Air quality

[Nieuwe paragraaf]

This summary is based on data on the proportion of children exposed to ETS (also known as exposure to second-hand tobacco smoke or passive smoking) in their homes. It contains information on the environment and health context and the policy relevance and an assessment of the situation in the WHO European Region.

Key message

Over half of all children aged 13–15 years are exposed to ETS at home in the majority of the countries for which comparable information is available. In the Balkans and the Caucasus, exposure exceeds 90%.

There is no comparable information for western European countries but studies suggest that 30–50% of children are exposed to ETS at home (1,2). These children are at increased risk of adverse effects on their health including sudden infant death syndrome (SIDS), respiratory infections, asthma, and possibly lymphoma and brain tumours. Policies to ban or restrict smoking and limit advertising are expected to lead to a reduction in exposure of children to ETS.

Figures

Presentation of data

Fig. 1 is drawn from the Global Youth Tobacco Survey (GYTS), which covered children aged 13–15 years. It is based on self-reported answers to the question as to whether they were “living in homes where others smoke in their presence”. The geographic coverage of comparable data is restricted by the fact that only countries in central and eastern Europe, central Asia, the Caucasus and the Balkans participated in the GYTS. The data suggest that across these countries the proportion of 13–15-year-olds exposed to ETS in their homes ranged from 40% to 97%. As regards western Europe, various studies indicate that the proportion of children exposed to ETS at home is 20–58% (1,2).

In Fig. 2, the data are also self-reported and reflect the proportion of 15-year-olds who smoked daily, as collected in the HBSC survey (in Germany, only selected regions were included in the survey). 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.

Children who smoke daily are a potential source of exposure to ETS for their non-smoking peers.

Fig. 1. Proportion of 13–15-year-olds exposed to ETS in their homes, 2002–2005

Note: Serbia and Montenegro became two separate Member States of WHO in September 2006. During the period covered in this fact sheet they were one country, two entities, and are shown as such.

Source: GYTS (3).

Fig. 2. Proportion of children aged 15 years smoking daily, 2001-2002

Source: HBSC survey (4).

Download Excel table with figure data

Rationale

The indicator provides information on the extent of exposure of children to ETS in the home, thus enabling an assessment to be made of the health threat from such exposure and the effectiveness of antismoking initiatives across the Region.

Health and environment context

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 (5–7). Tobacco smoke is a known human carcinogen (7) 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 SIDS, acute lower respiratory tract infections, chronic respiratory symptoms, middle ear disease, decreased pulmonary function and asthma. In children with asthma, ETS increases the severity and frequency of asthma attacks. Finally, there is some evidence to suggest that exposure to ETS during childhood may cause lymphoma and brain tumours.

The most recent estimates indicate that more than 72 000 people in the 25 EU countries die each year due to exposure to ETS at home (8).

WHO has estimated that 9–13% of all cancer cases can be attributed to exposure to ETS in a non-smoking population where 50% are exposed to ETS (9). If it is assumed that 35% of mothers smoke in the home, then 15–26% of lower respiratory illness in infants can be attributed to exposure to ETS (9). Applying these estimates to the population of the European Region suggests that 3000 to 4500 cases of cancer in adults and 300 000 and 550 000 episodes of lower respiratory illness in infants are attributable to ETS each year (9).

For additional information, see the ENHIS-2 fact sheets of April 2007 on post-neonatal mortality due to respiratory diseases and the prevalence of asthma and allergies in children.

Policy relevance and context

The burden of illness related to exposure to ETS in public places could be greatly reduced by smoking bans (5,10). Other interventions, such as separating smokers from non-smokers or mechanical air exchange, are less effective (5,11). In addition to limiting exposure to ETS, a ban on smoking indoors effectively encourages people to stop smoking. As parents give up smoking, their children will be less exposed to ETS. However, information and motivating activities are needed if smoking in the home is to be reduced.

As a more comprehensive review of the policy issues is provided in the ENHIS-2 fact sheet on policies to reduce the exposure of children to tobacco smoke (12), only a brief outline is provided here.

There are two key policies related to ETS exposure in Europe.

1. The WHO Framework Convention on Tobacco Control (FCTC) (13). This came into force in 2005 and has been ratified by most European countries, with progress towards ratification being made in the others.
2. The European Strategy for Tobacco Control (14). In 2004, the Fourth Ministerial Conference on Environment and Health adopted the Children’s Health and Environment Action Plan for Europe (CEHAPE), which includes four regional priority goals to reduce the burden of environment-related diseases in children. One of the goals (RPG III) aims at preventing and reducing respiratory diseases due to outdoor and indoor air pollution, thereby contributing to a reduction in the frequency of asthmatic attacks and ensuring that children can live in an environment with clean air.

ETS is the dominant form of indoor air pollution where tobacco is smoked, even in areas that are properly ventilated.

A tobacco control database has been established by the Regional Office as the first step in building a global tobacco control surveillance system (15). Ultimately, an internationally harmonized system providing surveillance of the exposure of non-smokers to ETS and monitoring the implementation of policies set out in the FCTC should be set up to allow exposure to ETS to be monitored.

Assessment

In the European Region there is a high rate of exposure of children to ETS. The 2002–2005 GYTS found that between 40% and 97% of children aged 13–15 years lived in homes where others smoked in their presence. In all the countries where the GYTS was conducted (see above), except for the Czech Republic and Lithuania, the proportion of children exposed to ETS in their homes was over 50%. In the Balkans, Armenia and Georgia, the proportion was over 90%.

Data for western Europe are available from studies conducted in the late 1990s. These found rates of exposure to ETS ranging from 20% in the Netherlands to 35% in the United Kingdom (England) for children aged up to 4 years, who are at particular risk of illness related to ETS (1). In France, 47% of the children aged 4–10 years were exposed to ETS, while a similar proportion was found among 13–14-year-olds in Ireland (1). Other studies found that the proportion of children aged 6–12 years living with a current smoker in the household was around 50%: 46% in Germany, 48% in Switzerland and 58% in Italy and the Netherlands (2).

ETS causes a number of fatal (for example, SIDS) and non-fatal (for example, asthma episodes) effects on health. The number of cases attributable to ETS varies between countries and regions, depending on the levels of smoking in those regions.

In an evaluation of the impact of ETS on SIDS, exposure–response functions developed by Anderson et al (16) were applied to the 4.6 million children under 1 year of age in countries covered by the Environment and Health Information System (ENHIS).

Where exposure is lowest (20%), between 110 and 250 SIDS cases may be attributed to ETS (10–22% of all SIDS cases). Where it is highest (50%), between 250 and 480 cases (22–42% of all SIDS cases) may be so attributed. Taking into account the estimated current smoking prevalence in ENHIS countries (15), around one quarter of all SIDS cases could be attributable to exposure to ETS in the home.

The impact of ETS on asthma episodes in children aged under 14 years was estimated using a recent meta-analysis (5) and current estimates of smoking prevalence in ENHIS countries (15).1 The results suggested that exposure to ETS increases the number of asthma episodes from 6% to 10%, depending on the underlying smoking prevalence. The average increase in the countries evaluated is 7.5%.

Such estimates must be considered in the light of difficulties encountered when attempting to estimate a quantified measure of exposure to ETS, in particular the scarcity in international databases of data required to conduct a health impact assessment of ETS at the European level.

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 actively, including their peers. The HBSC survey found that, on average, around 18% of boys and girls aged 15 years in Europe smoked cigarettes daily in 2001/2002 (4). Although this figure had not changed from 1997/1998, it masked national trends, including increases in some countries (Czech Republic, Estonia and Lithuania) and stable figures or slight decreases in western European countries. In the majority of the countries surveyed, 15-year-old girls were as likely, if not more so, to smoke daily as boys. This varied within the European 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 (4).

In view of the considerable health impact of ETS, particularly on children, measures to restrict smoking in indoor environments 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.

Metadata

Name: Exposure of children to environmental tobacco smoke

Definition: Proportion of children exposed to environmental tobacco smoke (ETS) in their homes

Code: RPG3_Air_Ex2

Data source

1. GYTS (3).

2. HBSC (4).

Description of data

Self-reported data on exposure to ETS in the home among children aged 13–15 years from a school-based survey. The question asked if the children lived in homes “where others smoke in their presence.”

Method for indicator calculation

Percentage of respondents in nationally representative survey sample.

Geographical coverage

Albania, Armenia, Belarus, Bulgaria, Croatia, the Czech Republic, Estonia, Georgia, Hungary, Kazakhstan, Kyrgyzstan, Lithuania, Poland, Republic of Moldova, Romania, the Russian Federation, Serbia and Montenegro (Montenegro), Serbia and Montenegro (Serbia), Slovakia, Slovenia, Tajikistan, The former Yugoslav Republic of Macedonia, Turkey, Ukraine.

Period of coverage

2002–2005.

Frequency of update

Not determined.

Data quality

Data from the GYTS participant countries are considered uniform and comparable using a common methodology and core questionnaire. Other than the GYTS, there is no comparable information. This assessment suggests that there is a strong need for a harmonized mechanism for collecting information over a broader geographical area and period of time in Europe.

For more information on meta data and calculation of this indicator, please refer to the methodology .

References

1. WHO European Centre for Environment and Health. Exposure to environmental tobacco smoke in Europe, a review. Copenhagen, WHO Regional Office for Europe, 2003 (technical report).
2. Pattenden S. et al. Parental smoking and children’s respiratory health: independent effects of prenatal and postnatal exposure. Tobacco Control, 2006, 15:294–301.
3. The Global Youth Tobacco Survey (GYTS), fact sheets, Tobacco Free Initiative [web site]. Geneva, World Health Organization, 2007 (http://www.who.int/tobacco/surveillance/gyts/en/index.html, accessed 4 March 2007).
4. Currie C et al, eds. Young people's health in context. Health Behaviour in School Children (HBSC) study: international report from the HBSC 2001/02 survey. Copenhagen, WHO Regional Office for Europe, 2004 (Health Policy for Children and Adolescents, No. 4) (http://www.hbsc.org/downloads/IntReport04, accessed 2 March 2007).
5. U.S. Department of Health and Human Services, Public Health Service. The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. Rockville, MD, Office of the Surgeon General, 2006 (http://www.surgeongeneral.gov/library/secondhandsmoke/, accessed 2 March 2007).
6. Courage CM, Tamburlini G, von Ehrenstein OS. Environmental tobacco smoke. In: Tamburlini G, von Ehrenstein OS, Bertollini R, eds. Children’s health and environment: a review of evidence. Copenhagen, European Environment Agency and the WHO Regional Office for Europe, 2002 (Environmental issue Report No. 29) (http://www.euro.who.int/document/e75518.pdf, accessed 2 March 2007).
7. Tobacco smoke and involuntary smoking. Lyons, World Health Organization, International Agency for Research on Cancer, 2004 (IARC monographs on the evaluation of carcinogenic risks to humans. Vol. 83) (http://monographs.iarc.fr/ENG/Monographs/index.php, accessed 4 March 2007).
8. Green Paper. Towards a Europe free from tobacco smoke: policy options at EU level. Brussels, Commission of the European Communities, 2007 (Com2007 27 final) (http://ec.europa.eu/health/ph_determinants/life_style/Tobacco/Documents/gp_smoke_en.pdf, accessed 2 March 2007).
9. Air quality guidelines for Europe, 2nd ed. Copenhagen, WHO Regional Office for Europe, 2000 (WHO Regional Publications, European Series, No. 91; http://www.euro.who.int/air/activities/20050223_3, accessed 2 March 2007).
10. Spencer N et al. Parent reported home smoking bans and toddler (18–30 month) smoke exposure: a cross-sectional survey. Archives of Disease in Childhood, 2005, 90:670–674 (http://adc.bmj.com/cgi/content/full/90/7/670, accessed 2 March 2007).
11. Graham H. When life’s a drag. London, HM Stationery Office, 1993.
12. WHO European Centre for Environment and Health. Policies to reduce the exposure of children to environmental tobacco smoke. Copenhagen, WHO Regional Office for Europe, 2007 (ENHIS-2 fact sheet No. 3.7).
13. WHO Framework Convention on Tobacco Control (WHO FCTC). Geneva, World Health Organization, 2003 (http://www.who.int/tobacco/framework/en/, accessed 2 March 2007).
14. European strategy on tobacco control. Copenhagen, WHO Regional Office for Europe, 2002 (http://www.euro.who.int/Document/E77976.pdf, accessed 2 March 2007).
15. Tobacco control database [online database]. Copenhagen, WHO Regional Office for Europe, 2006 (http://data.euro.who.int/tobacco/, accessed 2 March 2007).
16. Anderson HR, Cook DG. Passive smoking and sudden infant death syndrome: review of the epidemiological evidence. Thorax, 1997, 52:1003–1009.

Children’s Environment and Health Action Plan for Europe. Fourth Ministerial Conference on Environment and Health, Budapest, 23–25 June 2004 (EUR/04/5046267/7) (http://www.euro.who.int/document/e83338.pdf, accessed 2 March 2007).

Council of the European Union. Council recommendation of 2 December 2002 on the prevention of smoking and on initiatives to improve tobacco control, 2003/54/EC. Brussels, Publications Office, 2007 (http://eur-lex.europa.eu/smartapi/cgi/sga_doc?smartapi!celexapi!prod!CELEXnumdoc&lg=en&numdoc=32003H0054&model=guichett, accessed 2 March 2007).

Health-EU. The public health portal of the European Union. Brussels, European Union, 2007 (http://ec.europa.eu/health-eu/my_lifestyle/tobacco/index_en.htm, accessed 2 March 2007).

Tobacco Free Initiative [web site]. Geneva, World Health Organization, 2007 (http://www.who.int/tobacco/en/, accessed 2 March 2007).

National Center for Chronic Disease Prevention and Health Promotion [web site]. Atlanta, GA, Centers for Disease Control and Prevention, 2007 (http://www.cdc.gov/tobacco and

http://www.cdc.gov/tobacco/data_statistics/Factsheets/index.htm, accessed 4 March 2007).

Smoke-free Homes Program [web site]. Washington, DC, U.S. Environmental Protection Agency, 2007 (http://www.epa.gov/smokefree/, accessed 2 March 2007).

Tobacco control in the WHO European Region: current status and developments. Copenhagen, WHO Regional Office for Europe, 2002 (Fact sheet 06/02) (http://www.euro.who.int/document/CMA/rc52fstob0602e.pdf, accessed 2 March 2007).

For this indicator, a Health Impact assessment case study has been carried out: HIA for children exposed to Environmental Tobacco Smoke (ETS)

Authors: Vladimira Puklova, National Institute of Public Health, Prague, Czech Republic;

Jennifer Grad, WHO European Centre for Environment and Health, Bonn, Germany; Sylvia Medina, Institute of Environmental Health Surveillance, Saint Maurice, France; Elena Boldo Pascua, Instituto de Salud Carlos III (CISATER), Madrid, Spain.

This summary gives an overview of mortality in early childhood due to respiratory diseases in countries of the WHO European Region and changes over time. It provides information about possible environment-related risk factors and relevant policy action.

Key message

There are considerable variations in infant mortality due to respiratory diseases, with a gradual increase from western to eastern European countries. The average level is relatively low. Data for 1997–2002 reveal a decline in the post-neonatal mortality rates for nearly all countries.

Figures

Presentation of data

Fig. 1 presents the infant mortality rate due to respiratory diseases for the last available year for a majority of countries. Data are available in the WHO mortality database (1) for 29 Member States of the Region, although for some countries, the latest available data are for 2000 (France, Slovakia, Switzerland and The former Yugoslav Republic of Macedonia). The average for all countries is 0.8. The average of number of post-neonatal deaths due to respiratory diseases is presented in a logarithmic scale.

Fig. 2 shows changes in the post-neonatal mortality rate due to respiratory diseases in the Region from 1997 to 2002. The average of number of post-neonatal deaths due to respiratory diseases is presented in a logarithmic scale.

Fig. 1. Post-neonatal mortality rate due to respiratory diseases in the WHO European Region, 2001

Note. Data for France, Slovakia, Switzerland and The former Yugoslav Republic of Macedonia are for 2000.

Source: WHO mortality database (1).

Fig. 2. Changes in post-neonatal mortality rate due to respiratory diseases in the WHO European Region, 1997-2002

Source: WHO mortality database (1).

Download Excel table with figure data

Rationale

The indicator gives an indirect assessment of the adverse impact on health of environmental factors in a vulnerable age group. The post-neonatal respiratory mortality rate depends on many different factors, including indoor and outdoor air pollution.

Health and environment context

Respiratory illness is the most common cause of childhood morbidity in industrialized countries, although serious morbidity is low in the 15 developed countries of the European Union (EU) (2). In developing and emerging economies, acute lower respiratory infections (ALRI), particularly pneumonia, are common causes of death and serious morbidity in young children and infants. Causative infective agents differ between developed and developing regions of Europe: bacterial infections are common in developing countries while viral infections cause most ALRIs in developed countries. In temperate European countries there is a marked variation with the seasons in ALRI, with a significant rise in incidence in the winter months falling to relatively low levels in the summer.

Studies have found that there is a positive association between the level of air pollutants and mortality in children due to respiratory causes. Consequently, an increase in infant respiratory mortality rates may indicate higher indoor or outdoor air pollution levels, and conversely, decreasing mortality may indicate improved air quality (3). However, caution should be exercised in such interpretations.

Further to this, the association between infant respiratory mortality and ambient air pollution is not simple. Many forms of respiratory illness occur, and there are numerous causes, including outdoor air pollution, pollutants and allergens, in the home (such as the use of solid fuel for cooking and heating, tobacco smoke and dust) as well as infectious agents (4). Diet, lifestyle, the environment and social factors may also be important, possibly having a synergistic effect. Countries with a high infant respiratory mortality rate should generally be able to reduce total infant mortality significantly by implementing policies that address the causes of respiratory illness.

Policy relevance and context

In 2004, the Fourth Ministerial Conference on Environment and Health adopted the Children's Health and Environment Action Plan for Europe (CEHAPE), which includes four regional priority goals to reduce the burden of environment-related diseases in children. One of the goals (RPG III) aims at preventing and reducing respiratory diseases due to outdoor and indoor air pollution, thereby contributing to a reduction in the frequency of asthmatic attacks, and ensuring that children can live in an environment with clean air (5).

The following EU directives aim to achieve the ultimate goal of European clean air policy, which is to achieve levels of air quality that do not give rise to significant negative effects on or risks to human health and the environment.

• The Air Quality Framework Directive 96/62/EC (6) on the assessment and management of ambient air quality sets the quality standards for particulate matter, NO2, SO2 and O3 (updated with Directive 2002/3/EC), as well as common methods and criteria for assessment and management of pollutant levels.
• Council Directive 1999/30/EC (7) relates to the limit values for particulate matter, NO2 and NOx, SO2 and lead in ambient air.
• Directive 2000/69/EC (8) relates to the limit values for benzene and CO in ambient air.
• Directive 2002/3/EC relates to ambient air O3 (9).

In addition, the Sixth Community Environment Action Programme called for the development of a thematic strategy on air pollution with the objective of attaining "levels of air quality that do not give rise to significant negative impacts on and risks to human health and the environment" (10). This strategy, prepared by the Clean Air for Europe programme, was adopted in September 2005. It established interim health-related objectives for air quality in the EU and recommended that current legislation be modernized, focused on the most serious pollutants and aim to integrate environmental concerns into other policies and programmes (11).

WHO published its first Air quality guidelines for Europe in 1987, with a second edition in 2000 (12). After partial updating in 2006, the fully revised WHO air quality guidelines have now been published (13). According to WHO’s assessment of the burden of disease, globally more than 2 million premature deaths each year can be attributed to the combined effects of indoor air pollution from the use of solid fuel (approximately 1.5 million deaths) and urban outdoor air pollution (approximately 800 000 deaths) (4).

Assessment

On average, 13.6% of post-neonatal mortality in Europe is due to respiratory diseases, with an attributable mortality rate of 0.8 per 1000 live births. This average, however, masks wide variations ranging from 0.025 per 1000 live births in Austria to 6.2 per 1000 live births in Kyrgyzstan. In general, rates are considerably higher in eastern than western Europe.

A fall in infant respiratory mortality has been evident in recent years in many countries with high rates, such as Albania, Kyrgyzstan, Republic of Moldova and Romania. Even so, rates in those countries remain considerably higher than in the rest of the Europe. Mortality data from 2001 show that respiratory diseases contributed substantially to the overall post-neonatal infant mortality rate in Romania (54.56%), Kyrgyzstan (53.01%), Republic of Moldova (41.28%) and Bulgaria (35.62%). A major cause of the high infant mortality rates seen in eastern Europe is the relatively worse economic and environmental situation in those countries, which could be why a greater proportion of acute respiratory infections are severe.

Countries in western Europe show very low infant mortality rates from respiratory diseases, most probably because of high economic and social development and more effective environmental protection policies. The existing, although very low, infant mortality from respiratory diseases is more likely to be associated with increasing antimicrobial resistance, the emergence of novel pathogens or the lack of effective antiviral medications. In general, however, respiratory illness is detected early and treatment instituted rapidly.

Metadata

Name: Infant mortality from respiratory diseases

Definition: Annual mortality rate due to respiratory diseases in children older than one month and under one year of age

Code: RPG3_Air_E2

Data source

WHO mortality database (1).

Description of data

Annual number of deaths of children aged 28–364 days due to respiratory diseases and number of live births.

Method for indicator calculation

The number of deaths per 1000 live births is calculated by dividing the annual number of deaths of children aged 28–364 days due to respiratory diseases by the number of live births and multiplying the result by 1000.

Geographical coverage

Twenty-eight countries in the European Region, most of them members of the EU.

Period of coverage

1997–2001.

Frequency of update

Annual.

Data quality

Data are based on national statistics. The constitutional mandate of each Member State is to establish and maintain statistical services and provide information in the field of health.

This fact sheet presents the latest available data for 1997–2001. As these data are relatively old, new efforts are needed to monitor and reveal the current trends of such a dynamic indicator. Data for a number of countries (e.g. Belgium, Denmark and Monaco) are older than 1996. At the same time, geographical coverage should be improved to include data from all 52 Member States of the WHO European Region. Many countries have not reported their data to the WHO mortality database for each year in the time series, or have reported only one of the two parameters needed for calculating the indicator.

For more information on meta data and calculation of this indicator, plese refer to the methodology .

References

1. WHO mortality database [web site]. Geneva, World Health Organization, 2006 (http://www.who.int/healthinfo/morttables/en/, accessed 6 March 2007).
2. Technical Working Group on Priority Diseases. Baseline report on respiratory health in the framework of the European environment and health strategy. Brussels, Commission of the European Communities, 2003 (COM (2003)338 final) (http://ec.europa.eu/environment/health/pdf/respiratory_health.pdf, accessed 8 March 2007).
3. WHO European Centre for Environment and Health. Effects of air pollution on children’s health and development - a review of the evidence. Copenhagen, WHO Regional Office for Europe, 2005 (http://www.euro.who.int/document/E86575.pdf, accessed 6 March 2007).
4. Indoor air pollution [web site]. Geneva, World Health Organization, 2007 (http://www.who.int/indoorair, accessed 6 March 2007).
5. Children’s Environment and Health Action Plan for Europe. Fourth Ministerial Conference on Environment and Health, Budapest, 23–25 June 2004 (EUR/04/5046267/7) (http://www.euro.who.int/document/e83338.pdf, accessed 2 March 2007).
6. Council Directive 96/62/EC of 27 September 1996 on ambient air quality assessment and management. Official Journal of the European Union, L296, 21.11.1996 (http://europa.eu/scadplus/leg/en/lvb/l28031a.htm, accessed 6 March 2007).
7. Council Directive 1999/30/EC of 22 April 1999 relating to limit values for sulphur dioxide, nitrogen dioxide and oxides of nitrogen, particulate matter and lead in ambient air. Official Journal of the European Union, L163/41, 29.6.1999 (http://eur-lex.europa.eu/LexUriServ/site/en/oj/1999/l_163/l_16319990629en00410060.pdf, accessed 6 March 2007).
8. Directive 2000/69/EC of the European Parliament and of the Council of 16 November 2000 relating to limit values for benzene and carbon monoxide in ambient air. Official Journal of the European Union, L313/12, 13.12.2000 (http://eur-lex.europa.eu/LexUriServ/site/en/oj/2000/l_313/l_31320001213en00120021.pdf, accessed 6 March 2007).
9. Directive 2002/3/EC of the European Parliament and of the Council of 12 February 2002 relating to ozone in ambient air. Official Journal of the European Union, L67/14, 9.3.2002 (http://eur-lex.europa.eu/LexUriServ/site/en/oj/2002/l_067/l_06720020309en00140030.pdf, accessed 6 March 2007).
10. Decision No 1600/2002/EC of the European Parliament and of the Council of 22 July 2002 laying down the Sixth Community Environment Action Programme. Official Journal of the European Union, L242, 10.9.2002 (http://europa.eu.int/eur-lex/en/archive/2002/l_24220020910en.html, accessed 6 March 2007).
11. Proposal for a directive of the European Parliament and of the Council on ambient air quality and cleaner air for Europe. Brussels, 21.9.2005, COM(2005) 447 (http://ec.europa.eu/environment/air/cafe/pdf/cafe_dir_en.pdf, accessed 6 March 2007).
12. Air quality guidelines for Europe, 2nd ed. Copenhagen, WHO Regional Office for Europe, 2000 (WHO Regional Publications, European Series, No. 91; http://www.euro.who.int/air/activities/20050223_3, accessed 2 March 2007).
13. WHO air quality guidelines for particulate matter, ozone, nitrogen dioxide and sulphur dioxide. Global update 2005. Summary of risk assessment. Geneva, World Health Organization, 2006 (http://www.who.int/phe/air/aqg2006execsum.pdf, accessed 6 March 2007).

WHO European Centre for Environment and Health. Exposure of children to environmental tobacco smoke. Copenhagen, WHO Regional Office for Europe, 2007 (ENHIS-2 fact sheet No. 3.4).

WHO European Centre for Environment and Health. Exposure of children to air pollution (particulate matter) in outdoor air. Copenhagen, WHO Regional Office for Europe, 2007 (ENHIS-2 fact sheet No. 3.3).

WHO European Centre for Environment and Health. Children living in homes with problems of damp. Copenhagen, WHO Regional Office for Europe, 2007 (ENHIS-2 fact sheet No. 3.5).

Health aspects of air pollution. Copenhagen, WHO Regional Office for Europe, 2004 (http://www.euro.who.int/document/E83080.pdf, accessed 6 March 2007).

Health a key to prosperity – success in developing countries. Geneva, World Health Organization, 2000 (www.who.int/inf-new/conclu.htm, accessed 6 March 2007).

Public health and environment [web site]. Geneva, World Health Organization, 2007 (www.who.int/phe, accessed 6 March 2007).

Author: Momchil Sidjimov, National Centre for Public Health Protection, Sofia, Bulgaria.

The summary gives an overview on the prevalence of asthma and allergic rhinoconjunctivitis symptoms in children as found in the International Study of Asthma and Allergies in Childhood (ISAAC) (1). It also provides information about the environment and health context, the policy relevance and context and an assessment of the situation in the WHO European Region.

Key message

ISAAC found that asthma and rhinoconjunctivitis symptoms cause a significant burden of disease and that the prevalence of both is rising in European children. Allergic and asthmatic symptoms are associated with, among other things, indoor and outdoor air quality.

In 1999–2004, asthma prevalence in children across the European study centres varied from less than 5% to over 20%. Policies that promote early identification of the disease, ensure adequate treatment and, in particular, improve air quality, help to reduce this burden.

Figures

Presentation of data

The data in Fig. 1–4 are not indicative of prevalence in all European countries as only selected centres (represented by cities/regions) participated in the study. Thus, the intra-country comparison shows the differences between the centres. The highest prevalences of asthma symptoms in children aged 6–7 years (>20%) and 13–14 years (>25%) were found in Ireland and the United Kingdom. The lowest asthma rates for both age groups were found in Albania (<5%). Allergic rhinoconjunctivitis symptoms were reported by children aged 13–14 years most frequently in Malta (>20%).

Among children aged 13–14 years, the greatest increases in prevalence between ISAAC Phase One (1992–1998) and Phase Three (1999–2004) were found in Romania and Ukraine for asthma, and Poland, Romania and the Russia Federation for rhinoconjunctivitis. The prevalence of asthma and rhinoconjunctivitis fell in Ireland, Malta and the United Kingdom.

Where countries have multiple study centres, the average prevalence is given. Table 1 shows centre-specific prevalence.

Fig. 1. Prevalence of asthma symptoms in children aged 6–7 years and 13–14 years, ISAAC Phase Three, 1999–2004

Note. As the data were collected from specific centres only, prevalence figures are not country-representative. When data were collected from more than one centre, the number of centres is given in brackets.

Fig. 2. Prevalence of allergic rhinoconjunctivitis symptoms in children aged 6–7 years and 13–14 years, ISAAC Phase Three, 1999–2004

Note. As the data were collected from specific centres only, prevalence figures are not country-representative. When data were collected from more than one centre, the number of centres is given in brackets.

Fig. 3. Annual change in prevalence of asthma in children between

ISAAC Phase One (1992–1998) and Phase Three (1999–2004)

Note. The numbers of centres in countries for children aged 6–7 years and 13–14 years are given in brackets. Where there is no number, the data were collected from one centre.

Fig. 4. Annual change in prevalence of allergic rhinoconjunctivitis in children between ISAAC Phase One (1992–1998) and Phase Three (1999–2004)

Download Excel table with figure data

Note. The numbers of centres in countries for children aged 6–7 years and 13–14 years are given in brackets. Where there is no number, the data were collected from one centre.

Table 1. Range of prevalence between centres in countries with more than one ISAAC centre

Rationale

Prevalence of asthma and allergies among children has become an increasing problem in the last few decades. Asthma has become the most common chronic disease among children and is one of the major causes of hospitalization among those younger than 15 years of age (2). As more people are sensitized to allergens, allergic diseases may increase in Europe in the coming years.

Health and environment context

It is estimated that 20% of the world population suffer from allergic diseases (3). Recent reviews suggest that the prevalence of allergic diseases is increasing throughout Europe and is no longer restricted to specific seasons or environments (2,4). Asthma is an inflammatory disorder of the bronchial airways produced by allergies, viral respiratory infections and airborne irritants, while genetic factors predispose to develop asthma (2). Allergic rhinoconjunctivitis is characterized by sneezing, nasal congestion and itching of the nose, eyes or throat. As with other allergic disorders, this is due to an exaggerated response of the body’s immune system when exposed to specific non-infectious particles.

In the development of both asthma and allergic rhinoconjunctivitis, there is a complex interaction of genetic and environmental factors. A possible explanation is the "hygiene hypothesis“. This suggests that increased hygiene and the resulting lack of exposure to various microorganisms in early life affect the immune system so that individuals’ ability to fight off certain diseases is weakened and they are more susceptible to autoimmune diseases (5).

Good management of asthma can control the disorder and enable people to enjoy a high quality of life. Early diagnosis and appropriate treatment lead to much better disease control and outcomes. Allergy can be progressive, and neglecting its symptoms may lead to a worsening of the disease. Medication is not the only way to control asthma and allergies. It is also important to avoid triggers that irritate and inflame the airways. Primary prevention to reduce the level of exposure to common risk factors, particularly tobacco smoke, frequent lower respiratory infections during childhood and air pollution (indoor and outdoor), is an important step.

Poor outdoor air quality, exposure to indoor allergens and a stressful lifestyle have been connected with the prevalence of asthma and allergic rhinoconjunctivitis (6). An increasing trend in the prevalence of asthma and allergies is particularly apparent in urban areas, where children have been found to have more allergic reactions to outdoor and indoor allergens (7). The use of fossil fuels as well as higher volumes of road traffic in cities are thought to contribute to this (8,9). Recent evidence supports a causal relationship between exposure to air pollution and exacerbation of asthma, mainly due to exposure to particulate matter (PM) and ozone (9). There is little evidence, however, to support a causal association between the prevalence or incidence of asthma and air pollution in general. The incidence of allergic symptoms in children is associated with exposure to allergens in indoor environments with poor air quality (10). This includes biomass combustion products, high humidity and moulds, dust mites, pets and environmental tobacco smoke (ETS) (1). Children who are more frequently exposed to poor indoor air may be at greater risk of being affected by outdoor pollutants. Exposure to ETS can cause new cases of asthma in children who have not previously shown symptoms. Additionally, in asthmatic individuals it can trigger asthma attacks and make asthma symptoms more severe (11).

Additionally, there seems to be a parallel development between climate change and the increasing prevalence of asthma and allergies in children. As warmer temperatures and early spring are related to increased airborne pollen, sensitization to pollen allergens is likely to have doubled during the last three decades, particularly in young people in many areas in Europe (12).

Policy relevance and context

The failure to diagnosis asthma and allergic diseases leads to inadequate disease control and, consequently, higher treatment costs. In the management of asthma and allergies it is, therefore, important to raise the population’s awareness of the disease, the best management strategies and the importance of risk factors and behaviour in the prognosis. Many studies have shown that asthma is under-diagnosed, which often leads to delayed treatment (2). As environmental conditions contribute to asthma and allergies, the use of medication is not the only way to reduce the burden: policies that improve indoor and outdoor air quality are likely to have positive effects. Many countries also have web pages informing the public about proper preventive behaviour, such as avoiding house-dust allergens by using mattress covers or not keeping pets.

The Global Alliance against Chronic Respiratory Diseases (GARD), a voluntary alliance of internationally recognized organizations and institutions, is part of WHO’s activities to prevent and control asthma and allergic conditions. GARD includes the Global Initiative for Asthma (GINA), which was formed in 1992 by WHO and the National Heart, Lung and Blood Institute in the United States. It also includes the Global Initiative on Allergic Rhinitis and its impact on Asthma (ARIA), in which WHO is a participant. The WHO Practical Approach to Lung Health (PAL), a strategy designed to help primary health care workers improve their management of respiratory symptoms, is used in GARD’s implementation strategy (2). World Asthma Day is an annual event organized by GINA to improve asthma awareness and care around the world. The Prevention of Allergy and Allergic Asthma Project is an outcome of the joint meeting between WHO and the World Allergy Organization (3). This approach focuses mainly on different preventive measures for allergy and allergic asthma.

In 2004, the Fourth Ministerial Conference on Environment and Health adopted the Children’s Health and Environment Action Plan for Europe, which includes four regional priority goals to reduce the burden of environment-related diseases in children (13). One of the goals (RPG III) aims to prevent and reduce respiratory diseases due to outdoor and indoor air pollution, thereby contributing to a reduction in the frequency of asthmatic attacks, and to ensure that children can live in an environment with clean air.

As asthma is a reducible and preventable disease, the European Community action plan in the field of Public Health (2003–2008) aims to evaluate the impact of possible health policy interventions on its prevalence (14).

Assessment

Globally, the prevalence of asthma and allergies has increased over the last few decades. However, the ISAAC study, which focused on children, showed wide variations in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis and eczema. In general, the study found the highest asthma prevalence in English-speaking developed countries (Australia, Ireland, New Zealand, the United Kingdom and the United States). Differences between countries may be due to factors such as lifestyle, dietary habits, socioeconomic differences and environmental or climate factors (7,15). Additionally, awareness of the disease can affect its prevalence and severity in a population (15).

In the European Region, the countries with the highest prevalence of asthma and symptoms of allergy include Finland, Germany, Ireland, the United Kingdom and, recently, Romania. A lower asthma prevalence was found in Albania, Belgium, Estonia, Georgia, Italy, Lithuania, Spain and Sweden. In some countries with multiple study centres, variations in prevalence were seen in ISAAC Phase Three, particularly in Italy. Poland reported a high rate of allergic rhinoconjunctivitis symptoms but low asthma rates. This suggests that the prevalence rates of asthma may depend on awareness of asthma in the population studied (16).

Overall, the correlation between the prevalence of the two symptoms was high (between 0.47 in the oldest children in Phase Three and 0.80 in the youngest in Phase One), as was the correlation between the changes in those rates (0.47–0.51).

The high prevalence of asthma symptoms is not, however, necessarily connected with increased rates of other allergic symptoms surveyed. This may be due to the different risk factors for these interrelated yet distinct disorders or to a time shift in the onset of the symptoms.

The intercountry differences observed are also likely to have been partly influenced by the validity of the written questionnaires in a variety of cultures and languages (7).

The greatest year-on-year increase in asthma symptoms was seen in 13–14-year-olds in Romania and Ukraine, although considerable increases were also evident in Finland and Germany. In the countries with a high prevalence in 1992–1998 (Ireland, Sweden and the United Kingdom), a decreased prevalence was seen in 1999–2004 in 13–14-year-olds but not in 6–7-year-olds.

Metadata

Name: Prevalence of asthma and allergies in children

Definition: The prevalence rates of symptoms of asthma and allergic rhinoconjunctivitis in children aged 6–7 years and 13–14 years

Code: RPG3_Air_E1

Data source

ISAAC Phase One (1992–1998) and Phase Three (1999–2004) (1). Asher et al (15)

Description of data

Method for indicator calculation

The data were taken from the publication by Asher et al (15). Asthma symptoms were established by the question “Have you had wheezing or whistling in the chest in the past 12 months?” Current allergic rhinoconjunctivitis symptoms were estimated on the basis of positive answers to both questions: “In the past 12 months, have you (has your child) had a problem with sneezing or a runny or blocked nose when you (he/she) did not have a cold or the flu?” and, if yes, “In the past 12 months, has this nose problem been accompanied by itchy watery eyes?”

Country prevalence data are calculated as the centres’ average.

ISAAC Phases One and Three are repeated multi-country cross-sectional surveys. Two age groups were investigated by standardized questionnaires: children aged 6–7 years (reporting by parents) and 13–14 years (self-reporting).

Geographical coverage

In the European Region the following countries were covered by ISAAC: Albania, Austria, Belgium, Estonia, Finland, France, Georgia, Germany, Greece, Italy, Latvia, Malta, Poland, Portugal, Ireland, Romania, Russian Federation, Spain, Sweden, United Kingdom, Uzbekistan. ISAAC Phase One and Three cover 66 centres in 37 countries for children aged 6–7 years and 106 centres in 56 countries for children aged 13–14 years.

Period of coverage

Data stem from ISAAC Phase One conducted in 1992–1998 (mainly in 1994–1995) and Phase Three, conducted in 1999–2004 (mainly in 2002–2003).

Frequency of update

Not determined.

Data quality

The data presented in the graph are not country-representative, as only certain centres were involved in the study (mainly the urban ones). According to the ISAAC protocol, each research centre should recruit a random sample of 3000 children aged 13–14 years through school class registers. A minimum of 10 schools (or all the schools) per centre were needed to obtain a representative sample. If a selected school refused to participate, it was replaced by another chosen at random. Case definitions and severity were established by asking about symptoms, not by reference to labels or diagnoses (although these have been recorded). Each centre could optionally recruit an additional sample of 3000 children aged 6–7 years. A participation rate of at least 90% was sought.

For more information on meta data and calculation of this indicator, please refer to the methodology .

References

1. ISAAC [web site]. International Study of Asthma and Allergies in childhood (http://isaac.auckland.ac.nz/, accessed 9 March 2007).
2. Asthma. Geneva, World Health Organization, 2006 (Fact sheet No. 307) (http://www.who.int/mediacentre/factsheets/fs307/en/index.html, accessed 7 March 2007).
3. Prevention of Allergy and Allergic Asthma. Geneva, World Health Organization, 2003 (http://www.worldallergy.org/professional/who_paa2003.pdf, accessed 7 March 2007).
4. Green RJ. Inflammatory airway disease. Current Allergy and Clinical Immunology, 2003, 16:181.
5. Ullrich D. Hygiene hypothesis: are we too "clean" for our own good? Milwaukee, WI, Medical College of Wisconsin, 2004 (http://healthlink.mcw.edu/article/1031002421.html, accessed 12 March 2007).
6. Marshall GD. Internal and external environmental influences in allergic diseases. Journal of the American Osteopathic Association, 2004, 104(Suppl 5):S1–6.
7. ISAAC Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis and atopic eczema: ISAAC. Lancet, 1998, 351:1225–1232.
8. Nicolau N, Siddique N, Custovic A. Allergic disease in urban and rural populations: increasing prevalence with increasing urbanization. Allergy, 2005, 60:1357–1360.
9. WHO European Centre for Environment and Health. Effects of air pollution on children’s health and development - a review of the evidence. Copenhagen, WHO Regional Office for Europe, 2005 (http://www.euro.who.int/document/E86575.pdf, accessed 6 March 2007).
10. Bibi H et al. Comparison of positive allergy skin tests among asthmatic children from rural and urban areas living within small geographic area. Annals of Allergy, Asthma and Immunology, 2002, 88:416–420.
11. Fact sheet: National survey on Environmental Management of Asthma and Children’s Exposure to Environmental Tobacco Smoke. Washington, DC, United States Environmental Protection Agency, 2005 (http://www.epa.gov/smokefree/pdfs/survey_fact_sheet.pdf, accessed 7 March 2007).
12. Environmental hazards trigger childhood allergic disorders. Copenhagen, WHO Regional Office for Europe, 2003 (Fact sheet EURO/01/03) (http://www.euro.who.int/document/mediacentre/fswhde.pdf, accessed 7 March 2007).
13. Children’s Environment and Health Action Plan for Europe. Fourth Ministerial Conference on Environment and Health, Budapest, 23–25 June 2004 (EUR/04/5046267/7) (http://www.euro.who.int/document/e83338.pdf, accessed 2 March 2007).
14. Asthma. Brussels, Commission of the European Communities, Public Health Programme (2003–2008) (http://ec.europa.eu/health/ph_information/dissemination/diseases/asthma_en.htm, accessed 7 March 2007).
15. Asher MI et al. Worldwide time trends in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and eczema in childhood: ISAAC Phase One and Three repeat multicountry cross-sectional surveys. Lancet, 2006, 368:733–743.
16. Berg A et al. The effect of hydrolyzed cow’s milk formula for allergy prevention in the first year of life: The German Infant Nutritional Intervention Study, a randomized double-blind trial. Journal of Allergy and Clinical Immunology, 2003, 111:533–540.

World Allergy Organization [web site]. Milwaukee, WI, World Allergy Organization, 2007 (http://www.worldallergy.org/, accessed 7 March 2007).

Environmental Hazards and Health Effects Program. Asthma’s impact on children and adolescents. Atlanta, GA, Centers for Disease Control and Prevention, (http://www.cdc.gov/asthma/children.htm, accessed 7 March 2007).

A plea to abandon asthma as a disease concept. Lancet, 2006, 368:705.

Eder W et al. The asthma epidemic. The New England Journal of Medicine, 2006, 355:2226–2235 (http://content.nejm.org/cgi/content/full/355/21/2226, accessed 7 March 2007).

WHO European Centre for Environment and Health. Exposure of children to environmental tobacco smoke. Copenhagen, WHO Regional Office for Europe, 2007 (ENHIS-2 fact sheet No. 3.4).

WHO European Centre for Environment and Health. Children living in homes with problems of damp. Copenhagen, WHO Regional Office for Europe, 2007 (ENHIS-2 fact sheet No. 3.5).

Authors: Charlotte Wirl, Austrian Health Institute, Vienna, Austria, and Vladimíra Puklová, Czech National Institute of Public Health, Prague, Czech Republic.

This summary is based on data on the capacity to implement policies to reduce the exposure of children to ETS (also known as exposure to second-hand tobacco smoke or passive smoking) and promote smoke-free areas for children. It contains information on the environment and health context and the policy relevance and context, and an assessment of the situation in the WHO European Region. Suggestions for further monitoring, data underlying the indicator and references are provided.

Key message

Most countries in the WHO European Region implement policies to restrict smoking in public areas and on public transport, the direct advertisement of tobacco products and the sale of tobacco products to minors, with the aim of reducing the exposure of children to tobacco smoke in public areas and discouraging active smoking. However, some countries still have no legal restrictions on smoking, even in health care or educational facilities. The exposure of children to tobacco smoke, both before and after birth, has been linked to multiple health impacts, including sudden infant death syndrome (SIDS), respiratory problems, cancer and impaired mental and social development.

Figures

Presentation of data

Fig. 1 represents the score of the indicator by country. A higher score reflects a more extensive scope and comprehensive policies. The composite index was calculated on the basis of data retrieved from the WHO tobacco control database as of September 2006 (1).

Fig. 2 indicates the percentage of the 52 countries in the Region which either do or do not have a relevant policy contributing to the summary indicator (i.e. bans or restrictions on smoking, advertisement of tobacco products and sale of tobacco to minors).

Fig. 1. Degree of implementation of policies to reduce exposure of children to ETS in the WHO European Region

Note. No data available for Andorra, Cyprus, Monaco and San Marino.

Source: WHO tobacco control database (1) as of September, 2006.

Fig. 2. Proportion of countries in the WHO European Region implementing policies to reduce exposure of children to ETS

Source: WHO Tobacco Control Database (1). Download Excel sheet with figure data

Rationale

This indicator illustrates the existence and stage of implementation and enforcement of national legal instruments to ensure smoke-free areas, smoke-free public transport, restricted advertising of tobacco products and bans on the sale of tobacco to minors. Legal instruments are effective tools to provide protection against exposure to tobacco smoke.

Health and environment context

Exposure to ETS is defined as the involuntary breathing of air contaminated with tobacco smoke. It is well established that such exposure increases the risk of lung cancer. Epidemiological evidence and mechanistic studies show that ETS increases the risk of morbidity and mortality from cardiovascular disease in non-smokers (2).

Smoking by mothers, exposure to ETS during pregnancy and exposure of children to ETS all cause an increased risk of SIDS, low birth weight, reduced lung function, asthma, lower respiratory tract infections and middle ear infection in children. Prenatal and postnatal exposure may also be associated with reductions in mental and social development. Several studies suggest that exposure to ETS may be causally associated with childhood cancer (3). A detailed review of exposure to ETS in European countries can be found in ENHIS-2 fact sheet No. 3.4 of April 2007 on the exposure of children to ETS (4).

According to the most recent estimates, ETS causes more than 79 000 deaths each year in the 25 countries of the EU (5). These estimates include deaths from heart disease, stroke, lung cancer and some respiratory diseases. However, they omit deaths in adults due to other conditions related to exposure to ETS (such as pneumonia) and do not reveal the burden of the serious acute and chronic morbidities caused by passive smoking.

Policy relevance and context

The WHO Framework Convention on Tobacco Control (FCTC), the first legal instrument designed to reduce tobacco-related deaths and disease around the world, came into force in February 2005 (6). The FCTC has been ratified by most of the reporting states, and those that have not yet ratified it are taking the final steps towards doing so. The FCTC requires countries to enforce restrictions on tobacco advertising, sponsorship and promotion; set parameters for new packaging and labelling of tobacco products that provide reliable information about the health effects, hazards and emission of tobacco smoke; establish clean indoor air controls; and strengthen legislation to eliminate all forms of illegal trade in cigarettes and other tobacco products.

The European Strategy for Tobacco Control (7) reflects increased political commitment to, and public health expectations from, tobacco control in the European Region. It was adopted by the WHO Regional Committee for Europe in September 2002 and provides an evidence-based framework and guidance for effective national action and international cooperation. The strategy specifies guidelines for action in the Region to be carried out through national policies, legislation and action plans. It also makes recommendations on monitoring, evaluating and reporting on tobacco use and tobacco control policies. Finally, it specifies mechanisms, tools and a timeframe for international cooperation.

In 2004, the Fourth Ministerial Conference on Environment and Health adopted the Children’s Health and Environment Action Plan for Europe (CEHAPE), which includes four regional priority goals to reduce the burden of environment-related diseases in children (8). One of the goals (RPG III) aims at preventing and reducing respiratory diseases due to outdoor and indoor air pollution, thereby contributing to a reduction in the frequency of asthmatic attacks, and ensuring that children can live in an environment with clean air. ETS is the dominant form of indoor air pollution where tobacco is smoked, even in areas that are properly ventilated.

The European Union (EU) plays an active role in global tobacco control policies, and it ratified the FCTC in July 2006. The Community’s tobacco control activities include legislative measures such as Council Recommendation 2003/54/EC on the prevention of smoking and initiatives to improve tobacco control (9), Tobacco Products Directive 2001/37/EC “on the approximation of the laws, regulations and administrative provisions of the member states concerning the manufacture, presentation and sale of tobacco products” (10), Tobacco Advertising Directive 2003/33/EC on “the approximation of the laws, regulations and administrative provisions of the member states relating to the advertising and sponsorship of tobacco products” (11), tobacco control projects under the Public Health Programme and information campaigns (e.g. “Feel Free to Say No” 2002–2004; “HELP - For a life without tobacco” (12)). The comprehensive antismoking strategy supports Europe-wide smoking prevention and cessation activities, including health education measures, improved consumer information and assistance, and restrictions on the advertising and marketing of tobacco. The EU is also integrating tobacco control into a range of other Community policies in areas such as taxation and agriculture. In January 2007 the Commission presented the Green Paper Towards a Europe free from tobacco smoke: policy options at EU level and opened a new strategy aiming “to launch a broad consultation process and an open public debate, on the best way forward to tackle passive smoking in the EU” (13).

It should be stressed that the indicator is an indirect measure of the exposure of children to ETS. It is not able to assess the extent to which regulations covering public spaces affect smoking behaviour in private spaces and thus reduce the risk of the exposure of children to ETS at home.

Assessment

The most common instruments used to reduce exposure to ETS are laws dealing with aspects of smoking. Legislation to prevent the exposure of non-smokers, and children in particular, to ETS in public places are in place in most countries in the Region. In all countries policies are based on the principle that non-smokers should be protected from ETS in all public indoor environments. Policies tend not to focus exclusively on children, although they are generally considered a priority group. Many countries place a focus on child-specific environments such as nurseries, kindergartens, schools and play areas.

The indicator shows that most countries have introduced a wide range of comprehensive policies regulating tobacco, although many could go further. Three quarters of the countries have banned smoking in education and health care facilities. Most national legislation prohibits smoking in theatres and cinemas. Smoking in restaurants and bars is regulated less strictly: 15% of countries have imposed a ban, around 60% have some restrictions in places, and a quarter have no restrictions. Stronger policies should be implemented to protect the health of staff and customers in bars and restaurants, where the customers often include children and adolescents. The advertising of cigarettes and the sale of tobacco products to minors have been banned in more than 80% of the countries in the Region.

EU member states have been implementing stronger smoking control measures since European Council Recommendation 2003/54/EC (9) and most of them have enforced laws in response to EU Directives 2003/33/EC (10) and 2001/37/EC (11).

Metadata

Name: Policies to reduce the exposure of children to environmental tobacco smoke

Definition: Composite index of capacity to implement policies to reduce exposure to environmental tobacco smoke (ETS) and promote smoke-free areas for children

Code: RPG3_Air_A1

Data source

WHO tobacco control database (1).

Description of data

The tobacco control database (1) covers 41 indicators on tobacco use and control policies in 48 Member States in the Region. The data are drawn mainly from the regional survey of country-specific data (provided by the WHO national counterparts for the Action Plan for a Tobacco-free Europe) first undertaken in 2001, and other internationally recognized sources. The database covers five main areas: smoking prevalence, legislation, economics, cessation and general policy. It is constantly updated. An important advance on the 2001 exercise is that countries' information about their national legislation on tobacco control has been directly checked and cross-checked with information received from other sources.

Country data on three additional sub-indicators were collected for the purpose of this fact sheet: smoke-free public areas, smoke-free public transport and direct advertising of tobacco products. The data were collected in a meta-data sheet and assessed according to the scoring system.

Method for indicator calculation

For each component the following scoring is accepted:

0 – No restriction or prohibition

1 – Partial restriction, prohibition or voluntary agreement