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Evaluation of tobacco control policy implementation in European and Latin-American countries
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[eng] INTRODUCTION. Smoking is one of the major public health problems of our times, killing eight-million people a year from direct tobacco-related diseases. Active smoking has been associated with an increased risk of lung cancer and several other cancers, cardiovascular diseases, including ischaemic heart disease, bronchitis and emphysema, and ante- and perinatal mortality. Non-smokers exposed to second- hand smoke (SHS) are also at an increased risk for developing lung cancer and ischemic heart disease. Many efforts have been made globally to prevent and control tobacco use. Actions, however, have been accelerated by the WHO Framework Convention on Tobacco Control (FCTC) and the MPOWER package, which includes six cost-effective policies to fight the tobacco epidemic. Effective tobacco control policies denormalise smoking, result in a decrease of smoking prevalence and, in a reduction of tobacco- attributable morbidity and mortality. However, adoption of tobacco control policies and their implementation process has varied widely across countries. Hence, monitoring tobacco control policies, describing socio-political and economical drivers of their implementation and evaluating policies’ effectiveness and impact on tobacco-related indicators is key to continue to reduce the tobacco epidemic and move forward a tobacco-free world. OBJECTIVES. The main aim of this PhD thesis is to evaluate the impact of tobacco control policy implementation in Europe and Latin America (LA). The specific objectives are: a) to assess the use of the Tobacco Control Scale (TCS) as a research tool through a literature review; b) to evaluate the association between country-level implementation of tobacco control policies and smoking prevalence XV and quit ratios in the European Union (EU) over time; c) to assess the association between country-level socioeconomic factors (SES) and tobacco control policy implementation in Europe; d) to evaluate whether the hardening hypothesis can be confirmed at the in the EU and to analyse the determinants of hardcore and light smoking with a multilevel approach; and, finally, e) to monitor tobacco control policies in LA countries by developing and adapting the TCS to the region context. METHODS. This PhD thesis by articles consists of four studies. All studies have an observational design with either ecological (with countries as the unit of analysis) or multilevel (with individual data as first-level unit and country-related data as second-level unit of aggregated information) data. Additionally, a literature review on the topic is included. RESULTS. Our findings suggest that the TCS is a commonly used tool to measure country-level tobacco control policy implementation in research, and to explain potential variation of tobacco-related outcomes (i.e., smoking or exposure to SHS) in association with tobacco control policies. Indeed, our results show that higher TCS score(s) in 2007 are associated with both lower smoking prevalence (rsp=–0.444; p=0.02) and higher quit ratios (rsp=0.373; p=0.06) in 2014. Also, we observed that higher TCS score(s) in 2007 were associated with higher relative decreases in smoking prevalence (rsp=–0.415; p=0.03) between 2006–2014 in EU Member States (MS). Moreover, our results suggest a softening of the population of smokers in this region, since the hardcore smoking prevalence among adult smokers has increased by 0.55 (0.14–0.96) per each additional percentage point in the overall smoking prevalence. The odds of being a hardcore smoker increased over time and were higher in middle-aged men, people with financial difficulties and citizens of countries with lower country-levels of tobacco control policy implementation. However, no associations were found between the selected direct indicators of countries’ SES factors and their implementation level of tobacco control policies according to TCS scores, except for public spending on tobacco control. Cross- country differences in tobacco control efforts in Europe may partly be explained by their male-to-female ratio (used as a proxy of the stage of the epidemic at which countries are) and a geographical component as Western countries scored 15.69 points (pts) less on average in the total TCS than Northern countries (p=0.01). Finally, Panama with 70 pts and Uruguay with 68 pts are the countries that exhibit higher tobacco control policies according to the TCS-LA; while Guatemala (32 pts), Bolivia (30 pts) and Dominican Republic (29 pts) have implemented a lower number of tobacco control policies. Eight countries have implemented at least half of the tobacco control policies measured by the TCS-LA (with a score of 50 pts or more). CONCLUSION. Our findings show that tobacco control policies in Europe have had a positive effect on reducing the smoking prevalence and increasing the quit ratios, which have led to a softening of the population smokers. However, our results also suggest that tobacco control policies could have a differential impact on countries at different stages of the tobacco epidemic and on most vulnerable groups, increasing health inequalities. Hence, further research is needed to better understand the long-term effects of tobacco control policies on tobacco-related outcomes.
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FELIU, Ariadna. Evaluation of tobacco control policy implementation in European and Latin-American countries. [consulta: 13 de desembre de 2025]. [Disponible a: https://hdl.handle.net/2445/198330]