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The legal age for purchasing cigarettes is 16, but in 2010 18% of boys and 21% of girls aged 15 were smoking daily. This increased to 35% in boys and 30% in girls at age 17. In the province of Styria, 11-15 year old smokers reported easily obtaining cigarettes from tobacco shops (31.1%), vending machines (27.8%) and from other smokers (27.1%). A 2014 survey in two provinces and the capital city Vienna found that the sources of cigarettes for 13 year olds were friends (75%), tobacco shops (35%) and vending machines (10%). By the age of 15, 62% reported obtaining cigarettes from friends, 68% from tobacco shops and nearly 50% from vending machines. In the same year, a test series of mystery shopping in Upper Austria proved that nearly 60% of tobacco shops and gas stations sold cigarettes to 14 to 15 year old children. Although child smokers contribute tobacco tax, the proceeds are not invested into tobacco prevention.

Austria introduced smoke-free workplace legislation in 2001 (with the exception of the hospitality industry), but a 2006-2007 survey found only 72% of non-smokers reported a smoke-free or nearly smoke-free workplace. Five per cent suffered from daily passive smoking for >5 hours per day, 8% for 1-5 hours per day, 12% for <1 hour per day and 3% worked at home, where 10% of nonsmokers reported secondhand smoke exposure. A ban of smoking in public buildings in 2005 was not enforced and schools only became smoke-free in 2006 (excluding non-compulsory schools).

It was not before 2009 that sanctions for violations of non-smoker protection were introduced. Even then, loopholes for the hospitality industry made many of the regulations virtually meaningless. Although the hospitality industry was obliged to provide non-smoking rooms, an exception was made for small, single-room enterprises. In premises below 50 m² the innkeeper still can choose to be a smoking inn, if indicated by a sign. Owners of premises between 50 and 80 m² could apply for the same exemption at the building inspection. As expected, most small bars and pubs remained smoking for fear of losing guests to neighboring smoking establishments.

Inns over 80m² were allowed to stay without separation until mid-2010. Afterwards they were required to prevent smoke from entering the non-smoking section, but the law did not give detailed instructions. No authority was tasked with enforcement, and police, work inspectors and food inspectors were not allowed to control smoking in the hospitality industry. Reporting of violations was left to guests, but they were required to show proof by taking photos and knowing the name of the violator. The Austrian Council on Smoking and Health and other health NGOs received numerous reports of guests who did report violations facing abuse and harassment, including being labeled “squealers”, having their photo posted as unwanted guests at the entrance of premises they had reported, and being illegally forbidden to enter.

Austria’s weak laws contrast starkly with neighbouring Italy , where innkeepers had been obliged in 2005 to report offenders against new smoke-free laws to the police. The law was a success, with nearly full compliance and around 95% support for the ban following implementation. Even smokers recognized that the law helped them to smoke less, or quit completely. As has occurred elsewhere, the law also encouraged smoke-free homes .

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Abstract

BACKGROUND

Some available evidence suggests that high consumption of ultra-processed foods (UPFs) is associated with a higher risk of obesity. Collectively, this association and the nutritional characteristics of UPFs suggest that UPFs might also be associated with hypertension.

METHODS

We prospectively evaluated the relationship between UPF consumption and the risk of hypertension in a prospective Spanish cohort, the Seguimiento Universidad de Navarra project. We included 14,790 Spanish adult university graduates who were initially free of hypertension at baseline who were followed for a mean of 9.1 years (SD, 3.9 years; total person-years: 134,784). UPF (industrial formulations of chemical compounds which, beyond substances of common culinary use such as salt, sugar, oils, and fats, include substances also derived from foods but not used in culinary preparations) consumption was assessed using a validated semi-quantitative 136-item food-frequency questionnaire. Cox proportional hazards models were used to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for hypertension incidence.

RESULTS

During follow-up, 1,702 incident cases of hypertension were identified. Participants in the highest tertile of UPF consumption had a higher risk of developing hypertension (adjusted HR, 1.21; 95% CI, 1.06, 1.37; P for trend = 0.004) than those in the lowest tertile after adjusting for potential confounders.

CONCLUSIONS

In this large prospective cohort of Spanish middle-aged adult university graduates, a positive association between UPF consumption and hypertension risk was observed. Additional longitudinal studies are needed to confirm our results.

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Hypertension accounts for approximately 10.4 million deaths, 208.1 million disability-adjusted life-years, and 7% of the disease burden worldwide. 1 , 2 Moreover, hypertension is a risk factor for cardiovascular disease and responsible for at least 45% and 51% of deaths due to heart disease and stroke, respectively. 3 The prevalence of hypertension was approximately 22% worldwide in 2014 and 25% in the European region. 1

Modifiable risk factors for hypertension include an unhealthy diet (consumption of foods containing excess salt and saturated fat and insufficient fruit and vegetables intake), harmful alcohol use, lack of physical activity, and excess weight. 4 In several countries, ultra-processed foods (UPFs) are common sources of salt. According to Monteiro et al. UPFs are defined as drink and food products which, beyond substances of common culinary use such as salt, sugar, oils, and fats, include substances also derived from foods but not used in culinary preparation and are ready to eat, drink, or heat. 5–7 They have high amounts of salt, total fat, saturated fat, and trans fat, free sugar, and high energy density, and low fiber and micronutrients content. 8–11

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