Pattern of smoking initiation in Catalonia, Spain, from 1948 to 1992

Modelling annual prevalence of tobacco consumption in Spain, 1991-2020

The aim of this study was to estimate the series of tobacco smoking prevalence year-by-year in Spain, by sex and age group, for the period 1991-2020. Based on smoking prevalence obtained from national surveys and smoking-related auxiliary information from public statistics, we fitted a multinomial logistic mixed model with random area and time effects. Joinpoint regression was used to identify changes in the prevalence series across the period. To analyse the precision of the model-based estimates, we calculated the coefficients of variation. Between 1991 and 2020, the prevalence of smoking in Spain decreased in both sexes. In the 15-24 age group, the prevalence of smokers showed no differences by sex until 2007, after which prevalence in men exceeded that of women. However, in women aged 55 and over prevalence of smoking has been rising since 1991. After applying the model, the precision of smoking prevalence estimates improved. The reconstruction of a detailed series of tobacco smoking prevalence provides insight into the evolution of the tobacco epidemic in Spain. A detailed analysis by sex and age shows different trends in the prevalence of smoking among women that should be considered when control measures are formulated.

Trends in age of smoking initiation among the Chinese population born between 1950 and 1997

OBJECTIVES

Smoking prevalence has significantly increased among Chinese adolescences in the past decades. The aim of our study is to investigate the trends and changing patterns in age of smoking initiation among the Chinese population.

STUDY DESIGN

Pooled data from the 2006-2015 China Health and Nutrition Survey was used for analysis. A total of 10,032 adults aged ≥18 years who were born between 1950 and 1997 were separated into five birth cohorts (1950-1959, 1960-1969, 1970-1979, 1980-1989 and 1990-1997).

METHODS

Age-specific (10-24 years) smoking initiation rates were calculated by gender, educational level and urbanisation. The multiple logistic models were used for estimates of changes in smoking initiation age.

RESULTS

The mean age of smoking initiation decreased substantially from 22.0 years (95% confidence interval [CI]: 21.2-22.7) to 17.5 years (95% CI: 16.2-19.1) over five generations. A large decrease was seen in the initiation age group of 15-24 years in the 1980s cohort (15-19 years: odds ratio [OR] = 0.57; 95% CI: 0.19-0.97; 20-24 years: OR = 0.45; 95% CI: 0.18-0.82); a significant decrease was also found in the 1990s cohort (15-19 years: OR = 0.47; 95% CI: 0.11-0.94; 20-24 years old: OR = 0.34; 95% CI: 0.14-0.85). The peak age of smoking initiation changed from 20 years old to 18 years old over the five generations.

CONCLUSIONS

The age of smoking initiation has decreased rapidly in the Chinese population in the past decades. Chinese adolescents are becoming the main target group for the tobacco marketing industry, and national legislations are urgently required.

[Smoking control in Spain: current situation and priorities]

This paper presents a strategic analysis of the prevention of smoking in Spain. After a review of the situation of the epidemic and of the current prevention policies with the data available in 2019, it identifies the main problems to improve the prevention of smoking, while proposing strategies and key actions for the future. Considering as major objectives reducing the initiation of smoking and helping smokers quit, the different strategies of action and the key actions to be developed. In addition to helping smokers to stop smoking from the health services, key preventive actions include several public policies including taxation, banning advertising and other forms of promotion, the regulation of tobacco packaging, the expansion of smoke-free spaces, and information to the public on its effects. Some of them have followed a positive path for prevention in Spain but for others there is wide room for improvement. The MPOWER strategy of the WHO offers a guide for the development of the most effective tobacco control policies. In its light it is recommended to put emphasis on actions related to expanding smoke-free areas, to develop distance support services to stop smoking, to periodically carry out advertising campaigns of wide coverage to encourage quitting, to reinforce support for quitting in health care services, to finance pharmacological treatments, to expand the advertising ban to electronic devices that release nicotine, and to increase the tax burden on tobacco and other products delivering nicotine.

Validation of a method for reconstructing historical rates of smoking prevalence

The validity of methods for reconstructing historical rates of smoking prevalence has not been assessed before. Our objective was to assess their validity. We reconstructed smoking prevalence rates for each calendar year from 1940 to 2007 for men and women in Spain, using data on ages of smoking initiation and cessation available in the Spanish National Health Surveys of 2003-2004 and 2006-2007. To assess the validity of the reconstruction, we computed the differences between the reconstructed smoking prevalence and the contemporary observed smoking prevalence measured in the Spanish National Health Surveys of 1987, 1993, 1995, 1997, and 2001. We also compared reconstructed smoking prevalence trends with 35-year lagged lung cancer mortality rates in Spain as a proxy for the real prevalence trends. Reconstructed smoking prevalence rates compared with contemporary measured rates showed small differences in men (between -2.1% and 2.1%) and an overestimation in women (between 2.0% and 5.7%). Reconstructed smoking prevalence trends were significantly correlated with lagged lung cancer mortality trends (P = 0.004 for men, P < 0.0001 for women). The reconstruction of smoking prevalence rates through this methodology offers a feasible tool with which countries lacking previous smoking surveys can understand historical trends in their tobacco epidemic, which aids in designing and implementing adequate tobacco control interventions.

Estimating the probabilities of making a smoking quit attempt in Italy: stall in smoking cessation levels, 1986-2009

Background

No data on annual smoking cessation probability (i.e., the probability of successfully quit in a given year) are available for Italy at a population level. Mathematical models typically used to estimate smoking cessation probabilities do not account for smoking relapse. In this paper, we developed a mathematical model to estimate annual quitting probabilities, taking into account smoking relapse and time since cessation.

Methods

We developed a dynamic model describing the evolution of current, former, and never smokers. We estimated probabilities of smoking cessation by fitting the model with observed smoking prevalence in Italy, 1986-2009.

Results

Annual cessation probabilities were higher than 5% only in elderly persons and in women aged < 30 years, while in adults aged 30-49 and 50-59 cessations were about 2% and 3-5%, respectively. Most of quit probabilities stalled from 1986 to 2009.

Conclusions

Over the last 20 years, cessation probabilities among Italian smokers, particularly for those aged 30-59 years, have been very low and stalled. Quitting in Italy is considered as a practicable strategy only by women in the age of pregnancy and by elderly persons, when it’s likely that symptoms of tobacco-related diseases have already appeared. In order to increase cessation probabilities, smoking cessation treatment policies (introducing total reimbursement of cessation treatments, with a further development of quitlines and smoking cessation services) should be empowered and a country-wide mass media campaign targeting smokers aged 30-59 years and focusing on promotion of quitting should be implemented.

Stages of change, smoking characteristics, and cotinine concentrations in smokers: setting priorities for smoking cessation

OBJECTIVE

We assessed whether the salivary cotinine content of daily smokers varied with the readiness to quit and smoking characteristics.

METHODS

This cross-sectional study was conducted in Barcelona, Spain (n=1245) in 2004-2005. We administered a questionnaire to assess smoking behaviour and collected saliva to determine the cotinine content. We determined the distribution of 278 adult daily smokers across different stages of change and categorised them by individual and smoking characteristics. We used medians and interquartile ranges (IQR) to relate cotinine concentrations to different stages of change, tobacco consumption, and nicotine dependence based on the Fagerström Test for Nicotine Dependence (FTND).

RESULTS

Around 68%, 22%, and 11% of smokers were in precontemplation, contemplation, and preparation stages, respectively. A mean of 17.0 cigarettes was smoked daily, with no differences among stages of change. The median cotinine concentration was 151.3 ng/ml (IQR: 83.2-227.8 ng/ml), with no differences among stages of change. The cigarette consumption scores, FTND, and time to first cigarette of the day were positively associated with cotinine concentration.

CONCLUSIONS

The cotinine concentration was similar among the stages of change, but varied within each stage according to the number of cigarettes smoked, time to first cigarette of the day, and nicotine dependence.

[Optimal cut-point of salivary cotinine concentration to discriminate smoking status in the adult population in Barcelona]

OBJECTIVE

To assess the optimal cut-point for salivary cotinine concentration to identify smoking status in the adult population of Barcelona.

METHODS

We performed a cross-sectional study of a representative sample (n=1,117) of the adult population (>16 years) in Barcelona (2004-2005). This study gathered information on active and passive smoking by means of a questionnaire and a saliva sample for cotinine determination. We analyzed sensitivity and specificity according to sex, age, smoking status (daily and occasional), and exposure to second-hand smoke at home. ROC curves and the area under the curve were calculated.

RESULTS

The prevalence of smokers (daily and occasional) was 27.8% (95% CI: 25.2-30.4%). The optimal cut-point to discriminate smoking status was 9.2 ng/ml (sensitivity=88.7% and specificity=89.0%). The area under the ROC curve was 0.952. The optimal cut-point was 12.2 ng/ml in men and 7.6 ng/ml in women. The optimal cut-point was higher at ages with a greater prevalence of smoking. Daily smokers had a higher cut-point than occasional smokers.

CONCLUSIONS

The optimal cut-point to discriminate smoking status in the adult population is 9.2 ng/ml, with sensitivities and specificities around 90%. The cut-point was higher in men and in younger people. The cut-point increases with higher prevalence of daily smokers.

[Changes in the population smoking patterns: Barcelona, 1983-2006]

OBJECTIVE

To describe the distribution of smoking in the population and to assess existing trends.

SUBJECTS AND METHODS

Cross sectional study in a sample of the resident non-institutionalized population over 14 years of age (n = 6,050) in Barcelona (Catalonia, Spain) using the Health Survey of 2006 and comparing trends for 1983-2006 with previous surveys. Independent variables included sex and age. Dependent variables were having ever been a smoker, quitting, and being a current smoker. Prevalence and proportions were estimated, stratifying or adjusting for age.

RESULTS

The prevalence of daily smokers was 27.3% for men and 20.6% for women. Age groups smoking more were 25-34 years for men and 35-44 for women. From 1983 to 2006 the decline for men was sharp, and the prevalence for women is now decreasing. The change accelerated progressively for men, in absolute and relative terms. Estimating the probability of quitting for smokers, there was an increase in cessations over this period. The proportion of smokers of an older age is now much smaller.

CONCLUSIONS

The evolution of the smoking epidemic over the last years shows promising trends. Quit rates have increased, and the decline in prevalence increases among men and has started in women. Smokers are increasingly becoming a minority, although to improve public health it would be desirable to speed the process of change.

[Meta-analysis of effects on adolescent smoking cessation programs in Korea]

PURPOSE

Meta-analysis of this study was to analyze the character of adolescent smoking cessation programs, to calculate the effect size according to variables and to compare the weighted mean effect sizes on adolescent smoking cessation programs in Korea.

METHODS

Twenty two studies for meta-analysis were selected from dissertations, theses, articles and research papers that had been published from 1995 to 2003. The selected studies had a randomized or nonequivalent control group in a pretest-post test design and had reported statistical value to calculate the effect size.

RESULTS

The mean number of sessions was 6.5. The education time per each session varied from 40 to 150 min and the most applied theories were Bandura's social-cognitive theory and the cognitive-behavioral theory. Smoking-knowledge, smoking-attitudes and smoking-amount showed high effects on the first post test after mediating adolescent smoking cessation programs according to the criteria of Cohen. The effect size of urine-cotinine found no homogeneity on the first post test, but it was significantly effective on the second post test.

CONCLUSION

Adolescent smoking cessation programs analyzed in this study were relatively effective in smoking abstinence.

[Quitting and prevalence of smoking: gender, social class, and primary health care]

OBJECTIVE

To analyse the joint role of social class and primary health care in giving up smoking.

DESIGN

Cross-sectional study.

SETTING

Barcelona (Catalonia, Spain), 2000-2001.

PARTICIPANTS

A sample of the resident non-institutionalized population, restricted to people aged 15-50 who have a habitual primary care source (n=4178).

MAIN MEASUREMENTS

These were obtained from the Barcelona Health Interview Survey. Independent variables include sex, social class and usual source of primary health care. Dependent variables are having ever been a smoker, having quit, and being a current smoker. Age-adjusted proportions were calculated (95% CI).

RESULTS

Social class shows that more manual workers have been smokers. Men smoked more than women. Overall quitting is similar in both sexes. Quitting showed a social gradient in men. Measurement of source of care showed quitting was higher among users of private clinics, but CI overlapped. On stratifying the source of primary care by social class, an effect seemed to emerge for men, but the CI overlapped. Prevalence at the time of the survey was higher for men; a class gradient in current prevalence emerged for men, but was less visible for women, where CI overlapped.

CONCLUSIONS

Social class is a powerful determinant of smoking. Men in low-classed jobs are at greater risk of starting to smoke, are less likely to give up, and smoke more. The proportion of quitting seems lower in of public clinics users. Health advice is efficacious, but in population terms other factors seem to have greater influence.

Maternal smoking, social class and outcomes of pregnancy

Exposure to tobacco during pregnancy is an important risk factor for infant health. Recently the prevalence of smoking during pregnancy has declined in our area. The objective of this study was to analyse the association between several social variables and the fetal exposure to smoking, as well as the association between maternal smoking and some adverse gestational outcomes. Data collection was cross-sectional. The study population were women in the city of Barcelona (Catalonia, Spain) delivering a child without birth defects. The sample corresponded to the controls of the Birth Defects Registry of Barcelona, 2% of all pregnancy deliveries in the city from 1994 to 2003 (n = 2297). Information sources were hospital records and a personal interview of mothers. The analysis measured first the association between independent variables (instruction level, social class, occupation, nationality, planned pregnancy, parity, hospital funding and smoking status of the mother's partner) with two dependent variables: smoking at the initiation of pregnancy and quitting during pregnancy. Second, the persistence of smoking over pregnancy and all independent variables were studied with three variables indicating adverse outcomes of pregnancy: low gestation, low birthweight and intrauterine growth restriction (IUGR). Finally, the joint association between the persistence of smoking over pregnancy and social class taken as independent variables was determined with the three variables indicating adverse outcomes of pregnancy. Logistic regression models were fitted, adjusting for maternal age. Results are presented as odds ratios with their 95% confidence intervals. The prevalence of smoking at the onset of gestation was 41%, and 40% of these women quit during pregnancy, so that 25% delivered as active smokers. Fewer women with higher educational levels and from families with non-manual jobs smoked, as did immigrants, those planning pregnancy and women whose partner did not smoke. Smoking immigrants quit more frequently than nationals, as did those planning pregnancy, primiparae, and women whose partner did not smoke. Low gestation, low birthweight and IUGR were more frequent among smokers and women with a manual occupation, but manual occupation lost its significance when adjusting for smoking. The association between smoking and adverse results was higher for IUGR. In conclusion, the prevalence of smoking and quitting during pregnancy varied according to social factors. The influence of social factors on the outcome of pregnancy was mediated strongly by smoking in a country that provides access to health care free of cost. A priority in reducing inequalities in health is to help women from manual work backgrounds quit smoking.

Time trends and educational differences in the incidence of quitting smoking in Spain (1965-2000)

BACKGROUND

To analyze the pattern in the incidence of quitting smoking in Spain from 1965 to 2000 according to gender, age and educational level.

METHODS

We used data from 5 Spanish National Health Interview Surveys including 33532 ever smokers>or=20 years old. We reconstructed the history of smoking and the age at smoking cessation. We calculated the biannual incidence of quitting smoking according to sex, age and educational level. We fitted joinpoint regression to identify significant changes in trends.

RESULTS

The incidence of quitting smoking at ages 20-50 years has increased from 0.5% in 1965-1966 to 4.9% in 1999-2000 for males and from 1.1% in 1965-1966 to 5.0% in 1999-2000 in females. For those aged>50 years old, the incidence of quitting smoking has increased from 0.4% in 1965-1966 to 8.7% in 1999-2000 for males and from 7.9% in 1973-1974 to 8.8% in 1999-2000 in females. A level-off in cessation rates is observed both in men and women aged 20-50 years old with lower educational level in the last decade, while cessation among those with higher educational level continue to increase.

CONCLUSIONS

The different pattern of smoking cessation according to gender, age, and level of education suggests that health promotion actions and tobacco control policies might have had a different effect among different population subgroups.

Implementing and complying with the Smoke-free Hospitals Project in Catalonia, Spain

The objective of the study was to describe the implementation of measures for preventing tobacco consumption developed in the Catalan Network of Smoke-free Hospitals. Information from 25 hospitals that are actively involved in the Catalan Network of Smoke-free Hospitals (April 2004) was used. The degree of implementation of the Smoke-free Hospitals Project was analysed by means of the Self-Audit Questionnaire of the European Network for Smoke-free Hospitals; each hospital was analysed globally and according to the duration of its Network membership (<1 year: implementation stage; > or =1 year: consolidation stage). In terms of global indicators, there were high levels of commitment (64.8%), communication (74.7%), tobacco control (77.4%) and implementation of smoke-free environments (81.0%). A lower degree of implementation (<50%) was found in education and training, health promotion and healthy workplaces. According to the duration of Network membership, significant differences were observed for communication, environment, healthy workplaces and follow-up. Deficits were observed in areas such as specialist training and cessation support, and further input is required here. By identifying areas needing attention, providing a guide for policy development and by administering it periodically, one can ensure that progress is kept on track.

Effects of partner smoking status and gender on long term abstinence rates of patients receiving smoking cessation treatment

AIMS

To assess the effect of partner smoking status on the success of a cessation program.

DESIGN

Prospective cohort.

SETTING

Smoking Cessation Unit in Hospital of Bellvitge (Hospitalet de Llobregat, Barcelona).

PARTICIPANTS

A total of 1516 smokers of 10 or more cigarettes who started a smoking cessation program between January 1995 and December 2001 were included.

MEASUREMENTS

All patients gave information about smoking history and smoking partner status. Abstinence was determined by carbon monoxide exhaled.

FINDINGS

Significant differences were found in the abstinence rates at 12 months by smoking partner status: abstinence was achieved by 28.3% of patients with smoking partner, and by 46.5% of patients without smoking partner (p<0.001). Subjects whose partner was smoking at the beginning of the program appear to be more likely to relapse than subjects without smoking partners (p<0.001) and this is more pronounced in women than in men. However no significant gender differences were found in any group of smoking partner status.

CONCLUSIONS

Having a smoking partner is a determinant of relapse 1 year after the beginning of the cessation program. Interacting not just with the smoker, but also with his or her partner, could neutralize interpersonal influences making smokers more accessible to behavioural and pharmacological techniques.

Global Patterns and Determinants of Sex Differences in Smoking

The worldwide spread of tobacco use in recent decades raises questions about the relative prevalence of smoking among men and women. Does the degree of gender equality in nations promote equality in cigarette use? Does rising use of cigarettes by women stem from the stage of cigarette diffusion and earlier increases among men? Or have changes in economic factors and smoking policy affected the sexes differently? This study uses aggregate data for 106 nations, measures of smoking prevalence circa 2000, and lagged measures of gender equality, cigarette diffusion, and tobacco access to address these questions and evaluate the underlying theories. With the logged ratio of female to male prevalence as the dependent variable, regression results reveal that gender equality has inconsistent effects on women's smoking relative to men, cigarette diffusion has more consistent and moderately strong effects, and economic factors have weak effects. Global patterns of adoption of cigarettes by women appear most closely associated with the early adoption by men and then movement through a regular pattern of cigarette diffusion.

Radiation therapy alone in elderly with early stage non-small cell lung cancer

BACKGROUND

Radiation therapy (RT) alone is frequently used in elderly patients with medically inoperable early stage (I/II) non-small cell lung cancer (NSCLC). We retrospectively investigated the effectiveness of RT alone in this patient population treated in our institution.

MATERIAL AND METHODS

Between 1995 and 1999, a total of 33 patients were treated with RT alone in our institution, all being males. RT doses ranged 66-78 Gy (median, 70 Gy) using standard fractionation (2.0 Gy per fraction). The age range was 71-97 years (median, 75 years) with 11 patients being >or=80 years old. Twenty-two (67%) patients had a squamous cell carcinoma. There were 24 (73%) stage I and nine (27%) stage II patients.

RESULTS

Radiographic objective response rate was observed in 23 (70%) patients. The median survival time was 37.4 months and 3-year survival time was 50%, while the median cause-specific survival time was 48.1 months and a 3-year cause-specific survival rate was 55.3%. The median time to local recurrence was 36.8 months and a 3-year local recurrence-free survival rate was 50.2%, while the median time to distant metastasis was not achieved yet, the 3-year distant metastasis-free survival rate being 71.4%. One (3%) patient died of RT-induced acute lung toxicity, while only two (6%) patients experienced late grade 3 lung toxicity. No other high-grade toxicity was observed during this study.

CONCLUSIONS

RT alone was effective and low toxic in elderly with early stage (I/II) NSCLC and could be considered as treatment of choice in this patient population.

Nuevas y viejas adicciones: implicaciones para la salud pública

According to certain authors, any pleasure giving behaviour may become a habit, and depending on the circumstances, an addiction. The objective of this study is to examine the situation of addictions in Spain and the responses generated by health policies. In recent years, both the type and pattern of drug consumption in Spain, has undergone a noticeable change. Studies of the evolution of tobacco consumption suggest that the peak has passed, even though prevalence is still high. Alcohol consumption per capita has fallen by 25% in the last 25 years. During the same period, pattern of consumption has been modified. Sporadic drinking, in episodes of binging and drinking away from meals, is one of the patterns on the rise. According to the European Monitoring Centre for Drugs and Drug Addiction, in Spain, 27.8% of the population between 15- 64 years old has consumed an illegal drug at least once in their lives, with the prevalence rising to 38% among the 15- 34 year olds. Cannabis is the most consumed (29% among 1564 age group), followed by cocaine (5.9%), and ecstasy (4.6%). Spain, comparing with other countries of European Union, is the third in cannabis, ecstasy, and amphetamine and the first in cocaine consumption. With respect to the so-called behavioral addictions, no consensus in the field of psychiatry has been reached. The only psychological addiction with clear diagnostic criteria is gambling. The rest (Internet, sex, etc.), perhaps for their novelty, continue to be the object of controversy. New addictions, as much to addictive substances as to addictive behaviors, run parallel to the development of industrialized societies, leisure, free time, and a new way of life. This is the new challenge for Public Health.

[Combined radiochemotherapy in localised small-cell lung cancer. Concurrent treatment protocols?]

PURPOSE

We retrospectively reviewed our Institution's database to investigate the outcome and impact of combined radiochemotherapy (RT/CT; concomitant or in sequence) in localised small-cell lung cancer (L-SCLC).

MATERIAL AND METHODS

Between January 1995 to November 1999, 79 patients with L-SCLC received combined RT/CT at our Institution. RT was delivered concurrently or sequentially following the CT. Patients with treatment response received additional prophylactic cranial irradiation (PCI).

RESULTS

Of the patients treated, 54% had received concurrent CT/RT compared to 46% receiving RT following the CT. PCI was administered to 80% of the patients. Complete response was observed in 66% of patients. With a median follow up of 30 months, median overall survival was 15.9 months; 14.3 months for patients who received RT following CT and 21.6 months for those receiving concurrent CT/RT. The type of schedule of combined radiochemotherapy was an independent prognostic factor for survival free of local recurrence, as was additional PCI for distant metastasis-free survival.

CONCLUSIONS

Our results are similar to those reported previously in the literature. The main point of interest is that our patients were non-selected. We strongly support the use of concurrent CT/RT so as to achieve results comparable to the best in the literature.

Educational inequalities in smoking among men and women aged 16 years and older in 11 European countries

OBJECTIVE

To determine those groups who are at increased risk of smoking related diseases, we assessed in which male and female generations smoking was more prevalent among lower educated groups than among the higher educated, in 11 European countries.

DESIGN

Cross sectional analysis of data on smoking, covering the year 1998, from a social survey designed for all member states of the European Union.

SUBJECTS

Higher and lower educated men and women aged 16 years and older from 11 member states of the European Union.

OUTCOME MEASURES

Age standardised prevalence rates by education and prevalence odds ratios of current and ever daily smoking comparing lower educated groups with higher educated groups.

RESULTS

A north-south gradient in educational inequalities in current and ever daily smoking was observed for women older than 24 years, showing larger inequalities in the northern countries. Such a gradient was not observed for men. A disadvantage for the lower educated in terms of smoking generally occurred later among women than among men. Indications of inequalities in smoking in the age group 16-24 years were observed for all countries, with the exception of women from Greece and Portugal.

CONCLUSIONS

Preventing and reducing smoking among lower educated subgroups should be a priority of policies aiming to reduce inequalities in health in Europe. If steps are not taken to control tobacco use among the lower educated groups specifically, inequalities in lung cancer and other smoking related diseases should be anticipated in all populations of the European Union, and both sexes.

A multilevel analysis of tobacco use and tobacco consumption levels in France: are there any combination risk groups?

BACKGROUND

Both the predictors for tobacco use and the determinants of the amounts of tobacco consumed by smokers should be taken into account when designing prevention programmes.

METHODS

Using a sample of 12,948 individuals representative of the French population in 1999, multilevel models were used to carry out a comparative investigation for the predictors of tobacco use and the determinants of the amount of tobacco consumed by smokers.

RESULTS

At the individual level, a combination of risks (higher risk of smoking and larger amounts of tobacco consumed by smokers) was found for males, for individuals with a low level of education and for divorcees. At the level of the area of residence, both the risk of smoking (odds ratio 1.07, 95% confidence interval: 1.01-1.12 for an increase by one standard deviation) and the amount of tobacco consumed among smokers (percentage variation +4%, 95% confidence interval: 0% - +8%) increased with the gross domestic product per capita.

CONCLUSION

This study justifies the combined use, in such analyses, of consumption levels for smokers in addition to the risk of smoking, in order to identify the profiles with the highest risk. It was possible to identify various groups with both a high risk of tobacco use and a high level of consumption among smokers, on the basis of individual (male, divorced or less educated) and environmental (living in a high GDP area) factors. The prevention efforts should thus be focused on such groups.

Smoking Cessation in a Population-Based Cohort Study

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.

Age and education patterns of smoking among women in high-income nations

In suggesting that levels of female smoking in high-income nations result from patterns of adoption and abatement during the process of cigarette diffusion, theories of diffusion predict that age and education patterns of smoking shift from concentration among young and highly educated women to older and less educated women as cigarette use spreads through a population and begins to decline. Using survey data on individuals from 16 European nations, aggregate measures of cigarette diffusion, and multilevel statistical models, this study demonstrates that age and education patterns vary with the stage of cigarette diffusion as predicted by the diffusion theories, and provides some evidence concerning future patterns of change in female smoking across nations at diverse stages of cigarette diffusion.

Declining sex differences in mortality from lung cancer in high-income nations

After decades of widening, the difference in mortality from lung cancer between men and women has begun to narrow in recent years. Recognizing that the increase in smoking among women relative to men is the proximate cause of the changing sex difference in rates of lung cancer, I analyzed two approaches to identify the more distant sources of the changes. A gender-equality argument suggests that the difference is related to the more general equalization of women's and men's work and family roles, which also encourages the adoption of harmful behaviors such as smoking by women. An alternative explanation suggests that the convergence in mortality from lung cancer among men and women is the byproduct of a lag in the adoption, diffusion, and abatement of smoking by women. Using mortality data on 21 nations from 1955 to 1996, an analysis of logged rates of men's and women's lung cancer mortality and the logged ratio of the rates demonstrated little relationship between the sex difference and gender equality. However, I found a strong and consistent relationship between the sex difference and the stage of diffusion of the use of cigarettes.

[Smoking in Spain, 1945-1995. A retrospective analysis based on the Spanish National Health Interview Surveys]

BACKGROUND AND OBJECTIVE

To analyse trends in cigarette consumption in Spain between 1945 and 1995.

MATERIAL AND METHODS

Prevalence rates of daily cigarette smoking were derived from the individual information collected in the Spanish National Health Interview Surveys (1993, 1995 and 1997) for the period 1945-1995.

RESULTS

In males, the prevalence rate in 1945 was 42.4% (95% confidence interval [CI], 40,1-44,7%), increased till 59.1% in 1975 (95% CI, 58,0-60,2%), levelled-off during the decade 1975-1985, and decreased till 48.9% in 1995 (95% CI, 48,1-49,7%). In females, the prevalence rate of cigarette smoking was less than 5% till the 1970s, and it begun to steadily increase till the end of the study period (22,5%; 95% CI, 21,9-23,1%).

CONCLUSIONS

This analysis shows the different dynamics of the smoking epidemic among men and women in Spain.

Lung cancer mortality in European regions (1955-1997)

BACKGROUND

The different spread of tobacco smoking across European countries has caused a substantial variability in lung cancer mortality. The objective of this investigation was to analyse the trends in lung cancer mortality rates in three broad European regions (Northern and Western countries, Eastern countries, and Mediterranean countries) during the second half of the 20th century.

PATIENTS AND METHODS

Mortality data were obtained from the World Health Organisation database. Lung cancer mortality rates were age-standardised by the direct method to the world standard population. Trends from 1955 to 1997 were assessed by means of joinpoint regression analysis.

RESULTS

In men, rates in Eastern Europe increased to reach in the 1990s the highest values ever registered, while downward trends were observed in Northern and Western Europe since 1979, and in Mediterranean countries since the 1990s. In women, upward trends were observed in the three regions considered for the whole period.

CONCLUSIONS

Different smoking prevalences over time explain the shift of almost one decade in the trends in Mediterranean men as compared with Northern and other Western European men. The persisting upward trends in women in the three regions are of concern.

Trends in smoking and overweight during pregnancy: prevalence, risks of pregnancy complications, and adverse pregnancy outcomes

The prevalence of smoking during pregnancy is decreasing in some, but not all, developed countries, as the prevalence of overweight is increasing rapidly in most countries. During pregnancy, smoking increases the risk of placental abruption, but reduces the risk of preeclampsia, while overweight increases the risks of gestational diabetes, preeclampsia, and cesarean delivery. Both smoking and overweight are associated with dose-dependent increases in risks of stillbirth and very preterm birth (< 32 weeks). From a public health perspective, smoking and overweight today probably represent the most important modifiable risk factors for pregnancy complications and adverse pregnancy outcomes.

[The effects of implementing a smoking cessation intervention in Spain on morbidity, mortality and health care costs]

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.

[Tobacco consumption among adolescents. Value of the intervention of health-service staff]

OBJECTIVES

To describe the characteristics of tobacco consumption among adolescents seen at a health centre, find their opinions of the factors that affect consumption, and analyse the quality of the intervention of the health staff.

DESIGN

Descriptive, cross-sectional study of adolescents attending the health centre.

SETTING

Primary care (PC).

PATIENTS

All the young people between 10 and 20 who attended family medicine, paediatric or nursing clinics, whether on-demand or with appointments, on Tuesdays and Wednesdays between December 2000 and February 2001.

MAIN RESULTS

23.1% of all the girls smoked (95% CI, 14.9-33.1) versus 15.3% of boys (95% CI, 8.4-24.7). Among non-smokers the main reason for not smoking was health (94.4%). 50% of smokers had tried to give up, of whom 70.5% tried for health-related reasons. 49.4% (95% CI, 41.8-57.1) of those included in the study had been asked at the health centre on some occasion whether they smoked (10.1% of these [95% CI, 4.2-19.8] were aged 10-13; 73.4% [95% CI, 60.9-83.7] 14-17; and 76.7% [CI 95%: 61.4-88.2] 18-20); and 50.6% had never been asked. Of those who were asked and did smoke, 75% (95% CI, 55.1-89.3) were advised to give up and 4.7% of these (95% CI, 0.1-23.8) were offered help to do so. 28.81% of those who did not smoke (95% CI, 17.8-42.1) were encouraged to continue not to smoke.

CONCLUSIONS

Both smokers and non-smokers are highly aware of the repercussions of tobacco on health. Tobacco dependency in young people was not tackled well enough at health centre clinics, especially by paediatricians.

Ages at initiation of cigarette smoking and quit attempts among women: a generation effect

OBJECTIVES

This study sought to determine whether the age at initiation of regular cigarette smoking and the likelihood of quitting smoking through age 35 differ among women from younger versus older generations.

METHODS

Annual population-based, random surveys (total of 3676 female residents of Geneva, Switzerland, aged 35-74 years) were conducted from 1992 to 1998.

RESULTS

Women younger than 55 years were more likely to be past or current smokers, began smoking earlier (median age < 20 years), and smoked more cigarettes per day than older women, yet attempted to quit smoking more often before age 35 (log-rank P <.001).

CONCLUSIONS

Young female smokers have a higher propensity to quit smoking compared with older women. Encouraging young smokers to quit-in addition to preventing nonsmokers from starting-may be an important facet of reducing cigarette smoking prevalence among adolescents.

[Lung cancer mortality in Barcelona: evidence for an initial decline in men]

BACKGROUND

Tobacco use in Spain is still high, with many smoking related deaths. However, a decrease in smoking prevalence in men has been observed in recent years, with a stabilisation or an increase among women. This paper studies the evolution of cancer mortality in Barcelona city (Catalonia, Spain) according to age and sex over the period 1984-1998.

SUBJECTS AND METHOD

The evolution of annual mortality by age and sex was calculated. Specific mortality rates were estimated by age and sex strata; crude and standardized death rates for each year were also determined. Finally, for the 35-64 years population, specific mortality rates were estimated for each 5-year period (1984-1988, 1989-1993, and 1994-1998).

RESULTS

Mortality rates do not change for men aged 35-39, 50-54 and 55-59 years. There was a decrease in lung cancer mortality rates in the 1994-1998 period compared to the first period for those men in the 60-64 years group. In men in the 40-44 and 45-49 years groups, rates increased in the second and stabilize in the last period. Global rates in men in the 35-64 years group, both crude and adjusted, were in the first and last 5-year periods. Among women, rates are much lower, although there was a significant increase in the 35-39 and 45-49 years groups. Crude and adjusted rates in all women aged 35 to 64 years displayed an increase in the last 5-year period.

CONCLUSIONS

These results show that in Barcelona the decrease in smoking prevalence among males is now leading to an initial decrease in lung cancer mortality. The turning point seems to be in the period 1989-1993. On the contrary, there is a clear increase among young women, although the rates are still much lower.

Recent decline in cancer mortality in Catalonia (Spain). A joinpoint regression analysis

The aim of this paper was to analyse recent changes in cancer mortality in Catalonia (Spain) between 1975 and 1998 using joinpoint regression models. Mortality data were obtained from the Mortality Registry of Catalonia. For each sex, age-standardised (standard world population) mortality rates were computed by the direct method, and joinpoint analysis was used to identify the best fitting points where a statistically significant change in the rates had occurred. In men, the overall cancer mortality (except skin non-melanoma) was highest in 1991 and decreased thereafter. Lung cancer was the main cause of cancer mortality, with an increase until 1989, and a subsequent levelling off (-0.8% annual between 1989 and 1998). Colorectal cancer was the second cause of cancer death, both in men and women, with a levelling-off of the rates since 1991 and 1989, respectively. In women, the mortality rate decreased for total cancer (except skin non-melanoma) since 1991 (-0.9% annually). Breast cancer increased until 1975, levelled-off and begun to decline since 1992 (-3.8% annual). Lung cancer increased since 1988 (+2.1%) and became the third cancer cause of death among women in 1998. These changes are mainly due to the decline of smoking prevalence in males, but not in females, and to the introduction of new diagnostic techniques and improved therapies for female breast cancer.

Trends in cigarette smoking in Spain by social class

OBJECTIVE

. The aim of this study was to evaluate smoking trends among Spanish men and women by social class between 1987 and 1997.

METHODS

We used secondary analysis of the National Health Interview Surveys of 1987, 1993, 1995, and 1997. The main outcome measures were prevalence of smoking, smoking cessation activity (quit ratio), and smoking initiation in the manual and nonmanual social class in each year and smoking prevalence ratio, smoking cessation ratio, and smoking initiation ratio in 1997 versus 1987 in each social class.

RESULTS

Among men ages 25 years and older the prevalence of smoking in both the manual and the nonmanual social class decreased between 1987 and 1997 in all age groups, and the relative magnitude of the decrease was always greater in the nonmanual social class. In contrast, among women the prevalence of smoking increased in both social classes: in the 25- to 44-year age group the smoking prevalence ratios in 1997 versus 1987 were 1.20 in the nonmanual social class and 1.61 in the manual social class, while in the 45- to 64-year age group the prevalence ratios were 2.52 and 2.15, respectively. The quit rate among men increased in both social classes in all age groups between 1987 and 1997; in contrast, among women the quit rate increased only among those ages 25 to 44 years in the nonmanual social class. Smoking prevalence for people ages 16 to 24 years--smoking initiation--decreased among men and women between 1987 and 1997 in both social classes.

CONCLUSIONS

Smoking trends in Spain by social class have differed among men and women. The findings are considered in the context of policies and programs aimed at reducing smoking.

[Secular trends in smoking according to educational level between 1986 and 1996: The MONICA study. Catalonia]

OBJECTIVE

To describe trends from 1986-1996 in the prevalence of cigarette smoking between ages 25 to 64 in the MONICA-Catalonia study, according to educational level, and to validate these trends biochemically.

METHODS

Three cross-sectional surveys in independent random samples of the general population of central Catalonia area carried out in 1986-88, 1990-92 and 1994-96 following the World Health Organization's MONICA protocol. Serum thiocyanate was determined by the Bowler method.

RESULTS

A total of 2,571, 2,934 and 3,485 men and women were examined with response rates of 74, 67 and 72% in each survey respectively. The age-adjusted cigarette smoking prevalence decreased in men by 5.1% (95% CI: 1.5 to 8.7) and increased in women by +8.5% (95% CI: +5.6 to +11.4). The prevalence was 46.5% in men and 23.9% in women in 1994-96. The greatest decrease was in men aged 55-64 (9.9%) and the greatest increase was in women aged 35-44 (+14.8%). These trends were confirmed by serum thiocyanate levels, which decreased from 78.9 to 73.9 μmol/l (p = 0.07) in men and increased from 43.7 to 49.8 μmol/l (p < 0.01) in women during the study period. Cigarette smoking increased in less educated women (+10%) and decreased in university women (6%), while cigarette smoking in men decreased irrespective of educational level. Serum thiocyanate levels confirmed the relationship with educational level.

CONCLUSIONS

The prevalence of cigarette smoking decreased in men between 1986 and 1996 but remained high in 1996. Women showed a pattern of progressive adoption of smoking, especially those with lower educational level.

[Trends in cancer mortality in Catalonia (1975-1998)]

BACKGROUND

Aimed at assessing recent trends of cancer mortality in Catalonia (Spain), we analysed mortality rates for main tumour locations in men and women between 1975 and 1998.

MATERIAL AND METHOD

Mortality data were obtained from the Mortality Registry of Catalonia. For each sex, age-standardized (standard world population) mortality rates were determined by means of the direct method, and generalized lineal models with Poisson distribution were adjusted to obtain annual change percentages.

RESULTS

In men, the overall cancer mortality (except skin non-melanoma) was highest within 1991-1992 (age-standardized rate: 181.39/100,000) and decreased thereafter until 169.47/100,000 in 1995-1996. Lung cancer was the main cause of cancer mortality, displaying a 4% annual increase until 1989-1990, and a subsequent stabilization (-0.5% annual between 1989 -1990 and 1997 - 1998); Colorectal cancer was the second cause of cancer death, both in men and women, with a mortality rate stabilization since the 1990s. Prostate cancer became the third cause of cancer death in 1997-1998. In women, overall cancer (except skin non-melanoma) mortality rate was of 77.98/100,000 in 1997-98, showing a 0.9% annual decrease since 1989-1990. Breast cancer was the chief cause of cancer death within 1997-1998: after a sustained increase since 1975-1976, mortality started to decline (-2.0% annual) since 1989-1990. Lung cancer became the third cause of cancer death among women within 1997-1998, just after breast cancer and colorectal cancer, while gastric and uterine cancer became the fourth and fifth cancer death causes during this period, respectively.

CONCLUSION

After years of a steady increase, mortality rates for main cancer types stabilized since 1989-1990 in Catalonia.

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.

Trends in social class inequalities in health status, health-related behaviors, and health services utilization in a Southern European urban area (1983-1994)

BACKGROUND

The objective of this study was to describe the evolution of social class inequalities in Barcelona (Spain) residents in perceived health status, health-related behaviors, and utilization of health services between 1983 and 1994.

METHODS

The information was obtained from the Health Interview Surveys conducted in 1983, 1986, 1992, and 1994 in Barcelona. In this study we included noninstitutionalized people ages >14 years. Social class was obtained from the Spanish adaptation of the British Registrar General classification. We studied health status, health-related behaviors, and health services utilization variables. Age-adjusted percentages and the relative index of inequality were obtained.

RESULTS

Of the health status variables, having been confined to bed and acute restriction of activity in the 2 weeks prior to the interview showed an increase in inequalities by social class in 1994. The pattern of chronic conditions by social class in men did not change between 1983 and 1994. Women had a higher prevalence of chronic conditions and the inequalities among social classes had increased. In men there were no social class inequalities in smoking in 1983. In 1992 and 1994 smoking was more prevalent in men of social classes IV and V. In women, smoking was more prevalent in social classes I and II in 1983 than in social classes IV and V, something that had changed by 1994. Lack of usual physical activity in men was always more prevalent in social classes I and II, and this difference increased since more people of advantaged classes moved into inactivity. Health services utilization showed no inequalities in the years studied.

CONCLUSION

The changing pattern according to social class of smoking and physical activity practice needs to be taken into account by policy-makers and public health workers.