Impact of the use of small-area models on estimation of attributable mortality at a regional level.

The objective of this study is to assess the impact of applying prevalences derived from a small-area model at a regional level on smoking-attributable mortality (SAM). A prevalence-dependent method was used to estimate SAM. Prevalences of tobacco use were derived from a small-area model. SAM and population attributable fraction (PAF) estimates were compared against those calculated by pooling data from three national health surveys conducted in Spain (2011-2014-2017). We calculated the relative changes between the two estimates and assessed the width of the 95% CI of the PAF. Applying surveys-based prevalences, tobacco use was estimated to cause 53 825 (95% CI: 53 182-54 342) deaths in Spain in 2017, a figure 3.8% lower obtained with the small-area model prevalences. The lowest relative change was observed in the Castile-La Mancha region (1.1%) and the highest in Navarre (14.1%). The median relative change between regions was higher for women (26.1%), population aged ≥65 years (6.6%), and cardiometabolic diseases (9.0%). The differences between PAF by cause of death were never greater than 2%. Overall, the differences between estimates of SAM, PAF, and confidence interval width are small when using prevalences from both sources. Having these data available by region will allow decision-makers to implement smoking control measures based on more accurate data.

Time Dependence Between Tobacco Consumption and Lung Cancer Mortality in Spain.

OBJECTIVES: Lung cancer is the leading cause of cancer death and the second most common cancer in both sexes worldwide, with tobacco being its main risk factor. The aim of this study is to establish the temporal relationship between smoking prevalence and lung cancer mortality in Spain. METHODS: To model the time dependence between smoking prevalence and lung cancer mortality, a distributed lag non-linear model was applied adjusting for sex, age, year of mortality and population at risk. Smoking prevalence data from 1991-2020 were used. Considering a maximum lag of 25 years, mortality data from 2016-2020 were included. The effect of prevalence on mortality for each lag is presented in terms of relative risk (RR). To identify the lag at which smoking prevalence has the greatest effect on mortality, the RR of the different lags were compared. RESULTS: The optimal lag observed between smoking prevalence and lung cancer mortality in Spain was 15 years. The maximum RR was 2.9 (95%CI: 2.0-4.3) for a prevalence of 71% and a 15-year lag. The RR was 1.8 for a prevalence of 33%, an approximate median value between 1991-2020, and a 15-year lag. CONCLUSIONS: In Spain, lung cancer mortality is affected by smoking prevalence 15 years prior. Knowing the evolution of the smoking prevalence series in a country and establishing a lag time is essential to predict how lung cancer incidence and mortality will evolve.

Retracted papers originating from paper mills: a cross-sectional analysis of references and citations.

OBJECTIVES: The aims of this study are (1) to analyze the references cited by retracted papers originated from paper mills; (2) to analyze the citations received by retracted papers originated from paper mills; and (3) to analyze the potential relationships existing between paper mill papers and their references and their citations. STUDY DESIGN AND SETTING: This study was a cross-sectional study. All original papers retracted in 2022 identified as having originated from paper mills and had been published at least 12 months before their retraction (hereinafter "source-retracted papers") were included. The Retraction Watch database was used to identify the source-retracted papers and Web of Science was used to identify the references contained within them and the citations received by them. We described the characteristics of the papers and journals. Additionally, 2 networks of source-retracted papers mutually interconnected via their citations and references were built: 1 with only retracted references and retracted citations and the other with all references and citations (retracted or unretracted). RESULTS: A total of 416 paper mill papers retracted in 2022 (sourced retracted papers) were identified, with a median of 1247 (interquartilic range, 907.8-1673.5) days between publication and retraction. Of all authors identified, 92.3% were affiliated with Chinese institutions. There were 14,411 references contained in the source-retracted papers and 8479 citations received by them; the median number of references and citations was 35 (29-40) and 16 (9-25), respectively. In total, 473 references and citations had also been retracted for being paper mill papers. Among the 416 sourced-retracted papers, 169 (41.9%) and 178 (42.8%) were referenced or were cited by at least another retracted paper, the majority of which also originated from paper mills. The first network analysis, which included source-retracted papers along with their retracted references and citations, found 3 clusters of 53, 48, and 44 retracted papers that were mutually interconnected. The second network analysis, with all references and citations (retracted or unretracted) identified a large cluster of 2530 interconnected papers. CONCLUSION: Retracted papers originating from paper mills frequently reference and are cited by papers that are later retracted for having originated from paper mills, displaying inter-relationships. Detecting these inter-relationships can serve as an indicator for identifying potentially fraudulent publications.

Mortality attributable to secondhand smoke exposure in the autonomous communities of Spain.

INTRODUCTION AND OBJECTIVES: Exposure to secondhand smoke (SHS) causes cardiovascular disease, respiratory disease, and cancer. The aim of this study was to estimate the mortality attributed to SHS in people aged ≥ 35 years in Spain and its autonomous communities (AC) by sex from 2016 to 2021. METHODS: Estimates of SHS-attributable mortality were calculated by applying the prevalence-dependent method where SHS exposure was derived from the adjustment of small-area models and based on the calculation of population-attributed fractions. Sex, age group, AC, and cause of death (ischemic heart disease and lung cancer) were included. The estimates of attributed mortality are presented with their 95% confidence interval (95%CI). Crude and age-standardized rates were estimated for each sex and AC. RESULTS: From 2016 to 2021, SHS exposure caused 4,970 (95%CI, 4,787-5,387) deaths, representing 1.6% of total mortality for ischemic heart disease and lung cancer. The burden of attributed mortality differed widely among the AC, with Andalusia having the highest burden of attributed mortality (crude rate: 46.6 deaths per 100 000 population in men and 17.0/100 000 in women). In all the AC, the main cause of death in both sexes was ischemic heart disease. The highest burden of mortality was observed in nonsmokers. CONCLUSIONS: The burden of SHS-attributable mortality was high and varied geographically. The results of this study should be considered to advance tobacco control legislation in Spain.

Evolución de la prevalencia de sedentarismo en la población española entre los años 1987 y 2020 / Evolution of sedentarism prevalence in Spanish population between 1987 and 2020

Antecedentes y objetivo: El sedentarismo es un factor predictivo para numerosas enfermedades. El objetivo de este estudio fue valorar la evolución de la prevalencia de sedentarismo en la población española adulta entre los años 1987-2020. Métodos: Las fuentes de datos fueron las Encuestas Nacionales y Europeas de Salud. La prevalencia de sedentarismo se valoró en 3 escenarios (actividad principal, tiempo libre y todos los escenarios). Se estimaron prevalencias de sedentarismo global, por sexo y grupo de edad. En todos los escenarios la prevalencia también se estimó por comunidad autónoma. La tendencia de las prevalencias se analizó con los porcentajes de cambio anual (PCA) obtenidos a través de modelos joinpoint. Resultados: La prevalencia de sedentarismo en la actividad principal varió entre el 31,2% en 1987 y el 38,4% en 2020 (PCA: 0,7 [0,5 a 1,0]), siendo mayor en los varones que en las mujeres, y más elevada en los más jóvenes y en los más mayores. La prevalencia de sedentarismo en el tiempo libre varió entre el 55,1% en 1993 y el 36,4% en 2020 (PCA: −1,4 [−1,9 a −0,9]), siendo siempre superior en las mujeres, más alta en los mayores de 64 años y menor en los de 16-24 años. Cantabria y Canarias fueron las comunidades autónomas con la prevalencia de sedentarismo más baja en todos los escenarios. Conclusiones: La prevalencia de sedentarismo en la actividad principal está aumentando en España, mientras que durante el tiempo libre está descendiendo. Es importante aplicar medidas de prevención y promoción de la salud dirigidas a disminuir el sedentarismo en la población.(AU)

Background and objective: Sedentary behavior is a predictive factor for numerous diseases. The objective of this study was to assess the evolution of the prevalence of sedentary behavior in the Spanish adult population between 1987 and 2020. Methods: The data sources were the National and European Health Surveys. The prevalence of sedentary behavior was assessed in three scenarios (main activity, leisure time and all scenarios). Prevalence of sedentary behavior was estimated overall, by sex and age group. In all scenarios, prevalence was also estimated by Autonomous Community. The prevalence trend was analyzed with the annual percent change (APC) obtained through joinpoint models. Results: The prevalence of sedentary in the main activity ranged from 31.2% in 1987 to 38.4% in 2020 [PCA: 0.7 (0.5-1.0)], being higher in men than in women and higher in younger and older people. The prevalence of sedentary in the leisure time varied between 55.1% in 1993 and 36.4% in 2020 [PCA: −1.4 (−1.9 to −0.9)], being always higher in women, higher in those over 64 years of age and lower in those aged 16–24 years. Cantabria and the Canary Islands were the Autonomous Communities with the lowest prevalence of sedentary behavior in all scenarios. Conclusions: The prevalence of sedentary behavior in the main activity is increasing in Spain, whereas during leisure time it is decreasing. It is important to implement prevention and health promotion measures aimed at reducing sedentary behavior in the population.(AU)

Prevalence of obesity in Spain and its autonomous communities, 1987-2020.

INTRODUCTION AND OBJECTIVES: Obesity is a public health concern with a strong impact on the health of the population. The aim of this study was to analyze the trend in the prevalence of obesity and to identify changes in this trend in Spain and its 17 autonomous communities (AC) among the population aged ≥ 15 years from 1987 to 2020. METHODS: A trend analysis of the prevalence of obesity was conducted with data extracted from the complete historical series of the Spanish National Health Survey and the European Health Survey in Spain using joinpoint regression models. For each period identified in the trend analysis, we estimated the annual percentage change (APC) and its 95% confidence interval (95%CI). The results are presented for crude and standardized prevalences by the direct method accompanied by 95%CI, sex ratios, and relative changes in prevalences between periods. RESULTS: The prevalence of obesity increased from 7.3% (95%CI, 7.0-7.7) in 1987 to 15.7% (95%CI, 15.1-16.3) in 2020. In men, the prevalence increased until 2009 (APC,4.3; [95%CI, 3.8-5.0]) and then stabilized. In women, the prevalence increased until 2001 (APC,4.2; [95%CI, 2.7-8.8]) and subsequently also stabilized. The prevalence of obesity and its trend varied between AC, with three different patterns being observed with standardized prevalences: AC with a continuous increase, AC with an increase and subsequent stabilization, and AC with an increase and subsequent decrease. CONCLUSIONS: The prevalence of obesity has increased in Spain since 1987, although in the last decade it has remained stable at values above 15%. However, in the group aged 15 to 24 years, the prevalence of obesity showed an increasing trend throughout the study period.

Evolution and characteristics of studies estimating attributable mortality to second-hand smoke: a systematic review.

BACKGROUND: Several studies have estimated the impact of second-hand smoke (SHS) exposure on mortality in the population of different countries. This study aimed to identify and describe studies that have estimated the attributable mortality (AM) associated with SHS exposure in the adult population. METHODS: A literature search was conducted in MEDLINE, EMBASE, Cochrane Library and CINAHL databases up to January 2023. Studies that estimated the AM associated with SHS exposure in the adult population and used a prevalence-dependent method were included. The main characteristics of the studies and their results were described. RESULTS: Fifty-three studies were included. Most of them were conducted in North America (n = 13), Europe (n = 14) and China (n = 6) and included lung cancer (n = 46) or ischaemic heart disease (n = 22) as causes of death. There was considerable variety in the population under study regarding the relationship with tobacco: non-smokers (n = 30); never-smokers (n = 9); both non and never-smokers (n = 2); the whole population (n = 1) and not known (n = 11). The age at which AM was estimated also varied between studies, ranging from 15 to 40 years and older. CONCLUSIONS: Studies estimating AM associated with SHS exposure are heterogeneous in terms of the causes of death studied, the age at which mortality is attributed, or the population to which mortality referred: consensus should be reached. Despite their importance, studies assessing AM to SHS are infrequent in low- and middle-income countries.

Towards stronger tobacco control policies to curb the smoking epidemic in Spain.

Smoking and exposure to secondhand smoke pose a significant risk to the health of populations. Although this evidence is not new, the commitment of countries to implement laws aimed at controlling consumption and eliminating exposure to secondhand smoke is uneven. Thus, in North America or in Europe, locations like California or Ireland, are pioneers in establishing policies aimed at protecting the population against smoking and secondhand smoke. Identifying measures that have worked would help control this important Public Health problem in other countries that are further behind in tobacco control policies. In Spain, there has been almost 15 years of little political action in legislation oriented to control the tobacco epidemic. If we want to achieve the tobacco endgame, new legislative measures must be implemented. In this paper, we have elucidated tobacco control policies that could be implemented and show how different countries have done so.

[Evolution of smoking prevalence in Spain and its 17 autonomous regions (1987-2020)]. / Evolución de la prevalencia de consumo de tabaco en España y sus 17 comunidades autónomas (1987-2020).

BACKGROUND AND OBJECTIVES: Continuous monitoring of smoking prevalence is essential to understand the evolution of the tobacco epidemic in a population. The objective of this study was to analyze the evolution of smoking prevalence in Spain and its 17 Autonomous Regions (ARs) in population ≥15 years during the period 1987-2020. METHODS: Tobacco consumption data were derived from the National Health Survey of Spain and the European Health Survey in Spain. A smoker was defined as a person who smoked at the time of the survey. The trend in prevalences by sex in Spain and its ARs was analyzed by applying joinpoint models. Age-standardized prevalences were calculated for Spain by applying the direct method. RESULTS: In Spain, the prevalence of consumption decreased 29 percentage points in men and 4.5 in women between 1987-2020. In men, the smoking prevalence decreased in all the ARs and the absolute change varied between -19.5% in the Balearic Islands and -33.9% in Andalusia. In women, the evolution of smoking prevalence differed between ARs. The absolute change varied between -15.4% in Basque Country and 0.5% in Andalusia. CONCLUSIONS: The number of men and women smokers has decreased in Spain between 1987-2020. Different patterns of evolution of the prevalence of consumption are observed among the ARs, especially among women. This reinforces the need for policies adapted to more local contexts and that take into account the gender perspective.

[Evolution of sedentarism prevalence in Spanish population between 1987 and 2020]. / Evolución de la prevalencia de sedentarismo en la población española entre los años 1987 y 2020.

BACKGROUND AND OBJECTIVE: Sedentary behavior is a predictive factor for numerous diseases. The objective of this study was to assess the evolution of the prevalence of sedentary behavior in the Spanish adult population between 1987 and 2020. METHODS: The data sources were the National and European Health Surveys. The prevalence of sedentary behavior was assessed in three scenarios (main activity, leisure time and all scenarios). Prevalence of sedentary behavior was estimated overall, by sex and age group. In all scenarios, prevalence was also estimated by Autonomous Community. The prevalence trend was analyzed with the annual percent change (APC) obtained through joinpoint models. RESULTS: The prevalence of sedentary in the main activity ranged from 31.2% in 1987 to 38.4% in 2020 [PCA: 0.7 (0.5-1.0)], being higher in men than in women and higher in younger and older people. The prevalence of sedentary in the leisure time varied between 55.1% in 1993 and 36.4% in 2020 [PCA: -1.4 (-1.9 to -0.9)], being always higher in women, higher in those over 64 years of age and lower in those aged 16-24 years. Cantabria and the Canary Islands were the Autonomous Communities with the lowest prevalence of sedentary behavior in all scenarios. CONCLUSIONS: The prevalence of sedentary behavior in the main activity is increasing in Spain, whereas during leisure time it is decreasing. It is important to implement prevention and health promotion measures aimed at reducing sedentary behavior in the population.

Sedentary behavior and physical inactivity from a comprehensive perspective.

OBJECTIVE: To characterize the prevalence of physical activity in the population aged ≥16 years integrating sedentarism and physical inactivity. METHOD: A cross-sectional study using data from the Galician Risk Behavior Data System (n=12,928) was conducted. The population was classified into four categories: physically active (active and non-sedentary), active but sedentary (active and sedentary), lightly active (inactive and non-sedentary), and extremely sedentary (inactive and sedentary). Prevalences were calculated for each category and a multinomial logistic regression model was fitted. RESULTS: 58.0% of the population was physically active and the remaining 42.0% presented some degree of sedentarism and/or physical inactivity. Men were more likely to be extremely sedentary. The risk of sedentarism decreased with age, and workers and/or students were prone to a higher risk of extreme sedentarism in comparison to those who reported other status. Extremely sendentary behaviors were also more common in people with higher educational levels, individuals living alone, residents of urban environments, and smokers. CONCLUSIONS: Joint evaluation of sedentarism and physical inactivity provides a more comprehensive and realistic picture of population behaviors related with physical activity. Since sedentarism is the most prevalent behavior, this study recommends that interventions be conducted at work and at academic environments.

Validation of a small-area model for estimation of smoking prevalence at a subnational level.

INTRODUCTION: Small-area estimation methods are an alternative to direct survey-based estimates in cases where a survey's sample size does not suffice to ensure representativeness. Nevertheless, the information yielded by small-area estimation methods must be validated. The objective of this study was thus to validate a small-area model. METHODS: The prevalence of smokers, ex-smokers, and never smokers by sex and age group (15-34, 35-54, 55-64, 65-74, ≥75 years) was calculated in two Spanish Autonomous Regions (ARs) by applying a weighted ratio estimator (direct estimator) to data from representative surveys. These estimates were compared against those obtained with a small-area model applied to another survey, specifically the Spanish National Health Survey, which did not guarantee representativeness for these two ARs by sex and age. To evaluate the concordance of the estimates, we calculated the intraclass correlation coefficient (ICC) and the 95% confidence intervals of the differences between estimates. To assess the precision of the estimates, the coefficients of variation were obtained. RESULTS: In all cases, the ICC was ≥0.87, indicating good concordance between the direct and small-area model estimates. Slightly more than eight in ten 95% confidence intervals for the differences between estimates included zero. In all cases, the coefficient of variation of the small-area model was <30%, indicating a good degree of precision in the estimates. CONCLUSIONS: The small-area model applied to national survey data yields valid estimates of smoking prevalence by sex and age group at the AR level. These models could thus be applied to a single year's data from a national survey, which does not guarantee regional representativeness, to characterize various risk factors in a population at a subnational level.

Small-area models to assess the geographical distribution of tobacco consumption by sex and age in Spain.

INTRODUCTION: Complete and accurate data on smoking prevalence at a local level would enable health authorities to plan context-dependent smoking interventions. However, national health surveys do not generally provide direct estimates of smoking prevalence by sex and age groups at the subnational level. This study uses a small-area model-based methodology to obtain precise estimations of smoking prevalence by sex, age group and region, from a population-based survey. METHODS: The areas targeted for analysis consisted of 180 groups based on a combination of sex, age group (15-34, 35-54, 55-64, 65-74, and ≥75 years), and Autonomous Region. Data on tobacco use came from the 2017 Spanish National Health Survey (2017 SNHS). In each of the 180 groups, we estimated the prevalence of smokers (S), ex-smokers (ExS) and never smokers (NS), as well as their coefficients of variation (CV), using a weighted ratio estimator (direct estimator) and a multinomial logistic model with random area effects. RESULTS: When smoking prevalence was estimated using the small-area model, the precision of direct estimates improved; the CV of S and ExS decreased on average by 26%, and those of NS by 25%. The range of S prevalence was 11-46% in men and 4-37% in women, excluding the group aged ≥75 years. CONCLUSIONS: This study proposes a methodology for obtaining reliable estimates of smoking prevalence in groups or areas not covered in the survey design. The model applied is a good alternative for enhancing the precision of estimates at a detailed level, at a much lower cost than that involved in conducting large-scale surveys. This method could be easily integrated into routine data processing of population health surveys. Having such estimates directly after completing a health survey would help characterize the tobacco epidemic and/or any other risk factor more precisely.

Mortality Attributable to Environmental Tobacco Smoke Exposure in Spain in 2020.

INTRODUCTION AND OBJECTIVES: Exposure to environmental tobacco smoke (ETS) is associated with increased mortality and morbidity. The objective of this study was to estimate the impact of ETS exposure in Spain on mortality in 2020 in the population aged 35 years and over. METHODS: A method of estimating attributable mortality (AM) based on the prevalence of ETS exposure was applied. Prevalence data were obtained from a representative study conducted in Spain and the relative risks were derived from a meta-analysis. AM point estimates are presented along with 95% confidence intervals (95% CI), calculated using a bootstrap naive procedure. AM, both overall and by smoking habit, was estimated for each combination of sex, age group, and cause of death (lung cancer and ischemic heart disease). A sensitivity analysis was performed. RESULTS: A total of 747 (95% CI 676-825) deaths were attributable to ETS exposure, of which 279 (95% CI 256-306) were caused by lung cancer, and 468 (95% CI 417-523) by ischemic heart disease. Three-quarters (75.1%) of AM occurred in men and 60.9% in non-smokers. When chronic obstructive pulmonary disease and cerebrovascular disease are included, the burden of AM is estimated at 2242 deaths. CONCLUSIONS: ETS exposure is associated with 1.5% of all deaths from lung cancer and ischemic heart disease in the population aged 35 and over. These data underline the need for health authorities to focus on reducing exposure to ETS in all settings and environments.

Sedentary behavior and physical inactivity from a comprehensive perspective / Sedentarismo e inactividad física desde una perspectiva integral

Objective: To characterize the prevalence of physical activity in the population aged ≥16 years integrating sedentarism and physical inactivity. Method: A cross-sectional study using data from the Galician Risk Behavior Data System (n = 12,928) was conducted. The population was classified into four categories: physically active (active and non-sedentary), active but sedentary (active and sedentary), lightly active (inactive and non-sedentary), and extremely sedentary (inactive and sedentary). Prevalences were calculated for each category and a multinomial logistic regression model was fitted. Results: 58.0% of the population was physically active and the remaining 42.0% presented some degree of sedentarism and/or physical inactivity. Men were more likely to be extremely sedentary. The risk of sedentarism decreased with age, and workers and/or students were prone to a higher risk of extreme sedentarism in comparison to those who reported other status. Extremely sendentary behaviors were also more common in people with higher educational levels, individuals living alone, residents of urban environments, and smokers. Conclusions: Joint evaluation of sedentarism and physical inactivity provides a more comprehensive and realistic picture of population behaviors related with physical activity. Since sedentarism is the most prevalent behavior, this study recommends that interventions be conducted at work and at academic environments.(AU)

Objetivo: Caracterizar la prevalencia de actividad física en la población ≥16 años integrando sedentarismo e inactividad física. Método: Se realizó un estudio transversal con datos del Sistema de Datos de Conductas de Riesgo de Galicia (n = 12.928). La población se clasificó en cuatro categorías: físicamente activa (activa y no sedentaria), activa pero sedentaria (activa y sedentaria), poco activa (inactiva y no sedentaria) y extremadamente sedentaria (inactiva y sedentaria). Se calcularon las prevalencias para cada categoría y se ajustó un modelo de regresión logística multinomial. Resultados: El 58,0% de la población era físicamente activa y el 42,0% restante presentaba algún grado de sedentarismo o inactividad física. Los hombres eran más propensos a ser extremadamente sedentarios. El riesgo de sedentarismo disminuía con la edad, y los trabajadores o estudiantes eran propensos a un mayor riesgo de sedentarismo extremo en comparación con los que declaraban otra condición. Los comportamientos extremadamente sedentarios también fueron más frecuentes en personas con niveles educativos más altos, personas que vivían solas, residentes en entornos urbanos y fumadores. Conclusiones: La evaluación conjunta del sedentarismo y la inactividad física proporciona una imagen más completa y realista de los comportamientos de la población relacionados con la actividad física. Dado que el sedentarismo es el comportamiento más prevalente, este estudio recomienda que se realicen intervenciones en el ámbito laboral y académico.(AU)

Identification of pathogens in the invasive hornet Vespa velutina and in native Hymenoptera (Apidae, Vespidae) from SW-Europe.

Invasive species contribute to deteriorate the health of ecosystems due to their direct effects on native fauna and the local parasite-host dynamics. We studied the potential impact of the invasive hornet Vespa velutina on the European parasite-host system by comparing the patterns of diversity and abundance of pathogens (i.e. Microsporidia: Nosematidae; Euglenozoa: Trypanosomatidae and Apicomplexa: Lipotrophidae) in European V. velutina specimens with those in the native European hornet Vespa crabro, as well as other common Hymenoptera (genera Vespula, Polistes and Bombus). We show that (i) V. velutina harbours most common hymenopteran enteropathogens as well as several new parasitic taxa. (ii) Parasite diversity in V. velutina is most similar to that of V. crabro. (iii) No unambiguous evidence of pathogen release by V. velutina was detected. This evidence together with the extraordinary population densities that V. velutina reaches in Europe (around of 100,000 individuals per km2 per year), mean that this invasive species could severely alter the native pathogen-host dynamics either by actively contributing to the dispersal of the parasites and/or by directly interacting with them, which could have unexpected long-term harmful consequences on the native entomofauna.