The association between prenatal exposure to environmental tobacco smoke and childhood obesity: a systematic review

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The objective of the review was to determine if prenatal exposure to environmental tobacco smoke (ETS) increases the risk of obesity and overweight in children.


Childhood obesity has reached epidemic proportions in many developed countries. This is of great concern as childhood obesity is associated with early onset of chronic diseases such as coronary artery disease, type II diabetes and hypertension in adulthood. Extensive research suggests a multifactorial etiology. These factors include genetic markers, individual lifestyle, social and environmental factors, particularly the interaction between these factors. Among environmental factors, prenatal exposure to ETS has been linked to increased rates of obesity and overweight in childhood.

Inclusion criteria:

This review considered studies on children of women who were non-smokers and who reported exposure to ETS during pregnancy. The exposure of interest was exposure to ETS or second hand smoke during pregnancy, determined by either: i) self-reported maternal exposure; and/or ii) serum cotinine levels. Observational studies such as cohort studies, case control studies, retrospective studies and analytical cross-sectional studies were included. Outcomes of interest were weight, height and body mass index of children from birth up to 18 years.


A three-step search strategy was used to search for published and unpublished studies in the English language. No search range (years) was set. Two reviewers assessed the studies for inclusion and methodological quality using the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI) standardized appraisal instruments. Data was extracted by two people independently and entered into the JBI extraction tool. Extracted data was pooled in a statistical meta-analysis based on a random effects model.


Nineteen studies were included in the review. Eight of the studies were included in the final meta-analysis. Findings suggest that there was an association between prenatal exposure to ETS and childhood obesity (odds ratio [OR]: 1.905, CI: 1.23–2.94), and no association between ETS exposure and overweight (OR: 1.51, CI: 0.49–4.59). The high rates of heterogeneity between studies in both of the meta-analyses determined by the I2 statistic (97% and 99%, respectively) sanction caution in the interpretation and use of these findings.


Based on the evidence, childhood obesity is associated with exposure to prenatal ETS, however overweight does not appear to be associated with this type of exposure.

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