Agustín Montes

Mortality attributable to passive smoking in Spain, 2002

Objective: Exposure to environmental tobacco smoke (ETS) is associated with a variety of health effects, including lung cancer and ischaemic heart disease. The objective of this study was to estimate the number of deaths caused by exposure to ETS among non-smokers in Spain during the year 2002 Methods: Prevalence of ETS exposure among never smokers was gathered from three region based health interview surveys. The relative risks of lung cancer and ichaemic heart diseases were selected from three meta-analyses. Population attributable risk (PAR) was computed using a range of prevalences (minimum-maximum). The number of deaths attributable to ETS was calculated by applying PARs to mortality not attributable to active smoking in 2002. The analyses were stratified by sex, age and source of exposure (home, workplace and both combined). In addition, a sensitivity analysis was performed for different scenarios. Results: Among men, deaths attributable to ETS ranged from 408 to 1703. From 247 to 1434 of these deaths would be caused by the exposure only at home, 136–196 by exposure only in the workplace and 25–73 by exposure at both home and the workplace. Among women, the number of attributable deaths ranged from 820 to 1534. Between 807 and 1477 of these deaths would be caused by exposure only at home, 9–32 by exposure only in the workplace and 4–25 by exposure both at home and in the workplace. Conclusion: Exposure to ETS at home and at work in Spain could be responsible for 1228–3237 of deaths from lung cancer and ischaemic heart disease. These data confirm that passive smoking is an important public health problem in Spain that needs urgent attention.

Impact of the 2011 Spanish smoking ban in hospitality venues: indoor secondhand smoke exposure and influence of outdoor smoking.

INTRODUCTION The Spanish tobacco control law of 2006 was modified in January 2011, banning smoking in all hospitality venues. The objective of the study was to assess the impact of the 2011 Spanish smoking ban on secondhand smoke (SHS) exposure in hospitality venues, and to analyze the potential impact of outdoor smokers close to entrances on indoor SHS levels after the law came into force. METHODS Before-and-after evaluation study with repeated measures. The study was carried out in three regions of Spain (Catalonia, Galicia, and Madrid) and included a random sample of 178 hospitality venues. We measured vapor-phase nicotine and particulate matter 2.5 micrometers or less in diameter (PM2.5) as SHS markers at baseline (November-December 2010) and at follow-up (April-June 2011). We also recorded tobacco consumption variables such as the presence of butts, ashtrays, and smokers. In the posttest assessment, we also recorded the number of outdoor smokers close to the entrance. RESULTS A total of 351 nicotine and 160 PM2.5 measurements were taken. Both nicotine and PM2.5 concentrations decreased by more than 90% (nicotine from 5.73 to 0.57 µg/m(3), PM2.5 from 233.38 to 18.82 µg/m(3)). After the law came into force, both nicotine and PM2.5 concentrations were significantly higher in venues with outdoor smokers close to the entrance than in those without outdoor smokers. All the observational tobacco consumption variables significantly decreased (p < .001). CONCLUSIONS SHS exposure in hospitality venues dramatically decreased after the 2011 Spanish smoking ban. SHS from outdoor smokers close to entrances seems to drift inside venues. Smoking control legislation should consider outdoor restrictions to ensure complete protection against SHS.

The price of cigarettes in the European Union

BACKGROUND A major factor influencing tobacco use is its price. Fiscal policies on tobacco are a key ingredient of any comprehensive control strategy, as they can be used to raise prices. The European Union (EU) developed directives to ensure some harmonisation of the fiscal pressure on tobacco across its member states. OBJECTIVES To provide a simple comparison of tobacco prices in the EU, adjusting for the purchasing power of each currency. DESIGN For price comparisons, a 20 units pack of Marlboro was the reference product, and data refer to April 2000. Purchasing power parities (PPP) for each member state currency have been compiled. These are currency conversion rates, which convert to a common currency and equalise the purchasing power of different currencies. MAIN OUTCOME MEASURES Nominal prices of a Marlboro pack for each member state, and a price index, estimated taking as reference the EU mean. Adjusted prices and an adjusted price index have been estimated using PPP. RESULTS Nominal prices show wide variation, with the cheapest pack in Portugal (59) and the most expensive in the UK (196); the range of variation is three-fold. However, PPP adjusted prices reveal a different distribution. In three countries adjusted prices are outliers, but all other countries make two clusters, one around the average EU index of 100, the other around a lower value of 85. CONCLUSIONS These results suggest that fiscal harmonisation policies in the EU do not have an even effect at reducing availability by its impact in price.

Questionnaire-based second-hand smoke assessment in adults

BACKGROUND Numerous studies have assessed second-hand smoke (SHS) exposure but a gold standard remains to be established. This study aimed to review how SHS exposure has been assessed in adults in questionnaire-based epidemiological studies. METHODS A literature search of original papers in English, French, Italian or Spanish published from January 2000 to May 2011 was performed using PubMed. The variables recorded for each study included target population, sample size, validation of the SHS questions, study design and phrasing of every question used to assess SHS exposure. For each item, information such as the setting where exposure was assessed or the indicator used to ascertain SHS exposure was extracted. RESULTS We retrieved 977 articles, of which 335 matched the inclusion criteria. The main objective of 75.8% of the studies was to assess SHS exposure.The proportion of validated questions aiming to ascertain SHS exposure was 17.9%. Most studies collected data only for one (40.3%) or two settings (33.4%), most frequently the home (83.9%) and workplace (57%). The most commonly used indicator to ascertain exposure was the presence of smokers and 68.9% of the studies included an item to assess the intensity of SHS exposure. CONCLUSIONS The variability in the indicators and items used to ascertain SHS exposure is very high, whereas the use of items derived from validated studies remains low. Identifying the diverse settings where SHS exposure may occur is essential to accurately assess exposure over time. A standard set of items to identify SHS exposure in distinct settings is needed.

Variability in the correlation between nicotine and PM2.5 as airborne markers of second-hand smoke exposure.

The aim of this study was to assess the relationship between particulate matter of diameter≤2.5 µm (PM2.5) and airborne nicotine concentration as markers of second-hand smoke exposure with respect to the setting studied, the intensity of exposure, and the type of environment studied (indoors or outdoors). Data are derived from two independent studies that simultaneously measured PM2.5 and nicotine concentrations in the air as airborne markers of second-hand smoke exposure in public places and workplaces, including health care centres, bars, public administration offices, educational centres, and transportation. We obtained 213 simultaneous measures of airborne nicotine and PM2.5. Nicotine in the air was measured with active samplers containing a sodium bisulphate-treated filter that was analysed by gas chromatography/mass spectrometry. PM2.5 was measured with a SidePak AM510 Personal Aerosol Monitor. We calculated Spearmans rank correlation coefficient and its 95% confidence intervals (95% CI) between both measures for overall data and stratified by setting, type of environment (indoors/outdoors), and intensity of second-hand smoke exposure (low/high, according to the global median nicotine concentration). We also fitted generalized regression models to further explore these relationships. The median airborne nicotine concentration was 1.36 µg/m3, and the median PM2.5 concentration was 32.13 µg/m3. The overall correlation between both markers was high (Spearmans rank correlation coefficient=0.709; 95% CI: 0.635-0.770). Correlations were higher indoors (Spearmans rank correlation coefficient=0.739; 95% CI: 0.666-0.798) and in environments with high second-hand smoke exposure (Spearmans rank correlation coefficient=0.733; 95% CI: 0.631-0.810). The multivariate analysis adjusted for type of environment and intensity of second-hand smoke exposure confirmed a strong relationship (7.1% increase in geometric mean PM2.5 concentration per µg/m3 nicotine concentration), but only in indoor environments in a stratified analysis (6.7% increase; 95% CI: 4.3-9.1%). Although the overall correlation between airborne nicotine and PM2.5 is high, there is some variability regarding the type of environment and the intensity of second-hand smoke exposure. In the absence of other sources of combustion, air nicotine and PM2.5 measures can be used indoors, while PM2.5 should be used outdoors with caution.

Validity of self-reported exposure to second-hand smoke in hospitality venues

The aim was to assess the validity of self-reported exposure to second-hand smoke (SHS) in 50 hospitality venues of Madrid (Spain) in 2010, taking as a reference vapour-phase nicotine measured by active sampling. The questions posed in the questionnaire permitted distinguishing between the different levels of SHS. However, the moderate relationship found (Spearman׳s correlation=0.387, p<0.001) suggests that intensity of exposure to SHS in hospitality venues, based solely on self-reported information, should be used with caution.

Evolución del índice de precios al consumo del tabaco y las bebidas alcohólicas: España, 1992-2001

En el patron de enfermedad y mortalidad de nuestro pais, el impacto del consumo de tabaco y el del abuso de alcohol son notables1. Este viene condicionado por diversos factores, entre los que destaca el precio. Unas politicas de prevencion integrales deben incorporar la fiscalidad como una forma de incrementar el precio y disminuir la demanda, haciendo estos productos menos asequibles, especialmente a los adolescentes que se inician en su consumo y tienen menos dinero disponible para gastar. El Banco Mundial ha documentado la fiscalidad como una de las politicas mas utiles para disminuir el consumo de tabaco2 los incrementos del precio se traducen en menor consumo, a expensas por un lado de menos inicios en los adolescentes, y de menor consumo y mas intentos de cesacion entre los fumadores adultos. La elasticidad es mayor para los adolescentes3 y el resultado es positivo para la salud en todos estos casos. La relacion del consumo de alcohol con su precio es mas compleja: el grueso de los consumidores de alcohol no sufre sindrome de dependencia y los incrementos de precio parecen producir una disminucion del consumo global, pero no a expensas de los grandes bebedores4. Sin embargo, como buena parte de los efectos adversos del alcohol sobre la salud se manifiestan entre consumidores no dependientes (a expensas de lesiones por accidentes), la disminucion del consumo parece traducirse en lesiones y muertes prevenidas5,6.

Estimation of environmental tobacco smoke exposure: review of questionnaires used in Spain

INTRODUCTION In the last few years, health surveys and epidemiological studies on smoking have introduced questions on environmental tobacco smoke (ETS) exposure. However, a standardized questionnaire is lacking. METHODS Between January and May 2008, we reviewed surveys containing items on ETS exposure carried out in Spain by public administrations, scientific societies and research institutes. The wording of the questions was reviewed and classified according to the study type, target population, geographical setting and place of exposure. RESULTS We identified 27 surveys that included questions on passive smoking. Most were health surveys (81.5%) and were aimed at the general population (70.4%). The most frequent geographical setting consisted of autonomous regions (48.1%) and the most common place of exposure was the home (88.9%) DISCUSSION The results show wide variability in the questions used. Questionnaire items on ETS exposure should be homogenized to allow comparison of the results of surveys.

[Lung cancer as an index of tobacco exposure: association with non-lung cancer mortality].

OBJECTIVE To assess the possible role of tobacco smoke in non-lung cancer (excluding stomach cancer) using changes in lung cancer mortality rates as a proxy for tobacco exposure. METHODS A time series analysis of cancer mortality was performed to evaluate the possible association between changes in mortality rates for lung cancer and for non-lung, non-stomach cancer (NLNS) from 1970 to 2003 in Spanish males. To avoid problems with autocorrelation, Prais-Winsten regression was applied. RESULTS Changes in NLNS cancer death rates showed a parallel trend with lung cancer death rates in the study period, with an adjusted slope of 1.07, 95% CI of 0.98-1.17, and R2 of 0.97. CONCLUSION Variation in NLNS cancer death rates can be accurately modelled as a function of changes in lung cancer death rates for the study period, suggesting a possible association between tobacco exposure and NLNS cancers.

Conflicts Of Interest In Research On Electronic Cigarettes

INTRODUCTION The tobacco control community has raised some concerns about whether studies on electronic cigarettes (e-cigarettes) published in scientific journals hide conflicts of interest (COI) and whether such reports are biased. This study assessed potential COI in the e-cigarette scientific literature. METHODS Cross-sectional study was conducted on e-cigarette publications indexed in PubMed up to August 2014. We extracted information about the authors (affiliations, location, etc.), publication characteristics (type, topic, subject, etc.), results and conclusions, presence of a COI statement, and funding by and/or financial ties to pharmaceutical, tobacco, and/or e-cigarette companies. An algorithm to determine the COI disclosure status was created based on the information in the publication. Prevalence ratios (PRs) and confidence intervals (CIs) were calculated to identify associations with COI disclosure, controlling for several independent variables. RESULTS Of the 404 publications included in the analysis, 37.1% (n=150) had no COI disclosure statement, 38.6% declared no COI, 13.4% declared potential COI with pharmaceutical companies, 3.0% with tobacco companies, and 10.6% with e-cigarette companies. The conclusions in publications with COI, which were mainly tied to pharmaceutical companies, were more likely to be favourable to e-cigarette use (PR=2.23; 95% CI: 1.43–3.46). Publications that supported the use of e-cigarettes for both harm reduction (PR=1.81; 95%CI: 1.14–2.89) and smoking cessation (PR=2.02; 95% CI: 1.26–3.23) were more likely to have conclusions that were favourable to e-cigarettes. CONCLUSIONS One-third of the publications reporting studies on e-cigarettes did not have a COI disclosure statement, and this proportion was even higher in news articles, editorials and other types of publications. Papers with conclusions that were favourable to e-cigarette use were more likely to have COI. Journal editors and reviewers should consider evaluating publications, including funding sources, to determine whether the results and conclusions may be biased.