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Impact of environmental tobacco smoke exposure on anaesthetic and surgical outcomes in children: a systematic review and meta-analysis
  1. Christopher Chiswell1,
  2. Yasmin Akram2
    1. 1Department of Public Health, Birmingham Children's Hospital, Birmingham, UK
    2. 2Institute of Applied Health Research, University of Birmingham, Birmingham, UK
    1. Correspondence to Dr Christopher Chiswell, Department of Public Health, Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; Christopher.chiswell{at}


    Background Tobacco smoke exposure in adults is linked to adverse anaesthetic and surgical outcomes. Environmental tobacco smoke (ETS) exposure, including passive smoking, causes a number of known harms in children, but there is no established evidence review on its impact on intraoperative and postoperative outcomes.

    Objectives To undertake a systematic review of the impact of ETS on the paediatric surgical pathway and to establish if there is evidence of anaesthetic, intraoperative and postoperative harm.

    Eligibility criteria participants Children aged 0–18 years undergoing anaesthetic or surgical procedures, any country, English language papers.

    Exposure ETS exposure assessed via questioning, observation or biological marker.

    Outcome measures Frequency of respiratory and other adverse events during anaesthesia, surgery and recovery, and longer term surgical outcomes.

    Results 28 relevant studies were identified; 15 considered anaesthetic outcomes, 12 surgical outcomes, and 1 a secondary outcome. There was sufficient evidence to demonstrate that environmental smoke exposure significantly increased risk of perianaesthetic respiratory adverse events (Pooled risk ratio 2.52 CI 95% 1.68 to 3.77), and some evidence that ear and sinus surgery outcomes were poorer for children exposed to ETS.

    Conclusions ETS exposure increases the risk of anaesthetic complications and some negative surgical outcomes in children, and this should be considered when planning surgery. Research is required to demonstrate whether changes in household smoking behaviour prior to surgery reduces risk of adverse outcomes, and to close the evidence gap around other outcomes such as wound healing and respiratory infections.

    Trial registration number Review registration number 42014014557.

    • Public Health
    • Anaesthetics
    • Paediatric Surgery
    • Passive Smoking
    • Tobacco Smoke

    This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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    • Twitter Follow Christopher Chiswell at @chris_chiswell

    • Collaborators Dr Carole Cummins.

    • Contributors The manuscript has been read and approved by all authors. CC instigated the review. CC and YA drafted the protocol. YA performed the searches. CC and YA screened the results, quality-assessed the papers and extracted data. CC drafted the manuscript for publication and responded to reviewer comments in communication with YA.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Additional unpublished data from the study (data extraction forms, meta-analysis calculations) are available on request from the corresponding author.

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