Children aged 3 to 18 years with severe obstructive sleep apnea (OSA) who were exposed to secondhand smoke (SHS) had an increase in odds of obstructive apnea hypopnea index (OAHI) compared with children with no exposure to SHS, according to study results published in the International Journal of Pediatric Otorhinolaryngology.

OSA has a relatively low prevalence in children (4%) compared with habitual snoring (10%). Few studies have assessed the role of SHS on OSA severity, and those that have demonstrate contradicting results. The current retrospective, single-center, Institutional Review Board-approved study assessed the association between exposure to SHS and OSA severity in children between 3 and 18 years. Data were obtained by querying Electronic Medical Records (EMR). Investigators analyzed SHS as a binary variable and OSA as a continuous variable, measured using OAHI from polysomnography (PSG) in all children.

Among the 3776 children who underwent PSG, 167 were included for analysis, and 70 were found to have severe OSA (OAHI ≥10/h). Among the 167 participants, 90 (53.9%) were exposed to SHS and 77 (46.1%) were not exposed. Children who were exposed to SHS had a 1.48 increase in odds of OAHI compared with nonexposed children. Among the children with OSA, 46 had mild, 35 had moderate, and 70 had severe OSA, and significantly higher OAHI was seen in children exposed to SHS compared with the nonexposed group (29.0 vs 19.5; P =.04). In addition, exposed children had significantly more public insurance compared with nonexposed children (P <.0001).

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Linear regression analyses that individually predicted log OAHI from SHS, body mass index (BMI), age, sex, race, ethnicity, insurance (private vs public), type of procedure (airway vs non-airway), and estimated household income found that procedure type was the only predictor significantly associated with OAHI in the full sample (P <.001), and SHS was the only predictor significantly associated in the severe OSA group (P =.03). SHS exposure remained an independent predictor of OAHI in children with severe OSA after adjusting for BMI, estimated household income, and race, increasing risk by 48% (P =.01).

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The investigators concluded that although these findings do show a significant association between SHS exposure and increased OSA severity, “[t]his does not mean causation and further research is needed to further ascertain this result.” Furthermore, the results were limited by retrospective nature of the study, EMR, and a weak association in the subgroup. Nonetheless, “the study created a learning opportunity to review the data collection on smoking and to create standardized infrastructure that can help refine measures and improve our understanding of risk factors for OSA.”


Subramanyam R, Tapia IE, Zhang B, et al. Secondhand smoke exposure and risk of obstructive sleep apnea in children [published online November 29, 2019]. Int J Pediatr Otorhinolaryngol. doi:10.1016/j.ijporl.2019.109807