The Comprehensive Systematic Review of Association of Environmental Tobacco Smoke Exposure with the Incidence of Childhood Eczema
Keywords:
Environmental tobacco smoke, childhood eczema, atopic dermatitis, secondhand smoke, IgE sensitization, dose-responseAbstract
Background: Environmental tobacco smoke (ETS) is a pervasive indoor pollutant, yet its association with childhood eczema remains debated due to heterogeneous findings.
Methods: This systematic review synthesized 80 studies examining ETS exposure (prenatal/postnatal, questionnaire/biomarker-assessed) and childhood eczema (0–18 years), focusing on IgE-sensitized (atopic) versus non-atopic eczema. Primary outcomes were odds ratios (ORs), relative risks (RRs), and hazard ratios (HRs) with 95% confidence intervals.
Results: Passive smoke increased atopic dermatitis (AD) risk (OR 1.18; 95%CI 1.01–1.38) (1). Postnatal parental smoking during infancy was significantly associated with AD up to age 24 years (OR 1.25–1.39 for IgE-associated AD) (2). Prenatal maternal smoking with concurrent postnatal exposure yielded the strongest atopic eczema risk at age 4 (OR 2.14; 1.33–3.46) (3). Dose-response gradients were significant: maternal smoking ≥11 cigarettes/day gave RR 1.60 for AD by age 5.5 years (4). Both parents smoking increased total allergy risk (OR 4.72 versus 3.97 for one parent) (5). The critical novel finding: ETS specifically increased IgE-sensitized (atopic) eczema (OR 1.82 for prenatal; 1.62 for postnatal) but showed no association with non-atopic eczema (OR ~1.00) (2,3). Null or inverse findings (e.g., OR 0.46 for high maternal cotinine + vitamin D) (9) were explained by failure to distinguish atopic subtypes, short follow-up, or confounding by nutritional status.
Discussion: The weight of evidence supports a significant positive, dose-dependent association between postnatal household ETS exposure and atopic (IgE-mediated) childhood eczema, persisting into young adulthood. The atopic/non-atopic distinction is the primary explanatory mechanism for prior heterogeneity.
Conclusion: ETS is a modifiable risk factor specifically for IgE-associated childhood eczema. Future studies must stratify eczema by atopic status and use biomarker-validated ETS measurement.
References
1. Kantor R, Kim A, Thyssen J, Silverberg J (2016) Association of atopic dermatitis with smoking. Journal of American Academy of Dermatology. https://doi.org/10.1016/j.jaad.2016.07.017
2. Zettergren A, Andersson N, Merritt A-S, et al (2025) Early‐Life Secondhand Smoke Exposure and Development of Atopic Dermatitis up to Adulthood. Clinical and Experimental Allergy. https://doi.org/10.1111/cea.70204
3. Böhme M, Kull I, Bergström A, et al (2010) Parental smoking increases the risk for eczema with sensitization in 4-year-old children. Journal of Allergy and Clinical Immunology. https://doi.org/10.1016/j.jaci.2009.12.997
4. Shigehara K, Matsumoto N, Tsuge M, et al (2025) Maternal smoking during infancy increases the risk of allergic diseases in children: a nationwide longitudinal survey in Japan. Allergy, Asthma & Clinical Immunology. https://doi.org/10.1186/s13223-025-00952-9
5. Kuiper S, Schayck CV (2013) Allergen avoidance: the Isle of Wight study. https://doi.org/10.1093/MED/9780199651559.003.0062
6. Al-Alusi NA, Ramirez F, Langan S, Abuabara K (2020) 435 The association between tobacco smoke exposure during childhood and adolescence and atopic dermatitis activity and severity. Journal of Investigative Dermatology. https://doi.org/10.1016/j.jid.2020.03.443
7. Ahmad K, Kabir E, Ormsby GM, Khanam R (2021) Are wheezing, asthma and eczema in children associated with mother’s health during pregnancy? Evidence from an Australian birth cohort. Archives of Public Health. https://doi.org/10.1186/s13690-021-00718-w
8. Keil T, Lau S, Roll S, et al (2009) Maternal smoking increases risk of allergic sensitization and wheezing only in children with allergic predisposition: longitudinal analysis from birth to 10 years. Allergy European Journal of Allergy and Clinical Immunology. https://doi.org/10.1111/j.1398-9995.2008.01867.x
9. Brustad N, Wang T, Chen L, et al (2025) Effect of prenatal high-dose vitamin D on childhood atopic dermatitis is modified by maternal cotinine metabolome: A secondary analysis of a randomized clinical trial. Journal of American Academy of Dermatology. https://doi.org/10.1016/j.jaad.2025.08.044
10. Wang Y-W, Yeh K, Huang J-L, et al (2023) Longitudinal analysis of the impact of smoking exposure on atopic indices and allergies in early childhood. The World Allergy Organization Journal. https://doi.org/10.1016/j.waojou.2023.100802
11. Goudarzi H, Konno S, Kimura H, et al (2018) Contrasting associations of maternal smoking and pre-pregnancy BMI with wheeze and eczema in children. Science of the Total Environment. https://doi.org/10.1016/j.scitotenv.2018.05.152
12. Chiu C, Tsai M, Su K-W, et al (2023) Examining the Longitudinal Association between Smoking Exposure, Atopic Indices, and Allergies during Early Childhood. Paediatric asthma and allergy. https://doi.org/10.1183/13993003.congress-2023.pa5357
13. Song N, Mohammed S, Zhang J, et al (2014) Prevalence, severity and risk factors of asthma, rhinitis and eczema in a large group of Chinese schoolchildren. Journal of Asthma. https://doi.org/10.3109/02770903.2013.867973
14. Biagini J, Kroner J, kyzy AB, et al (2021) Longitudinal atopic dermatitis endotypes: An atopic march paradigm that includes Black children. Journal of Allergy and Clinical Immunology. https://doi.org/10.1016/j.jaci.2021.09.036
15. Vassilopoulou E, Rallis D, Milani G, et al (2023) Nurturing Infants to Prevent Atopic Dermatitis and Food Allergies: A Longitudinal Study. Nutrients. https://doi.org/10.3390/nu16010021
16. Lee J, Yun S, Oh I, et al (2020) Impact of Environmental Factors on the Prevalence Changes of Allergic Diseases in Elementary School Students in Ulsan, Korea: A Longitudinal Study. International Journal of Environmental Research and Public Health. https://doi.org/10.3390/ijerph17238831
17. Kimata H (2004) Cessation of passive smoking reduces allergic responses and plasma neurotrophin. European Journal of Clinical Investigation. https://doi.org/10.1111/j.1365-2362.2004.01297.x
18. Arafune J, Tsujiguchi H, Hara A, et al (2021) Increased Prevalence of Atopic Dermatitis in Children Aged 0–3 Years Highly Exposed to Parabens. International Journal of Environmental Research and Public Health. https://doi.org/10.3390/ijerph182111657
19. Ye M, Collender P, Langan S, et al (2023) 540 A longitudinal cohort study of atopic dermatitis and epigenetic age acceleration across childhood. Journal of Investigative Dermatology. https://doi.org/10.1016/j.jid.2023.03.546
20. Abuabara K, Hoffstad O, Troxel A, et al (2017) Patterns and predictors of atopic dermatitis disease control past childhood: An observational cohort study. Journal of Allergy and Clinical Immunology. https://doi.org/10.1016/j.jaci.2017.05.031
21. Kurukulaaratchy R, Matthews S, Arshad SH (2006) Relationship between childhood atopy and wheeze: what mediates wheezing in atopic phenotypes? Annals of Allergy, Asthma & Immunology. https://doi.org/10.1016/S1081-1206(10)61375-0
22. Lisik D, Ermis SSÖ, Milani G, et al (2025) Machine learning-derived asthma and allergy trajectories in children. European Respiratory Review. https://doi.org/10.1183/16000617.0160-2024
23. Kabir Z, Manning P, Holohan J, et al (2009) Second-hand smoke exposure in cars and respiratory health effects in children. European Respiratory Journal. https://doi.org/10.1183/09031936.00167608
24. Noakes P, Taylor A, Hale J, et al (2007) The effects of maternal smoking on early mucosal immunity and sensitization at 12 months of age. Pediatric Allergy and Immunology. https://doi.org/10.1111/j.1399-3038.2006.00490.x
25. Yap P, Hertz-Picciotto I, Joad J, et al (2005) RESPIRATORY INFECTIONS AND ATOPIC DISEASES IN CHILDREN, CZECH REPUBLIC. Epidemiology. https://doi.org/10.1097/00001648-200509000-00273
26. Lodge C, Zaloumis SG, Lowe A, et al (2014) Early-life risk factors for childhood wheeze phenotypes in a high-risk birth cohort. Jornal de Pediatria. https://doi.org/10.1016/j.jpeds.2013.09.056
27. Hachmeriyan A, Toneva A, Marinova-Achkar M, Pancheva R (2025) Early-Life Environmental Determinants of Allergic Conditions in Children with Atopic Heredity: A Single Center Cross-Sectional Study from Bulgaria. Medical Science. https://doi.org/10.3390/medsci13030198
28. Hedman L, Bjerg A, Perzanowski M, Rönmark E (2010) Good agreement between parental and self-completed questionnaires about allergic diseases and environmental factors in teenagers. Journal of Clinical Epidemiology. https://doi.org/10.1016/j.jclinepi.2009.08.017
29. Lee A, Lee S, Lee KS (2020) Association of secondhand smoke exposure with allergic multimorbidity in Korean adolescents. Scientific Reports. https://doi.org/10.1038/s41598-020-73430-4
30. Park K, Davis KL (2021) The Interplay Between Eczema and Breastfeeding Practices May Hide Breastfeeding’s Protective Effect on Childhood Asthma. Pediatrics. https://doi.org/10.1542/peds.2021-053843rrr
31. Biagini J, Kroner J, He H, et al (2022) Longitudinal Atopic Dermatitis Endotypes: An Atopic March Paradigm That Includes Black Children. Journal of Allergy and Clinical Immunology. https://doi.org/10.1016/j.jaci.2021.12.725
32. Collins SA (2014) Identification of early-life risk factor profiles for wheeze phenotypes. Jornal de Pediatria. https://doi.org/10.1016/j.jpeds.2014.04.022
33. Brandwein M, Gamrasni K, Landau T, et al (2022) Nurture, not nature: Impaired skin barrier in infants born to urban households. Pediatric Allergy and Immunology. https://doi.org/10.1111/pai.13868
34. Halken S (2004) Prevention of allergic disease in childhood: clinical and epidemiological aspects of primary and secondary allergy prevention. Pediatric Allergy and Immunology. https://doi.org/10.1111/j.1399-3038.2004.0148b.x
35. Kalhan TA, Loo E, Kalhan A, et al (2017) Atopic dermatitis and early childhood caries: Results of the GUSTO study. Journal of Allergy and Clinical Immunology. https://doi.org/10.1016/j.jaci.2016.10.038
36. Chen OM, Kaplan MS (2003) LONG-TERM RELATION BETWEEN BREASTFEEDING AND DEVELOPMENT OF ATOPY AND ASTHMA IN CHILDREN AND YOUNG ADULTS: A LONGITUDINAL STUDY. Pediatrics. https://doi.org/10.1542/peds.112.s2.454a
37. Kobyletzki L, Bornehag C, Lundin F, et al (2011) Abstracts of the 38th Annual Meeting of the Arbeitsgemeinschaft Dermatologische Forschung (ADF). Tuebingen, Germany. February 17–19, 2011. Experimental Dermatology. https://doi.org/10.1111/j.1600-0625.2010.01228.x
38. Takaro T, Scott J, Allen R, et al (2015) The Canadian Healthy Infant Longitudinal Development (CHILD) birth cohort study: assessment of environmental exposures. Journal of Exposure Science and Environmental Epidemiology. https://doi.org/10.1038/jes.2015.7
39. Nakamura T, Haider S, Fontanella S, et al (2021) Modelling trajectories of parentally reported and physician‐confirmed atopic dermatitis in a birth cohort study *. British Journal of Dermatology. https://doi.org/10.1111/bjd.20767
40. Baldacci S, Stanisci I, Sarno G, et al (2025) Efficacy of an intervention for improving indoor air quality in schools. Epidemiology. https://doi.org/10.1183/13993003.congress-2025.pa4736
41. Matzner L, Denkena J, Messingschlager M, et al (2025) Atopic Dermatitis (AD) Related Cord Blood DNA Methylation Patterns Are Linked to Maternal AD. Allergy European Journal of Allergy and Clinical Immunology. https://doi.org/10.1111/all.70130
42. Walter E, Dole N, Siega-Riz A, Entwisle B (2011) The National Children's Study in North Carolina: A Study of the Effect of the Environment on Children's Health, Growth and Development. North Carolina Medical Journal
43. Nolte H, Backer V, Porsbjerg C (2001) Environmental factors as a cause for the increase in allergic disease. Annals of Allergy, Asthma & Immunology. https://doi.org/10.1016/S1081-1206(10)62333-2
44. Brunekreef B, Smit J, Jongste JD de, et al (2002) The Prevention and Incidence of Asthma and Mite Allergy (PIAMA) birth cohort study: Design and first results. Pediatric Allergy and Immunology. https://doi.org/10.1034/j.1399-3038.13.s.15.1.x
45. Chan-Yeung M, Ferguson AC, Watson W, et al (2005) The Canadian Childhood Asthma Primary Prevention Study: outcomes at 7 years of age. Journal of Allergy and Clinical Immunology. https://doi.org/10.1016/J.JACI.2005.03.029
46. Lee E, Yang S-I, Suh D, et al (2025) Environmental factors shaping atopic dermatitis: Lessons from longitudinal cohort studies. Pediatric Allergy and Immunology. https://doi.org/10.1111/pai.70130
47. Li X, Zhu L, Li P (2017) A prospective study of early maternal intervention on the prevention of infantile eczema effect. The Journal of practical nursing. https://doi.org/10.3760/CMA.J.ISSN.1672-7088.2017.29.001
48. Owens L, Laing I, Zhang G, Souef PLL (2016) Early sensitization is associated with reduced lung function from birth into adulthood. Journal of Allergy and Clinical Immunology. https://doi.org/10.1016/j.jaci.2015.10.030
49. Yap P, Hertz-Picciotto I, Herr C, et al (2007) Atopic Dermatitis, Rhino Conjunctivitis, Asthma and Recurrent Bronchitis: Comparing Risk/Protective Factors in Czech Republic Children. Epidemiology. https://doi.org/10.1097/01.EDE.0000276765.94753.B0
50. Larsson M, Hägerhed-Engman L, Kolarik B, et al (2010) PVC--as flooring material--and its association with incident asthma in a Swedish child cohort study. Indoor Air: International Journal of Indoor Environment and Health. https://doi.org/10.1111/j.1600-0668.2010.00671.x
51. Ewing P, Otczyk DC, Occhipinti S, et al (2010) Developmental Profiles of Mucosal Immunity in Pre-school Children. Clinical and Developmental Immunology. https://doi.org/10.1155/2010/196785
52. Sherif N, Chow T (2023) Establishing Subclasses of Childhood Eczema, Their Risk Factors and Prognosis. Pediatrics. https://doi.org/10.1542/peds.2023-064344HA
53. Takaro T, Scott JA, Allen R, et al (2016) P080 Assessment of environmental exposures in the canadian healthy infant longitudinal development (CHILD) birth cohort. Occupational and Environmental Medicine. https://doi.org/10.1136/oemed-2016-103951.401
54. Douwes J, Strien RT, Doekes G, et al (2003) Early indoor microbial exposure lowers the risk of asthma: The PIAMA birth cohort study. Epidemiology. https://doi.org/10.1097/00001648-200309001-00094
55. Song N, Zhang J, Shamssain M, et al (2012) Prevalence and severity of asthma, rhinitis and eczema in Chinese school children. European Respiratory Journal
56. Arora R, Mikita CP (2006) The Canadian Childhood Asthma Primary Prevention Study: Outcomes at 7 Years of Age. Pediatrics. https://doi.org/10.1542/peds.2006-0900O
57. Wigle D, Arbuckle T, Walker M, et al (2007) Environmental Hazards: Evidence for Effects on Child Health. Journal of Toxicology and Environmental Health Part B, Critical Reviews. https://doi.org/10.1080/10937400601034563
58. Lopez DJ, Lodge C, Bui D, et al (2022) Establishing subclasses of childhood eczema, their risk factors and prognosis. Clinical and Experimental Allergy. https://doi.org/10.1111/cea.14139
59. Markevych I, Standl M, Lehmann I, et al (2017) Food diversity during the first year of life and allergic diseases until 15 years. Journal of Allergy and Clinical Immunology. https://doi.org/10.1016/j.jaci.2017.08.011
60. Alm B, Åberg N, Erdes L, et al (2008) Early introduction of fish decreases the risk of eczema in infants. Archives of Disease in Childhood. https://doi.org/10.1136/adc.2008.140418
61. Jaakkola N (2002) Passive Smoking During Pregnancy and Early Childhood: Occurrence, Determinants, Health Effects and Prevention
62. Chan C, Leung T, Choi K, et al (2020) Effects of gut microbiome and environment on the development of eczema in Chinese infants. Medicine. https://doi.org/10.1097/MD.0000000000020327
63. Chan C, Leung T, Choi K, et al (2021) Association of early‐life gut microbiome and lifestyle factors in the development of eczema in Hong Kong infants. Experimental Dermatology. https://doi.org/10.1111/exd.14280
64. Storrø O, Øien T, Dotterud C, et al (2010) A primary health-care intervention on pre- and postnatal risk factor behavior to prevent childhood allergy. The Prevention of Allergy among Children in Trondheim (PACT) study. BMC Public Health. https://doi.org/10.1186/1471-2458-10-443
65. Subbarao P, Anand SS, Becker A, et al (2015) The Canadian Healthy Infant Longitudinal Development (CHILD) Study: examining developmental origins of allergy and asthma. Thorax. https://doi.org/10.1136/thoraxjnl-2015-207246
66. Taylor A, Hale J, Wiltschut J, et al (2006) Effects of probiotic supplementation for the first 6 months of life on allergen‐ and vaccine‐specific immune responses. Clinical and Experimental Allergy. https://doi.org/10.1111/j.1365-2222.2006.02553.x
67. Westman M, Stjärne P, Bergström A, et al (2015) Chronic rhinosinusitis is rare but bothersome in adolescents from a Swedish population-based cohort. Journal of Allergy and Clinical Immunology. https://doi.org/10.1016/j.jaci.2015.02.019
68. Carson CG (2013) Risk factors for developing atopic dermatitis. Danish Medical Journal
69. Gilaberte Y, Pérez-Gilaberte JB, Poblador-Plou B, et al (2020) Prevalence and Comorbidity of Atopic Dermatitis in Children: A Large-Scale Population Study Based on Real-World Data. Journal of Clinical Medicine. https://doi.org/10.3390/jcm9061632
70. Kim YM, Kim J, Ha S, Ahn K (2021) Harmful Effect of Indoor Formaldehyde on Atopic Dermatitis in Children: A Longitudinal Study. Allergy Asthma and Immunology Research. https://doi.org/10.4168/aair.2021.13.3.468
71. Huang Y, Wen H, Guo Y, et al (2021) Prenatal exposure to air pollutants and childhood atopic dermatitis and allergic rhinitis adopting machine learning approaches: 14-year follow-up birth cohort study. Science of the Total Environment. https://doi.org/10.1016/j.scitotenv.2021.145982
72. Sbihi H, Petersen C, Boutin RCT, et al (2018) Built Environment, Microbiota and Asthma at Age 3: Longitudinal Follow-Up in a Canadian Birth Cohort. ISEE Conference Abstracts. https://doi.org/10.1289/isesisee.2018.o03.03.39
73. Carson CG, Halkjaer L, Jensen S, Bisgaard H (2012) Alcohol Intake in Pregnancy Increases the Child's Risk of Atopic Dermatitis. The COPSAC Prospective Birth Cohort Study of a High Risk Population. PLoS ONE. https://doi.org/10.1371/journal.pone.0042710
74. Keijzers G, Sweeny A, Crilly J, et al (2018) Parental-reported allergic disorders and emergency department presentations for allergy in the first five years of life; a longitudinal birth cohort. BMC Pediatrics. https://doi.org/10.1186/s12887-018-1148-1
75. Ramsey N, DiNardo A, Lupinek C, et al (2018) HELMINTH INFECTION AND ALLERGIC SENSITIZATION IN ESWATI CHILDREN. Annals of Allergy, Asthma & Immunology. https://doi.org/10.1016/J.ANAI.2018.09.185
76. To T, Borkhoff C, Anderson LN, et al (2024) Association of factors with childhood asthma and allergic diseases using latent class analysis. Scientific Reports. https://doi.org/10.1038/s41598-024-56805-9
77. Ulrik C, Linstow M von, Backer V (2001) [Atopy among children and adolescents in Copenhagen]. Ugeskrift for læger
78. Oliver BU, Chu E (2019) SnapshotDx Quiz: July 2019. Journal of Investigative Dermatology. https://doi.org/10.1016/j.jid.2019.05.004
79. Yamamoto‐Hanada K, Yang L, Hirai S, et al (2026) Unraveling the Natural History of Atopic Dermatitis: Prospective Disease Trajectories and Longitudinal IgE Sensitization from Birth to Adolescence. Clinical & Experimental Allergy. https://doi.org/10.1111/cea.70325
80. Tseng H-W (2025) Effect of exposure to ambient air volatile organic compounds on the severity of atopic dermatitis and lag-day effect. Asian Pacific Journal of Allergy and Immunology. https://doi.org/10.12932/AP-101124-1967
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Febryana Ramadhani, Ayub Quisa, Danny Gunawan
This work is licensed under a Creative Commons Attribution 4.0 International License.
