European Country Survey Research Articles

Data‐driven dynamical analysis of an age‐structured model: A graph‐theoretic approach

The dynamics of the propagation and outspread of infectious diseases are eminently intricate, mainly due to the heterogeneity of the host individuals. In this paper, an age‐stratified SEIR (susceptible‐exposed‐infected‐recovered) epidemiological model incorporating saturated treatment function and heterogeneous contact rates is developed to study infectious disease transmission dynamics among various age groups. The expression for the basic reproduction number and conditions for the global stability of the system have been derived by a recently developed graph‐theoretic (GT) approach. Digraph reduction creates a GT version of the Gauss elimination method for computing the . The global dynamics results have been formed by constructing the Lyapunov function using a GT approach. The endemic equilibrium exists uniquely if , whereas the disease‐free equilibrium is observed to be globally stable if . The numerical simulations are demonstrated by extracting the daily reported COVID‐19 cases for the second wave in Italy. The age‐dependent contact matrix for the Republic of Italy (data sourced from the POLYMOD study) is computed via paper–diary methodology (PDM) grounded on a population‐prospective survey in European countries. Our numerical findings imply that (i) for the age group (20–49) years and (50–69) years, the number of infected persons is quite double as compared with the exposed cases; (ii) approximately 50% of positive cases lies in (20–69) years age group; (iii) for the (00–19) years age group, only half of the exposed individuals got infected; and (iv) a consistent graph is detected for the age group of (70–99) years in both cases; it shows that almost all the exposed got infected.

Changes in electronic cigarette use and label awareness among smokers before and after the European Tobacco Products Directive implementation in six European countries: findings from the EUREST-PLUS ITC Europe Surveys.

Article 20 of the European Tobacco Product Directive (TPD), which went into effect in May 2016, regulates electronic cigarettes (e-cigarettes) in the European Union (EU). The aim of this study was to evaluate changes in e-cigarette use, design attributes of the products used and awareness of e-cigarette labelling and packaging among smokers from six EU Member States (MS) before and after TPD implementation. Data come from Wave 1 (2016, pre-TPD) and Wave 2 (2018, post-TPD) of the ITC Six European Country Survey among a sample of smokers and recent quitters who use e-cigarettes from six EU MS. Weighted logistic generalized estimating equations regression models were estimated to test the change in binary outcomes between Waves 1 and 2 using SAS-callable SUDAAN. In 2018, current daily/weekly e-cigarette use among adult smokers was just over 2%, but this varied from the highest in Greece (4%) to lowest in Poland (1.2%). From Waves 1 to 2, there was a significant increase in respondents reporting noticing and reading health and product safety information on leaflets inside e-cigarette packaging (8.39-11.62%, P < 0.001). There were no significant changes between waves of respondents reporting noticing or reading warning labels on e-cigarette packages/vials. e-cigarette use among smokers in these six EU countries is low. Although reported noticing and reading leaflets included in the packaging of e-cigarettes increased significantly from before to after the TPD, there was no significant change in reported noticing and reading of warning labels. Findings indicate the importance of continued monitoring of TPD provisions around e-cigarettes.

Transitions in product use during the implementation of the European Tobacco Products Directive: cohort study findings from the EUREST-PLUS ITC Europe Surveys.

The emergence of new types of tobacco and tobacco-related products on the European Union (EU) market has precipitated the possibility for both poly-tobacco use and transitions between products. In the EU, the regulatory environment has shifted with the implementation of the European Tobacco Products Directive (TPD) in May 2016, which may influence consumer transitions between products. The aim of this paper was to examine trends and transitions in tobacco products from 2016 to 2018 -before and after implementation of the TPD in the EU. Data come from Wave 1 (pre-TPD) and Wave 2 (post-TPD) of the EUREST-PLUS ITC Six European Country Survey, a cohort study of adults who at the time of recruitment were smokers from six EU countries- Germany, Greece, Hungary, Poland, Romania, and Spain. D (N = 3195). Bivariate and logistic regression analyses of weighted data was conducted using SAS-callable SUDAAN. Overall, among those who smoked factory-made cigarettes (FM) only at Wave 1, 4.3% switched to roll-your-own tobacco (RYO) only. Among RYO only users at Wave 1, 17.0% switched to FM only, however compared to all other countries, respondents from Hungary had the highest percentage of FM only users at Wave 1 switch to RYO only at Wave 2 (18.0%). The most prominent transition overall was from smoking RYO exclusively at Wave 1 to smoking FM tobacco exclusively at Wave 2, however this varied across countries. As the tobacco control regulatory environment of the EU develops, it is important to continue to monitor transitions between types of products, as well as trends in cessation.

Awareness and correlates of noticing changes to cigarette packaging design after implementation of the European Tobacco Products Directive: findings from the EUREST-PLUS ITC Europe Surveys.

The European Tobacco Products Directive (TPD), which went into effect in May 2016, regulates packaging design and labelling of cigarettes and roll-your-own (RYO) tobacco. The aim of the current study was to examine whether smokers and recent quitters in six European Union (EU) countries (Germany, Greece, Hungary, Poland, Romania and Spain) reported noticing TPD-related changes to packaging, and correlates of noticing these changes. Cross-sectional data from the Wave 2 of the ITC 6 European Country Survey in 2018 after implementation of the TPD. Bivariate analyses included adult smokers (n = 5597) and recent quitters (n = 412). Adjusted logistic regression analyses were restricted to the subset of current smokers (n = 5597) and conducted using SAS-callable SUDAAN. Over half of smokers (58.2%) and 30% of quitters noticed at least one of five types of TPD-related pack changes. Over one-quarter of all respondents noticed changes to health warnings (30.0%), standardized openings (27.7%), minimum pack unit size (27.9%), and the removal of tar, nicotine and carbon monoxide information (26.7%) on packaging. Cross-country differences were observed across all measures, with noticing all pack changes markedly lower in Spain than the other countries. Correlates of noticing specific pack changes included sociodemographic characteristics, smoking behaviours and related to packaging. This is one of the first cross-country studies to examine the extent to which TPD changes to cigarette and RYO tobacco packaging are being noticed by smokers and recent quitters. Findings indicate that the majority of smokers noticed at least one type of pack change, but this varied across countries and sub-populations.

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

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

A systematic cost-benefit analysis of 29 road safety measures

Economic evaluations of road safety measures are only rarely published in the scholarly literature. We collected and (re-)analyzed evidence in order to conduct cost-benefit analyses (CBAs) for 29 road safety measures. The information on crash costs was based on data from a survey in European countries. We applied a systematic procedure including corrections for inflation and Purchasing Power Parity in order to express all the monetary information in the same units (EUR, 2015). Cost-benefit analyses were done for measures with favorable estimated effects on road safety and for which relevant information on costs could be found. Results were assessed in terms of benefit-to-cost ratios and net present value. In order to account for some uncertainties, we carried out sensitivity analyses based on varying assumptions for costs of measures and measure effectiveness. Moreover we defined some combinations used as best case and worst case scenarios. In the best estimate scenario, 25 measures turn out to be cost-effective. 4 measures (road lighting, automatic barriers installation, area wide traffic calming and mandatory eyesight tests) are not cost-effective according to this scenario. In total, 14 measures remain cost-effective throughout all scenarios, whereas 10 other measures switch from cost-effective in the best case scenario to not cost-effective in the worst case scenario. For three measures insufficient information is available to calculate all scenarios. Two measures (automatic barriers installation and area wide traffic calming) even in the best case do not become cost-effective.Inherent uncertainties tend to be present in the underlying data on costs of measures, effects and target groups. Results of CBAs are not necessarily generally valid or directly transferable to other settings.

The tip of the iceberg? Budget restrictions and patient perspectives on cancer drug costs: An international survey in 29 hospitals and 56 patient organizations

BackgroundThe rising cost of cancer drugs are a challenge for health systems, providers, and sometimes patients’ individual financial capacities. We conducted a survey in European countries on negotiation options for providers and effects of high costs on providers and patients. Patients and methodsWe asked health care providers (members of the Organisation of European Cancer Institutes (OECI) hospitals) viewpoints on discount mechanisms, budget restrictions and patient related issues. Secondly, representatives from the member organisations of the European Cancer Patients Coalition (ECPC) were approached concerning consequences for patients, such as access and receiving appropriate treatment. ResultsResponse rates were 38% for OECI and 11% for ECPC. Among 29 participating OECI members, a wide range of discount mechanisms and payments methods are being used in cancer drug purchasing processes. 90% (26/29) of institutions allow joint drug price negotiations; however, only 69% (18/26) use this strategy Two-thirds of institutional responders are of the opinion that treatment choices are being affected by cost issues. 79% (n = 56) patient representatives of ECPC member organizations responded that patients may be missing out on best possible treatments due to high drug costs and 43% thought that patients may not be aware of that. ConclusionOur findings revealed a lack of systematic approach towards purchasing agreements, and a limited use of potentially powerful mechanisms such as joint negotiations. Furthermore, a large majority of patient representatives (79%) and providers (66%) indicated that the drug cost issue is likely to influence treatments decisions. Access issues and coverage delays seem to be present in all countries regardless of level of GDP.

Correlates of the support for smoke-free policies among smokers: A cross-sectional study in six European countries of the EUREST-PLUS ITC EUROPE SURVEYS.

INTRODUCTIONThis report describes the support for smoke-free policies in different settings among smokers in six European countries and the relationship between their opinions about the places where smoking should be banned and their beliefs about the harms of secondhand smoke to non-smokers.METHODSA cross-sectional survey (the ITC 6 European Country Survey, part of the EUREST-PLUS Project) was conducted using nationally representative samples of adult smokers in Germany, Greece, Hungary, Poland, Romania and Spain (n=6011). We describe the prevalence of agreement and support for smoke-free policies in different settings according to sociodemographics, smoking characteristics and beliefs about the danger of secondhand smoke to non-smokers.RESULTSThere was high agreement with smoking regulations in cars with preschool children and in schoolyards of primary/secondary schools (>90% overall) and low agreement with banning smoking in outdoor terraces of bars/pubs (8.6%; 95%CI: 7.5%-9.8%) and restaurants (10.1%; 95%CI: 8.9%-11.4%). The highest support for complete smoking bans inside public places came from smokers in Poland, among women, people aged ≥25 years, who had low nicotine dependence, and who tried to quit smoking in the last 12 months. About 78% of participants agreed that tobacco smoke is dangerous to non-smokers, ranging from 63.1% in Hungary to 88.3% in Romania; the highest agreement was noted among women, the 25-54 age groups, those with higher education, low cigarette dependence, and those who tried to quit in the last 12 months. The support for complete smoking bans in public places was consistently higher among smokers who agreed that secondhand smoke is dangerous to non-smokers.CONCLUSIONSSmokers in six European countries declared strong support for smoke-free policies in indoor settings and in settings with minors but low support in outdoor settings, particularly leisure facilities. More education is needed to increase the awareness about the potential exposure to secondhand smoke in specific outdoor areas.

Secondhand exposure to e-cigarette aerosols among smokers: A cross-sectional study in six European countries of the EUREST-PLUS ITC Europe Surveys.

INTRODUCTIONElectronic cigarette (e-cigarette) use has grown significantly in some European Union (EU) Member States (MS). A better understanding of the exposure to secondhand e-cigarette aerosols (SHA) is necessary to develop and implement comprehensive regulations on e-cigarette use in public places. This study aims to assess the observation of e-cigarette use in public places, the self-reported exposure to SHA, and the level of users’ comfort using e-cigarettes in the presence of others.METHODSThis is a cross-sectional study of the Wave 1 International Tobacco Control 6 European Countries Survey recruiting adult smokers (n=6011) across six EU MS: Germany, Greece, Hungary, Poland, Romania, and Spain, within the EURESTPLUS Project. A descriptive analysis was conducted to estimate the prevalence (%) of observed e-cigarette use in different places, frequency of self-reported exposure to SHA, and level of comfort using e-cigarettes in the presence of others.RESULTSIn all, 31.0% of smokers observed others using e-cigarette in public places, 19.7% in indoor places where smoking is banned, and 14.5% indoors at work. Almost 37% of smokers reported to be ever exposed to SHA, ranging from 17.7% in Spain to 63.3% in Greece. The higher prevalence of observed e-cigarette use and passive exposure to SHA was reported by smokers of younger age, of higher educational level and those being current or former e-cigarette users. Part (8.8%) of the smokers who were also e-cigarette users reported feeling uncomfortable using e-cigarettes in the presence of others.CONCLUSIONSA third of smokers from six EU MS reported being exposed to SHA. Prevalence differences were observed among the countries. In the context of scarce evidence on long-term health effects of exposure to SHA, precautionary regulations protecting bystanders from involuntary exposure should be developed.

Prevalence and correlates of different smoking bans in homes and cars among smokers in six countries of the EUREST-PLUS ITC Europe Surveys.

INTRODUCTIONSecond-hand smoke exposure has decreased in a number of countries due to widespread smoke-free legislation in public places, but exposure is still present in private settings like homes and cars. Our objective was to describe to what extent smokers implement smoking rules in these settings in six European Union (EU) Member States (MS).METHODSA cross-sectional survey was conducted with a nationally representative sample of adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (ITC six European countries survey, part of the EUREST-PLUS Project). We analysed data from 6011 smokers regarding smoking rules in their homes and in cars with children (no rules, partial ban, total ban). We described the prevalence of smoking rules by EU MS and several sociodemographic and smoking characteristics using prevalence ratios (PR) and 95% confidence intervals (CI) derived from Poisson regression models. \\RESULTSIn homes, 26.5% had a total smoking ban (from 13.1% in Spain to 35.5% in Hungary), 44.7% had a partial ban (from 41.3% in Spain to 49.9% in Greece), and 28.8% had no-smoking rules (from 20.2% in Romania to 45.6% in Spain). Prevalence of no-smoking rules in cars with children was 16.2% (from 11.2% in Germany to 20.4% in Spain). The correlates of not restricting smoking in homes and cars included: low education (PR=1.51; 95%CI: 1.20-1.90 and PR=1.55; 95%CI: 1.09-2.20), smoking >30 cigarettes daily (PR=1.53; 95%CI: 1.10-2.14 and PR=2.66; 95%CI: 1.40-5.05) and no attempts to quit ever (PR=1.18; 95%CI: 1.06-1.31 and PR=1.28; 95%CI: 1.06-1.54).CONCLUSIONSAmong smokers in six EU MS, no-smoking rules were more prevalent in homes than in cars with children. Whilst awareness about the health effects of exposure to tobacco smoke on children seemed to be high, more research is needed to better understand the factors that promote private smoke-free environments.

The Conceptual Model and Methods of Wave 1 (2016) of the EUREST-PLUS ITC 6 European Countries Survey.

Population-level interventions represent the only real approach for combatting the tobacco epidemic. There is thus great importance in conducting rigorous evaluation studies of tobacco control policies and regulations such as those arising from the WHO Framework Convention on Tobacco Control (FCTC) and the European Union’s 2014 Tobacco Products Directive (TPD). The ITC 6 European Countries Survey, a component of the Horizon 2020 Project entitled European Regulatory Science on Tobacco: Policy Implementation to Reduce Lung Disease (EUREST-PLUS), was created to evaluate and impact of the TPD in six EU Member States: Germany, Greece, Hungary, Poland, Romania, and Spain. In each country, a cohort survey of a representative national sample of 1000 smokers was conducted. This paper describes the conceptual model, methodology, and initial survey statistics of Wave 1 of the ITC 6E Survey, which was conducted June–September 2016. The ITC 6E Survey’s conceptual model, methodology, and survey instrument, were based on the broader 29-country ITC Project cohort studies, which have been conducted since 2002. The commonality of methods and measures allow a strong potential for cross-country comparisons between the 6 EU countries of the ITC 6E Project and 3 other EU countries (England, France, The Netherlands) in the ITC Project, as well as the broader set of ITC countries outside the EU.

Compliance with smoke-free legislation in six European countries (2016): findings from the ITC 6 European country survey (EUREST-PLUS project)

Compliance with smoke-free legislation in six European countries (2016): findings from the ITC 6 European country survey (EUREST-PLUS project)

Do European smokers opt for partial or total bans on smoking in homes and cars? Findings from the ITC 6 European country survey (EUREST-PLUS project)

Do European smokers opt for partial or total bans on smoking in homes and cars? Findings from the ITC 6 European country survey (EUREST-PLUS project)

Use of e-cigarettes and second-hand exposure to their aerosols in Europe: findings from the ITC 6 European country survey (EUREST-PLUS project)

Use of e-cigarettes and second-hand exposure to their aerosols in Europe: findings from the ITC 6 European country survey (EUREST-PLUS project)

Do European smokers opt for partial or total bans on smoking in homes and cars? Findings from the ITC 6 European Country Survey (EUREST-PLUS Project)

Do European smokers opt for partial or total bans on smoking in homes and cars? Findings from the ITC 6 European Country Survey (EUREST-PLUS Project)

Periodontal education and assessment in the undergraduate dental curriculum-A questionnaire-based survey in European countries.

This survey aimed to evaluate whether periodontal education and assessment in undergraduate dental curricula amongst the member countries of the European Federation of Periodontology (EFP) follow the competency-based curricular guidelines and recommendations developed by the Association for Dental Education in Europe. A multiple-choice questionnaire was emailed to 244 dental institutes amongst the 24 EFP member countries between November 2014 and July 2015. Data were received from 16 (66.7%) EFP member countries. Out of 117 responding dental institutes, 76 (64.95%) were included as valid responders. In most of the institutes (86.3%), a minimum set of competencies in periodontology was taken into account when constructing their dental education programmes. Out of 76 responders, 98.1% included lecture-based, 74.1% case-based and 57.1% problem-based teaching in their periodontal curricula, whilst a minority (15.9%) also used other methods. A similar pattern was also seen in the time allocation for these four educational methods, that is, the highest proportion (51.8%) was dedicated to lecture-based teaching and only a small proportion (5.7%) to other methods. Periodontal competencies and skills were most frequently assessed by clinical grading on clinic, multiple-choice examination (written examination) and oral examination, whereas competency tests and self-assessment were rarely used. Only in 11 (14.5%) cases, access flap procedures were performed by students. Great diversity in teaching methodology amongst the surveyed schools was demonstrated, and thus, to harmonise undergraduate periodontal education and assessment across Europe, a minimum set of recommendations could be developed and disseminated by the EFP.

Mobile-Only Consumers Arise from Heterogeneous Valuation of Fiixed Services

Mobile-only users are usually considered as a consequence of fixed-mobile substitution. Via a unique dataset based on a a large European country survey and consumers' invoice data, this study reveals heterogeneous preferences for fixed services among consumers. The data is fitted in a mixed logit model and willingness to pay (WTP) for fixed communications services are estimated. Results show that mobile-only consumers have a WTP for fixed services of 15 € per month, while the WTP of users of both fixed and mobile services is thrice higher. Considering that a typical monthly fee for fixed services is around 30 €, the heterogeneous preferences for fixed services constitute an alternative explanation for the existence of mobile-only users, despite the complementarity of fixed and mobile broadband.

Sustainable Development – European Union Enlargement Effects. A Central and Eastern European Countries Survey

Economic development in Central and Eastern Europe, with its stress on heavy industry and the lack of effective environmental policy, has a significant contribution to the environmental degradation of the region, over the last fifty years. The sequel and consequences are still felt concomitantly with the pursuance of the new policy. The environmental conditions pose barricades to development.But, in spite of the differences between industrialized countries and Central and Eastern European Countries, the latter countries have to compress the four stages: command and control – economization stage – ecologization of development stages – sustainable development. In so doing the principal aspects is to point out the sustainable development. It is important for policies in these countries to encourage the development of viable economy, an industrial ecology, dematerialization and ecoefficiency, diverse sectors with special attention to information technology, communication, business, financial and health services, education, postgraduate learning, transportation and distribution.Sustainable development is a process seeking to improve the system of social, economic and ecological performances. Often the performances in question are not congruent, sustainable development aiming particularly at congruence, the placing of three aspects in the situation of victory of everybody’s gain, of aligning economic, social and ecological values to the same accepted standard, also considering the simultaneous deployment of actors within an integrative framework.At a global level, in a sustainable world, with sustainable economy, population becomes stable, material and energetic consumption become settled and at a reduced level, impact onto the environment becomes stable, productivity is compatible with the ecosystem and the economic growth is a qualitative developing and improvement one.It is now the last time for the new democracies in Central and Eastern Europe, surveyed in their paper, to avoid the problems occurred in the Western Countries, to share their experiences, and to join the global effort for sustainable development.

Identifying Non-Working Numbers in Cell Phone RDD Samples via HRL-Lookup Technology

RDD cell phone samples contain a substantial proportion of non-working numbers, making cell phone surveys relatively expensive. We tested a technology which allows users to automatically identify non-working numbers in a sample (Home Location Register Lookup or short HLR-Lookup). HLRLookup is available virtually in all countries where the GSM-standard is used – in about 200 countries (1). Though the GSM-standard coexists with other standards in many countries, it is estimated that about 80% of cell phone subscribers use it (2). The results presented here are especially useful for conducting surveys in European countries, since in Europe the GSM-standard is used exclusively, as well as in world regions where GSM tends to dominate other standards (Africa, Americas, Asia Pacific, and Middle East). Our findings will be of limited use for the US, since to our knowledge the proportion of GSM-subscribers in the US is not as high as in other countries (3) and technological standards used in the US are incompatible with each other, which does not allow screening of all sampled numbers via HLR-Lookup. In the meantime while the evolving technology may become more compatible in the future, the possibility of using HLR-Lookup to screen cell-phone samples and check numbers which belong to operators of the GSM-network should be considered by survey researchers in the US.

P03-259 - Four European countries survey of patients with schizophrenia treated in everyday clinical practice: characteristics of patients in short-term hospitalization

AimThe survey performed in four European countries (Germany, Greece, Italy, Spain) aimed at characterizing patients with schizophrenia treated in everyday clinical practice in terms of demographic characteristics, presenting symptomatology, and current antipsychotic treatement. We present here characteristics of patients in short term hospitalization.MethodsA survey involving 744 psychiatrists gathered anonimous retrospective data from 3,996 patients with schizophrenia. To ensure representativeness of participating physicians, the dataset was adjusted post hoc. Principal component analysis was used to structure the patient attributes relevant for antipsychotic choice, identifying two discriminating variables (disease severity and socioeconomic level) accounting for 91% of the variance in the data. Methodology is described in full detail by Gorwood (2010).ResultsOut of 3,996 surveyed patients, 21.7% were in short term hospitalization, with a mean of 7.5 previous episodes and 5.5 previous hospitalizations. Two thirds of subjects lived with theirfamily, with primary caregiver in 47% of subjects) being a relative. Most frequently observed symptoms were delusions (in 54% of subjects) and ideals of persecution (in 41% of subjects). 71% of subjects were smokers, 21% had drug and 18% alcohol addiction. 43% of subjects had a verified cardiometabolic comorbidity and 21% were obese. 29% of subjects had verified medication non-adherence. Most frequently used drug was risperidone (in 22% of subjects). Ziprasidone was used in 11% of subjects. 10% of subjects were on depot medication and 19% on orally disintegrating tablets.ConclusionSubjects with schizophrenia in current short-term hospitalization have high rates of cardiometabolic risk factors or cardiometabolic comorbidity.