Effect of comprehensive smoke-free legislation on asthma and coronary disease trends in Spanish primary care patients

Effect of comprehensive smoke-free legislation on asthma and coronary disease trends in Spanish... Abstract Background To examine the impact of comprehensive smoke-free legislation (SFL) (Law 42/2010) on the incidence and prevalence of adult asthma and coronary disease in primary health care (PHC) patients from three Spanish regions, overall and stratified by sex. Methods Longitudinal observational study conducted between 2007 and 2013 in the population over 15 years of age assigned to 66 PHC teams in Catalonia, Navarre and the Balearic Islands. Crude rates and age-standardized (truncated: asthma ≥ 16 years and coronary disease ≥ 35 years) incidence and prevalence rates using the direct method based on the European Standard Population were estimated based on data from PHC electronic health records. Joinpoint analysis was used to analyse the trends of age-standardized incidence and prevalence rates. Trends were expressed as annual percentage change and average annual percent change (AAPC). Results The standardized asthma incidence rate showed a non-significant downward trend and the standardized prevalence rates rose significantly in the three regions. Standardized coronary disease incidence and prevalence rates were considerably higher for men than for women in all regions. The standardized coronary disease incidence rates in Catalonia (AAPC: −8.00%, 95% CI: −10.46; −5.47) and Navarre (AAPC: −3.66%, 95% CI: −4.95;-2.35) showed a significant downward trend from 2007 to 2013, overall and by sex. The standardized coronary disease prevalence trend rate increased significantly in the whole period in Catalonia and the Balearic Islands, although a non-significant downward trend was observed from 2010 in Catalonia. Conclusion No changes in the trends of adult asthma and coronary disease in PHC Spanish patients were detected after the introduction of comprehensive SFL. Introduction Evidence shows that secondhand smoke (SHS) exposure is causally associated with conditions such as asthma and acute coronary syndrome.1 Consequently, legislative measures have been adopted to protect people’s health in public areas and workplaces.2,3 Since the introduction of smoke-free legislation (SFL), various studies have assessed its repercussions from different points of view. For instance, a decrease in the number of hospital admissions for coronary disease in adults has been observed following the implementation of this legislation4–6 and a meta-analysis showed a 13% decrease in hospital admissions for acute myocardial infarction (AMI).7 According to a Cochrane review, results on the impact of SFL on hospital admissions for asthma remains inconsistent,8 although a meta-analysis showed a 24% decrease in hospital admissions for respiratory conditions.9 We should underscore that most studies on the impact of SFL in asthma and coronary disease have analysed hospital data and that few studies address the impact of the legislation in primary health care (PHC) patients. For instance, Kalkhoran et al.10 analysed non-hospital emergency visits for asthma (Uruguay) and observed a 15% decrease in the incidence rate ratio. In contrast, Been et al.11 did not find any reduction in new diagnoses of asthma in children after SFL implementation (UK). On 1 January 2006, the Spanish government introduced a smoking law (Law 28/2005)12 which included regulations on the sale, supply, consumption and advertising of tobacco products. Smoking was banned in all enclosed public and private workplaces with the exception of the hospitality sector, where partial restrictions were established depending on the size of the establishment. This law was expanded in January 2011 (Law 42/2010)13 and as a result smoking was forbidden in all enclosed public places, including bars, restaurants and nightclubs, and in some open-air public places such as playgrounds. The studies that analysed the effect of the Spanish partial law on hospital admissions for asthma and coronary disease showed a decrease in the incidence of AMI and inconclusive results for asthma.14–16 To our knowledge, no studies have been published on the impact of the comprehensive law on asthma (in PHC) and heart disease, although some studies evaluate the effect of this law on smoking and exposure to SHS.17,18 The aim of this study was to examine the impact of the Spanish comprehensive SFL (Law 42/2010) on the incidence and prevalence of adult asthma and coronary disease in PHC patients in three regions (Catalonia, Navarre and the Balearic Islands) during the period 2007–13, overall and stratified by sex. Methods Study design, participants and source of information This is a longitudinal observational study of the population assigned to 66 PHC teams (PHCTs) in three Spanish regions: Catalonia, Navarre and the Balearic Islands (22 PHCT per region). Inclusion criteria of the PHCT were: (i) use of electronic health records (EHRs) by 1 January 2005, in Catalonia and Navarre, and 2008 in the Balearic Islands; and (ii) agreement to participate in the study by over 80% health-care professionals of the PHCT. Random cluster sampling was stratified by region, with the PHCT as randomization unit.19 In each PHCT, general practitioners (GPs) with a patient list between 400–3000 were selected. GP with shorter patient lists were accepted if it was their first year in the PHCT. The study period was from 2007 to 2013 in Catalonia and Navarre. In the Balearic Islands it was from 2010 to 2013 because EHR were not sufficiently reliable before 2010. Inclusion criteria for patients were: (i) Population allocated to the selected PHCT for each year of the period in Catalonia and Navarre (≥80% patients entered in 2007). Some patients died or moved during the study period. In the Balearic Islands, data from 2010 to 2013 of patients allocated to the selected PHCT in 2013 were analysed retrospectively (no annual comprehensive register of patients was available); (ii) Aged between ≥16 and ≤100 years when entering the study and (iii) A minimum of one visit with the PHCT during the study period (in order to have data in the EHR collected during this period). In the case of coronary disease, the population was restricted to those ≥35 years to allow the use of the Framingham and REGICOR equations to calculate coronary risk.20Supplementary figure S1 shows the flowchart of the study. Data were extracted from the REGIPREV database.19 It contains encrypted and anonymized clinical information recorded in the EHR from these 66 PHCT. An algorithm was applied to obtain equivalent data from the health records software used in each region. An equivalence table based on that created by WONCA21,22 was formulated by the research team matching the codes of the International Classification of Diseases, 10th revision (ICD-10)23 used in Catalonia and the International Classification of Diseases, 9th revision (ICD-9) codes used in the Balearic Islands with the International Classification of Primary Care, Second edition (ICPC-2) used in Navarre. Variables For each year of the study (at 31st of December), the dichotomous dependent variables were: Diagnosis of coronary episode: any register (≥1) of the diagnosis codes of coronary disease (codes I-20 to I-25 of the ICD-10 codes, 410-413 and 429.7 of ICD-9 and K74-76 of the ICPC-2). Diagnosis of asthma episode: any register (≥1) of the diagnosis codes of asthma (codes J-45 and J-46 of the ICD-10, codes 493 of the ICD-9 and R96 of the ICPC-2). The following variables of each patient were collected when entering the study: age, sex, number of health problems and number of PHC visits during the year considered. The number of health problems was used as a morbidity indicator; it was calculated as the sum of the number of different active health problems (all chronic and acute problems, coded by ICPC-2). Data analyses Descriptive statistics were used to summarize overall information. Categorical variables were expressed as percentage, and continuous variables as mean (standard deviation) or median (interquartile range [IQR]). We performed a stratified analysis per region, overall and by sex. Crude rates and age-standardized (truncated: asthma, ≥16 years and coronary disease, ≥35 years) incidence and prevalence rates were calculated for each year using the direct method, and based on the European Standard Population. These were expressed as rates per 10 000 inhabitants. To analyse the trends of age-standardized incidence and prevalence rates, the joinpoint analysis was used to identify the best-fitting points (the ‘joinpoints’, in calendar years) where the rate changes significantly over time. Significant changes include changes in direction or in the rate of increase or decrease.24 Temporal trends were expressed as the annual percentage change (APC), computed over each specified time interval and the average annual percent change (AAPC), computed to summarize and compare these trends over the entire time period. Ninety-five percent confidence intervals (95% CI) of APC and AAPC were calculated. Analyses were performed using Stata/SE version 14.2 for Windows (Stata Corp.LP, College Station, TX). The joinpoint regression analysis was carried out using the joinpoint software from the Surveillance Research Programme of the US National Cancer Institute.25 Ethical aspects The study was approved by the Research Ethics Committee of the IDIAP Jordi Gol. Confidentiality was guaranteed by data encryption and anonymization. Results The asthma study population consisted of 472 348 patients in Catalonia, 272 415 in Navarre and 302 281 in the Balearic Islands. At the onset of the study, the mean age in years of the asthma and coronary disease populations was circa 45 and 55, respectively. In both populations more than half were women (>51%). Catalonia presented the highest median number of visits for the asthma (6, IQR: 2–13) and coronary disease populations (7, IQR: 2–15). The Balearic Islands recorded the highest number of active health problems per patient for both populations (asthma population median 8, IQR: 4–14; coronary disease population median 9, IQR: 5–15) (table 1). Table 1 Characteristics of the asthma and coronary disease study population by region (Catalonia, Navarre, Balearic Islands-Spain) at the onset of the study Asthma (≥16 years) Coronary disease (≥35 years) Catalonia (n =472 348) Navarre (n = 272 415) Balearic Islands (n =302 281) Catalonia (n = 301 403) Navarre (n =172 809) Balearic Islands (n =203 532) Age (years), SD 45.45 (18.78) 44.87 (19.37) 45.51 (17.73) 55.95 (15.25) 56.07 (15.08) 54.62 (14.08) Sex (female), number (%) 243590 (51.57) 139513 (51.21) 157538 (52.12) 157011 (52.09) 89321 (51.68) 106339 (52.25) Number of visits, mean (SD); median (IQR) 9.12 (11.30); 6.00 (2.00–13.00) 6.41 (8.62); 4.00 (1.00–9.00) 9.05 (12.10); 5.00 (1.00–12.00) 10.78 (12.65); 7.00 (2.00–15.00) 7.89 (9.89); 5.00 (2.00–11.00) 10.49 (13.15); 7.00 (2.00–14.00) Number of health problems, mean (SD); median IQR) 4.50 (4.44); 3.00 (1.00–6.00) 7.40 (5.05); 6.00 (4.00–10.00) 9.70 (7.68); 8.00 (4.00–14.00) 5.25 (4.75); 4.00 (2.00–7.00) 8.12 (5.28); 7.00 (4.00–11.00) 10.51 (8.00); 9.00 (5.00–15.00) Asthma (≥16 years) Coronary disease (≥35 years) Catalonia (n =472 348) Navarre (n = 272 415) Balearic Islands (n =302 281) Catalonia (n = 301 403) Navarre (n =172 809) Balearic Islands (n =203 532) Age (years), SD 45.45 (18.78) 44.87 (19.37) 45.51 (17.73) 55.95 (15.25) 56.07 (15.08) 54.62 (14.08) Sex (female), number (%) 243590 (51.57) 139513 (51.21) 157538 (52.12) 157011 (52.09) 89321 (51.68) 106339 (52.25) Number of visits, mean (SD); median (IQR) 9.12 (11.30); 6.00 (2.00–13.00) 6.41 (8.62); 4.00 (1.00–9.00) 9.05 (12.10); 5.00 (1.00–12.00) 10.78 (12.65); 7.00 (2.00–15.00) 7.89 (9.89); 5.00 (2.00–11.00) 10.49 (13.15); 7.00 (2.00–14.00) Number of health problems, mean (SD); median IQR) 4.50 (4.44); 3.00 (1.00–6.00) 7.40 (5.05); 6.00 (4.00–10.00) 9.70 (7.68); 8.00 (4.00–14.00) 5.25 (4.75); 4.00 (2.00–7.00) 8.12 (5.28); 7.00 (4.00–11.00) 10.51 (8.00); 9.00 (5.00–15.00) Abbreviation: SD, standard deviation; IQR, interquartile range. Patients belonged to 22 PHC Team in each region. Table 1 Characteristics of the asthma and coronary disease study population by region (Catalonia, Navarre, Balearic Islands-Spain) at the onset of the study Asthma (≥16 years) Coronary disease (≥35 years) Catalonia (n =472 348) Navarre (n = 272 415) Balearic Islands (n =302 281) Catalonia (n = 301 403) Navarre (n =172 809) Balearic Islands (n =203 532) Age (years), SD 45.45 (18.78) 44.87 (19.37) 45.51 (17.73) 55.95 (15.25) 56.07 (15.08) 54.62 (14.08) Sex (female), number (%) 243590 (51.57) 139513 (51.21) 157538 (52.12) 157011 (52.09) 89321 (51.68) 106339 (52.25) Number of visits, mean (SD); median (IQR) 9.12 (11.30); 6.00 (2.00–13.00) 6.41 (8.62); 4.00 (1.00–9.00) 9.05 (12.10); 5.00 (1.00–12.00) 10.78 (12.65); 7.00 (2.00–15.00) 7.89 (9.89); 5.00 (2.00–11.00) 10.49 (13.15); 7.00 (2.00–14.00) Number of health problems, mean (SD); median IQR) 4.50 (4.44); 3.00 (1.00–6.00) 7.40 (5.05); 6.00 (4.00–10.00) 9.70 (7.68); 8.00 (4.00–14.00) 5.25 (4.75); 4.00 (2.00–7.00) 8.12 (5.28); 7.00 (4.00–11.00) 10.51 (8.00); 9.00 (5.00–15.00) Asthma (≥16 years) Coronary disease (≥35 years) Catalonia (n =472 348) Navarre (n = 272 415) Balearic Islands (n =302 281) Catalonia (n = 301 403) Navarre (n =172 809) Balearic Islands (n =203 532) Age (years), SD 45.45 (18.78) 44.87 (19.37) 45.51 (17.73) 55.95 (15.25) 56.07 (15.08) 54.62 (14.08) Sex (female), number (%) 243590 (51.57) 139513 (51.21) 157538 (52.12) 157011 (52.09) 89321 (51.68) 106339 (52.25) Number of visits, mean (SD); median (IQR) 9.12 (11.30); 6.00 (2.00–13.00) 6.41 (8.62); 4.00 (1.00–9.00) 9.05 (12.10); 5.00 (1.00–12.00) 10.78 (12.65); 7.00 (2.00–15.00) 7.89 (9.89); 5.00 (2.00–11.00) 10.49 (13.15); 7.00 (2.00–14.00) Number of health problems, mean (SD); median IQR) 4.50 (4.44); 3.00 (1.00–6.00) 7.40 (5.05); 6.00 (4.00–10.00) 9.70 (7.68); 8.00 (4.00–14.00) 5.25 (4.75); 4.00 (2.00–7.00) 8.12 (5.28); 7.00 (4.00–11.00) 10.51 (8.00); 9.00 (5.00–15.00) Abbreviation: SD, standard deviation; IQR, interquartile range. Patients belonged to 22 PHC Team in each region. The asthma incidence rate reached 0.40% in Catalonia in 2009, 0.55% in Navarre in 2008 and 0.69% in the Balearic Islands in 2010. The Balearic Islands presented the highest overall and standardized rates between 2010 and 2013. Navarre showed a higher incidence rate than Catalonia over the entire study period. The same patterns were observed for both sexes. Navarre showed the highest overall and standardized asthma prevalence rate throughout the study period (range: 3.92–5.87%). The crude and standardized prevalence rates were higher for women than for men in the three regions (table 2, Supplementary table S1). Table 2 Overall crudea and age-standardizeda,b asthma and coronary disease incidence and prevalence rates for each year by region (Catalonia, Navarre and Balearic Islands-Spain) and sex, 2007–13 Asthma Coronary disease Year Total Incidence rates Prevalence rates Total Incidence rates Prevalence rates Overall crude Female Male Overall crude Female Male Overall crude Female Male Overall crude Female Male % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 Catalonia     2007 376 971 0.35 42.03 25.40 3.51 422.69 278.02 25 3837 0.61 38.14 95.68 3.91 251.06 621.34     2008 381 351 0.35 41.98 26.13 3.73 449.53 299.69 253 701 0.55 32.60 87.74 4.09 254.01 636.09     2009 382 650 0.40 48.13 31.26 3.97 479.58 325.70 252 141 0.57 34.46 86.38 4.24 255.69 649.79     2010 381 100 0.35 43.08 27.03 4.17 499.29 344.46 249 823 0.53 33.22 77.35 4.38 258.27 657.57     2011 376 892 0.29 34.62 23.66 4.36 516.22 349.88 246 620 0.45 25.66 65.66 4.47 255.74 657.82     2012 371 809 0.28 34.43 20.85 4.55 538.08 365.23 243 229 0.43 22.48 62.01 4.55 249.89 655.02     2013 362 918 0.32 38.28 25.95 4.81 567.24 392.15 236 557 0.43 24.22 59.69 4.61 250.08 655.82 Navarre     2007 222 920 0.52 59.94 44 .73 3 .92 444.67 347.40 155 302 0.40 24.77 63.41 4.01 245.40 653.38     2008 229 529 0.55 67.95 43 .44 4 .28 488.99 378.59 156 006 0.39 23.63 59.77 4.19 248.87 671.87     2009 232 847 0.52 61.27 43 .03 4 .62 523.16 417.67 155 370 0.38 26.00 52.90 4.35 256.17 674.07     2010 234 957 0.52 66.16 40 .04 4 .95 557.36 450.45 154 500 0.37 20.52 54.91 4.49 254.76 678.41     2011 234 154 0.45 56.76 32 .74 5 .22 586.21 478.70 152 454 0.36 21.66 50.84 4.62 253.98 679.97     2012 233 702 0.44 53.36 36 .69 5 .50 610.88 511.84 150 514 0.38 20.51 54.98 4.73 249.29 680.14     2013 229 459 0.49 60.28 39 .53 5 .87 649.70 551.66 146 768 0.37 18.83 50.54 4.85 244.03 676.01 Balearic Islands     2010 302 281 0.69 82.41 51.07 4.12 475.59 346.72 203 532 0.38 29.94 65.27 2.13 157.73 379.72     2011 302 281 0.58 74.61 41.13 4.47 520.82 380.81 203 532 0.47 33.62 76.91 2.50 177.71 423.60     2012 302 281 0.59 72.32 45.48 4.85 565.59 419.60 203 532 0.51 39.03 73.23 2.89 200.52 458.21     2013 302 281 0.57 72.56 41.78 5.19 607.29 454.11 203 532 0.51 35.85 73.42 3.28 217.86 492.69 Asthma Coronary disease Year Total Incidence rates Prevalence rates Total Incidence rates Prevalence rates Overall crude Female Male Overall crude Female Male Overall crude Female Male Overall crude Female Male % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 Catalonia     2007 376 971 0.35 42.03 25.40 3.51 422.69 278.02 25 3837 0.61 38.14 95.68 3.91 251.06 621.34     2008 381 351 0.35 41.98 26.13 3.73 449.53 299.69 253 701 0.55 32.60 87.74 4.09 254.01 636.09     2009 382 650 0.40 48.13 31.26 3.97 479.58 325.70 252 141 0.57 34.46 86.38 4.24 255.69 649.79     2010 381 100 0.35 43.08 27.03 4.17 499.29 344.46 249 823 0.53 33.22 77.35 4.38 258.27 657.57     2011 376 892 0.29 34.62 23.66 4.36 516.22 349.88 246 620 0.45 25.66 65.66 4.47 255.74 657.82     2012 371 809 0.28 34.43 20.85 4.55 538.08 365.23 243 229 0.43 22.48 62.01 4.55 249.89 655.02     2013 362 918 0.32 38.28 25.95 4.81 567.24 392.15 236 557 0.43 24.22 59.69 4.61 250.08 655.82 Navarre     2007 222 920 0.52 59.94 44 .73 3 .92 444.67 347.40 155 302 0.40 24.77 63.41 4.01 245.40 653.38     2008 229 529 0.55 67.95 43 .44 4 .28 488.99 378.59 156 006 0.39 23.63 59.77 4.19 248.87 671.87     2009 232 847 0.52 61.27 43 .03 4 .62 523.16 417.67 155 370 0.38 26.00 52.90 4.35 256.17 674.07     2010 234 957 0.52 66.16 40 .04 4 .95 557.36 450.45 154 500 0.37 20.52 54.91 4.49 254.76 678.41     2011 234 154 0.45 56.76 32 .74 5 .22 586.21 478.70 152 454 0.36 21.66 50.84 4.62 253.98 679.97     2012 233 702 0.44 53.36 36 .69 5 .50 610.88 511.84 150 514 0.38 20.51 54.98 4.73 249.29 680.14     2013 229 459 0.49 60.28 39 .53 5 .87 649.70 551.66 146 768 0.37 18.83 50.54 4.85 244.03 676.01 Balearic Islands     2010 302 281 0.69 82.41 51.07 4.12 475.59 346.72 203 532 0.38 29.94 65.27 2.13 157.73 379.72     2011 302 281 0.58 74.61 41.13 4.47 520.82 380.81 203 532 0.47 33.62 76.91 2.50 177.71 423.60     2012 302 281 0.59 72.32 45.48 4.85 565.59 419.60 203 532 0.51 39.03 73.23 2.89 200.52 458.21     2013 302 281 0.57 72.56 41.78 5.19 607.29 454.11 203 532 0.51 35.85 73.42 3.28 217.86 492.69 a Truncated crude rate (≥16-years old, 17 age groups). b Rates are per 10 000 inhabitants and age-standardized on the European Standard Population (direct method). Table 2 Overall crudea and age-standardizeda,b asthma and coronary disease incidence and prevalence rates for each year by region (Catalonia, Navarre and Balearic Islands-Spain) and sex, 2007–13 Asthma Coronary disease Year Total Incidence rates Prevalence rates Total Incidence rates Prevalence rates Overall crude Female Male Overall crude Female Male Overall crude Female Male Overall crude Female Male % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 Catalonia     2007 376 971 0.35 42.03 25.40 3.51 422.69 278.02 25 3837 0.61 38.14 95.68 3.91 251.06 621.34     2008 381 351 0.35 41.98 26.13 3.73 449.53 299.69 253 701 0.55 32.60 87.74 4.09 254.01 636.09     2009 382 650 0.40 48.13 31.26 3.97 479.58 325.70 252 141 0.57 34.46 86.38 4.24 255.69 649.79     2010 381 100 0.35 43.08 27.03 4.17 499.29 344.46 249 823 0.53 33.22 77.35 4.38 258.27 657.57     2011 376 892 0.29 34.62 23.66 4.36 516.22 349.88 246 620 0.45 25.66 65.66 4.47 255.74 657.82     2012 371 809 0.28 34.43 20.85 4.55 538.08 365.23 243 229 0.43 22.48 62.01 4.55 249.89 655.02     2013 362 918 0.32 38.28 25.95 4.81 567.24 392.15 236 557 0.43 24.22 59.69 4.61 250.08 655.82 Navarre     2007 222 920 0.52 59.94 44 .73 3 .92 444.67 347.40 155 302 0.40 24.77 63.41 4.01 245.40 653.38     2008 229 529 0.55 67.95 43 .44 4 .28 488.99 378.59 156 006 0.39 23.63 59.77 4.19 248.87 671.87     2009 232 847 0.52 61.27 43 .03 4 .62 523.16 417.67 155 370 0.38 26.00 52.90 4.35 256.17 674.07     2010 234 957 0.52 66.16 40 .04 4 .95 557.36 450.45 154 500 0.37 20.52 54.91 4.49 254.76 678.41     2011 234 154 0.45 56.76 32 .74 5 .22 586.21 478.70 152 454 0.36 21.66 50.84 4.62 253.98 679.97     2012 233 702 0.44 53.36 36 .69 5 .50 610.88 511.84 150 514 0.38 20.51 54.98 4.73 249.29 680.14     2013 229 459 0.49 60.28 39 .53 5 .87 649.70 551.66 146 768 0.37 18.83 50.54 4.85 244.03 676.01 Balearic Islands     2010 302 281 0.69 82.41 51.07 4.12 475.59 346.72 203 532 0.38 29.94 65.27 2.13 157.73 379.72     2011 302 281 0.58 74.61 41.13 4.47 520.82 380.81 203 532 0.47 33.62 76.91 2.50 177.71 423.60     2012 302 281 0.59 72.32 45.48 4.85 565.59 419.60 203 532 0.51 39.03 73.23 2.89 200.52 458.21     2013 302 281 0.57 72.56 41.78 5.19 607.29 454.11 203 532 0.51 35.85 73.42 3.28 217.86 492.69 Asthma Coronary disease Year Total Incidence rates Prevalence rates Total Incidence rates Prevalence rates Overall crude Female Male Overall crude Female Male Overall crude Female Male Overall crude Female Male % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 Catalonia     2007 376 971 0.35 42.03 25.40 3.51 422.69 278.02 25 3837 0.61 38.14 95.68 3.91 251.06 621.34     2008 381 351 0.35 41.98 26.13 3.73 449.53 299.69 253 701 0.55 32.60 87.74 4.09 254.01 636.09     2009 382 650 0.40 48.13 31.26 3.97 479.58 325.70 252 141 0.57 34.46 86.38 4.24 255.69 649.79     2010 381 100 0.35 43.08 27.03 4.17 499.29 344.46 249 823 0.53 33.22 77.35 4.38 258.27 657.57     2011 376 892 0.29 34.62 23.66 4.36 516.22 349.88 246 620 0.45 25.66 65.66 4.47 255.74 657.82     2012 371 809 0.28 34.43 20.85 4.55 538.08 365.23 243 229 0.43 22.48 62.01 4.55 249.89 655.02     2013 362 918 0.32 38.28 25.95 4.81 567.24 392.15 236 557 0.43 24.22 59.69 4.61 250.08 655.82 Navarre     2007 222 920 0.52 59.94 44 .73 3 .92 444.67 347.40 155 302 0.40 24.77 63.41 4.01 245.40 653.38     2008 229 529 0.55 67.95 43 .44 4 .28 488.99 378.59 156 006 0.39 23.63 59.77 4.19 248.87 671.87     2009 232 847 0.52 61.27 43 .03 4 .62 523.16 417.67 155 370 0.38 26.00 52.90 4.35 256.17 674.07     2010 234 957 0.52 66.16 40 .04 4 .95 557.36 450.45 154 500 0.37 20.52 54.91 4.49 254.76 678.41     2011 234 154 0.45 56.76 32 .74 5 .22 586.21 478.70 152 454 0.36 21.66 50.84 4.62 253.98 679.97     2012 233 702 0.44 53.36 36 .69 5 .50 610.88 511.84 150 514 0.38 20.51 54.98 4.73 249.29 680.14     2013 229 459 0.49 60.28 39 .53 5 .87 649.70 551.66 146 768 0.37 18.83 50.54 4.85 244.03 676.01 Balearic Islands     2010 302 281 0.69 82.41 51.07 4.12 475.59 346.72 203 532 0.38 29.94 65.27 2.13 157.73 379.72     2011 302 281 0.58 74.61 41.13 4.47 520.82 380.81 203 532 0.47 33.62 76.91 2.50 177.71 423.60     2012 302 281 0.59 72.32 45.48 4.85 565.59 419.60 203 532 0.51 39.03 73.23 2.89 200.52 458.21     2013 302 281 0.57 72.56 41.78 5.19 607.29 454.11 203 532 0.51 35.85 73.42 3.28 217.86 492.69 a Truncated crude rate (≥16-years old, 17 age groups). b Rates are per 10 000 inhabitants and age-standardized on the European Standard Population (direct method). The standardized asthma incidence rates showed a non-significant downward trend in the three regions. This trend was more pronounced in the Balearic Islands (AAPC: −4.99% per year, 95% CI: 13.76; 4.68). In Navarre and the Balearic Islands there was a higher decrease for men than for women. No region presented significant points of change (‘joinpoint’). The standardized asthma prevalence rates rose significantly in the three regions over the study period. Catalonia and Navarre showed two distinct time periods, 2007–09 and 2009–13, overall and by sex, with the exception of males in Catalonia. After 2009, increases in prevalence rates were smaller than in the previous period in these two regions. The Balearic Islands observed the highest steady and significant increase (AAPC: 8.87%, 95% CI: 7.49; 10.28), followed by Navarre (AAPC: 7.07%, 95% CI: 6.36; 7.77) over the study period (table 3). Table 3 Trends in age-standardizeda asthma incidence and prevalence rates by region (Catalonia, Navarre and Balearic Islands-Spain) and sex, 2007–13 Trend 1 Trend 2 AAPC (95% CI) Years APC (95% CI) P value Years APC (95% CI) P value 2007–13 P value Catalonia     Incidence         Overall 2007–13 –2.71 (–8.12; 3.01) 0.271 –2.71 (–8.12; 3.01) 0.271         Female 2007–13 –3.09 (–8.21; 2.31) 0.197 –3.09 (–8.21; 2.31) 0.197         Male 2007–13 –1.97 (–8.10; 4.57) 0.464 –1.97 (–8.10; 4.57) 0.464     Prevalence         Overall 2007–09 7.13 (0.14; 14.61) 0.048 2009 – 2013 4.22 (1.88; 6.62) 0.016 5.18 (3.89; 6.49) <0.001         Female 2007–09 6.41 (2.42; 10.55) 0.020 2009 – 2013 4.17 (2.84; 5.53) 0.005 4.91 (4.18; 5.65) <0.001         Male 2007–13 5.53 (4.33; 6.75) <0.001 5.53 (4.33; 6.75) <0.001 Navarre     Incidence         Overall 2007–13 –2.49 (–5.58; 0.71) 0.101 –2.49 (–5.58; 0.71) 0.101         Female 2007–13 –1.93 (–5.65; 1.94) 0.252 –1.93 (–5.65; 1.94) 0.252         Male 2007–13 –3.38 (–7.14; 0.52) 0.076 –3.38 (–7.14; 0.52) 0.076     Prevalence         Overall 2007–09 9.09 (5.02; 13.31) 0.010 2009–2013 6.07 (4.98; 7.17) 0.002 7.07 (6.36; 7.77) <0.001         Female 2007–09 8.61 (3.97; 13.45) 0.015 2009–2013 5.31 (4.05; 6.58) 0.003 6.40 (5.60; 7.20) <0.001     Male 2007–09 9.83 (5.94; 13.87) 0.008 2009–2013 7.13 (6.10; 8.17) 0.001 8.02 (7.35; 8.70) <0.001 Balearic Islands     Incidence         Overall 2010–13 –4.99 (–13.76; 4.68) 0.151 –4.99 (–13.76; 4.68) 0.151         Female 2010–13 –4.32 (–10.92; 2.78) 0.118 –4.32 (–10.92; 2.78) 0.118         Male 2010–l13 –5.32 (–20.91; 13.34) 0.321 –5.32 (–20.91; 13.34) 0.321     Prevalence         Overall 2010–13 8.87 (7.49; 10.28) 0.001 8.87 (7.49; 10.28) 0.001         Female 2010–13 8.50 (7.02; 9.99) 0.002 8.50 (7.02; 9.99) 0.002         Male 2010–13 9.50 (8.17; 10.85) 0.001 9.50 (8.17; 10.85) 0.001 Trend 1 Trend 2 AAPC (95% CI) Years APC (95% CI) P value Years APC (95% CI) P value 2007–13 P value Catalonia     Incidence         Overall 2007–13 –2.71 (–8.12; 3.01) 0.271 –2.71 (–8.12; 3.01) 0.271         Female 2007–13 –3.09 (–8.21; 2.31) 0.197 –3.09 (–8.21; 2.31) 0.197         Male 2007–13 –1.97 (–8.10; 4.57) 0.464 –1.97 (–8.10; 4.57) 0.464     Prevalence         Overall 2007–09 7.13 (0.14; 14.61) 0.048 2009 – 2013 4.22 (1.88; 6.62) 0.016 5.18 (3.89; 6.49) <0.001         Female 2007–09 6.41 (2.42; 10.55) 0.020 2009 – 2013 4.17 (2.84; 5.53) 0.005 4.91 (4.18; 5.65) <0.001         Male 2007–13 5.53 (4.33; 6.75) <0.001 5.53 (4.33; 6.75) <0.001 Navarre     Incidence         Overall 2007–13 –2.49 (–5.58; 0.71) 0.101 –2.49 (–5.58; 0.71) 0.101         Female 2007–13 –1.93 (–5.65; 1.94) 0.252 –1.93 (–5.65; 1.94) 0.252         Male 2007–13 –3.38 (–7.14; 0.52) 0.076 –3.38 (–7.14; 0.52) 0.076     Prevalence         Overall 2007–09 9.09 (5.02; 13.31) 0.010 2009–2013 6.07 (4.98; 7.17) 0.002 7.07 (6.36; 7.77) <0.001         Female 2007–09 8.61 (3.97; 13.45) 0.015 2009–2013 5.31 (4.05; 6.58) 0.003 6.40 (5.60; 7.20) <0.001     Male 2007–09 9.83 (5.94; 13.87) 0.008 2009–2013 7.13 (6.10; 8.17) 0.001 8.02 (7.35; 8.70) <0.001 Balearic Islands     Incidence         Overall 2010–13 –4.99 (–13.76; 4.68) 0.151 –4.99 (–13.76; 4.68) 0.151         Female 2010–13 –4.32 (–10.92; 2.78) 0.118 –4.32 (–10.92; 2.78) 0.118         Male 2010–l13 –5.32 (–20.91; 13.34) 0.321 –5.32 (–20.91; 13.34) 0.321     Prevalence         Overall 2010–13 8.87 (7.49; 10.28) 0.001 8.87 (7.49; 10.28) 0.001         Female 2010–13 8.50 (7.02; 9.99) 0.002 8.50 (7.02; 9.99) 0.002         Male 2010–13 9.50 (8.17; 10.85) 0.001 9.50 (8.17; 10.85) 0.001 Abbreviations: CI, confidence interval; APC, annual percentage change and AAPC, average annual percent change estimated by joinpoint regression analysis. a Truncated (≥16-years old, 17 age groups) rates per 10 000 inhabitants, age-standardized on the European Standard Population (direct method). Table 3 Trends in age-standardizeda asthma incidence and prevalence rates by region (Catalonia, Navarre and Balearic Islands-Spain) and sex, 2007–13 Trend 1 Trend 2 AAPC (95% CI) Years APC (95% CI) P value Years APC (95% CI) P value 2007–13 P value Catalonia     Incidence         Overall 2007–13 –2.71 (–8.12; 3.01) 0.271 –2.71 (–8.12; 3.01) 0.271         Female 2007–13 –3.09 (–8.21; 2.31) 0.197 –3.09 (–8.21; 2.31) 0.197         Male 2007–13 –1.97 (–8.10; 4.57) 0.464 –1.97 (–8.10; 4.57) 0.464     Prevalence         Overall 2007–09 7.13 (0.14; 14.61) 0.048 2009 – 2013 4.22 (1.88; 6.62) 0.016 5.18 (3.89; 6.49) <0.001         Female 2007–09 6.41 (2.42; 10.55) 0.020 2009 – 2013 4.17 (2.84; 5.53) 0.005 4.91 (4.18; 5.65) <0.001         Male 2007–13 5.53 (4.33; 6.75) <0.001 5.53 (4.33; 6.75) <0.001 Navarre     Incidence         Overall 2007–13 –2.49 (–5.58; 0.71) 0.101 –2.49 (–5.58; 0.71) 0.101         Female 2007–13 –1.93 (–5.65; 1.94) 0.252 –1.93 (–5.65; 1.94) 0.252         Male 2007–13 –3.38 (–7.14; 0.52) 0.076 –3.38 (–7.14; 0.52) 0.076     Prevalence         Overall 2007–09 9.09 (5.02; 13.31) 0.010 2009–2013 6.07 (4.98; 7.17) 0.002 7.07 (6.36; 7.77) <0.001         Female 2007–09 8.61 (3.97; 13.45) 0.015 2009–2013 5.31 (4.05; 6.58) 0.003 6.40 (5.60; 7.20) <0.001     Male 2007–09 9.83 (5.94; 13.87) 0.008 2009–2013 7.13 (6.10; 8.17) 0.001 8.02 (7.35; 8.70) <0.001 Balearic Islands     Incidence         Overall 2010–13 –4.99 (–13.76; 4.68) 0.151 –4.99 (–13.76; 4.68) 0.151         Female 2010–13 –4.32 (–10.92; 2.78) 0.118 –4.32 (–10.92; 2.78) 0.118         Male 2010–l13 –5.32 (–20.91; 13.34) 0.321 –5.32 (–20.91; 13.34) 0.321     Prevalence         Overall 2010–13 8.87 (7.49; 10.28) 0.001 8.87 (7.49; 10.28) 0.001         Female 2010–13 8.50 (7.02; 9.99) 0.002 8.50 (7.02; 9.99) 0.002         Male 2010–13 9.50 (8.17; 10.85) 0.001 9.50 (8.17; 10.85) 0.001 Trend 1 Trend 2 AAPC (95% CI) Years APC (95% CI) P value Years APC (95% CI) P value 2007–13 P value Catalonia     Incidence         Overall 2007–13 –2.71 (–8.12; 3.01) 0.271 –2.71 (–8.12; 3.01) 0.271         Female 2007–13 –3.09 (–8.21; 2.31) 0.197 –3.09 (–8.21; 2.31) 0.197         Male 2007–13 –1.97 (–8.10; 4.57) 0.464 –1.97 (–8.10; 4.57) 0.464     Prevalence         Overall 2007–09 7.13 (0.14; 14.61) 0.048 2009 – 2013 4.22 (1.88; 6.62) 0.016 5.18 (3.89; 6.49) <0.001         Female 2007–09 6.41 (2.42; 10.55) 0.020 2009 – 2013 4.17 (2.84; 5.53) 0.005 4.91 (4.18; 5.65) <0.001         Male 2007–13 5.53 (4.33; 6.75) <0.001 5.53 (4.33; 6.75) <0.001 Navarre     Incidence         Overall 2007–13 –2.49 (–5.58; 0.71) 0.101 –2.49 (–5.58; 0.71) 0.101         Female 2007–13 –1.93 (–5.65; 1.94) 0.252 –1.93 (–5.65; 1.94) 0.252         Male 2007–13 –3.38 (–7.14; 0.52) 0.076 –3.38 (–7.14; 0.52) 0.076     Prevalence         Overall 2007–09 9.09 (5.02; 13.31) 0.010 2009–2013 6.07 (4.98; 7.17) 0.002 7.07 (6.36; 7.77) <0.001         Female 2007–09 8.61 (3.97; 13.45) 0.015 2009–2013 5.31 (4.05; 6.58) 0.003 6.40 (5.60; 7.20) <0.001     Male 2007–09 9.83 (5.94; 13.87) 0.008 2009–2013 7.13 (6.10; 8.17) 0.001 8.02 (7.35; 8.70) <0.001 Balearic Islands     Incidence         Overall 2010–13 –4.99 (–13.76; 4.68) 0.151 –4.99 (–13.76; 4.68) 0.151         Female 2010–13 –4.32 (–10.92; 2.78) 0.118 –4.32 (–10.92; 2.78) 0.118         Male 2010–l13 –5.32 (–20.91; 13.34) 0.321 –5.32 (–20.91; 13.34) 0.321     Prevalence         Overall 2010–13 8.87 (7.49; 10.28) 0.001 8.87 (7.49; 10.28) 0.001         Female 2010–13 8.50 (7.02; 9.99) 0.002 8.50 (7.02; 9.99) 0.002         Male 2010–13 9.50 (8.17; 10.85) 0.001 9.50 (8.17; 10.85) 0.001 Abbreviations: CI, confidence interval; APC, annual percentage change and AAPC, average annual percent change estimated by joinpoint regression analysis. a Truncated (≥16-years old, 17 age groups) rates per 10 000 inhabitants, age-standardized on the European Standard Population (direct method). On the whole, the incidence of coronary disease rates was decreasing both in Catalonia and Navarre. However, this reduction was higher in Catalonia (range: 0.43–0.61%) than in Navarre (range: 0.36–0.40%). Conversely, it increased over the considered period in the Balearic Islands (range: 0.38%-0.51%). Navarre presented the highest coronary disease prevalence rate (range: 4.01–4.85%) and the Balearic Islands the lowest (range: 2.13–3.28%) in each year. Crude and standardized coronary disease incidence and prevalence rates were considerably higher for men than for women in all regions. Specifically, prevalence rates were over two-fold higher for men than for women (table 2, Supplementary table S2). The standardized coronary disease incidence rates in Catalonia and Navarre showed a significant downward trend from 2007 to 2013, overall and by sex, with higher AAPC in Catalonia (AAPC: −8.00%, 95% CI: −10.46; −5.47) than in Navarre (AAPC: −3.66%, 95% CI: −4.95; −2.35). In contrast, the Balearic Islands presented a non-significant upward trend (AAPC: 4.45%) over the study period with an AAPC of 6.78% per year in women. In Catalonia, the overall standardized coronary disease prevalence rate showed a significant upward trend of 1.52% per year between 2007 and 2010, and subsequently a downward trend of 0.52% per year between 2010 and 2013, although this decline was not significant. Male trends were of similar magnitude to the overall trends in both periods. In Navarre, the overall prevalence trends were similar to Catalonia but non-significant, with a ‘joinpoint’ in 2009. In the Balearic Islands, sharp and significant increases were observed, overall (AAPC: 10.01%, 95% CI: 7.30; 12.78) as well as in both sexes (AAPC: female: 11.38%, 95% CI: 8.21; 14.65; male: 8.85%, 95% CI: 6.11; 11.67) from 2010 to 2013 (table 4). Table 4 Trends in age-standardizeda coronary disease incidence and prevalence rates by region (Catalonia, Navarre and Balearic Islands-Spain) and Sex, 2007–13 Trend 1 Trend 2 AAPC (95% IC) Years APC (95% CI) P-value Years APC (95% CI) P-value 2007–13 P-value Catalonia     Incidence         Overall 2007–13 –8.00 (–10.46; –5.47) 0.001 –8.00 (–10.46; –5.47) 0.001         Female 2007–13 –8.09 (–12.02; –3.98) 0.004 –8.09 (–12.02; –3.98) 0.004         Male 2007–13 –8.14 (–9.90; –6.34) <0.001 –8.14 (–9.90; –6.34) <0.001     Prevalence         Overall 2007–10 1.52 (0.22; 2.83) 0.037 2010–2013 –0.52 (–1.76; 0.73) 0.213 0.49 (0.08; 0.90) 0.019         Female 2007–10 0.89 (–1.28; 3.11) 0.220 2010–2013 –1.20 (–3.30; 0.94) 0.137 –0.16 (–0.85; 0.54) 0.654         Male 2007–10 1.90 (1.36; 2.45) 0.004 2010–2013 –0.22 (–0.74; 0.29) 0.204 0.83 (0.66; 1.01) <0.001 Navarre     Incidence         Overall 2007–13 –3.66 (–4.95; –2.35) 0.001 –3.66 (–4.95; –2.35) 0.001         Female 2007–13 –4.50 (–7.65; –1.24) 0.017 –4.50 (–7.65; –1.24) 0.017         Male 2007–13 –3.22 (–5.58; –0.80) 0.019 –3.22 (–5.58; –0.80) 0.019  Prevalence         Overall 2007–09 1.95(–0.72; 4.69) 0.088 2009–2013 –0.27 (–1.07, 0.55) 0.293 0.47 (–0.01; 0.94) 0.053         Female 2007–09 2.56 (–1.70, 6.99) 0.124 2009–2013 –1.11 (–2.39, 0.18) 0.065 0.10 (–0.66; 0.85) 0.806         Male 2007–13 0.47 (–0.03; 0.97) 0.059 0.47 (–0.03; 0.97) 0.059 Balearic Islands     Incidence         Overall 2010–13 4.45 (–8.16; 18.79) 0.283 4.45 (–8.16; 18.79) 0.283         Female 2010–13 6.78 (–10.11; 26.84) 0.243 6.78 (–10.11; 26.84) 0.243         Male 2010–13 2.59 (–10.53; 17.63) 0.506 2.59 (–10.53; 17.63) 0.506     Prevalence         Overall 2010–13 10.01 (7.30; 12.78) 0.004 10.01 (7.30; 12.78) 0.004         Female 2010–13 11.38 (8.21; 14.65) 0.004 11.38 (8.21; 14.65) 0.004         Male 2010–13 8.85 (6.11; 11.67) 0.005 8.85 (6.11; 11.67) 0.005 Trend 1 Trend 2 AAPC (95% IC) Years APC (95% CI) P-value Years APC (95% CI) P-value 2007–13 P-value Catalonia     Incidence         Overall 2007–13 –8.00 (–10.46; –5.47) 0.001 –8.00 (–10.46; –5.47) 0.001         Female 2007–13 –8.09 (–12.02; –3.98) 0.004 –8.09 (–12.02; –3.98) 0.004         Male 2007–13 –8.14 (–9.90; –6.34) <0.001 –8.14 (–9.90; –6.34) <0.001     Prevalence         Overall 2007–10 1.52 (0.22; 2.83) 0.037 2010–2013 –0.52 (–1.76; 0.73) 0.213 0.49 (0.08; 0.90) 0.019         Female 2007–10 0.89 (–1.28; 3.11) 0.220 2010–2013 –1.20 (–3.30; 0.94) 0.137 –0.16 (–0.85; 0.54) 0.654         Male 2007–10 1.90 (1.36; 2.45) 0.004 2010–2013 –0.22 (–0.74; 0.29) 0.204 0.83 (0.66; 1.01) <0.001 Navarre     Incidence         Overall 2007–13 –3.66 (–4.95; –2.35) 0.001 –3.66 (–4.95; –2.35) 0.001         Female 2007–13 –4.50 (–7.65; –1.24) 0.017 –4.50 (–7.65; –1.24) 0.017         Male 2007–13 –3.22 (–5.58; –0.80) 0.019 –3.22 (–5.58; –0.80) 0.019  Prevalence         Overall 2007–09 1.95(–0.72; 4.69) 0.088 2009–2013 –0.27 (–1.07, 0.55) 0.293 0.47 (–0.01; 0.94) 0.053         Female 2007–09 2.56 (–1.70, 6.99) 0.124 2009–2013 –1.11 (–2.39, 0.18) 0.065 0.10 (–0.66; 0.85) 0.806         Male 2007–13 0.47 (–0.03; 0.97) 0.059 0.47 (–0.03; 0.97) 0.059 Balearic Islands     Incidence         Overall 2010–13 4.45 (–8.16; 18.79) 0.283 4.45 (–8.16; 18.79) 0.283         Female 2010–13 6.78 (–10.11; 26.84) 0.243 6.78 (–10.11; 26.84) 0.243         Male 2010–13 2.59 (–10.53; 17.63) 0.506 2.59 (–10.53; 17.63) 0.506     Prevalence         Overall 2010–13 10.01 (7.30; 12.78) 0.004 10.01 (7.30; 12.78) 0.004         Female 2010–13 11.38 (8.21; 14.65) 0.004 11.38 (8.21; 14.65) 0.004         Male 2010–13 8.85 (6.11; 11.67) 0.005 8.85 (6.11; 11.67) 0.005 Abbreviations: CI, confidence interval; APC, annual percentage change and AAPC, average annual percent change estimated by joinpoint regression analysis. a Truncated (≥35-years old, 13 age groups) rates per 10 000 inhabitants, age-standardized on the European Standard Population (direct method). Table 4 Trends in age-standardizeda coronary disease incidence and prevalence rates by region (Catalonia, Navarre and Balearic Islands-Spain) and Sex, 2007–13 Trend 1 Trend 2 AAPC (95% IC) Years APC (95% CI) P-value Years APC (95% CI) P-value 2007–13 P-value Catalonia     Incidence         Overall 2007–13 –8.00 (–10.46; –5.47) 0.001 –8.00 (–10.46; –5.47) 0.001         Female 2007–13 –8.09 (–12.02; –3.98) 0.004 –8.09 (–12.02; –3.98) 0.004         Male 2007–13 –8.14 (–9.90; –6.34) <0.001 –8.14 (–9.90; –6.34) <0.001     Prevalence         Overall 2007–10 1.52 (0.22; 2.83) 0.037 2010–2013 –0.52 (–1.76; 0.73) 0.213 0.49 (0.08; 0.90) 0.019         Female 2007–10 0.89 (–1.28; 3.11) 0.220 2010–2013 –1.20 (–3.30; 0.94) 0.137 –0.16 (–0.85; 0.54) 0.654         Male 2007–10 1.90 (1.36; 2.45) 0.004 2010–2013 –0.22 (–0.74; 0.29) 0.204 0.83 (0.66; 1.01) <0.001 Navarre     Incidence         Overall 2007–13 –3.66 (–4.95; –2.35) 0.001 –3.66 (–4.95; –2.35) 0.001         Female 2007–13 –4.50 (–7.65; –1.24) 0.017 –4.50 (–7.65; –1.24) 0.017         Male 2007–13 –3.22 (–5.58; –0.80) 0.019 –3.22 (–5.58; –0.80) 0.019  Prevalence         Overall 2007–09 1.95(–0.72; 4.69) 0.088 2009–2013 –0.27 (–1.07, 0.55) 0.293 0.47 (–0.01; 0.94) 0.053         Female 2007–09 2.56 (–1.70, 6.99) 0.124 2009–2013 –1.11 (–2.39, 0.18) 0.065 0.10 (–0.66; 0.85) 0.806         Male 2007–13 0.47 (–0.03; 0.97) 0.059 0.47 (–0.03; 0.97) 0.059 Balearic Islands     Incidence         Overall 2010–13 4.45 (–8.16; 18.79) 0.283 4.45 (–8.16; 18.79) 0.283         Female 2010–13 6.78 (–10.11; 26.84) 0.243 6.78 (–10.11; 26.84) 0.243         Male 2010–13 2.59 (–10.53; 17.63) 0.506 2.59 (–10.53; 17.63) 0.506     Prevalence         Overall 2010–13 10.01 (7.30; 12.78) 0.004 10.01 (7.30; 12.78) 0.004         Female 2010–13 11.38 (8.21; 14.65) 0.004 11.38 (8.21; 14.65) 0.004         Male 2010–13 8.85 (6.11; 11.67) 0.005 8.85 (6.11; 11.67) 0.005 Trend 1 Trend 2 AAPC (95% IC) Years APC (95% CI) P-value Years APC (95% CI) P-value 2007–13 P-value Catalonia     Incidence         Overall 2007–13 –8.00 (–10.46; –5.47) 0.001 –8.00 (–10.46; –5.47) 0.001         Female 2007–13 –8.09 (–12.02; –3.98) 0.004 –8.09 (–12.02; –3.98) 0.004         Male 2007–13 –8.14 (–9.90; –6.34) <0.001 –8.14 (–9.90; –6.34) <0.001     Prevalence         Overall 2007–10 1.52 (0.22; 2.83) 0.037 2010–2013 –0.52 (–1.76; 0.73) 0.213 0.49 (0.08; 0.90) 0.019         Female 2007–10 0.89 (–1.28; 3.11) 0.220 2010–2013 –1.20 (–3.30; 0.94) 0.137 –0.16 (–0.85; 0.54) 0.654         Male 2007–10 1.90 (1.36; 2.45) 0.004 2010–2013 –0.22 (–0.74; 0.29) 0.204 0.83 (0.66; 1.01) <0.001 Navarre     Incidence         Overall 2007–13 –3.66 (–4.95; –2.35) 0.001 –3.66 (–4.95; –2.35) 0.001         Female 2007–13 –4.50 (–7.65; –1.24) 0.017 –4.50 (–7.65; –1.24) 0.017         Male 2007–13 –3.22 (–5.58; –0.80) 0.019 –3.22 (–5.58; –0.80) 0.019  Prevalence         Overall 2007–09 1.95(–0.72; 4.69) 0.088 2009–2013 –0.27 (–1.07, 0.55) 0.293 0.47 (–0.01; 0.94) 0.053         Female 2007–09 2.56 (–1.70, 6.99) 0.124 2009–2013 –1.11 (–2.39, 0.18) 0.065 0.10 (–0.66; 0.85) 0.806         Male 2007–13 0.47 (–0.03; 0.97) 0.059 0.47 (–0.03; 0.97) 0.059 Balearic Islands     Incidence         Overall 2010–13 4.45 (–8.16; 18.79) 0.283 4.45 (–8.16; 18.79) 0.283         Female 2010–13 6.78 (–10.11; 26.84) 0.243 6.78 (–10.11; 26.84) 0.243         Male 2010–13 2.59 (–10.53; 17.63) 0.506 2.59 (–10.53; 17.63) 0.506     Prevalence         Overall 2010–13 10.01 (7.30; 12.78) 0.004 10.01 (7.30; 12.78) 0.004         Female 2010–13 11.38 (8.21; 14.65) 0.004 11.38 (8.21; 14.65) 0.004         Male 2010–13 8.85 (6.11; 11.67) 0.005 8.85 (6.11; 11.67) 0.005 Abbreviations: CI, confidence interval; APC, annual percentage change and AAPC, average annual percent change estimated by joinpoint regression analysis. a Truncated (≥35-years old, 13 age groups) rates per 10 000 inhabitants, age-standardized on the European Standard Population (direct method). Discussion Although a small, non-significant decrease in trends of standardized asthma incidence rates in patients over 15 years of age was observed in the three Spanish regions, the reduction was more pronounced in the Balearic Islands. In contrast, standardized asthma prevalence rates trends increased significantly in the three regions. This increase was smaller during the 2009–13 period in Catalonia and Navarre, and higher for men than women in all regions. Standardized coronary disease incidence and prevalence rates were considerably higher for men than for women in all regions. In Catalonia and Navarre, standardized coronary disease incidence rates showed a significant downward trend throughout the period studied. Conversely, trends of standardized coronary disease prevalence rates significantly increased in Catalonia from 2007 to 2010 overall and in males and also in the Balearic Islands throughout the study period. However, a non-significant downward trend was also observed after 2010 in Catalonia. Few published studies evaluate the impact of SFL on asthma and coronary disease from a PHC perspective. In addition, the methodology of these studies varies greatly further complicating comparison. We should also highlight that the effect of SFL on asthma is as yet unclear in the populations and settings where it has been analysed. Been et al.11 found no association between the introduction of SFL and the number of new wheezing/asthma cases among children ≤ 12 years visited by GP in UK.11 A quasiexperimental study in the US concluded that SFL reduced asthmatic symptoms in non-smoking children (3–15 years), but no association was found with self-reported asthma rates.26 A Spanish study that assessed the effects of partial SFL on asthma admissions rates at any age in Barcelona and Madrid failed to detect significant changes from 2003 to 2006 with fully adjusted models.15 Nevertheless, same authors found that asthma-related hospital admission rates increased by 12.1% immediately after the partial SFL in five Spanish regions, but decreased by 7.4% (95% CI: 0.2, 14.2) immediately after the comprehensive SFL, although the 1-year decrease was sustained only among men (9.9%, 95% CI: 3.9, 15.6).27 Kalkhoran et al.10 found a significant 15% decrease in the incidence of non-hospital emergency visits for bronchospasm in individuals aged ≥ 15 years following the implementation of Uruguay’s SFL compared with prior period. To our knowledge, no studies evaluate the impact of SFL on coronary disease in primary care, although data on the effect of SFL are available from hospital settings.28–30 Three studies evaluate the 2005 Spanish partial SFL with hospital data on coronary disease. Agüero et al.14 found a significant decrease of 11% in AMI incidence rates in the post-ban period compared with the previous period in Catalonia, particularly in women. In the city of Barcelona, Villalbí et al.31 analysed annual AMI hospitalization rates and found lower rates in 2006 than in 2005 for all age groups except in males under 45 years of age, i.e. an age-adjusted decrease of 10.68% in males and of 8.76% in women in 2006 compared with 2004. Using fully adjusted models, Galán et al.15 did not detect significant changes in hospital admission rates for AMI in Barcelona and Madrid in 2006 compared with the previous period. However, a significant AMI percentage rate change of—8.6% was observed in Barcelona compared with the period before the implementation of the SFL. Despite this, primary care records are considered the single most complete source of non-fatal myocardial infarction.32 In comparison with the abovementioned articles that present the percentage of change that occurs between two periods, the current study shows a significant decrease of 8% per year in the APC for men and women in Catalonia. Otherwise, a non-significant increase in the incidence of coronary disease was observed in the Balearic Islands, where data were only available for the last four years of the study. We hypothesize that this increase might respond to a higher registration of the condition for prescription purposes and not to changes in the characteristics of the population. Even though comprehensive SFL was introduced in Spain in 1 January 2011 and therefore its impact on the incidence of asthma and coronary disease should have been observed from this date onwards, no change in the trends of asthma and coronary disease were detected. It is likely that the prior effect of the 2005 Spanish partial SFL implemented on 1 January 2006 had weakened the impact of the comprehensive SFL, since a significant decrease in AMI hospital rates14,31 had already been observed. The lack of EHR in the period prior the partial SFL precludes the study of a larger period. Other factors that might have influenced these results are: immature computerization of EHR in the initial stages of implementation; changes in the software over time33–35; incentives to PHC providers to improve the management of hypertension, hyperlipidaemia and diabetes; and the programmes for quitting smoking prior to the implementation of the comprehensive SFL. Incidence rate trends have been use to analyse the impact of SFL. However, we have considered also relevant the trends in the prevalence of asthma and coronary disease as indirect indicators of the increase or decrease of these conditions. The prevalence rates show the year in which trends changed in Catalonia and Navarre, which do not coincide with the introduction of the new legislation. Limitations and strengths The evaluation of this public health law can be further complicated by factors not contemplated in this study that could influence the incidence and prevalence of asthma and coronary disease. Since the only variables collected were age, sex, number of health problems and number of PHC visits, no analyses adjusted by other variables known to be associated with the study conditions has been carried out. In addition, variation in the register of diagnostics in each region might generate differences in the number of active health problems for each patient and in the rates of asthma and coronary disease, for instance, the underregistration of asthma exacerbations in all regions, linking the diagnose with the episode in Navarre and the lack of integration of diagnostic data with electronic prescriptions in the Balearic Islands before 2012. As a result of these limitations and also due to the shorter study period in the Balearic Islands, the analysis was stratified by region. Otherwise, variations in study population size in Catalonia and Navarre along the study period were small and consistent with the variations in the whole population. Although rates of childhood asthma are usually considered to be more sensitive to SHS than rates of asthma in adults, this study only focuses on adult population as children data weren’t available. This is the first study that evaluates the effect of the Spanish comprehensive SFL on adult asthma and coronary disease in PHC patients. It is crucial to analyse the effect of a public health law in PHC patients under real conditions.36–38 The participation of three different Spanish regions and the use of EHR provides a wide range of valuable data. In addition, the use of joinpoint analysis evaluates longitudinal trends instead of just comparing two different periods, obtaining a more accurate analysis. Conclusions No changes in the trends of adult asthma and coronary disease in PHC Spanish patients were detected after the introduction of comprehensive SFL. The impact of the comprehensive SFL might have been lessened by the effect of the previous implementation of the partial SFL. This article provides baseline data for future research into the effectiveness of this law. In addition to specific factors associated with asthma and coronary disease, future studies should consider cigarette consumption, socio-economic status and asthma in children. Supplementary data Supplementary data are available at EURPUB online. Acknowledgements We thank all professionals of the 66 PHCTs who volunteered to participate in the study. The authors would also like to thank Josep M Elorza-Ricart, Magdalena Rosell-Murphy, Lluís Martínez, Javier Baquedano, Javier Arranz and Ma Ángeles Nuin for their assistance. Funding This work was supported by the Carlos III Health Institute (Ministry of Economy and Competitiveness, Spain) with a grant for research projects on health (PI11/01413) through the Network for Prevention and Health Promotion in Primary Care (redIAPP, RD12/0005/0001; RD16/0007/001), and by European Union ERDF funds. Conflicts of interest: None declared. Key points Trend of asthma incidence rates decreased non-significantly over the study period. 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Effects of Italian smoking regulation on rates of hospital admission for acute coronary events: a country-wide study . PLoS One 2011 ; 6 : e17419 . Google Scholar CrossRef Search ADS PubMed 30 Di Valentino M , Muzzarelli S , Rigoli A , et al. Reduced hospitalization for st-elevation myocardial infarction after introduction of smoking ban in public places in Canton Ticino, Southern Switzerland . J Am Coll Cardiol 2011 ; 57 : E508 . Google Scholar CrossRef Search ADS 31 Villalbí JR , Castillo A , Cleries M , et al. Acute myocardial infarction hospitalization statistics: apparent decline accompanying an increase in smoke-free areas . Rev Española Cardiol (English Ed) 2009 ; 62 : 812 – 5 . 32 Herrett E , Shah AD , Boggon R , et al. Completeness and diagnostic validity of recording acute myocardial infarction events in primary care, hospital care, disease registry, and national mortality records: cohort study . BMJ 2013 ; 346 : f2350 . Google Scholar CrossRef Search ADS PubMed 33 Simpson CR , Hippisley-Cox J , Sheikh A . Trends in the epidemiology of smoking recorded in UK general practice . Br J Gen Pract 2010 ; 60 : 121 – 92 . Google Scholar CrossRef Search ADS PubMed 34 Self TH , Wallace JL , Gray LA , et al. Are we failing to document adequate smoking histories? A brief review 1999-2009 . Curr Med Res Opin 2010 ; 26 : 1691 – 6 . Google Scholar CrossRef Search ADS PubMed 35 Rosell-Murphy M , Rodriguez-Blanco T , Morán J , et al. Variability in screening prevention activities in primary care in Spain: a multilevel analysis . BMC Public Health 2015 ; 15 : 473 . Google Scholar CrossRef Search ADS PubMed 36 Ramos R , Balló E , Marrugat J , et al. Validity for use in research on vascular diseases of the SIDIAP (information system for the development of research in primary care): the EMMA study . Rev Española Cardiol (English Ed) 2012 ; 65 : 29 – 37 . 37 Salvador Rosa A , Moreno Pérez J , Sonego D , et al. El Proyecto BIFAP: Base de datos para la Investigación Farmacoepidemiológica en Atención Primaria. Atención Primaria: 655–61. 38 Villalbí JR . Evaluación de políticas y planes de salud . Gaceta Sanitaria 2011 ; 25 : 17 – 24 . Available at: http://www.gacetasanitaria.org/es/evaluacion-politicas-planes-salud/articulo-resumen/S0213911111700048/ (23 January 2018, date last accessed). Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The European Journal of Public Health Oxford University Press

Effect of comprehensive smoke-free legislation on asthma and coronary disease trends in Spanish primary care patients

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
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1101-1262
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1464-360X
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10.1093/eurpub/cky010
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Abstract

Abstract Background To examine the impact of comprehensive smoke-free legislation (SFL) (Law 42/2010) on the incidence and prevalence of adult asthma and coronary disease in primary health care (PHC) patients from three Spanish regions, overall and stratified by sex. Methods Longitudinal observational study conducted between 2007 and 2013 in the population over 15 years of age assigned to 66 PHC teams in Catalonia, Navarre and the Balearic Islands. Crude rates and age-standardized (truncated: asthma ≥ 16 years and coronary disease ≥ 35 years) incidence and prevalence rates using the direct method based on the European Standard Population were estimated based on data from PHC electronic health records. Joinpoint analysis was used to analyse the trends of age-standardized incidence and prevalence rates. Trends were expressed as annual percentage change and average annual percent change (AAPC). Results The standardized asthma incidence rate showed a non-significant downward trend and the standardized prevalence rates rose significantly in the three regions. Standardized coronary disease incidence and prevalence rates were considerably higher for men than for women in all regions. The standardized coronary disease incidence rates in Catalonia (AAPC: −8.00%, 95% CI: −10.46; −5.47) and Navarre (AAPC: −3.66%, 95% CI: −4.95;-2.35) showed a significant downward trend from 2007 to 2013, overall and by sex. The standardized coronary disease prevalence trend rate increased significantly in the whole period in Catalonia and the Balearic Islands, although a non-significant downward trend was observed from 2010 in Catalonia. Conclusion No changes in the trends of adult asthma and coronary disease in PHC Spanish patients were detected after the introduction of comprehensive SFL. Introduction Evidence shows that secondhand smoke (SHS) exposure is causally associated with conditions such as asthma and acute coronary syndrome.1 Consequently, legislative measures have been adopted to protect people’s health in public areas and workplaces.2,3 Since the introduction of smoke-free legislation (SFL), various studies have assessed its repercussions from different points of view. For instance, a decrease in the number of hospital admissions for coronary disease in adults has been observed following the implementation of this legislation4–6 and a meta-analysis showed a 13% decrease in hospital admissions for acute myocardial infarction (AMI).7 According to a Cochrane review, results on the impact of SFL on hospital admissions for asthma remains inconsistent,8 although a meta-analysis showed a 24% decrease in hospital admissions for respiratory conditions.9 We should underscore that most studies on the impact of SFL in asthma and coronary disease have analysed hospital data and that few studies address the impact of the legislation in primary health care (PHC) patients. For instance, Kalkhoran et al.10 analysed non-hospital emergency visits for asthma (Uruguay) and observed a 15% decrease in the incidence rate ratio. In contrast, Been et al.11 did not find any reduction in new diagnoses of asthma in children after SFL implementation (UK). On 1 January 2006, the Spanish government introduced a smoking law (Law 28/2005)12 which included regulations on the sale, supply, consumption and advertising of tobacco products. Smoking was banned in all enclosed public and private workplaces with the exception of the hospitality sector, where partial restrictions were established depending on the size of the establishment. This law was expanded in January 2011 (Law 42/2010)13 and as a result smoking was forbidden in all enclosed public places, including bars, restaurants and nightclubs, and in some open-air public places such as playgrounds. The studies that analysed the effect of the Spanish partial law on hospital admissions for asthma and coronary disease showed a decrease in the incidence of AMI and inconclusive results for asthma.14–16 To our knowledge, no studies have been published on the impact of the comprehensive law on asthma (in PHC) and heart disease, although some studies evaluate the effect of this law on smoking and exposure to SHS.17,18 The aim of this study was to examine the impact of the Spanish comprehensive SFL (Law 42/2010) on the incidence and prevalence of adult asthma and coronary disease in PHC patients in three regions (Catalonia, Navarre and the Balearic Islands) during the period 2007–13, overall and stratified by sex. Methods Study design, participants and source of information This is a longitudinal observational study of the population assigned to 66 PHC teams (PHCTs) in three Spanish regions: Catalonia, Navarre and the Balearic Islands (22 PHCT per region). Inclusion criteria of the PHCT were: (i) use of electronic health records (EHRs) by 1 January 2005, in Catalonia and Navarre, and 2008 in the Balearic Islands; and (ii) agreement to participate in the study by over 80% health-care professionals of the PHCT. Random cluster sampling was stratified by region, with the PHCT as randomization unit.19 In each PHCT, general practitioners (GPs) with a patient list between 400–3000 were selected. GP with shorter patient lists were accepted if it was their first year in the PHCT. The study period was from 2007 to 2013 in Catalonia and Navarre. In the Balearic Islands it was from 2010 to 2013 because EHR were not sufficiently reliable before 2010. Inclusion criteria for patients were: (i) Population allocated to the selected PHCT for each year of the period in Catalonia and Navarre (≥80% patients entered in 2007). Some patients died or moved during the study period. In the Balearic Islands, data from 2010 to 2013 of patients allocated to the selected PHCT in 2013 were analysed retrospectively (no annual comprehensive register of patients was available); (ii) Aged between ≥16 and ≤100 years when entering the study and (iii) A minimum of one visit with the PHCT during the study period (in order to have data in the EHR collected during this period). In the case of coronary disease, the population was restricted to those ≥35 years to allow the use of the Framingham and REGICOR equations to calculate coronary risk.20Supplementary figure S1 shows the flowchart of the study. Data were extracted from the REGIPREV database.19 It contains encrypted and anonymized clinical information recorded in the EHR from these 66 PHCT. An algorithm was applied to obtain equivalent data from the health records software used in each region. An equivalence table based on that created by WONCA21,22 was formulated by the research team matching the codes of the International Classification of Diseases, 10th revision (ICD-10)23 used in Catalonia and the International Classification of Diseases, 9th revision (ICD-9) codes used in the Balearic Islands with the International Classification of Primary Care, Second edition (ICPC-2) used in Navarre. Variables For each year of the study (at 31st of December), the dichotomous dependent variables were: Diagnosis of coronary episode: any register (≥1) of the diagnosis codes of coronary disease (codes I-20 to I-25 of the ICD-10 codes, 410-413 and 429.7 of ICD-9 and K74-76 of the ICPC-2). Diagnosis of asthma episode: any register (≥1) of the diagnosis codes of asthma (codes J-45 and J-46 of the ICD-10, codes 493 of the ICD-9 and R96 of the ICPC-2). The following variables of each patient were collected when entering the study: age, sex, number of health problems and number of PHC visits during the year considered. The number of health problems was used as a morbidity indicator; it was calculated as the sum of the number of different active health problems (all chronic and acute problems, coded by ICPC-2). Data analyses Descriptive statistics were used to summarize overall information. Categorical variables were expressed as percentage, and continuous variables as mean (standard deviation) or median (interquartile range [IQR]). We performed a stratified analysis per region, overall and by sex. Crude rates and age-standardized (truncated: asthma, ≥16 years and coronary disease, ≥35 years) incidence and prevalence rates were calculated for each year using the direct method, and based on the European Standard Population. These were expressed as rates per 10 000 inhabitants. To analyse the trends of age-standardized incidence and prevalence rates, the joinpoint analysis was used to identify the best-fitting points (the ‘joinpoints’, in calendar years) where the rate changes significantly over time. Significant changes include changes in direction or in the rate of increase or decrease.24 Temporal trends were expressed as the annual percentage change (APC), computed over each specified time interval and the average annual percent change (AAPC), computed to summarize and compare these trends over the entire time period. Ninety-five percent confidence intervals (95% CI) of APC and AAPC were calculated. Analyses were performed using Stata/SE version 14.2 for Windows (Stata Corp.LP, College Station, TX). The joinpoint regression analysis was carried out using the joinpoint software from the Surveillance Research Programme of the US National Cancer Institute.25 Ethical aspects The study was approved by the Research Ethics Committee of the IDIAP Jordi Gol. Confidentiality was guaranteed by data encryption and anonymization. Results The asthma study population consisted of 472 348 patients in Catalonia, 272 415 in Navarre and 302 281 in the Balearic Islands. At the onset of the study, the mean age in years of the asthma and coronary disease populations was circa 45 and 55, respectively. In both populations more than half were women (>51%). Catalonia presented the highest median number of visits for the asthma (6, IQR: 2–13) and coronary disease populations (7, IQR: 2–15). The Balearic Islands recorded the highest number of active health problems per patient for both populations (asthma population median 8, IQR: 4–14; coronary disease population median 9, IQR: 5–15) (table 1). Table 1 Characteristics of the asthma and coronary disease study population by region (Catalonia, Navarre, Balearic Islands-Spain) at the onset of the study Asthma (≥16 years) Coronary disease (≥35 years) Catalonia (n =472 348) Navarre (n = 272 415) Balearic Islands (n =302 281) Catalonia (n = 301 403) Navarre (n =172 809) Balearic Islands (n =203 532) Age (years), SD 45.45 (18.78) 44.87 (19.37) 45.51 (17.73) 55.95 (15.25) 56.07 (15.08) 54.62 (14.08) Sex (female), number (%) 243590 (51.57) 139513 (51.21) 157538 (52.12) 157011 (52.09) 89321 (51.68) 106339 (52.25) Number of visits, mean (SD); median (IQR) 9.12 (11.30); 6.00 (2.00–13.00) 6.41 (8.62); 4.00 (1.00–9.00) 9.05 (12.10); 5.00 (1.00–12.00) 10.78 (12.65); 7.00 (2.00–15.00) 7.89 (9.89); 5.00 (2.00–11.00) 10.49 (13.15); 7.00 (2.00–14.00) Number of health problems, mean (SD); median IQR) 4.50 (4.44); 3.00 (1.00–6.00) 7.40 (5.05); 6.00 (4.00–10.00) 9.70 (7.68); 8.00 (4.00–14.00) 5.25 (4.75); 4.00 (2.00–7.00) 8.12 (5.28); 7.00 (4.00–11.00) 10.51 (8.00); 9.00 (5.00–15.00) Asthma (≥16 years) Coronary disease (≥35 years) Catalonia (n =472 348) Navarre (n = 272 415) Balearic Islands (n =302 281) Catalonia (n = 301 403) Navarre (n =172 809) Balearic Islands (n =203 532) Age (years), SD 45.45 (18.78) 44.87 (19.37) 45.51 (17.73) 55.95 (15.25) 56.07 (15.08) 54.62 (14.08) Sex (female), number (%) 243590 (51.57) 139513 (51.21) 157538 (52.12) 157011 (52.09) 89321 (51.68) 106339 (52.25) Number of visits, mean (SD); median (IQR) 9.12 (11.30); 6.00 (2.00–13.00) 6.41 (8.62); 4.00 (1.00–9.00) 9.05 (12.10); 5.00 (1.00–12.00) 10.78 (12.65); 7.00 (2.00–15.00) 7.89 (9.89); 5.00 (2.00–11.00) 10.49 (13.15); 7.00 (2.00–14.00) Number of health problems, mean (SD); median IQR) 4.50 (4.44); 3.00 (1.00–6.00) 7.40 (5.05); 6.00 (4.00–10.00) 9.70 (7.68); 8.00 (4.00–14.00) 5.25 (4.75); 4.00 (2.00–7.00) 8.12 (5.28); 7.00 (4.00–11.00) 10.51 (8.00); 9.00 (5.00–15.00) Abbreviation: SD, standard deviation; IQR, interquartile range. Patients belonged to 22 PHC Team in each region. Table 1 Characteristics of the asthma and coronary disease study population by region (Catalonia, Navarre, Balearic Islands-Spain) at the onset of the study Asthma (≥16 years) Coronary disease (≥35 years) Catalonia (n =472 348) Navarre (n = 272 415) Balearic Islands (n =302 281) Catalonia (n = 301 403) Navarre (n =172 809) Balearic Islands (n =203 532) Age (years), SD 45.45 (18.78) 44.87 (19.37) 45.51 (17.73) 55.95 (15.25) 56.07 (15.08) 54.62 (14.08) Sex (female), number (%) 243590 (51.57) 139513 (51.21) 157538 (52.12) 157011 (52.09) 89321 (51.68) 106339 (52.25) Number of visits, mean (SD); median (IQR) 9.12 (11.30); 6.00 (2.00–13.00) 6.41 (8.62); 4.00 (1.00–9.00) 9.05 (12.10); 5.00 (1.00–12.00) 10.78 (12.65); 7.00 (2.00–15.00) 7.89 (9.89); 5.00 (2.00–11.00) 10.49 (13.15); 7.00 (2.00–14.00) Number of health problems, mean (SD); median IQR) 4.50 (4.44); 3.00 (1.00–6.00) 7.40 (5.05); 6.00 (4.00–10.00) 9.70 (7.68); 8.00 (4.00–14.00) 5.25 (4.75); 4.00 (2.00–7.00) 8.12 (5.28); 7.00 (4.00–11.00) 10.51 (8.00); 9.00 (5.00–15.00) Asthma (≥16 years) Coronary disease (≥35 years) Catalonia (n =472 348) Navarre (n = 272 415) Balearic Islands (n =302 281) Catalonia (n = 301 403) Navarre (n =172 809) Balearic Islands (n =203 532) Age (years), SD 45.45 (18.78) 44.87 (19.37) 45.51 (17.73) 55.95 (15.25) 56.07 (15.08) 54.62 (14.08) Sex (female), number (%) 243590 (51.57) 139513 (51.21) 157538 (52.12) 157011 (52.09) 89321 (51.68) 106339 (52.25) Number of visits, mean (SD); median (IQR) 9.12 (11.30); 6.00 (2.00–13.00) 6.41 (8.62); 4.00 (1.00–9.00) 9.05 (12.10); 5.00 (1.00–12.00) 10.78 (12.65); 7.00 (2.00–15.00) 7.89 (9.89); 5.00 (2.00–11.00) 10.49 (13.15); 7.00 (2.00–14.00) Number of health problems, mean (SD); median IQR) 4.50 (4.44); 3.00 (1.00–6.00) 7.40 (5.05); 6.00 (4.00–10.00) 9.70 (7.68); 8.00 (4.00–14.00) 5.25 (4.75); 4.00 (2.00–7.00) 8.12 (5.28); 7.00 (4.00–11.00) 10.51 (8.00); 9.00 (5.00–15.00) Abbreviation: SD, standard deviation; IQR, interquartile range. Patients belonged to 22 PHC Team in each region. The asthma incidence rate reached 0.40% in Catalonia in 2009, 0.55% in Navarre in 2008 and 0.69% in the Balearic Islands in 2010. The Balearic Islands presented the highest overall and standardized rates between 2010 and 2013. Navarre showed a higher incidence rate than Catalonia over the entire study period. The same patterns were observed for both sexes. Navarre showed the highest overall and standardized asthma prevalence rate throughout the study period (range: 3.92–5.87%). The crude and standardized prevalence rates were higher for women than for men in the three regions (table 2, Supplementary table S1). Table 2 Overall crudea and age-standardizeda,b asthma and coronary disease incidence and prevalence rates for each year by region (Catalonia, Navarre and Balearic Islands-Spain) and sex, 2007–13 Asthma Coronary disease Year Total Incidence rates Prevalence rates Total Incidence rates Prevalence rates Overall crude Female Male Overall crude Female Male Overall crude Female Male Overall crude Female Male % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 Catalonia     2007 376 971 0.35 42.03 25.40 3.51 422.69 278.02 25 3837 0.61 38.14 95.68 3.91 251.06 621.34     2008 381 351 0.35 41.98 26.13 3.73 449.53 299.69 253 701 0.55 32.60 87.74 4.09 254.01 636.09     2009 382 650 0.40 48.13 31.26 3.97 479.58 325.70 252 141 0.57 34.46 86.38 4.24 255.69 649.79     2010 381 100 0.35 43.08 27.03 4.17 499.29 344.46 249 823 0.53 33.22 77.35 4.38 258.27 657.57     2011 376 892 0.29 34.62 23.66 4.36 516.22 349.88 246 620 0.45 25.66 65.66 4.47 255.74 657.82     2012 371 809 0.28 34.43 20.85 4.55 538.08 365.23 243 229 0.43 22.48 62.01 4.55 249.89 655.02     2013 362 918 0.32 38.28 25.95 4.81 567.24 392.15 236 557 0.43 24.22 59.69 4.61 250.08 655.82 Navarre     2007 222 920 0.52 59.94 44 .73 3 .92 444.67 347.40 155 302 0.40 24.77 63.41 4.01 245.40 653.38     2008 229 529 0.55 67.95 43 .44 4 .28 488.99 378.59 156 006 0.39 23.63 59.77 4.19 248.87 671.87     2009 232 847 0.52 61.27 43 .03 4 .62 523.16 417.67 155 370 0.38 26.00 52.90 4.35 256.17 674.07     2010 234 957 0.52 66.16 40 .04 4 .95 557.36 450.45 154 500 0.37 20.52 54.91 4.49 254.76 678.41     2011 234 154 0.45 56.76 32 .74 5 .22 586.21 478.70 152 454 0.36 21.66 50.84 4.62 253.98 679.97     2012 233 702 0.44 53.36 36 .69 5 .50 610.88 511.84 150 514 0.38 20.51 54.98 4.73 249.29 680.14     2013 229 459 0.49 60.28 39 .53 5 .87 649.70 551.66 146 768 0.37 18.83 50.54 4.85 244.03 676.01 Balearic Islands     2010 302 281 0.69 82.41 51.07 4.12 475.59 346.72 203 532 0.38 29.94 65.27 2.13 157.73 379.72     2011 302 281 0.58 74.61 41.13 4.47 520.82 380.81 203 532 0.47 33.62 76.91 2.50 177.71 423.60     2012 302 281 0.59 72.32 45.48 4.85 565.59 419.60 203 532 0.51 39.03 73.23 2.89 200.52 458.21     2013 302 281 0.57 72.56 41.78 5.19 607.29 454.11 203 532 0.51 35.85 73.42 3.28 217.86 492.69 Asthma Coronary disease Year Total Incidence rates Prevalence rates Total Incidence rates Prevalence rates Overall crude Female Male Overall crude Female Male Overall crude Female Male Overall crude Female Male % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 Catalonia     2007 376 971 0.35 42.03 25.40 3.51 422.69 278.02 25 3837 0.61 38.14 95.68 3.91 251.06 621.34     2008 381 351 0.35 41.98 26.13 3.73 449.53 299.69 253 701 0.55 32.60 87.74 4.09 254.01 636.09     2009 382 650 0.40 48.13 31.26 3.97 479.58 325.70 252 141 0.57 34.46 86.38 4.24 255.69 649.79     2010 381 100 0.35 43.08 27.03 4.17 499.29 344.46 249 823 0.53 33.22 77.35 4.38 258.27 657.57     2011 376 892 0.29 34.62 23.66 4.36 516.22 349.88 246 620 0.45 25.66 65.66 4.47 255.74 657.82     2012 371 809 0.28 34.43 20.85 4.55 538.08 365.23 243 229 0.43 22.48 62.01 4.55 249.89 655.02     2013 362 918 0.32 38.28 25.95 4.81 567.24 392.15 236 557 0.43 24.22 59.69 4.61 250.08 655.82 Navarre     2007 222 920 0.52 59.94 44 .73 3 .92 444.67 347.40 155 302 0.40 24.77 63.41 4.01 245.40 653.38     2008 229 529 0.55 67.95 43 .44 4 .28 488.99 378.59 156 006 0.39 23.63 59.77 4.19 248.87 671.87     2009 232 847 0.52 61.27 43 .03 4 .62 523.16 417.67 155 370 0.38 26.00 52.90 4.35 256.17 674.07     2010 234 957 0.52 66.16 40 .04 4 .95 557.36 450.45 154 500 0.37 20.52 54.91 4.49 254.76 678.41     2011 234 154 0.45 56.76 32 .74 5 .22 586.21 478.70 152 454 0.36 21.66 50.84 4.62 253.98 679.97     2012 233 702 0.44 53.36 36 .69 5 .50 610.88 511.84 150 514 0.38 20.51 54.98 4.73 249.29 680.14     2013 229 459 0.49 60.28 39 .53 5 .87 649.70 551.66 146 768 0.37 18.83 50.54 4.85 244.03 676.01 Balearic Islands     2010 302 281 0.69 82.41 51.07 4.12 475.59 346.72 203 532 0.38 29.94 65.27 2.13 157.73 379.72     2011 302 281 0.58 74.61 41.13 4.47 520.82 380.81 203 532 0.47 33.62 76.91 2.50 177.71 423.60     2012 302 281 0.59 72.32 45.48 4.85 565.59 419.60 203 532 0.51 39.03 73.23 2.89 200.52 458.21     2013 302 281 0.57 72.56 41.78 5.19 607.29 454.11 203 532 0.51 35.85 73.42 3.28 217.86 492.69 a Truncated crude rate (≥16-years old, 17 age groups). b Rates are per 10 000 inhabitants and age-standardized on the European Standard Population (direct method). Table 2 Overall crudea and age-standardizeda,b asthma and coronary disease incidence and prevalence rates for each year by region (Catalonia, Navarre and Balearic Islands-Spain) and sex, 2007–13 Asthma Coronary disease Year Total Incidence rates Prevalence rates Total Incidence rates Prevalence rates Overall crude Female Male Overall crude Female Male Overall crude Female Male Overall crude Female Male % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 Catalonia     2007 376 971 0.35 42.03 25.40 3.51 422.69 278.02 25 3837 0.61 38.14 95.68 3.91 251.06 621.34     2008 381 351 0.35 41.98 26.13 3.73 449.53 299.69 253 701 0.55 32.60 87.74 4.09 254.01 636.09     2009 382 650 0.40 48.13 31.26 3.97 479.58 325.70 252 141 0.57 34.46 86.38 4.24 255.69 649.79     2010 381 100 0.35 43.08 27.03 4.17 499.29 344.46 249 823 0.53 33.22 77.35 4.38 258.27 657.57     2011 376 892 0.29 34.62 23.66 4.36 516.22 349.88 246 620 0.45 25.66 65.66 4.47 255.74 657.82     2012 371 809 0.28 34.43 20.85 4.55 538.08 365.23 243 229 0.43 22.48 62.01 4.55 249.89 655.02     2013 362 918 0.32 38.28 25.95 4.81 567.24 392.15 236 557 0.43 24.22 59.69 4.61 250.08 655.82 Navarre     2007 222 920 0.52 59.94 44 .73 3 .92 444.67 347.40 155 302 0.40 24.77 63.41 4.01 245.40 653.38     2008 229 529 0.55 67.95 43 .44 4 .28 488.99 378.59 156 006 0.39 23.63 59.77 4.19 248.87 671.87     2009 232 847 0.52 61.27 43 .03 4 .62 523.16 417.67 155 370 0.38 26.00 52.90 4.35 256.17 674.07     2010 234 957 0.52 66.16 40 .04 4 .95 557.36 450.45 154 500 0.37 20.52 54.91 4.49 254.76 678.41     2011 234 154 0.45 56.76 32 .74 5 .22 586.21 478.70 152 454 0.36 21.66 50.84 4.62 253.98 679.97     2012 233 702 0.44 53.36 36 .69 5 .50 610.88 511.84 150 514 0.38 20.51 54.98 4.73 249.29 680.14     2013 229 459 0.49 60.28 39 .53 5 .87 649.70 551.66 146 768 0.37 18.83 50.54 4.85 244.03 676.01 Balearic Islands     2010 302 281 0.69 82.41 51.07 4.12 475.59 346.72 203 532 0.38 29.94 65.27 2.13 157.73 379.72     2011 302 281 0.58 74.61 41.13 4.47 520.82 380.81 203 532 0.47 33.62 76.91 2.50 177.71 423.60     2012 302 281 0.59 72.32 45.48 4.85 565.59 419.60 203 532 0.51 39.03 73.23 2.89 200.52 458.21     2013 302 281 0.57 72.56 41.78 5.19 607.29 454.11 203 532 0.51 35.85 73.42 3.28 217.86 492.69 Asthma Coronary disease Year Total Incidence rates Prevalence rates Total Incidence rates Prevalence rates Overall crude Female Male Overall crude Female Male Overall crude Female Male Overall crude Female Male % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 % Rate/ 10 000 Rate/ 10 000 Catalonia     2007 376 971 0.35 42.03 25.40 3.51 422.69 278.02 25 3837 0.61 38.14 95.68 3.91 251.06 621.34     2008 381 351 0.35 41.98 26.13 3.73 449.53 299.69 253 701 0.55 32.60 87.74 4.09 254.01 636.09     2009 382 650 0.40 48.13 31.26 3.97 479.58 325.70 252 141 0.57 34.46 86.38 4.24 255.69 649.79     2010 381 100 0.35 43.08 27.03 4.17 499.29 344.46 249 823 0.53 33.22 77.35 4.38 258.27 657.57     2011 376 892 0.29 34.62 23.66 4.36 516.22 349.88 246 620 0.45 25.66 65.66 4.47 255.74 657.82     2012 371 809 0.28 34.43 20.85 4.55 538.08 365.23 243 229 0.43 22.48 62.01 4.55 249.89 655.02     2013 362 918 0.32 38.28 25.95 4.81 567.24 392.15 236 557 0.43 24.22 59.69 4.61 250.08 655.82 Navarre     2007 222 920 0.52 59.94 44 .73 3 .92 444.67 347.40 155 302 0.40 24.77 63.41 4.01 245.40 653.38     2008 229 529 0.55 67.95 43 .44 4 .28 488.99 378.59 156 006 0.39 23.63 59.77 4.19 248.87 671.87     2009 232 847 0.52 61.27 43 .03 4 .62 523.16 417.67 155 370 0.38 26.00 52.90 4.35 256.17 674.07     2010 234 957 0.52 66.16 40 .04 4 .95 557.36 450.45 154 500 0.37 20.52 54.91 4.49 254.76 678.41     2011 234 154 0.45 56.76 32 .74 5 .22 586.21 478.70 152 454 0.36 21.66 50.84 4.62 253.98 679.97     2012 233 702 0.44 53.36 36 .69 5 .50 610.88 511.84 150 514 0.38 20.51 54.98 4.73 249.29 680.14     2013 229 459 0.49 60.28 39 .53 5 .87 649.70 551.66 146 768 0.37 18.83 50.54 4.85 244.03 676.01 Balearic Islands     2010 302 281 0.69 82.41 51.07 4.12 475.59 346.72 203 532 0.38 29.94 65.27 2.13 157.73 379.72     2011 302 281 0.58 74.61 41.13 4.47 520.82 380.81 203 532 0.47 33.62 76.91 2.50 177.71 423.60     2012 302 281 0.59 72.32 45.48 4.85 565.59 419.60 203 532 0.51 39.03 73.23 2.89 200.52 458.21     2013 302 281 0.57 72.56 41.78 5.19 607.29 454.11 203 532 0.51 35.85 73.42 3.28 217.86 492.69 a Truncated crude rate (≥16-years old, 17 age groups). b Rates are per 10 000 inhabitants and age-standardized on the European Standard Population (direct method). The standardized asthma incidence rates showed a non-significant downward trend in the three regions. This trend was more pronounced in the Balearic Islands (AAPC: −4.99% per year, 95% CI: 13.76; 4.68). In Navarre and the Balearic Islands there was a higher decrease for men than for women. No region presented significant points of change (‘joinpoint’). The standardized asthma prevalence rates rose significantly in the three regions over the study period. Catalonia and Navarre showed two distinct time periods, 2007–09 and 2009–13, overall and by sex, with the exception of males in Catalonia. After 2009, increases in prevalence rates were smaller than in the previous period in these two regions. The Balearic Islands observed the highest steady and significant increase (AAPC: 8.87%, 95% CI: 7.49; 10.28), followed by Navarre (AAPC: 7.07%, 95% CI: 6.36; 7.77) over the study period (table 3). Table 3 Trends in age-standardizeda asthma incidence and prevalence rates by region (Catalonia, Navarre and Balearic Islands-Spain) and sex, 2007–13 Trend 1 Trend 2 AAPC (95% CI) Years APC (95% CI) P value Years APC (95% CI) P value 2007–13 P value Catalonia     Incidence         Overall 2007–13 –2.71 (–8.12; 3.01) 0.271 –2.71 (–8.12; 3.01) 0.271         Female 2007–13 –3.09 (–8.21; 2.31) 0.197 –3.09 (–8.21; 2.31) 0.197         Male 2007–13 –1.97 (–8.10; 4.57) 0.464 –1.97 (–8.10; 4.57) 0.464     Prevalence         Overall 2007–09 7.13 (0.14; 14.61) 0.048 2009 – 2013 4.22 (1.88; 6.62) 0.016 5.18 (3.89; 6.49) <0.001         Female 2007–09 6.41 (2.42; 10.55) 0.020 2009 – 2013 4.17 (2.84; 5.53) 0.005 4.91 (4.18; 5.65) <0.001         Male 2007–13 5.53 (4.33; 6.75) <0.001 5.53 (4.33; 6.75) <0.001 Navarre     Incidence         Overall 2007–13 –2.49 (–5.58; 0.71) 0.101 –2.49 (–5.58; 0.71) 0.101         Female 2007–13 –1.93 (–5.65; 1.94) 0.252 –1.93 (–5.65; 1.94) 0.252         Male 2007–13 –3.38 (–7.14; 0.52) 0.076 –3.38 (–7.14; 0.52) 0.076     Prevalence         Overall 2007–09 9.09 (5.02; 13.31) 0.010 2009–2013 6.07 (4.98; 7.17) 0.002 7.07 (6.36; 7.77) <0.001         Female 2007–09 8.61 (3.97; 13.45) 0.015 2009–2013 5.31 (4.05; 6.58) 0.003 6.40 (5.60; 7.20) <0.001     Male 2007–09 9.83 (5.94; 13.87) 0.008 2009–2013 7.13 (6.10; 8.17) 0.001 8.02 (7.35; 8.70) <0.001 Balearic Islands     Incidence         Overall 2010–13 –4.99 (–13.76; 4.68) 0.151 –4.99 (–13.76; 4.68) 0.151         Female 2010–13 –4.32 (–10.92; 2.78) 0.118 –4.32 (–10.92; 2.78) 0.118         Male 2010–l13 –5.32 (–20.91; 13.34) 0.321 –5.32 (–20.91; 13.34) 0.321     Prevalence         Overall 2010–13 8.87 (7.49; 10.28) 0.001 8.87 (7.49; 10.28) 0.001         Female 2010–13 8.50 (7.02; 9.99) 0.002 8.50 (7.02; 9.99) 0.002         Male 2010–13 9.50 (8.17; 10.85) 0.001 9.50 (8.17; 10.85) 0.001 Trend 1 Trend 2 AAPC (95% CI) Years APC (95% CI) P value Years APC (95% CI) P value 2007–13 P value Catalonia     Incidence         Overall 2007–13 –2.71 (–8.12; 3.01) 0.271 –2.71 (–8.12; 3.01) 0.271         Female 2007–13 –3.09 (–8.21; 2.31) 0.197 –3.09 (–8.21; 2.31) 0.197         Male 2007–13 –1.97 (–8.10; 4.57) 0.464 –1.97 (–8.10; 4.57) 0.464     Prevalence         Overall 2007–09 7.13 (0.14; 14.61) 0.048 2009 – 2013 4.22 (1.88; 6.62) 0.016 5.18 (3.89; 6.49) <0.001         Female 2007–09 6.41 (2.42; 10.55) 0.020 2009 – 2013 4.17 (2.84; 5.53) 0.005 4.91 (4.18; 5.65) <0.001         Male 2007–13 5.53 (4.33; 6.75) <0.001 5.53 (4.33; 6.75) <0.001 Navarre     Incidence         Overall 2007–13 –2.49 (–5.58; 0.71) 0.101 –2.49 (–5.58; 0.71) 0.101         Female 2007–13 –1.93 (–5.65; 1.94) 0.252 –1.93 (–5.65; 1.94) 0.252         Male 2007–13 –3.38 (–7.14; 0.52) 0.076 –3.38 (–7.14; 0.52) 0.076     Prevalence         Overall 2007–09 9.09 (5.02; 13.31) 0.010 2009–2013 6.07 (4.98; 7.17) 0.002 7.07 (6.36; 7.77) <0.001         Female 2007–09 8.61 (3.97; 13.45) 0.015 2009–2013 5.31 (4.05; 6.58) 0.003 6.40 (5.60; 7.20) <0.001     Male 2007–09 9.83 (5.94; 13.87) 0.008 2009–2013 7.13 (6.10; 8.17) 0.001 8.02 (7.35; 8.70) <0.001 Balearic Islands     Incidence         Overall 2010–13 –4.99 (–13.76; 4.68) 0.151 –4.99 (–13.76; 4.68) 0.151         Female 2010–13 –4.32 (–10.92; 2.78) 0.118 –4.32 (–10.92; 2.78) 0.118         Male 2010–l13 –5.32 (–20.91; 13.34) 0.321 –5.32 (–20.91; 13.34) 0.321     Prevalence         Overall 2010–13 8.87 (7.49; 10.28) 0.001 8.87 (7.49; 10.28) 0.001         Female 2010–13 8.50 (7.02; 9.99) 0.002 8.50 (7.02; 9.99) 0.002         Male 2010–13 9.50 (8.17; 10.85) 0.001 9.50 (8.17; 10.85) 0.001 Abbreviations: CI, confidence interval; APC, annual percentage change and AAPC, average annual percent change estimated by joinpoint regression analysis. a Truncated (≥16-years old, 17 age groups) rates per 10 000 inhabitants, age-standardized on the European Standard Population (direct method). Table 3 Trends in age-standardizeda asthma incidence and prevalence rates by region (Catalonia, Navarre and Balearic Islands-Spain) and sex, 2007–13 Trend 1 Trend 2 AAPC (95% CI) Years APC (95% CI) P value Years APC (95% CI) P value 2007–13 P value Catalonia     Incidence         Overall 2007–13 –2.71 (–8.12; 3.01) 0.271 –2.71 (–8.12; 3.01) 0.271         Female 2007–13 –3.09 (–8.21; 2.31) 0.197 –3.09 (–8.21; 2.31) 0.197         Male 2007–13 –1.97 (–8.10; 4.57) 0.464 –1.97 (–8.10; 4.57) 0.464     Prevalence         Overall 2007–09 7.13 (0.14; 14.61) 0.048 2009 – 2013 4.22 (1.88; 6.62) 0.016 5.18 (3.89; 6.49) <0.001         Female 2007–09 6.41 (2.42; 10.55) 0.020 2009 – 2013 4.17 (2.84; 5.53) 0.005 4.91 (4.18; 5.65) <0.001         Male 2007–13 5.53 (4.33; 6.75) <0.001 5.53 (4.33; 6.75) <0.001 Navarre     Incidence         Overall 2007–13 –2.49 (–5.58; 0.71) 0.101 –2.49 (–5.58; 0.71) 0.101         Female 2007–13 –1.93 (–5.65; 1.94) 0.252 –1.93 (–5.65; 1.94) 0.252         Male 2007–13 –3.38 (–7.14; 0.52) 0.076 –3.38 (–7.14; 0.52) 0.076     Prevalence         Overall 2007–09 9.09 (5.02; 13.31) 0.010 2009–2013 6.07 (4.98; 7.17) 0.002 7.07 (6.36; 7.77) <0.001         Female 2007–09 8.61 (3.97; 13.45) 0.015 2009–2013 5.31 (4.05; 6.58) 0.003 6.40 (5.60; 7.20) <0.001     Male 2007–09 9.83 (5.94; 13.87) 0.008 2009–2013 7.13 (6.10; 8.17) 0.001 8.02 (7.35; 8.70) <0.001 Balearic Islands     Incidence         Overall 2010–13 –4.99 (–13.76; 4.68) 0.151 –4.99 (–13.76; 4.68) 0.151         Female 2010–13 –4.32 (–10.92; 2.78) 0.118 –4.32 (–10.92; 2.78) 0.118         Male 2010–l13 –5.32 (–20.91; 13.34) 0.321 –5.32 (–20.91; 13.34) 0.321     Prevalence         Overall 2010–13 8.87 (7.49; 10.28) 0.001 8.87 (7.49; 10.28) 0.001         Female 2010–13 8.50 (7.02; 9.99) 0.002 8.50 (7.02; 9.99) 0.002         Male 2010–13 9.50 (8.17; 10.85) 0.001 9.50 (8.17; 10.85) 0.001 Trend 1 Trend 2 AAPC (95% CI) Years APC (95% CI) P value Years APC (95% CI) P value 2007–13 P value Catalonia     Incidence         Overall 2007–13 –2.71 (–8.12; 3.01) 0.271 –2.71 (–8.12; 3.01) 0.271         Female 2007–13 –3.09 (–8.21; 2.31) 0.197 –3.09 (–8.21; 2.31) 0.197         Male 2007–13 –1.97 (–8.10; 4.57) 0.464 –1.97 (–8.10; 4.57) 0.464     Prevalence         Overall 2007–09 7.13 (0.14; 14.61) 0.048 2009 – 2013 4.22 (1.88; 6.62) 0.016 5.18 (3.89; 6.49) <0.001         Female 2007–09 6.41 (2.42; 10.55) 0.020 2009 – 2013 4.17 (2.84; 5.53) 0.005 4.91 (4.18; 5.65) <0.001         Male 2007–13 5.53 (4.33; 6.75) <0.001 5.53 (4.33; 6.75) <0.001 Navarre     Incidence         Overall 2007–13 –2.49 (–5.58; 0.71) 0.101 –2.49 (–5.58; 0.71) 0.101         Female 2007–13 –1.93 (–5.65; 1.94) 0.252 –1.93 (–5.65; 1.94) 0.252         Male 2007–13 –3.38 (–7.14; 0.52) 0.076 –3.38 (–7.14; 0.52) 0.076     Prevalence         Overall 2007–09 9.09 (5.02; 13.31) 0.010 2009–2013 6.07 (4.98; 7.17) 0.002 7.07 (6.36; 7.77) <0.001         Female 2007–09 8.61 (3.97; 13.45) 0.015 2009–2013 5.31 (4.05; 6.58) 0.003 6.40 (5.60; 7.20) <0.001     Male 2007–09 9.83 (5.94; 13.87) 0.008 2009–2013 7.13 (6.10; 8.17) 0.001 8.02 (7.35; 8.70) <0.001 Balearic Islands     Incidence         Overall 2010–13 –4.99 (–13.76; 4.68) 0.151 –4.99 (–13.76; 4.68) 0.151         Female 2010–13 –4.32 (–10.92; 2.78) 0.118 –4.32 (–10.92; 2.78) 0.118         Male 2010–l13 –5.32 (–20.91; 13.34) 0.321 –5.32 (–20.91; 13.34) 0.321     Prevalence         Overall 2010–13 8.87 (7.49; 10.28) 0.001 8.87 (7.49; 10.28) 0.001         Female 2010–13 8.50 (7.02; 9.99) 0.002 8.50 (7.02; 9.99) 0.002         Male 2010–13 9.50 (8.17; 10.85) 0.001 9.50 (8.17; 10.85) 0.001 Abbreviations: CI, confidence interval; APC, annual percentage change and AAPC, average annual percent change estimated by joinpoint regression analysis. a Truncated (≥16-years old, 17 age groups) rates per 10 000 inhabitants, age-standardized on the European Standard Population (direct method). On the whole, the incidence of coronary disease rates was decreasing both in Catalonia and Navarre. However, this reduction was higher in Catalonia (range: 0.43–0.61%) than in Navarre (range: 0.36–0.40%). Conversely, it increased over the considered period in the Balearic Islands (range: 0.38%-0.51%). Navarre presented the highest coronary disease prevalence rate (range: 4.01–4.85%) and the Balearic Islands the lowest (range: 2.13–3.28%) in each year. Crude and standardized coronary disease incidence and prevalence rates were considerably higher for men than for women in all regions. Specifically, prevalence rates were over two-fold higher for men than for women (table 2, Supplementary table S2). The standardized coronary disease incidence rates in Catalonia and Navarre showed a significant downward trend from 2007 to 2013, overall and by sex, with higher AAPC in Catalonia (AAPC: −8.00%, 95% CI: −10.46; −5.47) than in Navarre (AAPC: −3.66%, 95% CI: −4.95; −2.35). In contrast, the Balearic Islands presented a non-significant upward trend (AAPC: 4.45%) over the study period with an AAPC of 6.78% per year in women. In Catalonia, the overall standardized coronary disease prevalence rate showed a significant upward trend of 1.52% per year between 2007 and 2010, and subsequently a downward trend of 0.52% per year between 2010 and 2013, although this decline was not significant. Male trends were of similar magnitude to the overall trends in both periods. In Navarre, the overall prevalence trends were similar to Catalonia but non-significant, with a ‘joinpoint’ in 2009. In the Balearic Islands, sharp and significant increases were observed, overall (AAPC: 10.01%, 95% CI: 7.30; 12.78) as well as in both sexes (AAPC: female: 11.38%, 95% CI: 8.21; 14.65; male: 8.85%, 95% CI: 6.11; 11.67) from 2010 to 2013 (table 4). Table 4 Trends in age-standardizeda coronary disease incidence and prevalence rates by region (Catalonia, Navarre and Balearic Islands-Spain) and Sex, 2007–13 Trend 1 Trend 2 AAPC (95% IC) Years APC (95% CI) P-value Years APC (95% CI) P-value 2007–13 P-value Catalonia     Incidence         Overall 2007–13 –8.00 (–10.46; –5.47) 0.001 –8.00 (–10.46; –5.47) 0.001         Female 2007–13 –8.09 (–12.02; –3.98) 0.004 –8.09 (–12.02; –3.98) 0.004         Male 2007–13 –8.14 (–9.90; –6.34) <0.001 –8.14 (–9.90; –6.34) <0.001     Prevalence         Overall 2007–10 1.52 (0.22; 2.83) 0.037 2010–2013 –0.52 (–1.76; 0.73) 0.213 0.49 (0.08; 0.90) 0.019         Female 2007–10 0.89 (–1.28; 3.11) 0.220 2010–2013 –1.20 (–3.30; 0.94) 0.137 –0.16 (–0.85; 0.54) 0.654         Male 2007–10 1.90 (1.36; 2.45) 0.004 2010–2013 –0.22 (–0.74; 0.29) 0.204 0.83 (0.66; 1.01) <0.001 Navarre     Incidence         Overall 2007–13 –3.66 (–4.95; –2.35) 0.001 –3.66 (–4.95; –2.35) 0.001         Female 2007–13 –4.50 (–7.65; –1.24) 0.017 –4.50 (–7.65; –1.24) 0.017         Male 2007–13 –3.22 (–5.58; –0.80) 0.019 –3.22 (–5.58; –0.80) 0.019  Prevalence         Overall 2007–09 1.95(–0.72; 4.69) 0.088 2009–2013 –0.27 (–1.07, 0.55) 0.293 0.47 (–0.01; 0.94) 0.053         Female 2007–09 2.56 (–1.70, 6.99) 0.124 2009–2013 –1.11 (–2.39, 0.18) 0.065 0.10 (–0.66; 0.85) 0.806         Male 2007–13 0.47 (–0.03; 0.97) 0.059 0.47 (–0.03; 0.97) 0.059 Balearic Islands     Incidence         Overall 2010–13 4.45 (–8.16; 18.79) 0.283 4.45 (–8.16; 18.79) 0.283         Female 2010–13 6.78 (–10.11; 26.84) 0.243 6.78 (–10.11; 26.84) 0.243         Male 2010–13 2.59 (–10.53; 17.63) 0.506 2.59 (–10.53; 17.63) 0.506     Prevalence         Overall 2010–13 10.01 (7.30; 12.78) 0.004 10.01 (7.30; 12.78) 0.004         Female 2010–13 11.38 (8.21; 14.65) 0.004 11.38 (8.21; 14.65) 0.004         Male 2010–13 8.85 (6.11; 11.67) 0.005 8.85 (6.11; 11.67) 0.005 Trend 1 Trend 2 AAPC (95% IC) Years APC (95% CI) P-value Years APC (95% CI) P-value 2007–13 P-value Catalonia     Incidence         Overall 2007–13 –8.00 (–10.46; –5.47) 0.001 –8.00 (–10.46; –5.47) 0.001         Female 2007–13 –8.09 (–12.02; –3.98) 0.004 –8.09 (–12.02; –3.98) 0.004         Male 2007–13 –8.14 (–9.90; –6.34) <0.001 –8.14 (–9.90; –6.34) <0.001     Prevalence         Overall 2007–10 1.52 (0.22; 2.83) 0.037 2010–2013 –0.52 (–1.76; 0.73) 0.213 0.49 (0.08; 0.90) 0.019         Female 2007–10 0.89 (–1.28; 3.11) 0.220 2010–2013 –1.20 (–3.30; 0.94) 0.137 –0.16 (–0.85; 0.54) 0.654         Male 2007–10 1.90 (1.36; 2.45) 0.004 2010–2013 –0.22 (–0.74; 0.29) 0.204 0.83 (0.66; 1.01) <0.001 Navarre     Incidence         Overall 2007–13 –3.66 (–4.95; –2.35) 0.001 –3.66 (–4.95; –2.35) 0.001         Female 2007–13 –4.50 (–7.65; –1.24) 0.017 –4.50 (–7.65; –1.24) 0.017         Male 2007–13 –3.22 (–5.58; –0.80) 0.019 –3.22 (–5.58; –0.80) 0.019  Prevalence         Overall 2007–09 1.95(–0.72; 4.69) 0.088 2009–2013 –0.27 (–1.07, 0.55) 0.293 0.47 (–0.01; 0.94) 0.053         Female 2007–09 2.56 (–1.70, 6.99) 0.124 2009–2013 –1.11 (–2.39, 0.18) 0.065 0.10 (–0.66; 0.85) 0.806         Male 2007–13 0.47 (–0.03; 0.97) 0.059 0.47 (–0.03; 0.97) 0.059 Balearic Islands     Incidence         Overall 2010–13 4.45 (–8.16; 18.79) 0.283 4.45 (–8.16; 18.79) 0.283         Female 2010–13 6.78 (–10.11; 26.84) 0.243 6.78 (–10.11; 26.84) 0.243         Male 2010–13 2.59 (–10.53; 17.63) 0.506 2.59 (–10.53; 17.63) 0.506     Prevalence         Overall 2010–13 10.01 (7.30; 12.78) 0.004 10.01 (7.30; 12.78) 0.004         Female 2010–13 11.38 (8.21; 14.65) 0.004 11.38 (8.21; 14.65) 0.004         Male 2010–13 8.85 (6.11; 11.67) 0.005 8.85 (6.11; 11.67) 0.005 Abbreviations: CI, confidence interval; APC, annual percentage change and AAPC, average annual percent change estimated by joinpoint regression analysis. a Truncated (≥35-years old, 13 age groups) rates per 10 000 inhabitants, age-standardized on the European Standard Population (direct method). Table 4 Trends in age-standardizeda coronary disease incidence and prevalence rates by region (Catalonia, Navarre and Balearic Islands-Spain) and Sex, 2007–13 Trend 1 Trend 2 AAPC (95% IC) Years APC (95% CI) P-value Years APC (95% CI) P-value 2007–13 P-value Catalonia     Incidence         Overall 2007–13 –8.00 (–10.46; –5.47) 0.001 –8.00 (–10.46; –5.47) 0.001         Female 2007–13 –8.09 (–12.02; –3.98) 0.004 –8.09 (–12.02; –3.98) 0.004         Male 2007–13 –8.14 (–9.90; –6.34) <0.001 –8.14 (–9.90; –6.34) <0.001     Prevalence         Overall 2007–10 1.52 (0.22; 2.83) 0.037 2010–2013 –0.52 (–1.76; 0.73) 0.213 0.49 (0.08; 0.90) 0.019         Female 2007–10 0.89 (–1.28; 3.11) 0.220 2010–2013 –1.20 (–3.30; 0.94) 0.137 –0.16 (–0.85; 0.54) 0.654         Male 2007–10 1.90 (1.36; 2.45) 0.004 2010–2013 –0.22 (–0.74; 0.29) 0.204 0.83 (0.66; 1.01) <0.001 Navarre     Incidence         Overall 2007–13 –3.66 (–4.95; –2.35) 0.001 –3.66 (–4.95; –2.35) 0.001         Female 2007–13 –4.50 (–7.65; –1.24) 0.017 –4.50 (–7.65; –1.24) 0.017         Male 2007–13 –3.22 (–5.58; –0.80) 0.019 –3.22 (–5.58; –0.80) 0.019  Prevalence         Overall 2007–09 1.95(–0.72; 4.69) 0.088 2009–2013 –0.27 (–1.07, 0.55) 0.293 0.47 (–0.01; 0.94) 0.053         Female 2007–09 2.56 (–1.70, 6.99) 0.124 2009–2013 –1.11 (–2.39, 0.18) 0.065 0.10 (–0.66; 0.85) 0.806         Male 2007–13 0.47 (–0.03; 0.97) 0.059 0.47 (–0.03; 0.97) 0.059 Balearic Islands     Incidence         Overall 2010–13 4.45 (–8.16; 18.79) 0.283 4.45 (–8.16; 18.79) 0.283         Female 2010–13 6.78 (–10.11; 26.84) 0.243 6.78 (–10.11; 26.84) 0.243         Male 2010–13 2.59 (–10.53; 17.63) 0.506 2.59 (–10.53; 17.63) 0.506     Prevalence         Overall 2010–13 10.01 (7.30; 12.78) 0.004 10.01 (7.30; 12.78) 0.004         Female 2010–13 11.38 (8.21; 14.65) 0.004 11.38 (8.21; 14.65) 0.004         Male 2010–13 8.85 (6.11; 11.67) 0.005 8.85 (6.11; 11.67) 0.005 Trend 1 Trend 2 AAPC (95% IC) Years APC (95% CI) P-value Years APC (95% CI) P-value 2007–13 P-value Catalonia     Incidence         Overall 2007–13 –8.00 (–10.46; –5.47) 0.001 –8.00 (–10.46; –5.47) 0.001         Female 2007–13 –8.09 (–12.02; –3.98) 0.004 –8.09 (–12.02; –3.98) 0.004         Male 2007–13 –8.14 (–9.90; –6.34) <0.001 –8.14 (–9.90; –6.34) <0.001     Prevalence         Overall 2007–10 1.52 (0.22; 2.83) 0.037 2010–2013 –0.52 (–1.76; 0.73) 0.213 0.49 (0.08; 0.90) 0.019         Female 2007–10 0.89 (–1.28; 3.11) 0.220 2010–2013 –1.20 (–3.30; 0.94) 0.137 –0.16 (–0.85; 0.54) 0.654         Male 2007–10 1.90 (1.36; 2.45) 0.004 2010–2013 –0.22 (–0.74; 0.29) 0.204 0.83 (0.66; 1.01) <0.001 Navarre     Incidence         Overall 2007–13 –3.66 (–4.95; –2.35) 0.001 –3.66 (–4.95; –2.35) 0.001         Female 2007–13 –4.50 (–7.65; –1.24) 0.017 –4.50 (–7.65; –1.24) 0.017         Male 2007–13 –3.22 (–5.58; –0.80) 0.019 –3.22 (–5.58; –0.80) 0.019  Prevalence         Overall 2007–09 1.95(–0.72; 4.69) 0.088 2009–2013 –0.27 (–1.07, 0.55) 0.293 0.47 (–0.01; 0.94) 0.053         Female 2007–09 2.56 (–1.70, 6.99) 0.124 2009–2013 –1.11 (–2.39, 0.18) 0.065 0.10 (–0.66; 0.85) 0.806         Male 2007–13 0.47 (–0.03; 0.97) 0.059 0.47 (–0.03; 0.97) 0.059 Balearic Islands     Incidence         Overall 2010–13 4.45 (–8.16; 18.79) 0.283 4.45 (–8.16; 18.79) 0.283         Female 2010–13 6.78 (–10.11; 26.84) 0.243 6.78 (–10.11; 26.84) 0.243         Male 2010–13 2.59 (–10.53; 17.63) 0.506 2.59 (–10.53; 17.63) 0.506     Prevalence         Overall 2010–13 10.01 (7.30; 12.78) 0.004 10.01 (7.30; 12.78) 0.004         Female 2010–13 11.38 (8.21; 14.65) 0.004 11.38 (8.21; 14.65) 0.004         Male 2010–13 8.85 (6.11; 11.67) 0.005 8.85 (6.11; 11.67) 0.005 Abbreviations: CI, confidence interval; APC, annual percentage change and AAPC, average annual percent change estimated by joinpoint regression analysis. a Truncated (≥35-years old, 13 age groups) rates per 10 000 inhabitants, age-standardized on the European Standard Population (direct method). Discussion Although a small, non-significant decrease in trends of standardized asthma incidence rates in patients over 15 years of age was observed in the three Spanish regions, the reduction was more pronounced in the Balearic Islands. In contrast, standardized asthma prevalence rates trends increased significantly in the three regions. This increase was smaller during the 2009–13 period in Catalonia and Navarre, and higher for men than women in all regions. Standardized coronary disease incidence and prevalence rates were considerably higher for men than for women in all regions. In Catalonia and Navarre, standardized coronary disease incidence rates showed a significant downward trend throughout the period studied. Conversely, trends of standardized coronary disease prevalence rates significantly increased in Catalonia from 2007 to 2010 overall and in males and also in the Balearic Islands throughout the study period. However, a non-significant downward trend was also observed after 2010 in Catalonia. Few published studies evaluate the impact of SFL on asthma and coronary disease from a PHC perspective. In addition, the methodology of these studies varies greatly further complicating comparison. We should also highlight that the effect of SFL on asthma is as yet unclear in the populations and settings where it has been analysed. Been et al.11 found no association between the introduction of SFL and the number of new wheezing/asthma cases among children ≤ 12 years visited by GP in UK.11 A quasiexperimental study in the US concluded that SFL reduced asthmatic symptoms in non-smoking children (3–15 years), but no association was found with self-reported asthma rates.26 A Spanish study that assessed the effects of partial SFL on asthma admissions rates at any age in Barcelona and Madrid failed to detect significant changes from 2003 to 2006 with fully adjusted models.15 Nevertheless, same authors found that asthma-related hospital admission rates increased by 12.1% immediately after the partial SFL in five Spanish regions, but decreased by 7.4% (95% CI: 0.2, 14.2) immediately after the comprehensive SFL, although the 1-year decrease was sustained only among men (9.9%, 95% CI: 3.9, 15.6).27 Kalkhoran et al.10 found a significant 15% decrease in the incidence of non-hospital emergency visits for bronchospasm in individuals aged ≥ 15 years following the implementation of Uruguay’s SFL compared with prior period. To our knowledge, no studies evaluate the impact of SFL on coronary disease in primary care, although data on the effect of SFL are available from hospital settings.28–30 Three studies evaluate the 2005 Spanish partial SFL with hospital data on coronary disease. Agüero et al.14 found a significant decrease of 11% in AMI incidence rates in the post-ban period compared with the previous period in Catalonia, particularly in women. In the city of Barcelona, Villalbí et al.31 analysed annual AMI hospitalization rates and found lower rates in 2006 than in 2005 for all age groups except in males under 45 years of age, i.e. an age-adjusted decrease of 10.68% in males and of 8.76% in women in 2006 compared with 2004. Using fully adjusted models, Galán et al.15 did not detect significant changes in hospital admission rates for AMI in Barcelona and Madrid in 2006 compared with the previous period. However, a significant AMI percentage rate change of—8.6% was observed in Barcelona compared with the period before the implementation of the SFL. Despite this, primary care records are considered the single most complete source of non-fatal myocardial infarction.32 In comparison with the abovementioned articles that present the percentage of change that occurs between two periods, the current study shows a significant decrease of 8% per year in the APC for men and women in Catalonia. Otherwise, a non-significant increase in the incidence of coronary disease was observed in the Balearic Islands, where data were only available for the last four years of the study. We hypothesize that this increase might respond to a higher registration of the condition for prescription purposes and not to changes in the characteristics of the population. Even though comprehensive SFL was introduced in Spain in 1 January 2011 and therefore its impact on the incidence of asthma and coronary disease should have been observed from this date onwards, no change in the trends of asthma and coronary disease were detected. It is likely that the prior effect of the 2005 Spanish partial SFL implemented on 1 January 2006 had weakened the impact of the comprehensive SFL, since a significant decrease in AMI hospital rates14,31 had already been observed. The lack of EHR in the period prior the partial SFL precludes the study of a larger period. Other factors that might have influenced these results are: immature computerization of EHR in the initial stages of implementation; changes in the software over time33–35; incentives to PHC providers to improve the management of hypertension, hyperlipidaemia and diabetes; and the programmes for quitting smoking prior to the implementation of the comprehensive SFL. Incidence rate trends have been use to analyse the impact of SFL. However, we have considered also relevant the trends in the prevalence of asthma and coronary disease as indirect indicators of the increase or decrease of these conditions. The prevalence rates show the year in which trends changed in Catalonia and Navarre, which do not coincide with the introduction of the new legislation. Limitations and strengths The evaluation of this public health law can be further complicated by factors not contemplated in this study that could influence the incidence and prevalence of asthma and coronary disease. Since the only variables collected were age, sex, number of health problems and number of PHC visits, no analyses adjusted by other variables known to be associated with the study conditions has been carried out. In addition, variation in the register of diagnostics in each region might generate differences in the number of active health problems for each patient and in the rates of asthma and coronary disease, for instance, the underregistration of asthma exacerbations in all regions, linking the diagnose with the episode in Navarre and the lack of integration of diagnostic data with electronic prescriptions in the Balearic Islands before 2012. As a result of these limitations and also due to the shorter study period in the Balearic Islands, the analysis was stratified by region. Otherwise, variations in study population size in Catalonia and Navarre along the study period were small and consistent with the variations in the whole population. Although rates of childhood asthma are usually considered to be more sensitive to SHS than rates of asthma in adults, this study only focuses on adult population as children data weren’t available. This is the first study that evaluates the effect of the Spanish comprehensive SFL on adult asthma and coronary disease in PHC patients. It is crucial to analyse the effect of a public health law in PHC patients under real conditions.36–38 The participation of three different Spanish regions and the use of EHR provides a wide range of valuable data. In addition, the use of joinpoint analysis evaluates longitudinal trends instead of just comparing two different periods, obtaining a more accurate analysis. Conclusions No changes in the trends of adult asthma and coronary disease in PHC Spanish patients were detected after the introduction of comprehensive SFL. The impact of the comprehensive SFL might have been lessened by the effect of the previous implementation of the partial SFL. This article provides baseline data for future research into the effectiveness of this law. In addition to specific factors associated with asthma and coronary disease, future studies should consider cigarette consumption, socio-economic status and asthma in children. Supplementary data Supplementary data are available at EURPUB online. Acknowledgements We thank all professionals of the 66 PHCTs who volunteered to participate in the study. The authors would also like to thank Josep M Elorza-Ricart, Magdalena Rosell-Murphy, Lluís Martínez, Javier Baquedano, Javier Arranz and Ma Ángeles Nuin for their assistance. Funding This work was supported by the Carlos III Health Institute (Ministry of Economy and Competitiveness, Spain) with a grant for research projects on health (PI11/01413) through the Network for Prevention and Health Promotion in Primary Care (redIAPP, RD12/0005/0001; RD16/0007/001), and by European Union ERDF funds. Conflicts of interest: None declared. Key points Trend of asthma incidence rates decreased non-significantly over the study period. 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Journal

The European Journal of Public HealthOxford University Press

Published: Feb 1, 2018

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