Manel Nebot

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.

Impact of the Spanish Smoking Law on Exposure to Secondhand Smoke in Offices and Hospitality Venues: Before-and-After Study

Background/objectives A smoking law was passed by the Spanish Parliament in December 2005 and was enforced by 1 January 2006. The law bans smoking in all indoor workplaces but only in some hospitality venues, because owners are allowed to establish a smoking zone (venues > 100 m2) or to allow smoking without restrictions (venues < 100 m2). The objective of the study is to assess the impact of the Spanish smoking law on exposure to secondhand smoke (SHS) in enclosed workplaces, including hospitality venues. Materials and methods The study design is a before-and-after evaluation. We studied workplaces and hospitality venues from eight different regions of Spain. We took repeated samples of vapor-phase nicotine concentration in 398 premises, including private offices (162), public administration offices (90), university premises (43), bars and restaurants (79), and discotheques and pubs (24). Results In the follow-up period, SHS levels were markedly reduced in indoor offices. The median decrease in nicotine concentration ranged from 60.0% in public premises to 97.4% in private areas. Nicotine concentrations were also markedly reduced in bars and restaurants that became smoke-free (96.7%) and in the no-smoking zones of venues with separate spaces for smokers (88.9%). We found no significant changes in smoking zones or in premises allowing smoking, including discotheques and pubs. Conclusions Overall, this study shows the positive impact of the law on reducing SHS in indoor workplaces. However, SHS was substantially reduced only in bars and restaurants that became smoke-free. Most hospitality workers continue to be exposed to very high levels of SHS. Therefore, a 100% smoke-free policy for all hospitality venues is required.

Social class, education, and smoking cessation: Long-term follow-up of patients treated at a smoking cessation unit

Our objective was to examine social class and educational differences in long-term smoking cessation success among a cohort of smokers attending a specialized smoking clinic. We studied sustained abstinence after cessation among 1,516 smokers (895 men and 621 women) treated for smoking cessation between 1995 and 2001 at a university teaching hospital in the metropolitan area of Barcelona, Spain. We calculated 1-year and long-term (up to 8-year) abstinence probabilities by means of Kaplan-Meier curves and the hazard ratio of relapse by means of Cox regression, after adjusting for other predictors of relapse. Overall abstinence probability was .277 (95% CI = .254-.301). Men and women in social classes IV-V had significant hazard ratios of relapse after long-term follow-up (men: 1.36, 95% CI = 1.07-1.72; women: 1.60, 95% CI = 1.24-2.06), as compared with patients in social classes I-II. The same independent effect was observed for education: Men and women with primary or less than primary studies had higher hazard ratios of relapse (men: 1.75, 95% CI = 1.35-2.25; women: 1.92, 95% CI = 1.51-2.46), as compared with patients with a university degree. Similar estimates were obtained after adjustment for stage of change, Fagerström score for nicotine dependence, and type of treatment. Patients of lower socioeconomic status are at higher risk of relapse, and this association is independent of other well-known predictors of relapse. Social differences have to be taken into account in the clinical setting when tailoring specific actions to treat smoking dependence.

Factors associated with the onset of cannabis use: a systematic review of cohort studies

OBJECTIVE To determine the factors associated with the onset of cannabis use through a systematic review of cohort studies. METHODS An internet-based search was performed using several keywords and their combinations. Original studies with longitudinal design and the onset of cannabis use as dependent variable, as well as review studies were included, published between January 1980 and May 2004. Methodology quality of the studies was assessed independently by two reviewers, according to pre-established criteria, in order to classify studies in high, mid or low quality. Agreement between reviewers was assessed through kappa coefficient. RESULTS A total of 32 relevant studies were identified, of which 13 were of higher quality. Selection bias for the inclusion of consumers at the baseline measurement and lack or insufficient adjustment for confounders were the causes of exclusion. The factors of great evidence related to the onset of cannabis use were masculine sex, consumption of tobacco or alcohol, having a problematic relationship with parents, and cannabis consumption by friends. CONCLUSION Results highlight the importance of different individual, family and environmental factors on the onset of cannabis use. These must be considered to properly arrange intervention programs focusing on primary prevention among teenagers.

Evaluación de la efectividad de los programas escolares de prevención del consumo de tabaco, alcohol y cannabis: ¿Qué nos dicen los meta-análisis?

Consumption of tobacco, alcohol and illegal drugs is a major public health problem in developed countries. The aim of the study is to describe the impact and associated characteristics of preventive programs addressed at those problems in the school setting. Meta-analysis focusing on evaluations of programs focusing on smoking, alcohol and/or cannabis at the school setting are reviewed. The search was done at Cochrane Library and Medline databases of articles published between 1993 and 1999, and including as keywords programs, education, drugs prevention, prevention, smoking, alcohol, school, adolescence, teenagers, young people, evaluation, health education, effectiveness, review, meta-analysis. We found 5 meta-analysis of programs summarizing the effect of preventive programs, most of them dealing with legal and illegal drugs. However, most of the interventions reporting changes in behavior measured only smoking. More effective interventions addressed social influences, used active methodology and were implemented by teachers or peers. The importance of booster sessions, the quality of implementation and thorough evaluation is stressed. Overall, meta-analysis of evaluated programs shows a small effect, although the population impact may be relevant. Some limitations point to new areas of interest for future research.

Italy and Austria before and after study: second-hand smoke exposure in hospitality premises before and after 2 years from the introduction of the Italian smoking ban

UNLABELLED The aim of this paper was to compare nicotine concentration in 28 hospitality premises (HPs) in Florence and Belluno, Italy, where a smoking ban was introduced in 2005, and in 19 HPs in Vienna, Austria, where no anti-smoking law entered into force up to now. Airborne nicotine concentrations were measured in the same HPs in winter 2002 or 2004 (pre-ban measurements) and winter 2007 (post-ban measurements). In Florence and Belluno, medians decreased significantly (P < 0.001) from 8.86 [interquartile range (IQR): 2.41-45.07)] before the ban to 0.01 microg/m3 (IQR: 0.01-0.41) afterwards. In Austria (no smoking ban) the medians collected in winters 2004 and 2007 were, respectively, 11.00 (IQR: 2.53-30.38) and 15.76 microg/m3 (IQR: 2.22-31.93), with no significant differences. Measurements collected in winter 2007 in 28 HPs located in Naples, Turin, Milan (0.01 microg/m3; IQR: 0.01-0.16) confirmed post-ban results in Florence and Belluno. The medians of nicotine concentrations in Italy and Austria before the Italian ban translates, using the risk model of Repace and Lowery, into a lifetime excess lung cancer mortality risk for hospitality workers of 11.81 and 14.67 per 10,000, respectively. Lifetime excess lung cancer mortality risks for bar and disco-pub workers were 10-20 times higher than that calculated for restaurant workers, both in Italy and Austria. In winter 2007, it dropped to 0.01 per 10,000 in Italy, whereas in Austria it remained at the same levels. The drop of second-hand smoke exposure indicates a substantial improvement in air quality in Italian HPs even after 2 years from the ban. PRACTICAL IMPLICATIONS The nation-wide smoking ban introduced in Italy on January 10, 2005, resulted in a drop in second-hand smoke exposure in hospitality premises, whereas in Austria, where there is no similar nation-wide smoking ban, the exposure to second-hand smoke in hospitality premises remains high. Given that second-hand smoke is considered a group 1 carcinogen according to the International Agency for Research on Cancer classification, the World Health Organization Framework Convention on Tobacco Control strongly recommends the implementation of nation-wide smoke-free policies in order to improve the indoor air quality of hospitality premises and workplaces. Results from our study strongly supports this recommendation.

Secondhand tobacco smoke exposure in open and semi-open settings: a systematic review.

Background: Some countries have recently extended smoke-free policies to particular outdoor settings; however, there is controversy regarding whether this is scientifically and ethically justifiable. Objectives: The objective of the present study was to review research on secondhand smoke (SHS) exposure in outdoor settings. Data sources: We conducted different searches in PubMed for the period prior to September 2012. We checked the references of the identified papers, and conducted a similar search in Google Scholar. Study selection: Our search terms included combinations of “secondhand smoke,” “environmental tobacco smoke,” “passive smoking” OR “tobacco smoke pollution” AND “outdoors” AND “PM” (particulate matter), “PM2.5” (PM with diameter ≤ 2.5 µm), “respirable suspended particles,” “particulate matter,” “nicotine,” “CO” (carbon monoxide), “cotinine,” “marker,” “biomarker” OR “airborne marker.” In total, 18 articles and reports met the inclusion criteria. Results: Almost all studies used PM2.5 concentration as an SHS marker. Mean PM2.5 concentrations reported for outdoor smoking areas when smokers were present ranged from 8.32 to 124 µg/m3 at hospitality venues, and 4.60 to 17.80 µg/m3 at other locations. Mean PM2.5 concentrations in smoke-free indoor settings near outdoor smoking areas ranged from 4 to 120.51 µg/m3. SHS levels increased when smokers were present, and outdoor and indoor SHS levels were related. Most studies reported a positive association between SHS measures and smoker density, enclosure of outdoor locations, wind conditions, and proximity to smokers. Conclusions: The available evidence indicates high SHS levels at some outdoor smoking areas and at adjacent smoke-free indoor areas. Further research and standardization of methodology is needed to determine whether smoke-free legislation should be extended to outdoor settings.

Effectiveness of the pneumococcal polysaccharide vaccine in preventing pneumonia in the elderly

The objective of our study was to evaluate the effectiveness of the 23-valent pneumococcal polysaccharide vaccine (PPV) in preventing hospital admission for community-acquired pneumonia (CAP) in people ≥65 yrs of age. We conducted a matched case–control study in patients with CAP admitted to five Spanish hospitals. Cases were persons aged ≥65 yrs admitted to hospital through the emergency department, who presented a clinical and radiological pattern compatible with pneumonia, assessed using established criteria. We matched each case with three control subjects by sex, age (±5 yrs), date of hospitalisation (±30 days) and underlying disease. The study period was May 1, 2005 to January 31, 2007. The PPV immunisation status of cases and controls was investigated. Adjusted ORs for vaccination were calculated using logistic regression analysis. A total of 489 cases and 1,467 controls were included in the final analysis. The overall adjusted vaccination effectiveness for all patients was 23.6% (95% CI 0.9–41.0). The adjusted vaccination effectiveness for immunosuppressed patients was 21.0% (95% CI -18.7–47.5). Our results suggest that the PPV may potentially reduce hospitalisations for pneumonia in the elderly and supports vaccination programmes in this age group.

Social inequalities in health related behaviours in Barcelona

OBJECTIVE This study describes social class inequalities in health related behaviours (tobacco and alcohol consumption, physical activity) among a sample of general population over 14 years old in Barcelona. DESIGN Cross sectional study (Barcelona Health Interview Survey). SETTING Barcelona city (Spain). PARTICIPANTS A representative stratified sample of the non-institutionalised population resident in Barcelona was obtained. This study refers to the 4171 respondents aged over 14. DATA Social class was obtained from a Spanish adaptation of the British Registrar General classification. In addition, sociodemographic variables such as family structure and employment status were used. As health related behaviours tobacco consumption, alcohol consumption, usual physical activity and leisure time physical activity were analysed. Age adjusted percentages were compared by social class. Multivariate analysis was performed using logistic regression models. MAIN RESULTS Women in the upper social classes were more likely to smoke, the adjusted odds ratio (OR) for social class V in reference to social class I was 0.36 (95% confidence intervals (95%CI): 0.19, 0.67), while the opposite occurred among men although it was not statistically significant in multivariate analysis. Smoking cessation was more likely among men in the higher classes (OR for class V 0.41, 95%CI: 0.18, 0.90). Excessive alcohol consumption among men showed no differences between classes, while among women it was greater in the upper classes. Engaging in usual physical activity classified as “light or none” in men decreased with lowering social class (OR class IVa: 0.55 and OR class IVb: 0.47). Women of social classes IV and V were less likely to have two or more health risk behaviours (OR for class V 0.33, 95% CI: 0.18, 0.62). CONCLUSION Health damaging behaviours are differentially distributed among social classes in Barcelona. Health policies should take into account these inequalities.

Total and Inorganic Arsenic in Marketed Food and Associated Health Risks for the Catalan (Spain) Population

Inorganic arsenic (iAs) is considered to be a human carcinogen. In this paper, total (As) and iAs contents of 215 food products and drinks (i.e., seafood, fruits and vegetables, meat products, oils and fats, rice and rice products, seasonings, and alcoholic drinks) marketed in Catalonia (Spain) were quantified by inductively coupled plasma-mass spectrometry. The analytical method described was used for different food products, obtaining feasible results without the need to couple LC-ICP-MS for iAs. Daily As and iAs intakes for the average adult Catalan consumer were estimated at 354 and 6.1 μg/day/person, respectively, using consumption data from the Catalan Nutrition Survey (ENCAT). The highest As content was found in seafood, contributing 96% of dietary As intake, whereas rice presented the highest iAs values, corresponding to 67% of dietary iAs intake. As cooking process may affect iAs content, boiled rice was evaluated, showing an iAs reduction (up to 86%) when using higher water volumes (30:1 water/rice ratio) than those used in previous studies. This iAs exposure was slightly below the exposure risk range stated by the European Food Safety Authority (0.3-8 μg/kg of body weight/day), although the possibility of a risk to the population with high rice consumption cannot be excluded.