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PROPORTION OF DISEASE CAUSED OR PREVENTED BY A GIVEN EXPOSURE, TRAIT OR INTERVENTION1
Abstract
The structures of two epidemiologic parameters are explored. One, the “etiologic fraction, ” relates to markers of increased risk, and it is the proportion of disease attributable to the marker and/or to factors associated with it. The other, the “prevented fraction, ” is the equivalent of this for a marker of reduced risk. It is shown that both parameters depend—in different ways—-on the frequency of the marker among cases of the disease, and on the “standardized morbidity ratio” for those with the marker. Point estimation of these parameters is often straight-forward, particularly in case-control studies.
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“ETT has been used in econometrics to evaluate the effectiveness of social programs on their participants (Heckman, 1992) and has long been the target of research in epidemiology, where it came to be known as 'the effect of exposure on the exposed,' or 'standardized morbidity' (Miettinen, 1974; Greenland and Robins, 1986).”
From Causal inference in statistics: An overview (2009) · cites this paper as Miettinen, 1974
In the citing paper
“Population-attributable fractions, adjusted for aforementioned model covariates, were calculated using Miettinen’s formula, aPRs, and weighted prevalence estimates of each health condition and risk behavior by each cumulative ACEs count level”
From Adverse childhood experiences and health conditions and risk behaviors among high school students—Youth Risk Behavior Survey, United States, 2023 (2024) · cites this paper as [11]
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An Argument for a Consequentialist Epidemiology
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“Miettinen (25) and then Rothman’s (26) articulation of a causal formalism paved the way for a generation of epidemiologic scholars who have since elaborated on, improved, and elevated causal thinking and its operationalization causal modeling as the dominant analytic framework and approach in epidemiologic science.”
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Association of Frequency of Organic Food Consumption With Cancer Risk
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MethodSmith, K. R., & Ezzati, M. (2005) · Annual Review of Environment and Resources · doi:10.1146/annurev.energy.30.050504.144424 · Cited by 176
Global Cardiovascular and Renal Outcomes of Reduced GFR
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Sequential and average attributable fractions as aids in the selection of preventive strategies
Eide, G. E. (1995) · Journal of Clinical Epidemiology · doi:10.1016/0895-4356(94)00161-i · Cited by 178
Association between Tobacco Smoking and Active Tuberculosis in Taiwan
Lin, H.-H., Ezzati, M., Chang, H., & Murray, M. B. (2009) · American Journal of Respiratory and Critical Care Medicine · doi:10.1164/rccm.200904-0549oc · Cited by 181
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Population attributable risk of tobacco and alcohol for upper aerodigestive tract cancer
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“Population attributable risk (PAR) was estimated using the formula PAR = p(ec) (OR 1)/OR; where p(ec) denotes the proportion exposed among cases.(5,6) Confidence intervals for PARs were calculated from the upper and lower limit of the odds ratios (ORs) of tobacco alone, alcohol alone and their joint effect.”
MethodJaakkola, M. S., Nordman, H., Piipari, R., Uitti, J., Laitinen, J., Karjalainen, A., Hahtola, P., & Jaakkola, J. J. K. (2002) · Environmental Health Perspectives · doi:10.1289/ehp.02110543 · Cited by 179
“where OR is the adjusted OR due to the exposure of interest, an unbiased estimate of incidence ratio in a population-based case–control study (29).”
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“Attributable fraction (also referred to as etiologic fraction) was calculated using the formula Fc (R−1)/R, where Fc is the fraction of cases with the risk factor and R is the incidence-density ratio (when using incidence cases) or prevalence odds ratio (when using prevalent cases).(27) The calculations for the attrib…”
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“77 in the Korean population, the proportion of potential cases caused could be as high as 49% [21].”
BackgroundEtiology of Diarrhea in Young Children in Denmark: a Case-Control Study
Olesen, B. R. S., Neimann, J., Böttiger, B. E., Ethelberg, S., Schiellerup, P., Jensen, C., Helms, M., Scheutz, F., Olsen, K. E. P., Krogfelt, K. A., et al. (2005) · Journal of Clinical Microbiology · doi:10.1128/jcm.43.8.3636-3641.2005 · Cited by 170
“estimated by using the formula by Miettinen (22).”
MethodForm of day care and respiratory infections among Finnish children.
Louhiala, P., Jaakkola, J. J. K., Ruotsalainen, R. O., & Jaakkola, J. J. K. (1995) · American Journal of Public Health · doi:10.2105/ajph.85.8_pt_1.1109 · Cited by 169
The epidemiology of fatigue and depression: a French primary-care study
Fuhrer, R., & Wessely, S. C. (1995) · Psychological Medicine · doi:10.1017/s0033291700037387 · Cited by 169
Proportion of Lung and Bladder Cancers in Males Resulting from Occupation: A Systematic Approach
Vineis, P., & Simonato, L. (1991) · Archives of Environmental Health An International Journal · doi:10.1080/00039896.1991.9937423 · Cited by 167
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Variations in Mortality and Morbidity by Gestational Age among Infants Born at Term
Zhang, X., & Kramer, M. S. (2008) · The Journal of Pediatrics · doi:10.1016/j.jpeds.2008.09.013 · Cited by 165
Agarwal, A., Guindo, A., Cissoko, Y., Taylor, J. G., Coulibaly, D., Kone, A. K., Kayentao, K., DJIMDÉ, A. A., Plowe, C. V., Doumbo, O. K., et al. (2000) · Blood · doi:10.1182/blood.v96.7.2358.h8002358_2358_2363 · Cited by 164
“8-13) 138 (10-124) 10 (83) 5 (45) 6 (55) Hyperparasitemia (Ep.”
InfluentialBody mass index has a greater impact on pregnancy outcomes than gestational hyperglycaemia
Ricart, W., López, J., Mozas, J., Pericot, A., Sancho, M. A., González, N. L. G., Fernández-Balsells, M., Luna, R., Cortázar, A., Navarro, P., et al. (2005) · Diabetologia · doi:10.1007/s00125-005-1877-1 · Cited by 162
“(PFp) for protective factors [21].”
Tüchsen, F., Hannerz, H., Burr, H., et al. (2005) · Occupational and Environmental Medicine · doi:10.1136/oem.2005.020537 · Cited by 163
Maternal multivitamin use and orofacial clefts in offspring
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“where PAFH and PAFW are the PAFs for passive smoking exposure in the household and workplace, respectively [64].”
BackgroundThe share of violence attributable to drinking
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“p̀opulation attributable risk percent’ (Cole and MacMahon 1971), ètiologic fraction’ (Miettinen 1974) and”
BackgroundEnvironmental Tobacco Smoke and Adult-Onset Asthma: A Population-Based Incident Case–Control Study
Jaakkola, M. S., Piipari, R., Jaakkola, N., & Jaakkola, J. J. K. (2003) · American Journal of Public Health · doi:10.2105/ajph.93.12.2055 · Cited by 158
“where OR is the adjusted odds ratio for the exposure of interest, an unbiased estimate of an incidence ratio in a population-based case–control study.(20) We calculated 95% confidence intervals (CIs) using the corresponding odds ratio interval.”
MethodSims, A. M., Shephard, N., Carter, K. W., Doan, T., Dowling, A., Duncan, E. L., Eisman, J. A., Jones, G., Nicholson, G. C., Prince, R. L., et al. (2007) · Journal of Bone and Mineral Research · doi:10.1359/jbmr.071113 · Cited by 156
“specific markers was calculated using the dichotomized BMD data using the method of Miettenin.((23))”
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“The populationattributable fraction of motor vehicle crashes was estimated from the sample proportion of motor vehicle crashes in each exposure category and the adjusted odds ratios for motor vehicle crash in those categories, as described by Miettinen [29].”
MethodInfluenza in the elderly: report of an outbreak and a review of vaccine effectiveness reports
Strassburg, M. A., Greenland, S., Sorvillo, F. J., Lieb, L. E., & Habel, L. A. (1986) · Vaccine · doi:10.1016/s0264-410x(86)80002-0 · Cited by 154
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“Based on the risk ratios from these analyses we calculated three etiologic fractions using Miettinen’s formulas for proportion of disease caused or prevented by a given exposure (Miettinen, 1974).”
MethodByrne, J. P., Mann, N. C., Dai, M., Mason, S. A., Karanicolas, P. J., Rizoli, S. B., & Nathens, A. B. (2019) · JAMA Surgery · doi:10.1001/jamasurg.2018.5097 · Cited by 155
“Population ≤25 miles from HEMS base, median (IQR), % 97 (37-100) 85 (20-100) 52 (1-93) 13 (0-71) <.”
Commercial Tattooing as a Potentially Important Source of Hepatitis C Infection
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Drew, M. K., Vlahovich, N., Hughes, D. C., Appaneal, R., Burke, L. M., Lundy, B., Rogers, M. A., Toomey, M., Watts, D., Lovell, G. A., et al. (2017) · British Journal of Sports Medicine · doi:10.1136/bjsports-2017-098208 · Cited by 152
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An International Study of Smoking and Bladder Cancer
Morrison, A. S., Buring, J. E., Verhoek, W. G., et al. (1984) · The Journal of Urology · doi:10.1016/s0022-5347(17)50559-5 · Cited by 147
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“The population injury rates and 95% confidence intervals (CIs) were calculated with the Mid-P exact test using Miettinen’s modification [23].”
MethodStrain, T., Brage, S., Sharp, S. J., Richards, J. A., Tainio, M., Ding, D., Bénichou, J., & Kelly, P. (2020) · The Lancet Global Health · doi:10.1016/s2214-109x(20)30211-4 · Cited by 156
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The impact of prenatal care in different social groups
Greenberg, R. S. (1983) · American Journal of Obstetrics and Gynecology · doi:10.1016/0002-9378(83)90681-6 · Cited by 146
Violence, psychological distress and the risk of suicidal behaviour in young people in India
Pillai, A., Jothikaran, T. A. J., & Patel, V. (2008) · International Journal of Epidemiology · doi:10.1093/ije/dyn166 · Cited by 148
Risk Factors for Stillbirth in Developing Countries: A Systematic Review of the Literature
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Meta-analysis in medicine Where we are and where we want to go
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Statins and Pulmonary Fibrosis: The Potential Role of NLRP3 Inflammasome Activation
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Colorectal cancer deaths attributable to nonuse of screening in the United States
Meester, R. G. S., Doubeni, C. A., Lansdorp‐Vogelaar, I., Goede, S. L., Levin, T. R., Quinn, V. P., van Ballegooijen, M., Corley, D. A., & Zauber, A. G. (2014) · Annals of Epidemiology · doi:10.1016/j.annepidem.2014.11.011 · Cited by 139
“We used PAF over other estimations such as the prevented fraction [46,47] because the PAF metric can be used to provide policymakers estimates of potential future benefits of increased screening beyond current benefits of past exposure.”
MethodAplenc, R., Thompson, J., Han, P. P., et al. (2005) · Cancer Research · doi:10.1158/0008-5472.can-04-2606 · Cited by 137
“Notably, the MTHFR C677T variant allele attributive risk is f34%, thus indicating that among patients with the variant allele, approximately one third of all relapses are linked to the variant allele (25).”
BackgroundAsbestos and cancer: An overview of current trends in Europe.
Albin, M. C., Magnani, C., Krstev, S., Rapiti, E., & Shefer, I. (1999) · Environmental Health Perspectives · doi:10.1289/ehp.99107s2289 · Cited by 136
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“In addition, PARs (considered the estimate of the percentage of deaths that would not have occurred if all subjects were in the lowest risk category) were calculated (29, 30) by comparing subjects with the most-healthy lifestyle to all other subjects.”
MethodCausal Inference in Statistics
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The Global Burden of Occupational Disease
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The Epidemiology of Bladder Cancer
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“pylori infection with either CagA or pepsinogen status on occurrence of gastric cancer among this population, we estimated the population attributable fraction (PAF; %) as follows: Pr(OR 1) / OR, where Pr is the proportion of cases exposed to the factor and OR is the adjusted OR (21).”
BackgroundJayant, K., Balakrishnan, V. K., Sanghvi, L. D., & Dj, J. (1977) · British Journal of Cancer · doi:10.1038/bjc.1977.31 · Cited by 130
Samaan, Z., Anand, S., Zhang, X., Desai, D., Rivera, M., Pare, G., Thabane, L., Xie, C., Gerstein, H., Engert, J. C., et al. (2013) · Molecular Psychiatry · doi:10.1038/mp.2012.160 · Cited by 129
Cancer in Africa 2018: The role of infections
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Risk factors for hepatitis C virus infection in male adults in Rawalpindi–Islamabad, Pakistan
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Incidence and risk factors of cancer among men and women in Norwegian agriculture
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Association of overweight, trauma and workload with coxarthrosis: A health survey of 7,217 persons
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How Much Disease Burden can be Prevented by Environmental Interventions?
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“The attributable fraction is the proportional reduction in disease or death that would occur in an exposed population if exposure to a risk were reduced.(7,8) In this analysis, the environmental risks were reduced, not to zero, but rather to a baseline exposure (or counterfactual) that was “reasonably achievable” in t…”
BackgroundGreenland, S. (1987) · Statistics in Medicine · doi:10.1002/sim.4780060607 · Cited by 123
Inflammation, the metabolic syndrome, and risk of coronary heart disease in women and men
Pischon, T., Hu, F. B., Rexrode, K. M., Girman, C. J., Manson, J. E., & Rimm, E. B. (2007) · Atherosclerosis · doi:10.1016/j.atherosclerosis.2007.06.022 · Cited by 122
“Population attributable fractions were calculated from equations by Miettinen [20] and Bruzzi et al.”
MethodGenetic Risk, Lifestyle, and Age-Related Macular Degeneration in Europe
Colijn, J. M., Meester‐Smoor, M. A., Verzijden, T., de Breuk, A., da Silva, R. M., Merle, B. M. J., Cougnard‐Grégoire, A., Hoyng, C. B., Fauser, S., Coolen, A. C. C., et al. (2020) · Ophthalmology · doi:10.1016/j.ophtha.2020.11.024 · Cited by 121
A history of the population attributable fraction and related measures
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The burden of cancer at work: estimation as the first step to prevention
Rushton, L., Hutchings, S. J., & Brown, T. P. (2007) · Occupational and Environmental Medicine · doi:10.1136/oem.2007.037002 · Cited by 122
“ht://oem bm jcom / O ccup E niron M d: frst pulished as 10.(11)36/oem .”
BackgroundMethodSims, A.-M., Timms, A. E., Bruges‐Armas, J., et al. (2007) · Annals of the Rheumatic Diseases · doi:10.1136/ard.2007.081364 · Cited by 121
Powell, J. W., & Schootman, M. (1992) · The American Journal of Sports Medicine · doi:10.1177/036354659202000609 · Cited by 121
Relation of Cigarette Smoking to Myocardial Infarction in Young Women
Slone, D., Shapiro, S., Rosenberg, L. A., Kaufman, D. W., Hartz, S. C., Rossi, A. C., Stolley, P. D., & Miettinen, O. S. (1978) · New England Journal of Medicine · doi:10.1056/nejm197806082982302 · Cited by 119
Self-citationGlycemic Control and the Risk of Tuberculosis: A Cohort Study
Lee, P.-H., Fu, H. J., Lai, T.-C., Chiang, C., Chan, C., & Lin, H.-H. (2016) · PLoS Medicine · doi:10.1371/journal.pmed.1002072 · Cited by 122
“where Pi represents the current proportion of the population in the i th DM category (no DM, DM with good glycemic control, or DM with poor glycemic control), Pi0 represents the proportion of the population in the i DM category in the alternative scenario (had all diabetic patients achieved good glycemic control), and…”
ResultDual and simultaneous sensitivity analysis for matched pairs
Gastwirth, J. L. (1998) · Biometrika · doi:10.1093/biomet/85.4.907 · Cited by 117
Stürmer, T., Rothman, K. J., & Glynn, R. J. (2006) · Pharmacoepidemiology and Drug Safety · doi:10.1002/pds.1231 · Cited by 120
Attributable causes of cancer in China
Wang, J., Jiang, Y., Liang, H., Li, P., Xiao, H., Ji, J., Xiang, W., Shi, J. F., Fan, Y. G., Li, L., et al. (2012) · Annals of Oncology · doi:10.1093/annonc/mds139 · Cited by 119
Surface Water Supplies and Health
Craun, G. F. (1988) · American Water Works Association · doi:10.1002/j.1551-8833.1988.tb02992.x · Cited by 118
Healthy lifestyle and preventable death: Findings from the Japan Collaborative Cohort (JACC) Study
Tamakoshi, A., Tamakoshi, K., Lin, Y., Yagyu, K., & Kikuchi, S. (2009) · Preventive Medicine · doi:10.1016/j.ypmed.2009.02.017 · Cited by 115
Methods of adjustment for estimating the attributable risk in case‐control studies: A review
Bénichou, J. (1991) · Statistics in Medicine · doi:10.1002/sim.4780101113 · Cited by 115
Are atopy and specific IgE to mites and molds important for adult asthma?
Jaakkola, M. S., Ieromnimon, A., & Jaakkola, J. J. K. (2006) · Journal of Allergy and Clinical Immunology · doi:10.1016/j.jaci.2005.11.003 · Cited by 116
Study of MTHFR and MS polymorphisms as risk factors for NTD in the Italian population
Marco, P. D., Calevo, M. G., Moroni, A., et al. (2002) · Journal of Human Genetics · doi:10.1007/s100380200043 · Cited by 114
“The attributable fraction, representing the proportion of cases attributable to the presence of the mutation, was estimated using the equation proposed by Miettinen (1974). The SPSS statistical software program was used for all analysis.”
Austin, S. B., Field, A. E., Wiecha, J. L., Peterson, K. E., & Gortmaker, S. L. (2005) · Archives of Pediatrics and Adolescent Medicine · doi:10.1001/archpedi.159.3.225 · Cited by 114
Descriptive Epidemiology and Public Health Aspects of Low Back Pain
Heliövaara, M., Sievers, K., Impivaara, O., Maatela, J., Knekt, P., Mäkelä, M., & Aromaa, A. (1989) · Annals of Medicine · doi:10.3109/07853898909149216 · Cited by 110
Lindqvist, P. G., Epstein, E., Landin‐Olsson, M., Ingvar, C., Nielsen, K., Stenbeck, M., & Olsson, H. L. (2014) · Journal of Internal Medicine · doi:10.1111/joim.12251 · Cited by 111
“To computed PAR, the following formula was used: PAR = Pe 9 [adjusted odds ratio (OR) (cid:1) 1]/adjusted OR (Table 2, model 2), where Pe is the proportion of cases assigned to a given variable [12].”
The Burden of Cardiovascular Disease Attributable to Major Modifiable Risk Factors in Indonesia
Hussain, M. A., Mamun, A. A., Peters, S. A. E., Woodward, M., & Huxley, R. (2016) · Journal of Epidemiology · doi:10.2188/jea.je20150178 · Cited by 115
Metadata
- Authors
- MIETTINEN, O. S.
- Corresponding author
- MIETTINEN, OLLI S.
- Venue
- American Journal of Epidemiology
- Publisher
- Oxford University Press (OUP)
- Published
- 1974-05
- Volume
- 99
- Issue
- 5
- Pages
- 325-332
- ISSN
- 0002-9262 (ISSN-L)
- 1476-6256
- OpenAlex
- W1953501928
- Cited by
- 1,036
- References
- 0
- Citations by year
- 2026: 24 · 2025: 34 · 2024: 41 · 2023: 35 · 2022: 26 · 2021: 35 · 2020: 39 · 2019: 40 · 2018: 31 · 2017: 22 · 2016: 27 · 2015: 25 · 2014: 28 · 2013: 22 · 2012: 26
- FWCI
- 7.80
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- American Journal of Epidemiology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Physical Sciences › Mathematics › Statistics and Probability › Statistical Methods in Epidemiology
- Health Sciences › Medicine › Epidemiology › Historical and modern epidemiology studies
- Physical Sciences › Mathematics › Statistics and Probability › Advanced Causal Inference Techniques
- Keywords
- population attributable fraction, prevented fraction, attributable fraction, risk indicators, standardized morbidity ratio, case-control study, disease prevention
- MeSH terms
- Coffee, Coronary Disease, Drinking, Epidemiologic Methods, Humans, Hypercholesterolemia, Hypertension, Models, Theoretical, Morbidity, Myocardial Infarction, Population, Preventive Medicine, Smoking, Statistics as Topic
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