Exposure to ETS is defined as the involuntary or passive breathing of air contaminated with tobacco smoke by someone who is not smoking. Several comprehensive reviews of the effects of ETS on health have been conducted in the last few years (39–41). Tobacco smoke is a known human carcinogen (41) and no level of exposure to ETS is free of risk. Chronic exposure to ETS among adults increases the risk of death and illness from cancer and cardiovascular and respiratory diseases. In infants and young children, exposure to ETS increases the risk of sudden infant death syndrome (42), ARIs, chronic res-piratory symptoms, middle ear disease, decreased pulmonary function and asthma. In children with asthma, ETS increases the severity and frequency of asthma attacks.
Box 11. Children living close to busy roads
A recent study conducted by the EC Joint Research Centre (33) using GIS techniques and overlaying population density with the road network has shown that nearly 1 300 000 children under 15 years of age live within 50 m of roads in the EU15. Roads included motorways, national roads with double lanes, national roads and other principal roads as classified by Eurostat. In terms of the proportion of national child populations, the average was 2% with the highest values in Belgium and Luxembourg (3.5%) and the lowest in Finland and Sweden (1.2%). Those children are at high risk from air pollution as well as noise and traffic accidents. Furthermore, they are restricted in normal children’s activities such as playing, sports, and being healthily mobile.
A sample map showing road networks and population density (Fig. 21) suggests that the greatest problems are in big urban agglomerations with the highest concentration of people. The same methodology was used to assess the proportion of children living at a distance of 50 m, 200 m and 350 m from roads in London, Milan and Utrecht, three cities of comparable size, each covering approximately 100 km2. Altogether, nearly 90 000 children live within 50 m of roads, and 350 000 within 200 m. The city of Utrecht has the greatest proportion of children aged under 15 years living close to roads as defined above.
Fig. 21. A sample map overlaying the road network and population density
Source: The GISCO Database (34); European Environment Agency (35).
The proportion of children living at a distance of 50 m from roads in London, Milan and Utrecht is considerably lower than the respective national estimates. This difference is partly due to the fact that the road network database does not include the big busy streets within the cities unless they are designated as part of a national road. Further enhancement of the road database and availability of population density within the city will make it possible to make reliable estimates of exposure to traffic sources.
Over half of all children aged 13–15 years are exposed to ETS in their homes in the majority of the countries for which comparable information is available (Fig. 22). In the Balkans and the Caucasus, exposure exceeds 90%. The data used in Fig. 22 were drawn from the Global Youth Tobacco Survey (GYTS), which covered children aged 13–15 years (43) and are based on self-reported answers to the question as to whether they were “living in homes where others smoke in [their]presence”. The geo-graphic coverage of comparable data is restricted by the fact that only countries in central and east-ern Europe, central Asia, the Balkans and the Caucasus participated in the GYTS. For westeast-ern Europe, various studies indicate that the proportion of children exposed to ETS at home is 20–58% (37,44).
Fig. 22. Proportion of 13–15-year-olds exposed to ETS in their homes, 2002–2005
Note. TFYR Macedonia = The former Yugoslav Republic of Macedonia.
Source: GYTS (43).
On average, exposure to ETS in the 25 countries participating in the GYTS is very high: 84% of the 13–15-year-olds reported that they were exposed to tobacco outside their homes, and in some coun-tries the figures were even higher (Table 3) (45).
The impact of ETS on asthma episodes in children aged under 14 years was estimated using a recent meta-analysis (39) and current estimates of smoking prevalence in ENHIS countries (46). The results suggested that exposure to ETS increases the number of asthma episodes by an average of 7.5% in the range 6–10%, depending on underlying smoking prevalence. Such estimates must, how-ever, be treated with caution owing to the difficulties encountered when attempting to estimate a quantified measure of exposure to ETS, and specifically the scarcity of international databases with the information to allow a health impact assessment of ETS at the European level.
0 20 40 60 80 100
Czech Republic Lithuania Tajikistan Republic of Moldova Kyrgyzstan Slovenia Bulgaria Ukraine Kazakhstan Russian Federation Belarus Slovakia Estonia Hungary Albania Poland Turkey Romania Armenia Greece TFYR Macedonia*
Croatia Georgia Serbia and Montenegro (Montenegro) Serbia and Montenegro (Serbia)
Proportion of 13–15-years-olds exposed to ETS (%)
Table 3. Prevalence of exposure to ETS outside the home in 13–15-year-olds (%)
Country Survey Exposure out- Country Survey Exposure
out-year side the home year side the home
Albania 2004 80.6 Lithuania 2005 64.6
Armenia 2004 85.1 Poland 2003 90.4
Belarus 2004 90.1 Republic of Moldova 2004 96.7
Bulgaria 2002 75.7 Romania 2004 81.5
Croatia 2003 91.1 Serbia and Montenegro (Serbia) 2003 91.3
Czech Republic 2002 74.5 Slovakia 2003 85.7
Estonia 2003 90.7 Slovenia 2003 89.0
Georgia 2003 93.8 Tajikistan 2004 69.7
Hungary 2003 92.8 The former Yugoslav Republic 2003 80.2
Kazakhstan 2004 71.8 of Macedonia
Kyrgyzstan 2004 64.9 Turkey 2003 85.9
Latvia 2002 71.3 Ukraine 2005 84.4
Source: European tobacco control report (45).
Although exposure to ETS among children is strongly associated with patterns of smoking among parents, children may also be exposed to ETS outside the home by other people who smoke active-ly, including their peers. Fig. 23 shows the proportion of 15-year-olds who smoked daiactive-ly, using self-reported data collected in the HBSC survey in 2001/2002 (47). (Note that in Germany, only select-ed regions were includselect-ed in the survey.)
Fig. 23. Proportion of children aged 15 years smoking daily, 2001/2002
Note. TFYR Macedonia = The former Yugoslav Republic of Macedonia. Source: HBSC survey (47). Russian Federation Ukraine United Kingdom (Scotland) Portugal United Kingdom (England) Netherlands Norway France Belgium (Wallonia) United Kingdom (Wales)
Proportion of 15-year-old children smoking daily (%)
Girls Boys
On average, approximately 18% of 15-year-olds reported that they smoked every day, but there was considerable variation between countries and between girls and boys. Although the overall prevalence in 2001–2002 was similar to that in 1997–1998, it masks national trends, including increases in some countries (the Czech Republic, Estonia and Lithuania) and stable or slightly decreasing trends in western European countries. In the majority of the countries surveyed, 15-year-old girls were as likely, if not more so, to smoke every day as boys. This varied within the Region, with more boys than girls smoking in the east and more girls than boys smoking in the north and west. The pattern of gender differences in smoking is similar to changes observed in the adult population and may be associated with broader changes in the status of women in industrialized countries (47).
In view of the considerable impact on health of ETS, particularly in children, measures to restrict smoking should be a major public health objective. In particular, efforts to reduce the exposure of children to ETS should focus on promoting smoke-free homes and cars.
Damp
Damp inside the home induces the growth of moulds, dust mites and various microbial agents and, at the correct temperature, may set in train chemical reactions leading to the release of chemicals from building materials and furnishings. The amount of water vapour in the air is influenced by overcrowding and activities such as cooking, laundering and bathing, the use of certain fuels for heating and cooking, the indoor temperature and especially the degree of ventilation. Water leak-age due to structural damleak-age may also contribute.
Mould and damp are important risk factors for a variety of illnesses, particularly those of the respiratory and immune systems. Generally, there are four kinds of health problem: allergic ill-ness, irritation of the respiratory tract, infection and toxicological effects. In people who are sensitive to moulds, symptoms such as nasal irritation or congestion, dry or productive cough, wheezing, skin rashes or burning and watery or reddened eyes may occur. Those with severe allergies to moulds may have more serious reactions, such as hay-fever-like symptoms or short-ness of breath. Moulds can also trigger asthma attacks in susceptible individuals. Individuals with chronic illnesses or those with immune deficiencies are more likely to develop infections from certain moulds.
It has been suggested that damp is associated with mental health problems and other types of illness. Depression and the presence of general symptoms such as fatigue, headache, dizziness and difficulty concentrating have been linked to damp, mouldy living conditions (48).
Children, who tend to spend more time at home than adults and whose immune systems are still developing, are at increased risk of developing respiratory disorders when living in damp, mouldy housing. The prevalence of asthma, cough and wheezing among children living in homes with problems of damp or mould is 1.4–2.2 times higher than among children living in drier housing conditions. According to the currently available evidence, 13% of childhood asth-ma in developed countries could be attributable to damp (49).
A survey of the total population of Europe has shown a three- to ten-fold variation in self-reported exposure to damp among European countries. Fig. 24 shows the proportion of the population in selected European countries living in housing with self-reported problems of damp between 1995 and 2001.
Fig. 24. Proportion of the total population living in homes with self-reported problems of damp, 1995–2001
Note. The EU average is based on the available data in Eurostat database.
Source: Eurostat (50).
Overall, the exposed proportion decreased from 1995 to 2001, but in some countries there were no improvements. Differences between countries may be due to a combination of factors includ-ing climate characteristics, socioeconomic status, housinclud-ing characteristics, culture and lifestyle and the existence and effectiveness of related policies (e.g. on ventilation or thermal insulation).
Damp can have a range of impacts on health, and WHO has concluded that the strongest evidence exists for the association of damp with cough, wheezing and asthma (49). Children are particular-ly sensitive to these impacts. Damp is often associated with poor housing conditions related to socioeconomic inequalities, poor indoor air quality and inadequate housing hygiene, which includes factors such as overcrowding, low air exchange rate, low indoor temperature and poor insulation. All these factors have adverse effects on health. Reduction of mould and damp in hous-ing can be achieved by comprehensive policy action. Financial incentives and supporthous-ing instru-ments are necessary for the implementation of effective interventions such as the rehabilitation of housing stock.