Assessing tobacco retail environment, outdoor smoke-free policies and smoking behavior in Madrid neighborhoods

Assessing tobacco retail
environment, outdoor smoke-free
policies and smoking behavior in
Madrid neighborhoods
IP: X. Sureda
Coresearcher: M. Franco, U. Bilal, FJ Escobar, A Navas
Advisor: E. Fernández
Social and Cardiovascular Epidemiology Research Group, Alcalá University
and Johns Hopkins Bloomberg School of Public Health
Funding: European Research Council Starting Grant 2013
HeartHealthyHoods Agreement n. 336893 y Instituto de Salud Carlos III
(PI15/02146)

1. Introduction
http://hhhproject.eu
2008 MPOWER measures to reduce the demand for tobacco
• (M) Monitor tobacco use and prevention
policies
• (P) Protect people from tobacco smoke
• (O) Offer help to quit tobacco use
• (W) Warn about the dangers of tobacco
• (E) Enforce bans on tobacco advertising,
promotion and sponsorship
• (R) Raise taxes on tobacco

1. Introduction
Smoke-free legislation (42/2010)
Modified the previous law (Law 28/2005):
Banning smoking:
• All public places,
including hospitality places
• some outdoors areas, including hospital
premises, educational campuses, and
playgrounds

1. Introduction
Relocation of smokers to outdoor settings

1. Introduction
Henriksen L. Tob Control March 2015 Vol 24 No e1

Does your neighborhood
affect your health?
Large Social
Cardiovascular Health
Disparities Between
Neighborhoods
Hypertension
Prevalence in 12
Neighborhoods
in Madrid
How can we
prevent CVD?

1. Introduction
Density of tobacco point of sales and educational level in Madrid

Physical
Environment
Social
Environment
Cardiovascular
Health
HEART
HEALTHY
HOODS
Obesity
Physical
Activity
Diet
Alcohol
Physical Activity
Environment
Food
Environment
CVDCVD
Smoking
Tobacco
Environment
Social and Physical
Environment
Individual
Cardiovascular Health
Alcohol
Environment
Heart Healthy Hoods Study
Main Goal

1. Introduction
Individual characteristics
Availability of
tobacco
• Density
• Hours of sales
• Proximity
Smoke-free places
• Law enforcement: Smoking visibility
• SHS exposure
Neighborhoodsocioeconomiccharacteristics:
Unemployement,education,poverty,
inmigrationcomposition
Smoking
behaviour
Self-reported
SHS exposure
IndividualSocioeconomicStatus:
Occupation,Income,Education,Gender,Immigration
Physical and social environment

2. Objectives
1. To describe tobacco environment in neighborhoods in Madrid city:
1.1 To analize the relation between the socioeconomic environment and
tobacco availability.
1.2 To analize the relation between socioeconomic environment and
outdoor smoke-free places.
2. To determine possible differences between tobacco availability and
smoking behaviour and self-reported SHS exposure.
3. To determine possible differences between smoking visibility and/or signs
of tobacco consumption and self-reported smoking behaviour and SHS
smoke exposure.

3. Methods
Baseline visit
2500 individuos
1st assessment
Multilevel Association
Analysis
Questionnaires
Saliva collection
GIS
Systematic social observation
Mesurements of Tobacco airborne
markers
Secondary databases
GIS

3. Methods
HHH area: Madrid municipality,
inluding 21 districts and 128
neighborhoods
Physical and Social
environment assessment:
Ecological data
Neighborhood SE status Secondary data
bases (Madrid Regional Government open
databases)
Tobacco point of sales (tobacconist shop)
Secondary Databases (Comisionado para el
Mercado de Tabaco)

3. Methods
42 neighborhoods in Madrid (2
neighborhoods per district selected
according different SE charactersitics)
Physical and Social
environment assessment
Smoke-free policies implementation (smoking
visibility and SHS exposure) Systematic
social observation and airborne markers

3. Methods
Outdoor places to be sampled:
Without smoking prohibition:
•Bars and restaurants (n=20)
•Discotheques and pubs (n=5)
•Public transportation stops ands stations (n=10)
•Public building entrances (n=15)
•University campuses (n=5)
•Sports facilities (n=5)
•Health care centres entrances (n=5)
•School and high school entrances(n=5)
•Other public places of interest (open markets,
green spaces/parks) (n=5)

Outdoor places to be sampled:
With smoking prohibition:
•schools and high school courtyards (n=5)
•children’s playgrounds (n=5)
•hospital premises (n=5)
3. Methods

Measurements and variables: Systematic Social Observation
lugar fecha hora
área
(m2)
altura
(m)
ventilación señales
olor a
tabaco
cenicero cenizas
personal
fumando
usuarios
fumando
observaciones
Indicators of the presence of tobacco smoking: number of smokers, presence of
ashtrays, presence of cigarette butts and tobacco smell, presence of tobacco vending
machines, hours of sales in places where you can get tobacco.
Information for every
measurement
sampling: location, area,
outdoor or quasi-outdoor
space, smoke-free zone
signage
3. Methods

PM2.5 Measurements
Precalibrated hand-held-operated
monitor of particle size and mass
concentration (TSI SidePak AM510
Personal Aerosol Monitor).
0
50
100
150
200
250
1 2 3 4 5 6 7 8 9 10111213141516171819202122232425262728
Hall
Main entrance (outdoor)
29
Time (minutes)
PM2.5(µg/m3)
Measurements and variables: Tobacco Airborne Markers
3. Methods

Airborne nicotine:
We will use nicotine sampler’s devices connected
through a tub to a pump (flow 3.02 ml/min) to take
the measures. Nicotine samplers will contain a filter
that is 37 mm in diameter and treated with sodium
bisulphate
3. Methods

Individual data: cohort HHH
2500 men and women aged 40 - 75 years.
Residents in the study area and asigned to
one of the Primary Health Care Centres
selected for the study.
All the participants live and/or work in the
area of their health care centre and have
been living in the same area for at least 3
years.
3. Methods

- DCOT (determinants of cotinine
questionnaire)
- Administered by telephone
- Tobacco consumption
- SHS exposure
Measurements and variables: Questionnaire
3. Methods

Self-reported SHS exposure
- At home
- Work/education venues
- Leisure time and transportation
(public and private)
- General exposure
3. Methods

A1. PERSONAS FUMADORAS HABITUALES
Sólo para las personas que fuman diariamente (respuesta 1 a P2)
P3. ¿A qué edad empezó a fumar regularmente?
años
P4. ¿Qué tipo de tabaco consume habitualmente?
P5. ¿Cuántos ______ ha fumado en las últimas 24 horas?
P4 P5
1. Sí 2. No Cantidad / últimas 24 horas
1. Cigarrillos
2. Puros o cigarros
3. Puritos (Farias, Reig, Señoritas, caliqueños….)
4. Pipa
5. Tabaco de liar
6. Otros: (tabaco de mascar, porros, rapé)
P6. De promedio, ¿cuántos _______ fuma normalmente al día en un día laborable?
P7. ¿Y cuántos _______ en un día libre o de fin de semana?
P6. Un día laborable
P7. Un día libre o de fin de
semana
1. Cigarrillos
2. Puros o cigarros
3. Puritos (Farias, Reig, Señoritas, caliqueños….)
4. Pipa
5. Tabaco de liar
6. Otros: (tabaco de mascar, porros, rapé)
Smoking behaviour
- Tobacco consumption
- Cig/day
-Type of tobacco
consumed
-Quitting attempts
-Nicotine dependence
-Stages of change
-etc
3. Methods

Sociodemographic characteristics:
- sex
- age
- country of origen
- address (residence and work)
- educational level
- ocupation
- employement situation
- Etc.
3. Methods
Measurements and variables: Questionnaire

Biomarker (cotinine)
Half-life: 15-17h
9 ml of saliva
Cotinine analysis with liquid
chromatography coupled with tandem
mass spectrometry (LC/MS/MS) with
multiple reaction monitoring. (limit of
quantification: 0.1 ng/mL and limit of
detection: 0.03 ng/mL)
Measurements and variables: Saliva collection and cotinine analysis
3. Methods

GIS now represent an excellent methodology for advanced geospatial analysis and
for mapping.
GIS will be present transversely throughout all the project.
Geospatial data integration and analysis using Geographic Information
Systems (GIS)
3. Methods

Statistical Analysis
We will assign densities to the corresponding census tract or neighborhood to
produce descriptive maps of tobacco outlets and socioeconomic level of each area
To study the association between the SES and the presence and density of tobacco
outlets spatial Poisson regression with the number of establishments as dependent
variable and the characteristics of the neighborhood as independent variable will be
performed.
To study the association between the SES level of a district/ tobacco products
availability/smoking visibility and self-reported tobacco consumption and SHS
exposure a multilevel logistic regression model will be used
3. Methods

Limitation:
• Information bias derived from the questionnaires
• Difficult to include a representative sample of the different types of outdoor
locations sufficient variety of places and also sufficient number of each type
of place
• Use of space (leisure and tourism)
• Difficulty to get all data of tobacco point of sales (NOT OPEN DATA) and ilegal
point of sales
Strengths:
• This is the first study that evaluates the relationship between tobacco
environment (physical and social) in the place of residence and work using
objective measurements with tobacco airborne markers, social systematic
observation and the use of Geographic Information Systems.
• Having already recruited a cohort in which characterize tobacco consumption
and SHS exposure
4. Discussion

Public Health Implications
•Innovative approach in the field of tobacco epidemiology research, as it focuses on
population strategy from the point of view of the availability of tobacco and visibility
of tobacco consumption and SHS exposure in the urban environment
•Understanding the process of denormalization of tobacco after the implementation
of smoke-free laws social gradient in its implementation?
•Assess whether there is a relationship between the availability of tobacco products in
the environment to smoking behavior future policies for tobacco control
4. Discussion

Public Health Implications
To provide scientific evidence for researchers and policy makers to
intervene at the population level to prevent tobacco consumption and SHS
exposure
4. Discussion

Thank you!!! (specially Usama, Manuel, Patxi,
Ana, Esteve, Alba, Maria, Julia, Pedro, Paloma, Angélica y
Sónsoles)
PROYECTOS DE INVESTIGACIPROYECTOS DE INVESTIGACIÓÓN EN SALUD 2015N EN SALUD 2015

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