1. 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 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

2. 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. WHO Purposes Assess public health status Define public health priorities Evaluate programs Stimulate research Core Public Health Functions Assessment Policy development Assurance Advocacy Empowerment InformationAction What is surveillance and why do it?

3. 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

4. Emilia-Romagna LHU of Bologna Example: Data collection, analyses and dissemination of results are based at LHU level (and at regional level as well)

5. 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

6. 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

7. 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

8. 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)

9. 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

10. 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 The questionnaire 114 questions, many administered to specific subpopulations (e.g. cancer screening) or categories (e.g. present smokers)

11. Not only behaviors… 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 Compliance to smoking band

12. 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 rate12% Refusal rate 9% Not found 3%

13. Smoking habits

14. % Never Smokers 1 51,6 Former smokers 2 19,7 Smokers28,7 Smokers in abstention 3 1,2 Occasional smokers 4 0,5 Daily smokers27,0 Mean of cigarettes13 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

15. 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) Smoke in Italy Smokers (%) Pool HLU PASSI 2009

16. Trends over time The ongoing (monthly) data collection offers the possibility to compare annual/semestral/monthly prevalence Smokers (%) Pool LHU PASSI 2007-2009 Smokers in Piedmont (%) – 2007-2009

17. 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

18. Italian smoking ban – Went into effect in jan/2005 – Covers all enclosed public and work places

19. 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

20. 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 haven’t been in public places in the last month  Don’t know/ Don’t remember

21. Respect of the smoking ban Pooled data – 2009 (n=39,230) 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

22. Respect of the smoking ban in public places Pooled data – 2009 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 Respect of the smoking ban yearRespect always/almost always 200784,6 200887,1 200988,3

23. Household secondhand smoking Pooled data – 2009 (n=39,230) 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

24. 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)

25. “pre” estimation trend “post” estimation trend 1 st intervention: decrease in alcohol legal value 2 nd intervention: immediate withdrawal of license 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 (n=20,006)

26. Centro nazionale di epidemiologia, sorveglianza e promozione della salute (CNESPS), Istituto Superiore di Sanità, Roma Sandro BALDISSERA, Paolo D’ARGENIO, 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 D’ARGENZIO Direzione promozione della salute, Azienda provinciale per i servizi sanitari, Trento Pirous FATEH–MOGHADAM Dipartimento prevenzione AUSL Roma C Massimo O. TRINITO Zadigroma Eva BENELLI, Stefano MENNA The PASSI Coordinating Group at national level

27. Thank you!