Prevalence of Second-Hand Smoke Exposure After Introduction of the Italian Smoking Ban: The Florence and Belluno Survey

Aims and Background

A law banning smoking in enclosed public places was implemented in Italy on January 10, 2005. The aim of this paper is to present a cross-sectional survey on two representative samples of non-smokers of two Italian towns (Florence and Belluno), conducted one year after the introduction of the ban, in order to assess prevalence of second-hand smoke exposure, to record the attitudes towards the ban, and the perception about its compliance in a representative sample of non-smokers.

Methods

Computer-assisted telephone interviews were carried out in March 2006, from a random sample of households from telephone registries. Respondents were 402 non-smokers from Belluno and 1,073 from Florence.

Results

About 12% of Florentines and 7% of Belluno respondents were exposed at home; 39% and 19%, respectively, at work; 10% and 5% in hospitality venues; 20% and 10% in cars. The smoke-free law was almost universally supported (about 98%) even if a smaller proportion of people (about 90%) had the perception that the ban was observed.

Conclusions

Second-hand smoke exposure at home and in hospitality premises has dropped to ≤10%, whereas exposure at work remained higher. These results suggest the need for more controls in workplaces other than hospitality venues.

Community-acquired pneumonia in immunocompromised older patients: incidence, causative organisms and outcome

The number of elderly patients in the community with immunosuppressive conditions has increased progressively over recent decades. We sought to determine the incidence, causative organisms and outcome of community-acquired pneumonia (CAP) occurring in immunocompromised older patients. We prospectively compared cases of CAP in immunocompromised and non-immunocompromised patients admitted to five public hospitals in three Spanish regions. Of 320 cases studied, 115 (36%) occurred in immunocompromised patients, including: solid or hematological malignancy (97), corticosteroids or other immunosuppressive drugs (44), solid organ or stem cell transplant (five), and other conditions (eight). The etiology was established in 44% of immunocompromised patients vs. 32% of non-immunocompromised patients (p 0.03). Streptococcus pneumoniae was the most common causative organism in both groups (29% vs. 21%; p 0.08), followed by Legionella pneumophila (3% vs. 6%; p 0.01). Gram-negative bacilli were more frequent among immunocompromised patients (5% vs. 0.5%; p <0.01), particularly Pseudomonas aeruginosa (3% vs. 0%; p 0.04). Nocardiosis was only observed in immunocompromised patients (two cases). Bacteremia occurred similarly in the two groups. No significant differences were found with respect to ICU admission (8%, in both groups) or the length of stay (12.5 vs. 10.4 days). The early (<48 h) (3.5 vs. 0.5%; p 0.04) and overall case-fatality rates (12% vs. 3%; p <0.01) were higher in immunocompromised patients. In conclusion, a substantial number of older patients hospitalized for CAP are immunocompromised. Although relatively uncommon, CAP due to gram-negative bacilli, including P. aeruginosa, is more frequent among these patients. CAP occurring in immunocompromised patients causes significant morbidity and mortality.

Substance use among road traffic casualties admitted to emergency departments

OBJECTIVE

To describe the prevalence of recent psychoactive substance use and associated factors among road traffic casualties admitted to emergency departments.

METHODS

A cross-sectional study was carried out, including adults injured in road traffic crashes admitted to the emergency department (ED) of eight hospitals in Catalonia (Spain), during three cross-sections, each of 4 days duration (2005-2006). Information sources were an interview, an oral fluid specimen and the patient's clinical record. Dependent variables were presence of alcohol, cannabis, cocaine, ecstasy, opiates or benzodiazepines. Independent variables were socioeconomic characteristics and circumstances of the injuries and admission. Prevalence and exact 95% confidence intervals were estimated for men and women. Bivariate analyses and multivariate binomial regression modelling were carried out to study factors associated with substance use in male drivers and pedestrians.

RESULTS

The prevalence of substance use was higher in men (n = 226) than in women (n = 161) for any substance (34.4% and 16.2%), any illegal substance (19.3% and 7.6%), alcohol (18.5% and 9.2%) and cannabis (17.0% and 3.8%), respectively. In male drivers and pedestrians, alcohol use was associated with being in the 25-30-year age group, being injured at night and the weekend, and arriving at the ED by ambulance; cannabis use was only associated with being in the 18-30-year age group.

CONCLUSIONS

A high prevalence of recent psychoactive substance use, especially alcohol, cannabis and cocaine, was observed in all age groups. The results indicate the need to screen for substance use and to give simple advice to casualties at EDs.

Effectiveness of the pneumococcal polysaccharide vaccine in preventing pneumonia in the elderly

The objective of our study was to evaluate the effectiveness of the 23-valent pneumococcal polysaccharide vaccine (PPV) in preventing hospital admission for community-acquired pneumonia (CAP) in people ≥65 yrs of age. We conducted a matched case-control study in patients with CAP admitted to five Spanish hospitals. Cases were persons aged ≥65 yrs admitted to hospital through the emergency department, who presented a clinical and radiological pattern compatible with pneumonia, assessed using established criteria. We matched each case with three control subjects by sex, age (±5 yrs), date of hospitalisation (±30 days) and underlying disease. The study period was May 1, 2005 to January 31, 2007. The PPV immunisation status of cases and controls was investigated. Adjusted ORs for vaccination were calculated using logistic regression analysis. A total of 489 cases and 1,467 controls were included in the final analysis. The overall adjusted vaccination effectiveness for all patients was 23.6% (95% CI 0.9-41.0). The adjusted vaccination effectiveness for immunosuppressed patients was 21.0% (95% CI -18.7-47.5). Our results suggest that the PPV may potentially reduce hospitalisations for pneumonia in the elderly and supports vaccination programmes in this age group.

Italy and Austria before and after study: second-hand smoke exposure in hospitality premises before and after 2 years from the introduction of the Italian smoking ban

The aim of this paper was to compare nicotine concentration in 28 hospitality premises (HPs) in Florence and Belluno, Italy, where a smoking ban was introduced in 2005, and in 19 HPs in Vienna, Austria, where no anti-smoking law entered into force up to now. Airborne nicotine concentrations were measured in the same HPs in winter 2002 or 2004 (pre-ban measurements) and winter 2007 (post-ban measurements). In Florence and Belluno, medians decreased significantly (P < 0.001) from 8.86 [interquartile range (IQR): 2.41-45.07)] before the ban to 0.01 microg/m3 (IQR: 0.01-0.41) afterwards. In Austria (no smoking ban) the medians collected in winters 2004 and 2007 were, respectively, 11.00 (IQR: 2.53-30.38) and 15.76 microg/m3 (IQR: 2.22-31.93), with no significant differences. Measurements collected in winter 2007 in 28 HPs located in Naples, Turin, Milan (0.01 microg/m3; IQR: 0.01-0.16) confirmed post-ban results in Florence and Belluno. The medians of nicotine concentrations in Italy and Austria before the Italian ban translates, using the risk model of Repace and Lowery, into a lifetime excess lung cancer mortality risk for hospitality workers of 11.81 and 14.67 per 10,000, respectively. Lifetime excess lung cancer mortality risks for bar and disco-pub workers were 10-20 times higher than that calculated for restaurant workers, both in Italy and Austria. In winter 2007, it dropped to 0.01 per 10,000 in Italy, whereas in Austria it remained at the same levels. The drop of second-hand smoke exposure indicates a substantial improvement in air quality in Italian HPs even after 2 years from the ban.

PRACTICAL IMPLICATIONS

The nation-wide smoking ban introduced in Italy on January 10, 2005, resulted in a drop in second-hand smoke exposure in hospitality premises, whereas in Austria, where there is no similar nation-wide smoking ban, the exposure to second-hand smoke in hospitality premises remains high. Given that second-hand smoke is considered a group 1 carcinogen according to the International Agency for Research on Cancer classification, the World Health Organization Framework Convention on Tobacco Control strongly recommends the implementation of nation-wide smoke-free policies in order to improve the indoor air quality of hospitality premises and workplaces. Results from our study strongly supports this recommendation.

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.

Vaccination coverage in indigenous and immigrant children under 3 years of age in Catalonia (Spain)

Vaccination coverage in a representative sample of children under 3 years of age in Catalonia (Spain) was studied. Parents of children selected were contacted and asked for the child's vaccination card. A total of 630 children were included, of whom 570 were indigenous and 60 immigrants. Primary vaccination coverage was 96.5% for indigenous and 85% for immigrant children (p=0.0001), while the coverage of primary vaccination plus booster doses was 88.6% in indigenous and 78.3% in immigrant children (p=0.02). Efforts should be made to increase primary vaccination coverage in immigrant children and booster dose coverage in both indigenous and immigrant children.

[Dietary behavior disorders: opinions and expectancies on prevention and treatment strategies from the perspective of the several social actors]

AIMS

The prevalence increase of Eating Disorders in the last decades emphasizes the necessity to develop strategies from the public healthcare system which include the perspective of the principal implicated social actors. The present study aims to know their opinions and expectations regarding the prevention and treatment of Eating Disorders.

METHODS

Realization of 5 focus groups (with relatives, adolescents, professionals from the health and educational sector, representatives from institutions and support groups) and 14 semi-structured interviews (with Eating Disorder patients and relatives) about strengths and weaknesses of actual prevention and treatment programs, expectations of change and suggestions for improvement. Analysis of contents and triangulation of results.

RESULTS

The absence of resources and knowledge about Eating Disorders, the scarcity of transversal programs and insufficient coordination were named as the main weaknesses whereas interdisciplinary pilot programs were positively valued. As principal demands, major endowment of human and material resources, increased coverage of specialized services, promotion of specific training and improvement of coordination was asked for. Regarding prevention, preference toward an unspecific approach to the subject in order to hinder imitation between young people was highlighted. The care in Day Hospitals was considered one of the most appropriate treatment modalities for the characteristics of this disease being valued the potentially therapeutic effect of contact between Eating Disorder patients. The support network, the education field and the family were named as other important pillars in a multidisciplinary approach to the disease. There was also a demand for the development of combined programs.

CONCLUSIONS

The discussion of different psychotherapeutic approaches, the role of support groups in the caring network as well as the post-hospital follow-up were identified as issues open to future research.

Environmental tobacco smoke exposure in public places of European cities

BACKGROUND

Exposure to environmental tobacco smoke (ETS) has important public health implications. The results of the first European multi-centre study that measured ETS exposure in a range of public places (transport, educational settings, and leisure facilities such as bars and restaurants) are presented.

METHOD

Nicotine vapour phase was measured using ETS passive samplers containing a filter treated with sodium bisulfate.

RESULTS

Bars and discos are the places with the highest concentrations of nicotine from ETS, median ranging from 19 to 122 microg/m(3). Restaurants had the next highest values. Concentrations of nicotine generally range from 0.1-5 microg/m(3) in airports, and from 0.5-10 microg/m(3) in train stations. Nicotine was also found in schools and universities, yet schools tended to have the lowest concentrations compared to all the other public places sampled. In hospitals levels were generally below 5 microg/m(3).

CONCLUSIONS

Although there is some variability between cities, this study shows that tobacco smoke is present in most of the studied public places. The study also showed that in areas where smoking is prohibited, concentrations of nicotine are lower than in areas where smoking is allowed but they are not zero. The results of this study indicate that policies should be implemented that would effectively reduce levels of tobacco smoke in public areas.

Factors Associated With Smoking Onset: 3-Year Cohort Study of Schoolchildren

OBJECTIVE

To analyze the predictors of smoking onset among schoolchildren.

METHODS

A cohort study of 1056 children starting in first year secondary school at 44 schools in Barcelona was carried out. Participating children were invited to answer a lifestyle questionnaire every year for 4 years. Each questionnaire carried a personal code to allow the 4 questionnaires to be matched. Matching questionnaires were found for 729 children, 70% of the initial sample.

RESULTS

Over the study period, the prevalence of regular smokers increased from 1.7% to 22% among boys and from 1.6% to 38.2% among girls. The predictors of smoking onset among boys were scoring high on the pro-smoking attitudes index (odds ratio [OR]=1.2; 95% confidence interval [CI], 1.1-1.3), intention to smoke in the future (OR=2.2; 95% CI, 1.0-4.9), low self-efficacy in resisting pressures to smoke (OR=0.98; 95% CI, 0.96-0.99), having siblings that smoke (OR=2.5; 95% CI, 1.2-5.4), and spending some free time in bars (OR=2.4; CI, 1.1-4.9). Among girls, the predictors were having low self-esteem (OR=0.94; 95% CI, 0.88-0.99), scoring low on the anti-tobacco attitudes index (OR=0.92; 95% CI, 0.88-0.97), having siblings who smoke (OR=2.5; 95% CI, 1.2-5.5), spending some free time in discotheques (OR=4.5; 95% CI, 1.9-11.8), and living in high socioeconomic-status neighborhoods (OR=3.1; 95% CI, 1.4-10.9).

CONCLUSIONS

The results show the importance of cognitive variables as well as a variety of environmental variables, particularly the pattern of free time use and the influence of sibling models. Prevention programs must take into account smoking onset risk factors as a whole.

[Changing epidemiology of smoking: Barcelona, 2000-2001]

CONTEXT

In recent years various initiatives of prevention and social changes have been carried out that should have an effect on epidemiology of smoking in our area. Their real effect is little known, however, because of methodological changes in the existing population surveys. In this work the data on smoking in the last city of Barcelona health survey (ESBA 2000-01) are analyzed, with reference to the cumulative information obtained along 18 years from the first survey in 1983.

METHOD

ESBA 2000-01 is an interview health survey carried out on a weighted sample with 10,030 people. Data relative to tobacco use are showed for people 15-year-old or older included in the survey, stratified by age, sex, and class. Consumption context variables are also showed, and the tobacco consumption quitting among people who have smoked is analyzed.

RESULTS

The proportion of daily smokers in the population over 14 years of age is 29 %, while that of former smokers is 21 % and 2.2 % in this population are occasional smokers. The prevalence is maximum in the 35-44 year-old group, and the prevalence is reduced drastically after this age. Stratified analysis by age, sex, and occupational category shows interesting differences among daily smokers. A strong gradient is observed according to occupational category in males. The situation is more complex in women. The typical smoker began when 17-year-old, and now consumes 16 cigarettes a day. Consumption is somewhat higher in males and is maximum in the 35-44 year-old group. Two-third of the smokers (65.7 %) want to quit smoking and more than one third (36 %) has attempted it along the last year. Almost half of smokers (48.1 %) have received advice to quit smoking from their physician. One of every four (24.9 %) smokers has been warned for smoking in some places. Almost half smokers are the only smoker in their home, and barely a third are the only smokers at work. The proportion of quitting increases with age in both sexes, and nowadays the differences in the probability of quitting smoking are few when the data are stratified by age groups.

CONCLUSIONS

These results show the changing pattern of tobacco epidemiology in Barcelona: smoking is no longer the main behavior in no age and sex group, and the only social group in which more than half of its members smoke are 25-44 year-old not qualified worker males. This situation has occurred because of two processes: an important proportion of early quitting (demonstrated even in young adults) and a decrease in the beginning of the habit. Real differences are not observed between males and females with regard to the probability of quitting smoking. These data correct recent estimates that could be influenced by methodological changes in the instruments used.

[Exposure to smoking during pregnancy: Barcelona (Spain) 1994-2001]

BACKGROUND

Exposure to smoking during pregnancy is an important risk factor for child health. In the last few decades, the prevalence of smoking among fertile women has increased in Spain.

OBJECTIVES

To assess fetal exposure to smoking in a representative sample of pregnant women and its trends.

METHODS

The prevalence of smoking and smoking cessation were analyzed in a representative sample of women who gave birth in the city of Barcelona, extracted from a population-based registry of birth defects. The sample consisted of 1,801 women and covered the period 1994 to 2001.

RESULTS

Among pregnant women, 43.4 % smoked before pregnancy, and 42.2 % of these quit. At the time of giving birth, 25.2 % of the women were smokers. Over the period studied the prevalence of smoking among pregnant women clearly decreased. Although the proportion of cessations showed no significant changes, fetal exposure to tobacco decreased.

CONCLUSIONS

The prevalence of smoking among pregnant women was high, although many quit during pregnancy. Over the period studied, fetal exposure to smoking decreased. There is a need for more systematic interventions.

Cambios en el consumo de tabaco en la población general en Barcelona, 1983–2000

OBJECTIVES

To analyze the prevalence trends for smoking and its determinants in the general population of Barcelona from 1983 to 2000.

DESIGN

Time series study.

SETTING

Health survey based on home interviews of a representative sample of the general population of Barcelona.

PARTICIPANTS

In the years 1983, 1992, and 2000 we interviewed 3134, 5004, and 10,000 persons, respectively.

MAIN OUTCOME MEASURES AND RESULTS

Between 1983 and 2000 daily tobacco use showed a steady tendency to decrease among men, with a prevalence that decreased from 54.6% to 38.3%, while in women, smoking increased between 1983 and 1992 (from 20.9% to 25.4%) but remained stable in 2000 (24.5%). The proportion of smokers who said they wanted to quit increased in both sexes from 1992 (54.2%) to 2000 (65.7%). During this period the proportion of smokers who said their doctor had advised them to quit increased from 36.1% to 48.1%. The trends for both sexes showed that consumption of tobacco products was greater among less privileged socioeconomic groups.

CONCLUSIONS

The results of this study confirm the decrease in the prevalence of daily consumption of tobacco products and the increase in smokers who would like to quit, in parallel with the increase in advice from physicians to quit. However, the trends among younger groups remained stable, a finding that makes it necessary to intensify efforts aimed at this population group.

[Trends in tobacco, alcohol and cannabis consumption among secondary school pupils in Barcelona, Spain (1987-1999)]

OBJECTIVE

To describe trends in tobacco, alcohol, and cannabis consumption among secondary school pupils in Barcelona between 1987 and 1999.

METHODS

Cross-sectional surveys administered to representative samples of pupils in the second year of secondary school between 1987 and 1999. The questionnaires were anonymous and self-completed. We present data from 5013 secondary school pupils from Barcelona who participated in one of the five surveys.

RESULTS

Regular smoking (daily and weekly) showed a uniform decrease between 1987 and 1996. The results of the last survey (1999) showed an increase over those the 1996 survey, ranging from 13.4% for regular smoking to 38.7% for experimental smoking. Between 1987 and 1999, the percentage of schoolchildren who reported drinking at least half a glass of alcohol at some time showed an overall decrease of 14.0%. No differences in sex were found in problematic alcohol consumption, while a higher proportion of girls (14.0%) than boys (10.5%) reported getting drunk at some time. Whereas in 1996, 6.9% of the population studied had smoked cannabis at some time, in 1999 this proportion was 7.3%, with no differences between sexes.

CONCLUSIONS

During the study period regular smoking increased, alcohol consumption decreased and cannabis consumption tended to level-off. Differences between boys and girls tended to disappear.

[Impact of smoking and alcohol consumption on mortality in the population of Barcelona [Spain]: 1983-1998]

OBJECTIVES

To analyze the mortality attributable to smoking and alcohol consumption in the city of Barcelona from 1983 to 1998.

METHODS

All deaths among residents of the city of Barcelona from 1983 to 1998 were included. Population data were obtained from the city inhabitants register. The mortality attributable to smoking and alcohol consumption was calculated by population attributable fractions using relative risks from previous studies in the US population.

RESULTS

In 1998, 2,205 deaths were attributable to smoking, representing 13.8% of all deaths among the population aged 35 years or older and a decrease of 9.6% compared with deaths in 1983. From 1983 to 1998 there was an increase in smoking-attributable adjusted mortality rates for lung cancer (155.84/100,000 inhabitants in men and 9.39/100,000 in women in 1998) and chronic obstructive pulmonary disease (COPD) (95.89/100,000 in men and 11.29/ 100,000 in women in 1998). In 1998, deaths attributed to alcohol consumption accounted for 4.3% of total mortality, representing a reduction of 26% since 1983. Among men, the primary cause of alcohol-attributable mortality was liver cirrhosis (17.1%), although its relative importance decreased (accounting for 17.1% of alcohol-attributable mortality in 1998 compared with 24.3% in 1983).

CONCLUSIONS

The mortality attributable to smoking and alcohol consumption decreased in the city of Barcelona during the study period. Smoking-attributable mortality from lung cancer and COPD increased in both sexes. Alcohol consumption-attributable mortality from liver cirrhosis decreased in men.

[Nicotine measurement as an airborne marker of environmental tobacco smoke]

INTRODUCTION

Several studies have demonstrated the relationship between environmental tobacco smoke (ETS) and different types of health risk. Despite this evidence, measurement of ETS was highly inaccurate until a few years ago. The objective of this study was to review different studies using nicotine as an ETS airborne marker.

METHODS

We reviewed the various methods used in ETS measurement, especially the use of nicotine as an airborne marker. Nicotine was compared with other markers, and data from different studies measuring airborne nicotine concentration in public places and workplaces were collected.

RESULTS

Nicotine has all the desirable characteristics of an ETS marker. Several studies using nicotine as an airborne marker of ETS reported a wide range of values. In cafeterias and restaurants the concentration varied from 2.3 to 6.8 microg/m3. In workplaces without smoking regulations the concentration ranged from 3.4 to 14 microg/m3, whereas in places with smoking bans the concentration ranged from 0.09 to 0.7 microg/m3. Pubs and nightclubs had the highest concentrations, with values higher than 65 microg/m3.

DISCUSSION

The use of nicotine as an airborne marker provides an objective measurement of ETS exposure. The values obtained in studies using this marker show that in places with smoking restrictions or bans, ETS exposure is much lower than in places without smoking restrictions.

[Impact of medical counselling on giving up smoking during pregnancy]

OBJECTIVE

Women s tobacco consumption has increased in Spain in recent years, especially among women of reproductive age. This study aims to evaluate the impact of medical counselling integrated into pre-natal care on tobacco consumption during pregnancy and the period after delivery.

DESIGN

Quasi-experimental intervention study.Setting. Hospital del Mar, Barcelona.

PATIENTS

219 patients who attended the Hospital del Mar for delivery during 1996 (control group) and 169 patients seen during their pregnancies at the same hospital in 1997 (intervention group).

INTERVENTIONS

The control group patients had received normal care. The pregnant women in the intervention group received systematic structured counselling on giving up smoking, backed up by a special brochure composed for this purpose.

MEASUREMENTS AND RESULTS

The intervention and control groups showed no statistically significant differences either in their social or demographic variables or in their tobacco consumption. In both groups the evolution of their smoking during pregnancy was determined during their pre-natal visits and six months after delivery through a telephone interview. 44 of the women in the control group (20.1%) gave up smoking before their first pre-natal visit, and 11 (5%) gave up during pregnancy. In the intervention group 26 (17.7%) had given up spontaneously and 16 (10.9%) gave up during pregnancy. Of those who gave up completely during pregnancy, 36.4% of women in the control group and 64.3% in the intervention group remained abstinent at six months (P=.002).

CONCLUSIONS

Counselling at pre-natal check-ups to give up smoking lightly increases the number of women who give up and reduces significantly the number of post-delivery backsliders.

[Factors associated with smoking and the intention to smoke in secondary school pupils: results of the ESFA project in Barcelona, Spain]

OBJECTIVE

To describe the factors asssociated with smoking and intention to smoke among a representative sample of first-grade pupils of secondary education (12-13 years old) in Barcelona.

SUBJECTS AND METHODS

37 secondary schools were randomly selected to evaluate the impact of a European-wide smoking prevention program (European Smoking prevention Frame Approach, ESFA project). In these schools, 1041 pupils of first grade of secondary education responded to a questionnaire designed at the University of Maastricht to study life-style attitudes and behaviours, mainly smoking.

RESULTS

9.8% of boys and 12.6% of girls declared to smoke either regulary or ocasionally. Among the no-smokers, 61.4% of the boys and 73.3% of the girls reported to have the intention to smoke in the future. Among the boys, factors associated with smoking included social norms (odds ratio [OR] = 2.5; 95% confidence interval [CI]: 1.2-5.2), smoking by siblings (OR = 2.4; 95% CI, 1.1-5.2), attitudes against smoking (OR = 0.3; 95% CI, 0.1-0.6), practicing some sports in the leisure time (OR = 0.3; 95% CI, 0.1-0.7) and having more available pocket money (OR = 3.2; 95% CI, 1.5-6.8). Intention to smoke was only related to attitudes (OR = 0.3; 95% CI, 0.2-0.5). Among girls, smoking was associated to perceived pressure to smoke (OR = 2.5; 95% CI, 1.2-5.0), consumption by friends (OR = 6.0; 95% CI, 2.4-15.4) and attitudes against smoking (OR = 0.2; 95% CI, 0.1-0.4), while intention was only associated to attitudes (OR = 0.4; 95% CI, 0.2-0.6) and hanging out in the street in the leisure time (OR = 2.2; 95% CI, 0.3-3.5).

CONCLUSIONS

The results stress the need to deal simultaneoulsy with the different factors associated to smoking initiation and attitude shaping, including cognitive factors, environmental factors, and patterns of leisure time utilization.

[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.

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.

[Factors associated with reported vaccination coverage in early infancy: results of a telephone survey]

BACKGROUND

Barcelona's Continuing Immunization Plan affords the possibility Of monitoring the immunization coverage of the population by means of the voluntary family postal notification system. Prior studies have revealed that some families fail to provide notification while being correctly vaccinated, which can lead to actual coverage being underestimated. The objectives of this study are to estimate the early childhood immunization coverage of the population and to ascertain the factors associated with failure to provide notification of immunization.

METHODS

A phone survey was conducted on a sample of 500 children regarding whom there was no record of any notification of the first three childhood vaccine doses (diphtheria, tetanus, whooping cough and oral polio), in addition to a sample of 500 children who were on record as having been immunized. To estimate the actual immunization coverage, all children were considered to have been properly immunized when their family members did provide notification. As regards those who failed to reply, it was considered in the worst of cases that these were cases of children who had not be immunized. In the best of cases scenario, a coverage similar to those of the responses was assumed.

RESULTS

The response to the questionnaire was higher among those who had previously provided notification of immunization by way of the postal notification system (79.1%) than among those who had failed to provide notification of immunization (67%). The leading factors associated with failure to report immunization status were the size of the families, the use of private health care services and the place of birth of the parents. Solely six (6) cases of those who had failed to report immunization admitted to not having immunized their children, totaling 1.9% of the responses. The immunization coverage of the population in question would total 99.7% in the best of cases and 93.7% in the worst of cases scenario.

CONCLUSIONS

Immunization coverage of the population in question is quite high. The results underline the importance of promoting immunization notification among health care professionals, especially in the private sector.

[Tobacco in Barcelona's metropolitan transportation: observation study]

OBJECTIVE

To describe the extent of no-smoking notices, consumption and sales of tobacco in Barcelona's underground transport installations.

DESIGN

Descriptive, observation study.

SETTING

Community.

METHODS

A sample of 54 stations was selected at random. The presence of users smoking, staff smoking, notices about tobacco consumption and tobacco sales were evaluated.

INTERACTIONS

Platforms, entrance hall and corridors and/or stairs were observed for at least 5 minutes at each station.

MEASUREMENTS AND MAIN RESULTS

Users smoking were recorded in 87% of the observations, and cigarette stubs in 97.5% of observations, whereas company staff were only seen smoking in 5.6%. In 72.2% of the entrances there were tobacco sales-points. The users observed smoking were divided equally between the sexes, although the men were mainly middle-aged adults (64.3%) and the women were mainly young (60.6%). In 64.2% of the observations, some sort of notice was seen.

CONCLUSIONS

Both notices and compliance by staff are high, although users habitually consume tobacco. Tobacco sales-points at stations are very common. The findings justify the adoption of specific measures designed to improve compliance with the regulations.

[Determinant factors of smoking cessation during pregnancy]

BACKGROUND

To investigate sociodemographic factors and smoking habit characteristics associated with spontaneous smoking cessation during pregnancy.

DESIGN

SUBJECTS AND METHODS

Cross-sectional study including 726 pregnant smoking women who attended the antenatal clinic of the Vall d'Hebron University Hospital in Barcelona between July and December 1997 and who agreed to participate were studied. Information was obtained by a structured questionnaire which included items on age, educational level, marital status, previous and current smoking habit, partner smoking habit and partner's attitude towards the smoking habit of the pregnant woman.

RESULTS

At the first antenatal visit, 19.7% of women had given up smoking spontaneously. Light smokers (between 1 and 9 daily cigarettes; OR = 4.74) or moderate smokers (between 10 and 19 daily cigarettes; OR = 2.20) were more likely to stop smoking compared to heavy smokers (more than 20 daily cigarettes). If the partner did not smoke, smoking cessation was more likely among pregnant women (OR = 1.78). At the first antenatal visit, among those women who carried on smoking during pregnancy, there was a significative reduction in cigarette consumption of about half the usual daily number of cigarettes smoked.

CONCLUSIONS

One out of five pregnant women give up smoking spontaneously during pregnancy from the moment they know they were pregnant until the first antenatal visit. Women who are less likely to stop smoking during pregnancy are those who smoke a larger number of cigarettes. Family environment is an important influential factor in the smoking habit of the pregnant woman.

Social inequalities in health related behaviours in Barcelona

OBJECTIVE

This study describes social class inequalities in health related behaviours (tobacco and alcohol consumption, physical activity) among a sample of general population over 14 years old in Barcelona.

DESIGN

Cross sectional study (Barcelona Health Interview Survey).

SETTING

Barcelona city (Spain).

PARTICIPANTS

A representative stratified sample of the non-institutionalised population resident in Barcelona was obtained. This study refers to the 4171 respondents aged over 14.

DATA

Social class was obtained from a Spanish adaptation of the British Registrar General classification. In addition, sociodemographic variables such as family structure and employment status were used. As health related behaviours tobacco consumption, alcohol consumption, usual physical activity and leisure time physical activity were analysed. Age adjusted percentages were compared by social class. Multivariate analysis was performed using logistic regression models.

MAIN RESULTS

Women in the upper social classes were more likely to smoke, the adjusted odds ratio (OR) for social class V in reference to social class I was 0.36 (95% confidence intervals (95%CI): 0.19, 0.67), while the opposite occurred among men although it was not statistically significant in multivariate analysis. Smoking cessation was more likely among men in the higher classes (OR for class V 0.41, 95%CI: 0.18, 0.90). Excessive alcohol consumption among men showed no differences between classes, while among women it was greater in the upper classes. Engaging in usual physical activity classified as "light or none" in men decreased with lowering social class (OR class IVa: 0.55 and OR class IVb: 0.47). Women of social classes IV and V were less likely to have two or more health risk behaviours (OR for class V 0.33, 95% CI: 0.18, 0.62).

CONCLUSION

Health damaging behaviours are differentially distributed among social classes in Barcelona. Health policies should take into account these inequalities.

[Validity of the declared tobacco consumption in pregnancy]

OBJECTIVES

To analyse the relationship between the stated consumption of tobacco by pregnant women who say they smoked before pregnancy and the levels of cotinine in their urine at the start and end of pregnancy.

DESIGN

Observational, longitudinal study.

PARTICIPANTS

During 1997.

STUDY GROUP

147 pregnant women at their first pre-natal visit to outclinics of the Hospital del Mar.

CONTROL GROUP

50 non-smoker pregnant women monitored during their pregnancy.

MEASUREMENTS AND MAIN RESULTS

The numbers of cigarettes per day that they said they smoked on their first monitoring visit to our centre and at the last attendance before giving birth were recorded. Cotinine levels in the urine samples taken on these visits were measured. Mean cotinine in pregnant women who said they had given up smoking was higher than in non-smokers. There was a statistically significant linear relationship between the number of cigarettes stated and cotinine levels at the first and last pregnancy monitoring visits, as well as between the variation in the number of cigarettes and cotinine levels at these two visits. The negative predictive value of what they said about their tobacco habit was 82.9%.

CONCLUSIONS

There was a certain under-declaration by pregnant smokers, although their statements of consumption and cotinine levels correlated closely. The under-declaration did not increase despite reiterated advice to stop smoking, which means that, despite its limitations, it could be a useful indicator for evaluating the effect of interventions aimed at stopping women smoking during pregnancy.

Changes in the alcohol consumption pattern among schoolchildren in Barcelona

Alcohol consumption is a major health problem in most developed countries. In Mediterranean countries, experimentation with alcoholic beverages typically occurs during the early adolescent years within the family context. In this study we analysed alcohol consumption and its determinants in a survey of a sample of schoolchildren in 1994. The results were compared to those obtained in a previous study in 1987. In 1994 a random, stratified sample of all 8th grade classrooms of a city, public, private or subsidised school was, obtained. Some 759 13 and 14 year old pupils responded to a self-administered questionnaire on health-related habits. Overall, there was a high awareness of alcohol in the environment, as 20.7% of the pupils reported their father was a regular or occasional drinker and 41.6% declared some of their friends were drinking. Compared with the results of the 1987 survey, there was a marked decline in the proportion of schoolchildren reporting alcohol consumption by their father or their siblings. Regarding the pupils' consumption, 66.7% of them had tried drinking alcohol in 1994, 54.7% declared they were allowed to drink in family celebrations, and 17.2% had experienced being drunk. Most of these indicators showed a significant decrease compared with the 1987 data, with the exception of drunken episodes where there appears to be no changes. The results suggest that there are some changes in the Spanish context, where regular drinking among adolescents may be declining.

[The knowledge and application of regulations on smoking in secondary teaching centers]

OBJECTIVES

Despite the growing body of legal and normative regulations regarding promotion, sales and consumption of cigarettes, a few studies have already pointed to a low enforcement and commitment of these restrictions. This study explores the degree of awareness and compliance of these norms in the secondary school.

DESIGN

Cross-sectional, observational study. A telephone survey was carried out.

PARTICIPANTS

A simple of school principals or deputy principal was surveyed.

MEASUREMENTS

A questionnaire was designed to obtain respondents knowledge of the current policies regarding smoking, as well as on the existence of visible signals in the school wards. Besides, opinion on tolerance towards smoking behavior among the school teachers was ascertained.

RESULTS

Virtually at the respondents (98.8%) declared to know the existence of the regulations, although only 74.4% declared to have specific regulations at the school level. Smoking by teachers was allowed in their own offices in 61.6% of the centers. In open grounds, only 4.7% of the centers authorized adults to smoke while 18.6% permitted to smoke to the students. Public centers were less restrictive than private centers.

DISCUSSION

Principals of secondary schools are aware of the existing, policy, and in most cases largely restrict public consumption. However, there are still some important gaps regarding signals, consumption in outdoor public spaces and teachers consumption in their own offices. Specific interventions seem to be necessary to overcome this situation.

[Evaluation of a community intervention program ("Quit and Win") for smoking cessation]

OBJECTIVES

In recent years community intervention plans for motivating smokers to stop smoking have been developed. One of these programs is the <<Quit and Win>> initiative of the World Health Organization. Our study evaluated the impact of this intervention in a sample of persons who participated in the 1996 edition of the program in Barcelona, Spain.

METHODS

One year after the contest, a telephone follow-up survey was carried out in one-third of the participants. Subjects were questioned about their current smoking status and their participation in the contest, including motivation and whether they had remained abstinent throughout the contest.

RESULTS

A total of 941 valid cards were received from Barcelona residents, equivalent of 0.23% of all smokers. A selection was made of 307 persons for follow-up, 18 of which were excluded because they were former smokers. From the remaining 289 participants, we obtained valid responses from 196, 82 (41.8%) of which were abstinent when the survey was made. Participating in the contest with the intention to stop smoking permanently and continued abstinence throughout the contest period (one month) were significantly associated with abstention one year later. The overall agreement between participants' statements and the statements of a subsample (n=18) was 81.3%.

CONCLUSIONS

One year after the intervention the proportion of abstinent smokers was higher than in earlier studies. However, self-selection by the participation who responded to the follow-up questionnaire could have contributed to the final result. Overall, such initiatives could be useful in motivating predisposed persons to stop smoking.

[Preventive behaviors for the sexual transmission of AIDS, other infections, and pregnancy in high-school students]

OBJECTIVES

To describe preventive behaviors and behavioral intentions related to AIDS sexual transmission, other sexually transmitted diseases and unwanted pregnancies among 10th grade Barcelona students.

DESIGN

Cross-sectional study. Stratified random sample from Barcelona secondary schools in 1996.

SETTING

Secondary schools.

PARTICIPANTS

981 students at 35 10th grade classrooms.

MAIN RESULTS

82% of the students are 15-16 years old. 58% are girls. 16% have had sexual intercourse (boys 18% and girls 14%); among those, 43% of males and 30% of females have had only once sexual intercourse. 78% use always or almost always a condom. 22% of boys and 44% of girls have refused at least an opportunity of unprotected intercourse. Boys feel more confident to buy, carry on and use a condom, however girls feel more confident in convincing their partner and refusing unprotected sex. Among those with sexual experience, partner opinion predicts condom use (boys OR = 30.8 and girls OR = 8.8), as well as partner use (boys OR = 14.2 and girls OR = 15.4). Intention to use condoms with a regular partner is related to the perception of youth normative behaviors (boys OR = 10.9 and girls OR = 4.4) and friends opinion (boys OR = 6.2 and girls OR = 5.4). Condom use with a non regular partner is related also to the perception that its use avoids infections and unwanted pregnancies (boys OR = 9.9 and girls OR = 8.0). Intention to refuse unprotected sex relates, in both genders, to youth normative behaviors and self-efficacy to refuse unprotected intercourse.

CONCLUSIONS

16% of the 10th grade students have had a sexual intercourse. Only half part of them use always condom, although it is the contraceptive method more frequently used. Condom use relates mainly to partners opinions and their current use. Intentions to use condoms are associated also to friends opinion and youth social norm perception. Intention to use a condom with non regular partners aims avoiding diseases and unwanted pregnancies.

[Trends in smoking among school children: Barcelona, 1987-1996]

OBJECTIVE

Despite the growth of aids and of other causes of premature death, smoking is the main single cause of avoidable mortality in Spain. Given the addictive nature of tobacco and the difficulties experienced by many smokers to quit, the primary prevention of smoking is crucial. In recent years several initiatives have been developed to this end. The objective of this paper is to monitor smoking among schoolchildren by repeated surveys over a decade, to ascertain the impact of current interventions and to reorient them according to evidence.

DESIGN

Cross sectional surveys over a decade, from 1987 to 1996, while several smoking prevention efforts were developed. Survey instruments were similar self administered and anonymous questionnaires. SITE: Schools in Barcelona (Catalonia, Spain).

PARTICIPANTS

Around 1000 participants in each survey were selected through representative samples of 8th grade students (predominantly 13-14 years old), stratified by school type and size in each round.

MAIN RESULTS

Ever smoking declined, specially for boys (global decline 12.4%, p = 0.05). There is a clear and steady decline, statistically significant, in the proportion smoking in the month prior to the survey (global decline 50.5%, p < 0.0001). The proportion of regular smokers declines from 1987 to 1994, and then is stabilized (global decline 23%, p < 0.05). The proportion of daily smokers fluctuates, but globally it is the lowest of the decade in 1996. No changes are visible in the proportion who declare buying tobacco for personal use.

DISCUSSION

From 1987 to 1996 several smoking indicators show a decline among 8th grade schoolchildren in Barcelona, Spain. The pattern suggests a decline in global smoking experimentation and in the intensity of experimentation, with a small reduction in the prevalence of regular use, while the small proportion of daily smokers at this young age does not change.

Age at starting smoking and number of cigarettes smoked in Catalonia, Spain

BACKGROUND

Few studies have investigated the association between age at starting smoking and the average number of cigarettes smoked per day in adulthood. To provide further evidence on this issue, we analyzed data from the Catalan Health Interview Survey (CHIS).

METHODS

The CHIS was conducted in 1994 on a randomly selected sample (N = 15,000) of the population of Catalonia, Spain. A total of 4,897 current or exsmokers (3,276 males and 1,621 females) were included for analysis. Age-standardized proportions of subjects smoking <15, 15-24, and >/=25 cigarettes/day, age-standardized mean number of cigarettes smoked per day, and multivariate odds ratios (OR) of being a heavy smoker (>/=25 cigarettes/day) according to age at starting smoking (<15, 15-17, 18-19, >/=20 years) were computed.

RESULTS

Men who started smoking before the age of 15 smoked on average 5.5 cigarettes more than those who started at age 19 or over. Women who started smoking early in life smoked, on average, 6.8 cigarettes/day more than women who started later. The proportion of smokers of <15 cigarettes/day was higher among subjects who started smoking later. Both for males and for females, the OR of being a heavy smoker significantly increased with decreasing age at starting smoking (OR = 2.4 for males and 4.5 for females who started at age <15 versus >/=20 years). The level of education did not modify the relationship in males, whereas the association with age at starting was only apparent for more educated women.

CONCLUSIONS

This study confirms that age at starting smoking is inversely and strongly associated to the number of cigarettes smoked per day. Thus, actions aimed at the prevention or delay of smoking onset among adolescents would have an important beneficial effect.

Physical activity assessment in population surveys: can it really be simplified?

BACKGROUND

Several studies have used a simplified approach for the assessment of physical activity such as the frequency of exercise-induced sweating. In this study leisure-time physical activity has been assessed using this and another more detailed measure.

SUBJECTS AND METHODS

A sample of 4171 adults answered the Health Interview Survey of Barcelona in 1992. The respondents were classified into categories depending on participation in moderate and/or intense physical activity (> or =20 min) and also according to the frequency of exercise-induced sweating: 0, 1-2 and > or =3 times/week. Agreement between the two measures was calculated using the weighted Kappa (Kw) statistic with 95% confidence intervals (95% CI). Stratified analyses were performed.

RESULTS

Prevalence of physical activity > or =3 times/week was lower with the sweat question (12.5%) than with the questions about the frequency of performance of selected activities (19.6%). The physical activity patterns by age, gender and overweight were similar for the two measures, but differed by month of the year. Agreement was lower among the older age categories and was higher among males (Kw = 0.59, 95% CI: 0.57-0.62) than among females (Kw = 0.48, 95% CI: 0.46-0.50). Overall, the agreement was higher in the hotter months (Kw = 0.72 among males and 0.58 among females).

CONCLUSIONS

In the assessment of physical activity in the population by means of the sweat question there can be interference from other variables, apart from the intensity of the activity, which influence sweating during the exercise. Further assessments of the validity of exercise-induced sweating in representative samples of the general population would be useful.

Tuberculosis infection and disease among schoolchildren: the influence of the HIV epidemic and of other factors

BACKGROUND

The HIV/AIDS epidemic has caused an excess of tuberculosis cases in Spain and in other countries, but its impact on tuberculosis infection is less well understood. This study presents a massive screening undertaken to estimate the prevalence of tuberculous infection in a cohort of primary school entrants. The evolution of the risk of infection is studied by comparison with previous data in the same population.

METHODS

Tuberculin skin test screening with 2TU of PPD RT 23 of first grade students in the primary schools of Barcelona, in the 1994-95 school year (cohort born in 1988). Information was also sought from families of unscreened children. Contacts of PPD+ children were traced to locate index cases. The results were also linked to the case registry of the tuberculosis control programme.

RESULTS

The prevalence of tuberculin reactors free of BCG vaccination among the 11,080 schoolchildren screened belonging to the 1988 cohort was 0.76%. A 3% annual decline in the annual risk of infection is estimated by comparison with previous data. The identification of 24 cases with a previous history of tuberculosis disease and of 13 cases with active disease diagnosed after the screening was possible by the follow up of these tuberculin positive children and of the information provided by families of unscreened pupils. The screening detected 1.5 new cases of tuberculosis per 1000 tuberculin tests performed. Tuberculosis infection could be traced to HIV infected tuberculosis cases for at least 6% of the positive schoolchildren.

CONCLUSIONS

The decline of the annual risk of infection continues in Barcelona, although at a slower pace than before the HIV/AIDS epidemic, probably attributable to the influence of injecting drug users with smear positive tuberculosis and HIV/AIDS.