Passive smoking, salivary cotinine concentrations, and middle ear effusion in 7 year old children

Passive smoking and health: should we believe Philip Morris's "experts"?

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Respiratory health effects of exposure to environmental tobacco smoke

During the last 25 years, several hundred papers have been published on the respiratory health effects of environmental tobacco smoke (ETS). Various independent assessments have concluded that ETS causes lung cancer in adult nonsmokers and increases the risk of various noncancer effects, principally in children. The effects on children include pneumonia, bronchitis and bronchiolitis in young children; chronic middle ear effusion; increased frequency and severity of attacks among asthmatics; possible induction of asthma in previously asymptomatic individuals; small reductions in lung function; and symptoms of upper respiratory tract irritation. In nonsmoking adults, ETS exposure is associated with irritation of the eyes, nose, and throat, and with wheezing, symptoms of bronchitis, shortness of breath, and decreased lung function. The results of recent studies not only confirm and strengthen the above findings but also provide strong suggestive evidence that ETS causes sinonasal cancer and is a risk factor for sudden infant death syndrome. To mitigate such a preventable environmental health impact, public health measures to reduce involuntary ETS exposure are warranted.

The effects of in vitro cotitine on nasal ciliary beat frequency

Cotitine is one of the main metabolites of nicotine. It is stable and in vivo has a relatively long circulating half life. Nasal ciliated cells from non-smoking individuals were exposed in vitro to solutions of cotitine corresponding to serum levels in active and passive smokers. Ciliary beat frequency was measured by a computerized photometric technique. There was a significant drop in ciliary beat frequency compared with control ciliated cells in phosphate buffered saline. It is concluded that cotitine in active or passive smoking has a marked effect on ciliary function. It may be a factor leading to diminished mucociliary clearance and persistent middle ear effusion.

Otitis media in a population of black American and white American infants, 0-2 years of age

To determine the incidence of otitis media (OM) and the bacteriology of acute otitis media (AOM) in a clinic population of young children in Pittsburgh, 138 black infants and 60 white infants were followed from birth to 2 years of age, examined at monthly intervals and whenever an upper respiratory tract infection (URI) or OM intervened. By 24 months of age the cumulative incidence of episodes of AOM was 43% and 42%, and of episodes of middle-ear effusion (MEE) was 86% and 85% in black and white infants, respectively. The average rate of episodes of AOM was 0.41 and 0.39 and of episodes of MEE was 1.68 and 1.70 in black and white infants, respectively. Tympanocentesis was performed for episodes of AOM and the following organisms were isolated from black and white infants, respectively: Streptococcus pneumoniae 43% and 43% of episodes; Moraxella catarrhalis 24% and 24%; non-typable Haemophilus influenzae 18% and 24%; and Haemophilus influenzae type b 5% and 0%. In both black and white infants first born children had less ear disease. We found no difference in the incidence of otitis media during the first 2 years of life between black and white infants.

Association between creatinine-adjusted and unadjusted urine cotinine values in children and the mother's report of exposure to environmental tobacco smoke

OBJECTIVE

To examine the association between parents' report of their child's secondhand smoke exposure and various adjustments of cotinine concentrations in random urine samples.

METHODS

Urine cotinine and creatinine were measured in 109 six to 11-year-old children from predominantly upper middle-class families. Cotinine values were considered as: (a) unadjusted, (b) as a cotinine/creatinine ratio, (c) as adjusted based on a regression relationship between cotinine and creatinine, and (d) and (e) as a cotinine/creatinine ratio adjusted for age and sex.

RESULTS

Little overlap in cotinine values occurred between exposed and nonexposed children, and a dose-response relationship was noted between the parental report and the urine cotinine values (r = 0.67). A modest improvement occurred in the correlation when the cotinine/creatinine ratio was considered. Considering exposure to cigarette smoke outside the home as well as in the household only improved the correlation when the former exposure was heavy. A high degree of concordance exists between the parents' report of exposure and the child's urine cotinine.

CONCLUSIONS

The value of adjusting this biochemical parameter by various means may be a function of the particular sample being investigated, suggesting no one method is universally appropriate.

Relationship of environmental tobacco smoke to otitis media in young children

Otitis media (OM) continues to be a major health problem of children in the United States. The role of environmental tobacco smoke (ETS) as a predisposing factor has not been completely discerned. This study and discussion is an investigation and review of the influence of passive cigarette smoking on OM in children, and its effect on the practice of otolaryngology within the pediatric population. A prospective study of 175 children with recurrent OM and requiring tympanostomy tubes (case group) was compared to an age-matched group of 175 children (controls) to determine the role passive cigarette smoking has on the incidence of this disease. The results revealed that the case group more commonly had exposure to ETS (P = .04). Prospective follow-up of the case group revealed no significant difference in the clinical course of the children who were exposed to ETS and those who were not.

Smoking or quitting during pregnancy: associations with background and future social factors

Current and future social factors associated with smoking habits during pregnancy were assessed. Data on maternal smoking, social background and the family's development during the 21 years after delivery were gathered for a prospective longitudinal cohort study of 12,068 pregnant women and their children in Northern Finland in 1966 and for a second birth cohort of 9,362 mothers in 1985-86. The prevalence of smoking before pregnancy was 22% in the 1966 cohort (29% in 1985-86). 12% (18%) of the women continued smoking throughout their pregnancy. The following background factors were mainly associated with the mother's smoking and/or continuing during pregnancy in both cohorts when mother's age, parity, place of residence and social class were standardized: mother's age under 23, parity two or more, low social class, urban dwelling, unmarried, gainful employment and heavy smoking. The follow-up responses after 14 and 21 years, respectively, were mostly more favourable among the non-smoking mothers and those who quit smoking during pregnancy-e.g. stable family structure, child's smoking and drinking habits and application for intermediate education. Smoking throughout pregnancy or quitting of smoking late in pregnancy were associated with undesirable future development of the child and family in most of these aspects.

Smoking and Middle Ear Disease: Are they Related? A Review Article

The relationship between passive smoking and middle ear disease was reviewed. The hypothesis that acute otitis media, serous otitis media, and related diseases in children are caused by inhalation of second-hand smoke has been accepted by many. We reviewed the literature on this topic. There are many studies that do not support the hypothesis. There is no indication that the smokers themselves have a higher incidence of middle ear disease. Considering the difficulty of publishing negative studies, the need for academics to publish significant findings, and the poor foundation for some authors” conclusions in the literature, we find that the literature does not offer sufficient support for the hypothesis that second-hand smoke causes middle ear disease to accept the hypothesis.

Smoking and middle ear ciliary beat frequency in otitis media with effusion

The middle ear mucociliary system has been shown to play an important role in clearing middle ear effusions. There is conflicting epidemiological evidence, however, as to whether exposure to tobacco smoke plays a significant role in persistence of middle ear effusion in patients with otherwise normal mucociliary function. Samples of middle ear mucosa from 33 patients with persistent otitis media with effusion (OME) were taken at myringotomy, together with corresponding nasal brushings. The aim of this study was to observe the mean ear ciliary beat frequency (CBF) and to compare it with nasal ciliary activity. Nasal brushings were collected from 33 age and sex matched non-smoking controls with no history of nasal atopy or topical nasal treatment. Ear CBF in OME was significantly reduced in comparison to paired nasal samples (p < 0.001). Ear CBF in adult OME patients who smoked or in children who were passive smokers was significantly less than in patients who were not exposed to cigarette smoke (p < 0.01). This study indicates that impaired ciliary function due to tobacco smoke exposure is an aetiological factor in persistent OME.

The natural history of otitis media with effusion--a three-year study of the incidence and prevalence of abnormal tympanograms in four South West Hampshire infant and first schools

Otitis media with effusion (OME) is both extremely common in young children, and variable in its duration and severity. This study aims to gather and consider new and reliable information about the incidence and prevalence of OME in British school children. Eight hundred and fifty-six school children aged five to eight years from four South West Hampshire schools were examined over a three-year period by tympanometry, a method used to detect OME (> 90 per cent specificity and sensitivity) performed once per school term. Normal ears were recorded in 54.9 per cent of children throughout with 27 per cent recording evidence of effusion. However in only one out of 10 of the affected children did the fluid persist for a year or more. This impressive clearance is due in part to natural resolution, with the intervention of surgery occurring in about one in eight of the children with identified effusions. OME is more common in five-year-olds with an annual prevalence of 17 per cent compared to six per cent in eight-year-olds and is more common in the winter months. Because of the variability of the condition at least two screenings are recommended as a basis for good management.

Environmental tobacco smoke and otitis media

Environmental tobacco smoke (secondhand smoke) is a health hazard experienced by one half to two thirds of the nation's children younger than 5 years of age. Although the role of environmental tobacco smoke in the genesis of pulmonary disease in children has been increasingly recognized, somewhat less attention has been paid to the role of environmental tobacco smoke in the development of childhood otitis. This presentation will review current data regarding environmental tobacco smoke, with a particular emphasis on its effects on the ears and eustachian tube. Current American Academy of Otolaryngology-Head and Neck Surgery Foundation, Inc. education efforts will also be discussed.

Factors affecting resolution of otitis media with effusion in children

There is only limited knowledge of the factors which influence the outcome of otitis media with effusion in children in the long-term. This randomized controlled study assessed the therapeutic effect of adenoidectomy and adenotonsillectomy during a 5-year follow-up. Numerous pre-treatment independent variables concerning the child's upper and lower respiratory tract, atopic status and parental habits were assessed in relation to two dependent outcome measures. These were otoscopic clearance of effusion and no peak/peak tympanometric change. A total of 222 children was studied and reviewed annually for 5 years. Four of 43 independent variables were found to be repeatedly significant in relation to outcome: (a) whether or not adenoidectomy was performed; (b) age at operation; (c) history of earache prior to operation; and (d) parental smoking habits. The results provide further evidence of a beneficial effect of adenoid removal and the importance of the age at which surgery is advised. They also suggest the need to investigate further the relationship of superadded acute suppurative otitis media with otalgia and the outcome of chronic otitis media with effusion. Finally, avoidance of parental smoking will have a beneficial effect on children's middle ear disease.

Passive smoking amongst asthmatic children. Questionnaire or objective assessment?

An increasing number of studies have implicated passive smoking as a definite threat to non-smokers' health. Self-reports of smoking status may not always be reliable, particularly in situations where the smoker feels under pressure to give up smoking. In this study questionnaire and salivary cotinine, an objective measure of nicotine exposure, were studied in asthmatic and age-matched control children. We have consequently developed a sensitive assay for cotinine using high performance liquid chromatography (HPLC) to quantitate environmental tobacco smoke (ETS) exposure in a group of 5- to 7-year-old asthmatic and control children. We chose to use mixed unstimulated saliva collected by absorption into dental rolls in the mouth for 5 min. Our modified extraction procedure was highly reproducible with a > 90% retrieval rate of cotinine from spiked saliva. The parents were asked to fill in a questionnaire on atmospheric pollutants to obtain an estimate of declared ETS exposure in the home. Results showed that 31% of the asthmatic patients were exposed to ETS, according to the parents, but by HPLC 69% had been so exposed (n = 19). From the control group the figures were 40% and 50% of patients, respectively. Therefore, an objective assessment is essential as ETS is more ubiquitous than is apparent from the questionnaire alone. Finally, in this small number of individuals our objective assessment demonstrates that ETS exposure is more prevalent in asthmatic children (69%) than age-matched controls (51%).

Passive exposure to tobacco smoke in children aged 5-7 years: individual, family, and community factors

OBJECTIVE

To examine the importance of parental smoking on passive exposure to tobacco smoke in children and the social and geographical patterns of exposure.

DESIGN

Cross sectional study.

SETTING

Schools in 10 towns in England and Wales; five towns with high adult cardiovascular mortality and five with low rates.

SUBJECTS

4043 children aged 5-7 years of European origin.

MAIN OUTCOME MEASURES

Salivary cotinine concentration and parents self reported smoking habits.

RESULTS

1061 (53.0%) children were exposed to cigarette smoke at home or by an outside carer. Geometric mean cotinine rose from 0.29 (95% confidence interval 0.28 to 0.31) ng/ml in children with no identified exposure to 4.05 (3.71 to 4.42) ng/ml in households where both parents smoked and 9.03 (6.73 to 12.10) ng/ml if both parents smoked more than 20 cigarettes a day. The effect of mothers' smoking was greater than that of fathers', especially at high levels of consumption. After adjustment for known exposures geometric mean cotinine concentrations rose from 0.52 ng/ml in social class I to 1.36 ng/ml in social class V (P < 0.0001); and were doubled in high mortality towns compared with the low mortality towns (P = 0.002). In children with no identified exposure similar trends by social class and town were observed and the cotinine concentrations correlated with the prevalence of parental smoking, both between towns (r = 0.69, P = 0.02) and between schools within towns (r = 0.50, P < 0.001).

CONCLUSIONS

Mothers' smoking is more important that fathers' despite the lower levels of smoking by mothers. Children not exposed at home had low cotinine concentration, the level depending on the prevalence of smoking in the community.

Relation of infant feeding practices, cigarette smoke exposure, and group child care to the onset and duration of otitis media with effusion in the first two years of life

The relation of infant feeding practices, cigarette smoke exposure, and group child care to the onset and duration of otitis media with effusion (OME) was evaluated in a cohort of 698 healthy infants prospectively monitored by tympanometry in the home every 2 to 4 weeks until 2 years of age. Except for an experimental group of children who were offered early tube placement, the study children received conventional care from their personal physician or clinic. We used LISREL, a structural equation modeling procedure (computer software), to explore associations between environmental variables and OME onset and duration while controlling for interrelations among the variables. Supine feeding position and early initiation of group child care were associated with earlier onset of OME. Shorter duration of breast-feeding, increased packs of cigarettes smoked per day in the home, and increased hours per week in group child care were associated with an increase in the amount of time with OME during one or more of the age blocks studied (birth to 6, 6 to 12, 12 to 18, and 12 to 24 months). For a decrease in the amount of time with OME during the first 2 years of life, prolonged breast-feeding and upright feeding position should be encouraged, and cigarette smoke exposure should be minimized. Limiting early child care in large groups might also be advisable.

Exposure to environmental tobacco smoke as a risk factor for recurrent acute otitis media in children under the age of five years

Exposure to environmental tobacco smoke (ETS) has remained a controversial risk factor for otitis media in children. This study evaluates the association between exposure to ETS and recurrent acute otitis media (RAOM) in 85 cases and 85 age and gender matched controls under the age of 5 years. Cases and controls were obtained from outpatient otolaryngology and ophthalmology clinics, respectively, at the Children's Hospital of Eastern Ontario. Cases were defined as having four or more physician documented AOM episodes in the preceding 12 months and controls were otitis free in the prior 12 months. Exposure status was assessed via parental questionnaire. Controlling for other risk factors (via conditional logistic regression), such as daycare attendance, socioeconomic status, prematurity and family history of otitis media, a significant association between ETS and RAOM was evident (odds ratio = 2.68, 95% CI = 1.27-5.65). When categorized, a significant exposure response relationship between increasing level of exposure to ETS and increased risk of RAOM was evident. The population etiologic fraction indicated that up to 34% of RAOM cases may be accounted for by ETS exposure. We conclude that exposure to ETS is an important and modifiable risk factor for RAOM in children under the age of 5 years.

Simple selected ion monitoring capillary gas chromatographic-mass spectrometric method for the determination of cotinine in serum, urine and oral samples

A capillary gas chromatographic-mass spectrometric method using selected ion monitoring was developed for the analysis of cotinine in urine, serum and oral samples. The procedure requires 500 microliters of an oral sample, 250 microliters of a serum sample and 50 microliters of urine and can detect 5 ng/ml cotinine in oral samples, 10 ng/ml in serum and 50 ng/ml in urine with good precision and accuracy. The method was used to determine the cotinine concentration in samples of all three fluids collected from a group of smokers and non-smokers.

Protracted secretory otitis media. The impact of familial factors and day-care center attendance

This study's objective was to assess the impact of familial factors, day-care center attendance, and passive smoking on the incidence of protracted secretory otitis media (SOM). An unselected cohort of 1306 Swedish children were followed from birth to 7 years of age. Information about physician visits and insertions of tympanostomy tubes for SOM was collected at the ENT-departments in one Swedish county. The material was analyzed by life table methods and Cox's regression analysis. At the ages of 3, 5 and 7 years, 1%, 4% and 6%, respectively, of the children had been treated by tympanostomy tubes for SOM. The cumulative incidence of protracted SOM was four times higher among the children who had a sibling with the same health problem. Attendance at a day-care center of 12 or more months during the first 4 years of life increased the risk for protracted SOM by 2.6 times. No association was found between parents' smoking habits and the incidence of protracted SOM.

Effect of cigarette smoking on salivary epidermal growth factor (EGF) and EGF receptor in human buccal mucosa

The mouth acts as a primary target for cigarette smoke which is associated with several oral diseases and cancer. The present study investigated the effect of cigarette smoking on salivary EGF and the buccal EGF receptor. Samples of whole saliva and buccal biopsy were obtained from 15 healthy volunteers (10 smokers and 5 non-smokers). The smokers smoked 20 or more cigarettes/day for more than 5 years. Salivary cotinine (a major metabolite of nicotine) was determined by radioimmunoassay (RIA). The salivary cotinine level was consistent with the self-reported smoking status (smokers, 106-530 ng/ml saliva; non-smokers, < 2 ng/ml saliva). As compared to the non-smokers, the salivary EGF concentration (determined by RIA) was 32% lower in those smokers whose salivary cotinine level was 250 ng/ml or higher (non-smokers, 2.21 +/- 0.16; smokers, 1.57 +/- 0.09 ng/ml saliva; mean +/- S.E.M., P < 0.01). There was no significant difference in 125I-labeled EGF binding to the buccal receptor between the two groups. However, EGF stimulated the autophosphorylation of a 170-kDa protein band in the sample of non-smokers, but not in the smokers. The immunoblot analysis using anti-EGF receptor antibody indicated that the smoking-related deficiency in EGF receptor autophosphorylation was due to the functional alteration of the receptor proteins. In conclusion, cigarette smoking reduces the salivary EGF level and impairs the function of buccal EGF receptor, which may be associated with the pathology of smoking-related oral disease.

The effect of parental smoking on outcome after treatment for glue ear in children

A sample of 201 children aged between 2 and 9 years with bilateral chronic otitis media with effusion (OME) were treated prospectively and at random by adenoidectomy, adenotonsillectomy, or with neither procedure. In all cases only a unilateral grommet was inserted and the contralateral unoperated ear was examined one year post-operatively for persistence or resolution of the effusion. A self-administered questionnaire was completed by the parents concerning their smoking habits. The resolution of effusion following surgery was assessed in relation to smoking by by the mother and father separately and in combination. Clearance of glue was statistically less frequent where the child's mother or where both parents smoked. This was related to the number of cigarettes smoked by the mother or both parents. The adverse effect was demonstrable whether or not adenoidectomy or adenotonsillectomy had been performed for treatment. The findings lend further support or professional and governmental opinions of a deleterious effect of passive smoke exposure on children and in this case parental smoking has been shown to have an adverse effect on the outcome of OME following surgical treatment.

Cigarette smoking reduces human salivary eicosanoids

The effect of cigarette smoking on salivary eicosanoid levels was investigated in 10 smoker and 10 non-smoker volunteers. The smokers consumed an average of 20 cigarettes/day for the past 5 years or longer. The smoking status was validated by salivary cotinine level. Eicosanoids were extracted from saliva with ethanol, and the radioimmunoassay was performed to determine the concentrations of four major eicosanoids, i.e. prostaglandin E2 (PGE2), PGF2 alpha, 6-sulphidopeptide-containing leukotrienes (LTs) and 12-hydroxyeicosatetraenoic acid (12-HETE). The levels of PGE2, PGF2 alpha, and LTs were significantly lower in the saliva of smokers as compared to that of the non-smokers (1.74 +/- 0.32 vs 2.41 +/- 0.64, p = 0.006; 0.36 +/- 0.12 vs 0.54 +/- 0.18, p = 0.04; 2.24 +/- 0.96 vs 4.92 +/- 1.29, p = 0.006; mean +/- SD, ng/ml saliva). No significant differences were found in the levels of 12-HETE between the two groups. The results suggest that cigarette smoking reduces the concentrations of both the cyclooxygenase and 5-lipoxygenase products in saliva.

Determinants of passive smoking in children in Edinburgh, Scotland

OBJECTIVES

Using saliva cotinine as a quantitative marker, we examined the contribution of factors other than parental smoking to children's passive exposure to tobacco smoke.

METHODS

Saliva specimens from a random sample of 734 7-year-old schoolchildren in Edinburgh, Scotland, were analyzed for cotinine. Their parents completed a questionnaire covering smoking habits and conditions in the home.

RESULTS

A number of independent predictors of cotinine were identified in addition to the main one of smoking by household members. These predictors included home ownership, social class, day of the week, season of the year, number of parents present, crowding in the home, the number of children in the household, and sex. Cotinine was higher in children from less advantaged backgrounds, during winter, on Mondays, in girls, and when fewer other children were present. The effects were similar between children from nonsmoking and smoking homes.

CONCLUSIONS

Questionnaire measures of parental smoking are insufficient to fully characterize young children's exposure to passive smoking. Because socioeconomic variables contribute to measured exposure, passive-smoking studies that treat class as a confounder and control for it may be overcontrolling.

Parental smoking and persistent otitis media with effusion in children

A total of 163 children were entered into a case-control study to determine whether any causal relationship exists between otitis media with effusion (OME) requiring grommet insertion and parental smoking. One hundred children with persistent OME formed the case group and 63 children with normal ears formed the control group. The prevalence of parental smoking in each group was then compared. Information was collected by questionnaire and further details about the subjects with regard to surgery of the upper respiratory tract were also gathered. Analysis of findings in this study and previous reports has failed to demonstrate a significantly increased prevalence of smoking in at least one parent, amongst children with persistent otitis media with effusion requiring surgical intervention.

Meta-analysis of antibiotics for the treatment of otitis media with effusion

OBJECTIVE

To reconcile conflicting reports of antibiotic efficacy for otitis media with effusion in children.

DATA SOURCES

English-language MEDLINE search ("antibiotics" and "otitis" media with effusion") from January 1980 through December 1990. Current Contents 1990, consultation with experts, and references from review articles, textbook chapters, and retrieved reports.

STUDY SELECTION

Randomized clinical trials with concurrent controls (placebo or no drug), and children with at least one ear not violated by tympanocentesis. Ten of the initial 82 articles were selected after blind review of the methods sections.

DATA EXTRACTION

We independently evaluated each trial using 20 measures of internal and external validity, then extracted treatment and control responses for an end point of all affected ears free of effusion at the first posttreatment assessment.

DATA SYNTHESIS

Pooled analysis of 1325 children yielded a rate difference of 22.8% (95% Cl, 10.5 to 35.1) that was minimally affected by interstudy quality differences, and was unlikely to represent publication bias. Variations in trial outcomes were not attributable to chance, study design, or choice of drug, but were inversely related to the control group natural cure rate. Children with chronic bilateral effusions not related to a recent episode of acute otitis media tended to have lower natural cure rates, and a more favorable response to therapy.

CONCLUSIONS

Antibiotics have a clinically and statistically significant impact on the resolution of otitis media with effusion. The association between outcome and natural cure rate has important implications for the design and interpretation of future trials.

Exposure to passive smoking among bar staff

The median saliva cotinine concentration in 42 non-smoking bar staff in central London and Birmingham was 7.95 ng/ml, indicating a nicotine intake of about 0.6 mg per day. Pubs appear to give rise to exceptionally heavy exposure to environmental tobacco smoke. Passive smoking in pubs is of concern for its impact both on customers and on those for whom the pub is a place of work.

Serum cotinine as an objective marker for smoking habit in head and neck malignancy

Cigarette-smoking is a well-established aetiological factor in squamous cell carcinoma of the larynx. In Great Britain the majority of patients with laryngeal cancer are treated by radiotherapy with salvage surgery if necessary. A troublesome side effect of radiotherapy is mucositis which may exacerbate hoarseness, dysphagia, airway obstruction or pain. Although it is a common belief that continued smoking and alcohol consumption during radiotherapy may increase the frequency and severity of these side effects this has not been demonstrated objectively. This study confirms and illustrates the relationship between such radiotherapy reactions to continued smoke exposure by using an objective biochemical marker of smoking status.

Determinants of teenage smoking, with special reference to non-standard family background

The prevalence of teenage smoking in a cohort of 12,058 subjects born in northern Finland in 1966 is discussed in terms of its social and family determinants, especially in "non-standard" families (with one or more of the parents absent for at least part of the child's upbringing). The prevalence of experimental or daily smoking was 67.4%, the rate being 65.5% in the standard, two-parent families and 75.5% in the non-standard families, the difference being statistically significant (p less than 0.001). The corresponding prevalence of daily smoking was 6.4%, but the rate was 5.1% in standard families and 12.1% in non-standard families (p less than 0.001). An elevated risk of smoking existed among adolescents who had experienced death of their father or divorce of their parents and among girls who had experienced death of their mother. Maternal smoking during pregnancy and maternal age under 20 years at the time of delivery increased the risk, while being the first-born child reduced it. Among family factors existing in 1980, paternal smoking increased the risk for both sexes, while more than three siblings, mother's unemployment or gainful employment (i.e. not a housewife) were associated with smoking by the boys as was urban living, and for the girls migration by the family to a town. The results suggest that juvenile smoking may be a kind of indicator of possible problems experienced by the parents and/or the adolescents themselves with respect to parenthood and family development.

Impedance tympanometry and the home environment in seven-year-old children

The distribution of tympanogram types among 872 seven-year-old children from a random population sample was related to 14 features of the home environment reported by parents in a questionnaire. Parental smoking was an important determinant of middle ear underpressure and effusion, and accounted for much of the associations observed with dampness, crowding and rented accommodation. Gas cooking was associated with a higher prevalence of effusion, but a lower prevalence of underpressure; this may deserve further study. After adjustment for seasonal variation, tenure and household smokers, the weekly mean temperature in the bedrooms of 34 children with Type B tympanograms was 18.2 degrees C, compared to 17.9 degrees C for 190 children with Type A tympanograms. The equivalent figures for bedroom relative humidity were 51.8 per cent and 52.7 per cent. It is unlikely that heating or ventilation of the home is an important determinant of middle ear effusion and underpressure in this age-group.

Otitis media with effusion: is medical management an option?

Persistent middle ear effusion is a common cause of hearing impairment and remains underdiagnosed, particularly among younger children. Detection can be improved by adequate follow-up of otitis media. Decisions on management need to take into account the child's age, duration and severity of illness, degree of hearing impairment, and any evidence of learning difficulties. There is no definitive cure but both medical and surgical treatments may improve outcome. With increasing evidence that antihistamine-decongestant mixtures are ineffective, there may in the future be a role for antibiotics and steroids.