lowest is Calabria (64%)

• A similar situation is found for ban compliance in work places

Respect of the smoking ban

year Respect always/almost always

2007 84,6

2008 87,1

2009 88,3

Household secondhand smokingPooled data – 2009 (n=39,230)

• Regarding the smoking habit at home, the majority of respondents declared to prevent exposure to secondhand smoke in their homes

• The value increases in households with children less than 14 years old

7381

2117

62

0

20

40

60

80

100

notallowed

allowedpartially

allowed

general populationin presence of children <14 years

PASSI data use

• Health profiles and prioritization processes

• Intervention planning and evaluation– National and regional prevention plan

– Local intervention planning

• Dissemination of results (reports & fact sheets on specific issues)

“pre” estimation trend“post” estimation trend

1st intervention:decrease in alcohol legal

value

2nd intervention:immediate

withdrawal of license

Monthly estimates of the number of episodes of guiding under the influence of alcohol per 1,000 people - BRFSS California data April 1987-January 1994 (n=20,006)

Centro nazionale di epidemiologia, sorveglianza e promozione della salute (CNESPS), Istituto Superiore di Sanità, RomaSandro BALDISSERA, Paolo D’ARGENIO, Barbara DE MEI, Gianluigi FERRANTE, Valentina MINARDI, Valentina POSSENTI, Elisa QUARCHIONI, Stefania SALMASO

Dipartimento di sanità pubblica, Azienda USL di CesenaNicoletta BERTOZZI

Dipartimento di Statistica, Università degli studi Ca’ Foscari, VeneziaStefano CAMPOSTRINI

Dipartimento di sanità pubblica, AUSL ModenaGiuliano CARROZZI

Direzione generale della prevenzione sanitaria, Dipartimento prevenzione e comunicazione, Ministero della salute, RomaStefania VASSELLI

Dipartimento di prevenzione, ASL Caserta 2Angelo D’ARGENZIO

Direzione promozione della salute, Azienda provinciale per i servizi sanitari, TrentoPirous FATEH–MOGHADAM

Dipartimento prevenzione AUSL Roma CMassimo O. TRINITO

ZadigromaEva BENELLI, Stefano MENNA

The PASSI Coordinating Group at national level

Thank you!