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(Chest. 2002;122:562-568.)
© 2002 American College of Chest Physicians

Who Are the "Occasional" Snorers?*

Dan Teculescu, MD; Bernard Hannhart, MD; Catherine Aubry, MD; Bettina Montaut-Verient, MD; Jean-Marc Virion, PhD; Jean-Pierre Michaely, PhD and René Gueguen, PhD

* From INSERM Unit 420 (Drs. Teculescu and Hannhart, and Mr. Michaely), Vandoeuvre; the Center of Preventive Medicine (Dr. Aubry and Mr. Gueguen), Vandoeuvre; the Department of ENT Diseases (Dr. Montaut-Verient), Nancy University Hospital, Nancy; and the Center of Clinical Investigations (Mr. Virion), Vandoeuvre, France.

Correspondence to: Dan Teculescu, MD, INSERM Unité 420, BP 184, 54505 Vandoeuvre, France; e-mail: Dan.Teculescu{at}nancy.inserm.fr


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Study objectives: To assess the prevalence of occasional snoring in a group of middle-aged men, and to compare anthropometric variables and prevalence of sleep-related symptoms of subjects who occasionally snore with those of other snoring categories.

Design: A field survey of a sample of middle-aged men in France.

Participants: Male employees of a local university and subjects from the community attending a preventive medicine center. Participation rate was 93.5%.

Measurements: Anthropometric variables were recorded in 499 subjects aged 23 to 66 years (mean, 44.3 years). The subjects completed a standard sleep questionnaire and were classified according to the snoring frequency as never, rarely, sometimes, occasional, several nights per week, and every night. The subjects who snore occasionally represented 8.6% of the total.

Results: The anthropometric data of subjects who snore occasionally were similar to those of subjects who habitually snore. When compared with subjects who do not snore, older age and a larger neck girth were significant. Subjects who snore occasionally were also significantly more often subjects who snore loudly, and tended more frequently to have breathing stops during sleep.

Conclusions: Our epidemiologic study shows that approximately 9% of a sample of middle-aged men snore occasionally. Subjects who snore occasionally have anthropometric characteristics close to those of subjects who snore habitually. The prevalence of the main sleep-related symptoms is between that of subjects who do not snore and of subjects who snore habitually. In an epidemiologic setting, inclusion of subjects who snore occasionally as subjects who do not snore or subjects who snore habitually will lead to bias. The present results suggest they should be identified and considered as a separate category.

Key Words: breathing sleep disorder • male subjects • obstructive sleep apnea syndrome • occasional snoring • snoring frequency


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Many definitions have been proposed for snoring. In their review of the clinical significance of snoring, Lugaresi and Partinen1 favor the definition of Robin2 : "sounds made by vibrations in the soft palate and posterior faucial pillars during sleep." Long considered a simple familial or social nuisance,3 snoring came to medical attention when its significant association with obstructive sleep apnea syndrome (OSAS) was recognized.4 Epidemiologic surveys3 5 have found OSAS to be present in 2% of women and 4% of men in an active population, but such studies are rare for technical reasons (subject needs to agree to sleep for 1 night in the sleep laboratory) and financial reasons (participants are paid $100 and the cost of the polysomnographic procedure is high). A series of studies were devoted to the prevalence of snoring, with the dual objective of detecting subjects at risk for OSAS, and for better understanding the risk factors for snoring and its possible consequences. Stradling and Crosby6 reported that subjects who snore but do not have apnea could have excessive daytime sleepiness, and suggested that snoring significantly reduced sleep quality even in the absence of obstructive apneas.

In laboratory studies, snoring sound has been recorded using microphones placed either on the subject’s sternum or over the subject’s head,7 and then is digitally processed and analyzed.8 This approach is inapplicable in field surveys, where information on snoring is usually collected using questionnaires. A series of shortcomings and limitations of such questionnaires has been described: a large proportion of "do not know" responses9 10 11 ; underreporting by subjects12 or overreporting by wives of husbands’ snoring13 ; or lack of standardization of the questionnaires, etc. Some authors recorded snoring frequency dichotomously,14 15 others used a 3-point scale,11 16 17 some used a 4-point scale,18 19 20 21 22 and others used a 5-point scale.5 23 24 25 Some authors report "habitual" snoring without any operational definition,26 whereas in other studies snoring remains ill-defined.27 28

As stressed by Young,13 while self-report of symptoms may be (relatively) valid in patient settings, it is less so in population samples, where "no direct health benefit of accurate reporting is present." This probably partly explains the multiplication of questionnaires, making the comparison of results between different studies very difficult. A significant standardization effort was made in 1988 by the working group of the Scandinavian Society for Sleep Research and recently by the National Institutes of Health Specialized Centers of Research in Cardiopulmonary Disorders of Sleep (Universities of Pennsylvania and Wisconsin). The frequency of the main symptoms was defined on a quantitative and subjective (so-called Likert) scale.13 The Basic Nordic Sleep Questionnaire contained 27 items in 21 questions.29 The question about snoring frequency was labeled, "Do you snore while sleeping?" with a choice of five answers: 1, never or less than once per month; 2, less than once per week; 3, on 1 to 2 nights per week; 4, on 3 to 5 nights per week; and 5, every night or almost every night. To reduce misclassification, the American version introduced a "do not know" category.

Research teams using the Basic Nordic Sleep Questionnaire30 31 32 or the North American version5 33 to evaluate snoring prevalence labeled subjects who answered 4 or 5 as "habitual snorers" and subjects answering "never" or "less than once per week" as "nonsnorers." The latter category served as a reference group for the evaluation of the risk factors for snoring. The classification of the intermediate category, ie, the subjects who snore occasionally, remained problematic, however. The subjects who snored "at least once a week, but pattern may be irregular" were included among the subjects who habitually snore by some authors,34 whereas most authors included them among the subjects who do not snore.5 35 36 37 38 39

Strictly speaking, these subjects are neither subjects who do not snore, nor subjects who habitually snore. We therefore decided to analyze the subgroup of subjects who snore occasionally in a sample of middle-aged male subjects, with two objectives: first, to see whether their anthropometric data and life habits are closer to those of groups of habitual snorers or to the subjects who do not snore; and second, to see whether the prevalence of the other OSAS symptoms are different from those of the extreme groups mentioned above.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusion
 References
 
Subjects
Two groups of male subjects aged >= 20 year and sleeping with a bedmate were studied. The first group consisted of employees from a local university who attended a yearly preventive medical examination. An explanatory letter was sent to each subject, explaining the purpose of the study, stressing the noninvasive character of the protocol, and noting the right to deny participation. Three hundred thirty-four of the 357 male subjects present on the campus volunteered (93.6%). The second group was made up of male subjects from the community (northeastern France) who attended a free preventive medical check-up in a regional center of preventive medicine, serving approximately 2 million people. Of the 216 subjects who were approached (in consecutive order on the computer file) 202 subjects agreed to participate (93.5%). After a full explanation, written consent was obtained. The study protocol was approved by the Regional Committee on Ethics in Medical Research.

Anthropometry
Height and weight were measured using standard methods, and body mass index (BMI) was calculated. The circumferences of the neck (at the cricothyroid membrane level),38 waist, and hip were measured with a cloth tape, and the waist-to-hip ratio was obtained. All of the measurements were performed by the same observer.

Questionnaire
A French version of the 32-item Wisconsin University Sleep Cohort Study Questionnaire5 was completed by the subjects, with assistance from their spouses. Detailed explanations were given to the subjects; for example, subjects were urged to answer "do not know" rather than leave the question unanswered. The 3-month test-retest repeatability of the French version of the questionnaire was assessed in a subsample of the second group of subjects and was found to be satisfactory.40 For example, the question, "Have you ever been told that you snore?" had a Cohen’s {kappa} (concordance test) of 0.86; "How often do you seem to have momentary periods during sleep when you stop breathing or you breathe abnormally?" had a Cohen’s {kappa} of 0.50; and "How often do you, gasp, choke, or make snorting sounds during sleep?" had a Cohen’s {kappa} of 0.74.

Nose and Throat Examination
The policy of the Regional Ethics in Medical Research Committee was to exclude any invasive diagnostic procedure in epidemiologic research. Accordingly, we limited the instrument to a tongue blade and simplified the score proposed for clinical purposes by Wilms et al,41 assessing semiquantitatively the nasal septum, nasal mucosa, soft palate, uvula, tonsils, tongue, and chin abnormalities. All subjects were examined by the same observer; details of the ear, nose, and throat examination have been given elsewhere.42

Statistical Analysis
Data processing (analysis of variance, univariate analysis using Cochrane-Armitage trend test, and logistic regression)43 was performed using the Statistical Analysis System (version 8.1; SAS Institute; Cary, NC).


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusion
 References
 
Complete data were obtained in 499 subjects aged 23 to 66 years (mean, 44.3; SD, 9.9 years). To the question, "Please estimate how often you snore," 21.4% of the subjects answered "never," 11.2% answered "rarely," 20.6% answered "sometimes," 8.6% answered "at least once a week," 15.0% answered "several nights per week," 20.2% answered "every night," and 3.8% answered "do not know." The latter group was excluded from further analysis. Age, weight, BMI, neck circumference, waist circumference, and hip circumferences, and the waist/hip ratio showed a nearly linear increase through the six snoring frequency categories; height was somewhat lower in the last two groups, contributing to the increase in BMI (Table 1 ).


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  		Table 1.. Anthropometric Data According to Snoring Category*

 
In a second stage of the analysis, subjects who never snore, rarely snore, and sometimes snore were grouped together as subjects who do not snore; subjects snoring at least 3 nights per week or every night were grouped as habitual snorers; this yielded two extreme categories to be compared with the subjects who snore occasionally. As expected, habitual snorers differed significantly from subjects who do not snore in all of the anthropometric variables, except height (Table 2 ). Compared with subjects who do not snore, subjects who snore occasionally were significantly older and had a larger neck circumference; none of the differences with the habitual snorers were significant. Among the nose and throat data, soft palate and uvula abnormalities were significantly different across the three groups (Table 3 ).


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  		Table 2.. Anthropometric Data in Occasional Snorers, as Compared to Habitual Snorers and Nonsnorers*

 

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  		Table 3.. Nose and Throat Abnormalities in Nonsnorers, Occasional Snorers, and Habitual Snorers*

 
The prevalence of the main sleep-related symptoms among the three groups of subjects is presented in Table 4 . With the exception of, "Need for coffee to stay awake...," a significant increasing trend is present for the prevalence of all symptoms.


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  		Table 4.. Prevalence of Main Sleep-Related Symptoms in Nonsnorers, Occasional Snorers, and Habitual Snorers

 
Finally, we did a logistic regression analysis of the main sleep-related symptoms, using the subjects who snore occasionally as referent group (Table 5 ). Differences between subjects who snore occasionally and habitual snorers were found for loud snoring (odds ratio [OR], 2.70), snoring for > 20 years (OR, 4.80), and very difficult to wake up in the morning (OR, 8.80).


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  		Table 5.. Prevalence of Main Sleep-Related Breathing Disorders in Occasional vs Habitual Snorers and Nonsnorers

 
With respect to personal medical history, only two subjects gave a history of narcolepsy; 3.6% admitted to doctor-diagnosed sleep apnea. The prevalence of the latter was 1.2% in subjects who do not snore, 2.4% (nonsignificant) in subjects who snore occasionally, and 7.4% in habitual snorers (OR 6.7; confidence interval, 1.9 to 24.0). The prevalence of asthma, chronic bronchitis, coronary heart disease, allergy, and stroke was not significant between the groups. The prevalence of hypertension was low in subjects who snore occasionally (2.4%) and significantly higher among subjects who habitually snore (16.9%) as compared with subjects who do not snore (8.2%) [OR, 2.3; confidence interval, 1.2 to 4.1].


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusion
 References
 
Perusing the literature, we found that the classification of subjects who snore occasionally was rather arbitrary, as a consequence of the vague definition of this group. We analyzed the demographic data, life habits, and risk factors for snoring in a sample of 499 male subjects, aged 23 to 66 years, to evaluate the possible differences between subjects who snore occasionally and the extreme groups of subjects who snore habitually and subjects who do not snore. We found that subjects who snore occasionally represented approximately 9% of this sample of middle-aged men from the community, and that their anthropometric data were close to those of habitual snorers. The prevalence of loud snoring was significantly increased with respect to subjects who do not snore; the trend to a higher prevalence of breathing stops and difficult waking in the morning did not reach significance.

A number of weak points of this study should be acknowledged. Snoring was based on self-reporting, as is usual in epidemiologic studies. We only took into account frequency of snoring and did not analyze its duration, effect of position, or disruptiveness44 ; no count of number of snores per hour (snoring index) was obtained. Subjects with complaints of insomnia or excessive daytime sleepiness were not excluded to obtain a group of primary subjects who snore,45 nor did we exclude subjects with sleep apnea, to limit the sample to subjects who snore but do not have apnea. Finally, the number of subjects included was relatively limited, and this influenced the study power, especially when the prevalence of a symptom was low. With higher prevalence, the power was satisfactory: for example, at a 95% confidence level and a relative risk of 3.5, we had 94.9% power to detect a significant difference for loud snoring in the subjects who snore occasionally. The strengths of this study were the inclusion of a sample of subjects homogeneous with respect to age, gender, and race, and the use of a validated standard questionnaire.

The prevalence of occasional snoring in various populations is difficult to compare because of the use of different definitions, as mentioned before. In French youth, "sometimes snoring" was not different between girls (15%) and boys (15.9%),46 data that are comparable to those reported by Lugaresi et al1 in their San Marino study, which indicated a rate of 16.8% for men. Higher figures were reported from Wisconsin (31.0%),5 from the United Kingdom (47.1%),6 from Finland47 for men (60.0%), and from the United States for female nurses (65.%).17

Older age, excess weight, central obesity, and larger neck circumference are known risk factors for habitual snoring48 ; our data in habitual snorers confirm this. The quasicontinuum alteration of demographic data along the various categories of snoring (Table 1) adds a welcome reassuring validity to the self-report as an epidemiologic tool. It would be tempting, in this respect, to consider subjects who snore occasionally as a step in the natural history of snorers disease; prospective studies are necessary to test this hypothesis. Our attention was caught by the fact that the higher BMI in subjects who snore habitually was in part the result of their smaller height. Thirty-five years ago, as Fletcher et al49 described two types of COPD patients, the "pink puffer" and the "blue and bloated," they depicted the latter as stout. We wonder whether a link could exist between habitual snoring and the bronchitic type of airway obstruction in the frame of the overlap syndrome. Subjects who snore occasionally in the present study had mean anthropometric values similar to habitual snorers; the difference for subjects who do not snore was significant only for age and for neck circumference. Older age in subjects who snore occasionally was reported by Lindberg et al.50 Koskenvuo et al34 reported a higher proportion of BMI > 27, less leisure jogging, and a higher prevalence of systemic hypertension in subjects who snore occasionally compared with subjects who do not snore. The subjects who snore occasionally among the French adolescents studied by Delasnerie-Laupretre et al46 had a significantly higher BMI when compared with subjects who do not snore; the effect was present in both sexes. Scandinavian authors34 50 insisted on the role of smoking as a risk factor for snoring; in the present study, current smoking was only present as a (nonsignificant) trend.

The nose and throat examination (Table 3) showed that soft palate and uvula abnormalities are present not only in habitual snorers, but in those who snore occasionally as well. These two ear, nose, and throat findings were previously found to be risk factors for breathing pauses as well.42

We are not aware of any analysis of the prevalence of the main sleep-related symptoms in subjects who snore occasionally compared with subjects who snore habitually or subjects who do not snore. An association with loud snoring was somewhat expected in both habitual and occasional snorers. Because no direct measurement of snoring intensity was obtained in the present study, this effect could in part be caused by a better perception of snoring by this category of subjects or their bedmates. The prevalence of grasping/choking, breathing pauses, excessive daytime sleepiness, and nasal congestion/discharge at night was increased in habitual subjects who snore. When subjects who snore occasionally were taken as reference group, using a logistic regression procedure, we found habitual snorers to snore significantly more often for a long time (> 20 years; OR, 4.80), to snore loudly (OR, 2.70), and to experience difficulty in waking in the morning (OR, 8.80). Systemic hypertension was significantly more prevalent in habitual snorers (16.9% vs 8.2%) compared with subjects who do not snore, but the proportion was not increased in subjects who snore occasionally, a result at variance with the findings of Koskenvuo et al.34 Doctor-diagnosed sleep apnea was twice as frequent among subjects who snore occasionally compared with those who do not snore (2.4% vs 1.2%); however, the numbers were too small for statistical significance.


   Conclusion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
References
 
In a sample of 499 middle-aged French men, we found 9% to be subjects who snore occasionally according to the definition proposed by Young et al.5 The anthropometric characteristics of the subjects who snore occasionally were close to those of the habitual snorers; age and neck circumferences were significantly larger than those of subjects who do not snore. When responding to the questionnaire, subjects who snore occasionally admitted more often to loud snoring and to breathing pauses during sleep. They also had more frequent soft palate and uvula abnormalities.

Our results suggest that occasional snoring is at present not satisfactorily defined; inclusion of subjects who snore occasionally among subjects who do not snore or who snore habitually is not justified and represents a source of bias. Until a more precise definition is adopted, it seems advisable to consider subjects who snore occasionally a special, separate group. Subjects who snore occasionally possibly represent a step in the natural history of "heavy snorers’ disease"51 , but only prospective studies could test this hypothesis.


   Acknowledgements
 
The authors thank Mr. Bruno Phélut for help with computer files, Ms. Aline Berthelin for manuscript processing, and the study subjects for their willing participation.


   Footnotes
 
Abbreviations: BMI = body mass index; OR = odds ratio; OSAS = obstructive sleep apnea syndrome

This work was performed at the French National Institutes of Health and Medical Research (INSERM) Unit 420, Vandoeuvre, France.

Received for publication August 15, 2001. Accepted for publication January 23, 2002.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 

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