Background:Alternative tobacco and nicotine-containing products can challenge progress in tobacco control. Waterpipes and e-cigarettes gained popularity among youth at different times, driven by flavours, social influence, and perceived reduced harm. This study examined trends in waterpipe and e-cigarette use among youth in the European Union (EU) from 2012 to 2023. Methods:We analysed data from five waves (2012-2023) of the Special Eurobarometer surveys in 26 EU Member States (N = 20,466; ages 15-30). Multilevel Poisson models assessed trends by sociodemographic subgroups, adjusting for country-level factors. Adjusted prevalence ratios (aPRs) with 95% confidence intervals (CIs) are reported. Findings:From 2012 to 2023, ever waterpipe use fell from 31.2% (95% CI: 29.1-33.3%) to 14.9% (13.2-16.8%), and current use (since 2017) from 2.5% (1.8-3.5%) to 1.8% (1.2-2.7%). Ever e-cigarette use rose from 12.2% (10.8-13.8%) to 25.8% (23.7-28.2%), and current use from 1.6% (1.1-2.3%) to 5.3% (4.0-6.8%), with cross-country variation. Compared with 2017, ever waterpipe use was lower in 2023 (aPR: 0.52, 95%CI: 0.42-0.66). Ever e-cigarette use was lower in 2012 (0.47; 0.40-0.54) and 2014 (0.75; 0.67-0.84). Current waterpipe use increased in 2020 (1.96; 1.16-3.28) then declined, while current e-cigarette use rose in 2020 (1.64; 1.15-2.34) and 2023 (4.27; 2.73-6.67). By 2023, ever waterpipe use was lower across all subgroups despite earlier heterogeneity, whereas ever e-cigarette use was higher among women (1.41; 1.18-1.69), urban residents (1.27; 1.11-1.46), and those without financial difficulties (1.38; 1.20-1.60). Current e-cigarette use was also higher across all groups. Interpretation:Declining waterpipe use and rising e-cigarette use among young Europeans show divergent patterns and differences across sociodemographic groups, particularly among women and socioeconomically disadvantaged groups. Continued surveillance and targeted interventions are needed to address emerging vulnerabilities in high-risk populations. Funding:European Union's Horizon 2020.

Introduction:Heated tobacco products (HTPs) and nicotine pouches (NPs) are emerging nicotine containing products. This study aims to examine the prevalence and patterns of use of HTPs and NPs, and factors associated with starting to use HTPs among European Union (EU) Member State (MS) citizens. Methods:We conducted a secondary analysis of data from the Special Eurobarometer 539 survey on attitudes towards tobacco and related products, carried out between May and June 2023, which included 26359 individuals aged ≥ 15 years across the 27 EU MS. We performed two-level logistic regression models, including sociodemographic factors as independent variables, to identify factors associated with HTP and NP current and ever use and reasons to start using HTPs. Results:In 2023, 1.7% (95% CI: 1.4-1.9) of EU MS citizens were current users of HTPs and 1.0% (95% CI: 0.9-1.3) were current users of NPs; 81.2% (95% CI: 75.6-85.8) of all current HTP users were concurrently smoking tobacco, while 43.5% (95% CI: 34.4-53.1) of current NP users were also current smokers, whereas 4.3% (95% CI: 2.16-83.6) of HTP users and 18.3% (95% CI: 12.1-26.8) of NP users had never smoked tobacco. Individuals aged 15-24 years were more likely to be current users of HTPs (AOR=4.21; 95% CI: 2.67-6.64), ever users of HTPs (AOR=9.70; 95% CI: 7.66-12.29), current users of NPs (AOR=7.36; 95% CI: 4.11-13.18) and ever users of NPs (AOR=6.48; 95% CI: 4.95-8.47). Finally, individuals aged 15-24 years (AOR=5.31; 95% CI: 1.72-16.38) and 25-39 years (AOR=2.68; 95% CI: 1.19-6.42) were more likely to have reported to have commenced HTP use because they liked HTP flavors. Conclusions:Although the overall prevalence of HTP and NP use in 2023 within the EU remained low, usage was concentrated among younger individuals, with dual use with conventional tobacco products being common. The emergence of NP use among individuals who have never smoked, along with the role of HTP flavors on HTP initiation among young people, are particularly concerning.

We conducted a secondary analysis of Eurobarometer survey data from 27 European countries, collected in 2017 (n = 28 300) and 2023 (n = 26 358), to assess changes in public support for standardised tobacco packaging. In the pooled analysis, support remained unchanged in the 19 MS without relevant legislation (adjusted Prevalence Ratio [aPR]=0.94, 95% Confidence Interval: 0.86-1.03), whereas the 8 MS that had implemented the policy by 2023 were significantly more likely to experience an increase in support (interaction term: aPR = 1.28, 1.17-1.41). The increase in support offers reassurance to policymakers advocating for tobacco packaging regulations and encourages MS to consider the adoption of similar policies.

Introduction:In December 2024, the Council of the European Union (EU) adopted a recommendation to expand regulations on the use of nicotine-containing products both in indoor settings and specific outdoor areas. This study aimed to examine sociodemographic factors associated with exposure to conventional tobacco smoke and aerosols across the EU and support for relevant regulations. Methods:We performed a secondary analysis of cross-sectional data from the Special Eurobarometer 99.3 (n=26 358, May-June 2023) across 27 EU Member States (MS). We estimated the weighted prevalence of secondhand exposure to tobacco smoke and aerosols and support for bans on smoking, e-cigarettes and heated tobacco products in public settings. Multilevel Poisson regression models explored associations between sociodemographic factors and these outcomes. Results:Exposure to secondhand smoke and aerosols varied across EU MS. Younger individuals, those with higher education, living with children, and current and former tobacco and nicotine users (prevalence ratio (PR) 1.16, 1.01-1.33; and PR 1.22, 1.05-1.41, respectively) were more likely to report exposure to both tobacco smoke and aerosol from emerging products. Women (PR 1.05, 1.02-1.08; and PR 1.03, 1.02-1.05, respectively), those living with children (PR 1.05, 1.02-1.07; and PR 1.04, 1.02-1.07, respectively) and those with higher education levels (PR 1.10, 1.04-1.15; and PR 1.10, 1.06-1.14) were more likely to support bans, whereas those with financial difficulties (PR 0.94, 0.89-0.99 and PR: 0.95, 0.91-0.99, respectively), as well as current and former smokers (PR 0.61, 0.55-0.67; and PR 0.78, 0.73-0.84, respectively) and emerging product users (PR 0.84, 0.76-0.92; and PR 0.69, 0.62-0.76, respectively), were less supportive. Conclusion:Our analysis found that both exposure to secondhand smoke and aerosol and support for bans in public spaces vary substantially between population subgroups and across countries. Our findings can support EU MS in implementing targeted interventions to increase population support for and implement the recent EU Council recommendations.

The monthly reports from the Tobacco Market Commission in Spain (CMT, by its acronym in Spanish), while data-rich, have critical deficiencies that limit their usefulness for public health. A critical analysis reveals three fundamental problems: institutional ambiguity, methodological opacity, and relevant analytical omissions. The authorship of the reports is uncertain, as they are published under the name of an advisory committee with representation from the tobacco industry, which compromises their independence. Methodologically, they lack clear definitions for key variables and use excessively aggregated data categories, preventing rigorous analysis and the replicability of findings. The reports are based on data self-reported by the industry itself, with no evidence of independent audits, which constitutes a serious conflict of interest. Furthermore, they systematically omit crucial information that the CMT derives from its activities, such as breakdowns of tax revenue by product, price-elasticity analyses, estimates of illicit trade, and the sector's advertising and promotion expenditures. For these reports to become an effective tool for formulating evidence-based policies, a reform is essential to ensure transparency in authorship, methodological rigor, data verification, and the inclusion of relevant economic and fiscal analyses.

INTRODUCTION:The European Commission's Special Eurobarometer surveys on tobacco are widely used as comparable and representative data across the European Union for monitoring consumption patterns. Despite their broad use, certain challenges persist, including inconsistencies in survey timelines and variations in the collected information across waves. This study aims to identify available tobacco and related product indicators, and assess their temporal comparability, to support researchers to better understand the potential uses of these data and their alignment with other sources. METHODS:We explored questionnaires and reports in these surveys on tobacco from the Eurobarometer official website since its inception (1992, 2002, 2005, 2006, 2008, 2009, 2012, 2014, 2017, 2020 and 2023 waves). We extracted and compared questions and responses on use of tobacco and related products, as well as on sociodemographic variables. Finally, we compared all indicators, including frequency and wording, and further mapped the consistency of the indicators and type of product used across the different waves. RESULTS:Current, daily, former and never use of conventional cigarettes has been consistently assessed across all waves, enabling temporal comparisons. From 2009, the surveys have expanded to include e-cigarette use; since 2012, the surveys include various combusted products such as cigars, pipes, cigarillos, and waterpipes, and from 2020, heated tobacco products. By contrast, detailed data on product-specific use intensity and initiation remain limited. While indicators for secondhand smoke exposure and smoking cessation were present in multiple waves, their comparability is hindered by variations in question-wording and responses. CONCLUSIONS:Some challenges exist in using Eurobarometer surveys for temporal estimation of tobacco-related burden. Nonetheless, these surveys remain a valuable and unique tool for monitoring tobacco and related product use across the European Union. To further enhance their utility, periodic re-evaluation by tobacco control experts is recommended to ensure that the surveys maintain comparability with past data while capturing effectively emerging products and trends.

INTRODUCTION:Exposure to tobacco content in media among youth is a well-established risk factor for smoking initiation and continued use. This study assessed the prevalence and nature of tobacco imagery on Spanish prime-time television (TV) programming and its associations with program characteristics: genre, production nationality, and broadcast timing. METHODS:A content analysis of 63959 minutes of TV programming in 2021, excluding advertisements and trailers, across 18 broadcast channels examined the presence of tobacco imagery: actual tobacco use, tobacco cultural cues, smoking ban violations, tobacco brand appearances, or any of these. RESULTS:The analysis revealed that 2.4% of the TV programming time contained at least one instance of tobacco imagery, resulting in 8.5 million impressions for viewers aged 4-24 years. Feature films had the highest prevalence of tobacco-related content (adjusted prevalence ratio, APR=11.9; 95% CI: 9.5-14.9). Tobacco-related content appeared more frequently outside designated children's protection hours (PR=0.7; 95% CI: 0.6-0.80). However, its presence within the designated children's protection schedule remains a significant concern, generating 15.6 million tobacco impressions for young viewers. CONCLUSIONS:The seemingly modest content level of tobacco imagery (2.4%) translates into a substantial number of impressions for young viewers aged 4-24 years, including during the designated children's protection schedule. Reducing tobacco imagery in films and TV series represents a promising strategy for curbing youth smoking. However, the current reliance on youth protection schedules is inadequate. To better protect children from tobacco imagery, policies should mandate strong anti-tobacco disclaimers preceding programs featuring tobacco and certificates of No Pay-off for tobacco portrayals.

OBJECTIVE:To analyse the political strategies employed by tobacco industry representatives to exploit their statutory position on the Tobacco Market Commission's (TMC) Advisory Council (AC) to influence Spain's tobacco control policies between 2023 and 2024. METHODS:A qualitative document analysis was conducted on all 22 official AC meeting minutes (January 2023-December 2024) obtained through a transparency request. From these records, 29 written statements by industry members were selected and systematically coded to identify political strategies of interference, guided by the Policy Dystopia Model. RESULTS:Of the 29 statements analysed, most originated from the tobacco manufacturers' association Asociación Empresarial del Tabaco. The most frequent strategy was obstructing or delaying policy implementation, particularly regarding plain packaging (14 statements). Other tactics included managing unfavourable information (seven statements), asserting a right to participate in policy discussions (five statements) and making veiled threats of legal action against proposed regulations (two statements). CONCLUSIONS:The tobacco industry exploited its institutionalised role on the AC as a 'Trojan horse' to actively subvert public health policies, contravening Spain's obligations under WHO Framework Convention on Tobacco Control Article 5.3. This legally sanctioned position creates a clear channel for policy interference. Urgent reforms are necessary to insulate public health policymaking from the vested commercial interests of the tobacco industry.

BACKGROUND:Spain implemented an extensive outdoor smoking ban during the COVID-19 pandemic in 2020. We examined support for this restriction during and beyond the pandemic among people who currently and formerly smoked. METHODS:Cross-sectional study. The 2021 ITC EUREST-PLUS Spain Survey used a multistage sampling to obtain a representative sample of people who currently or formerly smoked (n=1006). We estimated prevalence ratios (PRs) to examine associations with ban support during and after the pandemic. Analyses accounted for the complex sampling design and were weighted to ensure representativeness. RESULTS:Most people who currently (79.2%) and formerly smoked (94.6%) supported the outdoor smoking ban when a safe interpersonal distance could not be maintained during the pandemic. Support for a permanent ban remained substantial (61.4% and 87.2%, respectively). Those who currently smoke were more likely to support bans during and after the pandemic if they had smoke-free homes (PR=1.11; PR=1.29, respectively), understood secondhand smoke harms to health (PR=1.40; PR=1.65), had tried to quit (PR=1.14; PR=1.30) and self-reported as healthy (PR=1.40; PR=1.47). Those who formerly smoked were more likely to support bans during the pandemic if they had smoke-free homes (PR=1.08) and did not self-report as healthy (PR=0.95); and after the pandemic if they had quit smoking for ≥6 months (PR=1.23) and used alternative tobacco products (PR=1.17). CONCLUSIONS:Most people who currently or formerly smoked in Spain supported the outdoor smoking ban during and after the COVID-19 pandemic. This high acceptance suggests that the pandemic may have created an opportunity to strengthen tobacco control.

Los informes mensuales del Comisionado para el Mercado de Tabacos (CMT) en España, aunque extensos en datos, presentan deficiencias críticas que limitan su utilidad para la salud pública. Un análisis crítico revela tres problemas fundamentales: ambigüedad institucional, opacidad metodológica y omisiones analíticas relevantes. La autoría de los informes es incierta, publicándose bajo el nombre de un comité consultivo con presencia de la industria tabaquera, lo que compromete su independencia. Metodológicamente, carecen de definiciones claras para variables clave y utilizan categorías de datos excesivamente agregadas, impidiendo un análisis riguroso y la replicabilidad de los hallazgos. Los informes se basan en datos autodeclarados por la propia industria, sin evidencia de auditorías independientes, lo que supone un grave conflicto de intereses. Además, omiten sistemáticamente información crucial que el CMT deriva de sus actividades, como desgloses de recaudación fiscal por producto, análisis de elasticidad-precio, estimaciones de comercio ilícito y gastos en publicidad y promoción del sector. Para que estos informes se conviertan en una herramienta eficaz para la formulación de políticas basadas en la evidencia, es imprescindible una reforma que garantice transparencia en la autoría, rigor metodológico, verificación de datos e inclusión de análisis económicos y fiscales relevantes.

In the European Union (EU), one in five youth currently smoke, with over half establishing regular smoking by age 18. Yet, evidence on the historical trends of smoking initiation remains scarce despite its importance for tobacco control. Using four waves of the Special Eurobarometer survey (2012–20; n = 110 753, aged ≥15), we retrospectively estimated trends in initiation rates (IRs) of regular cigarette smoking in the EU from 1940 to 2019 among individuals aged 10–24 by sex, region, and country for each calendar decade. EU-wide smoking IRs have decreased compared to the peak period, with narrowing disparities by sex and region. For males, the IRs have declined from 5.7% (95% CI = 5.6–5.9) in the 1970s to 3.2% (95% CI = 3.0–3.3) in the 2010s, and for females from 3.9% (95% CI = 3.7–4.0) in the 1990s to 2.4% (95% CI = 2.3–2.5) in the 2010s. The decline was more pronounced among young adults aged 18–24 than minors aged 10–17, with minors’ IRs surpassing those of young adults during the 2010s. Marked declines occurred among young adults in all regions, while among minors, a clear decrease was observed only for males in Northern Europe. Concerningly, the IRs among minors have trended upward in Eastern Europe for both sexes. Despite declining youth smoking initiation, an unacceptably high number of European youth still begin smoking regularly before the legal age of 18. Stricter and comprehensive tobacco control policies targeting youth, along with smoke-free generation initiatives, could substantially reduce future tobacco use and smoking-related mortality.

INTRODUCTION The use of emerging tobacco and nicotine products affects tobacco use behaviors among college students. Thus, we aimed to examine transitions in tobacco use patterns and identify their predictors among smokers in a cohort of nursing students in Catalonia (Spain). METHODS We conducted a prospective longitudinal study of Catalan nursing students between 2015-2016 and 2018-2019. We examined transitions in tobacco use patterns between baseline and follow-up among smokers from: 1) daily to nondaily smoking, 2) non-daily to daily smoking, 3) cigarette-only use to polytobacco use, 4) poly-tobacco use to cigarette-only use, 5) between products, 6) reducing consumption by >= 5 cigarettes per day (CPD); and 7) quitting smoking. We applied a Generalized Linear Model with a log link (Poisson regression) and robust variance to identify predictors of reducing cigarette consumption by >= 5 CPD and quitting smoking, obtaining both crude and adjusted (APR) prevalence ratios and their 95% confidence intervals (CIs). RESULTS Among daily smokers at baseline, 12.1% transitioned to non-daily smoking at follow-up, while 36.2% of non-daily smokers shifted to daily smoking. Among cigarette-only users, 14.2% transitioned to poly-tobacco use, while 48.4% of polytobacco users switched to exclusive cigarette use. Among all smokers (daily and non-daily smokers), 60.8% reduced their cigarette consumption by >= 5 CPD and 28.3% quit smoking. Being a non-daily smoker (APR=0.33; 95% CI 0.19-0.55) and having lower nicotine dependence (APR=0.78; 95% CI 0.64-0.96) were inversely associated with reducing cigarette consumption, while being a non-daily smoker (APR=1.19; 95% CI: 1.08-1.31) was directly associated with quitting smoking. CONCLUSIONS Nursing students who smoked experienced diverse transitions in tobacco use patterns over time. Evidence-based tobacco use preventive and cessation interventions are needed to tackle tobacco use among future nurses.