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Table 1.  
Characteristics of Participants According to Habitual Snoring
Characteristics of Participants According to Habitual Snoring
Table 2.  
Habitual Snoring According to Use of Benzodiazepine Receptor Agonists
Habitual Snoring According to Use of Benzodiazepine Receptor Agonists
Table 3.  
Habitual Snoring According to Use of Benzodiazepine Receptor Agonists, Stratified by BMI Categories
Habitual Snoring According to Use of Benzodiazepine Receptor Agonists, Stratified by BMI Categories
Table 4.  
Habitual Snoring According to Use of Benzodiazepine Receptor Agonists, Stratified by Smoking Status
Habitual Snoring According to Use of Benzodiazepine Receptor Agonists, Stratified by Smoking Status
1.
Durán  J, Esnaola  S, Rubio  R, Iztueta  A.  Obstructive sleep apnea–hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr.  Am J Respir Crit Care Med. 2001;163(3, pt 1):685-689.PubMedGoogle ScholarCrossref
2.
Nieto  FJ, Young  TB, Lind  BK,  et al.  Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study: Sleep Heart Health Study.  JAMA. 2000;283(14):1829-1836.PubMedGoogle ScholarCrossref
3.
Partinen  M, Jamieson  A, Guilleminault  C.  Long-term outcome for obstructive sleep apnea syndrome patients: mortality.  Chest. 1988;94(6):1200-1204.PubMedGoogle ScholarCrossref
4.
Lindberg  E, Janson  C, Gislason  T, Svärdsudd  K, Hetta  J, Boman  G.  Snoring and hypertension: a 10 year follow-up.  Eur Respir J. 1998;11(4):884-889.PubMedGoogle ScholarCrossref
5.
Shahar  E, Whitney  CW, Redline  S,  et al.  Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study.  Am J Respir Crit Care Med. 2001;163(1):19-25.PubMedGoogle ScholarCrossref
6.
Janson  C, Hillerdal  G, Larsson  L,  et al.  Excessive daytime sleepiness and fatigue in nonapnoeic snorers: improvement after UPPP.  Eur Respir J. 1994;7(5):845-849.PubMedGoogle Scholar
7.
Ulfberg  J, Carter  N, Talbäck  M, Edling  C.  Excessive daytime sleepiness at work and subjective work performance in the general population and among heavy snorers and patients with obstructive sleep apnea.  Chest. 1996;110(3):659-663.PubMedGoogle ScholarCrossref
8.
Lindberg  E, Janson  C, Svärdsudd  K, Gislason  T, Hetta  J, Boman  G.  Increased mortality among sleepy snorers: a prospective population based study.  Thorax. 1998;53(8):631-637.PubMedGoogle ScholarCrossref
9.
Gottlieb  DJ, Yao  Q, Redline  S, Ali  T, Mahowald  MW.  Does snoring predict sleepiness independently of apnea and hypopnea frequency?  Am J Respir Crit Care Med. 2000;162(4, pt 1):1512-1517.PubMedGoogle ScholarCrossref
10.
Morin  CM, LeBlanc  M, Bélanger  L, Ivers  H, Mérette  C, Savard  J.  Prevalence of insomnia and its treatment in Canada.  Can J Psychiatry. 2011;56(9):540-548.PubMedGoogle ScholarCrossref
11.
Kripke  DF, Langer  RD, Kline  LE.  Hypnotics’ association with mortality or cancer: a matched cohort study.  BMJ Open. 2012;2(1):e000850.PubMedGoogle ScholarCrossref
12.
Koskenvuo  M, Kaprio  J, Partinen  M, Langinvainio  H, Sarna  S, Heikkilä  K.  Snoring as a risk factor for hypertension and angina pectoris.  Lancet. 1985;1(8434):893-896.PubMedGoogle ScholarCrossref
13.
Svensson  M, Lindberg  E, Naessen  T, Janson  C.  Risk factors associated with snoring in women with special emphasis on body mass index: a population-based study.  Chest. 2006;129(4):933-941.PubMedGoogle ScholarCrossref
14.
Bloom  JW, Kaltenborn  WT, Quan  SF.  Risk factors in a general population for snoring: importance of cigarette smoking and obesity.  Chest. 1988;93(4):678-683.PubMedGoogle ScholarCrossref
15.
Schmidt-Nowara  WW, Coultas  DB, Wiggins  C, Skipper  BE, Samet  JM.  Snoring in a Hispanic-American population: risk factors and association with hypertension and other morbidity.  Arch Intern Med. 1990;150(3):597-601.PubMedGoogle ScholarCrossref
16.
Zhang  X, Giovannucci  EL, Wu  K,  et al.  Associations of self-reported sleep duration and snoring with colorectal cancer risk in men and women.  Sleep. 2013;36(5):681-688.PubMedGoogle Scholar
17.
Al-Delaimy  WK, Manson  JE, Willett  WC, Stampfer  MJ, Hu  FB.  Snoring as a risk factor for type II diabetes mellitus: a prospective study.  Am J Epidemiol. 2002;155(5):387-393.PubMedGoogle ScholarCrossref
18.
Williams  CJ, Hu  FB, Patel  SR, Mantzoros  CS.  Sleep duration and snoring in relation to biomarkers of cardiovascular disease risk among women with type 2 diabetes.  Diabetes Care. 2007;30(5):1233-1240.PubMedGoogle ScholarCrossref
19.
Hu  FB, Willett  WC, Colditz  GA,  et al.  Prospective study of snoring and risk of hypertension in women.  Am J Epidemiol. 1999;150(8):806-816.PubMedGoogle ScholarCrossref
20.
Grandner  MA, Petrov  ME, Rattanaumpawan  P, Jackson  N, Platt  A, Patel  NP.  Sleep symptoms, race/ethnicity, and socioeconomic position.  J Clin Sleep Med. 2013;9(9):897-905; 905A-905D. PubMedGoogle Scholar
21.
Bogunovic  OJ, Greenfield  SF.  Practical geriatrics: use of benzodiazepines among elderly patients.  Psychiatr Serv. 2004;55(3):233-235.PubMedGoogle ScholarCrossref
22.
Patil  SP, Schneider  H, Marx  JJ, Gladmon  E, Schwartz  AR, Smith  PL.  Neuromechanical control of upper airway patency during sleep.  J Appl Physiol (1985). 2007;102(2):547-556. PubMedGoogle ScholarCrossref
23.
Haxhiu  MA, Van Lunteren  E, Van de Graaff  WB,  et al.  Action of nicotine on the respiratory activity of the diaphragm and genioglossus muscles and the nerves that innervate them.  Respir Physiol. 1984;57(2):153-169.PubMedGoogle ScholarCrossref
24.
Issa  FG, Sullivan  CE.  Alcohol, snoring and sleep apnea.  J Neurol Neurosurg Psychiatry. 1982;45(4):353-359.PubMedGoogle ScholarCrossref
25.
Issa  FG, Sullivan  CE.  Upper airway closing pressures in snorers.  J Appl Physiol Respir Environ Exerc Physiol. 1984;57(2):528-535.PubMedGoogle Scholar
26.
Gislason  T, Benediktsdóttir  B, Björnsson  JK, Kjartansson  G, Kjeld  M, Kristbjarnarson  H.  Snoring, hypertension, and the sleep apnea syndrome: an epidemiologic survey of middle-aged women.  Chest. 1993;103(4):1147-1151.PubMedGoogle ScholarCrossref
27.
Wetter  DW, Young  TB, Bidwell  TR, Badr  MS, Palta  M.  Smoking as a risk factor for sleep-disordered breathing.  Arch Intern Med. 1994;154(19):2219-2224.PubMedGoogle ScholarCrossref
28.
Rezaeitalab  F, Moharrari  F, Saberi  S, Asadpour  H, Rezaeetalab  F.  The correlation of anxiety and depression with obstructive sleep apnea syndrome.  J Res Med Sci.2014;19(3):205-210. PubMedGoogle Scholar
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Original Investigation
February 2017

Association Between Benzodiazepine Receptor Agonists and Snoring Among Women in the Nurses’ Health Study

Author Affiliations
  • 1Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston
  • 2Channing Division of Network Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
  • 3Harvard Medical School, Boston, Massachusetts
  • 4Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 5Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
 

Copyright 2016 American Medical Association. All Rights Reserved.

JAMA Otolaryngol Head Neck Surg. 2017;143(2):162-167. doi:10.1001/jamaoto.2016.3174
Key Points

Question  Is use of benzodiazepine receptor agonists associated with snoring in women?

Findings  In this cohort study of 52 504 women, there was a statistically significantly higher prevalence of use of benzodiazepine receptor agonists among habitual snorers (11.4%) compared with nonhabitual snorers (10.6%). After multivariable adjustment, use of benzodiazepine receptor agonists was not associated with odds of snoring compared with women who did not use benzodiazepine receptor agonists.

Meaning  Use of benzodiazepine receptor agonists is not associated with snoring in women.

Abstract

Importance  Snoring is highly prevalent among adults. The use of benzodiazepine receptor agonists is also common, with higher prevalence of use with more advanced age. Benzodiazepine receptor agonists cause muscle relaxation, which may affect muscle tone and airway dynamics and thereby increase snoring. Previous studies examining the association between use of benzodiazepine receptor agonists and snoring were underpowered to detect clinically meaningful differences or did not report the magnitude of association.

Objective  To investigate the association between use of benzodiazepine receptor agonists and snoring in women.

Design, Setting, and Participants  Women aged 62 to 86 years provided information on snoring and covariates of interest in the 2008 survey of the Nurses’ Health Study, a cross-sectional cohort study of female registered nurses in the United States. Potential effect modification of the association between use of benzodiazepine receptor agonists and snoring by age, body mass index, waist circumference, smoking, alcohol consumption, and physical activity was explored. Logistic regression was used to adjust for potential confounders. Data analysis was conducted from November 2015 to March 2016.

Main Outcomes and Measures  Self-reported habitual snoring, defined as a few nights a week or more.

Results  Of 52 504 participants (mean [SD] age, 72.4 [6.7] years), 14 831 (28.2%) reported habitual snoring. There was a slightly higher prevalence of benzodiazepine receptor agonist use among habitual snorers (11.4%) compared with nonhabitual snorers (10.6%) (absolute difference, 0.8%; 95% CI, 0.2%-1.4%). After multivariable adjustment, use of benzodiazepine receptor agonists was not associated with snoring (odds ratio, 1.01; 95% CI, 0.95-1.07) compared with women who did not use benzodiazepine receptor agonists. Although there was no significant interaction with smoking, there were higher odds of snoring with use of benzodiazepine receptor agonists among current smokers (odds ratio, 1.34; 95% CI, 1.04-1.73).

Conclusions and Relevance  Use of benzodiazepine receptor agonists is not associated with odds of snoring in middle-aged and elderly women.

Introduction

Approximately 35% of the US population snores habitually.1 Previous studies have shown adverse health outcomes associated with snoring, and that snoring is associated with greater daytime sleepiness and decreased performance.2-9 Thus, identification of modifiable factors associated with snoring is an important public health issue.

Benzodiazepine receptor agonists are medications commonly used as sleep aids. Approximately 15 million prescriptions for benzodiazepine receptor agonists are written annually in the United States, and approximately 10% of the population has reported having used these medications.10,11 Benzodiazepine receptor agonists cause muscle relaxation, which may affect muscle tone and airway dynamics and thereby increase the risk of snoring.

Previous cross-sectional studies in women have shown associations between snoring and body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared), age, waist circumference, smoking status, physical activity, hypertension, and alcohol dependence.12,13 However, despite the fact that snoring and use of benzodiazepine receptor agonists are common, the association between the use of these medications and the risk of snoring is unclear. Previous studies primarily comprised younger women and were underpowered to detect differences in snoring by use of benzodiazepine receptor agonists or did not report the magnitude of the observed association.13,14 We investigated the association between use of benzodiazepine receptor agonists and snoring, and potential effect modifiers of this association, in 52 504 women who participated in the Nurses’ Health Study.

Methods
Study Participants

The Nurses’ Health Study is a cohort of female registered nurses originally enrolled in 1976. At study onset, there were 121 700 participants aged 30 to 55 years. Questionnaires are administered every 2 years, with an average follow-up rate of more than 90% of the eligible person-time. The 2008 questionnaire (http://www.nurseshealthstudy.org/participants/questionnaires) included a question about snoring. Of the 73 693 women who answered the long-form questionnaire in 2008, a total of 14 831 (20.1%) reported habitual snoring. After excluding participants with missing information, our study population was 52 504 women. Completion of the self-administered questionnaire was considered implied informed consent. The Partners Healthcare Institutional Review Board approved this study.

Ascertainment of Snoring

In the 2008 questionnaire, participants were asked, “Do you snore?” Possible responses were “every night,” “most nights,” “a few nights a week,” “occasionally,” “almost never,” and “don’t know.” Participants who reported snoring every night, most nights, or a few nights a week, were considered to be habitual snorers. Participants who reported snoring occasionally or almost never were considered to be nonhabitual snorers. Significant associations between several factors and self-reported snoring have been observed using a similar manner of assessment in other cohorts.4,12-15 In addition, assessment of snoring in the Nurses’ Health Study cohort in this manner has been associated with increased risk of colorectal cancer,16 increased risk of type 2 diabetes,17 and positive associations with biomarkers of cardiovascular disease risk.18

Ascertainment of Medication Use

In the 2008 questionnaire, participants were asked if they had regularly used “minor tranquilizers (eg, Valium, Xanax, Ativan, Librium)” or “Ambien, Sonata, or Lunesta.” Although “regularly” was not defined in the 2008 questionnaire, “regular use” was defined as 2 or more times per week in the previous biennial questionnaires sent to study participants. We classified women who answered yes to either of these questions as participants using benzodiazepine receptor agonist medications.

Ascertainment of Covariates

Covariates were selected based on previously reported factors associated with snoring. Factors considered included age,13-15,19 BMI,13-15,19 waist circumference,13,19 alcohol consumption,13,19 smoking status,14,15,19 race/ethnicity,20 physical activity,13,19 sleep position,19 hypertension,12 anxiety,28 and diabetes.17 Data on covariates were obtained from the biennial questionnaires. Data from the 2008 questionnaire were used, with the exception of waist circumference, which was from the 2000 questionnaire.

Statistical Analysis

Data analysis was conducted from November 2015 to March 2016. Analyses were performed in a cross-sectional manner using information on snoring and medication use that was collected on the 2008 questionnaire. Multiple logistic regression analyses were used to adjust for potential confounders. Given previously described associations between increased snoring and younger age, greater BMI and waist circumference, current smoking, greater alcohol consumption, and decreased physical activity, we explored potential effect modification of the association between use of benzodiazepine receptor agonists and snoring by these variables. We hypothesized that risk of snoring would increase with use of benzodiazepine receptor agonists in older women, given greater sensitivity to the effects of these medications among the elderly population.21 Obesity increases passive mechanical pressures by increasing fat deposition and redundant tissue in the neck and tongue, increasing the risk of airway obstruction.22 Thus, we hypothesized that use of benzodiazepine receptor agonists among women with a higher BMI and greater waist circumference increases the risk of snoring, given higher mechanical pressures and the muscle-relaxing effects of these medications. We also hypothesized that less physical activity decreases airway muscle tone and increases the risk of snoring with use of benzodiazepine receptor agonists. Smoking has been associated with irritation of nasopharyngeal mucosa, with resulting edema and narrowing of the airway.14 Furthermore, animal models have shown that nicotine is associated with increased upper airway muscle tone,23 withdrawal of which may increase upper airway resistance and increase risk of snoring. Use of benzodiazepine receptor agonists among smokers may result in further relaxation of airway muscle tone, leading to greater risk of snoring, compared with no use of these medications. Alcohol use has been hypothesized to increase snoring by increasing the frequency and duration of obstructive events in the upper airway secondary to depression of arousal mechanisms and oropharyngeal muscle hypotonia.24,25 Use of benzodiazepine receptor agonists may further depress arousal mechanisms and decrease oropharyngeal muscle tone, thereby increasing the risk of snoring.

Associations are expressed as odds ratios and 95% CIs. All statistical analyses were performed via SAS software, version 9.4 (SAS Institute Inc).

Results

Participant characteristics according to snoring status are shown in Table 1. Women who reported habitual snoring had a higher mean (SD) BMI (28.3 [5.8] vs 26.0 [5.0]) and waist circumference (90.2 [13.6] vs 85.7 [12.8] cm), were less physically active (median, 8.2 [interquartile range, 2.1-21.2] vs 11.5 [interquartile range, 3.2-26.3] metabolic equivalents), were more likely to be a current or past smoker (current, 5.9% vs 4.5%; past, 51.2% vs 48.2%), have a history of type 2 diabetes (17.3% vs 12.1%) or hypertension (69.9% vs 64.1%), and report use of benzodiazepine receptor agonists (11.4% vs 10.6%) compared with nonhabitual snorers.

In 2008, a total of 14 831 women (28.2%) reported habitual snoring. There was a slightly higher prevalence of the use of benzodiazepine receptor agonists among habitual snorers compared with nonhabitual snorers (11.4% vs 10.6%; absolute difference, 0.8%; 95% CI, 0.2% to 1.4%). However, after multivariable adjustment, use of benzodiazepine receptor agonists was not associated with snoring (odds ratio, 1.01; 95% CI, 0.95-1.07) (Table 2).

There was no statistically significant effect modification by BMI (Table 3), smoking status (Table 4), age, waist circumference, alcohol consumption, and physical activity (eTables 1-4 in the Supplement). Although there was no overall significant interaction, after multivariable adjustment, there was an increased odds of snoring with use of benzodiazepine receptor agonists among current smokers (odds ratio, 1.34; 95% CI, 1.04-1.73) compared with women who did not use benzodiazepine receptor agonists (Table 4).

We performed secondary analyses investigating the association between snoring and use of minor tranquilizers as described in the questionnaire, and the association between snoring and use of Ambien, Sonata, or Lunesta. Performing these analyses separately did not change the results.

Discussion

We found no overall association between use of benzodiazepine receptor agonists and snoring. Although there was no significant overall interaction between use of benzodiazepine receptor agonists and snoring by smoking, use of these medications among current smokers was associated with higher odds of snoring.

Snoring has been associated with adverse health effects, as well as increased daytime sleepiness and reduced performance.2-9 Benzodiazepine receptor agonists relax muscle tone, which may increase the odds of snoring. However, previous studies showed mixed results on the association between snoring and use of benzodiazepines, with one cross-sectional study revealing no significant association and another reporting a positive association.13,14 However, one of these studies had a low prevalence of the use of benzodiazepines among participants,13 and the other was in a smaller cohort of men and women with no reporting of the magnitude of the observed association.14 In our cohort of 52 504 women, we observed no overall association between use of benzodiazepine receptor agonists and snoring.

It has been previously suggested that factors associated with snoring may have different effects on women by age and BMI.13 We explored the association between use of benzodiazepine receptor agonists and snoring by age, BMI, waist circumference, smoking status, alcohol consumption, physical activity, and sleep position, and found that, although there was no significant overall interaction by any of these variables, there were significant differences in the observed associations among current smokers.

The association between higher BMI and increased odds of snoring has been well established.13,14 Previous authors have suggested that women with a higher BMI or waist circumference may have more fat deposits or redundant tissue in the oropharynx compared with normal-weight or underweight individuals, thereby predisposing them to higher odds of snoring.13 We found no overall association between use of benzodiazepine receptor agonists and snoring by BMI or waist circumference.

Smoking has been associated with irritation of nasopharyngeal mucosa, with resulting edema and narrowing of the airway.14 Furthermore, animal models have shown that nicotine is associated with increased upper airway muscle tone23; withdrawal from nicotine may increase upper airway resistance during sleep. Previous studies have reported an association between smoking and snoring.13-15,26,27 We found that the association between use of benzodiazepine receptor agonists and snoring by smoking status was of borderline statistical significance. However, there was a significantly higher odds of snoring among current smokers who used benzodiazepine receptor agonists compared with current smokers who did not use these medications. This finding may be owing to the muscle-relaxing effects of benzodiazepine receptor agonists being greater among individuals who smoke and have increased airway resistance and edema.

Older women experience altered pharmacokinetics and pharmacodynamics, resulting in a longer benzodiazepine receptor agonist half-life, and they may be more sensitive to the effects of these medications compared with younger women.21 However, the association between use of benzodiazepine receptor agonists and snoring did not vary by age. The lack of expected differences by age may be that older cohort participants were prescribed lower doses of benzodiazepine receptor agonists, given preexisting knowledge of the sensitivity of older individuals to these medications.

Alcohol consumption has been hypothesized to increase snoring by increasing the frequency and duration of obstructive events in the upper airway secondary to depression of arousal mechanisms and oropharyngeal muscle hypotonia.24,25 Use of benzodiazepine receptor agonists may further depress arousal mechanisms and decrease oropharyngeal muscle tone, thereby increasing the risk of snoring. However, we observed no association between use of benzodiazepine receptor agonists and the odds of snoring among different categories of alcohol use. Although a previous study described an association between alcohol dependence and snoring,13 the quantity of alcohol consumed by women in our cohort was relatively low, with few women reporting the consumption of 30 or more grams of alcohol daily (the equivalent of 2 standard alcoholic drinks per day).

Limitations

Our cohort comprises predominantly white women. Further investigation is required to examine the association between use of benzodiazepine receptor agonists and snoring in other populations. The study design was cross-sectional; therefore, we cannot address the temporal nature of the observed associations. However, our findings represent data from the largest cohort of women studied to date on this subject. Our questionnaire did not ask about individual benzodiazepine receptor agonists so we were able to investigate only the class of medications. Further investigation is needed to ascertain whether differences exist in the association between snoring and use of specific benzodiazepine receptor agonist agents. Although we found no association between alcohol consumption and the odds of snoring, it is possible that temporality of alcohol intake relative to sleep and use of benzodiazepine receptor agonists are important; this factor was not ascertained in our cohort. Further investigation is required to better understand these associations. Further investigation is also needed to better understand the potential association between the use of benzodiazepine receptor agonists and other aspects of sleep-related breathing disorders. Our exposure was defined as regular use of benzodiazepine receptor agonist medications. Although regular use was not defined on the 2008 questionnaire, it was defined as 2 or more times per week on previous biennial questionnaires. The outcome in our study was self-reported snoring. However, a previous study using data from the Nurses’ Health Study demonstrated that the prevalence of snoring in women who were living with spouses or partners was similar to that in women who were not living with spouses or partners, which suggests no obvious bias in self-report.19 In addition, many studies have evaluated snoring using this manner of assessment, revealing associations between snoring and several well-established factors such as hypertension, diabetes, and colorectal cancer.4,12-15

Conclusions

The use of benzodiazepine receptor agonists was not associated with odds of snoring; however, use of these medications among current smokers was associated with higher odds of snoring.

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Article Information

Accepted for Publication: August 21, 2016.

Corresponding Author: Brian M. Lin, MD, ScM, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114 (brian_lin@meei.harvard.edu).

Published Online: November 17, 2016. doi:10.1001/jamaoto.2016.3174

Author Contributions: Dr Lin had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Lin, Curhan.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Lin.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Lin, Curhan.

Administrative, technical, or material support: Hu.

Study supervision: Curhan.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: This work was supported by grants UM1CA186107 and DK91417 from the National Institutes of Health.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Durán  J, Esnaola  S, Rubio  R, Iztueta  A.  Obstructive sleep apnea–hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr.  Am J Respir Crit Care Med. 2001;163(3, pt 1):685-689.PubMedGoogle ScholarCrossref
2.
Nieto  FJ, Young  TB, Lind  BK,  et al.  Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study: Sleep Heart Health Study.  JAMA. 2000;283(14):1829-1836.PubMedGoogle ScholarCrossref
3.
Partinen  M, Jamieson  A, Guilleminault  C.  Long-term outcome for obstructive sleep apnea syndrome patients: mortality.  Chest. 1988;94(6):1200-1204.PubMedGoogle ScholarCrossref
4.
Lindberg  E, Janson  C, Gislason  T, Svärdsudd  K, Hetta  J, Boman  G.  Snoring and hypertension: a 10 year follow-up.  Eur Respir J. 1998;11(4):884-889.PubMedGoogle ScholarCrossref
5.
Shahar  E, Whitney  CW, Redline  S,  et al.  Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study.  Am J Respir Crit Care Med. 2001;163(1):19-25.PubMedGoogle ScholarCrossref
6.
Janson  C, Hillerdal  G, Larsson  L,  et al.  Excessive daytime sleepiness and fatigue in nonapnoeic snorers: improvement after UPPP.  Eur Respir J. 1994;7(5):845-849.PubMedGoogle Scholar
7.
Ulfberg  J, Carter  N, Talbäck  M, Edling  C.  Excessive daytime sleepiness at work and subjective work performance in the general population and among heavy snorers and patients with obstructive sleep apnea.  Chest. 1996;110(3):659-663.PubMedGoogle ScholarCrossref
8.
Lindberg  E, Janson  C, Svärdsudd  K, Gislason  T, Hetta  J, Boman  G.  Increased mortality among sleepy snorers: a prospective population based study.  Thorax. 1998;53(8):631-637.PubMedGoogle ScholarCrossref
9.
Gottlieb  DJ, Yao  Q, Redline  S, Ali  T, Mahowald  MW.  Does snoring predict sleepiness independently of apnea and hypopnea frequency?  Am J Respir Crit Care Med. 2000;162(4, pt 1):1512-1517.PubMedGoogle ScholarCrossref
10.
Morin  CM, LeBlanc  M, Bélanger  L, Ivers  H, Mérette  C, Savard  J.  Prevalence of insomnia and its treatment in Canada.  Can J Psychiatry. 2011;56(9):540-548.PubMedGoogle ScholarCrossref
11.
Kripke  DF, Langer  RD, Kline  LE.  Hypnotics’ association with mortality or cancer: a matched cohort study.  BMJ Open. 2012;2(1):e000850.PubMedGoogle ScholarCrossref
12.
Koskenvuo  M, Kaprio  J, Partinen  M, Langinvainio  H, Sarna  S, Heikkilä  K.  Snoring as a risk factor for hypertension and angina pectoris.  Lancet. 1985;1(8434):893-896.PubMedGoogle ScholarCrossref
13.
Svensson  M, Lindberg  E, Naessen  T, Janson  C.  Risk factors associated with snoring in women with special emphasis on body mass index: a population-based study.  Chest. 2006;129(4):933-941.PubMedGoogle ScholarCrossref
14.
Bloom  JW, Kaltenborn  WT, Quan  SF.  Risk factors in a general population for snoring: importance of cigarette smoking and obesity.  Chest. 1988;93(4):678-683.PubMedGoogle ScholarCrossref
15.
Schmidt-Nowara  WW, Coultas  DB, Wiggins  C, Skipper  BE, Samet  JM.  Snoring in a Hispanic-American population: risk factors and association with hypertension and other morbidity.  Arch Intern Med. 1990;150(3):597-601.PubMedGoogle ScholarCrossref
16.
Zhang  X, Giovannucci  EL, Wu  K,  et al.  Associations of self-reported sleep duration and snoring with colorectal cancer risk in men and women.  Sleep. 2013;36(5):681-688.PubMedGoogle Scholar
17.
Al-Delaimy  WK, Manson  JE, Willett  WC, Stampfer  MJ, Hu  FB.  Snoring as a risk factor for type II diabetes mellitus: a prospective study.  Am J Epidemiol. 2002;155(5):387-393.PubMedGoogle ScholarCrossref
18.
Williams  CJ, Hu  FB, Patel  SR, Mantzoros  CS.  Sleep duration and snoring in relation to biomarkers of cardiovascular disease risk among women with type 2 diabetes.  Diabetes Care. 2007;30(5):1233-1240.PubMedGoogle ScholarCrossref
19.
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