Juan Antonio Riesco Miranda

Study of the impact of laws regulating tobacco consumption on the prevalence of passive smoking in Spain

BACKGROUND In 2005, the Spanish parliament passed the Spanish anti-smoking law. This legislation restricted tobacco smoking in public places, including recreation venues (bars and restaurants), but smoking was not completely prohibited in bars and restaurants. The law was enforced in January 2006. With the objective of analysing the impact that this law has had on the general Spanish population, the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) designed and implemented a survey of a representative sample of the general Spanish population on two separate occasions: in 2005 and in 2007 (12 months after the ban came into effect). METHODS Two epidemiological, observational and cross-sectional surveys were performed among a random and representative sample of the general Spanish population, using the Computer-Assisted Telephone Interview system. RESULTS In the first survey, a total of 6533 subjects were interviewed, of whom 3907 (59.8%) were non-smokers and in the second, a total of 3289 subjects were interviewed, of whom 2174 (65.9%) were non-smokers. The overall prevalence of exposure to environmental tobacco smoke (ETS) decreased from 49.5% in 2005 to 37.9% in 2007 (22% reduction). The greatest reduction in prevalence of ETS exposure was in workplaces (from 25.8% to 11%, a decrease of 58.8%). Smaller reductions occurred in the home (from 29.5% to 21.4%, a decrease of 27%) and in recreation venues (from 37.4% to 31.8%, a decrease of 8%). CONCLUSIONS Implementation of the smoking ban resulted in a significant decrease in exposure to ETS.

Legislating tolerance: Spain's national public smoking law

While Spains national tobacco control legislation prohibits smoking in many indoor public places, the law provides for an exception to the prohibition of smoking by allowing separate seating sections and ventilation options in certain public places such as bars and restaurants, hotels and airports. Accordingly, Spains law is not aligned with Article 8 Guidelines of the World Health Organizations Framework Convention on Tobacco Control, which requires parties to ensure universal protection against secondhand smoke exposure in all enclosed public places, workplaces and on all means of public transport. Spains law is currently being promoted by the tobacco companies in other countries as a model for smoke-free legislation. In order to prevent weakening of smoke-free laws in other countries through industry-supported exceptions, we investigated the tactics used by the tobacco companies before the implementation of the new law and assessed the consequences of these actions in the hospitality sector. Internal tobacco industry documents made public through US litigation settlements dating back to the 1980s were searched in 2008–9. Documents show that tobacco companies sought to protect hospitality venues from smoking restrictions by promoting separate seating for smokers and ineffective ventilation technologies, supporting an unenforceable voluntary agreement between the Madrid local government and the hospitality industry, influencing ventilation standards setting and manipulating Spanish media. The Spanish National Assembly should adopt comprehensive smoke-free legislation that does not accommodate the interests of the tobacco industry. In doing so, Spains smoke-free public places law would be better aligned with the Framework Convention on Tobacco Control.

Recomendaciones para el tratamiento farmacológico del tabaquismo. Propuestas de financiación

. Todas estas guias coinciden en considerar que el tra-tamiento del tabaquismo es diferente para cada fuma-dor y depende fundamentalmente de la motivacion queeste tenga para abandonar de forma definitiva el consu-mo del tabaco. Asi, parece claro que los fumadores quese encuentren en fase de preparacion deben recibir 2 ti-pos de intervencion:

Pharmacological Tobacco Cessation Treatments: Proposals for Financing

Tobacco dependence is a recurring and addictive chronic disease and the leading preventable cause of death in the world. All health professionals are obliged to correctly diagnose and treat smokers to enable them to break the habit.1,2 In recent years, a wide range of recommendations and guidelines for treating smokers have been published for health professionals.1,2-5 In 2002 in Spain, a group of scientific societies published the first consensus document on the diagnosis and treatment of tobacco dependence.6 In 2003, the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) updated the current guidelines on treatment of tobacco dependence.7,8 All these guidelines agree that treatment of this condition must be on an individual basis and depends essentially on personal motivation for permanent cessation. Therefore, it seems clear that smokers who are preparing to quit should receive 2 types of help: a) behavioral therapy, aimed at combating their psychological dependence and b) pharmacological therapy to relieve their physical dependence on nicotine (level A evidence).1-8 During the last 10 years, there have been important developments in the pharmacological treatment of smoking. New drugs have come onto the market, the modes of use and doses of currently available drugs have been modified, and the indications of the different drugs have even varied slightly. Furthermore, the arrival of new pharmacological options in tobacco cessation has opened an important debate as to whether this option should be financed by the Spanish national health system.9,10 These new guidelines on the pharmacological treatment of smoking have 2 main objectives: to analyze the drugs approved by the Spanish health authorities for use as pharmacological treatment of tobacco dependence and to make reasoned proposals based on scientific evidence for public financing of these treatments. This article sets out the neurophysiological grounding of nicotine dependence and tobacco addiction. It also uses scientific evidence to justify the need for smokers who wish to make a serious attempt at quitting to receive pharmacological therapy when indicated. Similarly, the article reviews the mechanism of action, doses, indications, and contraindications of each of the drugs available in Spain (nicotine gum, tablets, and patches, bupropion, and varenicline) to help smokers quit. The article also examines the results and conclusions of a new approach to the treatment of tobacco dependence: gradual reduction of intake using nicotine gum as a first step towards permanent cessation. Finally, proposals for public financing of pharmacological treatment to help smokers quit are presented.

Tratamiento del tabaquismo en fumadores con enfermedad pulmonar obstructiva crónica

Unidad Especializada en Tabaquismo, Comunidad de Madrid, Madrid, España Servicio de Neumología, Hospital San Pedro de Alcántara, Cáceres, España CAP Drassanes, Barcelona, España Servicio de Neumología, Complejo Hospitalario de Navarra B, Pamplona, España Servicio de Neumología, Hospital San Juan, San Juan de Alicante, Alicante, España Servicio de Neumología, Hospital Universitario Gregorio Marañón, Madrid, España Servicio de Neumología, Hospital Valdemoro, Valdemoro, Madrid, España Servicio de Neumología, Hospital Fundación Alcorcón, Alcorcón, Madrid, España Servicio de Neumología, Hospital San Agustín, Avilés, Asturias, España Servicio de Neumología, Hospital Universitario de Salamanca, Salamanca, España

Abstinencia puntual y continuada con el tratamiento farmacológico del tabaquismo en la práctica clínica

BACKGROUND AND OBJECTIVE: The objective of the study was to evaluate the effectiveness of the pharmacological treatment of tobacco dependence according to the criteria established by SEPAR.ATIENTS AND METHOD: Longitudinal, prospective and multicentre study. We included smokers aged more than 18 years who attended 5 smokers clinics and received nicotine replacement therapy (NRT), bupropion or both. The punctual and continuous abstinence was studied at the 15, 30, 60, 90 and 180 days with each one of the proposed treatments. Effective results were defined as the intention to treat. RESULTS: There were 904 smokers, 476 males and 428 females, mean age 42.51 (10.09). Of the 904 individuals who started the treatment, 820, 776, 687, 719 and 679 were present at the follow-up sessions at 15, 30, 60, 90 and 180 days, respectively. The punctual global abstinence at 15 and 180 days was 65.6% and 43.1%, while the continuous one was 57.4% and 38.8% at two and six months, respectively. Significant differences were not observed with regard to the punctual or continuous abstinence among patients treated with NRT, bupropion or both.ONCLUSIONS: The pharmacological treatment of tobacco dependence used individually according to the recommendations of the clinical guidelines allows to obtain good results with regard to the momentous and continuous abstinence. The effectiveness of the different first line treatments is similar in all the phases of the therapeutic process.

Año SEPAR 2007: Año para la Prevención y el Control del Tabaquismo

logía y Cirugía Torácica (SEPAR) viene realizando, a través de la Fundación Respira, unas campañas anuales para la prevención y el tratamiento de enfermedades respiratorias con alta prevalencia1,2. Esta iniciativa ha facilitado que la SEPAR y la Fundación Respira no sólo incrementen su impacto social en la población general española, sino que además den cumplimiento a uno de sus principales objetivos como sociedad y fundación científicas: prevenir la morbimortalidad de las enfermedades respiratorias a través del incremento de la sensibilización e información de la población general española. En el momento actual el tabaquismo se considera una enfermedad adictiva y crónica, capaz de causar la muerte prematura a más de la mitad de aquellos que la presentan3,4. Los datos más recientes de nuestro país señalan que cada año el tabaco mata a 56.000 personas3. En este mismo estudio se identifica el tabaquismo como una de las principales causas de enfermedades respiratorias en España, causando el 87% de los cánceres de pulmón y el 93% de los casos de enfermedad pulmonar obstructiva crónica (EPOC)5. Teniendo en cuenta esta realidad, la Junta Directiva de la SEPAR acordó designar el año 2007 como Año SEPAR para la Prevención y el Tratamiento del Tabaquismo. Los principales objetivos que pretendemos cumplir a lo largo de este año son los siguientes: incrementar la educación sanitaria que la población general española tiene sobre esta enfermedad y su relación con multitud de afecciones respiratorias; sensibilizar a los colectivos modélicos (políticos, periodistas, artistas y otras personalidades) sobre la necesidad de prevenir y tratar este proceso, y difundir el mensaje de que hay tratamientos farmacológicos que son eficaces y seguros para ayudar a los fumadores a dejar de serlo. A fin de cumplir con estos objetivos hemos diseñado un completo plan de actividades, que van desde aquéllas con una finalidad científica o de investigación a otras cuyo fin es más bien de índole social. A continuación comentaremos algunas. Una de las principales actividades científicas que desarrollaremos en los próximos meses será la confección de unas nuevas recomendaciones para el tratamiento del tabaquismo. La última normativa sobre el tratamiento del tabaquismo, elaborada por el Área de Tabaquismo de la SEPAR, data de 2003; con anterioridad existía otra de 19996,7. En los últimos años han aparecido nuevosfármacos para dejar de fumar e incluso se han modificado la forma de uso y las indicaciones de los ya existentes8,9. Estas novedades exigen una actualización de las recomendaciones anteriores. Pero además en esta nueva edición queremos incluir un aspecto que sin duda resultará pionero: expondremos una propuesta razonada, bien ponderada y basada en la evidencia científica, sobre la financiación de los tratamientos farmacológicos para dejar de fumar. A finales de 2005 el Área de Tabaquismo de la SEPAR llevó a cabo un estudio cualitativo de base poblacional, en el que se realizaron hasta 6.800 encuestas y se obtuvieron datos representativos de todo el Estado español y de cada una de las comunidades autónomas sobre prevalencia y actitudes que hacia el tabaquismo pasivo tiene la población general española, así como datos sobre tasa de enfermedades asociadas a este proceso. Los resultados se han presentado en alguna de las reuniones científicas que el Área de Tabaquismo ha celebrado a lo largo de estos meses y están pendientes de publicación10-12. No obstante, los datos más llamativos son los siguientes: el 29,5% de los no fumadores están sometidos al humo ambiental del tabaco en sus hogares, el 25,8% lo están en su lugar de trabajo y, más llamativo aún, el 17,8% de los escolares está expuesto al humo del tabaco en los centros docentes. Estamos convencidos de que con la entrada en vigor de la nueva ley sobre regulación del consumo de tabaco estos parámetros se habrán modificado. Por ello, una de las principales actividades de investigación que queremos llevar a cabo durante este año es la repetición de este estudio. La SEPAR será la única sociedad científica española que dispondrá de datos reales sobre el impacto que la nueva ley reguladora del consumo de tabaco ha tenido en nuestro país13. Igualmente hemos diseñado un completo plan de comunicación social, uno de cuyos principales nexos de unión será una campaña itinerante a bordo del camión Planeta Respira. Se trata de un gran tráiler que recorrerá más de 30 ciudades españolas (todas las comunidades

Presente y futuro del Área de Tabaquismo de la SEPAR

Resumen El tabaquismo es la primera causa evitable de mortalidad prematura y morbilidad en nuestro medio. Segun datos de la Organizacion Mundial de la Salud, el tabaco se cobra mas de 5 millones de vidas al ano, cifra que presumiblemente ira en aumento y sera de 10 millones para el ano 2030. Los profesionales sanitarios estamos obligados a implicarnos activamente en este grave problema sanitario identificando, diagnosticando y tratando correctamente a todos los fumadores para ayudarles en el proceso de abandono y facilitar el logro de la abstinencia definitiva. Existe evidencia cientifica que el tabaquismo es causa directa o motivo de empeoramiento de muchas enfermedades respiratorias, que por su naturaleza competen basicamente al neumologo, que oficialmente, de acuerdo con la administracion sanitaria, es el especialista y experto en la materia. El Area de Tabaquismo de la SEPAR se inicio en el ano 1995. Sus principales objetivos fueron incrementar la sensibilizacion sobre el problema del tabaquismo entre los miembros de nuestra sociedad cientifica, mejorar sus conocimientos cientificos en esta afeccion, facilitar las intervenciones diagnosticas y terapeuticas en los fumadores y, por ultimo, promover las intervenciones para la prevencion y el tratamiento del tabaquismo por parte de la administracion politico-sanitaria. Hoy dia es una de las areas mas dinamicas de la SEPAR y cuenta con mas de 400 miembros. Muchos son los retos pendientes de nuestra area, pero el fundamental lo constituye seguir ocupando un lugar referente para la administracion, para nuestros pacientes, para otros profesionales sanitarios de otras especialidades y sociedades cientificas, y para todos los profesionales de la SEPAR en un aspecto clave que no merece dudas: defender el bienestar y la salud de nuestra poblacion frente a la principal causa de enfermedad y mortalidad evitable, el tabaco.

Impact of Legislation on Passive Smoking in Spain

Background: In 2005, the Spanish government approved Law 28/2005 on health measures against smoking; this was amended in 2010 by Law 42/2010. Objective: The purpose of this study was to assess the impact of these laws on passive smoking. Methods: Three epidemiological studies were conducted on a representative sample of the population via telephone surveys. The first was conducted prior to the first law coming into force, the second a year after its approval and the third a year after the approval of the second.Results: Six thousand eight hundred people were surveyed in 2005, 3,289 in 2007 and 3,298 in 2011. The first survey showed that 49.5% of nonsmokers were exposed to second-hand smoke (SHS) while by 2007, following the introduction of Law 28/2005, this exposure had been reduced to 37.9% (results previously published in 2008). The 2011 survey, conducted following the introduction of Law 42/2010, showed that just 21% of people were exposed. These data indicate that overall exposure to SHS was reduced by 22% between 2005 and 2007 and by a further 16.9% between 2007 and 2011. The overall impact of Law 42/2010 is estimated to be around 44% and Law 28/2005 around 22%. Conclusion: Legislation introduced in Spain has markedly reduced the exposure of nonsmokers to SHS.

Normativa sobre tratamiento del tabaquismo en pacientes hospitalizados.

Between 15 and 27% of patients admitted to Spanish hospitals are smokers. Hospitalization is an ideal time for a smoker to decide to quit. We performed a MEDLINE search of controlled, randomized or observational studies associated with helping hospitalized patients quit smoking, published between January 1, 2002 and September 30, 2015. On the basis of the results of those studies, we have issued some recommendations for the treatment of smoking in hospitalized patients. The recommendations were drawn up according to the GRADE system. Offering the smoker psychological counselling and prolonging follow-up for at least 4 weeks after discharge is the most effective recommendation for helping hospitalized patients to quit.Between 15 and 27% of patients admitted to Spanish hospitals are smokers. Hospitalization is an ideal time for a smoker to decide to quit. We performed a MEDLINE search of controlled, randomized or observational studies associated with helping hospitalized patients quit smoking, published between January 1, 2002 and September 30, 2015. On the basis of the results of those studies, we have issued some recommendations for the treatment of smoking in hospitalized patients. The recommendations were drawn up according to the GRADE system. Offering the smoker psychological counselling and prolonging follow-up for at least 4 weeks after discharge is the most effective recommendation for helping hospitalized patients to quit.