Epidémiologie du tabagisme et stratégie de lutte italienne Lorenzo Spizzichino

1. Ministero della Salute Epidémiologie du tabagisme et stratégie de lutte italienne Lorenzo Spizzichino Ministry of Health – ITALY Rome, 24/09/2010

2. Tobacco Control Strategy Monitoring of the law’s implementation is still ongoing and focuses on six aspects Surveillance (prevalence, behaviours) Sales of tobacco products Effects on Health Compliance with the Law Smoking cessation Prevention and communication activities

3. Tobacco Control Strategy Monitoring of the law’s implementation is still ongoing and focuses on six aspects Surveillance (prevalence, behaviours) Sales of tobacco products Effects on Health Compliance with the Law Smoking cessation Prevention and communication activities

4. Surveillance systems

5. Prevalence 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

6. Surveillance of prevalence 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%

7. Prevalence of smokers ISTAT 2009 Italy = 23% 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%). Range: 18,9% V.D’Aosta – 24,6% Lazio, E-R, Umbria

8. Surveillance of prevalence In Youth MINIMAL EFFECT IN REDUCING YOUNG SMOKERS PREVALENCE

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

10. Tobacco Control Strategy Monitoring of the law’s implementation is still ongoing and focuses on six aspects Surveillance (prevalence, behaviours) Sales of tobacco products Effects on Health Compliance with the Law Smoking cessation Prevention and communication activities

11. TOBACCO PRODUCT S CONSUMPTION DATA A specialAgencyfortobaccosales (AAMS) monthlysend data on salesoftobaccoproductstoministryofhealth. Data in Kg represent the grosssalesfrom fiscal wharehousesto the 57,000 tobacco’s shops and 16,000 authorizeddealerships Data are partitionedbyregions • cigarettes; • cigars • cigarillos; • Roll your own tobacco; • Snuff tobacco;

12. REDUCTION IN TOBACCO CONSUMPTION CIGARETTES SALES 2004- 2009 2004-2009: - 10% 2010: - 3,9% (about 5 packs less for each smoker) Increase of sales of other tobacco products (cigars and cigarillos) and, especially, of RYO cigarettes (less expensive and only 1.7% of the market)

13. CIGARETTES SALES 1993-2009 2008/2009 - 3.1% - 2,849 tons - 142,450,000 packs More than one pack of cigarettes not smoked by each smoker every month!

14. Tobacco Control Strategy Monitoring of the law’s implementation is still ongoing and focuses on six aspects Surveillance (prevalence, behaviours) Sales of tobacco products Effects on Health Compliance with the Law Smoking cessation Prevention and communication activities

15. LOWER MORBIDITY FOR HEART DISEASE HOSPITAL 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 -7,8% of AMI in 2005 respect to same period of 2004 Source: Ministry of Health – Italian Regions

16. Acute Miocardial Infarction & Smoke 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%)

17. IMPACT ON THE HOSPITAL ADMISSIONS FOR 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.

18. IMPACT ON THE HOSPITAL ADMISSIONS what’s next? After the ban in Scotland hospital admissions for Asthma decreasedaround 18% among children (<15 yrs)

19. Tobacco Control Strategy Monitoring of the law’s implementation is still ongoing and focuses on six aspects Surveillance (prevalence, behaviours) Sales of tobacco products Effects on Health Compliance with the Law Smoking cessation Prevention and communication activities

20. 2. LAW ENFORCEMENT Controls by Special Corps of “Carabinieri” for Health January - November 2005 6,076 inspections327 fines (5.4%): • 112 for currently smoking clients (1.8%) • 215 for inappropriate law enforcement (3.5%) (public and private workplaces, schools, Universities, hospitals, restaurants, train stations, airports, libraries, museums, postal offices, etc.)

21. Since 2005 around 17,000 controls The lawseemstoberespected, evenif the finesdoubled, from 2005 to 2010 The most of the fines for currently smoking clients in Hospitals

22. 2. LAW ENFORCEMENT 2007: National project led by Veneto Region: control of private workplaces Regions involved Health Local Unit involved N° of Companies visited N° of rooms visited 10 33 863 3,828 Opinion of safety responsibles Observational component

23. 2. LAW ENFORCEMENT 2007: National project led by Veneto Region: control of public workplaces Regions involved Health Local Unit involved N° of Companies visited N° of rooms visited 9 13 308 2,431 Opinion of safety responsiblesWho is respecting the law? Observational component

24. COMPLIANCE WITH THE LAWthe opinions of population 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%.

25. Tobacco Control Strategy Monitoring of the law’s implementation is still ongoing and focuses on six aspects Surveillance (prevalence, behaviours) Sales of tobacco products Effects on Health Compliance with the Law Smoking cessation Prevention and communication activities

26. SMOKING CESSATION 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 patients NRTs are drugs “Over the Counter” (don’t need medical prescription)

27. Drugs 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

28. Centres for quit smoking and national toll-free numbers SOS LILT 800 998877

29. SMOKING CESSATION clinical!

30. Tobacco Control Strategy Monitoring of the law’s implementation is still ongoing and focuses on six aspects Surveillance (prevalence, behaviours) Sales of tobacco products Effects on Health Compliance with the Law Smoking cessation Prevention and communication activities

31. Prevention activities targeting the youngs 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

32. Prevention and advocacy Training on anti-tobacco counselling for Midwives Smoke-free Mums Educational Campaign for parents Don’t smoke!

33. Network 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

34. Prevention and AdvocacyEducational Campaign 2009/2010 taac “Smoke kills: protect yourself!”

35. Legislative 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)

36. LESSONS 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

37. LESSONS LEARNED / 2 We 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

38. Ministero della Salute THE “NO SMOKING MINISTRY” EXPERIENCE OBJECTIVES 1. MAKE A PICTURE OF THE SITUATION IN THE MINISTRY OF HEALTH • Howmanyemployeessmoke? • Whicis the levelof SHS exposure? • Smokerswouldquit?

39. OBJECTIVES 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

40. 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.

41. RESULTS 1,244 questionnaires sent – 1,030 returned – 994 analysed (participation rate 82.8%) Mean age 47,5 (range 23 – 73) 43% are heavy smokers 13.3 cigarettes smoked every day 2% AFFIRMED of smoking in their room

42. CARACHTERISTICS OF EMPLOYEES 2% Of smokers AFFIRMED of smoking in their room 61,2% The ex and non smoker that consider a serious nuisance Second-hand smoke Ex and non smokers who declares to be exposed to SHS in their room 1,8% Ex and non smokers who declares to be exposed to SHS in other’s rooms 6,4% Ex and non smokers who declares to be exposed to SHS in other place of the Ministry’s building 24,4% 39,4% Smokers whom his GP suggested to quit smoking

43. THE OPPORTUNITY TO QUITFour tobacco cessation courses were activated between may and june 2009 • Procedure • Individual interview to test the motivation • Groups of max 20 person • 9 meetings one hour and half long • 1 meeting after 3 months • 1 meetings after 1 year

44. THE OPPORTUNITY TO QUITFour tobacco cessation courses were activated between may and june 2009

45. “No smoking Companies” Ministry of health n.1250 dipendenti ACEAElectrabel   n. 500 dipendenti Cassa Italiana Geometri  n. 150 dipendenti Ford                                    n. 170 dipendenti INAIL                                     n. 800 dipendenti  ISPESL                                  n. 800 dipendenti

46. THANKS! Ministry of Health Prevention Department Lorenzo Spizzichino Daniela Galeone