Approaches to measuring SHS exposure: Italy & Austria Before and After Study

1. Approaches to measuring SHS exposure: Italy & Austria Before and After Study Giuseppe Gorini, Epidemiologist, MD Occupational and Environmental Epidemiology Unit - CSPO , FLORENCE, ITALY e-mail: g.gorini@cspo.it

2. Italian smoking ban - I in indoor spaces including hospitality venues and workplaces, unless they have: • a separate room, with a size less than half of the size of the whole premise, • closed by automatic sliding doors • with a negative pressure of at least 5 Pascal • provided by very powerfulforced ventilation (flow rate of at least 30 litres per second per person, considering a crowding rate of 0.7 persons per square meter)

3. Italian smoking ban - II Fines: 27.5-275 €; 10 times higher for subjects responsible of enforcing the law in each public place. Since August 2005, owners of hospitality premises were no more responsible to enforce the legislation. In the survey conducted in 2005 amongst the owners of 1,641 hospitality premises, <1% reported to have built smoking areas, because of the high cost due to the tight standards on air quality.

4. Second-hand smoke exposure markers - 1 Nicotine: Tobacco-specific, sensitive personal monitor or environmental monitorflow rate: 2.4 mL/min gas chromatography (GC/MS) in Barcelona Labmean values in the sampling perioddetection limit: 0.01 µg/m3

5. Drop of Nicotine concentration (in µg/m3) in Hospitality Premisesimmediately after the ban:1. Florence: 4 Pubs, 3 Discos [Gorini, J Occup Environ Med, 2005]

6. PM Measurements Aerocet 531 counts individual particles using scattered laser light and calculates the equivalent mass concentration. All five important mass size ranges (PM1, PM2.5,PM7, PM10, and TSP) are displayed NOT tobacco-specific (air pollution outdoor, cooking,heating systems indoor) It’s possible to measure in real time (e.g., minute by minute) Met One ® Instruments, USA

7. Drop of PM concentration (in µg/m3) in Italian Hospitality Premises immediately after the ban:2. Milan & Trieste PM2.5 concentration -82% in Milan -73% in Trieste [Ruprecht, Tominz & Invernizzi, Epidemiol Prev, 2006]

8. Italy & Austria Before and After Study - 1 • Comparison of nicotine concentration before and AFTER 2 YEARS from the introduction of the ban in the Intervention (=Italy) and Control (=Austria) countries. • Settings: 19 Austrian (Vienna) and 28 Italian (Florence, Belluno) hospitality premises before and after the Italian ban. Post-ban samples were also collected in 27 hospitality premises in Turin, Milan, Naples.

9. Italy & Austria Before and After Study - 2 • Pre-ban measurements in Florence, Belluno, and Vienna, were collected in winter 2002 or in winter 2004 for 2 multicenter studies on SHS exposure in a sample of European cities (Athens, Barcelona, Belluno, Bratislava, Florence, Oporto, Ørebro, Paris,Vienna, Warsaw) [Nebot, Tob Control, 2005; Gasparrini, Epidemiol Prev, 2006].

10. Results: Italy (Florence, Belluno), before & after - 1

11. Results: Italy, before & after - 2

12. Results: Austria - 1

13. Results: Austria, overall - 2

14. Results: Italy, Discos & Pubs, before & after

15. Results: Italy, Restaurants, before & after

16. Results: Italy, post-ban measurements in Milan, Turin, Naples

17. Results: Italy, post-ban measurements in Milan, Turin, Naples - 2

18. Cigarette Sales in Italy (millions of Kg) Source: Tobacco Observatory Newsletter, Ref Editor, Milan, Italy

19. Cigarette Sales in Italy - 2 The Newsletter is funded by BAT, the buyer in 2003 of the former Italian state-owned tobacco manufacture, and owner of 30% of cigarette market share in Italy, second only to Philip Morris. The Newsletter reported that the lowest level of cigarette sales since 1998 in Italy was recorded in 2005. Considering that in 1990s a significant amount of cigarettes arrived in Italy through smuggling (black market), cigarette sales in 2005 were the lowest recorded in 30 years.

20. Outdoor Winter Smoking Covered Eating Places • The newsletter partly attributed the increase in cigarette sales in 2006 to these areasbuilt by many premises from winter 2005-2006. • These areas have a roof, three transparent plastic walls or glass walls, and a heating system. Usually removed in other seasons. • In January-March 2005, immediately after the Introduction of the ban, when it was just recorded the lowest levels of cigarette sales, no similar outdoor areas were available in Italian premises.

21. Outdoor Winter Smoking Covered Eating Places

22. We measured nicotine concentration in 3 outdoor spaces (6 measurements) with a median value of 8.28 µg/m3

23. Smoking Prevalence in Italy 2004: 26.2% 2005: 25.6% 2006: 24.3% 2007: 23.5% 2004-2007 %-reduction:-10.3% [Gallus, Prev Med, 2007 (in press)]

24. Acknowledgements - 1 Moshammer H, Neuberger M. Wien University Nebot M, Lopez MJ, Serrahima E. Public Health Agency of Barcelona Galeone D. Ministry of Health, Rome Sbrogiò L, Tamang E, Marcolina D, Venice Gasparrini A, Fondelli MC, CSPO, Florence Giordano L, Charrier L, Piccinelli C, Coppo A, Di Stefano F, D’Elia P, Molinar R. CPO, Turin Invernizzi G, Ruprecht A. National Cancer Institute, Milan Russo Krauss P. Health Authority of Naples

25. Acknowledgements - 2 • Funders: • Ministry of Health – Centre for Diseases Control, Rome, Italy. • European Commission in the framework of the “Europe Against Cancer” programme as part of the European Network for Smoking Prevention (ENSP) Framework Project application n. 2003307, and n. S12.324433 (2001 CVG-008).