Tres años con «Ley de medidas sanitarias frente al tabaquismo»: aire más limpio, pero no lo suficiente

Impact of the Spanish smoke-free laws on cigarette sales, 2000-2015: partial bans on smoking in public places failed and only a total tobacco ban worked

In January 2006, the Spanish government enacted a tobacco control law that banned smoking in bars and restaurants, with exceptions depending on the floor space of the premises. In January 2011, further legislation in this area was adopted, removing these exceptions. We analyse the effect produced on cigarette sales by these two bans. We approach this problem using an interrupted time series analysis while accounting for the potential effects of autocorrelation and seasonality. The data source used was the official data on legal sales of tobacco in Spain, from January 2000 to December 2015 (excluding the Canary Islands and the autonomous cities of Ceuta and Melilla). As confounder variables, we use the log-transformed average prices for manufactured and hand-rolled cigarettes (or the average minimum excise tax as a proxy), and log-transformed real-household disposable income. The implementation of a total smoke-free ban in Spain was associated with an immediate reduction in cigarette sales between 9% to 11%. In contrast, in the period immediately following the partial ban, no such reduction was detected, beyond the trend already present. Our results indicate that, in Spain, partial bans on smoking in public places failed, and that only a total tobacco ban worked.

[Second-hand smoke exposure in hospitality venues in Barcelona: measurement of respirable particles]

OBJECTIVES

To quantify the concentration of respirable particles equal to or smaller than 2.5μm (PM(2.5)) as a marker of second-hand smoke (SHS) exposure in a sample of hospitality venues in Barcelona 2 years after the Spanish smoking law came into effect.

METHODS

We performed a cross-sectional descriptive study from October to December 2007. The study population consisted of 40 hospitality venues in Barcelona selected by a random route sampling, with representation of the different types of smoking regulation included in the law (smoking allowed, smoking ban and venues with smoking areas). SHS levels were quantified by measuring PM(2.5) concentrations, which were measured using a laser photometer (Side Pack AM 510 Personal Aerosol Monitor). The measurements were carried out for 5 minutes outside the venue and for 30 minutes inside the venue. In addition, observational variables related to the characteristics of the venue and signs of tobacco consumption were recorded.

RESULTS

The concentration of PM(2.5) in venues where smoking was still allowed was five times higher than that in venues where smoking was banned (182μg/m(3) and 34μg/m(3), respectively) and exceeded the concentration established by the US Environmental Protection Agency (EPA) as harmful (35μg/m(3)). However, in venues where smoking was banned, the concentration was lower than the EPA standard and there were no significant differences with the outdoor PM(2.5) concentration.

CONCLUSIONS

Two years after the introduction of the Spanish smoking law, SHS exposure in venues where smoking was allowed was q still very high, representing a significant health risk for hospitality workers.

Tobacco-related tumours of the lung, bladder and larynx: changes in Spain

The association between tobacco use and lung cancer and other tumours has been confirmed by a large number of studies. In Spain, the prevalence of smoking has been declining since 1978. This study describes lung, bladder and laryngeal cancer mortality and incidence rates and their trends in Spain. Mortality data were furnished by the National Statistics Institute (2001-07) and incidence data by population-based cancer registries (1975-2004). Changes in rates were calculated using Poisson regression models, which enable trend changes to be estimated. In the case of lung cancer, mortality rates decreased among men [annual percentage change (APC) -1.3%] though not among women (APC 3.5%), whereas incidence rates increased in both sexes, overall and adjusted for registry, by 0.75% among men and 3.2% among women. Bladder cancer mortality rates decreased among men (APC -1.2%) and women (APC -0.8%), yet incidence rates increased across the sexes. While laryngeal cancer mortality rates decreased among men (APC -5.5%) and women (APC -0.03%) alike, incidence rates decreased (-1.28%) among men but not among women (3.95%). A decrease in male versus female mortality due to tobacco-related tumours is evident in Spain. Incidence rates are beginning to reflect the progressive cessation of smoking that has been observed among men rather than women.

Second-hand smoke in hospitals in Catalonia (2009): a cross-sectional study measuring PM2.5 and vapor-phase nicotine

OBJECTIVES

To describe second-hand smoke in the hospitals of the Catalan Network for Smoke-free Hospitals using Particulate Matter (PM(2.5)) and to assess the association between second-hand smoke exposure in main entrances (outdoors) and halls and between PM(2.5) and airborne nicotine concentrations.

METHODS

Cross-sectional study carried out in 2009 in the 53 hospitals affiliated with the network. We measured PM(2.5) (μg/m(3)) in all hospitals and measured airborne nicotine concentrations (μg/m(3)) in a subsample of 11 hospitals. For each assessment, we measured nine locations within the hospitals, computing medians, means, geometric means, interquartile ranges (IQRs), and 95% confidence intervals (CI) of the means and the geometric means. Further, we used Spearman's linear correlation coefficient r(sp)) to explore the association between PM(2.5) concentrations in halls and main entrances and between PM(2.5) and nicotine concentrations.

RESULTS

The overall median of the 429 PM(2.5) measurements was 12.48 μg/m(3) (IQR: 8.84-19.76 μg/m(3)). The most exposed locations were outdoor smoking points (16.64 μg/m(3)), cafeterias (14.82 μg/m(3)), and main entrances (14.04 μg/m(3)); dressing rooms were the least exposed (6.76 μg/m(3)). PM(2.5) concentrations in halls were positively correlated with those in main entrances (r(sp)=0.591, 95% CI: 0.377-0.745), as were PM(2.5) values and nicotine concentrations (r(sp)=0.644, 95% CI: 0.357-0.820).

CONCLUSIONS

Second-hand smoke levels in hospitals were low in most locations, with the highest levels observed in outdoor locations where smoking is allowed (smoking points and entrances). Smoking in main entrances was associated with increased second-hand smoke levels in halls. Use of PM(2.5) to evaluate second-hand smoke is feasible and shows a good correlation with airborne nicotine values.

[Changes in hospitality workers' expectations and attitudes after the implementation of the Spanish smoking law]

OBJECTIVE

To assess changes in hospitality workers' expectations and attitudes towards the Spanish smoking law before and 2 years after the smoking ban.

METHODS

We performed a longitudinal study of a cohort (n=431) of hospitality workers in five regions in Spain before the law came into effect and 24 months later. Expectations and attitudes towards the ban and knowledge about the effect of second-hand smoke on health were compared before and after the ban.

RESULTS

We recruited 431 hospitality workers in the baseline survey and 219 were followed-up 24 months later (overall follow-up rate of 50.8%). The percentage of hospitality workers who knew the law was 79.0% before it was passed and was 94.1% 24 months later (p<0.05). We observed an increase in support to the smoke-free ban in all public places, including bars and restaurants (54.1% to 65.8%; p<0.05). The percentages of support for the current ban, perception of compliance with the ban by employees and customers, and knowledge of the effect of second-hand smoke on health also increased.

CONCLUSIONS

Knowledge and support to the Spanish smoking law among hospitality workers increased 2 years after the implementation of the ban.

Exposure to second-hand smoke in primary health care centres in Catalonia, Spain (2006)

The aim of this study was to assess the exposure to second-hand smoke (SHS) in 90 primary health care centres in Catalonia, Spain. We conducted a cross-sectional study between March and October 2006. We measured vapour-phase nicotine as a marker of SHS in main halls, staff rooms, direction areas, and continued care. Sampler devices were exposed for 7 days, and samples were analysed by gas chromatography/mass spectrometry. We compared the median airborne nicotine concentrations with the non-parametric test for medians by sanitary region, sampled location, affiliation to the Smoke-free Primary Health Care Programme, and urban-rural area. From 300 sampler devices installed, 4 were lost, and detectable levels of nicotine were found in 89 samples (30.0%) in 48 different centres (53.3%). The overall median was 0.01 microg/m(3), with an interquartile range (IQR) of 0.01-0.07 microg/m(3). Median nicotine levels by locations were: reception hall 0.01 microg/m(3) (IQR: 0.01-0.06); staff room 0.01 microg/m(3) (IQR: 0.01-0.08); direction area 0.01 microg/m(3) (IQR: 0.01-0.01); continued care 0.01 microg/m(3) (IQR: 0.01-0.07). Results showed that airborne nicotine levels were very low, with 46.7% of primary health centres being free of SHS.

[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.

Impact of the Spanish smoking law on exposure to second-hand smoke and respiratory health in hospitality workers: a cohort study

Background

A smoke-free law came into effect in Spain on 1st January 2006, affecting all enclosed workplaces except hospitality venues, whose proprietors can choose among totally a smoke-free policy, a partial restriction with designated smoking areas, or no restriction on smoking on the premises. We aimed to evaluate the impact of the law among hospitality workers by assessing second-hand smoke (SHS) exposure and the frequency of respiratory symptoms before and one year after the ban.

Methods and Finding

We formed a baseline cohort of 431 hospitality workers in Spain and 45 workers in Portugal and Andorra. Of them, 318 (66.8%) were successfully followed up 12 months after the ban, and 137 nonsmokers were included in this analysis. We obtained self-reported exposure to SHS and the presence of respiratory symptoms, and collected saliva samples for cotinine measurement. Salivary cotinine decreased by 55.6% after the ban among nonsmoker workers in venues where smoking was totally prohibited (from median of 1.6 ng/ml before to 0.5 ng/ml, p<0.01). Cotinine concentration decreased by 27.6% (p = 0.068) among workers in venues with designated smoking areas, and by 10.7% (p = 0.475) among workers in venues where smoking was allowed. In Portugal and Andorra, no differences between cotinine concentration were found before (1.2 ng/ml) and after the ban (1.2 ng/ml). In Spain, reported respiratory symptom declined significantly (by 71.9%; p<0.05) among workers in venues that became smoke-free. After adjustment for potential confounders, salivary cotinine and respiratory symptoms decreased significantly among workers in Spanish hospitality venues where smoking was totally banned.

Conclusions

Among nonsmoker hospitality workers in bars and restaurants where smoking was allowed, exposure to SHS after the ban remained similar to pre-law levels. The partial restrictions on smoking in Spanish hospitality venues do not sufficiently protect hospitality workers against SHS or its consequences for respiratory health.