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Archivos
de
Bronconeumología
59
(2023)
305–310
w
ww.archbronconeumol.org
Original
Article
Mortality
Attributable
to
Environmental
Tobacco
Smoke
Exposure
in
Spain
in
2020
Mónica
Pérez-Ríos
a
,
b
,
c
,
Diana
Carolina
López-Medina
a
,
d
,
e
,
Carla
Guerra-Tort
a
,
Julia
Rey-Brandariz
a
,
b
,
Leonor
Varela-Lema
a
,
b
,
,
María
Isolina
Santiago-Pérez
f
,
Cristina
Candal
a
,
b
,
Agustin
Montes
a
,
b
,
c
,
María
José
López
g
,
b
,
Regina
Dalmau
h
,
Maraino
Provencio
i
,
Esteve
Fernández
j
,
k
,
Ana
Blanco
a
,
Alberto
Ruano-Ravina
a
,
b
,
c
a
Área
de
Medicina
Preventiva
y
Salud
Pública,
Universidade
de
Santiago
de
Compostela,
Santiago
de
Compostela,
Spain
b
Ciber
de
Epidemidemiología
y
Salud
Pública,
CIBEResp,
Madrid,
Spain
c
Instituto
de
Investigación
Sanitaria
de
Santiago
de
Compostela,
IDIS,
Santiago
de
Compostela,
Spain
d
Facultad
de
Medicina,
Universidad
Cooperativa
de
Colombia,
Colombia
e
Fundación
Carolina,
Colombia
f
Servicio
de
Epidemiología,
Dirección
General
de
Salud
Pública,
Xunta
de
Galicia,
Spain
g
Servicio
de
Evaluación
y
Métodos
de
Intervención,
Agència
de
Salut
Pública
de
Barcelona,
Spain
h
Hospital
Universitario
La
Paz,
Madrid,
Spain
i
Hospital
Universitario
Puerta
de
Hierro,
Majadahonda,
Madrid,
Spain
j
Unidad
de
Control
del
Tabaco,
Programa
de
Prevención
y
Control
del
Cáncer,
Institut
Català
d’Oncologia
(ICO),
L’Hospitalet
de
Llobregat
(Barcelona),
Spain
k
Ciber
de
Enfermedades
Respiratorias,
CIBERes,
Madrid,
Spain
a
r
t
i
c
l
e
i
n
f
o
Article
history:
Received
16
January
2023
Accepted
21
February
2023
Available
online
10
March
2023
Keywords:
Second-hand
tobacco
smoke
Mortality
Lung
cancer
Ischemic
heart
disease
Chronic
obstructive
pulmonary
disease
Cerebrovascular
disease
a
b
s
t
r
a
c
t
Introduction
and
objectives:
Exposure
to
environmental
tobacco
smoke
(ETS)
is
associated
with
increased
mortality
and
morbidity.
The
objective
of
this
study
was
to
estimate
the
impact
of
ETS
exposure
in
Spain
on
mortality
in
2020
in
the
population
aged
35
years
and
over.
Methods:
A
method
of
estimating
attributable
mortality
(AM)
based
on
the
prevalence
of
ETS
exposure
was
applied.
Prevalence
data
were
obtained
from
a
representative
study
conducted
in
Spain
and
the
relative
risks
were
derived
from
a
meta-analysis.
AM
point
estimates
are
presented
along
with
95%
confidence
intervals
(95%
CI),
calculated
using
a
bootstrap
naive
procedure.
AM,
both
overall
and
by
smoking
habit,
was
estimated
for
each
combination
of
sex,
age
group,
and
cause
of
death
(lung
cancer
and
ischemic
heart
disease).
A
sensitivity
analysis
was
performed.
Results:
A
total
of
747
(95%
CI
676–825)
deaths
were
attributable
to
ETS
exposure,
of
which
279
(95%
CI
256–306)
were
caused
by
lung
cancer,
and
468
(95%
CI
417–523)
by
ischemic
heart
disease.
Three-
quarters
(75.1%)
of
AM
occurred
in
men
and
60.9%
in
non-smokers.
When
chronic
obstructive
pulmonary
disease
and
cerebrovascular
disease
are
included,
the
burden
of
AM
is
estimated
at
2242
deaths.
Conclusions:
ETS
exposure
is
associated
with
1.5%
of
all
deaths
from
lung
cancer
and
ischemic
heart
disease
in
the
population
aged
35
and
over.
These
data
underline
the
need
for
health
authorities
to
focus
on
reducing
exposure
to
ETS
in
all
settings
and
environments.
©
2023
The
Author(s).
Published
by
Elsevier
Espa
̃
na,
S.L.U.
on
behalf
of
SEPAR.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(
http://creativecommons.org/licenses/by-nc-nd/4.0/
).
Introduction
More
than
15
years
ago,
Spanish
Act
28/2005,
regulating
the
sale
of
cigarettes
and
smoking
in
public
places,
entered
into
force.
This
act
was
amended
5
years
later
on
December
31,
2010
to
extend
the
ban
on
smoking
to
the
indoor
areas
of
all
leisure
venues.
1,2
Data
Corresponding
author.
E-mail
address:
leonor.varela@usc.es
(L.
Varela-Lema).
from
Spanish
and
European
health
surveys
show
that
the
over-
all
prevalence
of
exposure
to
environmental
tobacco
smoke
(ETS)
among
the
Spanish
population
has
remained
stable
since
2014,
and
the
most
recent
results
from
2020
confirm
this
trend.
3
However,
the
results
of
other
studies
differ.
Specifically,
data
from
the
2020
Attitudes
of
Europeans
towards
Tobacco
and
Electronic
Cigarettes
Special
Eurobarometer
study
show
that
in
Spain
the
prevalence
of
indoor
ETS
exposure
has
increased
compared
with
Eurobarometer
2017
data.
In
2020,
the
prevalence
of
exposure
in
bars
was
esti-
https://doi.org/10.1016/j.arbres.2023.02.017
0300-2896/©
2023
The
Author(s).
Published
by
Elsevier
Espa
̃
na,
S.L.U.
on
behalf
of
SEPAR.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(
http://
creativecommons.org/licenses/by-nc-nd/4.0/
).
M.
Pérez-Ríos,
D.C.
López-Medina,
C.
Guerra-Tort
et
al.
Archivos
de
Bronconeumología
59
(2023)
305–310
mated
at
22%,
10
percentage
points
above
the
2017
estimate
and
at
16%
in
restaurants,
13
points
above
the
2017
prevalence.
4
To
date,
a
causal
relationship
has
been
established
between
ETS
exposure
and
mortality
from
lung
cancer,
ischemic
heart
disease,
sudden
infant
death
syndrome,
chronic
obstructive
pulmonary
dis-
ease
(COPD)
and
cerebrovascular
disease,
although
the
data
from
the
latter
two
are
inconclusive.
5
The
latest
study
of
the
mortality
burden
attributable
to
ETS
exposure
in
Spain
estimated
1028
deaths
in
never-smokers
in
2011,
a
similar
figure
to
the
previous
study
conducted
in
2002.
6,7
That
was
20
years
ago,
and
ETS-attributable
mortality
(AM)
in
Spain
has
not
been
recalculated
since
then.
The
aim
of
this
study
was
to
estimate
ETS-AM
in
a
population
aged
35
and
over
in
Spain
in
2020.
Method
A
method
of
estimating
ETS-AM
based
on
the
calculation
of
pop-
ulation
attributable
fractions
(PAF)
was
used.
8
The
estimate
was
made
according
to
STREAMS-p
recommendations.
9
Calculation
Process
Firstly,
the
PAF
of
ETS
exposure
was
calculated
from
the
follow-
ing
formula:
PAF
=
(
q
+
p
×
RR)
1
q
+
p
×
RR
,
where
p
is
the
prevalence
of
ETS
exposure,
q
=
1
p
,
y
RR
is
the
risk
of
dying
from
lung
cancer
or
ischemic
heart
disease
observed
in
non-smokers
exposed
to
ETS
compared
to
non-exposed
subjects.
The
AM
was
then
estimated
by
multiplying
the
PAF
by
the
observed
mortality
(OM):
AM
=
PAF
×
OM.
The
number
of
deaths
attributable
to
ETS
exposure
was
dis-
tributed
according
to
smoking
habit
using
the
following
formulas:
Never-smokers
:
AM
ns
=
AM
p
ns
p
ns
+
p
exs
RR
exs
+
p
s
RR
s
,
Former
smokers
:
AM
exs
=
AM
p
exs
RR
exs
p
ns
+
p
exs
RR
exs
+
p
s
RR
s
,
Smokers
:
AM
s
=
AM
p
s
RR
s
p
ns
+
p
exs
RR
exs
+
p
s
RR
s
,
where
p
ns
,
p
exs
and
p
f
are
the
prevalences
of
never-smokers,
former
smokers
and
smokers,
respectively,
and
RR
exs
and
RR
s
are
the
rel-
ative
risks
of
mortality
from
lung
cancer
or
ischemic
heart
disease
in
former
smokers
and
smokers
compared
to
never-smokers.
AM,
both
overall
and
according
to
smoking
habit,
was
estimated
for
each
combination
of
sex,
age
group
(35–54,
55–64,
65–74,
75
and
older),
and
cause
of
death
(lung
cancer
and
ischemic
heart
dis-
ease).
The
results
by
age
were
distributed
into
2
groups,
35–64
years
and
65
years
or
older.
AM
point
estimates
were
presented
with
95%
confidence
intervals
(95%
CI),
calculated
by
a
naive
bootstrap
procedure
using
Efron’s
percentile
method.
Sources
of
Information
Mortality
due
to
Lung
Cancer
and
Ischemic
Heart
Disease
Deaths
for
which
the
main
cause
listed
was
tracheal,
lung
and
bronchial
cancer
(ICD-10
codes
C33-34)
and
ischemic
heart
disease
(ICD-10
codes
I20-25)
in
the
population
aged
35
years
and
older
were
extracted
by
sex
and
age
group
from
2020
statistical
micro-
data
on
mortality
by
cause
of
death
from
the
National
Institute
of
Statistics
(INE).
10
Prevalence
of
ETS
Exposure
and
Smoking
The
prevalence
of
ETS
exposure
and
the
prevalence
of
smokers,
former
smokers,
and
never-smokers
were
calculated
in
the
popula-
tion
aged
35
years
and
older,
by
sex
and
age
group,
from
microdata
from
the
2020
European
Health
Survey
(EES2020).
This
survey,
car-
ried
out
by
the
Spanish
Ministry
of
Health,
Consumption
and
Social
Welfare
and
the
INE
in
the
population
aged
15
and
over
living
in
main
family
homes
throughout
Spain,
collected
health
information
on
4
main
areas:
sociodemographic,
health
status,
use
of
health
ser-
vices,
and
health
determinants.
EES2020
fieldwork
was
conducted
between
July
2019
and
July
2020
and
22,072
people
aged
15
and
over
were
interviewed.
The
question
used
to
estimate
the
prevalence
of
ETS
exposure
was:
“How
often
are
you
exposed
to
tobacco
smoke
indoors?
Con-
sider
only
situations
where
other
people
are
smoking”,
and
there
were
4
possible
answers:
“every
day”,
“at
least
once
a
week
(but
not
every
day)”,
“less
than
once
a
week,”
and
“never
or
almost
never”.
People
who
reported
daily
or
weekly
exposure
were
classified
as
exposed.
A
smoker
was
defined
as
a
person
who
smoked
at
the
time
of
the
survey,
a
former
smoker
was
a
person
who
had
smoked
but
no
longer
smoked,
and
a
never-smoker
was
one
who
had
never
smoked.
Relative
Risks
The
risk
of
dying
from
ischemic
heart
disease
[1.27
(1.19–1.36)]
and
lung
cancer
[1.16
(1.03–1.3)]
among
never-smokers
compared
with
unexposed
never-smokers
was
extracted
from
the
Surgeon
General’s
Report.
5
The
relative
risks
of
smokers
and
former
smok-
ers,
by
sex
and
age
group,
are
derived
from
5
US
cohorts
comprising
nearly
1
million
people
over
the
age
of
29
during
the
period
2000–2010.
11
Sensitivity
Analysis
To
assess
the
impact
of
risks
on
the
estimated
AM,
the
calcu-
lation
was
repeated
using
mortality
risks
previously
applied
to
the
estimates
in
Spain.
12,13
Two
alternative
scenarios
were
also
evaluated,
one
using
the
estimated
chronic
obstructive
pulmonary
disease
(COPD)-AM
and
the
other
using
estimated
cerebrovascular
disease
(CVD)-AM,
since
the
Surgeon
General’s
Report
suggests
a
likely
causal
relationship
between
ETS
and
both
diseases.
The
OM
for
both
causes
of
death,
coded
as
the
main
cause,
are
derived
from
ICD-10
codes
J40-44
and
I60-69
recorded
in
2020,
and
the
risks
used
in
the
analysis
are
derived
from
the
Fischer
14
and
Oono
studies,
15
respectively.
Finally,
the
lung
cancer-
and
ischemic
heart
disease-
AM
in
never-smokers
was
estimated
from
the
OM
not
attributable
to
smoking.
Results
In
2020,
11.5%
of
the
Spanish
population
aged
35
years
and
older
reported
being
exposed
to
ETS
indoors,
with
the
highest
prevalence
being
recorded
in
men
(12.5%)
and
in
the
age
group
aged
35–64
years,
in
both
men
and
women.
The
highest
prevalence,
33.9%,
was
among
female
smokers
aged
35–64
years
(
Table
1
).
In
2020
in
Spain,
51,501
deaths
in
the
population
aged
35
years
and
over
were
caused
by
cancers
of
the
trachea,
lung
and
bronchi,
and
ischemic
heart
disease,
34,681
of
which
occurred
in
men.
ETS
exposure
was
attributable
to
747
(95%
CI
676–825)
deaths
in
the
population
aged
35
and
over,
accounting
for
1.5%
of
all
deaths
from
lung
cancer
and
ischemic
heart
disease
(
Fig.
1
),
of
which
279
306
M.
Pérez-Ríos,
D.C.
López-Medina,
C.
Guerra-Tort
et
al.
Archivos
de
Bronconeumología
59
(2023)
305–310
Table
1
Prevalence
of
Smoking
and
Exposure
to
Environmental
Tobacco
Smoke
in
the
Population
Aged
35
and
Over,
by
Sex
and
Age
Group.
Spain
2020.
Smoking
(%)
Prevalence
of
Exposure
to
Environmental
Tobacco
Smoke
(%)
Smokers
Former
Smokers
Never-smokers,
%
Overall
Smokers
Former
Smokers
Never-smokers,
%
Men
25.0
(23.9–26.2)
34.1
(32.9–35.3)
40.8
(39.6–42.1)
12.5
(11.7–13.5)
33.6
(31.2–36.2)
6.7
(5.6–7.9)
4.5
(3.6–5.6)
35–64
years
29.7
(28.3–31.2)
27.7
(26.3–29.1)
42.5
(41.0–44.1)
14.7
(13.6–15.9)
33.7
(21.3–36.5)
8.7
(7.1–10.5)
5.5
(4.4–6.9)
65
years
12.5
(11.1–14.1)
51.2
(49.0–53.4)
36.2
(34.1–38.4)
6.6
(5.5–7.8)
33.2
(27.3–39.6)
3.8
(2.7–5.2)
1.4
(0.8–2.6)
Women
17.9
(16.9–18.9)
19.7
(18.7–20.6)
62.5
(61.3–63.7)
10.5
(9.8–11.4)
33.4
(30.6–36.3)
8.4
(6.9–10.3)
4.7
(4.0–5.4)
35–64
years
23.6
(22.3–25.0)
23.4
(22.1–24.7)
53.0
(51.4–54.6)
13.2
(12.2–14.4)
33.9
(30.1–37.0)
9.1
(7.3–11.2)
5.9
(4.9–7.1)
65
years
5.7
(4.9–6.7)
11.8
(10.6–13.0)
82.5
(81.0–83.9)
4.8
(4.0–5.8)
28.7
(21.9–36.6)
5.8
(3.6–9.1)
3.0
(2.3–4.0)
Source:
European
Health
Survey
Table
2
Observed
Mortality,
Population
Attributable
Fraction
and
Environmental
Tobacco
Smoke-attributable
Mortality
Overall
and
According
to
Smoking
Habit.
Data
are
Presented
by
Cause
of
Death,
Sex
and
Age
Group.
Observed
Mortality
Population
Attributable
Fraction
(%)
Mortality
Attributable
to
ETS
Exposure
Overall
N
(95%
CI)
Smokers
N
(95%
CI)
Former
Smokers
N
(95%
CI)
Never-smokers,
%
N
(95%
CI)
Lung
cancer
280
(255.5–305.6)
161
(147.7–177.6)
96
(85.7–107.6)
22
(19.9–24.2)
Men
16,603
1.3
215
(190.9–240.3)
123
(108.9–137.6)
82
(71.4–92.7)
11
(9.7–12.3)
35–64
years
4,364
2.1
93
(82.4–102.7)
68
(59.8–76.0)
20
(17.6–22.7)
5
(4.3–5.4)
65
years
12,239
1.0
123
(102.7–144.2)
55
(44.6–66.5)
62
(51.9–72.1)
6
(5.0–7.3)
Women
5,297
1.2
64
(58.5–71.1)
39
(34.7–43.2)
14
(12.9–16.1)
11
(9.5–12.9)
35–64
years
1,972
2.0
39
(35.4–44.0)
28
(24.5–31.2)
8
(6.9–9.1)
4
(3.4–4.2)
65
years
3,325
0.8
25
(20.3–29.8)
11
(8.6–13.8)
7
(5.3–7.8)
7
(5.8–9.1)
Ischemic
heart
disease
468
(417.3–522.8)
131
(119.2–145.7)
163
(141.8–189.5)
173
(146.2–200.8)
Men
18,078
1.9
346
(303.3–394.1)
112
(100.5–123.3)
149
(127.8–174.2)
85
(72.8–99.6)
35–64
years
3,855
3.6
140
(127.3–152.4)
73
(65.1–80.5)
39
(34.9–43.2)
28
(25.3–30.7)
65
years
14,223
1.5
207
(166.0–252.3)
40
(30.7–50.3)
110
(88.7–133.8)
57
(45.3–70.7)
Women
11,523
1.1
121
(95.7–151.3)
19
(16.3–22.6)
15
(12.3–17.7)
87
(65.6–112.7)
35–64
years
675
3.3
23
(20.4–25.0)
11
(9.7–12.3)
5
(4.3–5.4)
7
(6.0–7.5)
65
years
10,848
0.9
99
(73.1–128.6)
8
(5.8–11.1)
10
(7.7–12.9)
81
(58.8–106.1)
Total
51,501
1.5
747
(676.2–825.3)
293
(267.3–322.8)
260
(228.1–296.9)
195
(166.4–224.1)
CI:
confidence
interval;
ETS:
environmental
tobacco
smoke.
Fig.
1.
Population
attributable
fraction
(PAF)
(%)
due
to
exposure
to
environmental
tobacco
smoke
by
lung
cancer
and
ischemic
heart
disease,
in
total,
by
sex,
by
age
group
(35–64,
65
and
above)
and
by
sex
and
age
group.
The
vertical
line
represents
the
total
PAF
for
lung
cancer
and
ischemic
heart
disease
in
the
population
aged
35
and
over
(1.5%).
(95%
CI
256–306)
deaths
were
due
to
lung
cancer
and
468
(95%
CI
417–523)
to
ischemic
heart
disease.
Overall,
75.1%
of
AM
occurred
in
men,
with
561
deaths
(95%
CI
494–634)
compared
to
185
(95%
CI
154–222)
in
women.
Just
under
two-thirds
(60.9%)
of
the
deaths
attributable
to
ETS
exposure
occurred
in
non-smokers:
260
(95%
CI
228–297)
in
former
smokers
and
195
(95%
CI
166–224)
in
never-
smokers.
The
remaining
293
(95%
CI
267–323)
occurred
in
smokers
(
Table
2
).
Sensitivity
Analysis
When
the
risks
published
by
Hackshaw
et
al.
for
lung
cancer
and
by
Law
et
al.
for
ischemic
heart
disease
are
used,
the
overall
AM
increases
by
26.5%,
with
an
estimated
945
(95%
CI
856–1039)
deaths
attributable
to
ETS
exposure,
albeit
with
an
increase
in
ischemic
heart
disease-AM
and
a
decrease
in
lung
cancer-AM.
When
the
burden
of
mortality
from
COPD
and
CVD
is
included
in
the
calculation,
the
estimated
AM
increases
3-fold
to
2242
deaths.
If
AM
is
estimated
from
the
OM
in
never-smokers,
141
deaths
are
attributable
to
ETS
exposure,
53
fewer
than
in
the
original
estimate
(
Table
3
).
Discussion
In
Spain,
in
2020,
exposure
to
ETS
caused
747
deaths
in
the
pop-
ulation
aged
35
and
over;
80%
of
these
deaths
occurred
in
men
and
60%
in
non-smokers.
Almost
two-thirds
(62.6%)
of
all
attributable
deaths
were
due
to
ischemic
heart
disease,
and
the
remaining
were
due
to
lung
cancer.
Compared
with
the
latest
AM
estimates
for
ETS
in
Spain
in
2011,
the
mortality
burden
among
never-smokers
has
decreased
considerably,
7
as
seen
from
the
analysis
of
smoking-AM.
16
The
impact
of
ETS
exposure
on
mortality
has
been
estimated
3
times
in
Spain.
The
first
estimate
dates
from
1990
and
addresses
307
M.
Pérez-Ríos,
D.C.
López-Medina,
C.
Guerra-Tort
et
al.
Archivos
de
Bronconeumología
59
(2023)
305–310
Table
3
Sensitivity
Analysis
Taking
into
Account
Alternative
Scenarios
Point
Estimates
of
Attributable
Mortality
are
Accompanied
by
95%
Confidence
Intervals
(95%
CI)
in
Parentheses.
Study
Considerations
Alternative
Scenarios
AM
Alternate
Scenario
N
(95%
CI)
Effect
on
Global
AM
RR
of
ischemic
heart
disease
derived
from
the
Surgeon
General’s
Report
Law
et
al.,
12
RR
1.23
(95%
CI
1.14–1.33)
545
(495.5–597.7)
Increases
AM
by
35.5%
RR
of
lung
cancer
derived
from
the
Surgeon
General’s
Report
Hackshaw
et
al.,
13
RR
Men:
1.34
(95%
CI
0.97–1.84),
RR
Women
1.24
(95%
CI
1.13–1.36)
400
(356.5–446.8)
Decreases
AM
by
9.1%
There
is
no
evidence
of
an
association
with
COPD
There
is
evidence
of
an
association
with
COPD
667
(585.5–780.2)
Increases
AM
by
89.3%
There
is
no
evidence
of
an
association
with
CVD
There
is
evidence
of
an
association
with
COPD
828
(714.7–951.2)
Increases
AM
by
110.8%
Include
OM
in
smokers
and
former
smokers
for
lung
cancer
and
ischemic
heart
disease
Estimate
OM
in
never-smokers
141
Decreases
AM
in
never-smokers
by
27.7%
AM:
attributable
mortality;
COPD:
chronic
obstructive
pulmonary
disease;
CVD:
cerebrovascular
disease;
RR:
relative
risk.
mortality
in
never-smokers
married
to
smokers.
In
that
study,
lung
cancer
deaths
were
estimated
at
89,
29
fewer
than
in
the
current
study
conducted
in
2020.
17
The
previous
estimate
of
AM
in
Spain,
as
noted
above,
was
from
2011.
7
The
most
notable
difference
between
the
2011
estimate
and
the
2020
estimate
is
the
decrease
in
the
prevalence
of
ETS
exposure.
It
should
be
noted
that
the
2011
preva-
lence
figures
were
derived
from
a
sample
of
2500
adults
aged
18
years
and
older
who
were
asked
in
detail
about
exposure
to
ETS
at
home
and
at
work.
The
prevalence
data
of
the
current
study
are
derived,
as
already
noted,
from
the
EES2020
survey,
which
assesses
the
overall
prevalence
of
exposure
to
ETS
in
enclosed
spaces,
so
there
are
no
estimates
of
exposure
by
type
of
setting.
This
is
an
important
limitation
of
the
EES2020,
which
extends
to
the
latest
National
Health
Surveys.
Asking
about
global
exposure
does
not
allow
us
to
characterize
in
detail
the
settings
in
which
the
popu-
lation
is
exposed,
and
hampers
any
detailed
analysis
of
AM.
The
questions
included
in
the
different
studies
assessing
ETS
exposure
are
known
to
vary,
18
so
it
is
difficult
to
compare
estimates
derived
from
studies
using
different
sources
of
ETS
exposure
prevalence.
However,
to
date,
it
has
not
been
possible
to
establish
a
minimum
set
of
questions
or
a
common
definition
of
exposure.
The
most
important
difference
between
the
2011
and
2020
esti-
mates
for
Spain
is
that
smokers
were
included
in
the
2020
AM
estimate.
In
previous
studies,
the
authors
had
excluded
smokers
from
ETS
exposure
impact
estimations
in
order
to
obtain
conserva-
tive
estimates,
but
this
approach
does
not
take
into
account
the
possible
synergistic
effect
of
smoking
plus
ETS
exposure
in
the
causes
of
death
studied.
Indeed,
the
effect
of
ETS
exposure
on
the
risk
of
lung
cancer
among
smokers
is
clear
and
significant.
19,20
Fur-
thermore,
according
to
the
results
of
the
International
Lung
Cancer
Consortium,
20
the
risk
of
a
smoker
not
exposed
to
ETS
developing
lung
cancer
is
2.83
(2.48–3.22),
while
for
an
exposed
smoker,
it
is
4.79
(4.32–5.32).
The
inclusion
of
smokers,
or
even
former
smokers,
is
nothing
new.
21–23
We
must
point
out
here
that
the
inclusion
of
smokers
in
the
estimation
of
ETS-AM
is
based
on
available
evidence.
The
previous
2
AM
estimates
in
Spain
calculated
the
mortality
bur-
den
in
never-smokers,
6,7
but
to
do
so
an
approximate
value
had
to
be
assigned
to
OM
in
never-smokers,
since
these
data
are
not
avail-
able
in
Spain.
To
this
end,
the
AM
in
smokers
and
former
smokers
was
extracted
from
the
global
OM,
accepting
the
possible
limita-
tions
of
this
estimate
and
obviating
the
synergistic
effect
of
active
smoking
and
passive
exposure,
since
the
applied
risks
were
not
adjusted
for
exposure
to
ETS.
Despite
the
differences
in
the
cal-
culation
processes,
the
sensitivity
analysis
clearly
shows
that
the
estimates
hardly
differ.
It
is
difficult
to
compare
the
results
of
this
study
with
those
recently
conducted
in
other
countries,
since
either
the
prevalence
of
exposure
in
other
studies
focuses
on
specific
settings
rather
than
overall
exposure
or
different
causes
of
death
are
reported.
24–27
In
any
case,
the
ETS-AM
burden
in
these
studies
is
estimated
to
be
close
to
1%
for
the
causes
analyzed.
The
estimates
presented
here
may
underestimate
the
ETS-AM
burden
for
different
reasons.
Firstly,
the
prevalence
of
ETS
exposure
was
derived
from
the
EES2020
survey,
which
does
not
take
account
of
ETS
exposure
in
people
who
reported
that
they
were
rarely
exposed.
Questions
in
the
EES2020
survey
are
less
detailed
and
the
scope
is
more
limited,
factors
that
may
have
led
to
some
underre-
porting
of
true
exposure,
even
though
the
validity
of
self-reported
exposure
measurements
in
surveys
is
acceptable.
This
is
an
appro-
priate
moment
to
remind
ourselves
that
there
is
no
safe
threshold
for
exposure
to
ETS.
Secondly,
in
this
study
we
have
only
included
diseases
listed
in
the
Surgeon
General’s
Report
as
causally
associ-
ated
with
ETS
exposure
with
the
highest
level
of
evidence
(Level
1).
5
To
date,
evidence
on
the
causal
relationship
between
ETS
exposure
and
CVD
or
COPD
is
inconclusive,
although
the
associations
are
bio-
logically
plausible
and
evidence
is
increasing.
5
Including
CVD
and
COPD
in
the
AM
estimate
triples
the
mortality
burden
attributable
to
ETS
exposure
and
would
account
for
more
than
2000
deaths
per
year.
Moreover,
the
estimate
refers
to
the
adult
population
and
does
not
include
the
impact
on
infant
mortality
associated
with
sudden
infant
death
syndrome.
Thirdly,
we
used
the
risks
derived
from
the
Surgeon
General’s
Report,
the
most
widely
used
source
of
risk
in
the
estimation
of
smoking-AM.
The
use
of
these
risks
will
result
in
a
lower
estimate
AM.
Moreover,
when
ETS-AM
was
estimated,
the
risk
of
exposed
smokers
and
former
smokers
was
assimilated
into
the
risk
of
exposed
never-smokers,
even
though
the
risk
among
smokers
is
approximately
4
times
higher.
20
This
study
has
a
number
of
limitations.
The
first
is
the
estima-
tion
method
itself,
in
which
the
induction
period
for
causes
of
death
associated
with
ETS
exposure
is
not
assessed,
since
prevalence
of
exposure
and
mortality
are
recorded
at
the
same
moment
in
time.
The
impact
of
this
assumption
could
vary
depending
on
the
cause
of
death
assessed,
and
could,
in
the
case
of
ischemic
heart
disease
for
example,
be
limited
due
to
the
shorter
induction
period
of
this
condition.
28,29
With
regard
to
relative
risk,
we
should
point
out
that
the
risks
applied
in
the
estimation
of
AM,
except
for
lung
cancer,
derive
mainly
from
studies
conducted
in
non-European
countries
where
the
characteristics
of
the
population,
and
therefore
their
exposure
to
ETS,
could
be
different.
However,
they
constitute
the
best
available
evidence
and
values
are
similar
to
those
obtained
in
other
studies.
18
With
regard
to
lung
cancer,
when
risks
were
taken
from
the
meta-analysis
performed
in
the
Surgeon
General’s
Report
in
2006,
only
data
from
studies
conducted
in
Europe
were
used
(see
Table
7.4
of
the
report).
Another
limitation
involves
the
year
to
which
the
estimates
refer,
i.e.,
2020,
the
year
of
the
SARS-CoV-
2
pandemic.
This
situation
may
have
affected
both
the
prevalence
308
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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