Impact of the WHO "best buys" for alcohol policy on consumption and health in the Baltic countries and Poland 2000-2020.

Alcohol use is a major risk factor for burden of disease. This narrative review aims to document the effects of major alcohol control policies, in particular taxation increases and availability restrictions in the three Baltic countries (Estonia, Latvia, and Lithuania) between 2000 and 2020. These measures have been successful in curbing alcohol sales, in general without increasing consumption of alcoholic beverages from unrecorded sources; although for more recent changes this may have been partly due to the COVID-19 pandemic. Moreover, findings from time-series analyses suggest improved health, measured as reductions in all-cause and alcohol-attributable mortality, as well as narrowing absolute mortality inequalities between lower and higher educated groups. For most outcomes, there were sex differences observed, with alcohol control policies more strongly affecting males. In contrast to this successful path, alcohol control policies were mostly dismantled in the neighbouring country of Poland, resulting in a rising death toll due to liver cirrhosis and other alcohol-attributable deaths. The natural experiment in this region of high-income European countries with high consumption levels highlights the importance of effective alcohol control policies for improving population health.

Alcohol-attributable mortality and alcohol control policy in the Baltic Countries and Poland in 2001-2020: an interrupted time-series analysis.

BACKGROUND: The Baltic countries-Lithuania, Latvia and Estonia-are characterized by a high rate of fully alcohol-attributable mortality, compared with Poland. Alcohol control policy measures implemented since 2001 in the Baltic countries included a restriction on availability and an increase in excise taxation, among others. The aim of the current study was to evaluate the relationship between alcohol control policy implementation and alcohol-attributable mortality in the Baltic countries and Poland. METHODS: Alcohol-attributable mortality data for 2001-2020 was defined by codes 100% alcohol-attributable for persons aged 15 years and older in the Baltic countries and Poland. Alcohol control policies implemented between 2001 and 2020 were identified, and their impact on alcohol-attributable mortality was evaluated using an interrupted time-series methodology by employing a generalized additive model. RESULTS: Alcohol-attributable mortality was significantly higher in the Baltic countries, compared with Poland, for both males and females. In the final reduced model, alcohol control policy significantly reduced male alcohol-attributable mortality by 7.60% in the 12 months post-policy implementation. For females, the alcohol control policy mean-shift effect was higher, resulting in a significant reduction of alcohol-attributable mortality by 10.77% in the 12 months post-policy implementation. The interaction effects of countries and policy tested in the full model were not statistically significant, which indicated that the impact of alcohol control policy on alcohol-attributable mortality did not differ across countries for both males and females. CONCLUSIONS: Based on the findings of the current study, alcohol control policy in the form of reduced availability and increased taxation was associated with a reduction in alcohol-attributable mortality among both males and females.

Alcohol control policies reduce all-cause mortality in Baltic Countries and Poland between 2001 and 2020.

Alcohol consumption in the Baltic countries and Poland is among the highest globally, causing high all-cause mortality rates. Contrary to Poland, the Baltic countries have adopted many alcohol control policies, including the World Health Organization (WHO) "best buys". The aim of this study was to evaluate the impact of these policies, which were implemented between 2001 and 2020, on all-cause mortality. Monthly mortality data for men and women aged 20+ years of age in Estonia, Latvia, Lithuania, and Poland were analysed for 2001 to 2020. A total of 19 alcohol control policies, fulfilling an a-priori defined definition, were implemented between 2001 and 2020 in the countries of interest, and 18 of them could be tested. Interrupted time-series analyses were conducted by employing a generalized additive mixed model (GAMM) for men and women separately. The age-standardized all-cause mortality rate was lowest in Poland and highest in Latvia and had decreased in all countries over the time period. Taxation increases and availability restrictions had short-term effects in all countries, on average reducing the age-standardized all-cause mortality rate among men significantly (a reduction of 2.31% (95% CI 0.71%, 3.93%; p = 0.0045)). All-cause mortality rates among women were not significantly reduced (a reduction of 1.09% (95% CI - 0.02%, 2.20%; p = 0.0554)). In conclusion, the alcohol control policies implemented between 2001 and 2020 reduced all-cause mortality among men 20+ years of age in Baltic countries and Poland, and thus, the practice should be continued.

Classifying alcohol control policies enacted between 2000 and 2020 in Poland and the Baltic countries to model potential impact.

AIMS: The study's aim is to identify and classify the most important alcohol control policies in the Baltic countries (Estonia, Latvia and Lithuania) and Poland between 2000 and 2020. METHODS: Policy analysis of Baltic countries and Poland, predicting potential policy impact on alcohol consumption, all-cause mortality and alcohol-attributable hospitalizations was discussed. RESULTS: All Baltic countries implemented stringent availability restrictions on off-premises trading hours and different degrees of taxation increases to reduce the affordability of alcoholic beverages, as well as various degrees of bans on alcohol marketing. In contrast, Poland implemented few excise taxation increases or availability restrictions and, in fact, reduced stipulations on prior marketing bans. CONCLUSIONS: This classification of alcohol control policies in the Baltic countries and Poland provides a basis for future modeling of the impact of implementing effective alcohol control policies (Baltic countries), as well as the effects of loosening such policies (Poland).

Do alcohol control policies have the predicted effects on consumption? An analysis of the Baltic countries and Poland 2000-2020.

BACKGROUND: Many population-based alcohol control policies are postulated to work via changes in adult alcohol per capita consumption (APC). However, since APC is usually assessed on a yearly basis, often there are not enough data to conduct interrupted time-series or other controlled analyses. The current dataset, with 21 years of observation from four countries (Estonia, Latvia, Lithuania, and Poland), had sufficient power to test for average effects and potential interactions of the World Health Organization's (WHO) three "best buys" for alcohol control: taxation increases leading to a decrease in affordability; reduced availability (via a decrease in opening hours of at least 20 %); and advertising and marketing restrictions. We postulated that the former two would have immediate effects, while the latter would have mid- to long-term effects. METHODS: Linear regression analysis. RESULTS: Taxation increases and availability reductions in all countries were associated with an average reduction in APC of 0.83 litres (ℓ) of pure alcohol per year (95 % confidence interval: -1.21 ℓ, -0.41 ℓ) in the same year, with no significant differences between countries. Restrictions on advertising and/or marketing had no significant immediate associations with APC (average effect 0.04 ℓ per year; 95 % confidence interval: -0.65 ℓ, 0.73 ℓ). Several sensitivity analyses corroborated these main results. CONCLUSIONS: The WHO "best buy" alcohol control policies of taxation increases and availability restrictions worked as postulated in these four northeastern European Union countries.

Social norms for e-cigarettes and smoking: associations with initiation of e-cigarette use, intentions to quit smoking and quit attempts: findings from the EUREST-PLUS ITC Europe Surveys.

BACKGROUND: Social norms have received little attention in relation to electronic cigarettes (EC). The current study examine social norms for EC use and smoking tobacco, and their associations with (i) initiation of EC use, (ii) intention to quit smoking and (iii) attempts to quit smoking. METHODS: Cross-sectional and longitudinal data analysis from Waves 1 and 2 of the ITC 6 European Country Survey and corresponding waves from England (the ITC Four Country Smoking and Vaping Survey). Current smokers at baseline, who heard of ECs and provided data at both waves were included (n = 3702). Complex samples logistic regression examined associations between the outcomes and descriptive (seeing EC use in public, close friends using ECs/smoking) and injunctive (public approves of ECs/smoking) norms, adjusting for country, demographics, EC use and heaviness of smoking. RESULTS: In longitudinal analyses, seeing EC use in public at least some days was the only social norm that predicted initiation of EC use between waves (OR = 1.66, 95%CI = 1.08-2.56). In the cross-sectional analysis, having an intention to quit was associated with seeing EC use in public (OR = 1.37, 95%CI = 1.04-1.81) and reporting fewer than three close friends smoke (OR = 0.59, 95%CI = 0.44-0.80). There was no association between any social norm and making a quit attempt between waves. CONCLUSIONS: Initiation of EC use is predicted by seeing EC use in public, which was also associated with greater intention to quit smoking. Friends' smoking was associated with lower intention to quit. These findings may allay concerns that increased visibility of ECs is renormalizing smoking amongst current smokers.

Cessation behaviours among smokers of menthol and flavoured cigarettes following the implementation of the EU Tobacco Products Directive: findings from the EUREST-PLUS ITC Europe Surveys.

The European Tobacco Products Directive (TPD) introduced a ban on characterizing flavours in cigarettes (2016), including menthol (2020). The longitudinal data analysis of the EUREST-PLUS International Tobacco Control (ITC) Project Europe Surveys (n = 16 534; Wave 1 in 2016 and Wave 2 in 2018) found significant but small declines in the weighted prevalence of menthol (by 0.94%; P = 0.041) and other flavoured cigarette use (by 1.32%; P < 0.001) following the 2016 TPD. The declines tended to be driven primarily by the menthol and flavoured cigarette (MFC) smokers switching to unflavoured tobacco. Cigarette consumption declined between waves, but there were no statistically significant difference in decline between MFC and unflavoured tobacco smokers on smoking and cessation behaviours between the waves.

European adult smokers' perceptions of the harmfulness of e-cigarettes relative to combustible cigarettes: cohort findings from the 2016 and 2018 EUREST-PLUS ITC Europe Surveys.

BACKGROUND: This study presents perceptions of the harmfulness of electronic cigarettes (e-cigarettes) relative to combustible cigarettes among smokers from six European Union (EU) countries, prior to the implementation of the EU Tobacco Products Directive (TPD), and 2 years post-TPD. METHODS: Data were drawn from the EUREST-PLUS ITC Europe Surveys, a cohort study of adult smokers (≥18 years) from Germany, Greece, Hungary, Poland, Romania and Spain. Data were collected in 2016 (pre-TPD: N = 6011) and 2018 (post-TPD: N = 6027). Weighted generalized estimating equations were used to estimate perceptions of the harmfulness of e-cigarettes compared to combustible cigarettes (less harmful, equally harmful, more harmful or 'don't know'). RESULTS: In 2016, among respondents who were aware of e-cigarettes (72.2%), 28.6% reported that they perceived e-cigarettes to be less harmful than cigarettes (range 22.0% in Spain to 34.1% in Hungary). In 2018, 72.2% of respondents were aware of e-cigarettes, of whom 28.4% reported perceiving that e-cigarettes are less harmful. The majority of respondents perceived e-cigarettes to be equally or more harmful than cigarettes in both 2016 (58.5%) and 2018 (61.8%, P > 0.05). Overall, there were no significant changes in the perceptions that e-cigarettes are less, equally or more harmful than cigarettes, but 'don't know' responses significantly decreased from 12.9% to 9.8% (P = 0.036). The only significant change within countries was a decrease in 'don't know' responses in Spain (19.3-9.4%, P = .001). CONCLUSIONS: The majority of respondents in these six EU countries perceived e-cigarettes to be equally or more harmful than combustible cigarettes.

Cervical cancer mortality in young adult European women.

BACKGROUND: The process of social, political and economic transformation, which took place in Central and Eastern Europe in the early 90's, has affected many spheres of Europeans' lives, including health-associated issues. These changes also had an impact on mortality rates due to cervical cancer (CC). Therefore, the aim of this study was to analyse CC mortality trends in Europe after 1990. METHODS: Data on death due to CC, uterine cancers and unspecified uterine cancers, in women aged 20-44, were taken from the WHO Mortality Database. Trends in European countries between 1990 and 2017 were assessed using the Joinpoint Regression Program. RESULTS: Most of the countries experienced a decrease in CC mortality. Although the lowest rates were observed in EU15 Member States, the highest decreases were observed in Central and Eastern Europe. However, there are still differences in mortality in these countries. There are also a few countries like Belarus, Latvia and Ukraine, which experienced an increase in mortality. The range of mortality across Europe in 2017 was between 0.6 and 5.2/100,000 women. CONCLUSIONS: It is essential to introduce well-organised screening programmes for early detection of CC with coverage of a correspondingly high percentage of the population, particularly in East-Central Europe, as well as to introduce high-coverage HPV vaccination in all European countries.

Dependence, plans to quit, quitting self-efficacy and past cessation behaviours among menthol and other flavoured cigarette users in Europe: The EUREST-PLUS ITC Europe Surveys.

INTRODUCTION: This study characterises smoking and cessation-related behaviours among menthol and other flavoured cigarette users in Europe prior to the implementation of the European Tobacco Products Directive (TPD) ban on the sale of flavoured cigarettes. METHODS: An analysis of cross-sectional data from the 2016 EUREST-PLUS ITC Europe Surveys was conducted among a sample of 10760 adult smokers from eight European Union Member States. Respondents were classified as menthol, other flavoured, unflavoured, or no usual flavour cigarette users and compared on smoking and cessation behaviours and characteristics. Data were analysed in SPSS Complex Samples Package using bivariate and multivariate regression analyses adjusted for sociodemographic characteristics, dependence, and country. RESULTS: In bivariate analyses, cigarette flavour was significantly associated with all outcomes (p<0.001). After adjusting for sociodemographic characteristics, these associations attenuated but remained significant and in the same direction for dependence, self-efficacy, plans to quit, past quit attempts, and ever e-cigarette use. In fully adjusted models, compared to smokers of non-flavoured cigarettes, menthol smokers were less likely to smoke daily (AOR=0.47, 95% CI: 0.32-0.71), smoke within 30 min of waking (0.52,0.43-0.64), consider themselves addicted (0.74,0.59-0.94), and more likely to have ever used e-cigarettes (1.26,1.00-1.57); other flavoured cigarette smokers were less likely to smoke daily (0.33,0.15-0.77), and have higher self-efficacy (1.82,1.20-2.77); no usual flavour smokers were less likely to smoke daily (0.34,0.22-0.51), smoke within 30 min of waking (0.66,0.55-0.80), consider themselves addicted (0.65,0.52-0.78), have ever made a quit attempt (0.69,0.58-0.84), have ever used e-cigarettes (0.66,0.54-0.82), and had higher self-efficacy (1.46,1.19-1.80). CONCLUSIONS: Smokers of different cigarette flavours in Europe differ on smoking and cessation characteristics. The lower dependence of menthol cigarette smokers could lead to greater success rates if quit attempts are made, however cross-country differences in smoking behaviours and quitting intentions could lead to the TPD ban on cigarette flavours having differential impact if not accompanied by additional measures, such as smoking cessation support.

Characterising smokers of menthol and flavoured cigarettes, their attitudes towards tobacco regulation, and the anticipated impact of the Tobacco Products Directive on their smoking and quitting behaviours: The EUREST-PLUS ITC Europe Surveys.

INTRODUCTION: Little research exists on the sociodemographic characteristics of menthol and flavoured cigarette (MFC) smokers in Europe. This study assessed the proportion of MFC smokers in Europe, their sociodemographic characteristics, and their attitudes towards tobacco control measures. METHODS: Cross-sectional data were collected in 2016 among 10760 adult current smokers from 8 European countries (ITC Europe Project and EUREST-PLUS). Smokers of menthol, other flavoured, unflavoured tobacco, or no usual brand were compared on sociodemographic characteristics, attitudes towards a range of tobacco control measures (e.g. ban on flavouring), and on intentions regarding their smoking behaviour following the ban on flavoured tobacco. Data were analysed in SPSS Complex Samples Package using univariate analyses. RESULTS: Among the respondents, 7.4% smoked menthol cigarettes and 2.9% other flavoured tobacco, but large differences existed between countries (e.g. 0.4% smokers smoked menthol cigarettes in Spain vs 12.4% in England). Compared to other groups, menthol cigarette smokers were younger, more likely to be female, better educated, had higher household income, and smoked fewer cigarettes (all p<0.001). A quarter of menthol smokers supported a ban on additives, compared with almost half of all other smokers (p<0.001). In case of a ban on flavourings, around a fifth of all MFC smokers intended to switch to another brand, and a third to reduce the amount they smoked or to quit smoking, but there was no consistent pattern across MFC smokers among the countries. CONCLUSIONS: The ban on flavourings introduced by the EU Tobacco Products Directive (extended to 2020 for menthols) will affect one in ten smokers in the countries surveyed, which provides an opportunity for targeting these groups with cessation programmes. However, smokers of menthol and flavoured cigarettes in the different European countries are a heterogeneous group and may need different approaches.

An attempt to assess knowledge about tobacco dependence among students at the Medical University in Wroclaw.

INTRODUCTION: Tobacco smoking is still one of the greatest, avoidable, singular causes of death. Although students of medical faculties are expected to have solid knowledge about smoking hazards, a significant number of them still smoke. AIM: The aim of the study was to assess knowledge on tobacco dependence in a sample of students at the Medical University in Wroclaw. MATERIAL AND METHODS: Between 2009-2011, non-compulsory lectures on the diagnosis and treatment of tobacco dependence were provided for 3(rd) to 6(th) year students of medicine at the Medical University in Wroclaw (170 students). The questionnaire contained 10 questions about smoking-related diseases and medicines used in tobacco dependence treatment. RESULTS: 21% of students smoked cigarettes and 79% were never smokers. 36% of the study group was exposed to passive smoking at the university. Nearly 80% of survey respondents agreed with the statement that cigarette smoking can lead to psychological addiction as strong as drug addiction, but more than 12% of the respondents perceived smoking just as a strong habit. Only 6 out of 10 surveyed students recognised tobacco dependence as an illness classified in an international classification of diseases and health problems (ICD-10). The correct amount of the chemical substances to be found in tobacco smoke was known by 67.1% of all surveyed students. The vast majority of the surveyed students indicated correctly 2 brands of nicotine replacement therapy, but none of them could name even one chemical and corresponding trade name of the pharmaceutical with central effect. CONCLUSIONS: The level of knowledge about the diagnosis and treatment of tobacco dependence among the students of the Medical Faculty in Wroclaw Medical University is low, and requires improvement through educational activities at both facultative and compulsory study level. Special attention should be paid to pharmaceutical treatment of the tobacco dependence syndrome.

Dietary intake and adipose tissue level of specific fatty acids in a selected group from the Lower Silesia population.

PURPOSE: The aim of the study was to assess the content of specific fatty acids in the diet and adipose tissue in a selected group of inhabitants of Lower Silesia in Poland. METHODS: The study group consisted of 95 inhabitants of Wroclaw and surrounding villages (22 men and 23 women from the urban area, 23 men and 27 women from the rural area). Fatty acid content in subcutaneous fat samples was assessed by gas-chromatography. Dietary assessment was carried out using food frequency questionnaire. Dietary intake was analyzed using computer programme The Food Processor SQL 10.5.2 produced by ESHA Research USA, with a Polish database. RESULTS: Mean daily energy and fatty acids intake was significantly higher among rural than urban inhabitants. Intake of alpha-linolenic acid (ALA), mainly from rapeseed oil, in urban inhabitants was 1.5 g/day in men and 1.6 g/day in women, and in rural inhabitants 2.6 g/day and 2.1 g/day, respectively. Dietary n-6 to n-3 ratio was higher among urban compared to rural inhabitants (6.7 vs. 5.5 among men and 6.4 vs. 5.5 among women, respectively). Content of ALA in adipose tissue was higher in rural women than in urban men (1.08% vs. 0.92% of total fat). Content of eicosapentaenoic acid (EPA) in adipose tissue in rural men (0.04% of total fat) and women (0.05% of total fat) was higher than in urban men (0.01% of total fat). The positive correlation (r=0.43) between the level of EPA in adipose tissue and percentage of energy from dietary EPA was observed among rural men. Overall, positive correlations were found between saturated (SFA) and polyunsaturated (PUFA) n-3 level in adipose tissue and percentage of energy from these fatty acids in a diet (r=0.20 and r=0.22, respectively). CONCLUSIONS: Mean daily n-3 fatty acid intake in urban inhabitants was lower than the recommended daily consumption in Poland. The positive correlation between fatty acids level in adipose tissue and dietary fatty acid intake was observed only for EPA among rural men, and in the all-study population for SFA and PUFA n-3. A high n-6 to n-3 ratio in the study group was observed.

Assessment of dietary intake in a sample of Polish population - baseline assessment from the prospective cohort 'PONS' study.

OBJECTIVE: The aim of this study was to assess the dietary intake of participants in the Polish-Norwegian Study (PONS). METHODS: The presented study comprised 3,862 inhabitants of Swietokrzyskie Province aged 45-64 (2,572 females and 1,290 males). Daily intakes of energy, protein, carbohydrate, fat and fatty acid were estimated using the Food Frequency Questionnaire (FFQ). RESULTS: Energy intake was significantly higher in males than females (1,461.4 vs 1,320.7 kcal/day), and in participants aged 45-54 than in those aged 55-64 (1,409.5 vs 1,338.5 kcal/day). The percentage of energy from saturated fatty acids was higher than dietary recommendations. Protein, fat and carbohydrate intakes were significantly higher in males compared to females, and in younger than in older group. Daily cholesterol intake was significantly higher in males compared to females and in younger than in older group. People with a higher level of education had a higher energy, protein and fat intake. CONCLUSION: Under-reporting of energy intake was observed in a significant percentage of participants, especially in males. Gender, age and education status had statistically significant impact on dietary intake. Increase in the intake of dietary fibre, mono- and polyunsaturated fatty acids with diet by the studied participants will make the diets more healthy.

Evaluation of mineral and vitamin intake in the diet of a sample of Polish population - baseline assessment from the prospective cohort 'PONS' study.

OBJECTIVE: The aim of this cohort study was to evaluate selected mineral and vitamin intake of the Polish-Norwegian Study (PONS) participants. METHODS: Daily mineral and vitamin intake of PONS study participants was estimated using Food Frequency Questionnaire (FFQ). Overall, 3,862 inhabitants of Swietokrzyskie Province aged 45-64 (2,572 females and 1,290 males) enrolled in the study. RESULTS: Mean calcium, iron, magnesium, phosphorus, potassium, and sodium intake were, in males: 660.6 mg/day, 15.4 mg/day, 218.5 mg/day, 889.3 mg/day, 2,453.4 mg/day and 2,571.5 mg/day, and in females: 703.6 mg/day, 13.9 mg/day, 220.8 mg/day, 916.3 mg/day, 2,497.3 mg/day and 2,301.8 mg/day, respectively. Iron and sodium intake was significantly higher in males compared to females. Calcium intake was lower in males than in females and in participants aged 55-64 then those aged 45-54. Estimated daily sodium intake was similar among individuals with and without hypertension. Mean vitamin C, thiamin, riboflavin, vitamin B6, A and E were, in males: 80.1 mg/day, 1.3 mg/day, 1.5 mg/day, 1.6 mg/day, 8,454.0 IU/day and 5.4 mg/day and in females: 83.7 mg/day, 1.1 mg/day, 1.6 mg/day, 1.6 mg/day, 9,494.6 IU/day and 4.9 mg/day, respectively. Females had a higher intake of vitamin C and A , while males had higher thiamin and vitamin E intakes. Higher daily vitamin C intake was observed in the younger than in the older group, and in participants with higher education than those with a lower level of education. CONCLUSION: Significant differences were observed in daily intake of some vitamins and minerals by gender, age, level of education, and place of residence. Some participants had a lower intake of some minerals and vitamins than Polish recommendations.

Prevalence of obesity - baseline assessment in the prospective cohort 'PONS' study.

OBJECTIVE: The aim of the study was to evaluate the prevalence of overweight and obesity in the population of Swietokrzyskie Province in Poland. METHODS: Body mass index (BMI), waist to hip ratio (WHR) and waist circumference (WC) in the Polish-Norwegian Study (PONS) was measured in 2,567 females and 1,287 males. Anthropometric measurements included fat mass, height, weight, waist and hip circumference. BMI and WHR were calculated. RESULTS: Data showed that 52% of males and 42% of females were overweight (25.0 ≤ BMI<30.0 kg/m2), and the prevalence of obesity (BMI ≥ 30.0 kg/m2) was 35% in both genders. The average BMI was higher in males (28.5 kg/m2) than in females (28.2 kg/m2). Analysis of WC showed that 36% of males and 45% of females had abdominal obesity, whereas measurements of WHR showed abdominal obesity in 64% of males and 79% of females. Generally, the prevalence of obesity was higher in the older age group (55-64 years) and in rural inhabitants. The prevalence of overweight increased with educational level, but the prevalence of obesity decreased with level of education in both males and females. CONCLUSIONS: Almost 80% of the PONS population were either overweight or obese; therefore, the PONS population is at increased risk of developing obesity-related diseases.