Global, regional, and national prevalence of second-hand smoke and attributable disease burden in 204 countries and territories, 1990–2023: a systematic analysis for the Global Burden of Disease Study 2023

Summary
Background Second-hand smoke (SHS) exposure remains a major source of morbidity and mortality among nonsmokers. This study presents the first dedicated Global Burden of Diseases, Injuries, and Risk Factors Study (GBD)
publication to systematically quantify SHS prevalence and evaluate its effect as a global risk factor across a broader
range of outcomes.
Methods Using the GBD 2023 comparative risk assessment framework, we estimated SHS exposure prevalence and
attributable disease burden across 204 countries and territories from 1990 to 2023, stratified by age and sex. Exposure
estimates were derived by synthesising population-based surveys and household composition data through
spatiotemporal Gaussian process regression. Relative risks for nine health outcomes, now including asthma, were
estimated using the Burden of Proof methodology, and applied to calculate attributable deaths and disability-adjusted
life-years (DALYs).
Findings In 2023, an estimated 2·71 billion (95% UI 2·44–3·02) people worldwide were exposed to SHS, including
767 million (687–858) children aged 0–14 years. Age-standardised prevalence was highest in southeast Asia, east Asia,
and Oceania (48·4% [44·0–53·4]), with female individuals in some countries experiencing nearly 1·8 times the
exposure prevalence of male individuals. Despite a 22·2% (10·6–32·4) decline in global age-standardised prevalence
since 1990, this progress has not been sufficient to reduce the absolute number of exposed individuals, which has
remained stable globally and has risen sharply in sub-Saharan Africa (98·5% [62·0–144·4] increase) and North Africa
and the Middle East (72·1% [47·8–101·8] increase). In 2023, SHS exposure accounted for 1·66 million (1·33–2·07)
deaths and 44·8 million (35·8–54·3) DALYs globally. Ischaemic heart disease was the leading contributor to
SHS-attributable DALYs (12·0 million [9·31–15·2]) overall, while lower respiratory infections predominated among
children (5·16 million [3·48–7·12]).
Interpretation We estimated that SHS remains a substantial driver of global health loss, particularly through
cardiovascular and paediatric respiratory diseases. Persistent geographical disparities and growing absolute numbers
of exposed individuals in several regions underscore the urgent need for accelerated implementation and enforcement
of comprehensive tobacco control measures, particularly to protect women and children in both public and domestic
environments.