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      Trends in smoking initiation in Europe over 40 years: A retrospective cohort study

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          Abstract

          Background

          Tobacco consumption is the largest avoidable health risk. Understanding changes of smoking over time and across populations is crucial to implementing health policies. We evaluated trends in smoking initiation between 1970 and 2009 in random samples of European populations.

          Methods

          We pooled data from six multicentre studies involved in the Ageing Lungs in European Cohorts consortium, including overall 119,104 subjects from 17 countries (range of median ages across studies: 33–52 years). We estimated retrospectively trends in the rates of smoking initiation (uptake of regular smoking) by age group, and tested birth cohort effects using Age-Period-Cohort (APC) modelling. We stratified all analyses by sex and region (North, East, South, West Europe).

          Results

          Smoking initiation during late adolescence (16–20 years) declined for both sexes and in all regions (except for South Europe, where decline levelled off after 1990). By the late 2000s, rates of initiation during late adolescence were still high (40–80 per 1000/year) in East, South, and West Europe compared to North Europe (20 per 1000/year). Smoking initiation rates during early adolescence (11–15 years) showed a marked increase after 1990 in all regions (except for North European males) but especially in West Europe, where they reached 40 per 1000/year around 2005. APC models supported birth cohort effects in the youngest cohorts.

          Conclusion

          Smoking initiation is still unacceptably high among European adolescents, and increasing rates among those aged 15 or less deserve attention. Reducing initiation in adolescents is fundamental, since youngsters are particularly vulnerable to nicotine addiction and tobacco adverse effects.

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          Most cited references25

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          The European Community Respiratory Health Survey.

          The European Community Respiratory Health Survey (ECRHS) was planned to answer specific questions about the distribution of asthma and health care given for asthma in the European Community. Specifically, the survey is designed to estimate variations in the prevalence of asthma, asthma-like symptoms and airway responsiveness; to estimate variations in exposures to known or suspected risk factors for asthma, and assess to what extent these variations explain the variations in the prevalence of disease; and to estimate differences in the use of medication for asthma. The protocol provides specific instructions on the sampling strategy adopted by the survey teams, as well as providing instructions on the use of questionnaires, the tests for allergy, lung function measurements, tests of airway responsiveness, and blood and urine collection. The principal data collection sheets and questionnaires are provided in the appendices, together with information on coding and quality control. The protocol is published as a reference for those who wish to know more of the methods used in the study, and also to give other groups who wish to collect comparable data access to the detailed methodology.
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            Trends in the prevalence of asthma and allergic rhinitis in Italy between 1991 and 2010.

            The prevalence of asthma increased worldwide until the 1990s, but since then there has been no clear temporal pattern. The present study aimed to assess time trends in the prevalence of current asthma, asthma-like symptoms and allergic rhinitis in Italian adults from 1990 to 2010. The same screening questionnaire was administered by mail or phone to random samples of the general population (age 20-44 yrs) in Italy, in the frame of three multicentre studies: the European Community Respiratory Health Survey (ECRHS) (1991-1993; n = 6,031); the Italian Study on Asthma in Young Adults (ISAYA) (1998-2000; n = 18,873); and the Gene Environment Interactions in Respiratory Diseases (GEIRD) study (2007-2010; n = 10,494). Time trends in prevalence were estimated using Poisson regression models in the centres that repeated the survey at different points in time. From 1991 to 2010, the median prevalence of current asthma, wheezing and allergic rhinitis increased from 4.1% to 6.6%, from 10.1% to 13.9% and from 16.8% to 25.8%, respectively. The prevalence of current asthma was stable during the 1990s and increased (relative risk 1.38, 95% CI 1.19-1.59) from 1998-2000 to 2007-2010, mainly in subjects who did not report allergic rhinitis. The prevalence of allergic rhinitis has increased continuously since 1991. The asthma epidemic is not over in Italy. During the past 20 yrs, asthma prevalence has increased by 38%, in parallel with a similar increase in asthma-like symptoms and allergic rhinitis.
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              The Tobacco Control Scale: a new scale to measure country activity.

              To quantify the implementation of tobacco control policies at country level using a new Tobacco Control Scale and to report initial results using the scale. A questionnaire sent to correspondents in 30 European countries, using a scoring system designed with the help of a panel of international tobacco control experts. The 30 countries are ranked by their total score on the scale out of a maximum possible score of 100. Only four countries (Ireland, United Kingdom, Norway, Iceland) scored 70 or more, with an eight point gap (most differences in scores are small) to the fifth country, Malta, on 62. Only 13 countries scored above 50, 11 of them from the European Union (EU), and the second largest points gap occurs between Denmark on 45 and Portugal on 39, splitting the table into three groups: 70 and above, 45 to 62, 39 and below. Ireland had the highest overall score, 74 out of 100, and Luxembourg was bottom with 26 points. However even Ireland, much praised for their ban on smoking in public places, did not increase tobacco taxes in 2005, for the first time since 1995. Although the Tobacco Control Scale has limitations, this is the first time such a scale has been developed and applied to so many countries. We hope it will be useful in encouraging countries to strengthen currently weak areas of their tobacco control policy.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: Formal analysisRole: MethodologyRole: Writing – review & editing
                Role: ResourcesRole: Writing – review & editing
                Role: Writing – review & editing
                Role: ResourcesRole: Writing – review & editing
                Role: ResourcesRole: Writing – review & editing
                Role: ResourcesRole: Writing – review & editing
                Role: ResourcesRole: Writing – review & editing
                Role: ResourcesRole: Writing – review & editing
                Role: Funding acquisitionRole: ResourcesRole: Writing – review & editing
                Role: ResourcesRole: Writing – review & editing
                Role: ResourcesRole: Writing – review & editing
                Role: ResourcesRole: Writing – review & editing
                Role: ResourcesRole: Writing – review & editing
                Role: ResourcesRole: Writing – review & editing
                Role: ResourcesRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: InvestigationRole: MethodologyRole: ResourcesRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                22 August 2018
                2018
                : 13
                : 8
                : e0201881
                Affiliations
                [1 ] Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
                [2 ] Department of Public Health and Pediatrics, University of Turin, Turin, Italy
                [3 ] Allergy and Lung Health Unit, School of Population and Global Health, The University of Melbourne, Melbourne, Australia
                [4 ] ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain
                [5 ] Universitat Pompeu Fabra (UPF), Barcelona, Spain
                [6 ] CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
                [7 ] Department of Respiratory Medicine and Sleep, Landspitali University Hospital (E7), Reykjavik, Iceland
                [8 ] University of Iceland, Faculty of Medicine, Reykjavik, Iceland
                [9 ] Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Clinical Center, Ludwig Maximilians University, Comprehensive Pneumology Centre Munich, German Centre for Lung Research, Muenchen, Germany
                [10 ] Occupational and Environmental Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
                [11 ] Department of Medical Sciences: Respiratory, Allergy and Sleep research, Uppsala University, Uppsala, Sweden
                [12 ] Population Health & Occupational Disease, National Heart and Lung Institute, Imperial College London, London, United Kingdom
                [13 ] MRC-PHE Centre for Environment and Health, Imperial College London, London, United Kingdom
                [14 ] Inserm UMR 1152, Pathophysiology and Epidemiology of Respiratory Diseases, Paris, France
                [15 ] University Paris Diderot Paris 7, UMR 1152, Paris, France
                [16 ] Institute of Respiratory Diseases, University of Sassari, Sassari, Italy
                [17 ] Centre for International Health, University of Bergen, Bergen, Norway
                [18 ] Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
                [19 ] Unit of Biostatistics and Clinical Epidemiology, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
                [20 ] Allergy Centre Charité, Department of Dermatology & Allergy, Charité—Universitätsmedizin Berlin, Berlin, Germany
                Legacy, Schroeder Institute for Tobacco Research and Policy Studies, UNITED STATES
                Author notes

                Competing Interests: TZ has received industry consulting, research grants and/or honoraria from: AstraZeneca, AbbVie, ALK, Almirall, Astellas, Bayer Health Care, Bencard, Berlin Chemie, FAES, HAL, Henkel, Kryolan, Leti, L'Oreal, Meda, Menarini, Merck, MSD, Novartis, Pfizer, Sanofi, Stallergenes, Takeda, Teva, UCB; TZ reports the following organizational affiliations: Committee member, WHO-Initiative “Allergic Rhinitis and its Impact on Asthma” (ARIA); Member of the Board, German Society for Allergy and Clinical Immunology (DGAKI); Head, European Centre for Allergy Research Foundation (ECARF); Secretary General, Global Allergy and Asthma European Network (GA2LEN); Member, Committee on Allergy Diagnosis and Molecular Allergology, World Allergy Organisation (WAO). All the other authors report no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, and no other relationships or activities that could appear to have influenced the submitted work. These competing interests do not alter the authors' adherence to PLOS ONE policies on sharing data and materials. There are no restrictions to the sharing of data from this study.

                ¶ Principal Investigators and Partners of the Ageing Lungs In European Cohorts study are provided in the Acknowledgments and the study website https://www.alecstudy.org/.

                Author information
                http://orcid.org/0000-0002-2778-658X
                Article
                PONE-D-18-06892
                10.1371/journal.pone.0201881
                6104979
                30133533
                71760849-7ca6-4117-ac8b-d554f5b3e51b
                © 2018 Marcon et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 5 March 2018
                : 24 July 2018
                Page count
                Figures: 3, Tables: 2, Pages: 14
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/100010661, Horizon 2020 Framework Programme;
                Award ID: 633212
                Award Recipient :
                This study has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 633212. DJ has received support from the European Union and the Medical Research Council. National funders who supported data collection in the original cohort and cross-sectional studies are listed in S2 Appendix. The funders had no role in the writing of the manuscript or the decision to submit it for publication. The corresponding author had full access to all the data and had final responsibility for the decision to submit for publication.
                Categories
                Research Article
                Biology and Life Sciences
                Behavior
                Habits
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                Medicine and Health Sciences
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                Tobacco Control
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                All relevant data are within the paper and its Supporting Information files.

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