EXPOSURE TO TOBACCO SMOKE IN THE EUROPEAN UNION 2nd Working Meeting on Adult Premature Mortality in the European Union October 2006, Warsaw, Poland

METHODOLOGY: CURRENT SMOKING STATUS Data from nation-wide random surveys for EU(15), EU(8+2) and Russia Available data for 8 new EU members (Czech Rep., Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia), 2 accession countries (Bulgaria, Romania), Russia and 14 old EU members (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Italy, Ireland, Netherlands, Portugal, Spain, Sweden, UK) Still, data for Malta, Cyprus and Luxembourg not available Adult population (15+, 18+ or 20+), for Baltic countries and Finland up to 64, for France to 74. Age-specific data originally obtained in 5-years or 10-years groups. Sampling mainly based on data from the national population registers. Face-to-face interviews, except Baltic countries and Finland (mail surveys) and France (CATI) In Baltic countries and Finland, same research approach and methodology (FinBalt); in other countries, health monitoring approach but slightly different methodology; in Poland and Denmark, studies focused on smoking behaviors For EU(8+2), survey data from ; for Russia from 1996; for EU(15) data from Limited knowledge on detailed sampling methodology and few data on response rate (mail surveys - about 60%, face-to-face – about 70%).

ANALYSIS Data for Greece and Ireland are not included into present analysis (prepared to be analyzed in final report) Analysis for adult population at age of 20 and over (low smoking-attributable health risk and less stable smoking behaviors in population at age of 15 to 19) Data obtained in 10-years age groups were adjusted for 5-years groups Basic analysis in the following age groups (20+, 20-64, 20-44, 45-64, 65+) and smoking categories (current, former and never smoking) Data presented for current smokers at age of 20 to 64: - data available for all countries - middle age group at high health risk Possible comparisons between: - particular EU(8+2) countries with Russia as a control country - particular EU(15) countries - new EU members and accession countries (EU8+2) vs. old EU(15) members Data presented separately for male and female population

CURRENT SMOKING BY GENDER, AGE 20-64, 2002 * EU15 without Greece, Ireland and Luxembourg

CURRENT SMOKING, MALES, AGE 20-64, 2002 * EU15 without Greece, Ireland and Luxembourg

CURRENT SMOKING, FEMALES, AGE 20-64, 2002 * EU15 without Greece, Ireland and Luxembourg

SUMMARY Current smoking rates 2 to 4 times higher in men than in women in EU(8+2) countries (much lower gender difference in EU(15)) In men, smoking prevalence is higher in Eastern than Western countries. In women, some EU(8+2) countries (Poland, Bulgaria, Hungary) have one of the highest smoking rates in Europe, however, other EU(8+2) countries (Russia, Lithuania, Romania) have the lowest rates Some methodological and analytical problems in international comparisons: - different research approaches - slight differences in data sources and studies methodology - small survey samples - no detailed data on sampling methods - no consistent smoking categories and social strata - data bases, analytical methods and reporting specific for country needs

POINTS FOR DISCUSSION Need for standardized analysis of existing data Need for new international research based on mutual approach, standarized methodology and data analysis What research approach? What standards for data sources and collection, type of study, sampling methods, analytical categories (smoking and social strata), statistical analysis and scientific publications? Access to new data sources Financial and organizational framework for new international research (Health EuroBarometer?, FinBalt? etc.)

TRENDS IN SMOKING PREVALENCE IN CEE COUNTRIES

METHODOLOGY: TRENDS IN SMOKING Data from population based random surveys National samples for 5 countries, population based sample for MONICA project in Czech Republic Sampling based on data from the national population registers. Adult population (15+, 16+, 20+ or 25+), for Baltic countries and Czech Republic up to 64 Long-term, at least 3 time-points data available for Poland ( ), Czech Republic ( ), Bulgaria ( ), Estonia ( ), Latvia ( ) and Lithuania ( ); fragmentary data from Hungary, Slovenia, Slovakia and Romania Annual surveys since 1985 in Poland, 2-years intervals in Baltic countries, 3 to 5-years intervals in Czech Republic, even longer intervals in Bulgaria Data from face-to-face interviews (3 countries) and mail surveys (3 Baltic states) In each country, studies based on comparable research approach (studies on health monitoring, MONICA and smoking behaviors) and methodology (general knowledge) Limited data on detailed sampling methodology and response rate

ANALYSIS Analysis in available study-specific age groups Basic analysis limited to daily, former and never smokers, excepts Czech Republic (current and non- smoking) Analysis presented for daily smokers (high health risk group with more stable smoking behavior) Comparison of smoking trends within countries For Poland, some data were aggregated into 5-years clusters Data presented separately for male and female population

SMOKING PREVALENCE (AGE 20+) POLAND

SMOKING PREVALENCE (AGE 25-64) CZECH REPUBLIC

SMOKING PREVALENCE (AGE 15+) BULGARIA

SMOKING PREVALENCE (AGE 20-64) LITHUANIA

SMOKING PREVALENCE (AGE 16-64) ESTONIA

SMOKING PREVALENCE (AGE 15-64) LATVIA

SUMMARY In men, smoking decline in Poland and Czech Republic since the mid-1980s; no changes in other countries In women, substantial increase in smoking in Bulgaria (slight increase in Lithuania, too); no changes in other countries Some methodological and analytical problems in comparisons of time trends, especially between countries: - long-term comparable smoking data are available only for few EU(8+2) countries - different in time research approaches, data sources and collection methods, way of sampling and sample sizes - no detailed data on sampling methods - no consistent smoking categories and social strata (lack of standarization, social changes and changes in political system) - changes in data recording and reporting methods

POINTS FOR DISCUSSION Need for more annual nation-wide surveys with comparable approach and methodology Need for internationally comparable time trends analysis Focus on age or/and birth cohort specific analysis of time trends in smoking Need for consistent analysis of smoking behavior and its health consequences Need for data aggregation in case of small study samples

TAR CONTENT IN CIGARETTES SOLD IN CEE MARKET

METHODOLOGY Available data from 9 countries: Bulgaria, Czech Rep., Estonia, Hungary, Latvia, Lithuania, Poland, Slovenia, USSR/Russia. Long term data on mean tar content in all or most popular cigarettes brands available for Poland, only ( ). For other CEE countries data available from 1 to 3 time points and based on chemical analysis of few cigarettes brands (excepts Russia in 1993 – 45 brands). Data available for the following time periods: (1 country), (3 countries), (8 countries), (3 countries). Analysis conducted both by international and national laboratories and by different study coordinators (Russian Institute of Carcinogenesis in Moscow, Cancer Center and Institute of Oncology in Warsaw, Technical Research Center in Helsinki), although based on ISO methods (i.e. CORESTA). For some countries, data based on secondhand sources: scientific papers and reports (IARC 1986, WHO 1997, Forey et al. 2002) or personal communication (Bulgaria, Slovenia).

MEAN TAR CONTENT (MG/CIGARETTE) IN CIGARETTES SOLD IN POLAND,

Country (year of study) Estimated tar level in CEE>30~25~20<10 Bulgaria (1993; 2005) 168,1 Czech Republic (1989; 1993) 2016 Estonia (1993) 24 Hungary (1973; 1992) Latvia (1993) 18 Lithuania (1993) 22 Poland (1984; 1993; 2000) 24189,8 Slovenia (2005) 6,5 USSR/Russia (1983; 1993) 2522 MEAN TAR YIELDS (mg/cigarette) IN CIGARETTES SOLD IN CEE MARKET IN THE LAST 30 YEARS

SALES-WEIGHTED TAR YIELDS (mg/cigarette) IN POLAND, FINLAND AND USA Source: Forey et al. 2002; Florek et al. 1998; Warsaw Cancer Center database 2006

SUMMARY Very limited knowledge on cigarettes toxicity, including tar content in new EU members and accession countries Poland as a case study for EU(8+2) – the most comprehensive and long-term data on tar and other toxic substances (PAHs, TSNA, heavy metals, CO, etc) from Both Polish and fragmentary data from other EU(8+2) countries show substantial decrease in mean tar content in cigarette sold in EU(8+2) market in the last 30 years These changes are connected with national and EU requirements regarding permitted levels of harmful substances in cigarettes Today, there is no difference between cigarettes sold in CEE, EU and USA market

POINTS FOR DISCUSSION Question: Do we need to analyze data on toxicity of cigarettes in relation to health consequences of smoking? Should we focus on tar content in cigarettes or analyze specific carcinogenic substances? Poland as a case study for CEE market Need for more information on tobacco products (i.e. percentage of filter-tipped or light cigarettes on the CEE market) Need for international chemical analysis on toxicity of cigarettes?