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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=27,901 aged ≥15 years in 28 Member States [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 utilised to monitor tobacco use and evaluate tobacco control policies.

Objective The aim of the study is to assess trends in public perceptions of health systems in 27 European Union (EU) member states following the financial crisis (2009–2013), in order to discuss observed changes in the context of the financial crisis. Design Repeated cross-sectional studies. Setting 27 EU countries. Participants EU citizens aged 15 years and older. Methods The study mainly uses the Eurobarometer Social Climate Survey, conducted annually between 2009 and 2013, thereby analysing 116 706 observations. A multilevel logistic regression was carried out to analyse trends over time and the factors associated with citizens' perceptions of their healthcare systems. Results Europeans generally exhibit positive perceptions of their national healthcare systems, 64.0% (95% CI 63.6% to 64.4%). However, we observed a significant drop in positive perceptions in the years following the crisis, especially within countries most affected by the crisis. Concerning fiscal characteristics, wealthier countries and those dedicating higher proportion of their national income to health were more likely to maintain positive perceptions. At the individual level, perceptions of healthcare systems were significantly associated with respondents' self-perceptions of their social status, financial capacity and overall satisfaction in life. Conclusions Our finding confirms previous observations that citizens' perceptions of their healthcare systems may reflect their overall prospects within the broader socioeconomic systems they live in; which have in turn been affected by the financial crisis and the policy measures instituted in response.

Standardised packaging of tobacco products is intended to reduce the appeal of smoking, but the tobacco industry claims this increases illicit trade. We examined the percentage of people reporting being offered illicit cigarettes before and after full implementation of standardised packaging in the UK, Ireland and France and compared this to other European Union countries. Reported ever illicit cigarette exposure fell from 19.8% to 18.1% between 2015 and 2018 in the three countries fully implementing the policy, and from 19.6% to 17.0% in control countries (p for difference=0.320). Standardised packaging does not appear to increase the availability of illicit cigarettes.

Objectives and setting The 2008 financial crisis had a particularly severe impact on Greece. To contain spending, the government capped public health expenditure and introduced increased cost-sharing. The Greek case is important for studying the impact of recessions on health systems. This study analysed changes in household health expenditure in Greece over the economic crisis and explored whether the impact differed across socioeconomic groups. Participants We used data from the Greek Household Budget Survey for the years 2004 and 2008-2017. The dataset comprised 51,654 households, with a total of 128,111 members. Design We compared pre- and post-crisis trends in Greek household out-of-pocket payments for healthcare from 2004-2017 using an interrupted time series analysis. This study explored spending in Euros and as a share of total household purchases. Results Our results indicated that the population level trend in household health spending was reversed after the crisis began (pre-crisis trend: €0.040 decrease per quarter (95% CI: -0.785 to -0.022), post-crisis trend: €0.315 increase per quarter (95% CI: -0.004 to 0.635)). We also found that spending on inpatient services and pharmaceuticals has been increasing since the start of the crisis, whereas outpatient services expenditure has been decreasing. Across all households, out-of-pocket payments incurred a greater financial burden after the crisis relative to pre-existing trends, but the poorest households incurred a disproportionately higher burden. Conclusions This was the first study to use an interrupted time series analysis to assess the impact of the economic crisis on household health expenditure in Greece. Our findings suggest that there was an erosion of financial protection for Greek households as a consequence of the economic crisis. This effect was particularly pronounced amongst poorer households, which is indicative of a regressive financing system.