Impact of the 2008 economic crisis on the burden of hepatitis B and C diseases in Southern European countries.

BACKGROUND: The economic crisis that began in 2008 has severely affected Southern (Greece, Italy, Portugal, Spain) Western European (SWE) countries of Western Europe (WE) and may have affected ongoing efforts to eliminate viral hepatitis. This study was conducted to investigate the impact of the economic crisis on the burden of HBV and HCV disease. METHODS: Global Burden of Diseases 2019 data were used to analyse the rates of epidemiological metrics of HBV and HCV acute and chronic infections in SWE and WE. Time series modelling was performed to quantify the impact of healthcare expenditure on the time trend of HBV and HCV disease burden in 2000-2019. RESULTS: Declining trends in incidence and prevalence rates of acute HBV (aHBV) and chronic HBV were observed in SWE and WE, with the pace of decline being slower in the post-austerity period (2010-2019) and mortality due to HBV stabilised in SWE. Acute HCV (aHCV) metrics and chronic HCV incidence and mortality showed a stable trend in SWE and WE, whereas the prevalence of chronic HCV showed an oscillating trend, decreasing in WE in 2010-2019 (p < 0.001). Liver cancer due to both hepatitis infections showed a stagnant burden over time. An inverse association was observed between health expenditure and metrics of both acute and chronic HBV and HCV. CONCLUSIONS: Epidemiological metrics for HBV and HCV showed a slower pace of decline in the post-austerity period with better improvement for HBV, a stabilisation of mortality and a stagnant burden for liver cancer due to both hepatitis infections. The economic crisis of 2008 had a negative impact on the burden of hepatitis B and C. Elimination of HBV and HCV by 2030 will be a major challenge in the SWE countries.

Time-Trends in Air Pollution Impact on Health in Italy, 1990-2019: An Analysis From the Global Burden of Disease Study 2019.

Objectives: We explored temporal variations in disease burden of ambient particulate matter 2.5 µm or less in diameter (PM2.5) and ozone in Italy using estimates from the Global Burden of Disease Study 2019. Methods: We compared temporal changes and percent variations (95% Uncertainty Intervals [95% UI]) in rates of disability adjusted life years (DALYs), years of life lost, years lived with disability and mortality from 1990 to 2019, and variations in pollutant-attributable burden with those in the overall burden of each PM2.5- and ozone-related disease. Results: In 2019, 467,000 DALYs (95% UI: 371,000, 570,000) were attributable to PM2.5 and 39,600 (95% UI: 18,300, 61,500) to ozone. The crude DALY rate attributable to PM2.5 decreased by 47.9% (95% UI: 10.3, 65.4) from 1990 to 2019. For ozone, it declined by 37.0% (95% UI: 28.9, 44.5) during 1990-2010, but it increased by 44.8% (95% UI: 35.5, 56.3) during 2010-2019. Age-standardized rates declined more than crude ones. Conclusion: In Italy, the burden of ambient PM2.5 (but not of ozone) significantly decreased, even in concurrence with population ageing. Results suggest a positive impact of air quality regulations, fostering further regulatory efforts.

Healthcare use and healthcare costs for patients with advanced cancer; the international ACTION cluster-randomised trial on advance care planning.

BACKGROUND: Advance care planning supports patients to reflect on and discuss preferences for future treatment and care. Studies of the impact of advance care planning on healthcare use and healthcare costs are scarce. AIM: To determine the impact on healthcare use and costs of an advance care planning intervention across six European countries. DESIGN: Cluster-randomised trial, registered as ISRCTN63110516, of advance care planning conversations supported by certified facilitators. SETTING/PARTICIPANTS: Patients with advanced lung or colorectal cancer from 23 hospitals in Belgium, Denmark, Italy, the Netherlands, Slovenia and the UK. Data on healthcare use were collected from hospital medical files during 12 months after inclusion. RESULTS: Patients with a good performance status were underrepresented in the intervention group (p< 0.001). Intervention and control patients spent on average 9 versus 8 days in hospital (p = 0.07) and the average number of X-rays was 1.9 in both groups. Fewer intervention than control patients received systemic cancer treatment; 79% versus 89%, respectively (p< 0.001). Total average costs of hospital care during 12 months follow-up were €32,700 for intervention versus €40,700 for control patients (p = 0.04 with bootstrap analyses). Multivariable multilevel models showed that lower average costs of care in the intervention group related to differences between study groups in country, religion and WHO-status. No effect of the intervention on differences in costs between study groups was observed (p = 0.3). CONCLUSIONS: Lower care costs as observed in the intervention group were mainly related to patients' characteristics. A definite impact of the intervention itself could not be established.

Burden of disease from second-hand tobacco smoke exposure at home among adults from European Union countries in 2017: an analysis using a review of recent meta-analyses.

Smoke-free legislation reduced second-hand smoke (SHS) exposure in public places, and indirectly promoted private smoke-free settings. Nevertheless, a large proportion of adults is still exposed to SHS at home. The aim of this paper is to quantify the burden of disease due to home SHS exposure among adults in the 28-European Union (EU) countries for year 2017. The burdens by gender from lung cancer, chronic obstructive pulmonary disease (COPD), breast cancer, ischemic heart disease (IHD), stroke, asthma, and diabetes were estimated in an original research analysis using the comparative risk assessment method. Relative risks of death/diseases by gender for adults exposed to SHS at home compared to not exposed ones were estimated updating existing meta-analyses. Prevalence of home SHS exposure by gender was estimated using a multiple imputation procedure based on Eurobarometer surveys. Data on mortality and disability adjusted life years (DALYs) were obtained from the Global Burden of Disease, Injuries and Risk Factors Study. In 2017, 526,000 DALYs (0.36% of total DALYs) and 24,000 deaths (0.46% of total deaths) were attributable to home SHS exposure in the 28-EU countries, mainly from COPD and IHD. South-Eastern EU countries showed the highest burden, with proportion of DALYs/deaths attributable to SHS exposure on total higher than 0.50%/0.70%, whereas northern EU-countries showed the lowest burden, with proportions of DALYs/deaths lower than 0.25%/0.34%. The burden from SHS exposure is still significant in EU countries. More could be done to raise awareness of the health risks associated with SHS exposure at home.

Who Smokes in Europe? Data From 12 European Countries in the TackSHS Survey (2017-2018).

BACKGROUND: Population data on tobacco use and its determinants require continuous monitoring and careful inter-country comparison. We aimed to provide the most up-to-date estimates on tobacco smoking from a large cross-sectional survey, conducted in selected European countries. METHODS: Within the TackSHS Project, a face-to-face survey on smoking was conducted in 2017-2018 in 12 countries: Bulgaria, England, France, Germany, Greece, Ireland, Italy, Latvia, Poland, Portugal, Romania, and Spain, representing around 80% of the 432 million European Union (EU) adult population. In each country, a representative sample of around 1,000 subjects aged 15 years and older was interviewed, for a total of 11,902 participants. RESULTS: Overall, 25.9% of participants were current smokers (31.0% of men and 21.2% of women, P < 0.001), while 16.5% were former smokers. Smoking prevalence ranged from 18.9% in Italy to 37.0% in Bulgaria. It decreased with increasing age (compared to <45, multivariable odds ratio [OR] for ≥65 year, 0.31; 95% confidence interval [CI], 0.27-0.36), level of education (OR for low vs high, 1.32; 95% CI, 1.17-1.48) and self-rated household economic level (OR for low vs high, 2.05; 95% CI, 1.74-2.42). The same patterns were found in both sexes. CONCLUSIONS: These smoking prevalence estimates represent the most up-to-date evidence in Europe. From them, it can be derived that there are more than 112 million current smokers in the EU-28. Lower socio-economic status is a major determinant of smoking habit in both sexes.

National burden of cancer in Italy, 1990-2017: a systematic analysis for the global burden of disease study 2017.

We monitored the burden of cancer in Italy and its trends over the last three decades, providing estimates of cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs), for cancer overall and 30 cancer sites using data from the Global Burden of Disease study 2017. An overview of mortality trends between 1990 and 2017 was also provided. In 2017, there were 254,336 new cancer cases in men and 214,994 in women, corresponding to an age-standardized incidence rate (ASIR) of 438 and 330/100,000, respectively. Between 1990 and 2017, incident cancer cases, and, to a lesser extent, ASIRs significantly increased overall and for almost all cancer sites, but ASIRs significantly declined for lung and other tobacco-related neoplasms. In 2017, there were 101,659 cancer deaths in men (age-standardized death rate, ASDR, 158.5/100,000) and 78,918 in women (ASDR 93.9/100,000). Cancer deaths significantly increased between 1990 and 2017 (+ 18%), but ASDR significantly decreased (- 28%). Deaths significantly increased for many cancer sites, but decreased for stomach, esophageal, laryngeal, Hodgkin lymphoma, and testicular cancer. ASDRs significantly decreased for most neoplasms, with the main exceptions of cancer of the pancreas and uterus, and multiple myeloma. In 2017, cancer caused 3,204,000 DALYs. Between 1990 and 2017, DALYs and age-standardized DALY rates significantly declined (-3.4% and -33%, respectively). Age-standardized mortality rates in Italy showed favorable patterns over the last few decades. However, the absolute number of cancer cases and, to a lower extent, of cancer deaths increased likely due to the progressive ageing of the population, this calling for a continuous effort in cancer prevention, early diagnosis, and treatment.

Burden of disease from breast cancer attributable to smoking and second-hand smoke exposure in Europe.

Smoking and second-hand smoke (SHS) exposure have been recently linked to a higher risk of breast cancer in women. The aim of this work is to estimate the number of deaths and disability-adjusted life years (DALYs) from breast cancer attributable to these two risk factors in the European Union (EU-28) in 2017. The comparative risk assessment method was used. Data on prevalence of smoking and SHS exposure were extracted from the Eurobarometer surveys, relative risks from a recent meta-analysis, and data on mortality and DALYs from breast cancer were estimated from the Global Burden of Disease, Injuries and Risk Factors Study. In 2017, 82 239 DALYs and 3354 deaths from breast cancer in the EU-28 could have been avoided by removing exposure to these two risk factors (smoking and SHS exposure). The proportion of DALYs from breast cancer lost respectively from smoking and SHS exposure was 2.6% and 1.0%, although geographically distributed with significant heterogeneity. These results represent the first estimates of breast cancer burden in women attributable to smoking and SHS exposure for the EU-28. It is important to increase awareness among women, health professionals and wider society of the association between smoking, SHS exposure and breast cancer, a relationship that is not widely recognised or discussed.

[Socioeconomic and regional inequalities in smoking cessation in Italy, 2014-2017]. / Disuguaglianze regionali e socioeconomiche nella cessazione del fumo in Italia, 2014-2017.

OBJECTIVES: to study regional differences in Italy of quit smoking attempts and of successful abstinence, in relation to socioeconomic status, cigarettes per day (cig/die), and smoking cessation method in a representative sample of the population resident in Italy. DESIGN: cross-sectional survey. SETTING AND PARTICIPANTS: in 2014-2017, PASSI survey (the ongoing Italian behavioural risk factor surveillancesystem) gathered data on smoking and sociodemographic characteristics of 35,157 smokers; 13,130 aged 18-69 years made >1 quit attempt in the previous year, 1,176 of them were successful quitters for >6 months. MAIN OUTCOME MEASURES: proportion of smokers who tried to quit; proportion of smokers who successfully quitted. RESULTS: about 35% of smokers made >1 quit attempt in the last year. Northern Italians and smokers with many economic difficulties were more likely to make a quit attempt, whereas heavy smokers were less likely. About 10% of attempters were abstinent for >6 months: from 6% in Campania and Abruzzo to 17% in the Bolzano province. Attempters who smoked <20 cig/die had higher likelihood to be abstinent, compared to those smoking <20 cig/die. Attempters with many economic difficulties had the lowest likelihood to be abstinent (7%), with no differences by region, educational level, quitting method. Attempters with no economic difficulties recorded the highest cessation rates (12%). Among them, those from Northern Italy, Tuscany, Marche, and Lazio (Central Italy), and Apulia (Southern Italy) compared to attempters from most Southern regions, and those with high education level or using traditional quitting methods compared to those using electronic cigarettes or unaided were more likely to be abstinent for >6 months. CONCLUSIONS: smokers with many economic difficulties in all Italy, and those with no economic difficulties residing in Umbria and in most Southern Italian regions, except for Basilicata and Puglia, recorded lower chances to quit. Regional differences may have two possible explanations integrating each other: Northern-Central regions are in a slightly more advanced stage in the tobacco epidemic; regions which developed specific tobacco control interventions in their Prevention Plans recorded higher quitting rates. Not-yet-implemented interventions could promote smoking cessation in smokers from Southern Italy and in those with lower socioeconomic status: reimbursement of smoking cessation treatments, a well-developed national Quitline linked to a webplatform and to mobile phone application or text-messaging, an opt-out smoking cessation service offered systematically to all smokers at every encounter in hospitals or health services.

Burden of disease attributable to second-hand smoke exposure: A systematic review.

Our aim was to provide a systematic review of studies on the burden of disease due to second-hand smoke (SHS) exposure, reviewing methods, exposure assessment, diseases causally linked to SHS, health outcomes, and estimates available to date. A literature review of studies on the burden of disease from SHS exposure, available in PubMed and SCOPUS, published 2007-2018 in English language, was carried out following the PRISMA recommendations. Overall, 588 studies were first identified, and 94 were eligible. Seventy-two studies were included in the systematic review. Most of them were based on the comparative risk assessment approach, assessing SHS exposure using mainly surveys on exposure at home/workplaces. Diseases more frequently studied were: lung cancer, ischemic heart disease, stroke, chronic obstructive pulmonary disease, asthma and breast cancer in adults; lower respiratory tract infection, otitis media, asthma, sudden infant death syndrome and low birth weight in children. The SHS exposure assessment and the reported population attributable fractions (PAF) were largely heterogeneous. As an example, the PAF from lung cancer varied between 0.6% and 20.5%. Moreover, PAF were estimated applying relative risks and SHS exposures with no consistent definitions or with different age classes. The research gap on the SHS exposure burden is shrinking. However, estimates are not yet available for a number of countries, particularly the Middle Eastern and African countries, and not all diseases with the strongest evidence of causation, such as sudden infant death syndrome, have been explored. Moreover, in some cases the applied methodology revealed relatively low quality of data.

Impact of National Smoke-Free Legislation on Educational Disparities in Smoke-Free Homes: Findings from the SIDRIAT Longitudinal Study.

Families with lower socioeconomic status are less likely to adopt household smoking bans (HSB). The aim of this study was to determine whether socioeconomic disparities in HSB prevalence in Italy decreased 7-9 years after the introduction of the Italian ban on smoking in public places. A longitudinal, 12-year, two-wave study was conducted on a sample of 3091 youths aged 6-14 years in 2002; 1763 (57%) were re-interviewed in 2012-2014. A Poisson regression with a robust error variance was used to assess the association between socioeconomic disparities and HSB prevalence. The adoption of HSBs significantly increased from 60% in 2002 to 75% in 2012-2014, with the increase recorded in youths with ≥1 smoking parent only (from 22% at baseline to 46% at follow-up). The presence of HSBs at baseline was more likely in families with ≥1 graduate parent compared to those with no graduate parents (prevalence ratio (PR) = 1.34, 95% confidence interval (CI) = 1.15-1.57), either in families with ≥1 smoking parent (PR = 1.36, 95% CI = 1.17-1.58) or in families with non-smoking parents (PR = 1.61, 95% CI = 1.01-2.56). Conversely, at follow-up socioeconomic disparities dropped since families with no graduate parents were 1.5-fold more likely to introduce a HSB between the two waves. The Italian ban on smoking in public places may have increased the adoption of smoke-free homes in families with smoking and non-graduate parents, causing the drop of the socioeconomic gap in smoke-free homes.

A prevention program for multiple health-compromising behaviors in adolescence: baseline results from a cluster randomized controlled trial.

OBJECTIVE: To describe the design and present the baseline findings of the evaluation study of 'Paesaggi di Prevenzione', a school-based prevention program tackling smoking, alcohol misuse, dietary risks, and physical inactivity in 12- to 14-year-olds. METHODS: The program was implemented from January 2011 to April 2012 in Emilia-Romagna, Italy, and comprised classroom activities and school-wide policies. A two-arm cluster randomized controlled trial was designed. Schools were the units of randomization and were matched by socioeconomic status, size, and type. RESULTS: Data from 4700 middle school students and 2952 high school students were collected anonymously from October to December 2010. Past-30-day smoking prevalence was 1.9% among middle school students and 20.8% among high school students. Past-30-day prevalence of alcohol intoxication was 2.2% among middle school students and 11.4% among high school students. A total of 39.7% of middle school students and 48.0% of high school students drank sugar-sweetened beverages four or more times per week; 7.5% of middle school students and 7.1% of high school students had intense physical activity every day. CONCLUSIONS: This study seems adequately powered and baseline variables appear evenly distributed between study groups. Findings are in line with those of the WHO Health Behaviour in School-Aged Children study.

[Hospitalization study on a cohort of families applying for tenement houses in Florence (Tuscany Region, Central Italy)]. / Studio sull'ospedalizzazione di una coorte di richiedenti casa popolare a Firenze.

OBJECTIVES AND DESIGN: to evaluate the morbidity of a materially deprived population of family members applying for public tenement houses in Florence, Central Italy, in the period 1977-2001. SETTING AND PARTICIPANTS: all yearly first hospital admissions concerning 4,773 persons resident in Florence who applied for tenement houses to local public bodies during 1997-2001 were collected. MAIN OUTCOME MEASURES: gender specific age-standardized hospitalization ratios (SHR) for all causes and cause-specific hospital admissions during 2001- 2005. The expected cases were calculated using as reference gender, age and cause specific hospitalization rates of Tuscany population for the 2001-2005 period. RESULTS: 2,777 hospital admissions were registered. Statistically significant excesses of standardized hospitalization ratio were observed in both genders for all causes (males: SHR 1.14, 95%CI 1.07-1.20; females: SHR 1.22, 95%CI 1.16-1.28), mental disorders (males: SHR 2.19, 95%CI 1.71- 2.76; females: SHR 1.77, 95%CI 1.35-2.27) and respiratory diseases (males: SHR 1.25, 95%CI 1.05-1.47; females: SHR 1.33, 95%CI 1.09-1.60). Other excesses were observed for endocrine, metabolic and immunity disorders only in males (SHR 1.38, 95%CI 1.04-1.79), and for injuries and poisoning only in females (SHR 1.24, 95%CI 1.03-1.48). Statistical significant deficits were observed for neoplasm and for diseases of circulatory system in both genders, and for diseases of the musculoskeletal system and connective tissue in males. CONCLUSION: the results, consistent with the available evidences on causes of illness in disadvantaged groups, point to the importance of built environment and adequate housing in reducing health inequalities.

Analyzing and comparing the association between control policy measures and alcohol consumption in Europe.

This paper focuses on the association between alcohol consumption and the introduction of control policy measures, within the AMPHORA 12 country European project. We estimated the "net" associations between intervention policies and total alcohol consumption, taking into account contextual socioeconomic factors and including all policies in the same regression model. The associations were estimated for each country, and the country-specific results were compared in a random-effects meta-analysis. The association between policy measures and total alcohol consumption was very heterogeneous among countries. Policies on restricting alcohol availability and on enhancing the minimum age for alcohol purchase appeared to be related to decreasing alcohol consumption. The evidence regarding the effect of the others kinds of interventions was more contradictory.

Analyzing the effect of selected control policy measures and sociodemographic factors on alcoholic beverage consumption in Europe within the AMPHORA project: statistical methods.

This paper describes the methods used to investigate variations in total alcoholic beverage consumption as related to selected control intervention policies and other socioeconomic factors (unplanned factors) within 12 European countries involved in the AMPHORA project. The analysis presented several critical points: presence of missing values, strong correlation among the unplanned factors, long-term waves or trends in both the time series of alcohol consumption and the time series of the main explanatory variables. These difficulties were addressed by implementing a multiple imputation procedure for filling in missing values, then specifying for each country a multiple regression model which accounted for time trend, policy measures and a limited set of unplanned factors, selected in advance on the basis of sociological and statistical considerations are addressed. This approach allowed estimating the "net" effect of the selected control policies on alcohol consumption, but not the association between each unplanned factor and the outcome.

A school-based peer-led smoking prevention intervention with extracurricular activities: the LILT-LdP cluster randomized controlled trial design and study population.

AIMS AND BACKGROUND: Few school programs are effective in preventing adolescents' tobacco smoking initiation. The "Lega contro i Tumori - Luoghi di Prevenzione" is a cluster randomized controlled trial designed to evaluate a school-based peer-led smoking prevention intervention with extracurricular activities for students aged 14-15 years. This paper presents the study design and the baseline characteristics of the study population. METHODS AND STUDY DESIGN: Twenty secondary schools located in the Reggio Emilia province took part in the study. Five schools were excluded because they already participated in smoking prevention interventions. The schools were randomized to control or intervention arms. The study population consisted of students attending the first grade. Components of the intervention included 1) the out-of-school "Smoking Prevention Tour" (SPT) at the "Luoghi di Prevenzione" Center, a 4-hour (4 sessions) extracurricular activity; 2) the "Smoke-free Schools" intervention, combining a life-skills-based peer-led intervention at school, an in-depth lesson on one of the SPT sessions, and enforcement surveillance of the school antismoking policy. Tobacco use was studied through a questionnaire administered before and 6 months after the intervention. RESULTS: Eleven high schools and 9 vocational secondary schools took part in the study for a total of 2,476 out of 3,050 eligible students (81.2%). The proportions of respondents in high schools and vocational secondary schools were 90.9% and 64.5%, respectively (P <0.001). Intervention and control arms showed a different distribution of gender and school type, whereas no difference was observed in any tobacco-use characteristic. CONCLUSIONS: This study is one of the few Italian trials to evaluate the effectiveness of a school-based program for preventing smoking initiation.

Decennial trends of social differences in smoking habits in Italy: a 30-year update.

PURPOSE: To update educational inequalities in smoking in Italy up to 2009, with an in-depth analysis of female prevalence. METHODS: Data from 15 national health surveys (1980, 1983, 1986-1987, 1990, 1994, 1999-2003, 2005-2009) were analyzed. The overall sample size was representative of the population older than 25 years of age (3,300,000 men and 3,620,000 women). Main measures smoking prevalence rates standardized to the 2,000 European population, prevalence ratios by educational level (high: university degree or high school diploma; low: primary or middle school diploma), area (north, center, south and islands), and age-group (25-44, 45-59, >=60 years). Trends in tobacco prevalence were also analyzed with a multivariate approach using the negative binomial distribution. RESULTS: Although male prevalence steadily declined of about 2% annually from 56.1% in 1980 to 30.2% in 2009, educational inequalities slightly widened, recording in 2009 a 53% higher prevalence in men with low educational level compared to graduates. Even though female prevalence stalled around 18% in the last three decades, this was the result of opposite trends by educational group. In fact, highly educated women, with the highest prevalence during 1980s, decreased their tobacco use, determining a reversal similar to men in educational inequalities in smoking. This reversal occurred from the 1980s onwards with a time gradient starting from north to south and from younger to older women. CONCLUSION: To achieve a fairer reduction in smoking habits, tobacco control policies focusing on lower social groups are needed.

The "Don't smoke in our home" randomized controlled trial to protect children from second-hand smoke exposure at home.

AIMS AND BACKGROUND: Increasing smoke-free homes is an important public health goal, but only few interventions have yielded positive results. The aim of the "Don't smoke in our home" trial was to evaluate a counseling intervention focused on promoting totally smoke-free homes and cars (TSFHC) delivered to women with children resident in four Tuscan towns. METHODS AND STUDY DESIGN: We used a two-group randomized controlled trial design. Participants were asked about their smoking habits and about restrictions on smoking in their homes and cars. All women received a self-help booklet promoting TSFHC, and 110 women randomized to the intervention also attended brief counseling on second-hand smoke exposure protection and received three gifts to remember the commitment to TSFHC. Follow-up was conducted by phone after four months. RESULTS: We recruited 218 women, 64 of whom had a university degree and 131 of whom were smokers; 62% reported smoking indoors and 58% in cars. Before the intervention, nonsmokers were more likely to report totally smoke-free homes (TSFH, 52%) and cars (TSFC, 53%) than smokers (26% and 17% respectively; P <0.001). Participants of the experimental arm had similar odds as controls of having implemented TSFH after the intervention, and nonsignificantly increased odds of having introduced TSFC (odds ratio [OR] 1.47; 95% confidence interval [CI] 0.69-3.11), particularly among smokers (OR 2.24, 95%CI 0.69-7.26). All participants independently of the study arm recorded significant increases of 12 and 15 percentage points in TSFH and TSFC, respectively. Few smokers quit smoking (7%), stopped smoking indoors (5%), and stopped smoking in cars (7%), with no differences between the intervention and control groups. CONCLUSIONS: Adding brief counseling to written materials did not significantly increase TSFHC. However, delivering written materials only may produce modest but noteworthy TSFHC increases at the population level, even though the participants in the study did not represent a population-based sample, given the high proportion of highly educated women. Further studies are required to confirm these results.

Italy SimSmoke: the effect of tobacco control policies on smoking prevalence and smoking attributable deaths in Italy.

BACKGROUND: While Italy has implemented some tobacco control policies over the last few decades, which resulted in a decreased smoking prevalence, there is still considerable scope to strengthen tobacco control policies consistent with the World Health Organization (WHO) policy guidelines. The present study aims to evaluate the effect of past and project the effect of future tobacco control policies on smoking prevalence and associated premature mortality in Italy. METHODS: To assess, individually and in combination, the effect of seven types of policies, we used the SimSmoke simulation model of tobacco control policy. The model uses population, smoking rates and tobacco control policy data for Italy. RESULTS: Significant reductions of smoking prevalence and premature mortality can be achieved through tobacco price increases, high intensity media campaigns, comprehensive cessation treatment program, strong health warnings, stricter smoke-free air regulations and advertising bans, and youth access laws. With a comprehensive approach, the smoking prevalence can be decreased by as much as 12% soon after the policies are in place, increasing to a 30% reduction in the next twenty years and a 34% reduction by 30 years in 2040. Without effective tobacco control policies, a total of almost 300 thousand lives will be prematurely lost due to smoking by the year 2040. CONCLUSION: Besides presenting the benefits of a comprehensive tobacco control strategy, the model helps identify information gaps in surveillance and evaluation schemes that will promote the effectiveness of future tobacco control policy in Italy.

Is human papillomavirus screening preferable to current policies in vaccinated and unvaccinated women? A cost-effectiveness analysis.

OBJECTIVES: Italy was the first European nation to offer free vaccination against human papillomavirus (HPV) types 16 and 18. The vaccination is actively encouraged and is available free of charge to 11-year-old girls. The introduction of new technologies such as HPV DNA testing and HPV vaccination requires cost-effectiveness analysis of cervical cancer strategies in Italy for both vaccinated and unvaccinated women. METHODS: A calibrated Markov model was developed to describe the natural history of HPV infection and cervical carcinogenesis. We performed a microsimulation generating the life histories of 10 million women. Changes in these life histories occur as consequences of prevention strategies. We estimated costs of screening activities using an activity-based costing analysis. We assessed lifetime risk due to cervical cancer, lifetime costs and quality-adjusted life-expectancy (QALE) for 18 scenarios. Strategies varied by screening interval (three and five years), primary and triage test (Pap test and HPV DNA test), and HPV 16 and 18 vaccination. RESULTS: The current screening policy (Pap test every three years) is more costly and less effective than HPV DNA test and Pap test triage every five years. For unvaccinated women an HPV DNA test every five years with a Pap test triage was cost-effective (ICER €5753/QALE). Vaccination followed by the same screening strategy was cost-effective (ICER €23,951/QALE) for women who are eligible to be vaccinated. CONCLUSIONS: Our findings strongly support changing the Pap screening policy to the use of HPV DNA as a primary test with Pap test triage for both vaccinated and unvaccinated women.