1 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] 2 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. 3 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. 4 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%). 5 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 6 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. 7 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