Respiratory effects of tobacco smoking on infants and young children

doi:10.1016/j.prrv.2007.11.007

Paediatric Respiratory Reviews

Volume 9, Issue 1, March 2008, Pages 11-20

https://doi.org/10.1016/j.prrv.2007.11.007 Get rights and content

Summary

Second-hand smoke (SHS) and tobacco smoke products (TSPs) are recognised global risks for human health. The present article reviews the causal role of SHS and TSPs for respiratory disorders in infants and young children. Several studies have shown an effect of TSPs exposure during pregnancy upon lung function in the newborn infant and of SHS on symptoms and lung function after birth. From 1997 to 1999 a set of systematic reviews concerning the relationship between second-hand exposure to tobacco smoke and respiratory health in children was published in Thorax by Cook and Strachan, covering hundreds of published papers. The evidence for a causal relationship between SHS exposure and asthmatic symptoms and reduced lung function is quite strong, whereas the evidence related to the development of allergy is much weaker. There is recent evidence relating to an interaction between TSP exposure and genetic ploymorphisms, demonstrating that certain individuals are more susceptible to the effect of TSP exposure on lung health. In the present review, an overview is given for the effects of TSP exposure and SHS upon lung health in children, with a focus on infants and young children. There is a need for intervention to reduce TSP exposure in young children, by educating parents and adolescents about the health effects of TSP exposure. Recent legislation in many European countries related to smoking in the workplace is of great importance for exposure during pregnancy. Studies are needed to identify possible critical periods for TSPs to induce harmful effects upon lung health in young children and on environment–gene interactions in order to prevent harm.

Section snippets

Exposure to tobacco smoke products (TSPs) and early lung function

Several studies concerning the effects of exposure to TSPs and lung function in newborns and early life have been published. In the first studies published concerning the relationship between exposure to TSPs and reduced lung function in infants, lung function was measured from 4–5 weeks of age.3, 26, 27 Small numbers are exposed pre- or postnatally exclusively, so one cannot exclude the possibility that postnatal exposure might influence the results. It was important to measure lung function

Exposure to tobacco smoke products (TSPs) and lung function in early school-aged children

Several studies report early negative effects upon lung function in children exposed to SHS. In large population studies, the mother's smoking during pregnancy has been shown to have a negative effect upon lung function during the school years.31, 32, 33 This effect was found in both children with asthma and children without asthma, but was significantly greater in children with asthma.³³ Cunningham and co-workers also reported this effect to be more pronounced in black children than white

Long-term effects of exposure to tobacco smoke products (TSPs) on lung function

There is currently little information about the long-term effect of TSPs during childhood. There is solid documentation for a negative effect of TSP exposure upon lung function in adolescence. Even if cross-sectional studies may retrospectively try to calculate the effect of environmental tobacco smoke exposure during pregnancy and early childhood, long-term prospective studies are necessary to reach reliable conclusions. Prospective long-term follow-up studies with lung function measured at

Environmental tobacco smoke exposure and the effect upon BHR

As discussed above, exposure to TSPs may to some extent result in structural changes in the airways leading to reduced lung function. BHR is an important characteristic of asthma, and not always related to baseline lung function. The level of BHR may be related to asthma severity. Goldstein et al. measured the airway response to salbutamol inhalation in infants from 5 to 141 weeks of age by using maximal expiratory flow–volume curves and found greatest the responsiveness in young infants

Tobacco smoke exposure and obstructive airways disease

A great number of studies have documented the relationship between exposure to TSPs and airways diseases.17, 18, 19, 49, 50 In their meta-analysis of the relationship between SHS exposure and respiratory symptoms and asthma in schoolchildren, Cook and Strachan included 60 of 1593 studies. The OR for children exposed to SHS was 1.21 for asthma, 1.24 for wheeze, 1.40 for chronic cough, 1.35 for phlegm and 1.31 for breathlessness.¹⁹ Cook and Strachan finally concluded that the evidence for an

TSP exposure and other effects upon the airways during infancy and early childhood

The risk for sudden infant death is doubled for TSP exposure, with an OR of 2.08.⁵³ The studies included in this meta-analysis demonstrated that both pre- and postnatal TSP exposure contributed, and were most probably causal. Elliot and co-workers found that infants dying from sudden infant death with mothers smoking 20 or more cigarettes a day had increased inner airway wall thickness compared with infants dying from sudden infant death without smoking mothers. They suggested that structural

Exposure to tobacco smoke products (TSPs) and development of allergy

There is disagreement over whether or not TSP exposure has any effect, either causal or protective, upon the development of allergy. Many studies have demonstrated an increased allergic sensitisation due to TSP exposure in children, especially during early life. From the German MAS study, it was concluded that children with pre- and postnatal SHS exposure had an increased OR (2.3) for allergic sensitisation to food allergens at the age of 3 years.⁵⁶

On the other hand, some studies, especially

Possible mechanisms of SHS exposure in relationship to obstructive airways disease and reduced lung function

There is a general lack of knowledge of the mechanisms of the TSP-induced reduction in lung function. Some of the papers reporting reduced lung function in the newborn infants of smoking mothers discussed whether this could be an effect of the general tendency towards smaller children in smoking mothers compared with non-smoking mothers.4, 28, 30 However, this would not explain the reduction in compliance (Crs), remaining significant after correction for body weight.⁴ It has been speculated

Environment–gene interactions and susceptibility to SHS

Several studies are currently focusing upon a gene–environment interaction in order to explain how different people have different susceptibility to SHS and to active smoking. In a genome-wide multipoint linkage analysis including 144 familiesm Colilla and co-workers demonstrated that three regions with minimal evidence for linkage showed a significant increase in lod score when stratified on the basis of exposure to second-hand smoke.⁶⁹ Similarly, Ramadas et al. recently demonstrated that the

How can exposure to tobacco smoke products (TSPs) be diminished?

In August 2000, Jarvis et al. demonstrated that the number of children no longer exposed to TSPs in England had almost doubled between 1988 and 1999, as assessed by cotinine measurement in saliva.⁷⁵ In an intervention study in the USA, a significant change in SHS exposure was found in the children of mothers who participated in 1–7 counselling support sessions to help change the attitude in the home against smoking after the birth of the child. After 12 months, the reported exposure in the

Conclusion

There is overwhelming evidence that exposure to parental smoking has obvious adverse effects upon young children's respiratory health. The smoking pregnant mother gives birth to children with reduced lung function, as measured by both tidal breathing measurements and passive respiratory mechanics, and it has been demonstrated that the fetus of the smoking mother is exposed to rather high levels of TSPs. The children of smoking parents have a reduced growth in lung function. Furthermore, there

Research directions

•
To identify critical time periods (ages) for the harmful effect of second-hand smoke
•
To learn more about the mechanisms underlying the harm inflicted by second-hand smoke
•
To identify gene–environment interactions related to second-hand smoke and active smoking in order to identify susceptible groups of children

Key points

•
It is important to influence the attitude of young girls to smoking in order to prevent harmful effects upon the fetus during pregnancy.
•
Consider the gene–environment interaction related to the impact of second-hand smoke exposure on making groups of patients more susceptible to harmful effects.

Educational aims

•
To demonstrate the effect of second-hand smoke exposure on the respiratory health of young children
•
To show the effect of environmental tobacco smoke exposure during pregnancy upon lung function in the newborn child
•
To discuss the effect of second-hand smoke exposure during childhood on lung function and lung growth
•
To show the effect of second-hand smoke on respiratory diseases and symptoms
•
To discuss the limited evidence for an effect of second-hand smoke upon allergic sensitisation and allergic

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Progress towards meeting the eight United Nations Millennium Development Goals has been accompanied by a substantial change in the global pattern of disease, with a significant shift towards chronic noncommunicable diseases (NCDs). Globally, early childhood deaths have declined, but years lived with disability have increased over the 20 years 1990–2010: cardiovascular disease by 17.7%; chronic respiratory disease by 8.5%; neurologic conditions by 12.2%; diabetes by 30.0%; and mental and behavioral disorders by 5.0%. These trends are continuing with further increases in the global burden of disease related to chronic NDCs reported in the 2013 updates. There is increasing recognition that many chronic diseases are initiated in early life. This chapter will review the role that environmental exposures, especially those occurring in early life, play in increasing long-term risk of respiratory disease.
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Regardless, the studies verify that changes in some brainstem nuclei are linked to CSE and these could relate to the abnormal physiologies reported. Smoking during and after pregnancy leads to an increased risk of respiratory and cardiovascular illnesses (Carlsen and Carlsen, 2008) to the infant. Given the brainstem houses nuclei of predominant functions related to cardiac, respiratory and sleep/arousal control, any changes in the normal status of these nuclei due to cigarette smoke exposure would lead to alterations in these functions.
Cigarette smoking during pregnancy is the largest modifiable risk factor for adverse outcomes in the infant. Investigations have focused on the psychoactive component of cigarettes, nicotine. One proposed mechanism leading to adverse effects is the interaction between nicotine and its nicotinic acetylcholine receptors (nAChRs). Much data has been generated over the past three decades on the effects of cigarette smoke exposure (CSE) on the expression of the nAChRs in the brainstem and physiological parameters related to cardiac, respiration and sleep, in the offspring of smoking mothers and animal models of nicotine exposure. This review summarises this data and discusses the main findings, highlighting that findings in animal models closely correlate with those from human studies, and that the major brainstem sites where the expression level for the nAChRs are consistently affected include those that play vital roles in cardiorespiration (hypoglossal nucleus, dorsal motor nucleus of the vagus, nucleus of the solitary tract), chemosensation (nucleus of the solitary tract, arcuate nucleus) and arousal (rostral mesopontine sites such as the locus coeruleus and nucleus pontis oralis). These findings provide evidence for the adverse effects of CSE during and after pregnancy to the infant and the need to continue with the health campaign advising against CSE.
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Objective This Consensus document was developed by the Italian Society of Preventive and Social Paediatrics and the Italian Society of Paediatric Allergy and Immunology.
The aim is to provide updated recommendations regarding allergy prevention in children.
Methods The document has been issued by a multidisciplinary expert panel and it is intended to be mainly directed to primary care paediatricians.
It includes 19 questions which have been preliminarily considered relevant by the panel. Relatively to each question, a literature search has been performed, according to the Italian National Guideline Program. Methodology, and a brief summary of the available literature data, has been provided.
Many topics have been analyzed including the role of mother’s diet restriction, use of breast/formula/hydrolyzed milk; timing of introduction of complementary foods, role (if any) of probiotics, prebiotics, vitamins, exposure to dust mites, animals and to tobacco smoke.
Results Some preventive interventions have a strong level of recommendation. (e.g., the dehumidifier to reduce exposure to mite allergens). With regard to other types of intervention, such as the use of partially and extensively hydrolyzed formulas, the document underlines the lack of evidence of effectiveness.
No preventive effect of dietary supplementation with polyunsaturated fatty acids, vitamins or minerals has been demonstrated.
There is no preventive effect of probiotics on asthma, rhinitis and allergic diseases. It has demonstrated a modest effect, but steady, in the prevention of atopic dermatitis.
Conclusions The recommendations of the Consensus are based on a careful analysis of the evidence available.
The lack of evidence of efficacy does not necessarily imply that some interventions may not be effective, but currently they can’t be recommended.
Parental awareness and attitude towards environmental tobacco smoke exposure in children with respiratory illnesses
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Environmental tobacco smoke (ETS) is one of the commonest indoor pollutants. There is overwhelming evidence that ETS exposure has obvious effects upon infants and children's respiratory health.1,2 ETS exposure is a recognized risk factor for developing recurrent cough, wheeze or asthma symptoms at any age during childhood.3
Physical, behavioral, and cognitive effects of prenatal tobacco and postnatal secondhand smoke exposure
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Both prenatal and postnatal exposure to tobacco is associated with decreased pulmonary function.101,102 Adverse lung effects begin as early as pregnancy demonstrated by one study that found a reduction in fetal lung growth by 33 weeks of gestation.103 A meta-analysis in 1996 found that children exposed to SHS experienced a 1.4% reduction in forced expiratory volume in 1 s, a 5% decrease in mid-expiratory flow rate, and a 4.3% decrease in end-expiratory flow rate,104 yet the mechanism of damage has not been elucidated.101
The purpose of this review is to examine the rapidly expanding literature regarding the effects of prenatal tobacco and postnatal secondhand smoke (SHS) exposure on child health and development. Mechanisms of SHS exposure are reviewed, including critical periods during which exposure to tobacco products appears to be particularly harmful to the developing fetus and child. The biological, biochemical, and neurologic effects of the small fraction of identified components of SHS are described. Research describing these adverse effects of both in utero and childhood exposure is reviewed, including findings from both animal models and humans. The following adverse physical outcomes are discussed: sudden infant death syndrome, low birth weight, decreased head circumference, respiratory infections, otitis media, asthma, childhood cancer, hearing loss, dental caries, and the metabolic syndrome. In addition, the association between the following adverse cognitive and behavioral outcomes and such exposures is described: conduct disorder, attention-deficit/hyperactivity disorder, poor academic achievement, and cognitive impairment. The evidence supporting the adverse effects of SHS exposure is extensive yet rapidly expanding due to improving technology and increased awareness of this profound public health problem. The growing use of alternative tobacco products, such as hookahs (a.k.a. waterpipes), and the scant literature on possible effects from prenatal and secondhand smoke exposure from these products are also discussed. A review of the current knowledge of this important subject has implications for future research as well as public policy and clinical practice.

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CME ArticleRespiratory effects of tobacco smoking on infants and young children

Summary

Section snippets

Exposure to tobacco smoke products (TSPs) and early lung function

Exposure to tobacco smoke products (TSPs) and lung function in early school-aged children

Long-term effects of exposure to tobacco smoke products (TSPs) on lung function

Environmental tobacco smoke exposure and the effect upon BHR

Tobacco smoke exposure and obstructive airways disease

TSP exposure and other effects upon the airways during infancy and early childhood

Exposure to tobacco smoke products (TSPs) and development of allergy

Possible mechanisms of SHS exposure in relationship to obstructive airways disease and reduced lung function

Environment–gene interactions and susceptibility to SHS

How can exposure to tobacco smoke products (TSPs) be diminished?

Conclusion

Research directions

Key points

Educational aims

CME Section

Lancet

Am J Prev Med

Lancet

J Pediatr

Lancet

Toxicol Appl Pharmacol

Chest

Lancet

Int J Pediatr Otorhinolaryngol

Eur J Pharmacol

J Allergy Clin Immunol

J Allergy Clin Immunol

Prev Med

Maternal smoking during pregnancy, urine cotinine concentrations, and birth outcomes. A prospective cohort study

Int J Epidemiol

The effect of maternal smoking during pregnancy on early infant lung function

Am Rev Respir Dis

In-utero exposure to cigarette smoking influences lung function at birth

Eur Respir J

Follicle growth is inhibited by benzo-[a]-pyrene, at concentrations representative of human exposure, in an isolated rat follicle culture assay

Hum Reprod

Smoking habits of Greek preschool children's parents

BMC Public Health

Tobacco use by youth: a surveillance report from the Global Youth Tobacco Survey project

Bull World Health Organ

Antepartum fetal and maternal carboxyhemoglobin and cotinine levels among cigarette smokers

Acta Paediatr

Environmental tobacco smoke exposure of young children – attitudes and health-risk awareness in the Nordic countries

Nicotine Tob Res

Influence of family factors on the incidence of lower respiratory illness during the first year of life

Br J Prev Soc Med

The burden of environmental tobacco smoke exposure on the respiratory health of children 2 months through 5 years of age in the United States: Third National Health and Nutrition Examination Survey, 1988 to 1994

Pediatrics

Meta-analysis on the association between environmental tobacco smoke (ETS) exposure and the prevalence of lower respiratory tract infection in early childhood

Pediatr Pulmonol

Passive smoking and respiratory function in very low birthweight children

Med J Aust

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Thorax

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CME Article
Respiratory effects of tobacco smoking on infants and young children