Exposure to secondhand and thirdhand smoke in private vehicles: Measurements in air and dust samples.

BACKGROUND: This study aimed to estimate airborne nicotine concentrations and nicotine, cotinine, and tobacco-specific nitrosamines (TSNAs) in settled dust from private cars in Spain and the UK. METHODS: We measured vapor-phase nicotine concentrations in a convenience sample of 45 private cars from Spain (N = 30) and the UK (N = 15) in 2017-2018. We recruited non-smoking drivers (n = 20), smoking drivers who do not smoke inside the car (n = 15), and smoking drivers who smoke inside (n = 10). Nicotine, cotinine, and three TSNAs (NNK, NNN, NNA) were also measured in settled dust in a random subsample (n = 20). We computed medians and interquartile ranges (IQR) of secondhand smoke (SHS) and thirdhand smoke (THS) compounds according to the drivers' profile. RESULTS: 24-h samples yielded median airborne nicotine concentrations below the limit of quantification (LOQ) (IQR:

Measurement of airborne nicotine, as a marker of secondhand smoke exposure, in homes with residents who smoke in 9 European countries.

OBJECTIVE: Smoke-free policies are effective in preventing secondhand smoke (SHS) exposure, but their adoption at home remains largely voluntary. This study aimed to quantify SHS exposure in homes with residents who smoke in Europe according to households' characteristics, tobacco consumption habits, and national contextual factors. METHODS: Cross-sectional study (March 2017-September 2018) based on measurements of air nicotine inside 162 homes with residents who smoke from nine European countries. We installed passive samplers for seven consecutive days to monitor nicotine concentrations. Through self-administered questionnaires, we collected sociodemographic information and the number of individuals who smoke, smoking rules, frequency, location, and quantity of tobacco use in households. Country-level factors included the overall score in the Tobacco Control Scale 2016, the smoking prevalence, and self-reported SHS exposure prevalence. Nicotine concentrations were analyzed as continuous and dichotomous variables, categorized based on the limit of quantification of 0.02 µg/m3. RESULTS: Overall, median nicotine concentration was 0.85 µg/m3 (interquartile range (IQR):0.15-4.42), and there was nicotine presence in 93% of homes. Participants reported that smoking was not permitted in approximately 20% of households, 40% had two or more residents who smoked, and in 79% residents had smoked inside during the week of sampling. We found higher nicotine concentrations in homes: with smell of tobacco smoke inside (1.45 µg/m3 IQR: 0.32-6.34), where smoking was allowed (1.60 µg/m3 IQR: 0.68-7.63), with two or more residents who smoked (2.42 µg/m3 IQR: 0.58-11.0), with more than 40 cigarettes smoked (2.92 µg/m3 IQR: 0.97-10.61), and where two or more residents smoked inside (4.02 µg/m3 IQR: 1.58-11.74). Household nicotine concentrations were significantly higher in countries with higher national smoking prevalence and self-reported SHS exposure prevalence (p < 0.05). CONCLUSIONS: SHS concentrations in homes with individuals who smoke were approximately twenty times higher in homes that allowed smoking compared to those reporting smoke-free household rules. Evidence-based interventions promoting smoke-free homes should be implemented in combination with strengthening other MPOWER measures.

Electronic Cigarette Use in 12 European Countries: Results From the TackSHS Survey.

BACKGROUND: Limited data on electronic cigarette prevalence, patterns, and settings of use are available from several European countries. METHODS: Within the TackSHS project, a face-to-face survey was conducted in 2017-2018 in 12 European countries (Bulgaria, England, France, Germany, Greece, Ireland, Italy, Latvia, Poland, Portugal, Romania and Spain). Overall, 11,876 participants, representative of the population aged ⩾15 years in each country, provided information on electronic cigarette. RESULTS: 2.4% (95% confidence interval [CI], 2.2-2.7%) of the subjects (2.5% among men and 2.4% among women; 0.4% among never, 4.4% among current- and 6.5% among ex-smokers) reported current use of electronic cigarette, ranging from 0.6% in Spain to 7.2% in England. Of the 272 electronic cigarette users, 52.6% were dual users (ie, users of both electronic and conventional cigarettes) and 58.8% used liquids with nicotine. In all, 65.1% reported using electronic cigarette in at least one indoor setting where smoking is forbidden; in particular, at workplaces (34.9%) and bars and restaurants (41.5%). Multivariable logistic regression analysis showed that electronic cigarette use was lower among older individuals (P for trend <0.001) and higher among individuals with high level of education (P for trend = 0.040). Participants from countries with higher tobacco cigarette prices more frequently reported electronic cigarette use (odds ratio 3.62; 95% CI, 1.80-7.30). CONCLUSION: Considering the whole adult population of these 12 European countries, more than 8.3 million people use electronic cigarettes. The majority of users also smoked conventional cigarettes, used electronic cigarettes with nicotine, and consumed electronic cigarettes in smoke-free indoor areas.

Transitions in smoking status in nursing students: A prospective longitudinal study.

AIM: To describe transitions in smoking status and their determining factors among nursing students between baseline (2015-2016) and follow-up (2018-2019). DESIGN: Observational prospective longitudinal study of 4381 nursing students in Catalonia (Spain). METHODS: We examined transitions in smoking status from: (i) current smokers to recent quitters, (ii) never smokers to new smokers and (iii) former smokers to quitters who relapsed. We fitted logistic regression models to assess the predictors of quitting smoking. RESULTS: The proportion of current smokers decreased from 29.7% at baseline to 23.6% at follow-up, with a cumulative incidence rate of quitting of 28.3% during follow-up. Nondaily smokers were more likely to quit than daily smokers. Of those who were never smokers at baseline, 4.6% were smokers at follow-up, and 23.2% of former smokers at baseline had relapsed at follow-up. CONCLUSIONS: Nondaily smokers were more likely to have quit smoking at follow-up among this cohort of nursing students. The early implementation of a comprehensive tobacco control program that includes tobacco-free campus policies, tobacco prevention interventions and cessation support during college years may decrease tobacco use among nursing students. IMPACT: Nursing students' tobacco use is concerning, as they are the future workforce of nurses who have a key role in tobacco product use prevention and cessation. During college years, nursing students have a greater likelihood of experimenting with several smoking status changes as well as to consolidate smoking behaviors. This is the first longitudinal study to highlight the factors associated with quitting smoking among a cohort of Spanish nursing students. Being a nondaily smoker at baseline predicted quitting at follow-up. Our findings support the early implementation of a comprehensive tobacco control program that includes tobacco-free campus policies, tobacco prevention interventions and tobacco cessation support during college years to decrease tobacco product use prevalence among nursing students. REPORTING METHOD: We have adhered to STROBE guidelines. No Patient or Public Contribution. This observational study has not been registered.

Secondhand Smoke Exposure in European Countries With Different Smoke-Free Legislation: Findings From the EUREST-PLUS ITC Europe Surveys.

INTRODUCTION: Exposure to secondhand smoke (SHS) poses serious and extensive health and economic-related consequences to European society and worldwide. Smoking bans are a key measure to reducing SHS exposure but have been implemented with varying levels of success. We assessed changes in the prevalence of self-reported SHS exposure and smoking behavior in public places among smokers in six European countries and the influence of the country's type of smoking ban (partial or total ban) on such exposure and smoking behavior. AIMS AND METHODS: The EUREST-PLUS ITC Europe Surveys were conducted among adult smokers in Germany, Greece, Hungary, Poland, Romania, and Spain in 2016 (Wave 1, n = 6011) and 2018 (Wave 2, n = 6027). We used generalized estimating equations models to assess changes between Waves 1 and 2 and to test the interaction between the type of smoking ban and (1) self-reported SHS exposure, (2) self-reported smoking in several public places. RESULTS: A significant decrease in self-reported SHS exposure was observed in workplaces, from 19.1% in 2016 to 14.0% in 2018 (-5.1%; 95% CI: -8.0%; -2.2%). Self-reported smoking did not change significantly inside bars (22.7% in Wave 2), restaurants (13.2% in Wave 2) and discos/nightclubs (34.0% in W2). SHS exposure in public places was significantly less likely (adjusted odds ratio = 0.35; 95% CI: 0.26-0.47) in the countries with total bans as compared to those countries with partial bans. CONCLUSION: The inverse association between smoking in public places and smoking bans indicates an opportunity for strengthening smoke-free legislation and protecting bystanders from exposure to SHS in public places. IMPLICATIONS: Prevalence of smokers engaging in and being exposed to smoking in public places varied by type of smoke-free legislation across six European Union countries in our study; those with total smoke bans reported significantly less exposure to SHS than those with partial or no bans. Our results indicate room for improvement, not only to decrease the prevalence of exposure to SHS in Europe but also to diminish the variability between countries through common, more restrictive smoke-free legislation, and importantly, strong and sustained enforcement.

Non-smokers' and smokers' support for smoke-free legislation in 14 indoor and outdoor settings across 12 European countries.

BACKGROUND: European countries differ considerably in the scope and the extent of their policies to protect people from the harms of secondhand smoke exposure. Public opinion may have a substantial influence on several stages of policy development, implementation, and compliance. For this reason, we aimed to evaluate the population level of support for smoke-free policies and its correlates. METHODS: We used data from the TackSHS Survey (2017-2018), a cross-sectional study with representative samples of the general population aged ≥15 years from 12 European countries. We described the proportion of non-smokers' and smokers' support for the implementation of smoke-free legislation in 14 indoor and outdoor settings and the country-level characteristics associated with it. RESULTS: In the total sample (n = 11,902), support for smoke-free legislation were the lowest for restaurants/bar patios (non-smokers = 53.0%; smokers = 29.2%) and the highest for workplaces (non-smokers = 78.5%; smokers = 66.5%). In the country-level analysis, the highest support among non-smokers was for workplaces in Bulgaria (93.1%) and the lowest for restaurants/bars patios in Greece (39.4%). Among smokers, the corresponding estimates were for children's playgrounds in Latvia (88.9%) and for cars in Portugal (21%). For most settings, support for smoke-free legislation was directly related with the countries' prevalence of secondhand smoke presence and reported smoking in each setting. DISCUSSION: Our results show that the majority of European adults (including a large proportion of smokers) are supportive of implementing smoke-free legislation in indoor settings and extending it to selected outdoor settings. Such expressive support can be seen as an opportunity to advance legislation and protect the European population from secondhand smoke exposure.

Regulation of Electronic Cigarette Use in Public and Private Areas in 48 Countries Within the WHO European Region: A Survey to In-country Informants.

BACKGROUND: The objective of this study is to describe the legislation regulating the use of electronic cigarettes (e-cigarettes) in various places in European countries. METHODS: A survey among experts from all countries of the World Health Organization (WHO) European Region was conducted in 2018. We collected and described data on legislation regulating e-cigarette use indoors and outdoors in public and private places, the level of difficulties in adopting the legislation, and the public support and compliance. Factors associated with the legislation adoption were identified with Poisson and linear regression analyses. RESULTS: Out of 48 countries, 58.3% had legislation on e-cigarette use at the national level. Education facilities were the most regulated place (58.3% of countries), while private areas (eg, homes, cars) were the least regulated ones (39.6%). A third of countries regulated e-cigarette use indoors. Difficulty and support in adopting the national legislation and its compliance were all at a moderate level. Countries' smoking prevalence and income levels were linked to legislation adoption. CONCLUSIONS: Although most WHO European Region countries had introduced e-cigarette use legislation at the national level, only a few of the legislation protect bystanders in indoor settings.

Use and Awareness of Heated Tobacco Products in Europe.

BACKGROUND: Heated tobacco products (HTP) are new forms of tobacco consumption with limited information available on their use among the general population. Our objective was to analyze the prevalence and associations of use of HTP across 11 countries in Europe. METHODS: Within the TackSHS Project, in 2017-2018 we conducted a cross-sectional study with information on HTP use in the following countries: Bulgaria, England, France, Germany, Greece, Italy, Latvia, Poland, Portugal, Romania and Spain. In each country, face-to-face interviews were performed on a representative sample of around 1,000 subjects aged ≥15 years, for a total of 10,839 subjects. RESULTS: Overall, 27.8% of study participants were aware of HTPs, 1.8% were ever HTP users (ranging from 0.6% in Spain to 8.3% in Greece), and 0.1% were current users. Men were more frequently HTP ever users than women (adjusted odds ratio [aOR] 1.47; 95% confidence interval [CI], 1.11-1.95). Ever HTP use was inversely related to age (P for trend <0.001) and more frequent in ex-smokers (compared with never smokers, aOR 4.32; 95% CI, 2.69-6.95) and current smokers (aOR 8.35; 95% CI, 5.67-12.28), and in electronic cigarette past users (compared with never users, aOR 5.48; 95% CI, 3.46-8.68) and current users (aOR 5.92; 95% CI, 3.73-9.40). CONCLUSIONS: In 2017-2018, HTP use was still limited in Europe among the general population; however, the dual use of these products, their high use among younger generations, and the interest of non-smokers in these products are worrying and indicate the need for close monitoring in terms of prevalence and the characteristics of users.

Smoke-free spaces: a decade of progress, a need for more?

Adoption of smoke-free measures has been one of the central elements of tobacco control activity over the past 30 years. The past decade has seen an increasing number of countries and proportion of the global population covered by smoke-free policies to some extent. Despite reductions in global smoking prevalence, population growth means that the number of non-smokers exposed to the harms caused by secondhand smoke remains high. Smoke-free policy measures have been shown to be useful in protecting non-smokers from secondhand smoke, and can additionally increase cessation and reduce smoking initiation. Policies tend to be aimed primarily at enclosed public or workplace settings with very few countries attempting to control exposure in private or semiprivate spaces such as homes and cars, and, as a result, children may be benefiting less from smoke-free measures than adults. Compliance with legislation also varies by country and there is a need for education and empowerment together with guidance and changing social norms to help deliver the full benefits that smoke-free spaces can bring. Restrictions and policies on use of electronic cigarettes (e-cigarettes) in smoke-free settings require more research to determine the benefits and implications of bystanders' exposure to secondhand e-cigarette aerosol, dual use and smoking cessation.

Beyond the European Union Tobacco Products Directive: smokers' and recent quitters' support for further tobacco control measures (2016-2018).

BACKGROUND: Several measures recommended by the WHO Framework Convention on Tobacco Control have not been implemented in the European Union, despite changes in the legislation such as the Tobacco Products Directive (TPD). This study aims to understand smokers' and recent quitters' levels of support for tobacco control measures that go beyond the TPD during and after its implementation. METHODS: Data from wave 1 (2016, n=6011) and wave 2 (2018, n=6027) of the EUREST-PLUS International Tobacco Control Policy Evaluation Project Six European Countries Survey, a cohort of adult smokers in Germany, Greece, Hungary, Poland, Romania, Spain were used to estimate the level of support for seven different tobacco control measures, overall and by country. RESULTS: In 2018, the highest support was for implementing measures to further regulate tobacco products (50.5%) and for holding tobacco companies accountable for the harm caused by smoking (48.8%). Additionally, in 2018, 40% of smokers and recent quitters supported a total ban on cigarettes and other tobacco products within ten years, if assistance to quit smoking is provided. Overall, support for tobacco control measures among smokers and recent quitters after the implementation of the TPD remained stable over time. CONCLUSION: There is considerable support among smokers and recent quitters for tobacco control measures that go beyond the current measures implemented. A significant percentage of smokers would support a ban on tobacco products in the future if the government provided assistance to quit smoking. This highlights the importance of implementing measures to increase smoking cessation in conjunction with other policies.

Burden of disease from second-hand tobacco smoke exposure at home among adults from European Union countries in 2017: an analysis using a review of recent meta-analyses.

Smoke-free legislation reduced second-hand smoke (SHS) exposure in public places, and indirectly promoted private smoke-free settings. Nevertheless, a large proportion of adults is still exposed to SHS at home. The aim of this paper is to quantify the burden of disease due to home SHS exposure among adults in the 28-European Union (EU) countries for year 2017. The burdens by gender from lung cancer, chronic obstructive pulmonary disease (COPD), breast cancer, ischemic heart disease (IHD), stroke, asthma, and diabetes were estimated in an original research analysis using the comparative risk assessment method. Relative risks of death/diseases by gender for adults exposed to SHS at home compared to not exposed ones were estimated updating existing meta-analyses. Prevalence of home SHS exposure by gender was estimated using a multiple imputation procedure based on Eurobarometer surveys. Data on mortality and disability adjusted life years (DALYs) were obtained from the Global Burden of Disease, Injuries and Risk Factors Study. In 2017, 526,000 DALYs (0.36% of total DALYs) and 24,000 deaths (0.46% of total deaths) were attributable to home SHS exposure in the 28-EU countries, mainly from COPD and IHD. South-Eastern EU countries showed the highest burden, with proportion of DALYs/deaths attributable to SHS exposure on total higher than 0.50%/0.70%, whereas northern EU-countries showed the lowest burden, with proportions of DALYs/deaths lower than 0.25%/0.34%. The burden from SHS exposure is still significant in EU countries. More could be done to raise awareness of the health risks associated with SHS exposure at home.

Lung function changes in patients with chronic obstructive pulmonary disease (COPD) and asthma exposed to secondhand smoke in outdoor areas.

BACKGROUND: Further evidence is needed on the effects that short- and long-term exposure to secondhand smoke (SHS) have on the respiratory health of patients with lung disease. Within the TackSHS project we aimed to assess the acute respiratory effects in lung function that result from short-term SHS exposure among patients with asthma and chronic obstructive pulmonary disease (COPD). METHODS: The study design was an intervention trial with measurements before/after exposure to SHS in legal outdoor smoking areas. We studied patients with asthma or COPD from Czechia, Ireland, and Spain. Forced spirometry, peak flow and carbon monoxide (CO) measurements were performed pre- and 24 h post- exposure. RESULTS: Overall, 60 patients were studied, 30 with asthma, and 30 with COPD; 35 (58.3%) were female. There were no significant differences observed in exhaled CO between pre- and 24 h post-exposure neither in women (p = 0.210), nor in men (p = 0.169).A statistically significant decrease in forced vital capacity (FVC) was seen, overall, in asthma participants (p = 0.02) and in forced expiratory volume in the first second (FEV1), (p = 0.02), FVC (p = 0.04) and peak expiratory flow rate (PEFR) (p = 0.04) in female asthmatic participants. The observed decreases in respiratory measurements in COPD were not significant. There were no reported increases in symptoms, respiratory medication, or use of health services 24 h after the exposure. CONCLUSION: We conclude that acute, short-term SHS exposure had a statistically significant effect on spirometry in female asthma patients but did not significantly modify spirometric indices 24 h later in COPD patients.

How widespread is electronic cigarette use in outdoor settings? A field check from the TackSHS project in 11 European countries.

Exposure to secondhand aerosol from electronic cigarettes (e-cigarettes) may pose harms to bystanders, but they are used in many indoor settings. Less evidence exists on e-cigarette use in outdoor settings. This study aims to assess the use of e-cigarettes in outdoor settings in Europe. A cross-sectional study was conducted at the entrances of primary schools (N = 200), children's playgrounds (N = 200), and outdoor hospitality venues (N = 220) during 2017-2018 in major cities of 11 European countries. We performed 30-min observations and recorded e-cigarette use at three-time points: at 0 min, 15 min, and 30 min. We described the number and proportion of settings with e-cigarette use observed at any of the three-time points according to country and other contextual variables. Results showed that there were 22 (11.0%) school entrances, eight (4.0%) playgrounds, and 47 (21.3%) outdoor hospitality venues where e-cigarette use was observed at any time point. School entrances and outdoor hospitality venues with observed e-cigarette use were more frequently found in countries with a higher prevalence (≥1.4%) of e-cigarette use (school entrances: 18.0% vs. 4.0%; p = 0.002, outdoor hospitality venues: 26.7% vs. 15.0%, p = 0.036). In conclusion, the outdoor setting with the highest visibility of e-cigarette use was outdoor areas of hospitality venues. Although still limited, e-cigarettes were also used in outdoor settings frequented by children. Governments should consider measures to restrict e-cigarette use outdoors to protect the health of bystanders, particularly in areas where children may be present.

Secondhand smoke exposure assessment in outdoor hospitality venues across 11 European countries.

OBJECTIVE: Due to partial or poorly enforced restrictions secondhand tobacco smoke (SHS) is still present in outdoor hospitality venues in many European countries. This study aimed to assess SHS concentrations in outdoor hospitality venues across Europe and identify contextual exposure determinants. METHODS: Cross-sectional study. We measured airborne nicotine and evidence of tobacco use in terraces of bars, cafeterias, and pubs from 11 European countries in 2017-2018. Sites were selected considering area-level socioeconomic indicators and half were visited during nighttime. We noted the smell of smoke, presence of smokers, cigarette butts, ashtrays, and number of physical covers. Contextual determinants included national smoke-free policies for the hospitality sector, the Tobacco Control Scale score (2016), and the national smoking prevalence (2017-2018). We computed medians and interquartile ranges (IQR) of nicotine concentrations and used multivariate analyses to characterize the exposure determinants. RESULTS: Nicotine was present in 93.6% of the 220 sites explored. Overall concentrations were 0.85 (IQR:0.30-3.74) µg/m3 and increased during nighttime (1.45 IQR:0.65-4.79 µg/m3), in enclosed venues (2.97 IQR:0.80-5.80 µg/m3), in venues with more than two smokers (2.79 IQR:1.03-6.30 µg/m3), in venues in countries with total indoor smoking bans (1.20 IQR:0.47-4.85 µg/m3), and in venues in countries with higher smoking prevalence (1.32 IQR:0.49-5.34 µg/m3). In multivariate analyses, nicotine concentrations were also positively associated with the observed number of cigarette butts. In venues with more than two smokers, SHS levels did not significantly vary with the venues' degree of enclosure. CONCLUSIONS: Our results suggest that current restrictions in outdoor hospitality venues across Europe have a limited protective effect and justify the adoption of total smoking bans in outdoor areas of hospitality venues.

Who Smokes in Europe? Data From 12 European Countries in the TackSHS Survey (2017-2018).

BACKGROUND: Population data on tobacco use and its determinants require continuous monitoring and careful inter-country comparison. We aimed to provide the most up-to-date estimates on tobacco smoking from a large cross-sectional survey, conducted in selected European countries. METHODS: Within the TackSHS Project, a face-to-face survey on smoking was conducted in 2017-2018 in 12 countries: Bulgaria, England, France, Germany, Greece, Ireland, Italy, Latvia, Poland, Portugal, Romania, and Spain, representing around 80% of the 432 million European Union (EU) adult population. In each country, a representative sample of around 1,000 subjects aged 15 years and older was interviewed, for a total of 11,902 participants. RESULTS: Overall, 25.9% of participants were current smokers (31.0% of men and 21.2% of women, P < 0.001), while 16.5% were former smokers. Smoking prevalence ranged from 18.9% in Italy to 37.0% in Bulgaria. It decreased with increasing age (compared to <45, multivariable odds ratio [OR] for ≥65 year, 0.31; 95% confidence interval [CI], 0.27-0.36), level of education (OR for low vs high, 1.32; 95% CI, 1.17-1.48) and self-rated household economic level (OR for low vs high, 2.05; 95% CI, 1.74-2.42). The same patterns were found in both sexes. CONCLUSIONS: These smoking prevalence estimates represent the most up-to-date evidence in Europe. From them, it can be derived that there are more than 112 million current smokers in the EU-28. Lower socio-economic status is a major determinant of smoking habit in both sexes.

Environmental and individual exposure to secondhand aerosol of electronic cigarettes in confined spaces: Results from the TackSHS Project†.

Secondhand electronic cigarette (e-cigarette) aerosol (SHA) might impair indoor air quality and expose bystanders. This study aims to investigate exposure to SHA in controlled conditions of enclosed settings simulating real-world scenario. An experiment was performed in a car and in a room, in which SHA was generated during a 30-minute ad libitum use of an e-cigarette. The experiment was replicated on five consecutive days in each setting. We measured PM2.5 , airborne nicotine concentrations, and biomarkers of exposure to SHA, such as nicotine metabolites, tobacco-specific nitrosamines, propylene glycol, and glycerol in bystanders' saliva samples before, during, and after the exposure period. Self-reported health symptoms related to exposure to SHA were also recorded. The results showed that the highest median PM2.5 concentration was recorded during the exposure period, being 21 µg/m3 in the room setting and 16 µg/m3 in the car setting-about twofold increase compared to the baseline. Most concentrations of the airborne nicotine and all biomarkers were below the limit of quantification in both settings. Bystanders in both settings experienced some short-term irritation symptoms, expressed as dry throat, nose, eyes, and phlegm. In conclusion, short-term use of an e-cigarette in confined spaces increased indoor PM2.5 level and caused some irritation symptoms in bystanders.

Do smokers want to protect non-smokers from the harms of second-hand smoke in cars? Findings from the EUREST-PLUS ITC Europe Surveys.

BACKGROUND: There is currently no comprehensive legislation protecting non-smokers and children from second-hand smoke (SHS) exposure in private cars at the European Union (EU) level. This study aims to assess smokers' support for smoke-free cars legislation in six EU countries. METHODS: Data come from the EUREST-PLUS ITC Europe Surveys: Wave 1 (2016, n = 6011) and Wave 2 (2018, n = 6027) conducted in Germany, Greece, Hungary, Poland, Romania and Spain. Support for smoke-free cars carrying pre-school children and non-smokers and voluntary implementation of smoke-free cars were assessed among adult smokers. Generalized estimating equations models were used to assess changes in support between waves. RESULTS: In 2018, 96.3% [95% confidence interval (CI) 95.4-97.0%] of the overall sample supported smoke-free legislation for cars carrying pre-school children, representing an increase of 2.4 percentage points in comparison to 2016. Smoke-free legislation for cars transporting non-smokers was supported by 85.2% (95% CI 83.1-87.1%) of smokers' in 2016 and 90.2% (95% CI 88.6-91.7%) in 2018. Among smokers who owned cars, there was a significant 7.2 percentage points increase in voluntary implementation of smoke-free cars carrying children from 2016 (60.7%, 95% CI 57.2-64.0%) to 2018 (67.9%, 95% CI 65.1-70.5%). All sociodemographic groups of smokers reported support higher than 80% in 2018. CONCLUSION: The vast majority of smokers in all six EU countries support smoke-free legislation for cars carrying pre-school children and non-smokers. This almost universal support across countries and sociodemographic groups is a clear indicator of a window of opportunity for the introduction of comprehensive legislation to protect non-smokers and children from SHS exposure in cars.

Impact of an Online Training Program in Smoking Cessation Interventions in Hospitals.

PURPOSE: To assess changes in the self-reported performance of smoking cessation interventions according to the 5A's model (Ask; Advise; Assess; Assist; and Arrange follow-up) among clinicians; and to identify the main barriers and facilitators in smoking cessation implementation before and after an online smoking cessation training program. DESIGN: Pre-post evaluation. METHODS: We assessed self-reported smoking cessation interventions in the implementation of the 5A's model among clinicians working in Catalan hospitals (Spain). In addition, we assessed individual-, behavioral-, and organizational-level factors that act as barriers and facilitators in the implementation of the 5A's model. We used a questionnaire of 63 items reflecting each of the 5A's performance (scored from 0 = none to 10 = most possible). The questionnaire was completed both immediately before and 6 months after the training. We analyzed the data of those participants who had a clinical role and answered pre- and post-questionnaires. We used the nonparametric test for paired data (Wilcoxon) to examine changes in scores. FINDINGS: A total of 127 clinicians completed the pre-post questionnaire; 63.0% were registered nurses, 17.3% were nursing assistants, 7.9% were physicians, and 11.8% were other professionals (p < .001). Overall, there were significant increases in the implementation of the assist component (from a score of 4.5 to 5.2; p < .003) and arrange a follow-up component (from 3.6 to 4.5; p < .001) of the intervention. Scores in the perception of the level of overall preparation, preparedness in using smoking cessation drugs, level of competence, and organizational recognition improved (p < .001) at the follow-up; however, the score in the perception that implementing smoking cessation is part of their job decreased (from 6.3 to 4.4; p < .001). CONCLUSIONS: The online training had a positive impact on the implementation of assist and arrange follow-up components. Although self-preparedness in the management of smokers increased, the motivation and involvement of key professionals decreased. Organizational factors related to the incorporation of resources (such as protocols, records, etc.) should be improved for the correct progression of smoking cessation interventions within the institutions. CLINICAL RELEVANCE: Smoking cessation training programs should incorporate some motivational content to increase the engagement of health professionals in smoking cessation interventions in their clinical practice.

Correlates of self-reported exposure to advertising of tobacco products and electronic cigarettes across 28 European Union member states.

BACKGROUND: Despite advertising bans in most European Union (EU) member states, outlets for promotion of tobacco products and especially e-cigarettes still exist. This study aimed to assess the correlates of self-reported exposure to tobacco products and e-cigarettee advertising in the EU. METHODS: We analysed data from wave 82.4 of the Eurobarometer survey (November-December 2014), collected through interviews in 28 EU member states (n=27 801 aged ≥15 years) and data on bans of tobacco advertising extracted from the Tobacco Control Scale (TCS, 2013). We used multilevel logistic regression to assess sociodemographic correlates of self-reported exposure to any tobacco and e-cigarette advertisements. RESULTS: 40% and 41.5% of the respondents reported having seen any e-cigarette and tobacco product advertisement respectively within the past year. Current smokers, males, younger respondents, those with financial difficulties, people who had tried e-cigarettes and daily internet users were more likely to report having seen an e-cigarette and a tobacco product advertisement. Respondents in countries with more comprehensive advertising bans were less likely to self-report exposure to any tobacco advertisements (OR 0.87; 95% CI 0.79 to 0.96 for one-unit increase in TCS advertising score), but not e-cigarette advertisements (OR 1.08; 95% CI 0.95 to 1.22). CONCLUSION: Ten years after ratification of the Framework Convention for Tobacco Control, self-reported exposure to tobacco and e-cigarette advertising in the EU is higher in e-cigarette and tobacco users, as well as those with internet access. The implementation of the Tobacco Products Directive may result in significant changes in e-cigarette advertising, therefore improved monitoring of advertising exposure is required in the coming years.

Incidence and Determinants of COVID-19 Among People Who Smoke (2018-2021): Findings From the ITC EUREST-PLUS Spain Surveys.

OBJECTIVE: To estimate the cumulative incidence of COVID-19 and its determinants among a nationally representative sample of adults from Spain who smoke. METHODS: This is a prospective cohort study that uses data from two waves (Wave 2 in 2018 and Wave 3 in 2021) of the ITC EUREST-PLUS Spain Survey. At baseline (Wave 1 in 2016), all respondents were adults (aged ≥18) who smoked. In total, 1008 respondents participated in Wave 2, and 570 out of 888 eligible participants were followed up in Wave 3 (64.2%). We estimated the cumulative incidence and the relative risk of COVID-19 (RR) and 95% confidence intervals (CI) during follow-up using self-reported information on sociodemographic, smoking-related and health-related characteristics and identified associated factors using multivariable Poisson models with robust variance adjusted for the independent variables. RESULTS: The overall cumulative incidence of self-reported COVID-19 was 5.9% (95% CI: 3.9-8.0%), with no significant differences between males (6.3%; 95% CI: 3.6-9.0%) and females (5.6%; 95% CI: 3.2-8.0%). After adjusting for age, sex, and educational level, COVID-19 incidence was positively associated with moderate nicotine dependence (RR: 2.37; 95% CI: 1.04-5.40) and negatively associated with having a partner who smoked (RR: 0.12; 95% CI: 0.03-0.42), and having friends but not a partner who smoked (RR: 0.28; 95% CI: 0.14-0.56). CONCLUSION: The correlates of having had COVID-19 among people who smoke should be considered when tailoring information and targeted non-pharmacological preventive measures.