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PPACTE, WP2: EUROPEAN SURVEY ON SMOKING

Final Report

Silvano GALLUS, Alessandra LUGO, Carlo LA VECCHIA Paolo BOFFETTA, Frank J CHALOUPKA, Paolo COLOMBO, Laura CURRIE, Esteve FERNANDEZ, Colin FISCHBACHER, Anna GILMORE, Fiona GODFREY, Luk JOOSSENS, Maria E LEON, David T LEVY, Gunnar ROSENQVIST, Hana ROSS, Joy TOWNSEND, Luke CLANCY

Dublin, 31 January 2012

Correspondence to: Silvano Gallus, ScD Department of Epidemiology Istituto di Ricerche Farmacologiche Mario Negri Via Giuseppe La Masa 19, 20156 Milano tel: +390239014657 – fax: +390233200231 – e-mail: [email protected]

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Acknowledgement of funding: The project ‘Pricing Policies and Control of Tobacco in Europe (PPACTE)’ is partly funded by the European Commission Seventh Framework Programme Grant Agreement HEALTH-F2-2009-223323. Authors wish to thank Dr Irene Tramacere for her invaluable assistance in the development of the European Survey Tool. They also express their gratitude to Dr Matteo Franchi for research assistance and Mrs Ivana Garimoldi for editorial assistance.

Conflict of interest statement The authors of the present report declare that there are no conflicts of interest.

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EXECUTIVE SUMMARY Objective. Inadequate data are available on within-country comparison in Europe. Thus, we conducted a survey, with a focus on pricing policies to control tobacco.

Method. Pricing Policies and Control of Tobacco in Europe (PPACTE) is a project aiming to provide the most comprehensive analysis of the effectiveness of tobacco pricing policy in Europe. Within the PPACTE project, a face-to-face representative survey on smoking was conducted in 2010 on a sample of 18,056 participants (8653 men and 9403 women) from 18 European countries. In each country, participants were representative of the population aged 15 or over in terms of age, sex, habitat and socio- economic characteristics.

Results. Overall, 27.2% of participants described themselves as current smokers (28.2% of men and 21.8% of women). Among current smokers, 13.0% (16.3% of men and 9.0% of women) reported to smoke 25 cigarettes or more per day. The highest prevalence of current smokers was found in Bulgaria (40.9%) and Greece (38.9%); the proportions of smokers were lowest in Italy (22.0%) and Sweden (16.3%). The prevalence for men ranged between 15.7% (Sweden) and 44.3% (Bulgaria), and that for women between 11.6% (Albania) and 38.1% (Ireland). For both sexes, the highest smoking prevalence was reported among the 25-44 year age group (39.8% of males and 32.0% of females), and the lowest one among the elderly (15.3% of males and 8.6% of females). The male-to-female prevalence ratio increased with age. In men, smoking prevalence was systematically higher in poorer countries (standardized GDP<20,000$) than in richer ones (GDP≥20,000$), while no significant difference was observed for women. Overall, 16.0% of the survey participants described themselves as ex-smokers Mean age at quitting was 39.3 years (±14.4) and ranged between 26.5 in Latvia and 46.0 in Italy. The prevalence of ex-smokers reporting “economic reason” as the main motivation to quit was 7.1% overall, ranging between 0.9% in Spain and 23.3% in Portugal. The overall number of cigarettes per day per capita was 4.2 (5.2 in men and 3.4 in women), ranging from 2.1 in Sweden to 8.9 in Greece.

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Overall, 19% of current daily smokers reported to smoke the first cigarette within 5 minutes after waking-up, lower in Spain (12%) and Czech Republic (14%), and higher in Ireland (34%) and Sweden (35%). Mean age at starting was 18 years overall, 18 among men and 19 among women (p<0.001), and did not exceed 20 years in none of the countries. Among current smokers, on average 88.1% bought cigarettes from legal tobacco shops (including vending machines), 4.9% from other countries or duty-free shops, 3.6% from smugglers, 3.4% smoked cigarettes offered by peers and 0.1% bought cigarettes over the internet. The prevalence of current smokers reporting they smoked smuggled cigarettes was higher in eastern European countries, in particular in Bulgaria (12.2%) and Latvia (25.9%). The mean cost for a pack of cigarette, standardized by GDP in PPS based on the EU average 2010, was 4.96€, highest in Ireland (7.85€) and Bulgaria (7.89€) and lowest in Czech Republic (3.68€) and Hungary (2.74€). Among current smokers, 74% accepted to show to the interviewer the latest purchased pack of cigarettes or hand-rolled tobacco. Overall, 86% showed manufactured packs and 11% hand-rolled tobacco. The proportion of hand-rolled on total cigarette pack showed was highest in England (32%), France (17%) and Finland (14%) and was less than 2% in Romania, Bulgaria, Italy, Latvia and Sweden. A reasonable estimate of the weight of one hand-rolled cigarette is 0.7-0.8 grams. The prevalence of current smokers showing a pack with health warnings in foreign language was 6% overall, particularly high in Latvia (26%). The prevalence of smokers showing a pack without health warnings was 1% overall, highest in Latvia (5%) and Croatia (9%). Overall, 5% of packs had a tax stamp in foreign language, highest in Austria (10%), France (11%) and Latvia (26%), and 4% of packs were without the stamp, highest in France and Bulgaria (8%), and England (15%). Overall, 4% of smokers bought their latest pack from other countries or duty-free shops, and 4% from smugglers (10% in Sweden, 15% in Bulgaria and 31% in Latvia). Once considering the tax evasion score (TES; an ad hoc defined measure of cigarettes purchased from illicit trades derived by analyzing the latest pack shown) the prevalence of tax evaders increased to 8%. TES was highest in Latvia (36%), Sweden (20%) and Bulgaria (18%), and lowest in Austria (1%), Greece (1%) and Portugal (0%).

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Overall, 79% of non smokers and 49% of current smokers moderately to strongly supported an increment in price by 5%, assuming that additional revenues were allocated to support smoking cessation measures. The corresponding estimates for an increment by 20% were 74% and 39%, respectively. Overall, 76% of non smokers and 67% of current smokers perceived as moderately to strongly useful to provide free smoking cessation support to control tobacco. The corresponding percentages for the extension of smoking bans were 64% and 38%, and for pricing policies were 62% and 37%, respectively. Assuming a 20% increase in cigarette price, 14% of smokers would quit smoking, 31% would consume less cigarettes, 14% would switch to cheaper brands, 4% to hand- rolled tobacco, 4% to illegal or smuggled cigarettes, 1% would “switch to/use also” smokeless tobacco, and 34% would not change their smoking habit. The proportion of current smokers that would switch to smokeless tobacco was higher in Bulgaria (11%) and Latvia (19%). The proportion of current smokers who would switch to smokeless tobacco in Sweden was 2%. Overall, 36% of current smokers have intention to quit smoking within the next 6 months (34% of men and 38% of women), with substantial differences across countries. The magnitude of an increment in cigarette price that would lead smokers to completely quit was ≤20% in 21% of current smokers, 21-40% in 19%, 41-60% in 18%, and 61-100% in 28% of current smokers. Overall, 62% (73% of non smokers and 34% of current smokers) of respondents banned smoking in their home, 19% allowed their guests to smoke in some specific indoor areas and 19% everywhere. Substantial differences were evident across various countries, total home-ban ranging between 31% in Croatia and 93% in Finland. Overall, 2% of the total population consumed smokeless tobacco (including Swedish snus). In Sweden, 12% of the sample reported use of smokeless tobacco (21% in men and 4% in women), and 11% reported regular use (19% in men and 4% in women). Regular use of smokeless tobacco in other countries was relatively infrequent (systematically lower than 2%).

Conclusions. We found substantial differences in terms of smoking prevalence, per capita number of cigarettes per day, smoking dependence, standardized cost of

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cigarettes, and hand-rolled and smuggled cigarette use across European countries. Male- to-female smoking prevalence ratio was higher in eastern European countries, in poorer areas and in countries with less advanced tobacco control measures. Smuggling covers between 4% and 8% of overall tobacco trades in Europe.

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TABLE OF CONTENTS Page List of Tables 11 List of Figures 12 Introduction 16 Smoking prevalence surveillance in Europe 16 Smoking dependence 18 Perceptions and attitudes towards an increase in cigarette price 19 Smoking behaviours according to an increase in cigarette price 19 Smuggling 20 Social acceptability of smoking 21 Smokeless tobacco 21 Pricing Policies and Control of Tobacco in Europe 22 Methods 22 Selection of countries 23 Sampling methods 23 Ethical issues 24 European survey tool 24 Weight of one hand-rolled cigarette 25 Tax Evasion Score 26 Statistical methods 26 Results 27 Smoking prevalence 27 Age at quitting and main reason to quit 28 Smoking dependence, cigarette type and age at starting smoking 29 Channels of cigarette distribution 30 Weekly expenditure 30 Latest pack 31 Attitudes toward an increase in price 33 Perceptions toward an increase in price 33 Smoking behaviours according to an increase in cigarette price 35 Voluntary smoking-ban at home 36 Smokeless tobacco 36 Comments 37 Smoking prevalence 37 Cigarette consumption and type of cigarettes 38 Strengths and limitations 38 Recommendations 39 References 42 Tables Table 1a (PPACTE survey) 46 Table 1b (PPACTE survey) 47 Table 2 (Smoking prevalence) 48 Table 3 (Smoking prevalence) 49 Table 4 (Channels of cigarette distribution) 50 Table 5 (Weight of one hand-rolled cigarette) 51 Table 6 (Latest pack) 52 Table 7 (Smokeless tobacco) 53

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Table 8 (Smokeless tobacco) 54 Figures Figure 1a (Smoking prevalence) 55 Figure 1b (Smoking prevalence) 56 Figure 2 (Smoking prevalence by sex) 57 Figure 3 (Smoking prevalence by age) 58 Figure 4 (Reason to quit) 59 Figure 5 (Smoking consumption) 60 Figure 6 (Smoking dependence) 61 Figure 7 (Channels of cigarette distribution) 62 Figure 8 (Latest cigarette pack) 63 Figure 9 (Latest cigarette pack) 64 Figure 10 (Latest cigarette pack) 65 Figure 11 (Latest cigarette pack) 66 Figure 12 (Tax evasion score) 67 Figure 13 (Tax evasion score and smuggling) 68 Figure 14 (Attitudes) 69 Figure 15 (Attitudes) 70 Figure 16 (Perceptions) 71 Figure 17 (Perceptions) 72 Figure 18 (Perceptions) 73 Figure 19 (Perceptions) 74 Figure 20 (Perceptions) 75 Figure 21 (Smoking behaviours) 76 Figure 22 (Smoking behaviours) 77 Figure 23 (Smoking behaviours) 78 Figure 24 (Home smoking ban) 79 Figure 25 (Smokeless tobacco) 80 List of Appendices 81 Appendices Appendix 1 (Questionnaire) 85 Appendix 2 (Smoking prevalence) 92 Appendix 3 (Smoking prevalence by sex) 93 Appendix 4 (Smoking prevalence by age) 94 Appendix 5 (Age at quitting) 95 Appendix 6 (Reason to quit) 96 Appendix 7 (Smoking consumption) 97 Appendix 8 (Smoking consumption) 98 Appendix 9 (Smoking dependence) 99 Appendix 10 (Age at starting) 100 Appendix 11 (Channels of cigarette distribution) 101 Appendix 12 (Weekly expenditure) 102 Appendix 13 (Weekly expenditure) 103 Appendix 14 (Latest cigarette pack) 104 Appendix 15 (Latest cigarette pack) 105 Appendix 16 (Latest cigarette pack) 106 Appendix 17 (Latest cigarette pack) 107 Appendix 18 (Attitudes) 108

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Appendix 19 (Attitudes) 109 Appendix 20 (Attitudes) 110 Appendix 21 (Attitudes) 111 Appendix 22 (Perceptions) 112 Appendix 23 (Perceptions) 113 Appendix 24 (Perceptions) 114 Appendix 25 (Perceptions) 115 Appendix 26 (Smoking behaviours) 116 Appendix 27 (Smoking behaviours) 117 Appendix 28 (Smoking behaviours) 118 Appendix 29 (Home smoking ban) 119 Appendix 30 (Smokeless tobacco) 120 Appendix 31 (Smokeless tobacco) 121

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LIST OF TABLES

Table 1a: Sample size overall and by sex, and age range, per capita Gross Domestic Product (GDP) based on Power Purchase Parity (PPP) in current international dollars ($), Tobacco Control Scale (TCS) score updated to 2010, and population aged 15 years or over, in million inhabitants, by country. PPACTE, 2010.

Table 1b: Information about CAPI survey methods and characteristics in 18 European countries. PPACTE, 2010.

Table 2: Percent (%) distribution and corresponding 95% confidence intervals (CI) of the population aged 15 years or over according to smoking habit, overall and by sex, in 18 European countries. PPACTE, 2010.

Table 3: Pearson’s correlation coefficients (r) and 95% confidence interval (CI) between country specific tobacco control scale (TCS) score, Gross Domestic Product (GDP) and prevalence of current smokers in Eurobarometer survey of 2009, and prevalence of smoking (current and ex-smokers) and other indicators.

Table 4: Percent (%) distribution of current smokers according to channel of distribution (over the previous 30 days) and age group. Source of distribution by country for the young (15-24 years). PPACTE, 2010

Table 5: Median weight in grams of 1 hand-rolled cigarette, and corresponding inter- quartile range (IQR), overall and by country, sex, age, education and smoking intensity, among hand-rolled cigarette smokers. PPACTE, 2010

Table 6: Percent (%) distribution of current smokers according to channel of distribution of the latest pack by age group. PPACTE, 2010

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Table 7: Distribution of participants according to smoking status and their use of smokeless tobacco in the total sample and in Sweden, overall and by gender. PPACTE, 2010.

Table 8: Percent distribution (%) of smokeless tobacco users by sales and distribution channels of smokeless tobacco, overall, for Sweden and for other selected European countries. PPACTE, 2010.

LIST OF FIGURES

Figure 1a: European countries coloured according to current cigarette smoking prevalence in men and women combined. PPACTE, 2010.

Figure 1b: Percent (%) distribution of the European population according to smoking status overall and by country, sorted by the prevalence of current smokers (descending order). PPACTE, 2010.

Figure 2: Prevalence of current smokers separately in men and women, overall and by specific country, sorted by the prevalence of current smokers in both sexes (descending order). PPACTE, 2010.

Figure 3: Sex-specific percent prevalence of current smokers, overall and according to age group, in the total sample and in strata of per capita GDP based on PPP, and TCS 2010. PPACTE, 2010.

Figure 4: Percent distribution among ex-smokers according to the main reason to quit, overall and by specific country, sorted by the prevalence of those reporting “Illness (any medical condition)” as the main reason to quit (descending order). PPACTE, 2010.

Figure 5: Number of cigarettes smoked per day (manufactured and hand-rolled) among current smokers separately in men and women, overall and by specific country, sorted

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by the consumption of cigarettes among current smokers in both sexes (descending order). PPACTE, 2010.

Figure 6: Percent distribution (%) of current daily smokers according to how soon after waking-up they smoke the first cigarette, overall and by specific country, sorted by “within 5 minutes” (descending order). PPACTE, 2010.

Figure 7: Percent (%) distribution of current smokers according to where they bought their packs of cigarettes during the last 30 days, overall and by specific country, sorted by legal shops, including vending machines (ascending order). PPACTE, 2010.

Figure 8: Percent (%) distribution of current smokers according to the type of their latest pack of cigarettes, overall and by specific country, sorted by “20 cigarette pack” (ascending order). PPACTE, 2010.

Figure 9: Percent (%) distribution of current smokers according to the type of health warnings on their latest pack of cigarettes, overall and by specific country, sorted by “local language” (ascending order). PPACTE, 2010.

Figure 10: Percent (%) distribution of current smokers according to the type of tax stamp (banderole) on their latest pack of cigarettes, overall and by specific country, sorted by “local stamp” (ascending order). PPACTE, 2010.

Figure 11: Percent (%) distribution of current smokers according to where they bought their latest packs of cigarettes, overall and by specific country, sorted by legal shops, including vending machines (ascending order). PPACTE, 2010.

Figure 12: Percent (%) distribution of current smokers according to the Tax Evasion Score (TES), overall and by specific country, sorted by TES (descending order). PPACTE, 2010.

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Figure 13: Percent (%) distribution of current smokers according to Tax Evasion Score (TES; total bar), and smuggling (dark blue bar), overall and by specific country, sorted by TES (descending order). PPACTE, 2010. Figure 14: Percent (%) distribution of European population by smoking status according to their attitudes toward an increment in cigarettes prices by 5%, overall and by specific country, sorted by prevalence of participants reporting a strong or moderate support (ascending order). PPACTE, 2010.

Figure 15: Percent (%) distribution of European population by smoking status according to their attitudes toward an increment in cigarettes prices by 20%, overall and by specific country, sorted by prevalence of participants reporting a strong or moderate support (ascending order). PPACTE, 2010.

Figure 16: Percent (%) distribution of the European population according to its perception of effectiveness of free psychological or pharmacological support for smoking cessation, including nicotine replacement therapy (patches, gums, etc) bupropion and varenicline, in order to control and limit tobacco use, overall and by specific country, sorted by prevalence of subjects considering the tobacco control strategy useful (ascending order). PPACTE, 2010.

Figure 17: Percent (%) distribution of the European population according to its perception of effectiveness of making smoking or cigarette sales illegal, in order to control and limit tobacco use, overall and by specific country, sorted by prevalence of subjects considering the tobacco control strategy useful (ascending order). PPACTE, 2010.

Figure 18: Percent (%) distribution of the European population according to their perception of effectiveness of raising the price of cigarettes, in order to control and limit tobacco use, overall and by specific country, sorted by prevalence of subjects considering the tobacco control strategy useful (ascending order). PPACTE, 2010.

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Figure 19: Percent (%) distribution of the European population according to their perception of effectiveness of extension of smoking bans, in order to control and limit tobacco use, overall* and by specific country, sorted by prevalence of subjects considering useful the tobacco control strategy (ascending order). PPACTE, 2010.

Figure 20: Prevalence of non smokers and current smokers considering useful (very and quite combined) each of the four tobacco control strategies considered. PPACTE, 2010.

Figure 21: Percent (%) distribution of current smokers according to their main response to a 20% increase in price of a pack of cigarettes, overall and by specific country, sorted by prevalence of participants answering “I would not change my smoking habit” (descending order). PPACTE, 2010.

Figure 22: Percent (%) distribution of current smokers that have intention to quit smoking within the next 6 months separately in men and women, overall and by specific country, sorted by prevalence of participants answering “Yes, I want to quit” in men and women combined (ascending order). PPACTE, 2010.

Figure 23: Percent (%) distribution of current smokers according to the amount of increase in price of cigarettes to let them quit smoking completely, overall and by specific country, sorted by prevalence of participants quitting for 20% increase or less” (ascending order) PPACTE, 2010.

Figure 24: Percent (%) distribution of the European population according to voluntary smoking ban in their home, overall and by specific country, sorted by prevalence of participant reporting a total smoking ban at home (ascending order). PPACTE, 2010.

Figure 25: Sex specific percent distribution (%) of the European population aged 15 years or over according to smokeless tobacco use, overall and by specific country. PPACTE, 2010 .

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INTRODUCTION The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) is the first WHO treaty developed in response to the globalization of the tobacco epidemic and ratified by 173 countries worldwide (June 2011). In its 20th article the FCTC recommends Parties to “promote national research and to coordinate research programmes at the regional and international levels in the field of tobacco control” [1]. Indeed, population-based national and international monitoring data are crucial to effectively plan and implement country-specific strategies to control tobacco. Various countries stand, in fact, in different stages of the tobacco epidemic [2], with different smoking prevalence and consumption, male to female smoking prevalence ratio, smoking attributable mortality [3], implemented tobacco control policies [4, 5] and sentiment toward smoking. Consequently, efficacy interventions to control tobacco should be planned and implemented according to all these country-specific tobacco characteristics [2]. However, only 34% of the global population is covered by reliable data on smoking prevalence [6]. Data on other aspects of the tobacco epidemic, including public attitudes toward tobacco control or economic costs of tobacco use, are also limited [6].

Smoking prevalence surveillance in Europe Despite having 15% of the world population, Europe faces nearly one third of the worldwide burden of tobacco-related diseases [7]. Some European countries have effective tobacco surveillance systems, including reliable, updated and representative data on smoking prevalence. However, only less than half of the European Union (EU) Member States (MS) measure smoking prevalence on annual or biennial basis [8]. Moreover, it is difficult to make comparisons among European countries, since various national surveys on tobacco are heterogeneous in terms of: i) sampling methodology (representative vs non representative; quota sampling vs multi-stage random sampling; household vs individual survey); ii) study design (general surveys vs surveys specifically focusing on tobacco; face-to-face vs telephone vs mail or internet- based interview); iii) population focus (overall population vs limited to a selected sex or age group); iv) response rate; v) sample size (differing by up to three orders of magnitude); and vi) definition of smoking status (phrasing of question used to define

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smoking; tobacco product considered; lifetime vs current smokers). Therefore, cross- national comparisons of data on tobacco using different surveys conducted with different methodologies [9, 10] should be interpreted cautiously [8, 11]. There are, in fact, substantial discrepancies in terms of smoking prevalence using different datasets in the same country over the same calendar period [11, 12] On the other hand, monitoring smoking prevalence in different countries using standard and uniform approaches in representative population samples is important in highlighting worthwhile tobacco control policy directions [8, 11]. Accordingly, the WHO FCTC recommends Parties to integrate tobacco surveillance into global programmes so that data are comparable [1]. In Europe just a few surveys on adult smoking include more than one country. Among these, the Eurobarometer is a periodical survey, conducted in all the EU MS plus Norway, aimed to evaluate Europeans’ attitudes towards tobacco. Eurobarometer was carried out on five occasions between 2002 and 2009 [13, 14, 15, 16, 17]. Apart from the year 2008, where data were collected using computer assisted telephone interviews (CATI), data were usually collected in the context of a computer assisted personal interview (CAPI). Several limitations undermine Eurobarometer utility for tobacco surveillance [8]. In particular, no breakdown within country by sex, age and socioeconomic characteristics is available, not even for smoking status. In 2007 WHO launched the Global Adult Tobacco Survey (GATS), a nationally representative household CAPI survey, using a standard core questionnaire and consistent methodology, including sample design, data collection and data management. GATS has been implemented in 14 countries, including 4 European ones (Poland, the Russian Federation, Turkey and Ukraine) [18]. Only 5 additional studies considered cross-national data on representative samples of adults in Europe, using a uniform and standard methodology. A survey conducted in 2001 on 18,387 adults provided data on smoking prevalence in 8 countries of the former Soviet Union [19, 20]. A CATI survey from 5 European countries (Germany, Greece, Poland, Sweden and UK) conducted in 2006 on a total of 3500 subjects aged 16-59, reported country-specific smoking prevalence for men and women combined, only [21]. A study provided data on prevalence in England (6527 participants) and in 10 EU countries combined (a total of 17,481 subjects) in 2004 on population aged 50-74 years

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[22]. A cross-sectional telephone survey was conducted as part of the Women in Europe Against Lung Cancer and Smoking (WELAS) Project, including a total of 5000 adult women from 5 European countries (France, Ireland, Italy, Czech Republic, and Sweden) [23, 24]. The World Health Survey was a survey conducted in 2002-2004 on more than 200,000 adults from around 50 low- and middle-income countries, including a few European ones [25, 26]. Although not representative of the general population, the European Prospective Investigation into Cancer and Nutrition – Physical Activity, Nutrition, Alcohol, Cessation of smoking, Eating out of home And obesity (EPIC-PANACEA) provided data on tobacco consumption [27]. This is a cross-sectional study nested in the EPIC project and conducted between 1992-2000. Despite the uniquely large dataset (469,543 subjects), the study was not designed to make comparisons in smoking prevalence, thus information on smoking is limited. Furthermore, the sample was limited to adults aged 35-70 years; moreover, the enrolment took place approximately 15 years ago, and no update information is available. A few other investigations collected information on smoking but did not publish within country results [5, 28, 29, 30], and some other studies have published data on adolescents only [31, 32, 33, 34, 35, 36, 37]. The PPACTE survey has been conducted to fill the gaps in available data on smoking prevalence and consumption, and to provide between-country comparisons.

Smoking dependence The assessment of nicotine dependence is one of the main objectives addressed in tobacco studies. Measures of tobacco dependence are mainly available from stopping smoking clinics and hence from selected groups of smokers [38, 39, 40]. Less information is available on tobacco dependence on a population level [40, 41]. Several tests have been developed to assess nicotine tobacco dependence. One of the most used tool is given by the Fagerström Test for Nicotine Dependence (FTND), based on a six- item questionnaire. Using that test, substantial differences in terms of smoking dependence have been observed in different countries according to their smoking prevalence [41]. The Heavy Smoking Index (HSI), a briefer measure including only two FTND items (time to first cigarette of day and number of daily cigarettes), was used in a

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few studies as a measure of smoking dependence [42, 43, 44]. A comparison between the two tests showed that the HSI can be used as a reasonably good screening test in order to identify daily smokers with high nicotine dependence [43, 44]. Thus, we added questions to derive the HSI in our PPACTE survey.

Perceptions and attitudes towards an increase in cigarette price Monitoring perceptions and attitudes towards various tobacco control strategies in different populations allows to understand in which country pricing policies may be more feasible and effective. However, scanty information is available, particularly in Europe, on perceptions and attitudes towards increases in cigarette price. A comprehensive updated revision of the literature [45] found only 4 European studies, 3 from Italy [46, 47, 48] and 1 from Germany [49], providing data on the attitudes and perceptions of adults towards increasing cigarette prices only. In those studies a substantial proportion (i.e., generally between 30% and 50%) of the population would support tax increases. Such a support becomes appreciably greater (i.e., 60 to 80% or over) whenever such tax increases are allocated for tobacco control initiatives. The support towards pricing policies increases over time and is appreciably greater in non smokers and, within smokers, among more educated, and the elderly [45]. The GATS conducted in Poland in 2009-2010 confirmed these findings [50]. Moreover, the large majority of the Italian population, and more than one out of three current smokers, was confident that an increase in cigarette price is an effective measure to control tobacco [46, 47, 48]. Given the paucity of data on the issue in Europe, we collected information on perceptions and attitudes towards increasing of price.

Smoking behaviours according to an increase in cigarette price Scanty European data are available on the willingness of smokers to quit according to an increase in cigarette prices. In an Italian study, 21% of smokers stated that they would reduce, and 10% stop smoking following a 1€ increase in price [46]. In the 2009 Eurobarometer survey, half of smokers claimed that price influences their choice of cigarettes. However, this varied considerably between countries and in Bulgaria, Lithuania, Romania, Turkey and the Former Yugoslav Republic of Macedonia it is at parity or more important than taste [17]. Various measures of smoking behaviour

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according to an increase in cigarette price among current smokers were also considered in the PPACTE survey. The International Tobacco Control Policy Evaluation Project (the ITC Project) is the first international cohort study of tobacco use whose objective is to measure the psychosocial and behavioural impact of key national level policies of the FCTC [51]. The project was conducted in France, Germany and the Netherlands. In those surveys, the proportion of smokers who have often or very often thought about the money spent on cigarettes in the last month was less than 25% in the Netherlands, almost 50% in Germany and almost 60% in France [52, 53].

Smuggling Smuggling is strictly related to fiscal or pricing policies as a strategy to control tobacco. In fact, tax avoidance and tax evasion undermine the effectiveness of tax policies and result in less revenues for governments, cheaper prices for smokers and increase of tobacco use [45, 54]. It is possible therefore that changes in the official price of cigarettes may be directly related to variation in smuggling. The issue however is still under debate, since some studies showed that the phenomenon of smuggling does not follow logic economic rules, and size of illicit trades is influenced by other issues, such as the control of the supply chain in Europe [55, 56]. The best available and updated data show that the size of illicit trades varies among countries from 1% to about 40-50% of the market, 11.6% globally and 8.5% in the EU [57]. However, the reliability of these estimates is open to discussion, and data on the size of illicit trades remain scarce. It is extremely important to measure and monitor in each country the proportion of smuggled cigarettes on total cigarette trades. The IARC handbooks on methods for evaluating tobacco control policies [58] and on tobacco taxation [45] describe the different methods to measure illicit trades, identifying the three most used ones: 1) Comparison of tax paid sales and individually reported consumption measures – the difference between consumption between data from official legal sales and data from representative surveys may reflect the extent of overall tax avoidance and evasion [12, 58]; 2) Survey of tobacco users’ purchase behaviours – representative surveys of tobacco product users collecting information on various aspects of purchase behaviour, including purchase source and price, can be helpful in assessing the extent of various

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forms of individual tax avoidance, including cross-border shopping, direct purchases, and duty-free purchases [56, 58]; 3) Observational data collection – in representative surveys, tobacco products can be examined through tax stamps, local warning labels, other pack markings, and product constituents to identify products that do not bear the appropriate stamps/labels/markings or that include constituents that differ from those contained in locally manufactured products [50]. All these 3 methods have several limitations. Thus, we collected data in order not only to estimate the size of illicit cigarette trades in 18 European countries, but also to cross-validate estimates using a combination of the three most used methods to measure illicit trades.

Social acceptability of smoking Socially unacceptable behaviours, including tobacco smoking, are likely under-reported. In particular, the more social pressure there is against smoking in a society, the larger the smoker’s propensity to deny smoking may be [12, 59]. This is confirmed by the widely different rates of deceivers in various subpopulations with more or less pressure against smoking [12, 60, 61]. Thus, in order to validate smoking prevalence estimates in various European countries, it is important to take into account social acceptability of smoking across various countries. A voluntary home smoking ban is associated with a negative tobacco sentiment [62, 63]. Thus, in our European survey we added a question on household smoking ban as a proxy of social acceptability of smoking.

Smokeless tobacco Smokeless tobacco use is extremely rare in most European countries. However, there exists a particular Swedish variety of oral moist snuff (snus) that is frequently used in Sweden and a few other Scandinavian countries. Besides Sweden, this smokeless tobacco is banned in the other countries of the EU. Thus, information on prevalence of smokeless tobacco use in Europe is adequate for Scandinavian regions only [64]. However, other types of smokeless tobacco could be used in Europe, or Swedish snus could be illegally imported in other countries. It is important therefore to monitor smokeless tobacco use in Europe. Therefore, some specific questions of the PPACTE survey focused on smokeless tobacco. Data have been collected on smokeless tobacco prevalence and consumption, and a specific

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question has been included on the willingness to switch from cigarette smoking to smokeless tobacco use, assuming an increment in the price of cigarettes, in order to understand the impact of fiscal policies on cigarette smokers. These data contribute to the debate on whether or not to inform the public that using oral, smokeless tobacco, including Swedish snus, is less hazardous to health than smoking tobacco [65, 66, 67, 68].

Pricing Policies and Control of Tobacco in Europe Pricing Policies and Control of Tobacco in Europe (PPACTE) is a project aiming to provide the most comprehensive analysis of the effectiveness of tobacco pricing policy in Europe. Within the Work-Package (WP) 2 of the PPACTE project, a European survey has been conducted in 18 strategically selected European countries. The European survey aimed to estimate prevalence, consumption, social acceptability of smoking, purchasing patterns and attitudes, perceptions, and behaviours towards fiscal policy in various European countries, thus substantially improving the gaps of knowledge on economic aspects of smoking in Europe [45, 69]. The present report gives a comprehensive presentation of the findings from the European survey.

METHODS Data were derived from a face-to-face survey conducted between January 2010 and July 2010 in 18 selected European countries using standardized methods [12]. Within the PPACTE project, the survey was coordinated by DOXA, the Italian Branch of the GALLUP International Association, and conducted by its European partners. The survey included a total of 18,056 subjects (8653 men and 9403 women) aged 15 years and older, representative, for each of the 18 selected European countries, of the general population aged 15 or over in terms of age, sex, habitat and socio-economic characteristics. Therefore, the present survey is representative of 311 million inhabitants aged 15 or over from 18 European countries. The sample size was around 1,000 participants for each country. The 18 countries included in this report were Albania, Austria, Bulgaria, Czech Republic, Croatia, England, Finland, France, Greece, Hungary,

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Ireland, Italy, Latvia, Poland, Portugal, Romania, Spain, Sweden. In Croatia, England, Finland, Greece, Hungary and Poland information was collected only for subjects aged 18 years or more. Table 1a shows details on country specific survey characteristics, including fieldwork dates, sample size, age range and country specific characteristics.

Selection of countries The 18 European countries considered in the present study were selected in order to consider both the nations with scanty and inadequate data on smoking and those with “good” data available. In this way, findings from the countries with good data can be used as a reference point to standardize findings from countries with poor data. Among the countries with satisfactory data, we prioritized those with full or partial smoking- bans in all workplaces in 2010 (Ireland, Italy, Scotland, Spain) and those that systematically increased prices of tobacco products over the last few years (France and UK). Among countries without good data existing, we focused on EU MS, including the incoming members (Romania and Bulgaria) and one candidate country (Croatia). In addition, Latvia and Albania were selected because of their apparently high prevalence of smuggling. Other countries, including Finland and in particular Sweden were selected for their frequent use of smokeless tobacco (Swedish snus).

Sampling methods Table 1b provides information on the sampling methods used in each country. Several countries (Albania, Croatia, Hungary, Italy, Poland and Romania) defined the sample through a multi-stage method. In the first stage, the primary unit of selection was a geographic area or voting centre. In the second stage, households or municipalities were selected. In the last stage, respondents were chosen randomly with different methodologies in order to be representative of the country specific population in terms of age, sex, habitat and socio-economic characteristics (working status, profession and income). In those countries where adult respondents had been selected from electoral rolls, the quota method had been used to select respondents 15 to 17 years old. Other countries (Austria, England, Finland, France and Ireland) used a quota method for the selection of the entire sample, stratifying the population according to selected variables including age, sex, and alternatively geographic area and/or profession, in order to

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obtain a representative sample of the country population. Some countries used other sampling methodologies, including a stratified random method (Bulgaria, Czech Republic and Latvia), or a simple random method (Greece). Most of the countries used statistical weights to assure the representativeness of the sample according to age, sex, geographic area and socio-economic characteristics.

Ethical issues The study protocol has been approved by the Institutional Review Board of the Istituto di Ricerche Farmacologiche Mario Negri. The procedures for recruitment of subjects, informed consent, data collection, storage and protection (based on anonymous identification code) are in accordance with the current country specific legislations. This was stated in an Institutional Review Board Ethical Statement, ratified and signed by DOXA and each of its European partners.

European survey tool Through collaboration with various work-package leaders of the PPACTE project and internationally renowned experts in the field of tobacco control, we developed a standardized questionnaire (European survey tool), subsequently translated into various country specific languages. DOXA partners provided selected general country specific data, including age and sex specific distribution of the population, the current price of a 20-cigarette pack of Marlboro and of the most popular domestic cigarette brand, and selected economic variables including Gross Domestic Product (GDP) and Purchasing Power Parity (PPP) in the period of the fieldwork. Individual-level data were collected by trained interviewers in the context of a computer assisted personal interview (CAPI). The questionnaire was divided in 5 sections. The first section included questions on demographic, socio-economic and anthropometric characteristics. The second section included information on smoking status, number of cigarettes smoked per day, age at starting and age at stopping, smoking dependence, channels of cigarette distribution and weekly expenditure on tobacco product. A “show your pack” section focused on the latest pack of cigarettes purchased by smokers in order to validate direct questions on smuggling. The fourth

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section included information on perceptions and attitudes towards an increase in cigarette price. For current smokers, this section included the intention to quit and smoking behaviours according to an increase in cigarette price. The last section included information on smokeless tobacco use. Appendix 1 shows the questionnaire used in the present survey (English version). Ever smokers were participants who have smoked 100 or more cigarettes (including manufactured and hand-rolled ones) in their lifetime. Ex-smokers were participants who smoked 100 or more cigarettes (including manufactured and hand- rolled cigarettes) in their lifetime but did not smoke at the time our survey took place. We asked to ever smokers questions which included the age at starting smoking on a regular basis as well as the number of cigarettes (manufactured and hand-rolled cigarettes were considered separately) consumed per day (for daily consumers) or per week (for less than daily consumers). For each country, 2010 per capita GDP based on PPP, in international current dollars ($), was obtained from International Monetary Fund (IMF) databases [70]. For the EU-MS, the Tobacco Control Scale (TCS) scores, updated to 2010 [4], were used to distinguish countries with limited implementation of tobacco control policies (TCS <45) from those with a high implementation policies (countries with TCS ≥45). Albania and Croatia, not included in the EU, were excluded from the TCS stratification analyses. Through Eurostat we obtained the country-specific population aged 15 or older [71]. Table 1a shows details on GDP and TCS and population by study country.

Weight of one hand-rolled cigarette Using data from the “show your pack” section for those smokers smoking hand-rolled cigarettes only, we derived the average grams of hand-rolled tobacco to roll one cigarette. Thus, for each smoker we calculated the number of packs consumed per week by dividing daily expenditure for tobacco products by the cost of the latest pack; this was multiplied by the weight (in grams) per pack, thus obtaining the number of grams consumed per day; this was divided by the number of cigarettes per day, to obtain the weight (in grams) per one hand-rolled cigarette. From all the 313 smokers consuming hand-rolled cigarettes only, we excluded 101 subjects with missing information on weekly expenditure, cost of latest pack, and

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size in grams of the latest pack of hand-rolled cigarettes. We further excluded 7 subjects with an extremely low (<0.3) and 20 smokers with an extremely high (more than 3g) number of grams per cigarette. Therefore we derived the weight of one hand-rolled cigarette using data from 185 smokers of hand-rolled cigarettes.

Tax Evasion Score In order to validate direct questions on smuggling, we created the Tax Evasion Score (TES) using data from the “show your pack” section. TES is a dichotomized variable which is 1 if the latest pack shown by smokers was apparently bought through illicit trades, and 0 otherwise. Thus smokers evading taxes (TES=1) where considered those showing a pack of cigarettes (or hand-rolled tobacco) bought from smugglers (i.e., if Q1e=6) OR with health warnings in foreign language (i.e., if Q1b=2) OR with lack of health warnings (i.e., if Q1b=3) OR with foreign stamp (i.e., if Q1c=2) OR with lack of stamp/duty-free pack (i.e., if Q1c=4), but NOT buying their latest pack over the internet (i.e., if Q1e=3) in other countries (i.e., if Q1e=4) or in duty-free shops (i.e., if Q1e=5).

Statistical methods In the present report, we considered descriptive statistics, including relative frequency (%) and corresponding 95% confidence interval (CI) for categorical variables, and mean and standard deviation (SD), or median and inter-quartile range (IQR) for continuous variables. The comparison between sexes and among countries was carried out using χ2 tests for categorical variables and t-tests for continuous ones. Statistical weights were used to assure representativeness of the population of each country considered in this report. In order to show findings for the overall sample, we applied a weighting factor, with each country contributing in proportion to its population aged 15 years or over. We used the Pearson’s-correlation coefficients (r) to analyze the relation between selected smoking characteristics from the PPACTE survey (i.e., prevalence of current smokers, prevalence of ex-smokers, male-to-female smoking prevalence ratio and current-to-ex smoking prevalence ratio) and the TCS score, the GDP and corresponding smoking obtained in the 2009 Eurobarometer survey [17].

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RESULTS In the present section we show findings from the PPACTE survey, describing various Tables and Figures. Some additional tables, included in the appendices show data in more details.

Smoking prevalence Table 2 provides the distribution of the study population according to smoking habit. Overall, 56.8% of 18,056 participants described themselves as never smokers (49.5% of men and 63.6% of women), 16.0% as ex-smokers (19.9% of men and 12.3% of women) and 27.2% as current smokers (28.2% of men and 21.8% of women). Figure 1a shows a map of the European countries considered in the present survey, coloured according to current cigarette smoking prevalence in both sexes combined (green= relatively low, yellow=intermediate and red=relatively high). Figure 1b shows the percent distribution of the European population according to smoking status, overall and by country, sorted by the prevalence of current smokers. The highest prevalence estimates of current smokers (daily and less than daily combined) were found in Bulgaria (40.9%) and Greece (38.9%); the proportions of smokers were lowest in Italy (22.0%) and Sweden (16.3%). Figure 2 shows the prevalence of current smokers separately in men and women, overall and by country. The prevalence for men ranged between 15.7% (Sweden) and 44.3% (Bulgaria), and that for women between 11.6% (Albania) and 38.1% (Ireland). The male-to-female smoking prevalence ratio (M/F) was 1.27 overall, higher in Albania (3.47) and in Latvia (2.63). In Sweden (0.93), Ireland (0.89) and Spain (0.84) smoking prevalence of women exceeded that of men. Figure 3 shows smoking prevalence by sex, according to age groups. Overall, the highest smoking prevalence was reported among the 25-44 year age group (39.8% of males and 32.0% of females), and the lowest one among the elderly (15.3% of males and 8.6% of females). Except for the young (15-24 years), where smoking prevalence was 26.0% for males and 27.0% for females, in all age groups men were more frequently current smokers than women, with a M/F increasing with age (0.96 for 15- 24, 1.24 for 25-44, 1.27 for 45-64 and 1.79 for ≥65 years). In men, smoking prevalence was systematically higher in poorer (per capita GDP per capita<20,000 $) countries

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(36.0%) than in richer (per capita GDP≥20,000 $) ones (28.9%; p<0.001). However, no significant difference was observed for women, smoking prevalence being 23.1% in poorer and 24.3% in richer countries (p=0.251). M/F was higher in poorer countries (1.56) than in richer ones (1.19). Countries with a TCS <45 showed a higher smoking prevalence in both sexes (37.3% in men and 26.6% in women) as compared to those with a TCS ≥45 (27.9% in men and 23.2% in women). M/F was higher in countries with limited tobacco control activities (1.40) as compared to those with relatively high activities (1.20). Among the young, smoking prevalence was highest in Hungary (49.3% in boys and 34.8% in girls) and in Bulgaria (40.5% in boys and 45.6% in girls), and lowest in Italy (12.8% in boys and 24.5% in girls) and the Czech Republic (21.6% in boys and 15.5% in girls) [see Appendix 4 for further details]. Table 3 shows the relation between selected smoking characteristics from the PPACTE survey and TCS score as well as the GDP and corresponding smoking patterns from the Eurobarometer survey. TCS score was inversely related to M/F (r= -0.61; p = 0.01) and to current-to-ex smoking prevalence ratio (C/E; r= -0.63; p < 0.01) and directly related to prevalence of ex-smokers (r= 0.66; p = 0.01). Prevalence of current smokers (r= 0.73; p < 0.01), prevalence of ex-smokers (r= 0.74; p < 0.01) and C/E (r= 0.75; p < 0.01) from the PPACTE and the Eurobarometer surveys were highly correlated.

Age at quitting and main reason to quit Overall, 16.0% of the survey participants described themselves as ex-smokers (19.9% of men and 12.3% of women). Mean age at quitting was 39.3 years (±14.4) overall, 39.9 (±14.1) among men and 38.4 (±14.7) among women (p=0.01). Age at quitting (unadjusted by age and cohort effects among smokers) was lower in Latvia (26.5 ±4.2), and in Finland (35.4 ±6.7), and higher in Romania (40.8 ±14.0) and Italy (46.0 ±22.1) [see Appendix 5 for further details]. Figure 4 shows the percent distribution of former smokers according to the main reason to quit cigarette smoking. Overall, 27.7% of ex-smokers reported that the most important reason to quit was “illness (any medical condition; present health)”, 24.4% “increased knowledge of the harmful effects of smoking (future health)”, 8.8% “pregnancy/birth of a child”, 7.1% “economic reason (cigarettes too expensive)”, 6.1%

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“physician’s advice”, 5.9% “pressure to quit by partner/relatives”, 0.6% “smoke-free legislation”, 0.5% “employer precluding hiring smokers” and 18.8% “other reason”. The prevalence of ex-smokers reporting as the most important reason to quit “illness (any medical condition)” was lower in Portugal (5.3%) and Spain (14.2%) and higher in Albania (49.2%) and Italy (50.5%). The prevalence of ex-smokers reporting “economic reason (cigarettes too expensive)” as the principal motivation to quit was lower in Spain (0.9%) and Italy (1.3%) and higher in Bulgaria (21.1%) and Portugal (23.3%).

Smoking dependence, cigarette type and age at starting smoking Among current smokers, 13.0% (16.3% of men and 9.0% of women) reported to smoke 25 cigarettes or more per day. Figure 5 shows the number of cigarettes smoked per day (manufactured and hand-rolled) for current smokers, by sex and country. Overall, male smokers smoked an average of 17.0 cigarettes per day, and female smokers 13.9 cigarettes per day. The proportion of hand-rolled cigarettes on total cigarettes smoked was 15.3% in men and 10.8% in women. This proportion was highest in the UK where 46.1% of cigarettes smoked among men were hand-rolled cigarettes. The corresponding percentage in women was 21.4%. The overall reported number of cigarettes per capita per day was 4.2 (5.2 in men and 3.4 in women), highest in Greece (8.9 in both sexes) and Bulgaria (6.3), and lowest in Italy (3.1) and Sweden (2.1). Among men, Greece (10.5) and Albania (9.4) had the highest per capita cigarette consumption per day, and Spain (4.0), the UK (4.0), and Sweden (2.1) had the lowest consumption. Among women the highest per capita number of cigarettes smoked per day was in Greece (7.3) and Ireland (5.8); the lowest was in Latvia (1.8), Finland (1.6) and Albania (1.6) [see Appendix 8 for further details]. Figure 6 shows the distribution of current daily smokers according to how soon after waking-up they smoke their first cigarette. Overall, 19.3% of current daily smokers reported to smoke their first cigarette within 5 minutes after waking-up, 39.8% after 6- 30 minutes, 16.4% after 31-60 minutes and 24.5% after 1 hour. The prevalence for “within 5 minutes” was lower in Spain (11.8%) and Czech Republic (14.0%), and higher in Ireland (34.0%) and Sweden (35.2%). The prevalence for those lighting up the first cigarette “after 1 hour” was lower in Greece (8.1%) and Bulgaria (13.2%), and higher in England (32.8%) and France (35.2%).

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Mean age at starting was 17.9 years (±4.6) overall, 17.5 (±3.9) among men and 18.5 (±5.4) among women (p<0.001). Age at starting was lower in Ireland (16.3 ±1.7), and Hungary (16.9 ±2.1) and Sweden (16.9 ±3.1), and higher in Romania (19.4 ±6.1 ) and Albania (19.4±2.5), and Poland (19.5 ±5.9) [see Appendix 10 for further details]. Age at starting was heterogeneous across countries (p<0.001).

Channels of cigarette distribution Current smokers were asked to report where they purchased their cigarettes over the latest 30 days (legal shops, vending machines and selected other channels). Figure 7 shows the average distribution of purchasing patterns, overall and by specific country, sorted by “smuggling and other countries/duty free”. Overall, 82.0% of current smokers smoked cigarettes “from national legal tobacco shops/legitimate retailer”, 6.1% “from vending machines”, 4.9% “from shops in other countries/duty-free shops”, 3.6% “from an individual selling cigarettes independently at local markets, delivery service, door-to- door, or just in the street” (smuggling), 3.4% “offered by peers” and 0.1% “bought over the internet”. The prevalence of current smokers reporting they smoked cigarettes from other countries or duty-free shops was higher in Austria (12.3%), Finland (13.2%) and France (13.2%). The prevalence of current smokers reporting they smoked smuggled cigarettes was highest in eastern European countries, in particular in Bulgaria (12.2%) and Latvia (25.9%). Prevalence of current smokers purchasing smuggled cigarettes over the latest 30 days (at least 1% of their total cigarette purchase) was 8.4% overall. More than 1 out of 5 current smokers buys smuggled cigarettes in Bulgaria (20.3%), Spain (22.1%), the Czech Republic (34.4%) and Latvia (38.0%) [see Appendix 11 for further details]. Table 4 shows the distribution of current smokers according to purchasing patterns and age group. The young appeared to use internet more frequently as a source of cigarette purchasing. In addition, as compared to other age groups, they appeared to smoke offered cigarettes by peers more often. Table 4 also shows channels of distribution by country for the young.

Weekly expenditure Current smokers of cigarettes spend a mean of 18.6€ (19.4€ for men and 17.7€ for

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women). Countries with the lowest weekly expenditure were Hungary (4.4€) and Albania and Latvia (10.1€). Greece and Ireland have the highest weekly expenditure (26.6€ and 47.5€, respectively). After standardization, mean weekly expenditure on cigarettes for current smokers was 21.3€ (22.4€ for men and 19.8€ for women). Countries with the lowest weekly expenditure were Hungary (6.8€) and the Czech Republic (14.7€), and those with the highest one were Albania (37.3€) and Ireland (37.4€) [see Appendix 12 for further details]. Mean cost for a pack of cigarette or other tobacco products was 4.51€ overall, (4.38€ in men and 4.65€ in women). In both sexes, the country with the highest cost was Ireland (9.97€). Albania (1.90€) and Hungary (1.78€) were the countries with the lowest cost for a pack of cigarettes. After standardization by GDP per capita expressed in purchasing power standards (PPS) per capita in 2010 (based on the EU average=100), the mean cost for a pack of cigarettes or other tobacco product was 4.96€ overall, 4.95€ in men and 4.94€ in women. The standardized cost for a pack of cigarettes was highest in Ireland (7.85€) and Bulgaria (7.89€) and lowest in Czech Republic (3.68€) and Hungary (2.74€) [see Appendix 13 for further details].

Latest pack Overall, 73.9% of current smokers accepted to show to the interviewer the latest purchased pack of cigarettes or hand-rolled tobacco. Participants who did not show the latest pack, gave self-reported information on the latest pack bought. Figure 8 shows the percent distribution of current smokers according to the type of their latest pack of cigarettes, overall and by specific country. Overall, 81.6% of current smokers bought a 20 cigarette pack, 4.3% a 10 cigarette pack, 10.9% hand- rolled tobacco and 3.3% other type of tobacco products. In England we observed the highest proportion of smokers showing a pack of hand-rolled tobacco (31.8% overall, 38.2% in men and 24.9% in women), followed by France (17%) and Finland (14%). Table 5 shows the median and corresponding IQR of the weight of 1 hand-rolled cigarette, overall and in strata of selected covariates. On a total of 185 smokers smoking exclusively hand-rolled cigarettes, the mean weight in grams of 1 hand-rolled cigarette was 0.94 (±0.54), and the median weight was 0.79 grams. The median value decreased to 0.71 g for heavy hand-rolled cigarette smokers.

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Figure 9 shows the percent distribution of current smokers according to the type of health warnings on their latest pack of cigarettes. Overall, 93.1% of current smokers showed a tobacco product with health warnings in the country specific language, 5.7% a product with health warnings in foreign language and 1.1% a pack without health warnings. The prevalence of current smokers showing a pack with health warnings in foreign language was lower in Portugal (0.0%) and Greece (0.3%), and was higher in Austria (12.2%) and particularly in Latvia (26.1%). The prevalence of current smokers showing a pack without health warnings was lower in England, France, Portugal and Sweden (0.0%), and was higher in Latvia (5.2%) and Croatia (8.6%). Figure 10 shows the percent distribution of current smokers according to the type of tax stamp (banderole) on their latest pack of cigarettes. Overall, 89.5% of current smokers showed a product with the tax stamp in the country specific language, 4.5% in a foreign language, 1.7% with a banderole removed or destroyed and 4.4% without the tax stamp or with a duty-free pack. The highest prevalence of current smokers showing a tobacco product with a foreign stamp was in Latvia (26.3%), followed by France (11.0%) and Austria (9.6%). Most often, current smokers showed a pack of cigarettes with a banderole removed or destroyed in Bulgaria (12.3%), followed by Latvia (6.0%) and the Czech Republic (4.2%). The cigarette packs without a stamp or with a duty-free pack were most frequently shown in England (15.2%), followed by Bulgaria (8.3%) and France (7.7%). Figure 11 shows the distribution of current smokers according to where they bought their latest pack of cigarettes, overall and by specific country. Overall, 85.2% of current smokers bought the latest pack of cigarettes “from national legal tobacco shops/legitimate retailers”, 5.5% “from vending machines”, 4.0% “from an individual selling cigarettes independently at local markets, delivery service, door-to-door, or just in the street” (smuggling), 3.7% “from shops in other countries/duty-free shops”, 1.6% “offered by peers” and 0.0% “over the internet”. The prevalence of current smokers reporting they bought the latest pack of cigarettes from other countries or duty-free shops was higher in France (9.2%), Austria (11.9%), and Finland (12.4%). The prevalence of current smokers reporting they bought smuggled cigarettes was higher in Sweden (10.4%), Bulgaria (14.5%) and particularly in Latvia (30.6%). The young used more frequently automatic vending machines as a source for

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cigarettes (Table 6). Figure 12 shows the percent distribution of current smokers according to TES, overall and by specific country. The proportion of TES was 8.1%. The highest prevalence of TES was observed in Latvia (36.4%), followed by Sweden (19.6%) and Bulgaria (18.1%). The countries with the lowest prevalence of TES were Austria (1.0%), Greece (0.8%) and Portugal (0.0%). Figure 13 shows the percent distribution of current smokers according to TES and to smuggling prevalence. The total bar represents the prevalence of TES, overall and in all European countries, while the dark blue bar represents the prevalence of those reporting to have bought their latest pack of cigarettes from smugglers. Thus, the light blue bar represents the difference in prevalence between TES and smuggling.

Attitudes toward an increase in price We asked current smokers as well as non smokers (never and ex-smokers) a question about the attitudes toward a 5% and 20% increase in price of cigarettes. We gave participants the assumption that the additional revenues were allocated to support smoking cessation measures such as free access to anti-smoking centres and free smoking cessation products. Figure 14 shows the distribution of participants by smoking status according to their attitudes towards an increment in cigarette prices by 5%. Overall, 46.2% of non smokers and 22.2% of current smokers were strongly in favour of a 5% increase, 33.0% and 26.4% were moderately in favour, and 10.9% and 19.7% were moderately against. Among non smokers and current smokers respectively, 9.9% and 31.8% were strongly against the increase in cigarette price. Figure 15 shows the same pattern for an increment of 20%. Overall, 45.3% of non smokers and 19.5% of current smokers were strongly in favour, 28.7% and 19.6% were moderately in favour, and 12.9% and 18.5% were moderately against. Among non smokers and current smokers respectively, 13.1% and 42.4% were strongly against a 20% increment in cigarette price.

Perceptions toward an increase in price Several strategies on how to control and limit tobacco use were proposed to all the

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European participants. Figure 16 shows the distribution of the European population according to their perception of effectiveness of free psychological or pharmacological support for smoking cessation, including nicotine replacement therapy (patches, gums, etc) bupropion and varenicline, in order to control and limit tobacco use. Overall, 34.7% of participants (31.4% of current smokers) found this strategy very useful, 38.8% (35.7% of current smokers) moderately useful, 14.3% rather useless and 12.2% completely useless. Figure 17 shows the corresponding estimates with reference to effectiveness of making smoking or cigarette sales illegal. Overall, 16.4% of respondents found this strategy very useful (11.5% of current smokers), 18.6% moderately useful (14.1% of current smokers), 24.2% rather useless and 40.8% completely useless. Figure 18 shows the distribution of the European population according to their perception of effectiveness of pricing policies to control and limit tobacco use. Overall, 24.1% of participants (28.6% of non smokers and 12.3% of current smokers) found this strategy very useful, 30.9% (33.2% of non smokers and 24.6% of current smokers) moderately useful, 23.3% rather useless (21.3% of non smokers and 28.6% of current smokers) and 21.7% completely useless (16.9% of non smokers 34.5% of never smokers and 43.5% of current smokers). Figure 19 shows the corresponding estimates for the effectiveness of smoking ban extensions. Overall, 26.9% of participants (13.9% of current smokers) found this strategy very useful, 29.7% (23.8% of current smokers) moderately useful, 22.0% rather useless and 21.4% completely useless. For comparative purpose, Figure 20 shows the prevalence of non smokers and current smokers who considered useful each of the four tobacco control strategies suggested to them. Overall, 76% of non smokers and 67% of current smokers perceived as moderately to strongly useful providing free smoking cessation support to control tobacco. The corresponding percentages for extension of smoking bans were 64% and 38%, and for pricing policies were 62% and 37%, respectively. Substantial differences in terms of perceptions on effectiveness of pricing policies to control tobacco were evident across countries, the population reporting increases in cigarette price as a useful strategy being 19% in Hungary and over 65% in Finland, Italy and Albania.

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Smoking behaviours according to an increase in cigarette price Figure 21 shows the distribution of current smokers according to their main response to a 20% increase in price of a pack of cigarettes. Overall, 14.2% of current smokers would quit smoking, 30.6% would consume less cigarettes, 21.5% would switch to a different tobacco type (13.7% would switch to cheaper brands, 3.8% to hand-rolled tobacco, 3.5% would switch at least part of their smoking consumption to illegal or smuggled cigarettes, 0.5% would “switch to/use also” smokeless tobacco (including snuff, snus or chewing tobacco), and 33.6% would not change their smoking habit. The lowest prevalence of current smokers that would not change smoking habit was observed in Romania (19.7%) and Spain (24.1%), and the highest one in France (45.8%) and Finland (49.3%). The proportion of current smokers who would switch to smuggled cigarettes was lower in Portugal (0.0%) and Hungary (0.3%) and higher in Bulgaria (11.2%) and Latvia (18.6%). The proportion of current smokers who would switch to smokeless tobacco was higher in Poland (1.4%) and Sweden (2.0%). Figure 22 shows the percent distribution of current smokers having intention to quit smoking within the next 6 months, separately in men and women. Overall, 36.0% of current smokers have intention to quit smoking (34.1% of men and 38.3% of women). The proportion of male current smokers with the intention to quit smoking was lowest in Hungary (7.7%) and the Czech Republic (10.9%), and highest in Spain (56.7%) and Romania (61.0%). The proportion of female current smokers with the intention to quit smoking was lowest in Hungary (10.0%) and Austria (14.7%), and was highest in Poland (54.3%) and Spain (57.6%). Figure 23 shows the percent distribution of current smokers according to the amount of increase in price of cigarettes that would be enough to let them quit smoking completely. Overall, 20.5% of current smokers reported that an increment of ≤20% in cigarette price would influence them to quit smoking completely, 19.1% reported their intention to quit smoking if the price of cigarettes increases between 21% and 40%, 18.2% reported the same intention for price increases ranging between 41% and 60%, 6.3% between 61% and 80%, 22.0% between 81% and 100%, 6.0% of current smokers reported their intention to quit given an increment of three or four times the current price and 7.9% given an increment of five or more times the current price. The prevalence of current smokers who reported that an increment of 20% or less would be

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enough to let them quit smoking completely was lower in Hungary (6.8%) and Latvia (6.9%), and was higher in Ireland (30.0%) and Romania (31.3%). The prevalence of current smokers that reported an increment of five or more times the current price would lead them to quit smoking completely was lower in Hungary (0.5%) and Portugal (4.0%), and was higher in Albania (16.3%) and Latvia (16.5%).

Voluntary smoking-ban at home Figure 24 shows the distribution of the European population according to voluntary smoking ban at home. Overall, 62.2% of participants (72.8% of non smokers and 34.0% of current smokers) banned smoking in their home, 18.9% (14.1% of non smokers and 31.5% of current smokers) allowed their guests to smoke in some specific indoor areas and 18.9% (13.1% of non smokers and 34.6% of current smokers) everywhere. Substantial differences were evident among various countries, total home-ban ranging between 30.6% in Croatia and 93.2% in Finland. The prevalence of voluntary home smoking ban was directly related with TCS (Pearson’s correlation coefficient, r=0.52, p=0.041) and per capita GDP (r=0.56, p=0.015) and inversely related to smoking prevalence (r=-0.53, p=0.024) and C/E (r=-0.62, p=0.007), whereas no relation was evident with M/F (r=-0.01, p=0.964). A geographic gradient was also evident, eastern European countries being those allowing smoking at home more frequently and northern European countries less frequently.

Smokeless tobacco Figure 25 shows percent distribution of the European population aged 15 years or over according to smokeless tobacco use, overall and by specific country. Overall, 2% of the total population consumed smokeless tobacco (including Swedish snus). In Sweden, 12% of the sample reported use of smokeless tobacco (21% in men and 4% in women), and 11% reported regular use (19% in men and 4% in women). Regular use of smokeless tobacco in other countries was relatively infrequent (systematically lower than 2%). Mean age at starting smokeless tobacco use was 23.6 years (± 10.8), based on 204 subjects. Among 153 men, mean age at starting was 22.8 (± 10.0) and among 51 women, mean age was 25.0 (± 12.9). In Sweden, mean age at starting was 23.6 years (±

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9.0) overall, 23.1 (± 9.4) in men and 26.1 (± 6.6) in women [see Appendix 31 for further details]. Table 7 shows the distribution of participants according to smoking status and their use of smokeless tobacco in the total sample and in Sweden, overall and by gender. In the total sample, smoking prevalence was higher in smokeless tobacco users (43%) than in non smokeless tobacco users (27%). In Sweden smoking prevalence among snus users was more frequent (22%) than among non snus users (16%). Moreover, the proportion of ex-smokers among users (36%) was higher than that among non snus users (23%). Out of 315 smokeless tobacco users, (123 from Sweden and 192 from other European countries), 262 (83%; 122 from Sweden and 140 from other European countries) provided information on sales and purchasing pattern. Table 8 shows the distribution of smokeless tobacco users by sales and purchasing pattern overall, for Sweden and for other selected European countries.

COMMENTS Smoking prevalence In the present study we found substantial differences in terms of smoking characteristics across European countries, the smoking prevalence being 27% overall, and ranging from 16% in Sweden to 41% in Bulgaria. With reference to total smoking prevalence, no specific pattern was evident according to geographic area. In fact, we found relatively high smoking rates in northern (37% in Ireland), central (29% in Austria) southern (39% in Greece and 32% in Portugal) and eastern European countries (41% in Bulgaria and 35% in Hungary). Overall, men (30.6%) were more frequently smokers than women (24.1%), although substantial differences in terms of M/F have been observed. For instance, in Sweden, Ireland and Spain smoking prevalence of women exceeded that of men. M/F was higher in countries with a lower per capita GDP (1.56) than those with a higher GDP (1.19), suggesting that high income countries are in a more advanced stage of the tobacco epidemic, as compared to middle income ones [2]. Also with reference to age group, substantial differences have been shown according to gender specific smoking

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prevalence, with a male-to-female prevalence ratio increasing with age. Among the young (15-24 years), smoking prevalence substantially differed across various countries, the smoking prevalence in Italy and the Czech Republic being half that in Hungary and Bulgaria. These estimates are however based on a limited number of subjects (overall, 1430 boys and 1430 girls), and should therefore be interpreted with caution. Advanced tobacco control measures in a population may be a cause, but also a consequence, of a low smoking prevalence. This notwithstanding, we did not find a significant relation between the TCS score [4] and prevalence of current smokers. However, TCS score was strongly and significantly related to the prevalence of ex- smokers and C/E smoking prevalence ratio.

Cigarette consumption and type of cigarettes Scarce information is available on the type of cigarettes smoked (hand-rolled vs manufactured). The use of hand-rolled cigarettes is increasing in various countries since these cigarettes are substantially less expensive than manufactured ones [72]. The proportion of hand-rolled cigarettes to total cigarettes consumed was highest in the UK, where pricing policies have been extensively implemented [4], thus suggesting that a non negligible proportion of smokers switched to hand-rolled cigarettes as a consequence of the increases in price in the UK. However, hand-rolled cigarettes are also frequently used in Finland, Spain and Poland, where cigarette prices are still relatively low [4]. Thus, also cultural habits are major determinants of hand-rolled cigarette use.

Strengths and limitations A limitation of the present study is that the sampling methods used were not identical in various European countries. This difference in sampling methods resulted in a variety of response rates, ranging between 11% and 79%. Strengths of our survey include the representativeness of various samples of the adult population of 18 selected European countries, the European Survey Tool provided by a core of tobacco control experts, the standardized questionnaire in each country with one single definition of current smokers, the face to face interviews which allowed us to validate direct questions on

38

smuggling through the use of a “show your pack” section. Moreover, we found a relatively high consistency between our findings and those from the Eurobarometer survey conducted in 2009 (rsp ranging between 0.73 and 0.75 for various smoking patterns). Moreover, there was a similarity between the results from the present survey conducted in Italy and those found in another Italian survey conducted over the same period on a representative sample of more than 3000 subjects using consistent methodology, the overall prevalence being 20% in the present survey and 21% in the larger one [73]. These facts suggest that the country specific sample size used in our surveys was adequate.

RECOMMENDATIONS • Reduce the variation in prevalence of current smokers in various European countries to uniform towards lower values. • Reduce current smoking prevalence in all (major) European countries below 20% by 2015. • Double by 2015 the number of European countries where ex-smokers are more frequent than current smokers. • Give priority to smoking cessation in men where male prevalence is exceedingly high (i.e., over 35%). • Focus on women in countries where female prevalence is over 25%. • Focus on intervention for smoking cessation in young (25-44 years) and middle aged population (45-64 years). On average, the first group will be 75 years old and the second 95 years old by 2050. Thus, tobacco related deaths will be concentrated in these age groups. • Increase the proportion of former smokers who stop for reasons other than illness, including economic reasons (Figure 4 reflects however cultural attitudes). • In England, as well as in Greece, Albania, Poland, Croatia, Hungary, Austria, Ireland, France, Spain and Finland, define specific interventions towards reduction of hand-rolled cigarettes, including increasing taxation of this type of tobacco.

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• Advise GPs, healthcare providers and other subjects involved in tobacco control to collect information on time between waking-up and the first cigarette smoked, in order to optimize (pharmacological) intervention for smoking cessation. • Implement adequate and effective measures to control smuggling in all countries where smuggling accounts for at least 5% of total cigarettes trades. • Implement measures to reduce cross-border shopping by increasing price where appreciable differences are present. • Cigarette sales over the internet are nowadays negligible in most Europe. Adopt continuous monitoring to avoid its diffusion. • Adopt effective measures to discourage use of cigarette packs without specific local language health warnings and local stamps, i.e., strong administrative measures. • Restrict access to vending machines, particularly for adolescents. • Divulgate to the media and politicians the message that an increase in cigarette price by 5% is supported by almost 50% of current smokers and 80% of non smokers. • Divulgate to the media and politicians the message that an increase in cigarette price by 20% is supported by almost 40% of current smokers and 70% of non smokers. • Divulgate to the media and politicians that there is a widespread appreciation towards the adoption of free psychological and pharmacological support for smoking cessation (overall, over 2/3 of the population, but lower prevalence in central Europe). • Divulgate the surprising message that 39% of non smokers and 26% of current smokers consider useful making smoking cigarette sales illegal, i.e. there is a large minority of the population which would support such a radical measure. • Overall, 37% of current smokers and 62% of non smokers consider useful increasing of price. • Divulgate to the public opinion (in particular to current smokers) the message that there is evidence of a strong inverse association between cigarette price and smoking prevalence and consumption. • Diffuse the message that an appreciable proportion of smokers would consider to

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stop even for moderate increases in price, i.e., about 20% for a 20% increase and 40% for a 40% increase. The proportion of smokers considering to stop is even larger in several countries with baseline higher costs of cigarettes. • Extend voluntary home smoking ban, particularly in Eastern Europe and Greece, where 20 to 40% of the population report no voluntary home smoking ban.

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Table 1a: Sample size overall and by sex, and age range, per capita Gross Domestic Product (GDP) based on Power Purchase Parity (PPP) in current international dollars ($), Tobacco Control Scale (TCS) score updated to 2010, and population aged 15 years or over, in million inhabitants, by country. PPACTE, 2010.

Country Initial Fieldwork dates Sample Size Age GDP TCS Population range 2010 2010 15+ (years) ($) (million) start stop Total Men Women Albania AL 01/07/2010 18/07/2010 1000 508 492 15-80 7,453 NA 2.44 Austria AT 14/06/2010 09/07/2010 1001 433 568 ≥15 39,634 32 7.13 Bulgaria BG 20/05/2010 08/06/2010 1027 494 533 ≥15 12,851 40 6.54 Croatia HR 01/07/2010 15/07/2010 948 439 509 ≥18 17,684 NA 3.75 Czech Republic CZ 29/03/2010 11/04/2010 1000 487 513 ≥15 24,869 34 9.01 England UK 03/06/2010 08/06/2010 1030 472 558 ≥18 34,920 77 42.73 Finland FI 13/04/2010 23/04/2010 962 447 515 18-79 34,585 52 4.46 France FR 27/05/2010 31/05/2010 1029 474 555 ≥15 34,077 55 52.73 Greece EL 07/06/2010 27/06/2010 965 484 481 18-64 28,434 32 9.68 Hungary HU 10/05/2010 04/06/2010 1002 492 510 ≥18 18,738 34 8.54 Ireland IE 05/06/2010 16/06/2010 1008 492 516 ≥15 38,550 69 3.51 Italy IT 15/01/2010 30/01/2010 1005 475 530 ≥15 29,392 47 51.86 Latvia LV 04/06/2010 18/06/2010 1061 486 575 15-74 14,460 44 1.94 Poland PL 14/06/2010 17/06/2010 938 463 475 18-79 18,936 43 32.39 Portugal PT 01/06/2010 29/06/2010 1000 474 526 ≥15 23,223 43 9.02 Romania RO 10/06/2010 16/06/2010 1080 531 549 ≥15 11,860 45 18.21 Spain ES 07/07/2010 14/07/2010 1000 491 509 ≥15 29,742 46 39.12 Sweden SE 06/06/2010 09/06/2010 1000 511 489 ≥15 38,031 51 7.79

Total TOT 15/01/2010 18/07/2010 18056 8653 9403 ≥15 - - 310.86

NA: not available

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Table 1b: Information about CAPI survey methods and characteristics in 18 European countries. PPACTE, 2010.

Country Initial Fieldwork dates Response Sample Age Sampling method Representativeness Weight rate (%) size range factor (years) start stop Albania AL 01/07/2010 18/07/2010 78 1000 15-80 Multi-stage random sampling No Austria AT 14/06/2010 09/07/2010 NA 1001 ≥15 Quota method Age, sex, habitat, SES Yes Bulgaria BG 20/05/2010 08/06/2010 74 1027 ≥15 Stratified random sampling No Croatia HR 01/07/2010 15/07/2010 35 948 ≥18 Multi-stage random sampling Yes Czech Stratified random sampling CZ 29/03/2010 11/04/2010 25 1000 ≥15 Age, sex, habitat No Republic with quota support England UK 03/06/2010 08/06/2010 NA 1030 ≥18 Quota method Age, sex, SES Yes Finland FI 13/04/2010 23/04/2010 30 962 18-79 Quota method Age, sex, habitat Yes France FR 27/05/2010 31/05/2010 NA 1029 ≥15 Quota method Age, sex, habitat, SES Yes Greece EL 07/06/2010 27/06/2010 11 965 18-64 Simple random sampling Age, sex, SES Yes Hungary HU 10/05/2010 04/06/2010 79 1002 ≥18 Multi-stage random sampling No Ireland IE 05/06/2010 16/06/2010 67 1008 ≥15 Quota method Age, sex, habitat, SES Yes Italy IT 15/01/2010 30/01/2010 42 1005 ≥15 Multi-stage random sampling Age, sex, habitat, SES Yes Latvia LV 04/06/2010 18/06/2010 45 1061 15-74 Stratified random sampling Yes Poland PL 14/06/2010 17/06/2010 40 938 18-79 Multi-stage random sampling Yes Portugal PT 01/06/2010 29/06/2010 NA 1000 ≥15 NA Yes Romania RO 10/06/2010 16/06/2010 54 1080 ≥15 Multi-stage random sampling Yes Random route with quota Spain ES 07/07/2010 14/07/2010 15 1000 ≥15 Age, sex, habitat Yes sampling Units: different locations in Sweden SE 06/06/2010 09/06/2010 NA 1000 ≥15 Cluster sampling No urban cities

Total TOT 15/01/2010 18/07/2010 - 18056 ≥15

NA: not available; “habitat”: geographic area and/or size of municipality; SES: socio-economic status

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Table 2: Percent (%) distribution and corresponding 95% confidence intervals (CI) of the population aged 15 years or over, according to smoking habit, overall and by sex, in 18 European countries*. PPACTE, 2010.

Total % Men % Women % Smoking status (95% CI) (95% CI) (95% CI)

Never smokers 56.8 (56.1-57.5) 49.5 (48.5-50.5) 63.6 (62.6-64.6) Ex-smokers 16.0 (15.5-16.5) 19.9 (19.1-20.7) 12.3 (11.6-13.0) Current smokers 27.2 (26.6-27.8) 30.6 (29.6-31.6) 24.1 (23.2-25.0) Daily smokers 24.9 (24.3-25.5) 28.2 (27.3-29.1) 21.8 (21.0-22.6) Less than daily smokers 2.3 (2.1-2.5) 2.4 (2.1-2.7) 2.3 (2.0-2.6) Cigarettes per day § < 15 12.0 (11.5-12.5) 11.7 (11.0-12.4) 12.3 (11.6-13.0) 15-24 11.2 (10.7-11.7) 13.5 (12.8-14.2) 9.1 (8.5-9.7) ≥ 25 3.5 (3.2-3.8) 4.9 (4.4-5.4) 2.1 (1.9-2.5) Total number of participants 18,056 8,653 9,403

§ The sum does not add up to the total of current smokers because of missing values * Total was computed weighting each country in proportion to the country specific population aged 15 years or over.

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Table 3: Pearson’s correlation coefficients (r) and 95% confidence interval (CI) between country specific tobacco control scale (TCS) score, Gross Domestic Product (GDP) and prevalence of current smokers in Eurobarometer survey of 2009, and prevalence of smoking (current and ex-smokers) and other indicators.

TCS score° GDP Eurobarometer°,* European survey r (95% CI) r (95% CI) r (95% CI) Prevalence of current smokers^ -0.32 (-0.70; 0.21) -0.19 (-0.61; 0.30) 0.73 (0.37; 0.90) p value 0.22 0.44 <0.01 Prevalence of ex-smokers 0.60 (0.15; 0.83) 0.66 (0.28; 0.86) 0.74 (0.38; 0.90) p value 0.01 <0.01 <0.01 Male-to-female smoking prevalence ratio^ -0.31 (-0.70; 0.22) -0.61 (-0.84; -0.20) p value 0.24 0.01 Current-to-ex smoking prevalence ratio^ -0.58 (-0.84; -0.12) -0.63 (-0.85; -0.23) 0.75 (0.40; 0.91) p value 0.01 <0.01 <0.01

° Based on 16 countries, only (Albania and Croatia excluded). * Correlation coefficients estimated between percent prevalence estimates of various smoking patterns from the PPACTE survey with corresponding smoking patterns from Eurobarometer [17]. ^ Daily

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Table 4: Percent (%) distribution of current smokers according to channel of distribution (over the previous 30 days) and age group. Source of distribution by country for the young (15-24 years). PPACTE, 2010 Channel of distribution (%) Legal shops Vending Internet Other Duty-free Smuggling Offered Country Initials (%) machines countries shop Age group (years) 15-24 81.0 7.2 0.4 2.7 1.3 3.4 4.1 25-44 81.4 7.0 0.1 3.5 1.3 3.3 3.4 45-64 82.3 4.4 0.1 3.7 2.3 4.4 2.8 ≥65 86.2 4.8 0.0 1.1 0.7 2.5 4.7 Total* TOT 82.0 6.1 0.1 3.3 1.6 3.6 3.4 Young (15-24 years) Albania AL 90.8 0.1 0.0 0.0 1.1 1.3 6.7 Austria AT 56.8 22.1 0.0 0.8 3.6 0.0 16.7 Bulgaria BG 77.1 0.0 0.0 0.2 2.0 13.5 7.3 Croatia HR 87.9 0.0 0.0 3.9 0.0 3.9 4.2 Czech Republic CZ 74.3 2.9 1.6 0.3 0.1 9.9 11.0 England UK 99.5 0.4 0.0 0.0 0.2 0.0 0.0 Finland FI 85.4 0.0 0.0 1.8 8.6 1.0 3.2 France FR 84.0 0.0 0.0 11.5 0.1 0.6 3.8 Greece EL 96.4 0.0 0.0 0.1 0.2 0.0 3.3 Hungary HU 93.3 5.4 0.0 0.0 0.0 0.0 1.3 Ireland IE 81.2 6.1 0.0 0.6 0.8 5.3 6.1 Italy IT 84.5 10.3 0.0 0.0 3.6 0.0 1.6 Latvia LV 60.3 0.0 0.0 0.4 4.2 24.5 10.5 Poland PL 87.6 0.0 0.0 0.0 0.0 8.2 4.2 Portugal PT 37.3 57.1 0.0 0.0 0.0 0.0 5.6 Romania RO 90.8 0.0 0.0 0.0 0.1 6.5 2.6 Spain ES 47.3 23.9 3.3 2.4 5.9 9.6 7.8 Sweden SE 86.7 3.7 0.0 0.3 0.0 3.3 6.0

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Table 5: Median weight in grams of 1 hand-rolled cigarette, and corresponding inter- quartile range (IQR), overall and by country, sex, age, education and smoking intensity, among hand-rolled cigarette smokers. PPACTE, 2010

N of Median weight in grams smokers (IQR) TOTAL 185 0.79 (0.56-1.22)

Country England 37 0.50 (0.38-0.71) Finland 28 1.11 (0.76-1.38) France 32 0.89 (0.80-1.39) Greece 37 0.59 (0.48-0.89) Ireland 12 0.54 (0.47-0.85) Spain 13 1.15 (0.75-1.63) Other countries 26 1.04 (0.71-1.70)

Sex Males 130 0.75 (0.56-1.29) Females 55 0.86 (0.48-1.19)

Age group (years) <25 32 0.70 (0.55-0.93) 25-44 79 0.86 (0.56-1.38) 45-64 67 0.76 (0.58-1.29) ≥65 7 0.57 (0.36-1.19)

Education Low 49 0.86 (0.58-1.30) Medium 77 0.72 (0.48-1.19) High 59 0.88 (0.56-1.22)

Cigarette consumption <20 cig/day 111 0.86 (0.56-1.29) ≥20 cig/day 74 0.71 (0.56-1.14)

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Table 6: Percent (%) distribution of current smokers according to channel of distribution of the latest pack by age group. PPACTE, 2010

Age group (years) Channel of 15-24 25-44 45-64 ≥65 Total distributions (%) (%) (%) (%) Legal shops 85.2 84.1 84.9 85.2 88.1 Vending machines 5.5 8.2 6.5 3.3 4.1 Internet 0.0 0.0 0.0 0.1 0.0 Other countries 2.6 1.7 3.1 2.5 1.7 duty-free 1.1 0.5 1.0 1.6 0.1 Smuggling 4.0 3.5 3.3 5.4 2.8 Offered 1.6 2.0 1.1 1.9 3.1

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Table 7: Distribution of participants according to smoking status and their use of smokeless tobacco in the total sample and in Sweden, overall and by gender. PPACTE, 2010.

Smokeless tobacco (%) Total sample Sweden Smoking status Non users Users Non users Users Total (N) 17741 315 877 123 Never 57.0 42.7 62.0 42.3 Ex 16.1 14.6 22.5 35.8 Current 26.9 42.7 15.5 21.9

Men (N) 8451 202 405 106 Never 49.8 35.2 64.5 41.5 Ex 19.9 22.1 21.7 35.9 Current 30.3 47.7 13.8 22.6

Women (N) 9290 113 472 17 Never 63.9 50.6 60.0 47.0 Ex 12.4 6.8 23.1 35.3 Current 23.7 42.6 16.9 17.7

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Table 8: Percent distribution (%) of smokeless tobacco users by sales and distribution channels of smokeless tobacco, overall, for Sweden and for other selected European countries. PPACTE, 2010.

Total*,# Sweden Non-Swedish countries# Channels of distribution (%) (%) (%) National legal tobacco shops 78.7 92.6 74.5 Internet 8.5 0.0 11.0 Shops in other countries 8.3 0.0 10.8 Duty-free shops 5.3 1.6 6.4 Smuggling 2.6 3.3 2.3 Offered 3.3 2.5 3.5

* Total was computed weighting each country in proportion to the country specific population aged 15 years or over. # The sum exceeds 100% because of 9 subjects reporting more than one choice. For Sweden one single choice was allowed.

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Figure 1a: European countries included in the European survey, coloured according to current cigarette smoking prevalence in men and women combined. PPACTE, 2010. [see Appendix 2 for further details]

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Figure 1b: Percent (%) distribution of the European population according to smoking status overall* and by country, sorted by the prevalence of current smokers (descending order). PPACTE, 2010. [see Appendix 2 for further details]

* Total was computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 2: Sex-specific prevalence of current smokers, overall* and by country, sorted by the prevalence of current smokers in both sexes (descending order). PPACTE, 2010. [see Appendix 3 for further details]

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 3: Sex-specific percent prevalence of current smokers, overall* and according to age group, in the total sample and in strata of per capita GDP based on PPP, and TCS 2010. PPACTE, 2010 [see Appendix 4 for further details].

TOTAL

Men Women

Men Women * Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 4: Percent distribution among ex-smokers according to the main reason to quit, overall* and by specific country, sorted by the prevalence of those reporting “Illness (any medical condition)” as the main reason to quit (descending order). PPACTE, 2010 [see Appendix 6 for further details].

* Computed weighting each country in proportion to the country specific population aged 15 years or over. “Other reason” includes “pressure by partner or relatives”, “smoke-free legislation” “work reason” and “other reasons”; “Physicians’ advice” includes “physician’s advice” and “pregnancy or birth of a child”.

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Figure 5: Number of cigarettes smoked per day (manufactured and hand-rolled) among current smokers separately in men and women, overall* and by specific country, sorted by the consumption of cigarettes among current smokers in both sexes (descending order). PPACTE, 2010 [see Appendix 7 for further details].

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 6: Percent distribution (%) of current daily smokers according to how soon after waking-up they smoke the first cigarette, overall* and by specific country, sorted by “within 5 minutes” (descending order). PPACTE, 2010 [see Appendix 9 for further details].

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 7: Percent (%) distribution of current smokers according to where they bought their packs of cigarettes during the last 30 days, overall* and by specific country, sorted by legal shops, including vending machines (ascending order). PPACTE, 2010 [see Appendix 11 for further details].

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 8: Percent (%) distribution of current smokers according to the type of their latest pack of cigarettes, overall* and by specific country, sorted by “20 cigarette pack” (ascending order). PPACTE, 2010 [see Appendix 14 for further details].

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 9: Percent (%) distribution of current smokers according to the type of health warnings on their latest pack of cigarettes, overall* and by specific country, sorted by “local language” (ascending order). PPACTE, 2010 [see Appendix 15 for further details].

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 10: Percent (%) distribution of current smokers according to the type of tax stamp (banderole) on their latest pack of cigarettes, overall* and by specific country, sorted by “local stamp” (ascending order). PPACTE, 2010 [see Appendix 16 for further details].

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 11: Percent (%) distribution of current smokers according to where they bought their latest packs of cigarettes, overall* and by specific country, sorted by legal shops, including vending machines (ascending order). PPACTE, 2010 [see Appendix 17 for further details].

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 12: Percent (%) distribution of current smokers according to the Tax Evasion Score (TES), overall and by specific country, sorted by TES (descending order). PPACTE, 2010.

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 13: Percent (%) distribution of current smokers according to Tax Evasion Score (TES; total bar), and smuggling (dark blue bar), overall and by specific country, sorted by TES (descending order). PPACTE, 2010.

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 14: Percent (%) distribution of the European population by smoking status according to its attitudes toward an increment in cigarettes prices by 5%, overall* and by specific country, sorted by prevalence of participants reporting a strong or moderate support (ascending order). PPACTE, 2010 [see Appendix 18 and 19 for further details].

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 15: Percent (%) distribution of European population by smoking status according to its attitudes toward an increment in cigarettes prices by 20%, overall* and by specific country, sorted by prevalence of participants reporting a strong or moderate support (ascending order). PPACTE, 2010 [see Appendix 20 and 21 for further details]

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 16: Percent (%) distribution of the European population according to its perception of effectiveness of free psychological or pharmacological support for smoking cessation, including nicotine replacement therapy (patches, gums, etc) bupropion and varenicline, in order to control and limit tobacco use, overall* and by specific country, sorted by prevalence of subjects considering the tobacco control strategy useful (ascending order). PPACTE, 2010 [see Appendix 22 for further details].

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 17: Percent (%) distribution of the European population according to its perception of effectiveness of making smoking or cigarette sales illegal, in order to control and limit tobacco use, overall* and by specific country, sorted by prevalence of subjects considering useful the tobacco control strategy (ascending order). PPACTE, 2010 [see Appendix 23 for further details]

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 18: Percent (%) distribution of the European population according to their perception of effectiveness of raising the price of cigarettes, in order to control and limit tobacco use, overall* and by specific country, sorted by prevalence of subjects considering useful the tobacco control strategy (ascending order). PPACTE, 2010 [see Appendix 24 for further details].

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 19: Percent (%) distribution of the European population according to their perception of effectiveness of extension of smoking bans, in order to control and limit tobacco use, overall* and by specific country, sorted by prevalence of subjects considering useful the tobacco control strategy (ascending order). PPACTE, 2010 [see Appendix 25 for further details].

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 20: Prevalence of non smokers and current smokers considering useful (very and quite combined) each of the four tobacco control strategies considered. PPACTE, 2010.

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 21: Percent (%) distribution of current smokers according to their main response to a 20% increase in price of a pack of cigarettes, overall* and by specific country, sorted by prevalence of participants answering “I would not change my smoking habit” (descending order). PPACTE, 2010 [see Appendix 26 for further details].

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 22: Percent (%) distribution of current smokers that have intention to quit smoking within the next 6 months separately in men and women, overall* and by specific country, sorted by prevalence of participants answering “Yes, I want quit” in men and women combined (ascending order). PPACTE, 2010 [see Appendix 27 for further details].

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 23: Percent (%) distribution of current smokers according to the amount of increase in price of cigarettes to let them quit smoking completely, overall* and by specific country, sorted by prevalence of participants quitting for 20% increase or less” (ascending order) PPACTE, 2010 [see Appendix 28 for further details].

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 24: Percent (%) distribution of the European population according to voluntary smoking ban in their home, overall* and by specific country, sorted by prevalence of participant reporting a total smoking ban at home (ascending order). PPACTE, 2010 [see Appendix 29 for further details].

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Figure 25: Sex specific percent distribution (%) of the European population aged 15 years or over according to smokeless tobacco use, overall* and by specific country. PPACTE, 2010 [see Appendix 30 for further details].

*Total was computed weighting each country in proportion to the country specific population aged 15 years or over.

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LIST OF APPENDICES

Appendix 1: Questionnaire in English language.

Appendix 2: Percent (%) distribution of the European population according to smoking status, overall and by country. PPACTE, 2010.

Appendix 3: Percent prevalence (%) of current smokers separately in men and women, overall and by country. PPACTE, 2010.

Appendix 4: Percentage (%) of current smokers, separately in men and women, according to age group, overall and by country. PPACTE, 2010.

Appendix 5: Mean age at quitting smoking according to country, overall and by sex. PPACTE, 2010.

Appendix 6: Percent (%) distribution of ex-smokers according to the reason that made them decide to quit cigarette smoking, overall and by country. PPACTE, 2010.

Appendix 7: Mean number of cigarettes smoked per day (manufactured and hand-rolled combined) among current smokers separately in men and women, overall and by country. PPACTE, 2010.

Appendix 8: Per capita number of cigarettes (manufactured and hand-rolled combined) according to country, overall and by sex. PPACTE, 2010.

Appendix 9: Percent (%) distribution of daily smokers, separately current and ex-smokers, according to how soon after they wake up they smoke their first cigarette, overall and by country. PPACTE, 2010.

Appendix 10: Mean age at starting smoking regularly according to country, overall and by sex. PPACTE, 2010.

Appendix 11: Percent (%) distribution of current smokers according to where they bought their packs of cigarettes during the last 30 days, overall and by country. PPACTE, 2010.

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Appendix 12: Mean weekly expenditure for a pack of cigarette or any tobacco products, overall and by sex. PPACTE, 2010.

Appendix 13: Mean cost of a pack of cigarette or any tobacco products, overall and by sex. PPACTE, 2010.

Appendix 14: Percent (%) distribution of current smokers according to the type of their latest pack of cigarettes, overall and by country. PPACTE, 2010.

Appendix 15: Percent (%) distribution of current smokers according to health warnings on their latest pack of cigarettes, overall and by country. PPACTE, 2010.

Appendix 16: Percent (%) distribution of current smokers according to the tax stamp (banderole) on their latest pack of cigarettes, overall and by country. PPACTE, 2010.

Appendix 17: Percent (%) distribution of current smokers according to where they bought their latest pack of cigarettes, overall and by country. PPACTE, 2010.

Appendix 18: Percent (%) distribution of current smokers according to their attitudes toward an increment in cigarettes prices by 5%, overall and by country. PPACTE, 2010.

Appendix 19: Percent (%) distribution of non smokers (never and ex-smokers combined)^ according to their attitudes toward an increment in cigarettes prices by 5%, overall and by country. PPACTE, 2010.

Appendix 20: Percent (%) distribution of current smokers according to their attitudes toward an increment in cigarettes prices by 20%, overall and by country. PPACTE, 2010.

Appendix 21: Percent (%) distribution of non smokers (never and ex-smokers combined) according to their attitudes toward an increment in cigarettes prices by 20%, overall and by country. PPACTE, 2010.

Appendix 22: Percent (%) distribution of the European population according to their perception

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of effectiveness of free psychological or pharmacological support for smoking cessation, including nicotine replacement therapy (patches, gums, etc) bupropion and varenicline, in order to control and limit tobacco use, overall and by country. PPACTE, 2010.

Appendix 23: Percent (%) distribution of the European population according to their perception of effectiveness of making smoking or cigarette sales illegal, in order to control and limit tobacco use, overall and by country. PPACTE, 2010.

Appendix 24: Percent (%) distribution of the European population according to their perception of effectiveness of raising the price of cigarettes, in order to control and limit tobacco use, overall and by country. PPACTE, 2010.

Appendix 25: Percent (%) distribution of the European population according to their perception of effectiveness of extension of smoking bans, in order to control and limit tobacco use, overall and by country. PPACTE, 2010.

Appendix 26: Percent (%) distribution of current smokers according to their response to a 20% increase in price of a pack of cigarettes, overall and by country. PPACTE, 2010.

Appendix 27: Percent (%) distribution of current smokers according to their intention to quit smoking within the next 6 months separately in men and women, overall and by country. PPACTE, 2010.

Appendix 28: Percent (%) distribution of current smokers according to how much the current cigarette price should be raised to make them quit smoking completely, overall and by country. PPACTE, 2010.

Appendix 29: Percent (%) distribution of the European population according to where people can smoke at their home, overall and by country. PPACTE, 2010.

Appendix 30: Percent distribution (%), overall* and by country, of the European population aged 15 years or over, according to current use of smokeless tobacco, overall and by gender. PPACTE, 2010.

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Appendix 31: Mean age at starting using smokeless tobacco according to country, overall and by sex. PPACTE, 2010.

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Appendix 1: Questionnaire in English language

DATA PROVIDED BY DOXA PARTNERS.

For each country: • Country population:

TOTAL AGE GROUP SEX 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Men Women

• Current price for a 20 cigarette pack of Marlboro; corresponding Nicotine and Tar contents.

• Current price for a 20 cigarette pack of the most popular domestic brand; corresponding Nicotine and Tar contents.

• Gross Domestic Product (GDP) and Power Purchase Parity (PPP)

• Local currency (conversion rate to €)

• Response rate

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SECTION A. Socio-economic and demographic characteristics:

A1. Age (years) |___|___|

A2. Sex |___| (M = Male, F = Female)

a) Education (years) |___|___| b) Levels of education (low – medium - high)

A3. Geographic area (Nielsen region)

A4. Income (5 levels)

A5. Your height |___|___|___| cm

A6. Your weight |___|___|___| Kg

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SECTION B. Tobacco:

B1. Have you smoked 100 cigarettes (including hand-rolled cigarettes) or more in your lifetime? - No 1 →→→ SKIP TO SECTION C - Yes 2

B2. Do you currently smoke cigarettes (including hand-rolled cigarettes)? - No 1 - Yes 2 →→→ SKIP TO QUESTION B5

(To ex smokers only - code 1 at B2) B3. How old were you when you quit cigarette smoking? |___|___| (if he/she quit smoking less than 1 year ago, write 98; if he/she does not answer, write 99)

(To ex smokers only - code 1 at B2) B4. What was the most important reason that made you decide to quit cigarette smoking? (do not read the answers – only one answer) → Illness (any medical condition) 1 → Physician’s advice 2 → Increased knowledge of the harmful effects of smoking 3 → Smoke-free legislation 4 → Pregnancy/birth of a child 5 → Economic reasons (cigarettes too expensive) 6 → Pressure to quit by partner/relatives 7 → Employer precluding hiring smokers 8 → Other reason 9 → (He/she does not know/ He/she does not answer) 0

(To smokers and ex smokers only - code 2 at B1) B5. Do (or did) you smoke cigarettes (including hand-rolled cigarettes) on a daily basis, or less than daily? → Daily 1 Manufactured cigarettes/day |___|___| Hand-rolled cigarettes/day |___|___| → Less than daily 2 →→→ SKIP TO QUESTION B7 Manufactured cigarettes/week |___|___| Hand-rolled cigarettes/week |___|___| (if none, write 00; if he/she does not answer, write 99)

(Only if code 1 at B5) B6. How soon after you wake up do (or did) you smoke your first cigarette? → Within 5 minutes 3 → 6-30 minutes 2 → 31-60 minutes 1 → After 1 hour 0

(To smokers and ex smokers only - code 2 at B1) B7. How old were you when you first started smoking regularly? |___|___| (if he/she does not answer, write 99 - if never started smoking regularly, write 98)

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(Ask questions B8-B13 to current smokers only - code 2 at B2) B8. Think about the total number of cigarettes you used/had during the last 30 days. As a percentage, how many of them did you buy from the places below or were offered by peers? SHOW CARD (if the interviewee does not buy cigarettes, write “000” in the first six fields and “100” in the last field) 1. Cigarettes from national legal tobacco shops / legitimate retailers (full price) [UK, Spain ] |___|___|___| % 2. Cigarettes from vending machines |___|___|___| % 3. Cigarettes bought over the internet |___|___|___| % 4. Cigarettes from shops in other countries |___|___|___| % 5. Cigarettes from duty-free shops |___|___|___| % 6. Cigarettes from an individual selling cigarettes independently at local markets, delivery service, door-to-door, or just in the street, or cheap cigarettes from legitimate retailers [UK, Spain] |___|___|___| % 7. Cigarettes offered by peers |___|___|___| %

B9. How much do you spend on tobacco products weekly, for your personal use? |___|___|___|.|___|___| € (or local currency) (if he/she does not answer, write 999.99)

B10. Please, could you show me the latest pack of cigarettes or hand rolling tobacco that you bought? → No 1 → Yes 2

INTERVIEWER: COLLECT ALL THE FOLLOWING INFORMATION FROM THE PACK. IF IT IS NOT POSSIBLE TO SEE THE LATEST PACK BOUGHT, THEN ASK THE INTERVIEWEE TO PROVIDE THE INFORMATION REQUIRED If you do not have it with you, could you remember the following information on your last pack of cigarettes or hand rolling tobacco?

a) Type of pack: 20 cigarette pack 1 10 cigarette pack 2 Hand-rolling tobacco 3 Grams: |___|___|___| Other, i.e. ______4

b) Health warnings → Health warnings in [country specific] language 1 → Health warnings in foreign language 2 → Lack of health warnings 3

c) Tax stamp (banderole) → [Country specific] stamp 1 → Foreign stamp 2 What country? ______→ Stamp removed or destroyed 3 → Lack of stamp/Duty-free pack 4

d) How much did you pay for it? |___|___|.|___|___| € (or local currency) (if he/she does not answer write 99)

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e) Where did you buy it? → National legal tobacco shops / legitimate retailers (full price) [UK, Spain] 1 → Vending machines 2 → Internet 3 → Shops in other countries 4 → Duty-free shops 5 → Individual selling cigarettes independently at local markets, delivery service, door-to-door, or just in the street, or cheap cigarettes from legitimate retailers [UK, Spain] 6 → Offered 7

B11. Considering the price of your latest pack of cigarettes or hand rolling tobacco, let’s assume that it will increase by 20%, i.e. approximately of [0.2 × B10d – if B10d is missing use approximately the current price for a 20 cigarette pack (of Marlboro)]. How would you respond to that increase? (read the answers – only one answer) → You would quit smoking 1 → You would consume less cigarettes 2 → You would switch to/use also smokeless tobacco (including snuff, snus or chewing tobacco) 3 → You would switch to/use also illegal or smuggled cigarettes 4 → You would switch to hand-rolled cigarettes 5 → You would switch to cheaper brands 6 → You would not change your smoking habit 7 → (He/she does not know/ He/she does not answer) 0

B12. Do you currently have an intention to quit smoking within the next 6 months? → No 1 → Yes 2 → (He/she does not know/ He/she does not answer) 0

B13. How much should the current cigarette price be raised to make you quit smoking completely? (do not read the answer – only one answer) → 20% or less 1 → 21%-40% 2 → 41%-60% 3 → 61%-80% 4 → 81%-100% (two times the current price) 5 → three/four times the current price 6 → five or more times the current price 7 → (He/she does not know/ He/she does not answer) 0

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SECTION C. Attitudes and Behaviours:

QUESTION C1 HAS A DIFFERENT WORDING FOR CURRENT SMOKERS (C1a) AND FOR NEVER OR EX SMOKERS (C1b)

(For current smokers - code 2 at B2) C1a. Please try now to assume an increase in price of the last pack of cigarette (or tobacco) you bought of 5%, that is approximately (insert the amount corresponding to 5% of the value inserted at question 10d; if this is missing then insert the amount corresponding to 5% of the price of a Marlboro in your country) or of 20%, that is approximately (insert the amount corresponding to 20% of the value inserted at question 10d; if this is missing then insert the amount corresponding to 20% of the price of a Marlboro in your country). If the revenue from these increases were allocated to support smoking cessation measures (i.e. free access to antismoking centers, free smoking cessation products, etc.) would you be in favour or against these increases? How strongly?

(For never or ex-smokers - code 1 at B1 or code 1 at B2) C1b. Please try now to assume an increase in price of cigarettes (or tobacco) of 5%, that is approximately (insert the amount corresponding to 5% of the price of a Marlboro in your country) or of 20% that is approximately (insert the amount corresponding to 20% of the price of a Marlboro in your country). If the revenue from these increases were allocated to support smoking cessation measures (i.e. free access to antismoking centers, free smoking cessation products, etc.) would you be in favour or against these increases? How strongly? 5% 20% → Strongly in favour 1 1 → Moderately in favour 2 2 → Moderately against 3 3 → Strongly against 4 4 → (He/she does not know/ He/she does not answer) 0 0

(To all) C2. To control and limit tobacco use, the government or the national political decision-makers could adopt several strategies. How useful do you assess each one?

He/she does Very Quite Rather Completely not know/ useful useful useless useless He/she does not answer Free psychological or pharmacological support for smoking cessation, including nicotine replacement 1 2 3 4 0 therapy (patches, gums, etc) bupropion and varenicline

Making smoking or cigarette sales illegal 1 2 3 4 0

Raising the price of cigarette 1 2 3 4 0

Extent of smoking bans 1 2 3 4 0

(To all) C3. At your home, where can people (including anyone living in the household and guests) smoke? 90

(read the answers – only one answer) → Everywhere 1 → In some specific indoor areas (e.g. in the kitchen, in the bathroom) 2 → Only outside 3

SECTION D. Smokeless tobacco

(To all) D1. Do you currently use any smokeless tobacco (including snuff, snus or chewing tobacco)? → No 1 ! thanks and close → Yes 2 ! How old were you when you first started using smokeless tobacco regularly? |___|___| (if he/she does not answer, write 99 - if never started using regularly, write 98)

.... (If code 2 at D1) D2. Where do you buy it? → National legal tobacco shops / legitimate retailers (full price) [UK] 1 → Internet 2 → Shops in other countries 3 → Duty-free shops 4 → Individual selling cigarettes independently at local markets, delivery service, door-to-door, or just in the street, or cheap cigarettes from legitimate retailers [UK] 5 → Offered by peers 6 → (He/she does not know/ He/she does not answer) 0

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Appendix 2: Percent (%) distribution of the European population according to smoking status, overall and by country. PPACTE, 2010

Smoking habit Daily Less than Ex- Never Country Initials smokers daily smokers smokers (%) Smokers (%) (%) (%) Albania AL 23.9 2.2 6.1 67.8 Austria AT 28.0 2.5 15.5 54.1 Bulgaria BG 39.8 1.1 15.4 43.7 Croatia HR 25.4 1.2 14.6 58.8 Czech Republic CZ 26.5 2.6 12.1 58.8 England UK 22.8 2.1 24.1 51.1 Finland FI 22.8 3.4 27.3 46.4 France FR 25.3 2.3 20.6 51.9 Greece EL 37.9 0.9 11.5 49.6 Hungary HU 34.4 1.1 9.2 55.3 Ireland IE 34.2 1.8 16.8 47.2 Italy IT 20.6 1.4 10.7 67.3 Latvia LV 27.1 1.7 14.2 57.0 Poland PL 23.8 4.2 8.2 63.9 Portugal PT 32.0 0.4 15.2 52.4 Romania RO 24.8 1.2 12.0 62.0 Spain ES 24.6 4.0 18.4 53.0 Sweden SE 14.2 2.1 24.1 59.6

Total* TOT 24.9 2.3 16.0 56.8

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Appendix 3: Percent prevalence (%) of current smokers separately in men and women, overall and by country. PPACTE, 2010

Percent prevalence (%) of current smokers MEN WOMEN Daily Less than Daily Less than Country Initials smokers daily smokers daily Smokers Smokers Albania AL 37.6 2.6 9.8 1.8 Austria AT 34.3 3.3 22.1 1.7 Bulgaria BG 43.5 0.8 36.4 1.3 Croatia HR 30.9 0.5 20.7 1.9 Czech Republic CZ 32.9 3.1 20.5 2.1 England UK 23.4 3.1 22.1 1.3 Finland FI 31.4 2.4 14.4 4.5 France FR 28.7 2.2 22.1 2.3 Greece EL 43.0 0.7 32.8 1.2 Hungary HU 41.3 1.4 27.8 0.8 Ireland IE 32.8 1.0 35.6 2.5 Italy IT 24.9 0.9 16.6 1.9 Latvia LV 40.6 2.3 15.2 1.1 Poland PL 29.3 3.7 18.4 4.7 Portugal PT 35.2 0.5 29.0 0.4 Romania RO 33.4 1.5 16.7 1.0 Spain ES 21.6 4.5 27.6 3.4 Sweden SE 13.5 2.2 14.9 2.0

Total* TOT 28.2 2.4 21.8 2.3 * Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Appendix 4: Percentage (%) of current smokers, separately in men and women, according to age group, overall and by country. PPACTE, 2010 MEN WOMEN

Age group Age group 15-24 25-44 45-64 ≥ 65 15-24 25-44 45-64 ≥ 65 Country Initials (%) (%) (%) (%) (%) (%) (%) (%) Albania AL 39.0 46.7 32.7 40.5 18.5 9.6 9.2 12.5 Austria AT 29.5 51.9 34.9 13.0 22.2 34.7 25.7 2.7 Bulgaria BG 40.5 59.1 44.1 23.1 45.6 49.0 36.6 12.6 Croatia HR 23.5 42.2 34.1 15.3 34.4 31.1 26.2 4.8 Czech Rep. CZ 21.6 46.5 41.3 17.2 15.5 25.9 34.4 6.5 England UK 29.3 32.3 23.3 18.5 29.4 26.2 24.1 14.7 Finland FI 42.9 39.6 34.7 11.2 28.3 23.6 17.6 6.1 France FR 28.1 49.1 24.4 11.9 32.8 36.2 22.8 5.7 Greece EL 41.9 47.2 40.1 - 26.5 38.6 32.1 - Hungary HU 49.3 45.7 42.2 33.3 34.8 32.3 26.9 15.8 Ireland IE 33.0 44.7 28.0 15.4 33.7 42.7 39.5 28.1 Italy IT 12.8 38.3 26.3 10.9 24.5 27.8 16.3 6.7 Latvia LV 31.9 50.6 47.1 26.4 15.6 23.2 15.6 2.3 Poland PL 21.8 32.0 43.1 14.6 21.2 26.1 24.9 9.4 Portugal PT 37.3 38.4 38.0 22.2 38.4 32.0 30.1 17.1 Romania RO 31.3 48.5 34.6 18.1 19.1 28.9 14.4 5.7 Spain ES 15.2 34.8 26.6 16.2 25.0 43.8 31.9 8.0 Sweden SE 21.5 18.8 17.1 9.0 26.7 20.7 21.6 5.8

Total* TOT 26.0 39.8 30.5 15.3 27.0 32.0 24.0 8.6 *Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Appendix 5: Mean age at quitting smoking^ according to country, overall and by sex. PPACTE, 2010

Mean age at quitting smoking (years) Ex-smokers (±SD)

Country Initial N° % TOTAL MEN WOMEN

Albania AL 61 6.1 36.5 (4.8) 37.0 (5.0) 32.8 (2.9) Austria AT 164 16.4 37.5 (8.6) 36.3 (8.8) 38.7 (8.5) Bulgaria BG 158 15.4 40.1 (8.6) 43.1 (8.2) 35.6 (8.5) Croatia HR 141 14.9 39.9 (6.8) 42.1 (7.4) 35.8 (5.3) Czech Republic CZ 121 12.1 38.3 (9.7) 41.7 (10.2) 33.2 (7.7) England UK 249 25.9 38.9 (23.6) 38.3 (22.8) 39.6 (24.6) Finland FI 212 20.6 35.4 (6.7) 37.1 (7.0) 32.9 (6.1) France FR 114 11.8 37.7 (23.8) 39.0 (24.0) 35.1 (23.0) Greece EL 92 9.2 40.1 (7.9) 41.5 (8.1) 38.0 (7.3) Hungary HU 167 16.6 40.7 (11.5) 39.4 (11.4) 41.5 (11.7) Ireland IE 108 10.8 38.2 (5.7) 40.4 (5.7) 34.9 (5.3) Italy IT 151 14.2 46.0 (22.1) 43.9 (21.0) 50.5 (22.9) Latvia LV 77 8.2 26.5 (4.2) 37.1 (4.3) 34.7 (4.0) Poland PL 156 15.6 40.5 (18.9) 41.4 (17.0) 39.2 (21.6) Portugal PT 131 12.1 36.8 (8.4) 37.8 (8.4) 35.0 (8.5) Romania RO 183 18.3 40.8 (14.0) 42.4 (13.7) 36.9 (14.3) Spain ES 241 24.1 37.7 (18.3) 38.6 (18.9) 36.8 (17.6) Sweden SE 238 23.1 40.1 (10.2) 41.3 (10.2) 38.8 (10.1)

Total* TOT 2764 16.0 39.3 (14.4) 39.9 (14.1) 38.4 (14.7)

^ Based on 2522 ex-smokers (unweighted number; 242 ex-smokers were excluded because of missing value). ° Unweighted numbers * Computed weighting each country in proportion to the country specific population aged 15 years or over.

95

Appendix 6: Percent (%) distribution of ex-smokers^ according to the reason that made them decide to quit cigarette smoking, overall and by country. PPACTE, 2010 Reason to quit smoking Illness Knowledge Other Pregnancy/ Economic Physician’s Pressure Smoke free Work (%) of effects reason Birth of a reason advice by legislation reason Country Initials (%) (%) child (%) (%) partner (%) (%) (%) (%) Albania AL 49.2 25.4 10.2 3.4 6.8 0.0 5.1 0.0 0.0 Austria AT 20.4 25.3 18.0 9.8 6.9 11.9 6.4 0.0 1.3 Bulgaria BG 27.0 16.5 13.8 5.3 21.1 9.2 6.6 0.7 0.0 Croatia HR 38.3 12.6 19.4 6.5 11.1 8.1 3.2 0.8 0.0 Czech Rep. CZ 14.4 5.9 7.6 28.0 6.8 17.0 19.5 0.9 0.0 England UK 27.1 23.0 20.6 9.4 8.8 4.0 5.9 0.0 1.3 Finland FI 31.3 24.7 21.2 9.2 2.8 2.0 7.9 0.7 0.2 France FR 32.0 15.0 27.2 11.4 6.2 6.0 2.1 0.0 0.0 Greece EL 26.9 31.0 3.1 8.1 4.1 16.1 10.7 0.0 0.0 Hungary HU 18.7 12.1 9.9 11.0 12.1 18.7 11.0 0.0 6.6 Ireland IE 19.5 29.5 14.6 9.4 10.6 6.4 8.7 0.0 1.3 Italy IT 50.5 38.8 0.0 4.2 1.3 2.4 2.9 0.0 0.0 Latvia LV 23.5 13.0 19.7 9.2 17.2 9.0 7.7 0.7 0.0 Poland PL 24.7 16.5 20.8 7.0 19.7 6.7 4.5 0.0 0.0 Portugal PT 5.3 28.3 0.0 8.2 23.3 13.3 19.2 1.8 0.6 Romania RO 30.6 31.1 12.8 2.7 9.5 9.0 3.4 0.0 0.9 Spain ES 14.2 34.7 27.1 7.2 0.9 4.6 7.8 3.4 0.0 Sweden SE 22.8 21.0 27.0 9.4 4.3 6.0 8.2 0.9 0.4

Total* TOT 27.7 24.4 18.8 8.8 7.1 6.1 5.9 0.6 0.5

^ Based on 2659 ex-smokers (unweighted number; 105 ex-smokers were excluded because of missing value). *Computed weighting each country in proportion to the country specific population aged 15 years or over.

96

Appendix 7: Mean number of cigarettes smoked per day (manufactured and hand- rolled combined) among current smokers separately in men and women, overall and by country. PPACTE, 2010

Mean number of cigarettes per day among smokers MEN WOMEN Manufactured Hand- Manufactured Hand- Country Initials cigarettes rolled cigarettes rolled cigarettes cigarettes Albania AL 21.4 2.2 13.8 0.3 Austria AT 16.6 0.4 15.9 1.8 Bulgaria BG 16.9 0.4 13.3 0.2 Croatia HR 20.0 2.2 12.5 1.3 Czech Republic CZ 14.1 0.9 10.6 0.6 England UK 8.2 7.0 11.0 3.0 Finland FI 11.8 4.4 7.7 0.7 France FR 11.2 3.6 11.2 2.2 Greece EL 21.1 2.9 20.0 1.4 Hungary HU 16.8 1.2 16.2 0.5 Ireland IE 14.8 2.2 14.7 0.5 Italy IT 15.7 0.2 11.7 0.2 Latvia LV 13.8 0.2 10.8 0.0 Poland PL 17.6 3.5 14.5 1.6 Portugal PT 19.3 0.2 15.6 0.3 Romania RO 17.1 0.1 11.1 0.0 Spain ES 12.2 3.2 10.6 2.2 Sweden SE 12.9 0.3 12.4 0.5

Total* TOT 14.4 2.6 12.4 1.5

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

97

Appendix 8: Per capita number of cigarettes (manufactured and hand-rolled combined) according to country, overall and by sex. PPACTE, 2010

Per capita number of cigarettes per day Country Initials TOTAL MEN WOMEN

Albania AL 5.6 9.4 1.6 Austria AT 5.3 6.4 4.2 Bulgaria BG 6.3 7.6 5.1 Croatia HR 4.9 6.9 3.1 Czech Republic CZ 3.9 5.4 2.5 England UK 3.6 4.0 3.3 Finland FI 3.5 5.5 1.6 France FR 3.9 4.6 3.3 Greece EL 8.9 10.5 7.3 Hungary HU 6.2 7.7 4.8 Ireland IE 5.8 5.7 5.8 Italy IT 3.1 4.1 2.2 Latvia LV 3.8 6.0 1.8 Poland PL 5.3 7.0 3.7 Portugal PT 5.7 6.9 4.7 Romania RO 3.9 6.0 2.0 Spain ES 4.0 4.0 4.0 Sweden SE 2.1 2.1 2.2

Total* TOT 4.2 5.2 3.4

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

98

Appendix 9: Percent (%) distribution of daily smokers^, separately current and ex-smokers, according to how soon after they wake up they smoke their first cigarette, overall and by country. PPACTE, 2010 First cigarette after waking-up Current daily smokers Ex-daily smokers Within 5 6-30 31-60 After 1 Within 5 6-30 31-60 After 1 Country Initials minutes minutes minutes hour minutes minutes minutes hour (%) (%) (%) (%) (%) (%) (%) (%) Albania AL 15.1 35.6 18.8 30.5 23.4 23.4 19.2 34.0 Austria AT 16.4 35.5 18.7 29.5 9.8 34.4 19.7 36.2 Bulgaria BG 28.1 41.6 17.1 13.2 14.7 41.3 24.0 20.0 Croatia HR 21.3 45.5 15.1 18.2 17.3 41.3 21.6 19.8 Czech Rep. CZ 14.0 38.1 24.9 23.0 8.9 19.8 22.8 48.5 England UK 20.8 35.0 11.5 32.8 16.3 24.0 19.4 40.3 Finland FI 17.5 37.7 22.6 22.2 16.6 29.7 13.5 40.2 France FR 17.0 32.2 15.6 35.2 15.9 23.3 14.5 46.3 Greece EL 23.4 56.4 12.2 8.1 28.4 47.0 17.5 7.1 Hungary HU 14.5 42.0 28.7 14.8 17.6 44.0 31.9 6.6 Ireland IE 34.0 30.2 12.9 22.8 24.0 27.8 17.4 30.8 Italy IT 14.6 46.3 17.8 21.2 13.2 29.1 23.8 34.0 Latvia LV 21.9 43.4 20.0 14.7 11.3 38.5 22.1 28.1 Poland PL 26.9 49.1 10.0 14.0 30.4 34.7 16.0 18.9 Portugal PT 27.7 25.2 29.4 17.8 19.2 25.9 29.2 25.7 Romania RO 22.7 38.1 12.8 26.4 18.2 45.9 13.9 22.0 Spain ES 11.8 41.5 18.8 27.9 16.2 32.0 10.7 41.1 Sweden SE 35.2 28.9 15.5 20.4 27.6 26.6 19.6 26.1

Total* TOT 19.3 39.8 16.4 24.5 17.0 29.0 18.0 36.1

^ Based on 7067 daily smokers (unweighted number; 119 daily smokers were excluded because of missing value). *Computed weighting each country in proportion to the country specific population aged 15 years or over.

99

Appendix 10: Mean age at starting smoking regularly according to country, overall and by sex. PPACTE, 2010

Mean age at starting smoking (years) (±SD) Country Initial TOTAL MEN WOMEN

Albania AL 19.4 (2.5) 18.5 (2.1) 22.9 (3.6) Austria AT 17.2 (2.2) 17.0 (2.2) 17.4 2.2) Bulgaria BG 18.7 (3.2) 17.6 (2.3) 19.9 (3.9) Croatia HR 18.9 (2.2) 18.4 (2.2) 19.6 (2.0) Czech Republic CZ 17.9 (2.3) 17.5 (1.8) 18.6 (2.9) England UK 17.1 (7.6) 16.7 (6.0) 17.6 (8.9) Finland FI 17.7 (2.2) 17.6 (2.2) 17.8 (2.3) France FR 17.8 (8.1) 17.6 (6.9) 18.1 (9.4) Greece EL 18.7 (2.9) 17.8 (2.4) 19.9 (3.3) Hungary HU 16.9 (2.1) 16.7 (2.4) 17.1 (1.7) Ireland IE 16.3 (1.7) 16.1 (1.8) 16.5 (1.6) Italy IT 18.0 (9.6) 16.7 (5.4) 19.9 (13.1) Latvia LV 18.8 (1.6) 18.1 (1.4) 20.4 (1.8) Poland PL 19.5 (5.9) 19.1 (5.4) 20.1 (6.4) Portugal PT 17.8 (2.9) 17.3 (2.5) 18.4 (3.3) Romania RO 19.4 (6.5) 18.9 (6.0) 20.6 (6.2) Spain ES 17.6 (4.8) 17.6 (5.4) 17.5 (4.2) Sweden SE 16.9 (3.1) 16.3 (2.5) 17.5 (3.5)

Total* TOT 17.9 (4.6) 17.5 (3.9) 18.5 (5.4)

* Computed weighting each country in proportion to the country specific population aged 15 years or over.

100

Appendix 11: Percent (%) distribution of current smokers^ according to where they bought their packs of cigarettes during the last 30 days, overall and by country. PPACTE, 2010 Channels of distribution Legal Vending Other Smuggling° Offered Internet shops machines countries/ (%) (%) (%) Country Initials (%) (%) duty free (%) Albania AL 91.4 0.0 0.6 1.7 [5.4] 6.2 0.0 Austria AT 67.2 15.5 12.3 0.1 [1.2] 4.8 0.0 Bulgaria BG 78.1 0.0 1.7 12.2 [20.3] 7.9 0.0 Croatia HR 86.9 0.1 3.3 6.0 [7.4] 3.8 0.0 Czech Rep. CZ 76.6 2.9 1.5 11.2 [34.4] 7.6 0.2 England UK 86.6 0.1 7.7 2.6 [4.2] 3.0 0.0 Finland FI 81.4 0.4 13.2 0.8 [2.8] 4.2 0.0 France FR 83.6 0.0 13.2 0.3 [1.3] 2.8 0.0 Greece EL 96.7 0.0 1.4 0.8 [1.5] 1.2 0.0 Hungary HU 92.6 1.2 0.3 0.0 [0.0] 5.9 0.0 Ireland IE 85.9 3.4 6.3 2.5 [6.2] 1.9 0.0 Italy IT 88.9 7.3 0.9 0.0 [0.2] 2.8 0.1 Latvia LV 63.0 0.0 3.2 25.9 [38.0] 7.8 0.0 Poland PL 86.9 0.2 0.3 8.8 [13.6] 3.8 0.0 Portugal PT 56.6 42.1 0.0 0.0 [0.0] 1.3 0.0 Romania RO 88.1 0.0 1.0 8.4 [13.9] 2.5 0.0 Spain ES 65.4 22.2 3.8 4.6 [22.1] 3.4 0.6 Sweden SE 82.0 2.0 3.3 9.9 [12.3] 2.8 0.0

Total* TOT 82.0 6.1 4.9 3.6 [8.4] 3.4 0.1

^ Based on 5209 current smokers (unweighted number; 59 current smokers were excluded because of missing value). *Computed weighting each country in proportion to the country specific population aged 15 years or over. ° Brackets include percentages of current smokers purchasing smuggled cigarettes (more than 1% of their total purchasing over the last 30 days).

101

Appendix 12: Mean weekly expenditure for a pack of cigarette or any tobacco products^, overall and by sex. PPACTE, 2010

Mean weekly expenditure (€) Mean weekly expenditure after

standardization for GDP in PPS (€)

Country Initials TOTAL MEN WOMEN TOTAL MEN WOMEN

Albania AL 10.1 10.7 8.0 37.3 39.5 29.6 Austria AT 24.7 26.1 22.7 19.9 21.1 18.3 Bulgaria BG 14.1 15.0 13.2 32.1 34.0 30.1 Croatia HR 14.8 17.3 11.8 22.8 26.7 18.2 Czech Republic CZ 12.0 13.1 10.5 14.7 15.9 12.8 England UK 24.5 22.3 26.8 21.8 19.9 24.0 Finland FI 19.5 23.1 12.8 17.3 20.4 11.3 France FR 24.9 24.3 25.5 23.0 22.5 23.6 Greece EL 26.6 28.7 24.0 28.7 30.8 25.8 Hungary HU 4.4 5.3 3.6 6.8 8.2 5.5 Ireland IE 47.5 49.8 45.5 37.4 39.2 35.8 Italy IT 18.2 19.9 15.9 17.5 19.2 15.2 Latvia LV 10.1 10.6 9.0 19.5 20.4 17.3 Poland PL 13.0 14.5 10.9 21.3 23.8 17.9 Portugal PT 20.8 22.7 18.7 26.0 28.4 23.3 Romania RO 12.8 14.0 10.6 27.9 30.5 23.0 Spain ES 18.3 21.2 15.9 17.7 20.6 15.4 Sweden SE 21.7 22.1 21.3 18.4 18.8 18.1

Total* TOT 18.6 19.4 17.7 21.3 22.4 19.8 ^ Based on 4942 current smokers (unweighted number; 326 current smokers were excluded because of missing value). by the analyses. *Computed weighting each country in proportion to the country specific population aged 15 years or over.

102

Appendix 13: Mean cost of a pack of cigarette or any tobacco products^, overall and by sex. PPACTE, 2010

Mean cost of tobacco product (€) Mean cost of tobacco product after

standardization for GDP in PPS (€)

Country Initials TOTAL MEN WOMEN TOTAL MEN WOMEN

Albania AL 1.90 1.81 2.19 7.04 6.70 8.11 Austria AT 5.06 5.21 4.85 4.08 4.20 3.91 Bulgaria BG 3.25 2.78 3.72 7.39 6.32 8.45 Croatia HR 3.93 4.37 3.41 6.05 6.72 5.25 Czech Republic CZ 3.02 2.98 3.10 3.68 3.63 3.78 England UK 6.08 6.10 6.06 5.43 5.45 5.41 Finland FI 5.13 4.76 5.83 4.54 4.21 5.16 France FR 5.45 5.06 5.91 5.05 4.69 5.47 Greece EL 3.63 3.70 3.55 3.90 3.98 3.82 Hungary HU 1.78 1.83 1.73 2.74 2.82 2.66 Ireland IE 9.97 9.57 10.31 7.85 7.54 8.12 Italy IT 4.12 3.91 4.40 3.96 3.76 4.23 Latvia LV 2.71 2.69 2.76 5.21 5.17 5.31 Poland PL 2.71 2.91 2.42 4.44 4.77 3.97 Portugal PT 3.58 3.53 3.65 4.48 4.41 4.56 Romania RO 3.34 3.66 2.73 7.26 7.96 5.93 Spain ES 5.42 5.64 5.24 5.26 5.48 5.09 Sweden SE 5.06 5.31 4.84 4.29 4.50 4.10

Total* TOT 4.51 4.38 4.65 4.96 4.95 4.94 ^ Based on 4942 current smokers (unweighted number; 326 current smokers were excluded because of missing value). *Computed weighting each country in proportion to the country specific population aged 15 years or over.

103

Appendix 14: Percent (%) distribution of current smokers^ according to the type of their latest pack of cigarettes, overall and by country. PPACTE, 2010

Type of pack 20 cigarettes 10 cigarettes Hand-rolled Other Country Initials pack pack tobacco (%) (%) (%) (%) Albania AL 93.5 1.2 5.4 0.0 Austria AT 95.8 0.5 3.3 0.4 Bulgaria BG 92.4 6.9 0.7 0.0 Croatia HR 90.0 1.1 7.5 1.4 Czech Rep. CZ 95.2 1.7 2.8 0.3 England UK 48.1 19.0 31.8 1.1 Finland FI 65.4 2.2 14.5 18.0 France FR 70.6 0.3 17.4 11.7 Greece EL 75.0 0.8 11.8 12.4 Hungary HU 96.1 0.8 3.1 0.0 Ireland IE 92.7 0.3 6.8 0.3 Italy IT 90.1 8.8 1.1 0.0 Latvia LV 92.3 4.5 1.8 1.4 Poland PL 90.8 0.6 5.6 2.9 Portugal PT 97.5 0.3 2.2 0.0 Romania RO 100.0 0.0 0.0 0.0 Spain ES 85.9 0.9 13.2 0.0 Sweden SE 96.3 0.0 1.8 1.8

Total* TOT 81.6 4.3 10.9 3.3

^ Based on 5254 current smokers (unweighted number; 14 current smokers were excluded because of missing value). *Computed weighting each country in proportion to the country specific population aged 15 years or over.

104

Appendix 15: Percent (%) distribution of current smokers^ according to health warnings on their latest pack of cigarettes, overall and by country. PPACTE, 2010

Health warnings Local Foreign Absent Country Initials language language (%) (%) (%) Albania AL 92.3 3.5 4.2 Austria AT 87.7 12.2 0.1 Bulgaria BG 85.7 9.8 4.5 Croatia HR 88.5 2.9 8.6 Czech Rep. CZ 97.3 2.1 0.7 England UK 89.0 11.0 0.0 Finland FI 88.5 7.6 3.9 France FR 91.6 8.4 0.0 Greece EL 99.2 0.3 0.6 Hungary HU 96.6 2.5 0.8 Ireland IE 91.6 7.5 0.9 Italy IT 99.2 0.2 0.6 Latvia LV 68.7 26.1 5.2 Poland PL 87.6 9.6 2.7 Portugal PT 100.0 0.0 0.0 Romania RO 92.6 6.4 1.1 Spain ES 96.9 1.3 1.8 Sweden SE 93.3 6.8 0.0

Total* TOT 93.1 5.7 1.1

^ Based on 5237 current smokers (unweighted number; 31 current smokers were excluded because of missing value). *Computed weighting each country in proportion to the country specific population aged 15 years or over.

105

Appendix 16: Percent (%) distribution of current smokers^ according to the tax stamp (banderole) on their latest pack of cigarettes, overall and by country. PPACTE, 2010

Tax stamp (banderole) Local Foreign Removed/ Absent stamp stamp destroyed (%) Country Initials (%) (%) stamp (%) Albania AL 95.6 0.8 0.4 3.2 Austria AT 84.0 9.6 2.6 3.9 Bulgaria BG 79.5 0.0 12.3 8.3 Croatia HR 88.4 8.1 1.6 1.9 Czech Rep. CZ 93.8 0.7 4.2 1.4 England UK 80.0 4.5 0.3 15.2 Finland FI 86.2 6.6 0.9 6.3 France FR 80.5 11.0 0.9 7.7 Greece EL 98.4 0.0 1.0 0.6 Hungary HU 94.1 0.0 0.6 5.3 Ireland IE 89.7 8.3 0.5 1.5 Italy IT 96.1 0.4 2.7 0.9 Latvia LV 66.9 26.3 6.0 0.8 Poland PL 90.1 8.4 0.6 0.9 Portugal PT 100.0 0.0 0.0 0.0 Romania RO 91.3 2.5 2.2 4.0 Spain ES 97.3 1.4 1.3 0.0 Sweden SE 87.1 8.8 0.7 3.4

Total* TOT 89.5 4.5 1.7 4.4

^ Based on 5030 current smokers (unweighted number; 238 current smokers were excluded because of missing value). *Computed weighting each country in proportion to the country specific population aged 15 years or over.

106

Appendix 17: Percent (%) distribution of current smokers^ according to where they bought their latest pack of cigarettes, overall and by country. PPACTE, 2010 Channels of distribution Legal Vending Smuggling Other Offered Duty-free Internet Country Initials shops machines (%) countries (%) (%) (%) (%) (%) (%) Albania AL 92.7 1.2 2.3 1.2 1.9 0.8 0.0 Austria AT 73.5 11.2 0.4 7.1 3.0 4.8 0.0 Bulgaria BG 79.3 0.2 14.5 0.0 4.8 1.2 0.0 Croatia HR 88.7 0.0 6.4 3.7 0.6 0.7 0.0 Czech Rep. CZ 86.6 0.7 8.6 0.7 2.8 0.7 0.0 England UK 83.6 0.0 4.5 3.3 4.8 3.9 0.0 Finland FI 84.2 0.6 1.4 5.3 1.5 7.1 0.0 France FR 88.9 0.0 0.5 9.2 1.5 0.0 0.0 Greece EL 99.3 0.0 0.6 0.0 0.0 0.1 0.0 Hungary HU 99.7 0.3 0.0 0.0 0.0 0.0 0.0 Ireland IE 86.4 2.6 1.8 5.3 1.4 2.5 0.0 Italy IT 97.8 1.5 0.3 0.0 0.3 0.0 0.0 Latvia LV 65.1 0.0 30.6 1.2 2.5 0.6 0.0 Poland PL 85.1 0.0 12.0 0.0 2.6 0.4 0.0 Portugal PT 58.7 41.3 0.0 0.0 0.0 0.0 0.0 Romania RO 88.9 0.0 9.8 0.0 0.9 0.4 0.0 Spain ES 69.8 26.2 1.3 1.5 0.0 1.0 0.2 Sweden SE 80.4 4.3 10.4 1.8 0.6 2.5 0.0

Total* TOT 85.2 5.5 4.0 2.6 1.6 1.1 0.0

^ Based on 5220 current smokers (unweighted number; 48 current smokers were excluded because of missing value). *Computed weighting each country in proportion to the country specific population aged 15 years or over.

107

Appendix 18: Percent (%) distribution of current smokers^ according to their attitudes toward an increment in cigarettes prices by 5%, overall and by country. PPACTE, 2010

Current smokers Attitudes toward increase in prices by 5% Strongly in Moderately Moderately Strongly Country Initials N° % favour in favour against against (%) (%) (%) (%) Albania AL 261 26.1 25.7 26.6 20.8 27.0 Austria AT 320 30.4 13.5 26.2 18.3 42.1 Bulgaria BG 420 40.9 13.6 18.0 13.6 54.8 Croatia HR 272 26.6 19.4 10.9 20.9 48.9 Czech Republic CZ 291 29.1 6.8 24.2 29.1 40.0 England UK 254 26.3 28.8 30.9 17.4 22.9 Finland FI 284 27.5 32.0 29.0 14.6 24.4 France FR 375 38.9 18.7 23.0 21.0 37.4 Greece EL 356 35.5 18.1 30.4 23.1 28.4 Hungary HU 372 36.0 3.5 11.4 12.6 72.6 Ireland IE 214 22.0 46.2 25.7 12.4 15.8 Italy IT 301 28.8 18.3 28.2 23.7 29.8 Latvia LV 258 28.0 26.6 23.0 21.2 29.2 Poland PL 321 32.4 18.5 29.1 24.3 28.1 Portugal PT 265 26.1 11.1 36.2 34.9 17.8 Romania RO 287 28.6 34.2 27.0 10.8 28.0 Spain ES 163 16.3 35.1 26.1 14.2 24.6 Sweden SE 254 24.9 27.7 41.9 12.3 18.1

Total* TOT 5268 27.2 22.2 26.4 19.7 31.8

^ Based on 4814 current smokers (unweighted number; 454 current smokers were excluded because of missing value). ° Unweighted numbers * Computed weighting each country in proportion to the country specific population aged 15 years or over.

108

Appendix 19: Percent (%) distribution of non smokers (never and ex-smokers combined)^ according to their attitudes toward an increment in cigarettes prices by 5%, overall and by country. PPACTE, 2010

Non smokers Attitudes toward increase in prices by 5% Strongly in Moderately Moderately Strongly Country Initials N° % favour in favour against against (%) (%) (%) (%) Albania AL 739 73.9 48.4 24.4 15.4 11.8 Austria AT 681 69.6 54.1 28.5 7.4 9.9 Bulgaria BG 607 59.1 49.7 29.0 12.5 8.8 Croatia HR 676 73.4 49.0 13.4 17.5 20.0 Czech Rep. CZ 709 70.9 46.4 36.3 11.4 6.0 England UK 708 73.7 57.6 27.9 7.0 7.5 Finland FI 745 72.5 68.2 21.9 5.9 4.0 France FR 590 61.1 38.8 31.0 15.4 14.9 Greece EL 646 64.5 45.5 38.0 10.6 5.9 Hungary HU 636 64.0 14.4 25.1 11.6 48.9 Ireland IE 791 78.0 62.1 24.4 6.7 6.9 Italy IT 760 71.2 37.6 45.2 10.5 6.8 Latvia LV 680 72.1 42.5 30.0 12.0 15.5 Poland PL 679 67.6 35.5 37.6 17.4 9.5 Portugal PT 815 74.0 47.5 43.6 8.0 0.9 Romania RO 713 71.4 68.1 18.8 5.1 8.0 Spain ES 837 83.7 51.2 29.2 9.7 10.0 Sweden SE 776 75.1 55.5 28.1 10.0 6.4

Total* TOT 12788 72.8 46.2 33.0 10.9 9.9

^ Based on 11208 non smokers (unweighted number; 1580 non smokers were excluded because of missing value). ° Unweighted numbers *Computed weighting each country in proportion to the country specific population aged 15 years or over.

109

Appendix 20: Percent (%) distribution of current smokers^ according to their attitudes toward an increment in cigarettes prices by 20%, overall and by country. PPACTE, 2010

Attitudes toward increase in prices by 20% Strongly in Moderately Moderately Strongly Country Initials favour in favour against against (%) (%) (%) (%) Albania AL 46.2 18.1 12.9 22.9 Austria AT 8.8 17.3 14.8 59.1 Bulgaria BG 3.9 9.1 12.2 74.8 Croatia HR 18.8 8.0 27.0 46.2 Czech Republic CZ 5.3 14.3 15.9 64.5 England UK 28.4 25.1 15.8 30.7 Finland FI 27.2 20.5 20.6 31.7 France FR 16.9 18.1 17.2 47.8 Greece EL 16.2 17.6 19.8 46.4 Hungary HU 2.5 10.7 8.8 77.9 Ireland IE 44.3 21.8 11.5 22.4 Italy IT 14.0 21.4 25.9 38.7 Latvia LV 19.0 11.6 25.8 43.6 Poland PL 19.2 17.1 27.2 36.6 Portugal PT 5.4 17.2 37.6 39.9 Romania RO 27.1 23.6 9.3 40.1 Spain ES 30.5 22.9 11.0 35.7 Sweden SE 23.4 36.4 15.6 24.7

Total* TOT 19.5 19.6 18.5 42.4

^ Based on 4814 current smokers (unweighted number; 454 current smokers were excluded because of missing value). *Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Appendix 21: Percent (%) distribution of non smokers (never and ex-smokers combined)^ according to their attitudes toward an increment in cigarettes prices by 20%, overall and by country. PPACTE, 2010

Attitudes toward increase in prices by 20% Strongly in Moderately Moderately Strongly Country Initials favour in favour against against (%) (%) (%) (%) Albania AL 71.4 14.9 6.8 6.9 Austria AT 55.7 23.3 9.0 12.0 Bulgaria BG 46.1 21.2 13.1 19.6 Croatia HR 45.1 15.0 19.4 20.5 Czech Republic CZ 45.7 30.2 16.7 7.4 England UK 50.5 28.7 9.5 11.3 Finland FI 65.9 19.5 8.4 6.2 France FR 36.6 24.2 19.4 19.8 Greece EL 48.7 28.3 11.5 11.5 Hungary HU 13.3 21.2 14.9 50.6 Ireland IE 60.5 22.2 7.0 10.3 Italy IT 41.3 38.1 11.2 9.5 Latvia LV 39.0 24.3 15.8 20.9 Poland PL 35.6 34.0 17.2 13.1 Portugal PT 25.6 50.8 20.9 2.8 Romania RO 60.9 22.7 7.3 9.1 Spain ES 57.3 21.0 9.6 12.1 Sweden SE 52.4 26.6 11.5 9.5

Total* TOT 45.3 28.7 12.9 13.1 ^ Based on 11317 non smokers (unweighted number; 1471 non smokers were excluded because of missing value). *Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Appendix 22: Percent (%) distribution of the European population^ according to their perception of effectiveness of free psychological or pharmacological support for smoking cessation, including nicotine replacement therapy (patches, gums, etc) bupropion and varenicline, in order to control and limit tobacco use, overall and by country. PPACTE, 2010

Effectiveness of free psychological or pharmacological support for smoking cessation Very Quite Rather Completely Country Initials useful useful useless useless (%) (%) (%) (%) Albania AL 62.5 20.9 8.2 8.5 Austria AT 27.9 34.0 21.5 16.6 Bulgaria BG 33.5 28.3 19.7 18.5 Croatia HR 20.6 16.7 27.5 35.2 Czech Republic CZ 30.1 39.1 19.4 11.4 England UK 35.2 43.0 11.5 10.4 Finland FI 27.5 47.1 17.5 7.9 France FR 34.4 38.6 13.9 13.1 Greece EL 35.2 40.5 14.5 9.8 Hungary HU 12.5 23.2 21.5 42.9 Ireland IE 46.3 36.8 8.9 8.0 Italy IT 24.9 44.0 17.7 13.3 Latvia LV 24.2 39.0 19.6 17.3 Poland PL 40.7 36.6 14.2 8.5 Portugal PT 29.5 62.5 4.8 3.3 Romania RO 46.9 30.1 12.0 11.0 Spain ES 45.9 34.7 10.7 8.7 Sweden SE 32.2 39.7 17.3 10.8

Total* TOT 34.7 38.8 14.3 12.2

^ Based on 17010 participants (unweighted number; 1046 participants were excluded because of missing value). *Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Appendix 23: Percent (%) distribution of the European population^ according to their perception of effectiveness of making smoking or cigarette sales illegal, in order to control and limit tobacco use, overall and by country. PPACTE, 2010

Effectiveness of making smoking or cigarettes sales illegal Very Quite Rather Completely Country Initials useful useful useless useless (%) (%) (%) (%) Albania AL 35.6 25.0 17.7 21.7 Austria AT 21.1 20.3 26.5 32.1 Bulgaria BG 17.3 21.9 28.6 32.1 Croatia HR 40.6 19.7 17.1 22.6 Czech Republic CZ 21.1 17.5 26.3 35.1 England UK 15.5 13.6 28.5 42.5 Finland FI 10.2 13.1 35.9 40.8 France FR 9.5 11.1 18.8 60.6 Greece EL 12.9 18.5 21.9 46.8 Hungary HU 4.5 6.8 30.8 57.9 Ireland IE 13.4 16.2 25.6 44.7 Italy IT 24.4 33.4 19.7 22.6 Latvia LV 12.5 16.7 30.6 40.3 Poland PL 21.6 28.1 24.7 25.6 Portugal PT 2.8 15.4 35.6 46.2 Romania RO 17.0 11.6 25.1 46.3 Spain ES 15.7 15.2 27.3 41.8 Sweden SE 9.6 11.2 20.9 58.3

Total* TOT 16.4 18.6 24.2 40.8

^ Based on 16947 participants (unweighted number; 1109 participants were excluded because of missing value). *Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Appendix 24: Percent (%) distribution of the European population^ according to their perception of effectiveness of raising the price of cigarettes, in order to control and limit tobacco use, overall and by country. PPACTE, 2010

Effectiveness of raising the price of cigarettes

Very Quite Rather Completely Country Initials useful useful useless useless (%) (%) (%) (%) Albania AL 47.8 21.2 15.1 15.9 Austria AT 23.3 27.0 29.7 20.0 Bulgaria BG 23.1 24.7 28.1 24.0 Croatia HR 27.0 19.5 24.5 29.0 Czech Republic CZ 33.8 29.6 19.6 17.0 England UK 25.0 34.2 23.3 17.6 Finland FI 26.9 39.2 23.3 10.6 France FR 16.4 27.6 22.9 33.1 Greece EL 32.1 31.9 19.2 16.8 Hungary HU 6.8 12.1 34.3 46.8 Ireland IE 21.6 30.7 25.5 22.2 Italy IT 27.7 39.4 20.3 12.5 Latvia LV 18.0 27.6 28.5 25.9 Poland PL 23.6 30.8 25.0 20.6 Portugal PT 12.0 29.0 35.8 23.3 Romania RO 25.2 25.7 21.9 27.3 Spain ES 29.3 28.8 23.1 18.9 Sweden SE 26.3 34.3 17.8 21.6

Total* TOT 24.1 30.9 23.3 21.7

^ Based on 17239 participants (unweighted number; 817 participants were excluded because of missing value). *Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Appendix 25: Percent (%) distribution of the European population^ according to their perception of effectiveness of extension of smoking bans, in order to control and limit tobacco use, overall and by country. PPACTE, 2010

Effectiveness of extension of smoking bans

Very Quite Rather Completely Country Initials useful useful useless useless (%) (%) (%) (%) Albania AL 60.6 22.8 8.1 8.4 Austria AT 25.9 25.5 26.3 22.3 Bulgaria BG 26.7 20.5 25.3 27.6 Croatia HR 30.1 19.5 21.4 29.0 Czech Republic CZ 32.4 30.0 19.4 18.1 England UK 26.7 32.0 21.9 19.4 Finland FI 23.0 37.9 22.6 16.5 France FR 14.4 20.6 27.9 37.1 Greece EL 31.0 28.8 21.5 18.7 Hungary HU 31.4 36.4 16.2 16.1 Ireland IE 24.9 27.3 20.4 27.4 Italy IT 32.2 36.5 20.3 11.1 Latvia LV 13.2 23.9 33.7 29.2 Poland PL 29.0 35.7 20.9 14.5 Portugal PT 10.0 38.4 34.8 16.8 Romania RO 26.7 25.5 21.5 26.3 Spain ES 34.8 27.6 16.8 20.7 Sweden SE 27.8 29.0 16.8 26.5

Total* TOT 26.9 29.7 22.0 21.4

^ Based on 17090 participants (unweighted number; 966 participants were excluded because of missing value). *Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Appendix 26: Percent (%) distribution of current smokers^ according to their response to a 20% increase in price of a pack of cigarettes, overall and by country. PPACTE, 2010 Response to a 20% increase in price of a pack of cigarettes

Quit Consume Switch to Switch to Switch to Switch to Not smoking less cheaper hand-rolled smuggled smokeless change Country Initials (%) cigarettes brands cigarettes cigarettes tobacco (%) (%) (%) (%) (%) (%) Albania AL 12.6 39.5 10.9 3.4 0.8 0.0 32.8 Austria AT 4.6 31.2 19.2 4.9 5.0 0.4 34.7 Bulgaria BG 12.4 36.3 8.1 2.7 11.2 0.0 29.3 Croatia HR 18.7 25.1 7.3 1.8 5.0 0.4 41.8 Czech Rep. CZ 9.7 27.9 31.0 3.5 2.3 0.4 25.2 England UK 21.1 21.1 8.0 4.0 2.4 0.4 43.0 Finland FI 8.8 26.2 6.4 2.5 6.4 0.4 49.3 France FR 9.4 25.1 8.9 4.2 6.2 0.4 45.8 Greece EL 14.8 40.6 13.3 3.3 0.9 0.1 27.0 Hungary HU 8.5 33.2 16.3 4.4 0.3 0.0 37.3 Ireland IE 18.3 32.6 6.2 3.3 3.3 0.5 35.8 Italy IT 12.8 41.0 11.3 2.9 1.2 0.5 30.3 Latvia LV 8.0 25.7 13.2 1.2 18.6 0.4 33.0 Poland PL 14.2 29.3 18.4 4.9 5.6 1.4 26.4 Portugal PT 6.6 28.1 34.7 1.2 0.0 0.0 29.5 Romania RO 23.8 50.1 5.4 0.6 0.4 0.0 19.7 Spain ES 18.2 25.3 22.2 6.3 3.1 0.8 24.1 Sweden SE 13.0 26.6 9.7 1.3 3.9 2.0 43.5

Total* TOT 14.2 30.6 13.7 3.8 3.5 0.5 33.6

^ Based on 4858 current smokers (unweighted number; 410 current smokers were excluded because of missing value). *Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Appendix 27: Percent (%) distribution of current smokers^ according to their intention to quit smoking within the next 6 months separately in men and women, overall and by country. PPACTE, 2010

Intention to quit smoking within the next 6 months TOTAL MEN WOMEN No Yes No Yes No Yes Country Initials (%) (%) (%) (%) (%) (%) Albania AL 74.6 25.4 75.1 24.9 72.6 27.5 Austria AT 83.4 16.6 82.1 17.9 85.3 14.7 Bulgaria BG 73.4 26.6 75.9 24.2 70.7 29.3 Croatia HR 78.5 21.5 79.7 20.3 77.0 23.0 Czech Rep. CZ 84.4 15.6 89.1 10.9 77.1 22.9 England UK 58.5 41.5 54.5 45.5 62.8 37.2 Finland FI 53.0 47.0 50.7 49.3 57.2 42.8 France FR 64.0 36.0 69.0 31.0 58.0 42.0 Greece EL 78.9 21.1 79.2 20.9 78.7 21.3 Hungary HU 91.4 8.6 92.3 7.7 90.0 10.0 Ireland IE 57.2 42.8 52.3 47.7 61.6 38.4 Italy IT 79.5 20.5 81.6 18.5 76.7 23.3 Latvia LV 67.0 33.1 68.2 31.8 63.7 36.3 Poland PL 54.7 45.4 61.0 39.0 45.7 54.3 Portugal PT 78.9 21.1 73.9 26.1 84.3 15.8 Romania RO 41.1 58.9 39.0 61.0 44.9 55.1 Spain ES 42.7 57.3 43.3 56.7 42.4 57.6 Sweden SE 57.2 42.8 56.2 43.8 58.2 41.8

Total* TOT 64.0 36.0 65.9 34.1 61.7 38.3

^ Based on 4725 current smokers (unweighted number; 543 current smokers were excluded because of missing value). *Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Appendix 28: Percent (%) distribution of current smokers^ according to how much the current cigarette price should be raised to make them quit smoking completely, overall and by country. PPACTE, 2010 Cigarette price raise that let smokers quit completely ≤20% 21%-40% 41%-60% 61%-80% 81%-100% Three/four Five or more Country Initials (%) (%) (%) (%) (%) times times (%) (%) Albania AL 16.3 5.0 13.8 7.5 23.1 18.1 16.3 Austria AT 7.7 14.4 29.4 8.1 28.9 4.4 7.1 Bulgaria BG 11.4 11.7 8.9 6.8 31.0 14.7 15.6 Croatia HR 11.6 18.7 18.3 6.8 28.1 5.9 10.6 Czech Rep. CZ 13.9 24.8 19.3 7.4 20.8 8.9 5.0 England UK 23.8 14.8 16.7 4.8 26.3 5.1 8.6 Finland FI 8.2 16.4 27.7 3.3 27.2 6.6 10.7 France FR 12.9 18.8 21.7 5.6 24.8 8.1 8.1 Greece EL 23.1 22.9 13.6 9.3 13.4 11.8 5.8 Hungary HU 6.8 58.5 21.0 4.9 6.8 1.5 0.5 Ireland IE 30.0 20.5 16.9 6.7 17.0 3.5 5.4 Italy IT 26.9 13.0 20.4 4.5 25.7 2.0 7.5 Latvia LV 6.9 11.1 15.5 6.8 30.6 12.6 16.5 Poland PL 27.4 19.8 15.4 4.4 24.8 1.7 6.5 Portugal PT 10.7 34.8 27.4 8.5 9.4 5.1 4.0 Romania RO 31.3 17.8 14.1 2.9 18.4 5.9 9.6 Spain ES 27.0 15.4 14.9 10.6 17.5 6.1 8.5 Sweden SE 14.6 21.1 19.5 9.8 22.0 4.9 8.1

Total* TOT 20.5 19.1 18.2 6.3 22.0 6.0 7.9

^ Based on 3619 current smokers (unweighted number; 1649 current smokers were excluded because of missing value). *Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Appendix 29: Percent (%) distribution of the European population^ according to where people can smoke at their home, overall and by country. PPACTE, 2010

Where people can smoke

Only In some Everywhere outside specific (%) Country Initials (%) indoor areas (%) Albania AL 55.8 14.6 29.6 Austria AT 70.9 14.7 14.4 Bulgaria BG 46.4 27.7 26.0 Croatia HR 30.6 27.0 42.4 Czech Republic CZ 58.1 30.9 11.0 England UK 77.0 12.0 11.0 Finland FI 93.2 5.0 1.8 France FR 63.9 22.1 14.0 Greece EL 36.1 20.3 43.6 Hungary HU 54.8 25.1 20.2 Ireland IE 66.3 11.5 22.2 Italy IT 63.7 15.1 21.2 Latvia LV 65.6 26.3 8.1 Poland PL 48.9 25.0 26.1 Portugal PT 52.9 35.1 12.0 Romania RO 61.5 27.5 11.0 Spain ES 59.4 13.0 27.5 Sweden SE 86.7 8.3 5.0

Total* TOT 62.2 18.9 18.9

^ Based on 17865 participants (unweighted number; 191 participants were excluded because of missing value). *Computed weighting each country in proportion to the country specific population aged 15 years or over.

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Appendix 30: Percent distribution (%), overall* and by country, of the European population aged 15 years or over, according to current use of smokeless tobacco, overall and by gender. PPACTE, 2010. Users (%) Occasional users (%) Regular users (%) Country Initial Total Men Women Total Men Women Total Men Women Albania AL 0.3 0.4 0.2 0.0 0.0 0.0 0.3 0.4 0.2 Austria AT 0.2 0.2 0.3 0.0 0.0 0.0 0.1 0.2 0.1 Bulgaria BG 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Croatia HR 0.4 0.3 0.5 0.0 0.0 0.0 0.0 0.0 0.0 Czech Republic CZ 2.1 3.5 0.8 0.0 0.0 0.0 1.3 2.7 0.0 England UK 1.1 1.0 1.1 0.2 0.2 0.2 0.9 0.8 0.9 Finland FI 2.0 2.7 1.4 0.0 0.0 0.0 2.0 2.7 1.4 France FR 1.4 1.4 1.5 0.0 0.0 0.0 0.2 0.4 0.1 Greece EL 0.6 0.7 0.5 0.0 0.0 0.0 0.1 0.2 0.0 Hungary HU 0.6 0.6 0.6 0.0 0.0 0.0 0.6 0.6 0.6 Ireland IE 1.3 1.6 0.9 0.2 0.3 0.0 1.0 1.2 0.8 Italy IT 0.6 0.8 0.5 0.0 0.0 0.0 0.6 0.7 0.5 Latvia LV 0.8 0.6 0.9 0.2 0.2 0.2 0.2 0.2 0.2 Poland PL 5.5 4.1 6.8 0.6 0.6 0.7 1.6 1.4 1.8 Portugal PT 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Romania RO 0.1 0.2 0.0 0.0 0.0 0.0 0.1 0.2 0.0 Spain ES 2.5 2.1 2.9 2.5 2.1 2.9 0.0 0.0 0.0 Sweden SE 12.3 20.7 3.5 0.6 1.2 0.0 11.4 18.9 3.5

Total TOT 1.9 2.0 1.7 0.4 0.4 0.5 0.9 1.1 0.6 *Total was computed weighting each country in proportion to the country specific population aged 15 years or over. ° The sum of regular and occasional users does not add up to “users” because of missing values on regular vs occasional users

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Appendix 31: Mean age at starting using smokeless tobacco^ according to country, overall and by sex. PPACTE, 2010

Mean age at starting using smokeless tobacco (years) (±SD) TOTAL MEN WOMEN Country Initial N° Mean age N° Mean age N° Mean age Albania AL 3 19.3 (±0.4) 2 19.0 (±0.5) 1 20.0 (-) Austria AT 3 25.5 (±1.6) 2 23.3 (±1.6) 1 30.0 (-) Bulgaria BG 0 - 0 - 0 - Croatia HR 0 - 0 - 0 - Czech Republic CZ 13 32.5 (±11.9) 13 32.5 (±11.9) 0 - England UK 11 18.5 (±9.2) 4 18.1 (±2.6) 7 18.8 (±11.7) Finland FI 19 27.4 (±8.1) 14 23.6 (±8.3) 5 34.8 (±5.7) France FR 3 20.8 (±10.7) 2 23.0 (±11.2) 1 14.0 (-) Greece EL 1 20.0 (–) 1 20.0 (–) 0 - Hungary HU 6 17.3 (±1.8) 3 17.7 (±1.8) 3 17.0 (±2.1) Ireland IE 10 19.2 (±4.0) 6 16.0 (±2.4) 4 24.1 (±5.2) Italy IT 6 24.0 (±24.1) 3 28.8 (±34.5) 3 18.3 (±4.3) Latvia LV 2 22.8 (±2.7) 1 29.0 (-) 1 18.0 (-) Poland PL 13 26.2 (±22.3) 5 17.2 (±4.1) 8 32.8 (±24.3) Portugal PT 0 - 0 - 0 - Romania RO 1 18.0 (-) 1 18.0 (-) 0 - Spain ES 0 - 0 - 0 - Sweden SE 113 23.6 (±9.0) 96 23.1 (±9.4) 17 26.1 (±6.6)

Total* TOT 204 23.6 (±10.8) 153 22.8 (±10.0) 51 25.0 (±129)

^ Based on 204 smokeless tobacco users (unweighted number; 111 smokeless tobacco users were excluded because of missing value). ° Unweighted numbers * Computed weighting each country in proportion to the country specific population aged 15 years or over.

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