Association between second hand smoke (SHS) exposure and caregiver stress in children with poorly controlled asthma

Objective: Urban children with asthma experience high rates of second hand smoke (SHS) exposure. The objective was to examine whether SHS exposure is associated with symptom frequency in children with poorly controlled asthma. Methods: Children were enrolled in a RCT to test the efficacy of an environmental control behavioral intervention versus an attention control group and followed over 12 months. SHS exposure assessed using salivary cotinine measurement. Frequency of child asthma symptoms, healthcare utilization, household smoking and caregiver daily life stress were obtained via caregiver report. Time of enrollment was recorded to assess seasonal factors. Symptom days and nights were the primary outcomes. Multivariable models and odds ratios examined factors that best predicted increased frequency of daytime/nighttime symptoms. Results: Children (n?=?222) with a mean age of 6.3 (SD 2.7) years, were primarily male (65%), African American (94%), Medicaid insured (94%), and had poorly controlled asthma (54%). The final multivariable model indicated symptoms in the fall (OR 2.78; 95% CI 1.16, 6.52) and increased caregiver daily life stress (OR 1.13, 95% CI 1.02, 1.25) were significantly associated with increased symptom days when controlling for cotinine level, intervention status, child age and home and car smoking restrictions. Conclusions: There was no impact of SHS exposure on increased symptom frequency. High caregiver daily life stress and symptoms in fall season may place children with asthma at risk for increased day/nighttime symptoms. Close monitoring of symptoms and medication use during the fall season and intervening on caregiver life stress may decrease asthma morbidity in children with poorly controlled asthma.     

Association of secondhand smoke exposure with asthma symptoms,medication use,and healthcare utilization among asthmatic adolescents

Objective: To investigate the association between secondhand smoke exposure (SHSe) and asthma symptoms, medication use, and emergency department (ED)/urgent care (UC) utilization among adolescents. Methods: We performed a secondary cross-sectional analysis of Population Assessment of Tobacco and Health Study Wave 2 (2014–2015) including asthmatic adolescents (N = 2198). Logistic regression models and Poisson regression models were built. Results: Participants with SHSe ≥1 hour in the past 7 days were at increased risk of reporting shortness of breath and harder to exercise aOR, 1.22; 95% CI, 1.04–1.43), wheezing (aOR, 1.26; 95% CI, 1.01–1.56), wheezing disturbing sleep (aOR, 1.88; 95% CI, 1.35–2.63), wheezing during/after exercise (aOR, 1.41; 95% CI, 1.19–1.66), wheezing limiting speech (aOR, 2.11; 95% CI, 1.55–2.86), dry cough at night (aOR, 1.86; 95% CI, 1.54–2.24), and asthma symptoms disturbing sleep (aOR, 2.25; 95% CI, 1.81–2.79). Participants with SHSe ≥1 hour were more likely to take asthma medications (aOR, 1.25; 95% CI, 1.03–1.52), including steroids (aOR, 1.86; 95% CI, 1.19–2.91), oxygen therapy (aOR, 2.88; 95% CI, 1.82–4.54), and controlling medications (aOR, 1.50; 95% CI, 1.24–1.82). Symptoms and medications varied by living with a smoker and home SHSe. Participants with SHSe were at increased risk of having a higher number of asthma attacks that required steroid use. Participants who lived with a smoker and had home SHSe were at increased risk of having higher ED/UC visits for asthma. Conclusions: SHSe reduction efforts are needed for asthmatic adolescents, and EDs/UCs are promising venues.     

Employed adults with asthma who have frequent workplace exposures

Abstract

Objective: The recent increase in asthma prevalence is thought to be partially due to environmental changes such as changes in air pollution and occupational exposures. Nationally representative information on workplace exposures among US adults with asthma is limited. Methods: We examined 2010 National Health Interview Survey data to determine the proportion of employed adults with asthma who had frequent workplace exposures. Results: Among adults with current asthma, 19.6% frequently worked outdoors, 17.5% were frequently exposed to workplace secondhand smoke and 28.1% were frequently exposed to workplace vapors, gas, dust or fumes. Adults ever told by a health professional that asthma is probably work-related, when compared to adults who were not, had increased odds of frequent work outdoors [prevalence odds ratio (POR)?=?2.76], frequent workplace exposure to secondhand smoke (POR?=?3.08) and frequent workplace exposure to vapors, gas, dust or fumes (POR?=?3.56). Conclusions: To our knowledge, this is the first population-based study in USA that estimates the proportion of working adults with asthma that have frequent workplace exposures. Increasing the understanding of workplace exposures among adults with asthma will help enable prevention of asthma through workplace exposure reduction or avoidance. Future studies should further examine industries and occupations of individuals with asthma and frequent workplace exposures.     

Gaps in health insurance coverage and emergency department use among children with asthma

Background: Gaps in health insurance coverage may complicate asthma management and increase emergency department (ED) use. Using two nationally-representative surveys, we characterize the prevalence of coverage gaps among children with asthma, and describe their association with ED visits in this population. Methods: De-identified data were obtained from the 2016 National Survey of Children’s Health (NSCH) and National Health Interview Survey (NHIS). Among children with asthma, we classified coverage over the past year as: (1) continuous private, (2) continuous public, (3) gap in coverage, and (4) continuously uninsured. The primary outcome was all-cause ED visits in the past year (both surveys). Secondary outcomes included unmet health care needs (NSCH), asthma-related ED visits or hospitalizations (NHIS) and asthma exacerbations (NHIS). Results: The analysis included 3739 (NSCH) and 854 (NHIS) children with asthma, representing a population of 5.5 million children in the US. Estimated prevalence of coverage gaps was 5% in the NSCH and 3% in the NHIS. On multivariable ordinal logistic regression using NSCH data, coverage gaps were associated with increased all-cause ED use (OR?=?2.5; 95% CI: 1.3, 4.7, p?=?0.005), compared to continuous private coverage. Further analysis confirmed higher odds of unmet health care needs, asthma exacerbations, and asthma-related ED visits among children with coverage gaps. Conclusions: Children with asthma who experience insurance coverage gaps have increased ED use, possibly related to poorer access to appropriate health care. Protecting insurance coverage continuity may reduce ED use and improve clinical outcomes in this population.     

Atopy,but not obesity is associated with asthma severity among children with persistent asthma

Background and Objective: Obesity is associated with an increased risk of asthma in children. Atopic sensitization is a major risk factor for asthma including severe asthma in children. It is unclear if obesity is associated with worse asthma control or severity in children and how its effects compare to atopy. We sought to examine relationships of weight status and atopy to asthma control and severity among a population of predominantly low income, minority children and adolescents with persistent asthma. Methods: A cross-sectional analysis of 832 children and adolescents, age range 5–17 years, with persistent asthma was performed. Clinical assessments included asthma questionnaires of symptoms, asthma severity score, health care utilization and medication treatment step, lung function testing, and skin prick testing as well as measures of adiposity. Data were collected between December 2010 and August 2014 from Johns Hopkins Hospital in Baltimore, MD and Children's Hospital of Boston, MA. Results: Obesity was not associated with worse asthma control or severity in this group of predominantly low income, minority children and adolescents with persistent asthma. However, a greater degree of atopy was associated with lower lung function, higher asthma severity score, and higher medication treatment step. Conclusion: Atopy may be a more important risk factor for asthma severity than obesity among low-income minority children and adolescents with persistent asthma living in Northeastern cities in the United States.     

An Ecological Momentary Assessment analysis of relations among coping, affect and smoking during a quit attempt

Aims This study used Ecological Momentary Assessment (EMA) data from smokers trying to quit to assess relations among coping, positive affect, negative affect and smoking. The effects of stress coping on affect and smoking were examined. Design Data from a randomized clinical trial of smoking cessation treatments were submitted to multi‐level modeling to test the effects of coping with stressful events on subsequent affect and smoking. Setting Center for Tobacco Research and Intervention, Madison, Wisconsin. Participants A total of 372 adult daily smokers who reported at least one stressful event and coping episode and provided post‐quit data. Measurements Participants' smoking, coping and affect were assessed in near real time with multiple EMA reports using electronic diaries pre‐ and post‐quit. Findings Multi‐level models indicated that a single coping episode did not predict a change in smoking risk over the next 4 or 48 hours, but coping in men was associated with concurrent reports of increased smoking. Coping predicted improved positive and negative affect reported within 4 hours of coping, but these affective gains did not predict reduced likelihood of later smoking. Pre‐quit coping frequency and gender moderated post‐quit stress coping relations with later positive affect. Men and those with greater pre‐quit coping frequency reported greater gains in positive affect following post‐quit coping. Conclusions Coping responses early in a quit attempt may help smokers trying to quit feel better, but may not help them stay smoke‐free.     

Low-level environmental tobacco smoke exposure and inflammatory biomarkers in children with asthma

Objective: The effects of low-level environmental tobacco smoke (ETS) exposure, on asthma control, lung function and inflammatory biomarkers in children with asthma have not been well studied. The objective of the study was to assess ETS exposure in school-age children with asthma whose parents either deny smoking or only smoke outside the home, and to assess the impact of low-level ETS exposure on asthma control, spirometry and inflammatory biomarkers. Methods: Forty patients age 8–18 years with well-controlled, mild-to-moderate persistent asthma treated with either inhaled corticosteroids (ICS) or montelukast were enrolled. Subjects completed an age-appropriate Asthma Control Test and a smoke exposure questionnaire, and exhaled nitric oxide (FeNO), spirometry, urinary cotinine and leukotriene E₄ (LTE₄) were measured. ETS-exposed and unexposed groups were compared. Results: Only one parent reported smoking in the home, yet 28 (70%) subjects had urinary cotinine levels ≥1?ng/ml, suggesting ETS exposure. Seven subjects (18%) had FeNO levels >25parts per billion, six of whom were in the ETS-exposed group. In the ICS-treated subjects, but not in the montelukast-treated subjects, ETS exposure was associated with higher urinary LTE₄, p?=?0.04, but had no effect on asthma control, forced expiratory volume in 1?s or FeNO. Conclusions: A majority of school-age children with persistent asthma may be exposed to ETS, as measured by urinary cotinine, even if their parents insist they don’t smoke in the home. Urinary LTE₄ was higher in the ETS-exposed children treated with ICS, but not in children treated with montelukast.     

Long-term control medication use and asthma control status among children and adults with asthma

Background: Uncontrolled asthma decreases quality of life and increases health care use. Most people with asthma need daily use of long-term control (LTC) medications for asthma symptoms and to prevent asthma attacks. Ongoing assessment of a person's level of asthma control and medication use is important in determining the effectiveness of current treatment to decrease the frequency and intensity of symptoms and functional limitations. Objective: To assess the use of LTC medication among children and adults with current asthma and identify contributing factors for LTC medication use. Methods: We used the 2006–2010 Behavioral Risk Factor Surveillance System (BRFSS) child and adult Asthma Call-back Survey (ACBS) data to assess the level of asthma control and LTC medication use. Asthma control was classified as well controlled and uncontrolled using guideline-based measures. We used multivariable logistic regression models to identify contributing factors for LTC medication use and having uncontrolled asthma. Results: Among persons with current asthma, 46.0% of children and 41.5% of adults were taking LTC medications and 38.4% of children and 50.0% of adults had uncontrolled asthma. Among children who had uncontrolled asthma (38.4%), 24.1% were taking LTC medications and 14.3% were not taking LTC medications. Among adults who had uncontrolled asthma (50.0%), 26.7% were taking LTC medications and 23.3% were not taking LTC medications. Conclusions: Using BRFSS ACBS data to assess the level of asthma control and LTC medication use can identify subpopulations of persons with asthma who receive suboptimal treatment, for which better asthma-related medical treatment and management are needed.     

Parent report and electronic medical record agreement on asthma education provided and children’s tobacco smoke exposure

Abstract

Objective: To examine the concordance between parent report and electronic medical record documentation of asthma health education provided during a single clinic visit and second-hand tobacco smoke exposure among children with asthma. Methods: Parents of children with asthma were recruited from two types of clinics using different electronic medical record systems: asthma-specialty or general pediatric health department clinics. After their child’s outpatient visit, parents were interviewed by trained study staff. Interview data were compared to electronic medical records for agreement in five categories of asthma health education and for the child’s environmental tobacco smoke exposure. Kappa statistics were used to identify strength of agreement. Chi square and t-tests were used to examine differences between clinic types. Results: Of 255 parents participating in the study 90.6% were African American and 96.1% were female. Agreement was poor across all clinics but was higher within the asthma specialty clinics than the health department clinics for smoke exposure (κ?=?0.410 versus 0.205), asthma diagnosis/disease process (κ?=?0.213 versus ?0.016) and devices reviewed (κ?=?0.253 versus ?0.089) with parents generally reporting more education provided. For the 203 children with complete medical records, 40.5% did not have any documentation regarding smoking exposure in the home and 85.2% did not have any documentation regarding exposure elsewhere. Conclusions: We found low concordance between the parent’s report and the electronic medical record for smoke exposure and asthma education provided. Un- or under-documented smoke exposure and health education have the potential to affect continuity of care for pediatric patients with asthma.     

The relationship between caregivers' subjective social status and asthma symptoms and management for urban children

Objective: Subjective social status (SSS) is a person's perception of his/her social standing among others. We explored the relationship between caregivers' SSS and asthma symptoms, visits, and medication use among children with persistent asthma. Methods: We analyzed baseline data of children (3–10 years) from the SB-TEAM trial in Rochester, NY. Using a modified MacArthur Scale of SSS, caregivers rated themselves “a lot worse off” to “a lot better off” compared to 4 groups (e.g., neighbors). “Low SSS” was defined by a response of “a lot worse off” or “somewhat worse off” for any of the referent groups. Caregivers reported their child's asthma symptoms, healthcare visits for asthma, and medication use. Bivariate and multivariate statistics were used. Results: We found that, of the 230 children enrolled (participation rate:78%, 62% Black, 72% Medicaid), 29% of caregivers had low SSS. Caregivers with low SSS had more depressive symptoms (46% vs. 28%) and lower social support (69.1 vs. 77.7). In multivariable analyses, children of caregivers with low SSS had fewer symptom-free days/2 weeks (5.8 vs. 7.9, p = .01). While they were more likely to have a routine asthma visit in the past year (35% vs. 23%, adjusted p = .03), there was no difference in their use of preventive medication. Conclusions: Many caregivers of children with persistent asthma report low SSS. While children of these caregivers had fewer symptom-free days, they were not more likely to use preventive medications. Efforts are needed to support these caregivers to ensure optimal preventive care and reduce morbidity.     

Assessing asthma severity among children and adults with current asthma

Background: Asthma severity is a key indicator to assess asthma care and management. Severity status may vary over time. Assessing asthma severity periodically is important for monitoring the health and well-being of people with asthma. Objective: To assess population-based asthma severity and to identify related-risk factors among children and adults with asthma. Methods: We used the 2006–2010 BRFSS child and adult Asthma Call-back Survey. Asthma severity was classified as intermittent or persistent. We performed multivariate logistic regression to identify related-risk factors. Results: Overall, 63.8% of persons with asthma had persistent asthma. Persistent asthma was more prevalent among children aged 0–4 years (71.8%; prevalence rate ratio [PR]?=?1.3). Among adults with current asthma, persistent asthma was more prevalent among those who were 45 years or older (aged 45–54: 69.4%; PR?=?1.1, aged 55–64: 72.6%; PR?=?1.2, and aged 65+: 77.8%; PR?=?1.3); annual household incomes of <$15?000 (74.1%; PR?=?1.1); and first diagnosed at age 55 years or older (first diagnosed at age 55–64: 80.4%; PR?=?1.1, at age 65?+?: 81.5%; PR?=?1.1). The prevalence of persistent asthma was also higher among current smokers who were also exposed to secondhand smoke (SHS) (74.7%; PR?=?1.1); and among those with Chronic Obstructive Pulmonary Disease (COPD) (77.1%; PR?=?1.2). Conclusions: Nearly two-thirds of children and adults with asthma had persistent asthma. Identifying related-risk factors could help improve targeted interventions or strategies to reduce modifiable predictors (low income, smoking, and SHS) of increased asthma severity. Such strategies could improve asthma care and quality of life.     

Parental coping,depressive symptoms,and children's asthma control and school attendance in low-income,racially, and ethnically diverse urban families

Objective: Low-income urban children of color are at elevated risk for poor asthma control. This cross-sectional study examined associations among parents' coping (primary control, secondary control, and disengagement), parental depressive symptoms, and children's asthma outcomes (asthma control and school attendance) in a predominantly low-income, racially/ethnically diverse sample of families. Methods: Parents (N = 78; 90% female) of children (33% female; 46% Black; 38% Latino) aged 5–17 years (M = 9.5 years) reported on their own coping and depressive symptoms, their child's asthma control, and full and partial days of school missed due to asthma. Results: Parents' secondary control coping (i.e., coping efforts to accommodate/adapt to asthma-related stressors) was negatively correlated, and disengagement coping (i.e. coping efforts to avoid/detach from stressors) was positively correlated, with their depressive symptoms. Secondary control coping was also correlated with fewer partial days of school missed. Primary control coping (i.e., coping efforts to change stressors) was not associated with depressive symptoms or asthma outcomes. Parents' depressive symptoms were also positively correlated with poorer asthma control and partial days of school missed. Regression models showed direct and indirect effects of secondary control and disengagement coping on asthma outcomes via depressive symptoms, after controlling for demographic factors. Conclusions: Parents' secondary control and disengagement coping are related to children's asthma outcomes. Secondary control coping may support parents' mental health and children's asthma control in low-income urban families.     

Prevalence and severity of asthma among Indian school children aged between 6 and 14 years: associations with parental smoking and traffic pollution

Objective: Phase three of the International Study of Asthma and Allergy in Children (ISAAC) was carried out at various sites in India. The prevalence of asthma symptoms in school children and the effect of environmental tobacco smoke and traffic pollution on the occurrence of asthma were analysed. Methods: Two groups of school children, aged 6–7?yr and 13–14?yr, participated according to the ISAAC protocol. Schools were randomly selected and responses to the ISAAC questionnaire were recorded. Results: The prevalence of asthma was 5.35% in the 6–7?yr age group and 6.05% in the 13–14?yr age group. The odds ratios (ORs) for the risk of asthma in children with exposure to mild, moderate and heavy traffic pollution compared with minimal traffic pollution were 1.63 (95% CI: 1.43, 1.85), 1.71 (95% CI: 1.49, 1.96) and 1.53 (95% CI: 1.31, 1.78), respectively, in the younger group. Similarly, in the older group, they were 1.19 (95% CI: 1.04, 1.36), 1.51 (95% CI: 1.31, 1.75) and 1.51 (95% CI: 1.29, 1.76). Asthma was associated with maternal smoking [6–7?yr group: OR?=?2.72 (2.05, 3.6); 13–14?yr group: OR?=?2.14 (1.72, 2.66)] and paternal smoking [6–7?yr group: OR?=?1.9 (1.70, 2.11); 13–14?yr group: OR?=?1.21 (1.09, 1.34)]. Conclusions: The prevalence of asthma was lower in the 6–7 than the 13–14?yr age group. Environmental tobacco smoke and traffic pollution were the factors most strongly associated with asthma in Indian children.     

A qualitative study of parent perspectives on barriers,facilitators and expectations for school asthma care among urban,African-American children

Objectives: Minority children experience the disproportionate burden of asthma and its consequences. Studies suggest ethnic groups may experience asthma differently with varied perceptions and expectations among parents of African-American and Latino children. Because parents coordinate asthma care with the school, where children spend a significant amount of their day, this study’s goal was to determine parents’ perspectives on school asthma management. Methods: Focus groups were conducted with parents of children with asthma at four urban schools whose student population is predominantly African-American. A semi-structured guide was utilized focusing on barriers, facilitators and expectations for asthma care at school. Grounded theory principles were applied in this study. Results: Twenty-two parents (91% females) representing 13 elementary and 10 middle school children with asthma (61% boys) participated in four focus groups. Most children (87%) had persistent asthma. The identified barriers to effective school-based asthma care included limited awareness of children with asthma by teachers/staff, communication issues (e.g. school/parent, within school), inadequate education and lack of management plans or systems in place. In contrast, the identified facilitators included steps that fostered education, communication and awareness, as supported by management plans and parent initiative. Parents described their expectations for increased communication and education about asthma, better systems for identifying children with asthma, and a trained asthma point person for school-based asthma care. Conclusions: Parents of children with asthma identified important barriers, facilitators and expectations that must be considered to advance school asthma management. Improved school-based asthma care could lead to better health and academic outcomes.     

Geographic and racial variation in asthma prevalence and emergency department use among Medicaid-enrolled children in 14 southern states

Background: Despite evidence-based prevention and practice guidelines, asthma prevalence, treatment, and outcomes vary widely at individual and community levels. Asthma disproportionate/ly affects low-income and minority children, who comprise a large segment of the Medicaid population. Methods: 2007 Medicaid claims data from 14 southern states was mapped for 556 counties to describe the local area variation in 1-year asthma prevalence rates, emergency department (ED) visit rates, and racial disparity rate ratios. Results: One-year period prevalence of asthma ranged from 2.8% in Florida to 6.4% in Alabama, with a median prevalence rate of 4.1%. At the county level, the prevalence was higher for Black children and ranged from 1.03% in Manatee County, FL, to 21.0% in Hockley County, TX. Black–White rate ratios of prevalence ranged from 0.49 in LeFlore County, MS, to 3.87 in Flagler County, FL. Adjusted asthma ED visit rates ranged from 2.2 per 1000 children in Maryland to 16.5 in Alabama, with a median Black–White ED-visit rate ratio of 2.4. Rates were higher for Black children, ranging from 0.80 per 1000 in Wicomico County, MD, to 70 per 1000 in DeSoto County, FL. Rate ratios of ED visits ranged from 0.25 in Vernon Parish, LA, to 25.28 in Nelson County, KY. Conclusions and relevance: Low-income children with Medicaid coverage still experience substantial variation in asthma prevalence and outcomes from one community to another. The pattern of worse outcomes for Black children also varies widely across counties. Eliminating this variation could substantially improve overall outcomes and eliminate asthma disparities.