Trends and correlates of the public's perception of healthcare systems in the European Union: a multilevel analysis of Eurobarometer survey data from 2009 to 2013

Objective: The aim of the study is to assess trends in public perceptions of health systems in 27 European Union (EU) member states following the financial crisis (2009–2013), in order to discuss observed changes in the context of the financial crisis. Design: Repeated cross-sectional studies. Setting: 27 EU countries. Participants: EU citizens aged 15 years and older. Methods: The study mainly uses the Eurobarometer Social Climate Survey, conducted annually between 2009 and 2013, thereby analysing 116 706 observations. A multilevel logistic regression was carried out to analyse trends over time and the factors associated with citizens' perceptions of their healthcare systems. Results: Europeans generally exhibit positive perceptions of their national healthcare systems, 64.0% (95% CI 63.6% to 64.4%). However, we observed a significant drop in positive perceptions in the years following the crisis, especially within countries most affected by the crisis. Concerning fiscal characteristics, wealthier countries and those dedicating higher proportion of their national income to health were more likely to maintain positive perceptions. At the individual level, perceptions of healthcare systems were significantly associated with respondents' self-perceptions of their social status, financial capacity and overall satisfaction in life. Conclusions: Our finding confirms previous observations that citizens’ perceptions of their healthcare systems may reflect their overall prospects within the broader socioeconomic systems they live in; which have in turn been affected by the financial crisis and the policy measures instituted in response

Are smokers 'hardening' or rather 'softening'? An ecological and multilevel analysis across 28 European Union countries

Background: tobacco control policies can reduce smoking prevalence. These measures may be less effective where smoking prevalence has significantly declined, as the remaining smokers have 'hardened'. Our aim was to empirically evaluate the 'hardening hypothesis' at the population level in the European Union (EU) and explore factors associated with hardcore smoking. Methods: we conducted two separate analyses in the EU using data on smoking from the Eurobarometer surveys (2009-2017, n=112 745). 1) A panel-data fixed-effects linear regression to investigate changes over time in the percentage of hardcore smokers in relation to standardised smoking prevalence at the country level. 2) A multilevel logistic regression analysis with hardcore (daily smokers, ≥15 cigarettes per day who have not attempted to quit in the last 12 months) or light (<5 cigarettes per day) smoking as the dependent variable and time as the main independent variable, controlling for individual and ecological variables. Results: we studied 29 010 current smokers (43.8% hardcore smokers and 14.7% light smokers). The prevalence of hardcore smoking among adult smokers increased by 0.55 (95% CI 0.14-0.96) percentage points per each additional percentage point in the overall smoking prevalence. The odds of being a hardcore smoker increased over time and were higher in middle-aged males and people with financial difficulties, while the odds of being a light smoker significantly declined among females. Conclusion: this study does not support the 'hardening hypothesis' in the EU between 2009 and 2017, but suggests a softening of the smoking population. Existing tobacco control policies are likely to be suitable to further decrease smoking prevalence in Europe

Associations of e-cigarette experimentation with support for tobacco control policies in the European Union, 2012-2014

Introduction: There are limited data on the potential effects of e-cigarette experimentation on support for tobacco control policies. To bridge this gap, we assessed associations between e-cigarette experimentation and support for tobacco control policies in the European Union 2012-2014. We also investigated variations across tobacco-use status, e-cigarette experimentation and sociodemographic characteristics. Methods: Datasets were used from the Special Eurobarometer for Tobacco surveys performed in 2012 (n=26 751) and 2014 (n=27 801). Tobacco control policies assessed were: banning advertising, policies to keep tobacco out of sight, banning online sales, banning flavors, standardized packaging, tax increases, and policies to reduce illicit trade in tobacco. We use multilevel logistic regression models to assess variations in socio-demographics and tobacco/e-cigarette use with support for these policies in 2014, and examined changes in support for these policies, between 2012 and 2014, separately by tobacco-use status (never, current, and former smokers). Results: Population support for tobacco control policies was high in 2014: policies to reduce illicit trade had the highest level of support at 70.1%, while tax increases were the least likely measure to be supported with 52.3% support. Among never and former smokers, experimentation with e-cigarettes was associated with reduced support for all tobacco control policies assessed. For example, never smokers who had experimented with e-cigarettes were less likely to support either tobacco advertising bans (adjusted odds ratio aOR=0.57, 95% confidence interval 0.46-0.71) or standardized packaging for tobacco (aOR=0.58, 95% CI: 0.47-0.71). Former smokers who had experimented with e-cigarettes were less likely to either support standardized packaging for tobacco (aOR=0.70, 95% CI: 0.60-0.82) or keeping tobacco out of sight (aOR=0.77, 95% CI: 0.65-0.90). Among current smokers, e-cigarette experimentation was not associated with support for the tobacco control policies assessed. Conclusions: E-cigarette experimentation was consistently associated with reduced support for tobacco control policies among never and former smokers but not among current smokers. The implications of these findings for tobacco control are unknown, but the data support concerns that e-cigarette experimentation may affect public support for established tobacco control policies within specific subgroups. Further research is needed to assess potential long-term impacts on tobacco control policies

Prevalence and determinants of SHS exposure in public and private areas after the 2010 smoke-free legislation in Greece

<div><p>The objective of the present survey was to assess the extent and socio-economic determinants of population exposure to secondhand smoke (SHS) in Greece in 2011. The national household survey Hellas Health IV was conducted in October 2011. SHS exposure was based on self-reported exposure within home, workplace and public places. Thirty-three per cent of the respondents reported living in a smoke-free home. Smokers (<i>p </i><<i> </i>0.001) and single individuals (<i>p </i><<i> </i>0.017) were less likely to prohibit smoking at home. SHS exposure at work, in restaurants and in bars/clubs/cafes was frequently mentioned by 41.6, 84.2 and 90.5%, respectively. SHS exposure in a bar/club/cafe was noted more among single individuals (<i>p </i>=<i> </i>0.004) and those aged 18–34<i> </i>years (<i>p </i>=<i> </i>0.007). Inhabitants of rural areas were more likely to report someone smoking indoors in all the above venues. Public health education and effective enforcement of the nationwide smoke-free legislation are imperative.</p></div

Tobacco taxation: the importance of earmarking the revenue to health care and tobacco control

Background: Increases in tobacco taxation are acknowledged to be one of the most effective tobacco control interventions. This study aimed at determining the mediating role of socioeconomical status (SES) and the earmarking of revenue to healthcare and tobacco control, in influencing population support for the adoption of a 2 Euro tobacco tax increase in Greece, amid the challenging economic environment and current austerity measures. Methods: Data was collected from two national household surveys, the “Hellas Health III” survey, conducted in October 2010 and the "Hellas Tobacco survey” conducted in September 2012. Data was analyzed from 694 and 1066 respondents aged 18 years or more, respectively. Logistic regression models were fitted to measure the adjusted relationship between socio-economic factors for the former, and support for increased taxation on tobacco products for the latter. Results: In 2012 amidst the Greek financial crisis, population support for a flat two euro tax increase reached 72.1%, if earmarked for health care and tobacco control, a percentage high both among non-smokers (76%) and smokers (64%) alike. On the contrary, when not earmarked, only 43.6% of the population was in support of the equivalent increase. Women were more likely to change their mind and support a flat two-euro increase if the revenue was earmarked for health care and tobacco control (aOR = 1.70; 95% C.I: 1.22-2.38, p = 0.002). Furthermore, support for an increase in tobacco taxation was not associated with SES and income. Conclusion: Despite dire austerity measures in Greece, support for an increase in tobacco taxation was high among both smokers and non-smokers, however, only when specifically earmarked towards health care and tobacco control. This should be taken into account not only in Greece, but within all countries facing social and economic reform

Effect of comprehensive smoke-free legislation on neonatal mortality and infant mortality across 106 middle-income countries:a synthetic control study

Background There are few quantitative studies into the effect of comprehensive smoke-free legislation on neonatal and infant mortality in middle-income countries. We aimed to estimate the effects of implementing comprehensive smoke-free legislation on neonatal mortality and infant mortality across all middle-income countries. Methods We applied the synthetic control method using 1990-2018 country-level panel data for 106 middle-income countries from the WHO, World Bank, and Penn World datasets. Outcome variables were neonatal (age 0-28 days) mortality and infant (age 0-12 months) mortality rates per 1000 livebirths per year. For each middle-income country with comprehensive smoke-free legislation, a synthetic control country was constructed from middle-income countries without comprehensive smoke-free legislation, but with similar prelegislation trends in the outcome and predictor variables. Overall legislation effect was the mean average of country-specific effects weighted by the number of livebirths. We compared the distribution of the legislation effects with that of the placebo effects to assess the likelihood that the observed effect was related to the implementation of smoke-free legislation and not merely influenced by other processes. Findings 31 (29%) of 106 middle-income countries introduced comprehensive smoke-free legislation and had outcome data for at least 3 years after the intervention. We were able to construct a synthetic control country for 18 countries for neonatal mortality and for 15 countries for infant mortality. Comprehensive smoke-free legislation was followed by a mean yearly decrease of 1.63% in neonatal mortality and a mean yearly decrease of 1.33% in infant mortality. An estimated 12 392 neonatal deaths in 18 countries and 8932 infant deaths in 15 countries were avoided over 3 years following the implementation of comprehensive smoke-free legislation. We estimated that an additional 104 063 infant deaths (including 95 850 neonatal deaths) could have been avoided over 3 years if the 72 control middle-income countries had introduced this legislation in 2015. 220 (43%) of 514 placebo effects for neonatal mortality and 112 (39%) of 289 for infant mortality were larger than the estimated aggregated legislation effect, indicating a degree of uncertainty around our estimates. Sensitivity analyses showed results that were consistent with the main analysis and suggested a dose-response association related to comprehensiveness of the legislation. Interpretation Implementing comprehensive smoke-free legislation in middle-income countries could substantially reduce preventable deaths in neonates and infants. Copyright (C) 2022 The Author(s). Published by Elsevier Ltd.Funding Agencies|Dutch Heart Foundation; Lung Foundation Netherlands; Dutch Cancer Society; Dutch Diabetes Research Foundation; Netherlands Thrombosis Foundation; Health Data Research UK</p

Who smokes in Europe? Data from 12 European countries in the TackSHS survey (2017-2018)

Background: Population data on tobacco use and its determinants require continuous monitoring and careful inter-country comparison. We aimed to provide the most up-to-date estimates on tobacco smoking from a large cross-sectional survey, conducted in selected European countries. Methods: Within the TackSHS Project, a face-to-face survey on smoking was conducted in 2017-2018 in 12 countries: Bulgaria, England, France, Germany, Greece, Ireland, Italy, Latvia, Poland, Portugal, Romania and Spain, representing around 80% of the 432 million European Union (EU) adult population. In each country, a representative sample of around 1,000 subjects aged 15 years and older was interviewed, for a total of 11,902 participants. Results: Overall 25.9% of participants were current smokers (31.0% among men and 21.2% among women, pAdditional co-authors: Gergana Geshanova, Giuseppe Gorini, Sheila Keogan, Hristo Ivanov, Maria-José Lopez, Angel Lopez-Nicolas, José Precioso, Krzysztof Przewozniak, Cornel Radu-Loghin, Ario Ruprecht, Joan B Soriano, Polina Starchenko, Marta Trapero-Bertran, Olena Tigova, Anna S Tzortzi, Constantine Vardavas, Vergina K Vyzikidou, Paolo Colombo, Esteve Fernandez, The TackSHS Project Investigator