Jose M. Martínez-Sánchez

Impact of the Spanish Smoking Law on Exposure to Second-Hand Smoke and Respiratory Health in Hospitality Workers: A Cohort Study

Background A smoke-free law came into effect in Spain on 1st January 2006, affecting all enclosed workplaces except hospitality venues, whose proprietors can choose among totally a smoke-free policy, a partial restriction with designated smoking areas, or no restriction on smoking on the premises. We aimed to evaluate the impact of the law among hospitality workers by assessing second-hand smoke (SHS) exposure and the frequency of respiratory symptoms before and one year after the ban. Methods and Finding We formed a baseline cohort of 431 hospitality workers in Spain and 45 workers in Portugal and Andorra. Of them, 318 (66.8%) were successfully followed up 12 months after the ban, and 137 nonsmokers were included in this analysis. We obtained self-reported exposure to SHS and the presence of respiratory symptoms, and collected saliva samples for cotinine measurement. Salivary cotinine decreased by 55.6% after the ban among nonsmoker workers in venues where smoking was totally prohibited (from median of 1.6 ng/ml before to 0.5 ng/ml, p<0.01). Cotinine concentration decreased by 27.6% (p = 0.068) among workers in venues with designated smoking areas, and by 10.7% (p = 0.475) among workers in venues where smoking was allowed. In Portugal and Andorra, no differences between cotinine concentration were found before (1.2 ng/ml) and after the ban (1.2 ng/ml). In Spain, reported respiratory symptom declined significantly (by 71.9%; p<0.05) among workers in venues that became smoke-free. After adjustment for potential confounders, salivary cotinine and respiratory symptoms decreased significantly among workers in Spanish hospitality venues where smoking was totally banned. Conclusions Among nonsmoker hospitality workers in bars and restaurants where smoking was allowed, exposure to SHS after the ban remained similar to pre-law levels. The partial restrictions on smoking in Spanish hospitality venues do not sufficiently protect hospitality workers against SHS or its consequences for respiratory health.

Smoking prevalence and smoking attributable mortality in Italy, 2010.

OBJECTIVE To provide updated information on smoking prevalence and attributable mortality in Italy. METHOD A representative survey on smoking was conducted in 2010 on a sample of 3020 Italian adults (1453 men and 1567 women). We used SAMMEC software to update smoking attributable mortality in Italy. RESULTS In 2010, 21.7% of Italians (23.9% of men and 19.7% of women) described themselves as current smokers. Smoking prevalence was higher in men than in women in all age groups, except for the middle-aged population (45-64 years; 25.6% in men and 25.9% in women). Age-standardized smoking prevalence was higher in men than in women among less educated subjects and in southern Italy. No substantial difference was observed either in educated subjects or in northern and central Italy. Overall, 71,445 deaths in Italy (52,707 men and 18,738 women, 12.5% of total mortality) are attributable to smoking. CONCLUSION The overall smoking prevalence of 21.7% in 2010 is the lowest registered over the last 50 years. Since 1998, smoking related deaths declined by almost 15%. Given that Italy has now reached the final stage of the tobacco epidemic, anti-smoking strategies should focus on support for smoking cessation.

Smoking behaviour, involuntary smoking, attitudes towards smoke-free legislations, and tobacco control activities in the European Union.

Background The six most important cost-effective policies on tobacco control can be measured by the Tobacco Control Scale (TCS). The objective of our study was to describe the correlation between the TCS and smoking prevalence, self-reported exposure to secondhand smoke (SHS) and attitudes towards smoking restrictions in the 27 countries of the European Union (EU27). Methods/Principal Findings Ecologic study in the EU27. We used data from the TCS in 2007 and from the Eurobarometer on Tobacco Survey in 2008. We analysed the relations between the TCS and prevalence of smoking, self-reported exposure to SHS (home and work), and attitudes towards smoking bans by means of scatter plots and Spearman rank-correlation coefficients (rsp). Among the EU27, smoking prevalence varied from 22.6% in Slovenia to 42.1% in Greece. Austria was the country with the lowest TCS score (35) and the UK had the highest one (93). The correlation between smoking prevalence and TCS score was negative (rsp = −0.42, p = 0.03) and the correlation between TCS score and support to smoking bans in all workplaces was positive (rsp = 0.47, p = 0.01 in restaurants; rsp = 0.5, p = 0.008 in bars, pubs, and clubs; and rsp = 0.31, p = 0.12 in other indoor workplaces). The correlation between TCS score and self-reported exposure to SHS was negative, but statistically non-significant. Conclusions/Significance Countries with a higher score in the TCS have higher support towards smoking bans in all workplaces (including restaurants, bars, pubs and clubs, and other indoor workplaces). TCS scores were strongly, but not statistically, associated with a lower prevalence of smokers and a lower self-reported exposure to SHS.

Assessment of exposure to secondhand smoke by questionnaire and salivary cotinine in the general population of Barcelona, Spain (2004-2005).

OBJECTIVES To estimate the prevalence of self-reported exposure to secondhand smoke (SHS) in different settings and to describe salivary cotinine concentration and its determinants among non-smokers. METHODS Cross-sectional study of a representative sample (N=775) of adult non-smokers in Barcelona, Spain (years 2004-2005). We assessed exposure to SHS using a questionnaire and measurement of salivary cotinine concentration. We calculated prevalence rates of self-reported exposure and medians and geometric means of salivary cotinine concentration. We adjusted for potential confounding factors with multinomial logistic regression models. RESULTS The prevalence rate of self-reported exposure to SHS among non-smokers in any setting was 75.7% (95% CI: 72.7%-78.8%). The prevalence of exposure to SHS tended to decrease with age. The geometric mean of cotinine concentrations among non-smokers was 1.49 ng/ml (95% CI: 1.39-1.60 ng/ml) among all subjects, and 1.80 ng/ml (95% CI: 1.37-2.35 ng/ml) in subjects who reported exposure to SHS in all settings. In bivariate and multivariate analyses, the cotinine concentration increased with the number of smokers and the number of cigarettes smoked per day in the presence of non-smokers in the household. CONCLUSIONS In this population, self-reported exposure to SHS is very high. Salivary cotinine concentrations in non-smokers are associated with exposure at home.

Secondhand Smoke Exposure in Spanish Adult Non-Smokers Following the Introduction of an Anti-Smoking Law

INTRODUCTION AND OBJECTIVES The aim was to investigate the prevalence of secondhand smoke exposure and active smoking in the Spanish population following the introduction of an anti-smoking law. METHODS This cross-sectional study involved a telephone survey (in June and July 2006) of a representative sample of the Spanish population aged at least 18 years-old (1221 men and 1301 women). The prevalence of secondhand smoke exposure among non-smokers was determined in terms of the context of exposure (i.e., at home, in the place of work or study, during leisure activities, or in transportation) and in general (i.e., in any context). In addition, the prevalence of active smoking in the general population was also determined. RESULTS Overall, 74,3% of non-smoking men and 70.1% of non-smoking women had been exposed to secondhand smoke in one of the four defined contexts. In men, the age-standardized prevalence of exposure was 26.4% at home, 39.8% at the place of work or study, 61.1% during leisure activities, and 37.2% in transportation. In women, the prevalence of secondhand smoke exposure was 31.4% at home, 30.7% at the place of work or study, 51.9% during leisure activities, and 45.5% in transportation. Prevalence of active smoking was 26.7% of men and 21.1% of women. CONCLUSIONS One-third of the Spanish non-smoking population are still exposed to second hand smoke in their work place or study center despite the ban introduced by the new law.

Secondhand smoke levels in public building main entrances: outdoor and indoor PM2.5 assessment

Background/Objectives To describe secondhand smoke (SHS) levels in halls and main entrances (outdoors) in different buildings by measurement of PM2.5 and airborne nicotine. Methods Cross-sectional study in a sample of 47 public buildings. The authors studied SHS levels derived from PM2.5 (micrograms per cubic metre) using TSI SidePak Personal Aerosol Monitors. The authors tested four locations within buildings: hall, main entrance (outdoor), control (indoor) and control (outdoor). The authors also measured airborne nicotine concentration (micrograms per cubic metre) in main entrances (outdoor). The authors computed medians and IQRs to describe the data. Spearman correlation coefficient (rsp) was used to explore the association between PM2.5 concentrations simultaneously measured in halls and main entrances as well as between PM2.5 and nicotine concentrations. Results The authors obtained an overall median PM2.5 concentration of hall 18.20 μg/m3 (IQR: 10.92–23.92 μg/m3), main entrance (outdoor) 17.16 μg/m3 (IQR: 10.92–24.96 μg/m3), control (indoor) 10.40 μg/m3 (IQR: 6.76–15.60 μg/m3) and control (outdoor) 13.00 μg/m3 (IQR: 8.32–18.72 μg/m3). The PM2.5 concentration in halls was more correlated with concentration in the main entrances (outdoors) (rsp=0.518, 95% CI 0.271 to 0.701) than with the control indoor (rsp=0.316, 95% CI 0.032 to 0.553). The Spearman correlation coefficient between nicotine and PM2.5 concentration was 0.365 (95% CI −0.009 to 0.650). Conclusions Indoor locations where smoking is banned are not completely free from SHS with levels similar to those obtained in the immediate entrances (outdoors) where smoking is allowed, indicating that SHS from outdoors settings drifts to adjacent indoors. These results warrant a revision of current smoke-free policies in particular outdoor settings.

Electronic cigarette use among adult population: a cross-sectional study in Barcelona, Spain (2013–2014)

Objective This study seeks to analyse the prevalence and correlates of electronic cigarette (e-cigarette) use, purchase location and satisfaction with its use in a sample of the general population of the city of Barcelona, Spain. Design, setting and participants We used participants from a longitudinal study of a representative sample of the adult (≥16 years old) population of Barcelona (336 men and 400 women). The field work was conducted between May 2013 and February 2014. We computed the prevalence, adjusted odds ratios (ORs) and their corresponding 95% confidence interval (CI). Results The prevalence of ever e-cigarette use was 6.5% (95% CI 4.7% to 8.3%): 1.6% current use, 2.2% past use and 2.7% only e-cigarette experimentation. 75% (95% CI 62.8% to 87.3%) of ever e-cigarette users were current cigarette smokers at the moment of the interview. E-cigarette use was more likely among current smokers (OR=54.57; 95% CI 7.33 to 406.38) and highly dependent cigarette smokers (OR=3.96; 95% CI 1.60 to 9.82). 62.5% of the ever users charged their e-cigarettes with nicotine with 70% of them obtaining the liquids with nicotine in a specialised shop. 39.6% of ever e-cigarette users were not satisfied with their use, a similar percentage of not satisfied expressing the smokers (38.9%) and there were no statistically significant differences in the satisfaction between the users of e-cigarettes with and without nicotine. Conclusions E-cigarette use is strongly associated with current smoking (dual use) and most users continue to be addicted to nicotine. Six out of 10 e-cigarette users preferred devices that deliver nicotine. The satisfaction with e-cigarette use is very low.

Secondhand smoke in hospitals of Catalonia (Spain) before and after a comprehensive ban on smoking at the national level.

OBJECTIVE To assess changes in secondhand smoke exposure by means of airborne nicotine concentrations in public hospitals of Catalonia (Spain) before and after a comprehensive national smoking ban. METHODS We monitored vapor-phase nicotine concentrations in 44 public hospitals in Catalonia (Spain) before the smoking ban (September-December 2005) and one year after (September-December 2006). We installed 5-7 sampling devices per hospital for 7 days in different places (228 pairs of samples), and 198 pairs of samples were available for the final analysis. RESULTS The median nicotine concentration declined from 0.23 microg/m(3) (interquartile range: 0.13-0.63) before the law to 0.10 microg/m(3) (interquartile range: 0.02-0.19) after the law (% decline=56.5, p<0.01). We observed significant reductions in the median nicotine concentrations in all hospital locations, although secondhand smoke exposure was still present in some places (main hospital entrance, emergency department waiting rooms, fire escapes, and cafeterias). CONCLUSIONS Secondhand smoke in hospitals has decreased after the ban. Assessment of airborne nicotine concentrations appears to be an objective and feasible system to monitor and reinforce the compliance of smoke-free legislations in this setting.

Impact of the Spanish smoke-free legislation on adult, non-smoker exposure to secondhand smoke: cross-sectional surveys before (2004) and after (2012) legislation.

Background In 2006, Spain implemented a national smoke-free legislation that prohibited smoking in enclosed public places and workplaces (except in hospitality venues). In 2011, it was extended to all hospitality venues and selected outdoor areas (hospital campuses, educational centers, and playgrounds). The objective of the study is to evaluate changes in exposure to secondhand smoke among the adult non-smoking population before the first law (2004-05) and after the second law (2011–12). Methods Repeated cross-sectional survey (2004–2005 and 2011–2012) of a representative sample of the adult (≥16 years) non-smoking population in Barcelona, Spain. We assess self-reported exposure to secondhand smoke (at home, the workplace, during leisure time, and in public/private transportation vehicles) and salivary cotinine concentration. Results Overall, the self-reported exposure to secondhand smoke fell from 75.7% (95%CI: 72.6 to 78.8) in 2004-05 to 56.7% (95%CI: 53.4 to 60.0) in 2011–12. Self-reported exposure decreased from 32.5% to 27.6% (−15.1%, p<0.05) in the home, from 42.9% to 37.5% (−12.6%, p = 0.11) at work/education venues, from 61.3% to 38.9% (−36.5%, p<0.001) during leisure time, and from 12.3% to 3.7% (−69.9%, p<0.001) in public transportation vehicles. Overall, the geometric mean of the salivary cotinine concentration in adult non-smokers fell by 87.2%, from 0.93 ng/mL at baseline to 0.12 ng/mL after legislation (p<0.001). Conclusions Secondhand smoke exposure among non-smokers, assessed both by self-reported exposure and salivary cotinine concentration, decreased after the implementation of a stepwise, comprehensive smoke-free legislation. There was a high reduction in secondhand smoke exposure during leisure time and no displacement of secondhand smoke exposure at home.

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.