Screening for children's exposure to environmental tobacco smoke in a pediatric primary care setting

BACKGROUND: The American Academy of Pediatrics (Elk Grove Village, Ill) has recommended that pediatricians assess their patients' environmental tobacco smoke (ETS) exposure, but the specific questions most likely to identify children with high ETS exposure are not known. Cotinine is a nicotine metabolite, present in hair, that can be used to quantify months of ETS exposure. OBJECTIVE: To develop a brief screening tool that will accurately predict ETS exposure as defined by child hair cotinine level. METHODS: We compared the performance of a series of easily administered screening questions regarding home ETS exposure to child hair cotinine levels. Subjects were a convenience sample of healthy children aged 2 weeks to 3 years of both self-reported smokers and nonsmokers. RESULTS: Hair samples and questionnaire data were obtained from 291 children. Based on clinical applicability and statistical significance, 3 questions ("Does the mother smoke?", "Do others smoke?", and "Do others smoke inside?") were selected as a valid screening tool to determine children's ETS exposure risk. Maternal report of smoking outside only or smoking few cigarettes per day had no impact on child hair cotinine levels. CONCLUSIONS: It was possible to derive a simple, specific, and valid screening tool that can be used in pediatric offices to identify children at risk for ETS exposure. Further research is needed to test this tool prospectively.     

Health effects related to environmental tobacco smoke exposure in children in the United States: data from the Third National Health and Nutrition Examination Survey

OBJECTIVE: To determine the effects of prenatal and postnatal smoke exposure on the respiratory health of children in the United States. DESIGN: Nationally representative cross-sectional survey, including questionnaire information, measurements of serum cotinine (a metabolite of nicotine), and pulmonary function measurement, of 5400 US children. SETTING AND PARTICIPANTS: Children aged 4 to 16 years in the Third National Health and Nutrition Examination Survey, October 25, 1988, to October 15, 1994. METHODS: We stratified the study participants into tertiles, on the basis of serum cotinine levels, and used logistic and linear regression modeling, adjusting for known covariates, to determine the effect of high environmental tobacco smoke (ETS) exposure (on the basis of a high cotinine level) on outcomes such as the prevalence of current asthma, the prevalence of frequent wheezing, school absence, and lung function. For children aged 4 to 11 years, we also determined the effect of prenatal maternal smoking on these outcomes. RESULTS: We observed effects of ETS exposure in all age groups, although the effects varied between age groups. Among all children significant effects associated with high cotinine levels were for wheezing apart from cold in the past year (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.1-2.8); 6 or more days of school absence in the past year (OR, 2.0; 95% CI, 1.4-2.8); and lung function decrements in the forced expiratory volume in 1 second (mean change, -1.8%; 95% CI, -3.2% to -0.4%) and the maximal midexpiratory flow (mean change, -5.9%; 95% CI, -8.1% to -3.4%). Although current and ever asthma were not significantly associated with high cotinine levels in the overall group (OR, 1.5; 95% CI, 0.8-2.7, and OR, 1.3; 95% CI, 0.8-2.2, respectively), they were increased significantly among 4- to 6-year-old children (OR, 5.3; 95% CI, 2.2-12.7, and OR, 2.3; 95% CI, 1.1-5.1, respectively). CONCLUSIONS: We investigated recent ETS exposures as important predictors of respiratory health outcomes in children 4 years and older. Environmental tobacco smoke exposure affects children of all ages, although the exact effects may vary between age groups.     

Impact of Environmental Tobacco Smoke on Children With Asthma,United States, 2003–2010

ObjectiveGiven widespread interventions to reduce environmental tobacco smoke (ETS) exposure and improve asthma control, we sought to assess the current impact of ETS exposure on children with asthma.MethodsWe analyzed 2003–2010 data for nonsmoking children aged 6 to 19 years with asthma from the National Health and Nutrition Examination Survey. Outcomes (sleep disturbance, missed school days, health care visits, activity limitation, and wheezing with exercise) were compared between ETS exposed children (serum cotinine levels 0.05 to 10 ng/mL) and unexposed children (<0.05 ng/mL) using ordinal regression adjusted for demographic characteristics. We also assessed whether associations were observable with low ETS exposure levels (0.05 to 1.0 ng/mL).ResultsOverall, 53.3% of children aged 6 to 19 years with asthma were ETS exposed. Age-stratified models showed associations between ETS exposure and most adverse outcomes among 6- to 11-year-olds, but not 12- to 19-year-olds. Even ETS exposure associated with low serum cotinine levels was associated with adverse outcomes for 6- to 11-year-olds. Race-stratified models for children aged 6 to 19 years showed an association between ETS exposure and missing school, health care visits, and activity limitation due to wheezing among non-Hispanic white children, and disturbed sleep among non-Hispanic white and Mexican children. Among non-Hispanic black children, there was no elevated risk between ETS exposure and the assessed outcomes: non-Hispanic black children had high rates of adverse outcomes regardless of ETS exposure.ConclusionsAmong children with asthma 6 to 11 years of age, ETS exposure was associated with most adverse outcomes. Even ETS exposure resulting in low serum cotinine levels was associated with risks for young children with asthma.     

Impact of repeated lifestyle counselling in an atherosclerosis prevention trial on parental smoking and children's exposure to tobacco smoke

Aim: To determine whether repeated infancy-onset lifestyle counselling alters parental smoking and children's exposure to tobacco smoke. Methods: In 1990, 1062 healthy infants were recruited to a randomized, ongoing atherosclerosis prevention trial (STRIP). Intervention families received at least twice a year individualized nutrition and lifestyle counselling. By 1999, 652 8-y-old children continued participation. Exposure to tobacco smoke was evaluated using serum cotinine concentration. Parents' smoking was also assessed using questionnaires and interviews. Results: Parents' smoking decreased during the study similarly in the intervention and control groups. Of the 8-y-old children, 46% had detectable serum cotinine concentration, suggesting exposure to tobacco smoke during the past few days. All children were non-smokers. Serum cotinine concentrations did not differ between the intervention and control children. Children's cotinine values were highest in the families where either father or both parents were smokers.

Conclusion: Participation in the atherosclerosis prevention trial slightly decreased smoking among the intervention and control parents. However, counselling led to no differences in parental smoking between the two groups, or in exposure of the intervention and control children to tobacco smoke. This study suggests that more detailed and targeted intervention is required to achieve a significant effect on children's tobacco smoke exposure.     

Environmental tobacco smoke (ETS) and respiratory health in children

Environmental tobacco smoke (ETS) is a major risk factor for poor lung health in children. Although parental smoking is the commonest source of ETS exposure to children, they are also exposed to ETS in schools, restaurants, public places and public transport vehicles. Apart from containing thousands of chemicals, the particle size in the ETS is much smaller than the main stream smoke, and therefore has a greater penetrability in the airways of children. Exposure to ETS has been shown to be associated with increased prevalence of upper respiratory tract infections, wheeze, asthma and lower respiratory tract infections. Even developing fetuses are exposed to ETS via the umbilical cord blood if the mother is exposed to tobacco smoke. The placenta also does not offer any barrier to the penetration of ETS into the fetus. The immune system in these babies is more deviated toward the allergic and asthmatic inflammatory phenotype and therefore makes them more prone to develop asthma later in life. An increased awareness of the harmful effects of ETS on children's health is warranted.     

Environmental tobacco smoke exposure and children's health

Almost half of the child population is involuntarily exposed to environmental tobacco smoke (ETS). The ETS exposure gives rise to an excessive risk of several diseases in infancy and childhood, including sudden infant death syndrome, upper and lower respiratory infections, asthma and middle ear diseases. It is also linked to cancer, and behavioural problems and neurocognitive deficits in children. CONCLUSIONS: Protecting children from ETS exposure is a complex and important issue. The best improvement in children's health is to be gained when parents stop smoking or, when that is not possible, they stop smoking in their children's environment. Paediatricians, because of their authority, and their frequent and regular contact with parents, play a leading role in protecting children from ETS exposure. An ideal approach to help parents to stop smoking seems to be initial minimal-contact advice provided by their paediatrician with feedback and supplemental printed materials, leading to greater intensity and duration of follow-up home visits.     

Effect of gestational smoke exposure on atopic dermatitis in the offspring

The adverse impact of smoking on respiratory diseases and birth outcomes in children is well‐known. However, the influence of smoke exposure including environmental tobacco smoke (ETS) and maternal smoking during pregnancy on atopic dermatitis (AD) is not clear. The purpose of this study was to evaluate the effect of gestational smoke exposure on the development of AD in the offspring on the basis of the maternal and cord blood cotinine. We recruited 261 mother and newborn pairs in 2004. Cord blood and information on perinatal factors of children were gathered at birth. At 2 yr of age, information about development of AD and environmental exposures were collected. We compared AD with non‐AD children for the concentration of cotinine in cord and maternal blood measured by high performance liquid chromatography–mass spectrometry. Multiple logistic regressions were performed to estimate the relationship of cotinine levels and AD. About 150 mother and child pairs completed the follow‐up study and specimen collection with 38 (25.3%) children developing AD. Two (1.3%) out of 150 mothers smoked during pregnancy, while 38 (25.3%) mothers reported having ETS exposure. Cotinine levels in cord blood and maternal blood were highly correlated (r = 0.71, p < 0.001). The risk of AD was found to increase with maternal and cord blood cotinine levels in a dose–response manner (p for trend = 0.01). Children exposed to high levels (>75th percentile) had a significantly increased risk of AD. Smoke exposure during pregnancy might increase the risk of AD in children. Avoidance of prenatal smoke exposure may be warranted for early prevention.     

家庭环境香烟烟雾暴露对哮喘患儿疾病控制状况的影响

目的 了解家庭环境香烟烟雾暴露(ETS)与哮喘患儿疾病控制情况的关系.方法 通过病例对照研究方法,对83名ETS和80名非ETS的哮喘儿童进行为期1年的随访,比较两组患儿的儿童哮喘控制测试(childhood asthma control test,C-ACT)评分良好(＞19分)的例次,哮喘控制用药增加天数、急救用药使用天数,以及尿cotinine含量.结果 ETS患儿C-ACT＞19分802例次,占总C-ACT评分例次的80.5%;非ETS患儿 C-ACT＞9分921例次,占95.9%,两组患儿的哮喘控制状况差异无统计学意义(P＜0.05);ETS患儿的尿cotinine含量、支气管扩张剂使用天数、吸入激素增加天数、全身激素使用天数也均明显多于非ETS患儿(P均＜0.05).ETS患儿以尿cotinine含量分为重度(＞4 ng/ml)和轻度(≤4 ng/ml),其中重度ETS患儿的C-ACT＞19分例次低于轻度ETS患儿,而支气管扩张剂使用天数、吸入激素增加天数、全身激素使用天数也均明显多于轻度ETS患儿,差异均有统计学意义(P均＜0.05).结论 ETS是儿童哮喘控制不良的重要危险因素之一.     

Do parents of urban children with persistent asthma ban smoking in their homes and cars?

OBJECTIVE: Environmental tobacco smoke (ETS) increases morbidity for children with asthma. One method to reduce children's ETS exposure is to completely ban smoking in the home and car. We sought to evaluate the degree to which urban children with persistent asthma are protected by household and car smoking bans, and to determine whether health care professionals are counseling parents to implement smoking bans. METHODS: We asked parents of children with asthma to complete an in-person interview including questions about asthma symptoms, smokers in the home, smoking bans (home and car), and the receipt of ETS counseling by health care professionals. RESULTS: We included 231 children with persistent asthma symptoms (response rate 94%). Nearly half of the children lived with a smoker. Overall, only 64% of households had complete restrictions on smoking in the home and car. Even among the children with severe persistent symptoms, less than two-thirds were protected by a complete smoking ban. Among households with smokers, only 51% had a ban on smoking in the home and 49% in the car. The majority of caregivers had been questioned by health care professionals about home smoke exposure; less were asked about exposure in the car (40%) or given suggestions to decrease the child's exposure (58%). CONCLUSIONS: To our knowledge this is the first study to establish the prevalence of smoking bans among children with persistent asthma. Many children with asthma, even those with the most severe symptoms, remain exposed to ETS in the home and in cars. Identifying and reducing smoke exposure among these children should be a health care priority.     

A review of interventions for reduction of residential environmental tobacco smoke exposures among children

OBJECTIVE:

To describe individual-level interventions to reduce residential environmental tobacco smoke (ETS) exposure among children and to summarize the evidence of the effectiveness of the interventions.

PATIENTS AND METHODS:

A search of electronic databases (from 1987 to 1998) was conducted for studies designed to reduce ETS exposure of children through the use of interventions that included strategies other than parental smoking cessation. Twelve articles that presented nine unique interventions (six interventions were designed for well children and three interventions targeted children with asthma) were found. Information about location, target population, design, sample size, tested intervention and results were summarized for each study.

RESULTS:

Only one of the six interventions designed for well children produced significant reductions in ETS exposure, while all three of the interventions that targeted children with asthma reported small to moderate reductions in ETS exposure or respiratory symptoms.

CONCLUSIONS:

The number of interventions for ETS reduction published to date is miniscule relative to the magnitude of the associated health problems. Some ETS reduction interventions for children have shown significant reductions in exposure, but most interventions, especially those designed for well children, have had little effect. Little is known about which specific intervention components may be effective. Parental characteristics that may predict positive response to intervention efforts have not been identified. More research is needed to develop effective interventions that can be integrated with physician visits in the perinatal and early childhood periods. Adapting standard guidelines on counselling for parental smoking cessation may be a promising approach if the barriers identified by health professionals can be addressed adequately.     

Assessment of foetal exposure to cigarette smoke after recent implementations of smoke-free policy in Italy

AIM: We investigated foetal exposure to cigarette smoke following maternal active and passive smoking at the end of the pregnancy in a cohort of mother-infant dyads after recent implementation of the Italian smoke-free legislation and information campaigns against smoking. METHODS: Study subjects were 979 mothers and their newborns attended at one of the major Florence hospitals between the end of 2004 and during 2005, when smoking banning legislation in all the enclosed places of employment was completely enforced. A structured questionnaire was completed by mothers and cord serum cotinine was used as a biomarker of foetal exposure to maternal smoke at the end of the pregnancy. RESULTS: Women (53.9%) declared to be non-smokers not exposed to environmental tobacco smoke (ETS), 33.5% to be exposed non-smokers, while 12.6% reported daily smoking during pregnancy. Based on the levels of cord serum cotinine, 78.9% newborns were not exposed to ETS, 13.5% were exposed to ETS and 7.7% were exposed to active maternal smoke. CONCLUSIONS: Smoke-free policies can be an effective strategy for reducing both first-hand and second-hand exposure to cigarette smoke in pregnant women and their newborns. Due to the implementation of smoke-free legislation and information campaigns against smoking, a significant trend towards less active smoking during pregnancy was observed in our study cohort, as well as a minimal exposure to ETS in non-smoking pregnant women and their newborns.     

Passive smoking is associated with lower serum HDL‐C levels in school children

Background: In recent years, a number of studies have reported that exposure to environmental tobacco smoke (ETS) reduces high‐density lipoprotein cholesterol (HDL‐C) levels in children, as well as in adults. Further, a number of countries have indicated that passive smoking increases the risk of early arteriosclerosis onset. Here, to evaluate the effects of ETS exposure, we conducted a cross‐sectional epidemiological study on primary school children in Japan using answers from a questionnaire survey, as well as urine cotinine and lipid metabolism‐related variable measurements. Methods: A total of 121 sixth‐grade primary school children participated in this study by completing a questionnaire about their food intake, lifestyle and family smoking habits. Early in the morning, we also measured height, weight, blood pressure, serum levels of total cholesterol, triglyceride, HDL‐C, and blood sugar, as well as urine levels of cotinine and creatinine under unfed conditions. Results: From the questionnaire, 40 and 81 children reported being exposed and not exposed to ETS, respectively. Serum HDL‐C levels, which were adjusted for the degree of corpulence and exercise habits, were significantly lower in the passive smoker group than the non‐passive‐smoker group (65.3 and 72.1 mg/dL, respectively; P= 0.012). In addition, proportional differences in serum HDL‐C levels were also observed based on the amount of cigarettes smoked at home by family members of the child. Conclusions: Results suggest that ETS exposure at home is associated in a dose‐related manner with lower serum HDL‐C levels in primary school children. In addition, our results suggest that smoking in the presence of children who are not usually exposed to ETS increases the risk of arteriosclerosis. Given these findings, we strongly recommend the establishment of anti‐passive‐smoking measures.     

Parent reported home smoking bans and toddler (18-30 month) smoke exposure: a cross-sectional survey.

AIMS: To study the relation between the use of parent reported home smoking bans and smoke exposure among children aged 18-30 months. METHODS: A total of 309 smoking households with children aged 18-30 months, who were part of the Coventry Cohort study, consented to participate in this cross-sectional survey. RESULTS: Although parents in almost 88% of smoking households reported using harm reduction strategies to protect their toddlers from smoke exposure, only 13.9% reported smoking bans in the house. Mean log urinary cotinine:creatinine ratio was significantly lower for those children whose parents reported no smoking in the house (1.11, 95% CI 0.64 to 1.49) compared with none/less strict strategies (1.87, 95% CI 1.64 to 2.10). In linear regression models fitted on log cotinine:creatinine ratio, no smoking in the house was independently associated with a significant reduction in cotinine:creatinine ratio (B = -0.55, 95% CI -0.89 to -0.20) after adjusting for mother's and partner's average daily cigarette consumption, housing tenure, and overcrowding. The final model accounted for 44.3% of the variance. CONCLUSIONS: Not smoking in the house was associated with a reduction in mean urinary cotinine:creatinine ratio in children aged 18-30 months; the relation persisted after adjustment for levels of mother's and partner's daily cigarette consumption and sociodemographic factors. Results suggest that home smoking bans in this age group have a small but significant effect on smoke exposure independent of levels of parental tobacco consumption.     

Association between exposure to environmental tobacco smoke (ETS) and breastfeeding behaviour

AIM: A cross-sectional study was conducted to investigate the association between breastfeeding behaviour and exposure to environmental tobacco smoke (ETS). METHOD: Questionnaires were collected from 552 women. Blood and urine specimens were taken from part of the population at the time of delivery. The study population was classified into two groups: those exposed to ETS and those unexposed, based on self-reports from the subjects involved in the study. Cotinine levels in the urine and blood specimens were analysed by HPLC-UV under strict quality control procedures. RESULTS: There was a significant negative association between the exposure to ETS at home or in the workplace and the prevalence of breastfeeding in each of the 6 months following delivery using multiple logistic regression adjusted for other covariates. The cotinine levels in the urine and blood were dose-dependent, but not significantly so. However, women with lower cotinine levels had a higher probability of breastfeeding than those with higher levels. CONCLUSION: Women who are exposed to ETS have a low likelihood of breastfeeding. It is necessary for the government to regulate ETS in public areas and confined spaces in order to reduce the levels of ETS that women are exposed to.     

Parent reported home smoking bans and toddler (18-30 month) smoke exposure: a cross-sectional survey

Aims: To study the relation between the use of parent reported home smoking bans and smoke exposure among children aged 18–30 months. Methods: A total of 309 smoking households with children aged 18–30 months, who were part of the Coventry Cohort study, consented to participate in this cross-sectional survey. Results: Although parents in almost 88% of smoking households reported using harm reduction strategies to protect their toddlers from smoke exposure, only 13.9% reported smoking bans in the house. Mean log urinary cotinine:creatinine ratio was significantly lower for those children whose parents reported no smoking in the house (1.11, 95% CI 0.64 to 1.49) compared with none/less strict strategies (1.87, 95% CI 1.64 to 2.10). In linear regression models fitted on log cotinine:creatinine ratio, no smoking in the house was independently associated with a significant reduction in cotinine:creatinine ratio (B = –0.55, 95% CI –0.89 to –0.20) after adjusting for mother''s and partner''s average daily cigarette consumption, housing tenure, and overcrowding. The final model accounted for 44.3% of the variance. Conclusions: Not smoking in the house was associated with a reduction in mean urinary cotinine:creatinine ratio in children aged 18–30 months; the relation persisted after adjustment for levels of mother''s and partner''s daily cigarette consumption and sociodemographic factors. Results suggest that home smoking bans in this age group have a small but significant effect on smoke exposure independent of levels of parental tobacco consumption.     

Breast-feeding and environmental tobacco smoke exposure.

BACKGROUND: Exposure to environmental tobacco smoke is associated with adverse effects in infants and children. OBJECTIVE: To explore whether an increase in urinary cotinine fumarate level is caused by ingested nicotine and cotinine in breast-feeding infants. METHODS: We studied newborns at risk for developing asthma and allergies based on a strong family history. We measured urinary cotinine levels in the infants as a measure of environmental tobacco smoke exposure and cotinine levels in the breast milk of breast-feeding mothers. RESULTS: Of 507 infants, urinary cotinine levels during the first 2 weeks of life were significantly increased in infants whose mothers smoked. Breast-fed infants had higher cotinine levels than non-breast-fed infants, but this was statistically significant (P<.05) only if mothers smoked. Urinary cotinine levels were 5 times higher in breast-fed infants whose mothers smoked than in those whose mothers smoked but did not breast-feed. CONCLUSIONS: Mothers should be encouraged to not smoke, and parents must be advised of the potential respiratory and systemic risks of environmental tobacco smoke exposure to their child, including the potential for future addiction to smoking.     

The impact of passive smoking on the development of lower respiratory tract infections in children

Environmental tobacco smoke is an important public health problem. The objective of this study was to evaluate the effect of passive smoking on lower respiratory tract infections (LRTIs) in children aged 2-12 years. A case-control study was conducted on matched-pair design. One-hundred and fifty children with LRTIs and 150 healthy children were included in the study. Data were collected through questionnaire and urine samples for the determination of cotinine levels, and were analysed by McNemar chi-square, paired t-test and Pearson correlation tests. The prevalence of parental self-reported, indoor smoking was 71.3% in children with LRTI and 72.0% in healthy children. Employing 30 ng mg(-1), the cut-off level of urinary cotinine/creatinine as commonly accepted, 87.3% of the children with LRTIs and 84.7% of healthy children were found to be passive smokers (p = 0.61, odds ratio (OR) = 0.93; confidence interval (CI) = 0.34-2.53). If 60 ng mg(-1) of urinary cotinine/creatinine was accepted as a cut-off level, it was observed that the rates of passive smoking were 76.7% and 50.7%, respectively (p = 0.000, OR = 4.72; 95% CI = 2.62-8.52). Dose-dependent exposure to environmental tobacco smoke was found to be associated with the incidence of LRTI.     

Adverse health effects related to tobacco smoke exposure in a cohort of three-year olds

AIM: To analyse the importance of mothers' smoking during pregnancy and/or environmental tobacco smoke (ETS) exposure in early childhood for children's health and well-being at the age of 3 years. METHODS: Four groups from a population based cohort (n=8850) were compared: children with nonsmoking mother during pregnancy and nonsmoking parents at the age of 3 years (n=7091); children with only foetal exposure (n=149); children exposed only postnatally (n=895) and children exposed both pre- and postnatally (n=595). Odds ratios and 95% confidence intervals were calculated. RESULTS: Children exposed both pre- and postnatally had more wheezing (1.14; 1.07-1.21) and rhinitis (1.16; 1.06-1.26), used more cough-mixture (1.07; 1.01-1.14) and broncodilatating drugs (1.08; 1.02-1.15) and suffered more from excessive crying (1.31; 1.13-1.51) and irritability (1.27; 1.09-1.48) compared to children with nonsmoking parents. Children exposed only postnatally had more rhinitis (1.24; 1.12-1.37), used more cough-mixture (1.14; 1.05-1.29) and suffered more from poor sleep (1.26; 1.07-1.47) than children of nonsmoking parents. Children with prenatal exposure only used more broncodilatating drugs (1.45; 1.03-2.04) and suffered more from poor sleep (2.06; 1.09-3.87). CONCLUSION: Health differences, small but significant, indicate that prenatal and/or postnatal ETS exposure alone, or in combination, seems to interfere with child health, supporting the importance of zero tolerance. However, as most smoking parents in Sweden try to protect their children from ETS exposure, the results also might indicate that protective measures are worthwhile.