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10.2. Individual characteristics

10.2.1. Lifestyles

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10.2. Individual characteristics


10.2.1. Lifestyles Tobacco use





Action on Smoking and Health: ASH UK


Chronic obstructive pulmonary disease.


Cardiovascular disease.


Disability adjusted life years.


European Community Household Panel


Economic and Social Council


European Health Interview Survey


European Network for Smoking Prevention


The 27 Member States of the European Union since 1 January 2007.


WHO Framework Convention on Tobacco Control


Gross Domestic Product


Non-communicable diseases


Nicotine replacement therpay


Organisation for Economic Co-operation and Development


Scientific Committee on Emerging and Newly Identified Health Risks


Second-hand smoke


Tobacco Control Scale


Tobacco Specific Nitrosamines


World Health Organization Introduction



According to the WHO Report on the Global Tobacco Epidemic 2008, 100 million people worldwide were killed by the tobacco epidemic in the 20th century.


Smoking is the largest single cause of preventable death and disease in Europe. Active smoking kills over 650,000 people every year in Europe. Many of these deaths occur prematurely, the victims losing on average 21 years of life expectancy. In the EU, tobacco kills more than AIDS, car accidents, alcohol, homicides, illegal drugs, suicides and fires combined.


Around 35% of men and 25% of women in the EU smoke. In general, men smoke more than women, although the trend is showing a narrowing difference. Those with less education and of younger age smoke more. In most European countries smoking is prevalent among lower socio-economic groups. European youth has the highest smoking prevalence rates in the world.


The patterns of smoking attributable mortality are indicative of smoking trends two to three decades ago. The smoking attributable mortality in western European countries is declining for both males and females. In Eastern Europe, mortality for males is now peaking or just beginning to decline, while still increasing among females.


Cigarette smoking harms nearly every organ of the human body, causing a wide range of diseases, 24 of which are fatal. Cancers (43%), cardiovascular diseases (28%) and respiratory diseases (18%) together account for the majority of deaths attributed to smoking. Moreover, smoking harms the society. In the EU, smoking is one of the preventable factors with the greatest impact on total disease burden (both mortality and morbidity) in terms of DALYs lost. Very conservative estimates put the costs for only two smoking related diseases (COPD and CVD) for the EU at an equivalent of 1% of region's GDP.


Success of interventions geared at smoking behaviour will determine the future health of the EU populations. Collective interventions, such as anti-smoking campaigns raise awareness on the adverse effects of smoking, induce individual cessation efforts and prevent the youth from taking up smoking. Individual interventions, such as pharmacological and behavioural therapies significantly increase the probability of long term smoking cessation.


As shown in Figure, tobacco use is a risk factor for six of the eight leading causes of death in the world (WHO, 2008). All the diseases caused by direct smoke and second-hand smoke have been identified in Tables and


Figure Tobacco as a risk factor for several world leading causes of death.


Table Diseases caused by smoking and by second-hand smoke

Source: CDC (2004); CDC (2006)


Diseases caused by smoking

Diseases caused by second-hand smoke


Chronic diseases





Brain tumors*



Blindness, cataract

Middle ear disease

Nasal irritation




Nasal sinus cancer*

Trachea, bronchus or lung

Aortic aneurism

Respiratory symptoms, impaired lung function

Breast cancer*

Acute myeloid leukemia

Coronary heart disease


Coronary heart disease



Sudden infant death syndrome (SIDS)

Lung cancer


Atheroschlerotic peripheral vascular disease



Kidney and ureter

COPD, asthma and other respiratory effects

Lower respiratory illness

COPD*, chronic respiratory symptoms*, asthma*, impaired lung function*


Hip fractures


Reproductive effects in women: low birth weight


Reproductive effects in women (including reduced fertility)


Reproductive effects in women: pre-term delivery*





For the diseases caused by second-hand smoke: Evidence of causation is sufficient, or, where marked with an asterisk, suggestive



Table Diseases and adverse health effects caused by active cigarette smoking.




Respiratory diseases and adverse health effects

Cardiovascular diseases and adverse health effects

Effects on Maternal and Child Health

Other diseases and adverse health effects

-          Lung

-          Mouth and throat: oral cavity, pharynx, larynx

-          Oesophagus (squamous cell and adenocarcinoma)

-          Stomach

-          Pancreas

-          Urinary bladder

-          Kidney (renal pelvis and renal cell carcinoma)

-          Uterine cervix

-          Breast cancer

-          Bone marrow (myeloid leukaemia) Nasal cavities

-          Nasal sinuses

-          Liver

-          Chronic obstructive pulmonary disease (COPD)

-          Acute respiratory illnesses, incl. bronchitis and pneumonia

-          Exacerbation of and poor control of asthma

-          Impaired lung growth and increased risk of respiratory diseases in children and young people exposed to cigarette smoke

-          Coronary health disease

-          Cerebrovascular disease

-          Aortic aneurysm

-          Peripheral arterial disease


Smoking in pregnancy

-          Pregnancy complications

-          Preterm delivery

-          Foetal growth restrictions and low birth weight

-          Increased likelihood of developing childhood asthma

Passive smoking and children:

-          Sudden infant death syndrome (SIDS)

-          Increased rate of respiratory infections


-          Gastric ulcer

-          Cataract

-          Periodontitis

-          Duodenal ulcer

-          Poor wound healing

-          Risk factor for diabetes and aggravation of its symptoms

-          Reduced fertility in males and females

-          Earlier onset of menopause

-          Crohn’s disease

-          Osteoporosis

-          Impotence

-          Premature skin ageing


Sources: ASPECT, 2004 and ASH) Data sources


Key indicators pertaining to smoking are the prevalence of smoking and the smoking-attributable mortality.

Countries estimate the percentage of adult smokers mostly on the basis of health interview surveys which can yield variable data, due to the lack of standardisation in regard to definitions, methods of data collection, stratification variables, sample sizes and age limits. For example, the definition of a 'smoker' can be a 'daily smoker', a 'regular smoker' or includes 'all smokers', thus also occasional smokers. Likewise, ages defined as 'adult' or '15 years and over' may mean the lower age limit is at the ages from 13 - 20 years and the upper age limit from 64 - 84 years. Moreover, population samples are not always representative of the whole country.


The data sources concerning smoking prevalence and mortality in the EU, most commonly found in the literature include Eurostat, WHO Health for All database (HFA) and OECD. All three sources provide methodological information on data collection. Eurostat uses data from the European Community Household Panel (ECHP) carried out during the period 1994-2001. In the future, new sources will replace the ECHP, such as data collection from survey modules of the European Health Interview Survey (EHIS) planned to start in 2007 and to be repeated every five years. For WHO-HFA database, the adult smoking prevalence is assessed from the standard questionnaire during a health interview of a representative sample of the population aged 15 years and above. Many countries are carrying out such health interview surveys on a more or less regular basis. However, most of the data are collected from multiple sources by the Tobacco or Health unit at WHO/EURO. OECD also uses a standard health interview survey instrument to measure smoking habits in a population, warning that “international comparability is limited due to the lack of standardization in the measurement of smoking habits in health interview surveys across OECD countries. There is variation in the wording of the question, the response categories and the related administrative methods.”

Mortality from smoking in developed countries is estimated directly from national vital statistics for the most frequently used source: Peto et al, 2006; updated in June of 2006. The WHO Tobacco Control database uses these data and they have well described sources and methodology.


The estimated data for the prevalence of the environmental smoke exposure were published in the “Lifting the smokescreen report” (European Commission, 2006 ), while directly reported data were collated for the European Community Respiratory Health Survey (Janson et al, 2006).


The data on prevalence of snuff use in Sweden are gathered through annual surveys conducted by Statistic Sweden or the national public health survey, “Health on Equal Terms”, carried out by the National Institute of Public Health.
 Data description and analysis


Prevalence and mortality


Smoking prevalence varies widely among EU27 member States. The proportion of adults who smoke in the EU27 ranges from 15.9% in Sweden to 37.6% in Greece. Despite wide variations in smoking prevalence among member States, the overall average for the 25 member States is broadly the same as it was before the EU enlargement in 2004. Consistent large-scale patterns are not apparent, although regional differences do occur. There are countries with higher and lower prevalence of smoking in Southern and Northern, as well as in Eastern and Western Europe.


In general, men smoke more than women. However, trends over the past decades show that the differences in smoking prevalence for men and women are declining. In Sweden, for example, the percentage of smokers is now higher among women than among men, whereas in Ireland the two sexes show similar rates.


Figures illustrate the trends in smoking prevalence among European men and women between 1990 and 2006.


Figure Regular daily smokers in the male population aged 15+


Figure Regular daily smokers in the female population aged 15+


More men than women are dying from smoking attributable diseases in all EU countries (Figure

Figure Percentage of all deaths attributable to smoking in 2000


The proportion of deaths attributed to smoking is presented in Table, for the main categories of diseases for the year 2000.


Table Deaths from selected causes (%), attributable to smoking, all ages, year 2000


Smoking, along with other behavioural factors, plays an important role in premature mortality or mortality before the age of 65. In the EU, these early deaths account for one third of general mortality, with death rates twice as high for men as for women.



Overall, the proportion of smoking attributable deaths among women is still rising, while male mortality peaked in the 1980s, as shown in Figure It is important to keep in mind that mortality data today reflect the smoking prevalence of two to three decades ago. That is why still more men are dying from smoking attributable diseases in all EU countries. Female mortality will probably increase in due time to reflect the current high prevalence of tobacco use among European women.


Figure Trends in smoking attributable mortality 1965-2000 in the EU25


The term 'Tobacco epidemic' refers to certain, regular patterns in tobacco consumption across the globe. There are four distinctive stages of tobacco consumption prevalence in a population. These trends are followed by similar patterns in smoking attributable mortality two to three decades later (Figure


Figure Features of the tobacco epidemic


The tobacco epidemic is at different stages in different European countries. Some countries are in stage four of the tobacco epidemic - e.g. Denmark, Germany, Finland and the UK. In central and eastern European countries the awareness of the harmful effects of tobacco smoking was low until the late 1980s. These countries, as well as some southern European countries are now at stage three of the epidemic, with smoking prevalence among males peaking or just beginning to decline, and smoking prevalence among women still increasing (ASPECT, 2004). Germany, for example, showed a decrease in total, male and female prevalence of smoking between 2000 and 2003, while Belgium recorded a drop in overall prevalence, but mainly due to the decrease of smoking in the male population between 2000 and 2002.


Sex, age and socio-economic status as smoking determinants


Men generally smoke more than women. Although more and more women are taking up smoking, this trend is not likely to reverse. The female smoking rates in some countries reached a plateau at lower levels than male rates, while in some countries it has started to decrease. The Global Youth Tobacco Survey however showed a worrisome trend: the difference in smoking rates between boys and girls is narrower than expected, especially in the Americas and in Europe. In the Americas, more girls smoke than boys, and there is only a small difference between sexes in Europe - 19.9% among boys, and 15.7% among girls. The unexpected increase in cigarette consumption among girls is likely to double the death toll from tobacco-related illnesses by the year 2020 (Warren et al, 2006).


Younger people generally smoke more than older ones. The Global Youth Tobacco Survey also revealed that Europe has the highest incidence of youth smoking in the world. Nearly 18% of Europeans aged 13 to 15 are smokers, more than twice the global average of 8.9% (Warren et al, 2006).


During the smoking epidemic there is a reversal from a positive to a negative association between socio-economic status and smoking. For what concern the socio-economic aspects of the tobacco epidemic, four stages can be distinguished (Cavelaars et al, 2000):

·          In stage 1, smoking is an exceptional behavior and mainly a habit of higher socio-economic groups;

·          In stage 2, smoking becomes increasingly common. Rates among men peak at 50%-80% and are equal among socioeconomic groups or higher among higher socioeconomic groups. Among women, these patterns usually lag 10-20 years behind those of men. Smoking is first adopted by women from higher socioeconomic groups;

·          In stage 3, prevalence rates among men decrease to about 40% since many men stop smoking, especially those with a higher educational level. Women reach their peak rate (35%-45%) during this stage, while at the end of this stage also their rates start to decline;

·          In stage 4, prevalence rates keep declining slowly for both men and women, and smoking becomes progressively more a habit of the lower socio-economic groups.


In most countries smoking is more prevalent among the lower educated, whereby the education is an indicator of the socio-economic status. However, there are variations among regions and countries.

A north-south pattern, with strong social gradients in northern European countries and weaker or reversed gradients in southern European countries, was found for women and to a lesser extent for men, in the 45-74 years of age group. This observation did not apply to younger men. The differences found reflect the tobacco epidemic stages.

Social gradients in smoking prevalence are steeper for younger men and women than for older generations. These steeper gradients of smoking prevalence are likely to translate into steeper gradients in smoking attributable morbidity and mortality in future (Cavelaars et al, 2000).


Consequences of smoking for the individual and the society


Smoking harms virtually every organ in the human body causing a wide range of diseases and a massive burden of chronic illness.

Cardiovascular disease (CVD) is the largest single cause of death in the EU, accounting for about 40% of deaths in both sexes (see Chapter 5.2.). Smoking contributes significantly to mortality from cardiovascular diseases. It has a synergistic effect with other risk factors for cardiovascular disease, such as high cholesterol levels in blood and hypertension (Keil U, et al., 1998).

Cancers (see Chapter 5.3) of the respiratory tract (lungs, bronchi, and larynx) are responsible for one in 20 deaths in the EU. These cancers are mainly due to smoking (European Communities, 2002).

Mortality due to COPD (see Chapter 5.7) varies from country to country and is influenced by smoking, as well as by other factors. Smoking is, according to the estimates from vital statistics, the cause of 62% of all deaths from COPD in the EU-25 (Peto et al., 2005).


Not only active smoking, but also passive inhalation of environmental tobacco smoke (ETS) causes adverse health effects, including lung cancer, COPD and CVD. It is estimated that 79,500 people die each year in the EU as a result of passive smoking (ERS, 2006; European Commission, 2003).

In 19901994, the self-reported prevalence in the European Community of passive smoking in nonsmokers was 17.9% at home and 20.6% at work. At the follow up, ten years later, the prevalence of passive smoking at home had declined by 8.7%, while the prevalence of passive smoking at work decreased by 10.9% (Janson et al, 2006).


Objective biomarkers for involuntary exposure to tobacco, such as serum cotinine, have been identified and validated. Measurements taken over a number of decades indicate a significant decline in serum cotinine concentration levels among non-smokers during the 1990s. This decline probably reflects the decrease in exposure on ETS due to anti-smoking interventions, such as restrictions of smoking in the workplace and other public places (Pirkle, 2006).


Disease burden


Tobacco is the leading cause for disease burden in the EU. The term 'Burden of disease' denotes the gap between the current health status and an ideal situation in which everyone lives into old age free of disease and disability. It is usually measured in disability adjusted life years (DALYs). Tobacco is a leading risk factor for disease burden in developed world, accounting for 12% of total DALYs (Lopez, 2005).


Tobacco is strongly linked to COPD and lung cancer and is known to have a synergistic effect with risk factors causing ischemic heart disease and cerebrovascular disease. The WHO has estimated that in 2000, non-communicable diseases (NCDs) accounted for about 75% burden of disease expressed in DALYs in European region. The most prominent NCDs, such as CVD, cancer and COPD have one preventable risk factor related to lifestyle in common: tobacco use (WHO, 2002).


Economic burden


The economic burden of smoking probably exceeds 1% of GDP in Europe. The impact of tobacco morbidity and mortality on the society can be expressed as



·          Direct costs”, associated with health care (hospitalisation, ambulatory care, prescription drugs, home health care and nursing home services) for smoking related diseases among smokers and second-hand smoke (SHS) victims, and

·          Indirect costs”, associated with the loss of human capital due to smoking attributable premature deaths, productivity losses, foregone income taxes and contributions to social security among smokers, patient-SHS victims and carers who would otherwise be in paid employment (informal care).


The current existing estimates of the total smoking-attributable costs for the two leading categories of smoking related diseases: COPD and CVD, in Europe amount to between €105.83 billion and €130.31 billion for the year 2000, or about 1% of the region’s GDP. The indirect costs of smoking account for two thirds of this amount. This is a very conservative estimate, considering the fact that only two major diseases have been included, and even for these two not all costs have been taken into account (e.g. the costs of informal care, the costs linked to the treatment of reproductive problems, the costs related to SHS and budgetary costs related to social services). A more comprehensive estimate of net social costs for Australia ranges between 2.1% and 3.4% of GDP (ASPECT, 2004; Collins & Lapsley, 2002).


Nicotine and addiction


The reason underlying the regular, daily smoking is nicotine addiction. Cigarette is a very efficient drug delivery system. When tobacco is smoked, nicotine rapidly peaks in the bloodstream and enters in the brain. Immediately after exposure to nicotine, there is a “kickcaused in part by the drug’s stimulation of the adrenal glands resulting in a discharge of adrenaline. The rush of adrenaline stimulates the body and causes a sudden release of glucose, as well as an increase in blood pressure, respiration and heart rate (NIDA, 2006).


Nicotine has several effects on the brain. The activation of reward pathways, the brain circuitry that regulates feelings of pleasure is of primary importance to the addictive potential of nicotine. The calming effect of nicotine reported by many users is probably associated to a decline in the withdrawal effects in addicted individuals, rather than the direct effects of nicotine (NIDA, 2006).

Nicotine is only one of the 2000 chemical constituents of tobacco. When tobacco is burned incompletely during smoking, almost 4000 chemicals can be found in the smoke.


Three kinds of smoke can be distinguished, each differing in terms of toxicant concentration, size of particles, effects of temperature and a host of other characteristics. Mainstream smoke is what emerges from the “mouth” or butt end of a puffed cigarette. Sidestream smoke is what arises from the lit end of a cigarette, mostly between puffs. Environmental tobacco smoke, smoke present in air, consists of exhaled mainstream smoke and sidestream smoke.


Dependence is stronger when tobacco smoke is inhaled into the lungs and increases with the quantity and speed of nicotine absorption. An improved understanding of addiction and of nicotine as an addictive drug has been instrumental in developing medications and behavioral treatments for tobacco addiction (NIDA, 2006).


Snuff is another efficient nicotine delivery system. Snuff is fine ground moist tobacco that is used in small portions of 1-2 grams that are placed between the lip or cheek and gum. Nicotine from oral tobacco is absorbed more slowly, but the peak levels are similar and the high level remains constant for a much longer time than after smoking. The average snuff dipper keeps the snuff pinch in their mouth approximately 11-14 hours per day (ENSP, 2003).


Health impact of smokeless tobacco


There is no safe or harmless tobacco product. Smokeless tobacco use, however, appears to be less harmful than smoking tobacco. An incomplete tobacco combustion that occurs during smoking releases 4000 chemical substances. In contrast, snuff contains more than 2500 chemical substances, of which 28 are known cancerogens. Major contributors are tobacco specific nitrosamines (TSNAs), the most common carcinogens in unburnt tobacco that are formed in the process of ageing, fermentation and curing of tobacco. The Swedish snuff manufacturer has developed a set of standards called the Gothiatek Standard that sets limits for harmful constituents in its product, known as snus.

Health effects of oral tobacco use include an increased risk of cancer (Boyle et al, 2003). Especially cancers of the oral cavity and pancreas are associated to snuff use, although an increased risk for oral cancer development could not be proven for Swedish snuff (SCENIHR, 2007). A recent study, however, reported an increased risk for pancreatic cancer in snus users (Luo et al, 2007). Other known health effects of snuff use include increase of blood pressure, increased risk for diabetes, musculoskeletal injuries, pregnancy and early childhood complications. The association with the cardiovascular disease is not unequivocally clear. (ENSP, 2003). Tobacco harm reduction


Individual interventions


An individual approach to smoking cessation includes pharmacotherapy and behavioral therapy. These are most effective when combined with collective interventions.

Only 3% of smokers manage to quit smoking using will power alone (ASH, 2006). Success depends to a great extent on motivation, but a combination of pharmacotherapy and behavioral therapy probably yields best results.


Nicotine replacement therapy (NRT) in the form of patches, chewing gum, lozenges, inhalers and nasal sprays helps relieve the withdrawal symptoms that prevent many smokers from quitting. It contains nicotine, but does not contain thousands of other harmful substances found in cigarettes and snuff.


The non-nicotine pharmacotherapy includes several drugs from different categories. Two of the most promising are bupropion and varenicline. They are both prescription drugs approved by national authorities of some countries to help patients stop smoking. Bupropion is an antidepressant drug that reduces withdrawal symptoms and lessens the urge to smoke. Varenicline, recently approved both in Europe and USA, is a partial nicotine agonist that prevents the nicotine-withdrawal symptoms and eliminates the reward from smoking.


Certain moods, times of the day or activities may present strong triggers for craving a cigarette. Pharmacotherapy is not a cure for these smoking triggers. Furthermore, the motivation to quit smoking determines the success rate of smoking cessation to a large extent. Some studies found that the integration of behavioral therapy can increase the quitting rate by another 50-100% (Fiore et al, 2000). Psychosocial interventions are helpful at all phases of tobacco addiction treatment, not only as a first-line intervention (Foulds et al, 2006). There is a wide range of psychosocial treatment options, including counselling via internet and telephone, as well as individual and group counselling.


Collective interventionstobacco control in the EU


Collective interventions geared towards the reduction of tobacco related harm can be categorized as follows:


·          measures to reduce the demand for tobacco products (price, taxation);

·          measures to reduce exposure to environmental tobacco smoke (smoking bans in public places);

·          measures to limit tobacco industry advertising, promotion and sponsorship;

·          measures to raise awareness about the addictive nature and health hazards of tobacco use; and

·          measures to raise awareness about treatment possibilities.


Curbing tobacco use is a longstanding EU health priority. The EU has been actively contributing to the reduction of tobacco consumption for more than twenty years. This contribution has evolved from prevention, training and research within the scope of the fight against cancer, to a broad strategic tobacco control approach. The current EU-wide efforts are based on four mutually reinforcing pillars:


·          legislative measures, based on the Community Treaties as well as more specific, secondary legislation;

·          support for Europe-wide and cross-national smoking prevention and cessation activities, financed via action programmes and the Community Tobacco Fund;

·          mainstreaming of tobacco control into a range of other Community policies; and

·          ensuring the Community’s achievements also have an impact outside the EU region by fostering international co-operation and taking on a major role in tobacco control at global level.


EU action focuses on supporting prevention, collaboration between Member States and research. The quest for a smoke free EU also forms part of the Environment and Health Action Plan through which passive smoking is now more actively tackled.

Legally, these efforts are firmly grounded in the Community Treaties and supported further by a range of specific regulations. The legal competencies of the EU enable it to make some unique contributions to tobacco control both in Europe and globally. The WHO Framework Convention on Tobacco Control (FCTC), which all Member States and the Community have signed, has been a significant factor in the further advancement of tobacco control at EU and Member State level.

Within the Treaties of the Community, articles 152 and 95 EC provide the legal base for EU policy and action in the area of tobacco control. These articles are concerned respectively with public health and internal market issues. Through the application of these two articles, a range of more specific measures and agreements have been developed to support the EU’s efforts in the area of tobacco control.

The provisions in the Treaty have been given force through a range of secondary legal measures to support tobacco control. Together, they underpin and complement the Community’s action, including a range of smoking prevention and cessation activities.

Binding legal measures include Directives on:


·          the advertising and sponsorship of tobacco products;

·          the structure and rates of excise duty applied on manufactured tobacco;

·          the manufacture, presentation and sale of tobacco products;

·          television broadcasting, banning the advertising of tobacco products; and

·          minimum safety and health requirements for the workplace.


Non-binding legal measures include:


1) a Council Recommendation on the prevention of smoking and on initiatives to improve tobacco control. This recommendation pays particular attention to measures restricting youth access to tobacco; and


2) a Resolution on banning smoking in public places. Since the adoption of the resolution in 1989, Member Statesgovernments have developed their own specific action to implement this resolution, which has been done at different pace.


EU competencies in health and safety as well as in taxation have also provided legal ground for tobacco control measures. There is a broad consensus on the effectiveness of six policy measures that can be implemented at (sub)national level. These measures differ as to the extent of their impact. Prices and taxation policies are attributed the greatest impact, followed by smoking bans in workplaces and public places. Bans on advertising of tobacco products , appropriate consumer information, warning labels and treatment for those wanting to quit smoking complete the six effective measures. A comprehensive strategy incorporating all six measures is most effective.


Policy makers can therefore build on a range of policy options that have been proven to be effective in the past. It is, however, also important that they remain vigilant to newly emerging challenges, such as whether to lift the ban on snuff use.


International organisations


The WHO Framework Convention on Tobacco Control (FCTC) is the first-ever global health treaty providing a comprehensive tobacco control framework (WHO, 2005). The FCTC objective is 'to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke.' The EU Council approved the FCTC in June 2004, and subsequently ratified it on 30 June 2005.


Significant measures to reduce the demand for tobaccosupported by the FCTC include:

·          price and tax measures;

·          protection from exposure to tobacco smoke, particularly in workplaces, public transport and indoor public places;

·          regulation of the contents of tobacco products;

·          regulation of tobacco product disclosures;

·          packaging and labeling of tobacco products, requiring large health warning labels and prohibiting the use of deceptive labels such as "light", "low tar", and "mild";

·          education, communication, training and public awareness;

·          tobacco advertising, promotion and sponsorship. Countries are to undertake a comprehensive ban on tobacco advertising, promotion and sponsorship within five years of ratifying the treaty if their constitutions allow this. If there are constitutional constraints, countries are required to put restrictions in place; and

·          demand reduction measures concerning tobacco dependence and cessation.


The FCTC also supports measures to reduce the supply of tobacco. These include:

1.      illicit trade in tobacco products (smuggling);

2.      sales to and by minors, and

3.      provision of support for economically viable alternative activities.


By signing the Treaty, countries also commit themselves to take supportive measures at national level. Key examples of these measures are:


·          the establishment of a national coordinating mechanism or focal point for tobacco control;

·          the inclusion of tobacco cessation services in national health programmes, and

·          promoting the participation of NGOs in the development of national tobacco control programmes.


Under the UN Charter, identifying solutions to international social and health problems falls within the remit of the Economic and Social Council (ECOSOC). Their Resolution 2004/62 on Tobacco Control supports the WHO Framework Convention on Tobacco Control and urges UN Member States to strengthen tobacco control measures and programmes.

On 7 February 2008 the WHO released a new Report on “Global Tobacco Epidemicshowing that while progress has been made, not a single country has fully implemented all key tobacco control measures. The report also outlined an approach that governments can adopt to prevent tens of millions of premature deaths by the middle of this century. In this new report which presents the first comprehensive analysis of global tobacco use and control efforts, the WHO has found that only 5% of the world’s population lives in countries that fully protect their population with any one of the key measures that reduce smoking rates. The report also reveals that governments around the world collect 500 times more money in tobacco taxes each year than they spend on anti-tobacco efforts. It finds that tobacco taxes, the single most effective strategy, could be significantly increased in nearly all countries by providing a source of sustainable funding to implement and enforce the recommended approach, i.e. a package of six policies called MPOWER. The six MPOWER strategies are:



·          Monitor tobacco use and prevention policies

·          Protect people from tobacco smoke

·          Offer help to quit tobacco use

·          Warn about the dangers of tobacco

·          Enforce bans on tobacco advertising, promotion and sponsorship

·          Raise taxes on tobacco


The report documents the epidemic's shift to the developing world, where 80% of the more than eight million annual tobacco-related deaths projected by 2030 are expected to occur. The global analysis, collated by the WHO from the information provided by 179 Member States, gives governments and other groups a baseline for monitoring efforts to stop the epidemic in the years to come. The MPOWER package provides countries with a roadmap to help them meet their commitment towards the WHO Framework Convention on Tobacco Control, which came into force in 2005. Other key findings in the report include:


·          Only 5% of the global population is protected by comprehensive national smoke-free legislation and 40% of countries still allow smoking in hospitals and schools;

·          Only 5% of the world’s population lives in countries with comprehensive national bans on tobacco advertising and promotion;

·          Just 15 countries, representing 6% of the global population, mandate pictorial warnings on tobacco packaging;

·          Services to treat tobacco dependence are fully available in only nine countries, covering 5% of the world’s population;

·          Tobacco tax revenues are more than 4000 times greater than spending on tobacco control in middle-income countries and more than 9000 times greater in lower-income countries. High-income countries collect about 340 times more money in tobacco taxes than they spend on tobacco control.


Snuff and tobacco harm reduction debate


Tobacco harm reduction is a “strategy which aims at minimizing the damage to the population’s health resulting from the use of tobacco products or their substitutes” (McKee and Gilmore, 2007).

Current tobacco control policies seek to reduce the supply of tobacco (e.g. through price and taxation policies) and the demand for tobacco (by e.g. raising awareness about its effects on health and supporting those who wish to quit). Most smokers will at some point attempt quitting and most of those will repeatedly fail, due to the addictive power of nicotine. The available treatments for nicotine addiction show modest success and are either based on medicinal nicotine (NRT) use or on abstinence (“quit-or-dieapproach) (Martinet et al, 2007).


Sweden is the only country of the European Union where snuff is not banned. It is undisputed that the low smoking prevalence, and consequently, the low smoking-attributable mortality among Swedish men are at least in part effects of the established and widespread use of snuff in that population. In the light of these facts, a part of the public health community promotes lifting a ban on snuff as an acceptable harm reduction strategy.

The advocates of this approach assert that the evidence from Sweden suggests that snuff is used as a substitute for smoking and for smoking cessation. Smokers who will not or cannot quit smoking should not be withheld a less hazardous form of tobacco. An alternative to the classicalquit or dieapproach could be legalizing snuff (Bates et al, 2003).

The critics of this approach maintain that smokeless tobacco is a risk to health and as such should not be legalised. In particular, the public health message on tobacco-related harm could be confusing for the general public. Furthermore, it remains unclear whether snuff in Sweden indeed has a role as an aid for quitting smoking. Results from different studies remain inconclusive, as they could not sufficiently demonstrate causal relationship between snuff use and quitting smoking. Other factors, such as effective tobacco control policies in Sweden may have contributed to this effect, commonly associated to snuff use. Other concerns include the gateway effectsnuff users may later become smokers - an argument which has not been proven (McKee and Gilmore, 2007; ENSP, 2003). The Swedish experience is limited to its male populationfemale smoking rates are still relatively high and prevalence of snuff use low, despite its availability. Finally, due to societal and cultural differences, it would be impossible to extrapolate future patterns of smoking or oral tobacco prevalence if oral tobacco were made available in EU countries where it is now unavailable (European Commission, 2007).


The European Commission is in the process of reviewing the ban and its Scientific Committee on Emerging and Newly Identified Health Risks (SCENHIR) has published a preliminary report on the Health Effects of Smokeless Tobacco Products in 2007, while the final opinion on the health effects of smokeless tobacco products was adopted in February 2008. The conclusions of this report and the final opinion of the SCENHIR are that smokeless tobacco products (STP) are addictive and hazardous to health, and that there is insufficient scientific evidence to support the use of STP as a smoking cessation aid. Furthermore, relative trends in progression from STP into and from smoking differ between countries; thus, it is not possible to extrapolate the patterns of tobacco use from one country where oral tobacco is available to other countries, due to societal and cultural differences (European Comission, 2008). Progress in tobacco control in 30 European countries, 2005-2007


The "Progress in Tobacco Control in 30 European Counrties 2005-2007" report (Joossens and Raw, 2008) describes the results of a survey on tobacco control activity in 30 European countries between 2005 and 2007 using the Tobacco Control Scale (TCS) and based on the six policies described by the World Bank.


Table Selected EUGLOREH countries and total TCS score in 2007


The average overall score has risen over the two years from 47 to 52 out of the scale maximum of 100. This increase is mainly due to three TCS subscales: the smoking bans in public places, the spending on tobacco control and advertising bans. No increase in average scores for pricing, health warnings and tobacco dependence treatment subscales was recorded. The best scoring countries, UK, Estonia, Spain, Romania, Switzerland, Lithuania, Latvia and Luxembourg, recorded increases of 10 points or more over the two years.

A significant improvement in tobacco control in Europe in this period is attributed to the success of the 2003 EU directive banning tobacco advertising and to the adoption of smoke-free legislation.


The report defines six areas for improvement in the reduction of tobacco use:

·          Tobacco control programmes should be comprehensive and should include at least the six measures described by the World Bank.

·          Countries should spend a minimum of € 3 per capita per year on tobacco control.

·          Countries should introduce comprehensive smoke-free legislation. This should include a total ban on smoking in work and public places, including bars, restaurants, health and educational facilities, and public transport.

·          Regular increases in tobacco taxes should be the policy at EU and Member State levels. The number of cigarettes that can be imported for personal consumption between EU countries should be reduced to 200 per person.

·          Pictorial health warnings on the two main sides of tobacco product packages should be mandatory for all EU countries. Future developments


Despite the progress made in tobacco control, smoking continues to be the largest single cause of death and disease in the European Union. Tobacco causes one in seven deaths in the EU, killing over 650 000 people every year. Worldwide, it causes 5,4 million deaths annually.


The tobacco epidemic is shifting its focus towards low income population, youth and women – the new, vulnerable target. It is estimated that within a few decades, 80% of tobacco-related deaths will occur in the developing world.


European youth is particularly vulnerable to tobacco advertising and its smoking rates exceed those of their peers elsewhere in the world. Consequently, more effort has to be invested into protecting this population from the tobacco-related harm.


Smoking is almost invariably more common among the poor. Consequently, the harmful effects of smoking add to their existing disproportionate health burden. There is clear evidence that tobacco control measures can make a considerable contribution to reducing social inequalities in health in Europe (Mackenbach et al, 2004).


Smoking epidemic is man-made and entirely preventable. It can and must be stopped through a concerted action of governments and civil society. There is broad consensus on the effectiveness of the six policy measures that can be implemented at (sub)national level. These measures differ as to the extent of their impact. Prices and taxation policies (1) are attributed most impact, followed by smoking bans in workplaces and public places (2). Bans on advertising of tobacco products (3), appropriate consumer information (4), warning labels (5) and treatment for those wanting to quit smoking (6) complete the six effective measures. A comprehensive strategy incorporating all six measures is most effective.


In Europe, research has shown that the implementation of these strategies for reducing tobacco-related harm has been successful, but also that more can be done (Joosens & Raw, 2007). In particular, increase of spending on tobacco control and the implementation of a comprehensive smoke-free legislation are seen as two areas that could bring further improvement. Economic evidence shows that tobacco control interventions are the second most cost effective way to spend health funds, after childhood immunization (ASPECT, 2005). The ban on smoking in public places that include all work places, health and educational facilities and public transport should become a priority for European governments. References


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Boyle P, Autier P, Bartelink H, Baselga J, Boffetta P, Burn J, Burns HJG, Christensen L, Denis L, Dicato M, Diehl L, Doll R, Franceschi S, Gillis CR, Gray N, Griciute L, Hackshaw A, Kasler M, Kogevinas M, Kvinnsland S, La Vecchia C, Levi F, McVie JC, Maisonneuve P, Martin-Moreno JM, Newton Bishop J, Oleari F, Perrin P, Quinn M, Richards M, Ringborg U, Scully C, Siracka E, Storm H, Tubiana M, Tursz T, Veronesi U, Wald N, Weber W, Zaridze DG, Zatonski W, zur Hausen H (2003): European Code Against Cancer and scientific justification: third version (2003). Annals of Oncology; 14: 9731005. Available at:


Cavelaars AEMJ, Kunst AE, Geurts JJM, Crialesi R, Grötvedt L (2000): Educational differences in smoking: international comparison. BMJ2000; 320(7242): 1102-1107.


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Data sources:

Eurostat. Statistical Database of the European Union

OECD Health Data. OECD Health Data database

WHO tobacco control database

WHO-HFA. WHO - Health For All Alcohol





Alcohol Policy Network


Blood Alcohol Concentration


Coronary Heart Disease


CHOsing Interventions that are Cost-Effective project


Driving under the influence of drugs, alcohol and medicine


European Comparative Alcohol Study


Enforcement of national Laws and Self-regulation on advertising and marketing of Alcohol


European Schools Project on Alcohol and Other Drugs


Food and Agriculture Organization


Food and Agriculture Organization Statistical Division


Foetal Alcohol Syndrome


Global Burden of Disease


Health Behaviour in School-aged Children


Organisation for Economic Co-operation and Development


Primary Health Care European Project


World Health Organization Introduction


Alcohol can affect almost every organ of the body and is related to more than 60 different disorders and diseases with short and long-term consequences. For a number of conditions, there is an increasing risk with increasing levels of alcohol consumption. Alcohol is a health determinant, leading to the need for better health statistics and available information for Member States to manage

harmful alcohol use.


Alcohol-related harm includes those health and social problems that occur to the drinker and those surrounding the drinker at both individual and societal levels, in which alcohol plays a causal role. Alcohol-related harm includes the “harmful use of alcohol”, a category in the ICD-10 classification of mental and behavioural disorders, which refers to a condition in which physical or psychological harm has occurred to the individual as a result of his or her drinking. A public health perspective also includes the risk of harm or hazardous alcohol consumption, as it is associated, for instance, to particular amounts or patterns of drinking.


Binge drinking has increased much among young people and is increasing among adults. The harm done by alcohol has a larger disporptionate effect on young men. Alcohol consumption is associated with violence. Data sources


The main information sources derived from Anderson & Baumberg (2006) are:.


European Commission


·          Updated country profiles provided by the members of the Alcohol Policy Network (APN), co-financed by the European Commission (

·          Eurostat NewCRONOS database

·          Eurobarometer surveys


Commission-funded projects


·          European Comparative Alcohol Study (ECAS) reports (2001-2)


World Health Organization (WHO)


·          Comparative Risk Assessment Study, carried out within the Global Burden of Disease (GBD) project

·          CHOsing Interventions that are Cost-Effective project (CHOICE)

·          Global Status Report on Alcohol

·          Global Status Report on Alcohol Policies

·          WHO-EURO Health for All Database

·          WHO-EURO Alcohol Control Database

·          WHO Global Alcohol Database


International comparative surveys


·          European Schools Project on Alcohol and Other Drugs (ESPAD; part-financed by Council of Europe)

·          Health Behaviour in School-aged Children (HBSC; WHO-EURO)


Food and Agriculture Organization


·          Statistical division (FAOSTAT) database


Organisation for Economic Co-operation and Development (OECD)


·          OECD Statistics Portal

·          International Handbook of Alcohol Problems and Dependence Data description and analysis

Alcohol consumption and patterns of drinking


The European Union is the heaviest drinking region of the world, with each adult drinking on average 11 litres of pure alcohol each year – a level over 2.5 times the rest of the world’s average. Within the EU there is a considerable variation in levels of recorded consumption, with Luxembourg drinking 2.5 times as much per adult as Malta, and even lower levels visible in non-EU European countries such as Iceland and Norway ( however, in the case of Luxembourg, consumption data may be affected by very large trans-border sales due to low taxes on alcohol).


Despite the present differences between countries, the recorded consumption is much closer together than it was previously (Figure Across the 20 countries, with data going back to the 1960s, the amount of variation has more than halved (Anderson & Baumberg 2006). While these trends are sometimes the accumulation of many years of gradual variation, it is also possible for large changes to occur in a short time period. For example, consumption rose by nearly 27% in Ireland between 1994 and 2000 and 17% in Finland between 2000 and 2005, while it dropped by 22% in Italy between 1974 and 1978.


Figure Trends in recorded alcohol consumption in population aged15 years


Some 53 million adults (14% of the adult population aged 16+) do not drink alcohol at all, and some 58 million can be classified as heavy drinkers (16% of the adult population), defined as women who consume on average more than 20g alcohol per day and men who consume more than 40g/day.

According to the 2006 Eurobarometer survey, 75% of EU25 citizens aged 15+ consumed alcohol at least once during the previous 12 months, and 65% had consumed alcohol during the previous 30 days. Twenty eight percent of past year EU25 drinkers (80 million people) reported that they consumed five or more drinks (50g alcohol) on one occasion at least once a week on average during the previous 12 months Table The proportion of the total population who were binge drinkers was 54% in Ireland and 33% in Spain, being much higher than in Finland (17%) and Sweden (11%). A much higher proportion of all men (31%) than women (12%) had binged at least once a week. Whereas 24% of all of those aged 15-24 had binged at least once a week, binge drinking was also common amongst those aged 55+, with 18% binging at least once a week.


Table Frequency of having had five or more drinks in a single occasion during previous year


Of the two thirds of EU25 citizens aged 15+ who had drunk alcohol at least once during the previous 30 days, one in ten reported that they usually had 5 or more drinks (50g alcohol) on one occasion when they consumed alcohol. Of the past month drinkers, a pattern of binge drinking was most common in Ireland, where 36% reported to drink 3-4 drinks (30-40g alcohol) on one occasion and a further 34% 5 or more drinks (50g alcohol). The proportion of EU15 adults who normally drank five or more drinks on a drinking occasion remained the same in 2006 as in 2003 (10%). However, given that 67% of EU15 adults reported alcohol consumption within the past 30 days in 2006 compared to 61% in 2003, the actual number of EU15 adults who normally drank five or more drinks (50g alcohol) on an occasion increased by 10% between 2003 and 2006.


Nearly all (over 9 in 10) 15-16 year-old students have drunk alcohol at some point in their life, starting on average just after 12½ years of age. Data from the 2003 European School Survey Project on Alcohol and Other Drugs (ESPAD) found that the average amount of alcohol drunk by 15-16 year olds on the last drinking occasion was 60g of alcohol. No EU15 country outside of southern Europe has an average level below 56g, while in the UK and Ireland the amount drunk on the last occasion even reaches over 80g of pure alcohol. Last occasion drinking levels are slightly lower in the EU10 and significantly lower in southern Europe, which averaged 38g of pure alcohol. The highest levels of both binge-drinking and drunkenness are found in the Nordic countries, UK, Ireland, Slovenia and Latvia. This contrasts with the low levels found in France, Italy, Lithuania, Poland and Romania – for example, binge-drinking 3+ times in the last month was reported by 31% of boys and 33% of girls in Ireland, but only 12%-13% of boys and 5%-7% of girls in France and Hungary. Across the whole EU though, over 1 in 8 (13%) of 15-16 year old students have been drunk more than 20 times in their life, and over 1 in 6 (18%) have binged (5+ drinks on a single occasion) three times or more in the last month. Binge-drinking in young people has increased across much of Europe in the last 10 years, more so in the early part of this period.


Acute harm from alcohol


A substantial proportion of incidents of aggression and violent crime involve one or more participants who have been drinking, with 25%-85% of violent crimes relating to alcohol, the proportion varying across countries and cultures. There is a relationship between alcohol consumption and the risk of involvement in violence, including homicide, which is stronger for intoxication than for overall consumption. Episodic heavy drinking, frequency of drinking and drinking volume are all independently associated with the risk of aggression, with frequency of drinking appearing to be the most important. There is an overall relationship between greater alcohol use and criminal and domestic violence, with particularly strong evidence from studies of domestic and sexual violence. The relationship is attenuated when other characteristics, such as culture, gender, age, social class, criminal status, childhood abuse and use of other drugs in addition to alcohol are taken into account. Generally the higher the level of alcohol consumption, the more serious is the violence

Parental drinking can affect the environment in which a child grows up through financial strain, poor parenting, marital conflicts and negative role models. A large number of studies have reported a variety of childhood mental and behavioural disorders to be more prevalent among children of heavy drinkers than others. Systematic reviews have suggested that alcohol is a cause of child abuse in 16% of cases.

The risk of drinking and driving increases with both the amount of alcohol consumed and the frequency of high volume drinking occasions, as well as blood alcohol concentration levels. A review of 112 studies provided strong evidence that impairment in driving skills begins with any departure from a zero blood alcohol concentration level (BAC). Comparison of blood alcohol concentrations (BACs) of drivers in accidents with the BACs of drivers not involved in accidents find that male and female drivers at all ages who had BACs between 0.2g/l and 0.49g/l had at least a three times greater risk of dying in a single vehicle crash. The risk increased to at least 6 times with a BAC between 0.5g/L and 0.79g/L and 11 times with a BAC between 0.8g/l and 0.99 g/L.

There is a relationship between the use of alcohol, largely in the short term, and the risk of fatal and non-fatal accidents and injuries. People who usually drink alcohol at lower levels, but who engage periodically in drinking large quantities of alcohol, are at particular risk. Alcohol increases the risk of attendance at hospital emergency rooms in a dose dependent manner; between 20% and 80% of emergency room admissions can be alcohol-related. Alcohol alters the treatment course of injured patients and can lead to surgical complications and a greater likelihood of death.


Heavy drinking is a major risk factor for suicide and suicidal behaviour among both young people and adults. There is a direct relationship between alcohol consumption and the risk of suicide and attempted suicide, which is stronger for intoxication than for overall consumption.


Each year in the European Union, it has been estimated that alcohol is related to:

-         2,000 homicides (4 in 10 of all murders)

-         17,000 deaths from road traffic accidents (1 in 3 of all road traffic fatalities), including 10,000 deaths of people other than the drink-driver

-         27,000 accidental deaths

-         10,000 suicides (1 in 6 of all suicides)

-         16% of all child abuse / neglect

-         5-9 million children living in families adversely affected by alcohol.


Table Change in death rates, by cause, from a 1 litre increase in per capita alcohol consumption


As can be seen in Table, there are significant relationships between a 1 litre increase in alcohol consumption and death rates from a number of conditions, which are stronger in lower consuming than higher consuming countries partially reflecting the increased proportional size of a one-litre change in low-consuming countries.


Chronic harm from alcohol


Alcohol is a toxic substance that is a cause of 60 or more different disorders. Alcohol consumption can result in addiction. The risk of alcohol dependence increases with both the volume of alcohol consumption and a pattern of drinking larger amounts on an occasion. For many conditions there is an increasing risk with increasing levels of alcohol consumption, with no evidence of a threshold effect, including, for example, cancer of the oral cavity, haemorrhagic stroke, hypertension, pancreatitis and breast cancer in women. The total amount of alcohol consumed over a lifetime alcohol intake increases the risk of harm. For example, a consumption of 15-30 g ethanol /day throughout life increases the risk of breast cancer in women by one third.


There is a linear relationship between alcohol consumption and symptoms of depression and anxiety, with an increasing prevalence of symptoms with greater consumption. Alcohol-dependent individuals demonstrate a two- to three-fold increase in the risk of depressive disorders, while there is evidence for a continuum in the magnitude of co-morbidity as a function of the level of alcohol use. There is a straight line relationship between the amount of alcohol consumed over a lifetime and a decreased volume of brain grey matter.


Long term exposure to alcohol increases the risk of liver cirrhosis and acute and chronic pancreatitis. The reduction in alcohol consumption, which took place in Southern European Countries after the 70s is associated to a strong reduction (almost 3 times) of liver cirrhosis (Figure


Figure Alcohol consumption and cirrhosis rates in southern Europe


Alcohol is a carcinogen; long term exposure increases the risk of cancers of the mouth, oesophagus (gullet), larynx (upper airway), liver and female breast, and - to a lesser extent - cancers of the stomach, colon and rectum in a linear relationship, with no evidence of a threshold effect.


The risk of coronary heart disease decreases to about 80% of the level of non-drinkers at 20 grams (two drinks) of alcohol per day, with most of the reduction in risk occurring by a consumption of one drink every second day. Some reviews have suggested that the protective effect is due to a systematic misclassification due to the inclusion as ‘abstainers’ of many people who had reduced or stopped drinking, a phenomenon associated with ageing and ill health. Alcohol raises blood pressure and increases the risk of hypertension and haemorrhagic stroke in a dose dependent manner. There is a J-shaped relationship between alcohol consumption and the risk of ischemic stroke. Episodic heavy drinking increases the risk of heart arrhythmias and sudden coronary death, even in people without any evidence of pre-existing heart disease.


Alcohol shows reproductive toxicity. Prenatal exposure to alcohol can be associated to a distinctive pattern of intellectual deficits that become apparent later in childhood, including reductions in general intellectual functioning and academic skills as well as deficits in verbal learning, spatial memory and reasoning, reaction time, balance, and other cognitive and motor skills. Although these deficits are most severe and have been documented most extensively in children with Foetal Alcohol Syndrome (FASD), children pre-natally exposed to lower levels of alcohol can also exhibit similar problems.


Heavy drinking during adolescence and young adulthood is associated with poorer neurocognitive functioning during the young adult years, and particularly with impairment of attention and visuospatial skills.


It has been estimated that each year in the European Union, alcohol causes:

-         45,000 deaths from liver cirrhosis

-         50,000 cancer deaths, of which 11,000 are female breast cancer deaths

-         17,000 deaths due to neuropsychiatric conditions

-         200,000 episodes of depression.


Overall burden


Adding up all the harm done by alcohol means that 7.4% of all ill-health and premature death in the European Union is due to alcohol, placing alcohol as the third most important risk factor after tobacco and high blood pressure. This is mainly for men, accounting for 12% of all male ill-health and premature death and a smaller but still sizeable 2% of all female ill-health and premature death. The larger proportion of the burden arises from alcohol-related neuropsychiatric conditions and accidents, Figure


Figure Alcohol-attributable burden of death and ill-health in the European Union


Economic costs of alcohol consumption


The burden of ill-health due to alcohol is disproportionally shouldered by young men in Europe, 13,000 of whom die in the EU each year, Figure This represents 1 in every 4 deaths of young men, rising to nearly 1 in 3 in the EU10. Alcohol is responsible for a slightly smaller but still substantial death toll in young women, with the 2,000 deaths corresponding to 11% of female mortality at this age across the EU.


The high level of harm to young people is due to the importance of intentional and unintentional injury as primary causes of death in young people, as opposed to heart disease later in life.


Figure The share of deaths attributable to alcohol in EU per age group (year 2000)


There is a substantial health gap across Europe, with a difference in life expectancy at birth between EU countries of as much as 10 years. Against this background, it is clear that many of the individual conditions that contribute to the health gap are linked to alcohol. For males dying between the ages of 20 and 64, injuries are responsible for nearly half (46%) of the difference in life expectancy between the three Baltic states (Estonia, Latvia and Lithuania) and the EU15, and for one fifth (22%) of the difference between central and eastern Europe (Poland, Czech Republic, Slovakia, Hungary, Slovenia, Romania, Bulgaria) and the EU15 (Zatonski 2008). Whereas in the EU15, alcohol is responsible for 29% of all male injuries and 19% of all female injuries, in the central and eastern European countries, the proportions are 38% and 29%, and in the three Baltic states 48% and 42% respectively. The estimates suggest that alcohol is responsible for a difference in the crude death rate of approximately 90 extra deaths per 100,000 people for men and 60 per 100,000 for women (as well as 16,000 DALYs per million people for men and 4,000 DALYs per million for women) in the EU10, compared to the EU15 (Anderson and Baumberg 2006).


Alcohol is a cause of health inequalities within countries. For example, in Sweden, alcohol is the 2nd most important cause of inequalities in the burden of ill-health for men (7th for women), with several other alcohol-related diseases such as ischemic heart disease and self-inflicted injuries also prominent (Ljung et al, 2005). Many of the conditions that are responsible for health inequalities are strongly linked to alcohol, including external causes (e.g. violence, accidents), stroke and liver disease (across the EU15), ischemic heart diseases (northern Europe) and cancer (southern Europe). The role of alcohol in these inequalities may be different in different countries. However, for example, the two countries with the largest inequalities in men aged 45-59 are France and Finland, but while the former finds this to be mainly due to liver cirrhosis and alcohol-related cancers, the latter finds this related primarily to violent deaths (Kunst et al, 1998). Research from Finland further suggests that socioeconomic variables act on the collective as well as the individual level. Areas with the most manual workers had 20% more mortality directly attributable to alcohol than areas with the least, even after accounting for the individual relationship of occupation to mortality (Blomgren et al, 2004).


This harm also has its social cost, which has been estimated to be €125 billion each year, equivalent to 1.3% of GDP. Actual spending on alcohol-related problems (Figure accounts for €66bn, while potential production not realised due to absenteeism, unemployment and premature mortality accounts for a further €59bn.


Figure The tangible cost of alcohol in Europe per cost element (year 2003) Control tools and policies.


Risk reduction strategies include a set of measures in a jurisdiction or society aimed at minimizing the health and social harms that result from alcohol consumption. They are implemented by alcohol policies, which include authoritative decisions that are made by governments through laws, rules and regulations, coming from the legitimate purview of legislators and other public interest group officials, and not from private industry or related advocacy groups (Babor et al, 2003). In the context of public health, the central purpose of alcohol policies is to serve the interests of public health and social well-being through their impact on health and social determinants, such as drinking patterns, the drinking environment and the health services available to treat problem drinkers.


Alcohol is a major economic commodity associated to substantial governmental tax receipt. Europe can be considered the centre of the global alcohol industry, acting as both the largest market and the major producer of alcoholic drinks. Therefore, it may be appropriate to recall that the trade in alcohol in the whole European Union accounts for 1.3% of all exports and 0.3% of all imports, thereby contributing8.9bn to the goods account balance, with such trade not necessarily affected by European and domestic policy to reduce the harm done by alcohol (Anderson and Baumberg 2006).


Maintaining the relative price of alcohol


When other factors are held constant, the more affordable alcohol is, the more it is consumed; and the less affordable it is, the less it is consumed (Anderson and Baumberg 2006). The way drinkers respond to and compensate for price changes is complex, because of the possibilities for substitution. Drinkers tend to shift to more expensive beverages if relative prices decrease, either within the same beverage category or across beverage categories. If prices are raised, they both reduce overall consumption but also shift to cheaper beverages. Heavy drinkers tend to buy the cheapest products within their favourite beverage category. The impact of an increase in alcohol price is stronger in the longer term than it is in its immediate effects. From a public policy perspective, it is the long term effects - taking into account alcohol’s dependence producing properties - that are more important. Young people are particularly sensitive to price. Policies that increase alcohol prices have been shown to reduce the proportion of young people who are heavy drinkers, reduce underage drinking and reduce per occasion binge drinking. Higher prices also delay intentions among younger teenagers to start drinking and slow progression towards drinking larger amounts. Heavy drinkers are also sensitive to price, with higher alcohol taxes or prices leading to reductions in deaths from liver cirrhosis, mortality rates from traffic accidents and reduced rates of crime, including assault, violence related injury, homicide, family violence, child abuse and other violence towards children.


While it may be predicted that the revenues from tax on alcohol depend on the total amount of alcohol drunk in a country, evidence suggests that this is not the case. There is no apparent correlation between the revenue from alcohol-specific taxes (as a % of government revenue or % of GDP) and per capita consumption (Figure The best predictors of the importance of alcohol-specific taxes are unsurprisingly the average alcohol tax rates, which relate very closely to the income from alcohol taxes.


Figure Alcohol consumption and alcohol tax revenue


Managing the sale of alcohol


The smaller the number of outlets for alcoholic beverages, the greater the difficulty in obtaining alcohol, a situation that is likely to deter alcohol use and problems (Anderson and Baumberg 2006). A number of studies have indicated that although changing either hours or days of alcohol sale can redistribute the times in which many alcohol related accidents and violent events related to alcohol take place, this occurs at the cost of an overall increase in problems.

Around-the-clock opening in Reykjavik, for instance, produced net increases in police work, emergency room admissions and drinking & driving cases (Ragnarsdottir et al, 2002).


There is also evidence that restricting days and hours of sale reduce problems. In the 1980s Sweden re-instituted Saturday closing for spirits and wine off-premise sales after studies showed that Saturday sales were associated with increased rates of domestic violence and public drunkenness (Olsson and Wikström 1982). Some 20 years later, when Saturday opening of government alcohol stores was re-instituted, there was a 3.6% increase in alcohol sales (Norstrom and Skog 2005).


Almost all countries legally restrict alcohol sales to minors. There is very strong evidence that changes in minimum drinking age laws can substantially effect youth drinking and alcohol-related harm, particularly road traffic accidents; however, the full benefits of a higher drinking age are only realized if the law is enforced (Anderson and Baumberg 2006).


Advertising controls


One Belgian and eight US-based well designed longitudinal studies show that the volume of advertisements and media exposure increase the likelihood of young people to start drinking, the amount they drink and the amount they drink on any one occasion (Anderson 2007). There have been no published longitudinal studies that do not find such an effect. These findings are similar to the impact of advertising on smoking and eating behaviour. It is difficult to study the relationship between expenditure on commercial communications, or whether or not there are bans on alcohol advertisements in a jurisdiction and drinking by young people. Where this has been done, some studies have found that increased expenditure on advertising is associated with increased alcohol-related harm amongst young people and that total bans have reduced alcohol-related harm, whereas others have not. In general, later studies seem to have found more of an effect of commercial communications. The evidence would thus show that there is a need to specify the extent to which alcohol advertising in certain categories of media and publications is allowed, and it would suggest that, as is the case with tobacco, consideration should be given to the prohibition of advertising of alcohol products on television and radio and in specified certain print media.


There are good examples of regulations on alcohol marketing in some countries. France’s Loi Evin is one such model which bans most advertising and sponsorship and restricts permitted advertising to the mere description of the product without any of the messages which make advertising particularly attractive to younger people. When the Loi Evin was challenged in the European Court of Justice, it was upheld, noting that it is in fact undeniable that advertising acts as an encouragement to consumption; the French rules on TV advertising are appropriate to ensure their aim of protecting public health and do not go beyond what is necessary to achieve such an objective (ECJ, 2004).


Setting and controlling blood alcohol levels.


Establishing a maximum blood-alcohol level (BAL) for driving is a well-established and widely diffused drinking-driving countermeasure. Over the years, the level specified as maximum has been lowered in a number of countries, (i.e. as low as zero or 0.2g/l in a number of countries and 0.5g/l or lower in most countries in Europe). Both establishing a BAL and lowering it are effective in reducing drinking-driving casualties (Anderson and Baumberg 2006). There is also convincing evidence that both intensive random breath testing, where police regularly stop drivers on a random basis to check their BAL, and sobriety checkpoints, where all cars are stopped and drivers suspected of drinking driving are breath-tested, reduce alcohol-related injuries and fatalities.


Setting lower BALs (including a zero level) for young or novice drivers; administrative driver's license suspension for a driver caught with a positive BAL particularly in legal systems in which a criminal drinking-driver case may be delayed or successfully fought by a defence lawyer; and the use of an ignition interlock, a mechanical device which does not allow a car to be driven by a driver with a BAL above a low level, for reducing repeat infractions by convicted drinking drivers are all effective measures for reducing drinking & driving casualties.


Finally, there are a number of measures that have shown to be not effective in reducing drinking and driving (Anderson and Baumberg 2006). These include designated drivers and ride services, such as the BOB campaign. No study has evaluated whether the use of designated drivers actually decreases alcohol-related motor vehicle-related injuries (Ditter et al, 2005). However, although the BALs of designated drivers are generally lower than those of their passengers they are still often higher than the legal limit for drinking and driving. Furthermore, an increase in passenger alcohol consumption is often found when a designated driver is available.


Educational programmes and information campaigns


Whilst the provision of information and persuasion to reduce alcohol related harm might seem appealing, particularly in relation to younger people, it is unlikely to achieve sustained behavioural change in an environment in which many competing messages are received in the form of marketing and social norms supporting drinking, and in which alcohol is readily available. Many careful systematic reviews have evaluated school based education which aimed at reducing alcohol related harm and found that classroom based education is not an effective intervention to reduce alcohol related harm; although there is evidence of positive effects on the increased knowledge about alcohol and in improved attitudes, there is no evidence for a sustained effect on behaviour (Jones et al, 2007).


In general, public information campaigns are also an ineffective antidote to the high quality, pro-drinking messages that appear far more frequently in the media (Anderson and Baumberg 2006). Furthermore, counter advertising (a variant of public information campaigns which provides information about a product, its effects and the industry that promotes it in order to decrease its appeal and use) has inconclusive effects. Whilst drinking guidelines have been used in a number of countries, there have been no evaluations that find an impact of these guidelines on alcohol related harm (Anderson and Baumberg 2006). The United Kingdom’s ‘sensible drinking guidelines’ when relied upon as a key prevention strategy in a liberalizing policy environment failed to deter increases in alcohol consumption. The exception to this evidence of inefficacy is the evidence for the impact of mass media campaigns to reduce drinking and driving, particularly in jurisdictions with strong policies in place for what concerns drinking and driving.


Drinking context


Licensed drinking environments are associated with drunkenness, drinking & driving and problem behaviours such as aggression and violence, with some licensed premises being associated with a disproportionate amount of harm. Nearly all evaluations in training bar staff in responsible beverage service when backed up with enforcement have demonstrated improved knowledge and attitudes among participants, although this wears off over time (Anderson and Baumberg 2006). These studies have also shown some effects on serving practices, but not always. Whilst servers are usually willing to intervene with customers who are visibly intoxicated, they generally will not intervene with individuals solely on the basis of the customer’s estimated blood alcohol concentration (BAC) or number of drinks consumed. In terms of the effects on customer intoxication, several studies have found that server training results in lower BAC levels of customers generally and fewer customers with high BAC levels. Studies on the impact of adhering to bar policies for avoiding intoxication have also found modest effects in reducing heavy consumption and high risk drinking, but were not as successful as originally expected. The impact of responsible beverage service is greatly enhanced when there is active, but ongoing enforcement of laws prohibiting the sale of alcohol to intoxicated customers.


Community based prevention programmes can be effective in reducing drinking and driving, alcohol related traffic fatalities and assault injuries (Giesbrecht, 2003). Community mobilization has been used to raise awareness of problems associated with on-premise drinking, develop specific solutions for the problems, and pressure bar owners to recognize that they have a responsibility towards the community in terms of such bar-related issues as noise level and customer behaviour. Evaluation results from community mobilization approaches as well as documentation from grassroots projects suggest that community mobilization can be successful in reducing aggression and other problems related to drinking in licensed premises.


Advice and treatment


Healthcare-based interventions for hazardous and harmful alcohol consumption reduce alcohol consumption, alcohol related problems and alcohol-related mortality. The community based Malmö study, undertaken during the 1970s, demonstrated that under the right conditions, the effects can be dramatic (Kristenson et al, 2002). An intervention for heavy drinkers resulted in half the deaths that occurred in the control group without the intervention at six year follow-up.


There is extensive evidence that shows the effectiveness and cost-effectiveness of opportunistic screening and brief interventions for people with hazardous and harmful alcohol use in the absence of severe dependence (Kaner et al, 2007). The population impact on excessive drinking could be significant if these programs were widely adopted in health care systems,.


For people with more severe alcohol dependence and related problems, a wide variety of specialized treatment approaches have been evaluated, including behavioural, psychosocial and pharmacological interventions of varying intensities in both community and residential settings (Miller and Wilbourne 2002). Evidence shows that individuals exposed to these treatments, especially when delivered in a timely manner, achieve better outcomes than those not receiving treatment. Moreover, for the average person, the effectiveness of these treatments tends to be comparable regardless of intensity, modality or setting.


For other relevant issues, check the following documents:


Television Without Frontiers Directive


Commission Recommendation on maximum permitted blood alcohol content, 2001


Council Recommendation on the drinking of alcohol by young people, in particular children and adolescents, 2001


European Commission Road Safety Action Programme 2003-2010


European Commission Communication on EU alcohol strategy, 2006


European alcohol and health forum, 2007


Projects funded under the Public Health Programme 2003-2008:


PHEPA: Primary Health Care European Project


EUROCAREAlcohol Policy Network in the Context of a Larger Europe: Bridging the Gap


ELSAEnforcement of national Laws and Self-regulation on advertising and marketing of Alcohol


Research projects on alcohol:


Genomics, mechanism and treatment of addiction


European Prospective Investigation into Cancer, Chronic Diseases, Nutrition and Lifestyle


DRUID: Driving under influence of drugs, alcohol and medicine


DG SANCO pages on Alcohol References


Anderson P, Baumberg B (2006): Alcohol in Europe: A Public Health Perspective - Report to the European Commission. London: Institute of Alcohol Studies. Available at:


Anderson P, (2007): Commercial Communications and Alcohol. Utrecht: National Foundation for Alcohol Prevention.


Babor TF, Caetano R, Casswell S, Edwards G, Giesbrecht N, Graham K, Grube JW, Gruenewald PJ, Hill L, Holder HD, Homel R, Österberg E, Rehm J, Room R and Rossow I (2003): Alcohol: No Ordinary Commodity. Research and Public Policy. Oxford, Oxford Medical Publication, Oxford University Press.


Blomgren J, Martikainen P, Mäkelä P, Valkonen T, (2004): "The Effects of Regional Characteristics on Alcohol-Related Mortality—a Register-Based Multilevel Analysis of 1.1 Million Men." Social Science and Medicine, 58: 2523-35.


Ditter SM, Elder RW, Shults RA, Sleet DA, Compton R, Nichols JL (2005): Effectiveness of designated driver programs for reducing alcohol-impaired driving a systematic review Am J Prev Med Jun;28(5 Suppl):280-7.


Eurobarometer (2007). Attitudes towards Alcohol. Available at: Accessed June 2007.


European Court of Justice (ECJ) (2004): C-262/02 and C-429/02.


Jones L, James M, Jefferson T, Lushey C, Morleo M, Stokes E, Sumnall H, Witty K, Bellis M (2007): A review of the effectiveness and cost-effectiveness of interventions delivered in primary and secondary schools to prevent and/or reduce alcohol use by young people under 18 years old Alcohol and schools: Review of effectiveness and cost effectiveness - Main report (PHIAC 14.3a). Available at:


Giesbrecht N (2003): Alcohol, tobacco and local control. A comparison of several community-based prevention trials. Nordic Studies on Alcohol and Drugs 20 25-40.


Kristenson H, Osterling A, Nilsson JA, Lindgarde F (2002): Prevention of alcohol-related deaths in middle-aged heavy drinkers, Alcoholism, Clinical and Experimental Research, 26, 478-484.


Kunst AE, Groenhof F, Mackenbach JP, EU Working Group on Socioeconomic Inequalities in Health (1998): Occupational Class and Cause Specific Mortality in Middle Aged Men in 11 European Countries: Comparison of Population Based Studies. British Medical Journal, 316: 1636-42.


Ljung R, Peterson S, Hallqvist J, Heimerson I, Diderichsen F (2005): Socioeconomic Differentials in the Burden of Disease in Sweden. Bulletin of the World Health Organization, 83: 92-99.


Miller W, Wilbourne P (2002): Mesa Grande: a methodological analysis of clinical trials of treatments for alcohol use disorders. Addiction, 97, 265-277.


Kaner EFS, Beyer F, Dickinson HO, Pienaar E, Campbell F, Schlesinger C, Heather N, Saunders J, Burnand B (2007): Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD004148. DOI10.1002/14651858.CD004148.pub3.


Olsson O, Wikström PH (1982): Effects of the experimental Saturday closing of liquor retail stores in Sweden. Contemporary Drug Problems 11, 325-353.


Rehm J (2005): Volume of Alcohol Consumption, Patterns of Drinking and Burden of Disease in the European Region - Implications for Alcohol Policy. 10th meeting of national counterparts for alcohol policy in the WHO European Region, Stockoholm 13-15 April 2005 [conference proceeding] Drugs and substance misuse1





Disability Adjusted Life Year


European Monitoring Centre for Drugs and Drug Addiction


European School Survey Project on Alcohol and Other Drugs


Health Behaviour among School Children


Hepatitis B Virus


Hepatitis C Virus


Injecting Drug Users


Needle and Syringe Programs


Population with Problem Drug Use


Problem Opioid Use


European Information Network on Drugs and Drug Addiction


Treatment demand indicator Introduction


The most commonly used illicit substances in Europe, with some variations among countries, are cannabis, amphetamine-type stimulants, amphetamine, ecstasy, methamphetamine, cocaine and opioids (mainly heroin and illicitly acquired/used prescription opioid medications). Other substances, such as LSD, GHB, Ketamine and a wide range of other - often synthetic - drugs are also sometimes used. Finally, the use of inhalants and the misuse of legally (or not legally) acquired medications (benzodiazepines besides opioids) can also play a significant role from the public health point of view2.


Increases in the prevalence of cocaine use in young adults (15-34 y) have been registered in all countries according to recent survey data. Use of cocaine and other stimulant drugs by socially integrated individuals is currently increasing. It is estimated, that one million current or former IDUs are infected with hepatitis C virus in Europe. Regular use of cannabis and the co-use of several substances are also increasing.


Drug use occurs overall mainly among adolescents and young adults, with usually higher prevalence among males than females, especially when considering regular drug use. The routes of administration of the drugs are, depending on the physical properties of the substances, smoking, snorting, swallowing and/or injecting. The last one is generally considered as one of the most harmful and can thus be used as an indicator of problem drug use. The frequency of use is also an important indicator to understand the characteristics of drug problems at individual and population levels.


The health problems related to drug use include acute problems such as poisoning, which can lead to death; severe mental or physical health problems; or different risk behaviours (e.g. drugged driving). These behaviours may cause fatal accidents or injuries as well as chronic problems such as drug dependence and other mental health (psychosis, depression, suicide) or physical health (infectious diseases, cirrhosis, cancer) problems typical consequence of or often associated with long term use of illicit drugs. The social situation of long term problem drug users should also be taken into account as employment rates and housing conditions are often bad.


The overall health burden associated with drug use in Europe is still difficult to estimate. However, between 1990 and 2004, more than 122 000 direct drug-related deaths were reported and it is estimated that there are between 100 000 and 200 000 former or current drug injectors living with HIV and about 1 million of them infected with the hepatitis C virus in Europe. Data sources


Data provided in this chapter, unless otherwise indicated, haveb been collected by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) through a network of national focal points (Reitox). These data are summarized every year in an annual report on the drug situation in Europe and in a statistical bulletin which are both available online.3

The EMCDDA monitors among others intensive forms of drug use, including problem drug use and addiction/dependence.

The data collected by the EMCDDA are organised along 5 key epidemiological indicators ((i) drug use among the general population; (ii) problem drug use; (iii) drug related infectious diseases; (iv) drug-related deaths and mortality among drug users; (v) demand for drug treatment), but also other important indicators and data in the following areas: interventions to reduce drug-related problems (prevention, treatment, harm reduction, etc.), drug market and crime (seizures, prices, drug-related offences, etc.), policy and legal frameworks etc.4 Data description and analysis


Overall estimates on the prevalence of use of the most frequently used drugs among the general population based on general population surveys have been presented in Table


Table Conservative estimates of prevalence and total numbers of users of different drugs in the European Union and Norway


Cannabis is by far the most frequently used illicit drug in Europe, but most individuals having used it at least once in their lifetime are not current users anymore. However, last year use of different drugs shows that more than 10% of Europeans have recently used cannabis and more than 1% cocaine. The variables most strongly associated with current drug use across the EU are young age, male gender, living in an urban area and preference of certain recreational environments such as nightclubs and bars5.


Early drug use


Use of illicit drugs can begin as early as in school age. According to the 2003 ESPAD survey, between 1 and 13% (on average 4%) of school children reported having tried cannabis for the first time when 13 years old or younger. Among 15-16 year olds, lifetime (i.e. at least once in their life) cannabis use ranges from more than 40% in some European countries to below 10% in others, with an average of 4% who have already used the drug 40 or more times in their lives (countries range in prevalence between 0 and 10%).


Overall prevalence rates for other illicit drug use are much lower than for cannabis among 15-16 year olds. In most countries, lifetime prevalence of cocaine use is 2% or lower. Lifetime ecstasy use was reported by 0 to 8% of school children with 6 EU countries reaching the prevalence of 5% or more. Amphetamines have been used by 0 to 7% of school children, with 4 EU countries having a prevalence of 5% or more6.


Data from the ESPAD survey shows an overall increase in the prevalence of cannabis use among school children between 1995 and 2003, with a more marked increase between 1995 and 1999 (Figure An increase in the lifetime prevalence of the use of other drugs has also occurred.


Figure Lifetime prevalence of cannabis among 15-16y-old students


Drug use among young adults (15-34 year old)


Most drug use is taking place among 15-34 year olds and lifetime prevalence might grow dramatically at the beginning of this age period. There are, however, considerable variations between countries in the prevalence of the use of different substances.


On average, 30% (3-50%) of young adults in Europe report lifetime use of cannabis, 13% (3-20%) used it in the last year (Figure and over 7% (1.515.5%) report use in the last month. For cocaine, the figure is 5.3% for average lifetime use, with six countries reporting prevalence levels of at least 5%. In the past year, 2.4% of young adults have used the drug and 1% have used it in the past month. For amphetamines and ecstasy, the average figures are 5.1% and 5% for lifetime use and 1.5% and 2% for last year use. Lifetime prevalence of LSD use ranges from 0.3% to 7.6%.


Figure Overview of last year drug prevalence estimates from various studies in selected EU Countries for young adults (aged 15 to 34)


Drug use in the European Union has generally increased in the 1990-ties both for all adults (aged 15-64) and young adults (15-34). Nowadays, we can observe some signs of stabilisation in the case of cannabis, amphetamines and ecstasy, but generally not for cocaine.

Increases in last year’s prevalence of cocaine use among the 1534 age group have been registered in all countries reporting recent survey data, although there may be some levelling off in the Member States with the highest prevalence levels. See Figure for trends in countries with available time-series data.


There is evidence of stabilising or even decreasing trends in amphetamine and ecstasy consumption but in some countries (United Kingdom, Spain and Denmark) data suggest a possible replacement between stimulants, with amphetamines and ecstasy use decreasing and cocaine use increasing7.



Figure Trends in last year prevalence of cocaine among young adults, measured by population surveys


Most of illicit drug use recorded in general population surveys tends to be discontinued after some time (typically after the vulnerable age period, when a person starts an adult life with work and family). However, the EMCDDA is currently working on understanding the proportion of cannabis users that go on to more intensive patterns of use, closely with a number of Member States. A crude estimation made by EMCDDA in 2004, based on limited data, suggested that around 1% of European adults, or about 3 million people, may be 'daily or almost daily' cannabis users.


Problem drug use


General population surveys might not be able to realistically describe more intensive to dependent forms of drug use, especially for substances with high addictive potential (e.g. heroin), mainly due to sampling frame-related methodological specificities8. Therefore, other important sources of information such as indirect estimates of the hidden population consisting of problem drug users (PDUs), treatment demands and drug overdoses statistics also have to be considered.

Problem drug use is defined by the EMCDDA as ‘injecting drug use or long duration / regular use of opioids, cocaine and / or amphetamines’.It is usually estimated as yearly prevalence rate per inhabitants aged 15-64 by indirect statistical methods. In total, problem drug users estimates from different countries suggest an annual prevalence of roughly between 1 and 8 cases per 1000 inhabitants aged 15-64.


In spite of the EMCDDA definition, most countriesestimates include only injecting drug users (IDUs) and problem opioids users (POUs), due to various reasons (e.g. unavailability of data, epidemiological situation in the country)9.

Three countries (Czech Republic, Slovakia and Finland) provided an estimate of problem amphetamines/methamphetamines users ranging from 1.55.3 cases 1 000 inhabitants aged 1564, whilst three other countries (Spain, Italy and United Kingdom) provided an estimate of problem cocaine users in the range of 3 to 6 per 1 000 inhabitants aged 1564.


Problem opioid users and injecting drug users still remain the main problem drug use subgroups found in almost all countries and experiencing the most severe problems related to the use of drugs (Table


Table Drug Use estimates: Problem opioid use and injecting drug use


Recent estimates on the prevalence of problem opioid users at national level range roughly between one and six cases per 1 000 population aged 1564. From the limited data available, an average annual prevalence of POUs of between four and five cases per 1 000 of the population aged 1564 can be derived. This translates into some 1.5 million (1.31.7 million) problem opioid users in the EU and Norway. Data from POUs estimates, police seizures, drug-related deaths and other sources indicate that there might be an increase in problem opioid use in some EU countries. This is related not only to problem heroin use, but increasingly also to diversion of substitution medications.


IDUs are at high risk of experiencing health problems such as infection with HIV or hepatitis or drug overdose. National estimates of such population group based on sophisticated statistical methods, are typically ranging between 0.5 and 6 cases per year for a population of 1 000 population aged 1564 in the period from 2001 to 2005. An exception here is Estonia, where a much higher estimate of 15 cases per 1000 has been reported. Extrapolation from the limited data available must be done with caution, but it does suggest an average prevalence of IDUs (current injectors) of between 3 and 4 cases for an adult  population of 1 000. This would suggest there may be around 1.1 million (0.91.3 million) injectors in the EU and Norway today. These are predominantly problem opioid injectors, although they may inject other drugs as well. Some countries also report a significant amphetamine/methamphetamine injecting problem.


Time trends in drug use


The important development of data collection in this field has allowed a better understanding of the main trends regarding drug use and drug-related problems. Many of the EU15 Member States have experienced an important increase in opioid, mainly heroin, and injecting drug use during the 80s and the 90s. This phenomenon has caused a dramatic increase in drug-related deaths and has been the driving force in the spread of HIV/AIDS and other infectious diseases among drug users. While EU Member States were developing extensive strategies and interventions to reduce these drug-related problems, other drug use patterns surfaced. Cannabis use among school-aged children and young adults increased rapidly along the 90s, ecstasy and other stimulant use became widespread among certain groups of recreational nightlife attendees while cocaine use started to grow among multiple groups, including problem opioid users. These general trends were, however, not present in all countries and the level of their intensity also differed between nations. Most of the Member States which have joined the EU in 2004 have experienced a somehow different development with only the second wave of drug use increase during the 90s.


Currently, there is a general indication that the overall trend in the prevalence of opioid use is relatively stable, but there are also some increases in heroin seizures and in the incidence of heroin use or injecting of diverted opioid medications in several countries. Data concerning cannabis indicate that the use among young people, after having reached very high prevalence levels and following a very early start in the life of young people, seems also on the decline although this trend is very recent and has still to be confirmed. The same applies to amphetamine and ecstasy use but not for cocaine use which could still be increasing.


Overall, it can be observed that illicit drug use has increased during the 90s in almost all European countries. This trend seems to have given place to a stabilization in recent years, but often at relatively high levels and with significant variations between countries.


Problem drug use has also changed in the recent years. The somehow homogenous population of opioid users has been replaced by a more diverse population including: ageing opioid users who also often use cocaine and multiple other substances, marginalized crack users, socially integrated problem cocaine and other stimulant users, intensive cannabis users, etc. Almost all of these groups are characterized by poly-drug use where multiple illicit and licit substances are used during the same period and often at the same time. This constitutes frequently a complication for treatment.


Morbidity: HIV & Hepatitis prevalence10


HIV prevalence among IDUs shows considerable variation in the EU (Figure, the reasons of which have not been very well understood yet. Data provided to the EMCDDA and the European Centre for the Epidemiological Monitoring of HIV/AIDS11 suggest also that by end of 2005 the transmission of HIV in injecting drug users (IDUs) continued in several countries of the European Union. In Estonia, Latvia and Lithuania, serious outbreaks occurred as recently as in 20012002. Croatia has a low prevalence of HIV among IDUs. From the available data on the number of IDUs and problem drug users it has been estimated that, in the EU, there might be between 100 000 and 200 000 people living with HIV who have been drug injectors in their lives.


Figure HIV prevalence among injecting drug usersstudies with national and subnational coverage, 2004-2005, all injecting drug users


In recent years, the predominance of IDUs among the new cases of HIV and AIDS was overrun by the heterosexual transmission group. Since data on new HIV cases is incomplete and missing from countries with large IDU-related epidemics, we have provided only a summary of the time trends based on AIDS cases (Figure


Figure AIDS incidence per year of diagnosis in EU Countries*, summary of years from 1996 to 2005, by transmission group


HIV infections have overall remained low during recent years but could still be currently increasing in several countries. Hepatitis C infections among injecting drug users is very widespread with a considerable proportion of them being infected. This situation will probably have important public health and financial consequences in the near future and access to treatment will be a critical issue.


While HIV infection in IDUs in Europe is mainly concentrated in few high-prevalence countries, viral hepatitis, and in particular infection caused by the hepatitis C virus (HCV), is much more evenly distributed and more highly prevalent. See Figure for national and subnational prevalence estimates based on IDU samples.

The available data on the number of IDUs and problem drug users lead to an estimate of around one million people living with an HCV infection in the EU who have been drug injectors in their lives.


Figure Estimated HCV antibody prevalence among injecting drug users, 2004-2005, all injecting drug users


Among the other infections prevalent in IDUs there is hepatitis B. The prevalence of markers for HBV infection varies to a greater extent than that of HCV markers, possibly due to differences in vaccination levels.


Mortality among drug users12


A multi-country study found that mortality among drug users is 6-20 times higher for males and 10-50 times higher for females, than that of the general population corresponding by age. It was found that in the six studied places, 10-23% of the overall mortality among adults aged 15-49 could be attributed to opioids use, mainly drug overdoses, AIDS accidents and suicides13.


Drug-related deaths, as defined by the EMCDDA, refer to deaths caused directly by the consumption of one or more drugs and that occur, generally, shortly after the consumption of the substance(s). These deaths are known as overdoses, poisonings or drug-induced deaths14.Between 1990 and 2004, from 6 500 to over 9 000 deaths were reported each year, adding up to more than 122 000 deaths during this period. These figures are considered a minimum estimate15.Drug-related morbidity and mortality has recently stabilised but often at a very high level. Figure shows the trend in drug-related deaths in the EU15.


Figure Indexed long term trend in acute drug-related deaths in the EU15 and Norway


More than one drug is mentioned in 60-90% of all death cases and these could therefore be generally considered 'polydrug deaths'. Opioids (mainly heroin or its metabolites) are present in most cases of acute drug-related deaths reported in the EU, accounting for 46% to 100%16.Other substances identified as having possibly played a role in deaths are alcohol, benzodiazepines, other opioids and, in some countries, cocaine. Deaths mentioning ecstasy are infrequent, but caused considerable concern as they often occur unexpectedly among socially integrated young people.


Overdose deaths due to cocaine are difficult to identify and often considered to be the result of a combination of causes. Studies have found that most cocaine deaths are often the result of cardiovascular and neurological problems brought on by the use of cocaine over a long time, particularly in users with predisposing conditions or risk factors (Darke, 2004). In the EU, over 400 cocaine deaths were identified during the last reporting year.


Treatment demand17


In many countries, opioids, mainly heroin, have been the main drug for which treatment is seeked. Of the total approximately 326 000 treatment requests reported in 2005, opioids were recorded as the main drug in about 40% of all cases. However, both the number as well as the relative proportion of treatment demands made by non-opioid clients is increasing in the Treatment Demand Indicator (TDI) data set, while the actual numbers of new clients demanding treatment for opioid use has been falling until recently in many countries (Figure From 1999 to 2005 the percentage of new heroin clients among all new drugs clients seeking treatment went down from 64% to 32%. Over the 19992005 period, the proportion of clients seeking treatment for primary cannabis use increased in all countries that reported data. After opioids and cannabis, cocaine is the drug most commonly reported as the reason for entering treatment in Europe. From 1999 to 2005, the proportion of new clients demanding treatment for cocaine use more than doubled. European data on drug users entering treatment for primary cocaine use are mainly related to cocaine powder use (85%), with only 15% referring to crack cocaine. Although the overall number of demands for treatment related to the use of amphetamines is increasing, this form of drug use is rarely the primary reason for attending drug treatment in the EU.


Figure Trend in the distribution of new clients entering treatment, subdivided by primary drug used Control tools and policies


The European Union has developed a specific project on the information exchange, risk-assessment and control of new psychoactive substances18.

Drug related problems have been a concern at European Union level since the late eighties, with the first European action plan to combat drug problems was adopted in 1990. The current European drug strategy runs for the period 2005-2012 and is complemented by two four-year action plans (2005-2008 and 2009-2012). It allows the EU to play an important role in supporting knowledge transfer and cooperation in Europe. While the strategy is legally not binding, it presents a framework for national policies and functions as an incentive to reach agreed targets.


Almost all European countries now have a national drug strategy and/or a national drug action plan. These encompass drug supply reduction (law enforcement) and drug demand reduction (prevention, treatment and harm reduction) interventions and generally set out a group of activities to be implemented and goals to be reached in a given timeframe. Monitoring, research and evaluation are also mentioned as key activities for a better understanding of the drug problem and of the impact of the interventions at national level.


Prevention is sometimes presented as the main priority in national drug strategies and action plans. In practice, school-based and community-located universal prevention are nowadays complemented by selective prevention interventions targeting different groups at-risk (school drop-outs, cannabis users) and different settings (nightlife, disadvantaged neighbourhoods). Environmental prevention strategies that aim at modifying the availability of alcohol and tobacco, the settings where substance use choices are made and the drug-related normative beliefs held by young people all appear to have been effective in reducing the acceptance of drug use. However, so far only some countries have embraced these approaches.


School-based universal prevention should be implemented with focus on social influence through standardised multi-session programmes which can be documented and evaluated. The implementation of this type of intervention is, however, limited and isolated information and awareness interventions are still widespread in Europe. In universal community-located prevention, the development of municipal drug plans has been reported by many Member States. Contents are mostly information events and, to a lesser extent, alternative leisure time provision. Finally, universal family-based prevention consists mostly of parents' evenings or information approaches, but seldom in intensive parent trainings.


The increase of opiate use and injecting drug use in the eighties and nineties, combined with the spread of blood borne diseases (mainly HIV/Aids and hepatitis B and C) among drug users have triggered the development of outpatient substitution treatment and harm reduction interventions in Europe. Methadone and buprenorphine, but also in a few cases other substances (codeine, slow-release morphine, diamorphine (heroin) etc.), have been prescribed in specialised centres or by general practitioners to a growing number of individuals. In 2005, it was estimated that at least 580 000 opioid users received drug substitution treatment in the EU Member States and Norway. This represents a more than sevenfold increase since 1993, when substitution cases in the EU were estimated to be around 73 000 (Farrell, 1995; EMCDDA, 2000). For countries where an estimation of the coverage of substitution treatment could be made19, results show significant differences, with rates varying from under 10% to about 50% of opiate users undergoing such treatment. Substitution treatment adds to other types of treatments including abstinence oriented inpatient and outpatient treatment and detoxification. Social reintegration programs, helping former problem drug users to access a job and a home, and to develop their social skills, are another important part of the response to the drug problem in Europe. However, the availability of these programs seems to still be insufficient.


Needle and syringe programs (NSPs) have developed into a priority response to prevent infectious diseases in most EU countries. While the first programmes started to operate in the mid-80s, by 2002, almost all EU Member States had formally introduced this measure as a response to health-risks related to drug injecting. The exchange or distribution of syringes is in general implemented in conjunction with interventions complemented by outreach health education. Four EU countries also have supervised drug consumption facilities. The geographical distribution of needle and syringe programme outlets and the level of provision of injecting material vary greatly between countries and pharmacy sales are likely to play a major role for the access to sterile injecting equipment. Eight countries are running formally organised pharmacy-based syringe exchange or distribution schemes. The overall turnover of syringes through these specialised programmes has increased greatly during the past decades.


Overall, the availability and accessibility of drug-related interventions (prevention, treatment, social rehabilitation, harm reduction) in Europe has clearly increased over the past two decades. This process has been complemented by the adoption of evidence-based responses, a diversification of approaches and continuous specialisation, in particular towards measures to get in touch with hard to reach target groups. Future developments


After a dramatic increase in drug use and drug-related problems during the last two decades, Europe now appears to be moving into a more stable period. By historical standards levels of drug use are high and, although inter-country variation is still observable and patterns of drug use still differ, the polarised picture of a few high prevalence countries and many low prevalence countries has been replaced by a more even distribution. And in some countries among young people in particular it is now becoming possible to talk about common European patterns of drug use.


Historically, the drugs debate has been polarised between responding to the needs of a relatively small number of highly problematic and chronic individuals, predominantly injectors and opiate users, on the one hand and the more general issues of responding to more widespread recreational and experimental use among young people. To some extent this is now changing as the changing picture of drug use has prompted an awareness of the need to consider the public health implications of different patterns of consumption. Increasing regular cannabis use, or the consumption of stimulant drugs such as cocaine by well integrated members of society, are becoming issues of concern for those providing drug services. This ’widening of brief’ is likely to continue into the future as Europe learns to deal with implications of more heterogonous patterns of drug consumption resulting into more heterogeneous patterns of intervention need.


Complicating future responses further is the growing recognition of the fact that poly-drug use (the co-use of several substances) is now identified as a dominant pattern among many groups of drug users and problem drug users in Europe. Polydrug use issues are not restricted to the use of controlled substances and many of those with substance misuse problems are also using alcohol and tobacco and sometimes prescribed medicines in a potentially harmful way. The different patterns of co-use of substances and their consequences on health have to be better studied and prevention, treatment and harm reduction intervention have to be improved accordingly. This is also reflected in an increasing tendency for public health strategies to take a holistic approach to the use of psychoactive substances.


Another challenge for the future will be the epidemiological surveillance of the misuse of prescribed drugs (opioids, benzodiazepines etc.) as well as the possible diffusion of new uncontrolled substances. The Internet now acts as a source of both information on drugs and as a means for promoting new products and stimulating innovation. A range of substances, both synthetic and natural, are being prompted as health tonics and lifestyle enhancers on the one hand, or as legal alternatives to prohibited drugs on the other. This problem is complicated further by a growth of online pharmaceutical suppliers and issues of jurisdiction and regulation within a global marketplace.


It is not just new drug consumption patterns and the complications caused by the combined use of different psychoactive substances that will remain the focus for drug responses in the future. Even if recruitment into heroin use is falling, those experiencing problems through their current or past use of this drug will remain major consumers of health resources in the future. Europe’s ageing population of problem drug users presents multiple health problems, including hepatitis C and HIV/AIDS, as well as a poor social situation. Many health services in Europe have developed accurate treatment modalities and assistance schemes to prevent future deterioration and improve the situation of this population. However, there are still improvements to be made, for instance for what concerns the coordination of the different actors and professions involved in helping problem drug users or regarding the accessibility of treatments in some regions.

The description of the drug situation presented above was possible through considerable investments in drug research and monitoring over the last twenty years. Drug policies and their evaluation can now benefit from more reliable data and information than ever before, both at national and at EU level. This development was strengthened through the adoption by Member States of a set of key epidemiological indicators which need to be fully implemented in the near future. Furthermore, there are still some areas that require further investigations. Poly-drug use, as already mentioned, risk behaviours among drug users, long-term treatment outcomes and other subjects could benefit from future research. The same goes for the development of best practices and the transfer of knowledge between Member States, an area in which the EMCDDA is developing a new web-based platform. References


Bargagli et al. (2002) ‘Mortality among problem drug users in Europe: a project of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Heroin Addiction and Related Clinical Problems 4: 512.


Darke S, Kaye S (2004) Non-fatal cocaine overdoses among injecting and non-injecting cocaine users in Sydney, Australia. Addiction, 99: 1315-1322.


European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Annual report. Available at:


EMCDDA (2000): Opioid use and drug injection


EMCDDA (2006): Select issue on Drug Use In Recreational Settings. Annual report 2006. Available at:


European School Survey Project on Alcohol and Other Drugs (ESPAD) (2003): Psychoactive Substance Use In Schoolchildren Between the Ages of 12 and 18 Handbook for Implementing School Surveys on Drug Abuse . Available at:


EURO-HIV (2005) HIV/AIDS Surveillance in Europe. Available at:


Farrell, M. (1995) Drug prevention: a review of legislation, regulation and delivery of methadone in 12 Member States of the European Union, European Commission, Luxembourg. Risky sexual behaviour


Information on risky sexual behaviour is provided in chapter 9.3.3., within the more general framework of sexual health. Inadequate oral hygiene




EGOHID                      European Global Oral Health Indicators Development Project Introduction



The major risk factors for oral diseases are the same as for major chronic non-communicable diseases such as obesity, heart disease, stroke, cancers, diabetes and mental illness (CED, 2007). Rather than attempting to tackle each single chronic disease alone, a more effective approach is needed with greater emphasis on prevention and health promotion. Directing action at the common-risk factorse.g. diet, smoking, alcohol, stress improvements – is an effective and efficient way for reducing the burden of these diseases. This common-risk approach implies a greater integration of oral health into general health promotion, which is all the more necessary given that oral health itself is a determinant of general health. This implies a broader concept of the role of oral health professionals, also for what concerns the early diagnosis of diseases.


Oral health, particularly for children, is a significant public health issue considering the lifetime impact of lack of care in childhood. Oral diseases, mainly caries and gengivities, are the most costly diseases. Promotion of oral health requires self-care and professional care as well as population based initiatives (Petersen et al, 2005).


A major factor in preventing caries may be the emergence towards the end of the last century of an important oral hygiene-based economic sector. Almost all experts highlight the benefits the spreading of fluoride-containing toothpaste has broughti.e. the reduced incidence and severity of caries. Fluoride containing toothpaste now accounts for 98% of the market in Europe. Since the introduction of fluoride toothpastes in the late 1960s a general caries decline has been observed in all developed countries. The use of fluorides has been demonstrated to be one of the most successful measures in public health history. Fluoride has been recognized as the central element in strategies to prevent dental caries, a disease that had major health, economic and social effects on all communities worldwide. Fluoride reduces the incidence of dental caries and slows or reverses the progression of existing lesions. Dramatic reduction in dental caries in children has been experienced where fluoride has been available from different sources. Although this decline is a major public health achievement, the burden of the disease is still considerable in all age groups. In particular, children of deprived socioeconomic status still have a high risk of caries.


Although the importance of gingivitis in public health terms been questioned, it should be prevented and controlled by personal oral hygiene in adults and children because it affects quality of life and social functioning, especially because of bleeding during eating or toothbrushing. Gingival inflammation is a necessary but not sufficient prerequisite for periodontitis.


The high relative risk of oral disease relates to socio-cultural determinants such as poor living conditions; low education; lack of traditions, beliefs and culture in support of oral health. Communities and countries with inappropriate exposure to fluorides imply higher risk of dental caries. Moreover, settings with poor access to safe water or sanitary facilities are environmental risk factors to oral health as well as for general health. In addition, control of oral disease depends on availability and accessibility of oral health systems but a reduced risk of the disease is only possible if services are oriented towards primary health care and prevention. Apart from the distal socio-environmental factors, the model emphasizes the role of intermediate, modifiable risk behaviours, i.e. oral hygiene practices, sugar consumption (amount, frequency of intake, types) as well as tobacco use and excessive alcohol consumption. Such behaviours may not only affect oral health status negatively as expressed by clinical measures, but also have an impact on the quality of life

Strategies for improving the performance of the European dental health system could target the reduction of disease inequalities. The development of appropriate oral health promotion strategies is needed to improve oral health behaviour and attitudes especially for children from some ethnic minorities or from a poor socio-economic background. International recommendations for oral health prevention and prophylaxis include daily tooth brushing with affordable fluoridated toothpaste. Data sources



Data were collected from national, regional or local oral health surveys or in specific communities including sample registration systems, surveillance systems, national survey data, and literature review. Data are obtainable from children based surveys and from a non institutionalized sample, which may include children not in school. Information available through national health public and private systems has also be used.


The indicators identified for this document are:


·   Proportion of daily tooth-brushing with fluoride toothpaste in 12 years old children


·   Percentage of 15-19 year olds adolescents with bleeding gingival


A number of other indicators, as recommended in the EGOHID project, exist to assess oral hygiene, but unfortunately no data are available yet on a European scale (Bourgeois et al, 2005). They are as follows:


·  Percentage of kindergartens where a preventive oral health program in which particularly supervised tooth brushing with fluoride containing toothpaste takes place.


·  Proportion of schools with based oral health promotion programmes in which daily supervised tooth brushing with fluoride containing toothpaste takes place.


·  Proportion of 12-year-old children according to dental fluorosis (Dean’s index). .


·   Frequency of daily intake of food and drink


·   Proportion of children and adolescents and adults who are using tobacco at a point in time. Data description and analysis


The Burden of oral hygiene


As it might be expected, the increased consumption and use of oral hygiene products has been associated to improved oral hygiene. International publications from comparable industrialised campaigns and countries in Europe focus on socially and economically underprivileged high risk groups targeted through integrated prevention programmes to promote good oral hygiene practice.(Petersen, 2003; Petersen et al, 2005)


Child population are likely to be heavily influenced by parental behaviour. The increased usage of fluoride containing toothpaste in children has been strongly correlated with the decline in the prevalence and severity of dental caries. The frequency of brushing is important with the current recommendation for optimal effect being twice daily (Arnadottir et al, 2004). . However, there are profound disparities in children’s oral hygiene in various countries; the best score was identified in Nordic countries (80-90%), while in other countries it varied around 60-70%. These differences may be related to environmental conditions, to a variety of behaviours related to oral hygiene or linked to socio-economic situations. (Gherunpong et al, 2006)


Table illustrates the difference in daily F tooth-brushing twice of children across Europe. Score less than 60% was observed in most East European countries i.e. Lithuania (37%), Latvia (48%), Hungary (53%) and Slovakia (58%). Tooth-brushing more than once a day among 13 year old schoolchildren in Nordic Countries in 2001/2002 according to sex (Male/Female) was similar in Sweden (82/77%), Denmark (83/74%) and Norway (86/75%). In Austria, 97 % claim to use F-toothpaste. Trends of tooth-brushing frequency from Finnish 12 year olds issue from the Finnish Adolescent Lifestyle Study in 2001, 2005 and 2007 were respectively 35%, 40% 41% for the girls vs. 20%, 30% and 35% for the boys (Honkala et al, 2003; Honkala and Rimpelä, 2007).


Table Children Daily F Toothbrushing Frequency and Percentage of 15-19 year old adolescents with gingival bleeding in Europe



Gingival bleeding is highly prevalent among adult populations in all regions of Europe. According to the results of recent epidemiologic surveys in industrialized countries, gingivitis affects most adolescents (Table and 40 to 50% of adults (Bourgeois et al, 2004). Prevalence, severity and extent in young subjects increases with age, beginning with milk-teeth, reaching a peak at puberty, to then declining somewhat during adolescence. Gingivitis varies widely from one study to another. Such differences are probably more a matter of methodology than of real differences in the disease itself. At population level, the incidence of dental plaque and gingivitis is much higher in boys than girls.


Improved dental hygiene seems to have reduced gingivitis in a number of industrialised countries. However, available epidemiological data do not enable the hypothesis of a reduction in periodontal disease to be confirmed, due to a lack of perspective on the natural development of these pathologies. National probabilistic studies in Denmark reported 60% prevalence for teenagers and 40-50% for adults. Only 5-6% of gum sites showed inflammation. In the UK, only about a third (32%) of five-year-olds had gingival inflammation compared to almost two thirds (63% and 65%) of eight and 12-year-olds and about half (52%) of older children, aged 15. Between 1993 and 2003 an increase in the proportion of children affected by gingivitis was observed among 5, 8 and 12 year olds. Among 15 year olds, 56 per cent of 15 year old boys had some gingivitis, compared to 48 per cent of girls (White et al, 2006). In Portugal, 90% of children at the age of 12 had poor oral hygiene (de Almeidia et al, 2003). In comparison with studies dating from the ’50s and ’60s, the data suggest gum health is improving, possibly due to the improved dental hygiene observed in industrialised countries as a whole, but also in a context in which no scientific or methodological guarantees exist.


Economic impact of oral hygiene


The oral hygiene market consists of various product groups such as dental floss, dental care, mouthwashes, fresheners, toothbrushes, toothpaste and tooth whiteners. Toothpaste constitutes by far the largest area of the global oral hygiene market. The sale of toothpaste generates 58.5% of the global market’s value. Europe generates 38.7% of the global market's value. Supermarkets and hypermarkets form the most significant distribution channel, account for 47.2% of the global market's value. During the 1997-2004 period, growth was constrained by increased price competition and the switch from manual toothbrushes to newer battery-powered/electric versions. However, power toothbrushes were generally used with less toothpaste than alternative formats, because of their smaller heads. Germany accounts for 18.5% of the European oral hygiene market. Total revenues of the German oral hygiene market amounted to USD 1.65 billion in 2005. In volume terms, sales of oral hygiene products decreased by an average of 0.2% annually over 2001-2005, to a total of 600.8 million units sold in 2005. In the UK (2003), between half and two thirds of all children reported using electric toothbrushes, while the use of mouthwash and sugar-free gum was reported by over 40% of 15-year-olds.(Euromonitor International (2007; Bourgeois & Llodra, In press).


Behaviours and Oral Hygiene Data


The large diffusion of toothbrushing is an interesting finding and might be more significant than it may seem at first. Unfortunately, we have no earlier data with which to compare, but empirically its use would seem to have increased substantially over the last two decades. Although general awareness of oral hygiene and oral healthcare products appears to have improved since the previous surveys, this does not mean that teeth are cleaned effectively. The fact that almost two thirds of 12-year-olds have gingival inflammation indicates that plaque control at this early age is often not particularly effective; this applies despite the good hygiene habits reported in the previous section. Plaque-induced chronic gingivitis in children can be managed through the mechanical removal of plaque and good oral hygiene. Good hygiene should have further benefits in terms of caries risk. Examiner variation may have contributed to these findings and the same goes for the apparent difference in prevalence between the countries. Obtaining examiner reproducibility for plaque and to a lesser degree, gingivitis, is notoriously difficult (White et al, 2006).


Clinical and public health research has shown that a number of individual, professional and community preventive measures are effective in preventing most oral diseases. However, optimal intervention in relation to oral disease is not universally available or affordable because of escalating costs and limited resources. This, together with insufficient emphasis on primary prevention of oral diseases, poses a considerable challenge for many countries. Most of the evidence relates to dental caries prevention and control of periodontal diseases. Gingivitis can be prevented by good personal oral hygiene practices, including brushing and flossing which are important also for the control of advanced periodontal lesions. Community water fluoridation is effective in preventing dental caries in both children and adults (WHO, 1994; OMullane et al. 2004)  Water fluoridation benefits all residents served by community water supplies regardless of their social or economic status. Salt and milk fluoridation schemes are shown to have similar effects when used in community preventive programmes. Professional and individual measures, including the use of fluoride mouth rinses, gels, toothpastes and the application of dental sealants are additional means for preventing dental caries. In a number of developing countries the introduction of affordable fluoridated toothpaste has been shown to be a valuable strategy, ensuring that people are exposed appropriately to fluorides.


The daily use of toothpaste containing fluoride (250-750 ppm for 3-6 year old children) is an effective method for preventing caries in permanent teeth of children and adolescents. There is a plenty of data to suggest that the use of low dose fluoride (250 ppm) will have a lesser effect on caries than higher dose toothpaste. The effects are dose-related, i.e., toothpaste with a higher concentration of fluoride, 1,500 ppm, yields a better effect than toothpaste with 1,000 ppm. Although the scientific literature does not evaluate the preventive effects of fluoride toothpaste in adult and elderly individuals, however, nothing would suggest that preventive effects would not be found in these age groups as well. (Marinho et al., 2003; Twetman et al2003; WHO, 1994)


The benefits of fluoride toothpaste are firmly established (Arnadottir et al, 2004). Taken together, the trials, which included more than 42,000 children, provide clear evidence that fluoride toothpastes used at least once a day are effective in preventing dental caries in permanent teeth. The caries preventive effect of fluoride toothpaste increased with higher initial levels of decayed, missing and filled permanent teeth, higher fluoride concentration and supervised brushing, but was not influenced by exposure to water fluoridation.


Oral Hygiene Products


While toothpaste is mature and considered increasingly mundane by consumers, the burgeoning popularity of specialised toothpastes, catering for different consumer groups and needs, continues to spur growth in developed markets. In the Netherlands, for example, Euromonitor's research shows that whitening, sensitive, child-specific and all-in-one toothpastes emerged as the fastest growing products in 2003, as consumers looked for benefits beyond basic protection (Euromonitor International, 2007). Meranwhile, in France, a product specific for young adults between 18 and 25 has been proposed. In the UK the growing demand for whitening and breath freshening products also resulted in many players extending their brands by such variants to their existing ranges. For the big manufacturers in this mature and traditionally sluggish sector, innovation has become the only way to go ahead. This has resulted in an increased categorisation across the various subsectors of oral care with multi-functional products combining toothpaste and mouthwash, vibrating floss and on-the-go mouth-freshening strips.

Consumer expectations are high, but the profits are higher for the manufacturers that can provide the increasingly image conscious consumer with oral hygiene solutions that fight plaque, give fresh breath and, very important, a brighter than white smile. Novel products featuring new uses have been flooding the market during 2003 and 2004 and include fresh breath strips and tooth whitening products. These products have tapped into consumer concerns of appearance and are expected to drive the sector’s growth in the medium term. Control tools and policies


The WHA60.17 resolution Sixtieth World Health Assembly (2007) “Oral health: action plan for promotion and integrated disease preventionurges Member States: (i) to adopt measures to ensure that oral health is incorporated as appropriate into policies for the integrated prevention and treatment of chronic non-communicable and communicable diseases, and into maternal and child health policies; (ii) to develop and implement the promotion of oral health and prevention of oral disease for preschool and school children as part of the health-promoting school activities; (iii) for those countries without access to optimal levels of fluoride and which have not yet established systematic fluoridation programmes, to consider the development and implementation of fluoridation programmes, giving priority to equitable strategies such as the automatic administration of fluoride, for example, in drinking-water, salt or milk, and the provision of affordable fluoride toothpaste (WHO, 2007).


The recommendations issue from the European health Strategy (2007) underlined that the major risk factors for oral diseases are the same as for major chronic non-communicable diseases such as obesity, heart disease, stroke, cancers, diabetes and mental illness (CED, 2007). Rather than attempting to tackle each chronic disease individually, a more effective approach is needed with greater emphasis on prevention and health promotion. Directing action to the common-risk factorse.g. diet, smoking, alcohol, stress improvements – is an effective and efficient way for reducing the burden of these diseases. This common-risk approach implies a greater integration of oral health into general health promotion, which is all the more necessary given that oral health itself is a determinant of general health. This implies a broader concept of the role of oral health professionals, also for what concerns the early diagnosis of diseases. The common-risk approach also needs to take into account the differing needs of different population groups according to their lifestyles, life stages and life conditions. Oral health inequalities are evident both across the EU and within Member States.


Member States have recognized the need for a greater emphasis on prevention and health promotion. Over the past decades, they have increasingly formulated priorities and targets for health policies which broaden oral health goals from simply tackling specific diseases to objectives expressed in terms of quality of life, reduction of health inequalities, quality of care and access to care. A EU health strategy should further empower national policies by facilitating coordinated action to promote oral health as an integral part of chronic disease prevention, amongst other issues through enhanced cooperation with other community actions and programmes. Future developments


The major challenges of the future will be to translate knowledge and experiences on disease prevention into action programmes (Petersen, 2003). Social, economic and cultural factors and changing population demographics influence the delivery of oral health services in countries and communities and how people care for themselves. Reducing disparities requires far-reaching wide-ranging approaches that target populations at high risk of specific oral diseases and involves improving access to existing care. Meanwhile, in several developing countries the most important challenge is to offer essential oral health care within the context of primary health programmes. These programmes should meet the basic health needs of the population, strengthen active outreach to the community, organize primary care and ensure effective patient referral


Focusing on health risks is the key for preventing disease, while risk factor assessment may measure the potential of prevention. The termrisk factor’ does have a negative connotation, but ideallyrisk assessment’ should include a range of protective and hazardous factors. Thus, in relation to oral health, risk analysis focuses on the protective benefits of oral hygiene practices and consumption of fruits/vegetables as well as the negative impacts of consumption of sugary foods and tobacco use. A more progressive health promotion approach which recognizes the importance of tackling the underlying social, political and environmental determinants of oral health is needed. For this approach to be successful in achieving sustainable changes in oral health, multi-sectoral working is essential.


Stronger links in preschool health programs for oral health education and services should be created and maintained (WHO, 2003). The establishment of preventive oral health programs, which mainly include supervised daily tooth brushing with a fluoride toothpaste in kindergartens made on a regular basis, has the potential to close the oral health gap in early childhood between advantaged and disadvantaged communities. Fluoride school based programmes are effective especially for children at high risk of dental caries and can help to minimize the inequalities in oral health within the schools. There is therefore strong evidence for the caries preventing effect of daily supervised tooth brushing with fluoride containing toothpaste in schools. Targets should be defined in each country using the high risk groups approach. It is an educational principle that in kindergartens young children develop their own abilities through playing and exercise. They are encouraged to enhance their knowledge through the completion of simple everyday tasks and are supported by teachers to plan, do and review activities.


Individuals can take actions for themselves and for people under their care, to prevent disease and maintain health. With appropriate diet and nutrition, primary prevention of many oral, dental and craniofacial diseases can be achieved. Lifestyle behaviour that affects general health such as tobacco use, excessive alcohol consumption and poor dietary choices also influence oral and craniofacial health. These individual behaviours are associated to an increased risk of craniofacial birth defects, oral and pharyngeal cancers, periodontal disease, dental caries, oral candidiasis and other oral conditions.


In Europe, an increasing awareness of oral health is observed among parents of all age groups of children. This very positive development is demonstrated by the reported tooth brushing behaviours and by the use of a range of oral hygiene products. Currently, there are opportunities to expand oral disease prevention and health promotion knowledge and practices among the public through community programmes and within health care settings. Oral health care providers can also play a role in promoting healthy lifestyles by incorporating tobacco cessation programmes and nutritional counselling into their practices. However, there are profound oral health disparities across regions, countries and within countries. These may relate to socioeconomic status, race or ethnicity, age, gender or general health status. Although common dental diseases are preventable, not all community members are informed of or are able to benefit from appropriate oral health-promoting measures. Under-served population groups are found in both developed and developing countries. In many countries, moreover, oral health care is not fully integrated into national or community health programmes. References


Arnadottir IB, Ketley CE, Van Loveren C, Seppa L, Cochran JA, Polido M, Athanossouli T, Holbrook WP, O'Mullane DM (2006): A European perspective on fluoride use in seven countries. Community Dent Oral Epidemiol 2004; 32: 69-73.


Bourgeois DM, Baehni PC (2003): Surveillance, epidemiology and periodontal diseases. In: Bourgeois DM, Llodra JC, eds. Health Surveillance in Europe. European Global Oral Health Indicators Development Project. 2003 Report Proceedings. Paris: Quintessence Publishing Co., 2004:8192.


Bourgeois DM, Llodra JC, Pitts N, Norblad A (2005): Health surveillance in Europe. A selection of essential indicators in Europe recommended by European Global Oral Health Indicators Development Project. 2005 Catalogue. Final Report. Lyon, France 2005. Available at: [] (accessed on 17 February 2008)


Bourgeois DM, Llodra JC. Strategies to promote better access to OTC products for oral health in Europe: A Delphi Survey. Int Dent J ( In Press).



Council of European Dentists’ (CED) (2007): Council of European Dentistsposition paperResponses to the European Commission’s discussion paper for a health strategy”. CED, Bruxelles, Belgium. Available at: [ index.php?ID=2741] (accessed on 12 February 2008).


de Almeida CM, Petersen PE, André SJ, Toscano A (2003): Changing oral health status of 6- and 12-year-old schoolchildren in Portugal. Community Dent Health. 2003; 20:211-6.


Euromonitor International (2007): Cosmetics and toiletries in the Netherlands. Oral hygiene in Netherlands. London, United Kingdom.


Gherunpong S, Tsakos G, Sheiham A. A sociodental approach to assessing dental needs of children: concept and models. Int J Paediatr Dent. 2006



Honkala S, Rimpelä A (2007): Toothbrushing according to the Adolescent
Lifestyle Study in Finland 2007. Unpublished document.


Koivusilta L, Honkala S, Honkala E, Rimpelä A (2003): Toothbrushing as a part
of adolescent lifestyle predicts educational level. J Dent Res 2003; 82:


Marinho VC, Higgins JP, Sheiham A, Logan S. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2003; (1): CD002278.


OMullane DM, Ketley CE, Cochran JA,Whelton HP, Holbrook WP, van Loveren C, Fernandes B, Seppa L, Athanassouli T. Fluoride ingestion from toothpaste: conclusions of European Union-funded multicentre project. Community Dent Oral Epidemiol 2004; 32: 74-76.



Petersen PE (2003): The World Oral Health Report 2003: continuous improvement of oral health in the 21st century – the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol. 2003; 31 Suppl 1:3-23.


Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, NDiaye C. The global burden of oral diseases and risk to oral heath. Bull World Health Organ. 2005; 83: 661-669.


Twetman S, Axelsson S, Dahlgren H, Holm AK, Kallestal C, Lagerlof F, Lingstrom P, Mejare I, Norderam G, Norlund A, Petersson LG, Soder B. Caries preventive effect of fluoride toothpaste: a systematic review. Acta Odontol Scand 2003; 61: 347-55.



White DA, Chadwick BL, Nuttall NM, Chestnutt IG and Steele JG. Oral health habits amongst children in the United Kingdom in 2003. Br Dent J. 2006; 200: 487-491.


WHO (2007). Resolution WHA60.17Oral health: action plan for promotion and integrated disease prevention”. WHO, Geneva, Switzerland. Available at: [] (accessed on 1 February 2008).


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World Health Organization. Fluorides and Oral Health. WHO Technical Report Series 846. Geneva: World Health Organization; 1994. Inadequate physical activity





WHO Global Physical activity Questionnaire


International Physical activity Questionnaire


Metabolic Equivalent Introduction


Physical activity is defined as bodily movement produced by skeletal muscles that results in energy expenditure above resting level (Caspersen et al, 1985). Health-enhancing physical activity is a term frequently used across the WHO European Region. It emphasizes the connection with health by focusing on “any form of physical activity that benefits health and functional capacity without undue harm or risk”. To gain health benefits, at least half an hour of physical activity of moderate-intensity on most days of each week is recommended (WHO, 2004a). Children should undertake at least 60 minutes of moderate to vigorous physical activity daily in forms that are developmentally appropriate, enjoyable and involve a variety of activities (Strong et al, 2005).


Moderate-intensity physical activity is the type of activity that noticeably raises the heartbeat, while vigorous activity causes rapid breathing and a substantial increase in heart rate (WHO, 2006a). Health-enhancing physical activity includes normal daily life activities, such as brisk walking or cycling to work, school or shopping, swimming, housework, using the stairs or gardening as well as recreational sport or dancing.


Physical inactivity is recognized as a major independent risk factor for chronic non-communicable diseases causing about 3.5% of the disease burden and up to 10% of deaths in the European Region (WHO, 2002; WHO, 2006b). Epidemiological research shows that physical inactivity substantially increases the risk for coronary heart disease, type 2 diabetes, colon and breast cancer and hip fracture in the elderly (Bauman and Miller, 2004). Regular physical activity can help prevent and reduce obesity and maintain a healthy weight (Hill and Wyatt, 2005). It can also promote psychological well-being by reducing symptoms of depression and, possibly, stress and anxiety. Moreover, regular physical activity  may confer other psychological and social benefits that affect health (WHO Regional Office for Europe, 2006a). For example, it can help build social skills in children (Evans and Roberts, 1987), positive self-image among women (Maxwell and Tucker, 1992) and self-esteem in children and adults (Sonstroem, 1984) as well as improve one’s quality of life. These benefits probably result from a combination of participation itself and the social and cultural benefits of physical activity. Finally, physical activity tends to be associated to other types of positive health behaviour, such as healthy eating and non-smoking, and can be used to help make other behavioural changes (UK Department of Health, 2004).


Physical activity is not just a public health issue; it also promotes the well-being of communities, especially in urban settings, the protection of the environment and comprises an investment in future generations. (WHO Regional Office for Europe, 2006c). Data sources


Surveillance of physical activity can be carried out in two different ways: by self-report questionnaire or by objective measurement devices such as pedometers (step counters) or accelerometers which allow measuring bodily movement. Most often, questionnaires have been used as this method is relatively inexpensive and easy to administer compared to objective measures. It is only recently that valid and reliable tools to assess levels of physical activity among populations have become available (Bull et al, 2004). These questionnaires take into account that non-leisure time physical activity such as undertaken for transport also has important potential health benefits (Andersen et al, 2000). The following two international physical activity questionnaires are now available as “multidomaininstruments to collect information on moderate and vigorous intensities undertaken in all settings of daily life.


The WHO Global Physical activity Questionnaire (GPAQ) (WHO, 2006d) aims at allowing comparisons in developing countries with culturally diverse populations, and has been translated and validated. GPAQ also provides context-specific estimates of occupational, transport and leisure-time physical activity.


The International Physical activity Questionnaire (IPAQ) (Karolinska Institute, 2006) allows direct comparison of levels of physical activity between countries and to estimate walking behaviour. Two versions (short and long) have been developed and validated, and are available in a number of languages. Most often the short version has been used so far.


In addition, studies have looked at physical inactivity (defined as no or very low levels of activity) (Bull et al, 2004) and/or sedentary behaviour (de Almeida, 2004). Sedentariness does not simply represent the opposite of physical activity but corresponds to a complementary dimension of behaviour (WHO Regional Office for Europe, 2007a). A sedentary lifestyle can, for example, well include some sessions of activity or exercise but not at the recommended level of regularity while time spent sitting might be more prevalent (WHO Regional Office for Europe, 2007b). 


Due to the fact that physical activity surveillance is still a young field, there is not yet one unified survey on physical activity prevalence in the European Union. Data is currently available from a variety of surveys with different degrees of coverage of the region. In the following, the main surveys are briefly presented.


Global surveys including EU countries


The World Health Survey, a cross-sectional study carried out by WHO (2002-2003) through personal interviews (CAPI) and paper and pencil method (PAPI), is a comprehensive health survey with several modules, one of them on risk factors including physical activity based on IPAQ (WHO, 2007a). Data are available for 8 EU Member States and Candidate Countries.


WHO global InfoBase


On-line repository of data on non-communicable disease risk factors, including physical inactivity (PIA) (WHO, 2006c): Based on the Surveillance of Risk Factors (SuRF) programme, which assembles chronic disease risk factor data collected from WHO Member States with complete source and survey information. In order to provide cross-country comparisons, national data sets are made comparable by adjusting for the following factors: risk factor definitions; a standard set of age groups for reporting; a standard reporting year; representativeness of the survey data; and population age-distribution by age standardizing the final results to the WHO standard population. Data are available for 27 EU Member States, Candidate and EFTA Countries.


European surveys


a) Eurobarometer survey series on adults: The Eurobarometer survey is conducted on behalf of the European Commission in all member States of the European Union. Starting with Eurobarometer 34 (1990) separate supplementary surveys on special topics have been conducted under almost each Eurobarometer number. Also in the nineties the Eurobarometer program has been complemented by the Central and Eastern Eurobarometer series, at a later date replaced by the Candidate Countries Eurobarometer


So far, three special Eurobarometer studies included questions on physical activity:

·            Special Eurobarometer Wave 58.2: Physical activity (EORG, 2003). The survey covered 15 member states and used IPAQ short, including also context specific questions. A scientific analysis of this survey has been published in 2006 (Sjöström et al., 2006).


·            Special Eurobarometer Wave 62.0: The citizens of the European Union and Sport (TNS Opinion and Social, 2004). The survey covered 25 member states and focused on sport participation, the organization of sport activities and the social dimension of sport. One question on sport participation was repeated from the 2003 survey but comparison of one single question across two time points should be viewed with caution.


·            Special Eurobarometer 246 / Wave 64.3: Health and Food (TNS Opinion and Social, 2006). This survey contained questions on physical activity but the with regard to the 2003 survey, some of the questions have been revised and the data has been analysed differently. As of now, no directly comparable data to the 2006 publication (Sjöström et al, 2006) is available.


b) Health behaviour in school-aged children survey (HBSC) (HBSC, 2002): This survey of health behaviour among young people aged 11, 13 and 15 years HBSC studies are carried out at four-year intervals. The 2001/2002 study was the sixth and most recent in the series and it included participation in physical activity (WHO, 2004b). It covered 29 EU countries or regions in the scope of the report (Austria, Belgium (Flanders), Croatia, the Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Israel, Italy, Latvia, Lithuania, Malta, the Netherlands, Norway, Poland, Portugal, Slovenia, Spain, Sweden, Switzerland, The former Yugoslav Republic of Macedonia, the United Kingdom (England, Scotland and Wales) as well as Ukraine and the Russian Federation. Data from this study will be used for this chapter (Fig. 2 and 3).


Selected multicentre studies


- European Youth Heart study (Riddoch CJ et al., 2004): International study measuring CVD risk factors including insufficient physical activity, covering Denmark, Estonia, Norway and Portugal

- FINBALT (Harro et al. 2006): International study monitoring health-related behaviours including physical activity among adults in Finland (since 1978) and the Baltic countries (Estonia since 1990, Latvia since 1998, Lithuania since 1994) every second year.



The quality of currently available data on physical (in)activity is affected by a number of aspects:


a)  Definition of physical activity

A recent review of instruments currently used for the measurement of physical activity revealed that there is no universal or even commonly used measure or instrument yet (Bull et al., 2004). While most often questionnaires are used the wording of the questions and the response format often varies. Different questions are needed to measure activity (e.g. assessing the time spent in and the intensity of a certain type of activity) and inactivity (e.g. assessing the hours spent sitting).


b)  Comparability of data sources

As outlined above, data are currently available from a variety of surveys and studies which use different instruments as well as different methods for data collection (e.g. self-administered questionnaires, telephone surveys or personal interviews). There is good evidence that different instruments will produce different estimates of a certain behaviour (Pratt et al. 1999) so results are not comparable across different surveys unless certain procedures are applied to adjust for differences in the methods used such as in the WHO InfoBase data repository (see above).


c)   Reliable trend data

Bull et al (2004) also showed that only a small number of countries globally had robust data to monitor trends over time; the best example from Europe was Finland, where physical activity has been measured in annual surveys since 1979 (Helakorpi et al., 2003)


d)  Lack of information on different settings where physical activity takes place

Most often leisure time physical activity is measured while data on work-, transport- or domestic-related activity are still rare.


e)  Data from accession countries

Data from the western part of the EU are more readily available than from accession countries, especially on non-leisure time physical activity. Data description and analysis


An analysis of a Eurobarometer survey in 15 EU countries in 2002 (Sjöström et al, 2006) showed that two thirds of the adult population did not reach recommended levels of physical activity (Figure On average, only 31% of respondents reported sufficient physical activity20. Activity varied widely between countries, ranging from around 40% of respondents being sufficiently active in the Netherlands and Germany to less than a quarter in France and Sweden. Men were more likely to be sufficiently active than women and the likelihood decreased with age.


Figure Proportion of adults (aged 15 years of over) in EU countries classified as sufficiently active, 2002


The 2002 and 2004 Eurobarometer surveys showed an increase in the proportion of people claiming to do sport once a week, from 30% to 38%. However, this result should be viewed with caution as it is limited to answers to a single question across two time points and it focuses on sport participation only.


There are examples of trend data available from some countries (WHO, 2006a): The Swiss Health Survey shows that the proportion of people classed as physically inactive increased from 35.7% in 1992 to 39.4% in 1997, but then decreased to 36.8% in 2002 (Lamprecht and Stamm, 2004). Physical activity has been measured in annual surveys in Finland since 1979 (Helakorpi et al, 2003). From the late 1970s to mid-1990s, Finland saw an overall increase in the proportion of those who are active twice a week from about 40% to about 60%, with women starting from a slightly lower level but ending at slightly higher levels. Since the mid-90s, the general increase in activity has levelled off, and the rise in women’s leisure-time activity slowed. In the United Kingdom, the best trend data come from the National Travel Survey. It showed that the average distance travelled per person per year on foot and by bicycle declined by 26% and 24% between 1975/1976 and 1999/2001, respectively (UK Department of Health, 2004).


Children and adolescents


The HBSC survey (see above) measured participation in physical activity in young people (WHO, 2004b). It found that about a third (34%) reported enough physical activity to meet current guidelines of one hour or more of at least moderate intensity on five or more days a week. Activity varied widely between countries, however, ranging from 11% of girls and 25% of boys in France to 51% of girls and 61% of boys in Ireland among 11-year-olds. Similar variations existed among all age groups; for example, the proportion of active 15-year-old boys was 49% in the Czech Republic and 25% in Portugal.


Figure Prevalence of sufficient physical activity in 11-year-old children in the European Region, 2001/2002


In most countries, boys were more active than girls, with activity levels declining with age for both sexes.


Figure Average proportion of physically active children aged 11, 13 and 15 years, selected countries in the WHO European Region, 2001/2002


Impact on health and costs of physical inactivity


The World health report 2002 (WHO, 2002) estimated that insufficient physical activity was associated to 600 000 deaths per year (6% of total deaths) and 5.3 million disability-adjusted life-years (DALYs) (3.5% of total DALYs) in the European WHO Region alone. In many countries, a significant proportion of health expenditure is related to costs incurred by lack of physical activity and obesity, plus an alarming economic price to pay for physical inactivity. Recent studies conducted in Switzerland and the United Kingdom show that physical inactivity can cost a country about €150-300 per citizen per year (UK DCMS and Strategy Unit, 2002; Martin et al, 2001).

Increasing incidences of obesity-related chronic diseases, such as type II diabetes and hypertension in adolescents, foretell an even larger burden of disease if no action to reverse them is taken. Inequalities between countries are rising, with those in the eastern part of the Region being the most affected (WHO, 2005).


Determinants of physical inactivity


The key determinants of physical activity include demographic factors (such as age and socioeconomic status), psychological factors (such as perceived competence and enjoyment, lack of awareness, cultural and language barriers), social factors (such as encouragement from parents or peers, cultural attitudes) and the physical environment (such as the availability of opportunities to be active) (WHO 2006a). Low physical activity disproportionately affects socially disadvantaged groups, who have less free time or poorer access to local recreational and leisure facilities (Popkin et al, 2005; Estabrooks et al, 2003; UK Health Education Authority, 1995). They are more likely to live in neighbourhoods with poor road safety, high-speed traffic, little green space and lack of safe places to play. All this further reduces their opportunities to be physically active on a daily basis (Gordon-Larsen et al, 2006). Fear of traffic can be a powerful deterrent for parents wishing to allow their children to walk or cycle to school or play outdoors, especially in deprived areas, which are often characterized by poor road safety and fast traffic ( Greyling et al, 2002).


Not only the urban environment in which people live but also other settings – at home, at school, at work and so on – often discourages them from being physically active. Longer travel distances, fewer green spaces and urban planning policies resulting in increasing urban sprawl play an important role in discouraging physical activity and increasing dependence on motorized transport (WHO, 2007b). Yet 50% of trips currently made by car in Europe are shorter than 6 km, a distance that could easily be covered by about 15 minutes of cycling. More than 30% of car trips are distances less than 3 km, and could be covered comfortably by about 20 minutes of brisk walking (European Commission, 2000a). It has been estimated that at least half of these short car trips could be replaced by cycling and walking (European Commission, 2000b).


In addition to environmental conditions, physical education in schools is important in the total amount of physical activity undertaken by children. A recent publication (Brettschneider and Naul, 2004) highlights this issue and shows that the amount of physical education at school and the way it is organized vary from country to country. Control tools and policies


Thanks to the range of conclusive findings over the past decade regarding physical activity as an important health determinant, there is now a solid foundation for a clear and strong call to action. The magnitude of the health problems consequent to physical inactivity and its interconnection with unhealthy diets, underline the need to raise the awareness and secure the commitment and support of a broad range of actors and stakeholders within and beyond public health. This implies strengthening existing partnerships, such as those with the education and sports sectors, and developing new ones with others that play a major role in shaping environments and communities, such as transport, environment, urban planning, employers, local administration and civil society. The concurrence of physical inactivity with unhealthy diets in the EU obesesogenic environment calls also for the involvement of those stakeholders influencing food choices (WHO, 2006a; WHO, 2006e).


A very intensive activity has been carried on this subject during the last ten years by both the European Commission and WHO. Some documents are listed below. Other actions and documents addressing obesity, diet and physical activity are quoted in section5.13. Obesity, overweight and other conditions related to an imbalanced nutrition


World Health Organization


At a side event of the WHO European Ministerial Conference on Counteracting Obesity, held in Istanbul, Turkey, in November 2006, twotwinbooklets were launched: Physical activity and health: evidence for action (WHO, 2006a) and Promoting physical activity and active living in urban environments: the role of local governments. The solid facts (WHO, 2006e). These booklets reach out to policy makers with strong advocacy messages and address policy makers to raise awareness about the magnitude of the problem and the opportunities to act through cross-sectoral collaboration.


The document Steps to health: a European framework to promote physical activity for health (WHO, 2007c) was one of the working documents for the WHO European Ministerial Conference on Counteracting Obesity and the final document was launched on 10 May 2007 in Helsinki, Finland, at the celebration of the Move for Health Day ( This framework document provides Member States of the WHO European Region, experts and policy-makers with guidance on designing and implementing physical activity-promoting policy and action, as part of a national public health agenda and through multisectoral cooperation.


A collection has been published by WHO Regional Office for Europe aimed at supporting the Member States of the WHO European Region in promoting physical activity as part of sustainable transport policies: Collaboration between the health and transport sectors in promoting physical activity (WHO, 2006g). This review aims at inspiring policy-makers and practitioners from the transport, health and environment sectors to work together to achieve healthier and more sustainable transport.


In addition, there is an important opportunity for synergistic action, taking advantage of relevant processes involving other sectors that play an important role in providing the environmental conditions that facilitate physical activity. These processes include the Children’s Environment and Health Programme for Europe (WHO, 2004c), the Transport, Health and Environment Pan-European Programme (UNECE and WHO, 2002) and the Healthy Cities initiative (


European Commission


In 2005, the EU launched the EU platform on diet, physical activity and health (European Commission, 2005a). Under the leadership of the European Commission, the platform brings together stakeholders from commercial, professional, consumer and other civil organizations to take voluntary action to halt and, hopefully, reverse the rise in obesity, particularly among children. The spirit of the platform is to work under the leadership of the European Commission and to provide an example, which others will choose to follow across Europe, of coordinated but autonomous action by different parts of society to deal with the many aspects of the problem.


In 2007, the European Union launched the White Paper A Strategy for Europe on Nutrition, Overweight and Obesity related health issues (European Commission, 2007a). The White Paper was developed based on consultation of an earlier published Green Paper Promoting healthy diets and physical activity: a European dimension for the prevention of overweight, obesity and chronic diseases (European Commission, 2005b, RIVM, 2006)). The White Paper embraces a broad understanding of physical activity from organized sports to active commuting or outdoor activities. It underlines that individual attempts for a healthy lifestyle must be supported by the development of conducive physical and social environments. The White Paper supports sustainable urban transport actions and specifies that walking and cycling projects are considered to be a key part of this goal.


The European Commission is preparing an Action Plan, which will identify a series of concrete actions and initiatives towards better and sustainable urban mobility that will be presented in early autumn 2008. This action plan is based on the results of the Green Paper on Urban Mobility (European Commission, 2007b).


The European Commission has also published a White Paper on Sport (European Commision, 2007c), which provides strategic orientation on the role of sport in the European Union, including physical activity. This Document is accompanied by an Action Plan (European Commission, 2007d), which addresses also the promotion of health-enhancing physical activity. Future developments


Regular moderate-intensity physical activity is a very cost-effective way of improving and maintaining people’s health. Available evidence indicates that physical activity is a major element of public health promotion, involving all sections of society. Action in this area is not the responsibility solely of the health, sport, leisure, work or education sectors. It is a task to be shared by these and other sectors, such as transport, urban planning, environment, employers and civil society. Likewise, the media is highly influential in promoting healthy lifestyles. Working together across sectors, in both the public and the commercial arenas, would promote more efficient action and therefore more effective progress towards healthier and more sustainable lifestyles. The synergies involved create a win-win situation for all actors. In addition, action should be supported at all levels, from local community level, through governments, to the international arena. It is important that strategies for collaboration and capacity-building at regional and local levels are included in national policy and action as local level initiatives have the greatest potential for encouraging physical activity.


Public health programmes for physical activity need to be planned with a long-term perspective and have clear and measurable goals and indicators. Surveillance of levels of physical activity among the population using standardized protocols is a crucial and necessary part of the public health response to current concerns regarding physical activity levels. References


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Caspersen CJ, Powell KE, Christensen GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Reports, 1985, 100:126-131.


EORG (2003): Special Eurobarometer Wave 58.2. Physical activity. Requested by Directorate General Health and Consumer Protection and coordinated by Directorate General Press and Communication. December 2003 [] (on-line publication, accessed 6 June 2007).


Estabrooks PA, Lee RE, Gyurcsik NC (2003): Resources for physical activity participation: does availability and accessibility differ by neighbourhood socioeconomic status? Annals of Behavioural Medicine, 25(2):100104.


European Commission (2000a): EU Transport in figures. Statistical pocketbook. Brussels, European Commission Directorate-General for Energy and Transport.


European Commission (2000b): WalCyng: How to enhance WALking and CYcliNG instead of short car trips and to make these modes safer. Brussels.


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European Commission (2005b): Green Paper. Promoting healthy diets and physical activity: a European dimension for the prevention of overweight, obesity and chronic diseases. Brussels, Commission of the European Communities (COM(2005) 637 final.



European Commission (2007a): White Paper on strategy for Europe on nutrition, overweight and obesity related health issues. Brussels, Commission of the European Communities. [].


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COM(2007) 391 final []



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Body Mass Index


Common Agricultural Policy


Common Market Organisation


Disability-Adjusted Life Years


Dietary Reference Intake


European Heath Examination Survey


European Health Interview Survey


European Hearth Network


Food-Based Dietary Guidelines


Inter-Service Group


Inter-Service Group established for the preparation of the School Fruit Scheme


Scientific Committee on Food


United Nations Economic Commission for Europe Introduction


A well balanced diet with nutritional and physiological requirements of the different age groups from birth to old age and with physical activity carried out by each individual is an absolute requirement for enjoying good health.


There are a number of diseases induced by an excessive or imbalanced diet. Some of them (i.e. cardiovascular diseases, cancer and diabetes) have already been dealt with in this Report (see section 5.2, 5.3 and 5.4), whereas obesity, overweight and the remaining ones are examined here.


Overweight, pre-obesity and obesity are associated with excessive food consumption and with the intake of excessive (as compared to physiological needs) energy-dense food (i.e. food containing large amounts of saturated fats and free sugars), often cheaper than good quality food. The prevalence of overweight and obesity is also growing rapidly in many European countries for both women and men. According to WHO estimates, excessive body weight, derived from excessive food consumption and inadequate physical activity, is responsible for more than 1 million life-years of ill health every year in the WHO Europe region.


Excess body weight associated to excess energy intake poses one of the most serious public health challenges for the 21st century in particular parts of the world, including the Member States of the European Union (EU) (Commission of the European Communities, 2005; WHO, 2000). A body mass index (BMI) above the optimum level of 21 kg/m2 is among the five global disease burden risk factors closely related to diet and physical activity; these are high blood pressure, high blood cholesterol level, high BMI, low fruit and vegetable intake and physical inactivity (James et al, 2004; WHO, 2002; WHO Regional Office for Europe, 2005).


Lifestyle factors, including eating habits and levels of physical activity/inactivity are often adopted during the early years of life. Childhood obesity is an important predictor of obesity in adulthood (Branca et al, 2007a; Branca et al, 2007b), and the best time to address the problem is early in life. Moreover, a systematic review shows that childhood obesity is strongly associated with risk factors for cardiovascular disease and diabetes, orthopaedic problems and mental disorders. A high BMI in adolescence predicts elevated adult mortality rates and cardiovascular disease, even if the excess body weight is lost. Many obesity-related health conditions once thought to be applicable only to adults are now being seen among children and with increasing frequency (Dietz, 1998). There is a true epidemic of overweight that is progressing in the WHO European region(53, Member States) among children and adolescents. It is predicted that about 38% of school-age children will be overweight by 2010 and that more than a quarter of these children will be obese.



Apart from the health consequences, overweight and obesity also impose an economic burden on society through increased medical costs to treat the diseases associated with it (direct costs); lost of productivity due to absenteeism and premature death (indirect costs); missed opportunities, psychological problems and poorer quality of life (intangible costs) (Branca et al, 2007a; Branca et al, 2007b). It is estimated that in the EU, obesity accounts for up to 7% of health care costs and this amount will further increase given the rising obesity trends (Commission of the European Communities, 2005). In 2002, the total direct and indirect annual costs of obesity in the EU15 (EU members before 2004) were estimated to be €32.8 billion per year (Fry and Finley, 2005). The WHO Regional Office for Europe prepared a compilation of direct cost studies worldwide including those carried out in the EU (Branca et al, 2007a; Branca et al, 2007b): health expenditure per inhabitant attributable to obesity ranges between US$ 17 (Germany, 2001) and US$ 202 (France, 1992).


In spite of the excessive food consumptions occurring in very large population groups throughout Europe, some nutrients ( e.g. folate, calcium, iodine and iron and specific vitamins) are not ingested in sufficient quantities by specific population groups, thus originating disease such as neural defects, osteoporosis, goiter , anaemia and hypovitaminoses, respectively. Prevalence of these diseases is particularly significant in certain risk groups among elderly, children, pregnant and lactating women. Data sources


a) Overweight and obesity and other diseases related to nutritional unbalances


The present review builds upon the compilation of studies on the prevalence of overweight and obesity among children, adolescents and adults, which was prepared for the WHO European Ministerial Conference on Counteracting Obesity (15-17 November 2006, Istanbul, Turkey) (Branca et al, 2007a; Branca et al, 2007b). To reflect the current situation in EU27, nationally representative prevalence data collected in 2000 and onwards were included only.


For all 27 EU Member States, national studies on the prevalence of overweight and/or obesity either among children, adolescents or adults were identified. The data for the United Kingdom (UK) were based on data representing separately England (Department of Health, 2006; Jotangia et al, 2005), Scotland (Bromley et al, 2005a; Bromley et al, 2005b) and Wales (Dolman et al, 2007). Only 1021, 1022 and 423 countries used measured weight and height for monitoring at the national level the nutritional status of children, adolescents and adults, respectively (“Alfred RusescuInstitute for Mother and Child Care, 2003; Antal et al, 2004; Aranceta-Bartrina et al, 2005; Aromaa and Koskinen, 2004Direction of Health, 2004; do Carmo et al, 2006; Gutiérrez-Fisac et al, 2004; Kapantais et al, 2004; Kirchengast et al, 2004; Kobzová et al, 2004; Lobstein and Frelut, 2003; National Public Health Authority, 2004; Novakova, 2006; ONeill et al, 2007; Padez et al, 2004; Rolland-Cachera et al, 2002; Savva et al, 2002; Savva et al, 2005; Serra Majem et al, 2003; Szponar et al, 2003; Whelton et al, 2007). Self- or parental-reported anthropometric data were collected in a national sample of children by three countries (Belgium, Netherlands Sweden) (Bayingana et al, 2006; Becker and Enghardt-Barbieri, 2004; Statistics Netherlands, 2006). These three countries as well as Finland also carried out national surveys in adolescents (Bayingana et al, 2006; Becker and Enghardt-Barbieri, 2004; Kautiainen, 2005; Statistics Netherlands, 2006).


The Pro Children study collected in 2003 parental reports of 11-year-old children from nationally representative schools in seven countries, and sub-national sample in another two (Belgium and Austria) (Yngve, 2005). The HBSC study conducted in 20012002 gathered self-reported data on weight and height in 11-, 13- and 15-year-old adolescents in 22 countries of the EU27 (Currie et al, 2004).


Data on self-reported height and weight as a basis for reports on prevalence of overweight and obesity among adults were available from 2324 countries (Asciak et al, 2003; Bayingana et al, 2006; Boström, 2007; Devriese et al, 2006; Ekholm et al, 2006; Federal Statistical Office, 2006; Gallus et al, 2006; Grabauskas et al, 2007; Helakorpi et al, 2007; lInstitut Roche de lObésité, 2006; Institute of Health Information and Statistics, 2004; Kapantais et al, 2006; Kelleher et al 2003; Ministry of Health and Consumption and Institute of National Statistics, 2007; National Institute for Health Development, 2007; Pudule et al, 2005; Rodler et al, 2005; Statistical Office of the European Communities, 2005a; Statistical Office of the European Communities, 2005b; Statistical Office of the European Communities, 2005c; Statistical Office of the European Communities, 2005d; Statistics Austria, 2007; Statistics Netherlands, 2007; Zaletel-Kragelj et al, 2004).


Trend data included all identified survey years when they were comparable regarding data collection methodology and age range of the subjects. The annual change in the prevalence was estimated by taking the difference between the earliest and the latest prevalence figure divided by the number of years between the 2 survey points. If both measured and self-reported data for a certain population group in a country were identified, this review only presents the objective data based on measured weight and height; self-reported data are given in the absence of measured data.


In adults, overweight and obesity are defined as a BMI25 kg/m2 and a BMI30 kg/m2, respectively; pre-obese is used to define adults with a BMI of 25.0-29.9 kg/m2 (WHO, 2000). For children and adolescents, there are various different approaches to defining overweight and obesity (Lobstein et al, 2004). This review uses the definition based on the percentile values of BMI adjusted for age and gender that correspond to BMI of 25 and 30 kg/m2 at age 18 years (Cole et al, 2000).


Data were categorized (where possible) into the following age groups; children aged 0-9 years; adolescents aged 10-19 years and adults aged 20 years and above.


Limitations of current prevalence data


The majority of the countries used self-reported weight and height to monitor the nutritional status in their population. A large number of studies have documented, however, that self-reporting tends to underestimate the actual weight, especially in overweight or obese people, while height tends mainly to be overestimated (Engstrom et al, 2003; Niedhammer et al, 2000; Paccaud et al, 2001; Visscher et al, 2006), although an underestimation of height has also been noted (Visscher et al, 2006). Moreover, socioeconomic differences in the validity of self-reports have been identified (Bostrom and Diderichsen, 1997; Niedhammer et al, 2000). A validation study conducted in Wales among adolescents, in the context of the HBSC survey, indicated that self-reported measurements underestimate the true prevalence of overweight by about a quarter and the prevalence of obesity by about a third (Elgar et al, 2005). These self-reporting biases can lead to changes in the distribution of BMI data, as well as to a misclassification of overweight and obese individuals.


Making comparisons between countries was difficult, due to their use of different data collection methods, response rates, age ranges, years of collection and definitions of overweight and obesity. Various investigators (Branca et al, 2007a; Branca et al, 2007b; James et al, 2004; WHO, 2000) have encountered the same difficulties in attempting earlier comparisons.  As for other diseases related to nutritional unbalances, data sources are specific reports listed under references.


b) Food consumption and dietary Patterns


For a detailed evaluation of dietary intake in Europe, there is a need for increasing the compatibility of sampling designs, dietary methods and selected population descriptors. In contrast to national surveys, European surveys can be used for comparisons of dietary intake data between countries, provided that the methods used to collect dietary intake data and food composition tables are comparable.

There are currently no Community requirements with regard to the collection of food consumption data at individual level. However, national dietary surveys are carried out in many European countries and provide valuable information for use in national policy and are central in nutritional surveillance; when they are repeated in a proper  way, trends over time  can be studied. Frequency of such surveys vary between every two(Finland) to seven years(Switzerland). An example is the recently completed German survey involving more than 20,000 people. However, food consumption data obtained  a national level can often not be compared directly. In addition to the national surveys, food consumption data are also  collected in sub-groups of population exploring specific  issues, like:


·          A food survey in a sample of Italian secondary school students (Leclerq et al, 2004) and

·          A survey in Bulgaria of school children’s eating habits.


To overcome this, the European Food Safety Authority (EFSA) is developing a concise European food consumption database with 15 broad food categories and 21 subcategories. In order to build the database, EFSA has established a European Network of Food Consumption Database Managers. The Network is composed of 31 members, each representing a European country and responsible for coordinating the collection, formatting and transfer of the most recent and relevant national food consumption data to EFSA. This database is intended for use as a screening tool for preliminary exposure assessments by the EFSA Scientific Panels and Member States. At the present time, the concise database is planned to contain food consumption data only for the adult population (16-64 years old). In the medium term, it is intended to include consumption data for children, and will be gradually transformed into a more comprehensive database with more specific food categories. The “concise food consumption database” is currently under development; EFSA is aiming at having a complete database, including all available data from Network members, by June 2008..

Preliminary information on the national food consumption surveys of each European country represented in the EFSA European Network of Food Consumption Database Managers is reported in Table


Table Preliminary information on national food consumption surveys of the European countries represented in the EFSA European Network of Food Consumption Database Managers.




Survey name



Subjects (number)

Age range


Days (number)



Data available - details not provided









Belgian National Food Consumption Survey





24-hour recall


General information at


National Survey of Food Intake and Nutritional Status





24-hour recall




Data not available









Data not available








Czech Republic

Individual food consumption study


2003 - 2004



24-hour recall


General information at:


The Danish national survey of dietary habits and physical activity




4 - >75

Individual dietary record


General information at:


Estonian Adult Nutrition Survey





24-hour recall


General information at:


The National FINDIET 2002 Study





24-hour recall


General information at:


Individuelle et Nationale sur les Consommations Alimentaires





Individual dietary record


Volatier J.L. Enquête INCA Individuelle et Nationale sur les Consommations Alimentaires. Tec & Doc Lavoisier ed. Paris 2000


German Nutrition Survey







Mensink G B M (2004) Food and nutrient intake in European Journal of Clinical Nutrition 58, 1000-1010


Data not available









Hungarian National Dietary Survey 2003-2004





Individual dietary record


General information at:


The Diet of Icelanders 2002





24-hour recall


The Diet of Icelanders, Dietary Survey of The Icelandic Nutrition Council 2002 Main findings. Steingrímsdóttir, L, Þorgeirsdóttir H, Ólafsdóttir AS


North South Ireland Food Consumption Survey (NSIFCS)





Individual dietary record


Refer to for further information on this survey


Istituto Nazionale della Nutrizione - Consumi Alimentari





Individual dietary record


Turrini A, Saba A, Perrone D, Cialfa E, D'Amicis A (2001): Food consumption patterns in Italy: the INN-CA Study 1994-1996. EurJClin. Nutr. 55 (7), 571-88.


Data not available









Estonian Adult Nutrition Survey





24-hour recall


General information at:


Data not available - not yet represented in the Network









Data not available - not yet represented in the Network









Norvegian national dietary survey among adults





Food Frequency Questionnaire




Household Food Consumption and Anthropometric Survey in Poland





24-hour recall


Szponar L., Sekula W., Nelson M., Weisell R.C.: The Household Food Consumption and Anthropometric Survey in Poland. Public Health Nutr., 2001, 4, 5(B), p. 1183-1186