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Flor LS, Anderson JA, Ahmad N, Aravkin A, Carr S, Dai X, Gil GF, Hay SI, Malloy MJ, McLaughlin SA, Mullany EC, Murray CJL, O'Connell EM, Okereke C, Sorensen RJD, Whisnant J, Zheng P, Gakidou E. Health effects associated with exposure to secondhand smoke: a Burden of Proof study. Nat Med 2024; 30:149-167. [PMID: 38195750 PMCID: PMC10803272 DOI: 10.1038/s41591-023-02743-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 11/28/2023] [Indexed: 01/11/2024]
Abstract
Despite a gradual decline in smoking rates over time, exposure to secondhand smoke (SHS) continues to cause harm to nonsmokers, who are disproportionately children and women living in low- and middle-income countries. We comprehensively reviewed the literature published by July 2022 concerning the adverse impacts of SHS exposure on nine health outcomes. Following, we quantified each exposure-response association accounting for various sources of uncertainty and evaluated the strength of the evidence supporting our analyses using the Burden of Proof Risk Function methodology. We found all nine health outcomes to be associated with SHS exposure. We conservatively estimated that SHS increases the risk of ischemic heart disease, stroke, type 2 diabetes and lung cancer by at least around 8%, 5%, 1% and 1%, respectively, with the evidence supporting these harmful associations rated as weak (two stars). The evidence supporting the harmful associations between SHS and otitis media, asthma, lower respiratory infections, breast cancer and chronic obstructive pulmonary disease was weaker (one star). Despite the weak underlying evidence for these associations, our results reinforce the harmful effects of SHS on health and the need to prioritize advancing efforts to reduce active and passive smoking through a combination of public health policies and education initiatives.
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Affiliation(s)
- Luisa S Flor
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA.
| | - Jason A Anderson
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Noah Ahmad
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Aleksandr Aravkin
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Sinclair Carr
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Xiaochen Dai
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Gabriela F Gil
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Simon I Hay
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Matthew J Malloy
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Susan A McLaughlin
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Erin C Mullany
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Christopher J L Murray
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Erin M O'Connell
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Chukwuma Okereke
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Reed J D Sorensen
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Joanna Whisnant
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Peng Zheng
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Emmanuela Gakidou
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
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Lee PN, Forey BA, Hamling JS, Thornton AJ. Environmental tobacco smoke exposure and heart disease: A systematic review. World J Meta-Anal 2017; 5:14-40. [DOI: 10.13105/wjma.v5.i2.14] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 01/10/2017] [Accepted: 03/02/2017] [Indexed: 02/05/2023] Open
Abstract
AIM To review evidence relating passive smoking to heart disease risk in never smokers.
METHODS Epidemiological studies were identified providing estimates of relative risk (RR) of ischaemic heart disease and 95%CI for never smokers for various indices of exposure to environmental tobacco smoke (ETS). “Never smokers” could include those with a minimal smoking experience. The database set up included the RRs and other study details. Unadjusted and confounder-adjusted RRs were entered, derived where necessary using standard methods. The fixed-effect and random-effects meta-analyses conducted for each exposure index included tests for heterogeneity and publication bias. For the main index (ever smoking by the spouse or nearest equivalent, and preferring adjusted to unadjusted data), analyses investigated variation in the RR by sex, continent, period of publication, number of cases, study design, extent of confounder adjustment, availability of dose-response results and biomarker data, use of proxy respondents, definitions of exposure and of never smoker, and aspects of disease definition. Sensitivity analyses were also run, preferring current to ever smoking, or unadjusted to adjusted estimates, or excluding certain studies.
RESULTS Fifty-eight studies were identified, 20 in North America, 19 in Europe, 11 in Asia, seven in other countries, and one in 52 countries. Twenty-six were prospective, 22 case-control and 10 cross-sectional. Thirteen included 100 cases or fewer, and 11 more than 1000. For the main index, 75 heterogeneous (P < 0.001) RR estimates gave a combined random-effects RR of 1.18 (95%CI: 1.12-1.24), which was little affected by preferring unadjusted to adjusted RRs, or RRs for current ETS exposure to those for ever exposure. Estimates for each level of each factor considered consistently exceeded 1.00. However, univariate analyses revealed significant (P < 0.001) variation for some factors. Thus RRs were lower for males, and in North American, larger and prospective studies, and also where the RR was for spousal smoking, fatal cases, or specifically for IHD. For case-control studies RRs were lower if hospital/diseased controls were used. RRs were higher when diagnosis was based on medical data rather than death certificates or self-report, and where the never smoker definition allowed subjects to smoke products other than cigarettes or have a limited smoking history. The association with spousal smoking specifically (1.06, 1.01-1.12, n = 34) was less clear in analyses restricted to married subjects (1.03, 0.99-1.07, n = 23). In stepwise regression analyses only those associations with source of diagnosis, study size, and whether the spouse was the index, were independently predictive (at P < 0.05) of heart disease risk. A significant association was also evident with household exposure (1.19, 1.13-1.25, n = 37). For those 23 studies providing dose-response results for spouse or household exposure, 11 showed a significant (P < 0.05) positive trend including the unexposed group, and two excluding it. Based on fewer studies, a positive, but non-significant (P > 0.05) association was found for workplace exposure (RR = 1.08, 95%CI: 0.99-1.19), childhood exposure (1.12, 0.95-1.31), and biomarker based exposure indices (1.15, 0.94-1.40). However, there was a significant association with total exposure (1.23, 1.12-1.35). Some significant positive dose-response trends were also seen for these exposure indices, particularly total exposure, with no significant negative trends seen. The evidence suffers from various weaknesses and biases. Publication bias may explain the large RR (1.66, 1.30-2.11) for the main exposure index for smaller studies (1-99 cases), while recall bias may explain the higher RRs seen in case-control and cross-sectional than in prospective studies. Some bias may also derive from including occasional smokers among the “never smokers”, and from misreporting smoking status. Errors in determining ETS exposure, and failing to update exposure data in long term prospective studies, also contribute to the uncertainty. The tendency for RRs to increase as more factors are adjusted for, argues against the association being due to uncontrolled confounding.
CONCLUSION The increased risk and dose-response for various exposure indices suggests ETS slightly increases heart disease risk. However heterogeneity, study limitations and possible biases preclude definitive conclusions.
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Kraja F, Kraja B, Mone I, Harizi I, Babameto A, Burazeri G. Self-reported Prevalence and Risk Factors of Non-communicable Diseases in the Albanian Adult Population. Med Arch 2016; 70:208-12. [PMID: 27594748 PMCID: PMC5010054 DOI: 10.5455/medarh.2016.70.208-212] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 05/25/2016] [Indexed: 10/27/2022] Open
Abstract
AIM There is growing evidence that non-communicable diseases (NCDs) are a major health problem in developing and transitional countries. The prevalence of NCDs and associated factors are under-researched in Albania. We aimed to assess the prevalence and socio-demographic and lifestyle correlates of NCDs in the Albanian adult population. METHODS The study was carried out in the framework of Albania Living Standard Measurement Survey (LSMS), a national population-based cross-sectional study conducted in 2012 including 12,554 men and women aged ≥35 years. All participants reported on the presence of at least one chronic condition, which in the analysis was dichotomized into "yes" vs. "no". Information on socio-demographic characteristics (age, gender, education, employment status, residence) and lifestyle factors (smoking and alcohol consumption) was also collected. Logistic regression was used to assess socio-demographic and behavioral correlates of NCDs. RESULTS Overall, the prevalence of chronic diseases in this population-based sample of Albanian adults was 2864/12554=22.8%. Upon multivariable adjustment for all covariates, positive correlates of chronic conditions were older age (OR=6.0, 95%CI=5.3-6.8), female gender (OR=1.2, 95%CI=1.1-1.4), residence in coastal areas of Albania (OR=2.0, 95%CI=1.7-2.5), unemployment (OR=1.8, 95%CI=1.6-2.0), low education (OR=1.6, OR=1.3-1.9) and current smoking (OR=1.2, 95%CI=1.1-1.5). Conversely, there was an inverse association with poverty (OR=0.8, 95%CI=0.7-1.0). CONCLUSIONS This study provides evidence on self-reported NCDs and its determinants in transitional Albania. These baseline data may be useful for assessment of future NCD trends in Albania and cross-comparisons with the neighboring countries.
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Affiliation(s)
- Fatjona Kraja
- University Clinic of Oncology, University Hospital Center Mother Teresa, Tirana Albania; Department of Biomedical Sciences, Faculty of Medicine, University of Medicine, Tirana, Albania
| | - Bledar Kraja
- Department of Biomedical Sciences, Faculty of Medicine, University of Medicine, Tirana, Albania; University Clinic of Gastrohepatology, University Hospital Center Mother Teresa, Tirana, Albania
| | - Iris Mone
- Department of Biomedical Sciences, Faculty of Medicine, University of Medicine, Tirana, Albania
| | - Ilda Harizi
- Diagnostic and Medical Center "Harrison", Tirana, Albania
| | - Adriana Babameto
- University Clinic of Gastrohepatology, University Hospital Center Mother Teresa, Tirana, Albania
| | - Genc Burazeri
- Department of International Health, School for Public Health and Primary Care (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Lv X, Sun J, Bi Y, Xu M, Lu J, Zhao L, Xu Y. Risk of all-cause mortality and cardiovascular disease associated with secondhand smoke exposure: a systematic review and meta-analysis. Int J Cardiol 2015; 199:106-15. [PMID: 26188829 DOI: 10.1016/j.ijcard.2015.07.011] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 05/13/2015] [Accepted: 07/03/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND Emerging studies have assessed the association between secondhand smoke (SHS) exposure and cardiovascular disease (CVD) as well as all-cause mortality. However, findings were not consistent due to the heterogeneity of study characteristics. METHODS PubMed and Embase were searched through May 2014 for prospective cohort and case-control studies investigating the associations of SHS exposure in never smokers with all-cause mortality and the risk of CVD. The main analysis was performed in studies using self-reported SHS exposure and secondary analysis was performed in studies using objectively measured SHS exposure. Summary estimates were calculated using random-effects models. RESULTS Twenty-three prospective and 17 case-control studies were included. The pooled relative risks (RR) for never smokers exposed to SHS in comparison with those unexposed were 1.18 [95% confidence interval (CI): 1.10-1.27] for all-cause mortality (12 studies), and 1.23 (1.16-1.31) for CVD (38 studies). The association of SHS exposure with CVD was markedly stronger among studies conducted in China (RR=1.65, 95% CI 1.27-2.13) than that in the US (RR=1.09, 95% CI 1.03-1.16). Studies using objectively measured SHS exposure demonstrated a slightly higher risk for CVD compared with those using self-reported SHS exposure. CONCLUSIONS Exposure to SHS significantly increased the risk for all-cause mortality and CVD. The risk associated with SHS exposure was large in China while the risk was only modest in the US. Studies using objectively measured SHS exposure may yield a higher risk of CVD than those using self-reported SHS exposure.
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Affiliation(s)
- Xiaofei Lv
- Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, National Clinical Research Center for Metabolic Diseases, and Shanghai Clinical Center for Endocrine and Metabolic Diseases, Rui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China
| | - Jichao Sun
- Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, National Clinical Research Center for Metabolic Diseases, and Shanghai Clinical Center for Endocrine and Metabolic Diseases, Rui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China; Laboratory of Endocrine and Metabolic Diseases, Institute of Health Sciences, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, and Shanghai Jiao-Tong University School of Medicine, Shanghai, China
| | - Yufang Bi
- Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, National Clinical Research Center for Metabolic Diseases, and Shanghai Clinical Center for Endocrine and Metabolic Diseases, Rui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China
| | - Min Xu
- Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, National Clinical Research Center for Metabolic Diseases, and Shanghai Clinical Center for Endocrine and Metabolic Diseases, Rui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China
| | - Jieli Lu
- Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, National Clinical Research Center for Metabolic Diseases, and Shanghai Clinical Center for Endocrine and Metabolic Diseases, Rui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China
| | - Liebin Zhao
- Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, National Clinical Research Center for Metabolic Diseases, and Shanghai Clinical Center for Endocrine and Metabolic Diseases, Rui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China
| | - Yu Xu
- Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, National Clinical Research Center for Metabolic Diseases, and Shanghai Clinical Center for Endocrine and Metabolic Diseases, Rui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China.
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Olasky SJ, Levy D, Moran A. Second hand smoke and cardiovascular disease in Low and Middle Income Countries: a case for action. Glob Heart 2012; 7:151-160.e5. [PMID: 23139915 DOI: 10.1016/j.gheart.2012.05.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Second hand tobacco smoke (SHS) is an environmental toxin and an established cause of cardiovascular disease in nonsmokers. Smoke free laws reduce SHS and its downstream cardiovascular disease, but until recently evidence to support smoke free law implementation in low and middle income country settings was limited. In 14 low and middle income nations surveyed by the Global Adult Tobacco Survey active smoking prevalence in adults (≥15 years old) was universally higher in males (range 21.6-60.2%) compared with females (0.5-24.4%), and the highest burden of SHS exposure was in women (strong positive association between male/female active smoking ratio and female SHS exposure prevalence). A systematic review was conducted of MEDLINE-indexed studies of self-reported SHS exposure and cardiovascular harms in low or middle income nations. Eight papers reported the association of SHS with ischemic heart disease and four reported the association of SHS with stroke. For all the studies, and almost all sources of SHS surveyed, a strong positive association between SHS and ischemic heart disease (main relative odds ratio range 1.17-2.36) and SHS and stroke (odds ratio or hazard ratio 1.41-1.49). Prevalence of SHS exposure is high in low and middle income nations, especially among women. Epidemiologic evidence supports the conclusion that SHS harms are the same across low, middle and high income nations. Governments have an obligation to protect citizens from SHS exposure, enforcing smoke-free legislation and providing public education about SHS harms.
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Affiliation(s)
- Sheera Joy Olasky
- Department of Sociology, New York University, New York, New York, United States of America
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