Estimates of annual cessation probabilities were higher than 5% only in persons older than 60 years and in women younger than 30 years, while in persons aged 30-59 years cessation estimates were around 2-5%. It’s noteworthy that most of cessation probabilities stalled from 1986 to 2009. Results may imply that quitting is considered only by women in the age of pregnancy and by elderly persons, when it’s likely that symptoms of tobacco-related diseases have already appeared. Accordingly, in Italy approximately half of former smokers endorsed present health (i.e., current health conditions) as the main reason they quit smoking [16
The annual cessation probabilities estimated for women aged 30-39 in the time period 1993-1999 resulted very low because most of cessation was captured in the previous age class (< 30 years). In fact, younger women in 1993-1999 recorded higher cessation probabilities in comparison to the other time periods.
In our model we assumed that smoking initiation occurs between 18 and 24 years of age, even though it is frequently reported that adolescent begin to smoke before 18 years of age [17
]. This assumption was varied by considering smoking initiation at 14 years of age, producing worst R2
values (0.523 and 0.496 for women and men, respectively). Moreover, adolescent smokers are often occasional smokers (triers, puffers, experimenters), and they do not necessarily progress to regular smoking [19
Estimates of annual cessation probabilities from our model were consistent with cessation probabilities obtained with similar models for Italy [9
], for USA [7
] and for Australia [8
], and with survey estimates of cessation rates in the Spanish [3
], Italian [4
], English [5
], and US population [6
Age-standardized quit rates were estimated for Italy around 2-3% for males and 1-4% for females aged 20-44 years [4
]. Cessation rates estimates for the English population over 16 years of age were between 2% and 3% for both genders in 2006 [5
]. Similar analyses for Spain reported the incidence of quitting smoking of 0-5% and 1-5% for males and females aged 20-50 years old, respectively, and of 0-9% and 8-9% for males and females aged > 50 years old, respectively [3
]. Cessation rates in California increased by 25% from 1980s to the 1990s, averaging 3.4% per year in the 1990s. Cessation increased for all age-groups, and by more than 40% among smokers aged 20-34 years [6
]. Since in our model we estimated the annual probability of smoking cessation independently whether or not smokers successfully quitted after that year, the resulting cessation estimates were slightly higher than those reported in the other studies. The previous Italian model [9
], as well as the other models and survey estimates that does not take into account time since quitting, accounted only for successful quitting (i.e., smoking abstinence for at least one year).
Empowering smoking cessation treatment policies and launching media campaigns focusing on quitting promotion among adults may increase quit attempts among Italian smokers, particularly those aged 31-59 years, whose probabilities of making a quit attempt resulted very low. Currently, the National Health System (NHS) does not reimburse smokers for pharmacotherapy or behavioral treatments [20
], and these methods in 2011 were used by 5% of former smokers [22
]. Moreover, about 40% of smokers reported having received advice to quit by their general practitioners [22
], and each of the almost 300 NHS Smoking Cessation Services treated an average of 70-77 smokers only each year [24
]. Finally, the two Italian quitlines annually received about 7-8,000 calls, thus reaching about 0.06-0.07% only of Italian smokers [25
]. Anti-tobacco media campaigns have been implemented in Italy in 2002-2005 annually, in 2009, and 2010 [27
] and their targets were young people to prevent smoking initiation. The MPOWER Report [28
] indicates health expenditures of less than US$1 per person in Italy for media campaign.
Limitations and strengths
Our model has some limitations due to simplifying assumptions or to lack of data. Migration was not taken into account because of the inadequate data on smoking prevalence among migrants. However, since the resident population is large with respect to immigrants, it is unlikely that the difference would significantly influence results although smoking prevalence among immigrants may differ from that in the resident population [10
Despite the dependence of smoking-related mortality on many factors, as the duration of smoking and smoking intensity, the excess risk of death is modeled simply as the relative risk for current and former smokers not to increase the model complexity.
Cancer Prevention Study II mortality rates for current, and never smokers were used since Italian data were not available. However, these estimates were in agreement with those found in Italian epidemiological studies for several mortality causes [29
In modelling relapse rates and relative risks of former smokers through the two negative-exponential curves, we used the parameters estimated from cross-sectional surveys conducted in the Netherlands since figures from Italy were not available. While relative risks for former smokers may be assumed to have similar patterns for the Netherlands and Italy, it is instead uncertain whether or not relapse in Italy follows the same pattern observed in the Netherlands.
In comparison with survey estimates of cessation rates, our model was based on the evolution of tobacco epidemic in the Italian population and provided a consistent model of how current and former smokers evolve over time. Since the knowledge of past time trends in cessation is necessary to characterize the dynamics of the tobacco epidemic, and since only few nations collect data on cessation rates, our model can be used to estimate cessation rates for those countries where this cannot be estimated from surveys on smoking habits. Moreover, the model lets to quantify the effects of smoking interventions on public health, taking into account the time since cessation of quitters. The latter is important, since many quitters relapsed and for most smoking related diseases the increased risks of former smokers only decreased gradually over time since cessation.