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Use your other hand to impotence quoad hanc suhagra 100 mg discount capture the testicle erectile dysfunction questions buy suhagra, and gently palpate it to erectile dysfunction vacuum pumps australia buy cheap suhagra line check its width and length impotence drugs over counter discount suhagra uk. If testicular cancer is indicated, refer the client to a urologist or surgeon immediately. A small or abnormally soft testicle may indicate an endocrine disorder or testicular atrophy. In acute epididymitis, the epididymis is enlarged and tender compared to the other side. In severe epididymo-orchitis, the testes and epididymis may not be distinguishable from each other through palpation. Chronic, painless induration of the epididymis indicates tuberculosis, schistosomiasis (also called bilharzia), or nonspecific chronic epididymitis. Cystic masses near the upper pole of the testicle that are separate from the testicle and epididymis are usually spermatoceles, which contain thin, milky fluid and sperm; spermatoceles usually are not clinically significant. The cord, which consists of blood vessels, tissue, and the vas deferens, is palpable between the upper border of the testicle and the external inguinal ring. When palpating the spermatic cord, you can identify the vas deferens by feeling for a firm tube approximately 3 mm in diameter in a posterio- medial location within the spermatic cord. A swollen area in the spermatic cord may be cystic (indicating, for example, a hydrocele or hernia) or solid (indicating, for example, a lipoma or rare connective tissue tumor). Diffuse swelling and induration of the spermatic cord are present with filariasis. If the client does the Valsalva maneuver, palpating the spermatic cord may reveal a varicocele. Palpating the spermatic cord may also reveal bead-like enlargements of the vas deferens, which indicates tubercu- losis, or the absence of the vas deferens, which, if bilateral, causes infertility. During the genital examination, teach the client how to perform a genital self-examination (see Appendix F). The genital self-examination also helps the client become more aware of his body’s functions and promotes responsible health behaviors. Self-examination of the testes is particularly important for men between 15 and 40 years old, and those with a history of undescended testicle. When palpating for an inguinal hernia, use only your smallest finger or index finger. Gently insert the examining finger in to the scrotal wall just above and lateral to the testicle. Note: A fold of the scrotal skin covers your finger as you push it in to the scrotal wall. Feel for the vas deferens, and follow the vas upward and laterally to the inguinal ring (which feels like a sphincter) or inguinal canal. Instead, gently hold your finger against the inguinal ring, and ask the client to do the Valsalva maneuver. But if the client has an inguinal hernia, you feel pressure from a soft mass pushing through the inguinal canal on to the tip of your finger; this may be abdominal tissue or the bowel. When abdominal tissue penetrates the inguinal canal through the internal inguinal ring, the client has an indirect hernia. If abdominal tissue penetrates the inguinal canal through an abnormal opening in the abdominal wall, you feel a direct hernia pressing against the more proximal portion of your examining finger, away from the tip. When palpating for an inguinal hernia, also palpate the inguinal lymph nodes for swelling and tenderness. Infection and cancers of the penis and scrotal wall, as well as those of the legs, can spread to the inguinal and subinguinal nodes. When assessing a client with these conditions, remember to check for inguinal node enlargement and tenderness. Overview: Palpating for an Inguinal Hernia When you palpate for an inguinal hernia, keep in mind the following important points: • Palpating for an inguinal hernia may routinely be performed as part of an abdom- inal or genital examination. Ask the client (who is wearing a drape) to assume the lateral recumbent position, with both knees flexed, with the upper knee flexed more than the lower knee; or ask the client to bend forward, place his elbows on the examination table, and place his feet comfortably apart (you will sit behind him). Next, look at the perineum, which should be smooth and unbroken, and should have a regular contour with no significant discoloration or bulges. Then check the anal orifice, which should be brown or pinkish-brown and should not have any visible protruding masses. After explaining to the client what you are about to do, obtain the rectal specimen. Then slowly and gently insert a cotton swab in to his anus, and gently rotate the swab to capture the purulent dis- charge on the swab. Before you continue the rectal examination, check for rectal fissures (deep cracks), hemorrhoids, and anal herpes. If the client has any of these conditions, use an anes- thetic gel to lessen his pain before proceeding with the rectal examination. Wait at least five minutes after applying the gel to ensure that the anesthetic has time to work. If the client has a history of pain or bleeding with defecation, carefully examine the anus for rectal fissures, which may be hidden between the skin folds. If the client has a history of erectile dysfunction (particularly if he also has a history of possible neurological disease, injury, pelvic surgery, or diabetes), check for the bulbocavernosus reflex before touching the anal area. Overview: Obtaining a Rectal Specimen When you obtain a rectal specimen, keep in mind the following information: • Lubricant gels contain phenols to keep them free of bacteria, and the phenols can inhibit accurate results from collected rectal specimens. To prevent false negatives even when an infection is present, use lubricants that do not contain phenols. Checking the urethral meatus (if prostatitis is indicated) Note: Before you begin the prostate examination, tell the client that he does not have to change position. Tell the client that it enables you to inspect the prostate gland and to check for tumors and other possi- ble disorders. Remind the client that he may feel the urge to defecate or urinate, that this is normal, and that he will not lose bowel or bladder control. Before inspecting the prostate gland, place your nonexamining hand on the client’s hip or against his buttock to stabilize him and to enable him to prepare himself psycho- logically for the examination. Place the ball (the soft, fleshy part of the tip) of your well-lubricated, gloved finger flat against the anus. Ask the client to do the Valsalva maneuver as you slowly insert your finger in to the anus. Note: Rarely, a client may have a spasm of the rectal sphincter, which can be very painful. If this occurs during the prostate examination, hold your finger still and wait for the spasm to subside. This usually takes at least one minute but may last several minutes, especially if the examination is not gentle or unhurried or if the client is anxious. Next, with your finger pressing against the anterior wall of the rectum, feel for the prostate gland. The prostate gland is a roughly heart-shaped, symmetric organ, with two halves (lobes) that may be separated by an indentation through the rectal canal. The base of the prostate gland is wider than its apex and will be farther away from the examining finger than from the apex. The prostate gland usually feels rubbery and smooth; it should not feel hard, nodular, irregular, enlarged, or tender. Note: Most clients feel a mild-to-severe burning sensation in the penis when the ex- amining finger pushes on the prostate gland. To do this, you must know the length and width of your examining finger in centimeters. Typically, a prostate gland is palpable 2 to 5 cm inside the anal sphincter through the anterior rectal wall. With your examining finger, find the median sulcus, move your finger from the sulcus to the lateral borders of the right and left lobes, and assess the size of each lobe. Typically, a prostate gland is approx- imately 3 cm wide and 4 cm long, and its two lobes are symmetrical in size and shape. If you have long fingers, try to palpate for the seminal vesicles, which are superior and lateral to the prostate gland, for palpability and tenderness. During the prostate examination, feel the rectal walls to check for polyps, fissures, internal hemorrhoids, and tumors.
In addition, 6 percent of men allocated to nitroglycerine withdrew from therapy due to adverse events (severe pain) versus 0 percent of placebo subjects. One trial (n=132 participants) compared the 313 efficacy and harms of nitroglycerine ointment to minoxidil. Men assigned to received nitroglycerine ointment group reported more frequent side effects than did men in the minoxidil group, including more frequent burning at the application 313 site (12. Topical Aminophylline plus Isosorbide dinitrate plus Co-dergocrine versus Placebo. Two crossover trials compared the efficacy and harms of Aminophylline plus Isosorbide dinitrate 312,314 plus Co-dergocrine versus placebo. None of the patients had prolonged erection or priapism, clinically significant cardiovascular adverse events (such as postural dizziness), headache, or pain at site of 314 312 application. In the second trial, men assigned to the active treatment reported that they experienced erections adequate for intercourse after 3. All successful applications for both the active treatment and placebo 312 groups occurred in a single participant. One crossover trial (n=132) compared the efficacy and harms of 313 minoxidil to placebo. Compared with placebo, men allocated to minoxidil reported more frequent burning at the application site (6 versus 0 percent). No hypotension was reported by either the minoxidil or placebo-treated participants. One trial (n=80) compared the efficacy and 144 harms of topical sildenafil to oral sildenafil. In men assigned to receive topical sildenafil, four (10 percent) reported mild headache. In those assigned to receive oral sildenafil, two participants (5 percent) developed severe headache, one participant (3 percent) reported disturbed visual function, and one participant (3 percent) experienced severe dyspepsia. Quantitative Synthesis No meta-analysis could be performed because of substantial degree of clinical heterogeneity across the trials with regard to patient characteristics, interventions, and the assessed outcomes. Overview of Trials 322,323,326 Three trials used crossover, and the remaining 17 used parallel design. Treatment 319,321,323,330 316 duration in several trials was 6 months and in one trial 12 months. Racial characteristics were reported in only three trials with the majority of the subjects being Caucasians. While trials generally enrolled men with hypogonadism and/or andropause, the specific sexual dysfunction and testosterone entrance criteria across trials varied widely. With respect to 145,323,326 testosterone, all but three trials mandated that participants have levels below a specified threshold. Specific entrance criteria regarding total serum testosterone levels varied: 200-350 322 317,318,320,327,329 231,328 5 324 ng/dl, <300 ng/dL, <340-350 ng/dL, <400 ng/dL, <436 ng/dL, and 325 <500 ng/dL. Five trials studied testosterone in combination with a 5,77,145,231 phosphodiesterase inhibitor. Two other trials studied a cream combining testosterone, 322,329 isosorbide dinitrate and co-dergocrine. Study Quality and Reporting 5,316,317,320,321,327,330 Information on pharmaceutical funding was provided for seven trials. Three of the trials reported 91 319,322,325 adequate allocation concealment and six trials an appropriate double-blinding 5,316,321,322,325,329 method. There was adequate description of study withdrawals, drop-outs by 5,231,321,324,325,327,328,330 treatment group in eight trials. Three trials received a total Jadad score of 5,321,325 316,330 322,327,329,331 5, two trials received a score of 2, and four received a score of 3. Seven trials reported 5,77,231,317,322,326,329 data on frequency of successful sexual intercourse attempts. Three other trials reported data on the frequency of full erection during intercourse or the ability to maintain 321,326,328 erection during sexual intercourse, and three trials reported intercourse 77,231,319 5,77,145,319,324 satisfaction. Two trials reported data for sexual performance defined as the frequency of days with either orgasm, erection, masturbation, ejaculation and/or 320,327 intercourse in the past week. With 5,316,323,324,326 respect to harms outcomes, five trials reported no adverse effects data. Several trials 231 reported that adverse effects were absent or were negligible and without a difference in 77,145,319 frequency between treatment groups. In one open label trial outcomes for efficacy and 324 harms were compared between oral testosterone and no treatment. Subjects were excluded from the trial if they had prostate abnormality or any illness considered likely to impair sexual function. The outcomes for efficacy and harms associated with the 316,319 use of oral testosterone versus placebo were compared in two trials. In the first trial, 150 men aged 60–74 years, with symptoms attributed to androgen decline, including decreased libido and erectile quality, and free testosterone <6 pg/ml, were randomized to either 160 mg oral testosterone undecanoate taken daily for 6 months, or 2 gm propionyl-L-carnitine plus 2 gm 319 acetyl-L-carnitine daily or placebo. In the first trial, the difference in the occurrence of adverse events between the two treatment groups was not statistically significant. In the second trial, 86 percent and 93 percent of men in the testosterone and placebo group, respectively, reported that their 316 erections were “less strong” at 12 weeks of the followup. One trial evaluated and compared the efficacy and harms between oral testosterone alone and oral testosterone combined 145 with sildenafil. These men were randomized to 2 months of treatment with either oral testosterone undecanoate alone (120 mg/d) or oral testosterone undecanoate (120 mg/d) plus sildenafil (50-100 mg). The study reported that apart from mild headache occurring in three patients taking 145 sildenafil 100 mg, no serious adverse events were observed. One trial evaluated and compared the efficacy and harms for oral testosterone versus propionyl-L 319 carnitine plus acetyl-L-carnitine. In this study, 150 men aged 60-74 years, with symptoms of androgen decline, and free testosterone below 6 pg/mL, were randomized to receive either 160 mg oral testosterone undecanoate daily for 6 months or 2 gm propionyl-L-carnitine plus 2 gm 319 acetyl-L-carnitine daily or placebo. Results comparing testosterone and propionyl-L-carnitine plus acetyl-L-carnitine are reported here. The occurrence of adverse events was not statistically significantly different between the two treatment groups. The corresponding median score in those assigned to the propionyl-L carnitine plus acetyl-L-carnitine group changed from 8 (range 5–22) to 24 (range 8–29) (within group difference: p <0. One trial evaluated and compared the efficacy and harms outcomes of oral testosterone plus sildenafil compared with sildenafil 93 145 alone. The men were randomized to receive a 2-month treatment with either oral testosterone undecanoate (120 mg daily) plus sildenafil (50-100 mg) or sildenafil alone. Patients with prostate hypertrophy, prostate cancer, and mammary carcinoma were excluded. Apart from mild headaches occurring in three patients taking sildenafil 100 mg, no serious adverse events were observed. Patients with major disorders, a history of substance abuse, obesity, or major psychopathology were excluded from the trial. Patients with psychiatric disorders or abnormal prostate exam result (men aged > 50 years) were excluded. In the third trial, men who received testosterone were more likely to report acne (testosterone: 20. Differences between men in the testosterone and placebo groups with respect to the occurrence of irritability (17. In the first trial, weekly frequency of erections in the testosterone and placebo treatment groups were 7. There was no difference in the degree of erection during 94 sex with partner (scale 1–6, with = “none” and 6 = “full”), with a mean score of 5. The active treatment arms each lasted for at least 6 months, while the placebo treatment lasted for 2 months. The weekly frequency of erection was not different between the two groups of testosterone and human chorionic gonadotropin treatment (7.
Cluster B traits of ined a consecutive series of 79 women with Major histrionic and borderline personality are associated Depression and found that half the sample experi-- with increased sexual esteem, despite impaired enced problems with sexual desire and arousal [260] sexual desire and dissatisfaction. Frohlich and Meston compared depressed developmental factors must be taken into account to nondepressed college women using the Beck De-- when considering the role of personality in women’s pression Inventory. This novel inding Body image self consciousness has negative effects was explained by the speculation that masturbation on female sexual function, above and beyond actual may relect a reliable form of pleasure compared to body size or general body image dissatisfaction partnered sexual activity [261] (Level 2). In the laboratory setting, desire Given the retrospective design in the studies re-- in response to viewing erotic stimuli was positively viewed, it is dificult to determine the order of causal-- correlated with higher body esteem [271] (Level ity, however, some have speculated that depression 2). Interestingly, inducing a state of increased body may play a causal role in the development of female awareness while exposed to a sexual stimulus sexual dysfunction. Another are more likely to have a “vulnerable self-system” recent study in 320 men and women found that body characterized by more depressed thoughts and low-- concerns negatively affect sexual pleasure and er self esteem compared to controls [262] (Level 3). Women were signiicantly more likely to report appearance f) Personality variables: concerns than men across sexual and non-sexual contexts. The relationship between body shame Some authors have speculated that mood or affect- and sexual pleasure and problems was mediated by related dificulties are deep-rooted as opposed to sexual self-consciousness during physical intimacy, acute reactions to the sexual dificulty. Women with that is, body shame was related to greater sexual histrionic personality disorder were compared to non- self-consciousness, which in turn predicted lower histrionic women and were found to have signiicantly sexual pleasure and sexual arousability. Despite lower sexual desire, more sexual boredom, and greater Screening for and treatment of anxiety disorders is orgasmic dysfunction, this group displayed higher recommended. Given that personality factors dissatisfaction with conlict resolution in their rela-- (i. Furthermore these women of an individual), assessment of personality as it found that relationship factors were major contribu-- might inluence sexual health is important but tors to their sexual desire problems [280] (Level 3). Body concerns are found to have negative effects on sexual function in women Dificulties expressing sexual needs, wishes and and should be assessed. Men Evidence based research about relationship factors seem to have more inhibitions to talk about emotional contributing to desire and arousal concerns is scant, and sexual issues [281-283] (Level 2 and 3). Moreover, as sexual desire Sexual dissatisfaction which leads to relationship increases with increasing westernization, there is a problems or couple maladjustment then leads to concomitant decline in sex guilt (Level 3). Additionally in some couples one to which these indings apply to other ethno/cultural problem may be unconsciously used to “resolve” or groups remains to be determined. There is a strong association be-- tween sexual function/satisfaction and feelings for a the above mentioned biological and psychosocial partner [33,275]. A biopsychosocial approach, a negative impact on the female partner’s sexual de-- advocated by many experts is recommended. In sire [276] (Level 2 and 3) and successfully address-- this approach (see Table 4) the factors are grouped ing the former restores the woman’s sexual quality of into biological, psychosexual, and contextual, and life [277] (Level 2). However, there are also qualita-- are subdivided along a timeline in predisposing, tive data showing women’s dissatisfaction with not precipitating, and maintaining considerations. A being involved in treatment decision making when fuller diagnostic workup using this model is likely their male partner’s sought treatment for erectile to help clinicians to come to a further understand-- dificulties, and that they would have welcomed a ing of the patient’s desire and arousal dificulties. Using a circular model of wom-- proach, however, there was a beneit to sexual de-- en’s sexual desire that emphasizes the responsive sire in women [291] (Level 3). That origins in the work of Masters and Johnson [292] women provide a variety of reasons and incentives and Kaplan [293,294] have also been studied. For other ness is an eastern practice with roots in Buddhist women, however, more intensive strategies will be meditation which focuses on present moment, non- required. When the low desire is better ac-- sexual desire and many other domains of sexual re-- counted for by depression, poor body image, sexual sponse and mood [296] (Level 3). Moreover, they are is based on the theory which states that thoughts, without adverse side effects. Newer cognitive- feelings, and behaviors interact and mutually inlu-- behavioural treatments which integrate mindfulness ence one another. By targeting negative or maladap-- meditation have shown excellent promise for tive thoughts, both behaviors and affect will improve. There is also evidence that brief problematic sexual context or behaviours in either cognitive behavioural interventions are helpful for partner which reduce attractiveness or trust and abil-- improving desire. This may include identifying and challenging beliefs that b) Hormonal treatments for low desire she is unattractive, idealizing an unrealistic mode of sexual response portrayed by media, or challenging Testosterone has been used in the treatment of low beliefs that unless she feels a high level of desire sexual desire since the 1930s; however, system-- all the time, then she is dysfunctional. This topic improves sexual desire disorder in 74% of couples is covered more thoroughly in Chapter 23. A modiied Masters and Johnson not approved testosterone for this purpose, it is sex therapy was also found to improve sexual func-- commonly prescribed off-label, despite recommen-- tion in 57% of women with sexual desire disorder dations against doing so by the American Endo-- [290] (Level 3). Other psychological modalities have crine Society (due to lack of long-term safety data). This is especially important given the inding day or 450 µg/day compared to placebo [297-299] in an epidemiological review that endogenous (Level 2). Similar effects were found among natu-- androgen levels are associated with risk for breast rally menopausal, estrogen replete women [300]. This area is open to debate A review of testosterone trials among estrogen re-- given that there has been another study showing plete surgically and naturally menopausal women antiproliferative effects of testosterone [306]. Other found that those women receiving the 300µg/day risks of testosterone therapy include the link with patch reported an increase in sexually satisfying cardiovascular health. Interestingly, a signiicant testosterone administration given that women with beneit was also found across placebo groups of high endogenous testosterone-to-estrogen ratios approximately 0. When natural versus surgical menopausal synthetic hormone, tibolone, is available in Europe women were compared, this beneicial effect was and has been investigated in a Dutch study of only seen in the naturally menopausal women. Twenty-four effects, and there were 4 new cases of breast cancer in the testosterone but not placebo group [302]. An earlier placebo-controlled cross-over study in 38 Dutch postmenopausal women, heterogeneous Most recently, testosterone among premenopausal, with respect to sexual functioning, found that tibolone estrogen-replete women has been studied. In addition, the level of free testosterone Vaginal lubrication was signiicantly improved on was supraphysiological in the majority of women. It is unknown if testosterone therapy would be of beneit to the large majority of women seeking treatment for sexual Recommendations: desire concerns. Testosterone therapy is effective for estrogen-re-- Despite its lack of approval, many women seek out plete naturally menopausal women, and margin-- testosterone therapy for problematic low desire. Most adverse the potential hazards must take place before any drug reactions with libanserin 100mg were mild to testosterone supplementation is considered. Be-- moderate and included dizziness, nausea, fatigue, cause positive studies of testosterone have re-- somnolence and insomnia. Given that libanserin’s quired women to be engaging in sexually satisfying mechanism of action is not understood, it is as yet events 2-3 times per month, the eficacy of testos-- unclear which women, in the long run, may or may terone on women in the larger population of treat-- not beneit from its use, whether long term use will ment-seekers is unknown. Future research should prove to be safe, and whether, on a long term basis, aim to use stricter inclusion criteria for low desire. The At present, no peer-reviewed publications concern-- protocol would describe the most parsimonious route ing eficacy of libanserin on women’s sexual desire from presentation of complaints to effective therapy. Despite this made public at the European Society of Sexual Med-- disagreement, at least two diagnostic procedures icine annual meeting in November 2009 and sum-- should be considered. Firstly, assessment of sexual marized at the Boehringer Ingelheim website[314] dysfunction in a biopsychosocial context should start (level1). The aim of the clinical interview is to gather was established that the complaints were of medical information concerning current sexual functioning, etiology and not resulting from other sources. Sexual problems are common ful), irrespective of whether women had an orgasm complications of anxiety disorders and impair sexual or whether the event was satisfying for the partner. An analysis of the 634 premenopausal model of sexual excitation and inhibition in men as European women showed women taking libanse-- well as in women, may clarify the role of anxiety rin 100mg had statistically signiicant improvements in women’s predisposition to sexual inhibition and in their level of sexual desire as measured by the to sexual excitation [315]. Such distributions lend the arousal problem of the individual women is support to the idea that variation in excitation and clinically irrelevant. They argued that sexual arousal inhibition proneness is normal, and that the midpart problems in medically healthy women are most likely of the range represents adaptive levels of inhibition. Of note, nonresponse One of the most important but dificult tasks is to as-- in the psychophysiological assessment does not sess whether inadequate sexual stimulation is un-- automatically imply organicity. The woman may derlying the sexual problems, which requires detailed have been too nervous or distracted for the stimuli probing of (a variety of) sexual activities, conditions to be effective, or the stimuli offered may not have under which sexual activity takes place, prior sexual matched her sexual preferences. This problem of functioning and sexual and emotional feelings for suboptimal sensitivity is not unique to this test, many the partner. Several studies have shown that nega-- other well established diagnostic tests of this nature tive sexual and emotional feelings for the partner have a similar disadvantage [317]. The clinician should always ask if the wom-- indings from the clinical interview and the psycho-- an has ever experienced sexual abuse, as this may physiological assessment. The irst is the use of self- seriously affect sexual functioning [217-219] (Level 2 report measures to supplement the clinical interview.
However the targeting of men with regard to Chlamydia is showing that if the screening is done appropriately then men will engage. Understanding men’s lifestyles is a significant factor in the development of health strategy aimed at supporting men to lead less damaging lives. It is, however, crucially important to understand that lifestyles are not simply the product of individual choice. Across and within Member States that those who are in poorer material and social conditions eat less healthily, exercise less, consume more alcohol and are more likely to smoke or misuse drugs. In the context of addressing premature mortality rates among men, there is a growing awareness of the need to target lifestyle modification early in life among those men engaged in damaging health behaviours (White & Holmes, 2006). It has been estimated that 15% of all deaths in the European Union-including 25% of all cancer deaths - could be attributed to smoking (Directorate General for Health & Consumers, 2010). Every year, over half a million Europeans die prematurely because of tobacco use or exposure to environmental tobacco smoke. In addition to the loss of human life, smoking-related deaths and illnesses impose enormous economic burdens - over ˆ100 billion per year. Although use of smokeless tobacco does not appear to increase the risk of respiratory diseases, it may increase the risk of some cancers - particularly oropharyngeal cancers (Lee & Hamling, 2009; Weitkunat et al. The most obvious of these are cancers of the respiratory system, but there is also an increased risk of cancers of the stomach, pancreas, liver, renal system, and bladder. Smoking is also a major risk factor for coronary heart disease and cerebrovascular disease. Because men are more likely than women 89 to smoke on a daily basis, they are more likely to experience a range of smoking-related illnesses. For example, mortality rates for chronic obstructive pulmonary disease are two to three times higher for males than for females (European Respiratory Society, 2003). Similarly, mortality rates for cancers of the respiratory system are markedly higher among men, but rates are falling among men at the same time as they are rising in women. Across Europe, men are more likely than women to have ever smoked tobacco and to be current smokers (European Commission, 2009). One Eurobarometer survey of over 25,000 people in 28 countries revealed that 63% of men had smoked tobacco at some point in their lives, compared to 45% of women (European Commission, 2009). The same study revealed that men were considerably more likely to be smokers (32% vs 21%). Indeed, in several countries girls are more likely than boys to smoke (Hibell et al. Although men are more likely than women to smoke, it is important to acknowledge variability in smoking prevalence between men in different countries and among men within the same country. The proportion of men who smoke on a daily basis ranges from a low of 17% in Sweden to a high of 51% in Latvia (Fig 1. In some countries half of the male population smoke; in others only 1 in 6 men do so. When daily smokers and occasional smokers are combined, the proportion of men who smoke ranges from a low of 27% in Finland to a high of 56% in Latvia. In four countries - Slovenia (56 %), Lithuania (55%), Bulgaria (51%), and Estonia (51 %) the majority of men are smokers. In all but one of these 29 countries for which valid data were available, men were more likely than women to be daily smokers. Although men are more likely than women to be smokers, there is wide variation in the ratio of male-to- female smokers, from 1:1 in Sweden to 4:1 in Portugal (i. However, there are several clear deviations to this pattern - most notably Portugal, which has a relatively low level of smoking among men and the lowest levels of smoking among women. In nearly all countries, men with post-secondary education are least likely to smoke. In some countries smoking prevalence decreases with each increasing level of education, but in most countries this simple trend is not observed. One explanation for this variation is that patterns of smoking move through four stages, and that at each stage smoking is more prevalent in different segments of the population (Mackenbach & Kunst, 2004). The Central and Eastern European countries appear to be in the earlier stages, when smoking becomes common across all socioeconomic groups and smoking prevalence increases among women, but lags behind men (Map 1. In the majority of countries, girls were more likely to be smokers, but the sex differences are moderate in most. As observed among adults, there was wide variation in the prevalence of smoking among boys across Europe: the proportion of 16 year old male smokers ranged from 15% in Iceland to 44% in Latvia. Although there were no definitive patterns, rates of smoking among young men tended to be higher in central and eastern Europe, and lower in northern Europe. Other European surveys reveal that boys and young men perceive significantly less risk associated with smoking tobacco (European Commission, 2009-233). Furthermore, there is wide variation between different countries within Europe in terms of the presence and comprehensiveness of restrictions on smoking in workplaces. Among people who work in enclosed workplaces, men are less likely than women to be employed in smoke-free workplaces (Ibid). There is wide variation between European nations in terms of restrictions on smoking in enclosed public spaces. At one extreme, the United Kingdom and the Republic of Ireland have introduced total bans on smoking in enclosed public spaces. A number of countries - Finland, France, Italy, Latvia, Malta, the 94 Netherlands, Slovenia, Sweden, Romania - restrict smoking to separate designated smoking areas. However, in many of the countries a more relaxed 10 approach to cigarette smoke is taken. Excessive alcohol consumption is the third most important cause of morbidity and mortality in Europe (Mladovsky et al. Prolonged excessive alcohol consumption is related to an increased risk of liver cirrhosis, pancreatitis, and cancers of the gastrointestinal tract, liver, and breast. There is some evidence that moderate consumption confers health benefits in relation to stroke and coronary heart disease, but for other cardiovascular diseases there are more straightforward links between increased consumption and greater risk. Episodic heavy drinking increases the risk of accidental injury or death, and the risk of being the perpetrator or victim of violence. Excessive alcohol consumption may also lead to negative outcomes for relationships, family, friendships, employment, and finances. Levels of per capita alcohol consumption in Europe are the highest in the world (Anderson & Baumberg, 2006). Although there is evidence from some areas of Europe that sex differences in alcohol consumption are decreasing, it is still the case that men are more likely than women to drink and to drink in ways that increase the risk of harm. Men are more likely than women to be dependent on alcohol, and alcohol related injury and mortality rates are significantly greater among men than women (Anderson & Baumberg, 2006). Across Europe deaths due to chronic liver disease are more common among men than women: in 23 out of 31 countries the male death rate is at least double that for women (Fig. The male: female ratios for alcohol consumption tend to be even greater in relation to patterns of heavier alcohol use. The proportion of men who drink on daily basis was 18% compared to 9% among women, and the proportion of men who usually drink 5 or more alcoholic drinks on a drinking day was 13% compared to 7% among women. Some of these reflect cross-European variation in drinking cultures, for example, the proportion of alcohol consumed as beer, wine, or spirits differs as does patterns of alcohol consumption with and without meals (Anderson & Baumberg, 2006). The proportion of men who have drunk alcohol in the last 12 months ranges from a low of 68% in Romania to a high of 94% in Lithuania (Fig 1. Furthermore, the male to female ratio of drinkers ranges from just over 1 to nearly 2. In countries with high prevalence the male to female ratio is practically constant and close to 1:1, increasing as the prevalence decreases (Map. This pattern is found for all men in Europe, and is also observed within different age bands and across countries. In all 25 countries with valid data, men in the lowest education category were the least likely to drink, and in 20 of these countries, there were stepwise increases in alcohol consumption across the four education categories. In all countries, the majority of 16 year old boys had consumed alcohol in the last year (ranging from a low of 52% in Iceland to a high of 96% in Denmark). The graph below shows that the proportion of boys who had consumed alcohol in the last 30 days ranged from 28% in Iceland to 82% in Denmark. In most countries there were not large sex differences in terms of whether young people had consumed any alcohol. However, data on volume of consumption revealed clearer and stronger sex differences.
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