{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,7]],"date-time":"2026-07-07T12:18:46Z","timestamp":1783426726311,"version":"3.54.6"},"reference-count":36,"publisher":"MDPI AG","issue":"13","license":[{"start":{"date-parts":[[2026,7,7]],"date-time":"2026-07-07T00:00:00Z","timestamp":1783382400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Objective: The association of smoking with sleep apnea is often based on subjective data. This study quantified the effects of smoking on sleep architecture using exhaled carbon monoxide (eCO) and polysomnography (PSG). Methods: A total of 183 patients with suspected obstructive sleep apnea (OSA) were included in this prospective study. Following full-night PSG, eCO was measured within 10 min. Data were analyzed using the Generalized Linear Model (GLM). Results: Although initial unadjusted analyses showed an inverse correlation between eCO levels and central apnea count, GLM revealed that male gender was the only independent predictor for central apnea, negating the effect of eCO. GLM analyses, adjusted for age, gender, BMI, and alcohol and drug use, revealed that cumulative smoking load (pack-years) was independently associated after multivariable adjustment with reduced REM sleep duration (B = \u22120.345, 95% CI [\u22120.571; \u22120.119], p = 0.003) and REM sleep percentage (B = \u22120.099, 95% CI [\u22120.158; \u22120.040], p = 0.001). Similarly, smoking duration (years) significantly predicted decreased REM sleep duration (B = \u22120.426, 95% CI [\u22120.724; \u22120.128], p = 0.005) and REM percentage (B = \u22120.119, 95% CI [\u22120.197; \u22120.041], p = 0.003). Formal interaction analyses did not detect a statistically significant interaction with body mass index (BMI) (p &gt; 0.05 for all interaction terms). Conclusions: In OSA, smoking is independently associated with alterations in REM sleep architecture rather than respiratory events. Cumulative smoking load and smoking duration are independently associated with alterations in REM sleep after adjusting for any other major clinical comorbidities.<\/jats:p>","DOI":"10.3390\/jcm15135301","type":"journal-article","created":{"date-parts":[[2026,7,7]],"date-time":"2026-07-07T09:53:46Z","timestamp":1783418026000},"page":"5301","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Association of Cumulative Smoking Exposure with REM Sleep Alterations in Obstructive Sleep Apnea: A Cross-Sectional Study Supported by Exhaled Carbon Monoxide Measurement"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3017-1025","authenticated-orcid":false,"given":"Kadir Burak","family":"Akg\u00fcn","sequence":"first","affiliation":[{"name":"Department of Pulmonology, Tayfur Ata S\u00f6kmen Faculty of Medicine, Hatay Mustafa Kemal University, 31060 Hatay, T\u00fcrkiye"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Derya Yavuz","family":"Demiray","sequence":"additional","affiliation":[{"name":"Department of Neurology, Tayfur Ata S\u00f6kmen Faculty of Medicine, Hatay Mustafa Kemal University, 31060 Hatay, T\u00fcrkiye"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,7]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1007\/s41105-021-00353-6","article-title":"Sleep Apnea Syndrome (SAS) Clinical Practice Guidelines 2020","volume":"20","author":"Akashiba","year":"2022","journal-title":"Sleep Biol. Rhythm."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1673","DOI":"10.1378\/chest.14-0772","article-title":"Where There Is Smoke\u2026There Is Sleep Apnea","volume":"146","author":"Krishnan","year":"2014","journal-title":"Chest"},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Grigoriou, I., Kotoulas, S.C., Porpodis, K., Spyratos, D., Papagiouvanni, I., Tsantos, A., Michailidou, A., Mourelatos, C., Mouratidou, C., and Alevroudis, I. (2024). The Interactions between Smoking and Sleep. Biomedicines, 12.","DOI":"10.20944\/preprints202406.1402.v1"},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Pataka, A., Kotoulas, S., Kalamaras, G., Tzinas, A., Grigoriou, I., Kasnaki, N., and Argyropoulou, P. (2022). Does Smoking Affect OSA? What about Smoking Cessation?. J. Clin. Med., 11.","DOI":"10.3390\/jcm11175164"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Pataka, A., Kotoulas, S.C., Karkala, A., Tzinas, A., Kalamaras, G., Kasnaki, N., Sourla, E., and Stefanidou, E. (2023). Obstructive Sleep Apnea and Smoking Increase the Risk of Cardiovascular Disease: Smoking Cessation Pharmacotherapy. J. Clin. Med., 12.","DOI":"10.3390\/jcm12247570"},{"key":"ref_6","first-page":"e49162","article-title":"Effects of Nicotine on the Central Nervous System and Sleep Quality in Relation to Other Stimulants: A Narrative Review","volume":"15","author":"Singh","year":"2023","journal-title":"Cureus"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1677","DOI":"10.3906\/sag-1601-140","article-title":"Exhaled carbon monoxide is a marker of heavy nicotine dependence","volume":"46","author":"Karalezli","year":"2016","journal-title":"Turk. J. Med. Sci."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"515","DOI":"10.1016\/j.tcm.2016.03.001","article-title":"Cardiovascular toxicity of nicotine: Implications for electronic cigarette use","volume":"26","author":"Benowitz","year":"2016","journal-title":"Trends Cardiovasc. Med."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1532","DOI":"10.2174\/1389450111009011532","article-title":"Heme Oxygenase-1 in Lung Disease","volume":"11","author":"Raval","year":"2010","journal-title":"Curr. Drug Targets"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"104","DOI":"10.1152\/japplphysiol.00658.2016","article-title":"Relationship between obstructive sleep apnea and endogenous carbon monoxide","volume":"122","author":"Azuma","year":"2017","journal-title":"J. Appl. Physiol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"56","DOI":"10.18332\/tid\/123429","article-title":"Smoking history and its relationship with comorbidities inpatients with obstructive sleep apnea","volume":"18","author":"Shao","year":"2020","journal-title":"Tob. Induc. Dis."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"100085","DOI":"10.1016\/j.sleepx.2023.100085","article-title":"Effects of smoking on sleep architecture and ventilatory parameters including apneas: Results of the Tab-OSA study","volume":"6","author":"Mauries","year":"2023","journal-title":"Sleep Med. X"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"147","DOI":"10.1111\/crj.13278","article-title":"Effects of smok\u0131ng on pat\u0131ents w\u0131th obstruct\u0131ve sleep apnea syndrome","volume":"15","author":"Yosunkaya","year":"2021","journal-title":"Clin. Respir. J."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1279","DOI":"10.1007\/s11325-015-1159-1","article-title":"The impact of active and former smoking on the severity of obstructive sleep apnea","volume":"19","author":"Varol","year":"2015","journal-title":"Sleep Breath."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"364","DOI":"10.1093\/ntr\/ntac126","article-title":"Association Between Smoking Behavior and Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis","volume":"25","author":"Zeng","year":"2023","journal-title":"Nicotine Tob. Res."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Ioannidou, D., Kalamaras, G., Kotoulas, S.C., and Pataka, A. (2021). Smoking and Obstructive Sleep Apnea: Is There An Association between These Cardiometabolic Risk Factors?\u2014Gender Analysis. Medicina, 57.","DOI":"10.3390\/medicina57111137"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1378\/chest.87.1.11","article-title":"Nicotine: A Different Approach to Treatment of Obstructive Sleep Apnea","volume":"87","author":"Gothe","year":"1985","journal-title":"Chest"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1413","DOI":"10.1073\/pnas.1620717114","article-title":"Complementary roles of gasotransmitters CO and H2 S in sleep apnea","volume":"114","author":"Peng","year":"2017","journal-title":"Proc. Natl. Acad. Sci. USA"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"447","DOI":"10.2147\/NSS.S500562","article-title":"Association Between Central Sleep Apnea and Left Atrial Enlargement in Snoring Patients with Preserved Ejection Fraction","volume":"17","author":"Sun","year":"2025","journal-title":"Nat. Sci. Sleep"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1793","DOI":"10.5665\/sleep.3202","article-title":"Testosterone Conversion Blockade Increases Breathing Stability in Healthy Men during NREM Sleep","volume":"36","author":"Chowdhuri","year":"2013","journal-title":"Sleep"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"A307","DOI":"10.1093\/sleep\/zsaf090.0706","article-title":"Testosterone Therapy and the Risk of Obstructive and Central Sleep Apnea in Transmasculine Patients: A Population-based Cohort Study","volume":"48","author":"Christ","year":"2025","journal-title":"Sleep"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"zsz274","DOI":"10.1093\/sleep\/zsz274","article-title":"Sex differences in obstructive sleep apnea phenotypes, the multi-ethnic study of atherosclerosis","volume":"43","author":"Won","year":"2020","journal-title":"Sleep"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"99","DOI":"10.54817\/IC.v65n1a09","article-title":"Effect of fractional exhaled carbon monoxide on patients with sleep apnea-hypopnea syndrome and its mechanism","volume":"65","author":"Jia","year":"2024","journal-title":"Investig. Cl\u00ednica"},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Pan, K.T., Leonardi, G.S., Ucci, M., and Croxford, B. (2021). Can Exhaled Carbon Monoxide Be Used as a Marker of Exposure? A Cross-Sectional Study in Young Adults. Int. J. Environ. Res. Public Health, 18.","DOI":"10.3390\/ijerph182211893"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"036012","DOI":"10.1088\/1752-7163\/ab231d","article-title":"Exhaled carbon monoxide levels in obstructive sleep apnoea","volume":"13","author":"Kis","year":"2019","journal-title":"J. Breath Res."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1255","DOI":"10.1093\/sleep\/27.7.1255","article-title":"Meta-Analysis of Quantitative Sleep Parameters From Childhood to Old Age in Healthy Individuals: Developing Normative Sleep Values Across the Human Lifespan","volume":"27","author":"Ohayon","year":"2004","journal-title":"Sleep"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"573","DOI":"10.30574\/ijsra.2026.18.1.0114","article-title":"The vital role of sleep in human health: Stages, mechanisms and the consequences of sleep disruption","volume":"18","author":"Alhomrani","year":"2026","journal-title":"Int. J. Sci. Res. Arch."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"533","DOI":"10.1016\/S2213-2600(19)30057-8","article-title":"Normal polysomnography parameters in healthy adults: A systematic review and meta-analysis","volume":"7","author":"Boulos","year":"2019","journal-title":"Lancet Respir. Med."},{"key":"ref_29","first-page":"101","article-title":"Sleep, sleepiness, and alcohol use","volume":"25","author":"Roehrs","year":"2001","journal-title":"Alcohol Res. Health J. Natl. Inst. Alcohol Abus. Alcohol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1527","DOI":"10.1111\/j.1530-0277.2006.00184.x","article-title":"Effects of Alcohol on Polysomnographically Recorded Sleep in Healthy Subjects","volume":"30","author":"Feige","year":"2006","journal-title":"Alcohol. Clin. Exp. Res."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"390","DOI":"10.1111\/pcn.70036","article-title":"Comparative effects of hypnotic agents on sleep architecture and respiratory outcomes in obstructive sleep apnea: A systematic review and network meta-analysis","volume":"80","author":"Kishi","year":"2026","journal-title":"Psychiatry Clin. Neurosci."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"406","DOI":"10.1001\/archinte.164.4.406","article-title":"The Effects of Age, Sex, Ethnicity, and Sleep-Disordered Breathing on Sleep Architecture","volume":"164","author":"Redline","year":"2004","journal-title":"Arch. Intern. Med."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"469","DOI":"10.1164\/ajrccm.150.2.8049831","article-title":"Acute effects of transdermal nicotine on sleep architecture, snoring, and sleep-disordered breathing in nonsmokers","volume":"150","author":"Davila","year":"1994","journal-title":"Am. J. Respir. Crit. Care Med."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"264","DOI":"10.1097\/00004714-199408000-00006","article-title":"Dose-dependent effects of transdermal nicotine on early morning awakening and rapid eye movement sleep time in nonsmoking normal volunteers","volume":"14","author":"Gillin","year":"1994","journal-title":"J. Clin. Psychopharmacol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"483","DOI":"10.1093\/sleep\/32.4.483","article-title":"for the Osteoporotic Fractures in Men (MrOS) Study Group. Association Between Sleep Architecture and Measures of Body Composition","volume":"32","author":"Rao","year":"2009","journal-title":"Sleep"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1849","DOI":"10.1002\/oby.24359","article-title":"BMI, Sleep Architecture, and Glucose Metabolism: Insights From the Baependi Heart Study","volume":"33","author":"Pessoa","year":"2025","journal-title":"Obesity"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/13\/5301\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,7]],"date-time":"2026-07-07T11:42:37Z","timestamp":1783424557000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/13\/5301"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,7]]},"references-count":36,"journal-issue":{"issue":"13","published-online":{"date-parts":[[2026,7]]}},"alternative-id":["jcm15135301"],"URL":"https:\/\/doi.org\/10.3390\/jcm15135301","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,7]]}}}