Environmental Tobacco Smoke Exposure and Respiratory Health in Children: An Updated Critical Review and Analysis of the Epidemiological Literature

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Abstract
The issue of environmental tobacco smoke (ETS) exposure of children and respiratory health effects remains a matter of considerable controversy. We undertook to conduct a comprehensive and updated critical review and objec tive analysis of the epidemiological literature relevant to possible associations between ETS exposure and respiratory health of children. There appears to be a consistent association between parental (primarily maternal) smoking and respiratory symptoms and certain diseases in preschool children (44 reports). On the other hand, there is no consistent association between parental smok ing and (1) respiratory symptoms or disease (46 reports); (2) middle ear dis ease (17 reports), (3) pulmonary function (38 reports), or (4) lung growth and development (5 reports) in school-age or older children. Possible explanations for these data and the age-related differences noted include (1) an ETS effect, with age-dependent variations in susceptibility and/or exposure to ETS; (2) pregnancy and/or lactational effects of maternal active smoking; (3) inac curacies related to unvalidated clinical data and smoking status misclassifica tion, and (4) variable treatment of socioeconomic status-related and other confounding factors. The available data relative to these issues is inconclusive, and which of these explanations pertain remains to be determined by further research.