Mortalidad atribuida al consumo de tabaco en las comunidades autónomas de España, 2017 / Smoking-attributable mortality in the autonomous communities of Spain, 2017

Introducción y objetivos: Estimar la mortalidad atribuida (MA) al consumo de tabaco en las comunidades autónomas (CCAA) de España en población de edad ≥ 35 años en 2017. Métodos: Se estimó la MA empleando un método dependiente de prevalencias basado en el cálculo de fracciones atribuidas poblacionales. La mortalidad observada procede del Instituto Nacional de Estadística; las prevalencias de consumo por sexo y edad, de la Encuesta Nacional de Salud de 2011 y 2017 y la Encuesta europea de 2014, y los riesgos relativos, del seguimiento de 5 cohortes norteamericanas. Se presentan estimaciones de MA y fracciones atribuidas poblacionales para cada comunidad autónoma por causa de muerte, sexo y edad y tasas de MA específicas y ajustadas. Resultados: El tabaco causó 53.825 muertes en España en la población de 35 o más años (el 12,9% de la mortalidad total). La carga de MA sobre la mortalidad observada varía del 10,8% en La Rioja al 15,3% en Canarias. Tras ajustar las tasas de MA por edad, las diferencias entre CCAA se mantienen, y las tasas más altas en los varones se observan en Extremadura y en las mujeres, en Canarias. Las tasas ajustadas de los varones se correlacionan negativamente con las de las mujeres. El porcentaje que suponen las enfermedades cardiovasculares sobre la MA total de cada comunidad autónoma oscila entre el 21,8% de Castilla-La Mancha y el 30,3% de Andalucía. Conclusiones: La carga de MA al consumo de tabaco varía entre las CCAA. Realizar un análisis detallado por regiones aporta información relevante para la implantación de políticas sanitarias dirigidas a frenar el impacto del tabaquismo (AU)

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 (AU)

Changes in leisure time and occupational physical activity over 8 years: the Cornellè Health Interview Survey Follow-Up Study.

AIM: To describe changes in leisure time and occupational physical activity status in an urban Mediterranean population-based cohort, and to evaluate sociodemographic, health-related and lifestyle correlates of such changes. METHODS: Data for this study come from the Cornellè Health Interview Survey Follow-Up Study, a prospective cohort study of a representative sample (n = 2500) of the population. Participants in the analysis reported here include 1246 subjects (567 men and 679 women) who had complete data on physical activity at the 1994 baseline survey and at the 2002 follow-up. We fitted Breslow-Cox regression models to assess the association between correlates of interest and changes in physical activity. RESULTS: Regarding leisure time physical activity, 61.6% of cohort members with "sedentary" habits in 1994 changed their status to "light/moderate" physical activity in 2002, and 70% who had "light/moderate" habits in 1994 did not change their activity level. Regarding occupational physical activity, 74.4% of cohort members who were "active" did not change their level of activity, and 64.3% of participants with "sedentary" habits in 1994 changed to "active" occupational physical activity. No clear correlates of change in physical activity were identified in multivariate analyses. CONCLUSION: While changes in physical activity are evident in this population-based cohort, no clear determinants of such changes were recognised. Further longitudinal studies including other potential individual and contextual determinants are needed to better understand determinants of changes in physical activity at the population level.

Mortality attributable to passive smoking in Spain, 2002.

OBJECTIVE: Exposure to environmental tobacco smoke (ETS) is associated with a variety of health effects, including lung cancer and ischaemic heart disease. The objective of this study was to estimate the number of deaths caused by exposure to ETS among non-smokers in Spain during the year 2002 METHODS: Prevalence of ETS exposure among never smokers was gathered from three region based health interview surveys. The relative risks of lung cancer and ischaemic heart diseases were selected from three meta-analyses. Population attributable risk (PAR) was computed using a range of prevalences (minimum-maximum). The number of deaths attributable to ETS was calculated by applying PARs to mortality not attributable to active smoking in 2002. The analyses were stratified by sex, age and source of exposure (home, workplace and both combined). In addition, a sensitivity analysis was performed for different scenarios. RESULTS: Among men, deaths attributable to ETS ranged from 408 to 1703. From 247 to 1434 of these deaths would be caused by the exposure only at home, 136-196 by exposure only in the workplace and 25-73 by exposure at both home and the workplace. Among women, the number of attributable deaths ranged from 820 to 1534. Between 807 and 1477 of these deaths would be caused by exposure only at home, 9-32 by exposure only in the workplace and 4-25 by exposure both at home and in the workplace. CONCLUSION: Exposure to ETS at home and at work in Spain could be responsible for 1228-3237 of deaths from lung cancer and ischaemic heart disease. These data confirm that passive smoking is an important public health problem in Spain that needs urgent attention.

Price and cigarette consumption in Europe.

OBJECTIVE: To analyse the variation in demand for tobacco according to price of cigarettes across the European region. DESIGN: Cross-sectional study. SETTING: All the 52 countries of the European region. PARTICIPANTS: For each European country, data were collected on annual per adult cigarette consumption (2000), smoking prevalence (most recent), retail price of a pack of local and foreign brand cigarettes (around 2000), the gross domestic product adjusted by purchasing power parities, and the adult population (2000). MAIN OUTCOME MEASURE: Price elasticity of demand for cigarettes (that is, the change in cigarette consumption according to a change in tobacco price) across all the European countries, estimated by double-log multiple linear regression. RESULTS: Controlling for male to female prevalence ratio, price elasticities for consumption were -0.46 (95% confidence interval (CI) -0.74 to -0.17) and -0.74 (95% CI -1.13 to -0.35) for local and foreign brand, respectively. The inverse relation between cigarette price and consumption was stronger in countries not in the European Union (price elasticity for foreign brand cigarettes of -0.8) as compared to European Union countries (price elasticity of -0.4). CONCLUSIONS: The result that, on average, in Europe smoking consumption decreases 5-7% for a 10% increase in the real price of cigarettes strongly supports an inverse association between price and cigarette smoking.

[Smoking cessation in a population-based cohort study]. / Abandono del consumo de tabaco en una cohorte de base poblacional.

OBJECTIVE: To study the incidence rates and the determinants of smoking cessation in a population-based cohort. MATERIAL AND METHODS: We used data from the Cornellà Health Interview Survey Follow-up Study. Subjects who declared they were daily smokers at baseline (1994) and had complete follow-up, with information on smoking status in 2002, entered into analysis. We calculated incidence rates and the relative risks of cessation (with 95% confidence intervals) using the Cox model. RESULTS: Out of 353 daily smokers, 100 quit smoking during the follow-up period (cumulative incidence of 28.3%). The incidence rate of cessation was higher among men (42.34 per 1000 person-years) than among women (24.97 per 1000 person-years), with a relative risk of cessation of 1.69 (95% confidence interval, 1.02-2.79) for men. Age and level of education were associated with a higher relative risk of quitting in men. CONCLUSIONS: The main determinants for smoking cessation are sociodemographic (sex, age, and level of education).

Price and consumption of tobacco in Spain over the period 1965-2000.

Changes in cigarette price have had an appreciable impact on smoking prevalence in several countries. We analysed the price elasticity of demand for cigarettes (effect of price of cigarettes on tobacco consumption) between 1965 and 2000 in Spain. For total consumption of cigarettes, a 1% increase in price is associated with a 0.19% decrease of consumption (price elasticity of -0.19; P<0.01). The real price of blond cigarettes was significantly and inversely associated with blond cigarette consumption: on average, smoking prevalence decreased 1.25% for a 1% increase in the real price of cigarettes (significant price elasticity of -1.25). For black cigarettes we found a lower but still high and significant elasticity of -0.61. There is an inverse relation between price and consumption of cigarettes in Spain, indicating that interventions at the economic level (such as real increases in prices) may have an important public health impact in tobacco control.

Price and consumption of tobacco in Italy over the last three decades.

Changes in cigarette price have had an appreciable impact on smoking consumption in several countries. We analysed the price elasticity of demand for cigarettes in Italy over the period 1970-2001. A 1% increase in price of cigarettes led to a 0.30% decline in smoking prevalence and to a 0.43% decline in cigarette consumption. The present analyses confirm the existence of an inverse association between price and prevalence/consumption of cigarettes in Italy, and indicate that economic aspects may have important public health implications in tobacco control.

[Odds ratio or prevalence ratio? Their use in cross-sectional studies]. / ¿Odds ratio o razón de proporciones? Su utilización en estudios transversales.

BACKGROUND: The most commonly used measures of association in cross-sectional studies are the odds ratio (OR) and the prevalence ratio (PR). Some cross-sectional epidemiologic studies describe their results as OR but use the definition of PR. The main aim of this study was to describe and compare different calculation methods for PR described in literature using two situations (prevalence < 20% and prevalence > 20%). MATERIAL AND METHODS: A literature search was carried out to determine the most commonly used techniques for estimating the PR. The four most frequent methods were: 1) obtaining the OR using non-conditional logistic regression but using the correct definition; 2) using Breslow-Cox regression; 3) using a generalized linear model with logarithmic transformation and binomial family, and 4) using the conversion formula from OR into PR. The models found were replicated for both situations (prevalence less than 20% and greater than 20%) using real data from the 1994 Catalan Health Interview Survey. RESULTS: When prevalence was low, no substantial differences were observed in either the estimators or standard errors obtained using the four procedures. When prevalence was high, differences were found between estimators and confidence intervals although all the measures maintained statistical significance. CONCLUSION: All the methods have advantages and disadvantages. Individual researchers should decide which technique is the most appropriate for their data and should be consistent when using an estimator and interpreting it.

¿Odds ratio o razón de proporciones? Su utilización en estudios transversales / Odds ratio or prevalence ratio? Their use in cross-sectional studies

Antecedentes: En los estudios transversales las medidas de asociación clásicamente descritas son la razón de odds (odds ratio, OR) y la razón de prevalencias (prevalence ratio, PR). Algunos estudios epidemiológicos con diseño transversal expresan sus resultados en forma de OR, pero utilizan la definición de PR. El objetivo principal de este trabajo es describir y comparar diferentes métodos de cálculo de la PR discutidos en la bibliografía reciente en dos escenarios (prevalencia 20 per cent). Material y métodos: Se realizó una búsqueda bibliográfica para conocer las técnicas más utilizadas para la estimación de la PR. Los 4 procedimientos más empleados fueron: a) seguir obteniendo OR mediante regresión logística no condicional, pero utilizando su definición correcta de OR; b) utilizar una regresión de Breslow-Cox; c) utilizar un modelo lineal generalizado con la transformación logaritmo y familia binomial, y d) utilizar una fórmula de conversión de una OR, obtenida mediante regresión logística tradicional, a una PR.Se han replicado para cada uno de los dos escenarios (prevalencia 20 per cent) los modelos hallados utilizando datos reales de la Encuesta de Salud de Catalunya de 1994. Resultados: No se observan grandes diferencias entre las estimaciones ni entre los errores estándar obtenidos al utilizar una u otra técnica cuando la prevalencia es baja. Cuando la prevalencia es alta existen diferencias entre los estimadores y entre los intervalos de confianza, aunque todas las medidas mantienen la significación estadística. Conclusión: Todos los métodos propuestos tienen sus pros y sus contras, y debe ser el propio investigador/a quien escoja la técnica que mejor se adapte a sus datos y ser coherente a la hora de utilizar un estimador y su interpretación (AU)

Prevalence of cigarette smoking by birth cohort among males and females in Spain, 1910-1990.

We analysed the prevalence of cigarette smoking among subsequent birth cohorts of Spanish males and females. Data were drawn from the Spanish NHIS conducted in 1993 ( = 26 400), 1995 ( = 8300) and 1997 ( = 8300). From the original computer files, the three surveys were pooled to obtain a single sample. A total of 33 223 subjects (16 036 men and 17 187 women) born between 1900 and 1979, >/= 16 years old, were directly interviewed and with complete information on the history of smoking included for analysis. Based on each respondent's sex and calendar year of birth, the person was classified into a particular sex-birth cohort in the decades from 1900-09 to 1970-79. For each year from date of birth to date of survey, respondents were further classified as either cigarette smoker or nonsmoker. The prevalence of cigarette smoking among successive cohorts of Spanish men and women was estimated, with correction for excess mortality of smokers. In men, the peak in smoking was reached in the 1950-59 birth cohort (prevalence rate of 68% at ages 20-29), after increases during the previous calendar years. Smoking among women was rare until 1960. Female smoking prevalence rates increased progressively among subsequent cohorts until 1980. The age distribution of smoking prevalence in women in 1990 mimics that observed in men 40 years earlier. A substantial delay in the spread of the tobacco epidemic among men is apparent. In women, the delay in the initiation of the smoking epidemic ended with a quick diffusion of the habit.

La publicidad del tabaco, ¿incrementa el hábito de fumar entre los adolescentes? Datos desde California / Tobacco advertising, does it increase smoking among teenagers? Data from California

La industria tabacalera ha estado dirigiendo campañas masivas y efectivas para aumentar las ventas de tabaco y asegurar la aparición de nuevos fumadores, principalmente adolescentes. En este artículo se describe cómo esas actividades publicitarias han cambiado en EE.UU. en los últimos años y la evidencia de su impacto especialmente en los adolescentes. En la última década, en dicho país se ha popularizado un programa de alcance nacional sobre control del tabaco. Estos programas financian con fondos públicos campañas de publicidad para promover una sociedad libre de humo y para movilizar a la población a tomar medidas preventivas ante las influencias que incitan al consumo de tabaco en los jóvenes. Los programas cuya meta sea prevenir el inicio del hábito tabáquico necesitan conocer el proceso temporal en el cual los adolescentes se convierten en adictos. El proceso de convertirse en fumador comienza antes de que el individuo experimente con cigarrillos, con el desarrollo de una predisposición cognitiva para fumar a menudo en la prepubertad. Existe evidencia de que las actividades promocionales de la industria desempeñan un papel importante incitando a los adolescentes no fumadores a estar en riesgo de experimentar y desarrollar de forma temprana signos de dependencia antes de llegar a la edad adulta. Los programas efectivos de control del tabaco pretenden contrarrestar la influencia de la industria tabacalera en los adolescentes y desalentar la demanda mediante el incremento de los precios y las barreras en la accesibilidad a los cigarrillos. Estos programas de salud pública han empezado a ofrecer resultados importantes reduciendo la mayor causa prevenible de muerte en los países desarrollados (AU)

The tobacco industry has continued to conduct large and effective promotional campaigns to increase tobacco sales and to ensure that there is a continuing pool of new smokers who are now mainly adolescents. This paper describes how these activities have changed in the United States in recent years and the evidence of their impact particularly on adolescents. Over the past decade, Statewide tobacco control programs have become increasingly popular in the United States. These programs use public monies to conduct mass media campaigns, to restructure the environment to emphasize a smoke free society and to mobilize the population to take action to prevent young people from being influenced to start to smoke. Programs that aim to prevent initiation need to be grounded in a knowledge of the time-related process by which adolescents become addicted. The smoking uptake process begins before experimenting with cigarettes with the development of a cognitive predisposition to smoke often in the pre-teen years. We present evidence that tobacco promotional activities play a major role in encouraging non-smoking adolescents to become at risk to experiment and to develop early signs of dependence prior to becoming adults. Effective tobacco control programs focus on countering the influence of the tobacco industry on adolescents, dampening demand with higher prices and barriers to easy access to cigarettes. These public health programs have started to show major results in reducing the most preventable cause of death in developed countries (AU)

Morbilidad, mortalidad y costes sanitarios evitables medianteuna estrategia de tratamiento del tabaquismo en España / The effects of implementing a smoking cessation intervention in Spain on morbidity, mortality and health care costs

Objetivo: Se valoran los efectos que tendría una intervención destinada a reducir el uso de tabaco en la población española de fumadores sobre la morbilidad, la mortalidad y los costes asociados al consumo de tabaco. Método: Se ha adaptado el modelo Health and Economic Consequences of Smoking patrocinado por la OMS y desarrollado por The Lewin Group. La intervención propuesta incluye el acceso a asistencia farmacológica de un 35% de los fumadores que intentan dejar de fumar, y obtienen una tasa global de cesación al año del 7,2%. Las enfermedades estudiadas son: cáncer de pulmón, enfermedad coronaria, enfermedad cerebrovascular, EPOC, asma y bajo peso al nacer. Se estiman los casos de enfermedad y muerte atribuibles al consumo de tabaco evitados y la reducción en el coste sanitario debidos a la intervención, proyectados a 20 años. Resultados: Sin intervención, en el año 1 del modelo 2.136.094 fumadores padecen alguna de las condiciones clínicas atribuibles al consumo de tabaco, el coste asistencial es de 4.286 millones de euros y las muertes atribuibles son 26.537. La intervención propuesta evita 2.613, 9.192, 17.415 y 23.837 casos de enfermedad atribuible al consumo de tabaco en los años 2, 5, 10 y 20 del modelo, respectivamente. Los costes asistenciales acumulados evitados son 3,5 millones de euros en el año 2 y 386 millones de (..) (AU)

Objective: We estimated the effect that a smoking cessation intervention in the Spanish population of smokers would have on smoking-related morbidity, mortality and healthcare costs. Methods: We adopted the model Health and Economic Consequences of Smoking sponsored by the WHO Health Organization and developed by the The Lewin Group. The smoking cessation intervention proposed incluides pharmacological treatment to 35% of smokers who are trying to quit smoking and obtains a quit rate of 7.2%. The diseases studied are: lung cancer, heart disease, stroke, chronic obstructive pulmonary disease, asthma exacerbation, and low birth weight. The smoking-related cases of disease and of averted death and the reduction in healthcare expenditure due to the intervention were estimated. Results: Without intervention, at year 1 of the model, 2,136,094 smokers would be affected by some smoking-related disease; healthcare expenditure would be 4,286 million € and deaths attributable to smoking would total 26,537. The proposed intervention (..) (AU)

[The effects of implementing a smoking cessation intervention in Spain on morbidity, mortality and health care costs]. / Morbilidad, mortalidad y costes sanitarios evitables mediante una estrategia de tratamiento del tabaquismo en España.

OBJECTIVE: We estimated the effect that a smoking cessation intervention in the Spanish population of smokers would have on smoking-related morbidity, mortality and health care costs. METHODS: We adopted the model Health and Economic Consequences of Smoking sponsored by the WHO Health Organization and developed by the The Lewin Group. The smoking cessation intervention proposed includes pharmacological treatment to 35% of smokers who are trying to quit smoking and obtains a quit rate of 7.2%. The diseases studied are: lung cancer, heart disease, stroke, chronic obstructive pulmonary disease, asthma exacerbation, and low birth weight. The smoking-related cases of disease and of averted death and the reduction in health care expenditure due to the intervention were estimated. RESULTS: Without intervention, at year 1 of the model, 2,136,094 smokers would be affected by some smoking-related disease; health care expenditure would be 4,286 million e and deaths attributable to smoking would total 26,537. The proposed intervention would prevent 2,613, 9,192, 17,415 and 23,837 cases of smoking-related disease at years 2, 5, 10 and 20 of the model, respectively. The saving in accumulated health care costs would amount to 3.5 million e at year 2 and 386 million e over 20 years. The accumulated prevented deaths are 284 at year 2 and 9,205 over 20 years. The intervention would save a total of 78,173 life-years by the end of the period considered. CONCLUSIONS: The availability of new effective smoking cessation interventions and the increase in accessibility to such interventions may contribute significantly to reducing morbidity, mortality and health care costs associated with smoking in Spain.

[Authorship and data reporting according to gender in four Spanish biomedical journals]. / Autoría y presentación de resultados según el género en cuatro revistas biomédicas españolas.

AIMS: To describe authorship according to gender in the articles published in four Spanish scientific journals of general medicine and public health, and to analyse the type of presentation of the results in relation to the sex of the subjects of the study. METHODS: We examined 423 articles from four Spanish scientific journals published during 1998. RESULTS: 70.7% of the articles revised had a man as the first author. The sex difference was significant in the editorials (12.4% of the women vs. 29.8% of the men, p < 0.05). Stratification of the results by sex was presented in 167 articles and in 85.6% of them the information about men. DISCUSSION: Gender inequalities in the publication of scientific works in the field of general medicine and public health are found.

Social class inequalities in the use of and access to health services in Catalonia, Spain: what is the influence of supplemental private health insurance?

OBJECTIVE: To analyse social class inequalities in the access to and utilization of health services in Catalonia (Spain), and the influence of having private health insurance supplementing the National Health System (NHS) coverage. DESIGN: 1994 Catalan Health Interview Survey, a cross-sectional survey conducted in 1994. SETTING: Catalonia (Spain). STUDY PARTICIPANTS: The participants were a representative sample of people aged over 14 years from the non-institutionalized population of Catalonia (n = 12,245). MAIN OUTCOME MEASURES: Health services utilization, perceived health, having only NHS or NHS plus a private health insurance, and social class. RESULTS: Although one-quarter of the population of Catalonia had a supplemental private health insurance, percentages were very different according to social class, ranging from almost 50% for classes I and II to 16% for classes IV and V in both sexes. No inequalities by social class were observed for the utilization of non-preventive health care services (consultation with a health professional in the last 2 weeks and hospitalization in the last year) among persons with poor self-perceived health status, i.e. those in most need. However, social inequalities still remain in the use of health services provided only partially by the NHS, and when characteristics of last consultation are taken into account. Subjects who paid for a private service waited an average of 18.8 minutes less than those attending the NHS. Within the NHS, social classes IV and V waited longer (35.5 minutes) than social classes I and II (28.4 minutes). CONCLUSION: The NHS in Catalonia, Spain, has reduced inequalities in the use of health services. Social inequalities remain in the use of those health services provided only partially by the NHS.

Autoría y presentación de resultados según el género en cuatro revistas biomédicas españolas / Authorship and data reporting according to gender in four Spanish biomedical journals

Introducción: La bacteriemia nosocomial es una causa frecuente de infección nosocomial en los recién nacidos admitidos en las unidades de cuidados intensivos neonatales y está asociada con factores de riesgo, reconocidos y no reconocidos, de infección nosocomial. Aún existen pocas evidencias sobre los factores de riesgo de bacteriemia nosocomial en recién nacidos de bajo peso al nacimiento. Objetivos: Investigar factores de riesgo de bacteriemia nosocomial en neonatos con un peso inferior a 1.500 g ingresados en la unidad de cuidados intensivos neonatal. Métodos: Se realizó un estudio prospectivo en recién nacidos de bajo peso al nacimiento ( 1.500 g) durante 22 meses. Para determinar la asociación estadística entre la bacteriemia nosocomial y los factores de riesgo perinatales y nosocomiales, se llevó a cabo un análisis bivariante de regresión logística (método de regresión por pasos). Resultados: Se estudió a un total de 72 pacientes con bacteriemia nosocomial y 174 sin ella. La permanencia del catéter umbilical un tiempo mayor o igual a 7 días y la permanencia del catéter periférico arterial durante un día o más resultaron ser los factores independientemente asociados con bacteriemia nosocomial. Conclusión: El mantenimiento del catéter umbilical más de 7 días, la permanencia del catéter periférico arterial más de 1 día y el peso al nacimiento inferior a 1.500 g fueron factores determinantes de bacteriemia nosocomial. Por la importancia de estas técnicas invasivas como fuente de bacteriemia nosocomial, es preciso revisar su tiempo de permanencia con el objetivo de disminuir la incidencia de bacteriemia nosocomial (AU)

Smoking initiation and cessation by gender and educational level in Catalonia, Spain.

BACKGROUND: The role of gender and socioeconomic status in smoking has been characterized in the United States and Northern European countries. However, there is scarce information of the dynamic of the tobacco epidemic in Southern European countries. The aim of this study was to analyze smoking initiation and cessation according to level of education and gender in Catalonia, Spain. METHODS: Data from the Catalan Health Survey (1994), a cross-sectional study based in a representative sample of the noninstitutionalized population of Catalonia, was used. The relative risks and 95% confidence interval of smoking initiation were computed by means of Cox's regression. The odds ratios and 95% confidence intervals of quitting smoking were derived from logistic regression models. Direct responses from 4,370 men and 5,213 women ages 25 years or over were included for analysis. RESULTS: Ever smoking was inversely related to level of education in men. Males with the highest educational level tended to have a lower probability of being a smoker at a given age than those with less than primary school (relative risk = 0.6; 95% confidence interval: 0.5-0.7). This pattern appeared with small variation across age groups. In women, a reverse trend was present: the higher the level of education the higher the relative risk of starting smoking (relative risk = 4.6; 95% confidence interval: 3.1-6.7). Quitting smoking was more likely among men and women with higher education as compared to men and women with less than primary school (men: odds ratio = 1.5; 95% confidence interval 1.1-2.1; women: odds ratio = 4.6; 95% confidence interval: 2.1-10.4). CONCLUSIONS: The differential effect of education according to gender may reflect different phases of the smoking epidemic. In Catalonia, the transition of smoking from upper and lower socioeconomic groups occurred recently among men, and women have currently begun to experience this transition.

[Influence of housework on health and use of health services by employed women with paid work and homemakers]. / Influencia del trabajo doméstico sobre la salud y la utilización de servicios sanitarios en mujeres con trabajo remunerado y amas de casa.

OBJECTIVE: To analyse the association between housework, burden, health status, and health services use in women (employed and homemakers) in Cornellà de Llobregat (Spain). METHODS: We included for analysis 520 women (employed and homemakers) aged 25 to 64 years old who were interviewed within the 1994 Cornellà Health Interview Survey. RESULTS: Living with elderly persons and being more than 4 members at home was associated with a poorer health status in employed women, who also had a less frequent use of health services when they lived with elderly persons. CONCLUSION: Employed women have a higher probability of declaring a poor health status when their domestic workload is high.