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.

Passive exposure and perceptions of smoke-free policies in hospital and university campuses among nursing students: A cross-sectional multicenter study.

INTRODUCTION: Outdoor smoke-free regulations reduce exposure to secondhand smoke (SHS) and help to denormalize tobacco use. As future key agents in health promotion, nursing students' attitudes should agree with tobacco-control policies. The objectives of this study were: 1) assess nursing students' exposure to SHS in nursing schools, 2) explore their perceptions of compliance with the existing smoke-free regulations in acute-care hospitals; and 3) describe their support for indoor and outdoor smoking bans on hospital and university campuses. METHODS: This was a cross-sectional multicenter study conducted in 2015-2016 in all 15 university nursing schools in Catalonia, Spain. A questionnaire gathered information on SHS exposure, awareness of the smoke-free regulation in acutecare hospitals, and support for smoke-free policies in indoor and outdoor areas of hospitals and university campuses. Participants were nursing students attending classes on the day of the survey. We performed descriptive analyses and calculated adjusted prevalence ratios (APR) and 95% confidence interval (CI). RESULTS: Of 4381 respondents, 99.1% had seen people smoking in outdoor areas of their university campus, and 75.2% had been exposed to SHS on the campus (6.0% indoors and 69.2% outdoors). Nearly 60% were aware of the smoking regulation in place in acute-care hospitals. There was widespread support for smoke-free indoor hospital regulation (98.7%), but less support (64.8%) for outdoor regulations. Approximately 33% supported the regulation to make outdoor healthcare campuses smoke-free, which was higher among third-year students compared to first-year students (APR=1.41; 95% CI: 1.24-1.62), among never smokers (41.4%; APR=2.84; 95% CI: 2.21-3.64) compared to smokers, and among those who were aware of the regulation (38.4%; 95% CI: 1.37-1.75). CONCLUSIONS: Exposure to SHS on university campuses is high. Nursing students express low support for strengthening outdoor smoking bans on hospital and university campuses. Interventions aiming to increase their support should be implemented.

Knowledge, attitudes, and training in tobacco dependence and cessation treatment among Nursing Students in Catalonia (ECTEC Study): Cross-Sectional Study.

Nursing students are part of the future health labor force; thus, knowing their knowledge and participation in tobacco control is of importance. Multicentre cross-sectional study conducted to assess nursing students' knowledge, attitudes, and training in tobacco dependence and treatment at 15 nursing schools in Catalonia. We employed a self-administered questionnaire. 4,381 students participated. Few respondents (21.1%) knew how to assess smokers' nicotine dependence, and less than half (41.4%) knew about the smoking cessation therapies. Most (80%) had been educated on the health risks of smoking, 50% about the reasons why people smoke and, one third on how to provide cessation aid. Students in the last years of training were more likely to have received these two contents. Nursing students lack sufficient knowledge to assess and treat tobacco dependence and are rarely trained in such subjects. Nursing curricula in tobacco dependence and treatment should be strengthened to tackle the first preventable cause of disease worldwide.

ITC EUREST-PLUS Spain: protocol of a prospective longitudinal study of smokers in Spain.

OBJECTIVE: The ITC EUREST-PLUS Spain Survey is a longitudinal study of a representative sample of Spanish adult (≥18 years old) smokers. This protocol describes the methods of the 2021 follow-up survey. METHOD: The ITC EUREST-PLUS Survey, a prospective cohort study of a representative sample of smokers in six European countries, was conducted in 2016 (baseline) and 2018 (waves 1 and 2). The 2021 ITC EUREST-PLUS Spain Survey is a continuation of the Spanish cohort with a new interview in 2021 (wave 3). Lost participants were replaced with new smokers recruited using the same multi-stage sampling design. This latest follow-up aims to examine current patterns and transitions of tobacco use and to evaluate the impact of new tobacco-related policies. COMMENTS: The ITC EUREST-PLUS Spain Survey will provide recent information about the impact of tobacco control policies on smoking behaviour.

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.

Long-term effectiveness of a nurse-led smoking cessation clinic at a comprehensive cancer center.

PURPOSE: Smoking cessation interventions should be promoted in cancer centers to improve clinical outcomes among cancer patients and the quality of life of cancer-free patients and survivors. The aim of the present study was to examine long-term abstinence (1, 3, and 5 years) among smokers who received an intensive nurse-led smoking cessation intervention. DESIGN: A prospective follow-up study was conducted in a smoking cessation clinic in Barcelona. METHODS: The study included 479 smokers who received a nurse-led smoking cessation intervention that included motivational interviewing, psychological support, behavioral change counseling, promotion of smoke-free policies, and relapse-prevention strategies, as well as pharmacotherapy if necessary, for 12 months. We calculated overall and sex-specific 1-, 3-, and 5-year abstinence probabilities (Kaplan-Meier curves) and adjusted hazard ratios (aHRs) of relapse with 95% confidence intervals (CIs) using Cox regression. FINDINGS: The overall probability of abstinence at 1 and 5 years was 0.561 (95% CI: 0.516-0.606) and 0.364 (95% CI: 0.311-0.417), respectively. Females had a higher, but not significant, hazard ratio for relapse compared to males (aHR = 1.180; 95% CI: 0.905-1.538). Attending <5 visits was the most remarkable determinant of relapsing compared to attending 5-9 visits or ≥10 visits, both overall and by sex (p for trend: overall, p < 0.001; males, p = 0.007; and females, p < 0.001). CONCLUSIONS: Abstinence probability decreased over the 5-year follow-up but was relatively high. Males had higher abstinence rates than females in all follow-up periods. Completeness of the intensive intervention was the main predictor of cessation. CLINICAL RELEVANCE: Smoking cessation interventions should consider sex and incorporate strategies to increase adherence to obtain higher long-term abstinence rates.

Variation in Nicotine Metabolization According to Biological Factors and Type of Nicotine Consumer.

This study aims to describe the nicotine metabolite ratio among tobacco smokers and electronic cigarette (e-cigarette) users and nonusers. We analyzed pooled data from a longitudinal and a cross-sectional study of the adult population from the city of Barcelona. The final sample included information on 166 smokers, 164 e-cigarettes users with nicotine, 41 e-cigarette users without nicotine, 95 dual users (users of both products), and 508 nonusers. We used log-linear models to control for the potential confounding effect of the daily number of cigarettes smoked. Salivary nicotine metabolic rate assessment included the rate of nicotine metabolism (cotinine/nicotine) and the nicotine metabolite ratio (trans-3'-hydroxycotinine/cotinine). Exclusive users of e-cigarette without nicotine have the lowest rate of nicotine metabolism (Geometric mean: 0.08, p-values < 0.001) while cigarette smokers have the highest (Geometric mean: 2.08, p-values < 0.001). Nonusers have lower nicotine metabolic rate than cigarette smokers (Geometric means: 0.23 vs. 0.18, p-value < 0.05). Younger individuals (18−44 years) have a higher rate of nicotine metabolism than older individuals (45−64 years and 65−89) (Geometric means: 0.53 vs. 0.42 and 0.31, respectively, p-values < 0.01) and individuals with lower body mass index (21−25 kg/m2) have a higher rate of nicotine metabolism than the rest (26−30 kg/m2 and 31−60 kg/m2) (Geometric means: 0.52 vs. 0.35 and 0.36, respectively-values < 0.01). Nicotine metabolic rates are useful biomarkers when reporting smoking status and biological differences between individuals.

Specific biomarker comparison in current smokers, e-cigarette users, and non-smokers.

INTRODUCTION: This study aims to address the existing gap in the literature, while adding evidence, by comparing tobacco-specific biomarkers (cotinine and nitrosamines: NNK, NNAL, NNN), and other biomarkers of e-cigarette use (humectants: glycerol, 1,2-PD, 1,3-PD) according to five study groups. METHODS: A pooling analysis including two different studies was conducted. In both analyses, we took saliva samples from smokers (n = 409) and non-smokers (n = 154), dual tobacco and e-cig users (n = 92), exclusive e-cig user with nicotine (n = 158), and exclusive e-cig users without nicotine (n = 38). We analyzed and compared the geometric means (GM) and geometric standard deviations (GSD) of the concentration of tobacco-specific biomarkers, and e-cigarette biomarkers among groups. We used log-linear models adjusted for sex and age to model the change percentage and their 95% confidence intervals. RESULTS: Cotinine was significantly higher in nicotine consumers and in e-cigarette users without nicotine when compared to non-smokers. TSNAs were generally significantly lower in non-smokers and higher in nicotine consumers. NNN and NNAL were lower in e-cigarette users with nicotine comparted to smokers, and NNN was higher in e-cigarette users without nicotine when compared to non-smokers. No differences were found in humectant biomarkers between e-cigarette groups. CONCLUSIONS: Although there was a reduction in TSNAs in e-cigarette exclusive users compared to smokers, and a reduction of cotinine concentrations in e-cigarette exclusive users without nicotine compared to smokers, there are still high levels of these biomarkers when compared to non-smokers, which may be a clue towards the harmful effect of e-cigarettes.

Compliance with the smoke-free policy in hospitals in Spain: the patients' perspective.

OBJECTIVE: To explore compliance with the smoke-free policy in hospitals in Catalonia, Spain, by exploring inpatients' perceptions. METHODS: We conducted a cross-sectional study of a random sample of 1047 inpatients from 13 public hospitals. We collected data about: (a) type of information about the smoke-free policy provided by the hospital, (b) patients' knowledge about the policy, (c) general appreciation of the compliance with the policy, and (d) specific appreciation of such compliance by noticing any sign of tobacco consumption. We described the data by several patients' and hospitals' characteristics and assessed their association with the perceived noncompliance using prevalence ratios (PR) and their 95% confidence intervals (CIs). RESULTS: Few patients were informed about the smoke-free policy (4.8% orally, 6.1% in writing, and 55.6% through sign postings). About 64% were aware of the regulation and 73.5% believed that it was properly obeyed. While 0.7% had never or rarely observed smoking indoors, 36.2% had seen someone smoking outdoors sometimes or many times. Signs of tobacco consumption were observed indoors and outdoors. Factors associated with the perception of noncompliance were: being less than 45 years old versus being more than 64 years old (adjusted PR, 2.33; 95% CI, 1.09-4.98) and currently smoking versus have never smoked (adjusted PR, 1.84; 95% CI, 1.02-3.34). CONCLUSION: Compliance with the smoke-free policy in hospitals according to the patients' view is notable, although several infringements were reported, mainly outdoors. The smoke-free policy in hospitals should be reinforced by prompting continuous awareness campaigns and the exemplary role of hospital workers.

Passive exposure to electronic cigarette aerosol in pregnancy: A case study of a family.

BACKGROUND: Passive exposure to the aerosols of electronic cigarettes (e-cigarettes) has been little studied. We assessed this exposure in late pregnancy in a woman and her 3-year-old child, exposed through e-cigarette use by another household member. METHODS: This prospective longitudinal case study involved a family unit consisting of an e-cigarette user, a pregnant woman who delivered an infant during the study, and the couple's older 3-year-old son. At 31, 36, and 40 weeks of the pregnancy, we measured biomarkers (nicotine metabolites, tobacco-specific nitrosamines, propanediols, glycerol, and metals) in the urine and hair of all three participants and in the saliva of the adults, in cord blood at delivery, and in the breast milk at the postpartum period. RESULTS: Samples from the e-cigarette user showed quantifiable concentrations of all analytes assessed (maximum urinary cotinine concentration, 4.9 ng/mL). Among samples taken from the mother, nicotine and its metabolites were found mainly in urine and also in saliva and hair, but not in cord blood. During the postpartum period, we found cotinine concentrations of 2.2 ng/mL in the mother's urine and 0.22 ng/mL in breast milk; 1,2-propanediol was generally detected in urine and saliva, but not in cord blood or breast milk. The maximum urinary cotinine concentration in the 3-year-old child was 2.6 ng/mL and propanediols also were detected in his urine. Nitrosamines were not detected in samples taken from the mother or the 3-year-old. Metals found in the refill liquid were detected at low levels in both the mother and the 3-year-old. CONCLUSIONS: We detected low but not negligible concentrations of e-cigarette-related analytes (including cord blood and breast milk) in an exposed pregnant non-user and in a 3-year-old child also living in the home. Passive exposure to e-cigarette aerosols cannot be disregarded and should be assessed in larger observational studies.

Exposure to secondhand aerosol from electronic cigarettes at homes: A real-life study in four European countries.

Electronic cigarette (e-cigarette) use emits potentially hazardous compounds and deteriorates indoor air quality. Home is a place where e-cigarettes may frequently be used amid its increasing prohibition in public places. This study assessed the real-life scenario of bystanders' exposure to secondhand e-cigarette aerosol (SHA) at home. A one-week observational study was conducted within the TackSHS project in four countries (Greece, Italy, Spain, and the United Kingdom) in 2019 including: 1) homes of e-cigarette users living together with a non-user/non-smoker; and 2) control homes with no smokers nor e-cigarette users. Indoor airborne nicotine, PM2.5, and PM1.0 concentrations were measured as environmental markers of SHA. Biomarkers, including nicotine and its metabolites, tobacco-specific nitrosamines, propanediol, glycerol, and metals were measured in participants' saliva and urine samples. E-cigarette use characteristics, such as e-cigarette refill liquid's nicotine concentration, e-cigarette type, place of e-cigarette use at home, and frequency of ventilation, were also collected. A total of 29 e-cigarette users' homes and 21 control homes were included. The results showed that the seven-day concentrations of airborne nicotine were quantifiable in 21 (72.4 %) out of 29 e-cigarette users' homes; overall, they were quite low (geometric mean: 0.01 µg/m3; 95 % CI: 0.01-0.02 µg/m3) and were all below the limit of quantification in control homes. Seven-day concentrations of PM2.5 and PM1.0 in e-cigarette and control homes were similar. Airborne nicotine and PM concentrations did not differ according to different e-cigarette use characteristics. Non-users residing with e-cigarette users had low but significantly higher levels of cotinine, 3'-OH-cotinine and 1,2-propanediol in saliva, and cobalt in urine than non-users living in control homes. In conclusion, e-cigarette use at home created bystanders' exposure to SHA regardless of the e-cigarette use characteristics. Further studies are warranted to assess the implications of SHA exposure for smoke-free policy.

Determination of soluble angiotensin-converting enzyme 2 in saliva samples and its association with nicotine.

INTRODUCTION: The Angiotensin-Converting Enzyme 2 (ACE2) is the main receptor of the SARS-CoV-2. There is contradictory evidence on how the exposure to nicotine may module the concentration of soluble ACE2 (sACE2). The aim of this study was to assess the association between nicotine and sACE2 concentrations in saliva samples. METHODS: Pooled analysis performed with data retrieved from two studies (n = 634 and n = 302). Geometric mean (GM) concentrations of sACE2, both total and relative to the total amount of protein in the sample, were compared according to sociodemographic variables and variables associated to nicotine. Multivariable linear regression models were fitted to explore the associations of sACE2 with nicotine adjusting for sex, age and body mass index. Spearman's rank-correlation coefficients were estimated between the concentrations of nicotine and cotinine, and pack-years, the concentration of relative sACE2 and the isoforms of sACE2. RESULTS: We observed a significant increase of 0.108‰ and 0.087 ng/µl in the relative and absolute salivary sACE2 GM concentrations, respectively, between the lowest and highest nicotine levels. Similar results were observed for cotinine. These associations did not change in the multivariable linear models. There was a low correlation of nicotine and cotinine concentration with the concentration of relative salivary sACE2 (rs = 0.153 and rs = 0.132, respectively), pack-years (rs = 0.222 and rs = 0.235, respectively) and with the concentration of isoform 40 KDa (rs = 0.193 and rs = 0.140, respectively). CONCLUSION: Salivary nicotine concentration seems to be limitedly associated with the concentration of sACE2.

Changes in the salivary cotinine cut-offs to discriminate smokers and non-smokers before and after Spanish smoke-free legislation.

INTRODUCTION: High levels of cotinine in non-smokers indicate passive exposure to tobacco smoke. This study aims to evaluate variations in salivary cotinine cut-offs to discriminate smokers and non-smokers before and after the implementation of smoke-free legislation (Law 28/2005 and Law 42/2010) in a sample of the adult population of Barcelona, Spain. METHODS: This longitudinal study analyzes salivary cotinine samples and self-reported information from a representative sample (n = 676) of the adult population from Barcelona before and after the approval of smoke-free legislation. We calculated the receiver operating characteristic (ROC) curves, to obtain optimal cotinine cut-off points to discriminate between smokers and non-smokers overall, by sex and age, and their corresponding sensitivity, specificity, and area under the curve. We used linear mixed-effects models, with individuals as random effects, to model the percentage change of cotinine concentration before and after the implementation of both laws. RESULTS: The mean salivary cotinine concentration was significantly lower post-2010 law (-85.8%, p < 0.001). The ROC curves determined that the optimal cotinine cut-off points for discriminating non-smokers and smokers were 10.8 ng/mL (pre-2005 law) and 5.6 ng/mL (post-2010 law), with a post-2010 law sensitivity of 92.6%, specificity of 98.4%, and an area under the curve of 97.0%. The post-2010 law cotinine cut-off points were 5.6 ng/mL for males and 1.9 ng/mL for females. CONCLUSION: The implementation of Spanish smoke-free legislation was effective in reducing secondhand smoke exposure and, therefore, also in reducing the cut-off point for salivary cotinine concentration. This value should be used to better assess tobacco smoke exposure in this population.

Measuring cigarette dependence: A comparison of two scales in two different groups of smokers.

INTRODUCTION: The Fagerström Test for Cigarette Dependence (FTCD) and the Cigarette Dependence Scale (CDS) are usually used to assess cigarette dependence in clinical- and population-based studies. Our objective was to compare these two scales within groups of smokers from both contexts. METHODS: The study was observational with smokers from a representative sample of the adult general population (n=188) and smokers attending a smoking cessation clinic in Barcelona, Spain (n=759). The FTCD and the CDS-5 (short version of 5 items) were used to assess cigarette dependence. We compared the standardized median scores obtained with both scales within each group of smokers by selected variables. To this aim, we re-scaled the scores of both scales to allow their comparison and assess their correlation within both groups. RESULTS: The scores obtained with both scales were highly correlated within both groups of smokers (p<0.001), indicating good agreement in the assessment of cigarette dependence. Nevertheless, higher standardized CDS-5 scores were observed more frequently in the population group overall (3.9 vs FTCD score=3.7, p=0.001), among women (4.5 vs 4.2; p<0.001), in the youngest group of smokers (3.9 vs 3.2; p<0.007) and in light smokers (time to the first cigarette >60 min; 1.7 vs 1.1; p<0.001). CONCLUSIONS: While the CDS-5 scored higher more frequently in the population group, the FTCD scored higher more frequently in the clinical group. These differences should be considered when designing either clinical- or population-based studies.

[Current use of electronic cigarettes among never smoker high school students]. / Consumo actual de cigarrillos electrónicos entre estudiantes de secundaria que nunca han fumado.

OBJECTIVE: To test whether electronic cigarettes use among secondary school students in Spain is associated with initiating nicotine use. METHOD: Secondary analysis of the ESTUDES 2019 survey, a cross-sectional study conducted on a representative sample of students aged 14-18 years and selected students who had never smoked (n=16,705). We computed the prevalence and estimated the factors associated with current electronic cigarettes use (at least once in the month before the interview), with and without nicotine. RESULTS: The prevalence of current electronic cigarettes use among students who have never smoked is 2.5% (95% confidence interval [95%CI]: 2.2-2.9). 0.1% (95%CI: 0.08-0.2) declared using liquids with nicotine at least sometimes and 2.4% (95%CI: 2.1-2.8) using liquids always without nicotine. Being male and under 17 years of age, reporting binge drinking behavior, and having regular friends who use cannabis, increases the probability of current use of electronic cigarettes. The latter two variables seem to act as contextual variables associated with electronic cigarettes use. CONCLUSIONS: The percentage of Spanish never smoker students who currently use electronic cigarettes is lower than in neighboring countries, except for the United Kingdom. Only one in every 1000 Spanish students between 14 and 18 years old who have never smoked initiates the current use of nicotine with an electronic cigarette. However, we must monitor the evolution of this indicator.

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.

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.

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.

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.