Empathy plays a pivotal role in healthcare professions, influencing patient satisfaction and treatment outcomes. Understanding the determinants of empathy in medical students is essential. However, findings from previous studies have been inconsistent. We hypothesized that part of this variability may be attributed to the influence of the geo-sociocultural context. In this study, we aimed to compare the longitudinal determinants of empathy in four cohorts of medical students from two distinct geo-sociocultural backgrounds. This study included 199 medical students from Porto Alegre, Brazil and Geneva, Switzerland who were in their 1 st and 4 th years of training and agreed to participate on both occasions. The outcome variable was empathy scores (total and subdimensions) assessed through the Jefferson Scale of Empathy for Medical Students (JSE-S). Independent variables included gender, personality, motives for studying medicine, specialty preferences, and the level of motivation for medical studies. Multivariate regression analyses were conducted to investigate the associations between independent variables and empathy at each site in years 1 and 4. In year 1, the personality trait openness to experience was associated with higher empathy (total score) in both Porto Alegre (b = 0.503, p ≤ 0.01) and Geneva (b = 0.592, p ≤ 0.001), with this association persisting over time. However, the relationships between empathy and the other independent variables varied significantly depending on the site. The determinants of empathy were significantly modulated by the geo-sociocultural context. The personality trait openness to experience was the only consistent determinant of empathy across both sites over time. Associations between empathy and gender, motives for studying medicine, and specialty preferences were site specific. Our findings underscore the importance of considering students’ backgrounds when assessing empathy teaching and learning.

Purpose: To investigate (1) whether physical activity is associated with lung function in children and adolescents, (2) whether this association is modified by the subjects’ weight status, and (3) whether this association is mediated by the body mass index. Methods: This is a cross-sectional study including 460 participants aged 7–17 years, randomly selected from 13 public schools in southern Brazil. Collected data included anthropometric measures, physical activity, screen time, and spirometric measures expressed as percent predicted values. Data were analyzed using multiple linear regression and 2-way analysis of variance. Results: There were positive associations between physical activity and forced vital capacity (β = 3.897, P = .001) and forced expiratory volume in the first second (β = 2.931, P = .021). The effect modification by weight status was not statistically significant (forced vital capacity: Pinteraction = .296 and forced expiratory volume in the first second: Pinteraction = .057). Body mass index did not mediate the association between physical activity and spirometric outcomes (P > .05). Conclusion: Regular physical activity was associated with higher forced vital capacity and forced expiratory volume in the first second in children and adolescents. The observed associations were not modified by weight status nor mediated by body mass index. Our results reinforce the importance of regular physical activity for the development of lung function during childhood and adolescence.

This study aimed to examine the factorial structure of the Jefferson Scale of Empathy-Medical student version (JSE-S) and assess items' discriminatory ability at higher and lower empathy levels in medical student populations from different countries and languages. JSE-S datasets were retrieved from previous studies of 4113 first- and/or second-year medical students from Switzerland, Portugal, Italy, Brazil, France, Spain, New Zealand, UK, Ireland, Mexico, and Peru. Parallel principal component analyses and item response theory were applied. Excluding item 18, the Compassionate Care subscale emerged in five samples (Switzerland, Portugal, Italy, France and UK/Ireland), Perspective Taking in three (Switzerland, Portugal and UK/Ireland) and Walking in Patient's Shoes in five (Switzerland, Portugal, Spain, UK/Ireland and Mexico/Peru). All subscales had items providing overlapping information. The JSE-S subscales had reliable high test performance at low empathy levels, while when the JSE-S increased, the standard error also increased. There was no consistent support across countries for the JSE-S three-factorial structure. Items provided redundant information and discriminatory power decreased when aiming to differentiate students at high empathy levels. A JSE-S revision to improve cross-cultural comparability, results' generalizability and validity should focus on suppressing or reformulating items that cannot differentiate medical students' empathy.

PURPOSE:To assess the quality of the available evidence on the effect of exercise for the improvement of lung function in healthy children and adolescents.METHOD:We performed a systematic review and meta-analysis of intervention studies examining the effects of regular exercise on spirometric parameters of healthy children and adolescents aged ≤18 years.RESULTS:Within the exercise groups, there were significant improvements in forced vital capacity (mean difference: 0.17 L; 95% confidence interval, 0.07 to 0.26; P < .05) and forced expiratory volume in the first second (mean difference: 0.14 L; 95% confidence interval, 0.06 to 0.22; P < .05). Results were consistent across different age groups and duration of interventions. In the between-group analysis, forced vital capacity, forced expiratory volume in the first second, and peak expiratory flow were higher in the exercise group compared with the nonexercise group, but the differences did not reach statistical relevance. There was significant statistical heterogeneity between studies.CONCLUSION:Regular exercise has the potential to improve lung function parameters in healthy children and adolescents; however, the small number of studies and the heterogeneity between them raise concern about the quality of the currently available evidence. These findings bring to attention the need for well-designed trials addressing this important public health issue.

Objective. To examine the factorial structure of the Jefferson Scale of Empathy–Medical student version (JSE-S) and assess items’ discriminatory ability at higher and lower empathy levels in medical student populations from different countries and languages. Methods. JSE-S datasets were retrieved from previous studies of 4,113 first- and/or second-year medical students from Switzerland, Portugal, Italy, Brazil, France, Spain, New Zealand, UK, Ireland, Mexico, and Peru. Parallel principal component analyses and item response theory were applied. Results. Excluding item 18, the Compassionate Care subscale emerged in five samples (Switzerland, Portugal, Italy, France and UK/Ireland), Perspective Taking in three (Switzerland, Portugal and UK/Ireland) and Walking in Patient’s Shoes in five (Switzerland, Portugal, Spain, UK/Ireland and Mexico/Peru). All subscales had items providing overlapping information. The JSE-S subscales had reliable high test performance at low empathy levels, while when the JSE-S increased, the standard error also increased. Conclusion. There was no consistent support across countries for the JSE-S three-factorial structure. Items provided redundant information and discriminatory power decreased when aiming to differentiate students at high empathy levels. Practice Implications. A JSE-S revision to improve cross-cultural comparability, results’ generalisability and validity should focus on suppressing or reformulating items that cannot differentiate medical students’ empathy.

Background Medical schools can contribute to the insufficient primary care physician workforce by influencing students’ career preferences. Primary care career choice evolves between matriculation and graduation and is influenced by several individual and contextual factors. This study explored the longitudinal dynamics of primary care career intentions and the association of students’ motives for becoming doctors with these intentions in a cohort of undergraduate medical students followed over a four-year period. Methods The sample consisted of medical students from two classes recruited into a cohort study during their first academic year, and who completed a yearly survey over a four-year period from their third (end of pre-clinical curriculum) to their sixth (before graduation) academic year. Main outcome measures were students’ motives for becoming doctors (ten motives rated on a 6-point scale) and career intentions (categorized into primary care, non-primary care, and undecided). Population-level flows of career intentions were investigated descriptively. Changes in the rating of motives over time were analyzed using Wilcoxon tests. Two generalized linear mixed models were used to estimate which motives were associated with primary care career intentions. Results The sample included 217 students (60% females). Career intentions mainly evolved during clinical training, with smaller changes at the end of pre-clinical training. The proportion of students intending to practice primary care increased over time from 12.8% (year 3) to 24% (year 6). Caring for patients was the most highly rated motive for becoming a doctor . The importance of the motives cure diseases , saving lives , and vocation decreased over time. Primary care career intentions were positively associated with the motives altruism and private practice , and negatively associated with the motives prestige , academic interest and cure diseases . Conclusion Our study indicates that career intentions are not fixed and change mainly during clinical training, supporting the influence of clinical experiences on career-related choices. The impact of students’ motives on primary care career choice suggests strategies to increase the attractivity of this career, such as reinforcing students’ altruistic values and increasing the academic recognition of primary care.

Empathy is a multifaceted personal ability combining emotional and cognitive features modulated by cultural specificities. It is widely recognized as a key clinical competence that should be valued during professional training. The Jefferson Scale of Empathy for medical students (JSE-S) has been developed for this purpose and validated in several languages, but not in French. The aims of this study were to gather validity evidence for a newly developed version of the JSE-S and compare it between two French-speaking contexts. In total, 1,433 undergraduate medical students from the universities of Lyon (UL), France and Geneva (UG), Switzerland participated in the study completing the JSE-S in French. Total and partial scores of the three subscales ("perspective taking," "compassionate care" and "walking in patient's shoes") were calculated for each site. Construct validity of the JSE-S was analyzed considering three sources of evidence: content, internal structure and relations to other variables. A first-order Confirmatory Factor Analysis using structural equation modeling examined the three latent variables of the JSE-S subscales. Cronbach's α coefficients were 0.75 (UG) and 0.81 (UL). The items' discrimination power ranged between 0.29 and 1.60 (median effect size of 1.24). The overall correlations between items and total or partial scores derived from the latent JSE-S subscales were consistently similar in both study sites. Findings of this study confirm the latent structure of the JSE-S in French and its cross-national reproducibility. The comparable underlying structure of the questionnaire tested in two distinct French-speaking contexts endorses the generalizability of its measure.

Objective: The aim of this study was to explore the relationship between cognitive and behavioural empathy in medical students. Methods: Fourteen 4th year medical students recruited on the basis of their scores on the self-reported Jefferson Scale of Empathy (JSE-S) were divided into two groups: low JSE-S scorers (n = 8) (M = 96.75, SD = 10.3) and high JSE-S scorers (n = 6) (M = 121.3, SD = 2.94). They were discreetly videotaped while taking history with an incognito standardized patient. Students' behavioural empathy was measured using the Verona Coding System (VR-CoDES-P) and rating of non-verbal behaviour. Results: Patients expressed the same number of concerns per encounter in both groups but gave more cues to high-scorers (p = 0.029). However, students of both groups demonstrated the same amount of verbal empathy (high: 16% vs low: 15% p = 1.00). High JSE-S scorers' non-verbal communication tended to be rated slightly higher than low JSE-S-scorers with a higher use of facial expression (p = 0.008). Conclusion: This study did not reveal any differences of students' verbal empathy to patients' cues and concerns between low and high JSE_S scorers. Practice implications: The VR-CoDES_P is a useful tool to assess medical students and physicians empathic behaviour, allowing to disentangle the different components of empathy. (c) 2021 The Authors. Published by Elsevier B.V. CC_BY_NC_ND_4.0

Background No consensus exists on whether medical students develop towards more deep (DA) or surface learning approaches (SA) during medical training and how this impacts learning outcomes. We investigated whether subgroups with different trajectories of learning approaches in a medical students’ population show different long-term learning outcomes. Methods Person-oriented growth curve analyses on a prospective cohort of 269 medical students (M age =21years, 59 % females) traced subgroups according to their longitudinal DA/SA profile across academic years 1, 2, 3 and 5. Post-hoc analyses tested differences in academic performance between subgroups throughout the 6-year curriculum until the national high-stakes licensing exam certifying the undergraduate medical training. Results Two longitudinal trajectories emerged: surface-oriented ( n = 157; 58 %), with higher and increasing levels of SA and lower and decreasing levels of DA; and deep-oriented ( n = 112; 42 %), with lower and stable levels of SA and higher but slightly decreasing levels of DA. Post hoc analyses showed that from the beginning of clinical training, deep-oriented students diverged towards better learning outcomes in comparison with surface-oriented students. Conclusions Medical students follow different trajectories of learning approaches during a 6-year medical curriculum. Deep-oriented students are likely to achieve better clinical learning outcomes than surface-oriented students.

This study examined conscientiousness and the perceived educational environment as independent and interactive predictors of medical students’ performance within Biggs’ theoretical model of learning. Conscientiousness, the perceived educational environment, and learning approaches were assessed at the beginning of the third year in 268 medical students at the University of Geneva, Switzerland. Performance was examined at the end of the third year via a computer-based assessment (CBA) and the Objective Structured Clinical Examination (OSCE). Path analysis was used to test the proposed model, whereby conscientiousness and the perceived educational environment predicted performance directly and indirectly via students’ learning approaches. A second model included interaction effects. The proposed model provided the best fit and explained 45% of the variance in CBA performance, and 23% of the variance in OSCE performance. Conscientiousness positively predicted CBA performance directly (β = 0.19, p < 0.001) and indirectly via a deep learning approach (β = 0.05, p = 0.012). The perceived educational environment positively predicted CBA performance indirectly only (β = 0.02, p = 0.011). Neither conscientiousness nor the perceived educational environment predicted OSCE performance. Model 2 had acceptable, but less optimal fit. In this model, there was a significant cross-over interaction effect (β = 0.16, p < 0.01): conscientiousness positively predicted OSCE performance when perceptions of the educational environment were the most positive, but negatively predicted performance when perceptions were the least positive. The findings suggest that both conscientiousness and perceptions of the educational environment predict CBA performance. Research should further examine interactions between personality traits and the medical school environment to inform strategies aimed at improving OSCE performance.

THEORY:Several medical education studies suggest that deep approaches to learning (DA) are associated with better academic performance, whereas surface approaches (SA) are associated with worse academic performance. However, no study has assessed how these approaches change at the individual level during undergraduate medical training and how these trajectories contribute to academic performance. We assessed individual patterns of change in learning approaches throughout five years of medical training to determine whether and how DA and SA evolve during the curriculum and whether initial levels and rates of change predict performance in Year 5. Hypotheses: We hypothesized that (1) medical students have a higher preference for DA in comparison with SA; (2) these preferences change along the medical curriculum; and (3) DA predicts better academic performance. Method: Participants were 268 Geneva medical students (59% female) who completed the revised two-factor study process questionnaire in Years 1, 2, 3, and 5 of their 6-year curriculum. Student academic performance was registered in Year 5. Multivariate latent growth modeling was used to assess individual trajectories in learning approaches and test their associations with performance in Year 5. Results: Medical students were inclined to use DA rather than SA. Nevertheless, from Year 2 onward their use of DA decreased while their use of SA increased. Students with higher initial levels of DA tended to have lower initial levels of SA. Moreover, increases in SA were significantly associated with decreases in DA. However, only initial levels of DA and non-repeater status in Year 1 were positive and significant predictors of academic performance in Year 5. Conclusions: Although students tended to use DA rather than SA when entering medical school, their preferences for DA tended to decline throughout medical training while increasing for SA. Learning approaches during early study years, characterized by engagement and meaningful learning, predicted later academic performance. DA should be promoted during the early years of medical studies to foster student learning and to improve academic performance.

Empathy remains a widely discussed topic within medical education research. Studies on empathy changes among medical students are not univocal: empathy may decline, remain stable or increase. A largely unexplored research question regards inter-individual variability in empathy change, namely if different longitudinal trajectories of empathy exist. Evidence on the association of empathy trajectories with personality and motives for studying medicine is also scarce. Here, latent growth modeling examined empathy (measured with the Jefferson Scale of Empathy) among 201 medical students (M-age = 20.74, 57% females) across three assessments: at entry year (Year 1) and during the first two clinical years (Years 4 and 5). Associations between empathy trajectories, personality in Year 1 and motives for studying medicine in Years 4 and 5 were tested. We identified two empathy trajectory groups: lower and decreasing (n = 59; 29%) and higher and stable (n = 142; 71%). Regression analyses indicated that higher openness in Year 1 was associated with an increased probability of higher and stable group membership (controlling for motives in Year 1). The effect of openness disappeared controlling for motives in Years 4 and 5 while caring for patients (in Years 4 and 5) and altruism (in Year 4) were positively associated with an increased probability of higher and stable group membership. In sum, we observed that empathy remains stable in most medical students and declines in fewer; openness and patients-oriented motives for studying medicine are associated with higher and stable empathy. Encouraging medical students' patients-oriented motives from preclinical throughout clinical years may prevent empathy decline.

Resumo: Introdução: A empatia é um atributo valorizado como competência médica que influencia positivamente a relação médico-paciente e repercute na adesão ao tratamento e na melhora clínica. Estudos prévios indicam que há correlação entre personalidade e empatia em estudantes de Medicina, mas não existem, até o momento, dados referentes na literatura nacional. Este estudo teve como objetivos analisar a capacidade de empatia e os domínios de personalidade e investigar a correlação entre empatia e personalidade em estudantes de Medicina brasileiros. Métodos: Aplicaram-se dois instrumentos em estudantes do primeiro ano do curso de Medicina, nos anos de 2015 e 2017, para avaliar empatia e personalidade por meio das seguintes escalas: Jefferson Scale Empathy - Students version (JSE-S) e NEO-Five Factor Inventory (NEO-FFI). Foi realizada análise descritiva dos dados contendo média, escores mínimo e máximo, correlação e regressão linear de personalidade e empatia. Resultados: Preencheram os instrumentos 164 (96,4%) estudantes, sendo 50,5% do sexo feminino. A média do escore global da JSE-S foi de 117,6 ± 10,9, sendo a média feminina (119,5 ± 10,5) e masculina (115,7 ± 11) com diferença significativa (p < 0,01). No NEO-FFI, a conscienciosidade obteve a maior média global (29,1 ± 3,8), e coube ao neuroticismo a menor média (21,7 ± 4,7). No grupo feminino, a maior média foi encontrada em conscienciosidade (29,4 ± 3,8); e a menor, em abertura para experiência (20,6 ± 3,3). No grupo masculino, conscienciosidade (29,4±3,9) e neuroticismo (21,6±4,2) obtiveram as maiores e menores médias. Constatou-se diferença significativa entre os sexos no escore global da JSE-S, em abertura para experiência e socialização. As correlações encontradas entre empatia e personalidade foram fracas, e nenhuma delas foi estatisticamente significativa. Conclusão: As médias dos domínios de personalidade diferem entre os sexos, e, no presente estudo, em avaliação transversal, não houve correlação forte da personalidade e empatia em estudantes de Medicina. Estudos com abordagem longitudinal são necessários para elucidar modulações na empatia e personalidade, nos diferentes momentos da formação médica.

We investigated the 10-year variation of asthma cost by the change of disease severity/control in adults from 11 European countries. We identified 562 adults (aged 29-56) with physician-diagnosed current asthma at the ECRHS II (1999-2003, baseline) and ECRHS III (2010-2013). At the two contacts, patients were classified as “intermittent” or “persistent” (GINA 2002); in addition, persistent asthmatics were classified as “controlled/partly controlled” (CP) or “uncontrolled” (U) (GINA 2016). The variation of disease status was considered “worsened” (from intermittent to persistent or from CP to U; n=98), “improved” (from persistent to intermittent or from U to CP; n=99) or “unchanged” (n=225). The annual cost per patient was computed from the societal perspective following the bottom-up approach, using rates/wages/prices obtained at national level in 2004 (ECRHS II; converted to a 2013 equivalent) and 2013 (ECRHS III). The variation of the annual cost per patient was estimated by the change in disease status using a 2-level random-intercept Laplace quantile regression model, adjusting for sex, age, ever smoking, low socio-economic status and cost at baseline (centre: level 2 unit). At baseline, the mean annual cost was €235, €501 and €2,247 Euro per patient with intermittent, CP persistent or U persistent asthma, respectively. Compared to patients whose disease status was unchanged, those with an improved or worsened asthma showed reduced [-143 (95%CI: -282, -5) €; p=0.043] and increased [267 (95%CI: 121, 414) €; p<0.001] annual costs, respectively. Our study suggests substantial cost savings if asthma severity/control improved among adult patients in Europe.

Previous research highlighted associations between students’ motivation for medical studies and their learning approaches on the one hand and empathy on the other. Internal motivational factors for studying medicine (e.g., care for patients, save lives) coupled with a deep approach to learning have been positively related to empathy in contrast to external motivational factors (e.g., future earning potential, prestige) and surface learning. However, assessments of these assumptions among medical school candidates are scarce. This study examined the relationship between different motivational factors and empathy among students enrolled in a selection year in medicine by testing the mediating role of learning approaches. A sample of 572 candidates for medical studies answered a self-reported questionnaire half way through their selection year. Measures included internal and external motivational factors for studying medicine, deep and surface learning approaches and empathy. Path-analysis tested the mediation effects of deep and surface approaches to learning on the relationship of internal and external motivational factors with empathy. The deep learning approach partially mediated the significant positive association between internal motivational factors and empathy, while the surface learning approach fully mediated the significant negative association between external motivational factors and empathy. These results suggest that learning approaches could be a pathway by which internal and external motives for studying medicine are related to empathy among medical school candidates. Pedagogical strategies and educational environments accounting for individual differences in motivation and learning may contribute to training students to become professional and caring doctors in the future.

Students' approaches to learning are central to the process of learning. Previous research has revealed that influencing students' approaches towards deep learning is a complex process and seems much more difficult than expected, even in student-activating learning environments. There is evidence that learning approaches are impacted not only by the learning environment, but also by how students perceive it. However the nature of the links between the environment itself, the way in which it is perceived by students and students' learning approaches is poorly understood. This study aimed at investigating the relationships between students' perception of their educational context and learning approaches in three learning environments differing by their teaching formats (lecture or problem-based-learning PBL) and integration level of the curriculum (traditional or integrated). We tested the hypothesis that a PBL format and an integrated curriculum are associated to deeper approaches to learning and that this is mediated by student perception. The study sample was constituted of 1394 medical students trained respectively in a traditional lecture-based (n=295), in an integrated lecture-based (n=612) and in an integrated PBL-based (n=487) curricula. They completed a survey including the Dundee-Ready-Educational-Environment-Measure (students' perceptions of the educational environment) and the Revised-Study-Process-Questionnaire (learning approaches). Data were analysed by path analysis. The model showed that the learning environment was related to students' learning approaches by two paths, one direct and one mediated via students' perception of their educational context. In the lecture-based curricula students' used deeper approaches when it was integrated and both paths were cumulative. In the PBL-based curriculum students' did not use deeper approaches than with lectures, due to opposite effects of both paths. This study suggested that an integrated lecture-based curriculum was as effective as a PBL curriculum in promoting students' deep learning approaches, reinforcing the importance of integrating the curriculum before choosing the teaching format.

Background: The present study is aimed at providing a real-world evaluation of the economic cost of asthma, COPD and chronic bronchitis among adults in Europe. Methods: A prevalence-based cost-of-illness study was carried out on subjects (aged 39-68 years) with asthma (n=965), COPD (post-bronchodilator FEV1/FVC < LLN) without asthma (n=196) or chronic bronchitis without asthma/COPD (n=576). These patients were identified in general population samples from 12 countries and were examined in clinical settings in the European Community Respiratory Health Survey III (2010-2013). The cost estimates (doctor visits, clinical tests, drugs/vaccinations, ED visits/hospital admissions, premature retirement/productivity losses/leisure time forgone) were computed from the societal perspective following the bottom-up approach on the basis of rates, wages and prices in 2013 (obtained at the national level from official sources). Results: The mean annual cost per patient with asthma was EUR 1467 (95%CI: 1112-1862) and it was largely driven (56.6%) by premature retirement/productivity losses/leisure time forgone. The cost of COPD ranged from EUR 227 (95%CI: 48-517) among the patients without coexisting chronic cough or phlegm to EUR 1725 (95%CI: 176-3918) among the patients with these symptoms. The cost of chronic bronchitis was EUR 233 (95%CI: 99-415). When the costs due to comorbidities were included in our estimates, the mean annual cost per patient dramatically increased for all diseases (e.g. asthma: EUR 3689; COPD with coexisting chronic cough or phlegm: EUR 4439). Conclusions: Among the European adults, the cost of asthma, COPD and chronic bronchitis is substantial even in patients identified from the general population.

INTRODUCTION Smoking is still the most preventable cause of disease and premature death in Switzerland, as elsewhere. We aimed to assess the main determinants of smoking cessation in the population-based cohort of SAPALDIA (Swiss Cohort Study on Air Pollution and Lung and Heart Diseases in Adults). METHODS The SAPALDIA study was initiated in 1991 with 9651 participants aged 18 to 60 years from eight areas (S1). Follow-up assessments were conducted in 2002 (S2; 8047 participants) and 2010/11 (S3; 6088 participants). At each survey, detailed information on health and potential health-related factors was collected and lung function measured. Using logistic regression, we assessed predictors of smoking cessation between S1 and S2 and between S2 and S3. RESULTS In both periods, highest educational level (summary odds ratio [OR] 1.49, 95% confidence interval [CI] 1.08-2.06; ref. lowest level), FEV1/FVC <0.5 (OR 6.19, 95% CI 2.44-15.7, ref. FEV1/FVC ≥0.7), higher age in men (OR 1.02, 95% CI 1.01-1.03, per year) and overweight (OR 1.38, 95% CI 1.16-1.64) were significant predictors of smoking cessation. Nicotine dependence (OR 0.97, 95% CI 0.96-0.98, per cigarette smoked a day) and female sex between age 45 and 60 (e.g., OR 0.74, 95% CI 0.61-0.91, at age 50) were negatively associated with smoking cessation. Moreover, smokers at S2 reporting a diagnosis of depression were less likely to quit smoking by S3 (OR 0.53, 95% CI 0.30-0.93). CONCLUSIONS Prospective tobacco control policies in Switzerland should be addressed to women, younger persons and persons of lower education.

Healthy lifestyles are integral in preventing and treating common cardiovascular and metabolic diseases. The aim of this study was to observe smoking habits, alcohol intake, physical activity and body mass index over a 10-year period in a population-based cohort, particularly focusing on participants with hypertension and type 2 diabetes mellitus. Included were 4155 participants from the first (2001-2003) and second (2010-2011) follow-ups of the Swiss Cohort Study on Air Pollution and Lung and Heart Disease in Adults (SAPALDIA). Information was collected via health questionnaire; height and weight were measured. In a healthy lifestyle score one point was attributed per criterion; non-smoking, low risk alcohol consumption, BMI<25kg/m2, and regular physical activity. Overall in 2010-2011, 16.4% were smokers, 7.7% had at risk alcohol consumption, 25.5% were physically inactive and 57.8% were overweight or obese. Both those with hypertension and diabetes had lower mean healthy lifestyle scores than those without disease. Women with incident hypertension from 2001 to 2011 had lower odds of improving their healthy lifestyle score during this time period compared to those without this disease. In contrast, women with incident diabetes had higher odds of lifestyle score improvement. In men, neither hypertension nor diabetes was associated with change in lifestyle score. Our findings suggest that, irrespective of disease status, preventative attention is needed, particularly in regards to physical activity and bodyweight. These needs could be met by population-based interventions, a necessary and suitable option in both preventing and treating the non-communicable disease epidemic which currently faces countries worldwide.

Characteristics of included and excluded participants. Table S2. Association between functional IL6 polymorphisms and diabetes. (DOCX 27 kb)