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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

Luísa Sório FlorInstitute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USAJason A AndersonInstitute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USABrooks W. MorganInstitute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USAMarie NgInstitute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USABhoomadevi A CFaculty of Allied Medical Sciences, Applied Science Private University, Amman, JordanHasan AalruzDepartment of Nursing, Al Zaytoonah University of Jordan, Amman, JordanUkachukwu Okoroafor AbaraoguDepartment of Medical Rehabilitation, University of Nigeria Nsukka, Enugu, NigeriaSamar Abd ElHafeezDepartment of Epidemiology, Alexandria University, Alexandria, EgyptMichael AbdelmassehDepartment of Surgery, Marshall University, Huntington, WV, USAMeriem AbdounDepartment of Health, University of Setif Algeria, Sétif, AlgeriaZinat AbdrakhmanovaHealth Research Institute, Al Farabi Kazakh National University, Almaty, KazakhstanRashad Abdul-GhaniUniversity of Science and Technology, Sana’aToufik Abdul‐RahmanAsrat Agalu AbejewSchool of Pharmacy, Bahir Dar University, Bahir Dar, EthiopiaOlugbenga Olusola AbiodunDepartment of Community Medicine, Babcock University, Ilishan-Remo, NigeriaOlumide AbiodunDepartment of Community Medicine, Babcock University, Ilishan-Remo, NigeriaRichard Gyan AboagyeSchool of Population Health, University of New South Wales, Sydney, NSW, AustraliaNagah M. AbourashedZoology Department, Benha University, Benha, EgyptDariush AbtahiDepartment of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, IranFuad Hamdi A. AbuadasPrimary Care Nursing Department, Al-Ahliyya Amman University, Amman, JordanAminu Kende AbubakarGraduate School of Public Health, St. Luke's International University, Tokyo, JapanBilyaminu AbubakarDepartment of Pharmacology and Toxicology, Usmanu Danfodiyo University, Sokoto, Sokoto, NigeriaRana Kamal Abu-FarhaClinical Pharmacy and Therapeutics Department, Applied Science Private University, Amman, JordanHana J AbukhadijahClinical Trials Unit, Hamad Medical Corporation, Doha, QatarAseel AburubFaculty of Allied Medical Sciences, Applied Science Private University, Amman, JordanSalahdein AburuzCollege of Pharmacy, University of Jordan, Amman, JordanApurba AcharyaInstitute of International Health, Charité Medical University Berlin, Berlin, GermanyKiran AcharyaLisa C. AdamsStanford University, Palo Alto, CA, USATajudeen Adesanmi AdebisiBabatope Oluwadamilare AdebiyiSchool of Public Health, University of the Western Cape, Bellville, South AfricaOluwatobi E AdegbileCenter for Disease Control and Prevention, Cephas Health Research Initiative Inc., Ilesa, NigeriaAdekola George AdepojuDepartment of Health Informatics, Indiana University Indianapolis, Indianapolis, IN, USADaniel Adeyemi AdepojuDepartment of Health Informatics, Indiana University Indianapolis, Indianapolis, IN, USAMiracle Ayomikun AdesinaDepartment of Physiotherapy, University of Ibadan, Ibadan, NigeriaWirawan AdikusumaResearch Center for Computing, National Research and Innovation Agency (BRIN), Cibinong, IndonesiaBereket Alemayehu AdmasuDepartment of Biostatistics and Bioinformatics, George Washington University, Washington, DC, USAAanuoluwapo Adeyimika AfolabiMahnaz AfshariSocial Determinants of Health Research Center, Saveh University of Medical Sciences, Saveh, IranMuhammad Sohail AfzalDepartment of Life Sciences, University of Management and Technology, Lahore, PakistanSaira AfzalDepartment of Community Medicine, King Edward Memorial Hospital, Lahore, PakistanDhiraj Motilal AgarwalVadu Rural Health Program, KEM Hospital Research Centre, Pune, IndiaFeleke Doyore AgideDepartment of Public Health, Kampala International University, Kampala, UgandaAntonella AgodiDepartment of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, Catania, ItalyAbdul Momin Rizwan AhmadDepartment of Health Sciences, University of York, York, EnglandAqeel AhmadCollege of Medicine, Shaqra University, Shaqra, Saudi ArabiaDanish AhmadSchool of Medicine and Psychology, Australian National University, Canberra, ACT, AustraliaKhabir AhmadKing Khaled Eye Specialist Hospital and Research Center, Riyadh, Saudi ArabiaSaheem AhmadDepartment of Health and Biological Sciences, Abasyn University, Peshawar, PakistanSajjad AhmadDepartment of Health and Biological Sciences, Abasyn University, Peshawar, PakistanSuhaib AhmadDepartment of Biosciences, University of Hail, Hail City, Saudi ArabiaAli AhmedDivision of Infectious Diseases and Global Public Health (IDGPH), University of California San Diego, San Diego, CA, USAAyman AhmedDivision of Infectious Diseases and Global Public Health (IDGPH), University of California San Diego, San Diego, CA, USAHaroon AhmedDepartment of Biosciences, COMSATS Institute of Information Technology, Islamabad, PakistanJahanzaib Mian AhmedFaculty of Pharmaceuticals and Allied Health Sciences, University of Balochistan Quetta, Quetta, PakistanKhalid A AhmedFaculty of Medicine, University of Khartoum, Khartoum, SudanMd Faisal AhmedDepartment of Applied Statistics and Data Science, Jahangirnagar University, Dhaka, BangladeshMohamed Mustaf AhmedMansoura University Hospitals, Mansoura University Hospital, Mansoura, EgyptM. AhmedInstitute for Global Health, SIMAD University, Mogadishu, SomaliaShahzaib AhmedDepartment of Medicine, Fatima Memorial Hospital College of Medicine and Dentistry, Lahore, PakistanDamilare Michael AkintundeMedecins Sans Frontieres - Holland, Doctors Without Borders, Omdurman, SudanTomi AkinyemijuDepartment of Population Health Sciences, Duke University, Durham, NC, USAHammad AkramDepartment of Infection Prevention & Control, Baylor Scott & White Health, Frisco, TX, USASalah Al AwaidyDepartment of Communicable Diseases, Ministry of Health, Muscat, OmanMohammad Al QadireAl al-Bayt University, Mafraq, JordanYazan Al ThaherSchool of Pharmacy, Cardiff University, Cardiff, WalesMohammad Ahmmad Mahmoud Al ZoubiMuaaz AlajlaniFaculty of Pharmacy, Syrian Private University, Damascus, SyriaMohammed Sultan Al-Ak’haliDepartment of Preventive Dental Sciences, Jazan University, Jazan, Saudi ArabiaMohammad Khursheed AlamDepartment of Biology, University of Hail, Hail, Saudi ArabiaMohammad Jahoor AlamDepartment of Biology, University of Hail, Hail, Saudi ArabiaRasmieh Al‐AmerSchool of Nursing, Yarmouk University, Irbid, JordanRuaa A. AlamoudiEndodontic Department, King Abdulaziz University, Jeddah, Saudi ArabiaShams M. F. Al-AnziSchool of Nursing, University of British Columbia, Vancouver, BC, CanadaFahmi Y. Al-AshwalDepartment of Clinical Pharmacy and Pharmacy Practice, University of Science and Technology (USTY), Sana'a, YemenAhmad Al‐AzayzihDepartment of Clinical Pharmacy, Jordan University of Science and Technology, Irbid, JordanAhmad M. Al-BashairehFaculty of Nursing, Philadelphia University, Amman, JordanMohammed AlbashtawyDepartment of Community and Mental Health, Al al-Bayt University, Mafraq, JordanAbdulelah Mastour AldhahirRespiratory Therapy Program, Jazan University, Jazan, Saudi ArabiaMohammed S AldossaryGeneral Directorate of Research and Studies, Ministry of Health, Riyadh, Saudi ArabiaRaouf AlebshehyDepartment of Health, University of Bath, Bath, EnglandAli Mamoon AlfalkiDepartment of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC, USAMohammed Ridha AlgethamiDepartment of Family and Community Medicine, University of Jeddah, Jeddah, Saudi ArabiaSaeed M. AlghamdiKhalid F. AlHabibDepartment of Cardiac Sciences, King Saud University, Riyadh, Saudi ArabiaMajdi MB AlhadidiFaculty of Nursing, Al Zaytoonah University of Jordan, Amman, JordanMuhamad Alhaj MoustafaDepartment of Internal Medicine, Mayo Clinic, Jacksonville, FL, USABaidaa AlhalabiDepartment of Nutrition, Homs University (formerly Al-Baath University), Homs, SyriaFadwa Naji AlhalaiqaCollege of Nursing, Qatar University, Doha, QatarAmidu AlhassanDepartment of Adult Health, University of Cape Coast, Cape Coast, GhanaMohammad Jamil Mohammad AlhawajrehSchool of Health Sciences, Hamdan Bin Mohammed Smart University, Dubai, United Arab EmiratesAshraf AlhumaidiDepartment of Oral and Maxillofacial Surgery, Xi'an Jiaotong University, Xi'an, ChinaInayat AliDepartment of Social and Cultural Anthropology, University of Vienna, Austria, Vienna, AustriaKamran AliCollege of Dental Medicine, Qatar University, Doha, QatarMohammad Daud AliDepartment of Pharmacy, Mohammed Al-Mana College for Medical Sciences, Dammam, Saudi ArabiaRafat AliDepartment of Biosciences, Jamia Millia Islamia, New Delhi, IndiaSyed Shujait AliUniversity of Swat, Swat, PakistanMontaha Al‐IedeThe School of Medicine, The University of Jordan, Amman, JordanSheikh Mohammad AlifInstitute of Health and Wellbeing, Federation University Australia, Melbourne, VIC, AustraliaSyed Mohamed AljunidDepartment of Public Health and Community Medicine, International Medical University, Kuala Lumpur, Malaysia

2026en

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BACKGROUND: Second-hand smoke (SHS) exposure remains a major source of morbidity and mortality among non-smokers. 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. FUNDING: Bloomberg Philanthropies and the Gates Foundation.

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DOI: 10.1016/s2468-2667(26)00168-4

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