Globl Helth Mtters This rticle by Boldo et l. demonstrtes tht in Europe, exposure to environmentl tobcco smoke (ETS) cused n estimted 24% to 32% of sudden infnt deth syndrome (SIDS) cses nd incresed the number of sthm episodes by 7% to 11% in children younger thn 14 yers of ge. The mjor source of exposure to ETS mong children is smoking by prents nd other household members. The Europen countries in this study included welthy countries such s Austri, Denmrk, Germny, nd the United Kingdom s well s those with struggling economies such s Bulgri, Croti, Estoni, nd Mcedoni. This diversity of welth cross the 27 countries included in the study provided rnge of exposures when correlted with the smoking rtes. The levels of exposure to ETS for the children in the study rnged from one-fifth to one-hlf. Using the dt from the 27 countries nd pplying the methods used by others to look t the ssocition of ETS to both SIDS nd sthm, the uthors mke compelling cse for recommending to governmentl nd ministeril officils tht their countries follow the World Helth Orgniztion (WHO) recommendtions to develop nd implement enforceble smoke-free policies to void the ETS impct on children s helth. Such recommendtion is logicl, progressive, nd highly protective of the most vulnerble members of the popultion. 1 This study lso demonstrtes the need for countries, s well s WHO nd the Europen Union, to develop eductionl progrms for prents nd children to recognize the dngers of smoking, ETS, nd other tobcco-relted diseses. Mrk Gregory Robson, PhD, MPH REFERENCE 1. World Helth Orgniztion. Protection from exposure to second-hnd tobcco smoke: policy recommendtions. Genev: WHO; 2007. Also vilble from: URL: http://whqlibdoc.who.int/publictions/2007/9789241563413_eng.pdf [cited 2010 Jn 2]. HEALTH IMPACT ASSESSMENT OF ENVIRONMENTAL TOBACCO SMOKE IN EUROPEAN CHILDREN: SUDDEN INFANT DEATH SYNDROME AND ASTHMA EPISODES Elen Boldo, MSc Sylvi Medin, MD, PhD Mttis Öberg, PhD Vldimír Puklová, RNDr Odile Mekel, MPH, PhD Kristiin Ptj, MD, PhD Dfin Dlbokov, PhD Michl Krzyznowski, DSc Mnuel Posd, MD, PhD Tobcco use is the second mjor cuse of deth in the world nd the fourth most common risk fctor for disese worldwide. A recent estimtion ttributes more thn five million deths yer to tobcco consumption, figure expected to rise to more thn eight million deths yer by 2030 if current smoking ptterns continue. 1 In ddition, smoking ffects not only the helth of smokers, but lso the helth of those round them who re exposed to environmentl tobcco smoke (ETS) such s children, reltives t home, nd coworkers in the workplce. ETS involves inhling crcinogens nd other toxic components, nd scientific evidence hs unequivoclly estblished tht exposure to ETS cuses deth, disese, nd disbility in children nd dults who do not smoke. Severl recent reports hve synthesized this evidence nd reched cler nd firm conclusions with regrd to the dverse consequences of exposure to ETS. 2 4 The U.S. Surgeon Generl review from 2006 suggested tht ETS exposure is cuslly ssocited with wide rnge of developmentl nd respirtory effects in children: low birthweight, sudden infnt deth syndrome (SIDS), lower respirtory trct infections such s bronchitis nd pneumoni, middle-er infections, symptoms of upper respirtory trct irrittion, smll reductions in lung function, sthm onset, nd dditionl episodes nd incresed severity of symptoms in children with sthm. Recent studies hve lso shown possible correltion between the use of cigrettes nd lcohol during pregnncy nd risk for ttention deficit hyperctivity disorder in the offspring. 5,6 On the other hnd, for dults, outcomes with the strongest evidence of the effect of ETS exposure include lung 478 Public Helth Reports / My June / Volume 125
Globl Helth Mtters 479 cncer, ischemic hert disese, nd sthm onset. In ddition, some condition-specific impcts of ETS include chronic respirtory symptoms such s wheezing, coughing, phlegm, nd dyspnoe mong children nd dults; serous otitis medi mong children; nd decresed pulmonry function in children. 7,8 Tobcco use is one of the chief preventble cuses of deth nd helth consequences for nonsmokers in the world. Smoking bns restrict tobcco smoking in workplces nd indoor public spces. 9,10 The doption nd implementtion of these public policies re gining momentum, with n incresing number of countries dopting complete smoking bns in public plces. 11,12 However, ssuming the lw is observed in public res, unregulted indoor environments such s privte residences or vehicles re still significnt remining indoor sites of ETS exposure, especilly for children. A lrger portion of children s ETS exposure occurs in such indoor environments, where mny prents nd other household members still expose their children to ETS. Children re more vulnerble to the physiologicl effects of ETS nd more sensitive to the dverse helth effects of ETS thn dults: physicl development is ongoing with sensitivity in severl orgns, the immune system is less protective, nd child s brething rte is higher thn n dult s. Children hve limited or no control over their indoor environments. 13 They often sit ner or on prents, fmily members, or cregivers, closer to the source of the pollutnt thn other pssive smokers. Becuse the home is predominnt loction for smoking fter the implementtion of smoking bns in public plces, children of smokers re exposed to ETS, especilly in the first yers of life, while eting, plying, nd even sleeping. This exposure t home my be dded to exposure t school nd in vehicles. 14 The World Helth Orgniztion s (WHO s) Implementing Environment nd Helth Informtion System (ENHIS) progrm set up comprehensive informtion nd knowledge system to support relevnt policies in Europe (www.enhis.org). This WHO progrm developed set of indictors to protect children s helth from environmentl risk fctors. These indictors cover most of the priority topic res specified in the Children s Environment nd Helth Action Pln for Europe (CEHAPE) s dopted in the Fourth Ministeril Conference on Helth nd Environment in 2004 nd will be used to monitor the implementtion of CEHAPE. 15 In ddition, helth impct ssessment (HIA) methods were developed in the frme of this progrm nd pplied to selected indictors, nd the ssessment results were integrted into the indictor fct sheets. 16 In this rticle, we present the HIA findings on children exposed to tobcco smoke using one specific indictor defined by the ENHIS progrm for this purpose. We hve estimted the ETS impct for SIDS (infnts from one month to one yer of ge) nd sthm episodes (children younger thn 14 yers of ge) on children exposed t home in 27 Europen countries. MATERIALS AND METHODS In brief, we first crried out fesibility study to test the vilble informtion for ETS HIA in interntionl dtbses. Second, we followed the methods for generting informtion from existing dt sources provided by ENHIS-2. 17 Finlly, we pplied the HIA pproch to ssess the potentil helth impcts of ETS on the Europen children popultion. 18 Dt sources Exposure dt nd exposure scenrios. The exposure mesure ws dult smoking prevlence from popultionbsed dtsets. According to reports from WHO 19 nd others, 20 the use of surveys of smoking prevlence in the dult popultion s proxy of children s ETS exposure is vlid under the ssumption tht smoking prevlence (percent of the dult popultion tht smokes tobcco products regulrly) mong ll dults ged 20 to 50 yers is similr to tht mong prents with children. Smoking prevlence ws vilble online by country, gender, nd time period (1994 1998, 1999 2001, or 2002 2005) in the WHO Tobcco Control Dtbse. 21 In ddition, the Globl Youth Tobcco Survey (GYTS), 22 developed by WHO nd the U.S. Centers for Disese Control nd Prevention (CDC), inquired bout children s exposure to ETS in their home or in other plces during the lst seven dys nd bout current smoking hbits of the prents. GYTS represents the lrgest school-bsed survey on ETS exposure of children (ged 13 to 15 yers) in 130 countries. We considered different scenrios bsed on ETS exposure vritions: 1. Upper ETS exposure estimte. The dt provided by the GYTS survey were used s the upper ETS exposure estimte. For countries tht hve not implemented or completed the GYTS, children s ETS exposure ws estimted through the dult smoking prevlence provided by the WHO Tobcco Control Dtbse. 21 If we ssume tht fmilies consist of fther nd mother living together nd tht prents hve the sme smoking prevlence nd the sme number of children
480 Globl Helth Mtters s the generl popultion, the percentge of children with t lest one smoking prent could be estimted s follows: 20 Any prentl smoking 5 mle smoking prevlence 1 femle smoking prevlence 2 (mle smoking prevlence * femle smoking prevlence) 2. Lower ETS exposure estimte. We used the most recent, highest smoking prevlence rte by gender for ech country (often the mle, except in Sweden) s n lterntive lower estimte. 21 We ssumed tht smoking prevlence mong prents should be in between these figures the upper nd the lower estimte. Helth dt. We bsed the selection of helth outcomes (SIDS cses nd sthm episodes) on two criteri: (1) strength of scientific evidence of ssocition with ETS nd (2) suitble exposure-response function (ERF). The number of SIDS cses (Interntionl Clssifiction of Diseses, 10th Revision [ICD-10] code R95) 23 for ech country in 1998, 2001, nd 2005 ws retrieved from Eurostt dtbses, 24 ccording to the proposed ETS exposure scenrios. Conversely, the lck of routine dt on sthm symptoms prevlence in interntionl dtbses did not llow us to estimte the number of ttributble cses due to ETS exposure. Therefore, we clculted the popultion-ttributble frction (PAF). ERFs. The most suitble ERFs expressed by odds rtios (ORs) between the popultion exposed to fctor nd tht not exposed for the quntifiction of helth effects due to ETS exposure were selected ccording to recent epidemiologic evidence review by WHO. 25 For SIDS, the pooled djusted OR of 1.94 (95% confidence intervl [CI] 1.55, 2.43) 26 for mternl smoking ws considered the most pproprite ERF for our HIA. This study included relevnt studies with djustment for confounding fctors tht could influence the SIDS prevlence, nd the OR estimte ws proposed s the bsis for quntifiction of disese burden in reltion to ny prentl smoking. For sthm prevlence, the most recent met-nlysis 4 provided n overll pooled OR of 1.23 (95% CI 1.14, 1.33) for children younger thn 14 yers of ge, relted to ny prentl smoking. Popultion dt. Children popultion dt in ech country were retrieved from Eurostt dtbses. 27 According to the proposed scenrios, we selected dt for children younger thn one yer of ge in 1998, 2001, nd 2005 to estimte the impct on SIDS. The prticipting countries were Austri, Bulgri, Croti, Czech Republic, Denmrk, Estoni, Finlnd, Frnce, Germny, Greece, Hungry, Irelnd, Itly, Ltvi, Lithuni, Netherlnds, Norwy, Polnd, Portugl, Romni, Slovki, Sloveni, Spin, Sweden, Switzerlnd, The Former Yugoslv Republic of Mcedoni (TFYR Mcedoni), nd United Kingdom. HIA methodology Using ORs nd different ETS exposure scenrios, we clculted country-specific estimtes of the PAF, which my be interpreted s the proportion of helth outcomes in the popultion ttributble to ETS exposure. We consider the generl eqution to clculte PAF, s described by Rockhill et l.: 28 PAF 5 Pe (OR 2 1) / (1 1 Pe [OR 2 1]), where Pe is the proportion of the children popultion exposed to the ETS, nd OR is the odds rtio of mortlity or morbidity ssocited with ETS. We ssumed Pe to be similr to the proposed scenrios of ETS exposure. We then multiplied these PAFs by the rte of disese nd child popultion size in ech country to estimte the nnul excess cses ttributble to ETS: Attributble number 5 N*Ip*PAF, where N is the totl number of people in the popultion, nd Ip is the rte of SIDS in the infnt popultion. For SIDS cses, we estimted the ttributble number of deths due to ETS exposure. For sthm, we clculted country-specific estimtes of PAF, s dt on dignosed sthm or sthm symptoms hve not been n object of reporting in the inter-country comprble form. Trend nlysis We exmined the trends of the highest ntionl smoking prevlence (lower ETS exposure scenrio) seen in 10 selected countries from 1998 to 2005 s possible progressive reduction in ETS exposure scenrio to ssess the potentil impct on SIDS. We selected the Czech Republic, Finlnd, Frnce, Germny, Hungry, Netherlnds, Norwy, Spin, Sweden, nd United Kingdom becuse SIDS cses 27 (children younger thn one yer of ge) 24 nd smoking prevlence dt (for mles, except in Sweden) were vilble for 1998, 2001, nd 2005. 21 RESULTS Tble 1 presents the dt reported or estimted for ETS exposure in the prticipting countries. Twenty-one countries reported dt for 2002 through 2005, five countries reported dt for 1999 through 2001, nd
Globl Helth Mtters 481 Tble 1. ETS exposure scenrios for helth impct ssessment estimtes in Europen countries Country Period Lower ETS exposure estimte (percent) Upper ETS exposure estimte b (percent) Austri 2002 2005 48 72 Bulgri 1999 2001 44 76 Croti 2002 2005 34 59 Czech Republic 2002 2005 31 50 Denmrk 2002 2005 28 45 Estoni 2002 2005 42 59 Finlnd 2002 2005 27 42 Frnce 2002 2005 30 45 Germny 2002 2005 37 57 Greece 1999 2001 47 67 Hungry 2002 2005 41 58 Irelnd 2002 2005 24 42 Itly 2002 2005 31 43 Ltvi 2002 2005 47 64 Lithuni 2002 2005 39 59 Netherlnds 2002 2005 31 48 Norwy 2002 2005 27 45 Polnd 2002 2005 38 59 Portugl 1999 2001 33 40 Romni 2002 2005 33 61 Slovki 1994 1998 41 55 Sloveni 1999 2001 28 48 Spin 2002 2005 34 49 Sweden 2002 2005 19 30 Switzerlnd 2002 2005 24 39 TFYR Mcedoni 1999 2001 40 64 United Kingdom 2002 2005 28 45 Source: World Helth Orgniztion, Regionl Office for Europe. Tobcco control dtbse [cited 2010 Jn 19]. Avilble from: URL: http://dt.euro.who.int/tobcco (Note: smoking prevlence for mles, except in Sweden) b Source: Centers for Disese Control nd Prevention (US). Smoking nd tobcco use: globl tobcco control: globl tobcco surveillnce system: Globl Youth Tobcco Survey (GYTS) [cited 2010 Jn 20]. Avilble from: URL: http://www.cdc.gov/tobcco/globl/gyts/index.htm (Note: Smoking prevlence ws modeled in Austri, Denmrk, Finlnd, Frnce, Germny, Irelnd, Itly, Netherlnds, Norwy, Portugl, Spin, Sweden, Switzerlnd, nd United Kingdom.) ETS 5 environmentl tobcco smoke TFYR 5 The Former Yugoslv Republic Slovki reported dt for 1994 through 1998. There were remrkble differences for lower nd upper ETS exposure estimtes cross countries. The percentge of children exposed to ETS rnged from 48% in Austri to 19% in Sweden for the lower scenrio. Considering the upper scenrio, Bulgri, Austri, Greece, Ltvi, nd Romni showed the highest smoking prevlence (more thn 60%), nd Sweden nd Switzerlnd the lowest (30% nd 39%, respectively). Tble 2 includes dt on the bsolute number of SIDS cses nd crude deth rte by country in 1998, 2001, nd 2005. The trends in reported highest smoking prevlence rtes in selected Europen countries re shown in Figure 1. There ws n overll improvement of 5% from the period 1994 1998 (35%) to 2002 2005 (30%) in ll countries, except the Czech Republic. For SIDS cses, the totl popultion younger thn one yer of ge ws round five million in the prticipting Europen countries. Depending on the ETS exposure scenrio, we estimted tht between 24% (n5310) nd 32% (n5420) of SIDS cses could be ttributble to exposure to ETS (Tble 3). The highest impct of ETS exposure ws observed in Ltvi, Irelnd, nd Lithuni. In reltion to the impct of ETS exposure on sthm episodes in children younger thn 14 yers of ge, in the lower exposure scenrio, the PAFs (Tble 4) were Tble 2. Absolute number of sudden infnt deth syndrome (ICD-10 R95) cses nd crude deth rte per 100,000 children younger thn one yer of ge Country 1998 N (rte/ 100,000) 2001 N (rte/ 100,000) 2005 N (rte/ 100,000) Austri 44 (52) 23 (29) 30 (38) Bulgri 2 (3) 4 (6) 4 (6) Croti NA 9 (21) 9 (22) Czech Republic 8 (9) 15 (17) 16 (16) Denmrk 18 (27) 25 (37) NA Estoni NA 4 (31) 5 (36) Finlnd 19 (32) 13 (23) 19 (33) Frnce 354 (48) 345 (43) 259 (33) Germny 602 (74) 427 (56) 298 (42) Greece 17 (16) 11 (11) 8 (8) Hungry 32 (32) 27 (28) 20 (21) Irelnd 34 (65) 38 (69) 19 (31) Itly 48 (9) 29 (5) NA Ltvi NA 18 (89) 17 (84) Lithuni NA 2 (6) 13 (43) Netherlnds 27 (14) 34 (16) 19 (10) Norwy 29 (49) 20 (34) 20 (35) Polnd NA 43 (11) 66 (19) Portugl 7 (6) NA NA Romni NA 12 (5) 14 (7) Slovki NA 7 (13) 24 (45) Sloveni NA NA NA Spin 80 (22) 72 (18) 88 (20) Sweden 31 (34) 28 (31) 23 (23) Switzerlnd 28 (35) 18 (23) 8 (11) TFYR Mcedoni NA NA 6 (26) United Kingdom 309 (43) 250 (37) 189 (26) Source: Europen Commission. Eurostt [cited 2010 Jn 20]. Avilble from: URL: http://epp.eurostt.ec.europ.eu/portl/pge/ portl/eurostt/home ICD-10 5 Interntionl Clssifiction of Diseses, 10th Revision NA 5 not vilble TFYR 5 The Former Yugoslv Republic
482 Globl Helth Mtters Figure 1. Trends in the smoking prevlence rtes in the mle dult popultion (except in Sweden) for selected Europen countries 50 Smoking prevlence (percent) 40 Percent 30 20 10 0 Czech Republic Finlnd Frnce Germny Hungry Netherlnds Country Norwy Spin Sweden United Kingdom Mle dult prevlence 1994 1998 Mle dult prevlence 1999 2001 Mle dult prevlence 2002 2005 Source: World Helth Orgniztion, Regionl Office for Europe. Tobcco control dtbse [cited 2010 Jn 19]. Avilble from: URL: http://dt.euro.who.int/tobcco/defult.spx?tbid=2444 between 3% nd 10%. The highest estimted proportion of sthm episodes ttributble to ETS exposure ws observed in Austri nd Greece. The men proportion in the evluted countries ws 7% to 11% of ttributble sthm episodes, depending on the ETS exposure scenrio. The decresing trends in the highest ntionl smoking prevlence seen in 10 selected countries from 1998 to 2005 my hve contributed to 38% decrese in the number of ttributble SIDS cses, from 2.6 cses per 100,000 children younger thn one yer of ge in 1998 to 1.6 cses per 100,000 children younger thn one yer of ge in 2005 (Tble 5). All prticipting countries, except Czech Republic, presented decresing trend in the number of ttributble SIDS cses (Figure 2). DISCUSSION ETS is mjor indoor ir pollutnt nd significnt risk fctor for children including risk of ftl (SIDS) nd nonftl (sthm episodes) dverse helth effects. In Europe, infnts exposure to ETS my be responsible for 24% to 32% of SIDS cses nd my increse the number of sthm episodes by men proportion of 7% to 11% in children younger thn 14 yers of ge. These findings re consistent with findings from other interntionl studies. 4,29 The estimtes of popultion impct presented in this rticle re given in rnges to reflect the uncertinty of ETS exposure ssessment. Confidence in these estimtes is bsed gretly on the ssumption of cusl ssocition nd the strong vlidity of prentl smoking s surrogte of relevnt ETS exposure in infnts nd children. The estimtes derived in this rticle re bsed on number of ssumptions nd uncertinties, which could bis the estimted number of cses for ech helth outcome. Three key components of the HIA nlyses must be considered: exposure ssessment, helth outcomes, nd ERFs. Exposure ssessment Children s involuntry exposure to ETS is frequently mesured in severl wys: ir smpling in enclosed spces, use of biomrkers, nd ppliction of survey instruments. Severl studies found strong ssocition between ir nicotine concentrtions, urinry cotinine levels, nd questionnire reported smoking, 30 32 which vlidtes the use of residentil ETS exposure mong children to ssess the impct of ETS. 30 The percentge of children exposed to ETS t home ws 71.5% in Europe; 33 thus, the dt provided by GYTS were included in the upper ETS exposure estimte in this study. On the other hnd, smoking prevlence in the Europen Region bsed on country-reported dt ws estimted t pproximtely 28.6% (40.0% mong mles
Globl Helth Mtters 483 nd 18.2% mong femles) in 2005. 34 In this HIA, the generl survey on smoking prevlence mong dults provided by the WHO Tobcco Control Dtbse ws considered n cceptble proxy for the lower estimtes of children ETS exposure. Member sttes greed to report dt, using identicl smpling procedures nd methodology, s prt of their commitment to Tobcco-free Europe nd the Frmework Convention on Tobcco Control. Limittions. We recognize the limittions of our results ssocited with the evlution of the rel exposure, nd it could led to over- or underestimtions of our findings. A potentil error my rise from using the ntionwide smoking prevlence men to represent exposures of children t risk. Exposure vries considerbly ccording to socioeconomic sttus, 35 37 nd the composition of tobcco smoke inhled involuntrily is vrible quntittively nd depends on the smoking ptterns of the smokers who re producing the smoke, s well s the composition nd design of the cigrettes or other smoking devices. 3 Moreover, there re vritions in societl ttitudes towrd ETS, which my influence indoor smoking behvior. Finlly, our model ssumed tht prents hve Tble 3. Helth impct ssessment of ETS exposure for SIDS cses in Europen countries Scenrio Lower ETS exposure estimte Upper ETS exposure estimte Country Attributble SIDS cses Attributble SIDS cses per 100,000 Attributble SIDS cses Attributble SIDS cses per 100,000 Austri 8 (5, 11) 10 (7, 14) 10 (7, 13) 13 (9, 17) Greece 4 (3, 5) 6 (4, 8) 6 (4, 7) 9 (6, 11) b Bulgri 1 (1, 1) 2 (2, 3) 1 (1, 2) 4 (2, 5) b Croti 2 (1, 3) 2 (1, 3) 3 (2, 4) 3 (2, 4) b Czech Republic 5 (3, 7) 8 (5, 11) 7 (5, 10) 12 (8, 15) b Denmrk 1 (1, 2) 11 (7, 15) 2 (1, 2) 14 (9, 18) Estoni 3 (2, 4) 6 (4, 8) 5 (3, 6) 8 (5, 11) b Finlnd 57 (37, 78) 7 (5, 10) 77 (51, 101) 10 (7, 13) Frnce 94 (62, 126) 13 (9, 18) 126 (86, 162) 17 (12, 23) Germny 2 (2, 3) 2 (2, 3) 3 (2, 4) 3 (2, 4) Hungry 7 (5, 9) 7 (5, 10) 9 (6, 11) 9 (6, 12) b Irelnd 8 (5, 10) 13 (8, 18) 12 (8, 15) 20 (13, 26) Itly 6 (4, 8) 1 (1, 2) 7 (5, 10) 1 (1, 2) Ltvi 9 (6, 11) 43 (29, 56) 11 (7, 13) 52 (36, 67) b Lithuni 4 (3, 6) 14 (9, 19) 6 (4, 7) 19 (13, 25) b Netherlnds 6 (4, 9) 3 (2, 4) 9 (6, 11) 4 (3, 6) Norwy 2 (1, 3) 4 (3, 6) 3 (2, 4) 6 (4, 8) Polnd 11 (7, 15) 3 (2, 4) 15 (10, 19) 4 (3, 5) Portugl 2 (1, 3) 2 (1, 2) 2 (1, 3) 2 (1, 3) Romni 2 (2, 3) 1 (1, 2) 4 (3, 5) 2 (1, 2) b Slovki 6 (4, 8) 11 (7, 14) 7 (5, 9) 13 (9, 17) b Sloveni 1 (0, 1) 4 (2, 5) 1 (1, 1) 5 (4, 7) b Spin 18 (12, 15) 4 (3, 6) 23 (16, 31) 6 (4, 7) Sweden 3 (2, 4) 3 (2, 5) 5 (3, 6) 5 (3, 7) Switzerlnd 3 (2, 4) 4 (2, 5) 4 (3, 5) 6 (4, 7) TFYR Mcedoni 2 (1, 2) 7 (5, 9) 2 (2, 3) 10 (7, 12) b United Kingdom 43 (27, 59) 6 (4, 9) 61 (41, 80) 9 (6, 12) Totl 310 (202, 420) 6 (4, 8) 420 (284, 547) 8 (6, 11) Smoking prevlence modeled by using the formul: ny prentl smoking 5 mle smoking prevlence 1 femle smoking prevlence 2 (mle smoking prevlence * femle smoking prevlence) b Source: Centers for Disese Control nd Prevention (US). Smoking nd tobcco use: globl tobcco control: globl tobcco surveillnce system: Globl Youth Tobcco Survey (GYTS) [cited 2010 Jn 20]. Avilble from: URL: http://www.cdc.gov/tobcco/globl/gyts/index.htm ETS 5 environmentl tobcco smoke SIDS 5 sudden infnt deth syndrome CI 5 confidence intervl TFYR 5 The Former Yugoslv Republic
484 Globl Helth Mtters Tble 4. Helth impct ssessment of ETS exposure for sthm in children younger thn 14 yers of ge in Europen countries Country Lower ETS exposure estimte PAF percent Scenrio Upper ETS exposure estimte PAF percent Austri 10.0 (6.3, 13.7) 14.2 (9.2, 19.2) Greece 9.7 (6.1, 13.4) 14.7 (9.5, 19.8) b Bulgri 9.2 (5.8, 12.6) 11.9 (7.6, 16.3) b Croti 7.2 (4.5, 10.0) 10.3 (6.5, 14.2) b Czech Republic 6.7 (4.2, 9.3) 9.4 (5.9, 12.9) b Denmrk 6.1 (3.8, 8.5) 11.9 (7.6, 16.3) Estoni 8.8 (5.6, 12.2) 8.8 (5.6, 12.2) b Finlnd 5.8 (3.6, 8.2) 9.4 (5.9, 12.9) Frnce 6.5 (4.0, 9.0) 11.4 (7.3, 15.6) Germny 7.9 (4.9, 10.9) 13.4 (8.6, 18.1) Hungry 8.5 (5.4, 11.8) 11.8 (7.5, 16.1) b Irelnd 5.3 (3.3, 7.4) 8.8 (5.6, 12.2) Itly 6.7 (4.2, 9.4) 9.0 (5.7, 12.4) Ltvi 9.8 (6.2, 13.5) 12.8 (8.2, 17.4) b Lithuni 8.3 (5.2, 11.5) 11.9 (7.6, 16.3) b Netherlnds 6.7 (4.2, 9.3) 9.9 (6.3, 13.7) Norwy 5.9 (3.7, 8.2) 9.4 (5.9, 12.9) Polnd 8.0 (5.1, 11.1) 11.9 (7.6, 16.3) Portugl 7.0 (4.4, 9.8) 8.4 (5.3, 11.7) Romni 7.1 (4.4, 9.9) 12.3 (7.9, 16.8) b Slovki 8.6 (5.4, 11.9) 11.0 (7.0, 15.1) b Sloveni 6.1 (3.8, 8.5) 9.9 (6.3, 13.7) b Spin 7.3 (4.6, 10.1) 9.9 (6.3, 13.7) Sweden 3.1 (1.9, 4.4) 6.5 (4.0, 9.0) Switzerlnd 5.2 (3.3, 7.3) 8.2 (5.2, 11.4) TFYR Mcedoni 8.4 (5.3, 11.7) 12.8 (8.2, 17.4) b United Kingdom 6.1 (3.8, 8.5) 9.4 (5.9, 12.9) Smoking prevlence modeled by using the formul: ny prentl smoking 5 mle smoking prevlence 1 femle smoking prevlence 2 (mle smoking prevlence * femle smoking prevlence) b Smoking prevlence from Globl Youth Tobcco Survey dtbse. Source: Centers for Disese Control nd Prevention (US). Smoking nd tobcco use: globl tobcco control: globl tobcco surveillnce system: Globl Youth Tobcco Survey (GYTS) [cited 2010 Jn 20]. Avilble from: URL: http://www.cdc.gov/tobcco/globl/gyts/index.htm ETS 5 environmentl tobcco smoke PAF 5 popultion-ttributble frction CI 5 confidence intervl TFYR 5 The Former Yugoslv Republic the sme smoking prevlence s the verge dult popultion nd tht the number of children is eqully distributed between smokers nd nonsmokers. This ssumption my be limittion of our study, lthough, s we stted previously, empiricl studies show generl concordnce when using different methods to mesure ETS exposure. Our findings support the vlidity of these surveys in cpturing vritions in child popultion exposures to ETS nd strengthen the relibility of HIA tht depend on ETS exposures. Helth outcomes The selection of helth outcomes (SIDS nd sthm episodes) ws bsed on the strength of scientific evidence of ssocition with ETS nd the vilbility of suitble ERFs. SIDS mortlity is well-defined helth outcome in HIA. Even though the ctul cuse (or cuses) of SIDS remins mystery, it is generlly ccepted tht SIDS my be reflection of multiple intercting risk fctors, 38 including prentl or postntl exposure to tobcco smoke. 26 Nevertheless, the temporl reltionship between chnges in ETS exposure nd resulting chnges in helth outcomes cn be further explined by other public helth mesures or fctors. Since erly 1990, the incidence of SIDS hs dropped shrply becuse of public helth cmpigns (e.g., the Bck to Sleep cmpign initited in severl Europen countries t the beginning of the 1990s 39 41 decrying the dngers of the prone sleep position). 42 The chnge in infnts sleeping positions cn prtilly explin the continuing decline in the number of SIDS cses in Europen countries since 1998. 39,41,43,44 Some uthors hve rgued tht the ttributed risk ssociting mternl smoking nd SIDS hs incresed following these cmpigns, due to decresed overll rte of SIDS resulting from those cmpigns. 45 In ddition, it should be noted tht SIDS remins the highest cuse of infnt deth beyond the neontl period in Europe, nd there re still severl potentilly modifible risk fctors (e.g., mternl smoking). Tble 5. Trends in the number of excess SIDS cses ttributble to lower ETS exposure estimte in selected Europen countries by yer Yer Lower ETS exposure estimte b Totl number of ttributble cses Number of ttributble cses per 100,000 1998 365 (238, 492) 2.6 (1.7, 3.5) 2001 300 (195, 404) 2.2 (1.4, 3.0) 2005 223 (144, 302) 1.6 (1.1, 2.2) Selected countries: Czech Republic, Finlnd, Frnce, Germny, Hungry, Netherlnds, Norwy, Spin, Sweden, nd United Kingdom b Source: World Helth Orgniztion, Regionl Office for Europe. Tobcco control dtbse [cited 2010 Jn 19]. Avilble from: URL: http://dt.euro.who.int/tobcco (Note: smoking prevlence for mles, except in Sweden) SIDS 5 sudden infnt deth syndrome ETS 5 environmentl tobcco smoke CI 5 confidence intervl
Globl Helth Mtters 485 Figure 2. Trends in the number of excess SIDS cses ttributble to lower ETS exposure estimte by country nd yer 40 35 Excess SIDS cses (per 100,000 children) 30 25 Yer 1998 Yer 2001 Yer 2004 20 15 10 5 0 Czech Republic Finlnd Frnce Germny Hungry Netherlnds Norwy Spin Sweden SIDS 5 sudden infnt deth syndrome ETS 5 environmentl tobcco smoke On the other hnd, dt on morbidity (sthm episodes) re usully less comprehensive nd the vilbility needs to be improved in ntionl nd interntionl dtbses. The results of the Interntionl Study of Asthm nd Allergies in Childhood (ISAAC) phses I (1992 1998) nd III (1999 2004) showed n increse in prevlence, nmely of sthm symptoms, in most Europen countries, 46 nd epidemiologic evidence shows tht sthmtic children re t greter risk of hving their symptoms worsen upon exposure to ETS in their homes. 47,48 However, t present, it is not possible to estimte the bsolute number of sthm ttcks relted to ETS exposure becuse the vilble dt on sthm prevlence 49 re not updted, only cover selected popultions, nd show lrge inter-regionl vribility. Therefore, the number of ttcks occurring in children with sthm is difficult to evlute in HIA nlysis. This study ssessed only two dverse helth outcomes, but the quntity of the potentil helth dmge due to ETS exposure is much greter. We must highlight tht mny helth outcomes relted to ETS exposure re not quntified becuse there is insufficient dt in interntionl dtbses (e.g., low birthweight or otitis medi) or becuse inclusion of certin helth effects in the nlysis could led to double-counting (e.g., wheezing nd coughing re symptoms of sthm, but not disese per se). ERFs The ERF ws centrl element in the impct nlysis. In our study, the quntifiction of helth effects for 95% CIs represented the lower nd upper confidence bounds from the ORs, nd it did not tke into ccount other possible uncertinties in the HIA estimtion. Anderson nd Cook in 1997 estimted tht mternl smoking doubles the risk of SIDS. 26 The evidence is sufficient to infer cusl reltionship between prentl smoking nd ever hving sthm mong children of school ge. The cusl interprettion is further strengthened by the trend for the OR to increse with the number of prents who smoke (i.e., none, one, or both). Therefore, evidence exists of n exposure-response reltionship with the number of prents who smoke, nd mternl smoking probbly hs greter impct on the exposure of children to ETS. 4 This HIA pplied conservtive pproch using the pooled rndom effect ssocited with smoking by either prent, slightly lower thn those for smoking by both prents. CONCLUSION ETS is linked with dverse helth effects mong children in Europe. A decrese in smoking prevlence could provide substntil helth gins in children. Becuse the effects of ETS re dose-response nd
486 Globl Helth Mtters there is no known sfe level of exposure to ETS, WHO encourges member sttes to follow these recommendtions to protect workers nd the public from exposure to ETS: 50 Provide 100% smoke-free environments. Ensure universl protection by lw. Provide proper implementtion nd dequte enforcement of the lw. Use public eduction to reduce ETS exposure indoors. Therefore, our key messge to decision-mkers is to follow the WHO recommendtions to develop nd implement enforceble smoke-free policies to void the ETS impct on children s helth. The World Helth Orgniztion s (WHO s) Europen Environment nd Helth Informtion System (ENHIS) progrm ws funded by the Europen Commission Directorte Generl for Helth nd Consumer Affirs (DG SANCO), Grnt SPC 2004124. The uthors cknowledge the contribution of ENHIS-2 project prtners (vilble t www.enhis.org). (Source: WHO. Children s helth nd the environment in Europe: bseline ssessment, 2007 [cited 2010 Jn 18]. Avilble from: URL: http://www.euro.who.int/informtionsources/publictions/ Ctlogue/20071007_1). Elen Boldo is Resercher t the Ntionl Epidemiology Centre, Consortium for Biomedicl Reserch in Epidemiology & Public Helth (CIBERESP), Crlos III Helth Institute (ISCIII) in Mdrid, Spin. Sylvi Medin is n Epidemiologist nd Coordintor of Europen nd Interntionl Activities t the Deprtment of Environmentl Helth, French Institute for Public Helth Surveillnce (InVS) in Sint Murice, Frnce. Mttis Öberg is Senior Resercher t the Krolinsk Institutet in Stockholm, Sweden. Vldimír Puklová is Resercher t the Ntionl Institute of Public Helth in Prgue, Czech Republic. Odile Mekel is hed of Innovtion in Helth t the NRW Institute of Helth nd Work in Bielefeld, Germny. Kristiin Ptj is Adjunct Professor Director, Pro Medico t the Assocition for Medicl Continuous Professionl Development nd Senior Resercher t the Ntionl Institute for Helth nd Welfre in Helsinki, Finlnd. Dfin Dlbokov is Mnger, EH Informtion Systems, nd Michl Krzyznowski is Regionl Adviser with the WHO Europen Centre for Environment nd Helth in Bonn, Germny. Mnuel Posd is Hed of the Deprtment t the Reserch Institute for Rre Diseses, Biomedicl Network Reserch Centre on Rre Diseses (CIBERER), ISCIII, in Mdrid. Address correspondence to Elen Boldo, MSc, Ntionl Epidemiology Centre, Crlos III Helth Institute, Avd. Monforte de Lemos, 5, Pb. 12, 28029 Mdrid (Spin); tel. +34 918 222 664; fx +34 913 877 815; e-mil <eiboldo@isciii.es>. REFERENCES 1. Mthers CD, Loncr D. Projections of globl mortlity nd burden of disese from 2002 to 2030. PLoS Med 2006;3:e442. 2. Cliforni Environmentl Protection Agency. Proposed identifiction of environmentl tobcco smoke s toxic ir contminnt. Scrmento (CA): Cliforni EPA; 2005. 3. World Helth Orgniztion, Interntionl Agency for Reserch on Cncer. IARC monogrphs on the evlution of crcinogenic risks to humns, volume 83: tobcco smoke nd involuntry smoking. 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