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1.  Specialty choice in times of economic crisis: a cross-sectional survey of Spanish medical students 
BMJ Open  2013;3(2):e002051.
To investigate the determinants of specialty choice among graduating medical students in Spain, a country that entered into a severe, ongoing economic crisis in 2008.
Since 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.
A nationwide cross-sectional survey conducted online in April 2011.
We invited all students in their final year before graduation from each of Spain's 27 public and private medical schools to participate.
Main outcome measures
Respondents’ 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.
978 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.
In 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.
PMCID: PMC3586052  PMID: 23408072
Medical Education & Training; Primary Care
3.  Heterogeneous Impact of the “Seguro Popular” Program on the Utilization of Obstetrical Services in Mexico, 2001–2006: A Multinomial Probit Model with a Discrete Endogenous Variable 
Journal of health economics  2008;28(1):20-34.
We evaluated the impact of Seguro Popular (SP), a program introduced in 2001 in Mexico primarily to finance health care for the poor. We focused on the effect of household enrollment in SP on pregnant women’s access to obstetrical services, an important outcome measure of both maternal and infant health.
We relied upon data from the cross-sectional 2006 National Health and Nutrition Survey (ENSANUT) in Mexico. We analyzed the responses of 3,890 women who delivered babies during 2001–2006 and whose households lacked employer-based health care coverage.
We formulated a multinomial probit model that distinguished between three mutually exclusive sites for delivering a baby: a health unit specifically accredited by SP; a non-SP-accredited clinic run by the Department of Health (Secretaría de Salud, or SSA); and private obstetrical care. Our model accounted for the endogeneity of the household’s binary decision to enroll in the SP program.
Women in households that participated in the SP program had a much stronger preference for having a baby in a SP-sponsored unit rather than paying out of pocket for a private delivery. At the same time, participation in SP was associated with a stronger preference for delivering in the private sector rather than at a state-run SSA clinic. On balance, the Seguro Popular program reduced pregnant women’s attendance at an SSA clinic much more than it reduced the probability of delivering a baby in the private sector. The quantitative impact of the SP program varied with the woman’s education and health, as well as the assets and location (rural versus urban) of the household.
The SP program had a robust, significantly positive impact on access to obstetrical services. Our finding that women enrolled in SP switched from non-SP state-run facilities, rather than from out-of-pocket private services, is important for public policy and requires further exploration.
PMCID: PMC2790917  PMID: 18824268
4.  Cigarette tar yields in relation to mortality from lung cancer in the cancer prevention study II prospective cohort, 1982-8 
BMJ : British Medical Journal  2004;328(7431):72.
Objective To assess the risk of lung cancer in smokers of medium tar filter cigarettes compared with smokers of low tar and very low tar filter cigarettes.
Design Analysis of the association between the tar rating of the brand of cigarette smoked in 1982 and mortality from lung cancer over the next six years. Multivariate proportional hazards analyses used to assess hazard ratios, with adjustment for age at enrolment, race, educational level, marital status, blue collar employment, occupational exposure to asbestos, intake of vegetables, citrus fruits, and vitamins, and, in analyses of current and former smokers, for age when they started to smoke and number of cigarettes smoked per day.
Setting Cancer prevention study II (CPS-II).
Participants 364 239 men and 576 535 women, aged ≥ 30 years, who had either never smoked, were former smokers, or were currently smoking a specific brand of cigarette when they were enrolled in the cancer prevention study.
Main outcome measure Death from primary cancer of the lung among participants who had never smoked, former smokers, smokers of very low tar (≤ 7 mg tar/cigarette) filter, low tar (8-14 mg) filter, high tar (≥ 22 mg) non-filter brands and medium tar conventional filter brands (15-21 mg).
Results Irrespective of the tar level of their current brand, all current smokers had a far greater risk of lung cancer than people who had stopped smoking or had never smoked. Compared with smokers of medium tar (15-21 mg) filter cigarettes, risk was higher among men and women who smoked high tar (≥ 22 mg) non-filter brands (hazard ratio 1.44, 95% confidence interval 1.20 to 1.73, and 1.64, 1.26 to 2.15, respectively). There was no difference in risk among men who smoked brands rated as very low tar (1.17, 0.95 to 1.45) or low tar (1.02, 0.90 to 1.16) compared with those who smoked medium tar brands. The same was seen for women (0.98, 0.80 to 1.21, and 0.95, 0.82 to 1.11, respectively).
Conclusion The increase in lung cancer risk is similar in people who smoke medium tar cigarettes (15-21 mg), low tar cigarettes (8-14 mg), or very low tar cigarettes (≤ 7 mg). Men and women who smoke non-filtered cigarettes with tar ratings ≥ 22 mg have an even higher risk of lung cancer.
PMCID: PMC314045  PMID: 14715602
5.  Impact of the Massachusetts tobacco control programme: population based trend analysis 
BMJ : British Medical Journal  2000;321(7257):351-354.
To assess the impact of the Massachusetts tobacco control programme, which, since its start in January 1993, has spent over $200m—“the highest per capita expenditure for tobacco control in the world”—funded by an extra tax of 25 cents per pack of cigarettes.
Population based trend analysis with comparison group.
Adult residents of Massachusetts and other US states excluding California.
Main outcome measures
Per capita consumption of cigarettes as measured by states' sales tax records; prevalence of smoking in adults as measured by several population-based telephone surveys.
From 1988 to 1992, decline in per capita consumption of cigarettes in Massachusetts (15%) was similar to that in the comparison states (14%), corresponding to an annual decline of 3-4% for both groups. During 1992-3, consumption continued to decline by 4% in the comparison states but dropped 12% in Massachusetts in response to the tax increase. From 1993 onward, consumption in Massachusetts showed a consistent annual decline of more than 4%, whereas in the comparison states it levelled off, decreasing by less than 1% a year. From 1992, the prevalence of adult smoking in Massachusetts has declined annually by 0.43% (95% confidence interval 0.21% to 0.66%) compared with an increase of 0.03% (-0.06% to 0.12%) in the comparison states (P<0.001).
These findings show that a strongly implemented, comprehensive tobacco control programme can significantly reduce tobacco use.
PMCID: PMC27453  PMID: 10926595

Results 1-5 (5)