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.
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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).
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).
Carreras, G. et al. Burden of disease attributable to second-hand smoke exposure: a systematic review. Prev. Med. 129, 105833 (2019).
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).
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).
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).
Minardi, V. et al. Compliance with the smoking ban in Italy 8 years after its application. Int. J. Public Health 59, 549–554 (2014).
Gallus, S. et al. Voluntary home smoking ban: prevalence, trend and determinants in Italy. Eur. J. Public Health 26, 841–844 (2016).
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).
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).
Fernández, E. et al. Changes in secondhand smoke exposure after smoke-free legislation (Spain, 2006–2011). Nicotine Tob. Res. 19, 1390–1394 (2017).
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).
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).
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).
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).
Hajdu, T. & Hajdu, G. Smoking ban and health at birth: evidence from Hungary. Econ. Hum. Biol. 30, 37–47 (2018).
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).
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).
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).
López, M. J. et al. Social inequalities in secondhand smoke exposure in children in Spain. Tob. Induc. Dis. 16, 14 (2018).
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).
Wdowiak, A., Wiktor, H. & Wdowiak, L. Maternal passive smoking during pregnancy and neonatal health. Ann. Agric. Environ. Med. 16, 309–312 (2009).
Argalášová, L. et al. Determinants of ETS exposure in a sample of Slovak pregnant women. Rev. Environ. Health 32, 201–205 (2017).
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).
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).
Levin, M. The occurrence of lung cancer in man. Acta Unio Int. Contra Cancrum 9, 531–541 (1953).
Rubin, D. B. Multiple Imputation for Nonresponse in Surveys (Wiley, New York, 1987).
Gelman, A., King, G. & Liu, C. Not asked and not answered: multiple imputation for multiple surveys. JASA 93, 846–857 (1999).
White, I. R., Royston, P. & Wood, A. M. Multiple imputation using chained equations: issues and guidance for practice. Stat. Med. 30, 377–399 (2011).
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).
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).
Eurostat. Fertility statistics. Mean age of women at childbirth across EU regions. https://ec.europa.eu/eurostat/statistics-explained/index.php/Fertility_statistics (2020) Accessed 29 Sep 2020.
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).
Royal College of Physicians. Passive Smoking and Children. A Report by the Tobacco Advisory Group (RCP, London, 2010).
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).
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).
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).
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).
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).
Stevens, G. A. et al. Guidelines for accurate and transparent health estimates reporting: the GATHER statement. Lancet 388, e19–e23 (2016).
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).
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).
Audigier, V. et al. Multiple imputation for multilevel data with continuous and binary variables. Stat. Sci. 33, 160–183 (2018).
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).
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” (http://www.ccm-network.it/progetto.jsp?id=node/1977&idP=740); 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.
The authors declare no competing interests.
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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). https://doi.org/10.1038/s41390-020-01223-6
European Journal of Pediatrics (2021)