Tobacco active and passive smoking in Italy Data Monitoring System PASSI (Progressi delle Aziende Sanitarie per la Salute in Italia) www.epicentro.iss.it/passi/english.asp

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Tobacco active and passivesmoking in ItalyData
Monitoring System PASSI (Progressi delle Aziende
Sanitarie per la Salute in Italia)www.epicentro.i
ss.it/passi/english.asp

• Valentina Minardi
• PASSI Coordinating Group
• National Centre for Epidemiology, Surveillance
  and Health Promotion
• Italian Health Institute

Workshop Italo-Tunisien sur le Tabagisme Rome,
23-24 Septembre 2010
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What is surveillance and why do it?
WHO
Public Health Surveillance Ongoing,
systematic collection, analysis, and
interpretation of health-related data essential
to the planning, implementation, and evaluation
of public health practices, closely integrated
with the timely dissemination of these data to
those responsible for prevention and control.
Information
Action

• Purposes
• Assess public health status
• Define public health priorities
• Evaluate programs
• Stimulate research

• Core Public Health Functions
• Assessment
• Policy development
• Assurance
• Advocacy
• Empowerment

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Background

• 57 million inhabitants
• 21 regions
• Universal health care and preventive services
• Local Health Units (LHU)
• 1 unit per 300,000 residents (100,000
  1,000,000)
• Stewardship
• interpretation of national guidelines (national
  health plans) by regional health authorities

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Example
Data collection, analyses and dissemination of
results are based at LHU level (and at regional
level as well)
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Data on health behaviors

• Collected by National Institute of Statistics
  (ISTAT) with several limitations
• Surveys made every 5 years
• national and regional level
• delay in dissemination of data
• items included not always useful for public
  health planning and evaluation
• ? Lack of data on health behavior at LHU
• level, where many health interventions are
  planned and (sometimes) evaluated

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PASSI (Progressi delle Aziende Sanitarie per la
Salute in Italia)

• 2005 and 2006
• Two pilot cross-sectional studies testing
  materials and methods for the future
  implementation of a surveillance system
• Knowledge shared by CDC/BRFSS and other
  international experts was very useful in setting
  up the system
• In 2006 the Ministry of Health funded the
  National Centre for Epidemiology, Surveillance
  and Health Promotion (CNESPS) to develop ongoing
  surveillance of behavioral risk factors and
  preventive measures included in the National
  Prevention Plan

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A system able to

• Collect useful and representative data on
  behaviors connected to health at LHU level
• Provide timely feedback ? planning and evaluation
  of programs/interventions
• Facilitate comparisons between LHU/regions ?
  identify best practices
• Permit comparisons with international data
• Evaluate trend on time
• Last but not least
• Promote the professional development of local and
  regional staff
• Increase the use of epidemiological data at local
  level

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Method

• Since 2007 ongoing (monthly) data collection in
  each participating LHU
• telephone interviews of at least 275
  persons/year/LHU
• Interviewers LHU personnel using a standardized
  questionnaire (questions adapted from BRFSS,
  ISTAT ? comparisons)
• Participants selected from LHU population
  registers using stratified random sampling
• Inclusion criteria age 18-69, residence in
  catchment area, availability of telephone number
  (mobile or land-line, obtained through various
  sources)

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The technological infrastructure of PASSI an
innovative system using free and open-source
software

• e-Passi a web-based infrastructure to collect,
  centralize and analyze data
• The infrastructure is flexible, user-friendly,
  and independent of local hardware and software
  installations
• A smart client application that uses a
  readily-available internet browser for
• stand-alone functions for data entry and
  real-time record saving on interviewers
  computers
• interview tracking (assignment, current status)
• CATI-like data entry
• automatic and secure upload of completed
  interviews

Source P. Brunetti, G. Dallago, S. Fontanari, S.
Menegon
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The questionnaire

• Topics included are priorities of the National
  and Regional Health Plan
• quality of life
• smoking habits
• physical activity
• diet
• alcohol consumption
• driving behavior
• cardiovascular risk factors
• cancer screening
• vaccinations
• mental health
• domestic accidents
• socio-demographic aspects

114 questions, many administered to specific
subpopulations (e.g. cancer screening) or
categories (e.g. present smokers)
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Not only behaviors
Compliance to smoking band

• Public health interventions
• Screening programs
• Counselling by general practitioners
• Optional modules on
• Police interventions for drunk drivers
• Evaluation of special health promotions programs
  implemented at regional level
• Diabetes
• Work place safety
• H1N1 Influenza
• Importance of social determinants of health
• All risk factors/compliance with public health
  programs are broken down by
• Income
• Education

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Data collection (2007-2009)

• 21/21 Regions have begun data collection since
  April 2007, though not all at the same time
• Health personnel involved and trained 1.000
• Complete interviews 115,000
• 21,498 in 2007
• 37,560 in 2008
• 39,230 in 2009
• 18,958 in gen-sept 2010 (delayed upload of
  interviews by LHU)
• 2009
• Response rate 88
• Substitution rate 12
• Refusal rate 9
• Not found 3

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Smoking habits
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Smoking habits

Never Smokers1 51,6
Former smokers2 19,7
Smokers 28,7
Smokers in abstention3 1,2
Occasional smokers4 0,5
Daily smokers 27,0
Mean of cigarettes 13
1 never smoked at all or smoked less than 100
cigarettes in lifetime 2 smoked at least 100
cigarettes during their lifetime and stopped
smoking since more than 6 months 3 smoked at
least 100 cigarettes during their lifetime and
stopped smoking since less than 6 months 4
smokers of less than one cigarette a day
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Smoke in Italy

• Higher (statistically significant)
• in younger age groups
• among men
• in people with intermediate level of education
  (lower and upper secondary)
• more economic difficulties
• Statistically significant differences comparing
  the Regions (range 25 Veneto - 32 Abruzzi)

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Trends over time

• The ongoing (monthly) data collection offers the
  possibility to compare annual/semestral/monthly
  prevalence

Smokers in Piedmont () 2007-2009
Smokers () Pool LHU PASSI 2007-2009
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Smoking cessation

• 41 of smokers declared at least one attempt to
  quit smoking in the last 12 months
• Nearly 1 in 5 of these came out
• 8 reported not smoking during the past 6 months
  (successful cessation)
• 9 were in abstention for less than 6 months
• 96 of former smokers quit smoking alone without
  any additional help or support

Among respondents who were smoker 12 months
before the interview
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Italian smoking ban

• Went into effect in jan/2005
• Covers all enclosed public and work places

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ENFASI Project 2004-05

• Before and after law enforcement owners opinion
  evaluation
• Source National Health Institute 2004-2005
• 50 public places in 33 auto-selected HLUs
• Respondents were owners of public places (pub,
  restaurant, etc.)
• 1 pre and 3 post evaluations of smoking ban
  compliance

Presence of smokers in the public place
() Studio ENFASI 2005
Compliance to the smoking ban in the public
places () Studio ENFASI 2005
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From ENFASI project

• Questionnaire section on smoking ban
• Q12 How do you think your customers will respond
  to the smoking ban?
• Everyone will comply
• Most customers will comply
• Some customers will comply and others will
  notMost customers will not comply
• Everyone will not comply

to PASSI

• Questionnaire section on smoking ban
• Q 3.11 In public places (as pubs,
  restaurants,...) you visited during the last 30
  days, in your view people comply to the smoking
  ban
• Always
• Nearly always
• Sometime
• Never
• I havent been in public places in the last month
• Dont know/ Dont remember

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Respect of the smoking ban Pooled data 2009
(n39,230)

• In Italy compliance with the law is good
• 87 of the interviewed reported that the ban is
  always or nearly always respected in public
  places and 88 think the same for work places

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Respect of the smoking ban in public
placesPooled data 2009
Respect of the smoking ban

• Comparing results from Regions a geographical
  gradient is noticed from north to south
• The region with the highest compliance rates are
  Valle D'Aosta and Friuli-Venezia Giulia (96) and
  the lowest is Calabria (64)
• A similar situation is found for ban compliance
  in work places

year Respect always/almost always
2007 84,6
2008 87,1
2009 88,3
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Household secondhand smokingPooled data 2009
(n39,230)

• Regarding the smoking habit at home, the majority
  of respondents declared to prevent exposure to
  secondhand smoke in their homes
• The value increases in households with children
  less than 14 years old

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PASSI data use

• Health profiles and prioritization processes
• Intervention planning and evaluation
• National and regional prevention plan
• Local intervention planning
• Dissemination of results (reports fact sheets
  on specific issues)

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Monthly estimates of the number of episodes of
guiding under the influence of alcohol per 1,000
people - BRFSS California data April 1987-January
1994 (n20,006)
1st intervention decrease in alcohol legal value
2nd intervention immediate withdrawal of license
pre estimation trend
post estimation trend
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The PASSI Coordinating Group at national level

• Centro nazionale di epidemiologia, sorveglianza e
  promozione della salute (CNESPS), Istituto
  Superiore di Sanità, Roma
• Sandro BALDISSERA, Paolo DARGENIO, Barbara DE
  MEI, Gianluigi FERRANTE, Valentina MINARDI,
  Valentina POSSENTI, Elisa QUARCHIONI, Stefania
  SALMASO
• Dipartimento di sanità pubblica, Azienda USL di
  Cesena
• Nicoletta BERTOZZI
• Dipartimento di Statistica, Università degli
  studi Ca Foscari, Venezia
• Stefano CAMPOSTRINI
• Dipartimento di sanità pubblica, AUSL Modena
• Giuliano CARROZZI
• Direzione generale della prevenzione sanitaria,
  Dipartimento prevenzione e comunicazione,
  Ministero della salute, Roma
• Stefania VASSELLI
• Dipartimento di prevenzione, ASL Caserta 2
• Angelo DARGENZIO
• Direzione promozione della salute, Azienda
  provinciale per i servizi sanitari, Trento

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Thank you!