2026
Tan MS, Filippidis FT, Li CX, Laverty AA, Fernández E, Martínez C, Peruga A, Vardavas CI, Feliu A.
Lancet Reg Health Eur. 2026;69:101815.
Abstract | Links | BibTeX | Etiquetes:
@article{pmid42633154,
title = {Trends in waterpipe and e-cigarette use among young people in the European Union, 2012-2023: a repeated cross-sectional study},
author = {Tan MS and Filippidis FT and Li CX and Laverty AA and Fernández E and Martínez C and Peruga A and Vardavas CI and Feliu A},
doi = {10.1016/j.lanepe.2026.101815},
issn = {2666-7762},
year = {2026},
date = {2026-10-01},
journal = {Lancet Reg Health Eur},
volume = {69},
pages = {101815},
abstract = {BACKGROUND: Alternative tobacco and nicotine-containing products can challenge progress in tobacco control. Waterpipes and e-cigarettes gained popularity among youth at different times, driven by flavours, social influence, and perceived reduced harm. This study examined trends in waterpipe and e-cigarette use among youth in the European Union (EU) from 2012 to 2023.nnMETHODS: We analysed data from five waves (2012-2023) of the Special Eurobarometer surveys in 26 EU Member States (N = 20,466; ages 15-30). Multilevel Poisson models assessed trends by sociodemographic subgroups, adjusting for country-level factors. Adjusted prevalence ratios (aPRs) with 95% confidence intervals (CIs) are reported.nnFINDINGS: From 2012 to 2023, ever waterpipe use fell from 31.2% (95% CI: 29.1-33.3%) to 14.9% (13.2-16.8%), and current use (since 2017) from 2.5% (1.8-3.5%) to 1.8% (1.2-2.7%). Ever e-cigarette use rose from 12.2% (10.8-13.8%) to 25.8% (23.7-28.2%), and current use from 1.6% (1.1-2.3%) to 5.3% (4.0-6.8%), with cross-country variation. Compared with 2017, ever waterpipe use was lower in 2023 (aPR: 0.52, 95%CI: 0.42-0.66). Ever e-cigarette use was lower in 2012 (0.47; 0.40-0.54) and 2014 (0.75; 0.67-0.84). Current waterpipe use increased in 2020 (1.96; 1.16-3.28) then declined, while current e-cigarette use rose in 2020 (1.64; 1.15-2.34) and 2023 (4.27; 2.73-6.67). By 2023, ever waterpipe use was lower across all subgroups despite earlier heterogeneity, whereas ever e-cigarette use was higher among women (1.41; 1.18-1.69), urban residents (1.27; 1.11-1.46), and those without financial difficulties (1.38; 1.20-1.60). Current e-cigarette use was also higher across all groups.nnINTERPRETATION: Declining waterpipe use and rising e-cigarette use among young Europeans show divergent patterns and differences across sociodemographic groups, particularly among women and socioeconomically disadvantaged groups. Continued surveillance and targeted interventions are needed to address emerging vulnerabilities in high-risk populations.nnFUNDING: European Union's Horizon 2020.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
BACKGROUND: Alternative tobacco and nicotine-containing products can challenge progress in tobacco control. Waterpipes and e-cigarettes gained popularity among youth at different times, driven by flavours, social influence, and perceived reduced harm. This study examined trends in waterpipe and e-cigarette use among youth in the European Union (EU) from 2012 to 2023.nnMETHODS: We analysed data from five waves (2012-2023) of the Special Eurobarometer surveys in 26 EU Member States (N = 20,466; ages 15-30). Multilevel Poisson models assessed trends by sociodemographic subgroups, adjusting for country-level factors. Adjusted prevalence ratios (aPRs) with 95% confidence intervals (CIs) are reported.nnFINDINGS: From 2012 to 2023, ever waterpipe use fell from 31.2% (95% CI: 29.1-33.3%) to 14.9% (13.2-16.8%), and current use (since 2017) from 2.5% (1.8-3.5%) to 1.8% (1.2-2.7%). Ever e-cigarette use rose from 12.2% (10.8-13.8%) to 25.8% (23.7-28.2%), and current use from 1.6% (1.1-2.3%) to 5.3% (4.0-6.8%), with cross-country variation. Compared with 2017, ever waterpipe use was lower in 2023 (aPR: 0.52, 95%CI: 0.42-0.66). Ever e-cigarette use was lower in 2012 (0.47; 0.40-0.54) and 2014 (0.75; 0.67-0.84). Current waterpipe use increased in 2020 (1.96; 1.16-3.28) then declined, while current e-cigarette use rose in 2020 (1.64; 1.15-2.34) and 2023 (4.27; 2.73-6.67). By 2023, ever waterpipe use was lower across all subgroups despite earlier heterogeneity, whereas ever e-cigarette use was higher among women (1.41; 1.18-1.69), urban residents (1.27; 1.11-1.46), and those without financial difficulties (1.38; 1.20-1.60). Current e-cigarette use was also higher across all groups.nnINTERPRETATION: Declining waterpipe use and rising e-cigarette use among young Europeans show divergent patterns and differences across sociodemographic groups, particularly among women and socioeconomically disadvantaged groups. Continued surveillance and targeted interventions are needed to address emerging vulnerabilities in high-risk populations.nnFUNDING: European Union's Horizon 2020.
Feliu A, Joossens L, Martinez C.
Tob Control. 2026;35:423–424.
@article{pmid42521419,
title = {Celebrating 20 years of the Tobacco Control Scale: Evolving to benchmark and advance policy implementation in a changing context},
author = {Feliu A and Joossens L and Martinez C},
doi = {10.1136/tc-2026-060471},
issn = {1468-3318},
year = {2026},
date = {2026-07-01},
urldate = {2026-07-01},
journal = {Tob Control},
volume = {35},
number = {4},
pages = {423--424},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
Gavilan Castillo E, Fernández E, Panera JA, Ballbè M, Antón L, Mercader C, Ferré M, Serrano H, Martínez C.
Can J Anaesth. 2026.
Abstract | Links | BibTeX | Etiquetes:
@article{pmid42507051,
title = {Exploring factors that influence the implementation of presurgical smoking cessation interventions: a cross-sectional survey},
author = {Gavilan Castillo E and Fernández E and Panera JA and Ballbè M and Antón L and Mercader C and Ferré M and Serrano H and Martínez C},
doi = {10.1007/s12630-026-03158-8},
issn = {1496-8975},
year = {2026},
date = {2026-07-01},
journal = {Can J Anaesth},
abstract = {PURPOSE: We aimed to evaluate the level of implementation of health care professionals in helping patients undergoing surgery quit smoking using the Ask, Advise, Assess, Assist, and Arrange Follow-Up (5As) brief intervention model, and to identify the main barriers and facilitators affecting the implementation during preoperative visits at hospitals in Catalonia, Spain.nnMETHODS: In a multicentre cross-sectional study, we administed an online survey to clinical health care professionals who perform preoperative visits (anesthesiologists, nurses, and psychologists). The main outcome variable was the implementation of 5As. We used the validated Knowledge, Attitudes, Behaviours, and Organization (KABO) questionnaire to assess barriers and facilitators. We performed univariate and bivariate analyses of the 5As and the KABO domains according to professional category and sociodemographic variables. We conducted multivariable analyses using generalized estimating equations controlling for covariates.nnRESULTS: The survey was completed by 216 professionals of 633 invited to participate (34.1%). Engagement was high in the categories Ask (median [interquartile range] 0-10 Likert scale score, 10.0 [9.0-10.0]) and Advise (7.5 [5.0-10.0]), but very low in Assist (1.0 [0.0-3.0]) and Arrange Follow-Up (0.0 [0.0-2.0]). "Individual skills" and "organizational support/resources" had significantly lower scores compared with other domains (Holm-adjusted P < 0.05), whereas "Individual commitment" and "Beliefs about patients' desire/readiness" had significantly higher scores.nnCONCLUSIONS: The level of implementation of smoking cessation in preoperative visits was poor. The main barriers detected were lack of knowledge and lack of resources and organizational support. Hospitals should promote strategies that address the main barriers identified and should apply interventions to help people quit smoking as a routine practice in preoperative visits.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
PURPOSE: We aimed to evaluate the level of implementation of health care professionals in helping patients undergoing surgery quit smoking using the Ask, Advise, Assess, Assist, and Arrange Follow-Up (5As) brief intervention model, and to identify the main barriers and facilitators affecting the implementation during preoperative visits at hospitals in Catalonia, Spain.nnMETHODS: In a multicentre cross-sectional study, we administed an online survey to clinical health care professionals who perform preoperative visits (anesthesiologists, nurses, and psychologists). The main outcome variable was the implementation of 5As. We used the validated Knowledge, Attitudes, Behaviours, and Organization (KABO) questionnaire to assess barriers and facilitators. We performed univariate and bivariate analyses of the 5As and the KABO domains according to professional category and sociodemographic variables. We conducted multivariable analyses using generalized estimating equations controlling for covariates.nnRESULTS: The survey was completed by 216 professionals of 633 invited to participate (34.1%). Engagement was high in the categories Ask (median [interquartile range] 0-10 Likert scale score, 10.0 [9.0-10.0]) and Advise (7.5 [5.0-10.0]), but very low in Assist (1.0 [0.0-3.0]) and Arrange Follow-Up (0.0 [0.0-2.0]). "Individual skills" and "organizational support/resources" had significantly lower scores compared with other domains (Holm-adjusted P < 0.05), whereas "Individual commitment" and "Beliefs about patients' desire/readiness" had significantly higher scores.nnCONCLUSIONS: The level of implementation of smoking cessation in preoperative visits was poor. The main barriers detected were lack of knowledge and lack of resources and organizational support. Hospitals should promote strategies that address the main barriers identified and should apply interventions to help people quit smoking as a routine practice in preoperative visits.
Saura J, Enríquez M, Feliu A, Roca X, Mondón S, Barrio P, Andreu M, Segura L, Ballbè M, Fu M, Fernández E, Martínez C, clinical DuCATA group.
Addict Behav Rep. 2026;23:100656.
Abstract | Links | BibTeX | Etiquetes:
@article{pmid41531671,
title = {Consumption patterns and withdrawal symptoms in dual cannabis-tobacco users in Spain: Cross-sectional study},
author = {Saura J and Enríquez M and Feliu A and Roca X and Mondón S and Barrio P and Andreu M and Segura L and Ballbè M and Fu M and Fernández E and Martínez C and DuCATA clinical group},
doi = {10.1016/j.abrep.2025.100656},
issn = {2352-8532},
year = {2026},
date = {2026-06-01},
journal = {Addict Behav Rep},
volume = {23},
pages = {100656},
abstract = {BACKGROUND: Cannabis use has increased worldwide, with over 188 million users annually. In Spain, past-year prevalence among people aged 15-64 is 10.6%. Dual use of cannabis and tobacco is common, increasing health risks and complicating cessation. This study examines consumption patterns and cannabis withdrawal severity among dual users undergoing treatment for cannabis use disorder (CUD).nnMETHOD: A cross-sectional study was conducted in substance use treatment programs in Catalonia, Spain. Participants were cannabis users initiating CUD treatment. A questionnaire collected sociodemographic data, cannabis and tobacco use characteristics (e.g., number of spliffs, tobacco amount), nicotine dependence, motivation to quit, and cannabis withdrawal symptoms. Hierarchical cluster analysis using Gower's distance identified behavioral patterns among participants.nnRESULTS: Data from 94 participants seeking CUD treatment were included. Daily tobacco use was reported by 91.5%, with a mean Fagerström score of 4.2/10. Most participants (88.1%) co-used cannabis with tobacco, and 75.8% experienced cannabis withdrawal symptoms, with women reporting greater severity. Cluster analysis revealed two profiles: Cluster 1 (71.0%) included mostly older males with higher motivation to quit and fewer withdrawal symptoms; Cluster 2 (29.0%) was younger, more sex-balanced, and showed higher nicotine dependence, and more severe withdrawal symptoms.nnCONCLUSIONS: Co-use of cannabis and tobacco is highly prevalent among individuals entering CUD treatment. Higher nicotine dependence is associated with more severe withdrawal symptoms. Older males with higher motivation and fewer withdrawal symptoms may have better prognosis, highlighting motivation as cessation predictor. Findings underscore the need to enhance motivation to quit both substances and integrated treatment. The DuCATA project has been registered at Clinicaltrials.gov under the identifier [NCT05512091].},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
BACKGROUND: Cannabis use has increased worldwide, with over 188 million users annually. In Spain, past-year prevalence among people aged 15-64 is 10.6%. Dual use of cannabis and tobacco is common, increasing health risks and complicating cessation. This study examines consumption patterns and cannabis withdrawal severity among dual users undergoing treatment for cannabis use disorder (CUD).nnMETHOD: A cross-sectional study was conducted in substance use treatment programs in Catalonia, Spain. Participants were cannabis users initiating CUD treatment. A questionnaire collected sociodemographic data, cannabis and tobacco use characteristics (e.g., number of spliffs, tobacco amount), nicotine dependence, motivation to quit, and cannabis withdrawal symptoms. Hierarchical cluster analysis using Gower's distance identified behavioral patterns among participants.nnRESULTS: Data from 94 participants seeking CUD treatment were included. Daily tobacco use was reported by 91.5%, with a mean Fagerström score of 4.2/10. Most participants (88.1%) co-used cannabis with tobacco, and 75.8% experienced cannabis withdrawal symptoms, with women reporting greater severity. Cluster analysis revealed two profiles: Cluster 1 (71.0%) included mostly older males with higher motivation to quit and fewer withdrawal symptoms; Cluster 2 (29.0%) was younger, more sex-balanced, and showed higher nicotine dependence, and more severe withdrawal symptoms.nnCONCLUSIONS: Co-use of cannabis and tobacco is highly prevalent among individuals entering CUD treatment. Higher nicotine dependence is associated with more severe withdrawal symptoms. Older males with higher motivation and fewer withdrawal symptoms may have better prognosis, highlighting motivation as cessation predictor. Findings underscore the need to enhance motivation to quit both substances and integrated treatment. The DuCATA project has been registered at Clinicaltrials.gov under the identifier [NCT05512091].
Pérez-Martín H, Lidón-Moyano C, González-Marrón A, Martín-Sánchez JC, Fu M, Ballbè M, Pérez-Ortuño R, Pascual JA, Fernández E, Martínez-Sánchez JM.
Biomarkers. 2026;31:249–257.
Abstract | Links | BibTeX | Etiquetes:
@article{pmid41969175,
title = {Changes in concentrations of tobacco specific nitrosamines in saliva in the general population of Barcelona before and after implementation of tobacco control legislation},
author = {Pérez-Martín H and Lidón-Moyano C and González-Marrón A and Martín-Sánchez JC and Fu M and Ballbè M and Pérez-Ortuño R and Pascual JA and Fernández E and Martínez-Sánchez JM},
doi = {10.1080/1354750X.2026.2657869},
issn = {1366-5804},
year = {2026},
date = {2026-06-01},
journal = {Biomarkers},
volume = {31},
number = {4},
pages = {249--257},
abstract = {CONTEXT: This study evaluated changes in salivary tobacco-specific nitrosamines (TSNAs) in smokers and non-smokers before and after Spain's smoke-free legislation.nnMETHODS: We conducted a longitudinal study of 272 adults in Barcelona, surveyed in 2004-2005 and 2013-2014, spanning the 2006 legislation and its 2011 extension. Saliva samples were analyzed for NNN, NNK, and NNAL, and geometric means with 95% confidence intervals were calculated. Data were stratified by sociodemographics, smoking status, smoking behavior, and anthropometrics. Linear mixed-effects models assessed adjusted percentage changes in TSNA concentrations.nnRESULTS: At baseline, overall TSNA concentrations were 1.5 [1.2-1.8] pg/mL for NNN, 1.4 [1.3-1.5] pg/mL for NNK, and 0.5 [0.5-0.6] pg/mL for NNAL. Among baseline smokers who quit, TSNAs decreased by -90.5% (NNN), -48.7% (NNK), and -86.2% (NNAL). Continuing smokers showed a 149.8% increase in NNN, while non-smokers showed no significant change.nnCONCLUSIONS: Concentrations of salivary TSNAs declined in those who quit smoking but increased for continuing smokers. Monitoring TSNAs in saliva is useful for assessing legislative impact.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
CONTEXT: This study evaluated changes in salivary tobacco-specific nitrosamines (TSNAs) in smokers and non-smokers before and after Spain's smoke-free legislation.nnMETHODS: We conducted a longitudinal study of 272 adults in Barcelona, surveyed in 2004-2005 and 2013-2014, spanning the 2006 legislation and its 2011 extension. Saliva samples were analyzed for NNN, NNK, and NNAL, and geometric means with 95% confidence intervals were calculated. Data were stratified by sociodemographics, smoking status, smoking behavior, and anthropometrics. Linear mixed-effects models assessed adjusted percentage changes in TSNA concentrations.nnRESULTS: At baseline, overall TSNA concentrations were 1.5 [1.2-1.8] pg/mL for NNN, 1.4 [1.3-1.5] pg/mL for NNK, and 0.5 [0.5-0.6] pg/mL for NNAL. Among baseline smokers who quit, TSNAs decreased by -90.5% (NNN), -48.7% (NNK), and -86.2% (NNAL). Continuing smokers showed a 149.8% increase in NNN, while non-smokers showed no significant change.nnCONCLUSIONS: Concentrations of salivary TSNAs declined in those who quit smoking but increased for continuing smokers. Monitoring TSNAs in saliva is useful for assessing legislative impact.
Hensen N, Smit RA, Barrero A, Breunese J, Burazeri G, Caini S, Fernández E, Gorini G, Grams L, Mercader CG, Walters BH, Hinderaker HK, Janda M, Jiménez-Rueda A, Jaffery JI, Kahlhöfer J, Francisca Kenter RM, Lödding P, Macaulay L, Marushko K, Ramiro-Pareta M, O'Donnell R, Porthe V, Pontes C, Piera-Jiménez J, Qirjako G, Rocliffe P, Semple S, Troelstra SA, van der Ploeg HP, Willemsen MC, Woods C, Ylli A, Vis C, Martínez C, Nassau FV, PIECES consortium.
Implement Sci Commun. 2026.
Abstract | Links | BibTeX | Etiquetes:
@article{pmid42337627,
title = {The PIECES multi-site comparative case study protocol: mixed methods implementation evaluation of adapting, implementing and tailoring primary cancer prevention programmes in diverse contexts},
author = {Hensen N and Smit RA and Barrero A and Breunese J and Burazeri G and Caini S and Fernández E and Gorini G and Grams L and Mercader CG and Walters BH and Hinderaker HK and Janda M and Jiménez-Rueda A and Jaffery JI and Kahlhöfer J and Francisca Kenter RM and Lödding P and Macaulay L and Marushko K and Ramiro-Pareta M and O'Donnell R and Porthe V and Pontes C and Piera-Jiménez J and Qirjako G and Rocliffe P and Semple S and Troelstra SA and van der Ploeg HP and Willemsen MC and Woods C and Ylli A and Vis C and Martínez C and Nassau FV and PIECES consortium},
doi = {10.1186/s43058-026-01002-0},
issn = {2662-2211},
year = {2026},
date = {2026-06-01},
journal = {Implement Sci Commun},
abstract = {BACKGROUND: Effective implementation of evidence-based programmes in real-world settings requires the capacity to adapt programmes and tailor implementation strategies to local contexts. Many primary cancer prevention (PCP) programmes that are effective in controlled settings struggle in routine practice. Although several frameworks outline principles of adaptation and tailoring, practical guidance on how to operationalise these processes remains limited. The PIECES project aims to help address this gap by developing, implementing, and evaluating structured support for tailored implementation of PCP programmes. Within the PIECES project, a toolkit was co-developed with practitioners and researchers to provide theory- and evidence-informed guidance for adapting, tailoring, implementing, and evaluating PCP programmes. The toolkit aims to strengthen implementation competencies through structured planning, collaborative learning, and evidence-informed decision-making. This paper presents the protocol for the PIECES study which evaluates the toolkit's usability, feasibility, and mechanisms of impact of PCP programmes across diverse healthcare and community settings.nnMETHODS: The PIECES study uses a multi-site pre-post comparative case study design with a mixed-methods implementation evaluation across 11 sites in Europe and Australia, reflecting variation in organisational structures, resources, and cultural contexts. The primary outcome is change in implementation competencies among toolkit users. Guided by the UK MRC Process Evaluation Framework and Proctor's implementation outcomes, the process evaluation examines toolkit usability, feasibility, user satisfaction, and perceived impact on implementation processes and outcomes. Quantitative and qualitative data, toolkit log data, and structured field notes will be collected at six-month intervals (2025-2027). In parallel, a realist evaluation will explore how, why, and under what conditions the toolkit supports tailored implementation. Together, these approaches provide complementary descriptive and explanatory insights into the mechanisms and contextual factors shaping tailored implementation of PCP programmes.nnDISCUSSION: This study is expected to contribute to implementation science by evaluating a structured, evidence-informed tool designed to strengthen capacity for tailored implementation of PCP programmes. Its multi-country design offers a natural field-laboratory to explore how implementation support tools function across varying contexts. By integrating process and realist evaluation approaches, the study is designed to generate practical and theoretical evidence to inform scalable, context-sensitive strategies and enhance the sustainability and impact of evidence-based prevention efforts.nnTRIAL REGISTRATION: ClinicalTrials.gov ID NCT06718322.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
BACKGROUND: Effective implementation of evidence-based programmes in real-world settings requires the capacity to adapt programmes and tailor implementation strategies to local contexts. Many primary cancer prevention (PCP) programmes that are effective in controlled settings struggle in routine practice. Although several frameworks outline principles of adaptation and tailoring, practical guidance on how to operationalise these processes remains limited. The PIECES project aims to help address this gap by developing, implementing, and evaluating structured support for tailored implementation of PCP programmes. Within the PIECES project, a toolkit was co-developed with practitioners and researchers to provide theory- and evidence-informed guidance for adapting, tailoring, implementing, and evaluating PCP programmes. The toolkit aims to strengthen implementation competencies through structured planning, collaborative learning, and evidence-informed decision-making. This paper presents the protocol for the PIECES study which evaluates the toolkit's usability, feasibility, and mechanisms of impact of PCP programmes across diverse healthcare and community settings.nnMETHODS: The PIECES study uses a multi-site pre-post comparative case study design with a mixed-methods implementation evaluation across 11 sites in Europe and Australia, reflecting variation in organisational structures, resources, and cultural contexts. The primary outcome is change in implementation competencies among toolkit users. Guided by the UK MRC Process Evaluation Framework and Proctor's implementation outcomes, the process evaluation examines toolkit usability, feasibility, user satisfaction, and perceived impact on implementation processes and outcomes. Quantitative and qualitative data, toolkit log data, and structured field notes will be collected at six-month intervals (2025-2027). In parallel, a realist evaluation will explore how, why, and under what conditions the toolkit supports tailored implementation. Together, these approaches provide complementary descriptive and explanatory insights into the mechanisms and contextual factors shaping tailored implementation of PCP programmes.nnDISCUSSION: This study is expected to contribute to implementation science by evaluating a structured, evidence-informed tool designed to strengthen capacity for tailored implementation of PCP programmes. Its multi-country design offers a natural field-laboratory to explore how implementation support tools function across varying contexts. By integrating process and realist evaluation approaches, the study is designed to generate practical and theoretical evidence to inform scalable, context-sensitive strategies and enhance the sustainability and impact of evidence-based prevention efforts.nnTRIAL REGISTRATION: ClinicalTrials.gov ID NCT06718322.
Teshima A, Possenti I, Bertacchi D, Bagnardi V, Specchia C, Martinez C, Fernández E, Gallus S, Lugo A.
Eur J Public Health. 2026;36.
Abstract | Links | BibTeX | Etiquetes:
@article{pmid42533755,
title = {Evaluating the effect of cigarettes smoking on oesophageal cancer risk: a systematic review and meta-analysis with dose-response relationships},
author = {Teshima A and Possenti I and Bertacchi D and Bagnardi V and Specchia C and Martinez C and Fernández E and Gallus S and Lugo A},
doi = {10.1093/eurpub/ckag123},
issn = {1464-360X},
year = {2026},
date = {2026-06-01},
journal = {Eur J Public Health},
volume = {36},
number = {4},
abstract = {Oesophageal cancer (OC) affects over 600 000 people annually, with tobacco smoking and alcohol consumption as primary risk factors. We aimed to synthesize existing evidence to quantify the dose-response relationship between smoking and OC risk. A systematic review and meta-analysis was conducted, examining case-control and cohort studies published up to April 2026. Pooled relative risks (RR) were estimated using random-effects models. Dose-response relationships by intensity, duration, and time since quitting of smoking were modelled using log-linear models, with linear or spline terms based on model fit. Of 221 eligible articles, 178 original studies were included. Compared with never smokers, the pooled RR of OC was 2.68 (95% confidence interval; CI: 2.37-3.03; n = 66) for current smokers, 1.71 (95% CI: 1.54-1.90; n = 61) for former smokers, and 2.15 (95% CI: 1.98-2.34; n = 144) for ever smokers. For current smokers compared with never smokers, the risk was 3.03 (95% CI: 2.42-3.79; n = 35) for squamous cell carcinoma (OSCC) and 2.25 (95% CI: 1.80-2.82; n = 14) for adenocarcinoma (OAC). OC risk increased non-linearly with smoking intensity, linearly with smoking duration, and decreased linearly with time since quitting. This meta-analysis reinforces the strong association between smoking and OC, with higher risk for OSCC than OAC. The observed non-linear dose-response relationship indicates that the risk of OC increases sharply even at low levels of smoking intensity, doubling below nine cigarettes and tripling below 17 cigarettes per day. These findings support complete smoking avoidance as the most effective prevention strategy of OC.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
Oesophageal cancer (OC) affects over 600 000 people annually, with tobacco smoking and alcohol consumption as primary risk factors. We aimed to synthesize existing evidence to quantify the dose-response relationship between smoking and OC risk. A systematic review and meta-analysis was conducted, examining case-control and cohort studies published up to April 2026. Pooled relative risks (RR) were estimated using random-effects models. Dose-response relationships by intensity, duration, and time since quitting of smoking were modelled using log-linear models, with linear or spline terms based on model fit. Of 221 eligible articles, 178 original studies were included. Compared with never smokers, the pooled RR of OC was 2.68 (95% confidence interval; CI: 2.37-3.03; n = 66) for current smokers, 1.71 (95% CI: 1.54-1.90; n = 61) for former smokers, and 2.15 (95% CI: 1.98-2.34; n = 144) for ever smokers. For current smokers compared with never smokers, the risk was 3.03 (95% CI: 2.42-3.79; n = 35) for squamous cell carcinoma (OSCC) and 2.25 (95% CI: 1.80-2.82; n = 14) for adenocarcinoma (OAC). OC risk increased non-linearly with smoking intensity, linearly with smoking duration, and decreased linearly with time since quitting. This meta-analysis reinforces the strong association between smoking and OC, with higher risk for OSCC than OAC. The observed non-linear dose-response relationship indicates that the risk of OC increases sharply even at low levels of smoking intensity, doubling below nine cigarettes and tripling below 17 cigarettes per day. These findings support complete smoking avoidance as the most effective prevention strategy of OC.
Feliu A, Martinez C, Vardavas C, Fernández E, Filippidis FT.
From vision to action: a framework to assess readiness for the tobacco endgame. Article
Tob Control. 2026.
Abstract | Links | BibTeX | Etiquetes:
@article{pmid42082364,
title = {From vision to action: a framework to assess readiness for the tobacco endgame},
author = {Feliu A and Martinez C and Vardavas C and Fernández E and Filippidis FT},
doi = {10.1136/tc-2025-059920},
issn = {1468-3318},
year = {2026},
date = {2026-05-01},
journal = {Tob Control},
abstract = {BACKGROUND: Tobacco endgame strategies aim to reduce smoking prevalence to minimal levels (<5%) through measures that expand traditional tobacco control approaches. Although some countries have set endgame targets, most still report prevalence rates >15%, and practical guidance on how to assess readiness for endgame implementation remains limited. This study aims to synthetise the key determinants of jurisdictions' readiness for tobacco endgame and proposes a self-assessment tool to evaluate it.nnMETHODS: A narrative review of peer-reviewed and grey literature published between January 2010 and September 2025 was conducted. Publications were identified through targeted searches of academic databases and relevant organisational websites. A thematic synthesis of evidence on political, social and structural determinants of readiness was undertaken to identify recurring domains, which were later used to inform the development of a self-assessment tool.nnRESULTS: Nine readiness domains were identified: relatively low smoking prevalence; advanced implementation of WHO Framework Convention on Tobacco Control measures; robust enforcement infrastructure; social denormalisation of smoking; broad public understanding and support for ending tobacco use; a positive political climate and strong political will and leadership; a cohesive tobacco control community and civil society; minimal tobacco industry interference with strong protective mechanisms; and sufficient resources to implement tobacco endgame action plan. These domains guided the development of an evidence-informed self-assessment tool to help jurisdictions evaluate readiness, identify gaps and prioritise strategic actions.nnCONCLUSION: The Assessment of Readiness for Tobacco Endgame tool offers an evidence-informed framework to assess tobacco endgame readiness, helping jurisdictions assess capacities, identify gaps and guide strategic decision-making.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
BACKGROUND: Tobacco endgame strategies aim to reduce smoking prevalence to minimal levels (<5%) through measures that expand traditional tobacco control approaches. Although some countries have set endgame targets, most still report prevalence rates >15%, and practical guidance on how to assess readiness for endgame implementation remains limited. This study aims to synthetise the key determinants of jurisdictions' readiness for tobacco endgame and proposes a self-assessment tool to evaluate it.nnMETHODS: A narrative review of peer-reviewed and grey literature published between January 2010 and September 2025 was conducted. Publications were identified through targeted searches of academic databases and relevant organisational websites. A thematic synthesis of evidence on political, social and structural determinants of readiness was undertaken to identify recurring domains, which were later used to inform the development of a self-assessment tool.nnRESULTS: Nine readiness domains were identified: relatively low smoking prevalence; advanced implementation of WHO Framework Convention on Tobacco Control measures; robust enforcement infrastructure; social denormalisation of smoking; broad public understanding and support for ending tobacco use; a positive political climate and strong political will and leadership; a cohesive tobacco control community and civil society; minimal tobacco industry interference with strong protective mechanisms; and sufficient resources to implement tobacco endgame action plan. These domains guided the development of an evidence-informed self-assessment tool to help jurisdictions evaluate readiness, identify gaps and prioritise strategic actions.nnCONCLUSION: The Assessment of Readiness for Tobacco Endgame tool offers an evidence-informed framework to assess tobacco endgame readiness, helping jurisdictions assess capacities, identify gaps and guide strategic decision-making.
Teshima A, Feliu A, Gallus S, Martinez C, Fernandez E.
Lancet Reg Health Eur. 2026;60:101511.
Abstract | Links | BibTeX | Etiquetes:
@article{pmid41216474,
title = {Impact of cigarette prices and age-of-sale policies on smoking prevalence among youth in 26 European Member States (2012-2023): a longitudinal ecological study using repeated cross-sectional data},
author = {Teshima A and Feliu A and Gallus S and Martinez C and Fernandez E},
doi = {10.1016/j.lanepe.2025.101511},
issn = {2666-7762},
year = {2026},
date = {2026-01-01},
journal = {Lancet Reg Health Eur},
volume = {60},
pages = {101511},
abstract = {BACKGROUND: Reducing tobacco and nicotine use and preventing smoking initiation among youth are key public health priorities. We evaluated the impact of cigarette prices and age-of-sale laws on youth smoking prevalence in the European Union (EU).nnMETHODS: In this ecological study with 26 EU Member States as the unit of analysis, we estimated smoking prevalence among individuals aged 15-24, using five Eurobarometer waves (2012-2023, n = 12,087). We used fixed-effects panel regression models to assess the association between cigarette prices, the introduction of 18+ age-of-sale laws for tobacco products and changes in youth smoking prevalence, controlling for time and tobacco control policy implementation.nnFINDINGS: Weighted youth smoking prevalence decreased from 28.4% (841/2818) in 2012 to 22.2% (490/2222) in 2023, although the trend was not consistently downward. A €1 increase in inflation-adjusted cigarette prices per pack was associated with a 3.4 percentage point reduction in male youth prevalence (95% CI: -6.40 to -0.45), while there was no significant association for females or at the EU level. Regional variation was observed, with price increases associated with substantial reductions in youth smoking among both sexes in Southern Europe and among males in Northern Europe. In contrast, no such associations were found in Western or Eastern Europe. Age-of-sale laws were not significantly associated with youth smoking prevalence at the EU level.nnINTERPRETATION: Current taxation and age-of-sale policies remain insufficient, with impacts varying by sex and region. Achieving the tobacco endgame requires harmonised EU-level measures and stronger enforcement, particularly of these two policies, to prevent the ongoing influx of new youth smoking initiates. This study suggests that their potential impact has been constrained by inadequate enforcement to date rather than by policy ineffectiveness.nnFUNDING: None.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
BACKGROUND: Reducing tobacco and nicotine use and preventing smoking initiation among youth are key public health priorities. We evaluated the impact of cigarette prices and age-of-sale laws on youth smoking prevalence in the European Union (EU).nnMETHODS: In this ecological study with 26 EU Member States as the unit of analysis, we estimated smoking prevalence among individuals aged 15-24, using five Eurobarometer waves (2012-2023, n = 12,087). We used fixed-effects panel regression models to assess the association between cigarette prices, the introduction of 18+ age-of-sale laws for tobacco products and changes in youth smoking prevalence, controlling for time and tobacco control policy implementation.nnFINDINGS: Weighted youth smoking prevalence decreased from 28.4% (841/2818) in 2012 to 22.2% (490/2222) in 2023, although the trend was not consistently downward. A €1 increase in inflation-adjusted cigarette prices per pack was associated with a 3.4 percentage point reduction in male youth prevalence (95% CI: -6.40 to -0.45), while there was no significant association for females or at the EU level. Regional variation was observed, with price increases associated with substantial reductions in youth smoking among both sexes in Southern Europe and among males in Northern Europe. In contrast, no such associations were found in Western or Eastern Europe. Age-of-sale laws were not significantly associated with youth smoking prevalence at the EU level.nnINTERPRETATION: Current taxation and age-of-sale policies remain insufficient, with impacts varying by sex and region. Achieving the tobacco endgame requires harmonised EU-level measures and stronger enforcement, particularly of these two policies, to prevent the ongoing influx of new youth smoking initiates. This study suggests that their potential impact has been constrained by inadequate enforcement to date rather than by policy ineffectiveness.nnFUNDING: None.
Sæbø G, Carnicer-Pont D, Lopez AM, Koprivnikar H, Pénzes M, González-Marrón A, Arteta N, Fernández E.
Tob Control. 2026.
Abstract | Links | BibTeX | Etiquetes:
@article{pmid41530058,
title = {Mapping loopholes in the current regulation of tobacco advertising, promotion, and sponsorship in Europe: a scoping review},
author = {Sæbø G and Carnicer-Pont D and Lopez AM and Koprivnikar H and Pénzes M and González-Marrón A and Arteta N and Fernández E},
doi = {10.1136/tc-2025-059329},
issn = {1468-3318},
year = {2026},
date = {2026-01-01},
journal = {Tob Control},
abstract = {OBJECTIVE: To review and synthesise European evidence identifying loopholes in 'Tobacco Advertising, Promotion and Sponsorship' (TAPS) regulations and actions undertaken by European countries to curb TAPS.nnDATA SOURCES: We conducted a comprehensive search across seven databases (Medline/PubMed, Embase, Web of Science, Sociological abstracts, Global health, CINAHL and PsycInfo) along with grey literature from relevant tobacco control organisation websites. Searches were restricted by publication date (2005-2023), geographical setting (EU & European Free Trade Association countries) and language (English).nnSTUDY SELECTION: All reviewers independently screened titles and abstracts using a purpose-designed Excel spreadsheet to identify sources addressing loopholes in national or supranational settings, deciding on inclusion accordingly.nnDATA EXTRACTION: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist, we extracted data based on the 'Population, Concept and Context' framework, covering tobacco product type, media communication channel and findings indicating TAPS loopholes. Two reviewers used an Excel sheet to extract data.nnDATA SYNTHESIS: Of 1477 sources, 140 were included in the review. Analysis identified five key loopholes: (a) smoking depictions and tobacco advertising in traditional mass media (films and television), (b) cross-border branding and sponsorships, (c) point-of-sale marketing, (d) e-cigarette and tobacco advertising and promotion on the internet and (e) promotion and advertising of tobacco and novel nicotine products on social media.nnCONCLUSIONS: Curbing TAPS through comprehensive national bans and cross-border cooperation remains challenging because of the permeability of mass media, social media and other digital tools. Further research is necessary to develop strategies for effective implementation and enforcement to ensure compliance with TAPS regulations.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
OBJECTIVE: To review and synthesise European evidence identifying loopholes in 'Tobacco Advertising, Promotion and Sponsorship' (TAPS) regulations and actions undertaken by European countries to curb TAPS.nnDATA SOURCES: We conducted a comprehensive search across seven databases (Medline/PubMed, Embase, Web of Science, Sociological abstracts, Global health, CINAHL and PsycInfo) along with grey literature from relevant tobacco control organisation websites. Searches were restricted by publication date (2005-2023), geographical setting (EU & European Free Trade Association countries) and language (English).nnSTUDY SELECTION: All reviewers independently screened titles and abstracts using a purpose-designed Excel spreadsheet to identify sources addressing loopholes in national or supranational settings, deciding on inclusion accordingly.nnDATA EXTRACTION: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist, we extracted data based on the 'Population, Concept and Context' framework, covering tobacco product type, media communication channel and findings indicating TAPS loopholes. Two reviewers used an Excel sheet to extract data.nnDATA SYNTHESIS: Of 1477 sources, 140 were included in the review. Analysis identified five key loopholes: (a) smoking depictions and tobacco advertising in traditional mass media (films and television), (b) cross-border branding and sponsorships, (c) point-of-sale marketing, (d) e-cigarette and tobacco advertising and promotion on the internet and (e) promotion and advertising of tobacco and novel nicotine products on social media.nnCONCLUSIONS: Curbing TAPS through comprehensive national bans and cross-border cooperation remains challenging because of the permeability of mass media, social media and other digital tools. Further research is necessary to develop strategies for effective implementation and enforcement to ensure compliance with TAPS regulations.
Liang R, Laverty AA, Feliu A, Martinez C, Peruga A, Vardavas C, Filippidis FT.
Eur J Public Health. 2026.
Abstract | Links | BibTeX | Etiquetes:
@article{pmid41603344,
title = {Public support for standardised packaging and policy implementation: an analysis of European survey data},
author = {Liang R and Laverty AA and Feliu A and Martinez C and Peruga A and Vardavas C and Filippidis FT},
doi = {10.1093/eurpub/ckag001},
issn = {1464-360X},
year = {2026},
date = {2026-01-01},
journal = {Eur J Public Health},
abstract = {We conducted a secondary analysis of Eurobarometer survey data from 27 European countries, collected in 2017 (n = 28 300) and 2023 (n = 26 358), to assess changes in public support for standardised tobacco packaging. In the pooled analysis, support remained unchanged in the 19 MS without relevant legislation (adjusted Prevalence Ratio [aPR]=0.94, 95% Confidence Interval: 0.86-1.03), whereas the 8 MS that had implemented the policy by 2023 were significantly more likely to experience an increase in support (interaction term: aPR = 1.28, 1.17-1.41). The increase in support offers reassurance to policymakers advocating for tobacco packaging regulations and encourages MS to consider the adoption of similar policies.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
We conducted a secondary analysis of Eurobarometer survey data from 27 European countries, collected in 2017 (n = 28 300) and 2023 (n = 26 358), to assess changes in public support for standardised tobacco packaging. In the pooled analysis, support remained unchanged in the 19 MS without relevant legislation (adjusted Prevalence Ratio [aPR]=0.94, 95% Confidence Interval: 0.86-1.03), whereas the 8 MS that had implemented the policy by 2023 were significantly more likely to experience an increase in support (interaction term: aPR = 1.28, 1.17-1.41). The increase in support offers reassurance to policymakers advocating for tobacco packaging regulations and encourages MS to consider the adoption of similar policies.
Saura J, Feliu A, Enríquez M, Roca X, Ballbè M, Fu M, Segura L, Fernández E, Martínez C.
Front Psychol. 2026;17:1744004.
Abstract | Links | BibTeX | Etiquetes:
@article{pmid42220376,
title = {Psychometric validation of the Cannabis Withdrawal Checklist in a Spanish sample with cannabis use disorder},
author = {Saura J and Feliu A and Enríquez M and Roca X and Ballbè M and Fu M and Segura L and Fernández E and Martínez C},
doi = {10.3389/fpsyg.2026.1744004},
issn = {1664-1078},
year = {2026},
date = {2026-01-01},
journal = {Front Psychol},
volume = {17},
pages = {1744004},
abstract = {INTRODUCTION: Cannabis is used globally. In Spain, it is often used in combination with tobacco, which may exacerbate withdrawal severity. Currently, no validated instrument exists to assess cannabis withdrawal symptoms in Spanish populations. This study aimed to validate the 15-item Cannabis (Marijuana) Withdrawal Checklist (CWC) for Spanish-speaking individuals who co-use cannabis and tobacco.nnMATERIALS AND METHODS: This psychometric validation study was nested within a multicenter longitudinal project conducted across 10 substance use treatment programs in Catalonia (Spain). The CWC was forward- and back-translated following COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) recommendations. Internal consistency, construct validity, and sensitivity to change over time were assessed using Cronbach's alpha, exploratory factor analysis (EFA), and mixed-effects analysis. Data from 82 participants were used to conduct the validation.nnRESULTS: The adapted CWC demonstrated high internal consistency (Cronbach's = 0.918 at baseline; 0.885 at 2 weeks of treatment). EFA supported a unidimensional structure explaining approximately 60% of the variance. Although symptom severity did not significantly change over follow-up, withdrawal intensity was positively associated with the level of cannabis use. The scale effectively captured clinically relevant symptoms such as irritability, craving, and sleep difficulties.nnCONCLUSION: The Spanish CWC showed strong reliability and acceptable psychometric properties, supporting its use for assessing cannabis withdrawal symptoms in Spanish-speaking adults, particularly those who co-use tobacco products. The scale may be valuable in both research and clinical settings, particularly for monitoring withdrawal during treatment interventions. Further validation using larger, more diverse samples is warranted.nnCLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, identifier NCT0551209.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
INTRODUCTION: Cannabis is used globally. In Spain, it is often used in combination with tobacco, which may exacerbate withdrawal severity. Currently, no validated instrument exists to assess cannabis withdrawal symptoms in Spanish populations. This study aimed to validate the 15-item Cannabis (Marijuana) Withdrawal Checklist (CWC) for Spanish-speaking individuals who co-use cannabis and tobacco.nnMATERIALS AND METHODS: This psychometric validation study was nested within a multicenter longitudinal project conducted across 10 substance use treatment programs in Catalonia (Spain). The CWC was forward- and back-translated following COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) recommendations. Internal consistency, construct validity, and sensitivity to change over time were assessed using Cronbach's alpha, exploratory factor analysis (EFA), and mixed-effects analysis. Data from 82 participants were used to conduct the validation.nnRESULTS: The adapted CWC demonstrated high internal consistency (Cronbach's = 0.918 at baseline; 0.885 at 2 weeks of treatment). EFA supported a unidimensional structure explaining approximately 60% of the variance. Although symptom severity did not significantly change over follow-up, withdrawal intensity was positively associated with the level of cannabis use. The scale effectively captured clinically relevant symptoms such as irritability, craving, and sleep difficulties.nnCONCLUSION: The Spanish CWC showed strong reliability and acceptable psychometric properties, supporting its use for assessing cannabis withdrawal symptoms in Spanish-speaking adults, particularly those who co-use tobacco products. The scale may be valuable in both research and clinical settings, particularly for monitoring withdrawal during treatment interventions. Further validation using larger, more diverse samples is warranted.nnCLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, identifier NCT0551209.
Martínez C, Pardavila-Belio MI, Laroussy K, Moreno C, Puig M, Agüeda Z, Sancho R, Lluch T, Canga-Armayor N, Pueyo-Garrigues M, Tricas-Sauras S, Lavilla-Gracia M, Duaso MJ, Vilaplana J, Roca J, Margalef M, Fernández E, Feliu A, INSTrUCT Research Group.
Tob Induc Dis. 2026;24.
Abstract | Links | BibTeX | Etiquetes:
@article{pmid42502418,
title = {Effect of brief smoking cessation online training on knowledge, attitudes, behaviors, and organizational factors in European health professions students: A pre-post study},
author = {Martínez C and Pardavila-Belio MI and Laroussy K and Moreno C and Puig M and Agüeda Z and Sancho R and Lluch T and Canga-Armayor N and Pueyo-Garrigues M and Tricas-Sauras S and Lavilla-Gracia M and Duaso MJ and Vilaplana J and Roca J and Margalef M and Fernández E and Feliu A and INSTrUCT Research Group},
doi = {10.18332/tid/217007},
issn = {1617-9625},
year = {2026},
date = {2026-01-01},
journal = {Tob Induc Dis},
volume = {24},
abstract = {INTRODUCTION: Health professionals play a critical role in tobacco prevention and cessation, but limited training during education often leaves their knowledge, attitudes, behaviors, and organizational support insufficient. Our aim was to assess the effect of an online brief smoking cessation training program on knowledge, attitudes, behaviors, and organizational factors among health professions students in Spain and the United Kingdom.nnMETHODS: A pre-post study was conducted among 756 undergraduate health professions students (652 from Spain and 104 from the UK) from four universities. Participants completed the validated Knowledge, Attitudes, Behaviors, and Organizational factors self-reported questionnaire for health professions Students (KABO_S) before and one month after the training. Generalized linear mixed models analyzed pre-post changes, adjusting for gender, age, and tobacco use.nnRESULTS: Significant increases were observed in the overall KABO_S score from 4.82 (SD=1.34) to 6.69 (SD=1.26) at one month (p<0.01). All dimensions increased in both countries (all p<0.01), with the greatest gains in individual knowledge/skills and attitudes/beliefs (median improvements ranging from 38.5% to 69.1%). Organizational resources showed the lowest gains (median improvement of 5.7% to 15.2%). Linear mixed models confirmed a significant increase in overall KABO_S scores (Spain: β=1.78; 95% CI: 1.67-1.90; UK: β=2.44; 95% CI: 2.13-2.74) and in each individual dimension (all p<0.001).nnCONCLUSIONS: Knowledge, attitudes, behaviors, and organizational factors improved significantly among health professions students in both countries. These findings suggest that this online training program may represent a promising addition to health professions curricula in Europe.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
INTRODUCTION: Health professionals play a critical role in tobacco prevention and cessation, but limited training during education often leaves their knowledge, attitudes, behaviors, and organizational support insufficient. Our aim was to assess the effect of an online brief smoking cessation training program on knowledge, attitudes, behaviors, and organizational factors among health professions students in Spain and the United Kingdom.nnMETHODS: A pre-post study was conducted among 756 undergraduate health professions students (652 from Spain and 104 from the UK) from four universities. Participants completed the validated Knowledge, Attitudes, Behaviors, and Organizational factors self-reported questionnaire for health professions Students (KABO_S) before and one month after the training. Generalized linear mixed models analyzed pre-post changes, adjusting for gender, age, and tobacco use.nnRESULTS: Significant increases were observed in the overall KABO_S score from 4.82 (SD=1.34) to 6.69 (SD=1.26) at one month (p<0.01). All dimensions increased in both countries (all p<0.01), with the greatest gains in individual knowledge/skills and attitudes/beliefs (median improvements ranging from 38.5% to 69.1%). Organizational resources showed the lowest gains (median improvement of 5.7% to 15.2%). Linear mixed models confirmed a significant increase in overall KABO_S scores (Spain: β=1.78; 95% CI: 1.67-1.90; UK: β=2.44; 95% CI: 2.13-2.74) and in each individual dimension (all p<0.001).nnCONCLUSIONS: Knowledge, attitudes, behaviors, and organizational factors improved significantly among health professions students in both countries. These findings suggest that this online training program may represent a promising addition to health professions curricula in Europe.