CONTROL OF ENVIRONMENTAL TOBACCO SMOKE

Letters to the editor CONTROL OF ENVIRONMENTAL TOBACCO SMOKE To the Editor: Winkelstein et al1 made an important contribution by examining ways in which parents modified their behavior or home environment to reduce their asthmatic children’s exposure to environmental tobacco smoke (ETS), and demonstrated that more modifications were associated with lower metabolites. This association held mostly for smoking outside the home and mostly for families in which only the parent smoked in the home. The authors stated that associations between parental efforts to reduce their children’s exposure and actual exposure have not been studied. They concluded by recommending studies of teaching parents to smoke outside the home. While we agree that little has been done in these regards, we have published findings that apparently were missed in their literature review. We recruited families with an asthmatic child who was exposed to parental cigarettes. Using established behavior change techniques, we were able to reduce exposure levels for up to 2 years.2,3 We have three currently funded trials attempting to replicate these findings in low income, minority, and community-based populations. Whereas Winkelstein et al provided a laudable recommendation of simply maintaining a smoke-free home, or at least recommended that smoking only be done outside the home, our experience is that there is considerable variability across families’ home environments and behavioral patterns that make this difficult. We identified that the conditions under which exposure is most likely were not necessarily the same as the conditions under which parents were most likely to smoke.4 More research on reduction of ETS exposure, and not confined to high risk groups, is critical. Secondhand smoke is a health risk for all people. Targeting ETS may be more politically acceptable: while the tobacco industry argues that it is an adult’s privilege to smoke, it is no one’s privilege to expose and therefore harm others. By shifting public sentiment more to-

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ward protecting nonsmokers from ETS, we may find that this results in decreases in smoking prevalence. We have discussed these cultural level influences more completely elsewhere.5 If we can control smoking prevalence, as well as ETS exposure prevalence by increasing our focus on ETS, and if this can more easily be achieved in the context of considerations of personal liberty, then we should shift our focus accordingly. We appreciate the opportunity to add our findings to those of Winkelstein et al and look forward to continued efforts to reduce the prevalence of passive smoking. DENNIS R WAHLGREN, MA MELBOURNE F HOVELL, PHD, MPH SUSAN B MELTZER, MPH Center for Behavioral Epidemiology and Community Health Graduate School of Public Health San Diego State University San Diego, California REFERENCES 1. Winkelstein ML, Tarzian A, Wood RA.

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Parental smoking behavior and passive smoke exposure in children with asthma. Ann Allergy Asthma Immunol 1997;78: 419 –23. Hovell MF, Meltzer SB, Zakarian JM, et al. Reduction of environmental tobacco smoke exposure among asthmatic children: a controlled trial. Chest 1994; 106:440 – 6. Wahlgren DR, Hovell MF, Meltzer SB, et al. Reduction of environmental tobacco smoke exposure in asthmatic children: a two-year follow-up. Chest 1997;111:81– 8. Emerson JA, Wahlgren DR, Hovell MF, et al. Parent smoking and asthmatic children’s exposure patterns: a behavioral epidemiology study. Addict Behav 1994; 6:677– 89. Wahlgren DR, Hovell MF, Slymen DJ, et al. Predictors of tobacco use initiation in adolescents: A two-year prospective study and theoretical discussion. Tobacco Control (in press).

Response: Thank you for bringing your research relating to children’s exposure to tobacco

smoke to our attention.1–3 Our investigation described the modifications that smoking parents made to reduce passive smoke exposure and related those modifications to the amount of cotinine present in the child’s urine.4 The interventions detailed in your investigations complement our research and emphasize the need for continued investigation in this area. We agree that there is considerable variability across family environments, and that health professionals need to obtain as much information about parental smoking behavior as possible. We also believe that attempts to provide a smoke-free home for all children with asthma remain essential. We look forward to the results of your current investigations and support all efforts to reduce the exposure of children with asthma to environmental tobacco smoke. MARILYN L WINKELSTEIN, RN, PHD ANITA TARZIAN, RN, MS University of Maryland School of Nursing Baltimore, Maryland ROBERT A WOOD, MD The Johns Hopkins University School of Medicine Baltimore, Maryland REFERENCES 1. Hovell MF, Meltzer SB, Zakarian JM, et al. Reduction of environmental tobacco smoke exposure among asthmatic children: a controlled trial. Chest 1994; 106:440 – 6. 2. Wahlgren DR, Hovell MF, Meltzer SB, et al. Reduction of environmental tobacco smoke exposure in asthmatic children: a two-year follow-up. Chest 1997;111:81– 8. 3. Emerson JA, Wahlgren DR, Hovell MF, et al. Parent smoking and asthmatic children’s exposure patterns: a behavioral epidemiology study. Addict Behav 1994; 6:677– 89. 4. Winkelstein ML, Tarzian A, Wood RA. Parental smoking behavior and passive smoke exposure in children with asthma. Ann Allergy Asthma Immunol 1997;78: 419 –23.

ANNALS OF ALLERGY, ASTHMA, & IMMUNOLOGY