Disease burdens from environmental tobacco smoke in Korean adults.

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Disease burdens from environmental tobacco smoke in Korean adults a

Seulkee Heo & Jong-Tae Lee

ab

a

Department of Public Health Science, Graduate School, Korea University, Seoul, Republic of Korea b

Department of Environmental Health, College of Health Science, Korea University, Seoul, Republic of Korea Published online: 26 Aug 2014.

Click for updates To cite this article: Seulkee Heo & Jong-Tae Lee (2014): Disease burdens from environmental tobacco smoke in Korean adults, International Journal of Environmental Health Research, DOI: 10.1080/09603123.2014.945513 To link to this article: http://dx.doi.org/10.1080/09603123.2014.945513

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International Journal of Environmental Health Research, 2014 http://dx.doi.org/10.1080/09603123.2014.945513

Disease burdens from environmental tobacco smoke in Korean adults Seulkee Heoa and Jong-Tae Leea,b* a


Department of Public Health Science, Graduate School, Korea University, Seoul, Republic of Korea; bDepartment of Environmental Health, College of Health Science, Korea University, Seoul, Republic of Korea (Received 3 February 2014; final version received 20 June 2014) In this study, we estimated the disease burdens attributable to environmental tobacco smoke (ETS) exposure in Korean adults in 2010 and analyzed the trend of that from 2005 to 2010. We obtained information on the study population from the 2010 Cause of Death Statistic and estimated the ETS-attributable fraction using data from the Korean Community Health Survey and the Korean National Health and Nutrition Examination Survey. The numbers of ETS-attributable deaths in female and male non-smokers were estimated to be 4.1 and 69.6 % of the numbers of deaths attributable to current smoke, respectively. The deaths attributable to ETS were larger in female than in male non-smokers (710 vs. 420). The ETS-attributable deaths increased slightly in 2005–2008 but decreased in 2009–2010. The number of potential years of life lost from ETS was 9077.24 years in 2010. If there were no exposure to ETS in adult non-smokers, we would expect to see 1130 fewer deaths (9.9 % of the deaths from current smoke). The results suggest that ETS poses considerable disease burdens for non-smokers, especially women, in Korea. Keywords: environmental tobacco smoke pollution; secondhand smoking; passive smoking; illness burden; years of potential life lost

Introduction Current smoking has been shown to be a risk factor for various cancers, including cancers of lung, urinary bladder, renal pelvis, oral cavity, pharynx, larynx, esophagus, lip, and pancreas (US Department of Health and Human Services 2011). Likewise, environmental tobacco smoke (ETS) is a common indoor air pollutant that causes various health problems. ETS is composed of both mainstream smoke drawn from smokers and sidestream smoke from the end of a smoldering tobacco product (Jung et al. 2012). At least 250 chemicals known or suspected to be toxic or carcinogenic to humans are present in sidestream or mainstream smoke (US Department of Health and Human Services 2011). Since the 1970s, many studies have shown evidence of the harmful health effects of ETS for non-smokers. According to summary reports of several expert agency panels, including the US Surgeon General and the California Environmental Protection Agency, ETS has been proven to be associated with a higher risk of coronary heart disease, stroke, lung cancer, and respiratory diseases in adults (California Environmental Protection Agency: Air Resources Board 2005; General 2006). The US Surgeon General also suggested that exposure to ETS might be causally associated with various health effects *Corresponding author. Email: [email protected] © 2014 Taylor & Francis


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S. Heo and J.-T. Lee

in children, including low birth weight, sudden infant death syndrome, asthma, and lower respiratory tract infections (General 2006; Boldo et al. 2010). Several studies of disease burden due to ETS have been conducted in countries other than the Republic of Korea by measuring attributable risks (Gan et al. 2007; Lopez et al. 2007; Öberg et al. 2011; Max et al. 2012). In the past decade, a number of studies have estimated the disease burden due to current smoking in terms of mortality and economic cost in the Republic of Korea (Yoon et al. 2001; Yoo 2003; Kang 2005; Lee & Shon 2005; Yoo et al. 2005; Jee et al. 2006). According to some of those studies, the number of attributable deaths (ADs) and years of life lost due to premature death caused by current smoking increased from the 1990s to the 2000s (Yoo 2003; Kang 2005). However, no research has been conducted to estimate the disease burden caused by ETS. The prevalence of exposure to ETS in Korean men in 2010 was 50.0 %, which was 1.4 times greater than that for Korean women (Korea Centers for Disease Control and Prevention 2010). The prevalence of exposure to ETS in Korean men (38.7 %) and Korean women (35.4 %) in 2005 was greater than the worldwide prevalence of ETS exposure (33.0 % in men and 35.0 % in women) in 2004 (Öberg et al. 2011). In addition, the prevalence of exposure to ETS at work in Korea was estimated to be greater than that in the United States, Canada, Australia, France, and Ireland (Korean Ministry of Health and Welfare 2012). The prevalence of exposure to ETS in adults consistently increased from 2005 (35.8 %) to 2010 (38.1 %) in both men and women (Korea Centers for Disease Control and Prevention 2010). Consequently, there are concerns that the health impact of ETS will increase in the Republic of Korea as exposure increases over time. We aimed to estimate the disease burden due to exposure to ETS, measured as ADs and years of life lost due to premature death. This study is a first step to estimate the disease burden from ETS and provide basic information for planning national health policies. Methods Data sources We obtained data on the prevalence of current smoking and ETS exposure in the study population from two national survey data-sets: phases III–V of the Korean National Health and Nutrition Examination Survey (KNHANES) (Korean Ministry of Health and Welfare 2005, 2007–2010) and phases II and III of the Korean Community Health Survey (KCHS) (Korea Centers for Disease Control and Prevention 2010). KNHANES III (2005), IV (2007–2009), and V-i (2010) are successive crosssectional surveys conducted by the Korean Ministry of Health and Welfare. KNHANES III and IV include the results from a questionnaire and medical examination for 50,603 adults aged 19 years and older. The KCHS is also a cross-sectional interview survey conducted by the Korea Centers for Disease Control and Prevention and includes a nationally representative sample of civilians aged 19 years and older. KCHS II (2009) and III (2010) include information on 456,929 adults. In both surveys, samples were selected using a stratified multistage probability sampling method based on information on administrative units and dwelling type. Trained interviewers administered face-to-face, paper-assisted personal interviews. Participants completed interview surveys on demographic and socioeconomic characteristics, healthrelated conditions, smoking and tobacco use, and exposure to ETS. The question about ETS was added in KNAHNES III and KCHS II.

International Journal of Environmental Health Research

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In the current study, ETS-related diseases refer to the following outcomes, according to the International Classification of Diseases, Injuries and Causes of Death, 10th version (ICD-10): lung cancer (C34), ischemic heart disease (IHD) (I20–I25), chronic obstructive pulmonary disease (COPD) (J40–J44, J47), asthma (J45–J46), and stroke (I60–I69). The total number of deaths from these diseases was obtained from the 2005–2010 Cause of Death Statistics (Statistics Korea 2005–2010), which contains records on deaths in adults aged 19 years or older.


Measure of disease burdens Prevalence of current smokers Current smokers were defined as adults who had smoked at least 100 cigarettes in their lifetime and currently smoked. Non-smokers were defined as participants who had stopped smoking or had not smoked 100 cigarettes in their lifetime. The prevalence of current smokers in 2005 and 2007–2010 was obtained from the results of the KNHANES, which are reported elsewhere (Korean Ministry of Health and Welfare 2005, 2007–2010). The average of the prevalence in 2005 and 2007 was used for the prevalence in 2006. We also analyzed the prevalence of current smokers in 2009–2010 from the raw data of the KCHS (Korea Centers for Disease Control and Prevention 2010). Prevalence of ETS exposure In the KNHANES, we treated participants as persons who were exposed to ETS if they reported that their household member had smoked at home and/or they could smell tobacco smoke because of co-workers smoking at work. The prevalence of exposure to ETS in 2005 and 2007–2010 was obtained from the results of the KNHANES, which are reported elsewhere (Korean Ministry of Health and Welfare 2005, 2007–2010). The average of the prevalence in 2005 and 2007 was used for the prevalence in 2006. The definition of exposure to ETS in the 2009–2010 KCHS was different from that in the KNHANES. Participants who answered “less than 1 h (except for 0 h)” or “more than 1 h” to the question “How long are you exposed to ETS at home in a day?” were considered to have been exposed to ETS at home. Self-reported workplace ETS exposure was defined as smelling smoke as a result of someone else’s smoking for more than 0 h in a day. In our study, any participants exposed to ETS at home or at work were considered to have been exposed to ETS in the KCHS. Estimation of attributable risk due to ETS PAFets, the population attributable fraction due to ETS exposure within a specific age/ sex group, was calculated using the standard epidemiological formula, Equation (1) PAFets ¼ Pets ðRRets 1Þ=½1 þ Pets ðRRets 1Þ

(1)

where Pets is the prevalence of exposure to ETS among non-smokers within a specific age/sex group and RRets is the relative risk of death in non-smokers exposed to ETS compared with non-smokers unexposed to ETS. The number of deaths among adult non-smokers was estimated by first calculating the current smoking-attributable disease mortality among smokers and subtracting it from the total number. The process is expressed by Equation (2)

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S. Heo and J.-T. Lee Dnons ¼ ½Dt ðDt AFcs Þ ð1 Pcs Þ

(2)

where, within a specific age/sex group, Dnons is the total number of deaths among nonsmokers, Dt is the total number of deaths among both smokers and non-smokers, PAFcs is the population attributable fraction due to current smoking, and Pcs is the prevalence of current smoking. We estimated PAFcs according to the standard epidemiological formula, Equation (3) (Max et al. 2012).


PAFcs ¼ ½Pcs ðRRcs 1Þ=½Pns þ Pcs RRcs

(3)

where RRcs is the relative risk of death from current smoking and Pns is the prevalence of non-smokers which is equal to (1 − Pcs). To determine the number of deaths in non-smokers, the number of deaths caused by current smoking is needed. ADcs, the number of deaths attributable to current smoke, and ADets, the number of deaths attributable to ETS, were calculated by Equations (4)–(5), respectively. ADcs ¼ ðDt PAFcs Þ

(4)

ADets ¼ ðDnons PAFets Þ

(5)

The relative risk (RR) (or odds ratio) of ETS-related diseases was obtained from previous studies conducted in the Republic of Korea if the data were available (Jee et al. 2004; Ko & Han 2010; Jung & Lee 2011). We obtained the RR of death from lung cancer in adults who were current smokers from a nine-year follow-up study conducted in the Republic of Korea (Jee et al. 2004). In that study, the RRs of mortality for lung cancer were 4.6 (95 % confidence interval [CI]: 4.0–5.3) in men who smoked and 2.5 (95 % CI: 2.0–3.1) in women who smoked, respectively, compared with non-smokers (Jee et al. 2004). The RR of death from IHD in Korean adults who were current smokers was obtained from a previous study in which the RR was 2.07 (95 % CI: 1.84–2.32) for men and 2.34 (95 % CI: 1.73–4.56) for women (Ko & Han 2010). For the diseases without an RR obtained from the national study, we adopted the RR from the previous studies conducted in other countries (Shinton & Beevers 1989; Fontham et al. 1994; He et al. 1999; Jaakkola et al. 2003; Eisner et al. 2005; Nakamura et al. 2009; Oono et al. 2011). Especially, we followed the guideline for the use of RR suggested by the World Health Organization (Öberg et al. 2010). When possible, the RR was obtained from meta-analysis. The RR obtained was sex specific for some diseases. Potential years of life lost We estimated the potential years of life lost (PYLL) attributable to current smoking and exposure to ETS, which is the average number of years of life expectancy remaining at the age of death from Equation (6) PYLL ¼

L X

dx ðL xÞ

(6)

x¼0

where x is the age at death, dx is the numbers of deaths at a given age x, and L is life expectancy at birth (Gardner & Sanborn 1990). We obtained data on life expectancy from the 2010 Life Tables for Korea (Statistics Korea 2011), which reported that the life expectancy at birth was 77.20 years for men and 84.07 years for women. PYLL


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attributable to current smoking (PYLLcs) was calculated by multiplying PAFcs by total PYLL, PYLL attributable to ETS (PYLLets) was calculated by multiplying the PAFets by the PYLL of non-smokers (Yoon et al. 2001), and PYLL among non-smokers was estimated using formula 2. Strategies for estimating disease burden We assessed ADs and PYLL of ETS-related diseases in 2010 using the calculated Pcs and Pets from the 2010 KCHS data. To obtain the variation in ADs and PYLL, the upper and lower limits of the 95 % CI of the risk were plugged into the formula. We also analyzed the annual trend of ADets from 2005 to 2010. We assessed the trend twice because we had two different data-sets for Pcs and Pets (from the KNHANES and the KCHS). First, we assessed the trend using combined Pcs and Pets from the KNHANES data for 2005–2008 and the KCHS data for 2009–2010. Secondly, we assessed the trend using only the data from the KNHANES in 2005–2010 to maintain consistent data quality. Finally, to determine the effect of past exposure on the disease burden, we estimated ADets in 2010 using averaged annual Pets in 2005–2010 from the KNHANES data. Consideration of past exposure might be legitimate because the health effect of ETS is believed to be cumulative for chronic health outcomes such as lung cancer (Jaakkola & Jaakkola 1997; Jaakkola & Samet 1999). In this process, we used only the KNHANES data because Pets in 2010 from the KCHS was different from Pets from the KNHANES because of inconsistencies in the measurement of ETS exposure. Each assessment was conducted using SAS version 9.3 (SAS Institute Inc., Cary, North Carolina, USA; http:// www.sas.com). Results The RRs used in this study are shown in Table 1. The Pcs in men was much higher than that in women (49.96 % vs. 3.40 %) (Table 2). The Pcs in men aged 30 years and older decreased with increasing age; in other words, the Pcs in younger men (excluding those in their 20s) was shown to be higher than that in older men. Pets in men was higher than the Pcs in women (22.19 % vs. 19.91 %), and the Pets in men aged 30 years and older decreased with increasing age. The estimated ADcs, ADets, PAFcs, and PAFets for the diseases are shown in Table 3. The estimates derived using the lower and upper limits of 95 % CI for the RR are shown in Tables 4–5, respectively. Given the high rate of smoking in men and the lower rate of smoking in women, more than half (51 %) of all deaths due to lung cancer in men in 2010 were attributable to current smoking compared with only 6 % in women. Approximately 2.9 % of deaths from lung cancer were among male non-smokers, and 3.3 % of deaths from lung cancer among female non-smokers were caused by ETS exposure. In 2010, 6108 people died of lung cancer due to current smoking, and 96 % were men. An additional 218 non-smokers died of lung cancer due to exposure to ETS, including 92 men (42.2 %) and 127 women (58.3 %). In 2010, 2134 deaths due to IHD were caused by current smoking and 204 deaths due to IHD were caused by ETS exposure (Table 3 and Figure 1). ADets from COPD among men and women was approximately 8.9 and 107.2 % of the ADcs from COPD among men and women, respectively (Figure 1). ADets from COPD among women exceeded ADcs from COPD among women (74 vs. 69) and ADets

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Table 1.

The RRs for the ETS-related diseases in this study. Current smoking

Disease

Estimate

95 % CI

Lung cancer

RR = 4.60 for men

4.0–5.3

RR = 2.50 for women RR = 2.07 for men

2.0–3.1


Ischemic heart disease Asthma

RR = 2.34 for women RR = 2.79

Chronic OR = 1.97 obstructive pulmonary disease Stroke RR = 1.51

1.84–2.32 1.73–4.56 1.18–6.55 1.22–3.18

1.45–1.58

Reference

ETS Estimate

95 % CI

OR = 1.29

1.04–1.60

California Environmental Protection Agency (2005) and Fontham et al. (1994)

Ko and Han RR = 1.22 for men (2010)

1.10–1.35

He et al. (1999)

Jee et al. (2004)

RR = 1.24 1.15–1.34 for women RR = 1.97 1.19–3.25

Nakamura et al. (2009) OR = 1.55 Jung and Lee (2011) Shinton and OR = 1.25 Beevers (1989)

Reference

Jaakkola et al. (2003)

1.09–2.21

Eisner et al. (2005)

1.12–1.38

Oono et al. (2011)

Note: CI = confidence interval; ETS = environmental tobacco smoke; OR = odds ratio; RR = relative risk.

from stroke among women also exceeded the ADcs from stroke among women (315 vs. 293), but the differences were not large. ADets was greater in women than in men for all ETS-related diseases (710 vs. 420) (Figure 1). Total ADets in women and men was approximately 4.1 and 69.6 % of those caused by current smoking, respectively. Overall, if non-smokers exposed to ETS had the same death rates as non-smokers not exposed to ETS, we would expect to see 1130 fewer deaths (9.9 % of the deaths caused by current smoking). Figure 2 represents each percentage increase of ADcs and ADets in both sexes compared with the previous age group. The ADcs and ADets showed the biggest change in subjects in their 30s and the smallest change in subjects in their 60s. Curves of change showed a similar consistent decreasing pattern in those in their 30s–60s between ADcs and ADets. The change in ADets in women older than 70 years largely increased compared with the change in ADcs in women in this same age group. Figure 3 shows the annual trend of total ADets between 2005 and 2010, which was estimated using KNHANES (2005–2008) and KCHS (2009–2010) data. ADets increased slightly in 2006–2008 and largely decreased after 2008. Compared with the previous year, ADets decreased approximately by 36.0 % (n = 788) in 2009 and 19.1 % (n = 267) in 2010, respectively. When we estimated ADets using only Pets data in 2005–2010 from the KNHANES, the trend also showed a decreasing pattern after 2008 even though the number of ADets was larger than the estimates from KCHS data (Figure 4). ADets decreased approximately 13.7 % (n = 303) in 2009 and 4.2 % (n = 80) compared with the previous year. We also used the annual average Pets from 2005 to 2010 to reflect the cumulative effect of ETS exposure. The number of ADets in 2010, estimated using the annual average Pets, was approximately 1.6 times higher than that estimated only using the annual Pets in 2010 (data not shown). ADets in men and women increased by 64 and 53 % compared with the estimates from the annual Pets in 2010, respectively.



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Figure 1. Attributable deaths caused by environmental tobacco smoking vs. attributable deaths caused by current smoking by disease and sex in the Republic of Korea in 2010. Note: COPD = chronic obstructive pulmonary disease; F = female; IHD = ischemic heart disease; M = male.

Finally, we estimated PYLL separately with two models: model 1 estimated PYLL for lung cancer and IHD, and model 2 estimated PYLL for all five diseases (Table 6). Total PYLLcs were 101,086.47 and 125,567.67 in models 1 and 2, respectively. Total PYLLets were 3831.14 (3.8 % of total PYLLcs) in model 1 and 9077.24 (7.2 % of total PYLLcs) in model 2. PYLLcs from lung cancer were 55,378.45 and from IHD were 45,708.03. PYLLets from lung cancer were 2171.38 (3.9 % of PYLLcs from lung cancer) and from IHD were 1659.76 (3.6 % of PYLLcs from IHD). PYLLcs in men were greater than those in women (96,338.27 vs. 4748.20) in model 1. On the contrary, PYLLets in men were smaller than those in women (1858.24 vs. 1972.90), and the difference was 114.66 in model 1. PYLLets showed a similar increasing pattern with increasing age as that of ADets. Discussion A previous study has shown a higher risk of coronary heart disease, lung cancer, respiratory diseases, and stroke associated with exposure to ETS (Zhang et al. 2005), and the mortality due to exposure to ETS has been estimated in many countries. As far as we know, although a number of studies (Yoon et al. 2001; Yoo 2003; Kang 2005; Lee & Shon 2005; Yoo et al. 2005; Jee et al. 2006) have estimated the disease and economic


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Figure 2. Percent increase in attributable deaths compared with the previous age group in the Republic of Korea in 2010. Note: ETS = environmental tobacco smoke; F = female; M = male.

Figure 3. Annual trend of the number of deaths attributable to ETS in the Republic of Korea in 2005–2010. Note: COPD = chronic obstructive pulmonary disease; IHD = ischemic heart disease.

burden caused by current smoking, no effort has been made to estimate the impact due to exposure to ETS in Korea. We estimated ADcs and ADets for lung cancer and IHD in Korea using the data-sets from the 2010 Cause of Death Statistics and the 2009 KCHS. We also estimated the disease burden due to current smoking and ETS in terms of



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Figure 4. Annual trend of the number of deaths attributable to ETS in the Republic of Korea in 2005–2010 (using only the KNHANES data). Note: COPD = chronic obstructive pulmonary disease; IHD = ischemic heart disease.

PYLL. In total, 454 deaths from lung cancer and IHD were caused by ETS in 2009. PYLL caused by current smoking was 83,156.83 years (78,255.24 for men and 4901.58 for women) and caused by exposure to ETS was 6670.04 years (2879.01 for men and 3791.03 for women). The annual trend of ADets from diseases (including lung cancer, IHC, asthma, COPD, and stroke) decreased remarkably after 2008. This might be due to the trend in the total number of deaths from those diseases, which decreased slightly from 2008 to 2009. A large decrease in Pets after 2008 also might be the reason for the decreased ADets. In the trend analysis, we used Pets in 2009–2010 estimated from the KCHS data, which was based on the question regarding the number of hours exposed to ETS. The definition of exposure to ETS solely based on the presence or the number of smokers at home/work regardless of the hours of exposure may have resulted in overestimation of Pets (Kaufman et al. 2002). Nevertheless, when we analyzed the trend of ADets only using the KNHANES data, with a definition of exposure to ETS based on the response to the presence of smokers at home or exposure to ETS at work, the trend slightly decreased after 2008. Thus, we expect that the disease burden from ETS in the Republic of Korea may continue to decrease over time, but continuous analysis is required. According to a guide to assess the disease burden from ETS (Öberg et al. 2010), data on exposure to ETS at home, in the workplace, and in public places should be available to calculate the disease burden. According to a population-based, cross-sectional telephone survey conducted in the Republic of Korea in 2002, 68 % of adult non-smokers reported that they were exposed to ETS at home, work, and public places during typical daily life (Hughes et al. 2008). However, we could not consider exposure to ETS in public places because the survey questions in the KCHS and KNHANES


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only addressed exposure at home or work. Our lower estimates of Pets would lead to an underestimation of PAFets. According to the recent research, exposure to ETS caused far more mortality in patients with IHD than in patients with lung cancer (Gan et al. 2007). Gan et al. (2007) reported 33,800 ETS-related deaths due to IHD and 22,200 ETS-related deaths due to lung cancer in 2002 in China. In 2006, 34,000 Americans died of IHD and 7000 died of lung cancer caused by exposure to ETS (Max et al. 2012). The results of this study do not seem to support these findings, although the number of ADets from lung cancer is larger than that of IHD, because the difference is not remarkable. A much smaller number of deaths due to lung cancer and IHD than in other countries might be the reason why we could not show a significantly different effect on deaths between lung cancer and IHD. Previous research on worldwide disease burden from exposure to ETS showed that the effect on death was larger in women than in men in 2004 (Öberg et al. 2011). The results of this study also showed that the disease burden from ETS was larger in women than in men (Figure 1). Researchers reported that the higher number of female nonsmokers than male non-smokers and the higher prevalence of ETS exposure in female non-smokers were the reasons for the difference (Öberg et al. 2011). The number of male and female non-smokers aged 20 years and older was 58,008 and 120,250, respectively, in Korea in 2010. Overall, the results provide evidence of the vulnerability of women compared with men in terms of the health effects of ETS. Most ADets occurred in those older than their 40s (Table 3). This might be due to the latent period for the onset of chronic diseases. For example, the latent period of lung cancer is 10–20 years from the start of exposure (Jaakkola & Jaakkola 1997; Jaakkola & Samet 1999). To reflect this concept, we used the average of annual Pets between 2005 and 2010. This period was not sufficiently long but led to larger ADets compared with ADets estimated from Pets only in 2010. The average Pets was smaller than Pets in 2010 because Pets has increased. A smaller Pets led to a smaller ADets because PAFets also decreased due to the construction of the formula. On the other hand, the increase in the total number of deaths from the outcomes in older ages might contribute to the increasing pattern of ADets with increasing age, whereas PAFets and Pets in both sexes decreased with increasing age (Tables 2 and 3). Consequently, it is assumed that the elderly population is most susceptible to the disease burden from ETS exposure. The process of analysis has several strengths. First, we focused on various major health outcomes, including lung cancer, IHD, COPD, asthma, and stroke. Some investigators selected only lung cancer and IHD for assessment of disease burden from ETS exposure (Gan et al. 2007; Lopez et al. 2007) because the evidence for these two diseases has been determined by the Environmental Protection Agency and the US Surgeon General to be sufficient to establish a causal relationship (California Environmental Protection Agency: Air Resources Board 2005; General 2006). Expert agency panels such as the California Environmental Protection Agency, the US Surgeon General, and the International Agency for Research on Cancer reported that evidence of asthma, COPD, and stroke was suggestive but not sufficient to conclude a causal relationship (California Environmental Protection Agency: Air Resources Board 2005; General 2006; Johnson et al. 2011; Reynolds 2013). However, evidence has shown a potential association between ETS exposure and many outcomes, including the onset of asthma in adults, COPD, and stroke (Max et al. 2012). A study by Jamrozik included adult deaths from lung cancer, IHD, and stroke to estimate the number of ADets in the United Kingdom (Jamrozik 2005). Oberg et al. (Öberg et al. 2011) included deaths from asthma, lower respiratory infections, otitis, lung cancer, and IHD to estimate the

International Journal of Environmental Health Research Table 2. (2010).

Prevalence of current smoking and ETSa exposure by age group in men and women

Smoking status

Age group, years (n)

Current smoking 20–29 (25,795) 30–39 (40,125) 40–49 (46,023) 50–59 (42,811) 60–69 (36,123) ≥ 70 (35,920) Total (226,767) ETS exposure


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20–29 (19,665) 30–39 (28,513) 40–49 (33,278) 50–59 (33,199) 60–69 (30,153) ≥ 70 (31,392) Total (176,200)

Male (%)

Female (n)

n = 103,512 46.87 57.84 53.83 44.16 32.82 25.01 49.96 n = 57,219 27.44 36.90 32.10 25.54 12.60 4.55 22.19

n = 123,285 3.45 2.99 3.18 3.40 2.86 4.57 3.40 n = 118,981 22.48 21.96 28.24 24.04 13.87 8.27 19.91

a

ETS = environmental tobacco smoke.

worldwide disease burden from exposure to ETS. The World Health Organization has suggested that investigators quantify the disease burden from exposure to ETS including these additional outcomes, recognizing that the evidence is not sufficient (Öberg et al. 2010). Consequently, an estimate of ADets depends on the assumption about the range of ETS-related diseases. We declare that inclusion of various ETS-related diseases would result in a larger estimate of total ADets in Korean adults. Second, we estimated not only the number of ADs but also the disease burden using PYLL. Using PYLL is more empirical for decision-making and evaluation of public health intervention because PYLL is presented as an index that focuses on the social and economic consequences of health outcomes (Gardner & Sanborn 1990). Third, we obtained the RR for lung cancer, IHD, and COPD due to current smoking from the previous studies of the Korean population. Several studies (Yoon et al. 2001; Yoo 2003) have estimated the disease burden due to current smoking by adopting the RR from the results of other countries because of the lack of available information on the Korean population. Thus, we expect that the estimation of PAFcs represents the actual impact of current smoking more appropriately. Fourth, we used a more informative survey question regarding exposure to ETS. Estimation of exposure to ETS is subjective to the definition of exposure. The World Health Organization defines exposure to ETS based on the length of time exposed to ETS (at least 15 min/day for at least 1 day per week) (Gan et al. 2007). In the KCHS, interviewees answered the closed question “How many hours are you exposed to ETS at home/workplace?” and the possible answers were as follows: (1) 0 h, (2) less than 1 h, and (3) more than 1 h. Many epidemiological studies use a less clearly defined but much more simplified definition based on the presence or the number of smokers in the household (Gan et al. 2007). According to a study, estimating the prevalence of exposure to ETS using data on hours of exposure to ETS is additionally required because the number of household smokers alone does not provide an actual individual level of exposure to ETS and may lead to misclassification of exposure (Kaufman et al. 2002), as mentioned before. We expect that the survey question used in the KCHS was much

20–29 30–39 40–49 50–59 60–69 ≥ 70 Total 20–29 30–39 40–49 50–59 60–69 ≥ 70 Total

4 (0.1) 36 (0.6) 201 (3.3) 758 (12.4) 1754 (28.7) 3114 (51.0) 5867 (96.1) 0 (0.0) 2 (0.0) 9 (0.1) 20 (0.3) 32 (0.5) 178 (2.9) 241 (3.9) 6108 (100.0)

ADcsb (%)

62.8 67.6 66.0 61.4 54.2 47.4 64.3 4.9 4.3 4.6 4.9 4.1 6.4 4.9

PAFcsc

0 (0.0) 1 (0.5) 4 (1.8) 18 (8.2) 35 (16.0) 34 (15.5) 92 (42.0) 0 (0.0) 2 (0.9) 13 (5.9) 25 (11.4) 28 (12.8) 58 (26.5) 127 (58.0) 219 (100.0)

ADetsd (%)

7.4 9.7 8.5 6.9 3.5 1.3 6.0 6.1 6.0 7.6 6.5 3.9 2.3 5.5

PAFetse 5 (0.2) 56 (2.6) 200 (9.4) 339 (15.9) 371 (17.4) 817 (38.3) 1788 (83.8) 0 (0.0) 0 (0.0) 4 (0.2) 8 (0.4) 21 (1.0) 313 (14.7) 346 (16.2) 2134 (100.0)

ADcs (%) 62.8 67.6 66.0 61.4 54.2 47.4 64.3 4.9 4.3 4.6 4.9 4.1 6.4 4.9

PAFcs

IHD

b

ETS = environmental tobacco smoke. ADcs = number of deaths attributable to current smoking. c PAFcs = population attributable fraction due to current smoking. d ADets = number of deaths attributable to ETS exposure. e PAFets = population attributable fraction due to ETS exposure. f IHD = ischemic heart disease. g COPD = chronic obstructive pulmonary disease.

a

Total

Female

Male

Sex

Lung cancer

ADets (%) 0 (0.0) 3 (1.5) 11 (5.4) 21 (10.3) 19 (9.3) 23 (11.3) 77 (37.7) 0 (0.0) 1 (0.5) 5 (2.5) 9 (4.4) 17 (8.3) 95 (46.6) 127 (62.3) 204 (100.0)

f

7.4 9.7 8.5 6.9 3.5 1.3 6.0 6.1 6.0 7.6 6.5 3.9 2.3 5.5

PAFets 2 (0.6) 2 (0.6) 8 (2.5) 12 (3.7) 32 (9.9) 196 (60.9) 252 (78.3) 0 (0.0) 0 (0.0) 1 (0.3) 1 (0.3) 2 (0.6) 66 (20.5) 69 (21.4) 322 (100.0)

ADcs (%) 45.6 50.9 49.1 44.1 37.0 30.9 47.2 5.8 5.1 5.4 5.7 4.9 7.6 5.8

PAFcs 0 (0.0) 0 (0.0) 1 (1.1) 2 (2.3) 4 (4.5) 14 (15.9) 21 (23.9) 0 (0.0) 0 (0.0) 2 (2.3) 2 (2.3) 5 (5.7) 57 (64.8) 67 (76.1) 88 (100.0)

ADets (%)

Asthma

Disease related to ETS exposure

21.0 26.4 23.7 19.9 10.9 4.2 17.7 17.9 17.6 21.5 18.9 11.9 7.4 16.2

PAFets 0 (0.0) 0 (0.0) 9 (1.1) 41 (4.9) 113 (13.6) 598 (72.0) 761 (91.7) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.1) 3 (0.4) 64 (7.7) 69 (8.3) 830 (100.0)

ADcs (%) 31.3 35.9 34.3 30.0 24.1 19.5 32.6 3.2 2.8 3.0 3.2 2.7 4.2 3.2

PAFcs 0 (0.0) 0 (0.0) 1 (0.7) 7 (4.9) 15 (10.6) 45 (31.7) 68 (47.9) 0 (0.0) 0 (0.0) 2 (1.4) 4 (2.8) 8 (5.6) 60 (42.3) 74 (52.1) 142 (100.0)

ADets (%)

COPDg

13.1 16.9 15.0 12.3 6.5 2.4 10.9 11.0 10.8 13.4 11.7 7.1 4.4 9.9

PAFets

Attributable deaths and fractions of current smoking and ETSa for selected diseases in the Republic of Korea in 2010.

Age (years)

Table 3.


6 (0.3) 39 (2.0) 150 (7.5) 228 (11.4) 339 (17.0) 943 (47.2) 1705 (85.3) 0 (0.0) 1 (0.1) 5 (0.3) 11 (0.6) 18 (0.9) 257 (12.9) 293 (14.7) 1998 (100.0)

ADcs (%)

19.3 22.8 21.5 18.4 14.3 11.3 20.3 1.7 1.5 1.6 1.7 1.4 2.3 1.7

PAFcs

1 (0.2) 5 (1.0) 19 (4.0) 34 (7.1) 42 (8.8) 62 (13.0) 162 (34.0) 1 (0.2) 5 (1.0) 21 (4.4) 35 (7.3) 41 (8.6) 213 (44.7) 315 (66.0) 477 (100.0)

ADets (%)

Stroke

6.4 8.4 7.4 6.0 3.1 1.1 5.3 5.3 5.2 6.6 5.7 3.4 2.0 4.7

PAFets

12 S. Heo and J.-T. Lee

20–29 30–39 40–49 50–59 60–69 ≥ 70 Total 20–29 30–39 40–49 50–59 60–69 ≥ 70 Total

4 (0.1) 34 (0.6) 188 (3.4) 703 (12.7) 1607 (29.1) 2817 (51.1) 5353 (97.0) 0 (0.0) 1 (0.0) 6 (0.1) 13 (0.2) 22 (0.4) 122 (2.2) 164 (3.0) 5517 (100.0)

ADcsc (%)

58.4 63.4 61.8 57.0 49.6 42.9 60.0 3.3 2.9 3.1 3.3 2.8 4.4 3.3

PAFcsd

0 (0.0) 0 (0.0) 1 (3.1) 3 (9.4) 5 (15.6) 5 (15.6) 14 (43.8) 0 (0.0) 0 (0.0) 2 (6.3) 4 (12.5) 4 (12.5) 8 (25.0) 18 (56.3) 32 (100.0)

e

1.1 1.5 1.3 1.0 0.5 0.2 0.9 0.9 0.9 1.1 1.0 0.6 0.3 0.8

PAFetsf 4 (0.2) 48 (2.9) 171 (10.2) 286 (17.0) 309 (18.4) 672 (39.9) 1490 (88.5) 0 (0.0) 0 (0.0) 2 (0.1) 4 (0.2) 12 (0.7) 175 (10.4) 193 (11.5) 1683 (100.0)

ADcs (%) 58.4 63.4 61.8 57.0 49.6 42.9 60.0 3.3 2.9 3.1 3.3 2.8 4.4 3.3

PAFcs

ADets (%) 0 (0.0) 1 (0.8) 5 (4.2) 11 (9.3) 9 (7.6) 11 (9.3) 37 (31.4) 0 (0.0) 0 (0.0) 3 (2.5) 6 (5.1) 11 (9.3) 61 (51.7) 81 (68.6) 118 (100.0)

IHD

1.1 1.5 1.3 1.0 0.5 0.2 0.9 0.9 0.9 1.1 1.0 0.6 0.3 0.8

PAFets 0 (0.0) 0 (0.0) 1 (2.4) 2 (4.7) 5 (11.8) 27 (63.7) 35 (82.6) 0 (0.0) 0 (0.0) 0 (0.1) 0 (0.2) 0 (0.6) 7 (16.5) 7 (17.4) 42 (100.0)

ADcs (%)

b

7.8 9.4 8.8 7.4 5.6 4.3 8.3 0.6 0.5 0.6 0.6 0.5 0.8 0.6

PAFcs 0 (0.0) 0 (0.0) 0 (0.0) 1 (4.8) 1 (4.8) 4 (19.0) 6 (28.6) 0 (0.0) 0 (0.0) 0 (0.0) 1 (4.8) 1 (4.8) 13 (61.9) 15 (71.4) 21 (100.0)

ADets (%)

Asthma

5.0 6.6 5.7 4.6 2.3 0.9 4.0 4.1 4.0 5.1 4.4 2.6 1.5 3.6

PAFets


IHD = ischemic heart disease. COPD = chronic obstructive pulmonary disease. c ADcs = the number of deaths attributable to current smoking. d PAFcs = population attributable fraction due to current smoking. e ADets = number of deaths attributable to environmental tobacco smoke exposure. f PAFets = population attributable fraction due to environmental tobacco smoke exposure.

a

Total

Female

Male

Sex

ADets (%)

Lung cancer

a

0 (0.0) 0 (0.1) 3 (1.4) 12 (5.4) 31 (14.0) 160 (72.0) 206 (92.8) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.1) 1 (0.3) 15 (6.8) 16 (7.2) 222 (100.0)

ADcs (%) 9.3 11.3 10.6 8.9 6.7 5.2 9.9 0.8 0.7 0.7 0.7 0.6 1.0 0.7

PAFcs 0 (0.0) 0 (0.0) 0 (0.0) 2 (7.4) 3 (11.1) 9 (33.3) 14 (51.9) 0 (0.0) 0 (0.0) 0 (0.0) 1 (3.7) 1 (3.7) 11 (40.7) 13 (48.1) 27 (100.0)

ADets (%)

COPDb

2.4 3.2 2.8 2.2 1.1 0.4 2.0 2.0 1.9 2.5 2.1 1.2 0.7 1.8

PAFets

5 (0.3) 35 (2.0) 136 (7.6) 206 (11.5) 304 (17.0) 843 (47.1) 1529 (85.5) 0 (0.0) 1 (0.1) 5 (0.3) 10 (0.6) 16 (0.9) 227 (12.7) 259 (14.5) 1788 (100.0)

ADcs (%)

17.4 20.7 19.5 16.6 12.9 10.1 18.4 1.5 1.3 1.4 1.5 1.3 2.0 1.5

0 (0.0) 2 (0.9) 10 (4.3) 17 (7.3) 21 (9.0) 31 (13.2) 81 (34.6) 0 (0.0) 2 (0.9) 10 (4.3) 17 (7.3) 20 (8.5) 104 (44.4) 153 (65.4) 234 (100.0)

ADets (%)

Stroke

PAFcs

Attributable deaths and fractions of current smoking and ETS derived using the lower limit of 95 % CI for the relative risk (2010).

Age (years)

Table 4.


3.2 4.2 3.7 3.0 1.5 0.5 2.6 2.6 2.6 3.3 2.8 1.6 1.0 2.3

PAFets

International Journal of Environmental Health Research 13

20–29 30–39 40–49 50–59 60–69 ≥ 70 Total 20–29 30–39 40–49 50–59 60–69 ≥ 70 Total

4 (0.1) 39 (0.6) 213 (3.2) 808 (12.1) 1896 (28.3) 3405 (50.9) 6365 (95.1) 0 (0.0) 2 (0.0) 12 (0.2) 27 (0.4) 44 (0.7) 244 (3.6) 329 (4.9) 6694 (100.0)

ADcsc (%)

66.8 71.3 69.8 65.5 58.5 51.8 68.2 6.8 5.9 6.3 6.7 5.7 8.8 6.7

PAFcsd

0 (0.0) 1 (0.3) 7 (1.7) 32 (7.7) 63 (15.4) 63 (15.3) 166 (40.4) 1 (0.2) 4 (1.1) 25 (6.0) 47 (11.3) 55 (13.2) 115 (27.8) 246 (59.6) 412 (100.0)

ADetse (%)

14.1 18.1 16.1 13.3 7.0 2.7 11.7 11.9 11.6 14.5 12.6 7.7 4.7 10.7

PAFetsf 6 (0.2) 63 (2.2) 228 (7.8) 389 (13.3) 432 (14.8) 960 (32.9) 2078 (71.2) 0 (0.0) 1 (0.0) 9 (0.3) 19 (0.6) 52 (1.8) 759 (26.0) 840 (28.8) 2918 (100.0)

ADcs (%) 66.8 71.3 69.8 65.5 58.5 51.8 68.2 6.8 5.9 6.3 6.7 5.7 8.8 6.7

PAFcs

ADets (%) 0 (0.2) 4 (1.4) 15 (5.4) 31 (11.1) 28 (10.3) 34 (12.4) 112 (40.8) 0 (0.1) 1 (0.3) 7 (2.4) 11 (4.1) 23 (8.2) 122 (44.2) 163 (59.2) 276 (100.0)

IHDa

14.1 18.1 16.1 13.3 7.0 2.7 11.7 11.9 11.6 14.5 12.6 7.7 4.7 10.7

PAFets 4 (0.6) 3 (0.5) 12 (1.9) 20 (3.1) 56 (8.7) 368 (56.8) 463 (71.4) 0 (0.0) 0 (0.0) 2 (0.3) 2 (0.3) 6 (0.9) 175 (27.0) 185 (28.6 648 (100.0)

ADcs (%)

b

72.2 76.2 74.9 71.0 64.6 58.1 73.5 16.1 14.2 15.0 15.9 13.7 20.2 15.9

PAFcs 0 (0.2) 0 (0.1) 1 (0.5) 2 (1.1) 5 (3.1) 18 (12.6) 26 (17.7) 0 (0.0) 1 (0.6) 3 (2.2) 4 (2.7) 9 (6.3) 104 (70.6) 121 (82.3) 147 (100.0)

ADets (%)

Asthma


IHD = ischemic heart disease. COPD = chronic obstructive pulmonary disease. c ADcs = the number of deaths attributable to current smoking. d PAFcs = population attributable fraction due to current smoking. e ADets = number of deaths attributable to environmental tobacco smoke exposure. f PAFets = population attributable fraction due to environmental tobacco smoke exposure.

a

Total

Female

Male

Sex

Lung cancer

38.2 45.4 41.9 36.5 22.1 9.3 33.3 33.6 33.1 38.9 35.1 23.8 15.7 30.9

PAFets 0 (0.0) 1 (0.1) 15 (1.0) 67 (4.4) 195 (12.9) 1081 (71.8) 1359 (90.2) 0 (0.0) 0 (0.0) 1 (0.1) 2 (0.1) 7 (0.5) 137 (9.1) 147 (9.8) 1506 (100.0)

ADcs (%) 50.5 55.8 54.0 49.0 41.7 35.3 52.1 7.0 6.1 6.5 6.9 5.9 9.1 6.9

PAFcs 0 (0.0) 0 (0.0) 2 (0.6) 9 (3.5) 24 (9.4) 78 (30.1) 113 (43.7) 0 (0.0) 1 (0.2) 3 (1.3) 7 (2.6) 15 (5.8) 119 (46.4) 145 (56.3) 257 (100.0)

ADets (%)

COPDb

24.9 30.9 28.0 23.6 13.2 5.2 21.2 21.4 21.0 25.5 22.5 14.4 9.1 19.4

PAFets

6 (0.3) 43 (1.9) 166 (7.4) 253 (11.3) 378 (16.9) 1056 (47.3) 1902 (85.1) 0 (0.0) 2 (0.1) 6 (0.3) 12 (0.5) 21 (0.9) 291 (13.0) 332 (14.9) 2234 (100.0)

ADcs (%)

21.4 25.1 23.8 20.4 16.0 12.7 22.5 2.0 1.7 1.8 1.9 1.6 2.6 1.9

1 (0.3) 7 (1.9) 27 (7.4) 49 (11.3) 61 (16.9) 93 (47.3) 238 (85.1) 1 (0.0) 7 (0.1) 31 (0.3) 51 (0.5) 61 (0.9) 319 (13.0) 470 (14.9) 708 (100.0)

ADets (%)

Stroke

PAFcs

Attributable deaths and fractions of current smoking and ETS derived using the upper limit of 95 % CI for the relative risk (2010).

Age (years)

Table 5.


9.4 12.3 10.9 8.8 4.6 1.7 7.8 7.9 7.7 9.7 8.4 5.0 3.0 7.0

PAFets

14 S. Heo and J.-T. Lee

30–39 40–49 50–59 60–69 ≥ 70 Total 20–29 30–39 40–49 50–59 60–69 ≥ 70 Total

Female

30–39 40–49 50–59 60–69 ≥ 70 Total 20–29 30–39 40–49 50–59 60–69 ≥ 70 Total

Female

Total

20–29

Male

Total

20–29

Age

Male

Sex

(1412.67–1588.22) (5956.89–6735.64) (15429.63–17736.10) (19259.98–22721.24) (6420.10–7760.56) (48658.80–56747.09) (12.99–26.31) (54.98–111.89) (226.32–459.68) (395.30–801.15) (408.94–833.29) (649.19–1300.76) (1747.72–3533.09) (50406.52–60280.18)

37.10 148.55 383.05 333.30 54.53 961.02 12.04 57.66 281.88 396.07 289.73 172.99 1210.36 2171.38

(6.29–61.50) (24.84–249.68) (62.58–659.41) (52.12–601.22) (8.26–101.89) (154.83–1681.35) (1.78–22.93) (8.51–110.22) (42.24–529.90) (58.83–751.49) (41.91–566.32) (24.88–340.43) (178.16–2321.29) (332.98–4002.64)

4.48 (0.74–7.65)

1504.34 6362.42 16621.22 21025.72 7095.77 52802.35 19.16 81.29 334.32 583.36 605.00 952.96 2576.10 55378.45

192.89 (179.52–205.32)

Lung cancer

101.17 269.64 339.56 152.18 23.64 897.22 5.17 17.47 130.18 165.82 206.03 237.87 762.54 1659.76

(17.15–167.68) (45.10–453.21) (55.47–584.54) (23.80–274.51) (3.58–44.17) (146.91–1542.96) (0.77–9.85) (2.58–33.40) (19.50–244.71) (24.63–314.63) (29.81–402.73) (34.22–468.11) (111.50–1473.42) (258.42–3016.39)

11.03 (1.81–18.86)

4101.60 (3851.67–4330.31) 11548.60 (10812.52–12226.06) 14734.08 (13677.78–15722.38) 9600.15 (8793.93–10374.31) 3076.18 (2783.26–3364.39) 43535.92 (40361.56–46523.40) 8.23 (5.58–11.30) 24.63 (16.66–33.90) 154.39 (104.52–212.29) 244.24 (165.50–335.42) 430.24 (290.81–592.58) 1310.38 (892.68–1788.63) 2172.11 (1475.74–2974.12) 45708.03 (41837.30–49497.51)

475.31 (442.38–505.96)

IHDc

b

(15.45–124.89) (45.51–386.00) (46.73–450.70) (56.53–654.23) (27.08–365.37) (212.30–2176.23) (0.00–0.00) (0.73–19.53) (2.27–59.81) (2.52–65.88) (4.28–114.41) (19.88–492.87) (29.68–752.50) (241.98–2928.73)

11.27 33.10 37.39 36.94 9.75 144.85 0.00 12.15 43.10 39.30 50.06 88.85 233.46 378.30

(5.16–9.38) (14.34–28.79) (14.45–35.66) (11.89–42.15) (2.74–12.99) (55.14–144.16) (0.00–0.00) (2.90–20.68) (10.73–69.96) (9.57–65.11) (11.34–91.09) (19.86–161.97) (54.40–408.80) (109.54–552.96)

16.40 (6.56–15.21)

83.32 252.82 280.17 375.03 194.39 1308.90 0.00 6.97 21.47 23.81 40.68 184.21 277.14 1586.04

123.18 (21.01–195.03)

Asthma

(4.43–21.86) (88.46–451.04) (261.59–1449.02) (360.92–2235.34) (182.73–1236.29) (898.13–5393.55) (0.00–0.00) (0.92–8.58) (3.59–33.52) (7.10–65.99) (12.84–120.49) (43.47–395.65) (67.91–624.22) (966.04–6017.77)

2.25 43.76 135.35 139.98 36.58 357.91 0.00 7.80 35.82 57.44 75.22 96.66 272.94 630.85

(0.59–2.84) (11.14–57.13) (32.14–188.79) (29.78–219.59) (7.20–62.87) (80.86–531.22) (0.00–0.00) (1.43–14.68) (6.76–65.42) (10.68–106.59) (13.36–147.55) (16.97–191.93) (49.21–526.17) (130.07–1057.39)

0.00 (0.00–0.00)

14.09 286.57 885.94 1294.23 684.06 3164.89 0.00 3.95 15.47 30.53 55.42 185.37 290.74 3455.63

0.00 (0.00–0.00)

COPDd 288.96 (260.88–320.14)

Stroke

245.19 689.34 735.90 393.50 70.11 2175.28 28.84 129.50 444.49 568.21 416.39 474.23 2061.66 4236.94

(126.49–346.19) (353.13–979.86) (372.67–1058.02) (195.22–577.41) (34.31–104.33) (1102.77–3124.89) (14.27–42.56) (64.00–191.26) (221.35–651.80) (281.59–836.99) (203.76–620.84) (230.67–711.09) (1015.64–3054.55) (2118.40–6179.44)

41.23 (20.95–59.08)

1611.84 (1461.37–1777.50) 4794.78 (4340.69–5296.30) 5197.55 (4687.44–5765.47) 4059.53 (3643.39–4527.61) 1496.54 (1338.29–1675.92) 17449.19 (15732.06–19362.96) 17.95 (15.87–20.37) 71.42 (63.13–81.05) 205.75 (181.89–233.48) 327.11 (289.21–371.14) 341.10 (301.48–387.15) 1027.01 (908.62–1164.33) 1990.34 (1760.19–2257.53) 19439.53 (17492.26–21620.48)

PYLL due to current smoking and exposure to ETS in the Republic of Korea in 2010.

Model 1 includes PYLL due to lung cancer and IHD. Model 2 includes lung cancer, IHD, asthma, COPD, and stroke. c IHD = ischemic heart disease. d COPD = chronic obstructive pulmonary disease. e PYLLcs = potential years of life lost due to current smoke. f PYLLets = potential years of life lost due to environmental tobacco smoke.

a

PYLLetsf (95 % CI)

PYLLcse (95% CI)

Table 6. Total (model 1)a

(5264.35–5918.53) (16769.42–18961.70) (29107.42–33458.48) (28053.91–33095.54) (9203.36–11124.95) (89020.36–103270.49) (18.57–37.61) (71.64–145.79) (330.83–671.97) (560.80–1136.57) (699.75–1425.87) (1541.86–3089.40) (3223.46–6507.21) (92243.81–109777.69)

138.27 418.20 722.62 485.48 78.17 1858.24 17.21 75.13 412.06 561.89 495.76 410.86 1972.90 3831.14

(23.45–229.18) (69.94–702.89) (118.05–1243.94) (75.91–875.74) (11.84–146.06) (301.74–3224.31) (2.55–32.78) (11.08–143.62) (61.74–774.61) (83.47–1066.12) (71.72–969.05) (59.10–808.54) (289.66–3794.71) (591.40–7019.02)

15.51 (2.55–26.51)

5605.94 17911.02 31355.31 30625.87 10171.95 96338.27 27.39 105.92 488.72 827.60 1035.24 2263.34 4748.20 101086.47

668.19 (621.91–711.28)


(6745.59–7842.78) (21244.07–25095.05) (34103.18–41123.68) (32114.75–40512.72) (10751.46–14402.53) (105862.85–130203.22) (34.44–57.98) (136.42–254.95) (518.58–998.78) (859.63–1639.58) (1018.35–2047.92) (2513.83–5142.25) (5081.24–10141.45) (110944.09–140344.67)

396.98 1184.39 1631.25 1055.90 194.61 4536.28 46.06 224.58 935.47 1226.84 1037.43 1070.59 4540.96 9077.24

(155.69–587.59) (448.56–1768.66) (537.32–2526.42) (312.80–1714.89) (56.08–326.24) (1540.51–7024.59) (16.82–75.34) (79.43–370.23) (300.57–1561.78) (385.31–2074.82) (300.18–1828.53) (326.60–1873.53) (1408.90–7784.23) (2949.41–14808.82)

73.14 (30.06–100.79)

7315.19 23245.19 37718.96 36354.65 12546.94 118261.25 45.34 188.26 731.41 1209.04 1472.43 3659.92 7306.42 125567.67

1080.33 (903.80–1226.45)

Total (model 2)b

International Journal of Environmental Health Research 15


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informative than the definition based on the presence of smokers and also simple enough not to lead a significant number of missing answers. Consequently, we expect that the prevalence of exposure to ETS was properly estimated. The findings in this study are subject to several limitations. First, the impact of exposure to ETS was underestimated because we analyzed disease burden only in adult non-smokers. Smokers are also affected by ETS. However, it was not feasible to analyze the separate effects of ETS and current smoking in this study because of a lack of information. We also could not estimate the disease burden in infants because we could not obtain data on the prevalence of exposure to maternal smoking in utero. Exposure to maternal smoking in utero is suspected to be associated with low birth weight, sudden infant death syndrome, asthma, and lower respiratory tract infections in children (Anderson & Cook 1997; Cook & Strachan 1997; Boldo et al. 2010). In a previous study, the proportion of deaths in infants among all ADets in white non-smokers was approximately 1.6 %, with a maternal smoking exposure prevalence rate in utero of 2.8 % in the United States in 2006 (Max et al. 2012). Based on the data, there were 97 and 41 infant deaths from sudden infant death syndrome and low birth weight, respectively, in the Republic of Korea in 2010. Overall, we expect that ADets in infants would not hugely increase the estimates of deaths in infants in this study. Second, the history of smoking was not considered because the Pcs and Pets used in this study were based on cross-sectional data. We also could not consider the effect of the amount, period, and age at the start of current smoking or ETS exposure. Thus, the estimate of ADcs and ADets might not be accurate. However, to reflect the effect of past exposure as well as cumulative risk, we used the average of annual Pets in 2005–2010 as mentioned previously. If data were stored for long enough to reflect this issue, the results of analysis would be more accurate. Third, because of a lack of available data, we used the RR for exposure to ETS from studies conducted in Western countries. We obtained the RR for lung cancer from exposure to ETS from the 2005 report of the California Environmental Protection Agency (California Environmental Protection Agency: Air Resources Board 2005), as Max et al. (2012) did. For IHD, we obtained the RR for exposure to ETS from a metaanalysis based on 18 epidemiological studies. Using the risk estimates from other countries for different disease conditions in Korean adults might have created inevitable bias in this study. Thus, to estimate the attributable risk of exposure to ETS more properly, a long-term observational study based on Korean non-smokers is required. Fourth, the variations of the disease burden in the current study might not be accurate because we calculated the variations by plugging the upper and lower limits of the 95 % CI of the risk into the formula for PAF. This method is believed to be unlikely to provide an accurate CI for PAF (Uter & Pfahlberg 2001). Numerous studies on PAF have not estimated CI for the attributable risk (Uter & Pfahlberg 2001) because they did not have the necessary raw data, which are used to calculate the CI, but borrowed relative risk from other studies. Still, validation or reconsideration should be focused on this problem because some studies on disease burden have provided CIs of PAF with this method. Some studies have reported that smoke-free laws or a smoking ban effectively reduces the prevalence of exposure to ETS in the community (Pickett et al. 2006; Haw & Gruer 2007), and a comprehensive smoking ban is believed to be helpful for the prevention of smoke-related diseases. For example, several studies have reported that smoke-free policies could contribute to a significant reduction in hospitalizations from acute coronary events (Barone-Adesi et al. 2011), acute myocardial infarction


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(Lightwood & Glantz 2009), and childhood asthma (Mackay et al. 2010). The government of the Republic of Korea started designated non-smoking areas in public spaces in 1999. Since 2012, a smoking ban has also widely expanded throughout many more public spaces. According to a previous study, comprehensive smoking ban policies in the Republic of Korea reduced the prevalence of smoking in men from 1992 to 2006 (Park et al. 2009). In addition, research results showing that ETS at home is more common than at work among female non-smokers in urban areas (Hughes et al. 2008) emphasize that interventions are required to reduce the exposure to ETS at home effectively. The future study objective in this field is to determine the efficacy of the policies for declines in the ETS-attributable risk in the Republic of Korea. Conclusion In conclusion, if non-smokers exposed to ETS had the same death rates as non-smokers not exposed to ETS, we would expect to see 1130 fewer deaths due to ETS (9.9 % of the mortality caused by current smoking) in 2010. PYLL of ETS-related diseases caused by exposure to ETS was 9077.24 years, which was approximately 7.2 % of that of the same diseases caused by current smoking. These results suggest that exposure to ETS poses considerable health problems for non-smokers, especially female adult non-smokers, in Korea. Abbreviations AD ADcs ADets CI COPD CS ETS IHD KCHS KNHANES Pcs Pets PAF PAFcs PAFets PYLL RR

Attributable death Number of deaths attributable to current smoking Number of deaths attributable to environmental tobacco smoke Confidence interval Chronic obstructive pulmonary disease Current smoking Environmental tobacco smoke Ischemic heart disease Korean Community Health Survey Korean National Health and Nutrition Examination Survey Prevalence of current smoking Prevalence of exposure to environmental tobacco smoke among nonsmokers Population attributable fraction Population attributable fraction due to current smoking Population attributable fraction due to exposure to environmental tobacco smoke Potential years of life lost Relative risk

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Burdens of Cardiometabolic Diseases Attributable to Dietary and Metabolic Risks in Korean Adults 2012-2013.