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Tesis Doctoral TESIS DOCTORAL EFECTIVIDAD DEL CONSEJO PARA DEJAR DE FUMAR COMBINADO CON LA DISCUSIÓN DETALLADA DE LOS RESULTADOS DE LA ESPIROMETRÍA POR PARTE DEL MÉDICO DE ATENCIÓN PRIMARIA SOBRE EL HÁBITO TABÁQUICO EN ADULTOS FUMADORES. Doctoranda: María del Mar Rodríguez Álvarez Director: Dr. Jordi Almirall Pujol DEPARTAMENTO DE MEDICINA Barcelona, 2012 DEPARTAMENTO DE MEDICINA Jordi Almirall Pujol, Profesor del Departamento de Medicina de la Universidad Autónoma de Barcelona, como Director, INFORMA: Que el trabajo titulado “EFECTIVIDAD DEL CONSEJO PARA DEJAR DE FUMAR COMBINADO CON LA DISCUSIÓN DETALLADA DE LOS RESULTADOS DE LA ESPIROMETRÍA POR PARTE DEL MÉDICO DE ATENCIÓN PRIMARIA SOBRE EL HÁBITO TABÁQUICO EN ADULTOS FUMADORES” realizado por María del Mar Rodríguez Álvarez, ha estado realizado bajo mi dirección y se encuentra en condiciones de ser leído y defendido como Tesis Doctoral delante del tribunal correspondiente de la Universidad Autónoma de Barcelona. Prof. Jordi Almirall Pujol Barcelona, 2012 3 A mi familia 5 Cuatro cosas es necesario extinguir en su principio: las deudas, el fuego, los enemigos y la enfermedad. Confucio (551-479 a. C.), filósofo chino 7 AGRADECIMIENTOS Esta tesis no hubiese estado posible sin la inestimable colaboración de muchas personas. En primer lugar querría agradecer la inestimable ayuda de mi director de tesis, el Dr. Jordi Almirall, que pacientemente ha seguido todo el proceso, haciendo las correcciones pertinentes, orientándome y guiándome en todo momento. Sin su colaboración y supervisión no habría sido posible realizar este proyecto. Al Dr. Torán, le he de agradecer su apoyo y confianza en este proyecto desde el inicio del mismo, facilitándome y poniendo a mi alcance todas las herramientas que he necesitado para sacar adelante el proyecto. Además agradecerle su dedicación y constancia en la creación y mantenimiento de la USR, que ha supuesto que desde el ámbito de la atención primaria se puedan llevar a cabo estos proyectos. A las instituciones públicas IDIAP Jordi Gol e Institut Català de la Salut, por haber apostado por este proyecto, facilitándome su realización mediante la concesión de la ayuda para la realización del doctorado en la Atención Primaria. A la Unidad de Suport a la Recerca de la Metropolitana Nord y Maresme, especialmente a Laura Muñoz que ha realizado el análisis estadístico, revisado todo el documento y pacientemente me ha facilitado todo el trabajo. Al resto de compañeros de la USR que han estado a mi lado y me han escuchado y ayudado en este proceso, sobre todo a Llorens Caballería por inestimable ayuda y disponibilidad a ayudarme en todo lo que necesitaba. A la dirección y todos los compañeros de la ABS Canet de Mar, especialmente a la Dra. Victoria Marina, Esther Valentín y Eva Calvo, por su apoyo durante todo este tiempo, al igual que todo el equipo de enfermería, especialmente a Montse Ollè y Ana Cortada que han participado en la realización de las espirometrías, por su inestimable colaboración, ayuda y disponibilidad, sin la cual no fuese posible haber realizado este proyecto. A Antonio Negrete, por su inestimable colaboración en el estudio. A mis amigos Merche, Juancho y Elena, culpables de que yo me aventurase a realizar esta tesis, por todo su apoyo, colaboración en el estudio y sobre todo por seguir siendo unos amigos incondicionales. A Silvia y Victoria, compañeras y sobre todo amigas que no han dudado en ayudarme con el proyecto y darme todo su apoyo este tiempo. A Felix, mi tutor, por haberme enseñado y transmitido lo que es ser médico de familia. A mi familia, en especial a mis padres, sin los cuales nada hubiese sido posible, por estar siempre ahí, por su apoyo incondicional, amor y respeto que me han sabido transmitir. A mi hermana Belén, que es y será siempre mi apoyo y mi confidente, y sobre todo por todo el amor que ha sabido siempre transmitirme. Y sobre todo a Agustín y a mis hijos, Uxía y Antón, por todo su apoyo, amor, paciencia y comprensión. Por saber entenderme, apoyarme y respetar todo el tiempo que no he podido compartir con ellos para poder realizar este proyecto. 11 A mis amigos, los de siempre y los que he conocido más tarde, pero que han estado ahí todos estos años dándome su apoyo. Al resto de equipos de Atención Primaria que han colaborado con este estudio. A los pacientes, sin los cuales no tendrían sentido estudios como este. ÍNDICE SYNOPSIS .................................................................................................................................. 19 LISTADO DE ABREVIATURAS ................................................................................................. 23 INTRODUCCIÓN ........................................................................................................................ 25 1.1 HISTORIA Y COMPOSICIÓN DEL TABACO ................................................................... 27 1.2 EFECTOS PERJUDICIALES DEL TABACO. EL TABACO COMO FACTOR DE RIESGO ................................................................................................................................................ 32 1.2.1 Tabaco y mortalidad .................................................................................................. 37 1.2.2 Tabaco y enfermedad respiratoria ............................................................................. 47 1.2.3 Tabaco y enfermedad cardiovascular ....................................................................... 54 1.2.4 Tabaco y cáncer ........................................................................................................ 66 1. 3 TABAQUISMO PASIVO ................................................................................................... 70 1.3.1 Tabaquismo pasivo en España ................................................................................. 71 1.3.2 Asociación entre tabaquismo pasivo y enfermedad .................................................. 73 1.3.3 Tabaquismo pasivo y población infantil ..................................................................... 78 1.4 BENEFICIOS DEL ABANDONO DEL TABACO ........................................................ 81 1.4.1 Abandono y mortalidad .............................................................................................. 82 1.4.2 Abandono y cáncer de pulmón ................................................................................. 82 1.4.3 Abandono y enfermedades respiratorias ................................................................... 83 1.4.4 Abandono y enfermedades cardiovasculares ........................................................... 84 1.4.5 Abandono y otros efectos beneficiosos ..................................................................... 86 1.5 TABACO Y COSTES ........................................................................................................ 87 1.6 EPIDEMIOLOGÍA DEL CONSUMO DEL TABACO .......................................................... 89 1.6.1 Datos epidemiologicos relativos a España ................................................................ 93 1.6.2 Datos epidemiologicos relativos a Cataluña .............................................................. 98 1.6.3 Datos epidemiologicos en población adolescente ................................................... 100 1.6.4 Epidemiologia del tabaquismo pasivo ..................................................................... 102 1.7 EL TABACO COMO ENFERMEDAD ADICTIVA Y CRÓNICA. FACTORES QUE INFLUYEN EN EL INICIO, MANTENIMIENTO Y CESACIÓN DEL HABITO TABÁQUICO . 104 1.7.1 Inicio y mantenimiento del hábito tabáquico ............................................................ 104 1.7.2 Abandono del hábito tabáquico. Factores relacionados .......................................... 108 1.7.3 Abandono del hábito tabáquico en España ............................................................. 113 1.8 INTERVENCIONES DESARROLLADAS PARA FOMENTAR EL ABANDONO DEL HABITO TABAQUICO .......................................................................................................... 115 1.8.1 Estrategias regulatorias ........................................................................................... 116 1.8.2 Estrategias regulatorias en España ......................................................................... 121 1.8.3 Estrategias sobre los sistemas de información sanitaria ......................................... 122 1.8.4 Estrategias de protección de la salud ...................................................................... 123 1.8.5 Estrategias de retroalimentación ............................................................................. 129 1.8.6 Otras Intervenciones ............................................................................................... 147 15 JUSTIFICACIÓN ....................................................................................................................... 149 OBJETIVOS .............................................................................................................................. 155 MATERIAL Y METODOS ......................................................................................................... 159 4.1 ÁMBITO DE ESTUDIO ................................................................................................... 161 4.2 POBLACIÓN DE ESTUDIO ............................................................................................ 162 4.3. CRITERIOS INCLUSIÓN ..............................................................................................
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