Study objective: To understand the context for tobacco smoking in young adolescents, estimating the effects of individual, family, social, and school related factors. Design: Cross sectional analysis performed by multilevel logistic regression with pupils at the first level and schools at the second level. The data came from a stratified sample of students surveyed on their own, their families' and their friends' smoking habits, their schools, and their awareness of cigarette prices and advertising. Setting: The study was performed in the Island of Gran Canaria, Spain. Participants: 1877 students from 30 secondary schools in spring of 2000 (model's effective sample sizes 1697 and 1738) . Main results: 14.2% of the young teenagers surveyed use tobacco, almost half of them (6.3% of the total surveyed) on a daily basis. According to the ordered logistic regression model, to have a smoker as the best friend increases significantly the probability of smoking (odds ratio: 6.96, 95% confidence intervals (CI) (4.93 to 9.84), and the same stands for one smoker living at home compared with a smoking free home (odds ratio: 2.03, 95% CI 1.22 to 3.36). Girls smoke more (odds ratio: 1.85, 95% CI 1.33 to 2.59). Experience with alcohol, and lack of interest in studies are also significant factors affecting smoking. Multilevel models of logistic regression showed that factors related to the school affect the smoking behaviour of young teenagers. More specifically, whether a school complies with antismoking rules or not is the main factor to predict smoking prevalence in schools. The remainder of the differences can be attributed to individual and family characteristics, tobacco consumption by parents or other close relatives, and peer group. Conclusions: A great deal of the individual differences in smoking are explained by factors at the school level, therefore the context is very relevant in this case. The most relevant predictors for smoking in young adolescents include some factors related to the schools they attend. One variable stood out in accounting for the school to school differences: how well they enforced the no smoking rule. Therefore we can prevent or delay tobacco smoking in adolescents not only by publicising health risks, but also by better enforcing no smoking rules in schools. P recisely what leads adolescents to take up smoking has been the subject of exhaustive study in the recent epidemiological literature.

BackgroundSpain has gone from a surplus to a shortage of medical doctors in very few years. Medium and long-term planning for health professionals has become a high priority for health authorities.MethodsWe created a supply and demand/need simulation model for 43 medical specialties using system dynamics. The model includes demographic, education and labour market variables. Several scenarios were defined. Variables controllable by health planners can be set as parameters to simulate different scenarios. The model calculates the supply and the deficit or surplus. Experts set the ratio of specialists needed per 1000 inhabitants with a Delphi method.ResultsIn the scenario of the baseline model with moderate population growth, the deficit of medical specialists will grow from 2% at present (2800 specialists) to 14.3% in 2025 (almost 21 000). The specialties with the greatest medium-term shortages are Anesthesiology, Orthopedic and Traumatic Surgery, Pediatric Surgery, Plastic Aesthetic and Reparatory Surgery, Family and Community Medicine, Pediatrics, Radiology, and Urology.ConclusionsThe model suggests the need to increase the number of students admitted to medical school. Training itineraries should be redesigned to facilitate mobility among specialties. In the meantime, the need to make more flexible the supply in the short term is being filled by the immigration of physicians from new members of the European Union and from Latin America.

This paper reviews economic and medical research publications to determine the extent to which the measures applied in Spain to control public health spending following the economic and financial crisis that began in 2008 have affected healthcare utilization, health and fairness within the public healthcare system. The majority of the studies examined focus on the most controversial cutbacks that came into force in mid-2012. The conclusions drawn, in general, are inconclusive. The consequences of this new policy of healthcare austerity are apparent in terms of access to the system but no systematic effects on the health of the general population are reported. Studies based on indicators of premature mortality, avoidable mortality or self-perceived health have not found clear negative effects of the crisis on public health. The increased demands for co-payment provoked a short-term cutback in the consumption of medicines, but this effect faded after 12-18 months. No deterioration in the health of immigrants after the onset of the crisis was unambigously detected. The impact of the recession in the general population in diseases associated with mental health is well documented, although the high levels of unemployment are identified as direct causes, and therefore it is social policies rather than measures affecting the healthcare system that would be primarily responsible. In addition, some health problems have a clear social dimension, which seems to have become more acute during the crisis, affecting in particular the most vulnerable population groups and the most disadvantaged social classes, thus widening the inequality gap. 3 Key points for decision makers Some health problems have a clear social dimension, which seems to have become more acute during the crisis  The public health system has borne a disproportionate share of the burden of spending cuts provoked by the crisis, but it has managed to avoid irreversible deterioration. The most tangible consequences of healthcare spending cuts and austerity measures concern problems of access to health care, both for specific population groups (undocumented immigrants) and for patients in general (longer waiting lists). The studies have common limitations: use of cross-sectional data and no consideration of lags between the cause (economic recession) and its effects (mortality, morbidity). In order to better estimate the effects of the crisis on health population, up-to-date data of cohorts from clinical records and registries would be needed. No attempt has been made in Spain so far to reform the health system with a view to achieving its long-term sustainability, in response to the 2008 recession and for preventing future recessions

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ObjectiveTo investigate the determinants of specialty choice among graduating medical students in Spain, a country that entered into a severe, ongoing economic crisis in 2008.SettingSince 2008, the percentage of Spanish medical school graduates electing Family and Community Medicine (FCM) has experienced a reversal after more than a decade of decline.DesignA nationwide cross-sectional survey conducted online in April 2011.ParticipantsWe invited all students in their final year before graduation from each of Spain's 27 public and private medical schools to participate.Main outcome measuresRespondents’ preferred specialty in relation to their perceptions of: (1) the probability of obtaining employment; (2) lifestyle and work hours; (3) recognition by patients; (4) prestige among colleagues; (5) opportunity for professional development; (6) annual remuneration and (7) the proportion of the physician's compensation from private practice.Results978 medical students (25% of the nationwide population of students in their final year) participated. Perceived job availability had the largest impact on specialty preference. Each 10% increment in the probability of obtaining employment increased the odds of preferring a specialty by 33.7% (95% CI 27.2% to 40.5%). Job availability was four times as important as compensation from private practice in determining specialty choice (95% CI 1.7 to 6.8). We observed considerable heterogeneity in the influence of lifestyle and work hours, with students who preferred such specialties as Cardiovascular Surgery and Obstetrics and Gynaecology valuing longer rather than shorter workdays.ConclusionsIn the midst of an ongoing economic crisis, job availability has assumed critical importance as a determinant of specialty preference among Spanish medical students. In view of the shortage of practitioners of FCM, public policies that take advantage of the enhanced perceived job availability of FCM may help steer medical school graduates into this specialty.