Price promotions and marketing within points of sale around high schools in Greece during the 2012 economic crisis

Introduction: Price promotions within points of sale (POS) are a significant risk factor for smoking initiation and pro-smoking beliefs among adolescents. The aim of the present study was to assess the quantity and types of tobacco advertisements and price promotions within POS located around schools (<300 m) in two major cities in Greece during the period of economic crisis (2011-2012). Methods: POS that were within close proximity (<300m) to high schools in the cities of Heraklion and Thessaloniki, Greece was assessed with the use of Google Maps and on foot surveillance, while indoor and outdoor advertising characteristics were assessed within each POS. A total of 226 POS were identified around the 23 schools assessed in the two cities (n=13 in Heraklion and n=10 in Thessaloniki). Results: On average there were 10 POS around each school, with one in eight POS directly visible from school gates. Advertising was more common inside than outside and price promotions were also more frequent indoors. British American Tobacco and Philip Morris International were responsible for >60% of outdoor price promotions. Conclusions: Price promotions were noted within the majority of POS close to schools. Aggressive promotional activities may hinder efforts to de-normalize tobacco use, especially during financial crisis when price promotions may pose as more attractive to potential consumers

Passive Exposure To E-cigarette Emissions: Immediate Respiratory Effects

INTRODUCTION The present work examined the effect of passive exposure to electronic-cigarette (e-cigarette) emissions on respiratory mechanics and exhaled inflammatory biomarkers. METHODS A cross-over experimental study was conducted with 40 healthy nonsmokers, 18-35 years old with normal physical examination and spirometry, with body mass index < 30 kg/m(2), who were exposed to e-cigarette emissions produced by a smoker, according to a standardized protocol based on two resistance settings, 0.5 ohm and 1.5 ohm, for e-cigarette use. All participants underwent a 30-minute control (no emissions) and two experimental sessions (0.5 and 1.5 ohm exposure) in a 35 m(3) room. The following Impulse Oscillometry (IOS) parameters were measured at pre and post sessions: impedance, resistance, reactance, resonant frequency (fres), frequency dependence of resistance (fdr=R5-R20), reactance area (AX), and fractional exhaled nitric oxide (FeNO). Differences between pre and post measurements were compared using t-tests and Wilcoxon signed rank tests, while analysis of variance (ANOVA) was used for comparisons between experimental sessions (registered under ClinicalTrials.gov ID: NCT03102684). RESULTS IOS and FeNO parameters showed no significant changes during the control session. For IOS during the 1.5 ohm exposure session, fres increased significantly from 11.38 Hz at baseline to 12.16 Hz post exposure (p=0.047). FeNO decreased significantly from 24.16 ppb at baseline to 22.35 ppb post exposure in the 0.5 ohm session (p=0.006). CONCLUSIONS A 30-minute passive exposure to e-cigarette emissions revealed immediate alterations in respiratory mechanics and exhaled biomarkers, expressed as increased fres and reduced FeNO

Measuring for change: A multi-centre pre-post trial of an air quality feedback intervention to promote smoke-free homes

Introduction Second-hand smoke exposure in the home is a serious cause of ill-health for children. Behaviour change interventions have been developed to encourage parents to keep homes smoke-free. This study evaluates a novel air quality feedback intervention using remote air quality monitoring with SMS and email messaging to promote smoke-free homes among families from deprived areas. Methods This paper presents a pre-post study of this intervention. Using internet connected monitors developed with the Dylos DC1700, daily SMS and weekly email feedback provided for 16 days to participants recruited in four European countries. Participants were recruited based on their stage of change, in order to target those most able to achieve smoke-free homes. The primary outcome measure was median change in mean fine particulate matter (PM2.5) concentration between baseline and follow-up periods, while secondary outcome measures included change in time over the World Health Organisation (WHO) guideline limit for PM2.5 exposure over 24 h (25 µg/m3) in those periods and the number of homes where PM2.5 concentrations reduced. Telephone interviews were conducted with participants in Scotland post-intervention to explore intervention experience and perceived effectiveness. Results Of 86 homes that completed the intervention study, 57 (66%) experienced pre-post reductions in measured PM2.5. The median reduction experienced was 4.1 µg/m3 (a reduction of 19% from baseline, p = 0.008). Eight homes where concentrations were higher than the WHO guideline limit at baseline fell below that level at follow-up. In follow-up interviews, participants expressed positive views on the usefulness of air quality feedback. Discussion Household air quality monitoring with SMS and email feedback can lead to behaviour change and consequent reductions in SHS in homes, but within the context of our study few homes became totally smoke-free

Measuring for change: A multi-centre pre-post trial of an air quality feedback intervention to promote smoke-free homes

Introduction: Second-hand smoke exposure in the home is a serious cause of ill-health for children. Behaviour change interventions have been developed to encourage parents to keep homes smoke-free. This study evaluates a novel air quality feedback intervention using remote air quality monitoring with SMS and email messaging to promote smoke-free homes among families from deprived areas. Methods: This paper presents a pre-post study of this intervention. Using internet connected monitors developed with the Dylos DC1700, daily SMS and weekly email feedback provided for 16 days to participants recruited in four European countries. Participants were recruited based on their stage of change, in order to target those most able to achieve smoke-free homes. The primary outcome measure was median change in mean fine particulate matter (PM2.5) concentration between baseline and follow-up periods, while secondary outcome measures included change in time over the World Health Organisation (WHO) guideline limit for PM2.5 exposure over 24 h (25 mu g/m(3)) in those periods and the number of homes where PM2.5 concentrations reduced. Telephone interviews were conducted with participants in Scotland post-intervention to explore intervention experience and perceived effectiveness. Results: Of 86 homes that completed the intervention study, 57 (66%) experienced pre-post reductions in measured PM2.5. The median reduction experienced was 4.1 mu g/m(3) (a reduction of 19% from baseline, p = 0.008). Eight homes where concentrations were higher than the WHO guideline limit at baseline fell below that level at follow-up. In follow-up interviews, participants expressed positive views on the usefulness of air quality feedback. Discussion: Household air quality monitoring with SMS and email feedback can lead to behaviour change and consequent reductions in SHS in homes, but within the context of our study few homes became totally smoke-free

Secondhand smoke exposure and other signs of tobacco consumption at outdoor entrances of primary schools in 11 European countries

Introduction Although smoking restrictions at child-related settings are progressively being adopted, school outdoor entrances are neglected in most smoke-free policies across Europe. Objectives To describe secondhand smoke (SHS) exposure and tobacco-related signs in outdoor entrances of primary schools in Europe according to area-level socioeconomic status (SES), smoke-free policy, national smoking prevalence, and geographical region. Methods In this cross-sectional study we monitored vapor-phase nicotine concentrations at 220 school outdoor entrances in 11 European countries (March 2017–October 2018). To account for nicotine presence, we used the laboratory's limit of quantification of 0.06 μg/m3 as point threshold. We also recorded the presence of smell of smoke, people smoking, cigarette butts, and ashtrays. Half of the schools were in deprived areas. We grouped countries according to their Tobacco Control Scale (TCS) score, smoking prevalence (2017–2018), and United Nations M49 geographical region. Results There were detectable levels of nicotine in 45.9% of the outdoor entrances, in 29.1% smell of smoke, in 43.2% people smoking, in 75.0% discarded butts, and in 14.6% ashtrays. Median nicotine concentration was below the laboratory's limit of quantificationAdditional co-authors: Vergina K. Vyzikidou, Giuseppe Gorini, Angel López-Nicolás, Joan B. Soriano, Gergana Geshanova, Joseph Osman, Ute Mons, Krzysztof Przewozniak, José Precioso, Ramona Brad, Maria J. López, and the TackSHS project Investigator

Secondhand smoke exposure in outdoor children’s playgrounds in 11 European countries

Introduction: Tobacco presence in outdoor children's playgrounds is concerning not only because it leads to secondhand smoke (SHS) exposure, but also cigarette butt pollution and tobacco normalization. Objectives: This study aimed to assess SHS exposure in children's playgrounds, according to area-level socioeconomic status (SES), smoke-free regulations, national smoking prevalence, and SHS exposure prevalence in playgrounds (2017-2018). Methods: We monitored vapor-phase nicotine concentration and tobacco-related variables in 20 different playgrounds in 11 European countries (n = 220 measurements) from March 2017 to April 2018. Playgrounds were selected according to area-level SES. Data on the number of people smoking, and cigarette butts inside the playground and on playground surroundings (<1 m away) were recorded. Playground smoking bans, the Tobacco Control Scale (TCS) score, national smoking prevalence and SHS exposure prevalence in playgrounds were used to group countries. To determine nicotine presence, we dichotomized concentrations using the limit of quantification as a cut-off point (0.06 μg/m3). Nicotine median concentrations were compared using non-parametric tests, and nicotine presence and tobacco-related observational variables using the Chi-squared test. Results: Airborne nicotine presence was found in 40.6% of the playgrounds. Median nicotine concentration was <0.06 μg/m3 (Interquartile range: <0.06-0.125) and higher median concentrations were found in more deprived neighborhoods, non-regulated playgrounds, in countries with lower overall TCS scores, higher national smoking prevalence and higher SHS exposure prevalence in playgrounds. Overall, people were smoking in 19.6% of the playgrounds. More than half of playgrounds had cigarette butts visible inside (56.6%) and in the immediate vicinity (74.4%). Presence of butts inside playgrounds was higher in sites from a low area-level SES, in countries with low TCS scores, and greater smoking prevalence and SHS exposure prevalence (p<0.05). Conclusions: There is evidence of SHS exposure in children's playgrounds across Europe. These findings confirm the need for smoking bans in playgrounds and better enforcement in those countries with smoking bans in playgrounds

Secondhand smoke exposure assessment in outdoor hospitality venues across 11 European countries

Objective: Due to partial or poorly enforced restrictions secondhand tobacco smoke (SHS) is still present in outdoor hospitality venues in many European countries. This study aimed to assess SHS concentrations in outdoor hospitality venues across Europe and identify contextual exposure determinants. Methods: Cross-sectional study. We measured airborne nicotine and evidence of tobacco use in terraces of bars, cafeterias, and pubs from 11 European countries in 2017-2018. Sites were selected considering area-level socioeconomic indicators and half were visited during nighttime. We noted the smell of smoke, presence of smokers, cigarette butts, ashtrays, and number of physical covers. Contextual determinants included national smoke-free policies for the hospitality sector, the Tobacco Control Scale score (2016), and the national smoking prevalence (2017-2018). We computed medians and interquartile ranges (IQR) of nicotine concentrations and used multivariate analyses to characterize the exposure determinants. Results: Nicotine was present in 93.6% of the 220 sites explored. Overall concentrations were 0.85 (IQR:0.30-3.74) μg/m3 and increased during nighttime (1.45 IQR:0.65-4.79 μg/m3), in enclosed venues (2.97 IQR:0.80-5.80 μg/m3), in venues with more than two smokers (2.79 IQR:1.03-6.30 μg/m3), in venues in countries with total indoor smoking bans (1.20 IQR:0.47-4.85 μg/m3), and in venues in countries with higher smoking prevalence (1.32 IQR:0.49-5.34 μg/m3). In multivariate analyses, nicotine concentrations were also positively associated with the observed number of cigarette butts. In venues with more than two smokers, SHS levels did not significantly vary with the venues' degree of enclosure. Conclusions: Our results suggest that current restrictions in outdoor hospitality venues across Europe have a limited protective effect and justify the adoption of total smoking bans in outdoor areas of hospitality venues

Secondhand Smoke Exposure and Other Signs of Tobacco Consumption at Outdoor Entrances of Primary Schools in Eleven European Countries

Introduction: Although smoking restrictions at child-related settings are progressively being adopted, school out-door entrances are neglected in most smoke-free policies across Europe. Objectives:To describe secondhand smoke (SHS) exposure and tobacco-related signs in outdoor entrances of primary schools in Europe according to area-level socioeconomic status (SES), smoke-free policy, national smoking prevalence, and geographical region. Methods:In this cross-sectional study we monitored vapor-phase nicotine concentrations at 220 school outdoor entrances in 11 European countries (March 2017–October 2018). To account for nicotine presence, we used the laboratory\u27s limit of quantification of 0.06μg/m3as point threshold. We also recorded the presence of smell of smoke, people smoking, cigarette butts, and ashtrays. Half of the schools were in deprived areas. We grouped countries according to their Tobacco Control Scale (TCS) score, smoking prevalence (2017–2018), and United Na-tions M49 geographical region. Results:There were detectable levels of nicotine in 45.9% of the outdoor entrances, in 29.1% smell of smoke, in43.2% people smoking, in 75.0% discarded butts, and in 14.6% ashtrays. Median nicotine concentration was below the laboratory\u27s limit of quantificationb0.06μg/m3(Interquartile range:b0.06–0.119). We found higher SHS levels in countries with lower TCS scores, higher national smoking prevalence, and in the Southern and East-ern European regions. People smoking were more common in schools from lower area-level SES and in countries with lower TCS scores (pb0.05). Conclusions: Smoking at school outdoor entrances is a source of SHS exposure in Europe. These findings support the extension of smoking bans with a clear perimeter to the outdoor entrances of schools

Secondhand smoke exposure assessment in outdoor hospitality venues across 11 European countries

Objective Due to partial or poorly enforced restrictions secondhand tobacco smoke (SHS) is still present in outdoor hospitality venues in many European countries. This study aimed to assess SHS concentrations in outdoor hospitality venues across Europe and identify contextual exposure determinants. Methods Cross-sectional study. We measured airborne nicotine and evidence of tobacco use in terraces of bars, cafeterias, and pubs from 11 European countries in 2017-2018. Sites were selected considering area-level socioeconomic indicators and half were visited during nighttime. We noted the smell of smoke, presence of smokers, cigarette butts, ashtrays, and number of physical covers. Contextual determinants included national smoke-free policies for the hospitality sector, the Tobacco Control Scale score (2016), and the national smoking prevalence (2017-2018). We computed medians and interquartile ranges (IQR) of nicotine concentrations and used multivariate analyses to characterize the exposure determinants. Results Nicotine was present in 93.6% of the 220 sites explored. Overall concentrations were 0.85 (IQR:0.30-3.74) μg/m3 and increased during nighttime (1.45 IQR:0.65-4.79 μg/m3), in enclosed venues (2.97 IQR:0.80-5.80 μg/m3), in venues with more than two smokers (2.79 IQR:1.03-6.30 μg/m3), in venues in countries with total indoor smoking bans (1.20 IQR:0.47-4.85 μg/m3), and in venues in countries with higher smoking prevalence (1.32 IQR:0.49-5.34 μg/m3). In multivariate analyses, nicotine concentrations were also positively associated with the observed number of cigarette butts. In venues with more than two smokers, SHS levels did not significantly vary with the venues’ degree of enclosure. Conclusions Our results suggest that current restrictions in outdoor hospitality venues across Europe have a limited protective effect and justify the adoption of total smoking bans in outdoor areas of hospitality venues.Additional co-authors: Vergina K. Vyzikidou, Giuseppe Gorini, Angel López-Nicolás, Joan B. Soriano, Gergana Geshanova, Joseph Osman, Ute Mons, Krzysztof Przewozniak, José Precioso, Ramona Brad, Maria J. López

Secondhand smoke exposure in outdoor children's playgrounds in 11 European countries

Introduction: Tobacco presence in outdoor children's playgrounds is concerning not only because it leads to secondhand smoke (SHS) exposure, but also cigarette butt pollution and tobacco normalization. Objectives: This study aimed to assess SHS exposure in children's playgrounds, according to area-level socioeconomic status (SES), smoke-free regulations, national smoking prevalence, and SHS exposure prevalence in playgrounds (2017–2018). Methods: We monitored vapor-phase nicotine concentration and tobacco-related variables in 20 different playgrounds in 11 European countries (n = 220 measurements) from March 2017 to April 2018. Playgrounds were selected according to area-level SES. Data on the number of people smoking, and cigarette butts inside the playground and on playground surroundings ( < 1 m away) were recorded. Playground smoking bans, the Tobacco Control Scale (TCS) score, national smoking prevalence and SHS exposure prevalence in playgrounds were used to group countries. To determine nicotine presence, we dichotomized concentrations using the limit of quantification as a cut-off point (0.06 μg/m3). Nicotine median concentrations were compared using non-parametric tests, and nicotine presence and tobacco-related observational variables using the Chi-squared test. Results: Airborne nicotine presence was found in 40.6% of the playgrounds. Median nicotine concentration was less than 0.06 μg/m3 (Interquartile range: less than 0.06–0.125) and higher median concentrations were found in more deprived neighborhoods, non-regulated playgrounds, in countries with lower overall TCS scores, higher national smoking prevalence and higher SHS exposure prevalence in playgrounds. Overall, people were smoking in 19.6% of the playgrounds. More than half of playgrounds had cigarette butts visible inside (56.6%) and in the immediate vicinity (74.4%). Presence of butts inside playgrounds was higher in sites from a low area-level SES, in countries with low TCS scores, and greater smoking prevalence and SHS exposure prevalence (p < 0.05). Conclusions: There is evidence of SHS exposure in children's playgrounds across Europe. These findings confirm the need for smoking bans in playgrounds and better enforcement in those countries with smoking bans in playgrounds.Additional co-authors: Giuseppe Gorini, Angel López-Nicolás, Joan B Soriano, Gergana Geshanova, Joseph Osman, Ute Mons, Krzysztof Przewozniak, José Precioso, Ramona Brad, Maria J López, the TackSHS project investigator