Epidemiologic Features of Tobacco Use in Spain
In Spain few long-term studies have been published on tobacco use. It is only since 1987 that data on the prevalence of cigarette consumption in Spain have become available from the various National Health Surveys (Encuestas Nacionales de Salud, ENSE). According to the 2001 ENSE, the prevalence of tobacco use in the Spanish population aged 16 years and older was 34.4%. In comparison with the results from the 1987 ENSE, which found a prevalence of 38.4%, the more recent figure reflects a slight decrease in tobacco use in Spain.1 Preliminary results from the 2003 ENSE (first trimester 2003) set tobacco use at 31% of the population older than 16 years of age. The data, however, are provisional and have not yet been published.
Tobacco use patterns vary considerably with sex and age. In the 2001 ENSE the percentage of men who smoked was 42.1%, whereas the figure for women was 27.2%. When changes in tobacco use in Spain between 1987 and 2001 were analyzed, it was found that smoking had decreased considerably among men from 55% to 42.1), whereas among women smoking had risen from 23% to 27.2%. The trend is for tobacco use to decrease in men and to increase in women, although among the latter the prevalence seems to be leveling off.
By age the highest percentage of smokers is seen in the 25-to-44-year-old group (48.2%), followed by 16-to-24-year-olds (41.7%).
Of note is the fact that among young women aged 16 to 24 years, the percentage of tobacco use is higher than in men (40.8% in men, vs 42.7% in women). This predominance of female smokers is seen again in the school-aged population. According to data from the most recent survey on drug use among schoolchildren (Plan Nacional Sobre Drogas for the year 2000), 30.5% of all students aged 14 to 18 years had smoked during the preceding month. The prevalence of tobacco use was higher among adolescent girls (35.8%) than among adolescent boys (25.2%).
It is important to use indicators that make it possible to monitor tobacco use and its trends in relation to sociodemographic factors, as this will allow us to design and amend preventive policies. In this connection it is worth drawing attention to the pertinence and usefulness of the Barcelona Health Survey (Encuesta de Salud de Barcelona, ESBA), which provides epidemiological data on tobacco use for periods earlier than those covered by the national-level ENSE performed by the Spanish Ministry of Health.
The data for overall prevalence and distribution by age group from the ESBA are similar to those from the ENSE, a similarity that emphasizes the need to focus prevention and control efforts on women and young persons.
A curious finding was the geographical variation in tobacco use in Spain, with appreciable differences in the prevalence of smoking between autonomous communities. The highest prevalence was found in Cantabria and Murcia, and the lowest prevalence in Castilla-La Mancha, the Balearic Islands, and Aragon.2
Smoking Worldwide
The prevalence of tobacco use varies across countries in overall terms and in distribution by sex. In the European Union, Canada, and the USA, tobacco use has leveled off and is beginning to decline. However, on a worldwide level the number of both male and female smokers continues to rise.
In the European Union the prevalence of tobacco use varies by country. In comparison with other European countries, Spain is near the top of the list in tobacco use. The countries where tobacco use is lowest are the United Kingdom (27%), Sweden (20%) Denmark (27%), Italy (27.5%), The Netherlands (27.5%), France (27%), and Portugal (23.3%). At the head of the ranking in the prevalence of tobacco use are Poland (34%), Russia (45%), Greece (45%), and Turkey (40%).3 The World Health Organization (WHO) has recommended reducing the number of smokers in each country to below 20%.
Other Determinants of Tobacco Use
Aside from sex and age, socioeconomic level has been identified as a variable that explains trends in tobacco use. In Spain the percentage of the population who have quit smoking is highest in the higher educational levels. The trend is toward higher rates of use in the less privileged classes, both for men and for women.2
The Barcelona Health Survey provides interesting data on smokers' intention to quit, previous attempts to quit, and their recall of health advice from their physicians to quit --information that is not available from the national-level ENSE surveys.
With regard to the intention to quit, the Barcelona Health Survey found a prevalence of 65.7%. This figure is similar to that in other studies that reported a figure of about 70% of all smokers who wished to quit. Almost half (46%) of all smokers try to quit each year, and more than 70% of all smokers have some contact with health services each year.4
In the Second Study of the Effectiveness of Preventive Activities carried out as part of the Preventive and Health Promotion Activities Program (Programa de Actividades Preventivas y Promoción de la Salud, PAPPS) of the Spanish Society of Family and Community Medicine (semFYC, 2001) it was found that 33% of all smokers had received advice against smoking. In the recent Population Survey to Evaluate and Determine the Perception of Preventive Activities carried out under the PAPPS program (2003), it was found that 45.3% of the population recalled having received advice at least once from their general practitioner to stop smoking. This figure is similar to the proportion of smokers in the ESBA (48.1%) who said they had been advised by their physician to stop smoking. It is noteworthy that health advice to quit smoking given by a health professional is the preventive activity with the highest cost-effectiveness ratio.5 The classic review by Schwartz of interventions to control smoking found that the median abstinence rate per year for physician's advice was 6%, with a range of 3% to 13%.6
Tobacco use involves a component of substance addiction (nicotine), a psychological component, and a social dependence component. This makes it necessary to investigate smokers´ attitudes toward tobacco use and to consider social trends related with smoking, in order to develop an all-encompassing approach to this important public health problem. The excellent article this editorial is based on explores epidemiological data on tobacco use, but also looks at motivational and social aspects that are potentially of great use to us in the prevention and control of smoking--where primary care clearly has a major role to play.
