Towards stronger tobacco control policies to curb the smoking epidemic in Spain.

Smoking and exposure to secondhand smoke pose a significant risk to the health of populations. Although this evidence is not new, the commitment of countries to implement laws aimed at controlling consumption and eliminating exposure to secondhand smoke is uneven. Thus, in North America or in Europe, locations like California or Ireland, are pioneers in establishing policies aimed at protecting the population against smoking and secondhand smoke. Identifying measures that have worked would help control this important Public Health problem in other countries that are further behind in tobacco control policies. In Spain, there has been almost 15 years of little political action in legislation oriented to control the tobacco epidemic. If we want to achieve the tobacco endgame, new legislative measures must be implemented. In this paper, we have elucidated tobacco control policies that could be implemented and show how different countries have done so.

Physical and social environmental factors related to co-occurrence of unhealthy lifestyle behaviors.

Previous work identifying determinants of co-occurrence of behavioral risk factors have focused on their association with individuals' characteristics with scant attention paid to their relationship to contextual factors. Data came from 21,007 individuals ≥15 years of age who participated in the cross-sectional 2011-2012 Spanish National Health Survey. Two indicators were defined by tobacco consumption, alcohol intake, diet, physical activity, and body mass index. The first indicator, based on dichotomized measures, ranges from 0 to 5. The second one (unhealthy lifestyle index), ranges from 0 to 15, with 0 denoting the healthiest score. Among the determinants, we examined social support, five perceived characteristics of the neighborhood, and the socioeconomic deprivation index of the census tract of residence. Data were analyzed using multilevel linear and logistic regression models adjusted for the main sociodemographic characteristics. Using the dichotomized indicator, the probability of having 3-5 risk factors versus <3 factors was associated with low social support (Odds Ratio [OR] 1.50; 95% Confidence Interval [CI]: 1.25-1.80). Issues surrounding neighborhood cleanliness (OR = 1.18; 95%CI: 1.04-1.33), air pollution (OR = 1.38; 95%CI: 1.16-1.64), and street crime (OR = 1.21; 95%CI: 1.03-1.42) were associated with determinants of co-occurrence. Risk factors co-occurrence increased as deprivation level increased: the OR for the highest deprivation quintile versus the lowest was 1.30 (95%CI: 1.14-1.48). Similar results were observed when using the unhealthy lifestyle index. Poorer physical and social environments are related to greater co-occurrence of risk factors for chronic diseases. Health promotion interventions targeting the prevention of risk factors should consider the contextual characteristics of the neighborhood environment.

Small area influences on the individual unhealthy lifestyle behaviors: A multilevel analysis of discriminatory accuracy.

We estimated the discriminatory power of area of residence (census tract) on the prevalence of main risk factors for chronic diseases. Results, based on a sample of 21,007 participants from the 2011-2012 National Health Survey of Spain, show a differential influence of the geosocial environment on the four health risk factors. Accounting for census tracts substantially increases the discriminatory power regarding at-risk alcohol consumption, unbalanced diet, and leisure-time sedentarism but not tobacco consumption. However, the socioeconomic characteristics of the tracts played a minor role. Further research on the specific geosocial contextual variables explaining variability in these risk factors is necessary.

Validity of the Global Activity Limitation Indicator (GALI) to evaluate severity of disability.

Our aim was to estimate the validity of the Global Activity Limitation Indicator (GALI) when measuring the severity level of disability. Data came from 153 residents of Spain, who requested an evaluation of their degree of disability. We compared disability classifications (severe vs. non-severe) from GALI against those from the 36-item questionnaire WHODAS 2.0, the current gold standard measure of disability. The sensitivity of GALI to detect severe disability was 58.3% [95% confidence interval (CI):43.2-72.4], and the specificity was 84.8% (95% CI: 76.4-91.0). Thus, the validity of GALI to accurately categorize the degree of severity of an individual's disability is not high, this in great part due to its limited sensitivity.

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.

Social inequalities in cardiovascular mortality in Spain from an intersectional perspective.

INTRODUCTION AND OBJECTIVES: There is an interaction between age, sex, and educational level, among other factors, that influences mortality. To date, no studies in Spain have comprehensively analyzed social inequalities in cardiovascular mortality by considering the joint influence of age, sex, and education (intersectional perspective). METHODS: Study of all deaths due to all-cause cardiovascular disease, ischemic heart disease, heart failure, and cerebrovascular disease among people aged ≥ 30 years in Spain in 2015. Data were obtained from the Spanish Office of Statistics. The relative index of inequality (RII) and the slope index of inequality (SII) were calculated by using Poisson regression models with age-adjusted mortality. 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 RII for all-cause cardiovascular mortality was 1.88 (95%CI, 1.80-1.96) in women and 1.44 (95%CI, 1.39-1.49) in men. The SII was 178.46 and 149.43 deaths per 100 000, respectively. The greatest inequalities were observed in ischemic heart disease and heart failure in younger women, with a RII higher than 4. There were no differences between sexes in inequalities due to cerebrovascular disease. CONCLUSIONS: Cardiovascular mortality is inversely associated with educational level. This inequality mostly affects premature mortality due to cardiac causes, especially among women. Monitoring this problem could guide the future Cardiovascular Health Strategy in the National Health System, to reduce inequality in the first cause of death.

Demand for health services and drug prescriptions among overweight or obese preschool children.

OBJECTIVES: To evaluate the association between excess weight and the demand of health services in preschool children compared with healthy weight. METHODS: The data come from the Longitudinal Study of Childhood Obesity cohort (1884 4-year-old children, residing in the Madrid region, Spain) who provided information through telephone questionnaire, physical examination and electronic medical records. We defined overweight, general and abdominal obesity based on body mass index, waist circumference and waist-to-height ratio. Using mixed models of multivariable negative binomial regression we calculated the incidence rate ratio (IRR) regarding primary care (PC) doctor visits, drug prescriptions and hospital admissions by weight status at the end of the 2-year follow-up. RESULTS: Childhood general obesity was associated with a higher demand for PC services related to psychological problems (IRR=1.53; 95% CI 1.02 to 2.28) and childhood abdominal obesity, according to waist-to-height ratio, was related to more frequent problems of the musculoskeletal system (IRR=1.27; 95% CI 1.00 to 1.62). Drugs were prescribed more frequently to children falling under all three definitions of excess weight, compared with healthy weight children. No differences in the number of hospital admissions were observed. CONCLUSIONS: The demand of health services related to early childhood obesity was small. Nevertheless, obesity was associated with a slightly greater demand for drug prescriptions and for PC doctor visits related to psychological and musculoskeletal problems.

Inequalities in the risk of disability due to traffic injuries in the Spanish adult population, 2009-2010.

BACKGROUND: Although traffic injuries (TIs) are an important cause of disability the related factors are little known. We aimed to estimate the differences in risk of TI-related disability according to individual characteristics that might generate health inequalities. METHODS: Cross-sectional study using a representative Spanish population sample drawn from the European Health Interview Survey 2009/2010. We calculated traffic crashes in the preceding year which resulted in injuries. Disability was measured using the Global Activity Limitation Indicator and four indicators of limitations (sensory, physical functional, self-care and domestic activities). Principal socio-demographic and behavioural/lifestyle variables were studied. We used multivariate logistic regression to estimate the risk (ORs) of TI-related disability in the sample as whole and disability-related factors in persons who had experienced TIs. RESULTS: Persons with TIs had a higher risk of global disability (OR = 1.61; 95%CI:1.17-2.20), physical functional limitations (OR = 1.96; 95%CI:1.33-2.89) and self-care limitations (OR = 1.73; 95%CI:0.98-3.05). Among persons with TIs, GALI-related risk was higher in women (OR = 3.06, p = 0.002) and persons aged over 30 years (OR31-45years = 6.81, p < 0.001; OR46-64years = 5.96, p = 0.011; OR>64years = 4.54, p = 0.047). Lower risk was observed among persons with a higher educational level (OR = 0.22, p = 0.003). The risk of disability among persons with TIs who consumed illegal drugs was OR = 3.9 (p = 0.023). CONCLUSIONS: Traffic injuries in the preceding year are associated with higher risk of disability, which is unevenly distributed. Individual (women and persons over 30 years), socio-economic (lower educational level) and behavioural (illegal drug use) factors are involved. Actions aimed at changing the unequal risk among vulnerable subgroups and providing health, social and protective services should be implemented.

Intersection of neighborhood dynamics and socioeconomic status in small-area walkability: the Heart Healthy Hoods project.

BACKGROUND: Previous studies found a complex relationship between area-level socioeconomic status (SES) and walkability. These studies did not include neighborhood dynamics. Our aim was to study the association between area-level SES and walkability in the city of Madrid (Spain) evaluating the potential effect modification of neighborhood dynamics. METHODS: All census sections of the city of Madrid (n = 2415) were included. Area-level SES was measured using a composite index of 7 indicators in 4 domains (education, wealth, occupation and living conditions). Two neighborhood dynamics factors were computed: gentrification, proxied by change in education levels in the previous 10 years, and neighborhood age, proxied by median year of construction of housing units in the area. Walkability was measured using a composite index of 4 indicators (Residential Density, Population Density, Retail Destinations and Street Connectivity). We modeled the association using linear mixed models with random intercepts. RESULTS: Area-level SES and walkability were inversely and significantly associated. Areas with lower SES showed the highest walkability. This pattern did not hold for areas with an increase in education level, where the association was flat (no decrease in walkability with higher SES). Moreover, the association was attenuated in newly built areas: the association was stronger in areas built before 1975, weaker in areas built between 1975 and 1990 and flat in areas built from 1990 on. CONCLUSION: Areas with higher neighborhood socioeconomic status had lower walkability in Madrid. This disadvantage in walkability was not present in recently built or gentrified areas.

Alcohol drinking patterns and risk of functional limitations in two cohorts of older adults.

BACKGROUND & AIMS: Several studies have found that moderate alcohol intake is associated with lower risk of functional limitations in older adults. However, no previous investigation has assessed this association in older adults from Mediterranean countries, who show characteristic drinking patterns. METHODS: Data were taken from the UAM and the Seniors-ENRICA cohorts in Spain, comprising community-dwelling people aged ≥60 years. At baseline, participants in both cohorts were classified as non-drinkers, ex-drinkers, moderate drinkers and heavy drinkers (the threshold between moderate and heavy intake was ≥40 g/day in men and ≥24 g/day in women). The Seniors-ENRICA cohort allowed assessment of a Mediterranean Drinking Pattern (MDP), defined as moderate alcohol intake, with wine preference (≥80% of alcohol consumed as wine) and drinking only with meals. The incidence of limitation in mobility, agility, and instrumental activities of daily living (IADL) was ascertained in each cohort at the end of a 3.5-year follow-up. Analyses were adjusted for sex, age, education, lifestyle, BMI, chronic conditions, and functional limitations at baseline others than the studied limitation. RESULTS: Compared with non-drinkers, ex-drinkers showed a higher risk of IADL limitation (pooled adjusted odds ratio [paOR]: 1.63; 95% confidence interval [CI]: 1.04-2.21). By contrast, moderate drinkers had a lower risk of limitations in mobility (paOR: 0.80; 95% CI: 0.63-0.97), agility (paOR: 0.82; 95% CI: 0.65-0.99) and IADL (paOR: 0.54; 95% CI: 0.39-0.69). Among individuals reporting poor or fair health, the MDP was associated with lower risk of mobility limitation (aOR: 0.51; 95% CI: 0.27-0.97). CONCLUSION: In older adults, moderate alcohol consumption, as well as the MDP in specific subgroups, is associated with lower risk of functional limitation. These results should not serve to promote alcohol intake, because older adults are particularly vulnerable to its harmful effects.

Disability related to road traffic crashes among adults in Spain.

BACKGROUND: Road traffic accidents cause substantial morbidity and disease burden; few studies have examined their impact on disability. OBJECTIVE: To estimate the magnitude and distribution of disability due to road traffic accidents according to socio-demographic variables, and its main socioeconomic and health determinants. METHODS: A cross-sectional study was conducted in community-dwelling participants in the "2008 Spanish National Disability Survey", a representative sample of 91,846 households with 20,425 disabled persons older than 15 years; 443 had disability due to road traffic accidents. RESULTS: The prevalence was 2.1 per 1000 inhabitants (95% CI:1.8-2.3), with no differences by sex. Risk was highest among persons aged 31 to 64 years, and onset of disability showed a sharp inflection point at age 16 years in both sexes. Odds ratios (ORs) were higher (OR=1.3; 95% CI:1.1- 1.7) for participants with secondary education than for those with the lowest educational levels and were lower (OR: 0.5; 95% CI:0.3-0.8) for participants with the highest household income levels than for those with lowest. Only 24% of disabled participants were gainfully employed. As compared to other sources of disability, traffic crashes caused greater disability in terms of mobility (OR=3.1;p<0.001), a greater need for health/social services (OR=1.5;p=0.003), and more problems with private transportation (OR=1.6;p<0.001), moving around outside the home (OR=1.6;p<0.001) and changes in economic activity (OR=2.4;p<0.001). CONCLUSIONS: The prevalence of disability due to road traffic accidents in Spain is lower than in other developed countries, with middle-aged and socio-economically underprivileged persons being the most affected. Disability due to road traffic accidents is related to a greater demand for social/health care support, problems of accessibility/commuting, and major changes in economic activity.

Patterns of alcohol consumption in the older population of Spain, 2008-2010.

BACKGROUND: Older adults are a growing segment of the European population and alcohol is an important cause of disease burden; thus, it is noteworthy that little information is available on alcohol intake among older adults in Europe. OBJECTIVE: The aim of this study was to examine alcohol consumption patterns and their association with demographic and clinical variables in the older population of Spain. DESIGN: This was a cross-sectional study. PARTICIPANTS/SETTING: The sample included 3,058 individuals, representative of the Spanish population aged ≥60 years during 2008-2010. MAIN OUTCOME MEASURE: Regular alcohol consumption was measured with a validated diet history questionnaire. The threshold between moderate and heavy drinking was ≥40 g alcohol/day in men (≥24 g in women). Binge drinking was defined as intake of ≥80 g alcohol in men (≥60 g in women) during any drinking occasion in the previous month, and problem drinking by a CAGE score ≥2. STATISTICAL ANALYSIS PERFORMED: The prevalence and 95% CI of the drinking patterns were calculated after accounting for sampling design. RESULTS: The prevalence of moderate drinking was 44.3% (95% CI 42.0% to 46.6%) and of heavy drinking was 7.8% (95% CI 6.7% to 8.9%). In total, 68.4% (95% CI 65.7% to 71.2%) of individuals obtained >80% of alcohol from wine and 61.8% (95% CI 58.9% to 64.6%) drank only with meals. Furthermore, 1% (95% CI 0.6% to 1.4%) showed binge drinking and 3.1% (95% CI 2.3% to 3.8%) showed problem drinking. Heavy alcohol consumption was significantly more frequent in men. Moderate alcohol consumption was significantly less frequent among women, persons who were not married, living alone, with a diagnosis of diabetes, receiving treatment for diabetes, and with suboptimal self-rated health. About 5% to 10% of individuals with diagnosed hypertension, diabetes, or cardiovascular disease showed heavy drinking. Among those taking sleeping pills or antidiabetes or antithrombotic treatment, 37% to 46% had moderate alcohol intake and 5% to 8% had heavy intake. CONCLUSIONS: Alcohol consumption among older adults in Spain is frequent and mostly consistent with the traditional Mediterranean drinking pattern. However, a proportion of individuals were heavy drinkers and used medication that may interact with alcohol.

Three-year changes in drinking patterns in Spain: a prospective population-based cohort study.

BACKGROUND: This study examined changes in alcohol drinking patterns (DP) and associated variables in a Mediterranean country. METHODS: Changes in DP between baseline (2008-2010) and follow-up (2012-2013) were examined on a Spanish population-based cohort of 2254 adults (18-59 years) using multinomial logistic regression. Heavy consumption was defined as ≥40 g/day of alcohol in men (≥24 g/day in women) and binge drinking (BD) as the intake of ≥80 g of alcohol in men (≥60 g in women) on one occasion in the previous month. Six patterns were defined: (1) non-drinkers; (2) ex-drinkers; (3) moderate drinkers without BD (MNB); (4) moderate drinkers with BD (MB); (5) heavy drinkers without BD (HNB); and (6) heavy drinkers with BD (HB). RESULTS: Overall, 45.2% of participants changed DP during follow-up. Over 24% of non-drinkers and 19.4% of ex-drinkers at baseline qualified as MNB at follow-up. The largest flow was from HNB to MNB (57.1%). Light-drinking patterns experienced the largest gains (ex-drinkers: 37.5% and MNB: 66.7%) by absorbing individuals lost by heavy-drinking patterns (MB: 50.8% and HNB: 48.4%). Men, younger individuals, and current smokers were more likely to report heavy-drinking patterns at one or both assessments. Being married or employed increased the likelihood of reporting light-drinking patterns at both surveys (p<0.05). Improving physical quality of life and exercise were associated with a shift from light- to heavy-drinking pattern during follow-up (p<0.05). CONCLUSIONS: DP in Spain changed over 3 years with a tendency to "regress" toward moderate patterns. Repeated measures of alcohol intake may reduce classification errors and biased results when examining the impact of alcohol on health.

Recent changes in school-based policies on physical activity and nutrition in Spain.

BACKGROUND: This study evaluates the changes in Spain between 2006 and 2012, of school-based policies encouraging healthy eating and the undertaking of physical activity (PA). METHODS: A longitudinal study was undertaken comprising 277 representative schools from all the regions of Spain. The questionnaires were completed by the school management board. An indicator for school policies on PA was constructed (score 0-4) from the following indicators: (i) participation in PA programmes, (ii) existence of written PA guidelines, (iii) training of teachers about PA and (iv) organization of extracurricular PA activities. For nutrition, indicators similar to the first three for PA were evaluated, together with access to healthy foods (score 0-4). In addition to comparing the scores for 2006 and 2012, multivariate linear regression was used to study the association between the characteristics of the schools and the changes in the scores. RESULTS: The indicators for school-based policies on nutrition and PA improved between 2006 and 2012: the average score for PA increased from 1.33 to 1.79 (P < 0.001) and that for nutrition from 1.28 to 1.92 (P < 0.001). The greatest changes were seen regarding the written guidelines for action and participation in PA and nutrition programmes as well as the training of teachers about nutrition. The schools with the least number of students had the highest changes in scores for policies on nutrition (P < 0.05). CONCLUSIONS: There has been an increase of school-based policies on PA and nutrition, although there is still room for improvement.

The influence of parental education on child mental health in Spain.

PURPOSE: To analyze the association between parental education and offspring's mental health in a nationally representative Spanish sample, and assess the contribution of other socioeconomic factors to the association. METHODS: We conducted a secondary analysis of data on 4- to 15-year-olds participating in the 2006 Spanish National Health Survey. Mental health was assessed using the parent-reported Strengths & Difficulties Questionnaire. Parents' respective educational levels were summarized in a single variable. Univariate and multivariate analyses, controlling for family-, child- and parent-related characteristics, were used to study the association. RESULTS: The final sample comprised 5,635 children. A strong association between parental education and parent-reported child mental health was observed among 4- to 11-year-olds, with odds ratios (ORs) increasing as parental educational level decreased. Where both parents had a sub-university level, maternal education showed a stronger association than did paternal education. Following adjustment for covariates, parental education continued to be the strongest risk factor for parent-reported child mental health problems, OR = 3.7 (95% CI 2.4-5.8) for the lowest educational level, but no association was found among 12- to 15-year-olds. Male sex, immigrant status, activity limitation, parent's poor mental health, low social support, poor family function, single-parent families, low family income and social class were associated with parent-reported child mental health problems in both age groups. CONCLUSIONS: Our results show that there is a strong association between parental education and parent-reported child mental health, and that this is indeed stronger than that for income and social class. Among adolescents, however, the effect of parental education would appear to be outweighed by other factors.

Questionnaire-based second-hand smoke assessment in adults.

BACKGROUND: Numerous studies have assessed second-hand smoke (SHS) exposure but a gold standard remains to be established. This study aimed to review how SHS exposure has been assessed in adults in questionnaire-based epidemiological studies. METHODS: A literature search of original papers in English, French, Italian or Spanish published from January 2000 to May 2011 was performed using PubMed. The variables recorded for each study included target population, sample size, validation of the SHS questions, study design and phrasing of every question used to assess SHS exposure. For each item, information such as the setting where exposure was assessed or the indicator used to ascertain SHS exposure was extracted. RESULTS: We retrieved 977 articles, of which 335 matched the inclusion criteria. The main objective of 75.8% of the studies was to assess SHS exposure.The proportion of validated questions aiming to ascertain SHS exposure was 17.9%. Most studies collected data only for one (40.3%) or two settings (33.4%), most frequently the home (83.9%) and workplace (57%). The most commonly used indicator to ascertain exposure was the presence of smokers and 68.9% of the studies included an item to assess the intensity of SHS exposure. CONCLUSIONS: The variability in the indicators and items used to ascertain SHS exposure is very high, whereas the use of items derived from validated studies remains low. Identifying the diverse settings where SHS exposure may occur is essential to accurately assess exposure over time. A standard set of items to identify SHS exposure in distinct settings is needed.

Behavioral risk factors and mental health: single and cluster associations in Spanish adolescents.

OBJECTIVE: The risk factors associated with mental health in adolescents are not well known in the general population of Mediterranean countries. Therefore, this study aimed to identify individual and clustered behavioral risk factors for psychological distress. METHODS: Cross-sectional study conducted between 2008 and 2009 among 4054 students representative of those in the fourth year of secondary education in the region of Madrid (Spain). Mental health was assessed using the General Health Questionnaire, with psychological distress defined as a score ≥3. The analyses were performed with logistic regression and adjusted for the main confounders. RESULTS: Psychological distress was more frequent in those who did insufficient physical activity (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.03-1.47), smokers (OR, 1.30; 95% CI, 1.07-1.59), and users of illegal drugs (OR, 1.46; 95% CI, 1.21-1.76). Psychological distress also showed a positive dose-response relationship with the number of risk behaviors for eating disorders (p for linear trend <0.001). Moreover, it was associated with both thin (OR, 1.37; 95% CI, 1.16-1.62) or very thin body image (OR, 2.15; 95% CI, 1.39-3.32) and perceived overweight (OR, 1.74; 95% CI, 1.40-2.15) or obesity (OR, 3.12; 95% CI, 2.23-4.37). Compared with individuals without classic risk behaviors (low physical activity, low consumption of fruits/vegetables, smoking, high-risk alcohol consumption), frequency of psychological distress was higher in those with 2 risk behaviors (OR, 1.47; 95% CI, 1.19-1.82) and was even greater in those with 3 or 4 risk behaviors (OR, 1.56; 95% CI, 1.21-2.01). CONCLUSIONS: During adolescence, psychological distress is associated with lifestyles, body image, and eating behaviors. Clustering of classic risk behaviors increases the likelihood of poor mental health.

Effect of a smoking ban and school-based prevention and control policies on adolescent smoking in Spain: a multilevel analysis.

We evaluated the impact of a smoking ban in schools and of school-based smoking prevention and control policies on adolescent smoking. Annual surveys carried out between 2001 and 2005 that were representative of students in the 4th year of secondary education in the Madrid region, with 203 schools and 9127 students participating. The student questionnaire gathered information about personal and family variables. The contextual factors were: the periods before (years 2001-2002) and after the law; and through a survey of school management boards: compliance with the law, policy reflected in the school regulations, existence of complaints against smoking, and undertaking of educational activities regarding smoking. Multilevel logistic regression models were constructed with two dependent variables: current smoking and the proportion giving up smoking. Smoking declined in 2003, the first year after the law came into force (Odds ratio: 0.80; CI 95%: 0.66-0.96), and this decline was maintained in 2005. By contrast, smoking increased in those schools that did not undertake educational programmes regarding smoking (Odds ratio: 1.34; CI 95%: 1.13-1.59), and in those that received complaints about smoking (Odds ratio: 1.12; CI 95%: 0.96-1.29). This association is partly due to the effect of the increase in giving up smoking. The inclusion of contextual variables into the model with the individual factors reduces the variability of smoking between schools by 32.6%. In summary, the coming into force of a law banning smoking in schools, and the implementing of educational policies for the prevention and control of smoking are related to a lower risk of adolescent smoking.

Towns with extremely low mortality due to ischemic heart disease in Spain.

BACKGROUND: The cause of coronary disease inframortality in Spain is unknown. The aim of this study is to identify Spanish towns with very low ischemic heart disease mortality, describe their health and social characteristics, and analyze the relationship with a series of contextual factors. METHODS: We obtained the number of deaths registered for each of 8,122 Spanish towns in the periods 1989-1998 and 1999-2003. Expected deaths, standardized mortality ratio (SMR), smoothed Relative Risk (RR), and Posterior Probability (PP) of RR > 1 were calculated using Bayesian hierarchical models. Inframortality was defined as any town that displayed an RR below the 10th percentile, an SMR of under 1 for both sexes, and a PP of RR > 1 less than or equal to 0.002 for male and 0.005 for female mortality, during the two periods covered. All the remaining towns, except for those with high mortality classified as "tourist towns", were selected as controls. The association among socioeconomic, health, dietary, lifestyle and vascular risk factors was analyzed using sequential mixed logistic regression models, with province as the random-effects variable. RESULTS: We identified 32 towns in which ischemic heart disease mortality was half the national rate and four times lower than the European Union rate, situated in lightly populated provinces spread across the northern half of Spain, and revealed a surprising pattern of geographic aggegation for 23 of the 32 towns. Variables related with inframortality were: a less aged population (OR 0.93, 95% CI 0.89-0.99); a contextual dietary pattern marked by a high fish content (OR 2.13, 95% CI 1.38-3.28) and wine consumption (OR 1.50, 95% CI 1.08-2.07); and a low prevalence of obesity (OR 0.47, 95% CI 0.22-1.01); and, in the case of towns of over 1000 inhabitants, a higher physician-population ratio (OR 3.80, 95% CI 1.17-12.3). CONCLUSIONS: Results indicate that dietary and health care factors have an influence on inframortality. The geographical aggregation suggests that other factors with a spatial pattern, e.g., genetic or environmental might also be implicated. These results will have to be confirmed by studies in situ, with objective measurements at an individual level.

Individual and contextual factors associated to smoking on school premises.

INTRODUCTION: Despite regulations, tobacco consumption in schools is still very common. The objective was to evaluate the relationship of personal, family, and school-level contextual factors with smoking on school premises. METHODS: A representative survey was undertaken of students in the 4th year of secondary education in the Madrid region (Spain), including 79 schools and 3,622 individuals. The student questionnaire gathered information about personal and family variables. The contextual factors were type of school, perception of compliance with the law, smoking policy, existence of complaints against smoking, and undertaking of educational activities regarding smoking. Analysis was carried out in the smoking population (n = 1,179) using multilevel logistic regression models. RESULTS: During the last 30 days, 50.6% of smokers had smoked on school premises. Having a father with a university education (in comparison with fathers who have not attained any educational level) reduces this probability (odds ratio [OR]: 0.43; 95% CI: 0.19-0.96), whereas smoking a larger number of cigarettes (p < .001), illicit drug consumption (p < .001), and low academic achievement (p = .052) increases it. The probability is reduced when there is no parental permission to smoke (OR: 0.66; 95% CI: 0.43-1.01) and is lower both in nonsubsidized private schools (OR: 0.29; 95% CI: 0.12-0.67) and in state subsidized private schools (OR: 0.17; 95% CI: 0.09-0.34) than in public schools. CONCLUSIONS: A very low level of educational attainment by the father, smoking a higher number of cigarettes, as well as illicit drug consumption, low academic achievement, having parental permission to smoke, and attending public schools are all related to a higher probability of smoking on school premises.