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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.

Background: tobacco control policies can reduce smoking prevalence. These measures may be less effective where smoking prevalence has significantly declined, as the remaining smokers have 'hardened'. Our aim was to empirically evaluate the 'hardening hypothesis' at the population level in the European Union (EU) and explore factors associated with hardcore smoking. Methods: we conducted two separate analyses in the EU using data on smoking from the Eurobarometer surveys (2009-2017, n=112 745). 1) A panel-data fixed-effects linear regression to investigate changes over time in the percentage of hardcore smokers in relation to standardised smoking prevalence at the country level. 2) A multilevel logistic regression analysis with hardcore (daily smokers, ≥15 cigarettes per day who have not attempted to quit in the last 12 months) or light (<5 cigarettes per day) smoking as the dependent variable and time as the main independent variable, controlling for individual and ecological variables. Results: we studied 29 010 current smokers (43.8% hardcore smokers and 14.7% light smokers). The prevalence of hardcore smoking among adult smokers increased by 0.55 (95% CI 0.14-0.96) percentage points per each additional percentage point in the overall smoking prevalence. The odds of being a hardcore smoker increased over time and were higher in middle-aged males and people with financial difficulties, while the odds of being a light smoker significantly declined among females. Conclusion: this study does not support the 'hardening hypothesis' in the EU between 2009 and 2017, but suggests a softening of the smoking population. Existing tobacco control policies are likely to be suitable to further decrease smoking prevalence in Europe.

OBJECTIVE: To assess attitudes towards the extension of outdoor smoke-free areas on university campuses. METHODS: Cross-sectional study (n=384) conducted using a questionnaire administered to medical and nursing students in Barcelona in 2014. Information was obtained pertaining to support for indoor and outdoor smoking bans on university campuses, and the importance of acting as role models. Logistic regression analyses were performed to examine agreement. RESULTS: Most of the students agreed on the importance of health professionals and students as role models (74.9% and 64.1%, respectively) although there were statistically significant differences by smoking status and age. 90% of students reported exposure to smoke on campus. Students expressed strong support for indoor smoke-free policies (97.9%). However, only 39.3% of participants supported regulation of outdoor smoking for university campuses. Non-smokers (OR=12.315; 95% CI: 5.377-28.204) and students ≥22 years old (OR=3.001; 95% CI: 1.439-6.257) were the strongest supporters. CONCLUSIONS: The students supported indoor smoke-free policies for universities. However, support for extending smoke-free regulations to outdoor areas of university campuses was limited. It is necessary to educate students about tobacco control and emphasise their importance as role models before extending outdoor smoke-free legislation at university campuses.

Introduction: The Tobacco Control Scale (TCS) was designed for advocacy purposes but has also been used as a research tool. In the present study, we characterized TCS use, its limitations and strengths, and critically assessed its use as a research instrument. Methods: We conducted an extensive search of the biomedical databases PubMed and Web of Science for the keyword 'tobacco control scale' in all fields. The search was limited to studies published in the period March 2006 to December 2019. Out of 69 hits, 32 studies met the inclusion criteria. Two reviewers independently extracted information from each publication regarding their general characteristics, publication and research aspects, and the characteristics of the use of the TCS. Results: We found that researchers have used the TCS as a tool to monitor tobacco control policies mainly in cross-sectional observational studies with ecological and multilevel designs directed to advocacy and the promotion of further research. Different outcomes, such as smoking prevalence and quit ratios, have been associated with tobacco control policy scores. The main reported limitations of the TCS were a low variance across countries and a failure to express enforcement and to incorporate the most recent legislation. Conclusions: The TCS has been commonly used to assess differences in outcomes according to tobacco control policies. However, there are still areas for improvement in its use in research regarding the lack of comparability of TCS scores across time. The lessons that have been learned should be used to adapt and expand the TCS overseas.

Background: Smoking is still highly prevalent in Europe. According to the WHO, tobacco control policies vary substantially across countries. The Tobacco Control Scale (TCS) was developed to quantify the implementation of tobacco control policies at country level in Europe. The objective was to assess the impact of tobacco control policies (quantified by TCS scores) on smoking prevalence and quit ratios and their relative changes from 2006-2014 in 27 European Union (EU27) countries. Methods: We conducted an ecological study at the country level. We used TCS scores in EU27 in 2007, and the prevalence of tobacco and quit ratios (No. ex-smokers/ No. ever smokers) data from the Eurobarometer surveys (2006 and 2014 waves). We analysed the relationship between the TCS scores and smoking prevalence and quit ratios and their relative changes by means of scatter plots, Spearman rank-correlation coefficients (rsp), and a multiple linear regression model adjusted for all TCS components. Results: In EU27, the smoking prevalence decreased by 14% (95%CI:7.3%-20.6%) (2006-2014) and varied from a relative decrease of 48.9% in Sweden to 0.4% in Bulgaria. The increase in the quit ratio in EU27 was 19.2% (95%CI:5.4%-33.1%) (2006-2014) and ranged from 125.8% in Sweden to 4.3% in Bulgaria. The correlation between TCS scores and smoking prevalence was negative (rsp=-0.444;p=0.02). A positive correlation was observed between TCS scores and quit ratios in 2014 (rsp=0.373;p=0.06) and in the relative changes in smoking prevalence (rsp=0.415;p=0.03). The percentage of smoking prevalence in 2014 explained by all TCS components in the regression model was 28.9% Conclusions: European countries with higher TCS scores, which indicates higher tobacco control efforts, have lower prevalence of smokers, higher quit ratios, and higher relative decreases in their smoking prevalence over the last decade. Funding: EC Horizon2020 HCO-6-2015 (EUREST-PLUS No. 681109); Government of Spain & European Regional Development Fund (RTICC RD12/0036/0053); Government of Catalonia (2014SGR999).

Background and challenges to implementation The Catalan Network of Smoke-Free Hospitals (XCHSF), with 82 hospitals of Catalonia, is coordinated by the Catalan Institute of Oncology and supported by the Health Department of the Catalan Government. This public health programme is intended to design, scale down, and evaluate tobacco-control policies within its members. In this context, we aim to describe the Tobacco Control Training Programme initiated in 2006 addressed to health professionals to provide knowledge and skills to effectively uphold tobacco cessation services. Intervention or response The XCHSF's Training Programme is based on the identified needs detected in a baseline study conducted in 2005. It offers specific contents provided annually by a qualified group of experts in the field. Three modalities have been launched since 2006: a) face-to-face training courses on specific topics about smoking cessation intervention, b) a Train-the-Trainer Programme, and c) an on-line course about brief intervention on smoking cessation. Courses information is spread among hospital coordinators and posted online. All courses are accredited by the Official Administration and a certificate of completion is provided after participants' knowledge assessment. Participants are also required to evaluate the course and the trainer/s. Results and lessons learnt Since its beginnings in 2006, the XCHSF's Training Programme has increased its offer from 1 to 7 different topics of courses. Results on participation up to July 2017 indicate that 1,427 professionals have attended face-to-face courses since 2006; more than 2,700 professionals have been trained through the Train-the-Trainer Programme since 2009, and 1,474 professionals have finished the online course through several editions since 2014. The overall satisfaction reaches ≥8.5/10. Conclusions and key recommendations Offering a wide and continuous range of training activities is essential for having skilled health professionals in smoking cessation in hospitals. The XCHSF's Training Programme is an educational resource that reinforces public health promotion in the territory and fosters the implementation of tobacco control strategies in hospitals.

Objective: to describe where smokers smoke outdoors, where non-smokers are exposed outdoors to secondhand smoke (SHS), and attitudes towards smoke-free outdoor areas after the implementation of national smoke-free legislation. Design: this cross-sectional study was conducted between June 2011 and March 2012 (n=1307 participants). Setting: Barcelona Participants: representative, random sample of the adult (≥16 years) population. Primary and secondary outcomes: proportion of smoking and prevalence of exposure to SHS in the various settings according to type of enclosure. Percentages of support for outdoor smoke-free policies according to smoking status. Results: smokers reported smoking outdoors most in bars and restaurants (54.8%), followed by outdoor places at work (46.8%). According to non-smokers, outdoor SHS exposure was highest at home (42.5%) and in bars and restaurants (33.5%). Among non-smoking adult students, 90% claimed exposure to SHS on university campuses. There was great support for banning smoking in the majority of outdoor areas, which was stronger among non-smokers than smokers. Over 70% of participants supported smoke-free playgrounds, school and high school courtyards, and the grounds of healthcare centres. Conclusions: extending smoking bans to selected outdoor settings should be considered in further tobacco control interventions to protect non-smokers from SHS exposure and to establish a positive model for youth. The majority of public support for some outdoor smoke-free areas suggests that it is feasible to extend smoking bans to additional outdoor settings.

The six most important cost-effective policies on tobacco control can be measured by the Tobacco Control Scale (TCS). The objective of our study was to describe the correlation between the TCS and smoking prevalence, self-reported exposure to secondhand smoke (SHS) and attitudes towards smoking restrictions in the 27 countries of the European Union (EU27).

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 Smokefree 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 crosssectional 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.

Background: in 2006, Spain implemented a national smoke-free legislation that prohibited smoking in enclosed public places and workplaces (except in hospitality venues). In 2011, it was extended to all hospitality venues and selected outdoor areas (hospital campuses, educational centers, and playgrounds). The objective of the study is to evaluate changes in exposure to secondhand smoke among the adult non-smoking population before the first law (2004-05) and after the second law (2011-12). Methods: repeated cross-sectional survey (2004-2005 and 2011-2012) of a representative sample of the adult (≥16 years) non-smoking population in Barcelona, Spain. We assess self-reported exposure to secondhand smoke (at home, the workplace, during leisure time, and in public/private transportation vehicles) and salivary cotinine concentration. Results: overall, the self-reported exposure to secondhand smoke fell from 75.7% (95%CI: 72.6 to 78.8) in 2004-05 to 56.7% (95%CI: 53.4 to 60.0) in 2011-12. Self-reported exposure decreased from 32.5% to 27.6% (−15.1%, p<0.05) in the home, from 42.9% to 37.5% (−12.6%, p = 0.11) at work/education venues, from 61.3% to 38.9% (−36.5%, p<0.001) during leisure time, and from 12.3% to 3.7% (−69.9%, p<0.001) in public transportation vehicles. Overall, the geometric mean of the salivary cotinine concentration in adult non-smokers fell by 87.2%, from 0.93 ng/mL at baseline to 0.12 ng/mL after legislation (p<0.001). Conclusions: secondhand smoke exposure among non-smokers, assessed both by self-reported exposure and salivary cotinine concentration, decreased after the implementation of a stepwise, comprehensive smoke-free legislation. There was a high reduction in secondhand smoke exposure during leisure time and no displacement of secondhand smoke exposure at home.