Abstract
INTRODUCTION: Most studies use the prevalence of current smoking as an indicator to quantify the burden of smoking. However, length and intensity of smoking, as well as time since cessation for former smokers are also known to impact smoking-related health risks. The aim of this study was to quantify and compare the burden of smoking across the European Union (EU) using a range of smoking burden indicators. METHODS: We conducted a cross-sectional analysis using data from the March 2017 Eurobarometer 87.1 (n=27901, people aged ≥15 years) in 28 European Union Member States (EU MS) and the Tobacco Control Scale. We defined five indicators of smoking burden including the prevalence of current and ever smoking, length of smoking, pack-years, and discounted pack-years, and ranked EU MS by each indicator. Two-level linear and logistic regressions were performed to assess the association between these indicators and sociodemographic and tobacco policy factors. RESULTS: Wide variations across the EU countries were observed in all smoking burden indicators. While some MS ranked consistently high (e.g. Greece, France) or consistently low (e.g. Ireland, United Kingdom) in all indicators, we found substantial discrepancies in ranking depending on the indicator used for MS such as Malta, Denmark, Finland and the Netherlands. All indicators of smoking burden were lower among women and respondents without financial difficulties; however, the magnitude of those inequalities varied two-fold among the different indicators. CONCLUSIONS: Using a range of smoking burden indicators can be more informative than relying on prevalence alone. Our analysis highlights the limitations of relying solely on prevalence of current smoking to estimate the burden of smoking and the potential value of more nuanced indicators. We recommend that multiple and more nuanced indicators that consider former smokers, intensity and duration of smoking should be utilized to monitor tobacco use and evaluate tobacco control policies.