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.

Food advertising during children's television programmes in Italy.

OBJECTIVE: Previous studies from European countries noted that food products promoted on TV for children did not comply with international guidelines, including the World Health Organization European Nutrient Profile Model (WHO-ENPM) and the EU Pledge Nutrition Criteria (EU-PNC, an initiative developed by leading food companies). We aim to provide new data from Italy. DESIGN: Evaluation of Italian TV advertisements. Data on nutritional values for food product advertised were compared with nutritional standards issued by the WHO-ENPM and the EU-PNC. SETTING: In total, 180 h of TV programmes from six Italian channels, 2016-2017. PARTICIPANTS: Eight hundred and ten consecutive advertisements during children's programmes. RESULTS: Out of 810 advertisements, 90 (11·1 %) referred to food products. Among these, 84·5 % of the foods promoted did not meet the WHO-ENPM and 55·6 % the EU-PNC guidelines. Advertisements promoting sweet and salty snacks (i.e. ≥ 70 % of all foods) v. other food products showed higher non-compliance with both the WHO-ENPM (OR: 73·8; 95 % CI: 4·09, 1330) and the EU-PNC (OR: 9·21; 95 % CI: 2·82, 30·1). CONCLUSIONS: In Italy, most food advertisements during children's programmes are not compliant with European nutritional standards. Almost all the advertisements for snacks do not meet international guidelines. As the WHO-ENPM guidelines do not propose standards for all the food products, including meals, there is an urgent need to define independent and easy-to-read guidelines for food advertisements targeting children. As a first step towards the complete ban of food advertisements targeting children recommended by other researchers, these guidelines should be enforced by all the TV broadcasts.

The effect of online gambling on gambling problems and resulting economic health costs in Germany.

Problematic and pathological gambling have emerged as substantial problems in many countries. One potential accelerating factor for this phenomenon during recent years is the Internet, which offers different kinds of games and online applications for gambling that are faster, more attractive due to a variety of design and marketing options, less costly and potentially more addictive than terrestrial gambling opportunities. However, the contributing role of the Internet for problematic gambling has not been analyzed sufficiently so far and remains inconclusive. The current study is based on a representative sample with 15,023 individuals from Germany. With a new concept of assessing online gambling with its relative fraction of total gambling activities and a control-function approach to account for possible endogeneity of online gambling, we estimate the impact of online gambling on gambling behavior while additionally controlling for a rich set of important covariates, like education, employment situation and family status. The results show that, on average, replacing 10% of offline gambling with online gambling increases the likelihood of being a problematic gambler by 8.8-12.6%. This increase is equivalent to 139,322 problematic gamblers and 27.24 million € per year of additional expenditures in the German health sector. Our findings underpin the necessity to keep online gambling restricted to prevent further developments of problematic and pathological gambling in Germany.

The costs of hazardous alcohol consumption in Germany.

Hazardous alcohol consumption in Germany is a main threat to health. By using insurance claim data from the German Statutory Health Insurance and a classification strategy based on ICD10 diagnoses-codes we analyzed a sample of 146,000 subjects with more than 19,000 hazardous alcohol consumers. Employing different regression models with a control function approach, we calculate life years lost due to alcohol consumption, annual direct and indirect health costs, and the burden of pain and suffering measured by the Charlson-Index and assessed pain diagnoses. Additionally, we simulate the net accumulated premium payments over expenses in the German Statutory Health Insurance and the Statutory Pension Fund for hazardous alcohol consumers from a lifecycle perspective. In total, €39.3 billion each year result from hazardous alcohol consumption with an average loss of 7 years in life expectancy. Hazardous alcohol consumers clearly do not "pay their way" in the two main German social security systems and also display a higher intangible burden according to our definitions of pain and suffering.

The costs and consequences of obesity in Germany: a new approach from a prevalence and life-cycle perspective.

With the steadily growing health burden of obesity in Germany, the measuring and quantification of its costs and relevant economic consequences have become increasingly important. The usual quantifications via previous cost-of-illness approaches mostly have several weaknesses, e.g., applying "indirect methods" by using "population-attributable fractions" to identify parts of costs that can be accrued to obesity, second using highly aggregated data and third often only displaying part of the costs. This article presents a new approach and a new estimation of the cost and consequences of obesity in Germany using claims data from a German health insurance company. A sample of 146,000 individuals was analyzed with both a prevalence and a life-cycle focus on the cost and consequences of obesity. With additional data sets, we calculate the deaths per year due to obesity, the excess costs per year and several intangible consequences usually referred to as "pain and suffering". Our results show that the cost estimations of obesity in Germany so far have been largely underestimated. The annual direct costs of obesity in Germany amount to approximately €29.39 billion and the indirect costs to an additional €33.65 billion. A total of 102,000 subjects die prematurely each year because of obesity, and there is a significant excess of unemployment, long-term nursing care, and pain and suffering due to obesity. From a lifetime perspective, every obese man is equal to an additional burden of €166,911 and each woman of €206,526 for the social security system in Germany. Obesity due to unhealthy eating is thus about to replace tobacco consumption in terms of costs and consequences as the main hazardous lifestyle factor and thus should be more intensively focussed by public health policy.

The burden and cost of disorders of the brain in Europe with the inclusion of harmful alcohol use and nicotine addiction.

Recent publications calculated an annual prevalence of 38% of the population within the European Union having a "disorder of the brain" including substance use disorders (SUD) (Wittchen et al., 2011). The overall economic burden was estimated at 789 billion € (Gustavsson et al., 2011). While these calculations included alcohol dependence, harmful use of alcohol, a common ICD-10 diagnosis, was not considered appropriately. Tobacco related figures were completely left out. We hence estimated burden and costs of these diagnoses for the European Union by extrapolating basic figures from Germany, which have average proportions of alcohol and tobacco related consumption and prevalence rates. Several German Data sets were used to estimate prevalence, disability adjusted life years (DALYs) and Cost-of-Illness for alcohol and tobacco use disorders in Germany. Results were obtained by focussing on the burden of SUD including well-known comorbidities. Results were then extrapolated to the European level. Compared with the earlier estimations DALYs increased from 2.8 million to over 6.6 million for SUDs. Costs augmented from 65.68 billion € PPP to about 350 billion € PPP. We discuss the robustness and validity of our findings under different assumptions and with regard to methodology. We further took into account that in the new DSM 5 alcohol abuse and alcohol dependence - and similar tobacco - will be collapsed into one category of "alcohol related disorder". If added to the burden and cost calculations the substance use disorders rank on top of all disorders of the brain in Europe. Regardless of the calculation procedure our figures represent lower estimates and have to be regarded as conservative approaches.

Do television food commercials target children in Germany?

OBJECTIVE: To examine whether the German food industry directs commercials for unhealthy products to children and whether self-administered voluntary restrictions on the promotion of less healthy foods (the EU Pledge) are effective to mitigate this exposure. DESIGN: By analysing German data from television (TV) channels, advertised products were categorized and food products classified as core foods (healthy) and non-core foods (less healthy). Marketing techniques were documented. Food commercials were furthermore compared with commercials for toy products, and comparisons were made between advertising patterns before and after the EU Pledge. SETTING: Data for ten German TV channels were recorded for two weekdays and two weekend days from 06.00 to 22.00 hours in 2007 and 2008. A second sample containing one weekday and one weekend day of three German TV channels was recorded again in 2010 for comparison in the same time period. SUBJECTS: In total 16 062 advertisements from 2007-2008 and 2657 from 2010 were analysed. RESULTS: In 2007-2008 19·9 % of TV commercials were for food products, of which 73 % were for non-core foods, 21 % for core foods and 6 % not classified. In three specified channels widely viewed by children and youth, 14·5 % of commercials were for food products, of which 88·2 % were for non-core foods. Commercials for unhealthy foods were broadcast significantly more often during children's peak viewing and in children's programmes, with a higher use of promotional characters and premiums than found in commercials for non-food products. In 2010, analysis of the three specified channels found that 18·5 % of commercials were for food products, of which 98·2 % were for non-core foods. While the use of premiums decreased compared with other commercials, the use of promotional characters in non-core food commercials increased, especially during children's programmes. CONCLUSIONS: Children in Germany are exposed to large numbers of food commercials. The exposure to commercials for non-core foods and the use of techniques attractive to children are widespread and appear to have remained unaffected by the announcement of the EU Pledge in December 2007. We conclude that the industry's voluntary agreement has failed to fulfil its declared purpose.

Television food advertising to children: a global perspective.

OBJECTIVES: We compared television food advertising to children in several countries. METHODS: We undertook a collaboration among 13 research groups in Australia, Asia, Western Europe, and North and South America. Each group recorded programming for 2 weekdays and 2 weekend days between 6:00 and 22:00, for the 3 channels most watched by children, between October 2007 and March 2008. We classified food advertisements as core (nutrient dense, low in energy), noncore (high in undesirable nutrients or energy, as defined by dietary standards), or miscellaneous. We also categorized thematic content (promotional characters and premiums). RESULTS: Food advertisements composed 11% to 29% of advertisements. Noncore foods were featured in 53% to 87% of food advertisements, and the rate of noncore food advertising was higher during children's peak viewing times. Most food advertisements containing persuasive marketing were for noncore products. CONCLUSIONS: Across all sampled countries, children were exposed to high volumes of television advertising for unhealthy foods, featuring child-oriented persuasive techniques. Because of the proven connections between food advertising, preferences, and consumption, our findings lend support to calls for regulation of food advertising during children's peak viewing times.

Effective prevention against risky underage drinking--the need for higher excise taxes on alcoholic beverages in Germany.

AIM: The study aimed to explore the place of taxation in preventing underage binge drinking in Germany. METHOD: We reviewed evidence on the role of excise taxes on alcohol in preventing alcohol problems and underage drinking. We analyzed historical German data on tax on alcoholic beverages and compared this with European data, finally calculating tax scenarios and their impact on underage binge drinking. RESULTS: Germany applies lower taxes than many other European countries and alcohol beverage prices have decreased by 30% relative to overall price levels during the last 40 years. CONCLUSION: An optimal tax rate for reducing underage drinking would be set between the European average tax rates and Scandinavian tax rate levels.