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Exposure to cigarette smoke is a significant risk factor related to a client's susceptibility to middle ear infections. Cigarette smoke can impair the immune response and lead to inflammation in the upper respiratory tract and Eustachian tubes, which can contribute to the development of otitis media (middle ear infections). This exposure is particularly harmful to children, as their immune systems are still developing, and their anatomy makes it easier for pathogens to reach the middle ear.

Allergies can also play a role in ear infections, but they primarily cause inflammation and congestion rather than directly increasing susceptibility in the same way that cigarette smoke exacerbates respiratory issues. Using q-tips can lead to earwax impaction or damage to the ear canal, but it is not a direct causative factor for middle ear infections. Dietary factors, while important for overall health and immunity, do not have a direct correlation with the development of ear infections compared to exposure to environmental toxins such as cigarette smoke. Thus, the connection between cigarette smoke and middle ear infections highlights the importance of understanding environmental risk factors in nursing assessments.