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A total of 53 studies were identified (Figure 1), with the sample size ranging from 126 to 73,363. Most studies were published in Chinese (n = 35) and a few were published in English (n = 18), with average NOS scores of 6.34 and 7.45, respectively. There were 48 case-control studies and 5 cohort studies, with average NOS scores of 6.52 and 8.60, respectively. The year in which each study began ranged from 1983 to 2019, with the majority being initiated from 1996 to 2009. In total, 31 of the studies were conducted on women, 4 studies were conducted on men, and 9 studies were conducted on children. The exposure sites were reported in only 16 studies (household or workplace). Among the 53 studies, two included four types of diseases each. Therefore, a total of 23 diseases (n = 59) were analyzed including: 15 types of cancer (n = 42)[49-86], 2 DRS (n = 7)[87-93], 2 DCS (n = 4)[55,94-95], and 4 other diseases (n = 6)[96-101] (Table 1). More details are shown in Supplementary Table S1, available in www.besjournal.com.
Table 1. Basic information regarding the selection of studies
Basic information Chinese English Total Number of participants NOS
(mean score)(n, %) (n, %) (n, %) Min Max Total 35 100.0 18 100.0 53 100.0 126 73,363 6.72 Language Chinese 35 100.0 − − 35 66.0 126 73,363 6.34 English − − 18 100.0 18 34.0 204 72,829 7.45 Study design Case-control 35 100.0 13 72.2 48 90.6 126 2,082 6.52 Cohort 0 0 5 27.8 5 9.4 15,486 73,363 8.60 Start year of
investigation1983–1995 8 22.9 1 5.6 9 17.0 126 1,776 6.56 1996–2009 17 48.6 16 88.9 33 62.3 210 73,363 6.91 2010–2021 9 25.7 1 5.6 10 18.9 218 1,284 6.30 None 1 2.9 0 0 1 1.9 552 552 6.00 Sex Women 15 39.5 16 61.5 31 48.4 244 73,363 7.19 Men 2 5.3 2 7.7 4 6.3 456 1,776 7.75 Both 13 34.2 7 26.9 20 31.3 210 23,415 7.05 Children 8 21.1 1 3.8 9 14.1 126 1,209 6.00 Exposure site Household 7 15.6 9 23.7 16 19.3 244 72,829 7.08 Workplace 9 20.0 7 18.4 16 19.3 244 72,829 7.08 Total 29 64.4 22 57.9 51 61.4 126 73,363 6.91 Cancer type Total 25 100.0 17 100.0 42 100.0 214 72,829 6.95 Lung Cancer[49-63] 9 36.0 6 35.3 15 35.7 244 72,829 6.73 Breast Cancer[64-71] 4 16.0 4 23.5 8 19.0 372 1,767 6.63 Bladder Cancer[72-74] 2 8.0 1 5.9 3 7.1 456 1,215 8.00 Liver Cancer[61,75,76] 2 8.0 1 5.9 3 7.1 794 23,415 7.00 Cervical Cancer[77,78] 2 8.0 0 0 2 4.8 312 413 6.00 Acute Lymphoblastic
Leukemia[79]1 4.0 0 0 1 2.4 613 613 6.00 Colon Cancer[80] 1 4.0 0 0 1 2.4 396 396 8.00 Colorectal Cancer[61] 0 0 1 5.9 1 2.4 23,415 23,415 9.00 Endometrial Cancer[81] 1 4.0 0 0 1 2.4 2,082 2,082 8.00 Esophageal Squamous
Cell Carcinoma[82]0 0 1 5.9 1 2.4 214 214 7.00 Intracranial Tumors[83] 1 4.0 0 0 1 2.4 537 537 6.00 Oral Cancer[84] 0 0 1 5.9 1 2.4 708 708 7.00 Papillary Thyroid Cancer[85] 1 4.0 0 0 1 2.4 369 369 6.00 Stomach Cancer[61] 0 0 1 5.9 1 2.4 23,415 23,415 9.00 Tongue Cancer[86] 1 4.0 0 0 1 2.4 876 876 7.00 Cancer[55] 0 0 1 5.90 1 2.4 72,829 72,829 9.00 DRS* Total 5 100.0 2 100.0 7 100.0 212 1,209 6.14 Asthma in Children[87-92] 5 100.0 1 50.0 6 85.7 212 1,209 6.00 Small Airway Obstruction[93] 0 0 1 50.0 1 14.3 648 648 7.00 DCS* Total 2 100.0 2 100.0 4 100.0 210 72,829 7.75 Stroke[55,94,95] 2 100.0 1 50.0 3 75.0 210 72,829 7.33 Cardiovascular Disease[55] 0 0 1 50.0 1 25.0 72,829 72,829 9.00 Other Diseases Total 3 100.0 3 100.0 6 100.0 126 28,177 7.17 Tuberculosis[96,97] 1 33.3 1 33.3 2 33.3 348 15,486 7.00 Legionnaires' Disease
(Children)[98]1 33.3 0 0 1 16.7 126 126 6.00 Otitis Media (Children)[99] 1 33.3 0 0 1 16.7 534 534 6.00 Type 2 Diabetes Mellitus[100] 0 0 1 33.3 1 16.7 28,177 28,177 9.00 All Causes of Mortality[101] 0 0 1 33.3 1 16.7 73,363 73,363 8.00 Note. For the basic information on sex, exposure site, and disease type, some studies contained more than one result, so the total number for each group could be more than that of the study design and the start year of investigation, respectively. *DRS: Diseases of the Respiratory System; DCS: Diseases of the Circulatory System; NOS: Newcastle Ottawa Scale. -
Among the 59 disease-specific studies, the definition of SHS exposure was clarified in 47.17% (n = 25) of cases. Of the studies, 22.64% (n = 12) were based on the time and frequency of exposure to SHS (Definition 1), and 24.53% (n = 13) were based on the family members who smoke (Definition 2).
The sources of SHS, according to three types of characteristics, were reported by 49.6% (n = 27) of studies. The first classification was “location”, such as household and workplace (Type 1); the second classification was “stage of life”, such as adulthood or childhood (< 18 or > 18 years), pregnant or post-pregnancy, or menopausal (Type 2); the third classification was based on specific family members (such as husband, parents), partners, or colleagues (Type 3). Because there was more than one type of SHS source in some articles, 20.75%, 24.53%, and 30.19% of the studies were classified according to the above three characteristics, respectively (Table 2). More details are shown in Supplementary Table S2, available in www.besjournal.com.
Table 2. Definition and characteristics of second-hand smoke exposure
Variables Definition of SHS (n, %) Characteristic of SHS (n, %) Undefined Definition 1 Definition 2 None Type 1 Type 2 Type 3 DCS 2 7.14 0 0 0 0 2 7.69 0 0 0 0 1 6.25 DRS 6 21.43 0 0 1 7.69 3 11.54 1 9.09 1 7.69 4 25.00 Cancers 17 60.71 10 83.33 11 84.62 15 57.69 10 90.91 12 92.31 11 68.75 Other diseases 3 10.71 2 16.67 1 7.69 6 23.08 0 0 0 0 0 0 Total 28 52.83 12 22.64 13 24.53 26 49.06 11 20.75 13 24.53 16 30.19 Note. Specific descriptions for the definitions and characteristics are provided in Supplementary Table S2. SHS, second-hand smoke; DRS, Diseases of the Respiratory System; DCS, Diseases of the Circulatory System. -
Following meta-analysis, we observed an OR of 1.79 (95% CI: 1.56–2.05) for all cancers, and ORs of 1.92 (95% CI: 1.42–2.59) for lung cancer, 1.57 (95% CI: 1.40–1.76) for breast cancer, 1.52 (95% CI: 1.12–2.05) for bladder cancer, and 1.37 (95% CI: 1.08–1.73) for liver cancer. The OR for DCS was 1.92 (95% CI: 1.29–2.85), and further 2.29 (95% CI: 1.26–4.16) for stroke. The OR for DRS was 1.76 (95% CI: 1.13–2.74), and further 1.82 (95% CI: 1.07–3.11) for asthma in children (Figures 2 and 3).
For the other 17 diseases for which meta-analysis was not performed, the ORs for colorectal cancer, endometrial cancer, cardiovascular disease, and tuberculosis were not statistically significant. Whereas the ORs for the other diseases ranged from 1.17 to 4.87, which did show a statistically significant difference. More details are provided in Table 3.
Table 3. The pooled odds ratios or odds ratios for SHS exposure
Diseases Subgroup Number of
observationsI2
(%)P-value Model POR/OR and 95% CI Egger's test POR/OR LL UL t P-value Cancers* 46 74.4 < 0.001 Random 1.79 1.56 2.05 2.74 0.000 Lung cancer* 17 83.2 < 0.001 Random 1.92 1.42 2.59 3.87 0.009 1983−1995* 4 0.3 0.390 Fixed 1.64 1.33 2.03 −3.17 0.125 1996−2009* 9 64.7 0.004 Random 1.34 1.03 1.74 3.02 0.072 2010−2019* 4 22.7 0.275 Fixed 7.85 5.11 12.07 −1.14 0.687 Women* 12 71.1 < 0.001 Random 1.65 1.22 2.24 2.41 0.076 Men* 2 0 0.843 Fixed 1.12 0.77 1.63 0.38 − Both* 5 92.5 < 0.001 Random 2.76 1.28 5.96 8.51 0.062 Household* 6 65.6 0.012 Random 1.59 1.08 2.35 0.03 0.991 Workplace* 6 72.1 0.003 Random 1.38 0.94 2.04 4.54 0.023 Total* 9 87.4 < 0.001 Random 2.20 1.33 3.62 4.60 0.061 Breast cancer* 8 38.8 0.121 Fixed 1.57 1.40 1.76 2.11 0.044 1983–1995* 2 0 0.763 Fixed 2.60 1.84 3.68 0.62 − 1996–2009* 6 0 0.853 Fixed 1.47 1.30 1.66 1.35 0.021 Household* 2 0 0.338 Fixed 1.38 1.15 1.65 3.42 − Workplace* 2 0 0.519 Fixed 1.16 0.89 1.51 −8.86 − Total* 8 38.8 0.121 Fixed 1.57 1.40 1.76 2.11 0.044 Bladder cancer* 4 40.9 0.166 Fixed 1.52 1.12 2.05 0.76 0.891 Liver cancer* 3 47.6 0.148 Fixed 1.37 1.08 1.73 0.02 0.997 Cervical cancer 2 1.84 1.04 3.28 3.91 2.21 6.92 Acute
Lymphoblastic
Leukemia1 3.32 1.94 5.68 Intracranial
Tumors2 1.78 1.10 2.86 1.91 1.10 3.33 Colon cancer 1 4.87 1.48 16.02 Colorectal cancer 1 1.26 0.83 1.89 Endometrial cancer 1 0.97 0.28 2.42 Stomach cancer 1 1.79 1.09 2.96 Esophageal
Squamous
Cell carcinoma1 2.04 1.14 3.70 Oral cancer 1 2.38 1.47 3.85 Papillary thyroid
Cancer1 3.86 1.47 10.15 Tongue cancer 1 2.69 1.67 4.32 Cancer 1 1.14 0.73 1.79 DCS* 4 52.9 0.095 Random 1.92 1.29 2.85 2.72 0.236 Stroke* 3 61.5 0.074 Random 2.29 1.26 4.16 2.59 0.410 Cardiovascular
Disease1 1.44 0.94 2.21 DRS* 7 87.7 < 0.001 Random 1.76 1.13 2.74 6.70 0.053 Asthma in Children* 6 89.7 < 0.001 Random 1.82 1.07 3.11 6.71 0.085 Small airway
Obstruction1 1.54 1.06 2.22 Other diseases 6 Tuberculosis 2 1.62 0.92 2.85 1.70 1.04 2.80 Legionnaires'
Disease (Children)1 2.10 1.22 3.63 Otitis media (Children) 1 2.24 1.52 3.16 Type 2 diabetes mellitus 1 1.17 1.00 1.37 All causes of mortality 1 1.08 1.00 1.17 Note. For the subgroups of sex and exposure site, some studies contained more than one result, so the number of results included in the subgroup analysis may be more than that of the disease-specific results. DRS: Diseases of the Respiratory System; DCS: Diseases of the Circulatory System. POR: pooled odds ratio; OR: odds ratio; LL: 95% lower limit; UL: 95% upper limit. *The results of meta-analysis. -
Because of the limited number of studies, subgroup analysis for different time periods, sexes, and exposure sites, were only performed for studies on lung cancer and breast cancer. Regarding the different time periods, the OR for lung cancer peaked in 2010–2019 (7.85, 95% CI: 5.11–12.07), and this value was significantly different from the values derived from the other two time periods, 1.64 (95% CI: 1.33–2.03) for 1983–1995 and 1.34 (95% CI: 1.03–1.74) for 1996–2009. For breast cancer, all of the studies were published before 2009, and the OR decreased from 2.60 (95% CI: 1.84–3.68) in 1983–1995 to 1.47 (95% CI: 1.30–1.66) in 1996–2009, which showed a significant difference. Regarding sex, exposure to SHS increased the risk of lung cancer in women (OR = 1.65, 95% CI: 1.22–2.24) and in both sexes (OR = 2.76, 95% CI: 1.28–5.96), but not in men (OR = 1.12, 95% CI: 0.77–1.63). Regarding exposure site, the ORs (1.38–2.20) showed a statistically significant difference for non-specified sites or households for the two diseases analyzed. While the ORs for the workplace were 1.38 (95% CI: 0.94–2.04) for lung cancer and 1.16 (95% CI: 0.89–1.51) for breast cancer. Further details are provided in Table 3 and the forest plots are shown in Supplementary Figure S1, available in www.besjournal.com.
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Publication bias was unlikely to be found in the studies of bladder cancer, liver cancer, DCS (including stroke), and DRS (including asthma in children), but may exist in the studies of all cancers (including lung cancer and breast cancer). The results of the Egger’s test are shown in Table 3 and the funnel plots are shown in Supplementary Material Figure 2.
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None of the studies were found to have a strong influence on the results for the six diseases analyzed (lung cancer, breast cancer, bladder cancer, liver cancer, stroke, and asthma in children) or the three overall disease types (overall cancers, DCS, and DRS) in the “leave-one-out” sensitivity analysis. The results are summarized in Supplementary Material Table 3.
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The authors have no possible conflicts of interest.
Table S1. Basic characteristics of the included studies
Diseases Trialname Year Study design Participants (n) Date of Investigation Gender Exposure
sitesLanguage NOS Cancers Lung cancer Yong Lin et al. 2010 Case-control 416 2006.12−2010.1 Female Workplace, Household Chinese 6 Hailong Shi et al. 2005 Case-control 1,490 2000.6−2002.12 Female Workplace Chinese 6 Lina Mu et al. 2021 Case-control 861 2005.3−2007.9 Both Total Chinese 6 Longde Wang et al. 2002 Case-control 1,776 1994.1−1998.4 Both, Male,
FemaleTotal Chinese 7 X.-R. Wang et al. 2009 Case-control 363 2002.7.1−2004.6.30 Female Total English 7 T.H. Lam et al. 1987 Case-control 741 1983−1986 Female Household English 7 Lap Ah Tse et al. 2009 Case-control 668 2004−2006 Male Total,
Household,
WorkplaceEnglish 7 Liu Q et al. 1993 Case-control 632 1983.6−1984.6 Female Household English 6 Wen, W. et al. 2006 Cohort 72,829 1997.3−2000.5 Female Total,
Household,
WorkplaceEnglish 9 Yongbing Xiang et al. 2003 Case-control 828 1992.2−1993.12 Female Workplace Chinese 6 Chunyan Lin et al. 1994 Case-control 244 1985−1990 Female Household,
WorkplaceChinese 6 Dandan Guan et al. 2020 Case-control 1,284 2015.6−2018.12 Female Total Chinese 7 Jifei Ma et al. 2021 Case-control 750 2015.1−2016.6 Both Total Chinese 6 Haiyan Li et al. 2020 Case-control 296 2011.1−2019.6 Both Total Chinese 6 Jun Li et al. 2020 Cohort 23,415 2008−2011 Both Total English 9 Breast cancer Ping shi et al. 2010 Case-control 446 2005.1−2006.12 Female Total Chinese 6 Xiaodan Yang et al. 2014 Case-control 604 2009.7.1−2012.10.11 Female Total Chinese 6 Kajia Cao et al. 2001 Case-control 696 1992−1996 Female Total Chinese 6 Meiling Qi et al. 2014 Case-control 849 2008.10−2010.2 Female Total,
Household,
WorkplaceEnglish 7 Mingbai Hu et al. 2013 Case-control 407 2009.1−2011.2 Female Total English 6 Bin Li et al. 2015 Case-control 1,767 2007−2013 Female Total,
Household,
WorkplaceEnglish 7 Changming Gao et al. 2013 Case-control 1,351 2004.6−2007.12 Female Total English 9 Xinying Lin et al. 2001 Case-control 372 None Female Total Chinese 6 Cancers Bladder cancer Wei Zhang et al. 2006 Case-control 1,215 1996−1999 Male,
FemaleTotal,
ousehold,
WorkplaceChinese 9 Yuhua Zhou et al. 2014 Case-control 824 2005.9−2008.6 Both Household Chinese 7 Li Tao et al. 2010 Case-control 231 1996.7−1999.6 Both,
Male,
FemaleTotal English 8 Liver cancer Jianxue Duan et al. 2018 Case-control 794 2010.1.1−2016.12.31 Both Total Chinese 6 Huabin Wu et al. 2012 Case-control 1,254 2003.1.1−2010.10.31 Both Total Chinese 6 Jun Li et al. 2020 Cohort 23,415 2008−2011 Both Total English 9 Acute lymphoblastic leukemia Yongjun Fang et al. 2010 Case-control 613 2006.6.1− Children Total Chinese 6 Cancer Wen, W. et al. 2006 Cohort 72,829 1997.3−2000.5 Female Total,
ousehold,
WorkplaceEnglish 9 Cervical cancer Jian Li et al. 2010 Case-control 312 2007.9−2010.6 Female Total Chinese 6 Rongxian Xu et al. 2014 Case-control 413 2007.11−2008.12 Female Total Chinese 6 Colon cancer Qinting Jiang et al. 2004 Case-control 396 1990.5−2002.5
1989−1990Both Workplace Chinese 8 Colorectal cancer Jun Li et al. 2020 Cohort 23,415 2008−2011 Both Total English 9 Endometrial cancer Jing Gao et al. 2006 Case-control 2,082 1997.1−2002.12 Female Total,
Household,
WorkplaceChinese 8 Esophageal squamous cell carcinoma Zemin Wang et al. 2006 Case-control 214 2002−2003 Both Total English 7 Intracranial tumors Min Wu et al. 2010 Case-control 537 2007.1−2008.7 Both Household,
WorkplaceChinese 6 Oral cancer Baochang He et al. 2016 Case-control 708 2010.9−2015.1 Female Total English 7 Papillary thyroid ancer Yan Zhou et al. 2016 Case-control 369 2103.4−2014.6 Both Total Chinese 6 Stomach cancer Jun Li et al. 2020 Cohort 23,415 2008−2011 Both Total English 9 Tongue cancer Lingjun Yan et al. 2016 Case-control 876 2010.9−2015.1 Both Total Chinese 7 Asthma in Children Xiaojuan Liu et al. 2013 Case-control 218 2011.1−2012.12 Children Total Chinese 6 Fang Wang et al. 2013 Case-control 726 2010 Children Total Chinese 6 Mei Xiong et al. 2013 Case-control 552 None Children Total Chinese 6 DRS* Tongzhang Zheng et al. 2002 Case-control 1,209 1999.1−2001.3 Children Total English 6 Shixue Ma et al. 2006 Case-control 212 2002.1−2004.6 Children Total Chinese 6 Maohong Luo et al. 2004 Case-control 262 1998−1999 Children Total Chinese 6 Small airway obstruction Yusheng Chen et al. 2013 Case-control 648 2011.10.17−2011.11.1 Both Total English 7 Stroke Xianjia Ning et al. 1993 Case-control 256 1990.10−1990.12 Female Total Chinese 7 Yanong Shao et al. 1997 Case-control 210 1996.10−1997.3 Both Total Chinese 6 DCS* Wen, W. et al. 2006 Cohort 72,829 1997.3−2000.5 Female Total,
Household,
WorkplaceEnglish 9 Cardiovascular disease Wen, W. et al. 2006 Cohort 72,829 1997.3−2000.5 Female Total,
Household,
WorkplaceEnglish 9 Other diseases All cause mortality Kim, C. et al. 2016 Cohort 65,226 1996−2000/2009 Female Total English 8 Legionnaires' diseases (Children) Suping Wang et al. 1994 Case-control 126 1991.4.4−1992.4.3 Children Total Chinese 6 Otitis media (Children) Ke Li et al. 2018 Case-control 534 2013.1−2016.12 Children Total Chinese 6 Tuberculosis Birong Dong et al. 2001 Case-control 348 1996.3−1997.3 Both Total Chinese 6 Leung, Chi C. et al. 2010 Cohort 15,486 2000.1−2003.12 Female Total English 8 Type 2 diabetes mellitus Huang, C. et al. 2019 Cohort 28,177 2004−2008 Female Total English 9 Note. * DRS: Diseases of the Respiratory System; DCS: Diseases of the Circulatory System Table S2. The definition and types of characteristics of second-hand smoke exposure
Definition of SHS Undefined Definiton 1 Exposure to SHS at home /workplace ≥ 15 min/d, 1 d/week. Exposure to SHS ≥ 15 min/d. Exposure to SHS: once (5 min), twice ( ≥ 5 min but ≤ 1min), more than twice (≥ 1 min). Lived or worked with smokers ≥ 1 h/d, ≥ 1 year. Exposure to SHS 1 time/wk, 1–2 d/week, 3–5 d/week, daily, or almost daily. Definition 2 Exposure to family members (especially husband) had ever smoked at home and/or the smoke of others in the workplace. Living with smoking husband in the same household for at least one year continuously. Living with 1 or more smokers in the same household. Exposure to parents. Types of
Characteristics of SHSNone Type 1 Location, such as household and workplace. Type 2 Adulthood and childhood (before age 18 or after age 18). Adulthood only. Before age 18 years or after age 18 years. Menopausal status. Childhood and adulthood. Pregnant with the child,and after the birth of the child. Table S3. "Leave One Out" sensitivity test
Disease Trialname POR LL UL Cancers T.H. Lam et al. 1.52 1.42 1.62 Liu Q et al. 1.53 1.44 1.63 Chunyan Lin et al. 1.53 1.44 1.63 Chunyan Lin et al. 1.53 1.43 1.63 Xinying Lin et al. 1.51 1.42 1.61 Kajia Cao et al. 1.53 1.43 1.63 Longde Wang et al. 1.54 1.44 1.64 Yongbing Xiang et al. 1.53 1.44 1.63 Qinting Jiang et al. 1.53 1.43 1.63 Hailong Shi et al. 1.58 1.48 1.69 Zemin Wang et al. 1.53 1.43 1.63 Wen W. et al. 1.53 1.44 1.63 Jing Gao et al. 1.61 1.51 1.72 Wen W. et al. 1.54 1.45 1.64 Wei Zhang et al. 1.54 1.44 1.64 Wei Zhang et al. 1.53 1.44 1.63 Lap Ah Tse et al. 1.54 1.45 1.65 X.-R. Wang et al. 1.54 1.44 1.64 Jian Li et al. 1.53 1.43 1.63 Yong Lin et al. 1.53 1.43 1.63 Yong Lin et al. 1.52 1.43 1.62 Yongjun Fang et al. 1.52 1.42 1.61 Li Tao et al. 1.53 1.44 1.64 Min Wu et al. 1.53 1.43 1.63 Ping shi et al. 1.53 1.43 1.63 Min Wu et al. 1.53 1.43 1.63 Huabin Wu et al. 1.54 1.45 1.65 Mingbai Hu et al. 1.53 1.44 1.63 Changming Gao et al. 1.54 1.44 1.64 Rongxian Xu et al. 1.51 1.42 1.61 Xiaodan Yang et al. 1.53 1.43 1.63 Meiling Qi et al. 1.53 1.44 1.63 Yuhua Zhou et al. 1.52 1.43 1.62 Bin Li et al. 1.55 1.45 1.66 Yan Zhou et al. 1.53 1.43 1.63 Baochang He et al. 1.52 1.43 1.62 Lingjun Yan et al. 1.52 1.42 1.62 Jianxue Duan et al. 1.53 1.43 1.63 Jun Li et al. 1.53 1.43 1.63 Jun Li et al. 1.54 1.44 1.64 Jun Li et al. 1.54 1.45 1.64 Haiyan Li et al. 1.51 1.42 1.61 Dandan Guan et al. 1.53 1.43 1.63 Jun Li et al. 1.54 1.44 1.64 Lina Mu et al. 1.54 1.45 1.64 Jifei Ma et al. 1.51 1.41 1.61 Combined 1.53 1.44 1.63 DCS Xianjia Ning et al. 1.59 1.23 2.05 Yanong Shao et al. 1.90 1.35 2.68 Wen W. et al. 1.92 1.43 2.58 Wen W. et al. 1.72 1.33 2.21 Combined 1.75 1.37 2.23 DRS Tongzhang Zheng et al. 1.40 1.18 1.68 Maohong Luo et al. 1.34 1.15 1.56 Shixue Ma et al. 1.32 1.14 1.54 Fang Wang et al. 1.77 1.49 2.09 Xiaojuan Liu et al. 1.32 1.14 1.54 Mei Xiong et al. 1.38 1.18 1.62 Yusheng Chen et al. 1.38 1.17 1.62 Combined 1.40 1.21 1.63 Lung cancer T.H. Lam et al. 1.46 1.29 1.65 Liu Q et al. 1.51 1.35 1.70 Chunyan Lin et al. 1.50 1.34 1.69 Chunyan Lin et al. 1.52 1.35 1.71 Longde Wang et al. 1.54 1.37 1.73 Yongbing Xiang et al. 1.52 1.34 1.71 Hailong Shi et al. 1.71 1.51 1.94 Wen W. et al. 1.51 1.34 1.69 X.-R. Wang et al. 1.54 1.37 1.74 Lap Ah Tse et al. 1.56 1.38 1.56 1.38 1.76 Yong Lin et al. 1.50 1.33 1.68 Yong Lin et al. 1.49 1.32 1.68 Jun Li et al. 1.55 1.37 1.75 Haiyan Li et al. 1.45 1.30 1.63 Dandan Guan et al. 1.50 1.34 1.69 Lina Mu et al. 1.55 1.37 1.76 Jifei Ma et al. 1.44 1.28 1.61 Combined 1.52 1.35 1.70 Breast cancer Kajia Cao et al. 1.55 1.38 1.74 Xinying Lin et al. 1.49 1.32 1.68 Ping shi et al. 1.55 1.38 1.75 Mingbai Hu et al. 1.57 1.39 1.76 Changming Gao et al. 1.60 1.40 1.83 Meiling Qi et al. 1.57 1.39 1.78 Xiaodan Yang et al. 1.56 1.38 1.75 Bin Li et al. 1.69 1.47 1.94 Combined 1.57 1.40 1.76 Bladder cancer Wei Zhang et al. 1.73 1.23 2.44 Wei Zhang et al. 1.50 1.08 2.08 Li Tao et al. 1.61 1.10 2.35 Yuhua Zhou et al. 1.28 0.91 1.81 Combined 1.52 1.12 2.05 Liver cancer Huabin Wu et al. 1.43 0.93 2.20 Jianxue Duan et al. 1.26 0.98 1.63 Jun Li et al. 1.46 1.14 1.88 Combined 1.37 1.08 1.73 Stroke Xianjia Ning et al. 1.67 1.22 2.30 Yanong Shao et al. 3.15 1.77 5.60 Wen, W. et al. 1.89 1.38 2.58 Combined 1.92 1.43 2.58 Asthma in Children Tongzhang Zheng et al. 1.37 1.12 1.67 Maohong Luo et al. 1.31 1.11 1.54 Shixue Ma et al. 1.28 1.09 1.52 Mei Xiong et al. 1.35 1.13 1.61 Xiaojuan Liu et al. 1.28 1.08 1.52 Fang Wang et al. 1.83 1.52 2.21 Combined 1.38 1.17 1.62 Note. POR: pooled odds ratio; OR: odds ratio; LL: 95% lower limit; UL: 95% upper limit.
doi: 10.3967/bes2023.003
The Association between Exposure to Second-Hand Smoke and Disease in the Chinese Population: A Systematic Review and Meta-Analysis
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Abstract:
Objective To analyze the association between exposure to second-hand smoke (SHS) and 23 diseases, categorized into four classifications, among the Chinese population. Methods We searched the literature up to June 30, 2021, and eligible studies were identified according to the PECOS format: Participants and Competitors (Chinese population), Exposure (SHS), Outcomes (Disease or Death), and Study design (Case-control or Cohort). Results In total, 53 studies were selected. The odds ratio (OR) for all types of cancer was 1.79 (1.56–2.05), and for individual cancers was 1.92 (1.42–2.59) for lung cancer, 1.57 (1.40–1.76) for breast cancer, 1.52 (1.12–2.05) for bladder cancer, and 1.37 (1.08–1.73) for liver cancer. The OR for circulatory system diseases was 1.92 (1.29–2.85), with a value of 2.29 (1.26–4.159) for stroke. The OR of respiratory system diseases was 1.76 (1.13–2.74), with a value of 1.82 (1.07–3.11) for childhood asthma. The original ORs were also shown for other diseases. Subgroup analyses were performed for lung and breast cancer. The ORs varied according to time period and were significant during exposure in the household; For lung cancer, the OR was significant in women. Conclusion The effect of SHS exposure in China was similar to that in Western countries, but its definition and characterization require further clarification. Studies on the association between SHS exposure and certain diseases with high incidence rates are insufficient. -
Table 1. Basic information regarding the selection of studies
Basic information Chinese English Total Number of participants NOS
(mean score)(n, %) (n, %) (n, %) Min Max Total 35 100.0 18 100.0 53 100.0 126 73,363 6.72 Language Chinese 35 100.0 − − 35 66.0 126 73,363 6.34 English − − 18 100.0 18 34.0 204 72,829 7.45 Study design Case-control 35 100.0 13 72.2 48 90.6 126 2,082 6.52 Cohort 0 0 5 27.8 5 9.4 15,486 73,363 8.60 Start year of
investigation1983–1995 8 22.9 1 5.6 9 17.0 126 1,776 6.56 1996–2009 17 48.6 16 88.9 33 62.3 210 73,363 6.91 2010–2021 9 25.7 1 5.6 10 18.9 218 1,284 6.30 None 1 2.9 0 0 1 1.9 552 552 6.00 Sex Women 15 39.5 16 61.5 31 48.4 244 73,363 7.19 Men 2 5.3 2 7.7 4 6.3 456 1,776 7.75 Both 13 34.2 7 26.9 20 31.3 210 23,415 7.05 Children 8 21.1 1 3.8 9 14.1 126 1,209 6.00 Exposure site Household 7 15.6 9 23.7 16 19.3 244 72,829 7.08 Workplace 9 20.0 7 18.4 16 19.3 244 72,829 7.08 Total 29 64.4 22 57.9 51 61.4 126 73,363 6.91 Cancer type Total 25 100.0 17 100.0 42 100.0 214 72,829 6.95 Lung Cancer[49-63] 9 36.0 6 35.3 15 35.7 244 72,829 6.73 Breast Cancer[64-71] 4 16.0 4 23.5 8 19.0 372 1,767 6.63 Bladder Cancer[72-74] 2 8.0 1 5.9 3 7.1 456 1,215 8.00 Liver Cancer[61,75,76] 2 8.0 1 5.9 3 7.1 794 23,415 7.00 Cervical Cancer[77,78] 2 8.0 0 0 2 4.8 312 413 6.00 Acute Lymphoblastic
Leukemia[79]1 4.0 0 0 1 2.4 613 613 6.00 Colon Cancer[80] 1 4.0 0 0 1 2.4 396 396 8.00 Colorectal Cancer[61] 0 0 1 5.9 1 2.4 23,415 23,415 9.00 Endometrial Cancer[81] 1 4.0 0 0 1 2.4 2,082 2,082 8.00 Esophageal Squamous
Cell Carcinoma[82]0 0 1 5.9 1 2.4 214 214 7.00 Intracranial Tumors[83] 1 4.0 0 0 1 2.4 537 537 6.00 Oral Cancer[84] 0 0 1 5.9 1 2.4 708 708 7.00 Papillary Thyroid Cancer[85] 1 4.0 0 0 1 2.4 369 369 6.00 Stomach Cancer[61] 0 0 1 5.9 1 2.4 23,415 23,415 9.00 Tongue Cancer[86] 1 4.0 0 0 1 2.4 876 876 7.00 Cancer[55] 0 0 1 5.90 1 2.4 72,829 72,829 9.00 DRS* Total 5 100.0 2 100.0 7 100.0 212 1,209 6.14 Asthma in Children[87-92] 5 100.0 1 50.0 6 85.7 212 1,209 6.00 Small Airway Obstruction[93] 0 0 1 50.0 1 14.3 648 648 7.00 DCS* Total 2 100.0 2 100.0 4 100.0 210 72,829 7.75 Stroke[55,94,95] 2 100.0 1 50.0 3 75.0 210 72,829 7.33 Cardiovascular Disease[55] 0 0 1 50.0 1 25.0 72,829 72,829 9.00 Other Diseases Total 3 100.0 3 100.0 6 100.0 126 28,177 7.17 Tuberculosis[96,97] 1 33.3 1 33.3 2 33.3 348 15,486 7.00 Legionnaires' Disease
(Children)[98]1 33.3 0 0 1 16.7 126 126 6.00 Otitis Media (Children)[99] 1 33.3 0 0 1 16.7 534 534 6.00 Type 2 Diabetes Mellitus[100] 0 0 1 33.3 1 16.7 28,177 28,177 9.00 All Causes of Mortality[101] 0 0 1 33.3 1 16.7 73,363 73,363 8.00 Note. For the basic information on sex, exposure site, and disease type, some studies contained more than one result, so the total number for each group could be more than that of the study design and the start year of investigation, respectively. *DRS: Diseases of the Respiratory System; DCS: Diseases of the Circulatory System; NOS: Newcastle Ottawa Scale. Table 2. Definition and characteristics of second-hand smoke exposure
Variables Definition of SHS (n, %) Characteristic of SHS (n, %) Undefined Definition 1 Definition 2 None Type 1 Type 2 Type 3 DCS 2 7.14 0 0 0 0 2 7.69 0 0 0 0 1 6.25 DRS 6 21.43 0 0 1 7.69 3 11.54 1 9.09 1 7.69 4 25.00 Cancers 17 60.71 10 83.33 11 84.62 15 57.69 10 90.91 12 92.31 11 68.75 Other diseases 3 10.71 2 16.67 1 7.69 6 23.08 0 0 0 0 0 0 Total 28 52.83 12 22.64 13 24.53 26 49.06 11 20.75 13 24.53 16 30.19 Note. Specific descriptions for the definitions and characteristics are provided in Supplementary Table S2. SHS, second-hand smoke; DRS, Diseases of the Respiratory System; DCS, Diseases of the Circulatory System. Table 3. The pooled odds ratios or odds ratios for SHS exposure
Diseases Subgroup Number of
observationsI2
(%)P-value Model POR/OR and 95% CI Egger's test POR/OR LL UL t P-value Cancers* 46 74.4 < 0.001 Random 1.79 1.56 2.05 2.74 0.000 Lung cancer* 17 83.2 < 0.001 Random 1.92 1.42 2.59 3.87 0.009 1983−1995* 4 0.3 0.390 Fixed 1.64 1.33 2.03 −3.17 0.125 1996−2009* 9 64.7 0.004 Random 1.34 1.03 1.74 3.02 0.072 2010−2019* 4 22.7 0.275 Fixed 7.85 5.11 12.07 −1.14 0.687 Women* 12 71.1 < 0.001 Random 1.65 1.22 2.24 2.41 0.076 Men* 2 0 0.843 Fixed 1.12 0.77 1.63 0.38 − Both* 5 92.5 < 0.001 Random 2.76 1.28 5.96 8.51 0.062 Household* 6 65.6 0.012 Random 1.59 1.08 2.35 0.03 0.991 Workplace* 6 72.1 0.003 Random 1.38 0.94 2.04 4.54 0.023 Total* 9 87.4 < 0.001 Random 2.20 1.33 3.62 4.60 0.061 Breast cancer* 8 38.8 0.121 Fixed 1.57 1.40 1.76 2.11 0.044 1983–1995* 2 0 0.763 Fixed 2.60 1.84 3.68 0.62 − 1996–2009* 6 0 0.853 Fixed 1.47 1.30 1.66 1.35 0.021 Household* 2 0 0.338 Fixed 1.38 1.15 1.65 3.42 − Workplace* 2 0 0.519 Fixed 1.16 0.89 1.51 −8.86 − Total* 8 38.8 0.121 Fixed 1.57 1.40 1.76 2.11 0.044 Bladder cancer* 4 40.9 0.166 Fixed 1.52 1.12 2.05 0.76 0.891 Liver cancer* 3 47.6 0.148 Fixed 1.37 1.08 1.73 0.02 0.997 Cervical cancer 2 1.84 1.04 3.28 3.91 2.21 6.92 Acute
Lymphoblastic
Leukemia1 3.32 1.94 5.68 Intracranial
Tumors2 1.78 1.10 2.86 1.91 1.10 3.33 Colon cancer 1 4.87 1.48 16.02 Colorectal cancer 1 1.26 0.83 1.89 Endometrial cancer 1 0.97 0.28 2.42 Stomach cancer 1 1.79 1.09 2.96 Esophageal
Squamous
Cell carcinoma1 2.04 1.14 3.70 Oral cancer 1 2.38 1.47 3.85 Papillary thyroid
Cancer1 3.86 1.47 10.15 Tongue cancer 1 2.69 1.67 4.32 Cancer 1 1.14 0.73 1.79 DCS* 4 52.9 0.095 Random 1.92 1.29 2.85 2.72 0.236 Stroke* 3 61.5 0.074 Random 2.29 1.26 4.16 2.59 0.410 Cardiovascular
Disease1 1.44 0.94 2.21 DRS* 7 87.7 < 0.001 Random 1.76 1.13 2.74 6.70 0.053 Asthma in Children* 6 89.7 < 0.001 Random 1.82 1.07 3.11 6.71 0.085 Small airway
Obstruction1 1.54 1.06 2.22 Other diseases 6 Tuberculosis 2 1.62 0.92 2.85 1.70 1.04 2.80 Legionnaires'
Disease (Children)1 2.10 1.22 3.63 Otitis media (Children) 1 2.24 1.52 3.16 Type 2 diabetes mellitus 1 1.17 1.00 1.37 All causes of mortality 1 1.08 1.00 1.17 Note. For the subgroups of sex and exposure site, some studies contained more than one result, so the number of results included in the subgroup analysis may be more than that of the disease-specific results. DRS: Diseases of the Respiratory System; DCS: Diseases of the Circulatory System. POR: pooled odds ratio; OR: odds ratio; LL: 95% lower limit; UL: 95% upper limit. *The results of meta-analysis. S1. Basic characteristics of the included studies
Diseases Trialname Year Study design Participants (n) Date of Investigation Gender Exposure
sitesLanguage NOS Cancers Lung cancer Yong Lin et al. 2010 Case-control 416 2006.12−2010.1 Female Workplace, Household Chinese 6 Hailong Shi et al. 2005 Case-control 1,490 2000.6−2002.12 Female Workplace Chinese 6 Lina Mu et al. 2021 Case-control 861 2005.3−2007.9 Both Total Chinese 6 Longde Wang et al. 2002 Case-control 1,776 1994.1−1998.4 Both, Male,
FemaleTotal Chinese 7 X.-R. Wang et al. 2009 Case-control 363 2002.7.1−2004.6.30 Female Total English 7 T.H. Lam et al. 1987 Case-control 741 1983−1986 Female Household English 7 Lap Ah Tse et al. 2009 Case-control 668 2004−2006 Male Total,
Household,
WorkplaceEnglish 7 Liu Q et al. 1993 Case-control 632 1983.6−1984.6 Female Household English 6 Wen, W. et al. 2006 Cohort 72,829 1997.3−2000.5 Female Total,
Household,
WorkplaceEnglish 9 Yongbing Xiang et al. 2003 Case-control 828 1992.2−1993.12 Female Workplace Chinese 6 Chunyan Lin et al. 1994 Case-control 244 1985−1990 Female Household,
WorkplaceChinese 6 Dandan Guan et al. 2020 Case-control 1,284 2015.6−2018.12 Female Total Chinese 7 Jifei Ma et al. 2021 Case-control 750 2015.1−2016.6 Both Total Chinese 6 Haiyan Li et al. 2020 Case-control 296 2011.1−2019.6 Both Total Chinese 6 Jun Li et al. 2020 Cohort 23,415 2008−2011 Both Total English 9 Breast cancer Ping shi et al. 2010 Case-control 446 2005.1−2006.12 Female Total Chinese 6 Xiaodan Yang et al. 2014 Case-control 604 2009.7.1−2012.10.11 Female Total Chinese 6 Kajia Cao et al. 2001 Case-control 696 1992−1996 Female Total Chinese 6 Meiling Qi et al. 2014 Case-control 849 2008.10−2010.2 Female Total,
Household,
WorkplaceEnglish 7 Mingbai Hu et al. 2013 Case-control 407 2009.1−2011.2 Female Total English 6 Bin Li et al. 2015 Case-control 1,767 2007−2013 Female Total,
Household,
WorkplaceEnglish 7 Changming Gao et al. 2013 Case-control 1,351 2004.6−2007.12 Female Total English 9 Xinying Lin et al. 2001 Case-control 372 None Female Total Chinese 6 Cancers Bladder cancer Wei Zhang et al. 2006 Case-control 1,215 1996−1999 Male,
FemaleTotal,
ousehold,
WorkplaceChinese 9 Yuhua Zhou et al. 2014 Case-control 824 2005.9−2008.6 Both Household Chinese 7 Li Tao et al. 2010 Case-control 231 1996.7−1999.6 Both,
Male,
FemaleTotal English 8 Liver cancer Jianxue Duan et al. 2018 Case-control 794 2010.1.1−2016.12.31 Both Total Chinese 6 Huabin Wu et al. 2012 Case-control 1,254 2003.1.1−2010.10.31 Both Total Chinese 6 Jun Li et al. 2020 Cohort 23,415 2008−2011 Both Total English 9 Acute lymphoblastic leukemia Yongjun Fang et al. 2010 Case-control 613 2006.6.1− Children Total Chinese 6 Cancer Wen, W. et al. 2006 Cohort 72,829 1997.3−2000.5 Female Total,
ousehold,
WorkplaceEnglish 9 Cervical cancer Jian Li et al. 2010 Case-control 312 2007.9−2010.6 Female Total Chinese 6 Rongxian Xu et al. 2014 Case-control 413 2007.11−2008.12 Female Total Chinese 6 Colon cancer Qinting Jiang et al. 2004 Case-control 396 1990.5−2002.5
1989−1990Both Workplace Chinese 8 Colorectal cancer Jun Li et al. 2020 Cohort 23,415 2008−2011 Both Total English 9 Endometrial cancer Jing Gao et al. 2006 Case-control 2,082 1997.1−2002.12 Female Total,
Household,
WorkplaceChinese 8 Esophageal squamous cell carcinoma Zemin Wang et al. 2006 Case-control 214 2002−2003 Both Total English 7 Intracranial tumors Min Wu et al. 2010 Case-control 537 2007.1−2008.7 Both Household,
WorkplaceChinese 6 Oral cancer Baochang He et al. 2016 Case-control 708 2010.9−2015.1 Female Total English 7 Papillary thyroid ancer Yan Zhou et al. 2016 Case-control 369 2103.4−2014.6 Both Total Chinese 6 Stomach cancer Jun Li et al. 2020 Cohort 23,415 2008−2011 Both Total English 9 Tongue cancer Lingjun Yan et al. 2016 Case-control 876 2010.9−2015.1 Both Total Chinese 7 Asthma in Children Xiaojuan Liu et al. 2013 Case-control 218 2011.1−2012.12 Children Total Chinese 6 Fang Wang et al. 2013 Case-control 726 2010 Children Total Chinese 6 Mei Xiong et al. 2013 Case-control 552 None Children Total Chinese 6 DRS* Tongzhang Zheng et al. 2002 Case-control 1,209 1999.1−2001.3 Children Total English 6 Shixue Ma et al. 2006 Case-control 212 2002.1−2004.6 Children Total Chinese 6 Maohong Luo et al. 2004 Case-control 262 1998−1999 Children Total Chinese 6 Small airway obstruction Yusheng Chen et al. 2013 Case-control 648 2011.10.17−2011.11.1 Both Total English 7 Stroke Xianjia Ning et al. 1993 Case-control 256 1990.10−1990.12 Female Total Chinese 7 Yanong Shao et al. 1997 Case-control 210 1996.10−1997.3 Both Total Chinese 6 DCS* Wen, W. et al. 2006 Cohort 72,829 1997.3−2000.5 Female Total,
Household,
WorkplaceEnglish 9 Cardiovascular disease Wen, W. et al. 2006 Cohort 72,829 1997.3−2000.5 Female Total,
Household,
WorkplaceEnglish 9 Other diseases All cause mortality Kim, C. et al. 2016 Cohort 65,226 1996−2000/2009 Female Total English 8 Legionnaires' diseases (Children) Suping Wang et al. 1994 Case-control 126 1991.4.4−1992.4.3 Children Total Chinese 6 Otitis media (Children) Ke Li et al. 2018 Case-control 534 2013.1−2016.12 Children Total Chinese 6 Tuberculosis Birong Dong et al. 2001 Case-control 348 1996.3−1997.3 Both Total Chinese 6 Leung, Chi C. et al. 2010 Cohort 15,486 2000.1−2003.12 Female Total English 8 Type 2 diabetes mellitus Huang, C. et al. 2019 Cohort 28,177 2004−2008 Female Total English 9 Note. * DRS: Diseases of the Respiratory System; DCS: Diseases of the Circulatory System S2. The definition and types of characteristics of second-hand smoke exposure
Definition of SHS Undefined Definiton 1 Exposure to SHS at home /workplace ≥ 15 min/d, 1 d/week. Exposure to SHS ≥ 15 min/d. Exposure to SHS: once (5 min), twice ( ≥ 5 min but ≤ 1min), more than twice (≥ 1 min). Lived or worked with smokers ≥ 1 h/d, ≥ 1 year. Exposure to SHS 1 time/wk, 1–2 d/week, 3–5 d/week, daily, or almost daily. Definition 2 Exposure to family members (especially husband) had ever smoked at home and/or the smoke of others in the workplace. Living with smoking husband in the same household for at least one year continuously. Living with 1 or more smokers in the same household. Exposure to parents. Types of
Characteristics of SHSNone Type 1 Location, such as household and workplace. Type 2 Adulthood and childhood (before age 18 or after age 18). Adulthood only. Before age 18 years or after age 18 years. Menopausal status. Childhood and adulthood. Pregnant with the child,and after the birth of the child. S3. "Leave One Out" sensitivity test
Disease Trialname POR LL UL Cancers T.H. Lam et al. 1.52 1.42 1.62 Liu Q et al. 1.53 1.44 1.63 Chunyan Lin et al. 1.53 1.44 1.63 Chunyan Lin et al. 1.53 1.43 1.63 Xinying Lin et al. 1.51 1.42 1.61 Kajia Cao et al. 1.53 1.43 1.63 Longde Wang et al. 1.54 1.44 1.64 Yongbing Xiang et al. 1.53 1.44 1.63 Qinting Jiang et al. 1.53 1.43 1.63 Hailong Shi et al. 1.58 1.48 1.69 Zemin Wang et al. 1.53 1.43 1.63 Wen W. et al. 1.53 1.44 1.63 Jing Gao et al. 1.61 1.51 1.72 Wen W. et al. 1.54 1.45 1.64 Wei Zhang et al. 1.54 1.44 1.64 Wei Zhang et al. 1.53 1.44 1.63 Lap Ah Tse et al. 1.54 1.45 1.65 X.-R. Wang et al. 1.54 1.44 1.64 Jian Li et al. 1.53 1.43 1.63 Yong Lin et al. 1.53 1.43 1.63 Yong Lin et al. 1.52 1.43 1.62 Yongjun Fang et al. 1.52 1.42 1.61 Li Tao et al. 1.53 1.44 1.64 Min Wu et al. 1.53 1.43 1.63 Ping shi et al. 1.53 1.43 1.63 Min Wu et al. 1.53 1.43 1.63 Huabin Wu et al. 1.54 1.45 1.65 Mingbai Hu et al. 1.53 1.44 1.63 Changming Gao et al. 1.54 1.44 1.64 Rongxian Xu et al. 1.51 1.42 1.61 Xiaodan Yang et al. 1.53 1.43 1.63 Meiling Qi et al. 1.53 1.44 1.63 Yuhua Zhou et al. 1.52 1.43 1.62 Bin Li et al. 1.55 1.45 1.66 Yan Zhou et al. 1.53 1.43 1.63 Baochang He et al. 1.52 1.43 1.62 Lingjun Yan et al. 1.52 1.42 1.62 Jianxue Duan et al. 1.53 1.43 1.63 Jun Li et al. 1.53 1.43 1.63 Jun Li et al. 1.54 1.44 1.64 Jun Li et al. 1.54 1.45 1.64 Haiyan Li et al. 1.51 1.42 1.61 Dandan Guan et al. 1.53 1.43 1.63 Jun Li et al. 1.54 1.44 1.64 Lina Mu et al. 1.54 1.45 1.64 Jifei Ma et al. 1.51 1.41 1.61 Combined 1.53 1.44 1.63 DCS Xianjia Ning et al. 1.59 1.23 2.05 Yanong Shao et al. 1.90 1.35 2.68 Wen W. et al. 1.92 1.43 2.58 Wen W. et al. 1.72 1.33 2.21 Combined 1.75 1.37 2.23 DRS Tongzhang Zheng et al. 1.40 1.18 1.68 Maohong Luo et al. 1.34 1.15 1.56 Shixue Ma et al. 1.32 1.14 1.54 Fang Wang et al. 1.77 1.49 2.09 Xiaojuan Liu et al. 1.32 1.14 1.54 Mei Xiong et al. 1.38 1.18 1.62 Yusheng Chen et al. 1.38 1.17 1.62 Combined 1.40 1.21 1.63 Lung cancer T.H. Lam et al. 1.46 1.29 1.65 Liu Q et al. 1.51 1.35 1.70 Chunyan Lin et al. 1.50 1.34 1.69 Chunyan Lin et al. 1.52 1.35 1.71 Longde Wang et al. 1.54 1.37 1.73 Yongbing Xiang et al. 1.52 1.34 1.71 Hailong Shi et al. 1.71 1.51 1.94 Wen W. et al. 1.51 1.34 1.69 X.-R. Wang et al. 1.54 1.37 1.74 Lap Ah Tse et al. 1.56 1.38 1.56 1.38 1.76 Yong Lin et al. 1.50 1.33 1.68 Yong Lin et al. 1.49 1.32 1.68 Jun Li et al. 1.55 1.37 1.75 Haiyan Li et al. 1.45 1.30 1.63 Dandan Guan et al. 1.50 1.34 1.69 Lina Mu et al. 1.55 1.37 1.76 Jifei Ma et al. 1.44 1.28 1.61 Combined 1.52 1.35 1.70 Breast cancer Kajia Cao et al. 1.55 1.38 1.74 Xinying Lin et al. 1.49 1.32 1.68 Ping shi et al. 1.55 1.38 1.75 Mingbai Hu et al. 1.57 1.39 1.76 Changming Gao et al. 1.60 1.40 1.83 Meiling Qi et al. 1.57 1.39 1.78 Xiaodan Yang et al. 1.56 1.38 1.75 Bin Li et al. 1.69 1.47 1.94 Combined 1.57 1.40 1.76 Bladder cancer Wei Zhang et al. 1.73 1.23 2.44 Wei Zhang et al. 1.50 1.08 2.08 Li Tao et al. 1.61 1.10 2.35 Yuhua Zhou et al. 1.28 0.91 1.81 Combined 1.52 1.12 2.05 Liver cancer Huabin Wu et al. 1.43 0.93 2.20 Jianxue Duan et al. 1.26 0.98 1.63 Jun Li et al. 1.46 1.14 1.88 Combined 1.37 1.08 1.73 Stroke Xianjia Ning et al. 1.67 1.22 2.30 Yanong Shao et al. 3.15 1.77 5.60 Wen, W. et al. 1.89 1.38 2.58 Combined 1.92 1.43 2.58 Asthma in Children Tongzhang Zheng et al. 1.37 1.12 1.67 Maohong Luo et al. 1.31 1.11 1.54 Shixue Ma et al. 1.28 1.09 1.52 Mei Xiong et al. 1.35 1.13 1.61 Xiaojuan Liu et al. 1.28 1.08 1.52 Fang Wang et al. 1.83 1.52 2.21 Combined 1.38 1.17 1.62 Note. POR: pooled odds ratio; OR: odds ratio; LL: 95% lower limit; UL: 95% upper limit. -
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22141Supplementary Materials.pdf