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A lo largo de las últimas décadas, la prevalencia del tabaquismo ha seguido en la Unión Europea tendencias diferentes según el sexo. Mientras que entre los varones la prevalencia ha disminuido notablemente, entre las mujeres se ha incrementado o se ha estancado. En algunos países en que estos cambios se iniciaron más precozmente, la prevalencia del tabaquismo es hoy mayor entre las mujeres que entre los varones. Este documento cuantifica estas tendencias, con referencia a la situación española. En 1995, fumaban 60 millones de hombres y 42 millones de mujeres en la Unión Europea. El 48% de las fumadoras consumían cigarrillos light, lo que supone veinte millones de mujeres que los utilizan. Hay documentos de la industria del tabaco que indican que la promoción de cigarrillos light tiene como intención tranquilizar a sus clientes y frenar a quienes se preocupan por el mantenimiento de su salud y se plantean dejar de fumar. Hay datos que confirman que esta política consigue sus objetivos y que las concepciones erróneas de los fumadores sobre los cigarrillos light puede hacerles persistir en el consumo. Existen datos que indican que el tabaco puede jugar un papel en el control del peso. Las mujeres están más preocupadas por su peso que los hombres, y para las mujeres jóvenes la imagen corporal es muy importante. Éstas tienen a menudo la percepción de tener exceso de peso. Aunque es más común el miedo al sobrepeso que el exceso de peso real, la evidencia sugiere que el temor a ganar peso puede mantener a las mujeres en el hábito de fumar, y que las consideraciones sobre cómo mantener el control del peso influyen en las mujeres jóvenes al comenzar a fumar. El consejo sobre cómo controlar el peso debería formar parte de los programas de tratamiento del tabaquismo dirigidos a las mujeres. Además, cualquier intervención preventiva sobre mujeres adolescentes fumadoras debería abordar la cuestión del aumento de peso.

Abstract Background Because of the magnitude of the global tobacco epidemic, the World Health Organisation developed the Framework Convention on Tobacco Control (FCTC), an international legally binding treaty to control tobacco use. Adoption and implementation of specific tobacco control measures within FCTC is an outcome of a political process, where social norms and public opinion play important roles. The objective of our study was to examine how a country’s level of tobacco control is associated with smoking prevalence, two markers of denormalisation of smoking (social disapproval of smoking and concern about passive smoking), and societal support for tobacco control. Methods An ecological study was conducted, using data from two sources. The first source was the Tobacco Control Scale (TCS) from 2011, which quantifies the implementation of tobacco control policies in European Union (EU) countries. Data on smoking prevalence, societal disapproval of smoking, concern about passive smoking, and societal support for policy measures were taken from the Eurobarometer survey of 2009. Data from Eurobarometer surveys were aggregated to country level. Data from the 27 European Union member states were used. Results Smoking prevalence rates in 2009 were negatively associated with a country’s TCS 2011 score, although not statistically significant (r = −.25; p = .21). Experience of societal disapproval was positively associated with higher TCS scores, though not significantly (r = .14; p = .48). The same was true for societal support for tobacco control (r = .27; p = .18). The TCS score in 2011 was significantly correlated with concern about passive smoking (r = .42; p =.03). Support for tobacco control measures was also strongly correlated with concern about passive smoking (r = .52, p = .006). Conclusions Smokers in countries with a higher TCS score were more concerned about whether their smoke harms others. Further, support for tobacco control measures is higher in countries that have more of these concerned smokers. Concerns about passive smoking seem central in the implementation of tobacco control measures, stressing the importance of continuing to educate the public about the harm from passive smoking.

Background: Monitoring tobacco control policy implementation is one of the keys for tobacco consumption reduction in Latin America (LA). This study reports on the adaptation of the Tobacco Control Scale (TCS) for use in LA countries and the level of tobacco control policy implementation in this region according to the scale., Methods: Ecological cross-sectional survey. The questionnaire to measure tobacco control policies was a translated (into Spanish and Portuguese) and adapted version of the last TCS as used in Europe. The resulting TCS-LA maintains the same structure as the original TCS, with eight policy domains and 100 points (pts) as maximum score; however, four policy domains were adapted because the exact same rationale could not be applied. At least two non-governmental tobacco control experts were contacted per country to answer the TCS-LA., Results: Informants from 17 out of 18 countries completed the questionnaire. Using the TCS-LA, Panama (70 pts), Uruguay (68 pts) and Ecuador (61 pts) exhibited the strongest tobacco control policies, while Guatemala (32 pts), Bolivia (30 pts) and Dominican Republic (29 pts) have implemented a lower number of tobacco control policies. Eight countries reached 50% of the TCS-LA total possible score, indicating a relatively good implementation level of tobacco control policies., Conclusions: Panama, Uruguay and Ecuador are the tobacco control policy leaders in LA; however, tobacco control in the region has room for improvement since nine countries have a total score under 50 pts. The TCS is a feasible and adaptable tool to monitor tobacco control in other WHO regions beyond Europe., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Illicit tobacco trade is focused on Iran as a main target in the WHO's eastern Mediterranean region. Serial studies of Cigarette Packs Survey with same method were conducted in Tehran between 2003 and 2015 to evaluate consumed smuggled cigarettes. This study as the fourth Cigarette Packs Survey is designed to indicate the trends of illicit cigarette trade in Tehran in the last two decades., Methods: A cross-sectional household study was carried out in early 2021 in Tehran on 3042 persons who smoked at least one daily cigarette for a year. The sampling method was like the sampling method used in three previous studies. Participants aged≥15 years were asked to reveal their current cigarette pack, which was either legal cigarettes (having governmental label); or illegal cigarettes (without governmental label)., Results: The subjects included 2536 males (83.4%) and the mean age was 39.9±12.1 years; 1854 subjects (60.9%) showed foreign cigarettes and 1188 (39.1%) showed domestic cigarettes; 2705 (88.9%) consumed legal cigarettes and 337 (11.1%) consumed illegal cigarettes. Consumption of illegal cigarettes by gender showed greater use of smuggled cigarettes in males (11.7%vs 8.1%). No significant differences were seen based on the marital and educational status in terms of illegal cigarettes prevalence., Conclusion: Compare with previous studies, the trend of consumption of illicit cigarettes was decreasing in past two decades. This could be due to new regulation on monitoring cigarette distribution and changing illegal brands to legal as joint production., (© 2022 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

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).

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., Competing Interests: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported., (© 2020 Feliu A. et al.)

Objective: To update a systematic review published in 2013 that focused on evaluating the effectiveness of interventions within the scope of physical therapy, including exercise, manual therapy, electrotherapy, and combined or multimodal approaches to managing shoulder pain., Design: Umbrella review., Literature Search: An electronic search of PubMed, Web of Science, and CINAHL was undertaken. Methodological quality was assessed using the AMSTAR (A MeaSurement Tool to Assess systematic Reviews) checklist for systematic reviews., Study Selection Criteria: Nonsurgical treatments for subacromial shoulder pain., Data Synthesis: Sixteen systematic reviews were retrieved. Results were summarized qualitatively., Results: A strong recommendation can be made for exercise therapy as the first-line treatment to improve pain, mobility, and function in patients with subacromial shoulder pain. Manual therapy may be integrated, with a strong recommendation, as additional therapy. There was moderate evidence of no effect for other commonly prescribed interventions, such as laser therapy, extracorporeal shockwave therapy, pulsed electromagnetic energy, and ultrasound., Conclusion: There is a growing body of evidence to support exercise therapy as an intervention for subacromial shoulder pain. Ongoing research is required to provide guidance on exercise type, dose, duration, and expected outcomes. A strong recommendation may be made regarding the inclusion of manual therapy in the initial treatment phase. J Orthop Sports Phys Ther 2020;50(3):131-141. Epub 15 Nov 2019. doi:10.2519/jospt.2020.8498 .

Objectives: We investigated the potential impact of reduced tobacco use scenarios on total life expectancy and health expectancies, i.e., healthy life years and unhealthy life years., Methods: Data from the Belgian Health Interview Survey 2013 were used to estimate smoking and disability prevalence. Disability was based on the Global Activity Limitation Indicator. We used DYNAMO-HIA to quantify the impacts of risk factor changes and to compare the "business-as-usual" with alternative scenarios., Results: The "business-as-usual" scenario estimated that in 2028 the 15-year-old men/women would live additional 50/52 years without disability and 14/17 years with disability. The "smoking-free population" scenario added 3.4/2.8 healthy life years and reduced unhealthy life years by 0.79/1.9. Scenarios combining the prevention of smoking initiation with smoking cessation programs are the most effective, yielding the largest increase in healthy life years (1.9/1.7) and the largest decrease in unhealthy life years (- 0.80/- 1.47)., Conclusions: Health impact assessment tools provide different scenarios for evidence-informed public health actions. New anti-smoking strategies or stricter enforcement of existing policies potentially gain more healthy life years and reduce unhealthy life years in Belgium.

Background: Tobacco use is still highly prevalent in Europe, despite the tobacco control efforts made by the governments. The development of tobacco control policies varies substantially across countries. The Tobacco Control Scale (TCS) was introduced to quantify the implementation of tobacco control policies across European countries OBJECTIVE: To assess the midterm association of tobacco control policies on smoking prevalence and quit ratios among 27 European Union (EU) Member States (EU27)., Methods: Ecological study. We used the TCS in EU27 in 2007 and the prevalence of tobacco and quit ratios data from the Eurobarometer survey (2006 (n=27 585) and 2014 (n=26 793)). We analysed the relationship between the TCS scores and smoking prevalence and quit ratios and their relative changes (between 2006 and 2014) by means of scatter plots and multiple linear regression models., Results: In EU27, countries with higher scores in the TCS, which indicates higher tobacco control efforts, have lower prevalence of smokers, higher quit ratios and higher relative decreases in their prevalence rates of smokers over the last decade. The correlation between TCS scores and smoking prevalence (r sp =-0.444; P=0.02) and between the relative changes in smoking prevalence (r sp =-0.415; P=0.03) was negative. A positive correlation was observed between TCS scores and quit ratios (r sp =0.373; P=0.06). The percentage of smoking prevalence explained by all TCS components was 28.9%., Conclusion: EU27 should continue implementing comprehensive tobacco control policies as they are key for reducing the prevalence of smoking and an increase tobacco cessation rates in their population., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

To address the illicit cigarette trade, the European Union (EU) has signed agreements with the four major Transnational Tobacco Companies (TTCs) that involve establishing extensive systems of cooperation. All agreements foresee two types of payments: annual payments (totalling US$ 1.9 billion over 20 years) and supplementary seizure payments, equivalent to 100% of the evaded taxes in the event of seizures of their products. While limited by the fundamental lack of transparency in this area, our analysis suggests that these agreements have served largely to secure the TTCs' interests and are threatening progress in tobacco control. The seizure payments are paltry and a wholly inadequate deterrent to TTC involvement in illicit trade. Despite the agreements, growing evidence indicates the TTCs remain involved in the illicit trade or are at best failing to secure their supply chains as required by the agreements. The intention of the seizure-based payments to deter the tobacco industry from further involvement in the illicit cigarette trade has failed because the agreements contain too many loopholes that provide TTCs with both the incentive and opportunity to classify seized cigarettes as counterfeit. In addition, the shifting nature of cigarette smuggling from larger to smaller consignments often results in seizures that are too small to qualify for the payments. Consequently, the seizure payments represent a tiny fraction of the revenue lost from cigarette smuggling, between 2004 and 2012, 0.08% of the estimated losses due to illicit cigarette trade in the EU. Our evidence suggests the EU should end these agreements., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objective: Little evidence, other than that commissioned by the tobacco industry, exists on the size of the illicit tobacco trade. This study addresses this gap by examining the level and nature of illicit cigarettes and hand-rolled tobacco in 18 European countries., Design: Face-to-face cross-sectional survey on smoking., Setting: 18 European countries., Participants: For each country, around 1000 subjects representative of the population aged 15 and over were enrolled. Current cigarette smokers were asked to show their latest purchased pack of cigarettes or hand-rolled tobacco., Main Outcome Measure: A comprehensive measure called an Identification of an Illicit Pack (IIP) was used to study the extent of illicit trade, defining a pack as illicit if it had at least one of the following tax evasion indicators: (1) it was bought from illicit sources, as reported by smokers, (2) it had an inappropriate tax stamp, (3) it had an inappropriate health warning or (4) its price was substantially below the known price in their market., Results: Overall, the proportion of illicit packs was 6.5%. The highest prevalence of IIP was observed in Latvia (37.8%). Illicit packs were more frequent among less educated smokers and among those living in a country which shared a land or sea border with Ukraine, Russia, Moldova or Belarus. No significant association was found with price of cigarettes., Conclusions: This study indicates that IIP is less than 7% in Europe and suggests that the supply of illicit tobacco, rather than its price, is a key factor contributing to tax evasion., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)