Constantine I Vardavas - University of Crete

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Constantine I Vardavas
University of Crete

Publications Authored By Constantine I Vardavas

Tob Control
Tob Control 2016 May 6;25(3):333-40. Epub 2015 Feb 6.
Department of Social and Behavioral Sciences, Center for Global Tobacco Control, Harvard School of Public Health, Boston, Massachusetts, USA Clinic of Social and Family Medicine, Department of Social Medicine, School of Medicine, University of Crete, Heraklion, Greece.

We investigated the impact of cigarette price differences across the European Union (EU) on cross-border tobacco purchasing because of cheaper price among current cigarette smokers.
Individual-level tobacco-related data (including cross-border tobacco purchasing behavior) were from the Special Eurobarometer 385 (V.77.Read More

1), a cross-sectional survey of persons aged ≥15 years from 27 EU Member States during 2012. Country-specific weighted average prices (WAP) per 1000 cigarettes (as of 1 July 2012) were obtained from the European Commission, and divided by 50 to yield WAP per cigarette pack. The dispersion in EU cigarette prices was measured with the coefficient of variation. Multivariate logistic regression was applied to measure the relationship between EU-wide cigarette price differential and cross-border tobacco purchasing because of cheaper price among current cigarette smokers (n=6896).
The coefficient of variation for cigarette WAP within the EU was 0.39 (mean price=€3.99/pack). Of all current cigarette smokers in the EU, 26.2% (27.5 million persons) engaged in a cross-border tobacco purchase within the past 12 months, of which 56.3% did so because of cheaper price in another country. EU-wide cigarette price differential was significantly associated with making a cross-border tobacco purchase because of cheaper price (adjusted OR=1.34; 95% CI 1.22 to 1.47).
Reducing differences in cigarette tax and price within the EU, coupled with a stricter limitation on the quantity of cigarettes that it is possible to carry from one Member State to another, may help reduce cross-border tax avoidance strategies.

Tob Control
Tob Control 2016 May 24. Epub 2016 May 24.
Clinic of Social and Family Medicine, School of Medicine, University of Crete, Heraklion, Greece.

This study assessed changes in levels of ever use, perceptions of harm from e-cigarettes and sociodemographic correlates of use among European Union (EU) adults during 2012-2014, as well as determinants of current use in 2014.
We analysed data from the 2012 (n=26 751) and 2014 (n=26 792) waves of the adult Special Eurobarometer for Tobacco survey. Point prevalence of current and ever use was calculated and logistic regression assessed correlates of current use and changes in ever use, and perception of harm.Read More

Correlates examined included age, gender, tobacco smoking, education, area of residence, difficulties in paying bills and reasons for trying an e-cigarette.
The prevalence of ever use of e-cigarettes increased from 7.2% in 2012 to 11.6% in 2014 (adjusted OR (aOR)=1.91). EU-wide coefficient of variation in ever e-cigarette use was 42.1% in 2012 and 33.4% in 2014. The perception that e-cigarettes are harmful increased from 27.1% in 2012 to 51.6% in 2014 (aOR=2.99), but there were major differences in prevalence and trends between member states. Among those who reported that they had ever tried an e-cigarette in the 2014 survey, 15.3% defined themselves as current users. Those who tried an e-cigarette to quit smoking were more likely to be current users (aOR=2.82).
Ever use of e-cigarettes increased during 2012-2014. People who started using e-cigarettes to quit smoking tobacco were more likely to be current users, but the trends vary by country. These findings underscore the need for more research into factors influencing e-cigarette use and its potential benefits and harms.

Eur J Public Health
Eur J Public Health 2016 Apr 27;26(2):344-9. Epub 2015 Oct 27.
2 Center for Global Tobacco Control, Harvard School of Public Health, Boston, MA, USA 3 Clinic of Social and Family Medicine, University of Crete, Heraklion, Greece.

To explore whether exposure to secondhand smoke (SHS) among non-smokers in the European Union (EU) showed any association with sociodemographic factors and/or the extent of national tobacco control policies.
A secondary analysis was performed on data from 26 751 individuals ≥15 years old from 27 EU member states (EU MS), collected during the 2012 Special Eurobarometer survey (wave 77.1).Read More

Respondents were asked whether they had been exposed to SHS in eating or drinking establishments during the past 6 months, and/or in their workplace. Data on smoke-free policies were extracted from the European Tobacco Control Status Report and the European Tobacco Control Scale (TCS) in 2013.
In total, 29.0% of non-smoking participants reported being exposed to SHS in indoor areas. Males (vs. females) as well as individuals with difficulties to pay bills (vs. those with no difficulties), had significantly greater odds of being exposed to SHS in bars, restaurants and workplaces. For every unit increase of a country's score on the Smoke-free Component of the TCS (indicating greater adherence to smoke-free legislations) the odds ratio of reporting exposure to SHS was 0.82 in bars, 0.85 in restaurants and 0.94 in workplaces.
Differences in exposure to SHS clearly exist between and within EU MS, despite the fact that they all have signed the Framework Convention on Tobacco Control, with the burden found to disproportionally affect younger people and individuals with financial difficulties. Moreover, enforcement of smoke-free legislation was inversely associated with SHS exposure, highlighting the importance of enforcing comprehensive smoking bans.

Tob Control
Tob Control 2015 Dec 21;24(e4):e233-40. Epub 2014 Oct 21.
Department of Social and Behavioral Sciences, Center for Global Tobacco Control, Harvard School of Public Health, Boston, USA Department of Social Medicine, Clinic of Social and Family Medicine, School of Medicine, University of Crete, Heraklion, Greece.

This study assessed the role of cigarette design and marketing characteristics in initial smoking, cigarette brand choice and the perception of reduced harm of cigarette brands among adults in the European Union in 2012.
Data were from the Eurobarometer 385 (V.77.Read More

1) survey conducted in 2012 (n=26 566). Multivariate logistic regression was used to assess associations between cigarette design/marketing features with aspects of initial smoking (among current and former smokers), cigarette brand choice and perception of reduced harm of cigarette brands (among current smokers; p<0.05).
Respondents aged ≥55 years had lower OR than 15-24-year-olds of reporting initial smoking because of the presence of menthol flavour (adjusted OR (AOR)=0.42; 95% CI 0.24 to 0.72) or a specific sweet, fruity or spicy flavour (AOR=0.38; 95% CI 0.20 to 0.73). Females had higher OR than males of reporting initial smoking because of the presence of menthol flavour (AOR=2.89; 95% CI 2.07 to 4.02). Furthermore, female smokers were more likely to choose a cigarette brand based on specific tastes such as menthol or spicy, fruity or sweet flavours (AOR=1.33; 95% CI 1.14 to 1.56), or on the levels of tar, nicotine and carbon monoxide (AOR=1.30; 95% CI 1.11 to 1.52). Characteristics such as light-coloured packaging, the shape and size of cigarettes and the pack, the use of terms in the brand name such as 'silver' or 'blue' or descriptors such as 'natural' or 'organic' were all associated with perceptions of reduced harm among specific demographic groups.
These findings call for a stronger regulation of tobacco ingredients, packaging features and other marketing strategies that may increase the attractiveness of tobacco products or promote perceptions of harm reduction.

Eur Addict Res
Eur Addict Res 2015 11;21(1):47-52. Epub 2014 Nov 11.
Center for Global Tobacco Control, Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, Mass., USA.

Tobacco product warning labels are a key health communication medium with plain packaging noted as the next step in the evolution of tobacco packaging. We assessed the self-reported impact of text versus pictorial health warnings and the determinants of support for plain packaging of tobacco products in the European Union (EU).
The Special Eurobarometer 385 survey was analyzed for 26,566 adults from 27 EU countries in 2012.Read More

The self-reported impact of warning labels (text or pictorial) and determinants of EU-wide support for plain packaging were assessed using multivariate logistic regression.
Current smokers in countries where cigarette pictorial warnings were implemented had higher odds of reporting that health warning labels had any effect on their smoking behavior (making a quit attempt or reducing number of cigarettes smoked per day) compared to respondents in countries with text-only warning labels (adjusted odds ratio, aOR = 1.31; 95% confidence interval, 95% CI: 1.10-1.56). Population support for plain packaging of tobacco packs was higher in countries where cigarette pictorial warnings already existed (aOR = 1.17; 95% CI: 1.07-1.28).
These findings indicate that the implementation of pictorial warnings at an EU level may have a positive behavioral impact among smokers and pave the way for population support for plain packaging in the EU.

Prev Med
Prev Med 2015 Dec 21;81:87-91. Epub 2015 Aug 21.
School of Public Health, Imperial College London, United Kingdom. Electronic address:

Sedentary lifestyle is associated with more than three million deaths annually. Data from the 2013 Eurobarometer survey were analyzed to assess levels of physical activity across the European Union (EU) and to explore factors associated with adequate and high physical activity.
A representative sample of n=19,978 individuals aged 18-64 years from the 28 EU countries (sub-sample of the Eurobarometer survey, wave 80.Read More

2) was analyzed. Frequency and average duration of walking, moderate and vigorous physical activity was assessed with a self-reported questionnaire. Participants were then classified as physically inactive or adequately/highly active, based on the World Health Organization's (WHO) recommendations. The total amount of MET-minutes (MET-min) per week was also calculated for each respondent.
The proportion of physically inactive individuals was 28.6%, (12.4% in Sweden to 53.7% in Cyprus), while 59.1% of the respondents (37.9% in Portugal and Cyprus to 72.2% in Sweden) were classified as highly active. The mean total weekly physical activity was 2151 MET-min (95%CI: 2095-2206), of which 891 MET-min (95%CI: 858-924) were contributed by vigorous exercise, 559 MET-min (95%CI: 540-578) by moderate exercise (excluding walking) and 690 MET-min (95%CI: 673-706) by walking. Male gender, younger age, residence in rural areas and Northern Europe, higher education level and ability to pay bills were independently associated with higher physical activity.
One fourth of the EU population did not meet the WHO's recommendations for physical activity, with wide inequalities between and within countries. Wide-reaching environmental approaches are required to promote physical activity and address these inequalities.

Eur J Public Health
Eur J Public Health 2015 Oct 30;25(5):814-8. Epub 2015 Mar 30.
2 Department of Social and Behavioral Sciences, Center for Global Tobacco Control, Harvard School of Public Health, Boston, MA, USA 3 Clinic of Social and Family Medicine, School of Medicine, University of Crete, Heraklion, Greece.

Factors that influence smoking initiation and age of smoking onset are important considerations in tobacco control. We evaluated European Union (EU)-wide differences in the age of onset of regular smoking, and the potential role of peer, parental and tobacco product design features on the earlier onset of regular smoking among adults <40 years old in 27 EU countries.
We analysed data from 4442 current and former smokers aged 15-39 years, collected for the Eurobarometer 77.Read More

1 survey (2012). Respondents reported their age at regular smoking onset and factors that influenced their decision to start smoking, including peer influence, parental influence and features of tobacco products. Multi-variable logistic regression, adjusted for age; geographic region; education; difficulty to pay bills; and gender, was used to assess the role of the various pro-tobacco influences on early onset of regular smoking (i.e. <18 years).
Among ever smokers, the mean age of onset of regular smoking was 16.6 years, ranging from 15.8 to 18.8 years in member countries. 68.1% responded that they started smoking regularly when they were <18 years old. Ever smokers who reported they were influenced by peers (OR = 1.70; 95%CI 1.30-2.20) or parents (OR = 1.60; 95%CI 1.21-2.12) were more likely to have started smoking regularly <18 years old. No significant association between design and marketing features of tobacco products and an early initiation of regular smoking was observed (OR = 1.04; 95%CI 0.83-1.31).
We identified major differences in smoking initiation patterns among EU countries, which may warrant different approaches in the prevention of tobacco use.

Tob Control
Tob Control 2015 Sep 16;24(5):442-8. Epub 2014 Jun 16.
Department of Social and Behavioral Sciences, Center for Global Tobacco Control, Harvard School of Public Health, Boston, Massachusetts, USA.

This study assessed the prevalence and determinants of e-cigarette use among persons aged ≥15 years in 27 European Union (EU) member countries during 2012.
The 2012 Eurobarometer 385 (77.1) survey was analysed for n=26 566 respondents.Read More

Knowledge, perception of harm, and determinants of e-cigarettes use were assessed, while separate regression analyses among current (n=7352) and former cigarette smokers (n=5782) were performed. National estimates of the number of e-cigarette users were also extrapolated.
20.3% of current smokers, 4.7% of ex-smokers, and 1.2% of never cigarette smokers in the EU reported having ever used an e-cigarette (overall approximately 29.3 million adults). Among smokers, ever e-cigarette use was more likely among 15-24-year-olds (aOR 3.13, 95% CI 2.22 to 4.54) and 25-39-year-olds (aOR 2.00, 95% CI 1.47 to 2.78) in comparison to older smokers, and among those who smoked 6-10 cigarettes/day (aOR 1.53, 95% CI 1.10 to 2.13) or 11-20 cigarettes/day (aOR 2.07, 95% CI 1.52 to 2.81) in comparison to very light smokers (≤5 cigarettes/day). Moreover, e-cigarette use was more likely among smokers who had made a past year quit attempt (aOR 2.08, 95% CI 1.67 to 2.58). E-cigarette use among ex-smokers was associated only with the respondents' age, with younger ex-smokers being more likely to have ever used an e-cigarette.
A substantial number of EU adults have ever used e-cigarettes. Ever users were more likely to be younger, current smokers, or past-year quit attempters. These findings underscore the need to evaluate the potential long term impact of e-cigarette use on consumer health, cessation and nicotine addiction and formulate a European framework for e-cigarette regulation within the revised EU Tobacco Product Directive.

Purpose . The explosive rise in Internet use calls for effective ways to utilize new forms of social media to enhance school smoking prevention programs. We attempted to design and test an educational intervention for youth tobacco prevention.Read More

Design . Intervention design and posttest pilot implementation. Setting . A single high school in Athens, Greece. Subjects . Two hundred twenty-five students (aged 15-18 years). Intervention . A Facebook-integrated educational intervention in six simple steps was designed and tested during an ad hoc smoking prevention lecture to high school students in Greece in order to stimulate social mobilization in online networks. Measures . Number of students with an active Facebook account, percentage posting antismoking messages within a 72-hour period, number of Facebook friends reached. Analysis . Descriptive statistics. Results . Assessed 3 days after the lecture, 15.9% of students had posted a smoking-related sentence in their Facebook account, a take-home message that was spread as a note on their wall via news feed to their 20,095 cumulative Facebook friends. Conclusion . One smoking-related take-home message can spread virally to a large number of adolescents through their Facebook friends. This intervention provides insight into a novel way of providing health information to youth, a hard-to-reach and vulnerable population.

Chron Respir Dis
Chron Respir Dis 2015 May 10;12(2):120-31. Epub 2015 Mar 10.
Center for Global Tobacco Control, Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, MA, USA.

Exposure to secondhand smoke (SHS) has been linked to disease, disability, and premature death. While several countries have enacted smoke-free legislations, exposure to SHS may still occur in unregulated private environments, such as in the family car. We performed a systematic review of peer-reviewed literature in PubMed and Web of Science up to May 2013.Read More

Articles were selected if they provided a quantitative measure of SHS exposure (biological or atmospheric markers); the study was conducted inside a car; and the assessed exposure was attributable to cigarette combustion. From 202 articles identified, 12 met the inclusion criteria. Among all studies that assessed smoking in cars with at least one window partially open, the particulate matter 2.5 μm or less in diameter (PM2.5) concentrations ranged from 47 μg/m(3) to 12,150 μg/m(3). For studies with all windows closed, PM2.5 ranged from 203.6 μg/m(3) to 13,150 μg/m(3). SHS concentration in a car was mediated by air-conditioning status, extent of airflow, and driving speed. Smoking in cars leads to extremely high exposure to SHS and increased concentration of atmospheric markers of exposure-even in the presence of air-conditioning or increased airflow from open windows. This clearly shows that the only way to protect nonsmokers, especially children, from SHS within cars is by eliminating tobacco smoking.

Prev Med
Prev Med 2015 Mar 6;72:83-8. Epub 2015 Jan 6.
Department of Social and Behavioral Sciences, Center for Global Tobacco Control, Harvard School of Public Health, Boston, MA, USA.

We assessed the prevalence of dental disease among U.S. children and adolescents aged 6-17 years, as well as the impact of unmet dental needs on school absenteeism because of illness/injury within the past 12 months.Read More

Data were from the 2011/2012 National Survey of Children's Health (n=65,680). Unmet dental need was defined as lack of access to appropriate and timely preventive or therapeutic dental healthcare when needed within the past 12 months. The impact of unmet dental needs on school absenteeism was measured using a multivariate generalized linear model with Poisson probability distribution (p<0.05).
Within the past 12 months, 21.8% (10.8 million) of all U.S. children and adolescents aged 6-17 years had "a toothache, decayed teeth, or unfilled cavities." Of all U.S. children and adolescents aged 6-17 years, 15.8% (7.8 million) reported any unmet dental need (i.e., preventive and/or therapeutic dental need) within the past 12 months. The mean number of days of school absence because of illness/injury was higher among students with an unmet therapeutic dental need in the presence of a dental condition compared to those reporting no unmet dental need (β=0.25; p<0.001).
Enhanced and sustained efforts are needed to increase access to dental services among underserved U.S. children and adolescents.

Eur J Public Health
Eur J Public Health 2014 Dec 10;24(6):974-9. Epub 2014 Mar 10.
1 Center for Health Services Research, Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.

Economic crises may have a significant impact on public health. The objective of this study was to assess trends in health-related behaviours and cardiovascular risk factors within Greece before, at the beginning and during the current financial crisis by comparing data from three waves of the Greek cross-sectional household 'Hellas Health' surveys.
Data from three waves were analysed.Read More

The first wave was conducted in 2006 (n = 1005), the second in 2008 (n = 1490) and the third in 2011 (n = 1008). Samples were representative of the Greek adult population in terms of age and residency. Smoking status, height, weight and fruit and vegetable consumption were self-reported. Physical activity levels were assessed with the International Physical Activity Questionnaire.
The prevalence of smoking in Greece decreased from 42.6 to 38.1% during the crisis period 2008-11 (P = 0.026), but not during 2006-8. The prevalence of high levels of physical activity increased among Greek adults (from 21.9 to 31.7%, P < 0.001) in all socio-economic and demographic groups, with the exception of the highest socio-economic status (SES) group. On the contrary, the consumption of at least five portions of fruit and vegetables per day significantly decreased during the crisis among those of lower SES (from 9.0 to 4.1%, P = 0.006). Prevalence of obesity did not show significant trends.
During the economic crisis, fruit and vegetable consumption alarmingly decreased, especially among those of lower SES, whereas trends in smoking prevalence and physical activity levels seem favourable. These results indicate that the economic crisis may unequally impact cardiovascular risk factors among different socio-economic groups.

Prev Med
Prev Med 2014 Dec 21;69:21-7. Epub 2014 Aug 21.
Center for Global Tobacco Control, Department of Social and Behavioral Sciences, Harvard School of Public Health, USA.

We investigated the impact of proximity of tobacco retail outlets to schools on tobacco-related behavior and attitudes of school personnel in sub-Saharan Africa.
A pooled analysis of the 2006-2011 Global School Personnel Surveys from 19 sub-Saharan African countries was performed (n=12,201). Multivariate logistic regression analyses were applied to measure the relationship between proximity of tobacco outlets to school premises and school personnel's tobacco-related behavior and attitudes (p<0.Read More

Among all school personnel, there was a significant association between the presence of tobacco outlets on school premises and current cigarette smoking (adjusted odds ratio [aOR]=3.89; 95% confidence interval [CI]: 2.17-7.20), current smokeless tobacco use (aOR=2.63; 95%CI: 1.04-6.65), and permissiveness towards tobacco industry sponsorship activities in school (aOR=2.27; 95%CI: 1.37-3.78). Complete smoke-free school policies were associated with lower odds of current cigarette smoking (aOR=0.42; 95%CI: 0.23-0.74), but were not significantly associated with current smokeless tobacco use. Among lifetime any tobacco users, there was a significant association between the presence of tobacco outlets on school premises and use of combustible (aOR=2.03; 95%CI: 1.09-3.75) and smokeless (aOR=3.85; 95%CI: 1.51-9.81) tobacco products on campus within the past year.
Policies limiting the distance of tobacco outlets from schools, coupled with complete tobacco-free school policies may reduce tobacco use among school personnel.

PLoS One 2014 3;9(12):e114256. Epub 2014 Dec 3.
Tobacco Control Unit, Cancer Prevention and Control Program, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain; Cancer Prevention and Control Group, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain; Department of Clinical Sciences, Universitat de Barcelona, Barcelona, Spain.

Currently, there is an intensive debate about the regulation of the use of electronic cigarettes (e-cigarettes) in indoor places. The aim of this study was to assess the attitudes toward e-cigarette use in indoor workplaces and selected public and private venues among the general population in Barcelona (Spain) in 2013-2014.
This is a cross-sectional study of a representative sample of the population of Barcelona (n = 736).Read More

The field work was conducted between May 2013 and February 2014. We computed the prevalence and the adjusted odds ratios (OR) derived from multivariable logistic regression models.
The awareness of e-cigarettes was 82.3%. Forty five percent of respondents did not agree with the use of e-cigarettes in public places and 52.3% in workplaces. The proportion of disapproval of the use of e-cigarettes in indoor places was higher at 71.5% for schools and 65.8% for hospitals and health care centers; while the prevalence of disapproval of e-cigarette use in homes and cars was lower (18.0% and 32.5%, respectively). Respondents who disagreed on the use of e-cigarettes in indoor workplaces were more likely to be older (OR = 1.64 and 1.97 for groups 45-64 and ≧65 years old, respectively), those with a high educational level (OR = 1.60), and never and former smokers (OR = 2.34 and 2.16, respectively). Increased scores in the Fagerström test for cigarette dependence were also related to increased support for their use.
Based on this population based study, half of the general population of Barcelona does not support the use of e-cigarettes in indoor workplaces and public places, with the percentage reaching 65% for use in schools, hospitals and health care centers. Consequently, there is good societal support in Spain for the politicians and legislators to promote policies restricting e-cigarettes use in workplaces and public places, including hospitality venues.

Eur. J. Pediatr.
Eur J Pediatr 2014 Nov 3;173(11):1459-66. Epub 2014 Jun 3.
Center for Global Tobacco Control, Department of Social and Behavioral Sciences, Harvard School of Public Health, 401 Park Drive Landmark Center 4th Floor West Wing 677 Huntington Avenue, Boston, MA, 02215, USA,

Comprehensive smoke-free legislations prohibiting smoking in indoor areas of workplaces, bars, and restaurants have been adopted in most of the USA; however, limited efforts have focused on regulating secondhand smoke (SHS) exposure in the family car. The objective of this study was to identify the determinants and national/state-specific population support for smoke-free cars, in the presence of any occupant in general, but particularly when children are present. National data of US adults aged ≥18 years (n = 164,819) were obtained from the 2010/2011 Tobacco Use Supplement of the Current Population Survey.Read More

Among all US adults, a significantly greater proportion supported smoke-free cars when it was specified that the occupant was a child compared to when not specified (93.4 vs. 73.7 %, p < 0.05). Age, race/ethnicity, gender, current tobacco use, marital status, and the existence of household smoke-free regulations all mediated population support for smoke-free cars.
While differences within the US population were noted, this study however showed overwhelming support for smoke-free car policies, particularly when children are present. Policies which prohibit smoking in indoor or confined areas such as cars may benefit public health by protecting nonsmoking children and adults from involuntary SHS exposure.

Scand J Public Health
Scand J Public Health 2014 Nov 22;42(7):589-92. Epub 2014 Jul 22.
Department of Primary Care and Public Health, School of Public Health, Imperial College London, UK.

Increased taxation on tobacco products is an effective method of reducing tobacco use. This study assessed population support among respondents aged ≥15 years, from 27 European Union (EU) countries for increased taxation and other tobacco control measures during the 2009-2012 period.
Nationally representative data were obtained from the 2009 (n=26,788) and 2012 (n=26,751) cross-sectional Eurobarometer surveys.Read More

Estimates were compared using chi-square statistics. The effect of the relative change in gross domestic product (GDP) on the change in support for increased taxation during 2009-2012 was calculated using the Pearson correlation coefficient and linear regression models.
Between 2009 and 2012, population support for increased taxes on tobacco products declined (56.1% to 53.2%; p<0.001). However, support for other tobacco control measures increased significantly. After adjusting for baseline GDP per capita (2009), a 10% increase in GDP per capita was associated with 4.5% increase in support of tax increases. When Latvia and Lithuania were excluded from the analyses (because of their marked deviation from the general trend), there was a strong correlation between the change in GDP and support for increased taxes (ρ=0.64; p<0.001). Also, after adjusting for baseline GDP, support for higher taxes on tobacco increased by 7.0% for every 10% increase in GDP between 2009 and 2012.
Population support for tax increases declined in the EU between 2009 and 2012, especially in countries with declines in GDP nonetheless, public support for other tobacco control measures remains high, thus indicating a viable environment for more comprehensive tobacco control.

Int J Occup Med Environ Health
Int J Occup Med Environ Health 2014 Oct 12;27(5):875-81. Epub 2014 Sep 12.
Department of Social and Behavioral Sciences, Center for Global Tobacco Control, Harvard School of Public Health, Boston, MA, USA,

Secondhand smoke (SHS) is a defined occupational hazard. The association though between SHS exposure in semi-open air venues and tobacco specific carcinogen uptake is an area of debate.
A cross sectional survey of 49 semi-open air cafes in Athens, Greece was performed during the summer of 2008, prior to the adoption of the national smoke free legislation.Read More

All venues had at least 1 entire wall open to allow for free air exchange. Indoor concentrations of particulate matter smaller than 2.5 microns (PM2.5) attributable to SHS were assessed during a work shift, while 1 non-smoking employee responsible for indoor and outdoor table service from each venue provided a post work shift urine sample for analysis of 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL).
Post work shift NNAL concentrations were correlated with work shift PM2.5 concentrations attributable to SHS (r = 0.376, p = 0.0076). Urinary NNAL concentrations among employees increased by 9.5%, per 10 μg/m(3) increase in PM2.5 concentrations attributable to SHS after controlling for the time of day and day of week.
These results indicate that the commonly proposed practice of maintaining open sliding walls as a means of free air exchange does not lead to the elimination of employee exposure to tobacco specific carcinogens attributable to workplace SHS.

Tob Control
Tob Control 2014 Sep 6;23(5):452-4. Epub 2013 Mar 6.
Department of Social and Behavioral Sciences, Center for Global Tobacco Control, Harvard School of Public Health, Boston, Massachusetts, USA.

Greece is in an economic crisis compounded by the costs caused by smoking. The present investigation estimates the economic and public health benefits ensuing from the recent cigarette excise tax increase in 2011 and projects the potential benefits from an additional €2.00 per pack cigarette tax increase.Read More

The effects of the recent cigarette excise tax increase were calculated on outcome measures: total price per pack, including specific excise, ad valorem tax, and value-added tax consumption; tax revenue; and per capita consumption of cigarettes. Additionally, smoking-attributable mortality, years of potential life lost, and productivity losses were estimated. Projected effects of an additional €2.00 per pack tax increase on consumption and tax revenue were also assessed.
The cigarette excise tax increase in 2011 created €558 million in new tax revenue. Cigarette consumption reached a recent low of 24.9 billion sticks sold or 2197 sticks per person in 2011, indicating a 16% decrease in per capita cigarette consumption from the previous year. An additional €2.00 per pack increase in Greek cigarette taxes is projected to result in reduced cigarette sales by an additional 20% and lead to an increase in total cigarette tax revenues by nearly €1.2 billion and the prevention of 192,000 premature deaths.
Nations such as Greece, should employ taxation as a crucial measure to promote public health and economic development in such dire times. International economic organisations should aggressively pursue programmes and policies that champion the economic benefits of tobacco taxation.

Prev Med
Prev Med 2014 Aug 30;65:87-91. Epub 2014 Apr 30.
Center for Global Tobacco Control, Department of Social and Behavioral Sciences, Harvard School of Public Health, 401 Park Drive, Landmark Center, 4th Floor West Wing, Boston, MA 02215, USA. Electronic address:

Previous research has shown that long or slim cigarette design can mitigate perception of harmfulness. Cadmium (Cd) is a toxicant in cigarettes and is associated with adverse outcomes. We assessed the relationship between cigarette rod length/circumference and blood Cd levels among U.Read More

S. smokers using data from the 1999-2010 National Health and Nutrition Examination Survey.
The analyses were performed on 4486 current cigarette smokers aged ≥20years old. Cigarette rod length included regular (68-72mm), king (79-88mm), long (94-101mm), and ultra-long (110-121mm) cigarettes currently smoked. Overall and gender stratified multivariate linear regression analyses were performed, adjusting for other influential covariates.
Gender stratified analysis indicated that female smokers of long and ultra-long cigarette had 20% and 27% higher mean Cd levels compared to smokers of regular sized cigarettes respectively, despite the fact that all the ultra-long cigarettes were slim cigarettes. Furthermore, among females, slim cigarette users did not reduce blood cadmium levels compared to non-slim users.
Female smokers of long or ultra-long cigarettes had higher mean blood Cd levels compared to smokers of regular cigarettes independent of slim design. Further research into this association is warranted.

Prev Med
Prev Med 2014 Aug 14;65:99-102. Epub 2014 May 14.
Center for Health Services Research, University of Athens, Alexandroupoleos 25, 11527, Athens, Greece. Electronic address:

To identify determinants of use of smoking cessation aids among current and former smokers in the European Union (EU).
Data from n=9921 current and ex-smokers from 27 European countries (Eurobarometer 77.1, February-March 2012) were analysed.Read More

Multivariate binary logistic regression was used to assess for correlates of use of any recommended aid with proven efficacy, defined as use of pharmacotherapy or psychosocial counselling (p<0.05). The regression analyses assessed for socio-demographic characteristics, EU region, as well as scope of national smoking cessation policies.
Among current smokers who had made a quit attempt and ex-smokers, 19.9% had used any recommended aid with proven efficacy. Respondents from Northern (adjusted odds ratio [aOR]=1.90), Western (aOR=3.21) and Eastern Europe (aOR=1.69) were more likely to have used an efficacious smoking cessation aid compared to respondents from Southern Europe (all p<0.05). Respondents in countries with comprehensive tobacco cessation programmes that offered cost-covered national quit lines, medication, and other cessation services had increased likelihood of using efficacious cessation aids (OR=1.29; 95% Confidence Interval: 1.07-1.55).
These findings underscore the need for enhanced and sustained efforts to ensure increased access to cessation services and aids as part of a comprehensive tobacco control programme.

Am J Public Health
Am J Public Health 2014 Aug 12;104(8):e67-75. Epub 2014 Jun 12.
The authors are with the Center for Global Tobacco Control, Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, MA. Olalekan A. Ayo-Yusuf is also with the Office of the Dean/Director, School of Oral Health Sciences, University of Limpopo, MEDUNSA campus, Pretoria, South Africa.

We compared patient-reported receipt of smoking cessation counseling from US dentists and physicians.
We analyzed the 2010 to 2011 Tobacco Use Supplement of the Current Population Survey to assess receipt of smoking cessation advice and assistance by a current smoker from a dentist or physician in the past 12 months.
Current adult smokers were significantly less likely to be advised to quit smoking during a visit to a dentist (31.Read More

2%) than to a physician (64.8%). Among physician patients who were advised to quit, 52.7% received at least 1 form of assistance beyond the simple advice to quit; 24.5% of dental patients received such assistance (P < .05). Approximately 9.4 million smokers who visited a dentist in 2010 to 2011 did not receive any cessation counseling.
Our results indicate a need for intensified efforts to increase dentist involvement in cessation counseling. System-level changes, coupled with regular training, may enhance self-efficacy of dentists in engaging patients in tobacco cessation counseling.

Int J Environ Health Res
Int J Environ Health Res 2014 17;24(5):401-11. Epub 2013 Sep 17.
a Department of Hygiene, Epidemiology and Medical Statistics , National and Kapodistrian University of Athens , Athens , Greece.

The objective of the present survey was to assess the extent and socio-economic determinants of population exposure to secondhand smoke (SHS) in Greece in 2011. The national household survey Hellas Health IV was conducted in October 2011. SHS exposure was based on self-reported exposure within home, workplace and public places.Read More

Thirty-three per cent of the respondents reported living in a smoke-free home. Smokers (p < 0.001) and single individuals (p < 0.017) were less likely to prohibit smoking at home. SHS exposure at work, in restaurants and in bars/clubs/cafes was frequently mentioned by 41.6, 84.2 and 90.5%, respectively. SHS exposure in a bar/club/cafe was noted more among single individuals (p = 0.004) and those aged 18-34 years (p = 0.007). Inhabitants of rural areas were more likely to report someone smoking indoors in all the above venues. Public health education and effective enforcement of the nationwide smoke-free legislation are imperative.

Eur J Public Health
Eur J Public Health 2014 Jun 27;24(3):477-9. Epub 2014 Mar 27.
1 Department of Health Economics, National School of Public Health, Athens, Greece.

Our aim was to calculate the morbidity, hospitalizations and subsequent hospital costs for the treatment of the smoking-attributable fraction of diseases in Greece using a prevalence-based annual cost approach. In 2011, smoking accounted for 199,028 hospital admissions (8.9% of the national total), with attributable hospital treatment costs calculated at more than €554 million, which represents 10.Read More

7% of the national hospital budget. These results pose a compelling reason for the European Union to champion tobacco control as a means of reducing the financial and social burden of disease in Greece and other countries currently facing a financial maelstrom.

Drug Alcohol Depend
Drug Alcohol Depend 2014 Jun 15;139:60-70. Epub 2014 Mar 15.
Center for Global Tobacco Control, Department of Social and Behavioral Sciences, Harvard School of Public Health, USA.

The concurrent use of multiple tobacco products (i.e., poly-tobacco use) might hinder efforts to reduce overall tobacco use, particularly considering that use of some non-cigarette tobacco products may be popular in some regions due to social, cultural, or economic reasons.Read More

This study assessed poly-tobacco use patterns among persons aged ≥15 years old from 44 countries.
Data from 44 countries in all six World Health Organization regions were obtained from the 2008 to 2012 Global Adult Tobacco Surveys (n=19 countries), and the Special Eurobarometer 385 (77.1) survey, 2012 (n=25 countries). Correlates of poly-tobacco use were assessed using multivariate logistic regression analyses (p<0.05).
Overall prevalence of poly-tobacco use ranged from 0.8% (Mexico) to 11.9% (Denmark). In 28 countries, 20% or more of current smokers of manufactured cigarettes concurrently used at least one other tobacco product and this proportion was highest in India (66.2%) and lowest in Argentina (4.4%). After adjusting for other factors, the likelihood of being a poly-tobacco user among all respondents was lower among females (aOR=0.09; 95% CI: 0.08-0.11), and among respondents from upper-middle-income (aOR=0.53, 95% CI: 0.43-0.66), and lower-middle-income countries (aOR=0.64; 95% CI: 0.51-0.81) compared to high-income countries. Increased likelihood of poly-tobacco use was observed among respondents from the South-East Asian region compared to those from the European region (aOR=1.58, 95% CI: 1.35-1.85), as well as among respondents aged ≥65 years (aOR=2.10; 95% CI: 1.73-2.54), compared to those aged <25 years.
The pattern of tobacco use varied widely, underscoring the need for intensified efforts towards implementing policies that address all tobacco products, not only manufactured cigarettes.

Prev Med
Prev Med 2014 Apr 17;61:61-5. Epub 2014 Jan 17.
Center for Global Tobacco Control, Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, USA.

This study assessed trends in age verification prior to cigarette sales to U.S. middle and high school students, and refusal to sell cigarettes to students aged <18 years during 2000-2009.Read More

Data were obtained from the 2000-2009 National Youth Tobacco Survey. Trends during 2000-2009 were assessed using binary logistic regression (p<0.05).
The proportion of all students, who reported being asked to show proof of age prior to a cigarette purchase in the past 30 days did not change significantly between 2000 (46.9%) and 2009 (44.9%) (p=0.529 for linear trend). No significant trend in the proportion of students aged < 18 years who were refused a sale when attempting to buy cigarettes was observed between 2000 (39.8%) and 2009 (36.7%) (p=0.283 for linear trend). Refusal of a cigarette sale was significantly higher among under-aged boys compared to girls (adjusted odds ratio=1.48; 95% confidence interval: 1.28-1.70).
About half of U.S. middle and high school students who reported making a cigarette purchase were not asked for proof of age, and about three of five under-aged buyers successfully made a cigarette purchase in 2009. Intensified implementation and enforcement of policies requiring age verification among youths is warranted to reduce access and use of tobacco products.

Drug Alcohol Depend
Drug Alcohol Depend 2014 Mar 24;136:28-35. Epub 2013 Dec 24.
Center for Global Tobacco Control, Department of Social and Behavioral Sciences, Harvard School of Public Health, USA.

Cigarette rod length as a design feature may play a specific role in harm perception and tobacco use. Internal tobacco industry documents have shown targeting of females with long/ultra-long cigarettes. This study assessed trends and differences in smoking of long/ultra-long cigarettes among U.Read More

S. smokers aged ≥20 years during 1999 through 2012.
Data were obtained from the 1999/2000 through 2011/2012 National Health and Nutrition Examination Survey. The proportion of current smokers who reported using long/ultra-long cigarettes during each survey year was calculated and compared using χ(2) statistics. Linear and quadratic trends during 1999 through 2012 were assessed using binary logistic regression (p<0.05). Multi-variable analyses were performed to assess current disparities in smoking of long/ultra-long cigarettes.
Despite overall declines in current smoking of long/ultra-long cigarettes during the 1999 through 2012 period (p<0.001 for both linear and quadratic trends), the proportion of smokers of long/ultra-long brands increased in recent years, with over a third (38.7%) of current smokers reporting smoking of long/ultra-long cigarettes during 2011/2012. Current smokers of long/ultra-long cigarettes were more likely to be female compared to males (aOR=3.09; 95%CI: 2.09-4.58), of black race compared to whites (aOR=2.07; 95%CI: 1.30-3.28), or aged 45-64, or ≥65 years (aOR=2.39 and 5.27, respectively), compared to 18-24 year olds.
Specific gender, age and race/ethnic characteristics of smokers of long/ultra-long cigarettes were noted, hence potentially contributing to the widening of health disparities. Cigarette rod length should be considered an important aspect of cigarette engineering/design in regulatory efforts to reduce the burden of tobacco-related disease.

Secondhand smoke (SHS) exposure is a risk factor of respiratory, cardiovascular and inflammatory diseases, however its association with inflammatory markers among highly SHS exposed adolescents has not yet been explored.
Participants included in this study were a subset of 68 non-smoking adolescents, aged 12.5-17.Read More

5 from the Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) study, recruited from Crete Greece. Smoking and SHS exposure was assessed via serum cotinine concentrations. Cytokines (Interleukin-1β, 2, 4, 5 and 6, tumor necrosis factor-α, interferon-γ, tumor growth factor-β1), immunoglobulins IgG, IgA, IgM, complement factors C3, C4, high sensitivity C-reactive protein, and endothelial inflammatory markers [soluble E-selectin, soluble L-selectin, soluble intercellular adhesion molecules (sICAM-1) and soluble vascular cell adhesion molecules-1 (sVCAM-1)] were assessed. Inflammatory markers in the lower 25th percentile and upper 75th percentile groups of cotinine levels were compared and multivariate linear regression analysis was performed controlling for age, sex and BMI.
Cotinine concentrations were notably elevated (geometric mean 0.82ng/ml, 95%CI 0.62-1.07) in this study population. A significant decrease in IL-4 (130.09 vs. 25.77pg/ml, p=0.014) and IL-6 (19.52 vs. 5.52pg/ml, p=0.008) concentrations between the upper 75th percentile cotinine level group and lower 25th percentile cotinine level group was observed. In a multivariate linear regression analysis, cotinine concentrations had a weak inverse association with IL-4 and IL-6 (p=0.028 and p=0.06) which was not statistically significant when adjusted for multiple comparisons (modified Bonferroni, p>0.016). No differences in the other variables was noted.
Among highly SHS exposed adolescents, cotinine levels had weak inverse association with IL-4 and IL-6, which did not achieve statistical significance. However, our results potentially indicate an immunosuppressive role of SHS. Further research is warranted to explore this hypothesis.

Nicotine Tob. Res.
Nicotine Tob Res 2014 Jan 21;16(1):100-7. Epub 2013 Sep 21.
Department of Social and Behavioral Sciences, Center for Global Tobacco Control, Harvard School of Public Health, Boston, MA.

Research suggests that smokers of slim, long, or ultralong cigarettes may have a perception of reduced harm from their own brand. This study compared serum cotinine and urinary total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanonol (NNAL) levels among smokers of regular-sized (68-72mm), king-sized (79-88mm), and long (94-101mm) or ultralong (110-121mm) cigarettes.
Nationally representative data from the 2007-2008 and 2009-2010 National Health and Nutrition Examination Survey were analyzed for 3,699 current smokers aged ≥20 years.Read More

Biomarker levels were summarized using geometric means (GMs). Multivariate linear regression analyses were performed to assess the effect of cigarette rod length on log-transformed serum cotinine and creatinine-adjusted urinary total NNAL levels.
The GM of serum cotinine level was higher among smokers of long/ultralong cigarettes (263.15ng/ml) compared with smokers of regular-sized (173.13ng/ml) or king-sized (213.79ng/ml) cigarettes. Similarly, the GM of creatinine-adjusted NNAL levels was higher among smokers of long/ultralong cigarettes (0.48ng NNAL/mg of creatinine) compared with smokers of regular-sized (0.34ng NNAL/mg of creatinine) or king-sized (0.33ng NNAL/mg of creatinine) cigarettes. After adjusting for potential confounders, mean cotinine and NNAL levels were both significantly higher among smokers of long/ultralong cigarettes compared with levels observed in smokers of either regular-sized or king-sized cigarettes. However, no significant differences were observed between smokers of regular-sized and king-sized cigarettes in mean levels of cotinine or NNAL.
Significantly elevated tobacco biomarker levels were observed among smokers of long/ultralong cigarettes compared with smokers of regular-sized or king-sized cigarettes. This underscores the need to educate the public about the dangers of all tobacco products.

J Adolesc Health
J Adolesc Health 2014 Jan 20;54(1):47-53. Epub 2013 Sep 20.
Department of Social and Behavioral Sciences, Center for Global Tobacco Control, Harvard School of Public Health, Boston, Massachusetts.

This study compared data from 32 countries to assess predictors and patterns of cigarette and smokeless tobacco (SLT) use among students aged 13-15 years old.
Data from the 2007-2008 Global Youth Tobacco Surveys were analyzed for students aged 13-15 years in 31 countries located in all six World Health Organization regions. In addition, the 2011 National Youth Tobacco Survey was analyzed for U.Read More

S. students aged 13-15 years. Country-specific prevalence of current smoking, current SLT use, and concurrent use patterns were assessed.
The national prevalence of current cigarette smoking among students aged 13-15 years ranged from 1.8% (Rwanda) to 32.9% (Latvia), whereas current SLT use ranged from 1.1% (Montenegro) to 14.4% (Lesotho). In the U.S. and most European countries surveyed, current smoking prevalence was significantly higher than SLT prevalence, in contrast to patterns observed in low- and middle-income countries. Also, in most of the surveyed countries outside of Europe and the United States, SLT use among girls was as common as their use of cigarettes, and not significantly different from use by boys. When compared with U.S. adolescents, the odds of SLT use were highest among African adolescents (adjusted odds ratio = 3.98; 95% CI: 2.19-7.24) followed by those in the Southeast Asian region (adjusted odds ratio = 2.76; 95% CI: 1.38-5.53).
Region-specific patterns of tobacco use were noticed. Furthermore, it is alarming that in several low- and middle-income countries, the prevalence of SLT use among females did not differ from that among males, suggesting the possibility of a future shared burden of disease between both males and females.

Addict Behav
Addict Behav 2014 Jan 20;39(1):140-5. Epub 2013 Sep 20.
Center for Health Services Research, School of Medicine, National and Kapodistrian University of Athens, 25 Alexandroupoleos Street, GR 11527, Athens, Greece. Electronic address:

The objective of the present study was to explore the trends in the intention to quit smoking among adults in Greece between 2006 and 2011, a period characterized by financial instability and newly endorsed tobacco control initiatives.
Trend analysis of 3 representative national and cross-sectional surveys, 'Hellas Health I' (2006), "Hellas Health III" (2010) and Hellas Health IV (2011).
Since 2006, the intention to quit smoking has significantly increased among both genders (33.Read More

3% [in 2006] to 42.4% [in 2011], p=0.002), among respondents aged >54years (26.9% [in 2006] to 45.1% [in 2011], p=0.019) and among residents of rural areas (26.4% [in 2006] to 46.7% [in 2011], p=0.001). Both highest (32.1% [in 2006] to 49.4% [in 2011], p=0.036) and lowest (31.7% to 46.0%, p=0.021) socioeconomic (SE) strata showed an increase in the proportion of smokers who intend to quit. However, in 2011, quit attempts were more frequent (35.3%, p=0.009) in smokers of high socioeconomic status. Moreover, smoking prevalence has significantly decreased (43.1% [in 2006] to 38.1% [in 2011], p=0.023), mainly among men (52.4% to 45.7%, p=0.037), respondents of low socioeconomic status (38.9% to 29.4%, p=0.008) and residents of urban areas (45.2% to 37.9%, p=0.005).
Over the past 5years and possibly as a combined result of the implemented tobacco control policies and austerity measures, the intention to quit smoking has increased among all SE strata, however actual quit attempts were higher among those less disadvantaged. Further effort should be made to support quit attempts, especially among vulnerable populations.

PLoS One 2013 17;8(12):e83058. Epub 2013 Dec 17.
Center for Global Tobacco Control, Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, Massachusetts, United States of America.

Secondhand smoke (SHS) exposure causes disease and death among nonsmokers. With a plethora of smoke-free legislation implemented and a steady decrease in cigarette consumption noted over the past decade in the U.S.Read More

, this study assessed trends in indoor SHS exposure among U.S. adolescents in grades 6-12 during 2000-2009.
Data were obtained from the 2000-2009 National Youth Tobacco Survey - a national survey of U.S. middle and high school students. SHS exposure within an indoor area within the past seven days was self-reported. Trends in indoor SHS exposure during 2000-2009 were assessed overall and by socio-demographic characteristics, using the Wald's test in a binary logistic regression. Within-group comparisons were performed using chi-squared statistics (p<0.05).
The proportion of U.S. middle and high school students who were exposed to indoor SHS declined from 65.5% in 2000 to 40.5% in 2009 (p<0.05 for linear trend). Significant declines were also observed across all population subgroups. Between 2000 and 2009, prevalence of indoor SHS exposure declined significantly among both middle (58.5% to 34.3%) and high school (71.5% to 45.4%) students. Prevalence of indoor SHS exposure was significantly higher among girls (44.0% in 2009) compared to boys (37.2% in 2009) during each survey year. Similarly, prevalence of indoor SHS exposure during 2000-2009 was highest among non-Hispanic whites (44.2% in 2009) and lowest among non-Hispanic Asians (30.2% in 2009). During each survey year, prevalence was highest among the oldest age group (≥18 years) and lowest among the youngest (9-11 years). Also, prevalence was significantly higher among current cigarette smokers (83.8% in 2009) compared to nonsmokers (34.0% in 2009).
Significant declines in indoor SHS exposure among U.S. middle and high school students occurred during 2000-2009. While the results are encouraging, additional efforts are needed to further reduce youth indoor SHS exposure.

Nicotine Tob. Res.
Nicotine Tob Res 2013 Nov 16;15(11):1956-61. Epub 2013 Aug 16.
Center for Global Tobacco Control, Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, MA.

NNAL [4-(methylnitrosamino)-1-(3-pyridyl)-1-butanonol] is a valid biomarker of tobacco use. However; no study has assessed its use in distinguishing current smokeless tobacco (SLT) users from nonusers. Therefore, this study used aggregated data from the 2007-2008 and 2009-2010 waves of the National Health and Nutrition Examination Survey to determine an optimal threshold for identifying SLT users with NNAL.Read More

Optimal urinary total NNAL concentrations for discriminating SLT-only users from nonusers of any tobacco were determined using receiver operating characteristic analysis. Percentage agreement between self-reported SLT use status and NNAL levels was calculated overall and by sociodemographic characteristics. All analyses were weighted and performed with Stata, Version 11, and MedCalc for Windows, Version
In total, 264 individuals reported exclusively using SLT (and no other combustible tobacco product) within the past 5 days, whereas 14,824 were self-reported nonusers of any combustible or smokeless tobacco product. The optimal NNAL cutoff point was 34.0 pg/ml, which was associated with a high sensitivity (95.2%), specificity (93.4%), and overall correct classification rate (93.5%). The area under the curve was 98.3% and the corresponding Youden's Index was 88.7%. There was high agreement between the proposed NNAL cutoff point and self-reported SLT-only use (95.6%) and self-reported SLT nonuse (93.9%).
The proposed cutoff point of 34.0 pg/ml had high sensitivity and specificity and may be used by clinicians and researchers to verify or detect recent SLT use. This study also indicated that self-reported SLT use among adults is a reliable measure and has high agreement with biochemical assessment.

Hormones (Athens)
Hormones (Athens) 2013 Jul-Sep;12(3):379-85
Department of Social Medicine, Preventive Medicine and Nutrition Clinic, Medical School, University of Crete, Greece.

To identify the cardiovascular disease (CVD) risk-factor status and dietary habits of the surviving elderly participants of the initial Seven Countries Study (SCS) cohort and newly recruited middle-aged men from the same villages.
Our total cohort of remaining survivors of the SCS consisted of 27 men aged 90 years old and over, while a younger cross-sectional study of 85 men between 53 and 73 years of age of the same catchment area were also examined. Biochemical, anthropometric, dietetic and lifestyle CVD risk factors information was obtained.Read More

It was found that being overweight and having systolic blood pressure higher than the recommended were highly prevalent (>75%) among both age groups as well as abdominal obesity (about 50%). Hypercholesterolemia was highly prevalent in the younger population (68.8%), while smoking rates were relatively low among elderly. The daily meat consumption of SCS participants had doubled, from 35g in the 1960s to 76g among the SCS survivors in 2010 (p=0.002), while daily fruit and vegetable consumption had dropped from 656g to 266g (p<0.001). The younger participants also had increased dietary meat (130g/day) (p<0.001) and decreased fruits-vegetables intake (412g/day) (p<0.001) compared to 50 years ago. However, the younger population and elderly subjects showed higher fish intake (91g/day and 38g/day respectively, p<0.001) compared to 1960 and favorable olive oil consumption. In regard to nutrient intake, the majority of the subjects did not meet the recommendations for CVD prevention.
The study population is at increased risk for the development of CVD, while current dietary habits of the SCS survivors partially differed from those of 50 years ago.

Eur J Public Health
Eur J Public Health 2013 Oct 31;23(5):772-6. Epub 2012 Oct 31.
1 Center for Health Services Research, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.

Greece has one of the highest rates of adult smoking globally. The objective of the present survey was to explore the epidemiology of tobacco use in Greece after the implementation of recent legislative tobacco control measures and to compare it with previous cross-sectional data from 2006.
The nationwide household survey 'Hellas Health III' was conducted in 2010.Read More

A sample of 1000 adults (mean age 47.1 ± 17.1 years) were interviewed. Individuals who had smoked at least once during the past 30 days were classified as smokers. Results were compared with those from the similar 'Hellas Health I' study, which was conducted in 2006.
The prevalence of smoking was calculated at 41% (45% among men and 38% in women, P = 0.04). Greek men smoke more cigarettes (23.2 vs. 19.3 per day, P = 0.002), and they become regular smokers earlier in life. In age groups <55 years, most gender inequalities are attenuated. Socio-economic status does not affect tobacco use in Greece. In comparison with 2006, smoking prevalence, especially among young adults, has fallen from 48 to 35% in 2010. Moreover, a substantial reduction in the number of cigarettes smoked among all age groups was noticed.
Trends in smoking prevalence and consumption among adults seem favourable in Greece during the past 4 years; a substantial reduction of younger smokers and in the number of cigarettes smoked among all age groups is documented. This constitutes a significant public health achievement and an indicator that young adults are a susceptible population to legislative action.

Smoking is known to have a long-term impact on lung function; however, the acute physiological response of smoking a single cigarette and the influential role of pack years and cigarettes per day on pulmonary indices remains an area of interest, especially among young smokers.
50 naive smokers (ages: 18-26, 24 males: mean pack years 3.8) participated in this experimental study.Read More

Respiratory resistance (R), reactance (X), and impedance (Z) were assessed through impulse oscillometry. The participants' fraction of exhaled nitric oxide (FENO) was measured. All tests were performed immediately before and after smoking one single cigarette.
Smoking a single cigarette was found to immediately increase airway impedance (Z 5 Hz) by 0.024 kPa/(L/s) (P = .002), airway resistance at R 5 Hz, R 10 Hz, and R 20 Hz by 0.024 kPa/(L/s)(P < .001), 0.016 kPa/(L/s)(P = .019), and 0.023 kPa/(L/s) (P = .007), respectively, after adjusting for BMI, age, gender, and pack years. FENO concentrations also decreased from 11.70 ppb to 9.85 ppb, P < .001. Sensitivity analyses indicated that the participants' number of pack years and cigarettes per day influenced pulmonary reactance at 10 Hz and 20 Hz, however only at baseline with these differences found to disappear immediately after smoking.
The present study indicates that the consumption of a single cigarette may alter lung mechanics and FENO production among young smokers. Further research is needed to assess the mechanisms and washout period after which these parameters return to normal.

Tob Control
Tob Control 2013 Sep 6;22(5):299-301. Epub 2012 Nov 6.
Department of Social Medicine, Clinic of Social and Family Medicine, University of Crete, Heraklion, Greece.

As tobacco advertising bans are enacted in accordance with the Framework Convention on Tobacco Control, it is essential to assess enforcement and how the industry may circumvent such measures.
During this longitudinal study, we compared the characteristics of points-of-sale (POS) advertising within 300 m of all high schools in Heraklion, Greece before (n=101 POS and 44 billboards in 2007) and after (n=106 POS in 2011) an outdoor advertising ban was implemented in 2009. Cigarette advertisements in all retailers near all high schools were assessed.Read More

Following the ban, tobacco industry billboards around schools were eradicated (from 44 to 0). The proportion of POS that had external advertisements dropped from 98% to 66% (p<0.001), more so in regulated convenience stores (from 97% to 35%, p<0.001) than in kiosks (98% to 92%, p=0.192), which were exempt from the ban. The proportion of convenience stores that had advertisements on the door (79.5% to 20.4%, p<0.001), ads that could be seen from the street (92.3% to 22.4%, p<0.001) or illuminated exterior ads (46.2% to 10.2%, p<0.001) was also significantly reduced. Overall, the average number of exterior advertisements per POS fell from 7.4 to 3.9 (p<0.05). This reduction was noted in regulated convenience stores (4.8±3.0 vs 0.9±2.1, p<0.001) and in unregulated kiosks (9.0±6.7 vs 6.5±4.5, p=0.019).
The outdoor advertising restriction in Greece has led to a reduced number of tobacco advertisements per POS, and the eradication of billboard advertising. Nevertheless, there is a need to regulate kiosks, which were identified as a key vector for tobacco advertising, and to increase compliance among regulated convenience stores.

Pediatrics 2013 Sep 5;132(3):e578-86. Epub 2013 Aug 5.
Center for Global Tobacco Control, Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, MA 02115, USA.

To assess the prevalence and correlates of use of conventional and novel smokeless tobacco products among a national sample of US middle and high school students.
Data from the 2011 National Youth Tobacco Survey were analyzed to determine national estimates of current use of conventional ("chewing tobacco", "snuff," or "dip"), novel ("snus" and "dissolvable tobacco products"), and any smokeless tobacco products (novel and/or conventional products) within the past 30 days.
The overall prevalence of current use of any smokeless tobacco product was 5.Read More

6% (n = 960). Among all students, 5.0% used chewing tobacco, snuff, or dip; 1.9% used snus; and 0.3% used dissolvable tobacco products. Among users of any smokeless tobacco, 64.0% used only conventional products, 26.8% were concurrent users of novel plus conventional products, whereas 9.2% exclusively used novel products. Approximately 72.1% of current any smokeless tobacco users concurrently smoked combustible tobacco products, and only 40.1% expressed an intention to quit all tobacco use. Regression analyses indicated that peer (adjusted odds ratio [aOR]: 9.56; 95% confidence interval [CI]: 7.14-12.80) and household (aOR: 3.32; 95% CI: 2.23-4.95) smokeless tobacco use were associated with smokeless tobacco use, whereas believing that all forms of tobacco are harmful was protective (aOR: 0.55; 95% CI: 0.38-0.79).
Conventional smokeless tobacco products remain the predominant form of smokeless tobacco use. Most users of novel smokeless tobacco products also concurrently smoked combustible tobacco products. Smokeless tobacco use was associated with lower perception of harm from all tobacco products and protobacco social influences, indicating the need to change youth perceptions about the use of all tobacco products and to engage pediatricians in tobacco use prevention and cessation interventions.

PLoS One 2013 4;8(9):e72945. Epub 2013 Sep 4.
Center for Global Tobacco Control, Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, Massachusetts, United States of America ; Smoking and Lung Cancer Research Center, Hellenic Cancer Society, Athens, Greece ; Clinic of Social and Family Medicine, Department of Social Medicine, University of Crete, Heraklion, Greece.

Successful smoke-free legislation is dependent on political will, enforcement and societal support. We report the success and pitfalls of a non-enforced nationwide smoke-free legislation in Greece, as well as ways in which compliance and enforcement-related factors, including ashtrays and signage, may impact indoor secondhand smoke (SHS) concentrations.
A follow-up study of venues (n=150, at baseline, n=75 at 2-year follow-up) in Greece assessed indoor particulate matter with a diameter less than 2.Read More

5 micrometers (PM 2.5 ) concentrations attributable to SHS smoke every six months for two years (n=455 venue/measurements).
Following the implementation of the 2010 smoke-free legislation, mean PM2.5 concentrations attributable to SHS fell from 175.3 µg/m(3) pre-ban to 84.52 µg/m(3) immediately post-ban, increasing over subsequent waves (103.8 µg/m(3) and 158.2 µg/m(3) respectively). Controlling for potential influential factors such as ventilation, time of day, day of week, city and venue type, all post-ban measurements were still lower than during the pre-ban period (Wave 2 beta: -118.7, Wave 3 beta: -87.6, and Wave 4 beta: -69.9). Outdoor or indoor signage banning smoking was not found to affect SHS concentrations (beta: -10.9, p=0.667 and beta: -18.1, p=0.464 respectively). However, ashtray or ashtray equivalents were strong determinants of the existence of indoor SHS (beta: +67 µg/m(3), p=0.017).
While the public may be supportive of smoke-free legislation, adherence may decline rapidly if enforcement is limited or nonexistent. Moreover, enforcement agencies should also focus on the comprehensive removal of ashtray equivalents that could act as cues for smoking within a venue.

Xenobiotica 2013 Jun 4;43(6):509-13. Epub 2012 Dec 4.
Department of Society, Human Development and Health, Center for Global Tobacco Control, Harvard School of Public Health, Boston, MA, USA.

1. Exposure to secondhand smoke (SHS) can occur in many places; however, regulations banning smoking may reduce the sources of exposure to SHS to personal areas such as the family car, a source of brief but potently intense exposure. 2.Read More

Fifteen non-smoking volunteers were exposed to sidestream SHS concentrations of 5000 µg/m(3), within a simulated car setting. The Fraction of Exhaled Nitric Oxide (FeNO) was calculated, dynamic flow volumes were assessed through spirometry; while airway impedance (Z), resistance (R), and reactance (X) was assessed through impulse oscillometry before and after exposure. 3. Exposure to sidestream SHS within this experimental condition did not affect dynamic flow volumes, however FENO decreased from 15.34 ppb to 11.15 ppb, (p < 0.001). Increases in airway resistance at R5Hz by 0.114 kPa/(L/s) (p = 0.002), at R10Hz by 0.093[kPa/(L/s)] (p = 0.006) and at R20Hz by 0.093[kPa/(L/s)] (p = 0.008) were noted. Correspondingly overall peripheral and central airway resistance was also found to increase by 40% (by 0.083 kPa/(L/s), p = 0.038) and 25% (by 0.045 kPa/(L/s), p = 0.047) respectively. 4. Brief but elevated exposure to sidestream SHS can alter airway resistance, and impedance indicating a potential additional mechanistic pathway between exposure to SHS and the development of respiratory disease. Further research is needed to verify these pilot results.

Tob Control
Tob Control 2013 May 17;22(3):194-200. Epub 2012 Jan 17.
Department of Social Medicine, Faculty of Medicine, University of Crete, Heraklion, Crete, Greece.

To date, no research exists on the role that different sources of exposure to second-hand smoke (SHS) have on 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) and nicotine uptake, assessed via urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and cotinine concentrations of non-smoking pregnant women, nor the differences in NNAL concentrations among pregnant women who quit smoking in comparison to those who do not.
As part of the 'Rhea' mother childbirth cohort in Crete, Greece, 1317 mother-child pairs were followed-up until delivery, while among a subsample, maternal urine was assessed for its NNAL (n=117) and cotinine concentrations (n=377).
Pregnant women who continued to smoke during pregnancy were found to have geometric mean urinary NNAL concentrations of 0.Read More

612 pmol/ml, in comparison to the 0.100 pmol/ml of ex-smokers and 0.0795 pmol/ml of non-smokers exposed to SHS. Exposure to SHS in the home was associated with a 4.40 ng/ml increase in urinary cotinine levels, while reported exposure to SHS in cars was associated with an even higher (8.73 ng/ml) increase in cotinine concentrations and was strongly related to NNAL concentrations. Exposure to SHS in the workplace and in public places was also shown to increase cotinine and NNAL concentrations. The NNAL:cotinine ratio was found to be higher among pregnant women who were exposed to SHS but did not smoke (p<0.001).
Using cotinine levels as an indicator of NNK, exposure due to SHS during pregnancy leads to an underestimation of exposure to NNK uptake. Moreover, each source of exposure contributed to the increase in cotinine levels, indicating the importance of avoiding SHS exposure from any source.

JAMA 2013 May;309(19):1992-4
Center for Global Tobacco Control, Harvard School of Public Health, Boston Massachusetts, USA.
J Aerosol Med Pulm Drug Deliv
J Aerosol Med Pulm Drug Deliv 2012 Dec 6;25(6):349-54. Epub 2012 Mar 6.
Center for Global Tobacco Control, Division of Society, Human Development and Health, Harvard School of Public Health, Boston, MA 02115, USA.

Our aim was to assess second-hand smoke (SHS) exposure in hospitality venues after the smoke-free legislation implemented in September 2010 in Greece and to compare with when a partial ban was in place and in 2006 when no ban was in place.
Hospitality venues were prospectively assessed for their indoor concentrations of particulate matter (PM(2.5)) during the partial ban phase (n=149) and the complete ban phase (n=120, 80% followed up), while overall and matched by venue comparisons were also performed (no ban vs.Read More

partial ban vs. complete ban). Comparisons with previously collected data in 2006 when no ban was in place also was performed.
Indoor air levels of PM(2.5) attributable to SHS dropped following the transition from a partial to a complete ban by 34% (137 μg/m(3) vs. 90 μg/m(3), p=0.003). This drop was larger in bars (from 195 μg/m(3) to 121 μg/m(3)), than in cafes (124 μg/m(3) vs. 87 μg/m(3)) or restaurants (42 μg/m(3) vs. 39 μg/m(3)). PM(2.5) concentrations between 2006 (no ban) and the partial ban of 2010 were also found to decrease by 94 μg/m(3); however, among matched venues, the levels of indoor air pollution were not found to change significantly (218 μg/m(3) vs. 178 μg/m(3), p=0.58). Comparing the 2010 complete ban results (n=120) with previously collected data from 2006 when no ban was in place (n=43), overall PM(2.5) concentrations were found to fall from 268 μg/m(3) to 89 μg/m(3), while a matched analysis found a significant reduction in PM(2.5) concentrations (249 μg/m(3) vs. 46 μg/m(3), p=0.011).
The complete ban of smoking in hospitality venues in Greece led to a reduction in SHS exposure, in comparison to when the partial ban or no ban was in place; however, exposure to SHS was not eliminated indicating the need for stronger enforcement.

Indian J Endocrinol Metab
Indian J Endocrinol Metab 2012 Sep;16(5):809-14
Department of Social Medicine, Preventive Medicine and Nutrition Clinic, Medical School, University of Crete, P.O. Box 1393 Heraklion, Crete, Greece.

To investigate the presence of atherogenic factors among preschool children of Crete, Greece.
This was a cross-sectional study. The study population included 1189 children, aged four to seven years, examined from January to May 2005, in public kindergartens.Read More

Biochemical, anthropometric, and blood pressure measurements were performed.
Of the boys 27.4% were classified as overweight or obese (obese 10.8%). The respective percentage for girls was 28.5% (obese 9%); 7.4% percent of the boys and 7.9% of the girls had blood pressure above the ninety-fifth percentile. TC of > 200 mg / dl was found in 14.4% and LDL-C of > 130 mg / dl in 13.8% of the children. Children with serum TG of > 100 mg / dl had a significantly higher mean WC and BMI than those with triglyceride levels of ≤ 80 mg / dl (59.7 vs. 55.9 cm and 17.9 vs. 16.6 kg / m(2); P < 0.05). Similarly, children with HDL-C < 45 mg / dl had significantly higher WC and BMI than children with HDL-C ≥ 60 mg / dl (57.7 vs. 53.5 cm and 17.1 vs. 16.5 kg / m(2); P < 0.05). Obese children had an Odds Ratio of 2.87 (95% confidence interval, 1.05 - 7.85, P = 0.041) for hypertriglyceridemia, as compared to non-obese children.
Levels of obesity and especially central obesity were strongly related to other atherogenic risk factors in Cretan preschool children indicating the presence of this major public health problem in early ages.


The aim of the study was to asses quality of life and symptoms of obstructive sleep apnea syndrome (OSAS) patients after adhering to 6 months of continuous positive airway pressure (CPAP) treatment.
A group of 50 patients (41 men and 9 women) were diagnosed by polysomnography and treated with CPAP therapy for 6 months. Their symptoms and health-related quality of life were assessed by administering a validated and translated version of the sleep apnea quality of life index (SAQLI).Read More

Sleepiness was measured using the Epworth Sleepiness Scale (ESS) and through electronic monitoring of CPAP usage per night of sleep.
Mean CPAP usage was 4.5 ± 0.5 h per night. Comparisons between quality of life indexes before and after CPAP treatment showed an improvement in the total SAQLI score (3.8 ± 0.9 vs. 5.8 ± 0.8 after CPAP, p < 0.01), in daily functioning (4.2 ± 1.4 vs. 6.0 ± 0.9, p < 0.01), social interactions (4.8 ± 1.3 vs.6.3 ± 0.7, p < 0.01), emotional functioning (4.4 ± 1.4 vs. 5.7 ± 1.0, p < 0.01), symptoms (1.6 ± 0.8 vs. 5.8 ± 1.2, p < 0.01), and in the ESS (13.7 ± 6.5 vs. 3.9 ± 3.8, p < 0.01). Regarding the patients' symptoms, improvement was noticed for "sleepiness while watching a spectacle" (96%), "reading" (95%), "carrying on a conversation" (95%), "driving" (92.9%), "restless sleep" (87.8%), and "urinating more than once per night" (84.8%). Smaller improvements were observed for the reported "dry mouth-throat upon awakening" (36.1%),"excessive fatigue" (54.5%), and "decreased energy" (55.3%).
We conclude that OSAS patients who adhere to nighttime CPAP therapy show significant improvement of their quality of life, daytime sleepiness, and other symptoms after 6 months of treatment with CPAP.

Chest 2012 Jun 22;141(6):1400-6. Epub 2011 Dec 22.
Center for Global Tobacco Control, Harvard School of Public Health, 677 Huntington Ave, Landmark, 3rd Floor E, Boston, MA 02115, USA.

Debate exists over the scientific evidence for claims that electronic cigarettes (e-cigarettes) have no health-related ramifications. This study aimed to assess whether using an e-cigarette for 5 min has an impact on the pulmonary function tests and fraction of exhaled nitric oxide (Feno) of healthy adult smokers.
Thirty healthy smokers (aged 19-56 years, 14 men) participated in this laboratory-based experimental vs control group study.Read More

Ab lib use of an e-cigarette for 5 min with the cartridge included (experimental group, n = 30) or removed from the device (control group, n = 10) was assessed.
Using an e-cigarette for 5 min led to an immediate decrease in Feno within the experimental group by 2.14 ppb (P = .005) but not in the control group (P = .859). Total respiratory impedance at 5 Hz in the experimental group was found to also increase by 0.033 kPa/(L/s) (P < .001), and flow respiratory resistance at 5 Hz, 10 Hz, and 20 Hz also statistically increased. Regression analyses controlling for baseline measurements indicated a statistically significant decrease in Feno and an increase in impedance by 0.04 kPa/(L/s) (P = .003), respiratory resistance at 5 Hz by 0.04 kPa/(L/s) (P = .003), at 10 Hz by 0.034 kPa/(L/s) (P = .008), at 20 Hz by 0.043 kPa/(L/s) (P = .007), and overall peripheral airway resistance (β, 0.042 kPa/[L/s]; P = .024), after using an e-cigarette.
e-Cigarettes assessed in the context of this study were found to have immediate adverse physiologic effects after short-term use that are similar to some of the effects seen with tobacco smoking; however, the long-term health effects of e-cigarette use are unknown but potentially adverse and worthy of further investigation.

Tob Induc Dis
Tob Induc Dis 2012 27;10(1):21. Epub 2012 Dec 27.
Center for Global Tobacco Control, Department of Society, Human Development and Health, Harvard School of Public Health, Boston, MA, USA ; Smoking and Lung Cancer Research Center, Hellenic Cancer Society, Athens, Greece.

Increases in tobacco taxation are acknowledged to be one of the most effective tobacco control interventions. This study aimed at determining the mediating role of socioeconomical status (SES) and the earmarking of revenue to healthcare and tobacco control, in influencing population support for the adoption of a 2 Euro tobacco tax increase in Greece, amid the challenging economic environment and current austerity measures.
Data was collected from two national household surveys, the "Hellas Health III" survey, conducted in October 2010 and the "Hellas Tobacco survey" conducted in September 2012.Read More

Data was analyzed from 694 and 1066 respondents aged 18 years or more, respectively. Logistic regression models were fitted to measure the adjusted relationship between socio-economic factors for the former, and support for increased taxation on tobacco products for the latter.
In 2012 amidst the Greek financial crisis, population support for a flat two euro tax increase reached 72.1%, if earmarked for health care and tobacco control, a percentage high both among non-smokers (76%) and smokers (64%) alike. On the contrary, when not earmarked, only 43.6% of the population was in support of the equivalent increase. Women were more likely to change their mind and support a flat two-euro increase if the revenue was earmarked for health care and tobacco control (aOR = 1.70; 95% C.I: 1.22-2.38, p = 0.002). Furthermore, support for an increase in tobacco taxation was not associated with SES and income.
Despite dire austerity measures in Greece, support for an increase in tobacco taxation was high among both smokers and non-smokers, however, only when specifically earmarked towards health care and tobacco control. This should be taken into account not only in Greece, but within all countries facing social and economic reform.

Int J Food Sci Nutr
Int J Food Sci Nutr 2011 Nov 16;62(7):685-91. Epub 2011 May 16.
Clinic of Preventive Medicine and Nutrition, Department of Social Medicine, University of Crete, Greece.

Thirty-one brands of margarines from the Greek market were analyzed for their fatty acid composition including trans-fatty acids by gas chromatography. Trans fatty acids (TFAs) were found within the range of 0.16-0.Read More

97% of total fat content, with no sample found to have TFA in a concentration more than 1% of the total fat content. Increased levels of either saturated or cis-unsaturated was observed in each brand. Saturated, cis-monounsaturated and cis-polyunsaturated were found in the ranges of 11.26-51.75%, 22.98-60.37% and 12.09-56.30% of total fat content respectively, with mean values of 30.81 ± 10.40%, 34.41 ± 10.46% and 34.28 ± 14.02% of total fat. The chemical analysis of Greek margarines over the past decades has indicated that the TFA content of Greek margarines has declined over the past 20 years by approximately 95%.

Tob Induc Dis
Tob Induc Dis 2011 23;9. Epub 2011 Jun 23.
Center for Global Tobacco Control, Department of Society, Human Development and Health, Harvard School of Public Health, (677 Huntington Avenue), Boston, MA (02115), USA.
BMC Public Health
BMC Public Health 2011 28;11:508. Epub 2011 Jun 28.
Dept, of Health Promotion, School of Public Health, Sacker Faculty of Medicine, Tel Aviv University, POB 39040, Ramat Aviv 69978 Israel.

Tobacco smoke exposure (TSE) is a serious threat to child health. Roughly 40% of children worldwide are exposed to tobacco smoke, and the very young are often "captive smokers" in homes in which others smoke.The goal of this research project is to develop and evaluate an intervention to reduce young child tobacco smoke exposure.Read More

The objective of this paper is to document our approach to building the intervention, to describe the planned intervention, and to explore the conceptual issues regarding the intervention and its evaluation.
This project is being developed using an iterative approach. We are currently in the middle of Stage 1. In this first stage, Intervention Development, we have already conducted a comprehensive search of the professional literature and internet resources, consulted with experts in the field, and conducted several Design Workshops. The planned intervention consists of parental group support therapy, a website to allow use of an "online/offline" approach, involvement of pediatricians, use of a video simulation game ("Dr. Cruz") to teach parents about child TSE, and personalized biochemical feedback on exposure levels. As part of this stage we will draw on a social marketing approach. We plan to use in-depth interviews and focus groups in order to identify barriers for behavior change, and to test the acceptability of program components.In Stage II, we plan to pilot the planned intervention with 5-10 groups of 10 parents each.In Stage III, we plan to implement and evaluate the intervention using a cluster randomized controlled trial with an estimated 540 participants.
The major challenges in this research are twofold: building an effective intervention and measuring the effects of the intervention. Creation of an effective intervention to protect children from TSE is a challenging but sorely needed public health endeavor. We hope that our approach will contribute to building a stronger evidence base for control of child exposure to tobacco smoke.

Xenobiotica 2011 Jun 7;41(6):456-63. Epub 2011 Mar 7.
Department of Social Medicine, Faculty of Medicine, University of Crete, Heraklion, Crete, Greece.

Exposure to toxic metals during pregnancy may have detrimental effects on foetal development. We assessed the role of sociodemographic characteristics and active and passive smoking on blood concentrations of metals (As, Cd, Pb, Hg, Sb, U, Mn and Mo). Venous blood drawn from 50 pregnant women, randomly selected from the mother-child birth cohort 'Rhea'.Read More

Extensive questionnaire data on active and passive smoking were collected. Urinary cotinine was measured to validate self-reported exposure and non-smoking status. Smokers had higher concentrations of Cd (1.0 µg/L) as compared with non-smokers (0.29 µg/L, P < 0.001) and a tendency for higher As and Hg. Among non-smokers, blood As and Hg concentrations were also associated with exposure to passive smoking in public venues and the family home and to overall greater secondhand smoke (SHS) exposure (As: 0.97µg/L among heavy-exposed compared with 0.20 µg/L among the low-exposed, P < 0.05; Hg: 2.1 µg/L vs. 0.9 µg/L respectively, P < 0.05). Controlling for fish and seafood intake altered the statistical significance but not the direction of the above associations. Smoking was associated with higher Cd concentrations in pregnant women, although the association between passive smoking and elevated As and Hg concentrations was indicative, however inconclusive.

Within the healthcare system, nurses have the ability to influence their patients' smoking habits through counselling. Therefore, it is of great importance to appropriately train health professionals on smoking cessation strategies with the aim to help them provide advice to their patients. In light of the above, the objective of this study was to assess the association between Greek nursing students' beliefs towards tobacco control/smoking cessation and the professional training received.Read More

During February 2009, we conducted a cross sectional national survey among all 3rd year nursing students of the two university based nursing departments in Greece (University of Athens, University of the Peloponnese). The Global Health Professional Student Survey (GHPSS) questionnaire was applied and following written informed consent 73% provided a completed questionnaire (n = 192/263 enrolled students).
Overall, 33% were current active smokers, while 74% reported ever to experiment smoking. In regards to their beliefs towards tobacco control policies, non smokers were more positive in regards to banning smoking in restaurants (94% vs. 61%, p < 0.001), in bars and cafes (82% vs. 34%, p < 0.001), and all public places (93% vs. 51%, p < 0.001) when compared to current smokers. In comparison with students who had not received training on the importance of asking patients about their smoking habits, those that did were more likely to believe that nurses should have a role in smoking cessation and should act as role models for their patients.
Resources should be invested in improving the quality of undergraduate education in nursing departments in Greece with respect to tobacco control and smoking cessation.


Chronic obstructive pulmonary disease (COPD) remains a major public health problem that affects the quality of life of patients, however smoking cessation may emeliorate the functional effects of COPD and alter patient quality of life. OBJECTIVE-DESIGN: The aim of this study was to validate the Clinical COPD Questionnaire (CCQ) into Greek and with such to evaluate the quality of life in patients with different stages of COPD, as also assess their quality of life before and after smoking cessation.
The internal validity of questionnaire was high (Cronbach's a = 0.Read More

92). The reliability of equivalent types in 16 stabilized patients also was high (ICC = 0.99). In general the domains within the CCQ were strongly correlated with each other, while each domain in separate was strongly correlated with the overall CCQ score (r2 = 0.953, r2 = 0.915 and r2 = 0.842 in regards to the functional, symptomatic and mental domain, respectively). The CCQ scores were also correlated with FEV1, (r2 = -0.252, p < 0.001), FEV1/FVC, (r2 = -0.135, p < 0.001) as also with the quality of life questionnaire SF-12 (r2 = -0.384, p < 0.001). Smoking cessation also lead to a significant reduction in CCQ score and increase in the SF-12 score.
The self administered CCQ indicates satisfactory validity, reliability and responsiveness and may be used in clinical practice to assess patient quality of life. Moreover the CCQ indicated the health related quality of life gains attributable to smoking cessation among COPD patients, projecting smoking cessation as a key target in COPD patient management.

J Aerosol Med Pulm Drug Deliv
J Aerosol Med Pulm Drug Deliv 2011 Feb 20;24(1):35-41. Epub 2010 Oct 20.
Laboratory of Physiology, School of Medicine, University of Athens, Greece.

Exposure to second-hand smoke (SHS) is increasingly recognized as an occupational hazard to workers in the service industry. In areas of the world with moderate climates, open windows and doors are assumed to provide a work environment with only marginally increased exposures to SHS.
We measured indoor fine particulate matter (PM2.Read More

5) in 50 semiopen air venues in Greece during the summer. Cotinine levels from a nonsmoking employee of each of these venues were measured from a postshift urine sample.
In these semiopen-air venues, the mean level of indoor PM 2.5 levels were 113.5 ± 72.3 μg/m(3). The mean postshift urinary cotinine levels of nonworking workers in these venues was 15 ng/mL. PM2.5 levels were strongly correlated with urinary cotinine concentrations (Spearman's r = 0.914). Linear regression analyses indicated that when taking into account the time of the measurement, the day of the week, for each 1 cigarette/100 m(3) the indoor PM2.5 concentrations increased by 26.6 μg/m(3) [95% confidence interval (CI): 7.6-45.7 μg/m(3), p = 0.007) and urinary cotinine levels of nonsmoking workers increased by 5.0 ng/mL (95% CI: 0.4 to 9.6, p = 0.034).
In a sample of bars and restaurants with windows and doors open, indoor PM2.5 concentrations were elevated and increased proportionately to the density of smoking. Cotinine levels of nonsmoking employees increased with indoor PM2.5 concentrations, and also with the density of smoking. Open windows and doors do not protect workers from exposure to second-hand smoke.

J Public Health Policy
J Public Health Policy 2011 Feb 9;32(1):46-59. Epub 2010 Dec 9.
Center for Global Tobacco Control, Department of Society, Human Development and Health, Harvard School of Public Health, 677 Hungtington Avenue, Landmark Center, 3rd Floor East, Boston, MA 02115, USA.

Compliance with laws making certain environments smoke free has focused mainly on smokers' behavior, while the role of non-smokers has scarcely been investigated. Our cross-sectional study interviewed 4043 adults (2037 smokers and 2006 non-smokers) in the general population of Greece during April 2009. Non-smokers reported that they would actively work for compliance with the law.Read More

The non-smokers were older, more educated (odds ratio, OR 1.4), and were more likely to be annoyed by the smell of environmental tobacco smoke (OR 2.4) or report that it irritates their eyes (OR 1.8). Policymakers should evaluate how non-smokers could actively support smoke-free laws through reporting of violations using media campaigns that inform them of their rights, and other measures.

Research has indicated that general practitioners (GPs) have good clinical judgment in regards to diagnosing and managing herpes zoster (HZ) within clinical practice in a country with limited resources for primary care and general practice. The objective of the current study was to assess the burden of HZ and post herpetic neuralgia (PHN) within rural general practices in Crete, Greece.
The current study took place within a rural setting in Crete, Greece during the period of November 2007 to November 2009 within the catchment area in which the Cretan Rural Practice-based Research Network is operating.Read More

In total 19 GP's from 14 health care units in rural Crete were invited to participate, covering a total turnover patient population of approximately 25, 000 subjects. For the purpose of this study an electronic record database was constructed and used as the main tool for monitoring HZ and PHN incidence. Stress related data was also collected with the use of the Short Anxiety Screening Test (SAST).
The crude incidence rate of HZ was 1.4/1000 patients/year throughout the entire network of health centers and satellite practices, while among satellite practices alone it was calculated at 1.3/1000 patients/year. Additionally, the standardised incidence density within satellite practices was calculated at 1.6/1000 patients/year. In regards to the stress associated with HZ and PHN, the latter were found to have lower levels of anxiety, as assessed through the SAST score (17.4 ± 3.9 vs. 21.1 ± 5.7; p = 0.029).
The implementation of an electronic surveillance system was feasible so as to measure the burden of HZ and PHN within the rural general practice setting in Crete.

Maternal smoking is the most significant cause of preventable complications during pregnancy, with smoking cessation during pregnancy shown to increase birth weight and reduce preterm birth among pregnant women who quit smoking. Taking into account the fact that the number of women who smoke in Greece has increased steadily throughout the previous decade and that the prevalence of smoking among Greek females is one of the highest in the world, smoking cessation should be a top priority among Greek health care professionals.
The Maternal Smoking Cessation during Pregnancy Study (M-SCOPE), is a Randomized Control Trial (RCT) that aims to test whether offering Greek pregnant smokers a high intensity intervention increases smoking cessation during the third trimester of pregnancy, when compared to a low intensity intervention.Read More

Prospective participants will be pregnant smokers of more than 5 cigarettes per week, recruited up to the second trimester of pregnancy. Urine samples for biomarker analysis of cotinine will be collected at three time points: at baseline, at around the 32nd week of gestation and at six months post partum. The control group/low intensity intervention will include: brief advice for 5 minutes and a short leaflet, while the experimental group/intensive intervention will include: 30 minutes of individualized cognitive-behavioural intervention provided by a trained health professional and a self-help manual especially tailored for smoking cessation during pregnancy, while counselling will be based on the ''5 As.'' After childbirth, the infants' birth weight, gestational age and any other health related complications during pregnancy will be recorded. A six months post-partum a follow up will be performed in order to re-assess the quitters smoking status.
If offering pregnant smokers a high intensity intervention for smoking cessation increases the rate of smoking cessation in comparison to a usual care low intensity intervention in Greek pregnant smokers, such a scheme if beneficial could be implemented successfully within clinical practice in Greece. Identifier NCT01210118.

Pediatr Allergy Immunol
Pediatr Allergy Immunol 2010 Dec;21(8):1171-8
Department of Social Medicine, Faculty of Medicine, University of Crete, Crete, Greece.

While it has been indicated that exposure to second-hand smoke (SHS) can cause a local in vivo response, limited evidence exists on its possible systemic effects from population-based levels of exposure. We investigated into a possible systemic response in the immune parameters and lymphocyte subsets, i.e.Read More

B cell (CD19+), T cell (CD4+CD45RO+, CD4+CD45RA+, CD3+CD45RO+, CD3+CD45RA+) and natural killer (CD3+CD16CD56+) lymphocyte subsets relative to exposure to SHS. Blood was drawn from healthy, verified non-smoker, adolescent subjects (n = 68, mean age 14.2) and analysed for cotinine, antioxidants and lymphocyte immunophenotyping. SHS exposure was assessed using serum cotinine. Biomarker quantified exposure to SHS was correlated with a linear dose-response reduction in the percentages of memory CD4+CD45RO+ (p = 0.005) and CD3+CD45RO+ T-cell subsets (p = 0.005 and p = 0.003, respectively) and a linear increase in the percentage of naïve CD4+CD45RA+ and CD3+CD45RA+ T-cell subsets (p = 0.006 and p = 0.003, respectively). Additionally, higher exposure to SHS was associated with a higher CD4+CD45RA+ count (532 vs. 409 cells/ml, p = 0.017). Moreover, after controlling for age, gender, body mass index and plasma antioxidants, SHS exposure was found to be associated with the percentage of circulating naïve and memory CD4+ and CD3+ T-cell subpopulations, as revealed through a linear regression analysis. These findings indicate a systemic immunological response in healthy adolescents exposed to population-based levels of SHS exposure and imply an additional biological pathway for the interaction between exposure to SHS and its adverse effects on human health.

J Epidemiol
J Epidemiol 2010 26;20(5):355-62. Epub 2010 Jun 26.
Department of Social Medicine, Faculty of Medicine, University of Crete, Heraklion, Crete, Greece.

Pregnant women are exposed to tobacco smoke through active smoking and contact with secondhand smoke (SHS), and these exposures have a significant impact on public health. We investigated the factors that mediate active smoking, successful quitting, and SHS exposure among pregnant women in Crete, Greece.
Using a cotinine-validated questionnaire, data were collected on active smoking and exposure to secondhand smoke from 1291 women who had successfully completed the first contact questionnaire of the prospective mother-child cohort (Rhea) in Crete during the 12th week of pregnancy.Read More

Active smoking at some time during pregnancy was reported by 36% of respondents, and 17% were current smokers at week 12 of gestation. Those less likely to quit smoking during pregnancy were those married to a smoker (OR, 1.76; P = 0.008), those who were multiparous (1.72; P = 0.011), and those with young husbands. Of the 832 (64%) nonsmokers, almost all (94%, n = 780) were exposed to SHS, with the majority exposed at home (72%) or in a public place (64%). Less educated women and younger women were exposed more often than their better educated and older peers (P < 0.001). Adjusting for potential confounders, parental level of education, age, and ethnicity were the main mediators of exposure to SHS during pregnancy.
Active smoking and exposure to SHS are very prevalent among pregnant women in Greece. The above findings indicate the need for support of population-based educational interventions aimed at smoking cessation in both parents, as well as of the importance of establishing smoke-free environments in both private and public places.

Allogeneic blood transfusion leads to the infusion into the recipient of large amounts of antigens that may create conditions which are related to immune system modulation. The aim of this study was to determine the effects of smoking habit on vascular endothelial growth factor (VEGF) and interleukin 6 (IL-6) levels in the plasma of blood donors. Blood samples from 170 consecutive blood donors was collected and analyzed for serum markers, while questionnaire data was collected.Read More

Serum cotinine levels were calculated for non-smokers, while serum cytokine IL-6 and VEGF concentrations were also calculated among 88 randomly selected subjects. Controlling for the donors age and gender, a strong tendency was found for smoking within 24 h of the blood donation to be associated with a higher VEGF concentration of the donated blood (ß = 141.13, p = 0.06), while the donor age was independently related to VEGF levels (p = 0.001). Additionally the IL-6 levels in the transfused blood were independently associated with the donors age (p = 0.001) and gender (p = 0.002) but not with their smoking status. Further research is needed so as to assess the need of updating blood donation guide lines to regulate the time intervals between the time from the last cigarette and blood donation.

Eur J Cardiovasc Prev Rehabil
Eur J Cardiovasc Prev Rehabil 2010 Aug;17(4):440-6
Department of Social Medicine, Faculty of Medicine, University of Crete, Greece.

Farmers from Crete as first studied within the framework of the Seven Countries Study, were historically known for holding the title of the 'gold standard' of health status globally and had a very low prevalence of both cardiovascular disease (CVD) and cancer. Taking the above into account we evaluated the changes in CVD risk factors among farmers in Crete, Greece and compared our findings with data from the 1960s.
Cross-sectional.Read More

Five hundred and two farmers (18-79 years old) from the Valley of Messara in Crete were randomly selected and examined in 2005. Complete clinical, biochemical, dietetic, anthropometrical and lifestyle CVD risk factors were assessed, matched and compared with published data from the 1960s.
In comparison with 45 years ago, present day male farmers from Crete were found to have a 30% higher BMI (29.8 vs. 22.9 kg/m, P<0.001) and a 16% higher total cholesterol level (239.6 vs. 206.9 mg/dl, P<0.001) and also a not so favourable daily dietary intake (increase in meat and saturated fat and decrease in fruit, P<0.001, respectively), while a significant reduction in systolic blood pressure and energy intake was noticed. In regards to changes in subcutaneous adipose tissue fatty acid composition, a decrease in monounsaturated (P<0.001) and an increase in saturated fatty acids (P<0.001) was also found elucidating the temporal change in dietary habits.
The population's lack of adherence to the Mediterranean diet, have led to the fact that currently farmers from Crete are likely to be at a higher risk for developing CVD in comparison with earlier generations.

Eur. J. Pediatr.
Eur J Pediatr 2010 Jun 2;169(6):741-8. Epub 2009 Dec 2.
Department of Social Medicine, University of Crete, PO Box 2208, Heraklion, 71003 Crete, Greece.

Maternal smoking during pregnancy is a significant threat to the fetus. We examined the association between active maternal smoking and smoking cessation during early pregnancy with newborn somatometrics and adverse pregnancy outcomes including preterm delivery, low birth weight, and fetal growth restriction. One thousand four hundred mother-child pairs with extensive questionnaire data were followed up until delivery, within the context of a population-based mother-child cohort study (Rhea study), in Crete, Greece, 2007-2008.Read More

Comparing smokers to nonsmokers, the adjusted odds ratio (OR) was 2.8 [95% confidence interval (CI), 1.7, 4.6] for low birth weight and 2.6 (95%CI: 1.6, 4.2) for fetal growth restriction. This corresponded to a 119-g reduction in birth weight, a 0.53-cm reduction in length, and a 0.35-cm reduction in head circumference. Smoking cessation early during pregnancy modified significantly these pregnancy outcomes indicating the necessity for primary smoking prevention.

Tob Control
Tob Control 2010 Jun;19(3):259
Department of Social Medicine, Faculty of Medicine, University of Crete, PO Box 2208, Heraklion 71003, Crete, Greece.
Fam Pract
Fam Pract 2010 Feb 1;27(1):48-54. Epub 2009 Nov 1.
Clinic of Social and Family Medicine, Department of Social Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece.

The need for a cost-effective decision-making process is increasingly seen as a challenge within modern family practice. The role of family practice research is well recognized in countries with readily available resources and capacity. However, the situation is different in a number of countries with limited financial resources and current low research capacity.Read More

This article reports on an empirical model of 10 steps developed and applied in Crete, Greece. It aims to exchange views on how to better design and undertake actions in order to develop future family practice research in countries with limited resources.

Am. J. Physiol. Lung Cell Mol. Physiol.
Am J Physiol Lung Cell Mol Physiol 2010 Jan 18;298(1):L3-L12. Epub 2009 Sep 18.
FAME Laboratory, Institute of Human Performance and Rehabilitation, Centre for Research and Technology Thessaly, 32 Siggrou St., Trikala GR42100, Greece.

A vast number of studies on the unfavorable effects of secondhand smoke (SHS) exist within the international literature, the majority of which evaluate longitudinal epidemiological data. Although limited, the experimental studies that assess the acute and short-term effects of exposure to SHS are also increasing in number. They include cellular, animal, and human studies that indicate a number of pathophysiological mechanisms through which the deleterious effects of SHS may arise.Read More

This current review evaluates the existing biological evidence regarding the acute health effects of SHS exposure. Analyses on the inhaled toxicants and the carcinogenicity of SHS are included as well as in-depth discussions on the evidence for acute SHS-induced respiratory, cardiovascular, metabolic, endocrine and immune effects, and SHS-induced influences on oxygen delivery and exercise. The influence of the length of exposure and the duration of the observed effects is also described. Moreover, recent findings regarding the underlying pathophysiological mechanisms related to SHS are depicted so as to generate models that describe the SHS-induced effects on different systems within the human body. Based on the presented biological evidence, it is concluded that brief, acute, transient exposures to SHS may cause significant adverse effects on several systems of the human body and represent a significant and acute health hazard. Future research directions in this area include research on the concentrations of tobacco smoke constituents in the alveolar milieu following SHS exposure, individual susceptibility to SHS, as well as the effects of SHS on neurobehavioral activity, brain cell development, synaptic development, and function.

Int J Environ Res Public Health
Int J Environ Res Public Health 2010 Jan 8;7(1):78-88. Epub 2010 Jan 8.
Clinic of Social and Family Medicine, Department of Social Medicine, Faculty of Medicine, University of Crete, Heraklion, 71003, Greece.

As the Framework Convention on Tobacco Control (FCTC) calls for public health awareness on tobacco use, mass media campaigns should be appropriately designed so as to maximize their effectiveness. In this methodological pilot study, 95 Greek adolescents (mean age 15 +/- 1.8 years), were shown seven different anti tobacco ads, and asked to rate the ad theme, message and emotional context on a 1-7 Likert scale.Read More

Health related ads were rated the highest, and as identified through the logistic regression analysis, adolescents who perceived an ad to be emotional or to have a clear message that was relevant to them, were more likely to rate the ad as more effective. The strong agreement between the above findings and the existing literature indicates the applicability of this pilot study's methodological approach.

Inflamm Allergy Drug Targets
Inflamm Allergy Drug Targets 2009 Dec;8(5):328-33
Department of Social Medicine, Faculty of Medicine, University of Crete, Heraklion 71003, Crete, Greece.

During the past years several factors have been established as risk markers for the development of heart disease, including both active and passive smoking. Current evidence has indicated that exposure to passive smoking can lead to a 70-80% increase in the risk of coronary heart disease, nearly as much as light smoking. This disproportionate effect could possibly be explained by a number of different interactions between human physiology of the cardiovascular system and passive smoke exposure.Read More

In this review we present the different mechanisms through which passive smoking may induce an inflammatory response that may lead to the development of cardiovascular disease, on a whole and through certain of its toxic constituents. Passive smoke itself, is a volatile mixture of numerous toxins, chemicals and carcinogens, that interact with in vivo mechanisms and induce vascular damage, including endothelium inflammation, atherosclerosis development, lipid peroxidisation, alterations in cytokines and acute phase proteins (such as CRP), as well as platelet aggravation. Acting alone or in synergy, the above mentioned effects suggest a causal relationship between exposure to passive smoking and the development of cardiovascular disease.

Nurse Educ Today
Nurse Educ Today 2009 Nov 13;29(8):840-4. Epub 2009 May 13.
University Hospital of Heraklion, Crete, Greece.

The importance of education in the development of nursing as a profession and as a science has been emphasized over the last decade. Therefore, this article aims to highlight the current situation of undergraduate and postgraduate nursing education in Greece and to propose directions for its improvement. Undergraduate nursing education in Greece is two dimensional.Read More

Prospective students can obtain a degree as a registered nurse through both university-based degree studies and Technological Educational Institute (TEI) studies that differ significantly in both the provision of clinical experience and theoretical background due to their different course curricula and teaching staff. University graduates are provided with a better theoretical background while TEI graduates are usually better in clinically skills, even though both programmes lead to professional registration and are in accordance with European Union directives. Postgraduate studies in nursing science are mainly organized by the University of Athens, but recently joint postgraduate degrees of other university departments and TEIs, are possible. Changes that will lead to one common undergraduate nursing education leading to registration as a registered nurse, and organized in such a way that will reduce the gap between theory and practice is a proposal that is gradually gaining acceptance by the profession. However, the development of a single nursing degree in Greece is complex, and close cooperation between the government and the professional authorities is essential.

Int J Adolesc Med Health
Int J Adolesc Med Health 2009 Apr-Jun;21(2):179-86
Hellenic American University, Athens, Greece.

Knowledge on health and disease prevention and adolescent satisfaction from the health care system are factors that can affect the adolescent's health status.
To assess the sources of health information of adolescents in a sample of teenagers from Athens and Crete, Greece.
Data were obtained from a convenience sample of 369 adolescents aged 12-18 years from urban areas of Athens and Crete, Greece.Read More

Data on health care information sources and overall adolescent health literacy were collected with the use of a questionnaire exploring education on health topics over the past year, sources of health information, and interaction with their physician.
More than half the study participants indicated having received information within the past year on oral health, sexually transmitted diseases, physical activity, smoking, and nutrition. The family (71.8%) and the physician (51.5%; boys vs. girls: 44.2% vs. 57.9%, p = .009) are most usually consulted for health information. Girls were found to seek out more sources of health information than boys and to receive more information from their friends (26.9% vs. 11.0%, p < .001), magazines (23.4% vs. 15.1%, p = .046), other health professionals (boys vs. girls: 11.2% vs. 5.8%, p = .068), and pamphlets (boys vs. girls: 21.3% vs. 9.9%, p = .003).
A large percentage of adolescents, especially boys, are insufficiently informed on major health issues. Health education programming for youth in Greek schools is imperative to promote healthier lifestyles and to prevent chronic and infectious diseases.

Int J Palliat Nurs
Int J Palliat Nurs 2009 May;15(5):242-8
University General Hospital of Heraklion.

Euthanasia has become a prominent social and ethical issue in which nurses play an important role. This study evaluated, for the first time in Greece, the acceptance and enactment of passive euthanasia among Greek nursing staff, measured in relation to the type of patients cared for. Passive euthanasia, illegal in Greece, is defined as either withdrawing or withholding life-sustaining treatment.Read More

Fifty-one per cent responded that they would not be willing to withhold life-sustaining treatment if legalized, while almost 30% responded that they had withheld life-sustaining treatment from a patient at least once in the past; specifically 47.7% of intensive care unit nurses (OR 8.2; 95% CI: 1.6-41.3), 20% of cancer ward nurses (OR 2.7; 95% CI: 0.5-15.6) and 8.3% of other nurses from other wards (P = 0.001). Age, gender and self-reported levels of religiosity among Greek nurses were not found to affect statistically any variable regarding euthanasia and its enactment.

Eur J Public Health
Eur J Public Health 2009 Apr 13;19(2):212-7. Epub 2009 Feb 13.
Department of Social Medicine, Faculty of Medicine, University of Crete, Crete, Greece.

Graphical tobacco product labelling is a prominent source of health information and has an important position among tobacco control initiatives. However, little is known about its effectiveness among adolescents. With this above in mind, we aimed to research into how adolescents perceive the proposed EU graphic tobacco product warning labels as an effective means of preventing smoking initiation in comparison to the current EU text-only warning labels.Read More

Five hundred seventy four adolescents (13-18, 54% male) from Greece were privately interviewed, with the use of a digital questionnaire and randomly shown seven existing EU text-only and proposed EU graphic warning labels. Non-smoking respondents were asked to compare and rate the warnings effectiveness in regard to preventing them from smoking on a 1-5 Likert type scale.
Irrespective of the warning category shown, on all occasions, non-smoking adolescents rated the suggested EU graphic labels as more effective in preventing them from smoking in comparison to the existing EU text-only warnings. Controlling for gender, age, current smoking status and number of cigarettes smoked per month, younger adolescents were found to opt for graphic warnings more often, and also perceive graphic warning labels as a more effective means of preventing them from smoking, in comparison to their elder peers (P < 0.001).
The proposed EU graphic warning labels may play an important role in preventing of smoking initiation during the crucial years of early adolescence when smoking experimentation and early addiction usually take place.

Tob Control
Tob Control 2009 Apr;18(2):79-80
University of Crete, Greece.
Tob Induc Dis
Tob Induc Dis 2009 31;5(1). Epub 2009 Mar 31.
Department of Social Medicine, Faculty of Medicine, University of Crete, Greece.

Smoke-free environments in Greece are scarce. Despite existent legislation that forbids smoking in all health care service centers, smoking is still evident. Using a random sample of hospital personnel from a large university hospital in Greece, we evaluated their smoking habits, perceptions and compliance towards hospital smoking regulations.Read More

57.8% of the nursing personnel and 34.5% of medical/research staff were found to be current smokers (p < 0.05). Although 66% of the staff does not oppose the complete hospital smoking ban, 95% responded that they would prefer it to be partial. The above findings warrant the necessity for nurturing efforts to reduce smoking and increase the health professionals' awareness of their position as a role model to both patients and the society.

Int J Environ Res Public Health
Int J Environ Res Public Health 2009 Feb 2;6(2):433-44. Epub 2009 Feb 2.
National and Kapodistrian University of Athens, Department of Nursing, Athens, Greece.

Childhood exposure to secondhand smoke (SHS) is a serious threat to public health and can be influenced by parental lifestyle habits and beliefs. Taking the above into account we aimed at locating predictors of parental induced exposure to SHS in the house and family car among 614 children who visited the emergency department of two large pediatric hospitals in Athens, Greece. The multivariate analysis revealed that the factors found to mediate household exposure to paternal SHS were the number of cigarettes smoked per day (O.Read More

R 1.13, p<0.001) while, having a non-smoking spouse had a protective effect (O.R 0.44, p=0.026). Maternally induced household SHS exposure was related to cigarette consumption. For both parents, child exposure to SHS in the family car was related to higher numbers of cigarettes smoked (p<0.001), and for fathers was also more often found in larger families. Additionally, lower educated fathers were more likely to have a spouse that exposes their children to SHS inside the family car (O.R 1.38 95%C.I: 1.04-1.84, p=0.026). Conclusively, efforts must be made to educate parents on the effects of home and household car exposure to SHS, where smoke free legislation may be difficult to apply.

Mediators Inflamm.
Mediators Inflamm 2009 23;2009:812102. Epub 2010 Feb 23.
Department of Thoracic Medicine, University General Hospital, Medical School of the University of Crete, 71110 Heraklion, Greece.

Little is known about the longitudinal effects of smoking cessation on sputum inflammatory cells. We aimed to investigate the changes in sputum inflammatory cells and T-lymphocyte subpopulations after 6 and 12 months smoking cessation. Induced sputum was obtained from 68 healthy smokers before and after 6 months (n = 21) and 1 year (n = 14) smoking cessation and from ten healthy never-smokers.Read More

Inflammatory cells were identified by morphology and T-lymphocyte subpopulations by flow cytometry. Sputum macrophages were decreased after 12 months of smoking cessation in comparison to baseline, while neutrophils increased. Moreover, CD8+ T-cells were decreased in smokers before smoking cessation compared to never-smokers and increased in smokers after 6 months of smoking cessation in comparison to baseline; result that was maintained after 1 year of smoking cessation. These novel findings indicate that smoking cessation can equilibrate certain inflammatory cells of smokers with those of nonsmokers, within 6 months of smoking cessation.

Tob Induc Dis
Tob Induc Dis 2008 9;4. Epub 2008 Sep 9.
Department of Social Medicine, Faculty of Medicine, University of Crete, Heraklion, Crete, Greece.

Cigarette smoke itself is an abundant source of free radicals and a major cause of oxidative stress, to which plasma antioxidants function as a vital protective and counterbalancing mechanism. The objective of this study was to investigate into the relationship between smoking status and serum and dietary micronutrient concentrations.
Cross-sectional study SUBJECTS - SETTING: 502 farmers from the Valley of Messara in Crete were randomly selected and examined.Read More

Complete three-day and 24-hr recall questionnaires were collected along with anthropometrical, physical activity and clinical data from all participating subjects.
After adjusting for age, gender and number of fasting days adhered to per year, current smokers were found to have a lower dietary intake of vitamin C (112.1 mg vs. 136.4 mg, p = 0.03), fibre (16.6 g vs. 19.1 g, p = 0.006) and fruits and vegetables (339 g vs. 412 g, p = 0.014), while dietary vitamin B1 intake was found to be higher (1.7 mg vs. 1.4 mg, p = 0.02) in comparison to non/ex smokers. Dietary intake of meat, folate and vitami A, E, B2, B6 and B12 did not differ between the groups. Controlling age, gender, fasting days and dietary micronutrient intake, serum folate levels were found to be lower among smokers (geometric mean 15.3 nmol/L vs. 17.7 nmol/L, p = 0.023), while serum iron and vitamin B12 levels were not affected by smoking status.
Current smoking status affects dietary nutrient intake as well as plasma folate levels. The above coherence between antioxidant depletion and reduced antioxidant intake may predispose smokers to the premature development of tobacco related mortality and morbidity.

Int J Environ Res Public Health
Int J Environ Res Public Health 2008 Sep;5(3):125-9
Department of Social Medicine, School of Medicine, University of Crete, Greece.

Exposure to secondhand smoke (SHS) is a serious threat to public health, and a significant cause of lung cancer and heart disease among non-smokers. Even though Greek hospitals have been declared smoke free since 2002, smoking is still evident. Keeping the above into account, the aim of this study was to quantify the levels of exposure to environmental tobacco smoke and to estimate the attributed lifetime excess heart disease and lung cancer deaths per 1000 of the hospital staff, in a large Greek public hospital.Read More

Environmental airborne respirable suspended particles (RSP) of PM2.5 were performed and the personnel's excess mortality risk was estimated using risk prediction formulas. Excluding the intensive care unit and the operating theatres, all wards and clinics were polluted with environmental tobacco smoke. Mean SHS-RSP measurements ranged from 11 to 1461 microg/m3 depending on the area. Open wards averaged 84 microg/m3 and the managing wards averaged 164 microg/m3 thus giving an excess lung cancer and heart disease of 1.12 (range 0.23-1.88) and 11.2 (range 2.3-18.8) personnel in wards and 2.35 (range 0.55-12.2) and 23.5 (range 5.5-122) of the managing staff per 1000 over a 40-year lifespan, respectively. Conclusively, SHS exposure in hospitals in Greece is prevalent and taking into account the excess heart disease and lung cancer mortality risk as also the immediate adverse health effects of SHS exposure, it is clear that proper implementation and enforcement of the legislation that bans smoking in hospitals is imperative to protect the health of patients and staff alike.

BMC Public Health
BMC Public Health 2007 14;7:112. Epub 2007 Jun 14.
Preventive Medicine and Nutrition Clinic, Department of Social Medicine, School of Medicine, University of Crete, Heraklion, Crete, Greece.

Smoking is Greece's largest public health threat. Greece has the highest adult smoking prevalence among all E.U countries, which in turn possibly predisposes Greek children and adolescents to smoke.Read More

The purpose of our study was to research into the smoking habits of preschool children's parents since children of that age could be vulnerable to parental negative role modeling and to investigate into the necessity of conducting a public health awareness programme aimed at the general population.
A cross-sectional study was performed on the parents of children enrolled in kindergarten in western Crete-Greece (2809 parents), and interviewed during the 2004-2005 Cretan school health promotion programme.
63% of households had at least one parent a current smoker and in 26% both parents were found to be current smokers. Smoking prevalence among adults with preschool children was estimated at 44% (52% of fathers and 36% of mothers). Paternal education and nationality were statistically significantly related to smoking (p < 0.001), unlike place of residence (p = 0.862) and level of maternal education (p = 0.132).
Smoking prevalence is high even among parents with preschool children. Taking into account the parents' significant primary role in the children's upbringing and the effect that parental induced passive smoking has on children's health and health attitude; one can deduce that the health of Greek children is under threat. It is of major importance that educational and policy intervention measures are implemented to reduce such a situation that could contribute to promoting the initiation of smoking among Greek adolescents.

Eur J Public Health
Eur J Public Health 2007 Apr 25;17(2):211-3. Epub 2006 Oct 25.
Preventive Medicine and Nutrition Clinic, Department of Social Medicine Faculty of Medicine, University of Crete, Greece.

Smoking is one of the largest public heath problems and a cause of major concern not only among European members such as Greece but also worldwide. Greece over the past years has been suffering from a smoking epidemic with dramatic consequences on the economy and the cost of health services. Therefore, the purpose of this study is to describe the extent of tobacco usage, the methods used to control tobacco consumption, and the main reasons of anti-tobacco legislation failure over the past decades in Greece.Read More

Data were collected from the international PubMed database and from the Greek database, Iatrotek, during January 2006 and the tobacco legislation was discussed with other counterparts in Greece and was rechecked with the Greek ministry of Health and Social Welfare.
Currently Greece has the highest smoking prevalence not only among members of the European Union but also among all members of the OECD. Recent epidemiological studies estimate that 40% of the adult population are daily smokers, with one in two adolescents in certain areas also current smokers. Although anti-smoking policies do exist, and have been enforced over the years, many factors have contributed to their failure with a pro-tobacco culture and an increasing number of adolescent smokers exacerbating the problem.
It is obvious that the strict enforcement of a nationwide anti-tobacco policy must be a priority on the national health agenda, if we are to ever effectively combat the high prevalence of smoking in Greece.

BMC Public Health
BMC Public Health 2007 23;7:302. Epub 2007 Oct 23.
Department of Social Medicine, Faculty of Medicine, University of Crete, Greece.

Exposure to environmental tobacco smoke is a major threat to public health. Greece, having the highest smoking prevalence in the European Union is seriously affected by passive smoking. The purpose of this study was to measure environmental tobacco smoke (ETS) exposure in the non smoking areas of hospitality venues and offices in Greece and to compare the levels of exposure to levels in the US, UK and Ireland before and after the implementation of a smoking ban.Read More

Experimental measurements of particulate matter 2.5 microm (PM2.5), performed during a cross sectional study of 49 hospitality venues and offices in Athens and Crete, Greece during February - March 2006.
Levels of ETS ranged from 19 microg/m3 to 612 microg/m3, differing according to the place of measurement. The average exposure in hospitality venues was 268 microg/m3 with ETS levels found to be highest in restaurants with a mean value of 298 microg/m3 followed by bars and cafes with 271 microg/m3. ETS levels were 76% lower in venues in which smoking was not observed compared to all other venues (p < 0.001). ETS levels in Greek designated non-smoking areas are similar to those found in the smoking sections of UK hospitality venues while levels in Ireland with a total smoking ban are 89% lower and smoke-free communities in the US are 91 - 96% lower than levels in Greece.
Designated non-smoking areas of hospitality venues in Greece are significantly more polluted with ETS than outdoor air and similar venues in Europe and the United States. The implementation of a total indoor smoking ban in hospitality venues has been shown to have a positive effect on workers and patrons' health. The necessity of such legislation in Greece is thus warranted.

Eur. J. Pediatr.
Eur J Pediatr 2006 Dec 28;165(12):891-6. Epub 2006 Jul 28.
Preventive Medicine and Nutrition Clinic, Department of Social Medicine, Faculty of Medicine, University of Crete, P.O. Box 2208, 71003, Heraklion, Crete, Greece.

Greece has the highest adult smoking prevalence in the European Union, affecting not only those who smoke but also threatening the health of those who are involuntarily exposed to passive smoke, especially young Greek children.
The aim of this study was to quantify passive smoking biomarkers (serum nicotine and cotinine levels) among preschool children in Crete in relation to parental smoking habits.
All children enrolled in kindergarten in western Crete (1,757 preschool children and 2,809 parents) were interviewed during the 2004-2005 Cretan health promotion programme out of which a sample of 81 children was randomly selected according to parental smoking status and blood samples for cotinine and nicotine assay were taken.Read More

The geometric means of serum nicotine values in children with both parents current smokers and in those with both parents non-smokers were 0.71 ng/ml (95%CI 0.62, 0.80) and 0.59 ng/ml (95%CI 0.49, 0.69), respectively, (p=0.073). Cotinine geometric mean values were found at 1.69 ng/ml (95%CI 0.93, 3.06) and 0.15 ng/ml (95%CI 0.09, 0.28), respectively, (p<0.001). Girls with smoker parents had also greater cotinine geometric mean values than boys (3.35 versus 0.85 ng/ml, respectively, p=0.018).
Our findings prove that Greek preschool children, especially young girls, are exposed to substantial levels of passive smoke which therefore stresses the need for immediate action so as to prevent the predisposition and early addiction of Greek preschool children to tobacco.