Changes in prevalence and socioeconomic inequalities in secondhand smoke exposure in Spanish children, 2016-2019.

INTRODUCTION: Children are vulnerable to secondhand smoke (SHS) exposure, especially those with lower socioeconomic status. This study assesses the changes in prevalence and socioeconomic inequalities in SHS exposure in children younger than 12 years old in Spain between 2016 and 2019. METHODS: We conducted two cross-sectional studies among representative samples of households with children aged <12 years in Spain, in 2016 (n=2411) and 2019 (n=2412). Families were interviewed to assess children's SHS exposure in private settings and outdoor public venues and their adoption of home and car smoke-free rules. We used the education level of the home main earner as a proxy for socioeconomic position. Changes over time in the prevalence and socioeconomic inequalities of SHS exposure and smoke-free rules were estimated through adjusted Poisson regression models with robust variance according to sociodemographic covariates (adjusted prevalence ratios, APRs). RESULTS: In 2019, 70.5% of children were exposed to SHS in Spain. No changes between 2016 and 2019 were found for overall SHS exposure, exposure at home, and at school entrances. SHS exposure increased at public transport stations (APR=1.24; 95% CI: 1.03-1.49) and outdoor hospitality venues (APR=1.17; 95% CI: 1.07-1.29) while it decreased in cars (APR=0.74; 95% CI: 0.56-0.98) and parks (APR=0.87; 95% CI: 0.77-0.98). Households with lower education level had higher prevalence of SHS exposure at home in 2019 compared with those with university studies (primary: APR=1.30; 95% CI: 1.11-1.51; secondary: APR=1.12; 95% CI: 1.00-1.25) and were less likely to adopt home indoor smoke-free rules (primary: APR=0.88; 95% CI: 0.79-0.99; secondary: APR=0.95; 95% CI: 0.89-1.02). Socioeconomic inequalities in SHS exposure at home persisted between 2016 and 2019 (p>0.05), while decreased in smoke-free rules in cars (p=0.039). CONCLUSIONS: Reported SHS exposure among children in Spain remained high between 2016 and 2019. Inequalities persisted at home, highlighting the need for measures to reduce such exposure with an equity perspective.

Validation of a small-area model for estimation of smoking prevalence at a subnational level.

INTRODUCTION: Small-area estimation methods are an alternative to direct survey-based estimates in cases where a survey's sample size does not suffice to ensure representativeness. Nevertheless, the information yielded by small-area estimation methods must be validated. The objective of this study was thus to validate a small-area model. METHODS: The prevalence of smokers, ex-smokers, and never smokers by sex and age group (15-34, 35-54, 55-64, 65-74, ≥75 years) was calculated in two Spanish Autonomous Regions (ARs) by applying a weighted ratio estimator (direct estimator) to data from representative surveys. These estimates were compared against those obtained with a small-area model applied to another survey, specifically the Spanish National Health Survey, which did not guarantee representativeness for these two ARs by sex and age. To evaluate the concordance of the estimates, we calculated the intraclass correlation coefficient (ICC) and the 95% confidence intervals of the differences between estimates. To assess the precision of the estimates, the coefficients of variation were obtained. RESULTS: In all cases, the ICC was ≥0.87, indicating good concordance between the direct and small-area model estimates. Slightly more than eight in ten 95% confidence intervals for the differences between estimates included zero. In all cases, the coefficient of variation of the small-area model was <30%, indicating a good degree of precision in the estimates. CONCLUSIONS: The small-area model applied to national survey data yields valid estimates of smoking prevalence by sex and age group at the AR level. These models could thus be applied to a single year's data from a national survey, which does not guarantee regional representativeness, to characterize various risk factors in a population at a subnational level.

Small-area models to assess the geographical distribution of tobacco consumption by sex and age in Spain.

INTRODUCTION: Complete and accurate data on smoking prevalence at a local level would enable health authorities to plan context-dependent smoking interventions. However, national health surveys do not generally provide direct estimates of smoking prevalence by sex and age groups at the subnational level. This study uses a small-area model-based methodology to obtain precise estimations of smoking prevalence by sex, age group and region, from a population-based survey. METHODS: The areas targeted for analysis consisted of 180 groups based on a combination of sex, age group (15-34, 35-54, 55-64, 65-74, and ≥75 years), and Autonomous Region. Data on tobacco use came from the 2017 Spanish National Health Survey (2017 SNHS). In each of the 180 groups, we estimated the prevalence of smokers (S), ex-smokers (ExS) and never smokers (NS), as well as their coefficients of variation (CV), using a weighted ratio estimator (direct estimator) and a multinomial logistic model with random area effects. RESULTS: When smoking prevalence was estimated using the small-area model, the precision of direct estimates improved; the CV of S and ExS decreased on average by 26%, and those of NS by 25%. The range of S prevalence was 11-46% in men and 4-37% in women, excluding the group aged ≥75 years. CONCLUSIONS: This study proposes a methodology for obtaining reliable estimates of smoking prevalence in groups or areas not covered in the survey design. The model applied is a good alternative for enhancing the precision of estimates at a detailed level, at a much lower cost than that involved in conducting large-scale surveys. This method could be easily integrated into routine data processing of population health surveys. Having such estimates directly after completing a health survey would help characterize the tobacco epidemic and/or any other risk factor more precisely.

Trends in smoking-attributable mortality in Spain: 1990-2018.

BACKGROUND: This study sought to analyse the trend in smoking-attributable mortality (SAM) in Spain among the population aged ≥35 years across the period 1990-2018. METHODS: SAM was estimated by applying a prevalence-independent method, which uses lung cancer (LC) mortality as a proxy of tobacco consumption. We sourced observed mortality from the National Institute of Statistics (Spain), LC mortality rates in smokers and never smokers from the Cancer Prevention Study I-II, and relative risks from 5 US cohorts. Estimates of annual SAM by cause of death, sex and age are shown, along with crude and annual standardised SAM rates. The trend in standardised all-cause and LC rates was analysed using a joinpoint regression model. RESULTS: Tobacco caused 1 717 150 deaths in Spain in the period 1990-2018. Among men, cancers replaced cardiovascular diseases-diabetes mellitus (CVD-DM) as the leading group of tobacco-related cause of death in 1994. Among women, CVD-DM remained the leading cause of death throughout the period. Trend analysis of standardised SAM rates due to all causes and LC showed a decrease in men and an increase in women. CONCLUSIONS: The tobacco epidemic in Spain across the period 1990-2018 has had an important impact on mortality and has evolved differently in both genders. SAM is expected to increase dramatically in women in the coming years. SAM data highlight the importance of including a gender perspective in SAM analyses, in designing more effective and comprehensive public health interventions and in developing gender-specific tobacco control policies to curb tobacco consumption.

Smoking-attributable mortality in the autonomous communities of Spain, 2017.

INTRODUCTION AND OBJECTIVES: To estimate smoking-attributable mortality (SAM) in the regions of Spain among people aged ≥ 35 years in 2017. METHODS: SAM was estimated using a prevalence dependent method based calculating the population attributable fraction. Observed mortality was derived from the National Statistics Institute. The prevalence of smoking by age and sex was based on the Spanish National Health Survey for 2011 and 2017 and the European Survey for 2014. Relative risks were reported from the follow-up of 5 North American cohorts. SAM and population attributable fraction were estimated for each region by age group, sex, and causes of death. Cause-specific and adjusted SAM rates were estimated. RESULTS: Smoking caused 53 825 deaths in the population aged ≥ 35 years (12.9% of all-cause mortality). SAM ranged from 10.8% of observed mortality in La Rioja to 15.3% in the Canary Islands. The differences remained after rates were adjusted by age. The highest adjusted SAM rates were observed in Extremadura in men and in the Canary Islands in women. Adjusted SAM rates in men were inversely correlated with those in women. The percentage of total SAM represented by cardiovascular diseases in each region ranged from 21.8% in Castile-La Mancha to 30.3% in Andalusia. CONCLUSIONS: The distribution of SAM differed among regions. Conducting a detailed region-by-region analysis provides relevant information for health policies aiming to curb the impact of smoking.

Factors related to caregivers' risk perception of secondhand smoke exposure on children's health.

INTRODUCTION: Home is one of the main places for children's secondhand smoke (SHS) exposure. The implementation of smoke-free rules at home might be influenced by caregivers' risk perception of SHS exposure. This study aimed to analyze factors related to caregivers' risk perception of SHS exposure in children. METHODS: We conducted a cross-sectional telephone survey among a representative sample of 2411 parents or legal guardians of children aged <12 years in Spain in 2016. The main study variable was caregivers' healthrisk perception of SHS exposure on children. We investigated correlates of risk perception using multivariate Poisson regression models with robust variance. RESULTS: Overall, 59.6% reported SHS exposure negatively affects children's health a lot, while 34.1% that it affects quite a bit, and 5.5% and 0.8% a little bit or not at all, respectively. The factors associated with a higher caregivers' risk perception were high education level (adjusted prevalence ratio, APR=1.11; 95% CI: 1.01-1.24), living in a non-smoking family unit (APR=1.17; 95% CI: 1.07-1.27), in a home with smoke-free rules (APR=1.34; 95% CI: 1.19-1.51), and with girls only (APR=1.14; 95% CI: 1.06-1.22). CONCLUSIONS: Caregivers' risk perception of SHS exposure is influenced by social determinants and smoking habits in family units. These findings support the need for interventions with a social equity perspective to reduce children's SHS exposure.

Social inequalities in tobacco-attributable mortality in Spain. The intersection between age, sex and educational level.

INTRODUCTION: First study of social inequalities in tobacco-attributable mortality (TAM) in Spain considering the joint influence of sex, age, and education (intersectional perspective). METHODS: Data on all deaths due to cancer, cardiometabolic and respiratory diseases among people aged ≥35 years in 2016 were obtained from the Spanish Statistical Office. TAM was calculated based on sex-, age- and education-specific smoking prevalence, and on sex-, age- and disease-specific relative risks of death for former and current smokers vs lifetime non-smokers. As inequality measures, the relative index of inequality (RII) and the slope index of inequality (SII) were calculated using Poisson regression. The RII is interpreted as the relative risk of mortality between the lowest and the highest educational level, and the SII as the absolute difference in mortality. RESULTS: The crude TAM rate was 55 and 334 per 100,000 in women and men, respectively. Half of these deaths occurred among people with the lowest educational level (27% of the population). The RII for total mortality was 0.39 (95%CI: 0.35-0.42) in women and 1.61 (95%CI: 1.55-1.67) in men. The SII was -41 and 111 deaths per 100,000, respectively. Less-educated women aged <55 years and men (all ages) showed an increased mortality risk; nonetheless, less educated women aged ≥55 had a reduced risk. CONCLUSIONS: TAM is inversely associated with educational level in men and younger women, and directly associated with education in older women. This could be explained by different smoking patterns. Appropriate tobacco control policies should aim to reduce social inequalities in TAM.

Smoking-Attributable mortality in Spain in 2016.

INTRODUCTION: Smoking-attributable mortality (SAM) is a valuable indicator that can be used to characterize the course and health burden of the smoking epidemic. The aim of this paper was to estimate SAM in Spain in 2016 in the population aged 35 and over, using the best available evidence. METHODS: A smoking prevalence-dependent analysis based on the estimation of population-attributable fractions was performed. Smoking prevalence (never, former, and current smokers) was calculated from a combination of the Spanish Health Survey (2016) and the European Health Survey (2014); the relative risk of death among current and former smokers was taken from the follow-up of various cohorts; and mortality rates were obtained from National Center for Statistics data. SAM estimates are presented globally, and by sex, age groups, and major disease categories: cancer, cardiometabolic diseases and respiratory diseases. RESULTS: In 2016, 56,124 deaths were attributed to tobacco consumption, 84% in men (47,000), and 50% in the population aged over 74 (27,795). Overall, 50% of SAM was due to cancer (28,281), 65% of which was lung cancer. One in 4 attributable deaths (13,849) occurred before the age of 65. CONCLUSIONS: One in 7 deaths in Spain in 2016 were attributable to smoking. This estimation of SAM clearly highlights the great impact of smoking on mortality in Spain, mainly due to lung cancer and chronic obstructive pulmonary disease.

[Association between exposure to second-hand smoke and health status in children]. / Asociación entre el humo ambiental de tabaco y el estado de salud en la población infantil.

OBJECTIVE: This study aimed to estimate the association between second-hand smoke (SHS) exposure in children and asthma, wheezing and perceived health. METHOD: A cross-sectional study based on a telephone survey was performed on a representative sample of 2411 children under 12 years old in Spain. Exposure to SHS in private and public settings, and the prevalence of asthma, wheezing and perceived poor health were described. The association between health indicators and SHS exposure was analyzed using multivariate Poisson regression models with robust variance according to age and educational level. RESULTS: The prevalence of SHS exposure in children was 29.2% in private settings and 42.5% in public settings. There was no association between SHS exposure and asthma, wheezing and perceived poor health in children ≤5 years. In children aged 6-11 years with parents with primary/secondary education, presenting asthma (adjusted prevalence ratio [aPR]: 2.1; 95% confidence interval [95%CI]: 1.2-3.8) and worse perceived health (aPR: 1.6; 95%CI: 1.1-2.1) were positively associated with SHS exposure in private settings. In children with parents with university studies, a negative association between SHS exposure and asthma (aPR: .3; 95%CI: 0.1-0.7) and wheezing (aPR: 0.3; 95%CI: 0.1-0.8) was observed. CONCLUSIONS: There are differences in the association between SHS exposure and asthma, wheezing and poor perceived health according to educational level. Interventions with an equity perspective aimed at reducing SHS exposure in childhood should be implemented.

Sociodemographic factors associated with secondhand smoke exposure and smoking rules in homes with children.

BACKGROUND: This study aims to identify sociodemographic characteristics associated with secondhand smoke (SHS) exposure and the adoption of smoking bans in homes with children in Spain. METHODS: We performed, in 2016, a cross-sectional study to a representative sample of Spanish households with children under 12 years old. We administered a telephone survey to the parents asking about smoking patterns at home, children's SHS exposure and sociodemographic characteristics. Poisson regression models with robust variance were built to assess sociodemographic characteristics associated with household SHS exposure and the adoption of smoking rules. RESULTS: In this study participated 2411 families, 25.8% of which reported exposure at home and 84.4% implemented smoking bans. SHS exposure was associated with having one (aPR = 2.09; 95% CI: 1.43-3.04) or two Spanish parents (aPR = 1.71; 95% CI: 1.24-2.36), lower educational attainment (primary: aPR = 1.74; 95% CI: 1.45-2.10; secondary: aPR = 1.37; 95% CI: 1.17-1.60 compared with university studies), a family structure different from two-parent family (aPR = 1.38; 95% CI: 1.14-1.67) and parents between 31 and 40 years (aPR = 0.75; 95% CI: 0.57-0.99) and 41-50 years (aPR = 0.62; 95% CI: 0.47-0.81) compared with 18- to 30-year-old parents. The adoption of smoking bans was associated with two-parent family (aPR = 1.09; 95% CI: 1.01-1.17), living with non-smokers (aPR = 1.46; 95% CI: 1.31-1.62), parents of foreign origin (aPR = 1.09; 95% CI: 1.04-1.14) and younger children (0-3 years: aPR = 1.05; 95% CI: 1.01-1.09) compared with the oldest children (8-11 years). CONCLUSION: The parent's origin and the family structure were associated with SHS exposure and the adoption of smoking bans at home. Moreover, the number of smokers living at home was relevant for the adoption of smoking bans, and the educational attainment for SHS exposure. These factors should be taken into consideration when designing or implementing smoke-free home programmes.

Burden of respiratory disease attributable to secondhand smoke exposure at home in children in Spain (2015).

This study aimed to estimate the number of incident cases and hospital admissions attributable to secondhand smoke (SHS) exposure at home for asthma, otitis media (OM), and lower respiratory infections (LRI) in children in Spain. The burden of respiratory disease caused by SHS exposure was estimated in terms of incident cases and hospitalized cases for asthma, OM, and LRI. Estimates were calculated using the population attributable fraction. The age-specific (0-1 year, 0-4 years, 5-11 years, and 0-11 years) prevalence of SHS exposure in children was estimated through a telephone survey performed in a representative sample of Spanish households with children in 2016. The risk estimates for all diseases were selected from international meta-analyses. The number of hospitalized cases was obtained for each disease from the Hospital Minimum Data Set provided by the Ministry of Health of Spain. Incident cases were obtained from the Global Health Data Exchange. In 2015, SHS exposure caused an estimated total of 136,403 incident cases of the following respiratory diseases: 9058 (8.5%) cases of asthma, 120,248 (8.5%) of OM, and 7097 (13.5%) of LRI in children aged 0-14 years old in Spain. Likewise, SHS exposure caused a total of 3028 hospitalized cases, with 379 (8.5%) for asthma and 167 (8.5%) for OM in children 0-11 years old, and 2482 (11.6%) for LRI in children <2 years old. The high burden of respiratory disease attributed to SHS exposure supports the need to improve protection of children against SHS exposure by extending smoke-free regulations to homes and cars.

Validity of self-reported indicators to assess secondhand smoke exposure in the home.

INTRODUCTION: Questionnaires are widely used to assess secondhand smoke (SHS) exposure. However, the validity of self-reported SHS exposure indicators has been rarely assessed. We aimed to assess correlations, sensitivity, specificity, and predictive values between self-reported SHS exposure indicators and airborne nicotine concentrations. METHODS: We performed a cross-sectional study with a convenience sample of 175 homes in Barcelona and Santiago de Compostela, Spain. Airborne nicotine samples were collected from participants' homes and a self-administered questionnaire was completed on SHS exposure in the home. Spearman correlations coefficients and sensitivity, specificity and predictive values were assessed between self-reported SHS exposure indicators and nicotine concentrations in the home. RESULTS: All self-reported SHS exposure indicators correlated moderately strongly with airborne nicotine concentrations (Spearman correlations coefficient ranging from 0.58 to 0.65). Moreover, sensitivities and negative predictive values between self-reported indicators and the presence of nicotine in the home were below 66.4% while specificities and positive predictive values were over 78.4%. The "number of people usually smoking in the home" showed the best results (rs = 0.65, p < 0.001; sensitivity = 50.4%, specificity = 95.2%, PPV = 95.0, NPV = 51.3). CONCLUSIONS: The self-reported SHS indicators assessed in this study showed moderate and strong correlations, low sensitivities, and high specificities. Among them, the best results were obtained with the "number of people usually smoking in the home".

Second-hand smoke exposure in homes with children: assessment of airborne nicotine in the living room and children's bedroom.

BACKGROUND: The introduction of 'smoke-free laws' has reduced the population's exposure to second-hand smoke (SHS), although SHS is still an issue in homes and other public places. Children are vulnerable to its health effects, and their greatest exposure occurs at home. OBJECTIVES: To assess airborne nicotine concentration of the living room and children's bedroom of homes with children under 13 years of age, and to analyse factors associated with these levels. METHODS: We conducted a cross-sectional study in Barcelona in 2015-2016, selecting a convenience sample from families with at least one child under 13 years of age. The sample comprised 50 families with smokers and 50 without. We measured airborne nicotine concentrations in the living room and children's bedroom, and, using a questionnaire administered to the parents, collected information about smoking habits at home. RESULTS: Homes without smokers showed nicotine concentrations below the limit of detection (<0.02 µg/m3), while those with at least one smoker showed 0.16 µg/m3 in the living room and 0.12 µg/m3 in the bedroom. When smoking was allowed inside home, these values increased to 1.04 and 0.48 µg/m3, respectively. Moreover, nicotine concentrations in both rooms were strongly correlated (r=0.89), and higher nicotine levels were associated with the number of cigarettes smoked in the living room, smoking rules, the number of smokers living at home and tobacco smell. CONCLUSIONS: Homes with smokers present SHS in the living room and in the children's bedroom. Therefore, programmes focused on reducing children's SHS exposure are urgently needed.

Social inequalities in secondhand smoke exposure in children in Spain.

INTRODUCTION: Children are particularly vulnerable to the health effects of secondhand smoke (SHS). The objectives of this study are to describe SHS exposure of children younger than 12 years in Spain and to identify potential social inequalities associated with SHS exposure. METHODS: A cross-sectional study was conducted in a representative sample of the population younger than 12 years in Spain. A computer-assisted telephone interview was conducted with parents or legal guardians in 2016, to assess the children's SHS exposure at home, in the car, at school and at the nursery gates, in public transport, and during leisure time. The socio-demographic variables included were the child's age and sex, the highest educational attainment at home, and occupational social class. Prevalence and 95% confidence intervals were calculated for SHS exposure in each setting and for overall exposure. RESULTS: In all, 71.8% of the children were exposed to SHS: 25.8% were exposed at home, 4.6% in the car, 8.2% in public transport, 31.9% at outdoor nursery or school gates, and 48% during leisure time. The higher the educational attainment at home, the lower the exposure (38.8% for primary school or lower, 28.7% for secondary school and 20.8% university level). The more deprived the social class, the higher the exposure (21.7% class I-II, 23.4% class III-IV and 31.1% class V-VII). SHS exposure in cars and overall exposure also decreased with higher educational achievement. CONCLUSIONS: In Spain, a large proportion of children are still exposed to SHS. Furthermore, there are clear social inequalities. To reduce SHS exposure, there is an urgent need for evidence-based interventions with an equity perspective.

Changes in Secondhand Smoke Exposure After Smoke-Free Legislation (Spain, 2006-2011).

INTRODUCTION: In 2011, the Spanish partial smoke-free legislation was extended to affect all enclosed settings, including hospitality venues and selected outdoor areas. This study evaluated the change in self-reported exposure to secondhand smoke among the adult, nonsmoking population. METHODS: Two cross-sectional surveys were conducted on nationally representative samples of the adult (≥18 years) nonsmoking Spanish population. One was conducted in 2006 (6 months after the first ban) and the other in 2011, 6 months after the new ban was implemented. We assessed the prevalence and 95% confidence interval (CI) of self-reported exposure to secondhand smoke in various settings, and the corresponding adjusted prevalence ratios (PR) and 95% CIs. RESULTS: Overall, the self-reported exposure to secondhand smoke fell from 71.9% (95% CI: 70.1%-73.7%) in 2006 to 45.2% (95% CI: 43.1%-47.3%) in 2011 (PR = 0.43; 95% CI: 0.39-0.47). Specifically, self-reported exposure significantly decreased from 29.2% to 12.7% (PR = 0.36; 95% CI: 0.31-0.42) in the home, from 35.0% to 13.0% (PR = 0.40; 95% CI: 0.33-0.49) at work/education venues, from 56.2% to 32.2% (PR = 0.44; 95% CI: 0.39-0.48) during leisure time (mainly hospitality venues, but also venues other than work/education venues and home), and from 40.6% to 12.7% (PR = 0.24; 95% CI: 0.21-0.29) in transportation vehicles/stations. CONCLUSIONS: The prevalence of secondhand smoke exposure among nonsmokers decreased after implementation of a comprehensive smoke-free legislation in Spain. In addition to the expected reduction in exposure during leisure time, we observed reductions in settings that were not subject to the new legislation, such as homes, outdoor bus stops, and train stations. IMPLICATIONS: Exposure to secondhand smoke in selected outdoor settings may be further reduced by extending smoke-free legislation.

Mortality Attributable to Secondhand Smoke Exposure in Spain (2011).

INTRODUCTION: The objective of this study was to assess the mortality attributable to secondhand smoke (SHS) exposure among never-smokers in Spain in 2011, after the implementation of the Spanish smoking law. METHODS: Data on SHS exposure were obtained from a computer-assisted telephone survey carried out in a representative sample of the adult Spanish population. We included the two main diseases widely associated with SHS exposure: lung cancer and ischaemic heart disease. The relative risks for these diseases were selected from previously published meta-analyses. The number of deaths attributable to SHS was calculated by applying the population attributable fraction to mortality not attributable to active smoking in 2011. The analyses were stratified by sex, age and setting of exposure (home, workplace, and both combined). In addition, a sensitivity analysis was performed for distinct scenarios. RESULTS: In 2011, a total of 586 deaths in men and 442 deaths in women would be attributable to SHS exposure. The total number of deaths from lung cancer attributable to SHS exposure would be 124, while the total number of deaths from ischaemic heart disease would be 904. The inclusion of ex-smokers or SHS exposure in leisure time in the study would considerably increase the total number of attributable deaths (by 20% and 130%, respectively). CONCLUSIONS: The total number of deaths attributable to SHS exposure at home and at work in Spain would be 1028 in 2011. Efforts are still needed to reduce the current prevalence of exposure-mainly due to exposure in nonregulated settings such as homes or cars and some outdoor spaces-and the associated morbidity and mortality.

Changes in the Prevalence of Tobacco Consumption and the Profile of Spanish Smokers after a Comprehensive Smoke-Free Policy.

BACKGROUND: A partial smoke-free regulation in Spain was introduced on January 1, 2006, which was subsequently amended to introduce a comprehensive smoke-free policy from 2 January 2011 onward. The objective of this study was to compare the prevalence of tobacco consumption in Spain and the profile of smokers before (2006) and after (2011) the comprehensive smoking ban passed in 2010. METHODS: Two independent, cross-sectional, population-based surveys were carried out among the adult (≥ 18 years old) Spanish population in 2006 and 2011 through telephone interviews. Both surveys used the same methods and questionnaire. Nicotine dependence was assessed with the Fagerström Test for nicotine dependence and readiness to quit according to the stages of change. RESULTS: The prevalence of tobacco consumption showed a nonsignificant decrease from 23.4% in 2006 to 20.7% in 2011. No changes were observed in nicotine dependence or readiness to quit. In 2011, most smokers (76%) showed low nicotine dependence and were mainly in the precontemplation stage (72%). CONCLUSIONS: The prevalence of smokers has slightly decreased since the introduction of the total smoking ban in Spain. No differences were found in nicotine dependence or readiness to quit.

Validity of self-reported exposure to second-hand smoke in hospitality venues.

The aim was to assess the validity of self-reported exposure to second-hand smoke (SHS) in 50 hospitality venues of Madrid (Spain) in 2010, taking as a reference vapour-phase nicotine measured by active sampling. The questions posed in the questionnaire permitted distinguishing between the different levels of SHS. However, the moderate relationship found (Spearman׳s correlation=0.387, p<0.001) suggests that intensity of exposure to SHS in hospitality venues, based solely on self-reported information, should be used with caution.

Variability in the correlation between nicotine and PM2.5 as airborne markers of second-hand smoke exposure.

The aim of this study was to assess the relationship between particulate matter of diameter≤2.5 µm (PM2.5) and airborne nicotine concentration as markers of second-hand smoke exposure with respect to the setting studied, the intensity of exposure, and the type of environment studied (indoors or outdoors). Data are derived from two independent studies that simultaneously measured PM2.5 and nicotine concentrations in the air as airborne markers of second-hand smoke exposure in public places and workplaces, including health care centres, bars, public administration offices, educational centres, and transportation. We obtained 213 simultaneous measures of airborne nicotine and PM2.5. Nicotine in the air was measured with active samplers containing a sodium bisulphate-treated filter that was analysed by gas chromatography/mass spectrometry. PM2.5 was measured with a SidePak AM510 Personal Aerosol Monitor. We calculated Spearman's rank correlation coefficient and its 95% confidence intervals (95% CI) between both measures for overall data and stratified by setting, type of environment (indoors/outdoors), and intensity of second-hand smoke exposure (low/high, according to the global median nicotine concentration). We also fitted generalized regression models to further explore these relationships. The median airborne nicotine concentration was 1.36 µg/m3, and the median PM2.5 concentration was 32.13 µg/m3. The overall correlation between both markers was high (Spearman's rank correlation coefficient=0.709; 95% CI: 0.635-0.770). Correlations were higher indoors (Spearman's rank correlation coefficient=0.739; 95% CI: 0.666-0.798) and in environments with high second-hand smoke exposure (Spearman's rank correlation coefficient=0.733; 95% CI: 0.631-0.810). The multivariate analysis adjusted for type of environment and intensity of second-hand smoke exposure confirmed a strong relationship (7.1% increase in geometric mean PM2.5 concentration per µg/m3 nicotine concentration), but only in indoor environments in a stratified analysis (6.7% increase; 95% CI: 4.3-9.1%). Although the overall correlation between airborne nicotine and PM2.5 is high, there is some variability regarding the type of environment and the intensity of second-hand smoke exposure. In the absence of other sources of combustion, air nicotine and PM2.5 measures can be used indoors, while PM2.5 should be used outdoors with caution.