María José López

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% (pu200a=u200a0.068) among workers in venues with designated smoking areas, and by 10.7% (pu200a=u200a0.475) 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.

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 18.20u2005μg/m3 (IQR: 10.92–23.92u2005μg/m3), main entrance (outdoor) 17.16u2005μg/m3 (IQR: 10.92–24.96u2005μg/m3), control (indoor) 10.40u2005μg/m3 (IQR: 6.76–15.60u2005μg/m3) and control (outdoor) 13.00u2005μg/m3 (IQR: 8.32–18.72u2005μg/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.

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

OBJECTIVEnTo 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.nnnMETHODSnWe 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.nnnRESULTSnThe 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).nnnCONCLUSIONSnSecondhand 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.

Second-hand smoke in hospitals in Catalonia (2009): a cross-sectional study measuring PM2.5 and vapor-phase nicotine.

OBJECTIVESnTo describe second-hand smoke in the hospitals of the Catalan Network for Smoke-free Hospitals using Particulate Matter (PM(2.5)) and to assess the association between second-hand smoke exposure in main entrances (outdoors) and halls and between PM(2.5) and airborne nicotine concentrations.nnnMETHODSnCross-sectional study carried out in 2009 in the 53 hospitals affiliated with the network. We measured PM(2.5) (μg/m(3)) in all hospitals and measured airborne nicotine concentrations (μg/m(3)) in a subsample of 11 hospitals. For each assessment, we measured nine locations within the hospitals, computing medians, means, geometric means, interquartile ranges (IQRs), and 95% confidence intervals (CI) of the means and the geometric means. Further, we used Spearmans linear correlation coefficient r(sp)) to explore the association between PM(2.5) concentrations in halls and main entrances and between PM(2.5) and nicotine concentrations.nnnRESULTSnThe overall median of the 429 PM(2.5) measurements was 12.48 μg/m(3) (IQR: 8.84-19.76 μg/m(3)). The most exposed locations were outdoor smoking points (16.64 μg/m(3)), cafeterias (14.82 μg/m(3)), and main entrances (14.04 μg/m(3)); dressing rooms were the least exposed (6.76 μg/m(3)). PM(2.5) concentrations in halls were positively correlated with those in main entrances (r(sp)=0.591, 95% CI: 0.377-0.745), as were PM(2.5) values and nicotine concentrations (r(sp)=0.644, 95% CI: 0.357-0.820).nnnCONCLUSIONSnSecond-hand smoke levels in hospitals were low in most locations, with the highest levels observed in outdoor locations where smoking is allowed (smoking points and entrances). Smoking in main entrances was associated with increased second-hand smoke levels in halls. Use of PM(2.5) to evaluate second-hand smoke is feasible and shows a good correlation with airborne nicotine values.

Secondhand smoke exposure at home: Assessment by biomarkers and airborne markers

OBJECTIVEnWe assessed and characterized the relationship among biomarkers of secondhand smoke (SHS) exposure in non-smokers according to their exposure at home as measured by airborne markers.nnnMETHODSnWe conducted an observational study on exposure to SHS at home using airborne markers (nicotine and benzene) and biomarkers from the non-smokers living in these homes. We selected 49 non-smoking volunteers from different homes: 25 non-smokers living with at least one smoker and 24 non-smokers living in smoke-free homes. We installed two passive devices to measure nicotine and benzene concentrations in the main room of the house (i.e., the living room). One week later, the researcher returned to the volunteers home to collect the two devices, obtain saliva and urine samples, and administer a SHS questionnaire.nnnRESULTSnSalivary and urinary cotinine concentrations highly correlated with air nicotine concentrations measured at the volunteershomes (rsp=0.738 and rsp=0.679, respectively). The concentrations of airborne markers of SHS and biomarkers in non-smokers increased with increasing self-reported intensity and duration of SHS exposure at home during the previous week (p<0.05). The multivariable regression model showed a significant association with nicotine in air at home (β=0.126, p=0.002 for saliva and β=0.115, p=0.010 for urine).nnnCONCLUSIONSnOur findings suggest that, even in countries with comprehensive smoke-free legislation, exposure to SHS at home continues to be the main source of exposure for non-smokers who live in non-smoke-free homes. Therefore, public health policies should promote smoke-free homes.

Dependencia a la nicotina y preparación para dejar de fumar en la población española

OBJECTIVEnTo describe the nicotine dependence and readiness to quit smoking in the smoker population.nnnMETHODSnCross-sectional study on a representative sample of the Spanish population of >=18 years old. We gathered information by means of telephone interviews conducted between June and July of 2006. We studied the nicotine dependence with the Fagerström Test for Nicotine Dependence (FTND) and the readiness to quit according to the stages of change from the Transtheoretical Model in a sample of cigarette smokers.nnnRESULTSn22.5% of participants (95% CI: 20.9-24.2%) smokers cigarettes. They smoked an average of 14.4 cigarettes per day (standard deviation 9.15) and the mean FTND score was 2.8, with no differences by the stages of change. 64.3% (95% CI: 60.3-68.2%) of smokers were in the precontemplation stage, 25.4% (95% CI: 21.8-28.9%) in contemplation, and 10.4% (95% CI: 7.9-12.9%) in preparation, with no differences by sex. The most nicotine dependent smokers (FTND>=6) had mainly primary studies, started to smoke at earlier ages, and smoked more cigarettes per day.nnnCONCLUSIONSnMost Spanish smokers have low nicotine dependence and are in precontemplation stage. Smoking cessation programmes should be addressed to reduce dependence, help smokers to progress through the stages of change, and, consequently, reduce the prevalence of smokers in the population.

Exposición al humo ambiental de tabaco en locales de hostelería de Barcelona: medición de partículas respirables

OBJECTIVESnTo quantify the concentration of respirable particles equal to or smaller than 2.5μm (PM(2.5)) as a marker of second-hand smoke (SHS) exposure in a sample of hospitality venues in Barcelona 2 years after the Spanish smoking law came into effect.nnnMETHODSnWe performed a cross-sectional descriptive study from October to December 2007. The study population consisted of 40 hospitality venues in Barcelona selected by a random route sampling, with representation of the different types of smoking regulation included in the law (smoking allowed, smoking ban and venues with smoking areas). SHS levels were quantified by measuring PM(2.5) concentrations, which were measured using a laser photometer (Side Pack AM 510 Personal Aerosol Monitor). The measurements were carried out for 5 minutes outside the venue and for 30 minutes inside the venue. In addition, observational variables related to the characteristics of the venue and signs of tobacco consumption were recorded.nnnRESULTSnThe concentration of PM(2.5) in venues where smoking was still allowed was five times higher than that in venues where smoking was banned (182μg/m(3) and 34μg/m(3), respectively) and exceeded the concentration established by the US Environmental Protection Agency (EPA) as harmful (35μg/m(3)). However, in venues where smoking was banned, the concentration was lower than the EPA standard and there were no significant differences with the outdoor PM(2.5) concentration.nnnCONCLUSIONSnTwo years after the introduction of the Spanish smoking law, SHS exposure in venues where smoking was allowed was q still very high, representing a significant health risk for hospitality workers.

Exposure to second-hand smoke in primary health care centres in Catalonia, Spain (2006).

The aim of this study was to assess the exposure to second-hand smoke (SHS) in 90 primary health care centres in Catalonia, Spain. We conducted a cross-sectional study between March and October 2006. We measured vapour-phase nicotine as a marker of SHS in main halls, staff rooms, direction areas, and continued care. Sampler devices were exposed for 7 days, and samples were analysed by gas chromatography/mass spectrometry. We compared the median airborne nicotine concentrations with the non-parametric test for medians by sanitary region, sampled location, affiliation to the Smoke-free Primary Health Care Programme, and urban-rural area. From 300 sampler devices installed, 4 were lost, and detectable levels of nicotine were found in 89 samples (30.0%) in 48 different centres (53.3%). The overall median was 0.01 microg/m(3), with an interquartile range (IQR) of 0.01-0.07 microg/m(3). Median nicotine levels by locations were: reception hall 0.01 microg/m(3) (IQR: 0.01-0.06); staff room 0.01 microg/m(3) (IQR: 0.01-0.08); direction area 0.01 microg/m(3) (IQR: 0.01-0.01); continued care 0.01 microg/m(3) (IQR: 0.01-0.07). Results showed that airborne nicotine levels were very low, with 46.7% of primary health centres being free of SHS.

The Spanish smoking law: a model to be followed?

During the last few years, numerous countries have developed and implemented smoking control policies (IARC 2009). However, the overall approach to tobacco control has been considerably different among them. In Spain, a new Smoking Law came into force in January 2006 (Ministerio de Sanidad 2005), including regulations on the sale, supply, consumption, and publicity of tobacco products (Fernandez 2006). Among its main goals, the law intended to protect non-smokers from secondhand smoke (SHS). For this reason, smoking was prohibited in all enclosed public and private workplaces with the exception of the hospitality sector, where partial restrictions were established depending on the size of the venue. Hospitality venues larger than 100 m could be completely smoke-free, or keep a smoking section (up to 30% of the total area) physically separated and independently ventilated. Owners of venues smaller than 100 m, however, might decide to be smoke-free or to allow smoking without restrictions. The Spanish smoking law is currently being promoted by the tobacco industry as a ‘‘model’’ to be followed by other countries (Muggli et al. 2009; Schneider and PotschkeLanger 2008). However, the scientific evidence, far from supporting the partial restrictions, has clearly shown that total bans are the only way of protecting hospitality workers (IARC 2009). In Spain, where it is estimated that only 10–20% of hospitality venues banned smoking (MartinLuengo 2007)—probably as a consequence of unfounded fears of a potential negative impact on sales—the studies evaluating the impact on SHS levels have shown extremely high levels of SHS exposure in most hospitality workers. A recent overall evaluation study (GTT-SEE 2009) collected the scientific evidence of the impact of the Spanish law on different issues such as public attitudes regarding the law, tobacco consumption, secondhand smoke exposure or health effects. Regarding public attitudes, data from a national survey (CIS 2005) showed that in November 2005 more than 77% of the general population agreed with the smoking law that was going to be enacted. These data seem to be consistent with those shown in the paper of Halpern and Taylor (2009), where a strong support was found for smoking bans in workplaces in Spain (66% employees and 97% employers). The paper of Lazuras et al. (2009) shows that smokers are less supportive of smoke-free public places than nonsmokers, but both groups—smokers and non-smokers—are predominantly supportive of these measures, even in countries with pro-smoking social norms and high smoking rates. In Spain, where the support was also lower among smokers, regional surveys (Departament de Salut 2009) carried out before and after the implementation of the law, showed that this support increased after the law in both smokers and nonsmokers. The impact of the law on tobacco consumption has also been analyzed. So far, the available information (GTT-SEE 2009) does not suggest any impact of the Spanish smoking law on the tobacco consumption indicators. The decrease in the prevalence of smokers and the number of cigarettes smoked, as well as the increase in quitting, continues the time trend observed before the implementation of the law, according to the expected smoking epidemic model evolution (Lopez et al. 1994). M. J. Lopez belongs to the Smoking Working Group of the Spanish Society of Epidemiology.

Long-term effect of the influenza A/H1N1 pandemic: attitudes and preventive behaviours one year after the pandemic

This study aimed to describe changes in attitudes and behaviours regarding influenza A infection 1 year after the end of the pandemic. A cross-sectional study was performed based on two population-based telephone surveys including 1027 (February, 2010) and 1000 (February, 2011) participants in Spain. The percentages of the respondents who reported that they had adopted preventive measures to avoid Influenza infection declined 1 year after the pandemic. Influenza-related consultations decreased, whereas confidence in vaccination increased. Despite the decrease observed in adopting preventive measures, some behaviours were still being adopted long time after the pandemic in general population.