The ACAB project

What is it?
ACAB is a three-year scientific project aimed at improving the environment and health in Tuscany. The acronym ACAB refers to the content of the study: ACABAttributable CAncer Burden in Tuscany: smoking, environmental and occupational risk factors and evaluation of prevention strategies. That is: attributable cancer burden due to smoking, air pollution, environmental, and occupational carcinogens in Tuscany and evaluation of prevention policies.

Who is funding it?
The project is funded by Tuscany Region in the framework of the Health Research Call “Bando Ricerca Salute” 2018.

Who is participating in the project?
ACAB is coordinated by the Institute for cancer research, prevention and oncological network (ISPRO). The Local Health Authority (Azienda USL Toscana Centro) and the Department of Statistics, Computer Science, Applications of the University of Florence are participating in the project. The Regional Health Agency (ARS) of Tuscany, the Institute for Maternal and Child health IRCCS ‘Burlo Garofolo’ of Trieste and the LaMMA Consortium collaborate as external partners.

What does ACAB aim at?
First of all, ACAB will provide a description of the state of health of the Tuscan population, drawing up for each Local Health Authority and for each territorial district an updated estimate of the number of deaths, years of life lost or years lived with disability due to the main pathologies.

It will then focus on the number of deaths and years of life lived with disability caused by cancer due to three risk factors: tobacco smoke, air pollution, and exposure to carcinogenic substances in the workplace.

ACAB will quantify the burden of disease that could have been avoided by reducing or eliminating the three risk factors and will assess the benefit (today and in the future) of implementing tobacco control policies, curbing emissions of particulate matter and other air pollutants, and making workplaces healthier.

In a nutshell, ACAB serves to calculate how much health we have lost due to important risk factors and how much we could gain by implementing effective prevention interventions. This information is essential to guide public health choices and make us more aware that protecting the environment and changing our lifestyles is fundamental to improving the health of the community in which we live.

The symbol
ACAB’s symbol is a flower: the Crocus Etruscus, chosen by 500 experts from the Italian Botanical Society as the representative plant of the Tuscany region. Delicate, colourful, brave.

Research team


Istituto per lo Studio, la Rete e la Prevenzione Oncologica (ISPRO)


Dipartimento di Statistica, Informatica, Applicazioni (DISIA), Università di Firenze


Dipartimento di Prevenzione, Azienda USL Toscana Centro (AUSL TC)


Osservatorio di Epidemiologia

Francesco Profili
Fabio Voller

IRCCS materno infantile Burlo Garofolo

Lorenzo Monasta

Consorzio LaMMA

Divisione Fisica dell’Atmosfera
Qualità dell’aria

Timeline of project developements


Revisione della letteratura


Raccolta dei dati epidemiologici e di esposizione al fumo, all’inquinamento atmosferico e ai principali cancerogeni occupazionali


Sviluppo dei metodi per la stima dei DALY


Stima degli YLL e YLD per le principali cause di malattia


Valutazione dell’esposizione al fumo e all’inquinamento atmosferico


Definizione/stima delle curve dose-risposta


Sviluppo di un modello compartimentale per le dinamiche di abitudine al fumo


Stima degli YLL per le principali patologie oncologiche


Sviluppo dei metodi per la stima del carico di malattia attribuibili al fumo, all’inquinamento atmosferico e ai principali cancerogeni occupazionali


Stima degli YLD per le principali patologie oncologiche

in corso

Valutazione dell’esposizione ai principali cancerogeni occupazionali

in corso

Stima del carico di malattia attribuibile al fumo, all’inquinamento atmosferico e ai principali cancerogeni occupazionali

in corso

Formulazione di scenari controfattuali per l’abitudine al fumo e uso del modello compartimentale a fini di valutazione di impatto

in corso

Smoking, air pollution and exposure
to occupational carcinogens in Tuscany:
impact on oncological diseases
and evaluation of preventive policies


Averag life expectancy: Measure of the average time an individual is expected to live.

Burden of disease: The impact that diseases or injuries have on the population. The burden of disease is usually measured in terms of number of deaths, Years of Life Lost (YLL), Years Lived with Disability (YLD) or Disability-Adjusted Life Years (DALYs), referring to a specific time interval - for example a specific year - and to one or more diseases - for example cancer diseases. The analysis of the burden of disease allows to identify the most serious health problems affecting a population.

Burden of disease attributable to a risk factor: The burden of disease that could be avoided by removing or reducing to a counterfactual level the exposure to the risk factor.

Counterfactual level: A hypothetical level of exposure to a risk factor different from the observed one, often ideal, defined in absolute or relative terms. For example, with reference to the exposure to fine airborne particles, we can define as counterfactual levels: the limit imposed by European legislation for the annual average concentration of this pollutant, the level of particles observed in a low-polluted geographical area or the observed level in the area of interest decreased by 10%.
With reference to smoking, we can define as counterfactual levels: a percentage of smokers in the population equal to 0 or a percentage of smokers equal to 95% of the actual one (corresponding to a 5% reduction of smokers). The interpretation of the disease burden is different depending on the counterfactual level adopted in the analysis.

Disability-Adjusted Life Years (DALYs): Measure that combines years of life lost due to premature mortality and years of healthy life lost. DALYs from a specific cause are calculated as the sum of Years of Life Lost (YLL), Years Lived with Disability (YLD) resulting from that cause.

Global Burden of Disease (GBD): Comprehensive and systematic worldwide assessment of mortality, disease and their risk factors. The first GBD study was commissioned by the World Bank in 1990 and carried out by the World Health Organization (WHO) and the Harvard University. It quantified the health effects of 107 diseases and 10 risk factors on 8 world regions, introducing the Disability-Adjusted Life Years (DALYs) metric. Subsequent GBD studies were carried out by the WHO. Since 2013 GBD was led by the Institute of Health Metrics Evaluation (IHME). The 2019 GBD study is composed by a consortium of more than 7,000 researchers in over 156 countries and it provides estimates on 286 causes of death, 369 diseases and injuries and 87 risk factors in 204 countries and territories, by age and sex, from 1990 to the present.

Risk factor: Factor the exposure to which is associated with an increased risk of occurrence of a certain disease or injury. Individual risk factors are those related to people's lifestyle (diet, exercise, smoking, alcohol consumption). Environmental risk factors are those that are related to external elements and features of the physical environment where we live (e.g. air, soil and water pollution, extreme weather conditions, features of natural and built environment). Occupational risk factors are those related to workplace environment and working activities (e.g. exposure to contaminants used in the production process).

Years of Life Lost (YLL): Measure of premature mortality that takes into account both the frequency of deaths and the age at which it occurs. For a subject dying at age 70, YLL correspond to the average life expectancy at that age. In a population, YLL are calculated considering the number of deaths and the standard life expectancy at the age at which each death occurs. YLL are a component of DALYs.

Years lived with disability (YLD): Measure of the burden of living with a disease or a disability. YLD calculation accounts for both the number of non-fatal conditions occurring in the population and the disability deriving from them. YLD are calculated considering the duration of each non-fatal condition and assigning it a specific severity weight. Higher the weight and duration are, higher is the disability burden produced by the non-fatal condition. A disease may be characterized by one or more stages representing different non-fatal conditions. As an example, the disability from cancer may be calculated defining four non-fatal conditions of different duration and severity: diagnosis/treatment, controlled phase, metastatic phase and terminal phase. YLD are a component of DALYs.