Spain has made significant progress in the past 20 years in the protection of passive smokers, including Act 42/2010, which restricts the use of tobacco in public spaces1. This type of legislation has been shown to improve cardiovascular health and mortality from tobacco-related diseases2. However, these measures have not succeeded in reducing the number of active smokers3.

The 2017 results of the Survey on Alcohol, Tobacco and other Drugs in Spain (AGES), conducted biennially by the Ministry of Health and Consumption, reveal a worrying statistic. Daily consumption of tobacco in the Spanish population aged 15 to 64 years has increased by 3.2% (34%) since 2015, with a return to 1997 consumption levels4. This increase in smoking in Spain is reflected by a higher daily consumption among men aged 15-34 years and women aged 35-64 years, the highest of all the historical series. The highest percentage of daily smokers since 2003 was also observed among men aged 35-64 years.

The group of young men between the ages of 15-34 years who smoke is characterized by easy access to tobacco, a lower perception of the damage caused by smoking, and a lack of motivation to try to quit. Moreover, this population group reports the highest use of electronic nicotine-delivery devices and cannabis, closely associated with tobacco consumption4. Mechanisms for taking action in this group should include a range of measures that have been proven to reduce the prevalence of smoking: increasing the price of tobacco, for example, has proven to be the most efficacious and cost-effective measure4. For every 10% increase in the price of tobacco, sales fall by around 4%5,6. It would also be necessary to price the different tobacco products on the same level, as rolling tobacco has a lower tax burden and is less expensive than manufactured cigarettes, leading to substantially increased sales in recent years. Plain packaging has also made smoking less attractive among adolescents, it has increased smokers’ motivation to make a serious attempt to give up, and has led to lower volumes of tobacco sales in countries such as Australia7,8. Awareness-raising campaigns and interventions in families or in schools and colleges would complement the above measures, and would discourage new smokers from taking up the habit. It seems that in Spain there is room for improvement, since compliance with the recommendations for tobacco control from the World Bank9 is low in terms of fiscal measures (50% of recommended), expenditure on public information campaigns (6%), and plain packaging and graphic warnings on cigarette packs (40%)10.

Another population group of great interest are smokers between 35 to 64 years of age, who are characterized by high nicotine dependence, despite awareness of the risk of their smoking habit. In total, 67.8% of this group have not only considered quitting, but have also made at least 1 serious attempt to stop. The EDADES survey does not specify whether individuals used any treatment to help quit4, although other studies show that only 12% of smokers who are trying to quit ask a healthcare professional for help. In addition, only 10% of smokers who make a serious attempt to quit are able to do so without assistance6.

In this population, the EDADES survey reflects an increase in the number of women smokers. Despite the fact that tobacco use is generally lower, women find it more difficult to stop smoking than men, and relapse more often.

These relapses appear to be due to anxiety, depression, and a greater concern about weight gain. For this reason, specific interventions in this group aimed at increasing self-efficacy, improving mood, and reducing anxiety are of great importance11. In the population aged 35-64 years, it is particularly important that other measures are implemented, such as quality care by health professionals, whether general practitioners or specialists, offering psychological counselling and pharmacological treatment for smoking cessation. It also seems reasonable to subsidize drug treatment for smoking, since these are safe and effective interventions and abstinence rates are twice as high compared to placebo. Subsidizing these treatments by the Spanish national health system would increase success in cessation attempts, and would facilitate access to treatment by the more deprived social classes where the prevalence of smoking is higher. It is estimated that subsidizing these drugs would lead 200,000 smokers in Spain to quit12. Moreover, cases of chronic obstructive pulmonary disease could be identified in this age group, a chronic disease in which the pharmacological treatment of smoking has been shown to be cost-effective13.

The Spanish Society of Pulmonology and Thoracic Surgery recently proposed a series of recommendations for tobacco control, such as increasing the price of tobacco, monitoring and controlling compliance with applicable tobacco control legislation, extending the ban on smoking to other public places, implementing plain packaging, and helping smokers quit. The implementation of these measures in Spain could stop this epidemic.

In conclusion, the health authorities of Spain must not limit tobacco control policies to measures aimed at restricting the use of tobacco in public spaces, although the consequent decrease of passive smoking also generates a significant impact on the health of the exposed population14,15. They must also implement fiscal and regulatory strategies that have already demonstrated their effectiveness in reducing the number of smokers, and provide quality assistance in smoking cessation.