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Noncommunicable diseases (NCDs), including cancer, are responsible for almost 70% of all deaths worldwide. Tobacco use is a risk factor common to most NCDs. This article discusses tobacco control policies and highlights major achievements and open challenges to reduce smoking prevalence and attributable morbidity and mortality in the 21st century. The introduction of the WHO Framework Convention on Tobacco Control in 2005 has been a key achievement in the field and has already facilitated a drop in both smoking prevalence and exposure to secondhand smoke. Indicatively, the size of the worldwide population benefiting from at least one cost‐effective tobacco control policy has quadrupled since 2007. In addition, plain cigarette packaging has been successfully introduced as a tobacco control policy, surmounting efforts of the tobacco industry to challenge this based on trade and investment law. Nevertheless, tobacco control still faces major challenges. Smoking prevalence needs to be further reduced in a rather expedited manner. Smoke‐free environments should be extended, and the use of plain tobacco packaging with large pictorial health warnings for all tobacco products should be further promoted in some parts of the world. Some of these measures will require prompt determination and diligence. For example, bold political decisions are needed to significantly increase real prices of tobacco products through excise taxes, ban added ingredients that are currently used to increase the attractiveness of tobacco products and ban the tobacco industry's corporate social responsibility initiatives. Finally, the debate on harm reduction strategies for tobacco control still needs to be resolved.

Objectives: The Spanish Government has strengthened tobacco control policies since 2005, including changes in tobacco taxes. Because these changes have targeted cigarettes mainly, the tobacco industry has marketed cheaper alternative tobacco products, offering smokers the possibility to down-trade. This paper traces the evolution of patterns of demand for cigarettes and other tobacco products in Spain over the period 2005-2011 in order to assess the impact of such tax loopholes. Methods: We use data on tobacco products prices and sales as well as changes in the structure and levels of tobacco taxes to relate tax changes to price changes and subsequent market share changes. Results: Tax reforms have lifted the bottom end of the cigarette price distribution, but the industry has been successful in marketing fine cut tobacco at cheap prices. There have been partial attempts to correct this asymmetric tax treatment, but these have not avoided a remarkable increase in the market share of fine cut tobacco. The absence of a minimum tax on quantity for the rest of tobacco products allows the industry to place them as potential future down-trading vehicles. Conclusions: In order to address public health objectives, tax policies should aim to equalise the cost of smoking across different tobacco products. Otherwise the tobacco industry can exploit tax loopholes to market cheap alternatives to cigarettes. This requires all tobacco products to bear a minimum tax on quantity, whose levels need to be adjusted in order to reflect the equivalence between different forms of smoking. ; Support by Ministerio de Educación, project ECO2008-06395-C05-04, co-funded by European Regional Development Fund, and Fundación Séneca through project 08646/PHCS/08 is gratefully acknowledged (A. López-Nicolás and MB. Cobacho). Support by Instituto de Salud Carlos III, Government of Spain (RTICC RD06/0020/0089) and Ministry of Universities and Research, Government of Catalonia (Grant 2009SGR192) is gratefully acknowledged (E. Fernández).

ObjectiveThe aim of this study is to assess the level of protection of secondhand smoke in outdoor locations among countries belonging to the WHO European Region.MethodThis cross-sectional study measures the level of protection provided by laws in outdoor locations. A protocol to evaluate the outdoor smoke-free legislation was developed according to the recommendations provided by the WHO Guidelines for implementing smoke-free outdoor places. For each law 6 main sectors and 28 outdoor locations were evaluated.Results68 laws from 48 countries were reviewed, totally assessing 1758 locations. Overall 3.1% of the locations specified 100% smoke-free outdoor regulation without exceptions, 2.5% permitted smoking in designated outdoor areas, 37.5% allowed smoking everywhere, and 56.9% did not provide information about how to deal with smoking in outdoor places. In the Education sector 17.8% of the laws specified smoke-free outdoor regulation, mainly in the primary and secondary schools. Three pioneering laws from recreational locations and two from general health facilities specified 100% outdoor smoke-free regulation.ConclusionOutdoor smoke-free policies among countries belonging to the WHO European Region are limited and mainly have been passed in the primary and secondary schools, which protect minors from the hazards of secondhand smoke in educational settings.

OBJECTIVES: This study aimed to determine students' satisfaction with a 2-day course on scientific writing in health sciences and to assess their perceptions of the long-term impact on their knowledge, attitudes and skills. SETTING: 27 iterations of a 2-day course on writing and publishing scientific articles in health sciences. PARTICIPANTS: 741 students attending the 27 courses. DESIGN: Prospective longitudinal study. PRIMARY AND SECONDARY OUTCOME MEASURES: Immediately after each course, students completed a first questionnaire, rating their satisfaction with different aspects of the classroom sessions on a Likert scale (0-5). Approximately 2 years after the course, students completed a follow-up questionnaire, using a Likert scale (0-4) to rate their knowledge, skills and attitudes in relation to scientific writing before and after attending the course. RESULTS: 741 students (70% women) participated in the 27 iterations of the course; 568 (76.8%) completed the first questionnaire and 182 (24.6%) completed the follow-up questionnaire. The first questionnaire reflected high overall satisfaction (mean score, 4.6). In the second questionnaire, students reported that the course had improved their knowledge (mean improvement: 1.6; 95% CI 1.6 to 1.7), attitudes (mean improvement: 1.3; 95% CI 1.2 to 1.4) and skills (mean improvement: 1.4; 95% CI 1.3 to 1.4) related to writing and publishing scientific papers. Most respondents (n=145, 79.7%) had participated in drafting a scientific paper after the course; in this subgroup, all the specific writing skills assessed in the second questionnaire significantly improved. CONCLUSIONS: Students were satisfied with the format and the contents of the course, and those who responded to the follow-up survey considered that the course had improved their knowledge, attitudes and skills in relation to scientific writing and publishing. Courses are particularly important in countries without strong traditions in scientific publication. ; Esteve Fernández was partly funded by the Department of Universities and Research, Government of Catalonia (2014SGR999)

A straightforward, high-throughput method was developed and fully validated for the simultaneous determination of the specific tobacco biomarkers nicotine and its main metabolite cotinine in a wide dynamic range and supporting the most common human biological matrices (urine, oral fluid and hair). Sample preparation was performed inside the very HPLC injection vials by pipetting 0.5 mL of the liquid samples, deuterated internal standards in alkaline solution and dichloromethane as extraction solvent. Solid samples (i.e. around 10 mg hair) were first submitted to alkaline digestion in the HPLC vials and processed accordingly. The organic phase (reached through the upper aqueous layer) was directly injected without further treatment. Instrumental analysis was performed using hydrophilic interaction (HILIC) ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS). Total chromatographic time was 2 min. The method covers a wide dynamic range making it fit-for-purpose for the analysis of samples covering entire populations, irrespective of the level of exposure or tobacco use. Calibration curves (r (2) > 0.995) covered the range 1-2000 ng/mL (or 0.05-100 ng/mg hair) for nicotine and 0.1-2000 ng/mL (or 0.005-100 ng/mg hair) for cotinine. Within-run and between-run precision and accuracy were typically below 10 %, and always below 20 % at the lower limit of quantification. The method was successfully applied to the analysis of samples from different projects involving multiple matrices. ; The study was funded by Instituto de Salud Carlos III-FEDER, Government of Spain (grant PI081339 and PI081436) [25, 31–33] and the Spain's National Committee on Smoking Prevention (grant CNPT0701) [34].

We have considered trends in age-standardized mortality from gastric cancer in 25 individual European countries, as well as in the European Union (EU) as a whole, in six selected central-eastern European countries and in the Russian Federation over the period 1950-1999. Steady and persisting falls in rates were observed, and the fall between 1980 and 1999 was approximately 50% in the EU, 45% in eastern Europe and 40% in Russia. However, the declines were greater in Russia and eastern Europe, since rates were much higher, in absolute terms. Joinpoint regression analysis indicated that the falls were proportionally greater in the last decade for men (-3.83% per year in the EU) and in the last 25 years for women (-3.67% per year in the EU) than in previous calendar years. Moreover, steady declines in gastric cancer mortality were observed in the middle-aged and the young population as well, suggesting that they are likely to persist in the near future. In terms of number of deaths avoided, however, the impact of the decline in gastric cancer mortality will be smaller, particularly in the EU. [Authors]

Chronic exposure to specific carcinogens present in secondhand smoke has been associated with different types of cancers. Hair is an ideal matrix to develop a proper biomarker as it absorbs substances in circulation and allows measuring their average concentration over long periods of time. A method was developed for the simultaneous quantification of nicotine, cotinine, NNN, NNK and NNAL in 20 mg human hair samples. Concentrations were significantly different depending on the declared exposure. This study shows for the first time that NNK is present in hair samples from non-smokers in concentrations much higher than any other tobacco specific nitrosamine. NNN could also be detected in samples from the most exposed non-smokers while, as previously reported, NNAL was undetectable. NNK correlates well with nicotine and cotinine (rsp = 0.774 and rsp = 0.792 respectively, p < 0.001 in both cases). However, NNN concentrations did not correlate with any of the other analytes. Ratios between NNK and nicotine show variability with different concentrations of NNK present in samples with similar nicotine values. NNK has proven to be the best marker of tobacco specific nitrosamines in hair. Monitoring NNK may provide a good estimation of cancer risk associated with exposure to secondhand smoke. ; This study was funded by Instituto de Salud Carlos III, Subdirección General de Evaluación y Fomento de la Investigación, PN I + D + I 2008-2011, co-funded by the European Regional Development Fund (FEDER), Government of Spain (Grants PI081339, PI081436 and RTICC RD12/0036/0053).

Adoption of smoke-free measures has been one of the central elements of tobacco control activity over the past 30 years. The past decade has seen an increasing number of countries and proportion of the global population covered by smoke-free policies to some extent. Despite reductions in global smoking prevalence, population growth means that the number of non-smokers exposed to the harms caused by secondhand smoke remains high. Smoke-free policy measures have been shown to be useful in protecting non-smokers from secondhand smoke, and can additionally increase cessation and reduce smoking initiation. Policies tend to be aimed primarily at enclosed public or workplace settings with very few countries attempting to control exposure in private or semiprivate spaces such as homes and cars, and, as a result, children may be benefiting less from smoke-free measures than adults. Compliance with legislation also varies by country and there is a need for education and empowerment together with guidance and changing social norms to help deliver the full benefits that smoke-free spaces can bring. Restrictions and policies on use of electronic cigarettes (e-cigarettes) in smoke-free settings require more research to determine the benefits and implications of bystanders' exposure to secondhand e-cigarette aerosol, dual use and smoking cessation.

European countries have made significant progress in implementing tobacco control policies to reduce tobacco use; however, whether socioeconomic status (SES) of a country may influence the implementation of such policies is unknown. The aim of this study is to assess the association between country-level SES and the implementation level of tobacco control policies in 31 European countries. An ecological study using data from Eurostat, Human Development Reports on several SES indicators and the Tobacco Control Scale (TCS) of 2016 was conducted to measure country-level tobacco control policies. We analysed the relationship between SES indicators and the TCS by means of scatter-plots and Spearman's rank correlation coefficients (r(sp)) and multivariable linear regression analysis. In Europe, no statistically significant association was found between SES factors and the level of implementation of tobacco control policies. Only public spending on tobacco control was associated with all SES factors, except for Gini Index (an income inequality index). The strongest associations of TCS scores for this policy domain were found with the Human Development Index (r(sp) = 0.586; p < 0.001) and the Gross Domestic Product per capita (in Euros) (r(sp) = 0.562; p = 0.001). The adjusted linear regression model showed an association of tobacco control policy implementation with countries' geographical location (Western Europe, β = − 15.7; p = 0.009, compared to Northern Europe). In conclusion, no association was found between SES factors and the level of implementation of tobacco control policies in 31 European countries; policymakers should be aware that tobacco control policies could be successfully implemented despite socioeconomic constraints, especially when these policies are of low cost and cost-effective (i.e., smoke-free bans and taxation).

Background: The objective of this study is to describe the legislation regulating the use of electronic cigarettes (e-cigarettes) in various places in European countries. Methods: A survey among experts from all countries of the World Health Organization (WHO) European Region was conducted in 2018. We collected and described data on legislation regulating e-cigarette use indoors and outdoors in public and private places, the level of difficulties in adopting the legislation, and the public support and compliance. Factors associated with the legislation adoption were identified with Poisson and linear regression analyses. Results: Out of 48 countries, 58.3% had legislation on e-cigarette use at the national level. Education facilities were the most regulated place (58.3% of countries), while private areas (eg, homes, cars) were the least regulated ones (39.6%). A third of countries regulated e-cigarette use indoors. Difficulty and support in adopting the national legislation and its compliance were all at a moderate level. Countries' smoking prevalence and income levels were linked to legislation adoption. Conclusions: Although most WHO European Region countries had introduced e-cigarette use legislation at the national level, only a few of the legislation protect bystanders in indoor settings.

•We evaluate the implementation of smoke-free campuses before and after new smoke-free legislation.•We measured PM2.5 concentrations and registered smoke-free zone signage and indications of smoking in the outdoor areas.•Median PM2.5 concentration significantly fell from 12.22 μg/m3 before the law to 7.80 μg/m3 after the law.•Smoke-free campuses were highly implemented in most of the hospitals.

Abstract Background Diverse projects and guidelines to assist hospitals towards the attainment of comprehensive smoke-free policies have been developed. In 2006, Spain government passed a new smoking ban that reinforce tobacco control policies and banned completely smoking in hospitals. This study assesses the progression of tobacco control policies in the Catalan Network of Smoke-free Hospitals before and after a comprehensive national smoking ban. Methods We used the Self-Audit Questionnaire of the European Network for Smoke-free Hospitals to score the compliance of 9 policy standards (global score = 102). We used two cross-sectional surveys to evaluate tobacco control policies before (2005) and after the implementation of a national smoking ban (2007) in 32 hospitals of Catalonia, Spain. We compared the means of the overall score in 2005 and 2007 according to the type of hospital, the number of beds, the prevalence of tobacco consumption, and the number of years as a smoke-free hospital. Results The mean of the implementation score of tobacco control policies was 52.4 (95% CI: 45.4–59.5) in 2005 and 71.6 (95% CI: 67.0–76.2) in 2007 with an increase of 36.7% (p 300 beds (41.1% increase; p < 0.01), hospitals with employees' tobacco consumption prevalence 35–39% (72.2% increase; p < 0.05) and hospitals that had recently implemented smoke-free policies (74.2% increase; p < 0.01). Conclusion The national smoking ban appears to increase tobacco control activities in hospitals combined with other non-bylaw initiatives such as the Smoke-free Hospital Network.

INTRODUCTION: The tobacco control community has raised some concerns about whether studies on electronic cigarettes (e-cigarettes) published in scientific journals hide conflicts of interest (COI) and whether such reports are biased. This study assessed potential COI in the e-cigarette scientific literature. METHODS: Cross-sectional study was conducted on e-cigarette publications indexed in PubMed up to August 2014. We extracted information about the authors (affiliations, location, etc.), publication characteristics (type, topic, subject, etc.), results and conclusions, presence of a COI statement, and funding by and/or financial ties to pharmaceutical, tobacco, and/or e-cigarette companies. An algorithm to determine the COI disclosure status was created based on the information in the publication. Prevalence ratios (PRs) and confidence intervals (CIs) were calculated to identify associations with COI disclosure, controlling for several independent variables. RESULTS: Of the 404 publications included in the analysis, 37.1% (n=150) had no COI disclosure statement, 38.6% declared no COI, 13.4% declared potential COI with pharmaceutical companies, 3.0% with tobacco companies, and 10.6% with e-cigarette companies. The conclusions in publications with COI, which were mainly tied to pharmaceutical companies, were more likely to be favourable to e-cigarette use (PR=2.23; 95% CI: 1.43-3.46). Publications that supported the use of e-cigarettes for both harm reduction (PR=1.81; 95%CI: 1.14-2.89) and smoking cessation (PR=2.02; 95% CI: 1.26-3.23) were more likely to have conclusions that were favourable to e-cigarettes. CONCLUSIONS: One-third of the publications reporting studies on e-cigarettes did not have a COI disclosure statement, and this proportion was even higher in news articles, editorials and other types of publications. Papers with conclusions that were favourable to e-cigarette use were more likely to have COI. Journal editors and reviewers should consider evaluating publications, including funding sources, to determine whether the results and conclusions may be biased. ; This study was funded in part by the Sociedad Española de Epidemiología. The Tobacco Control Unit of the Institut Català d'Oncologia is funded by the Government of Catalonia (Directorate of Research and Universities grant 2017SGR319). The funding institutions, had no role in the study design and execution, in the analysis and/or reporting of the results and necessarily do not endorse them. E. Fernández was supported by the Instituto Carlos III, Government of Spain, co-funded by the European Regional Development Fund (FEDER) (INT16/00211 and INT17/00103). Cristina Martínez was supported by the Instituto Carlos III, Government of Spain, co-funded by the European Regional Development Fund (FEDER) (INT17/00116) and the Catalan Government, PERIS (9015-586920/2017). ; Sí

Background/nCharacterizing and comparing the determinant of cotinine concentrations in different populations should facilitate a better understanding of smoking patterns and addiction. This study describes and characterizes determinants of salivary cotinine concentration in a sample of Spanish adult daily smoker men and women. Methods: A cross-sectional study was carried out between March 2004 and December 2005 in a representative sample of 1245 people from the general population of Barcelona, Spain. A standard questionnaire was used to gather information on active tobacco smoking and passive exposure, and a saliva specimen was obtained to determine salivary cotinine concentration. Two hundred and eleven adult smokers (>16 years old) with complete data were included in the analysis. Determinants of cotinine concentrations were assessed using linear regression models. Results: Salivary cotinine concentration was associated with the reported number of cigarettes smoked in the previous 24 hours (R2 = 0.339; p < 0.05). The inclusion of a quadratic component for number of cigarettes smoked in the regression analyses resulted in an improvement of the fit (R2 = 0.386; p < 0.05). Cotinine concentration differed significantly by sex, with men having higher levels./nConclusion: This study shows that salivary cotinine concentration is significantly associated with the number of cigarettes smoked and sex, but not with other smoking-related variables. ; This project was funded by the Instituto de Salud Carlos III (grants FIS PI020261 & PI081436) and the Thematic Network of Cooperative Research on Cancer (grant RD06/0020/0089), Government of Spain, and the Ministry of Universities and Research (grant 2009SGR192), Government of Catalonia. We also thank Chupa Chups Spain for providing the Smint® candies.