tobacco control in southern europe · italy & austria before and after study •nicotine...

Tobacco Control in

Southern Europe

Giuseppe Gorini

[email protected]

mailto:[email protected]

Presentation plan

• The impact of the smoking ban in Italy (2005)

• Smoking bans in Spain (2006, 2011)

• Smoking bans in Greece (2009, 2010, 2011)

• Implementation of the WHO-FCTC in Italy

The smoking ban

(article 51- Law 3/2003)

entered into force

on 10th January 2005

Italy

The Italian smoking ban is not classified as a 100% smoke-free law, but it works

as it was. Why?

Smoking room: with a size less than half of the size of the whole premise, closed by automatic sliding doors, with a negative pressure of at least 5 Pascal, provided by very powerful forced ventilation (flow rate of ≥30 litres per second per person, considering a crowding rate of 0.7 persons per square meter)

Actually, <1% of hospitality venues reported to have built smoking rooms, because of the high cost due to the tight standards on air quality.

Gorini G, et al. Ann Oncol, 2007

A long legislative process

Positive key-points in the history of the Italian smoking ban:

the leadership of two consecutive Health Ministers, both physicians, who introduced the bill four times between 2000-2002;

the troian horse strategy: repeated presentations and final approval of the bill as an amendment within a framework bill on public administration. This strategy enabled timely approval of the ban;

the stringent air quality standards in the 2003 regulation that made building smoking rooms impracticable and prohibitively expensive.

[Gorini, Ann Ist Sup Sanità, 2011]

Limiting factors in the legislative

process • the 6-month delay in approving the

regulation on smoking rooms;

• the 1.5-year delay in approving the regulation establishing owners’ responsibility for enforcing the ban in hospitality premises

• the legal action in August 2005 which shifted responsibility for enforcement from owners of hospitality premises to police.

Press review,1998-2008, 50 Italian newspapers Key-words: smoking, cigarette, surname of Ministers of Health in

charge

106

62

147

91 92

188

33

5 827

49

0

20

40

60

80

100

120

140

160

180

200

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

anno

N. art

ico

li p

ub

blicati

[Gorini,2011]

Press articles and debates in this

long period (2000-2004) succeeded in

“training” Italians to this radical change

The long legislative process of the bill and its related regulations (2000-2004), stimulated journalists to publish articles informing people about tobacco control issues, such as health gains of smoke-free bars, or of quitting smoking.

Impact in terms of:

1. Attitudes of Italians towards the smoking ban and its compliance

2. Drop of Second Hand Smoke (SHS) Exposure in hospitality premises

3. Health gains for hospitality workers

4. Cigarette Sales & smoking prevalence

5. Rates of hospital admission for acute myocardial infarction (AMI)

6. Economic Impact of the Smoking Ban in Hospitality Industry

Attitudes of Italians towards

the smoking ban and its compliance at

the very beginning -- 2005 DOXA Survey 90%: perception of

compliance with the smoking ban in bars & restaurants

-- 2005 Survey

amongst owners of 1,641 hospitality premises :

92% all customers complied with the ban

only 11% asked to some customers to stop smoking

% in favour of a

smoking ban

90%83%

75

80

85

90

95

2001 DOXA Survey 2005 DOXA Survey

Compliance with the Italian

smoking ban: an 8-year update

PASSI surveys, 2008-2012

• PASSI (Italian behavioural risk factor surveillance system) is an ongoing surveillance system from 2008 onwards, coordinated by the National Institute of Health and supported by the Ministry of Health.

• In 2008- 2012 187,865 people have been interviewed (about 37,000 persons per year).

• For the current analysis only areas participating in the entire 5-year period were considered (N = 176,236).

[Minardi, Int J Public Health, 2014]

Respondents (%) reporting the smoking ban was

fully/almost fully implemented

in hospitality premises, PASSI survey

75

85

95

2008 2009 2010 2011 2012

%

Italy Northern Center Southern & Islands


Respondents (%) reporting the smoking ban was

fully/almost fully implemented

in workplaces, PASSI survey

80

85

90

95

2008 2009 2010 2011 2012

%



Respondents (%) reporting 100% smoke-free homes,

PASSI survey

65

70

75

80

85

2008 2009 2010 2011 2012

%



Smoke-free homes by smoking habits

40

50

60

70

80

90

2008 2009 2010 2011 2012

%

Smoke-free Homes, Smokers Smoke-free homes, Non-smokers


Self-reported SHS exposure, 2010, Italy

Prevalence of SHS exposure was 10.2% in

public places, 15.6% at home and 17.9%

in cars, according to DOXA 2010 survey.

Among 15–24 years were 21.4% in public

places, 27.1% at home and 32.9% in cars.

By multivariate analysis, males, the young,

subjects from southern Italy and former

smokers were more frequently exposed.

[Martinez-Sanchez, Eur J Public Health, 2012]

Perception of the compliance with the ban

was consistent with inspections and site visits

• In 2005-2012, the Italian Police carried out

25,600 random inspections: 2.4% of the sites

were found people smoking and 4.0% had

inappropriate no-smoking signs.

• In 2010-2012 NHS inspections in 1,298 HPs,

693 workplaces, and 2,404 hospital areas in 9

Italian regions. People smoking cigarettes were

found in <2%.

[Ministry of Health, 2013]

Police inspections, 2002-2012

0

1000

2000

3000

4000

5000

6000

7000

2002 2004 2005 2007 2008 2009 2010 2011 2012

Fines for inappropriate no smoking signs

Fines for currently smoking clients

No fines


In 2002 inspections only in postal offices, hospitals, outpatient clinics, libraries,

Museums, airports. In 1975: ban in schools, cinemas, public transportations;

in 1995: ban in public offices

Trend in police fines, 2002-2012

28,5

16,9

1,5

10

31,8 2,8 2,2 3,6 2,9 2,5

5,23,63,9 3,5

5,64,7

3,3

0

5

10

15

20

25

30

2002 2004 2005 2007 2008 2009 2010 2011 2012

%

Fines for currently smoking clients

Fines for inappropriate no smoking signs


Fines (%) by type of venue, 2007-2012

0,3%

0,9%

2,9%

2,0%

0,9%

1,5%

3,9%

0,7%

2,7%

4,7%5,8%

5,7%

6,1%

2,3%

4,6%

4,9%

2,4%

1,2%

2,8%

1,1%Postal Offices

Airports

Train Stations

Schools and Universities

Outpatient departments

Indoor markets

Hospitals

Libraries & Museums

Restaurants, Pubs & Discos

Casinos, Bingos

% fines forinappropriate nosmoking signs

% fines for smokers


NHS Inspections, 2010-2012

Hospitals

N=2,404

rooms

Workplaces

N=693

(2,822 rooms)

Hospitality

premises

N=1,298

Smokers 2% 2% 1%

Ashtrays 2% 3% 5%

Butts 3% 2% 1%

Smoking smell 7% 5% 5%


carried out by food and work inspectors

of Local Health Authorities in 9 Italian Regions

Interviews to hospitality owners: North to South gradient

% owners reported that

customers complied with

the ban Regions


Impact in terms of:




4. Cigarette consumption & smoking prevalence



Nicotine: Tobacco-specific, sensitive

personal monitor or environmental monitor

flow rate: 2.4 mL/min

gas chromatography (GC/MS) in Barcelona Lab

mean values in the sampling period

detection limit: 0.01 µg/m3

Second-hand smoke exposure markers - 1

Drop of Nicotine concentration

(in µg/m3) in Hospitality Premises

immediately after the ban: 1. Florence: 4 Pubs, 3 Discos

Before the ban

(Nov-Dec 2004)

After the ban

(Feb-Mar 2005) Reduction

Mean 149.1 4.8 97%

Median 138.9 4.5

Range 33.0 - 276.5 1.7 - 8.7

[Gorini, J Occup Environ Med, 2005]

µg/m3

Italy & Austria Before and After Study

• Nicotine concentration before & after 2 years from the introduction of the Italian smoking ban in Italy (Experimental Country) & Austria (Control Country) in:

• 28 hospitality premises (HPs) in Florence,

Belluno and 19 HPs in Vienna with

measurements in 2002-2004 and in 2007 (post-

ban)

• Only post-ban measurements in 27 HPs in

other 3 Italian towns (Torino, Milano, Napoli)

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

Nicotine Nicotine

(N° of premises)

concentration

(median,

µg/m3)

concentration

(median,

µg/m3)

2.03 0.1

35.16 0.01

19.02 0.25

8.86 0.01

Bars (3) 6 7 0.003

Overall (28) 58 59 <0.001

Restaurants (10) 22 21 <0.001

Discos & Pubs (15) 30 31 <0.001

N°

samples

N°

samples

Before After

P-value the Italian smoking the Italian smoking

[Gorini, Indoor Air, 2008]

Results: Austria - 1

Nicotine Nicotine

(N° of premises)

concentration

(median,

in µg/m3)

concentration

(median,

in µg/m3)

2.53 2.57

24.31 28.24

49.6 31.43

11 15.76Overall (19) 46 47 0.681

Bars (4) 9 9 0.145

Discos & Pubs (6) 14 15 0.921

N°

samples

N°

samples

Restaurants (9) 23 23 0.965

Before After

P-value the Italian smoking the Italian smoking

Impact in terms of:



3. Health gains for hospitality workers 4. Cigarette consumption & smoking prevalence



Occupational exposure to SHS in Italy, 2001

[Mirabelli, Kauppinen, J Occup Environ Health 2005]

Lavori

manuali

139.550

(17%)Ristorazione

alberghi

375.000

(47%)Impiegati

292.000

(36%)

In Italy in 2001, 806,550 workers (3.7%) were exposed to SHS for >=75% working time

CAREX Study

Hospitality

workers

(47%)

Manual

workers

(17%)

Clerks

(36%)

[Eurobarometer, 2015]

5%

0 2 4 6 8 10 12

GreeceRomania

PolandMalta

CroatiaAustriaCyprusLatvia

Zcech Rep.Bulgaria

SpainGermanySloveniaLituaniaHungary

FranceEstonia

BelgiumSlovakiaPortugal

DenmarkItaly

UKNetherlandsLuxembourg

IrelandFinlandSweden

%

> 5 hrs/day

(-68%: 256,000 workers)

5%

1%

Urine cotinine in hospitality workers

in Rome before & after 1 year from the

introduction of the law Valente, Tob Control 2007 73% reduction (from 17.8 to 4.9 ng/ml)

[Valente, tob Control, 2007]

Health gains in hospitality

workers: quitting smoking

24%

61%

15%

0 20 40 60 80

smoke the same cig/day

smoke fewer cig/day

quitted smoking

Survey among 1,641 hospitality owners, Italy, 2005

Galeone, Health Minister, 2006

Impact in terms of:







0

20

40

60

80

100

120

1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015

Mil

lio

n o

f k

ilo

s /

%

Legal cigarette sales (millions of kilos) prevalence, men (DOXA survey)

prevalence, women (DOXA survey) prevalence, men (ISTAT survey)

prevalence, women (ISTAT survey)

Tobacco consumption & smoking

prevalence in Italy, 1960-2015

2004-2014: from 29.7% to 24.5% in men (-17%)

from 16.8% to 14.8% in women (-12%)

from 22.9% to 19.5% overall (-15%)

2004-2014: Cigarettes -24%

Impact in terms of:







Reduction of hospital admissions

for AMI, Italy, 2005-2006

• 4% reduction in whole Italy

• In particular, in people <70 years and in low

socio-economic areas (-15%)

• SHS is a trigger factor for AMI, as anger

episodes, exposure to traffic pollution,

intensive physical exercise.

[Barone-Adesi, 2006,2011; Galeone, 2007; Cesaroni, 2008; Richiardi, 2008; Gasparrini, 2009]

AMI hospital admissions, Italy

Introduction of statins: -2.7% mortality reduction for AMI, 1980-2000, Italy

Introduction of anti-hypertensive drugs: -1.7%

[Palmieri, Am J Public Health, 2010; Gorini Epidemiol Prev, 2010]

[Barone-Adesi,2011]

-4%

Acute effects of SHS exposure on cardio-

vascolar system

• Platelet activation

• Endothelial dysfunction

• Inflammation and infection

• Atherosclerosis (Low HDL levels, Plaque instability, Increased oxidized LDL)

• Increased oxidative stress

• Decreased energy metabolism

• Increased insulin resistance

• Increased infarct size

• Decreased heart rate variability

• Increased arterial stiffness

• Increased risk of coronary disease events

Prothrombotic states

[Barnoya & Glantz, 2005]

Economic impact on hospitality industry, Italy

No available studies

Survey on 1,600 hospitality owners in 2005:

• 55% reported no loss or a little increase in

income

• 12% reported a significant loss

The Italian Federation of hospitality industry

(FIPE) reported a significant loss in Casinos

and Bingos

Smoking ban extended in outdoor school

areas (playgrounds, parking)

• Entered into force in November 2013

• Low compliance: in 2014 less than half of high schools complied with the outdoor ban; in some schools, students started again to smoke in places where they no more smoked (toilets)

• Italians were not “trained” for this new restriction.

• No media campaign; no discussion in media or social network on this issue

Outdoor areas in pubs, bars, restaurants

Environmental nicotine concentration (3 settings):

8.28 µg/cubic meter

[Gorini, 2008]

PLoS ONE 2012;7(8): e42130. doi:10.1371/journal.pone.0042130

I would like to express my deep

sorrow over the passing away of 2

great EU researchers on SHS

exposure:

Manel Nebot, Barcelona, Spain

Giovanni Invernizzi, Milan, Italy

Nicotine measurements were higher in:

• Outdoor areas in HPs (high SHS

exposure levels)

• Outdoor areas close to the entrance of

“public” buildings (SHS enters buildings,

causing non-negligible exposures)

[Lopez, PlosOne, 2012]

Ecodiesel car vs. SHS: 1:10

[Invernizzi, Tob Control, 2004]

Diesel truck vs. SHS: 1:5

[De Marco, Multidiscip Respir Med, 2016]

The exhaust pipe of one truck powered by a diesel engine of about

13.000/14.000 cc3 was connected with a flexible hose to a hole in the window of

a container of 36 cubic meter. The truck operated idling for 8 min and then, after

adequate office ventilation, a smoker smoked two cigarettes.

Results

• The indoor air pollution generated by 2-3

cigarettes is 4-6 times higher than that

produced by a diesel truck, and 10 times

higher than that produced by an eco diesel

car.

[Invernizzi, Tob Control, 2004; De Marco, Multidiscip Respir Med, 2016]

Smoking ban in cars, Italy, 2016

In the transposition of the NTP Directive

entered into force in Italy on February 2,

2016, two articles not comprised in the

Directive have been added:

smoking ban in cars with children

smoking ban in outdoor areas around pediatric

and gynecologic departments in hospitals

Smoking bans in Spain

• 2006: banning smoking in all workplaces;

• HPs >100 sq.mt: smoking area

• HPs <100 sq.mt: choose whether to allow

smoking or not

• 2011: banning in all HPs

Failure of the “Spanish model”: nicotine

concentration after 2 years from the ban

implementation

• Levels of nicotine dropped in workplaces

(offices) from 0.21 (before) to 0.05 μg/cubic

mt (-60%)

• In bars/restaurants where smoking was

allowed nicotine concentration increased from

7.07 (before) to 10.12 μg/cubic mt (+40%)

• 400 repeated measurements before and after

6, 12, 24 months

[Lopez, Tob Control, 2011]

Hospitality workers in Spain

• HPs where smoking was totally banned:

salivary cotinine -56% (from 1.6 to 0.5 ng/ml)

-72% self-reported respiratory symptoms

• HPs with designated smoking areas:

salivary cotinine -28%

• HPs where smoking was allowed:

salivary cotinine -11%

[Fernandez, PlosOne, 2009]

Success of the 2011 ban in HPs

• Measurements of PM2.5, and nicotine in

178 HPs

• -90% decrease:

• Nicotine: from 5.73 to 0.57 μg/cubic mt

• PM2.5: from 233.38 to 18.82 μg/cubic mt

[Lopez, NTR, 2012]

Self-reported SHS exposure, Spain: cross-

sectional representative surveys

[Fernandez, NTR, 2016; Sureda, PlosOne, 2014]

0

20

40

60

80

2004-2005 2006 (post 1) 2011 (post 2)

Self

-rep

ort

ed

SH

S e

xp

o (

%)

Overall Work/education venues Leisure time Transportation/stations Home

-37%

-18%

-8%

-43%

-56%

-5%

-10% -69%

Change in smoking prevalence,

Spain, 2006-2011

• From 23.4% in 2006 to 20.7% in 2011

• -11.5% in 5 years

[Perez-Rios, PlosOne, 2015]

Mortality attributable to SHS exposure,

Spain 2002, 2011

• In 2002, 1228-3237 deaths from lung

cancer and ischaemic heart disease.

• In 2011, 1028 deaths (-50% on average)

[Lopez, Tob Control, 2007; Lopez, NTR, 2015]

Greece

Smoking bans in Greece

• 2009: a law based on the “Spanish model”

• September 2010: in HPs <300 sq. Mt

indoors + covered outdoor areas

• June 2011: in HPs >300 sq.mt.

• Skepticism in 2010 by the media because

the 2009 partial ban was ignored by the

public.

SHS exposure in HPs in Greece

• The PM2.5 concentration dropped from

2006 (pre-ban) the coming into force of the

2010 complete ban from 249 to 46

μg/cubic mt

• Thus, the complete ban led to a reduction

in SHS exposure.

• However, exposure was not eliminated

[Vardavas, 2012]

• Immediately

after the 2010

smoking ban,

-50%

• Subsequently,

increased

[Vardavas, PLosOne, 2013]

SHS exposure in HPs in Greece

2011 2010

Enforcement inadequate

• Population support may not be sufficient to

sustain smoke-free legislation if

enforcement is absent.

• Between wave 2 and 3 change in the

political leadership, less supportive of the

law. No enforcement

• Strong political leadership may be critical

in enforcing smoke-free legislation.

[Vardavas, PLosOne, 2013]

SHS exposure in bars in EU-28


SHS exposure in restaurants in EU-28


Self-reported SHS exp at work (%)

0 10 20 30 40 50 60

GreeceRomania

CyprusPolandAustria

ItalyCroatia

LituaniaZcech Rep.

MaltaBulgaria

LatviaHungary

EU28SlovakiaEstonia

PortugalFrance

SpainBelgium

GermanySlovenia

NetherlandsIreland

LuxembourgUK

DenmarkFinlandSweden

%

Occasionally

< 1 hr/day

1-5 hrs/day

> 5 hrs/day

2833

3721

33

161213

1213

109

6

3125

1724

11

7119

97

64

5

0 10 20 30 40 50 60

Greece

Romania

Poland

Austria

Italy

//

Portugal

France

Spain

Belgium

Germany

Netherlands

Ireland

UK

//

%

Occasionally

<1hr/day - >5 hrs/day

Status of the FCTC

implementation in Italy

Giuseppe Gorini

[email protected]

mailto:[email protected]

Legge 18 marzo 2008, n.75 (GU Serie Generale n.91 del 17-4-2008)

Ratifica ed esecuzione della Convenzione Quadro dell’Organizzazione

mondiale della sanità – OMS – per la lotta al tabagismo, fatta a

Ginevra il 21 maggio 2003.

Italy signed WHO-FCTC on June 20, 2003,

and ratified it on July 2, 2008

WHO FCTC CONTENTS • Core demand reduction provisions:

– Price and tax measures to reduce the demand for tobacco

(Art. 6);

– Non-price measures to reduce the demand for tobacco,

namely:

• Protection from exposure to tobacco smoke (Art. 8);

• Regulation of the contents of tobacco products (Art. 9);

• Regulation of tobacco product disclosures (Art. 10);

• Packaging and labelling of tobacco products (Art. 11);

• Education, communication, training and public

awareness (Art. 12);

• Tobacco advertising, promotion and sponsorship

(Art.13);

• Demand reduction measures concerning tobacco

dependence and cessation (Art.14).

WHO FCTC CONTENTS (cont.)

•The core supply reduction provisions:

– Illicit trade in tobacco products (Art. 15);

– Sales to and by minors (Art. 16);

– Provision of support for economically viable

alternative activities (Art. 17 & 18).

Simulation model Italy SimSmoke

• Entering into force in 2010 each new policy

with estimates of the impact in 2011-2030

in terms of:

• Decrease in smoking prevalence according

to a review of the effect of each policy

• Reduction of smoking-attributable deaths

Price (tax) increase: a simulation

25% increase in 2010-2011: from €5.0 to €6.3





In following years price should remain similar to

the 2015

Almost doubling the price

5

10

15

20

25

30

2010 2015 2020 2025 2030

Pre

vale

nza d

i fu

mo

(%

)

uomini, status quo

uomini, aumentoprogressivo delprezzodonne, status quo

donne, aumentoprogressivo delprezzo

Men, 2030: - 12% compared to status quo

Women, 2030: - 11%

Men, status quo

Men, increasing

price

Women, status

quo

Women,

increasing price

3

4

5

6

7

8

2010 2015 2020 2025 2030

nu

mero

di fu

mato

ri (

in m

ilio

ni)

uomini, status quo

Uomini, aumento

progressivo del

prezzo

donne, status quo

Donne, aumento

progressivo del

prezzo

Men, 2030: -723,000 smokers

Women, 2030:

-439,000 smokers

Men, status quo

Men, increasing

price

Women, status

quo

Women,

increasing price

0

10

20

30

40

50

60

70

2010 2015 2020 2025 2030

de

ce

ss

i a

ttri

bu

ibili a

fu

mo

(in

mig

lia

ia)

Uomini, status quo

Uomini, aumento

progressivo del

prezzo

Donne, status quo

Donne, aumento

progressivo del

prezzo

Men, 2011-30: -33,000

deaths

Women, 2011-30 : -4,000

deaths

Men, status quo

Men, increasing

price

Women, status

quo

Women,

increasing price

Evidence-based mass media

campaigns

Campaigns reduce smoking prevalence,

increase quit attempts and successful quitting

Messages with negative emotional contents,

are effective

Anti-tobacco Italian ads are too “politically

correct”

We need a change on contents of anti-tobacco

ads in Italy

[CDC, 2006; Durkin, 2012; Hammond, 2012]

Are you stupid? Smoking hurts, 2015

CDC TIPS from Former Smokers

Campaign, USA, 2012-2013

Hooked

5

10

15

20

25

30

2010 2015 2020 2025 2030

Pre

va

len

za

di

fum

o (

%)

Uomini, status quo

Uomini, campagnemediatiche bendiffuse Donne, status quo

Donne, campagnemediatiche bendiffuse

Men, 2030: - 8%

Women, 2030: - 8%

Men, status quo

Men, evidence-based

media campaigns

Women, status quo

Women, evidence-

based media

campaigns

Smoking cessation policies

Empowering the national quitline which actually

doesn’t follow callers during their quit attempts.

Quitline only passively receives the first call.

That’s all

More health professionals should deliver brief

advice (current: about 40%)

Empowering 350 NHS smoking cessation centers

(each treats only 100 smokers per year)

Reimbursement of therapy to quit

5

10

15

20

25

30

2010 2015 2020 2025 2030

Pre

va

len

za

di

fum

o (

%)

Uomini, status quo

Uomini, politichepromuoventi lacessazioneDonne, status quo

Donne, politichepromuoventi lacessazione

Men, 2030: - 6%

Women, 2030: - 6%

Men, status quo

Men, empowering

smoking cessation

Women, status quo

Women, empowering

smoking cessation

0

10

20

30

40

50

60

70

2010 2015 2020 2025 2030

de

ce

ss

i a

ttri

bu

ibili a

fu

mo

(in

mig

lia

ia)

Uomini, status quo

Uomini, politiche

promuoventi la

cessazione

Donne, status quo

Donne, politiche

promuoventi la

cessazione

Men, status quo

Men, empowering

smoking cessation

Women, status quo

Women, empowering

smoking cessation

Men 2011-30: - 18,000 deaths

compared to status quo

Women 2011-30 :

-7,000 deaths

Internet-based interventions for smoking

cessation (Cochrane)

• They are effective

• RR=1.48 (95%CI:1.11-2.78)

Civljak M, Stead LF, Hartmann-Boyce J, Sheikh A, Car J.

Internet-based interventions for smoking cessation.

Cochrane Database Syst Rev. 2013 Jul 10;7:CD007078.

http://www.ncbi.nlm.nih.gov/pubmed/23839868










http://www.exsmokers.eu/lt-lt/index.html

Introduction of pictorial warnings in EU28: a

great occasion to re-launch tobacco control

Transposition of the NTP Directive 40/2014

entered into force in Italy on February 2016

Thanks to:

• Esteve Fernandez, Catalan Institue of

Oncology, Barcelona, Spain

• Maria Josè Lopez, Public Health Agency

of Barcelona, Spain

• Constantine Vardavas, Crete, Greece

Thank you

tobacco control in southern europe · italy & austria before and after study •nicotine...

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