M.
Pérez-Ríos,
D.C.
López-Medina,
C.
Guerra-Tort
et
al.
Archivos
de
Bronconeumología
59
(2023)
305–310
estimate
and
OM.
Finally,
it
should
be
noted
that
the
definition
of
exposure
refers
exclusively
to
ETS
and
does
not
include
exposure
to
residual
or
third-hand
smoke,
despite
growing
evidence
of
its
noxious
impact
on
health.
30
The
main
advantage
of
this
study
is
that
it
provides
ETS
expo-
sure
data
across
Spain.
Another
benefit
is
that
for
the
first
time
in
Spain,
AM
point
estimates
are
presented
with
confidence
intervals
obtained
using
robust
methods
that
minimize
the
high
variabil-
ity
associated
with
the
relatively
small
magnitude
of
the
point
estimates.
The
quality
of
death
records
in
Spain
adds
to
the
accu-
racy
of
the
estimates
obtained.
For
example,
in
2020,
only
0.7%
of
deaths
in
individuals
aged
35
and
over
were
coded
as
ICD-10
R99,
unknown
cause.
Furthermore,
recommendations
aimed
at
improv-
ing
the
quality
of
estimates
in
the
attribution
of
mortality
have
been
followed
when
calculating
AM.
9
A
total
of
747
deaths
may
not
seem
high,
especially
when
com-
pared
with
the
mortality
burden
of
56,000
deaths
attributable
to
smoking
in
Spain,
31
but
these
figures
account
for
2
deaths
every
day
in
the
population
aged
35
years
and
over
in
Spain.
We
must
emphasize
that
all
these
deaths
are
unnecessarily
premature
and
preventable.
Furthermore,
these
estimates
refer
to
mortality,
but
we
must
not
forget
the
important
impact
of
ETS
exposure
on
mor-
bidity,
especially
asthma
or
otitis
media
in
children.
In
conclusion,
exposure
to
ETS
is
an
important
risk
factor
that
impacts
mortality
in
Spain,
due
to
both
the
magnitude
of
the
risk
and
the
persistent
magnitude
of
exposure
among
the
population.
The
greater
part
of
the
AM
associated
with
ETS
occurs
in
people
who
do
not
smoke.
These
data
underline
the
need
for
health
authorities
at
all
administrative
levels,
and
especially
the
Ministry
of
Health,
to
actively
campaign
for
reducing
exposure
to
ETS
in
the
Spanish
population
in
all
settings.
Authors’
Contributions
Mónica
Pérez-Ríos:
concept
design,
obtaining
funding,
writ-
ing
original
draft,
editing;
Diana
Carolina
López-Medina,
Carla
Guerra-Tort
and
María
Isolina
Santiago-Pérez:
concept
design,
data
analysis,
critical
review
of
the
manuscript;
Julia
Rey-Brandariz:
interpretation
of
study
data
and
critical
review
of
the
manuscript;
Leonor
Varela-Lema:
concept
design,
interpretation
of
study
data
and
critical
review
of
the
manuscript;
Cristina
Candal,
Agustin
Montes,
María
José
López,
Regina
Dalmau,
Mariano
Provencio,
Ana
Blanco
and
Esteve
Fernández:
interpretation
of
study
data
and
critical
review
of
the
manuscript,
Alberto
Ruano-Ravina:
con-
cept
design,
interpretation
of
study
data
and
critical
review
of
the
manuscript.
All
authors
have
read
and
approved
the
final
manuscript.
Funding
Instituto
de
Salud
Carlos
III
(ISCIII),
reference:
PI22/00727,
co-
funded
by
the
European
Union.
Conflict
of
Interests
The
authors
state
that
they
have
no
conflict
of
interests.
Appendix
A.
Supplementary
data
Supplementary
data
associated
with
this
article
can
be
found,
in
the
online
version,
at
doi:10.1016/j.arbres.2023.02.017
.
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