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InSpain implemented a national smoke-free legislation that prohibited smoking in enclosed public places and workplaces except in hospitality venues. Init was extended to all hospitality venues and selected outdoor areas hospital campuses, educational centers, and playgrounds. The objective of the study is to evaluate changes in exposure to secondhand smoke among the adult non-smoking population before the first law and after the second law — Overall, the self-reported exposure to secondhand smoke fell from Self-reported exposure decreased from Overall, the geometric mean of the salivary cotinine concentration in adult non-smokers fell by Secondhand smoke exposure among non-smokers, assessed both by self-reported exposure and salivary cotinine concentration, decreased after the implementation of a stepwise, comprehensive smoke-free legislation.

There was a high reduction in secondhand smoke exposure during leisure time and no displacement of secondhand smoke exposure at home. This is an open-access article distributed under the terms of the Creative Commons Attributionwhich permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. The funders had no role in study de, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist.

Exposure to secondhand smoke SHS has been causally associated with many adverse health effects [1]. Worldwide, it has been estimated that, inexposure to SHS was responsible fordeaths due to ischemic heart disease, 21, deaths due to lung cancer,due to lower respiratory infections, and 36, due to asthma [2].

In Spain, between and deaths due to lung cancer and ischemic heart diseases have been attributed to SHS exposure [3]. Exposure to SHS can occur in different settings, including in the home, at the workplace, in other private and public places bars, restaurants, cafes, etc. Questionnaires, Smoke with the looking for sex for free, and airborne markers have been used to evaluate SHS among non-smokers.

The prevalence of SHS exposure in adult non-smokers varies considerably, depending on the country, the development of the tobacco epidemic [4]the comprehensiveness of smoke-free legislation, and the location of exposure to SHS. In Barcelona, in the period of —, the prevalence of self-reported exposure to SHS among non-smokers in all settings was similar to that of the whole country [6]. Some studies evaluated the impact of that law and showed important reductions in the exposure to SHS at the workplace [8]but no ificant changes occurred either at home or during leisure time [9] ; furthermore, and importantly, exposure to SHS was not reduced in bars or restaurants [8][10][11].

Due to the evidence provided by those evaluations, and after intensive advocate work, the law was amended [12]. The new Spanish legislation extended the smoking ban to all hospitality venues bars, cafes, pubs, restaurants, discos, and casinos without exception, [13] and extended the ban to some outdoors areas, including hospital premises, educational campuses, and playgrounds. The law included economic penalties for infringements and its enforcement is a responsibility of the regional and local health authorities.

After the implementation of the new law, SHS levels measured as the quantities of airborne nicotine and PM2. However, the impact of the more restrictive smoke-free legislation has not been assessed for SHS exposure in the general population. The objective of this study was to evaluate whether a measurable change in SHS exposure could be detected in the adult non-smoking population with the implementation of the stepped Spanish smoke-free legislation.

We compared SHS exposure measurements self-report data and levels of salivary cotinine before the first law —05 and after the second law —12 legislation. This study had a repeated cross-sectional de. We included a representative, random sample of the population of Barcelona Spain. Surveys were conducted before and after the implementation of smoke-free legislation.

The pre-legislation data were obtained between March and December We used the same strategy to collect the post-legislation data between June and March Detailed information about the pre-legislation survey sampling, face-to-face questionnaire, saliva collection, and cotinine analysis has been provided in studies [6][16].

The pre-legislation survey years —05included a final sample of 1, individuals and the post-legislation survey included a final sample of 1, individuals.

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Sample size calculations were performed with 5. We obtained data and addresses for Barcelona residents from the updated official city census years and provided by the Municipal Institute of Statistics of Barcelona. Individuals aged 16 years and older were eligible to participate in the study.

A letter was mailed to eligible individuals to inform them about the purpose of the study and that they had been selected at random. The letter also informed them that the study required a visit from an interviewer that would administer the questionnaire and collect a saliva sample.

The individuals were informed that they were free to decline participation, and that they could find out more about the study with a telephone call or ; the contact information was provided in the letter. Participants that could not be located after several attempts at different times of the day and different days of the week and those that declined to participate in the study were replaced at random.

The replacements were chosen from eligible individuals of the same sex, within a 5-year age group, and within the same district of residence. Substitutions ed for Individuals that agreed to participate were interviewed at home by trained interviewers. Participants were asked to an informed consent form before proceeding with the face-to-face interview. In case of subjects aged 16 an 17, parental written consent was obtained.

The same questionnaire was used in both surveys on traditional paper in the pre-legislation survey and in computer-assisted form in the post-legislation survey. Additional questions were included in the second survey regarding the smoke-free legislation.

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After completing the questionnaire, respondents were asked to provide a sample of saliva for the cotinine analysis, and weight and height were measured. The Research and Ethics Committee of Bellvitge University Hospital approved the study protocols and the informed consent forms, including parental written consent. This group included individuals that had never smoked and ex-smokers. Based on these two questions, we derived a dichotomous variable of exposure to SHS at home: 1 non-exposed individuals, which included those with no exposure according to answers to both questions, and 2 exposed individuals, which included all others.

For analysis, we derived a dichotomous variable of exposure to SHS during leisure time: 1 non-exposed individuals, which included those with no exposure according to the answer to the question, and 2 exposed individuals, which included all others.

Exposure to SHS in any setting was defined as exposure in at least one of the above mentioned settings. We asked the participants to provide a saliva sample to determine the cotinine levels. Cotinine is the main metabolite of nicotine; it is a stable, specific, sensitive biomarker of tobacco smoke in biological fluids, with a half-life of 15—17 h, and it reflects SHS exposure in the last 5—7 days [18]. We followed the same protocol in both surveys for collecting the saliva sample [6][16]. Briefly, participants were asked to rinse their mouths and then suck on a lemon candy Smint R to stimulate saliva production.

They were asked to provide about 9 mL of saliva by spitting into a funnel placed in a test tube. The limit of quantification was 0. The values from the second analysis were used in the statistical analysis. The models were adjusted for sex, age, and educational level. Geometric means GM and geometric standard deviations GSD were computed to describe the cotinine concentrations among non-smokers, due to its skewed distribution [17][19].

The data were fitted with generalized linear regression models of the log-transformed salivary cotinine concentration, adjusted for potential confounders.

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We also estimated the percentage changes in salivary cotinine concentration by comparing the geometric mean of the concentrations before and after the legislation. Samples with values below the limit of detection were ased a value of 0. Statistical analyses were performed with SPSS v A total of 2, participants were interviewed; 1, subjects were in the pre-legislation survey and 1, were in the post-legislation survey.

The samples were similar in the proportions of men and women, but we found ificant differences in age and educational level. Of the non-smokers, 62 in the pre-legislation and 48 in the post-legislation surveys were not included in Smoke with the looking for sex for free analysis, because they did not provide a saliva sample; in addition, 12 10 in the pre-legislation and 2 in the post-legislation survey were excluded, because cotinine analysis was not possible i.

Therefore, the final sample for analysis included a total of non-smokers; Footnote to Figure 1. Among people who declared to be non-smokers, we excluded those with unreliable cotinine levels for non-smokers this is, they had smoked at the time of the interview. We also excluded people who did not provide the saliva sample or in which the cotinine analysis was not possible because of insufficient sample or technical error. The prevalence of self-reported exposure to SHS in any setting fell from Overall, the prevalence of SHS exposure declined more sharply among women than among men The prevalence of exposure to SHS was reduced to a similar extent for individuals with different educational levels Appendix S1.

After controlling for sex, age, and educational level, self-reported exposure to SHS in any setting after the legislation was ificantly reduced PR: 0. Figure 2 shows the distribution of cotinine values among the non-smokers before and after legislation. The proportion of non-smokers with cotinine concentrations below the quantification limit 0. Table 2 compares the geometric mean values of salivary cotinine concentrations before and after the legislation among non-smokers.

The are stratified according to socio-demographic variables. The geometric mean of the cotinine concentrations among all adult non-smokers fell from 0. After adjusting for sex, age, and educational level, the reduction in cotinine concentration was The adjusted reduction in cotinine concentration after the implementation of the law was similar for participants of all ages. However, adult non-smokers with a university education showed the greatest adjusted reduction in cotinine concentration Table 2.

We found that self-reported exposure to SHS and salivary cotinine levels ificantly decreased after the implementation of the legislation. This reduction was observed at workplaces, during leisure time, and even in settings not regulated by the law, like in the home and public transportation. The reduction in SHS exposure between —05 and —12 was greater for women than men and for individuals aged 45 to 64 compared with other age groups. Haw and Gruer [20] also evaluated changes in self-reported exposure to SHS among adult non-smokers after the implementation of smoke-free legislation in Scotland.

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Relationship of secondhand smoke exposure with sociodemographic factors and smoke-free legislation in the European Union