10.2. Individual characteristics
According to the WHO Report on the Global Tobacco Epidemic
2008, 100 million people worldwide were killed by the tobacco epidemic in the 20th
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
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 risk 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
As shown in Figure 10.2.1.1.1,
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 10.2.1.1.1 and 10.2.1.2.
Figure 10.2.1.1.1. Tobacco as a risk
factor for several world leading causes of death.
10.2.1.1.1. Diseases caused by smoking and by second-hand
(2004); CDC (2006)
caused by smoking
caused by second-hand smoke
Middle ear disease
Nasal sinus cancer*
Trachea, bronchus or lung
Respiratory symptoms, impaired lung
Acute myeloid leukemia
Coronary heart disease
Coronary heart disease
Sudden infant death syndrome (SIDS)
Atheroschlerotic peripheral vascular
Kidney and ureter
COPD, asthma and other respiratory
Lower respiratory illness
COPD*, chronic respiratory symptoms*,
asthma*, impaired lung function*
Reproductive effects in women: low birth
Reproductive effects in women (including
Reproductive effects in women: pre-term
For the diseases caused by second-hand
smoke: Evidence of causation is sufficient, or, where marked with an
Sources: ASPECT, 2004 and ASH)
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
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
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.
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
Figures 10.2.1.1.2. 10.2.1.1.3. illustrate the trends in
smoking prevalence among European men and women between 1990 and 2006.
10.2.1.1.2. Regular daily smokers in the male population aged 15+
10.2.1.1.3. Regular daily smokers in the female population aged 15+
More men than women are dying from smoking attributable
diseases in all EU countries (Figure 10.2.1.1.4.).
Percentage of all deaths attributable to smoking in 2000
The proportion of deaths attributed to smoking is
presented in Table 10.2.1.1.3., for the main categories of diseases for the
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
Overall, the proportion of smoking attributable deaths
among women is still rising, while male mortality peaked in the 1980s, as shown
in Figure 10.2.1.1.5. 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.
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 10.2.1.1.6).
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
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
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,
In 1990–1994, 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
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,
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).
The economic burden of smoking probably exceeds 1% of GDP
in Europe. The impact of tobacco morbidity and mortality on the society can be
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
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,
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 “kick” caused 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,
Nicotine has several effects on the brain. The activation
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 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
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,
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,
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
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
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 interventions – tobacco control in the EU
Collective interventions geared towards the reduction of
tobacco related harm can be categorized as follows:
to reduce the demand for tobacco products (price, taxation);
to reduce exposure to environmental tobacco smoke (smoking
bans in public places);
to limit tobacco industry advertising, promotion and sponsorship;
to raise awareness about the addictive nature and health hazards of tobacco
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:
measures, based on the Community Treaties as well as more specific, secondary
for Europe-wide and cross-national smoking prevention and cessation activities,
financed via action programmes and the Community Tobacco Fund;
of tobacco control into a range of other Community policies; and
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
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:
advertising and sponsorship of tobacco products;
structure and rates of excise duty applied on manufactured tobacco;
manufacture, presentation and sale of tobacco products;
broadcasting, banning the advertising of tobacco products; and
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 States’ governments 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
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.
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 tobacco,
supported 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
packaging and labeling
of tobacco products, requiring large health warning labels and prohibiting the
use of deceptive labels such as "light", "low tar", and
communication, training and public awareness;
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
measures concerning tobacco dependence and cessation.
The FCTC also supports measures to reduce the supply of
tobacco. These include:
1. illicit trade in tobacco
2. sales to and by minors,
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
participation of NGOs in the development of national tobacco control
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
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 Epidemic” showing 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
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
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-die” approach)
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 classical
“quit or die” approach 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
effect – snuff users may later become smokers - an argument which has not been
and Gilmore, 2007; ENSP, 2003). The Swedish experience is limited to its male
population – female 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
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 10.2.1.1.4. Selected EUGLOREH countries and total TCS score in
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:
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.
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.
warnings on the two main sides of tobacco product packages should be mandatory
for all EU countries.
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.
Action on smoking and health (ASH) (2007): Stopping
smoking: the benefits and aids to quitting; ash.essential information on.
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European Commission (2007): SCENHIR – Health Effects of
Smokeless Tobacco Products, Preliminary Report. European Commission, 2007.
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European Network for Smoking Prevention (ENSP) (2003):
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Antó JM, Cerveri I, Kerhof M, Leynaert B, Luczynska C, Neukirch F, Vermeire P,
Wjst M and Burney P (2006): Changes in active and passive smoking in the
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WHO-HFA. WHO - Health For All
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
10.2.1.2.2. Data sources
The main information sources derived from Anderson &
Baumberg (2006) are:.
country profiles provided by the members of the Alcohol Policy Network (APN),
co-financed by the European Commission
Comparative Alcohol Study (ECAS) reports (2001-2)
World Health Organization (WHO)
Risk Assessment Study, carried out within the Global Burden of Disease (GBD)
Interventions that are Cost-Effective project (CHOICE)
Status Report on Alcohol
Status Report on Alcohol Policies
Health for All Database
Alcohol Control Database
Global Alcohol Database
International comparative surveys
Schools Project on Alcohol and Other Drugs (ESPAD; part-financed by Council of
Behaviour in School-aged Children (HBSC; WHO-EURO)
Food and Agriculture Organization
division (FAOSTAT) database
Organisation for Economic Co-operation and Development
Handbook of Alcohol Problems and Dependence
description and analysis
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
10.2.1.2.1). 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.
Trends in recorded alcohol consumption in population aged ≥15 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 10.2.1.2.1. 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.
Frequency of having had five or more drinks in a single occasion during
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
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
Each year in the European Union, it has
been estimated that alcohol is related to:
homicides (4 in 10 of all murders)
deaths from road traffic accidents (1 in 3 of all road traffic fatalities), including 10,000 deaths of people other than the drink-driver
suicides (1 in 6 of all suicides)
16% of all
child abuse / neglect
children living in families adversely affected by alcohol.
Change in death rates, by cause, from a 1 litre increase in per capita alcohol
As can be seen in Table 10.2.1.2.2, 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 10.2.1.2.2).
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
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
It has been estimated that each year in the
European Union, alcohol causes:
deaths from liver cirrhosis
cancer deaths, of which 11,000 are female breast cancer deaths
deaths due to neuropsychiatric conditions
episodes of depression.
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
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 10.2.1.2.4. 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 10.2.1.2.4. 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 10.2.2.5) accounts for €66bn,
while potential production not realised due to absenteeism, unemployment and
premature mortality accounts for a further €59bn.
Figure 10.2.1.2.5. The tangible cost of
alcohol in Europe per cost element (year 2003)
10.2.1.2.4. 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 contributing €8.9bn 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
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 10.2.1.2.6). 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.
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). SSaturday opening of government alcohol stores was
re-instituted, there was a 3.6% increase in alcohol sales (Norstrom and Skog
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).
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
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
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.
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
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
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,
European alcohol and health forum, 2007
Projects funded under the Public Health
PHEPA: Primary Health Care European Project
EUROCARE – Alcohol Policy Network in the Context of a
Larger Europe: Bridging the Gap
ELSA – Enforcement 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
DG SANCO pages on Alcohol
Anderson P, Baumberg B (2006): Alcohol in Europe: A Public Health
- Report to the European Commission. London: Institute of Alcohol Studies.
Anderson P, (2007): Commercial Communications and
Utrecht: National Foundation for Alcohol
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
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
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.
http://ec.europa.eu/health/ph_determinants/life_style/alcohol/documents/ebs272_en.pdf. Accessed June 2007.
European Court of Justice (ECJ) (2004): C-262/02 and
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: http://guidance.nice.org.uk/page.aspx?o=427775
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
2007, Issue 2. Art. No.: CD004148. DOI: 10.1002/14651858.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]
and substance misuse1
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
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 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
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 10.2.3.1.
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.
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 10.2.3.1). An
increase in the lifetime prevalence of the use of other drugs has also
10.2.1.3.1. Lifetime prevalence of cannabis among 15-16y-old students
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
10.2.3.2) and over 7% (1.5–15.5%) 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%.
10.2.1.3.2. 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 15–34 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 10.2.1.3.3 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 10.2.1.3.3. 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.
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 countries’
estimates 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 1.5–5.3 cases 1 000
inhabitants aged 15–64, 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 15–64.
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 10.2.1.3.2).
– Problem 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 15–64. From the limited data available, an average annual
prevalence of POUs of between four and five cases per 1 000 of the
population aged 15–64 can be derived. This translates into some 1.5 million
(1.3–1.7 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
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 15–64 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 (0.9 – 1.3
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.
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.
HIV prevalence among IDUs shows considerable variation in
the EU (Figure 10.2.3.4), 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 2001–2002. 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 10.2.1.3.4. HIV prevalence among injecting
drug users – studies 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 10.2.1.3.5).
Figure 10.2.1.3.5. AIDS incidence per year of
diagnosis in EU Countries*, summary of years from 1996 to 2005, by transmission
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 10.2.1.3.6 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 10.2.1.3.6. 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
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
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
10.2.3.7 shows the trend in drug-related deaths in the EU15.
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
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
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 10.2.3.8). 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 1999–2005 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.
Control tools and policies
The European Union has developed a specific project on
the information exchange, risk-assessment and control of new psychoactive
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
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.
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
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. Poly–drug 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
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.
Bargagli et al. (2002) ‘Mortality among problem drug users in Europe: a
project of the European Monitoring Centre for Drugs and Drug Addiction
Addiction and Related Clinical Problems 4: 5–12.
Darke S, Kaye S (2004) Non-fatal cocaine overdoses among injecting
and non-injecting cocaine users in Sydney, Australia. Addiction, 99: 1315-1322.
Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Annual report.
Available at: http://www.emcdda.europa.eu/html.cfm/index42161EN.html
Opioid use and drug injection http://www.emcdda.europa.eu/html.cfm/index41527EN.html
(2006): Select issue on Drug Use In Recreational Settings. Annual report 2006.
Available at: http://annualreport.emcdda.europa.eu
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
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.
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
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 factors – e.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
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 brought – i.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
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.
10.2.1.5.2. 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
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:
of kindergartens where a preventive oral health program in which particularly
supervised tooth brushing with fluoride containing toothpaste takes place.
of schools with based oral health promotion programmes in
which daily supervised tooth brushing with fluoride containing toothpaste takes
of 12-year-old children according to dental fluorosis (Dean’s index). .
of daily intake of food and drink
of children and adolescents and adults who are using tobacco at a point in
10.2.1.5.3. 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 10.2.1.5.1 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).
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 10.2.5.1) 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; O’Mullane 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 al, 2003; 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
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
prevention” urges 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 factors – e.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
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 term ‘risk factor’ does have a negative connotation, but ideally ‘risk
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.
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
Quintessence Publishing Co., 2004:81–92.
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: [http://www.egohid.eu]
(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 (
Council of European Dentists’ (CED) (2007): Council of
European Dentists’ position paper “Responses to the European Commission’s
discussion paper for a health strategy”. CED, Bruxelles, Belgium. Available at:
[http://www.eudental.eu/ 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;
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
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.
O’Mullane 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
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Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S,
N’Diaye 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:
WHO (2007). Resolution WHA60.17 “Oral health: action plan
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(document eleven) Oral health promotion: an essential
element of a health-promoting school. WHO, Geneva, Switzerland.
World Health Organization. Fluorides and Oral Health. WHO
Technical Report Series 846. Geneva: World Health Organization; 1994.
Inadequate physical activity
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).
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 “multidomain” instruments 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.
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:
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).
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
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).
- 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
The quality of currently available data on physical
(in)activity is affected by a number of aspects:
a) Definition of physical
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
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
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.
10.2.1.6.3. 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 10.2.6.1). 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 10.2.1.6.1. Proportion of adults
(aged 15 years of over) in EU countries classified as sufficiently active, 2002
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.
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 10.2.1.6.3. 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.
10.2.1.6.4. 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,
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 section ”5.13. 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, two
“twin” booklets 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 (http://www.euro.who.int/moveforhealth). 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
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
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 (http://www.euro.who.int/healthy-cities).
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
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
10.2.1.6.5. 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.
Bauman A and Miller Y (2004): The public
health potential of health enhancing physical activity. In:
Oja P, Borms J., eds. Health-enhancing physical activity.
International Council of Sport Science and Physical Education.
Brettschneider WD, Naul R (2004): Study on young
people’s lifestyles and sedentariness and the role of sport in the context of
education and as a means of restoring the balance. Paderborn, University of
Paderborn, 2004 (http://europa.eu.int/comm/sport/documents/lotpaderborn.pdf, accessed 11 April 2007).
Caspersen CJ, Powell KE, Christensen GM. Physical
activity, exercise, and physical fitness: definitions and
distinctions for health-related research. Public Health Reports, 1985,
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 [http://ec.europa.eu/public_opinion/archives/ebs/ebs_183_6_en.pdf] (on-line publication, accessed 6 June
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):100–104.
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
European Commission (2005a): EU platform on diet, physical
activity and health. Brussels, European Commission,
Directorate-General for Health and Consumer Protection. [http://ec.europa.eu/health/ph_determinants/life_style/nutrition/documents/eu_platform_en.pdf]
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. [http://ec.europa.eu/health/ph_determinants/life_style/nutrition/documents/nutrition_wp_en.pdf].
European Commission (2007b): GREEN PAPER “Towards a new culture for urban
mobility” Directorate General Transport and Energy. Brussels, COM(2007) 551 final. [http://ec.europa.eu/transport/clean/green_paper_urban_transport/doc/2007_09_25_gp_urban_mobility_en.pdf]
European Commission (2007c): WHITE PAPER ON
SPORT. Directorate General Education and Culture, Brussels.
COM(2007) 391 final [http://ec.europa.eu/sport/whitepaper/wp_on_sport_en.pdf]
European Commission (2007d): COMMISSION
STAFF WORKING DOCUMENT ACTION PLAN "PIERRE DE COUBERTIN"
Accompanying document to the WHITE PAPER ON
SPORT. Directorate General Education and Culture, Brussels. SEC(2007) 934. [http://ec.europa.eu/sport/whitepaper/sec934_en.pdf].
Evans J, Roberts G (1987): Physical competence and the
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Excessive food intake and imbalanced diet
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,
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
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.
a) Overweight and obesity and other diseases related to
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
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 Rusescu”
Institute 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; O’Neill 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 2001–2002 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;
l’Institut Roche de l’Obésité, 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,
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 BMI
≥25 kg/m2 and a BMI ≥30 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
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
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 10.2.1.7.0.
Table 10.2.1.7.0 Preliminary
information on national food consumption surveys of the European countries
represented in the EFSA European Network of Food Consumption Database Managers.
available - details not provided
National Food Consumption Survey
information at www.iph.fgov.be
Survey of Food Intake and Nutritional Status
food consumption study
2003 - 2004
information at: www.chprszu.cz
Danish national survey of dietary habits and physical activity
4 - >75
information at: www.dfvf.dk
Adult Nutrition Survey
information at: www.lshtm.ac.uk
National FINDIET 2002 Study
information at: www.ktl.fi
et Nationale sur les Consommations Alimentaires
J.L. Enquête INCA Individuelle et Nationale sur les Consommations
Alimentaires. Tec & Doc Lavoisier ed. Paris 2000
G B M et.al. (2004) Food and nutrient intake in European Journal of Clinical
Nutrition 58, 1000-1010
National Dietary Survey 2003-2004
information at: http://lib.bioinfo.pl/pmid:16184880
Diet of Icelanders 2002
Diet of Icelanders, Dietary Survey of The Icelandic Nutrition Council 2002
Main findings. Steingrímsdóttir, L, Þorgeirsdóttir H, Ólafsdóttir AS
South Ireland Food Consumption Survey (NSIFCS)
to www.iuna.net for further information on this survey
Nazionale della Nutrizione - Consumi Alimentari
A, Saba A, Perrone D, Cialfa E, D'Amicis A (2001): Food consumption patterns
in Italy: the INN-CA Study 1994-1996. Eur. J. Clin. Nutr. 55 (7), 571-88.
Adult Nutrition Survey
information at: www.lshtm.ac.uk
not available - not yet represented in the Network
not available - not yet represented in the Network
national dietary survey among adults
Food Consumption and Anthropometric Survey in Poland
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.