Elsevier

The Lancet

Volume 377, Issue 9760, 8–14 January 2011, Pages 139-146
The Lancet

Articles
Worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries

https://doi.org/10.1016/S0140-6736(10)61388-8Get rights and content

Summary

Background

Exposure to second-hand smoke is common in many countries but the magnitude of the problem worldwide is poorly described. We aimed to estimate the worldwide exposure to second-hand smoke and its burden of disease in children and adult non-smokers in 2004.

Methods

The burden of disease from second-hand smoke was estimated as deaths and disability-adjusted life-years (DALYs) for children and adult non-smokers. The calculations were based on disease-specific relative risk estimates and area-specific estimates of the proportion of people exposed to second-hand smoke, by comparative risk assessment methods, with data from 192 countries during 2004.

Findings

Worldwide, 40% of children, 33% of male non-smokers, and 35% of female non-smokers were exposed to second-hand smoke in 2004. This exposure was estimated to have caused 379 000 deaths from ischaemic heart disease, 165 000 from lower respiratory infections, 36 900 from asthma, and 21 400 from lung cancer. 603 000 deaths were attributable to second-hand smoke in 2004, which was about 1·0% of worldwide mortality. 47% of deaths from second-hand smoke occurred in women, 28% in children, and 26% in men. DALYs lost because of exposure to second-hand smoke amounted to 10·9 million, which was about 0·7% of total worldwide burden of diseases in DALYs in 2004. 61% of DALYs were in children. The largest disease burdens were from lower respiratory infections in children younger than 5 years (5 939 000), ischaemic heart disease in adults (2 836 000), and asthma in adults (1 246 000) and children (651 000).

Interpretation

These estimates of worldwide burden of disease attributable to second-hand smoke suggest that substantial health gains could be made by extending effective public health and clinical interventions to reduce passive smoking worldwide.

Funding

Swedish National Board of Health and Welfare and Bloomberg Philanthropies.

Introduction

The harmful effects of second-hand smoke have been recorded since 1928.1 In the 1970s, scientific interest in potential adverse health effects of second-hand smoke expanded.2, 3 Since then, evidence about ill health because of second-hand smoke has accumulated from many studies done in different parts of the world. However, second-hand smoke remains a common indoor air pollutant in many regions. Comprehensive legislation to protect non-smokers from exposure to second-hand smoke in all indoor workplaces and public places has been implemented in some countries and subnational jurisdictions, but 93% of the world's population is still living in countries not covered by fully smoke-free public health regulations.4, 5, 6, 7, 8

Knowledge about the links between second-hand smoke and specific diseases has been summarised in comprehensive assessments or reviews by the International Agency for Research on Cancer,9 WHO,10 the California Environmental Protection Agency,11 and the US Surgeon General.12 Studies of the effects of smoke-free laws have drawn attention to the importance of second-hand smoke as a preventable cause of disease and disability. The International Agency for Research on Cancer reported in 2009 that “wide-ranging bans on smoking in the workplace are followed by as much as a 10–20% reduction in acute coronary events in the first year post-ban”.13, 14 The 171 countries that are parties to the WHO Framework Convention on Tobacco Control “recognize that scientific evidence has unequivocally established that exposure to tobacco smoke causes death, disease, and disability”.15 Furthermore, they recognise that there is no safe level of exposure to tobacco smoke and therefore recommend effective measures to provide protection from exposure to tobacco smoke, as envisioned by Article 8 of the WHO Framework Convention. The guidelines for implementation of Article 8 stipulate that smoking and tobacco smoke be totally eliminated in all indoor workplaces, indoor public places, and on public transport, and be eliminated as appropriate in other public places.16

Some country-specific studies of the health effects attributable to second-hand smoke have been reported;17, 18, 19 however, this study provides the first assessment of the worldwide burden of disease from second-hand smoke. Information about the magnitude and distribution of the burden of disease from second-hand smoke is particularly important for policy makers to plan preventive strategies. We aimed to estimate the worldwide burden of disease attributable to second-hand smoke, measured as deaths and disability-adjusted life-years (DALYs) lost for children and adult non-smokers.

Section snippets

Framework for estimation

We estimated the burden of disease from second-hand smoke by the comparative risk assessment method.20, 21 In this approach, the contribution of a risk factor to disease is based on the population attributable fraction, which is derived from the proportion of people exposed to the pollutant of interest and the relative risk of disease related to the exposure, and defined as the proportional reduction in disease or death that would occur if exposure was reduced to zero.20, 21

Proportion exposed

Results

Worldwide, 40% of children, 33% of male non-smokers, and 35% of female non-smokers were exposed to second-hand smoke. The highest proportions exposed were estimated in Europe, the western Pacific, and region B of southeast Asia, with more than 50% of some population groups exposed (table 2). Proportion of people exposed was lower in the Americas and eastern Mediterranean regions and the lowest in Africa (table 2).

Second-hand smoke was estimated to have caused 603 000 premature deaths and the

Discussion

Exposure to second-hand smoke is still one of the most common indoor pollutants worldwide. On the basis of the proportions of second-hand smoke exposure, as many as 40% of children, 35% of women, and 33% of men are regularly exposed to second-hand smoke indoors. We noted wide regional variations of exposure, ranging from 13% or less in Africa to 50% or more in the western Pacific or eastern Europe. These differences can be mostly explained by the stages of the tobacco epidemic of a country

References (39)

  • M Ezzati et al.

    Selected major risk factors and global and regional burden of disease

    Lancet

    (2002)
  • E Schönherr

    Contribution to the statistical and clinical features of lung tumours (in German)

    Z Krebsforsch

    (1928)
  • The Health Consequences of Smoking. A Report of the Surgeon General: 1972

    (1972)
  • AW Musk et al.

    History of tobacco and health

    Respirology

    (2003)
  • WHO Report on the Global Tobacco Epidemic 2009: implementing smoke-free environments

    (2009)
  • MP Eriksen et al.

    The diffusion and impact of clean indoor air laws

    Annu Rev Public Health

    (2008)
  • A McNabola et al.

    The control of environmental tobacco smoke: a policy review

    Int J Environ Res Public Health

    (2009)
  • L Fontana et al.

    Application and effects of smoking ban in bars and restaurants of Rome (in Italian)

    G Ital Med Lav Ergon

    (2007)
  • MS Jaakkola et al.

    Impact of smoke-free workplace legislation on exposures and health: possibilities for prevention

    Eur Respir J

    (2006)
  • Tobacco Smoke and Involuntary Smoking

    (2004)
  • International Consultation on Environmental Tobacco Smoke (ETS) and Child Health

    (1999)
  • Proposed Identification of Environmental Tobacco Smoke as a Toxic Air Contaminant

    (2005)
  • The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General

    (2006)
  • Evaluating the effectiveness of smoke-free policies

    (2009)
  • D Menzies et al.

    Respiratory symptoms, pulmonary function, and markers of inflammation among bar workers before and after a legislative ban on smoking in public places

    JAMA

    (2006)
  • WHO Framework Convention on Tobacco Control

    (2009)
  • Guidelines for implementation of the WHO Framework Convention on Tobacco Control

    (2009)
  • Q Gan et al.

    Disease burden of adult lung cancer and ischaemic heart disease from passive tobacco smoking in China

    Tob Control

    (2007)
  • A Woodward et al.

    How many deaths are caused by second hand cigarette smoke?

    Tob Control

    (2001)
  • Cited by (0)

    View full text