The Association between Exposure to Second-Hand Smoke and Disease in the Chinese Population: A Systematic Review and Meta-Analysis

WANG Yu Tong HU Kui Ru ZHAO Jian AI Fei Ling SHI Yu Lin WANG Xue Wei YANG Wen Yi WANG Jing Xin AI Li Mei WAN Xia

WANG Yu Tong, HU Kui Ru, ZHAO Jian, AI Fei Ling, SHI Yu Lin, WANG Xue Wei, YANG Wen Yi, WANG Jing Xin, AI Li Mei, WAN Xia. The Association between Exposure to Second-Hand Smoke and Disease in the Chinese Population: A Systematic Review and Meta-Analysis[J]. Biomedical and Environmental Sciences, 2023, 36(1): 24-37. doi: 10.3967/bes2023.003
Citation: WANG Yu Tong, HU Kui Ru, ZHAO Jian, AI Fei Ling, SHI Yu Lin, WANG Xue Wei, YANG Wen Yi, WANG Jing Xin, AI Li Mei, WAN Xia. The Association between Exposure to Second-Hand Smoke and Disease in the Chinese Population: A Systematic Review and Meta-Analysis[J]. Biomedical and Environmental Sciences, 2023, 36(1): 24-37. doi: 10.3967/bes2023.003

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

Funds: This study was supported by the Chinese Academy of Medical Sciences (CAMS) Innovation Fund for Medical Sciences (CIFM) [NO.2016-12M-3-001]; and the China Medical Board “Strengthen Capacity of Study and Application on Burden of Disease in Health Care System of China-Establishment and Development of Chinese Burden of Disease Research and Dissemination Center” [NO.15-208]
More Information
    Author Bio:

    WANG Yu Tong, female, born in 1996, Master Candidate, majoring in burden of disease methodology and tobacco control

    Corresponding author: WAN Xia, PhD, Tel: 86-10-65233870, E-mail: xiawan@ibms.pumc.edu.cn
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  • Figure  1.  The study selection process.

    Figure  2.  The odds ratios for second-hand smoke exposure.

    Figure  3.  The disease-specific odds ratios for second-hand smoke exposure.

    S1.  The subgroup odds ratios for second-hand smoke exposure.

    S2.  The disease-specific funnel plots.

    Table  1.   Basic information regarding the selection of studies

    Basic informationChineseEnglishTotalNumber of participantsNOS
    (mean score)
    (n, %)(n, %)(n, %)MinMax
    Total35100.018100.053100.012673,3636.72
    LanguageChinese35100.03566.012673,3636.34
    English18100.01834.020472,8297.45
    Study designCase-control35100.01372.24890.61262,0826.52
    Cohort00527.859.415,48673,3638.60
    Start year of
    investigation
    1983–1995822.915.6917.01261,7766.56
    1996–20091748.61688.93362.321073,3636.91
    2010–2021925.715.61018.92181,2846.30
    None12.90011.95525526.00
    SexWomen1539.51661.53148.424473,3637.19
    Men25.327.746.34561,7767.75
    Both1334.2726.92031.321023,4157.05
    Children821.113.8914.11261,2096.00
    Exposure siteHousehold715.6923.71619.324472,8297.08
    Workplace920.0718.41619.324472,8297.08
    Total2964.42257.95161.412673,3636.91
    Cancer typeTotal25100.017100.042100.021472,8296.95
    Lung Cancer[49-63]936.0635.31535.724472,8296.73
    Breast Cancer[64-71]416.0423.5819.03721,7676.63
    Bladder Cancer[72-74]28.015.937.14561,2158.00
    Liver Cancer[61,75,76]28.015.937.179423,4157.00
    Cervical Cancer[77,78]28.00024.83124136.00
    Acute Lymphoblastic
    Leukemia[79]
    14.00012.46136136.00
    Colon Cancer[80]14.00012.43963968.00
    Colorectal Cancer[61]0015.912.423,41523,4159.00
    Endometrial Cancer[81]14.00012.42,0822,0828.00
    Esophageal Squamous
    Cell Carcinoma[82]
    0015.912.42142147.00
    Intracranial Tumors[83]14.00012.45375376.00
    Oral Cancer[84]0015.912.47087087.00
    Papillary Thyroid Cancer[85]14.00012.43693696.00
    Stomach Cancer[61]0015.912.423,41523,4159.00
    Tongue Cancer[86]14.00012.48768767.00
    Cancer[55]0015.9012.472,82972,8299.00
    DRS*Total5100.02100.07100.02121,2096.14
    Asthma in Children[87-92]5100.0150.0685.72121,2096.00
    Small Airway Obstruction[93]00150.0114.36486487.00
    DCS*Total2100.02100.04100.021072,8297.75
    Stroke[55,94,95]2100.0150.0375.021072,8297.33
    Cardiovascular Disease[55]00150.0125.072,82972,8299.00
    Other DiseasesTotal3100.03100.06100.012628,1777.17
    Tuberculosis[96,97]133.3133.3233.334815,4867.00
    Legionnaires' Disease
    (Children)[98]
    133.300116.71261266.00
    Otitis Media (Children)[99]133.300116.75345346.00
    Type 2 Diabetes Mellitus[100]00133.3116.728,17728,1779.00
    All Causes of Mortality[101]00133.3116.773,36373,3638.00
      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.
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    Table  2.   Definition and characteristics of second-hand smoke exposure

    VariablesDefinition of SHS (n, %)Characteristic of SHS (n, %)
    UndefinedDefinition 1Definition 2 NoneType 1Type 2Type 3
    DCS27.14000027.69000016.25
    DRS621.430017.69311.5419.0917.69425.00
    Cancers1760.711083.331184.621557.691090.911292.311168.75
    Other diseases310.71216.6717.69623.08000000
    Total2852.831222.641324.532649.061120.751324.531630.19
      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.
    下载: 导出CSV

    Table  3.   The pooled odds ratios or odds ratios for SHS exposure

    DiseasesSubgroupNumber of
    observations
    I2
    (%)
    P-valueModelPOR/OR and 95% CIEgger's test
    POR/ORLLULtP-value
    Cancers*4674.4< 0.001Random1.791.562.052.740.000
    Lung cancer*1783.2< 0.001Random1.921.422.593.870.009
    1983−1995*40.30.390Fixed1.641.332.03−3.170.125
    1996−2009*964.70.004Random1.341.031.743.020.072
    2010−2019*422.70.275Fixed7.855.1112.07−1.140.687
    Women*1271.1< 0.001Random1.651.222.242.410.076
    Men*200.843Fixed1.120.771.630.38
    Both*592.5< 0.001Random2.761.285.968.510.062
    Household*665.60.012Random1.591.082.350.030.991
    Workplace*672.10.003Random1.380.942.044.540.023
    Total*987.4< 0.001Random2.201.333.624.600.061
    Breast cancer*838.80.121Fixed1.571.401.762.110.044
    1983–1995*200.763Fixed2.601.843.680.62
    1996–2009*600.853Fixed1.471.301.661.350.021
    Household*200.338Fixed1.381.151.653.42
    Workplace*200.519Fixed1.160.891.51−8.86
    Total*838.80.121Fixed1.571.401.762.110.044
    Bladder cancer*440.90.166Fixed1.521.122.050.760.891
    Liver cancer*347.60.148Fixed1.371.081.730.020.997
    Cervical cancer21.841.043.28
    3.912.216.92
    Acute
    Lymphoblastic
    Leukemia
    13.321.945.68
    Intracranial
    Tumors
    21.781.102.86
    1.911.103.33
    Colon cancer14.871.4816.02
    Colorectal cancer11.260.831.89
    Endometrial cancer10.970.282.42
    Stomach cancer11.791.092.96
    Esophageal
    Squamous
    Cell carcinoma
    12.041.143.70
    Oral cancer12.381.473.85
    Papillary thyroid
    Cancer
    13.861.4710.15
    Tongue cancer12.691.674.32
    Cancer11.140.731.79
    DCS*452.90.095Random1.921.292.852.720.236
    Stroke*361.50.074Random2.291.264.162.590.410
    Cardiovascular
    Disease
    11.440.942.21
    DRS*787.7< 0.001Random1.761.132.74 6.700.053
    Asthma in Children*689.7< 0.001Random1.821.073.116.710.085
    Small airway
    Obstruction
    11.541.062.22
    Other diseases6
    Tuberculosis21.620.922.85
    1.701.042.80
    Legionnaires'
    Disease (Children)
    12.101.223.63
    Otitis media (Children)12.241.523.16
    Type 2 diabetes mellitus11.171.001.37
    All causes of mortality11.081.001.17
      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.
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    S1.   Basic characteristics of the included studies

    DiseasesTrialnameYearStudy designParticipants (n)Date of InvestigationGenderExposure
    sites
    LanguageNOS
    CancersLung cancerYong Lin et al.2010Case-control4162006.12−2010.1FemaleWorkplace, HouseholdChinese6
    Hailong Shi et al.2005Case-control1,4902000.6−2002.12FemaleWorkplaceChinese6
    Lina Mu et al.2021Case-control8612005.3−2007.9BothTotalChinese6
    Longde Wang et al.2002Case-control1,7761994.1−1998.4Both, Male,
    Female
    TotalChinese7
    X.-R. Wang et al.2009Case-control3632002.7.1−2004.6.30FemaleTotalEnglish7
    T.H. Lam et al.1987Case-control7411983−1986FemaleHouseholdEnglish7
    Lap Ah Tse et al.2009Case-control6682004−2006MaleTotal,
    Household,
    Workplace
    English7
    Liu Q et al.1993Case-control6321983.6−1984.6FemaleHouseholdEnglish6
    Wen, W. et al.2006Cohort72,8291997.3−2000.5FemaleTotal,
    Household,
    Workplace
    English9
    Yongbing Xiang et al.2003Case-control8281992.2−1993.12FemaleWorkplaceChinese6
    Chunyan Lin et al.1994Case-control2441985−1990FemaleHousehold,
    Workplace
    Chinese6
    Dandan Guan et al.2020Case-control1,2842015.6−2018.12FemaleTotalChinese7
    Jifei Ma et al.2021Case-control7502015.1−2016.6BothTotalChinese6
    Haiyan Li et al.2020Case-control2962011.1−2019.6BothTotalChinese6
    Jun Li et al.2020Cohort23,4152008−2011BothTotalEnglish9
    Breast cancerPing shi et al.2010Case-control4462005.1−2006.12FemaleTotalChinese6
    Xiaodan Yang et al.2014Case-control6042009.7.1−2012.10.11FemaleTotalChinese6
    Kajia Cao et al.2001Case-control6961992−1996FemaleTotalChinese6
    Meiling Qi et al.2014Case-control8492008.10−2010.2FemaleTotal,
    Household,
    Workplace
    English7
    Mingbai Hu et al.2013Case-control4072009.1−2011.2FemaleTotalEnglish6
    Bin Li et al.2015Case-control1,7672007−2013FemaleTotal,
    Household,
    Workplace
    English7
    Changming Gao et al.2013Case-control1,3512004.6−2007.12FemaleTotalEnglish9
    Xinying Lin et al.2001Case-control372NoneFemaleTotalChinese6
    CancersBladder cancerWei Zhang et al.2006Case-control1,2151996−1999Male,
    Female
    Total,
    ousehold,
    Workplace
    Chinese9
    Yuhua Zhou et al.2014Case-control8242005.9−2008.6BothHouseholdChinese7
    Li Tao et al.2010Case-control2311996.7−1999.6Both,
    Male,
    Female
    TotalEnglish8
    Liver cancerJianxue Duan et al.2018Case-control7942010.1.1−2016.12.31BothTotalChinese6
    Huabin Wu et al.2012Case-control1,2542003.1.1−2010.10.31BothTotalChinese6
    Jun Li et al.2020Cohort23,4152008−2011BothTotalEnglish9
    Acute lymphoblastic leukemiaYongjun Fang et al.2010Case-control6132006.6.1−ChildrenTotalChinese6
    CancerWen, W. et al.2006Cohort72,8291997.3−2000.5FemaleTotal,
    ousehold,
    Workplace
    English9
    Cervical cancerJian Li et al.2010Case-control3122007.9−2010.6FemaleTotalChinese6
    Rongxian Xu et al.2014Case-control4132007.11−2008.12FemaleTotalChinese6
    Colon cancerQinting Jiang et al.2004Case-control3961990.5−2002.5
    1989−1990
    BothWorkplaceChinese8
    Colorectal cancerJun Li et al.2020Cohort23,4152008−2011BothTotalEnglish9
    Endometrial cancerJing Gao et al.2006Case-control2,0821997.1−2002.12FemaleTotal,
    Household,
    Workplace
    Chinese8
    Esophageal squamous cell carcinomaZemin Wang et al.2006Case-control2142002−2003BothTotalEnglish7
    Intracranial tumorsMin Wu et al.2010Case-control5372007.1−2008.7BothHousehold,
    Workplace
    Chinese6
    Oral cancerBaochang He et al.2016Case-control7082010.9−2015.1FemaleTotalEnglish7
    Papillary thyroid ancerYan Zhou et al.2016Case-control3692103.4−2014.6BothTotalChinese6
    Stomach cancerJun Li et al.2020Cohort23,4152008−2011BothTotalEnglish9
    Tongue cancerLingjun Yan et al.2016Case-control8762010.9−2015.1BothTotalChinese7
    Asthma in ChildrenXiaojuan Liu et al.2013Case-control2182011.1−2012.12ChildrenTotalChinese6
    Fang Wang et al.2013Case-control7262010ChildrenTotalChinese6
    Mei Xiong et al.2013Case-control552NoneChildrenTotalChinese6
    DRS*Tongzhang Zheng et al.2002Case-control1,2091999.1−2001.3ChildrenTotalEnglish6
    Shixue Ma et al.2006Case-control2122002.1−2004.6ChildrenTotalChinese6
    Maohong Luo et al.2004Case-control2621998−1999ChildrenTotalChinese6
    Small airway obstructionYusheng Chen et al.2013Case-control6482011.10.17−2011.11.1BothTotalEnglish7
    StrokeXianjia Ning et al.1993Case-control2561990.10−1990.12FemaleTotalChinese7
    Yanong Shao et al.1997Case-control2101996.10−1997.3BothTotalChinese6
    DCS*Wen, W. et al.2006Cohort72,8291997.3−2000.5FemaleTotal,
    Household,
    Workplace
    English9
    Cardiovascular diseaseWen, W. et al.2006Cohort72,8291997.3−2000.5FemaleTotal,
    Household,
    Workplace
    English9
    Other diseasesAll cause mortalityKim, C. et al.2016Cohort65,2261996−2000/2009FemaleTotalEnglish8
    Legionnaires' diseases (Children)Suping Wang et al.1994Case-control1261991.4.4−1992.4.3ChildrenTotalChinese6
    Otitis media (Children)Ke Li et al.2018Case-control5342013.1−2016.12ChildrenTotalChinese6
    TuberculosisBirong Dong et al.2001Case-control3481996.3−1997.3BothTotalChinese6
    Leung, Chi C. et al.2010Cohort15,4862000.1−2003.12FemaleTotalEnglish8
    Type 2 diabetes mellitusHuang, C. et al.2019Cohort28,1772004−2008FemaleTotalEnglish9
      Note. * DRS: Diseases of the Respiratory System; DCS: Diseases of the Circulatory System
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    S2.   The definition and types of characteristics of second-hand smoke exposure

    Definition of SHSUndefined
    Definiton 1Exposure 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 2Exposure 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 SHS
    None
    Type 1Location, such as household and workplace.
    Type 2Adulthood 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.
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    S3.   "Leave One Out" sensitivity test

    DiseaseTrialnamePORLLUL
    Cancers
    T.H. Lam et al.1.521.421.62
    Liu Q et al.1.531.441.63
    Chunyan Lin et al.1.531.441.63
    Chunyan Lin et al.1.531.431.63
    Xinying Lin et al.1.511.421.61
    Kajia Cao et al.1.531.431.63
    Longde Wang et al.1.541.441.64
    Yongbing Xiang et al.1.531.441.63
    Qinting Jiang et al.1.531.431.63
    Hailong Shi et al.1.581.481.69
    Zemin Wang et al.1.531.431.63
    Wen W. et al.1.531.441.63
    Jing Gao et al.1.611.511.72
    Wen W. et al.1.541.451.64
    Wei Zhang et al.1.541.441.64
    Wei Zhang et al.1.531.441.63
    Lap Ah Tse et al.1.541.451.65
    X.-R. Wang et al.1.541.441.64
    Jian Li et al.1.531.431.63
    Yong Lin et al.1.531.431.63
    Yong Lin et al.1.521.431.62
    Yongjun Fang et al.1.521.421.61
    Li Tao et al.1.531.441.64
    Min Wu et al.1.531.431.63
    Ping shi et al.1.531.431.63
    Min Wu et al.1.531.431.63
    Huabin Wu et al.1.541.451.65
    Mingbai Hu et al.1.531.441.63
    Changming Gao et al.1.541.441.64
    Rongxian Xu et al.1.511.421.61
    Xiaodan Yang et al.1.531.431.63
    Meiling Qi et al.1.531.441.63
    Yuhua Zhou et al.1.521.431.62
    Bin Li et al.1.551.451.66
    Yan Zhou et al.1.531.431.63
    Baochang He et al.1.521.431.62
    Lingjun Yan et al.1.521.421.62
    Jianxue Duan et al.1.531.431.63
    Jun Li et al.1.531.431.63
    Jun Li et al.1.541.441.64
    Jun Li et al.1.541.451.64
    Haiyan Li et al.1.511.421.61
    Dandan Guan et al.1.531.431.63
    Jun Li et al.1.541.441.64
    Lina Mu et al.1.541.451.64
    Jifei Ma et al.1.511.411.61
    Combined1.531.441.63
    DCS
    Xianjia Ning et al.1.591.232.05
    Yanong Shao et al.1.901.352.68
    Wen W. et al.1.921.432.58
    Wen W. et al.1.721.332.21
    Combined1.751.372.23
    DRS
    Tongzhang Zheng et al.1.401.181.68
    Maohong Luo et al.1.341.151.56
    Shixue Ma et al.1.321.141.54
    Fang Wang et al.1.771.492.09
    Xiaojuan Liu et al.1.321.141.54
    Mei Xiong et al.1.381.181.62
    Yusheng Chen et al.1.381.171.62
    Combined1.401.211.63
    Lung cancer
    T.H. Lam et al.1.461.291.65
    Liu Q et al.1.511.351.70
    Chunyan Lin et al.1.501.341.69
    Chunyan Lin et al.1.521.351.71
    Longde Wang et al.1.541.371.73
    Yongbing Xiang et al.1.521.341.71
    Hailong Shi et al.1.711.511.94
    Wen W. et al.1.511.341.69
    X.-R. Wang et al.1.541.371.74
    Lap Ah Tse et al. 1.56 1.381.561.381.76
    Yong Lin et al.1.501.331.68
    Yong Lin et al.1.491.321.68
    Jun Li et al.1.551.371.75
    Haiyan Li et al.1.451.301.63
    Dandan Guan et al.1.501.341.69
    Lina Mu et al.1.551.371.76
    Jifei Ma et al.1.441.281.61
    Combined1.521.351.70
    Breast cancer
    Kajia Cao et al.1.551.381.74
    Xinying Lin et al.1.491.321.68
    Ping shi et al.1.551.381.75
    Mingbai Hu et al.1.571.391.76
    Changming Gao et al.1.601.401.83
    Meiling Qi et al.1.571.391.78
    Xiaodan Yang et al.1.561.381.75
    Bin Li et al.1.691.471.94
    Combined1.571.401.76
    Bladder cancer
    Wei Zhang et al.1.731.232.44
    Wei Zhang et al.1.501.082.08
    Li Tao et al.1.611.102.35
    Yuhua Zhou et al.1.280.911.81
    Combined1.521.122.05
    Liver cancer
    Huabin Wu et al.1.430.932.20
    Jianxue Duan et al.1.260.981.63
    Jun Li et al.1.461.141.88
    Combined1.371.081.73
    Stroke
    Xianjia Ning et al.1.671.222.30
    Yanong Shao et al.3.151.775.60
    Wen, W. et al.1.891.382.58
    Combined1.921.432.58
    Asthma in Children
    Tongzhang Zheng et al.1.371.121.67
    Maohong Luo et al.1.311.111.54
    Shixue Ma et al.1.281.091.52
    Mei Xiong et al.1.351.131.61
    Xiaojuan Liu et al.1.281.081.52
    Fang Wang et al.1.831.522.21
    Combined1.381.171.62
      Note. POR: pooled odds ratio; OR: odds ratio; LL: 95% lower limit; UL: 95% upper limit.
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  • 收稿日期:  2022-04-24
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  • 刊出日期:  2023-01-20

The Association between Exposure to Second-Hand Smoke and Disease in the Chinese Population: A Systematic Review and Meta-Analysis

doi: 10.3967/bes2023.003
    基金项目:  This study was supported by the Chinese Academy of Medical Sciences (CAMS) Innovation Fund for Medical Sciences (CIFM) [NO.2016-12M-3-001]; and the China Medical Board “Strengthen Capacity of Study and Application on Burden of Disease in Health Care System of China-Establishment and Development of Chinese Burden of Disease Research and Dissemination Center” [NO.15-208]
    作者简介:

    WANG Yu Tong, female, born in 1996, Master Candidate, majoring in burden of disease methodology and tobacco control

    通讯作者: WAN Xia, PhD, Tel: 86-10-65233870, E-mail: xiawan@ibms.pumc.edu.cn

English Abstract

WANG Yu Tong, HU Kui Ru, ZHAO Jian, AI Fei Ling, SHI Yu Lin, WANG Xue Wei, YANG Wen Yi, WANG Jing Xin, AI Li Mei, WAN Xia. The Association between Exposure to Second-Hand Smoke and Disease in the Chinese Population: A Systematic Review and Meta-Analysis[J]. Biomedical and Environmental Sciences, 2023, 36(1): 24-37. doi: 10.3967/bes2023.003
Citation: WANG Yu Tong, HU Kui Ru, ZHAO Jian, AI Fei Ling, SHI Yu Lin, WANG Xue Wei, YANG Wen Yi, WANG Jing Xin, AI Li Mei, WAN Xia. The Association between Exposure to Second-Hand Smoke and Disease in the Chinese Population: A Systematic Review and Meta-Analysis[J]. Biomedical and Environmental Sciences, 2023, 36(1): 24-37. doi: 10.3967/bes2023.003
    • Second-hand smoke (SHS), also known as passive smoking or environmental tobacco smoke, is composed of side stream smoke released from the combustion of tobacco products (such as cigarettes, cigars, or pipes) and mainstream smoke exhaled by smokers[1]. It contains more than 7,000 chemicals, of which hundreds are toxic and approximately 70 are reportedly linked with cancer[2,3]. In 2014, the Surgeon General reported that SHS is associated with various diseases in both adults and children[4], and many more recent studies have shown similar results, especially those relating to cancer[5,6], diseases of the respiratory system (DRS)[7,8], and diseases of the circulatory system (DCS)[9,10]. The World Health Organization Framework Convention on Tobacco Control (FCTC) article 8 proposed restrictive provisions on SHS exposure[11].

      Studies have reported the health problems caused by SHS exposure in China. In 2010, the exposure rate reached 72.4%. Although the exposure rate decreased slightly in 2018 (44.9% in the household and 50.9% in the workplace)[12], it still attributed a significant disease burden. In 2010, the number of the disability adjusted life years (DALYs) caused by SHS exposure in China was 9,308 million person years, resulting in 381,547 reported deaths. In 2019, the DALYs increased to 9,683 million person years, resulting in 416,054 deaths[13]. Studies have shown that the development of the tobacco epidemic in China is different from that in Western countries. For active smoking, several studies have shown substantial differences in the level of risk between countries. Using lung cancer as an example, the relative risks (RRs) ranged from 2.4 to 6.5 in China, which were much lower than in Western countries (range, 9.4 to 23.2)[14]. The risk values reported for many studies in Western countries are generally greater than 10[15-17]. The unique cooking style involved in preparing Chinese cuisine has an impact on the levels of indoor air pollution in Chinese households. Therefore, it is of significance to explore the risks associated with SHS exposure and different diseases among the Chinese population.

      A literature search identified 30 meta-analyses on the association between SHS exposure and diseases among the Chinese population, three of which were written in English and the other 27 in Chinese. In these meta-analyses, the number of included studies ranged from 6 to 51, covering the following 11 diseases: lung cancer (n = 9)[18-26], low birth weight (n = 5)[27-31], breast cancer (n = 3)[32-34], congenital heart disease (n = 3)[35-37], stroke (n = 2)[38,39], asthma in children (n = 2)[40,41], adverse pregnancy outcomes (n = 2)[42,43], COPD (n = 1)[44], birth defects (n = 1)[45], childhood autism (n = 1)[46], and gestational diabetes mellitus (n = 1)[47]. All of these studies were completed before 2017, with the exception of the latest study of lung cancer, which was published in 2020. Of the studies, 25 were not completed within the last five years and only one disease was analyzed in each paper. Therefore, there is a lack of comprehensive data and up-to-date evidence on the risk of various diseases associated with SHS exposure among the Chinese population.

      The aim of this study was to systematically review the risk of all diseases related to SHS exposure in the Chinese population based on an exhaustive search of observational studies published up until June 31, 2021. Our findings provide a basis for future studies, and the data may be used for burden of disease estimations.

    • This study was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies published up until June 30, 2021, were identified through a search of Chinese databases (including CNKI, Wanfang, and VIP) and English databases (including PubMed, EMBASE, and Cochrane Library), with the keywords: “tobacco” “smoking” “cigarette” “smoker” “smokers” “smoke” “nicotine” “China” “Chinese”. The complete search used for PubMed was:

      ((((((((tobacco[Title/Abstract]) OR (smoking[Title/Abstract])) OR (cigarette[Title/Abstract])) OR (smoker[Title/Abstract])) OR (smoke[Title/Abstract])) OR (smokers[Title/Abstract])) OR (nicotine[Title/Abstract])) AND (((case-control[Title/Abstract]) OR (case control[Title/Abstract])) OR (cohort[Title/Abstract]))) AND ((China[Title/Abstract]) OR (Chinese[Title/Abstract])).

      Additional records were manually identified by searching the references of published articles, reviews, and previous meta-analyses. Based on the above search method, all articles on passive smoking and SHS exposure were included in this study.

    • Inclusion Criteria This was structured according to the PECOS format. 1) Participants (P): Studies were carried out among the Chinese population, and the participants were representative; 2) Exposure (E): SHS exposure; 3) Comparison (C): To actively compare with individuals unexposed to SHS; 4) Outcomes (O): Effect values for SHS exposure and corresponding outcome events [Odds Ratios (ORs), Relative Risks (RRs), or Hazard Ratios (HRs)]; 5) Types of study (S): Case-control and cohort studies without restriction to language or time period; 6) Studies with a score of 6 or above using the Newcastle Ottawa Scale (NOS) assessment[48].

      Exclusion Criteria 1) Duplicate studies or abstracts without the full text being available; 2) Gene or cell research, and animal experiments; 3) Special groups, such as coal miners, pregnant women, and drug users. 4) The outcomes of the study were symptoms rather than diseases, such as elevated blood sugar.

    • Study screening and data extraction were carried out independently by two researchers, with verification by a third reviewer. The title, first author, year of publication, time of investigation, sampling method, location, definition of SHS, number of cases and controls, basic information about participants, and other relevant parameters were extracted. The risk of bias according to the PRISMA recommendations was assessed independently by the two researchers mentioned above.

    • We evaluated the quality of the included studies from two aspects. First, the mean value of the NOS scores for each group. Second, a description of whether each study clearly defined the definition and source of SHS exposure.

    • In this study, HRs were the effect values for three studies on the risk of death, and the RRs for the five cohort studies. Because of the limited number of the above two types of studies, the OR was used as the uniform effect value. In addition, two types of analysis strategies were used in this study. 1) For those diseases for which only one or two studies had been conducted, a simple statistical description was used. 2) For those diseases for which three or more studies had been conducted, meta-analysis was conducted using the Stata 15.1 software (Computer Resource Center, U.S.A).

      Therefore, meta-analysis was performed for the studies on cancer (including lung cancer, breast cancer, bladder cancer, and liver cancer), DRS (including asthma in children), and DCS (including stroke). The heterogeneity of the effects across studies was evaluated using I2 and Q tests. The fixed effect model was used when I2 < 50% or P > 0.1. The random effect model was otherwise used. The time of investigation was divided into three periods (1983–1995, 1996–2009, and after 2010) based on the changes in the definition of SHS exposure. The participants were divided into four groups: Men, Women, Men and Women, and Children. The exposure sites were divided into Household, Workplace, and Non-specified Sites. Subgroup analysis was performed for the groups mentioned above. Funnel plots, with Egger's tests, were used to evaluate publication bias, and the “leave-one-out” method was used for sensitivity analysis.

    • 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.

      Figure 1.  The study selection process.

      Table 1.  Basic information regarding the selection of studies

      Basic informationChineseEnglishTotalNumber of participantsNOS
      (mean score)
      (n, %)(n, %)(n, %)MinMax
      Total35100.018100.053100.012673,3636.72
      LanguageChinese35100.03566.012673,3636.34
      English18100.01834.020472,8297.45
      Study designCase-control35100.01372.24890.61262,0826.52
      Cohort00527.859.415,48673,3638.60
      Start year of
      investigation
      1983–1995822.915.6917.01261,7766.56
      1996–20091748.61688.93362.321073,3636.91
      2010–2021925.715.61018.92181,2846.30
      None12.90011.95525526.00
      SexWomen1539.51661.53148.424473,3637.19
      Men25.327.746.34561,7767.75
      Both1334.2726.92031.321023,4157.05
      Children821.113.8914.11261,2096.00
      Exposure siteHousehold715.6923.71619.324472,8297.08
      Workplace920.0718.41619.324472,8297.08
      Total2964.42257.95161.412673,3636.91
      Cancer typeTotal25100.017100.042100.021472,8296.95
      Lung Cancer[49-63]936.0635.31535.724472,8296.73
      Breast Cancer[64-71]416.0423.5819.03721,7676.63
      Bladder Cancer[72-74]28.015.937.14561,2158.00
      Liver Cancer[61,75,76]28.015.937.179423,4157.00
      Cervical Cancer[77,78]28.00024.83124136.00
      Acute Lymphoblastic
      Leukemia[79]
      14.00012.46136136.00
      Colon Cancer[80]14.00012.43963968.00
      Colorectal Cancer[61]0015.912.423,41523,4159.00
      Endometrial Cancer[81]14.00012.42,0822,0828.00
      Esophageal Squamous
      Cell Carcinoma[82]
      0015.912.42142147.00
      Intracranial Tumors[83]14.00012.45375376.00
      Oral Cancer[84]0015.912.47087087.00
      Papillary Thyroid Cancer[85]14.00012.43693696.00
      Stomach Cancer[61]0015.912.423,41523,4159.00
      Tongue Cancer[86]14.00012.48768767.00
      Cancer[55]0015.9012.472,82972,8299.00
      DRS*Total5100.02100.07100.02121,2096.14
      Asthma in Children[87-92]5100.0150.0685.72121,2096.00
      Small Airway Obstruction[93]00150.0114.36486487.00
      DCS*Total2100.02100.04100.021072,8297.75
      Stroke[55,94,95]2100.0150.0375.021072,8297.33
      Cardiovascular Disease[55]00150.0125.072,82972,8299.00
      Other DiseasesTotal3100.03100.06100.012628,1777.17
      Tuberculosis[96,97]133.3133.3233.334815,4867.00
      Legionnaires' Disease
      (Children)[98]
      133.300116.71261266.00
      Otitis Media (Children)[99]133.300116.75345346.00
      Type 2 Diabetes Mellitus[100]00133.3116.728,17728,1779.00
      All Causes of Mortality[101]00133.3116.773,36373,3638.00
        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

      VariablesDefinition of SHS (n, %)Characteristic of SHS (n, %)
      UndefinedDefinition 1Definition 2 NoneType 1Type 2Type 3
      DCS27.14000027.69000016.25
      DRS621.430017.69311.5419.0917.69425.00
      Cancers1760.711083.331184.621557.691090.911292.311168.75
      Other diseases310.71216.6717.69623.08000000
      Total2852.831222.641324.532649.061120.751324.531630.19
        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).

      Figure 2.  The odds ratios for second-hand smoke exposure.

      Figure 3.  The disease-specific odds ratios for second-hand smoke exposure.

      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

      DiseasesSubgroupNumber of
      observations
      I2
      (%)
      P-valueModelPOR/OR and 95% CIEgger's test
      POR/ORLLULtP-value
      Cancers*4674.4< 0.001Random1.791.562.052.740.000
      Lung cancer*1783.2< 0.001Random1.921.422.593.870.009
      1983−1995*40.30.390Fixed1.641.332.03−3.170.125
      1996−2009*964.70.004Random1.341.031.743.020.072
      2010−2019*422.70.275Fixed7.855.1112.07−1.140.687
      Women*1271.1< 0.001Random1.651.222.242.410.076
      Men*200.843Fixed1.120.771.630.38
      Both*592.5< 0.001Random2.761.285.968.510.062
      Household*665.60.012Random1.591.082.350.030.991
      Workplace*672.10.003Random1.380.942.044.540.023
      Total*987.4< 0.001Random2.201.333.624.600.061
      Breast cancer*838.80.121Fixed1.571.401.762.110.044
      1983–1995*200.763Fixed2.601.843.680.62
      1996–2009*600.853Fixed1.471.301.661.350.021
      Household*200.338Fixed1.381.151.653.42
      Workplace*200.519Fixed1.160.891.51−8.86
      Total*838.80.121Fixed1.571.401.762.110.044
      Bladder cancer*440.90.166Fixed1.521.122.050.760.891
      Liver cancer*347.60.148Fixed1.371.081.730.020.997
      Cervical cancer21.841.043.28
      3.912.216.92
      Acute
      Lymphoblastic
      Leukemia
      13.321.945.68
      Intracranial
      Tumors
      21.781.102.86
      1.911.103.33
      Colon cancer14.871.4816.02
      Colorectal cancer11.260.831.89
      Endometrial cancer10.970.282.42
      Stomach cancer11.791.092.96
      Esophageal
      Squamous
      Cell carcinoma
      12.041.143.70
      Oral cancer12.381.473.85
      Papillary thyroid
      Cancer
      13.861.4710.15
      Tongue cancer12.691.674.32
      Cancer11.140.731.79
      DCS*452.90.095Random1.921.292.852.720.236
      Stroke*361.50.074Random2.291.264.162.590.410
      Cardiovascular
      Disease
      11.440.942.21
      DRS*787.7< 0.001Random1.761.132.74 6.700.053
      Asthma in Children*689.7< 0.001Random1.821.073.116.710.085
      Small airway
      Obstruction
      11.541.062.22
      Other diseases6
      Tuberculosis21.620.922.85
      1.701.042.80
      Legionnaires'
      Disease (Children)
      12.101.223.63
      Otitis media (Children)12.241.523.16
      Type 2 diabetes mellitus11.171.001.37
      All causes of mortality11.081.001.17
        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.

      Figure S1.  The subgroup odds ratios for second-hand smoke exposure.

    • 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.

      Figure S2.  The disease-specific funnel plots.

    • 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.

    • Our findings suggested that exposure to SHS increases the risk of various systemic diseases, especially for all cancers (OR = 1.77, 95% CI: 1.54–2.05), DCS (OR = 1.92, 95% CI: 1.29–2.85), and DRS (OR = 1.76, 95% CI: 1.13–2.74). The ORs fluctuated over time for lung cancer and breast cancer.

    • Overall, although the studies included had NOS scores of 6 or more, the overall mean score was only 6.72, so the quality was low overall. The quality of Chinese studies was relatively poor, with a lower average NOS score of 6.34, compared with English studies (mean = 7.45). In addition, the quality of cohort studies (mean = 8.60) was generally higher than that of case-control studies (mean = 6.52). As for the definition and characteristics of SHS, in National Tobacco Surveys and the National Behavior Risk Factors Surveillance System of China, the prevalence of SHS exposure was taken as one of the key indicators for supervision, which means it is important to clarify the definition of SHS exposure. In 1984, it was defined as “more than 15 minutes per day”[102], while in 1996, it was changed to “at least one day per week for more than 15 minutes”[103]. In 2010, the limit of 15 minutes was removed[104]. However, only 47.17% of the included literature in our study was reported with a clear definition. This may be an area for further development in the future. If the definition of SHS exposure was more accurate, the OR may increase, which may be one explanation for the fluctuation in the OR for lung cancer after 2010.

    • Cancer incidence and mortality in China, 2016”, a publication released by the National Cancer Center in 2022, showed that the cancer with the highest incidence in men was lung cancer, while it was breast cancer in women[105]. The current study focused on lung cancer and breast cancer, with a specific focus on changes in ORs according to sex, time period, and exposure site. Data on other diseases were limited by the available literature, thereby not allowing for in-depth subgroup analyses. Our study provides a basis for subsequent studies by comparing the results with those of previous domestic and international literature.

      Lung Cancer We observed an OR of 1.92 (95% CI: 1.42–2.59) for lung cancer, which did not differ significantly from the six previously-published meta-analyses among the Chinese population (OR range, 1.13 to 2.11). In 2018, a review reported that the OR among the global population was 1.245 (95% CI: 1.026–1.511)[106], and the association among the Chinese population was slightly higher. The OR for Chinese women was 1.65 (95% CI: 1.22–2.24) in our study, which was supported by three previous studies (OR range, 1.50–1.58)[18-20], but two other data sets showed that there was no correlation among Chinese women[21,22]. This may be due to the increase in research on women after 2000. A study published in 2018 observed an OR of 1.33 (95% CI: 1.17–1.51) among women globally[107], and the results among Chinese women were slightly higher. The OR for Chinese men was not statistically significant in this study (OR = 1.12, 95% CI: 0.77–1.63), which was supported by a previous study (OR = 1.00, 95% CI: 0.68–1.48, for hospital-based studies)[23]. Since the other two previous results were significant [OR = 1.34, 95% CI: 1.08–1.65[19] and OR = 1.85, 95% CI: 1.10–3.10 (population-based studies)[23]], the association among Chinese men requires further study. It is noteworthy that the OR values have rapidly increased since 2010. The tobacco industry in the West has been promoting low-tar cigarettes as a healthier alternative to regular cigarettes since the 1950s. In China, the sale of cigarettes with a tar content of more than 15 mg per cigarette was banned by the State Tobacco Monopoly Administration in 2004. From this study, we see that the health risk associated with SHS did not reduce with low-tar cigarettes.

      Breast Cancer We observed an OR of 1.57 (95% CI: 1.40–1.76) for breast cancer, which was similar to three previous meta-analyses (OR range, 1.62–1.94) of the Chinese population[32-34], but was more reliable because of lower heterogeneity. Globally, there were a few pooled ORs from meta-analyses, including 1.07 (95% CI: 1.02–1.13) for 11 prospective studies and 1.30 (95% CI: 1.10–1.54) for 20 retrospective studies in 2015[108], 1.235 (95% CI: 1.102–1.385) in 2018[106], and 1.07 in the results of the Global Burden of Disease (GBD) 2017[3]. Therefore, the risk in Chinese women may be slightly higher than the global level. The ORs decreased in 1996–2009, compared with those in 1983–1995, and this difference was statistically significant. However, we could not draw any conclusions regarding the secular trend of ORs in breast cancer because there were no studies published after 2010. Future studies on breast cancer are therefore needed.

      Subgroup Analysis of the Exposure Sites in Lung and Breast Cancer Our results revealed that exposure in households or in non-specific places increased the risk of lung cancer and breast cancer, which was supported by five previous meta-analyses of the Chinese population[18-20,23,32]. However, the risk was not significant in the workplace, which may indicate that the smoke-free policy or law was well implemented in the workplace. It also suggests that smoke-free policies in public places or homes need to be reinforced. Another factor is that in most studies, SHS exposure was defined as exposure to family members only, workplace was not included in this definition (Supplementary Table S2, definition 2), but the impact of the workplace should not be ignored.

      Other Diseases Currently, no meta-analyses have been conducted for bladder cancer or liver cancer among the Chinese population. Globally, a meta-analysis in 2009 showed no statistically significant association between bladder cancer and SHS exposure (OR = 0.99, 95% CI: 0.86–1.14)[109]. However, because only three studies were included, the reliability of these results is under question. In our study, the OR for the association between SHS and stroke was 2.29 (95% CI: 1.26–4.16), which is similar to previous meta-analyses results for the Chinese population in 2005 (OR = 3.22, 95% CI: 2.04–5.07)[38]. Globally, the pooled estimates were 1.64 (95% CI: 1.12–2.40) in 2012[110] and 1.35 (95% CI: 1.22–1.50) in 2015[111]. Because of the limited number of articles available, subgroup analysis based on sex could not be performed. From literature published in 2016, the OR for Chinese women was 2.11 (95% CI: 1.19–3.74)[39]. However, the NOS scores of the included studies were not specified in the literature, meaning that the quality of the included studies was unconfirmed. There is sufficient evidence to prove that parental smoking, especially by the direct care-giver, decreases pulmonary function[112] and increases asthma prevalence[113] in children. The results of our study (OR = 1.82, 95% CI: 1.07–3.11) were lower than those of a previous study (OR = 3.13, 95% CI: 2.23–4.03)[40], but did not show statistical significance. Furthermore, there was no significant difference between our data and the global data reported in 2013 (OR = 1.32, 95% CI: 1.23–1.42)[114] and 2020 (OR = 1.24, 95% CI: 1.20–1.28)[115].

    • The limitations of the current study include the limited number of eligible studies in the literature and the resulting bias. A large number of studies are currently being undertaken regarding the association between exposure to SHS and certain diseases. Cancer has become one of the major health problems that seriously threatens the health of the Chinese population. However, our study revealed that research into diseases affected by SHS has mainly focused on lung cancer and breast cancer. For other highly-prevalent cancers associated with SHS, such as gastric cancer, colon cancer, and liver cancer, only one to three studies were included in our analysis because of the low quality of the literature or the lack of relevant research. Only original results were included for such studies, and meta-analyses were not performed. The number of cohort studies was also low, with only five such studies out of the 53 extracted from the database. There was heterogeneity among the studies in the meta-analysis of diseases, with the exception of breast cancer, bladder cancer, and liver cancer, which may have led to bias. Publication bias exists in the results for lung cancer and breast cancer; therefore, a minimum sample size should be ensured in future studies. In addition, the definition of SHS exposure varied widely between the included studies, with some not even reporting a definition, which may also have conferred some bias.

    • SHS exposure is a known cause of various diseases. After meta-analysis, exposure to SHS was found to be positively associated with cancer (including lung cancer, breast cancer, and liver cancer), DCS (including stroke), and DRS (including asthma in children) among the Chinese population. Our findings did not show a significant difference from global findings. The same is not the case for active smoking. The definition and characteristics of SHS exposure need to be further clarified. The variations in risk during different time periods may reflect changes to this definition. Further studies are required to confirm the correlation between SHS exposure in the workplace and the risk of disease among men. There remains a lack of research on some other diseases caused by SHS. Our results provide a reference for public health professionals, researchers, and policymakers in the development of effective SHS exposure prevention strategies.

    • WANG Yu Tong: Identified the studies; checked and analyzed the data; wrote the initial draft of the manuscript. HU Kui Ru, ZHAO Jian, AI Fei Ling, SHI Yu Lin, WANG Xue Wei, AI Li Mei, YANG Wen Yi, WANG Jing Xin: Identified the studies; extracted and checked the data. WAN Xia: Conceived and designed the study; checked and verified the data; contributed to the revision and finalization of the paper; was responsible for submitting the article for publication.

    • The authors have no possible conflicts of interest.

      Table S1.  Basic characteristics of the included studies

      DiseasesTrialnameYearStudy designParticipants (n)Date of InvestigationGenderExposure
      sites
      LanguageNOS
      CancersLung cancerYong Lin et al.2010Case-control4162006.12−2010.1FemaleWorkplace, HouseholdChinese6
      Hailong Shi et al.2005Case-control1,4902000.6−2002.12FemaleWorkplaceChinese6
      Lina Mu et al.2021Case-control8612005.3−2007.9BothTotalChinese6
      Longde Wang et al.2002Case-control1,7761994.1−1998.4Both, Male,
      Female
      TotalChinese7
      X.-R. Wang et al.2009Case-control3632002.7.1−2004.6.30FemaleTotalEnglish7
      T.H. Lam et al.1987Case-control7411983−1986FemaleHouseholdEnglish7
      Lap Ah Tse et al.2009Case-control6682004−2006MaleTotal,
      Household,
      Workplace
      English7
      Liu Q et al.1993Case-control6321983.6−1984.6FemaleHouseholdEnglish6
      Wen, W. et al.2006Cohort72,8291997.3−2000.5FemaleTotal,
      Household,
      Workplace
      English9
      Yongbing Xiang et al.2003Case-control8281992.2−1993.12FemaleWorkplaceChinese6
      Chunyan Lin et al.1994Case-control2441985−1990FemaleHousehold,
      Workplace
      Chinese6
      Dandan Guan et al.2020Case-control1,2842015.6−2018.12FemaleTotalChinese7
      Jifei Ma et al.2021Case-control7502015.1−2016.6BothTotalChinese6
      Haiyan Li et al.2020Case-control2962011.1−2019.6BothTotalChinese6
      Jun Li et al.2020Cohort23,4152008−2011BothTotalEnglish9
      Breast cancerPing shi et al.2010Case-control4462005.1−2006.12FemaleTotalChinese6
      Xiaodan Yang et al.2014Case-control6042009.7.1−2012.10.11FemaleTotalChinese6
      Kajia Cao et al.2001Case-control6961992−1996FemaleTotalChinese6
      Meiling Qi et al.2014Case-control8492008.10−2010.2FemaleTotal,
      Household,
      Workplace
      English7
      Mingbai Hu et al.2013Case-control4072009.1−2011.2FemaleTotalEnglish6
      Bin Li et al.2015Case-control1,7672007−2013FemaleTotal,
      Household,
      Workplace
      English7
      Changming Gao et al.2013Case-control1,3512004.6−2007.12FemaleTotalEnglish9
      Xinying Lin et al.2001Case-control372NoneFemaleTotalChinese6
      CancersBladder cancerWei Zhang et al.2006Case-control1,2151996−1999Male,
      Female
      Total,
      ousehold,
      Workplace
      Chinese9
      Yuhua Zhou et al.2014Case-control8242005.9−2008.6BothHouseholdChinese7
      Li Tao et al.2010Case-control2311996.7−1999.6Both,
      Male,
      Female
      TotalEnglish8
      Liver cancerJianxue Duan et al.2018Case-control7942010.1.1−2016.12.31BothTotalChinese6
      Huabin Wu et al.2012Case-control1,2542003.1.1−2010.10.31BothTotalChinese6
      Jun Li et al.2020Cohort23,4152008−2011BothTotalEnglish9
      Acute lymphoblastic leukemiaYongjun Fang et al.2010Case-control6132006.6.1−ChildrenTotalChinese6
      CancerWen, W. et al.2006Cohort72,8291997.3−2000.5FemaleTotal,
      ousehold,
      Workplace
      English9
      Cervical cancerJian Li et al.2010Case-control3122007.9−2010.6FemaleTotalChinese6
      Rongxian Xu et al.2014Case-control4132007.11−2008.12FemaleTotalChinese6
      Colon cancerQinting Jiang et al.2004Case-control3961990.5−2002.5
      1989−1990
      BothWorkplaceChinese8
      Colorectal cancerJun Li et al.2020Cohort23,4152008−2011BothTotalEnglish9
      Endometrial cancerJing Gao et al.2006Case-control2,0821997.1−2002.12FemaleTotal,
      Household,
      Workplace
      Chinese8
      Esophageal squamous cell carcinomaZemin Wang et al.2006Case-control2142002−2003BothTotalEnglish7
      Intracranial tumorsMin Wu et al.2010Case-control5372007.1−2008.7BothHousehold,
      Workplace
      Chinese6
      Oral cancerBaochang He et al.2016Case-control7082010.9−2015.1FemaleTotalEnglish7
      Papillary thyroid ancerYan Zhou et al.2016Case-control3692103.4−2014.6BothTotalChinese6
      Stomach cancerJun Li et al.2020Cohort23,4152008−2011BothTotalEnglish9
      Tongue cancerLingjun Yan et al.2016Case-control8762010.9−2015.1BothTotalChinese7
      Asthma in ChildrenXiaojuan Liu et al.2013Case-control2182011.1−2012.12ChildrenTotalChinese6
      Fang Wang et al.2013Case-control7262010ChildrenTotalChinese6
      Mei Xiong et al.2013Case-control552NoneChildrenTotalChinese6
      DRS*Tongzhang Zheng et al.2002Case-control1,2091999.1−2001.3ChildrenTotalEnglish6
      Shixue Ma et al.2006Case-control2122002.1−2004.6ChildrenTotalChinese6
      Maohong Luo et al.2004Case-control2621998−1999ChildrenTotalChinese6
      Small airway obstructionYusheng Chen et al.2013Case-control6482011.10.17−2011.11.1BothTotalEnglish7
      StrokeXianjia Ning et al.1993Case-control2561990.10−1990.12FemaleTotalChinese7
      Yanong Shao et al.1997Case-control2101996.10−1997.3BothTotalChinese6
      DCS*Wen, W. et al.2006Cohort72,8291997.3−2000.5FemaleTotal,
      Household,
      Workplace
      English9
      Cardiovascular diseaseWen, W. et al.2006Cohort72,8291997.3−2000.5FemaleTotal,
      Household,
      Workplace
      English9
      Other diseasesAll cause mortalityKim, C. et al.2016Cohort65,2261996−2000/2009FemaleTotalEnglish8
      Legionnaires' diseases (Children)Suping Wang et al.1994Case-control1261991.4.4−1992.4.3ChildrenTotalChinese6
      Otitis media (Children)Ke Li et al.2018Case-control5342013.1−2016.12ChildrenTotalChinese6
      TuberculosisBirong Dong et al.2001Case-control3481996.3−1997.3BothTotalChinese6
      Leung, Chi C. et al.2010Cohort15,4862000.1−2003.12FemaleTotalEnglish8
      Type 2 diabetes mellitusHuang, C. et al.2019Cohort28,1772004−2008FemaleTotalEnglish9
        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 SHSUndefined
      Definiton 1Exposure 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 2Exposure 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 SHS
      None
      Type 1Location, such as household and workplace.
      Type 2Adulthood 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

      DiseaseTrialnamePORLLUL
      Cancers
      T.H. Lam et al.1.521.421.62
      Liu Q et al.1.531.441.63
      Chunyan Lin et al.1.531.441.63
      Chunyan Lin et al.1.531.431.63
      Xinying Lin et al.1.511.421.61
      Kajia Cao et al.1.531.431.63
      Longde Wang et al.1.541.441.64
      Yongbing Xiang et al.1.531.441.63
      Qinting Jiang et al.1.531.431.63
      Hailong Shi et al.1.581.481.69
      Zemin Wang et al.1.531.431.63
      Wen W. et al.1.531.441.63
      Jing Gao et al.1.611.511.72
      Wen W. et al.1.541.451.64
      Wei Zhang et al.1.541.441.64
      Wei Zhang et al.1.531.441.63
      Lap Ah Tse et al.1.541.451.65
      X.-R. Wang et al.1.541.441.64
      Jian Li et al.1.531.431.63
      Yong Lin et al.1.531.431.63
      Yong Lin et al.1.521.431.62
      Yongjun Fang et al.1.521.421.61
      Li Tao et al.1.531.441.64
      Min Wu et al.1.531.431.63
      Ping shi et al.1.531.431.63
      Min Wu et al.1.531.431.63
      Huabin Wu et al.1.541.451.65
      Mingbai Hu et al.1.531.441.63
      Changming Gao et al.1.541.441.64
      Rongxian Xu et al.1.511.421.61
      Xiaodan Yang et al.1.531.431.63
      Meiling Qi et al.1.531.441.63
      Yuhua Zhou et al.1.521.431.62
      Bin Li et al.1.551.451.66
      Yan Zhou et al.1.531.431.63
      Baochang He et al.1.521.431.62
      Lingjun Yan et al.1.521.421.62
      Jianxue Duan et al.1.531.431.63
      Jun Li et al.1.531.431.63
      Jun Li et al.1.541.441.64
      Jun Li et al.1.541.451.64
      Haiyan Li et al.1.511.421.61
      Dandan Guan et al.1.531.431.63
      Jun Li et al.1.541.441.64
      Lina Mu et al.1.541.451.64
      Jifei Ma et al.1.511.411.61
      Combined1.531.441.63
      DCS
      Xianjia Ning et al.1.591.232.05
      Yanong Shao et al.1.901.352.68
      Wen W. et al.1.921.432.58
      Wen W. et al.1.721.332.21
      Combined1.751.372.23
      DRS
      Tongzhang Zheng et al.1.401.181.68
      Maohong Luo et al.1.341.151.56
      Shixue Ma et al.1.321.141.54
      Fang Wang et al.1.771.492.09
      Xiaojuan Liu et al.1.321.141.54
      Mei Xiong et al.1.381.181.62
      Yusheng Chen et al.1.381.171.62
      Combined1.401.211.63
      Lung cancer
      T.H. Lam et al.1.461.291.65
      Liu Q et al.1.511.351.70
      Chunyan Lin et al.1.501.341.69
      Chunyan Lin et al.1.521.351.71
      Longde Wang et al.1.541.371.73
      Yongbing Xiang et al.1.521.341.71
      Hailong Shi et al.1.711.511.94
      Wen W. et al.1.511.341.69
      X.-R. Wang et al.1.541.371.74
      Lap Ah Tse et al. 1.56 1.381.561.381.76
      Yong Lin et al.1.501.331.68
      Yong Lin et al.1.491.321.68
      Jun Li et al.1.551.371.75
      Haiyan Li et al.1.451.301.63
      Dandan Guan et al.1.501.341.69
      Lina Mu et al.1.551.371.76
      Jifei Ma et al.1.441.281.61
      Combined1.521.351.70
      Breast cancer
      Kajia Cao et al.1.551.381.74
      Xinying Lin et al.1.491.321.68
      Ping shi et al.1.551.381.75
      Mingbai Hu et al.1.571.391.76
      Changming Gao et al.1.601.401.83
      Meiling Qi et al.1.571.391.78
      Xiaodan Yang et al.1.561.381.75
      Bin Li et al.1.691.471.94
      Combined1.571.401.76
      Bladder cancer
      Wei Zhang et al.1.731.232.44
      Wei Zhang et al.1.501.082.08
      Li Tao et al.1.611.102.35
      Yuhua Zhou et al.1.280.911.81
      Combined1.521.122.05
      Liver cancer
      Huabin Wu et al.1.430.932.20
      Jianxue Duan et al.1.260.981.63
      Jun Li et al.1.461.141.88
      Combined1.371.081.73
      Stroke
      Xianjia Ning et al.1.671.222.30
      Yanong Shao et al.3.151.775.60
      Wen, W. et al.1.891.382.58
      Combined1.921.432.58
      Asthma in Children
      Tongzhang Zheng et al.1.371.121.67
      Maohong Luo et al.1.311.111.54
      Shixue Ma et al.1.281.091.52
      Mei Xiong et al.1.351.131.61
      Xiaojuan Liu et al.1.281.081.52
      Fang Wang et al.1.831.522.21
      Combined1.381.171.62
        Note. POR: pooled odds ratio; OR: odds ratio; LL: 95% lower limit; UL: 95% upper limit.
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