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Prev Med. 2019 Sep 7:105833. doi: 10.1016/j.ypmed.2019.105833. [Epub ahead of print]

Burden of disease attributable to second-hand smoke exposure: A systematic review.

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Oncologic Network, Prevention and Research Institute (ISPRO), via Cosimo il Vecchio 2, 50139 Florence, Italy. Electronic address:
Istituto di Ricerche Farmacologiche Mario Negri IRCCS (IRFMN), Via La Masa 19, 20156 Milan, Italy.
Oncologic Network, Prevention and Research Institute (ISPRO), via Cosimo il Vecchio 2, 50139 Florence, Italy.
Catalan Institute of Oncology (ICO), Granvia de L'Hospitalet, 199-203, PC 08908 L'Hospitalet de Llobregat, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Granvia de L'Hospitalet, 199, PC 08908 L'Hospitalet de Llobregat, Spain; Department of Clinical Sciences, Campus de Bellvitge, School of Medicine and Health Sciences, University of Barcelona, Feixa Llarga, s/n, PC 08907 L'Hospitalet de Llobregat, Spain.
Public Health Agency of Barcelona (ASPB). Pl. Lesseps, 1, PC 08023 Barcelona, Spain; CIBER Epidemiologia y Salud Pública (CIBERESP), Av. Monforte de Lemos, 3-5, Pabellón 11, Planta 0. PC 28029, Madrid, Spain; Institut d'Investigació Biomèdica de Sant Pau (IIB Sant Pau), Sant Antoni Maria Claret, 167, PC 08025 Barcelona, Spain.
Hospital Universitario La Princesa (IISP), Diego de León, 62 1st floor, PC 28006 Madrid, Spain.
Polytechnic University of Cartagena (UPCT), Plaza Cronista Isidoro Valverde, s/n, PC 30202 Cartagena, Spain.
Faculty of Health Sciences and Sport, University of Stirling, Stirling FK9 4LA, Scotland, UK.
Catalan Institute of Oncology (ICO), Bellvitge Biomedical Research Institute (IDIBELL), Spain.
Public Health Agency of Barcelona (ASPB), Spain.
Istituto di Ricerche Farmacologiche Mario Negri IRCCS (IRFMN), Italy.
Istituto DOXA, Worldwide Independent Network/Gallup International Association, Italy.
University of Stirling (UNISTIR), UK.
TobaccoFree Research Institute Ireland (TFRI), Ireland.
Hellenic Cancer Society - George D. Behrakis Research Lab (HCS), Greece.
Fondazione IRCCS Istituto Nazionale dei Tumori (INT), Italy.
Istituto per lo Studio, la Prevenzione, e la Rete Oncologica (ISPRO), Italy.
Polytechnic University of Cartagena (UPCT), Spain.
European Network on Smoking and Tobacco Prevention (ENSP), Belgium.
Fundación para la Investigación Biomédica del Hospital Universitario La Princesa (IISP), Spain.


Our aim was to provide a systematic review of studies on the burden of disease due to second-hand smoke (SHS) exposure, reviewing methods, exposure assessment, diseases causally linked to SHS, health outcomes, and estimates available to date. A literature review of studies on the burden of disease from SHS exposure, available in PubMed and SCOPUS, published 2007-2018 in English language, was carried out following the PRISMA recommendations. Overall, 588 studies were first identified, and 94 were eligible. Seventy-two studies were included in the systematic review. Most of them were based on the comparative risk assessment approach, assessing SHS exposure using mainly surveys on exposure at home/workplaces. Diseases more frequently studied were: lung cancer, ischemic heart disease, stroke, chronic obstructive pulmonary disease, asthma and breast cancer in adults; lower respiratory tract infection, otitis media, asthma, sudden infant death syndrome and low birth weight in children. The SHS exposure assessment and the reported population attributable fractions (PAF) were largely heterogeneous. As an example, the PAF from lung cancer varied between 0.6% and 20.5%. Moreover, PAF were estimated applying relative risks and SHS exposures with no consistent definitions or with different age classes. The research gap on the SHS exposure burden is shrinking. However, estimates are not yet available for a number of countries, particularly the Middle Eastern and African countries, and not all diseases with the strongest evidence of causation, such as sudden infant death syndrome, have been explored. Moreover, in some cases the applied methodology revealed relatively low quality of data.


Burden of disease; Population attributable fraction; Second-hand smoke; Systematic review; Tobacco

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