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Lung cancers attributable to environmental tobacco smoke and air pollution in non-smokers in different European countries: a prospective study

Paolo Vineis132*, Gerard Hoek2, Michal Krzyzanowski3, Federica Vigna-Taglianti4, Fabrizio Veglia4, Luisa Airoldi5, Kim Overvad6, Ole Raaschou-Nielsen7, Francoise Clavel-Chapelon8, Jacob Linseisen9, Heiner Boeing10, Antonia Trichopoulou11, Domenico Palli12, Vittorio Krogh13, Rosario Tumino14, Salvatore Panico15, H Bas Bueno-De-Mesquita16, Petra H Peeters17, Eiliv Lund E18, Antonio Agudo19, Carmen Martinez20, Miren Dorronsoro21, Aurelio Barricarte22, Lluis Cirera23, J Ramon Quiros24, Goran Berglund25, Jonas Manjer26, Bertil Forsberg27, Nicholas E Day28, Tim J Key29, Rudolf Kaaks30, Rodolfo Saracci31 and Elio Riboli1

Author Affiliations

1 Imperial College London, London UK (Paolo Vineis: and University of Torino, Italy)

2 Department of Environmental and Occupational Health, Utrecht University, Utrecht, The Netherlands

3 World Health Organization, European Centre for Environment and Health, Bonn, Germany

4 ISI Foundation, Turin, Italy

5 Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy

6 Department of Clinical Epidemiology, Aalborg Hospital, Aarhus University Hospital, Aalborg, Denmark

7 Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, Denmark

8 INSERM, (Institut National de la Santé et de la Recherche Médicale), ERI 20, EA 4045, and Institut Gustave Roussy, Villejuif, F-94805, France

9 Division of Clinical Epidemiology, Deutsches Krebsforschungszentrum, Heidelberg, Germany

10 German Institute of Human Nutrition, PotsdamRehbücke, Germany

11 Department of Hygiene and Epidemiology, Medical School, University of Athens, Greece

12 Molecular and Nutritional Epidemiology Unit, and Molecular Biology Laboratory, CSPO-Scientific Institute of Tuscany, Florence, Italy

13 Department of Epidemiology, National Cancer Istitute, Milan, Italy

14 Cancer Registry, Azienda Ospedaliera "Civile M.P. Arezzo", Ragusa, Italy

15 Dipartimento di Medicina Clinica e Sperimentale, Università Federico II, Naples, Italy

16 Centre for Nutrition and Health, National Institute for Public Health and the Environment, Bilthoven, The Netherlands

17 Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands

18 Institute of Community Medicine, University of Tromso, Norway

19 Department of Epidemiology, Catalan Institute of Oncology Barcelona, Consejería de Sanidad y Servicios Sociales, Spain

20 Andalusian School of Public Health, Granada, Spain

21 Department of Public Health of Guipuzkoa, San Sebastian, Spain

22 Public Health Institute, Navarra, Spain

23 Department of Epidemiology, Regional Health Council, Murcia, Spain

24 Public Health and Health Planning Directorate, Asturias, Spain

25 Malmö Diet and Cancer Study, Lund University, Malmö, Sweden

26 Dept of Surgery, Malmö University Hospital, Malmö, Sweden

27 Department of Public Health and Clinical Medicine, University of Umeå, Sweden

28 MRC Dunn Human Nutrition Unit, Cambridge, UK

29 Cancer Research UK Epidemiology Unit, University of Oxford, UK

30 International Agency for Research on Cancer, Lyon, France

31 "IFC-National Research Council, Pisa, Italy"

32 Department of Epidemiology and Public Health, Imperial College London, St Mary's Campus, Norfolk Place, London W2 1PG, UK

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Environmental Health 2007, 6:7  doi:10.1186/1476-069X-6-7

Published: 15 February 2007



Several countries are discussing new legislation on the ban of smoking in public places, and on the acceptable levels of traffic-related air pollutants. It is therefore useful to estimate the burden of disease associated with indoor and outdoor air pollution.


We have estimated exposure to Environmental Tobacco Smoke (ETS) and to air pollution in never smokers and ex-smokers in a large prospective study in 10 European countries (European Prospective Investigation into Cancer and Nutrition)(N = 520,000). We report estimates of the proportion of lung cancers attributable to ETS and air pollution in this population.


The proportion of lung cancers in never- and ex-smokers attributable to ETS was estimated as between 16 and 24%, mainly due to the contribution of work-related exposure. We have also estimated that 5–7% of lung cancers in European never smokers and ex-smokers are attributable to high levels of air pollution, as expressed by NO2 or proximity to heavy traffic roads. NO2 is the expression of a mixture of combustion (traffic-related) particles and gases, and is also related to power plants and waste incinerator emissions.


We have estimated risks of lung cancer attributable to ETS and traffic-related air pollution in a large prospective study in Europe. Information bias can be ruled out due to the prospective design, and we have thoroughly controlled for potential confounders, including restriction to never smokers and long-term ex-smokers. Concerning traffic-related air pollution, the thresholds for indicators of exposure we have used are rather strict, i.e. they correspond to the high levels of exposure that characterize mainly Southern European countries (levels of NO2 in Denmark and Sweden are closer to 10–20 ug/m3, whereas levels in Italy are around 30 or 40, or higher).

Therefore, further reduction in exposure levels below 30 ug/m3 would correspond to additional lung cancer cases prevented, and our estimate of 5–7% is likely to be an underestimate. Overall, our prospective study draws attention to the need for strict legislation concerning the quality of air in Europe.