Hisinger-Mölkänen et al.

World Allergy Organization Journal (2018) 11:6

https://doi.org/10.1186/s40413-018-0184-5

ORIGINAL RESEARCH Open Access

Smoking, environmental tobacco smoke

and occupational irritants increase the risk
of chronic rhinitis
Hanna Hisinger-Mölkänen1* , Päivi Piirilä2, Tari Haahtela3, Anssi Sovijärvi4 and Paula Pallasaho5

Abstract
Background: Allergic and non-allergic rhinitis cause a lot of symptoms in everyday life. To decrease the burden
more information of the preventable risk factors is needed. We assessed prevalence and risk factors for chronic
nasal symptoms, exploring the effects of smoking, environmental tobacco smoke, exposure to occupational irritants,
and their combinations.
Methods: In 2016, a postal survey was conducted among a random population sample of 8000 adults in Helsinki,
Finland with a 50.5% response rate.
Results: Smoking was associated with a significant increase in occurrence of chronic rhinitis (longstanding nasal
congestion or runny nose), but not with self-reported or physician diagnosed allergic rhinitis. The highest
prevalence estimates of nasal symptoms, 55.1% for chronic rhinitis, 49.1% for nasal congestion, and 40.7% for runny
nose, were found among smokers with occupational exposure to gases, fumes or dusts.
Besides active smoking, also exposure to environmental tobacco smoke combined with occupational exposure
increased the risk of nasal symptoms.
Conclusions: Smoking, environmental tobacco smoke, and occupational irritants are significant risk factors for nasal
symptoms with an additive pattern. The findings suggest that these factors should be systematically inquired in
patients with nasal symptoms for appropriate preventive measures. (192 words).
Keywords: Allergic rhinitis, Environmental tobacco smoke, Occupational exposure, Rhinitis, Smoking

Background Rhinitis symptoms and chronic rhinosinusitis are signifi-

It is estimated that 500 million people worldwide suffer cantly more common among smoking individuals than
from allergic rhinitis and in addition 200 million from among non-smokers [12] . Smoking is also associated with
non-allergic rhinitis [1, 2]]. These conditions render a the development of nasal polyposis [13]. The harmful effects
considerable burden on both the patients and society in of environmental tobacco smoke are also known from previ-
terms of life quality, disability and costs [3–5]. ous studies [14–17]. Occupational exposure to gases, dusts
Allergic rhinitis is considered to be part of a systemic al- or fumes is a risk factor for rhinitis and sinusitis [16, 18] as
lergic condition often with comorbidities [6]. Rhinitis is a well as for asthma and COPD [19], and eczema [9] . The
risk factor for asthma and eczema [7–9], and affects combined effects of smoking, environmental tobacco smoke
asthma and COPD control [10, 11]. Non-allergic rhinitis and occupational irritants on nasal symptoms have been less
is a heterogenous group of conditions with variable eti- well estimated.
ology, e.g. hormonal, drug-induced, irritatative or idio- The FinEsS study is a Nordic joint project on the
pathic [2]. occurrence and risk factors of respiratory conditions in
Finland, Estonia and Sweden. The present study
assessed the prevalence of nasal symptoms and their as-
* Correspondence: hanna.hisinger-molkanen@fimnet.fi
sociation with smoking, environmental tobacco smoke,
1
Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Hisinger-Mölkänen et al. World Allergy Organization Journal (2018) 11:6 Page 2 of 7

and occupational irritants in a population based cohort Exposure to tobacco smoke at work. Are you now or
of 8000 Finnish adults. have you been heavily exposed to tobacco smoke at
work?
Methods Exposure to tobacco smoke at home. Are you now or
Study population have you been heavily exposed to tobacco smoke at
In 2016, a postal questionnaire was mailed to a ran- home?
domly selected sample of 8000 adults aged 20–69 years Exposure to environmental tobacco smoke. A positive
in 10-year age cohorts corresponding the gender and answer to either exposure to tobacco smoke at work or
age distribution of the Finnish population. The genders at home.
were randomized separately. The sample was obtained Exposure to gases, dusts or fumes at work (occupa-
from the Finnish National Population Registry (permis- tional irritants). Are you now or have you been heavily
sion Dnro 254/410/15; 8.1.2015). exposed to gases, dusts or fumes at work?
The invited individuals were given the possibility to re-
spond either by mail or on the internet. Reminders were Statistical analysis
sent twice. The questionnaire was mailed in Finnish, All analyses were performed using SPSS version 23.0.
Swedish or English, depending on the individuals` lan- Comparisons of proportions were tested with the Mann-
guage. Of the 8000 selected, 17 refused to participate, 7 Whitney U-test. p < 0.05 was regarded as statistically sig-
mailed an empty questionnaire and one had died. Of the nificant. Multiple logistic regression models were per-
7975 invited 4026 (50.5%) responded. Twenty-eight formed using smoking, exposure to tobacco smoke, and
questionnaires were excluded because they were not ad- exposure to gases, dusts or fumes at work as risk factors
equately fulfilled. For the present analysis, 510 individ- for chronic nasal symptoms. Odds ratios (ORs) are pre-
uals of the whole study population were excluded, sented with 95% confidence intervals (95%CI).
because the questions about smoking habits, environ-
mental tobacco smoke or exposure to gases, dusts or Results
fumes at work were not answered. Thus, the final sam- The characteristics of the study population are shown in
ple included 3488 individuals (1997, 57.3% women; Table 1. In total, 26.6% of the responders were smokers,
1491, 42.7% men). and 26% ex-smokers. Smoking was more common
The study was approved by the Coordinating Ethics among younger individuals, 31.6% of the responders
Committee of Helsinki and Uusimaa Hospital District aged 20–29 years were smokers compared to 21.4% of
(200/13/03/00/2015). those aged 60–69 years (p = 0.00). Exposure to gases,
dusts or fumes was reported by 26.8% of the responders.
Questionnaire Exposure to these irritants was slightly less frequent
In Helsinki, previous postal surveys were conducted in among younger individuals, 24.7% of those aged 20–
1996 and 2006 [17]. In 2016 we used the same question- 29 years had been exposed compared to 28.6% of those
naire as in 1996 and 2006, but also additional questions aged 60–69 years (p = 0.068).
about occupational and environmental exposure, nasal In the whole study sample, prevalence of chronic rhin-
symptoms and allergy were included. itis (longstanding nasal congestion or runny nose) was
36.9%, of nasal congestion 29.8%, and of runny nose
Questions and definitions 27.9%. Smoking, environmental tobacco smoke and oc-
Chronic rhinitis. A positive answer to either having long- cupational irritants increased the prevalence in an addi-
standing nasal congestion or runny nose or both. tive manner (Fig. 1, Table 2). Smoking alone increased
Nasal congestion. Have you had longstanding nasal slightly the nasal symptoms, but was not associated with
congestion? self-reported allergic rhinitis or physician-diagnosed al-
Runny nose. Have you had longstanding rhinitis? lergic rhinitis. However, if a smoker was also exposed to
Self-reported allergic rhinitis. Do you have now or have occupational irritants, the prevalence of nasal symptoms
you had previously allergic rhinitis (e.g. hay fever) or al- was the highest. This additive effect of exposure to to-
lergic eye symptoms? bacco smoke and occupational irritants on chronic nasal
Physician diagnosed allergic rhinitis. Have you been di- symptoms remained when data were stratified by phys-
agnosed by a doctor as having allergic rhinitis? ician diagnosed allergic rhinitis (Table 2).
Smoker. Current smoker or having stopped smoking The prevalence of physician diagnosed allergic rhinitis
during the last year. was 27.9% in the whole study sample. It was reported by
Ex-smoker. Stopped smoking more than 12 months 26.9% of smokers, by 28.9% of ex-smokers and by 27.8%
prior to the study. of non-smokers (p = 0.072). In men, environmental to-
Non-smoker. Neither current smoker nor ex-smoker. bacco smoke or occupational irritants did not associate
Hisinger-Mölkänen et al. World Allergy Organization Journal (2018) 11:6 Page 3 of 7

Table 1 Age, gender, smoking, environmental tobacco smoke and occupational irritants of the studied population
All Men Women
N (%) 3488 1491(42.7%) 1997(57.3%)
Mean (SD) age, years 45.0(14.7) 45.3(14.4) 44.9(14.9)
Age 20–29 643(18.4%) 246(16.5%) 397(19.9%)
30–39 785(22.5%) 361(24.2%) 424(21.2%)
40–49 564(16.2%) 249(16.7%) 315(15.8%)
50–59 712(20.4%) 305(20.5%) 407(20.4%)
60–69 740(21.2%) 314(21.1%) 426(21.3%)
Smokers 929 (26.6%) 464(31.1%) 465(23.3%)
Ex-smokers 907(26.0%) 425(28.5%) 482(24.1%)
Non-smokers 1764(50.6%) 659(44.2%) 1105(55.3%)
Exposure to tobacco smoke at work 326(9.3%) 169(11.3%) 157(7.9%)
Exposure to tobacco smoke at home 358(10.3%) 170(11.4%) 188(9.4%)
Exposure to occupational irritants 934(26.8%) 479(32.1%) 455(22.8%)
Age, gender, smoking and exposure characteristics of the studied population. Occupational irritants = exposure to gases, dust or fumes at work. The figures
indicate the number of subjects except age groups indicated in years

with physician diagnosed allergic rhinitis. Among Results of the multiple logistic regression analysis are
women, however, 33.7% of those exposed to occupa- given in Table 3. Current smoking, without exposure to
tional irritants had physician diagnosed allergic rhinitis occupational irritants, yielded an odds ratio (OR) 1.22
compared with 26.1% among the non-exposed (p = (95%CI 1.00–1.49) for chronic rhinitis, and 1.26 (95%CI
0.032). Also in women, if occupational exposure was 1.01–1.56) for nasal congestion. Exposure to environ-
combined with environmental tobacco exposure the mental tobacco smoke at home or at work did not, as
prevalence increased from 26.1% in non-exposed to such, increase the risk significantly in our model due to
41.3% among exposed (p = 0.024). collinearity.
The prevalence of longstanding nasal symptoms was high Occupational irritants were associated almost signifi-
also in those responders who did not report physician diag- cantly with chronic rhinitis OR 1.28 (95%CI 0.97–1.69),
nosed allergic rhinitis, as 30.8% of them reported chronic with nasal congestion OR 1.20 (95%CI 0.90–1.60), and sig-
rhinitis, 25% nasal congestion, and 21.4% runny nose. nificantly with runny nose OR 1.49 (95%CI 1.11–1.99).

Fig. 1 Prevalence of chronic rhinitis, nasal congestion and runny nose in different exposures and their combinations
Hisinger-Mölkänen et al. World Allergy Organization Journal (2018) 11:6 Page 4 of 7

Table 2 Prevalence of chronic rhinitis, nasal congestion and runny nose

Unexposed Smoker ETS at home ETS at work Occupatio-nal irritants ETS + Smoker +
Occupational irritants Occupational irritants
All responders
Chronic rhinitis 31.7% 36.1% 36.4% 44.3% 46.4% 45.9% 55.1%
0.073 0.29 0.01 0.000 0.007 0.000
Nasal congestion 24.9% 29.4% 30.6% 42.3% 40.1% 43.5% 49.1%
0.049 0.17 0.000 0.000 0.000 0.000
Runny nose 23.8% 25.2% 26.4% 25.8% 36.7% 32.9% 40.7%
0.54 0.51 0.65 0.000 0.056 0.000
Responders with physician diagnosed allergic rhinitis
Chronic rhinitis 51.4% 50.0% 54.1% 70.0% 66.7% 65.5% 69.6%
0.77 0.76 0.051 0.006 0.14 0.002
Nasal congestion 42.9% 43.0% 51.4% 66.7% 57.1% 65.5% 64.1%
0.98 0.33 0.012 0.010 0.019 0.000
Runny nose 40.1% 39.2% 40.5% 46.7% 59.0% 48.3% 53.3%
0.86 0.96 0.48 0.001 0.39 0.023
Responders without physician diagnosed allergic rhinitis
Chronic rhinitis 24.3% 31.1% 28.6% 32.8% 37.7% 35.7% 49.6%
0.008 0.39 0.12 0.000 0.056 0.000
Nasal congestion 18.2% 24.5% 21.4% 31.3% 32.8% 32.1% 43.4%
0.007 0.47 0.008 0.000 0.010 0.000
Runny nose 17.7% 20.1% 20.2% 16.4% 27.0% 25.0% 36.0%
0.28 0.56 0.79 0.001 0.17 0.000
Prevalence of chronic rhinitis, nasal congestion and runny nose stratified according to risk factors: smoking, environmental tobacco smoke (ETS), occupational
irritants, or their combinations among all responders and among responders with and without physician diagnosed allergic rhinitis. Probability figures are
indicated below each prevalence figure. p-values are given between unexposed and those, who are exposed to one or more of the risk factors

The risk was not further increased, if the responders were Occupational irritants were associated with runny nose in
also exposed to environmental tobacco smoke. both genders, and among women also with chronic rhinitis
Current smoking combined with exposure to occupa- and nasal congestion. The risk increase is modest but obvi-
tional irritants gave the highest risk estimates for nasal ously becomes significant in large populations.
symptoms: OR 1.80 (95%CI 1.39–2.33) for chronic rhin- The prevalence of longstanding nasal symptoms was
itis, 1.82 (95%CI 1.40–2.35) for nasal congestion, and high: 36.9% reported chronic rhinitis, 29.8% nasal con-
1.68 (95%CI 1.28–2.19) for runny nose. gestion, and 27.9% runny nose. These symptoms were
even more common than previously reported in Sweden
Discussion [20, 21], but comparable to recent studies from Finland
Current smoking in combination with occupational expos- and Sweden [14, 18] .
ure to gases, dusts or fumes resulted in increased occur- We found exposure to occupational irritants to be a
rence of chronic nasal symptoms in both genders significant risk factor for chronic nasal symptoms, which
suggesting an additive harmful effect. Smoking alone was is consistent with previous observations [20, 22, 23].
associated with chronic rhinitis and nasal congestion. However, in a recent Swedish study occupational

Table 3 Risk factors for long-term nasal symptoms in a multiple logistic regression model
Chronic rhinitis Nasal congestion Runny nose Physician diagnosed
allergic rhinitis
Unexposed 1 1 1 1
Smoker 1.22(1.00–1.49) 1.26(1.01–1.56) 1.08(0.86–1.36) 0.98(0.78–1.21)
ETS at home 0.75(0.49–1.14) 0.70(0.45–1.09) 0.75(0.47–1.21) 1.09(0.90–1.33)
ETS at work 0.99(0.58–1.73) 1.12(0.64–1.95) 0.57(0.30–1.09) 1.00(0.64–1.56)
Occupational irritants 1.28(0.97–1.69) 1.20(0.90–1.60) 1.49(1.11–1.99) 1.00(0.74–1.36)
ETS + occupational irritants 1.11(0.57–2.16) 1.31(0.66–2.58) 1.34(0.64–2.81) 1.37(0.67–2.78)
Smoker + occupational irritants 1.80(1.39–2.33) 1.82(1.40–2.35) 1.68(1.28–2.19) 0.94(0.71–1.25)
The figures indicate odds ratios (CI 95%). ETS Environmental tobacco smoke
Hisinger-Mölkänen et al. World Allergy Organization Journal (2018) 11:6 Page 5 of 7

exposure to gases, dust or fumes was not associated with previous results from Estonia; Larsson et al. found no sig-
current rhinitis [18]. As their definition of current rhin- nificant association between ETS exposure at home and
itis included individuals with allergic rhinitis or chronic respiratory symptoms [33]. It is likely that our study group
nasal symptoms, the results are not fully comparable. includes individuals that have been exposed to ETS at
Chronic nasal symptoms were more frequent among home in the past as smoking inside is not as common
smokers and ex-smokers in the whole study group as anymore as it has been in previous decades. Family mem-
found also in Sweden [20, 21] In the earlier report from bers may also quit or reduce smoking inside the home
FinEsS studies from 1997 to 2003, smoking was not as- more easily if one in their family develops respiratory
sociated with rhinitis symptoms [14]. In that report, symptoms. The lack of association might at least partly be
however, the definition of rhinitis symptoms included explained by these mechanisms.
also individuals with self-reported allergic rhinitis, which Responders who have been exposed to environmental
may explain the difference. In a study from Vietnam, tobacco smoke at work reported to have nasal conges-
using the same FinEsS-questionnaire, smoking was not a tion significantly more often in both groups. However,
risk factor for nasal symptoms [24]. The results may be second hand smoke neither at home nor at work was a
confounded by the much higher exposure to air pollu- significant risk factor in our logistic regression model.
tion in Vietnam. Our results are in agreement with a study from
In our study, the prevalence of physician diagnosed al- Switzerland showing that second hand smoke was not
lergic rhinitis was the same among non-smokers (27.1%) independently associated with rhinitis symptoms [33].
compared to current smokers (26.6%). Current smoking We have found earlier, that smoking and occupational
did not either increase the prevalence of nasal symptoms irritants have an additive effect on the incidence of
in those with physician diagnosed allergic rhinitis. How- COPD [19]. In the present study, we suggest that this
ever, smoking was associated with chronic nasal symp- additive exposure is also a risk factor for chronic nasal
toms in the whole study sample, and increased the risk of symptoms. The combined effect was seen in all age
nasal congestion significantly among those without phys- groups and whether or not allergic rhinitis was present.
ician diagnosed allergic rhinitis (p = 0.007). Our findings Non-allergic rhinitis is divided into several subgroups.
are in line with previous findings from U.S. [25] and sug- Half of the patients with non-allergic rhinitis does not have
gest that the association between nasal symptoms and to- a clear etiology for their symptoms (e.g. occupational, hor-
bacco exposure might be independent of allergy. monal, drug-induced) and are sometimes classified as
The possible association between tobacco smoke and al- having an idiopathic rhinitis [2]. Our results suggest that
lergy has been studied previously. Smoking has been asso- these symptoms are, at least partly, explained by smoking,
ciated with an increased risk of allergic disease [26, 27] environmental tobacco smoke or exposure to occupational
There is also evidence that tobacco smoke exposure would irritants. These risks are preventable by anti-smoking ef-
prevent from allergic sensitization [25, 28]. In a study forts and reduction of occupational exposure.
from The Netherlands Vonk et al. [29] found that prenatal
smoke exposure was associated with a decreased risk for Study limitations
the development of atopy. In another study from Canada The observations are derived from a questionnaire sur-
Hancox et al. present that personal and parental smoking vey based on a random population sample with a partici-
is associated with a lower risk of allergic sensitization in pation rate of 51%. With two reminders, we find the
people with a family history of atopy [30]. In our study the representativeness satisfactory. Participation rates have
prevalence of allergic rhinitis was independent of the decreased by time in epidemiological studies which is a
smoking status. general problem. The response rate has been about the
Environmental tobacco smoke is known to be a mod- same in other epidemiological studies as in our study,
est risk factor for chronic nasal symptoms. Our results for example 55% in Copenhagen City Heart Study. [34]
are in accordance with earlier findings [14] This associ- and 53% in a Swedish follow up study on the prevalence
ation has also been confirmed in children [31]. We ob- of asthma [35].
served that environmental tobacco smoke both at home The FinEsS questionnaire has been used in several other
and at work slightly increased the occurrence of chronic studies. Some new questions of nasal symptoms were
nasal symptoms, which is in line with previous observa- added, which improved the detection of the nasal condi-
tions [32]. Environmental tobacco smoke has also pre- tions. An obvious limitation of the present survey is the
disposed to sinusitis [16]. lack of individual clinical evaluation of the responders.
In our study, exposure to environmental tobacco smoke We did not take into account ambient air pollution, which
at home did not increase the prevalence of chronic nasal could potentially confound our findings. However, in
symptoms in responders with or without physician diag- Finland air pollution is minimal and well controlled, even
nosed allergic rhinitis. Our findings are in line with in cities.
Hisinger-Mölkänen et al. World Allergy Organization Journal (2018) 11:6 Page 6 of 7

Conclusions 3. Bousquet PJ, Demoly P, Devillier P, Mesbah K, Bousquet J. Impact of allergic

In conclusion, smoking, environmental tobacco smoke rhinitis symptoms on quality of life in primary care. Int Arch Allergy
Immunol. 2013;160(4):393–400.
and occupational exposure to gases, dusts or fumes in- 4. Axelsson M, Lindberg A, Kainu A, Ronmark E, Jansson SA. Respiratory
crease significantly the prevalence of chronic nasal symp- symptoms increase health care consumption and affect everyday life - a
toms both in men and women. The combined effect of cross-sectional population-based study from Finland, Estonia, and Sweden.
Eur Clin Respir J. 2016 May 27;3:31024.
smoking and occupational exposure was the most marked 5. Smith P, Price D, Harvey R, Carney AS, Kritikos V, Bosnic-Anticevich SZ, et al.
risk factor yielding the highest prevalence estimates. Thus, Medication-related costs of rhinitis in Australia: a NostraData cross-sectional
anti-smoking efforts at population level and measures to study of pharmacy purchases. J Asthma Allergy. 2017 May 9;10:153–61.
6. Cingi C, Gevaert P, Mosges R, Rondon C, Hox V, Rudenko M, et al. Multi-
stop smoking and irritant exposure at work may reduce morbidities of allergic rhinitis in adults: European Academy of Allergy and
nasal symptoms. The campaign for Tobacco-Free Finland Clinical Immunology Task Force Report. Clin Transl Allergy 2017 Jun 1;7:17–
at 2030 [30] and the Healthy Workplaces Campaign [31] 017-0153-z. eCollection 2017.
7. Pallasaho P, Juusela M, Lindqvist A, Sovijarvi A, Lundback B, Ronmark E. Allergic
have been launched and should be strongly promoted. rhinoconjunctivitis doubles the risk for incident asthma–results from a
population study in Helsinki, Finland. Respir Med. 2011 Oct;105(10):1449–56.
Acknowledgements 8. Shaaban R, Zureik M, Soussan D, Neukirch C, Heinrich J, Sunyer J, et al.
Not applicable. Rhinitis and onset of asthma: a longitudinal population-based study. Lancet.
2008 Sep 20;372(9643):1049–57.
Ethical approval and consent to participate 9. Ronmark EP, Ekerljung L, Lotvall J, Wennergren G, Ronmark E, Toren K, et al.
The study was approved by the Coordinating Ethics Committee of Helsinki Eczema among adults: prevalence, risk factors and relation to airway
and Uusimaa Hospital District (200/13/03/00/2015). All participants diseases. Results from a large-scale population survey in Sweden. Br J
consented. Dermatol. 2012 Jun;166(6):1301–8.
10. Pongracic JA, Krouse RZ, Babineau DC, Zoratti EM, Cohen RT, Wood RA,
Funding et al. Distinguishing characteristics of difficult-to-control asthma in inner-city
This study was supported by a special governmental subsidy for health children and adolescents. J Allergy Clin Immunol. 2016 Oct;138(4):1030–41.
sciences research (Helsinki University Central Hospital project grants TYH 11. Kim JK, Lee SH, Lee BH, Lee CY. Kim do J, min KH, et al. factors associated
2013354 and Y2017SK004), Nummela Sanatorium Foundation, Research with exacerbation in mild- to-moderate COPD patients. Int J Chron Obstruct
Foundation for Pulmonary Diseases (Heli), Väinö and Laina Kivi Foundation, Pulmon Dis. 2016 Jun 16;11:1327–33.
and Ida Montin Foundation. 12. Lee WH, Hong SN, Kim HJ, Ahn S, Rhee CS, Lee CH, et al. Effects of
cigarette smoking on rhinologic diseases: Korean National Health and
Availability of data and materials nutrition examination survey 2008-2011. Int Forum Allergy Rhinol. 2015
The datasets supporting the conclusions of this article are included within Oct;5(10):937–43.
the article. 13. Houser SM, Keen KJ. The role of allergy and smoking in chronic
rhinosinusitis and polyposis. Laryngoscope. 2008 Sep;118(9):1521–7.
14. Pallasaho P, Kainu A, Juusela M, Meren M, Sovijarvi A. High prevalence
Authors’ contributions of rhinitis symptoms without allergic sensitization in Estonia and
All authors were involved in the discussions and contributed to writing the Finland. Eur Clin Respir J 2015 Apr 8;2:https://doi.org/10.3402/ecrj.v2.
manuscript. All authors read and approved the final manuscript. 25401. eCollection 2015.
15. Hung HJ, Chen CY, Wang SL, Wu TN, Lee CH, Cheng SY. Environmental
Consent for publication tobacco smoke: relationship to early pregnancy discomforts. Am J Health
Not applicable. Behav. 2017 May 1;41(3):320–8.
16. Hur K, Liang J, Lin SY. The role of secondhand smoke in sinusitis: a
Competing interests systematic review. Int Forum Allergy Rhinol. 2014 Jan;4(1):22–8.
The authors declare that they do not have any competing interests. 17. White AJ, D'Aloisio AA, Nichols HB, DeRoo LA, Sandler DP. Breast cancer and
exposure to tobacco smoke during potential windows of susceptibility.
Cancer Causes Control. 2017 May 18;
Publisher’s Note 18. Ronmark EP, Ekerljung L, Mincheva R, Sjolander S, Hagstad S, Wennergren G,
Springer Nature remains neutral with regard to jurisdictional claims in et al. Different risk factor patterns for adult asthma, rhinitis and eczema:
published maps and institutional affiliations. results from West Sweden Asthma Study. Clin Transl Allergy 2016 Aug 4;6:
28–016–0112-0. eCollection 2016.
Author details 19. Pallasaho P, Kainu A, Sovijarvi A, Lindqvist A, Piirila PL. Combined effect of
1
Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland. 2HUS smoking and occupational exposure to dusts, gases or fumes on the
Medical Imaging Center, Helsinki University Hospital, Helsinki, Finland. 3Skin incidence of COPD. COPD 2014 Feb;11(1):88–95.
and Allergy Hospital, Helsinki University Hospital, University of Helsinki, 20. Eriksson J, Ekerljung L, Pullerits T, Holmberg K, Ronmark E, Lotvall J, et al.
Helsinki, Finland. 4HUS Medical Imaging Center, Helsinki University Hospital, Prevalence of chronic nasal symptoms in West Sweden: risk factors and
and University of Helsinki, Helsinki, Finland. 5Espoo City Health Services, relation to self-reported allergic rhinitis and lower respiratory symptoms. Int
Helsinki, Finland. Arch Allergy Immunol. 2011;154(2):155–63.
21. Eriksson J, Ekerljung L, Ronmark E, Dahlen B, Ahlstedt S, Dahlen SE, et al.
Received: 19 September 2017 Accepted: 16 February 2018 Update of prevalence of self-reported allergic rhinitis and chronic nasal
symptoms among adults in Sweden. Clin Respir J. 2012 Jul;6(3):159–68.
22. Thilsing T, Rasmussen J, Lange B, Kjeldsen AD, Al-Kalemji A, Baelum J.
References Chronic rhinosinusitis and occupational risk factors among 20- to 75-
1. Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ, Togias A, et al. year-old Danes-a GA(2) LEN-based study. Am J Ind Med. 2012 Nov;
Allergic rhinitis and its impact on asthma (ARIA) 2008 update (in 55(11):1037–43.
collaboration with the World Health Organization, GA(2)LEN and AllerGen). 23. Schyllert C, Ronmark E, Andersson M, Hedlund U, Lundback B, Hedman L,
Allergy. 2008 Apr;63(Suppl 86):8–160. et al. Occupational exposure to chemicals drives the increased risk of
2. Hellings PW, Klimek L, Cingi C, Agache I, Akdis C, Bachert C, et al. Non- asthma and rhinitis observed for exposure to vapours, gas, dust and fumes:
allergic rhinitis: position paper of the European academy of Allergology and a cross-sectional population-based study. Occup Environ Med. 2016 Oct;
clinical immunology. Allergy. 2017 May 5; 73(10):663–9.
Hisinger-Mölkänen et al. World Allergy Organization Journal (2018) 11:6 Page 7 of 7

24. Lam HT, Van T Tng N, Ekerljung L, Ronmark E, Lundback B. Allergic rhinitis
in northern vietnam: increased risk of urban living according to a large
population survey. Clin Transl Allergy 2011 Aug 11;1(1):7-7022-1-7.
25. Shargorodsky J, Garcia-Esquinas E, Navas-Acien A, Lin SY. Allergic
sensitization, rhinitis, and tobacco smoke exposure in U.S. children and
adolescents. Int Forum Allergy Rhinol. 2015 Jun;5(6):471–6.
26. Noakes PS, Hale J, Thomas R, Lane C, Devadason SG, Prescott SL. Maternal
smoking is associated with impaired neonatal toll-like-receptor-mediated
immune responses. Eur Respir J. 2006 Oct;28(4):721–9.
27. Kim SY, Sim S, Choi HG. Atopic dermatitis is associated with active and
passive cigarette smoking in adolescents. PLoS One. 2017 Nov 1;12(11):
e0187453.
28. Bottema RW, Reijmerink NE, Kerkhof M, Koppelman GH, Stelma FF, Gerritsen J,
et al. Interleukin 13, CD14, pet and tobacco smoke influence atopy in three
Dutch cohorts: the allergenic study. Eur Respir J. 2008 Sep;32(3):593–602.
29. Vonk JM, Boezen HM, Postma DS, Schouten JP, van Aalderen WM, Boersma
ER. Perinatal risk factors for bronchial hyperresponsiveness and atopy after a
follow-up of 20 years. J Allergy Clin Immunol. 2004 Aug;114(2):270–6.
30. Hancox RJ, Welch D, Poulton R, Taylor DR, McLachlan CR, Greene JM, et al.
Cigarette smoking and allergic sensitization: a 32-year population-based
cohort study. J Allergy Clin Immunol. 2008 Jan;121(1):38–42.e3.
31. Faraldo-Garcia A, Lopez-Silvarrey A, Pertega S, Cruz MJ, Sampedro M,
Sanchez-Lastres J, et al. Cross-sectional study about impact of parental
smoking on rhinitis symptoms in children. Clin Otolaryngol. 2017 Mar 17;
32. Tammemagi CM, Davis RM, Benninger MS, Holm AL, Krajenta R.
Secondhand smoke as a potential cause of chronic rhinosinusitis: a case-
control study. Arch Otolaryngol Head Neck Surg. 2010 Apr;136(4):327–34.
33. Larsson ML, Loit HM, Meren M, Polluste J, Magnusson A, Larsson K, et al.
Passive smoking and respiratory symptoms in the FinEsS study. Eur Respir J.
2003 Apr;21(4):672–6.
34. Browatzki A, Ulrik CS, Lange P. Prevalence and severity of self-reported
asthma in young adults, 1976-2004. Eur Respir J. 2009 Nov;34(5):1046–51.
35. Backman H, Raisanen P, Hedman L, Stridsman C, Andersson M, Lindberg A,
et al. Increased prevalence of allergic asthma from 1996 to 2006 and further
to 2016-results from three population surveys. Clin Exp Allergy. 2017 Nov;
47(11):1426–35.

Submit your next manuscript to BioMed Central

and we will help you at every step:
• We accept pre-submission inquiries
• Our selector tool helps you to find the most relevant journal
• We provide round the clock customer support
• Convenient online submission
• Thorough peer review
• Inclusion in PubMed and all major indexing services
• Maximum visibility for your research

Submit your manuscript at

www.biomedcentral.com/submit