RESUMO Objetivo: Estimar a mortalidade atribuível ao tabagismo passivo na população de 35 anos ou mais, por sexo, nas 27 capitais brasileiras, no período de 2009 a 2021. Métodos: Utilizou-se um método dependente de prevalência, baseado no cálculo de Frações Atribuíveis à População (FAP). As mortes por doenças causalmente relacionadas ao tabagismo passivo foram obtidas do Sistema de Informações sobre Mortalidade do Sistema Único de Saúde (SIM/SUS); a prevalência, dos inquéritos do Sistema de Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico (Vigitel, 2009-2021); e os riscos relativos, de uma metanálise. A Mortalidade Atribuível (MA) ao tabagismo passivo e suas taxas foram estimadas por capital, ano, sexo e causas de morte. As tendências das taxas brutas de mortalidade atribuível ao tabagismo passivo foram analisadas aplicando modelos de regressão joinpoint. Resultados: O tabagismo passivo foi responsável por 64.913 mortes em todas as capitais brasileiras entre 2009 e 2021. As doenças cardiovasculares foram a principal causa de morte em ambos os sexos. A taxa de MA ao tabagismo passivo diminuiu de 33,1/100 mil mortes em 2009 para 15,4/100 mil mortes em 2021. Essa redução foi observada em todas as 27 capitais brasileiras, tanto de forma global quanto por sexo. Conclusão: O tabagismo passivo foi responsável por 1,4% de todas as mortes nas capitais brasileiras no período de 2009 a 2021 e apresentou uma tendência favorável, com as taxas diminuindo pela metade ao longo do período.

This study aimed to identify the key concepts involved in designing epidemiological surveys to estimate the prevalence of second-hand tobacco smoke (SHS) exposure in Portugal and Brazil. A two-round Delphi study was conducted. Firstly, a group of experts was asked for their opinions on the relevance of various concepts (exposure scenarios, recall, time, environmental context, exposure intensity, and relationship to smoking) and domains. Based on their responses, a new questionnaire was developed. The experts ranked the importance of different questions. A thematic analysis was carried out. The experts considered it important to evaluate SHS exposure in general, as well as in specific settings, such as the home, workplace, public and private transport (with or without children), and leisure settings. They reported that recalling the number of hours of exposure spent indoors and outdoors on working and non-working days, and in the last month, provided a more detailed assessment. They also stated that exposure intensity should be assessed either by the presence and number of smokers or by the perception of a smoke-heavy environment. Differences in responses according to the country in which experts reside were minimal. The researchers provided clear, precise, and consistent recommendations for collecting comparable data across studies to enact smoke-free policies. This reinforces the feasibility of using standardised questionnaires to evaluate SHS exposure across countries.

ABSTRACT Objective: To estimate the mortality attributable to passive smoking in the population aged 35 years old and older, by gender, in the 27 Brazilian state capitals, from 2009 to 2021. Methods: A prevalence-dependent method was used, based on the calculation of population attributable fractions (PAF). Deaths from diseases causally related to passive smoking were obtained from the Mortality Information System of the Brazilian Unified Health System (SIM/SUS); prevalence data were taken on SHS exposure were obtained from Vigitel surveys (2009-2021); and relative risks were obtained from a meta-analysis. Mortality attributable to passive smoking and mortality rates were estimated by capital city, year, gender, and cause of death. Trends in crude mortality rates attributable to passive smoking were analyzed using joinpoint regression models. Results: Passive smoking accounted for 64,913 deaths in all Brazilian state capitals between 2009 and 2021. Cardiovascular diseases were the main cause of death in both genders. The mortality rate attributed to passive smoking decreased from 33.1/100,000 deaths in 2009 to 15.4/100,000 deaths in 2021. This reduction was observed in all 27 Brazilian state capitals, both overall and by gender. Conclusion: Passive smoking was responsible for 1.4% of all deaths in Brazil during the period 2009-2021 and showed a favorable trend, with rates decreasing by half during the period.

Introduction and objectives Timely regional-specific estimates of smoking-attributable mortality (SAM) are crucial for healthcare planning and tobacco control advocacy. Currently, this information is lacking in Portugal. The aim of this study was to estimate SAM by region in 2019 among the Portuguese population aged >= 35 years.Methods SAM was estimated using an independent-prevalence method. Observed mortality was obtained from Portugal Statistics; lung cancer mortality rates in smokers and never-smokers from the Cancer Prevention Study I-II and updated relative risks from five contemporary US cohort studies. SAM was estimated for each NUTS-II region by sex, age, and cause of death. Crude SAM rates, sex and age-specific rates, and age-adjusted rates were calculated using the direct method.Results In 2019, tobacco consumption caused 13,847 deaths, representing 12.3% of total mortality among the Portuguese population aged >= 35 years. Of the total SAM, 71.2% occurred in men and 22.2% in those under 65 years; 42.5% was due to cancer, 35.4% to cardiovascular and metabolic diseases, and 22.2% to respiratory diseases. SAM greatly varied among regions from 2.1% in Madeira to 36.2% in the North region. In men, cancer was the leading cause of death in all regions, while in women it was cardiovascular and metabolic diseases.Conclusion In Portugal, tobacco-mortality burden is high and varies significantly by region, sex and age. Therefore, estimates disaggregated by sociodemographic data and region may better support decision-makers while tailoring and implementing tobacco control policies addressing health population needs. The apparent lower tobacco burden among women and in some Portuguese regions may dramatically rise in the near future. This and the high SAM in Portugal, particularly in some regions, highlights the need to accelerate tobacco control both at national and regional levels.

Los tratamientos farmacológicos para el tabaquismo asociados al asesoramiento psicológico triplican las posibilidades de abandono del tabaco. Sin embargo, la accesibilidad a estos fármacos está limitada por su coste económico. Con esta revisión pretendemos demostrar el efecto de la financiación parcial o total en términos de eficacia, efectividad, coste-efectividad y calidad de vida. Así se realizó una búsqueda bibliográfica de artículos relacionados con las cuestiones mencionadas anteriormente: análisis de la eficacia, efectividad y coste-efectividad de los tratamientos farmacológicos de la dependencia nicotínica y el efecto de su financiación. Se demuestra que la financiación del tratamiento farmacológico puede aumentar la eficacia y efectividad de las intervenciones para dejar de fumar. Dicha financiación aumenta la motivación para realizar un intento de abandono. Además, estas estrategias pueden incrementar la autoeficacia, generar influencia social y modificar las actitudes hacia el abandono. Aunque la financiación del tratamiento farmacológico beneficia a todos los fumadores, hay ciertas poblaciones de fumadores que son más sensibles a las estrategias de financiación como grupos sociales con menos ingresos y menor nivel educativo. Se ha demostrado que estas estrategias de financiación de las intervenciones para dejar de fumar mejoran la salud y la calidad de vida de la población, así como la economía, a la vez que reducen el consumo de tabaco.

Introduction: Estimating the prevalence of second-hand tobacco smoke exposure is a public health priority while evaluating the population-attributable disease burden and impact of smoking bans. We conducted a systematic review to analyze how secondhand tobacco smoke exposure has been assessed, and how its prevalence has been estimated among the Portuguese population since the implementation of the partial smoking ban in 2008. Methods: A literature search was conducted in the Web of Science, MEDLINE and Embase databases until November 2022, applying a pre-designed search strategy and following the PRISMA 2020 guidelines. The search was not restricted by study period, study design, sample size or language, and was complemented by a manual literature search. A modified Newcastle-Ottawa scale was used to assess the quality of the studies. Results: Thirteen cross-sectional studies were included. The prevalence of second-hand tobacco smoke exposure among the three European studies ranged from 8.2% (adult population exposed at home in 2010) to 93.3% (adolescent/adult population exposed in bar/restaurant terraces in 2016). Three nationwide studies estimated children’s exposure at home: ranging from 32.6% in 2010 - 2011 to 14.4% in 2016. According to the most recent studies, 49.8% of women living in Porto were exposed during the third trimester of pregnancy in 2010 - 2011; 32.6% and 38.4% of children were exposed at home, respectively in Lisbon and the Azores. Conclusion: A significant proportion of the Portuguese population, especially children and pregnant women, remain exposed to secondhand tobacco smoke. A comprehensive smoke-free policy is needed, not only in outdoor public places, but also in indoor private settings.

Lung cancer (LC) is a leading cause of cancer-related mortality worldwide. Lung Cancer Screening (LCS) programs that use low-dose computed tomography (LDCT) have been shown to reduce LC mortality by up to 25 % and are considered cost-effective. The European Health Union has encouraged its Member States to explore the feasibility of LCS implementation in their respective countries. The task force conducted a comprehensive literature review and engaged in extensive discussions to provide recommendations. These recommendations encompass the essential components required to initiate pilot LCS programs following the guidelines established by the World Health Organization. They were tailored to align with the specific context of the Portuguese healthcare system. The document addresses critical aspects, including the eligible population, methods for issuing invitations, radiological prerequisites, procedures for reporting results, referral processes, diagnostic strategies, program implementation, and ongoing monitoring. Furthermore, the task force emphasized that pairing LCS with evidence-based smoking cessation should be the standard of care for a high-quality screening program. This document also identifies areas for further research. These recommendations aim to guarantee that the implementation of a Portuguese LCS program ensures high-quality standards, consistency, and uniformity across centres.

The retraction of health sciences publications is a growing concern. To understand the patterns in a particular country-context and design specific measures to address the problem, it is important to describe and characterize retractions. We aimed to assess the evolution of health science retractions in Brazil and Portugal and to describe their features. We conducted a cross-sectional study including all health sciences retracted articles with at least one author affiliated to a Portuguese or Brazilian institution identified through Retraction Watch database. A total of 182 retracted articles were identified. The number of retractions increased over time, but the proportion related to the whole of publications remained stable. A total of 50.0% and 60.8% of the Portuguese and Brazilian retracted articles, respectively, were published in first and second quartile journals. Scientific misconduct accounted for 60.1% and 55.9% of retractions in Brazil and Portugal. In both countries, the most frequent cause of misconduct was plagiarism. The time from publication to retraction decreases as the journal quartile increases. The retraction of health sciences articles did not decrease over time in Brazil and Portugal. There is a need to develop strategies aimed at preventing, monitoring and managing scientific misconduct according to the country context.

Tobacco control (TC) is underpinned in two main strategies: preventing youth initiation and promoting tobacco cessation among users 1 . Healthcare professionals (HCPs), and specially physicians, should lead TC advocacy efforts, emphasize their role as TC leaders and exemplars

Abstract Abstract Health systems worldwide are implementing lung cancer screening programmes to identify early-stage lung cancer and maximise patient survival. Volumetry is recommended for follow-up of pulmonary nodules and outperforms other measurement methods. However, volumetry is known to be influenced by multiple factors. The objectives of this systematic review (PROSPERO CRD42022370233) are to summarise the current knowledge regarding factors that influence volumetry tools used in the analysis of pulmonary nodules, assess for significant clinical impact, identify gaps in current knowledge and suggest future research. Five databases (Medline, Scopus, Journals@Ovid, Embase and Emcare) were searched on the 21st of September, 2022, and 137 original research studies were included, explicitly testing the potential impact of influencing factors on the outcome of volumetry tools. The summary of these studies is tabulated, and a narrative review is provided. A subset of studies (n = 16) reporting clinical significance were selected, and their results were combined, if appropriate, using meta-analysis. Factors with clinical significance include the segmentation algorithm, quality of the segmentation, slice thickness, the level of inspiration for solid nodules, and the reconstruction algorithm and kernel in subsolid nodules. Although there is a large body of evidence in this field, it is unclear how to apply the results from these studies in clinical practice as most studies do not test for clinical relevance. The meta-analysis did not improve our understanding due to the small number and heterogeneity of studies testing for clinical significance. Critical relevance statement Many studies have investigated the influencing factors of pulmonary nodule volumetry, but only 11% of these questioned their clinical relevance in their management. The heterogeneity among these studies presents a challenge in consolidating results and clinical application of the evidence. Key points • Factors influencing the volumetry of pulmonary nodules have been extensively investigated. • Just 11% of studies test clinical significance (wrongly diagnosing growth). • Nodule size interacts with most other influencing factors (especially for smaller nodules). • Heterogeneity among studies makes comparison and consolidation of results challenging. • Future research should focus on clinical applicability, screening, and updated technology. Graphical abstract

reports of data from original research.• Policy Case Studies -brief articles on policy development at a regional or national level.• Study Protocols -Articles describing a research protocol of a study.• Methodology Papers -Papers that present different methodological approaches that can be used to investigate problems in a relevant scientific field and to encourage innovation.• Tobacco Industry Monitoring Letters -brief articles on tobacco industry tactics.

reports of data from original research.• Policy Case Studies -brief articles on policy development at a regional or national level.• Study Protocols -Articles describing a research protocol of a study.• Methodology Papers -Papers that present different methodological approaches that can be used to investigate problems in a relevant scientific field and to encourage innovation.• Tobacco Industry Monitoring Letters -brief articles on tobacco industry tactics.

INTRODUCTION There is growing concern about smoking among women, considering the trend toward reducing the gender gap in some WHO regions. In high-income countries, female smoking is declining but is increasingly concentrated among disadvantaged women1. In low-/middle-income countries, the pattern is more complex1. Women began smoking after men, lagging behind around 20–30 years2. Over time, the increasing female smoking trend narrowed the gender gap, and even more so among youth1. This gender gap is narrowest in highand upper-middle-income countries; in the region of the Americas and Europe, where 1 in 3 tobacco users are female3. In contrast, in most lowand low-middle-income countries, particularly in Africa, the Eastern Mediterranean, and the Western Pacific regions, female smoking remains under 5% and is expected to decline3. All WHO regions are on track to decrease female prevalence by at least 30% by 2025, with the exception of Europe, which remains the region with the highest tobacco use among females3. Female prevalence is lower than males in most countries. According to WHO estimates, in 2020, worldwide prevalence of tobacco use among people aged ≥15 years was 22.3% in both sexes (male: 36.7%; female: 7.8%)3. Furthermore, tobacco use will continue to decrease, reaching 20.4% in 2025 (male: 34.3%; female: 6.6%)3. Nevertheless, female smoking-attributable mortality is estimated to increase, following the tobacco-epidemic model2. Women who smoke have a relatively greater risk of smoking-related diseases than men, such as heart disease, stroke, decreased lung function, COPD, and LC in earlier ages4. Remarkably, women face unique problems linked to tobacco and their biological/reproductive life-cycle: female-specific cancers (cancer of the cervix); coronary heart disease, stroke, and thromboembolism (increased risk with oral contraceptives); menstruation (irregular cycles and dysmenorrhea); early menopause; osteoporosis; and impact on fertility/pregnancy and fetus/ child development, including the damaging effects of nicotine on brain development. Furthermore, women tend to face more difficulty to quit smoking4 and are more exposed to SHS5. The tobacco companies have targeted women by marketing light, mild, and menthol cigarettes, tailoring their advertisements to women. The greatest health challenge is to avert the increase in smoking among disadvantaged women, which fosters health inequalities1. Moreover, the launch of novel nicotine/tobacco products may menace the decreasing worldwide

Paper-questionnaires applied in the classroom have been the most common data-gathering to survey medical students. Recently, there has been a shift to online-surveys since they provide rapid data collection, facilitate data entry, and may lower costs. However, concerns include sample representativeness and data reliability/validity. Aim: To compare response rates (RR) among Portuguese Medical Schools (MS) participating in a national-survey exploring tobacco control curricula. Methods: All deans were approached by the PI, and then decided on online or paper-questionnaires. None follow-up incentives were used. All 8 Portuguese MS agreed to participate. Target population included 1865 finalists, ranging from 30 to 363 in each MS. Two MS are fully committed with medical education (ME) research: engaging students and delivering special training. We performed a descriptive analysis and compared frequencies using chi-square tests and calculating odds ratio (OR). Results: Most schools (5/8) applied the survey online. General response rate (RR) was 24.6%, range: 12.7%-100%. Among MS applying the survey online, RR was 21.5%(CI 95%19.29% -24.02%;range: 12.7%-100%). Among MS applying paper-questionnaires, RR was 28.7%(CI 95%25.4% -32.13%;range:15.2-64.8%), OR=1.462(CI95%:1.178-1.813), p=0.0005. Among MS committed with ME research, RR was 70.9%(CI 95% 63.72%- 77.1%), while in others RR was 19.4%(CI95%17.59%-21.36%), p<0.0001;OR=10.08(CI95%:7.147-14.36). Conclusions: Survey participation was substantially higher in MS promoting medical education research, suggesting that the main driver is school commitment and not data-gathering tools.

Lung cancer screening(LCS) programs are increasing worldwide. Incidental findings (IFs) on LCS are defined as low-dose CT findings unrelated to the primary purpose of identifying lung cancer. Most IFs on LCS are benign and clinically insignificant but are being increasingly recognized, and some require urgent referral for further diagnostic workup. Other findings are expected and are known as smoking-related comorbidities, including COPD, cardiovascular disease, emphysema, and interstitial lung disease, and their diagnosis can have a significant impact on patient prognosis. The purpose of this pictorial essay is to illustrate the most common IFs on LCS, organized by organ. We will discuss the current literature on IFs on LCS, focusing on their prevalence, appropriate communication, and triggering of clinical pathway systems.

Aim and Methods: A cross-sectional study surveying GPs/hospitalists was conducted in Portugal in order to assess self-reported barriers with physicians’ brief intervention on smoking cessation. Self-administered questionnaires were collected during national medical conferences. Participants were asked to score barriers to intervene in brief smoking cessation using a Likert scale. Systematic and consecutive sampling were carried out. Descriptive and inferential analysis was performed using chi-squared and McNemar tests. Results: Response rate was 64%. Of the 456 participants, 38.9.% were males and 35.7% were GPs; median age was 37 years (24-70). Among participants 69.5% reported not applying 5As brief intervention in routine clinical practice. The higher scored barriers to brief cessation counselling were intervening in non-motivated smokers (73.2%) and poor cessation training (62.1%), p<0.001; followed by time constraints (55.6%), and belief on smoking cessation poor efficacy (51.4%), p>0.05. Sex, age, medical speciality, training in smoking cessation, and smoking behaviour did not influence how physicians scored the barriers. The only exception was that younger physicians valorated significantly more lack of training as a main barrier to intervene in smokers while compared with older physicians (OR=1.22; 95%CI:1.07-1.40, p=0.003). Conclusions: The great majority of physicians do not intervene systematically in smoking-cessation. Most score high the barriers to intervene in smokers, and report false beliefs, highlighting the need for training programs including motivational skills by qualified experts.

INTRODUCTION:Smokers are frequent users of healthcare services. Admissions to hospital can serve as a "teachable moment" for quitting smoking. Clinical guidelines recommend initiating smoking cessation services during hospitalization; however, in Southern European countries less than 5% of inpatients receive a brief intervention for smoking cessation.OBJECTIVES:The aims of this study were (i) to examine rates of smoking abstinence during and after hospitalization; (ii) to measure changes in smoking patterns among persons who continued smoking after discharge; and (iii) to identify predictors of abstinence during hospitalization and after discharge.METHODS:A cohort study of a representative sample of current adult smokers hospitalized in two Spanish and two Portuguese hospitals. We surveyed smokers during hospitalization and recontacted them one month after discharge. We used a 25-item ad hoc questionnaire regarding their smoking pattern, the smoking cessation intervention they have received during hospitalization, and hospital and sociodemographic characteristics. We performed a descriptive analysis using the chi-square test and a multivariate logistic regression to characterize the participant, hospital, and smoking cessation intervention (5As model) characteristics associated with smoking abstinence.RESULTS:Smoking patients from both countries presented high abstinence rates during hospitalization (Spain: 76.4%; Portugal: 70.2%); however, after discharge, their abstinence rates decreased to 55.3% and 46.8%, respectively. In Spain, smokers who tried to quit before hospital admission showed higher abstinence rates, and those who continued smoking reduced a mean of five cigarettes the number of cigarettes per day (p ≤ 0.001). In Portugal, abstinence rates were higher among women (p = 0.030), those not living with a smoker (p = 0.008), those admitted to medical-surgical wards (p = 0.035), who consumed their first cigarette within 60 min after waking (p = 0.006), and those who were trying to quit before hospitalization (p = 0.043).CONCLUSIONS:Half of the smokers admitted into the Spanish hospitals are abstinent one month after discharge or have reduced their cigarettes per day. Nevertheless, success rates could be increased by implementing evidence-based tobacco cessation programs at the organizational-level, including post-discharge active quitting smoking support.CLINICAL RELEVANCE:Three-quarters of the inpatients who smoke remain abstinent during hospitalization and over half achieve to maintain their abstinence or at least reduce their consumption one month after discharge, proving that admission to hospitals is an excellent teachable moment to quit smoking.