How Can We Measure Alcohol Outlet Density Around Schools? A Comparison Between Two Buffer-Based Methods.

Measuring the density of alcohol outlets around schools is a critical step towards understanding the drivers of drinking among adolescents. Different methodologies have been used in the literature for this purpose, but the implications of using one methodology or another have not been clearly assessed. Our aim was to compare different methods to measure alcohol outlet density and highlight under which characteristics of the environment might be best using each approach. We used Geographic Information Systems to geolocate schools (n = 576) and alcohol outlets (n = 21,732) in Madrid. We defined the density of alcohol outlets as the number of establishments within an area of 400 m around schools measured using two buffering methods: crow flies' and street network distances. We evaluated the agreement between both methods visually and through regression models, including street connectivity, population density, and density of recreational venues as predictors of disagreement. The density of alcohol outlets around schools was higher using crow flies' distances compared to street network distances. The differences between methodologies were wider in areas of higher density of outlets, especially in the downtown areas, where there are higher population density and street connectivity. Our results suggest that the spatial characteristics and morphology of the study area (e.g., street connectivity and population density) should be considered when deciding the methodology to be used to measure alcohol outlet density. Future studies should explore the implications of different exposure measures in their association with drinking prevalence and consumption patterns among different geographical contexts.

Accessibility and availability of alcohol outlets around schools: An ecological study in the city of Madrid, Spain, according to socioeconomic area-level.

Neighborhood accessibility and availability of alcohol products has been associated with increased alcohol consumption and harms among adolescents. This availability has been shown to be higher in neighborhoods with lower socio-economic status (SES). The aim of this study was to examine inequalities in alcohol outlet density and proximity around schools by area-level SES in Madrid, Spain. Data on schools, SES, alcohol outlets and population density at census tract level were obtained through public databases from the local government of Madrid. We examined (1) density as the number of alcohol outlets around schools within 3 buffers (i.e. 200 m, 400 m and 800 m) and (2) proximity as the distance from schools to their nearest alcohol outlet. We performed multilevel analyses to examine the associations between alcohol outlet density and proximity and SES, adjusted by population density. Secondary schools (n = 576) located in less deprived areas had lower densities of alcohol outlets at walking distances of 200 and 400 m (50% and 37% lower, respectively p < 0.05). No significant differences were found for the proximity measures. The socioeconomic level of the area in which adolescents go to school is a determinant of their exposure to alcohol, where those who study in high SES areas have lower exposure to alcohol outlets. This study highlights the need to prioritize equity in the design and implementation of policies to limit alcohol accessibility among adolescents, including establishing minimum distances between schools and alcohol outlets or limiting the number of outlets per inhabitant in neighborhoods.

Understanding how alcohol environment influences youth drinking: A concept mapping study among university students. / Influencia del entorno en el consumo de alcohol en jóvenes: Un estudio utilizando concept mapping con estudiantes universitarios.

The aim of the study was to identify the environmental factors that influence alcohol consumption, according to university students, and assess the relative importance and the frequency attributed to each factor. A study using Concept Mapping methodology was performed with a sample of nursing students, who participated in two face-to-face data collection sessions. In session 1, a consensus about the environmental aspects that influence their alcohol consumption was obtained. In session 2, the statements obtained were rated according to their relative importance and frequency in alcohol use (1 = minimum; 5 = maximum). Subsequently, all data were analyzed with the RCMAP of the statistical package R 3.6.1.Approximately 60 students participated in each session. Most were women aged 20 to 24. In session 1, a total of 55 statements were obtained and classified into 7 different clusters: Advertising (9 statements); Family environment (4 statements); Social pressure (12 statements); Responsibilities/norms (4 statements); Holidays and leisure time (7 statements); Emotional situations (8 statements); Accessibility (11 statements). Factors related to social pressure, holidays and leisure time, and alcohol accessibility were considered the most important and frequent in alcohol consumption. In contrast, alcohol advertising was considered the least important (mean 2.6 out of 5) and frequent (mean 2.1 out 5) factor. In conclusion, the factors considered most relevant among nursing students match those having more resources allocated for prevention and health promotion, except for alcohol advertising, which was perceived as less important and frequent compared with the other factors.

El objetivo del estudio fue identificar los factores del entorno que influyen en el consumo de alcohol según la perspectiva de estudiantes universitarios, y evaluar la importancia y la frecuencia atribuida a cada factor. Se utilizó la metodología del Concept Mapping con una muestra de estudiantes de enfermería, que participaron en dos sesiones de recogida de datos. En la sesión 1, se obtuvo un consenso sobre los aspectos del entorno que influyen en su consumo de alcohol. En la sesión 2, los ítems obtenidos se clasificaron en función de la importancia y la frecuencia de estos factores en el consumo de alcohol (1 = mínimo; 5 = máximo). Todos los datos se analizaron con el RCMAP del paquete estadístico R 3.6.1.Alrededor de 60 estudiantes participaron en cada sesión. La mayoría eran mujeres de 20 a 24 años. En la sesión 1, se obtuvieron un total de 55 ítems que fueron clasificados en 7 grupos: Publicidad (9 ítems); Ambiente familiar (4 ítems); Presión social (12 ítems); Responsabilidades/normas (4 ítems); Vacaciones y tiempo libre (7 ítems); Situaciones emocionales (8 ítems); Accesibilidad (11 ítems). Los factores relacionados con la presión social, las vacaciones y el tiempo libre y la accesibilidad del alcohol, fueron considerados los más importantes y frecuentes en el consumo de alcohol. Contrariamente, la publicidad del alcohol fue considerada el factor menos importante (media 2,6 sobre 5) y frecuente (media 2,1 sobre 5). En conclusión, los factores considerados más relevantes entre los estudiantes coinciden con los que se destinan más recursos para la prevención y la promoción de la salud, a excepción de la publicidad del alcohol, que se percibió como menos importante y frecuente comparado con los otros factores.

Availability and promotion of alcohol across different outlet typologies and under different area-level socioeconomic status. / Disponibilidad y promoción de alcohol según la tipología de los locales y las condiciones socioeconómicas del área.

We aimed to characterize the availability and promotion of alcohol at alcohol outlets in Madrid and to compare them according to type of outlet and area-level socioeconomic status. We used the OHCITIES instrument to characterise the alcohol outlets in 42 census tracts of Madrid in 2016. We specified alcohol availability as the density of alcohol outlets and the number of alcohol outlets with extended opening hours (12 or more). We registered any type of promotion associated to alcohol outlets that could be perceived from outside the outlet. We calculated and compared proportions of availability and promotion by alcohol outlet (on- and off-premise) using chi-squared and Fisher Exact tests. We estimated the availability and promotion of alcohol densities per census tract according to area-level socioeconomic status. To assess statistical significance, we used Kruskal-Wallis tests. We recorded 324 alcohol outlets, 241 on-premise and 83 off-premise. Most of the outlets had extended opening hours (73.77%) and at least one sign promoting alcohol (89.51%). More on-premise outlets had extended opening hours and higher presence of alcohol promotion than off-premise (p < 0.001). Higher density of alcohol outlets, extended opening hours and presence of alcohol promotion were found in higher socioeconomic areas (all p < 0.001). These results were also observed for on-premise alcohol outlets. Alcohol availability and promotion were associated with alcohol outlets in Madrid. Future alcohol policies regulating the availability and promotion of alcohol should consider outlet types and area-level socioeconomic status.

El objetivo fue caracterizar la disponibilidad y promoción de alcohol asociados a los locales de venta y consumo de alcohol en Madrid, así como explorar las diferencias en su distribución en función de la tipología del local y las características socioeconómicas del área. Se utilizó el instrumento OHCITIES para caracterizar locales situados en 42 secciones censales de Madrid durante 2016. Se registró la densidad de locales y el número de locales con amplios horarios de apertura (12 o más horas). Se registró cualquier tipo de promoción asociada al local visible desde el exterior. Se compararon los porcentajes de características de disponibilidad y promoción asociada a los locales de consumo y venta de alcohol utilizando el test de chi cuadrado y la prueba exacta de Fisher. Se estimó la densidad de disponibilidad y promoción por sección censal y se exploró su distribución en función de las características socioeconómicas del área mediante el test de Kruskal-Wallis. Se registraron 324 locales, 241 de consumo y 83 de venta. La mayoría tenía un horario amplio de apertura (73,77%) y algún elemento promocional (89,51%). Los locales de consumo tenían horarios más amplios de apertura y más elementos promocionales que los de venta (p < 0,001). Se encontraron mayor densidad de locales, amplitud de horarios y elementos promocionales en áreas de nivel socioeconómico alto (todos p < 0,001). La disponibilidad y promoción estuvieron asociadas con los locales de venta y consumo de alcohol en Madrid. Futuras políticas cuyo objetivo sea la prevención del consumo de alcohol deben tener en cuenta la influencia de los tipos de locales y las características socioeconómicas del área en la distribución de la disponibilidad y promoción de alcohol.

Tobacco Retail Environment and Smoking: A Systematic Review of Geographic Exposure Measures and Implications for Future Studies.

INTRODUCTION: To review the geographic exposure measures used to characterize the tobacco environment in terms of density of tobacco outlets and proximity to tobacco outlets, and its association with smoking-related outcomes. METHODS: We used PubMed and Google Scholar to find articles published until December 2019. The search was restricted to studies that (1) measured the density of and/or proximity to tobacco outlets and (2) included associations with smoking outcomes. The extraction was coordinated by several observers. We gathered data on the place of exposure, methodological approaches, and smoking outcomes. RESULTS: Forty articles were eligible out of 3002 screened papers. Different density and proximity measures were described. 47.4% density calculations were based on simple counts (number of outlets within an area). Kernel density estimations and other measures weighted by the size of the area (outlets per square kilometer), population, and road length were identified. 81.3% of the articles which assessed proximity to tobacco outlets used length distances estimated through the street network. Higher density values were mostly associated with higher smoking prevalence (76.2%), greater tobacco use and smoking initiation (64.3%), and lower cessation outcomes (84.6%). Proximity measures were not associated with any smoking outcome except with cessation (62.5%). CONCLUSION: Associations between the density of tobacco outlets and smoking outcomes were found regardless of the exposure measure applied. Further research is warranted to better understand how proximity to tobacco outlets may influence the smoking outcomes. This systematic review discusses methodological gaps in the literature and provides insights for future studies exploring the tobacco environment. IMPLICATIONS: Our findings pose some methodological lessons to improve the exposure measures on the tobacco outlet environment. Solving these methodological gaps is crucial to understand the influence of the tobacco environment on the smoking outcomes. Activity spaces should be considered in further analyses because individuals are exposed to tobacco beyond their residence or school neighborhood. Further studies in this research area demand density estimations weighted by the size of the area, population, or road length, or measured using Kernel density estimations. Proximity calculations should be measured through the street network and should consider travel times apart from the length distance.

Estimating and mapping cigarette butt littering in urban environments: A GIS approach.

BACKGROUND: Cigarette butts are some of the most common form of litter in the World, causing severe environmental damage. Analysing spatial distribution of cigarette butts in the urban environment may lead to useful insights for further interventions to reduce this form of litter. In this study, we present a GIS-based methodology to estimate the density of cigarette butts across a large urban area. METHODS: We collected information about discarded cigarette butts in outdoor public spaces by systematic social observation in a diverse sample of areas in Madrid, Spain. We used these data to estimate the density of cigarette butts in public spaces around the entire city by performing GIS analyses based on Kernel Density Estimations. Last, we validated these measures using on-field observations in a set of locations across the city. RESULTS: Hospitality venues and public transportation stops were the places with the highest concentrations of cigarette butts, followed by the entrances to educational venues and playgrounds. Central districts showed the highest amount of cigarette butts in contrast to peripheral ones. We found that our measure had good validity, with a correlation coefficient of 0.784. DISCUSSION: This is the first study estimating and mapping cigarette butt litter in a large urban area. We identified a set of outdoor public places with high concentrations of cigarette butts and found geographical unevenness in the distribution of this pervasive form of litter across the study area. Our findings demonstrate the ubiquitous nature of cigarette butts in the urban environment and the need for interventions to reduce its impact on both people's health and the environment.

Mapping the visibility of smokers across a large capital city.

BACKGROUND: Smoking visibility may affect smoking norms with implications for tobacco initiation, particularly amongst youths. Understanding how smoking is distributed across urban environments would contribute to the design and implementation of tobacco control policies. Our objective is to estimate the visibility of smokers in a large urban area using a novel GIS-based methodological approach. METHODS: We used systematic social observation to gather information about the presence of smokers in the environment within a representative sample of census tracts in Madrid city in 2016. We designed a GIS-based methodology to estimate the visibility of smokers throughout the whole city using the data collected in the fieldwork. Last, we validated our results in a sample of 40 locations distributed across the city through direct observation. RESULTS: We mapped estimates of smokers' visibility across the entire city. The visibility was higher in the central districts and in streets with a high density of hospitality venues, public transportation stops, and retail shops. Peripheral districts, with larger green areas and residential or industrial land uses, showed lower visibility of smokers. Validation analyses found high agreement between the estimated and observed values of smokers' visibility (R = 0.845, p=<0.001). DISCUSSION: GIS-based methods enable the development of novel tools to study the distribution of smokers and their visibility in urban environments. We found differences in the visibility by population density and leisure, retail shops and business activities. The findings can support the development of policies to protect people from smoking.

Exposure to second-hand tobacco smoke in waterpipe cafés in Barcelona, Spain: An assessment of airborne nicotine and PM2.5.

BACKGROUND: Waterpipe tobacco smoking has grown in popularity worldwide, with the prevalence of use increasing in Spain from 6.2% to 10.8% in the last decade, despite the smoking ban enacted in 2010 for all hospitality premises. OBJECTIVE: To assess exposure to second-hand smoke from waterpipes based on the concentrations of airborne nicotine and particulate matter ≤2.5 µm in diameter (PM2.5) in a sample of waterpipe cafés in the city of Barcelona (Spain). METHODS: This cross-sectional study included a sample of 20 waterpipe cafés. Airborne nicotine and PM2.5 were sampled for 30 min in each venue using a nicotine sampling device connected by a tube to a pump and a TSI SidePak Personal Aerosol Monitor. Five outdoor control locations were also measured. We computed medians, interquartile ranges (IQRs), and maximum values and compared them according to venues' and sampling characteristics using the Kruskall-Wallis and U-Mann Whitney tests. Nicotine and PM2.5 were correlated by calculating the Spearman-rank correlation coefficient. RESULTS: The median concentration of nicotine and PM2.5 were 1.15 and 230.50 µg/m3 in waterpipe cafés and 0.03 and 10.00 µg/m3 in control locations (p<0.05 in both cases). The Spearman correlation coefficient between both markers was 0.61 (95% confidence interval: 0.18-0.84). No differences were found in nicotine or PM2.5 concentration according to the venues' and sampling characteristics studied, with the exception of area. After stratifying for area, venues >100 m2, located in a tourist area, with >15 lit waterpipes, >8 waterpipes/100 m2, and a ratio of 2 users per waterpipe or less had significantly higher nicotine concentration. DISCUSSION: Despite the current smoking ban, which includes hospitality venues, we found nicotine and PM2.5 levels in Barcelona waterpipe cafés that exceeded the threshold recommended by the World Health Organization. This exposure poses serious risks to the health of both workers and customers and constitutes a non-compliance of the legislation.

Psycho-social factors related to obesity and their associations with socioeconomic characteristics: the RECORD study.

OBJECTIVES: We aimed to describe the main psycho-social factors related to obesity in an adult population and to develop a unified construct (psycho-social profiles), to explore the associations between socioeconomic characteristics and these psycho-social profiles. METHODS: In its second wave, the RECORD Study assessed 6460 participants aged 30-79 years living in the Paris region between 2011 and 2014. Factor analyses followed by cluster analysis were applied to identify psycho-social profiles related to obesity. The two psycho-social profiles were adverse profile-negative body image, underestimation of the impact of weight in quality of life, low weight-related self-efficacy, and weight-related external locus of control; and favorable profile-positive body image, high self-efficacy, and internal locus of control. The relationship between three socioeconomic dimensions-current socioeconomic status, childhood socioeconomic status, and neighborhood education status-and psycho-social profiles was assessed through binomial logistic regression adjusted for age, gender, depression, living alone, and weight status. RESULTS: Contrary to hypotheses, there were no associations between socioeconomic characteristics and obesity-related psycho-social profiles after adjustment for body mass index. Depressive symptoms (OR 2.21, 95% CI 2.70, 4.04) and being female (3.31, 95% CI 2.70, 4.40) were associated with an adverse psycho-social profile. CONCLUSIONS: Psycho-social profiles could help to understand the multifactorial nature of the determinants of obesity. LEVEL OF EVIDENCE: Level V, cross-sectional descriptive study.

Regulating the local availability of tobacco retailing in Madrid, Spain: a GIS study to evaluate compliance.

BACKGROUND: In Spain, tobacco sales are limited to tobacco-exclusive stores and associated vending machines. A minimum of 150 m between stores is required, unless they exceed a legal sales threshold. Minimum distances to schools are recommended but not defined. We evaluated compliance with these regulations in Madrid, Spain. METHODS: Information about tobacco-exclusive stores and their sales volume was obtained in 2014. We used geographic information system to identify stores closer than 150 m between them and examine whether they exceeded the sales threshold. We estimated distances between stores and schools, considering different distance intervals (<150 m, 150-300 m and >300 m) and calculations (crow flies and street network). We assessed the association of area-level demographic and socioeconomic characteristics with the distribution of tobacco stores. RESULTS: 5.3% (34/638) of tobacco stores were within 150 m of each other. Among those, 76% (26/34) did not meet the regulation sales threshold. These stores were in areas with lower proportion of young population (<15 years) and higher proportion of people with university-level education. 75% (476/638) of stores were situated closer than 300 m to schools. No differences were identified in sociodemographic and economic characteristics by the store distance to schools. CONCLUSION: Most tobacco stores are compliant with the regulations in Spain. However, these regulations are insufficient to reduce tobacco availability. More restrictive regulations are needed to limit the geographic distribution of tobacco retailers, and health criteria should also be considered in the current legislation. The evaluation of the Spanish regulatory model may provide useful insights for other jurisdictions looking to decrease the tobacco retail availability.

The urban environment of alcohol: a study on the availability, promotion and visibility of its use in the neighborhoods of Barcelona. / Entorno urbano de alcohol: un estudio sobre disponibilidad, promoción y visibilidad del consumo en barrios de Barcelona.

INTRODUCTION: This paper describes the presence of alcohol in the public space, assessing establishments that offer it, its advertising, and signs of consumption, as factors that may influence its consumption. METHOD: Descriptive observational study based on cluster sampling with two-step selection. Results are described, and the spatial association between variables is assessed. RESULTS: In the 20 census tracts studied, 306 premises were identified that offered alcoholic beverages: 204 were on-premises and 102 were off-premises, mainly supermarkets and food retail stores. Their spatial distribution was uneven, concentrated in two central districts. We identified 72 publicity items, mostly sponsorship of musical events. There were many promotional items linked to on- premises, especially in their terraces. Five people were detected promoting consumption or selling alcohol in the Old Town. In each time slot, between 39 and 51 signs of consumption on the public space were observed (mostly abandoned beer cans), more frequent at night and in the Old Town. There is an association between the presence of establishments that offer alcohol and advertising. There is no relationship between these variables and signs of consumption in the public space; these are concentrated in the Old Town, which has greater presence of tourism. CONCLUSIONS: The urban environment is characterized by elements that stimulate alcohol use and its distribution is uneven, with a strong influence of tourism-related activities. Further regulation of alcohol promotion, availability and consumption in the public space may change its social image and decrease its use.

Introducción. Se describe la presencia de alcohol en el espacio público, valorando los establecimientos que lo ofrecen, la publicidad, y los indicios de consumo, como factores que pueden inducir el consumo. Método. Estudio observacional descriptivo basado en un muestreo por conglomerados con selección bietápica. Se describen los resultados, y se valora la asociación espacial entre variables. Resultados. En las 20 secciones censales estudiadas se identificaron 306 establecimientos que ofrecían bebidas alcohólicas: 204 de venta y consumo y 102 de venta sin consumo, básicamente supermercados y comercio alimentario. Su distribución territorial fue desigual, concentrada en dos distritos céntricos. Se identificaron 72 elementos de promoción y publicidad destacando el patrocinio de actividades musicales. Se observan elementos promocionales vinculados a los locales de venta y consumo, sobre todo en sus terrazas. Se detectaron cinco personas realizando venta ambulante o promoción del consumo en el casco antiguo. En cada franja horaria se apreciaron entre 39 y 51 indicios de consumo en la vía pública (mayoritariamente envases de cerveza abandonados), más frecuentes de noche y en el casco antiguo. Hay una asociación entre la presencia de establecimientos que ofrecen alcohol y la de elementos de publicidad. No se aprecia relación entre estas variables y los indicios de consumo en el espacio público; éstos se concentran en el casco antiguo, con mayor presencia del turismo. Conclusiones. El medio urbano se caracteriza por elementos que estimulan el consumo de alcohol y su distribución es desigual, muy influida por las actividades orientadas al turismo. Mejorar la regulación de su promoción, disponibilidad y consumo en el espacio público puede contribuir a cambiar su imagen social y disminuir su uso.

Sex and Age Specific Projections of Smoking Prevalence in Spain: A Bayesian Approach.

Objectives: To project future smoking prevalence rates in Spain by sex and age groups using Bayesian methods and to estimate the probability of a 30% relative reduction between 2010 and 2025. Methods: We used the data from the Spanish National Health Surveys (2003, 2006, and 2011) to obtain information about current and former smoking. We reconstructed annual smoking rates from 1989 through 2011 by sex and 5-year age groups. The prevalence were projected for the period 2012-2025 using a Bayesian logistic binomial model and estimated the probability to achieve the 30% relative reduction endorsed by the WHO. We calculated the 95% credible interval (CrI) of the posterior distribution, which includes a 95% of the distribution of potential smoking prevalences. Results: In men, the projections show a decline for crude (-2.64% annually, 95% CrI: -3.32; -1.97) and adjusted (-2.50%, 95% CrI:-3.14; -1.87) prevalence. In women, the projections show a decline for crude prevalence (-0.36%, 95% CrI: -1.02; -0.30)) and the age-adjusted prevalence (-1.02%, 95% CrI: -1.61, -0.47). By age groups, the decline is greater among women aged 15-39 years (-3.92%, 95% CrI: -4.92; -2.96)) while for women aged 40-64 years an increase (1.84%, 95% CrI: 1.06; 2.58) is expected. In men, the probability to achieve the WHO target is 0.728 and in women is less than 0.001. The age group 15-39 shows the highest probability to achieve the target. Conclusions: The results suggest smoking prevalence will decrease during 2012-2025 in all age groups for both sexes except for women aged 40-64. We found that the WHO target of a 30% reduction in prevalence is likely to be achieved overall and in the 15-39 years age groups for both sexes, but not achieved for older women and it is uncertain whether it will be achieved for older men. These results highlight the need to strengthen public health interventions that focus on reducing tobacco use in adult women aged 40-64 years old. Implications: We project a decrease in smoking prevalence in during 2012-2025 except for women aged 40-64. The WHO Target of a 30% relative reduction could be achieved in the population aged 15-39; but not in women and the results are inconclusive in men. These results highlight the need to strengthen public health interventions that focus on reducing tobacco use in adult women aged 40-64 years old.

Second-hand smoke exposure in outdoor hospitality venues: Smoking visibility and assessment of airborne markers.

INTRODUCTION: After the implementation of smoke-free policies in indoor hospitality venues (including bars, cafeterias, restaurants, and pubs), smokers may have been displaced to their outdoor areas. We aimed to study smoking visibility and second-hand smoke exposure in outdoor hospitality venues. METHODS: We collected information on signs of tobacco consumption on entrances and terraces of hospitality venues in 2016 in the city of Madrid, Spain. We further measured airborne nicotine concentrations and particulate matter of less than 2.5 µm in diameter (PM2.5) in terraces with monitors by active sampling during 30 min. We calculated the medians and the interquartile ranges (IQR) of nicotine and PM2.5 concentrations, and fitted multivariate models to characterize their determinants. RESULTS: We found 202 hospitality venues between May and September (summer), and 83 between October and December 2016 (fall) that were opened at the time of observation. We found signs of tobacco consumption on 78.2% of the outdoor main entrances and on 95.1% of outdoor terraces. We measured nicotine and PM2.5 concentrations in 92 outdoor terraces (out of the 123 terraces observed). Overall median nicotine concentration was 0.42 (IQR: 0.14-1.59) µg/m3, and overall PM2.5 concentration was 10.40 (IQR: 6.76-15.47) µg/m3 (statistically significantly higher than the background levels). Multivariable analyses showed that nicotine and PM2.5 concentrations increased when the terraces were completely closed, and when tobacco smell was noticed. Nicotine concentrations increased with the presence of cigarette butts, and when there were more than eight lit cigarettes at a time. CONCLUSIONS: Outdoor hospitality venues are areas where non-smokers, both employees and patrons, continue to be exposed to second-hand smoke. These spaces should be further studied and considered in future tobacco control interventions.

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.

Manufactured and roll-your-own cigarettes: A changing pattern of smoking in Barcelona, Spain.

AIMS: The objectives of the present study were to describe smoking prevalence and compare the smoking attributes of adult smokers according to the type of tobacco product consumed. METHODS: Repeated cross-sectional surveys (2004-2005 and 2011-2012) of a representative sample of the adult (≥16 years) population in Barcelona, Spain, were used to assess self-reported tobacco consumption, smoking attributes, and salivary cotinine concentration. The survey conducted in 2004-2005 included information on 1245 subjects and the survey in 2011-2012 on 1307 individuals. RESULTS: Smoking prevalence decreased over the study period (from 26.6% to 24.1% in self-reported daily smokers). The prevalence of daily smokers who reported the use of manufactured cigarettes declined from 23.7% in 2004-2005 to 17.3% in 2011-2012. The prevalence of roll-your-own cigarette users increased from 0.4% to 3.7%. According to data obtained in 2011-2012, the proportion of self-reported roll-your-own cigarette users was higher among men (19.8% vs. 9.5% of women), participants aged 16-44 years (22.9% vs. 5.8% of participants aged 45-65 years and 4.0% of participants aged ≥65 years), and participants with secondary and university education (17.7% and 18.5% vs. 7.9% of participants with less than primary and primary education). We did not observe differences in cotinine concentrations according to the type of tobacco product consumed. CONCLUSIONS: Systematic collection of data on smoking prevalence and smoker attributes from representative samples of the population is necessary for policymakers to develop efficient tobacco control interventions. Considering the increase of roll-your-own cigarette users and the unclear health consequences of their use, policymakers should aim to implement tax policies to equalize the prices of different types of tobacco products.

Second-hand smoke exposure in indoor and outdoor areas of cafés and restaurants: Need for extending smoking regulation outdoors?

Smoke-free legislation in indoor public places has concentrated smokers in the areas outside building entrances or other outdoor areas. This study assessed the drift of second-hand smoke between outdoor and indoor areas of cafés and restaurants in Barcelona, Spain, and characterized the exposure on outdoor terraces. Using a cross-sectional design, we monitored vapor-phase nicotine in indoor areas and outside entrances simultaneously (n=47), and on some outdoor terraces (n=51). We computed the median nicotine concentration and interquartile range (IQR) to describe the data and performed multivariate analysis to describe nicotine concentration and its determinants. The overall median nicotine concentration indoors was 0.65µg/m(3) (IQR: 0.29-1.17µg/m(3)), with significant differences based on the number of smokers at the entrance (p=0.039). At outside entrances, the overall median nicotine concentration was 0.41µg/m(3) (IQR: 0.21-1.17µg/m(3)). The nicotine concentrations indoors and at the corresponding outside entrances were not significantly different, and the multivariate analysis confirmed the relationship between these variables. On terraces, the overall median nicotine concentration was 0.54µg/m(3) (IQR: 0.25-1.14µg/m(3)), but it increased to 0.60µg/m(3) when a tobacco smell was perceived, 0.72µg/m(3) on closed terraces, 1.24µg/m(3) when there were >6 smokers, and 1.24µg/m(3) when someone smoked >20min. Multivariate analysis confirmed the outdoor terrace area, the season, the type of enclosure, and the number of smokers as the most relevant variables explaining nicotine concentration (R(2)=0.396). These findings show that second-hand smoke exposure exists in indoor areas due to smokers smoking at the outside entrances. In addition, exposure may occur on outdoor terraces when smokers are present and the terrace is enclosed to some extent. Thus, the current Spanish law does not fully protect non-smokers from second-hand smoke and supports extending regulation to some outdoor areas.

Secondhand smoke in psychiatric units: patient and staff misperceptions.

BACKGROUND: Mental health units have usually been exempted from complete smoke-free policies. The aim of this study was to compare the self-reported level of exposure to secondhand smoke (SHS) of patients and staff in psychiatric units to objective measures, and examine preference for different types of smoking bans. METHODS: Cross-sectional survey about ban preferences and self-reported exposure to SHS by means of a self-administered questionnaire administered to patients and staff from 65 inpatient psychiatric units in Catalonia (95.5% of all units). We measured air concentrations of particulate matter ≤ 2.5 µm (PM2.5 in µg/m(3)) as a marker of SHS in these units. RESULTS: 600 patients and 575 professionals completed the questionnaire. 78.7% of them were objectively exposed to SHS (PM2.5>10 µm/m(3)) but 56.9% of patients and 33.6% of staff believed they were not exposed at all and 41.6% of patients and 28.4% of staff believed the environment was not at all unhealthy. Nurses had a higher smoking prevalence than psychiatrists (35.8% vs 17.2%; p<0.001), and nurses had a higher perception of being moderately highly exposed to SHS (40.3% vs 26.2%; p<0.001). PM2.5 levels were significantly different depending on the type of smoking ban implemented but unrelated to the perception of SHS levels by both patients and staff. Only 29.3% of staff and 14.1% of patients strongly supported total smoking bans. CONCLUSIONS: Patients and staff have substantial misperceptions about the extent of their exposure to SHS and low awareness about the harmful environment in which they stay/work. This might have an influence on the preference for less restrictive smoke-free bans. It is particularly noteworthy that less that one-third of mental health staff supported smoke-free units, suggesting an urgent need for further education about the harmful health effects of SHS.

Cigarettes vs. e-cigarettes: Passive exposure at home measured by means of airborne marker and biomarkers.

BACKGROUND: There is scarce evidence about passive exposure to the vapour released or exhaled from electronic cigarettes (e-cigarettes) under real conditions. The aim of this study is to characterise passive exposure to nicotine from e-cigarettes' vapour and conventional cigarettes' smoke at home among non-smokers under real-use conditions. METHODS: We conducted an observational study with 54 non-smoker volunteers from different homes: 25 living at home with conventional smokers, 5 living with nicotine e-cigarette users, and 24 from control homes (not using conventional cigarettes neither e-cigarettes). We measured airborne nicotine at home and biomarkers (cotinine in saliva and urine). We calculated geometric mean (GM) and geometric standard deviations (GSD). We also performed ANOVA and Student's t tests for the log-transformed data. We used Bonferroni-corrected t-tests to control the family error rate for multiple comparisons at 5%. RESULTS: The GMs of airborne nicotine were 0.74 µg/m(3) (GSD=4.05) in the smokers' homes, 0.13 µg/m(3) (GSD=2.4) in the e-cigarettes users' homes, and 0.02 µg/m(3) (GSD=3.51) in the control homes. The GMs of salivary cotinine were 0.38 ng/ml (GSD=2.34) in the smokers' homes, 0.19 ng/ml (GSD=2.17) in the e-cigarettes users' homes, and 0.07 ng/ml (GSD=1.79) in the control homes. Salivary cotinine concentrations of the non-smokers exposed to e-cigarette's vapour at home (all exposed ≥ 2 h/day) were statistically significant different that those found in non-smokers exposed to second-hand smoke ≥ 2 h/day and in non-smokers from control homes. CONCLUSIONS: The airborne markers were statistically higher in conventional cigarette homes than in e-cigarettes homes (5.7 times higher). However, concentrations of both biomarkers among non-smokers exposed to conventional cigarettes and e-cigarettes' vapour were statistically similar (only 2 and 1.4 times higher, respectively). The levels of airborne nicotine and cotinine concentrations in the homes with e-cigarette users were higher than control homes (differences statistically significant). Our results show that non-smokers passively exposed to e-cigarettes absorb nicotine.

Secondhand smoke exposure at home: assessment by biomarkers and airborne markers.

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