Impact of the WHO "best buys" for alcohol policy on consumption and health in the Baltic countries and Poland 2000-2020

Alcohol use is a major risk factor for burden of disease. This narrative review aims to document the effects of major alcohol control policies, in particular taxation increases and availability restrictions in the three Baltic countries (Estonia, Latvia, and Lithuania) between 2000 and 2020. These measures have been successful in curbing alcohol sales, in general without increasing consumption of alcoholic beverages from unrecorded sources; although for more recent changes this may have been partly due to the COVID-19 pandemic. Moreover, findings from time-series analyses suggest improved health, measured as reductions in all-cause and alcohol-attributable mortality, as well as narrowing absolute mortality inequalities between lower and higher educated groups. For most outcomes, there were sex differences observed, with alcohol control policies more strongly affecting males. In contrast to this successful path, alcohol control policies were mostly dismantled in the neighbouring country of Poland, resulting in a rising death toll due to liver cirrhosis and other alcohol-attributable deaths. The natural experiment in this region of high-income European countries with high consumption levels highlights the importance of effective alcohol control policies for improving population health.

Alcohol control policies reduce all-cause mortality in Baltic Countries and Poland between 2001 and 2020

Alcohol consumption in the Baltic countries and Poland is among the highest globally, causing high all-cause mortality rates. Contrary to Poland, the Baltic countries have adopted many alcohol control policies, including the World Health Organization (WHO) "best buys". The aim of this study was to evaluate the impact of these policies, which were implemented between 2001 and 2020, on all-cause mortality. Monthly mortality data for men and women aged 20+ years of age in Estonia, Latvia, Lithuania, and Poland were analysed for 2001 to 2020. A total of 19 alcohol control policies, fulfilling an a-priori defined definition, were implemented between 2001 and 2020 in the countries of interest, and 18 of them could be tested. Interrupted time-series analyses were conducted by employing a generalized additive mixed model (GAMM) for men and women separately. The age-standardized all-cause mortality rate was lowest in Poland and highest in Latvia and had decreased in all countries over the time period. Taxation increases and availability restrictions had short-term effects in all countries, on average reducing the age-standardized all-cause mortality rate among men significantly (a reduction of 2.31% (95% CI 0.71%, 3.93%; p = 0.0045)). All-cause mortality rates among women were not significantly reduced (a reduction of 1.09% (95% CI - 0.02%, 2.20%; p = 0.0554)). In conclusion, the alcohol control policies implemented between 2001 and 2020 reduced all-cause mortality among men 20+ years of age in Baltic countries and Poland, and thus, the practice should be continued.

Classifying alcohol control policies enacted between 2000 and 2020 in Poland and the Baltic countries to model potential impact

AIMS

The study's aim is to identify and classify the most important alcohol control policies in the Baltic countries (Estonia, Latvia and Lithuania) and Poland between 2000 and 2020.

METHODS

Policy analysis of Baltic countries and Poland, predicting potential policy impact on alcohol consumption, all-cause mortality and alcohol-attributable hospitalizations was discussed.

RESULTS

All Baltic countries implemented stringent availability restrictions on off-premises trading hours and different degrees of taxation increases to reduce the affordability of alcoholic beverages, as well as various degrees of bans on alcohol marketing. In contrast, Poland implemented few excise taxation increases or availability restrictions and, in fact, reduced stipulations on prior marketing bans.

CONCLUSIONS

This classification of alcohol control policies in the Baltic countries and Poland provides a basis for future modeling of the impact of implementing effective alcohol control policies (Baltic countries), as well as the effects of loosening such policies (Poland).

Do alcohol control policies have the predicted effects on consumption? An analysis of the Baltic countries and Poland 2000-2020

BACKGROUND

Many population-based alcohol control policies are postulated to work via changes in adult alcohol per capita consumption (APC). However, since APC is usually assessed on a yearly basis, often there are not enough data to conduct interrupted time-series or other controlled analyses. The current dataset, with 21 years of observation from four countries (Estonia, Latvia, Lithuania, and Poland), had sufficient power to test for average effects and potential interactions of the World Health Organization's (WHO) three "best buys" for alcohol control: taxation increases leading to a decrease in affordability; reduced availability (via a decrease in opening hours of at least 20 %); and advertising and marketing restrictions. We postulated that the former two would have immediate effects, while the latter would have mid- to long-term effects.

METHODS

Linear regression analysis.

RESULTS

Taxation increases and availability reductions in all countries were associated with an average reduction in APC of 0.83 litres (ℓ) of pure alcohol per year (95 % confidence interval: -1.21 ℓ, -0.41 ℓ) in the same year, with no significant differences between countries. Restrictions on advertising and/or marketing had no significant immediate associations with APC (average effect 0.04 ℓ per year; 95 % confidence interval: -0.65 ℓ, 0.73 ℓ). Several sensitivity analyses corroborated these main results.

CONCLUSIONS

The WHO "best buy" alcohol control policies of taxation increases and availability restrictions worked as postulated in these four northeastern European Union countries.

Alcohol-Related Deaths in Poland During a Period of Weakening Alcohol Control Measures

This population epidemiology study describes trends in overall and age- and sex-specific alcohol-related deaths in Poland between 2002 and 2017, following the weakening in 2001 of policy measures designed to reduce alchohol consumption.

Support for e-cigarette policies among smokers in seven European countries: longitudinal findings from the 2016-18 EUREST-PLUS ITC Europe Surveys

BACKGROUND

The 2016 European Tobacco Products Directive (TPD) required Member States (MS) to implement new regulations for electronic cigarettes (ECs). We conducted a longitudinal study to assess changes over 2 years in smokers' support for EC policies and identify predictors of support in seven European countries after TPD implementation.

METHODS

Prospective cohort surveys were conducted among adult smokers in Germany, Greece, Hungary, Poland, Romania, Spain and England in 2016 (n = 9547; just after TPD) and 2018 (n = 10 287; 2 years after TPD). Multivariable logistic regression models employing generalized estimating equations assessed changes in support for four EC policies, and tested for country differences and strength of key predictors of support.

RESULTS

Banning EC use in smoke-free places was supported by 53.1% in 2016 and 54.6% in 2018 with a significant increase in Greece (51.7-66.0%) and a decrease in Spain (60.1-48.6%). Restricting EC/e-liquid nicotine content was supported by 52.2 and 47.4% in 2016 and 2018, respectively, with a significant decrease in England (54.2-46.5%) and Romania (52.5-41.0%). An EC promotion ban was supported by 41.1 and 40.2%. A flavour ban was supported by 33.3% and 32.3% with a significant increase in Hungary (34.3-43.3%). Support was generally higher in Poland, Hungary and Greece vs. England. Support was lower among dual and EC-only users, and low-income smokers.

CONCLUSIONS

Smokers in all countries strongly supported banning EC use in smoke-free places and restricting nicotine content after TPD implementation, with no clear trends for changes in policy support.

Impact of the Tobacco Products Directive on self-reported exposure to e-cigarette advertising, promotion and sponsorship in smokers-findings from the EUREST-PLUS ITC Europe Surveys

BACKGROUND

Advertising, promotion and sponsorship of electronic cigarettes (ECAPS) have increased in recent years. Since May 2016, the Tobacco Products Directive 2014/40/EU (TPD2) prohibits ECAPS in various advertising channels, including media that have cross-border effects. The objective of this study was to investigate changes in exposure to ECAPS in a cohort of smokers from six European Union member states after implementation of TPD2.

METHODS

Self-reported exposure to ECAPS overall and in various media and localities was examined over two International Tobacco Control Policy Evaluation survey waves (2016 and 2018) in a cohort of 6011 adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (EUREST-PLUS Project) using longitudinal generalized estimating equations models.

RESULTS

Self-reported ECAPS exposure at both timepoints varied between countries and across examined advertising channels. Overall, there was a significant increase in ECAPS exposure [adjusted odds ratio (aOR): 1.25, 95% CI: 1.09-1.44]. Between waves, no consistent patterns of change in ECAPS exposure across countries and different media were observed. Generally, ECAPS exposure tended to decline in some channels regulated by TPD2, particularly on television and radio, while exposure tended to increase in some unregulated channels, such as at points of sale.

CONCLUSIONS

The findings suggest that the TPD2 was generally effective in reducing ECAPS in regulated channels. Nonetheless, further research is warranted to evaluate its role in reducing ECAPS exposure, possibly by triangulation with additional sources of data.

Quitting behaviours and cessation methods used in eight European Countries in 2018: findings from the EUREST-PLUS ITC Europe Surveys

BACKGROUND

We examined quit attempts, use of cessation assistance, quitting beliefs and intentions among smokers who participated in the 2018 International Tobacco Control (ITC) Europe Surveys in eight European Union Member States (England, Germany, Greece, Hungary, the Netherlands, Poland, Romania and Spain).

METHODS

Cross-sectional data from 11 543 smokers were collected from Wave 2 of the ITC Six European Country (6E) Survey (Germany, Greece, Hungary, Poland, Romania and Spain-2018), the ITC Netherlands Survey (the Netherlands-late 2017) and the Four Countries Smoking and Vaping (4CV1) Survey (England-2018). Logistic regression was used to examine associations between smokers' characteristics and recent quit attempts.

RESULTS

Quit attempts in the past 12 months were more frequently reported by respondents in the Netherlands (33.0%) and England (29.3%) and least frequently in Hungary (11.5%), Greece (14.7%), Poland (16.7%) and Germany (16.7%). With the exception of England (35.9%), the majority (56-84%) of recent quit attempts was unaided. Making a quit attempt was associated with younger age, higher education and income, having a smoking-related illness and living in England. In all countries, the majority of continuing smokers did not intend to quit in the next 6 months, had moderate to high levels of nicotine dependence and perceived quitting to be difficult.

CONCLUSIONS

Apart from England and the Netherlands, smokers made few quit attempts in the past year and had low intentions to quit in the near future. The use of cessation assistance was sub-optimal. There is a need to examine approaches to supporting quitting among the significant proportion of tobacco users in Europe and increase the use of cessation support as part of quit attempts.

Transitions from and to roll-your-own tobacco, perceptions and health beliefs among smokers: findings from the EUREST-PLUS ITC Europe Surveys

BACKGROUND

The prevalence of roll-your-own tobacco (RYO) in Europe has been increasing. The aim of this study was to investigate transitions between factory-made (FM) cigarettes and RYO in a longitudinal sample of European smokers, and their perceptions of relative harmfulness and knowledge of health effects.

METHODS

We used data collected from the EUREST-PLUS ITC 6 European Country (6E) Surveys in 2016 (n = 6011 smokers) and in 2018 (n = 6027) in Germany, Greece, Hungary, Poland, Romania and Spain. A total of 3195 cohort respondents were interviewed in both years. Use of RYO and FM, knowledge of health effects of smoking as well as perceptions about RYO were assessed. We used logistic regression models to explore sociodemographic correlates of transitions from one product to the other, of perceptions and knowledge related to smoking health effects.

RESULTS

Approximately 7.4% of exclusive FM smokers transitioned to RYO and 29.5% of exclusive RYO smokers transitioned to FM cigarettes from 2016 to 2018. RYO use in 2018 was more frequent among smokers of low education and income, but none of these factors were associated with transitions. Most RYO smokers perceived RYO as cheaper than FM and 21.7% of them considered RYO to be less harmful than FM. Knowledge of the health effects of smoking was not associated with type of product smoked.

CONCLUSIONS

RYO is popular among European smokers; its lower cost seems to be a major factor for RYO users; reasons for transitions to and from RYO are less clear and need to be further investigated.

Effectiveness of tobacco warning labels before and after implementation of the European Tobacco Products Directive-findings from the longitudinal EUREST-PLUS ITC Europe surveys

BACKGROUND

Tobacco product packaging is a key part of marketing efforts to make tobacco use appealing. In contrast, large, prominent health warnings are intended to inform individuals about the risks of smoking. In the European Union, since May 2016, the Tobacco Products Directive 2014/40/EU (TPD2) requires tobacco product packages to carry combined health warnings consisting of a picture, a text warning and information on stop smoking services, covering 65% of the front and back of the packages.

METHODS

Key measures of warning label effectiveness (salience, cognitive reactions and behavioural reaction) before and after implementation of the TPD2, determinants of warning labels' effectiveness and country differences were examined in a longitudinal sample of 6011 adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (EUREST-PLUS Project) using longitudinal Generalized Estimating Equations (GEE) models.

RESULTS

In the pooled sample, the warning labels' effectiveness increased significantly over time in terms of salience (adjusted OR = 1.18; 95% CI: 1.03-1.35), while cognitive and behavioural reactions did not show clear increases. Generally, among women, more highly educated smokers and less addicted smokers, the effectiveness of warning labels tended to be higher.

CONCLUSION

We found an increase in salience, but no clear increases for cognitive and behavioural reactions to the new warning labels as required by the TPD2. While it is likely that our study underestimated the impact of the new pictorial warning labels, it provides evidence that health messages on tobacco packaging are more salient when supported by large pictures.

Corrigendum: Patterns of tobacco use, quit attempts, readiness to quit and self-efficacy among smokers with anxiety or depression: Findings among six countries of the EUREST-PLUS ITC Europe Surveys

[This corrects the article DOI: 10.18332/tid/98965.].

Dependence, plans to quit, quitting self-efficacy and past cessation behaviours among menthol and other flavoured cigarette users in Europe: The EUREST-PLUS ITC Europe Surveys

INTRODUCTION

This study characterises smoking and cessation-related behaviours among menthol and other flavoured cigarette users in Europe prior to the implementation of the European Tobacco Products Directive (TPD) ban on the sale of flavoured cigarettes.

METHODS

An analysis of cross-sectional data from the 2016 EUREST-PLUS ITC Europe Surveys was conducted among a sample of 10760 adult smokers from eight European Union Member States. Respondents were classified as menthol, other flavoured, unflavoured, or no usual flavour cigarette users and compared on smoking and cessation behaviours and characteristics. Data were analysed in SPSS Complex Samples Package using bivariate and multivariate regression analyses adjusted for sociodemographic characteristics, dependence, and country.

RESULTS

In bivariate analyses, cigarette flavour was significantly associated with all outcomes (p<0.001). After adjusting for sociodemographic characteristics, these associations attenuated but remained significant and in the same direction for dependence, self-efficacy, plans to quit, past quit attempts, and ever e-cigarette use. In fully adjusted models, compared to smokers of non-flavoured cigarettes, menthol smokers were less likely to smoke daily (AOR=0.47, 95% CI: 0.32-0.71), smoke within 30 min of waking (0.52,0.43-0.64), consider themselves addicted (0.74,0.59-0.94), and more likely to have ever used e-cigarettes (1.26,1.00-1.57); other flavoured cigarette smokers were less likely to smoke daily (0.33,0.15-0.77), and have higher self-efficacy (1.82,1.20-2.77); no usual flavour smokers were less likely to smoke daily (0.34,0.22-0.51), smoke within 30 min of waking (0.66,0.55-0.80), consider themselves addicted (0.65,0.52-0.78), have ever made a quit attempt (0.69,0.58-0.84), have ever used e-cigarettes (0.66,0.54-0.82), and had higher self-efficacy (1.46,1.19-1.80).

CONCLUSIONS

Smokers of different cigarette flavours in Europe differ on smoking and cessation characteristics. The lower dependence of menthol cigarette smokers could lead to greater success rates if quit attempts are made, however cross-country differences in smoking behaviours and quitting intentions could lead to the TPD ban on cigarette flavours having differential impact if not accompanied by additional measures, such as smoking cessation support.

Smoking in public places in six European countries: Findings from the EUREST-PLUS ITC Europe Survey

INTRODUCTION

Surveillance of tobacco consumption in public places is an important measure to evaluate the impact of tobacco control interventions over time. The objective of this study was to estimate the prevalence of smoking as seen by smokers and their smoking behaviour in public places, in six European countries.

METHODS

We used baseline data of the International Tobacco Control Six European countries (ITC 6E) Survey, part of the EUREST-PLUS Project, conducted in 2016 in national representative samples of about 1000 adult smokers aged 18 years and older in Germany, Greece, Hungary, Poland, Romania and Spain. For each setting (workplaces, restaurants, bars/pubs and discos) participants were asked whether they had seen someone smoking during their last visit there and whether they too had smoked there. We report the overall and by-country weighted prevalence of seeing someone smoking and the smokers' own smoking behaviour at each setting. We also assess the relationship between seeing someone smoking and smoking themselves at these settings.

RESULTS

The prevalence of smoking as seen by smokers was 18.8% at workplaces, with high variability among countries (from 4.7% in Hungary to 40.8% in Greece). Among smokers visiting leisure facilities in the last year, during their last visit 22.7% had seen someone smoking inside restaurants and 12.2% had smoked themselves there, while for bars/pubs the corresponding prevalences were 33.9% and 20.4%, and inside discos 44.8% and 34.8%.

CONCLUSIONS

Smoking is still prevalent at leisure facilities, particularly at discos in Europe, with high variability among countries. More extensive awareness campaigns and stricter enforcement are needed to increase the compliance of smoke-free regulations, especially in leisure facilities.

Correlates of the support for smoke-free policies among smokers: A cross-sectional study in six European countries of the EUREST-PLUS ITC EUROPE SURVEYS

INTRODUCTION

This report describes the support for smoke-free policies in different settings among smokers in six European countries and the relationship between their opinions about the places where smoking should be banned and their beliefs about the harms of secondhand smoke to non-smokers.

METHODS

A cross-sectional survey (the ITC 6 European Country Survey, part of the EUREST-PLUS Project) was conducted using nationally representative samples of adult smokers in Germany, Greece, Hungary, Poland, Romania and Spain (n=6011). We describe the prevalence of agreement and support for smoke-free policies in different settings according to sociodemographics, smoking characteristics and beliefs about the danger of secondhand smoke to non-smokers.

RESULTS

There was high agreement with smoking regulations in cars with preschool children and in schoolyards of primary/secondary schools (>90% overall) and low agreement with banning smoking in outdoor terraces of bars/pubs (8.6%; 95%CI: 7.5%-9.8%) and restaurants (10.1%; 95%CI: 8.9%-11.4%). The highest support for complete smoking bans inside public places came from smokers in Poland, among women, people aged ≥25 years, who had low nicotine dependence, and who tried to quit smoking in the last 12 months. About 78% of participants agreed that tobacco smoke is dangerous to non-smokers, ranging from 63.1% in Hungary to 88.3% in Romania; the highest agreement was noted among women, the 25-54 age groups, those with higher education, low cigarette dependence, and those who tried to quit in the last 12 months. The support for complete smoking bans in public places was consistently higher among smokers who agreed that secondhand smoke is dangerous to non-smokers.

CONCLUSIONS

Smokers in six European countries declared strong support for smoke-free policies in indoor settings and in settings with minors but low support in outdoor settings, particularly leisure facilities. More education is needed to increase the awareness about the potential exposure to secondhand smoke in specific outdoor areas.

Social norms towards smoking and electronic cigarettes among adult smokers in seven European Countries: Findings from the EUREST-PLUS ITC Europe Surveys

INTRODUCTION

This study explores whether current smokers' social norms towards smoking and electronic cigarettes (e-cigarettes) vary across seven European countries alongside smoking and e-cigarette prevalence rates. At the time of surveying, England had the lowest current smoking prevalence and Greece the highest. Hungary, Romania and Spain had the lowest prevalence of any e-cigarette use and England the highest.

METHODS

Respondents were adult (≥18 years) current smokers from the 2016 EUREST-PLUS ITC (Romania, Spain, Hungary, Poland, Greece, Germany) and ITC 4CV England Surveys (N=7779). Using logistic regression, associations between country and (a) smoking norms and (b) e-cigarette norms were assessed, adjusting for age, sex, income, education, smoking status, heaviness of smoking, and e-cigarette status.

RESULTS

Compared with England, smoking norms were higher in all countries: reporting that at least three of five closest friends smoke (19% vs 65-84% [AOR=6.9-24.0; Hungary-Greece]), perceiving that people important to them approve of smoking (8% vs 14-57% [1.9-51.1; Spain-Hungary]), perceiving that the public approves of smoking (5% vs 6-37% [1.7-15.8; Spain-Hungary]), disagreeing that smokers are marginalised (9% vs 16-50% [2.3-12.3; Poland-Greece]) except in Hungary. Compared with England: reporting that at least one of five closest friends uses e-cigarettes was higher in Poland (28% vs 36% [2.7]) but lower in Spain and Romania (28% vs 6-14% [0.3-0.6]), perceiving that the public approves of e-cigarettes was higher in Poland, Hungary and Greece (32% vs 36-40% [1.5-1.6]) but lower in Spain and Romania in unadjusted analyses only (32% vs 24-26%), reporting seeing e-cigarette use in public at least some days was lower in all countries (81% vs 12-55% [0.1-0.4]; Spain-Greece).

CONCLUSIONS

Smokers from England had the least pro-smoking norms. Smokers from Spain had the least pro-e-cigarette norms. Friend smoking and disagreeing that smokers are marginalised broadly aligned with country-level current smoking rates. Seeing e-cigarette use in public broadly aligned with country-level any e-cigarette use. Generally, no other norms aligned with product prevalence.

Cross-border purchasing of cigarettes among smokers in Six Countries of the EUREST-PLUS ITC Europe Surveys

INTRODUCTION

The availability of lower-cost cigarettes in neighboring countries provides price-sensitive smokers with incentives to purchase cheaper out-of-country cigarettes. This study estimates the prevalence of and factors associated with cross-border purchasing of cheaper cigarettes among smokers from Germany, Greece, Hungary, Poland, Romania, and Spain. The prevalence of cross-border purchasing was estimated by residential location, defined as living in regions bordering a lower-price country (where prices were at least €1/pack lower), regions bordering a similar- or higher-price country, and internal non-border regions.

METHODS

Data were from a survey of nationally representative samples of adult smokers (n=6011) from Germany, Greece, Hungary, Poland, Romania, and Spain. The primary outcome was purchasing cheaper out-of-country cigarettes in the previous six months. Residential location was defined using The Nomenclature of Territorial Units for Statistics (NUTS2 in Germany and NUTS3 in the other countries). Multivariable logistic regression tested differences in purchasing cheaper out-of-country cigarettes by country and residential location.

RESULTS

Residential location was associated with purchasing cheaper out-of-country cigarettes in Germany and Poland (p<0.05): 31% of German and 11% of Polish smokers living in regions bordering lower-price countries reported purchasing cheaper out-of-country cigarettes in the previous six months. Smokers living in regions bordering lower-price countries had 4.21 times greater odds of purchasing cheaper out-of-country cigarettes compared to smokers living in non-border regions.

CONCLUSIONS

Overall, only a minority of smokers in the six countries purchased cheaper cigarettes outside their country. However, smokers living in regions bordering countries where cigarettes were at least €1/pack lower than their home country had significantly higher odds of purchasing cheaper out-of-country cigarettes. This effect was especially prominent among German smokers. Tax harmonization policies designed to minimize cross-border price differentials can eliminate lower-priced alternatives for price-sensitive smokers.

Cigarette brand loyalty among smokers in six European countries: Findings from the EUREST-PLUS ITC Europe Surveys

INTRODUCTION

This study aims to describe the degree of smokers' loyalty to a specific brand of tobacco products and the variables related to choosing a specific brand among smokers in six European countries.

METHODS

A cross-sectional analysis was conducted for a representative sample of adult smokers from Germany, Greece, Hungary, Poland, Romania, and Spain (approximately 1000 smokers per country). The prevalence of smokers' having a usual brand of cigarettes smoked (factory-made or roll-yourown cigarettes), the brand of choice, the factors for choosing a specific brand and the degree of loyalty to that brand (not at all, a little, somewhat and a lot) were assessed by country, sociodemographics and smoking-related variables.

RESULTS

In total, 86.6% of the smokers reported having a usual brand. In three out of the six countries, one brand holds the loyalty of between 17.8% and 24.5% of the smokers that reported having a usual brand for factory-made cigarettes. Most participants reported being loyal 'a lot' to their brand of choice (44.4%). The reasons most reported for choosing a cigarette brand were the taste (83.2%) and the price (51.7%).

CONCLUSIONS

Brand loyalty is high among factory-made and roll-your-own cigarette smokers in six European countries. Future research on longitudinal trends of brand loyalty to evaluate the effect of tobacco control policies in these European countries is warranted.

Secondhand exposure to e-cigarette aerosols among smokers: A cross-sectional study in six European countries of the EUREST-PLUS ITC Europe Surveys

INTRODUCTION

Electronic cigarette (e-cigarette) use has grown significantly in some European Union (EU) Member States (MS). A better understanding of the exposure to secondhand e-cigarette aerosols (SHA) is necessary to develop and implement comprehensive regulations on e-cigarette use in public places. This study aims to assess the observation of e-cigarette use in public places, the self-reported exposure to SHA, and the level of users' comfort using e-cigarettes in the presence of others.

METHODS

This is a cross-sectional study of the Wave 1 International Tobacco Control 6 European Countries Survey recruiting adult smokers (n=6011) across six EU MS: Germany, Greece, Hungary, Poland, Romania, and Spain, within the EURESTPLUS Project. A descriptive analysis was conducted to estimate the prevalence (%) of observed e-cigarette use in different places, frequency of self-reported exposure to SHA, and level of comfort using e-cigarettes in the presence of others.

RESULTS

In all, 31.0% of smokers observed others using e-cigarette in public places, 19.7% in indoor places where smoking is banned, and 14.5% indoors at work. Almost 37% of smokers reported to be ever exposed to SHA, ranging from 17.7% in Spain to 63.3% in Greece. The higher prevalence of observed e-cigarette use and passive exposure to SHA was reported by smokers of younger age, of higher educational level and those being current or former e-cigarette users. Part (8.8%) of the smokers who were also e-cigarette users reported feeling uncomfortable using e-cigarettes in the presence of others.

CONCLUSIONS

A third of smokers from six EU MS reported being exposed to SHA. Prevalence differences were observed among the countries. In the context of scarce evidence on long-term health effects of exposure to SHA, precautionary regulations protecting bystanders from involuntary exposure should be developed.

Patterns of tobacco use, quit attempts, readiness to quit and self-efficacy among smokers with anxiety or depression: Findings among six countries of the EUREST-PLUS ITC Europe Surveys

INTRODUCTION

We compared smoking behaviors, past quit attempts, readiness to quit and beliefs about quitting among current cigarette smokers with probable anxiety or depression (PAD) to those without PAD, from six European Union (EU) Member States (MS).

METHODS

A nationally representative cross-sectional sample of 6011 adult cigarette smokers from six EU MS (Germany, Greece, Hungary, Poland, Romania, Spain) was randomly selected through a multistage cluster sampling design in 2016. Respondents were classified as having PAD based on self-reported current diagnosis or treatment for anxiety or depression, or a positive screen for major depression, according to a validated two-item instrument. Sociodemographic characteristics, patterns of tobacco use, past quitting, readiness to quit, self-efficacy and beliefs about quitting were assessed for patients with and without PAD. Logistic regression was used to examine predictors of PAD. All analyses were conducted using the complex samples package of SPSS.

RESULTS

Among smokers sampled, 21.0% (95% CI: 19.3-22.9) were identified as having PAD. Logistic regression analyses controlling for socioeconomic variables and cigarettes smoked per day found smokers with PAD were more likely to have made an attempt to quit smoking in the past (AOR=1.48; 95% CI: 1.25-1.74), made a quit attempt in the last 12 months (AOR=1.75; 95% CI: 1.45-2.11), and report lower self-efficacy with quitting (AOR=1.83; 95% CI: 1.44-2.32) compared to smokers without PAD. Additionally, it was found that individuals with PAD were more likely to report having received advice to quit from a doctor or health professional and having used quitline support as part of their last quit attempt.

CONCLUSIONS

Smokers with PAD report a greater interest in quitting in the future and more frequent failed quit attempts than smokers without PAD; however, the high rates of untreated anxiety or depression, nicotine dependence, low confidence in the ability to quit, infrequent use of cessation methods, as well as socioeconomic factors may make quitting difficult.

Prevalence and correlates of different smoking bans in homes and cars among smokers in six countries of the EUREST-PLUS ITC Europe Surveys

INTRODUCTION

Second-hand smoke exposure has decreased in a number of countries due to widespread smoke-free legislation in public places, but exposure is still present in private settings like homes and cars. Our objective was to describe to what extent smokers implement smoking rules in these settings in six European Union (EU) Member States (MS).

METHODS

A cross-sectional survey was conducted with a nationally representative sample of adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (ITC six European countries survey, part of the EUREST-PLUS Project). We analysed data from 6011 smokers regarding smoking rules in their homes and in cars with children (no rules, partial ban, total ban). We described the prevalence of smoking rules by EU MS and several sociodemographic and smoking characteristics using prevalence ratios (PR) and 95% confidence intervals (CI) derived from Poisson regression models. \.

RESULTS

In homes, 26.5% had a total smoking ban (from 13.1% in Spain to 35.5% in Hungary), 44.7% had a partial ban (from 41.3% in Spain to 49.9% in Greece), and 28.8% had no-smoking rules (from 20.2% in Romania to 45.6% in Spain). Prevalence of no-smoking rules in cars with children was 16.2% (from 11.2% in Germany to 20.4% in Spain). The correlates of not restricting smoking in homes and cars included: low education (PR=1.51; 95%CI: 1.20-1.90 and PR=1.55; 95%CI: 1.09-2.20), smoking >30 cigarettes daily (PR=1.53; 95%CI: 1.10-2.14 and PR=2.66; 95%CI: 1.40-5.05) and no attempts to quit ever (PR=1.18; 95%CI: 1.06-1.31 and PR=1.28; 95%CI: 1.06-1.54).

CONCLUSIONS

Among smokers in six EU MS, no-smoking rules were more prevalent in homes than in cars with children. Whilst awareness about the health effects of exposure to tobacco smoke on children seemed to be high, more research is needed to better understand the factors that promote private smoke-free environments.

Impact of anti-smoking advertising on health-risk knowledge and quit attempts across 6 European countries from the EUREST-PLUS ITC Europe Survey

INTRODUCTION

Exposure to anti-smoking advertising and its effects differ across countries. This study examines the reported exposure to anti-smoking advertising among smokers and its relation to knowledge of smoking harms and quit attempts in six European countries.

METHODS

Data come from Wave 1 of the International Tobacco Control (ITC) 6 European Country (6E) Survey (Germany, Greece, Hungary, Poland, Romania, Spain) carried out among smokers between June and September 2016 (n=6011). Key measures included whether participants had noticed anti-smoking advertising in the last six months in 6 different channels, their knowledge of 13 adverse smoking/second-hand smoking health effects and if they had made at least one quit attempt in the last 12 months. Multivariate logistic regression models were used in the analysis.

RESULTS

Across the six countries, only 35.2% of smokers reported being exposed to any anti-smoking advertising. Television was the most common channel identified (25.7%), followed by newspapers and magazines (13.8%), while social media were the least reported (9.5%). Participants 18-24 years old were significantly more likely to have noticed advertisements on the Internet than participants >55 years old (24.3% vs 4.9%; OR=5.15). Participants exposed to anti-smoking advertising in all six channels were twice more likely to have a higher knowledge of smoking risks than those not exposed (2.4% vs 97.6%, respectively; OR=2.49). The likelihood of making a quit attempt was increased by 10% for each additional channel through which smokers were exposed to anti-smoking advertising.

CONCLUSIONS

Knowledge of health risks of smoking tended to be higher in countries that aired a campaign in recent years. Exposure to anti-smoking advertising, in the six channels combined, was related to higher smoking knowledge of risks and to more quit attempts. Future anti-smoking mass media campaigns should consider advertising in all dissemination channels to increase the awareness of the dangers of smoking.

The Conceptual Model and Methods of Wave 1 (2016) of the EUREST-PLUS ITC 6 European Countries Survey

Population-level interventions represent the only real approach for combatting the tobacco epidemic. There is thus great importance in conducting rigorous evaluation studies of tobacco control policies and regulations such as those arising from the WHO Framework Convention on Tobacco Control (FCTC) and the European Union's 2014 Tobacco Products Directive (TPD). The ITC 6 European Countries Survey, a component of the Horizon 2020 Project entitled European Regulatory Science on Tobacco: Policy Implementation to Reduce Lung Disease (EUREST-PLUS), was created to evaluate and impact of the TPD in six EU Member States: Germany, Greece, Hungary, Poland, Romania, and Spain. In each country, a cohort survey of a representative national sample of 1000 smokers was conducted. This paper describes the conceptual model, methodology, and initial survey statistics of Wave 1 of the ITC 6E Survey, which was conducted June-September 2016. The ITC 6E Survey's conceptual model, methodology, and survey instrument, were based on the broader 29-country ITC Project cohort studies, which have been conducted since 2002. The commonality of methods and measures allow a strong potential for cross-country comparisons between the 6 EU countries of the ITC 6E Project and 3 other EU countries (England, France, The Netherlands) in the ITC Project, as well as the broader set of ITC countries outside the EU.

Characteristics and correlates of electronic cigarette product attributes and undesirable events during e-cigarette use in six countries of the EUREST-PLUS ITC Europe Surveys

INTRODUCTION

This study assessed characteristics and correlates associated with e-cigarette product attributes and identified correlates of experiencing undesirable events during e-cigarette use among adult smokers across six European Union (EU) Members States (MS) prior to the implementation of the Tobacco Products Directive (TPD) in 2016.

METHODS

We conducted a cross-sectional survey with a nationally representative sample of adult cigarette smokers from six EU MS (Germany, Greece, Hungary, Poland, Romania, Spain) reporting e-cigarette use; randomly selected through a multistage cluster sampling design from June to September 2016. Stepwise logistic regressions were used to identify factors associated with use of flavors, noticing health warnings, mixing e-liquids, experiencing 'dry puff', e-liquid leaking during use and e-liquid spilling during refill.

RESULTS

Current daily or weekly prevalence of e-cigarette use among this sample of adult smokers was 7.5%. The most common attributes of e-cigarettes used included those that are flavored, contain nicotine, and are of tank style. Noticing health warnings on e-cigarette packaging and leaflets, respectively, was low (10.2% and 28%, respectively). Use of e-liquid refill nozzle caps, described as easy for a child to open, was associated with spilling during refill (OR=6.73; 95% CI: 2.02-22.37). Participants who adjusted occasionally or regularly the power (voltage) or temperature of their e-cigarette had greater odds of ever experiencing a 'dry puff' (OR=6.01; 95% CI: 2.68-13.46). Mixing different e-liquids was associated with leaking during use (OR=7.78; 95% CI: 2.45-24.73) and spilling during refill (OR=8.54; 95% CI: 2.29-31.88).

CONCLUSIONS

Ongoing evaluation of factors associated with e-cigarette attributes and of the correlates of experiencing e-cigarette undesirable events during use, related to product design, is crucial to monitoring the impact of the implementing Acts of the EU TPD.

Extent and correlates of self-reported exposure to tobacco advertising, promotion, and sponsorship in smokers: Findings from the EUREST-PLUS ITC Europe Surveys

INTRODUCTION

Tobacco advertising, promotion, and sponsorship (TAPS) are known to promote tobacco consumption and to discourage smoking cessation. Consequently, comprehensive TAPS bans are effective measures to reduce smoking. The objective of this study was to investigate to what extent smokers are exposed to TAPS in general, and in various media and localities, in different European countries.

METHODS

A Cross-sectional analysis of national representative samples of adult smokers in 2016 from Germany, Greece, Hungary, Poland, Romania, and Spain (EUREST-PLUS Project, n=6,011), as well as England (n=3,503) and the Netherlands (n=1,213) (ITC Europe Surveys) was conducted. Prevalence of self-reported TAPS exposure is reported by country, and socio-economic correlates were investigated using logistic regression models.

RESULTS

Self-reported exposure to TAPS varied widely among the countries, from 15.4 % in Hungary to 69.2 % in the Netherlands. In most countries, tobacco advertising was most commonly seen at the point of sale, and rarely noticed in mass media. The multivariate analysis revealed some variation in exposure to TAPS by sociodemographic factors. Age showed the greatest consistency across countries with younger smokers (18-24-year-olds) being more likely to notice TAPS than older smokers.

CONCLUSIONS

TAPS exposure tended to be higher in countries with less restrictive regulation but was also reported in countries with more comprehensive bans, although at lower levels. The findings indicate the need for a comprehensive ban on TAPS to avoid a shift of marketing efforts to less regulated channels, and for stronger enforcement of existing bans.

Regional variation in mortality from ischaemic heart disease in Poland, 2006-2010

BACKGROUND

Spatial differences in mortality in Poland are large and remain unexplained to a large extent. Ischaemic heart disease (IHD) is a good candidate for explaining regional inequalities in mortality in Poland due to the high level of mortality from this cause and the large spatial differences.

AIM

We describe the contribution of IHD to all-cause mortality in Poland in 2006-2010 on a powiat (Polish district) level and explain the differences in mortality by selected socio-economic factors.

METHODS

We use mortality data from the population registry at the NUTS-4 level for 2006-2010. We map age-standardised all-cause and IHD mortality rates. The contribution of IHD mortality to all-cause mortality was also assessed through variance decomposition. Correlation coefficients between age-standardised mortality rates and selected socio-economic variables were estimated for all powiats and for a group excluding large cities.

RESULTS

We demonstrated that regional differences between powiats in IHD mortality do not constitute a major factor behind regional mortality disparities in Poland. However, the spatial patterns for all-cause and IHD mortality in Polish powiats were both related to the level of urbanisation, with group of powiats characterised by the lowest IHD mortality comprising only large cities. The negative effect of large cities on the level of all-cause and IHD mortality was confirmed by the significant correlation between the socio-economic contextual variables, standing for the level of urbanisation, and IHD mortality.

CONCLUSIONS

Ease of access to medical care in large cities and in particular to cardiology units is an important factor behind the levels of all-cause and IHD mortality in Poland.

Dietary intake and adipose tissue level of specific fatty acids in a selected group from the Lower Silesia population

PURPOSE

The aim of the study was to assess the content of specific fatty acids in the diet and adipose tissue in a selected group of inhabitants of Lower Silesia in Poland.

METHODS

The study group consisted of 95 inhabitants of Wroclaw and surrounding villages (22 men and 23 women from the urban area, 23 men and 27 women from the rural area). Fatty acid content in subcutaneous fat samples was assessed by gas-chromatography. Dietary assessment was carried out using food frequency questionnaire. Dietary intake was analyzed using computer programme The Food Processor SQL 10.5.2 produced by ESHA Research USA, with a Polish database.

RESULTS

Mean daily energy and fatty acids intake was significantly higher among rural than urban inhabitants. Intake of alpha-linolenic acid (ALA), mainly from rapeseed oil, in urban inhabitants was 1.5 g/day in men and 1.6 g/day in women, and in rural inhabitants 2.6 g/day and 2.1 g/day, respectively. Dietary n-6 to n-3 ratio was higher among urban compared to rural inhabitants (6.7 vs. 5.5 among men and 6.4 vs. 5.5 among women, respectively). Content of ALA in adipose tissue was higher in rural women than in urban men (1.08% vs. 0.92% of total fat). Content of eicosapentaenoic acid (EPA) in adipose tissue in rural men (0.04% of total fat) and women (0.05% of total fat) was higher than in urban men (0.01% of total fat). The positive correlation (r=0.43) between the level of EPA in adipose tissue and percentage of energy from dietary EPA was observed among rural men. Overall, positive correlations were found between saturated (SFA) and polyunsaturated (PUFA) n-3 level in adipose tissue and percentage of energy from these fatty acids in a diet (r=0.20 and r=0.22, respectively).

CONCLUSIONS

Mean daily n-3 fatty acid intake in urban inhabitants was lower than the recommended daily consumption in Poland. The positive correlation between fatty acids level in adipose tissue and dietary fatty acid intake was observed only for EPA among rural men, and in the all-study population for SFA and PUFA n-3. A high n-6 to n-3 ratio in the study group was observed.

The PONS study and its place in the strategy of health gain in Poland

After 30 years (1960-1990) of adult health decline, since the beginning of the political and economic transformation in the early 1990s.a dramatic reversal of health trends is being observed in Poland, In contrast, in the countries of Western Europe, a significant, steady health gain has been observed already since the end of World War II. At the beginning of the 21 st century one in three men in Poland still do not reach the age of 65, which dramatically contrasts with the one-digit premature mortality in Western Europe (EU15). In Poland very high proportion of this mortality (men ~30%, women ~15%) occur in working age population hampering social and economic development. Non-communicable diseases and risk factors (smoking, drinking, obesity) are major cause of heath inequality and contribute to poverty. This health gap, leading to an over-proportional loss of human capital in Eastern Europe, is one of the most crucial challenges for the European Union during the period of economic crisis.

Cancer risk factors in Poland: the PONS Study

INTRODUCTION

The burden of cancer in Eastern Europe is expected to increase, and in 2006, Polish males were ranked second in lifetime risk of lung cancer. The Polish-Norwegian Study (PONS) is a population study in the Kielce District, and the presented study describes the distribution of preventable causes of cancer according to gender, age, education, and urban/rural status.

METHODS

PONS comprises individuals 45-64 years of age at baseline. A structured lifestyle interview was conducted, and the following risk factors were recorded: smoking, alcohol consumption and obesity. Binomial regression analysis was used to estimate age and gender adjusted prevalence ratios (PR) for the associated factors.

RESULTS

A total of 3,862 adults were included in the analysis. Approximately 17% reported current tobacco smoking on a daily basis, 34% were former smokers, and 49% were non- smokers. Current smoking was more prevalent in males (20%) than females (15%), but there was no clear association with educational level or urban/rural status. Females also reported a lower frequency of alcohol consumption than males. Among males, 15% reported drinking alcohol more than once a week, as compared to 2% of the females. There was no clear association with urban/rural status, or with level of education. The total prevalence of obesity (BMI ≥ 30) was 30%; the prevalence of obesity class 2 (BMI ≥ 35) and class 3 (BMI ≥ 40) was 8% and 1.7%, respectively. Obesity increased by age, especially in females, and was less frequent among people with high education and people with urban residence.

CONCLUSIONS

The Kielce region of Poland is experiencing a significant burden of cancer risk factors, including obesity and tobacco smoking, but smoking may be a decreasing habit. It is necessary to increase the awareness of the population to the harmful eff ects of smoking and obesity to prevent cancer and other lifestyle related diseases.

Application of advanced data collection and quality assurance methods in open prospective study - a case study of PONS project

INTRODUCTION

Large-scale epidemiologic studies can assess health indicators differentiating social groups and important health outcomes of the incidence and mortality of cancer, cardiovascular disease, and others, to establish a solid knowledgebase for the prevention management of premature morbidity and mortality causes. This study presents new advanced methods of data collection and data management systems with current data quality control and security to ensure high quality data assessment of health indicators in the large epidemiologic PONS study (The Polish-Norwegian Study).

MATERIAL AND METHODS

The material for experiment is the data management design of the large-scale population study in Poland (PONS) and the managed processes are applied into establishing a high quality and solid knowledge.

RESULTS

The functional requirements of the PONS study data collection, supported by the advanced IT web-based methods, resulted in medical data of a high quality, data security, with quality data assessment, control process and evolution monitoring are fulfilled and shared by the IT system. Data from disparate and deployed sources of information are integrated into databases via software interfaces, and archived by a multi task secure server.

CONCLUSIONS

The practical and implemented solution of modern advanced database technologies and remote software/hardware structure successfully supports the research of the big PONS study project. Development and implementation of follow-up control of the consistency and quality of data analysis and the processes of the PONS sub-databases have excellent measurement properties of data consistency of more than 99%. The project itself, by tailored hardware/software application, shows the positive impact of Quality Assurance (QA) on the quality of outcomes analysis results, effective data management within a shorter time. This efficiency ensures the quality of the epidemiological data and indicators of health by the elimination of common errors of research questionnaires and medical measurements.

Assessment of dietary intake in a sample of Polish population - baseline assessment from the prospective cohort 'PONS' study

OBJECTIVE

The aim of this study was to assess the dietary intake of participants in the Polish-Norwegian Study (PONS).

METHODS

The presented study comprised 3,862 inhabitants of Świętokrzyskie Province aged 45-64 (2,572 females and 1,290 males). Daily intakes of energy, protein, carbohydrate, fat and fatty acid were estimated using the Food Frequency Questionnaire (FFQ).

RESULTS

Energy intake was significantly higher in males than females (1,461.4 vs 1,320.7 kcal/day), and in participants aged 45-54 than in those aged 55-64 (1,409.5 vs 1,338.5 kcal/day). The percentage of energy from saturated fatty acids was higher than dietary recommendations. Protein, fat and carbohydrate intakes were significantly higher in males compared to females, and in younger than in older group. Daily cholesterol intake was significantly higher in males compared to females and in younger than in older group. People with a higher level of education had a higher energy, protein and fat intake.

CONCLUSION

Under-reporting of energy intake was observed in a significant percentage of participants, especially in males. Gender, age and education status had statistically significant impact on dietary intake. Increase in the intake of dietary fibre, mono- and polyunsaturated fatty acids with diet by the studied participants will make the diets more healthy.

Epidemiological analysis of health situation development in Europe and its causes until 1990

The enormous health gap between the 'new' (eastern) and 'old' (western) parts of the EU has evolved over many decades. The epidemiological transition - that is the decrease in the relative importance of infant and early child mortality and the shift in the composition of mortality risks from communicable to non-communicable diseases - which started in the western part of the region at the beginning of the 20th century, was substantially delayed in most of eastern Europe. However, after the World War II, health improvement in the east initially out-paced the west, such that, by the mid-1960s, only 1-2 years separated the average life expectancy for both sexes between the east and west. This convergence was short-lived and it reversed dramatically between the mid 1960s and 1990. During this period, adult health status in the east stagnated or deteriorated, whereas in the west it improved steadily: by 1990, life expectancy at the age of 20 years was more than fi ve years shorter in the east for men, and more than four years shorter for women. The biggest contributors to the health gap were cardiovascular diseases and injuries. A substantial fraction of the gap can, with confidence, be attributed to the higher volume and more irregular pattern of alcohol consumption in the east, and to the delayed onset of the tobacco smoking epidemics. Much of the remainder of the gap is likely to be attributable to the composition of the diet, but the contribution of different dietary factors cannot be estimated with confidence. Leading candidates are a high consumption of saturated animal fats, a low consumption of fresh fruit and vegetables (especially in winter and spring), a very low consumption of fats supplying omega 3 fatty acids – both vegetable oils and fi sh oils rich in alpha-linolenic acid – and a high consumption of salt. Behaviours unfavourable to health did not change in the east, as they did in the west in response to the credible dissemination of scientific findings linking disease and injury risks both to individual behaviours and to the social and economic circumstances that fostered those behaviours. The eastern countries failed to equip themselves with the science and with the forms of social organisation that were needed to effectively counter epidemics of chronic disease and injury. The poor health-related behavioural determinants resulted from the institutional infrastructures based on an authoritarian, conservative and medicalised model of health, which inhibited modern approaches to social problems, an almost exclusive focus of epidemiology on communicable as opposed to non-communicable diseases, a lack of understanding and access to modern epidemiology and public health, a lack of understanding and access to evidence-based medicine, and a lack of public health education and health promotion.

Prevalence of diabetes mellitus and IFG in the prospective cohort 'PONS' study - baseline assessment

OBJECTIVE

The aim of this cross-sectional study was to assess the prevalence of diabetes mellitus and impaired fasting glucose (IFG) in the Polish-Norwegian Study (PONS) population in Poland.

METHODS

The presented results are part of the PONS project, and cover information from 3,854 people aged 45-64 (2,567 females and 1,287 males) who are inhabitants of Świętokrzyski Province.

RESULTS

In the study group there were 62.8% participants with normoglycaemia, 28.9% participants with IFG and 8.4% participants with diabetes. In those with diabetes, there were 95 participants (2.5%) whose diabetes was unknown prior to this study. Among 5.9% patients with known diabetes 52.9% of the participants had a fasting blood glucose level of ≥ 126 mg%. There were 46.8% males and 70.8% females with normoglycaemia, 41.0% males and 22.8% females with IFG, and 12.2% males and 6.4% females with diabetes. The prevalence of diabetes was higher in participants in the older age group (55-64) compared to younger participants (45-54). The prevalence of diabetes decreased with increasing education and was higher among overweight or obese participants compared to normal weight participants.

CONCLUSION

The prevalence of diabetes mellitus in study population was generally high, but especially high in males, and the awareness of diabetes in the population was generally low. Among participants with known diabetes more than half was not well controlled.

Evaluation of mineral and vitamin intake in the diet of a sample of Polish population - baseline assessment from the prospective cohort 'PONS' study

OBJECTIVE

The aim of this cohort study was to evaluate selected mineral and vitamin intake of the Polish-Norwegian Study (PONS) participants.

METHODS

Daily mineral and vitamin intake of PONS study participants was estimated using Food Frequency Questionnaire (FFQ). Overall, 3,862 inhabitants of Świętokrzyskie Province aged 45-64 (2,572 females and 1,290 males) enrolled in the study.

RESULTS

Mean calcium, iron, magnesium, phosphorus, potassium, and sodium intake were, in males: 660.6 mg/day, 15.4 mg/day, 218.5 mg/day, 889.3 mg/day, 2,453.4 mg/day and 2,571.5 mg/day, and in females: 703.6 mg/day, 13.9 mg/day, 220.8 mg/day, 916.3 mg/day, 2,497.3 mg/day and 2,301.8 mg/day, respectively. Iron and sodium intake was significantly higher in males compared to females. Calcium intake was lower in males than in females and in participants aged 55-64 then those aged 45-54. Estimated daily sodium intake was similar among individuals with and without hypertension. Mean vitamin C, thiamin, riboflavin, vitamin B6, A and E were, in males: 80.1 mg/day, 1.3 mg/day, 1.5 mg/day, 1.6 mg/day, 8,454.0 IU/day and 5.4 mg/day and in females: 83.7 mg/day, 1.1 mg/day, 1.6 mg/day, 1.6 mg/day, 9,494.6 IU/day and 4.9 mg/day, respectively. Females had a higher intake of vitamin C and A , while males had higher thiamin and vitamin E intakes. Higher daily vitamin C intake was observed in the younger than in the older group, and in participants with higher education than those with a lower level of education.

CONCLUSION

Significant differences were observed in daily intake of some vitamins and minerals by gender, age, level of education, and place of residence. Some participants had a lower intake of some minerals and vitamins than Polish recommendations.

Metabolic syndrome in Poland - the PONS Study

INTRODUCTION

In Central and Eastern European countries, cardiovascular disorders (CVD) in middle age are much more common than in Western Europe, and it is imperative to understand the causes underlying this excess disease burden. The metabolic syndrome comprises a constellation of metabolic abnormalities that increase the risk of cardiovascular disease.

METHODS

Data were obtained by structured interview, and by measurements of anthropometric factors and blood analyses among 3,862 individuals. Metabolic syndrome was defined according the International Diabetes Federation Task Force on Epidemiology and Prevention, as the presence of at least 3 of 5 abnormalities: 1) abdominal obesity, 2) glucose intolerance, 3) high triglycerides, 4) low HDL cholesterol, 5) high blood pressure.

RESULTS

Overall, 1,518 participants (39.5%) had metabolic syndrome. The prevalence among females was 34.3% (877 females) vs. 49.9% (641 males) among males, and increased with age in both genders. Abdominal obesity was the most common abnormality (2,897 participants, 75.1%), followed by high blood pressure (2,741 participants, 71%), glucose intolerance (1,437 participants, 37.3%), elevated triglycerides (817 participants, 21.2%) and low HDL (615 participants, 15.9%).

CONCLUSION

The prevalence of metabolic syndrome and metabolic abnormalities is high and represents strong risk factors for CVD morbidity and mortality. However, these factors are all potentially preventable by lifestyle modification and/or by pharmacological treatment. There is an urgent need for the health service to act, and to increase public awareness of metabolic syndrome.

Alcohol drinking patterns and habits among a sample of PONS study subjects: preliminary assessment

INTRODUCTION

Alcohol drinking is a major contributing factor to death, disease, injury and social problems such as violence or child neglect and abuse, especially in Eastern Europe.

OBJECTIVES

To preliminary evaluate the prevalence and social and behavioural patterns of alcohol drinking in a pilot group of the Polish-Norwegian Study (PONS study) subjects.

MATERIAL AND METHODS

Open-ended prospective cohort study conducted in Świetokrzyskie province. A pilot group of subjects aged 45-64 years has been examined. Data on alcohol drinking were collected for 3,845 respondents with the use of the Health State Questionnaire administered by the CAPI method.

RESULTS

In males, 72.3% drank alcohol currently, 22.7% were former drinkers, and only 5% never drinkers. Among females, the percentage of current alcohol drinkers was significantly lower than in males, while the percentages of former and never drinkers was higher (50.3%, 35.4% and 14.6%, respectively). 7.4% of males and 0.8% of females drank alcohol daily or almost daily, and weekly alcohol drinking was respectively at level of 32.2% and 15.7%. Males drank mainly vodka (or other spirits) and beer, females grape wine and vodka.

CONCLUSIONS

PONS study includes interesting dataset for assessing prevalence and patterns of alcohol drinking at population level. Alcohol drinking seems to be common among PONS subjects. Comparison with nation-wide surveys shows on higher number of alcohol abstainers and lower number of binge drinkers among PONS study subjects. On the other hand, frequency and social patterns of alcohol drinking seem to be consistent with data found in national studies.

Patterns of leisure time physical activity and its determinants among a sample of adults from Kielce region, Poland - the 'PONS' study

The aim of the study was to evaluate the prevalence, socio-demographic patterns and behavioural characteristics of leisure time physical activity in a pilot group of respondents of the Polish-Norwegian Study (PONS).

MATERIALS AND METHODS

PONS is an open-ended prospective study set in Świętokrzyski Province with study cohort consisting of adults aged 45-64 years. The physical activity section of the questionnaire was based on the International Physical Activity Questionnaire.

RESULTS

43% of the respondents had not walked for at least 10 minutes in their leisure time during the last week. The majority did not engage in any moderate or vigorous physical activity (PA). Being physically active was more prevalent among residents of urban areas and among respondents with a higher level of education. Performing PA was also positively associated with higher net income per household member. On average, respondents had spent 47 hours in a sedentary position during last week. The majority of subjects reported watching TV for 6-20 hours per week. Not having enough time and lack of willingness were given as the main reasons for being inactive.

CONCLUSIONS

A significant proportion of participants were inactive in their leisure time, even activity less than 10 minutes during the last 7 days was common. Walking was the most popular form of PA in this domain. Urban residence, higher level of education and better financial situation were strongly associated with higher levels of PA.

Depressive episodes and depressive tendencies among a sample of adults in Kielce, south-eastern Poland

INTRODUCTION AND OBJECTIVES

Previous community research has shown differences in depression and depressive symptoms across different socioeconomic and demographic groups. However, very few population-based studies on depression have been conducted in Poland. The purpose of the present study is to assess depressive episodes and depressive tendencies, and associations of the latter with selected socio-economic and demographic predictors among a sample of adults from Poland.

MATERIALS AND METHODS

Data stem from a community health survey carried out as part of a large prospective study among people aged 45-64 in the Kielce province of south-eastern Poland (n=3,862). Self-reported depressive episodes, depressive tendencies (7 items) and use of antidepressants were measured. Depressive tendencies were modelled as a latent variable and analyzed against selected demographic and socioeconomic predictors.

RESULTS

The prevalence of depressive episodes was higher among females (25.0%) than among males (14.7%). When depressive tendencies were modelled as a latent variable, the following predictors were associated with high scores: age (females only), living in rural districts, being a pensioner (not including old age pension), and being unemployed (males only). Scores on depressive tendencies were negatively associated with high education, being self-employed (borderline significance only) and high personal income.

CONCLUSIONS

Depressive episodes were prevalent among the sample. If the associations between depressive tendencies and demographic variables shown in this study are confirmed by future studies, it suggests that action should be taken to offer improved preventive action and improved mental health services – such as early treatment – to females, people living in rural areas, and selected low status segments of the population in particular.

A cross-sectional study of cardiovascular disease and associated factors

OBJECTIVE

Cardiovascular diseases (CVD) are a major cause of mortality and morbidity in Poland. Data on risk factors of CVD in this country are limited. The presented study investigated risk factors of self-reported CVD within the Polish- Norwegian Study (PONS).

METHODS

PONS is an ongoing prospective study in Poland. The data used was provided by 3,853 participants, aged 45-64, during baseline interviews.

RESULTS

Prevalence of chronic diseases among participants was as follows: hypertension, 38.4%; diabetes, 5.9%; and CVD, 11.0%. There was no association between CVD and gender and place of residence. CVD was associated with ever-smoking (OR= 1.25; 95% CI: 1.00-1.55), whereas there was an inverse association with alcohol drinking in the year preceding enrolment in the study (OR= 0.50; 95% CI: 0.39-0.63). CVD was associated with body mass index (BMI), as well as with measures of abdominal adiposity, in the following order: waist to height ratio>waist circumference>waist to hip ratio; however, none of these measures showed a stronger association with CVD than BMI. Both hypertension (OR= 1.33; 95% CI: 1.05-1.68) and diabetes (OR= 1.33; 95% CI: 1.05-1.68) were associated with CVD in adjusted models.

CONCLUSIONS

This study shows the association between several risk factors and prevalence of self-reported CVD and provides information about distribution of those factors among an adult population in Poland. The results of the ongoing PONS study in a prospective setting will provide more accurate risk estimates for the observed associations, as well as risk estimates for other risk factors of CVD, including dietary factors, and attributable risks for various factors.

POlish-Norwegian Study (PONS): research on chronic non-communicable diseases in European high risk countries - study design

OBJECTIVE

A large-scale population study of health and disease would represent the most powerful tool to address these important issues in Poland. The aim is to extensively survey the study population with respect to important factors related to health and wellbeing, and subsequently, the intention is to follow-up the population for important health outcomes, including the incidence and mortality of cancer, cardiovascular disease, and other major causes of morbidity and mortality. The infrastructure for establishing a large cohort of people in Poland is needed; therefore, the PONS (Polish-Norwegian Study) project represents an eff ort to establish such infrastructure.

METHODS

The PONS Study is enrolling individuals aged 45-64 years. Structured lifestyle and food frequency questionnaires are administered. Study participants undergo medical check-up, anthropometric measurements and provide blood and urine sample for long-term storage. Fasting glucose and lipids profile are checked in the laboratory.

RESULTS

This report describes the design, justification and methodology of the presented prospective cohort study. Recruitment of participants began in September 2010, and by the end of 2011 it is planned to achieve a total of between 10,000 – 15,000 participants.

SUMMARY

The PONS study is the fi rst prospective cohort study with blood and urine collection ever conducted in Central and Eastern Europe. It will provide reliable new data on both established and emerging risk factors for several major chronic diseases in a range of different circumstances.

Cigarette smoking among a sample of PONS study subjects: preliminary assessment

AIM

To evaluate the prevalence, socio-demographic patterns and behavioural characteristics of tobacco smoking in a pilot group of PONS respondents.

MATERIALS AND METHODS

Open-ended prospective cohort study conducted in Świetokrzyskie Province. A pilot group of subjects aged 45-64 years was examined. Data on smoking were collected with the use of the Health State Questionnaire administered by the CAPI method.

RESULTS

62.6% of males and 45.5% of females participating in the PONS study were ever smokers. In the male population, the percentage of current and former smokers were 19.8% and 42.8%. In females, these percentages were at the lower level of 15.3% and 30.3%, respectively. Self-reported data on smoking prevalence seem to be consistent with objective assessment of exposure to tobacco smoke (measured by carbon monoxide level in exhaled lung air), especially for non-smokers.

CONCLUSIONS

The analysis found substantial differences in the level of current and former smoking between PONS study and nation-wide surveys conducted in the adult Polish population. Percentages of current smokers in the PONS study are two or even more times lower, and the prevalence of former smoking is almost two times higher than among adult Poles. The above differences may result from social characteristics of the fi rst group of PONS subjects and their health behaviours. PONS subjects who decided to take pat in the fi rst phase of the study are proportionally better educated than a comparable age group of the adult Polish population, and therefore may be more health-oriented than respondents from the general population. Therefore, it is recommended that the next phase of the PONS study should promote and focus on the less educated inhabitants of the study areas, especially males.

Prevalence of obesity - baseline assessment in the prospective cohort 'PONS' study

OBJECTIVE

The aim of the study was to evaluate the prevalence of overweight and obesity in the population of Świętokrzyskie Province in Poland.

METHODS

Body mass index (BMI), waist to hip ratio (WHR) and waist circumference (WC) in the Polish-Norwegian Study (PONS) was measured in 2,567 females and 1,287 males. Anthropometric measurements included fat mass, height, weight, waist and hip circumference. BMI and WHR were calculated.

RESULTS

Data showed that 52% of males and 42% of females were overweight (25.0 ≤ BMI<30.0 kg/m2), and the prevalence of obesity (BMI ≥ 30.0 kg/m2) was 35% in both genders. The average BMI was higher in males (28.5 kg/m2) than in females (28.2 kg/m2). Analysis of WC showed that 36% of males and 45% of females had abdominal obesity, whereas measurements of WHR showed abdominal obesity in 64% of males and 79% of females. Generally, the prevalence of obesity was higher in the older age group (55-64 years) and in rural inhabitants. The prevalence of overweight increased with educational level, but the prevalence of obesity decreased with level of education in both males and females.

CONCLUSIONS

Almost 80% of the PONS population were either overweight or obese; therefore, the PONS population is at increased risk of developing obesity-related diseases.

Prevalence of hypertension in a sample of Polish population - baseline assessment from the prospective cohort 'PONS' study

OBJECTIVE

The aim of this cohort study was to evaluate the prevalence of hypertension and cardiovascular risk factors in the studied population.

METHODS

Presented results are a part of the Polish-Norwegian Study (PONS) project. The study group consisted of 3,862 inhabitants of Świętokrzyskie Province aged 45-64 years (2,572 females and 1,290 males).

RESULTS

Prevalence, awareness and control of hypertension was evaluated in the studied population of 3,854 urban and rural inhabitants. Mean blood pressure in the whole studied population was 139.6/81.9 mmHg; of the studied population 61.7% were hypertensive. Hypertension was more prevalent in the studied males (70.63%) than in the females (57.24%). In both males and females, the older subgroups (55-64 y.o.) had significantly higher blood pressure than the younger subgroups (45-54). Education had a significant impact on the prevalence of hypertension, and the highest prevalence of hypertension was observed in the middle level educated groups of females and males. No significant difference was observed between rural and urban inhabitants. In both females and males, the prevalence of hypertension significantly decreased with level of education. Hypertension was well-controlled in only 13.8% of the subjects. More studied females than males achieved good control of blood pressure (14.09 vs. 12.7%), and better control of blood pressure was significantly more frequent in better those who were better educated. Hypertension was not diagnosed in 23.2% of studied population. Significantly, more males than females had undiagnosed hypertension (30.4 vs. 19.5%). No significant difference between rural and urban populations was observed. Interestingly, both in females and males, the better educated groups had more undiagnosed hypertension than those who were well-educated.

CONCLUSIONS

The studied group had a high prevalence of hypertension (61.7%), which was less frequent and better controlled in the studied females than in the males. No significant difference was observed between the urban and rural populations. Level of education had significant impact on the prevalence of hypertension.

Liver cirrhosis mortality in Europe, with special attention to Central and Eastern Europe

BACKGROUND AND AIMS

Over the last decades, Europe has experienced dramatic changes in the geographical variation of liver cirrhosis rates. We attempt to provide a comprehensive analysis of patterns and trends in liver cirrhosis mortality in European countries and regions.

METHODS

Age-standardized (world standard) liver cirrhosis mortality rates per 100,000 person-years at ages 20-64 for 35 separate countries were computed using the World Health Organization Mortality Database.

RESULTS

In the analyzed period (1959-2002), a very strong East-to-West gradient in mortality rates was observed. An increase of the burden of mortality due to liver cirrhosis appeared in Eastern Europe in two specific areas: South-eastern Europe and North-eastern Europe. In the first group of countries, liver cirrhosis mortality was 10-20 times higher than in most other European states, levels never before observed in Europe. In the countries of North-eastern Europe (former Soviet Union countries) liver cirrhosis mortality was characterized by dramatic changes (both positive and negative) in specific periods of time.

CONCLUSIONS

Despite the fact that the etiology of liver cirrhosis is multifactorial, it seems that alcohol drinking is the factor that best explains the observed patterns in frequency of this disease in Europe. Alcohol control policies in Central and Eastern Europe could lead to an appreciable reduction of premature mortality from liver cirrhosis.