Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Burden of disease from exposure to secondhand smoke in children in Europe



Secondhand smoke (SHS) exposure at home and fetal SHS exposure during pregnancy are a major cause of disease among children. The aim of this study is quantifying the burden of disease due to SHS exposure in children and in pregnancy in 2006–2017 for the 28 European Union (EU) countries.


Exposure to SHS was estimated using a multiple imputation procedure based on the Eurobarometer surveys, and SHS exposure burden was estimated with the comparative risk assessment method using meta-analytical relative risks. Data on deaths and disability-adjusted life years (DALYs) were collected from National statistics and from the Global Burden of Disease Study.


Exposure to SHS and its attributable burden stalled in 2006–2017; in pregnant women, SHS exposure was 19.8% in 2006, 19.1% in 2010, and 21.0% in 2017; in children it was 10.1% in 2006, 9.6% in 2010, and 12.1% in 2017. In 2017, 35,633 DALYs among children were attributable to SHS exposure in the EU, mainly due to low birth weight.


Comprehensive smoking bans up to 2010 contributed to reduce SHS exposure and its burden in children immediately after their implementation; however, SHS exposure still occurs, and in 2017, its burden in children was still relevant.


  • Exposure to secondhand smoke at home and in pregnancy is a major cause of disease among children.

  • Smoking legislation produced the adoption of voluntary smoking bans in homes; however, secondhand smoke exposure at home still occurs and its burden is substantial.

  • In 2017, the number of deaths and disability-adjusted life years in children attributable to exposure to secondhand smoke in the European Union countries were, respectively, 335 and 35,633.

  • Low birth weight caused by secondhand smoke exposure in pregnancy showed the largest burden.

  • Eastern European Union countries showed the highest burden.

Access options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Fig. 1: Rank of the proportion of disability-adjusted life years (DALYs) attributable to secondhand smoke on total DALYs among children in 2017 in the European Union.
Fig. 2: Proportion of DALYs attributable to SHS on total DALYs by cause and country, 2017.


  1. 1.

    US Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General (US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA, 2006).

  2. 2.

    Öberg, M., Jaakkola, M. S., Woodward, A., Peruga, A. & Prüss-Ustün, A. Worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries. Lancet 377, 139–146 (2011).

    Article  Google Scholar 

  3. 3.

    Carreras, G. et al. Burden of disease attributable to second-hand smoke exposure: a systematic review. Prev. Med. 129, 105833 (2019).

    Article  Google Scholar 

  4. 4.

    Cheng, K. W., Glantz, S. A. & Lightwood, J. M. Association between smokefree laws and voluntary smokefree-homes rules. Am. J. Prev. Med. 41, 566–572 (2011).

    Article  Google Scholar 

  5. 5.

    Martínez-Sánchez, J. M. et al. Do smoke-free policies in work and public places increase smoking in private venues? Tob. Control 23, 204–207 (2014).

    Article  Google Scholar 

  6. 6.

    Monson, E. & Arsenault, N. Effects of enactment of legislative (public) smoking bans on voluntary home smoking restrictions: a review. Nicotine Tob. Res. 19, 141–148 (2017).

    Article  Google Scholar 

  7. 7.

    Minardi, V. et al. Compliance with the smoking ban in Italy 8 years after its application. Int. J. Public Health 59, 549–554 (2014).

    Article  Google Scholar 

  8. 8.

    Gallus, S. et al. Voluntary home smoking ban: prevalence, trend and determinants in Italy. Eur. J. Public Health 26, 841–844 (2016).

    Article  Google Scholar 

  9. 9.

    Jarvis, M. J., Sims, M., Gilmore, A. & Mindell, J. Impact of smoke-free legislation on children’s exposure to secondhand smoke: cotinine data from the Health Survey for England. Tob. Control 21, 18–23 (2012).

    Article  Google Scholar 

  10. 10.

    Akhtar, P. C. et al. Smoking restrictions in the home and secondhand smoke exposure among primary schoolchildren before and after introduction of the Scottish smoke-free legislation. Tob. Control 18, 409–415 (2009).

    CAS  Article  Google Scholar 

  11. 11.

    Fernández, E. et al. Changes in secondhand smoke exposure after smoke-free legislation (Spain, 2006–2011). Nicotine Tob. Res. 19, 1390–1394 (2017).

    Article  Google Scholar 

  12. 12.

    Akhtar, P. C., Currie, D. B., Currie, C. E. & Haw, S. J. Changes in Child Exposure to Environmental Tobacco Smoke (CHETS) study after implementation of smoke-free legislation in Scotland: national cross sectional survey. BMJ 335, 545 (2007).

    Article  Google Scholar 

  13. 13.

    Faber, T. et al. Effect of tobacco control policies on perinatal and child health: a systematic review and meta-analysis. Lancet Public Health 2, e420–e437 (2017).

    Article  Google Scholar 

  14. 14.

    Been, J. V. et al. Smoke-free legislation and paediatric hospitalisations for acute respiratory tract infections: national quasi-experimental study with unexpected findings and important methodological implications. Tob. Control 27, e160–e166 (2018).

    Article  Google Scholar 

  15. 15.

    Mackay, D., Haw, S., Ayres, J. G., Fischbacher, C. & Pell, J. P. Smoke-free legislation and hospitalizations for childhood asthma. N. Engl. J. Med. 363, 1139–1145 (2010).

    CAS  Article  Google Scholar 

  16. 16.

    Hajdu, T. & Hajdu, G. Smoking ban and health at birth: evidence from Hungary. Econ. Hum. Biol. 30, 37–47 (2018).

    Article  Google Scholar 

  17. 17.

    Been, J. V., Millett, C., Lee, J. T., van Schayck, C. P. & Sheikh, A. Smoke-free legislation and childhood hospitalisations for respiratory tract infections. Eur. Respir. J. 46, 697–706 (2015).

    CAS  Article  Google Scholar 

  18. 18.

    Millett, C., Lee, J. T., Laverty, A. A., Glantz, S. A. & Majeed, A. Hospital admissions for childhood asthma after smoke-free legislation in England. Pediatrics 131, e495–e501 (2013).

    Article  Google Scholar 

  19. 19.

    Martínez-Sánchez, J. M. et al. Exposure to secondhand smoke in Italian non-smokers 5 years after the Italian smoking ban. Eur. J. Public Health 22, 707–712 (2012).

    Article  Google Scholar 

  20. 20.

    López, M. J. et al. Social inequalities in secondhand smoke exposure in children in Spain. Tob. Induc. Dis. 16, 14 (2018).

    PubMed  PubMed Central  Google Scholar 

  21. 21.

    Robinson, O. et al. The association between passive and active tobacco smoke exposure and child weight status among Spanish children. Obesity 24, 1767–1777 (2016).

    Article  Google Scholar 

  22. 22.

    Wdowiak, A., Wiktor, H. & Wdowiak, L. Maternal passive smoking during pregnancy and neonatal health. Ann. Agric. Environ. Med. 16, 309–312 (2009).

    PubMed  Google Scholar 

  23. 23.

    Argalášová, L. et al. Determinants of ETS exposure in a sample of Slovak pregnant women. Rev. Environ. Health 32, 201–205 (2017).

    Article  Google Scholar 

  24. 24.

    Fernández, E. et al. Tackling second-hand exposure to tobacco smoke and aerosols of electronic cigarettes: the TackSHS Project Protocol. Gac. Sanit. 34, 77–82 (2020).

    Article  Google Scholar 

  25. 25.

    Öberg, M., Jaakkola, M. S., Prüss-Üstün, A., Schweizer, C. & Woodward, A. Second-Hand Smoke: Assessing the Environmental Burden of Disease at National and Local Levels (World Health Organization, Geneva, 2010).

  26. 26.

    Levin, M. The occurrence of lung cancer in man. Acta Unio Int. Contra Cancrum 9, 531–541 (1953).

    CAS  PubMed  Google Scholar 

  27. 27.

    Rubin, D. B. Multiple Imputation for Nonresponse in Surveys (Wiley, New York, 1987).

  28. 28.

    Gelman, A., King, G. & Liu, C. Not asked and not answered: multiple imputation for multiple surveys. JASA 93, 846–857 (1999).

    Article  Google Scholar 

  29. 29.

    White, I. R., Royston, P. & Wood, A. M. Multiple imputation using chained equations: issues and guidance for practice. Stat. Med. 30, 377–399 (2011).

    Article  Google Scholar 

  30. 30.

    Raghunathan, T. E., Lepkowski, J. M., van Hoewyk, J. & Solenberger, P. A multivariate technique for multiply imputing missing values using a sequence of regression models. Surv. Methodol. 27, 85–95 (2001).

    Google Scholar 

  31. 31.

    Resche-Rigon, M. & White, I. R. Multiple imputation by chained equations for systematically and sporadically missing multilevel data. Stat. Methods Med. Res. 27, 1634–1649 (2018).

    Article  Google Scholar 

  32. 32.

    Eurostat. Fertility statistics. Mean age of women at childbirth across EU regions. (2020) Accessed 29 Sep 2020.

  33. 33.

    Leonardi-Bee, J., Smyth, A., Britton, J. & Coleman, T. Environmental tobacco smoke and fetal health: systematic review and meta-analysis. Arch. Dis. Child. Fetal Neonatal Ed. 93, F351–F361 (2008).

    CAS  Article  Google Scholar 

  34. 34.

    Royal College of Physicians. Passive Smoking and Children. A Report by the Tobacco Advisory Group (RCP, London, 2010).

  35. 35.

    Jones, L. et al. Parental and household smoking and the increased risk of bronchitis, bronchiolitis and other lower respiratory infection in infancy: systematic review and meta-analysis. Respir. Res. 12, 5 (2011).

    Article  Google Scholar 

  36. 36.

    Li, J. S., Peat, J. K., Xuan, W. & Berry, G. Meta-analysis on the association between environmental tobacco smoke (ETS) exposure and the prevalence of lower respiratory tract infection in early childhood. Pediatr. Pulmonol. 27, 5–13 (1999).

    CAS  Article  Google Scholar 

  37. 37.

    Tinuoye, O., Pell, J. P. & Mackay, D. Meta-analysis of the association between secondhand smoke exposure and physician-diagnosed childhood asthma. Nicotine Tob. Res. 15, 1475–1483 (2013).

    Article  Google Scholar 

  38. 38.

    Jones, L., Hassanien, A., Cook, D., Britton, J. & Leonardi-Bee, J. Parental smoking and the risk of middle ear disease in children. Arch. Pediatr. Adolesc. Med. 166, 18–27 (2012).

    Article  Google Scholar 

  39. 39.

    GBD 2016 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 390, 1345–1422 (2017).

    Article  Google Scholar 

  40. 40.

    Stevens, G. A. et al. Guidelines for accurate and transparent health estimates reporting: the GATHER statement. Lancet 388, e19–e23 (2016).

    Article  Google Scholar 

  41. 41.

    Continente, X. et al. Burden of respiratory disease attributable to secondhand smoke exposure at home in children in Spain (2015). Prev. Med. 123, 34–40 (2019).

    Article  Google Scholar 

  42. 42.

    Reece, S. et al. Secondhand smoke exposure during pregnancy: a cross-sectional analysis of data from Demographic and Health Survey from 30 low-income and middle-income countries. Tob. Control 28, 420–426 (2019).

    Article  Google Scholar 

  43. 43.

    Audigier, V. et al. Multiple imputation for multilevel data with continuous and binary variables. Stat. Sci. 33, 160–183 (2018).

    Article  Google Scholar 

  44. 44.

    Behbod, B., Sharma, M., Baxi, R., Roseby, R. & Webster, P. Family and carer smoking control programmes for reducing children’s exposure to environmental tobacco smoke. Cochrane Database Syst. Rev. 1, CD001746 (2018).

    PubMed  Google Scholar 

Download references


E.F. thanks CERCA Programme/Generalitat de Catalunya for institutional support. This work was supported by the European Union’s Horizon 2020 research and innovation program [grant number 681040]; the 2017 Italian Health Ministry CCM Programme Project “Choosing health priorities and selecting effective interventions to prevent the burden of chronic non-communicable diseases” (; the Ministry of Research and Universities from the Government of Catalonia to EF [grant number 2017SGR319]; the Instituto Carlos III and co-funded by the European Regional Development Fund, FEDER [INT16/00211 and INT17/00103], Government of Spain to E.F. and the Italian League Against Cancer (Milan) to S.G. This manuscript was prepared by the TackSHS Project Consortium and does not necessarily reflect the views of the European Commission. The European Commission is not responsible for any use that may be made of the information that contains in this manuscript.

Author information





G.C., A.L., B.C., S.G., E.F., and G.G. made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; M.J.L., A.L.N., A.L., M.T.P., J.B.S., and E.F. contributed in drafting the article or revising it critically for important intellectual content; G.C., A.L., B.C., S.G., M.J.L., A.L.N., A.L., M.T.P., J.B.S., E.F., and G.G. gave the final approval of the version to be published.

Corresponding author

Correspondence to Giulia Carreras.

Ethics declarations

Competing interests

The authors declare no competing interests.

Patient consent statement

Patient consent was not required.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Carreras, G., Lachi, A., Cortini, B. et al. Burden of disease from exposure to secondhand smoke in children in Europe. Pediatr Res 90, 216–222 (2021).

Download citation

Further reading


Quick links