- Email: [email protected]
Do Parents of Urban Children With Persistent Asthma Ban Smoking in Their Homes and Cars?
Do Parents of Urban Children With Persistent Asthma Ban Smoking in Their Homes and Cars? Jill S. Halterman, MD, MPH; Maria Fagnano, BA; Kelly M. Conn, MPH; Peter G. Szilagyi, MD, MPH 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 pro-
tected 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.
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homes with smoking bans to which exceptions were made, and this observation has been substantiated in other studies.27,28 In addition to lowering children’s exposure to ETS, restrictions on smoking in the home also are associated with greater rates of cessation among smokers.29 –31 Overall, between 1/4 and 1/3 of all young children are exposed to ETS in their home, 32–34 and in the National Cooperative Inner-City Asthma Study, 59% of families reported at least one smoker in the home.35 Prior studies have shown the prevalence of smoking bans among children with asthma who live with a smoker is less than 50%.26,28 It is not clear to what extent smoking bans are used to protect children with persistent asthma, and whether pediatricians are taking advantage of their unique opportunity to counsel parents of children with asthma regarding ETS at office visits. The objectives of this study were 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 of children with asthma to implement smoking bans.
KEY WORDS: childhood asthma; environmental tobacco smoke; smoking bans Ambulatory Pediatrics 2006;6:115–119
nvironmental tobacco smoke (ETS) is associated with worsening symptoms and decreased pulmonary function among young children with asthma.1–10 Children with asthma who are exposed to maternal smoking have higher requirements for medications and more frequent visits to the emergency department.11–16 This is particularly pertinent for young urban children because they experience greater exposure to ETS compared with other children.17–19 Avoiding triggers, including ETS exposure, is recommended as an important component of asthma management,20 and pediatricians can play a key role in protecting children from tobacco exposure. However the majority of pediatricians do not routinely address smoke exposure at office visits,21,22 or offer cessation counseling to parents.22,23 Children most frequently are exposed to ETS in the home.24,25 Thus, one method to help reduce children’s ETS exposure requires parents to completely ban smoking in their home. A study by Wakefield et al 26 showed that children living in homes with absolute smoking bans had significantly lower levels of urinary cotinine (a quantitative measure of smoke exposure) than children from
METHODS Setting and Participants We conducted this study by using interview data from an office-based asthma intervention based in 3 urban pediatric clinics in Rochester, NY. We included children ages 2–12 years with physician diagnosed asthma who had asthma symptoms noted in their medical record within the previous 2 years. Children were eligible for enrollment if
From the Department of Pediatrics, University of Rochester School of Medicine and Dentistry and Golisano Children’s Hospital at Strong, Rochester, NY. Address correspondence to Jill S. Halterman, MD, MPH, University of Rochester School of Medicine, Box 777, Strong Memorial Hospital, 601 Elmwood Ave, Rochester, NY 14642 (e-mail: jill_halterman@urmc. rochester.edu). Received for publication August 3, 2005; accepted October 13, 2005.
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they arrived at the office for any scheduled visit with a physician or nurse practitioner. We included asthmatic children presenting to the office for any reason, including well-child care, asthma care, or care for another acute illness. A member of the study team approached the caregivers in the waiting room prior to the child’s office visit to offer participation in an intervention study to improve asthma care. From October of 2003 to August 2004, we approached 320 caregivers of children with asthma in the waiting room to elicit written informed consent and administer a brief written questionnaire, and 301 agreed to participate (response rate 94%). The questionnaire included inquiries about their child’s asthma symptoms, current medications, primary caregiver smoking status, number of smokers living in the home, smoking bans in the home and car, ETS counseling by a health care professional, and the family’s sociodemographic background. For this study we included only children with persistent asthma symptoms (n ⫽ 231) because we were particularly interested in smoke exposure among these symptomatic children. Asthma severity was assessed by parent report using criteria set forth by the National Heart, Lung, and Blood Institute.36,37 Persistent severity was defined as having daytime asthma symptoms ⬎2 times per week during the past 2 weeks, or nighttime asthma symptoms ⬎1 times per week during the past 2 weeks. The University of Rochester’s Institutional Review Board approved the study protocol. Definitions ETS Exposure We inquired about the smoking status of the primary caregiver (“How much does this child’s primary caregiver smoke? Never, occasionally or daily”; responses dichotomized as never vs. occasionally / daily), and the number of smokers living in the home (“How many people living in this child’s home smoke?”). We determined whether a household had a smoker in the home other than the primary caregiver on the basis of responses to the 2 questions above (primary caregiver smoking status and number of smokers in the home). We used a method of inquiry regarding smoking bans that was previously validated using children’s cotinine measurements.26 Parents were asked to choose from the following options to describe the situation regarding smoking in the child’s home: (1) smoking is allowed in any common room of the home, (2) smoking is limited to part of the house where the child rarely goes, or (3) there is no smoking inside at all. If the parent reported no smoking inside at all, we then asked if there were any exceptions to this situation. Only parents reporting no smoking inside the home with no exceptions were considered to have a complete smoking ban in the home.26 A similar mechanism of inquiry was used to determine the presence or absence of a car smoking ban. Among parents who owned a car, those reporting no smoking inside the car, with no exceptions to this situation, were considered
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to have a complete car smoking ban.26 We defined a complete smoking ban as having no ETS exposure in any setting (home or car) with no exceptions. ETS Counseling We assessed a history of ETS counseling by health care providers by asking caregivers whether, in the past year, a physician or nurse ever; 1) specifically asked whether anyone in the child’s home smokes, 2) asked whether anyone smokes with the child in the car, and 3) talked about how to decrease the child’s exposure to smoke. The primary caregivers who smoked also were asked if a physician or nurse had ever suggested that they stop smoking and if a health care provider had offered them resources (e.g. referrals to programs, counseling, nicotine replacement) to help them quit smoking within the past year. Asthma Severity All of the children in this study had persistent asthma symptoms as defined by national criteria. We further categorized asthma severity as mild-moderate persistent (daytime symptoms more than 2x a week but not everyday/all the time and nighttime symptoms one or more times a week, but not frequently/every night) versus severe persistent (daytime symptoms everyday/all the time and/or nighttime symptoms frequently/every night).36,37 Analysis We used standard cross tabulations and 2 analyses to test for differences in proportions. Odds ratios and 95% confidence intervals were used to estimate risk. We performed all analyses by SPSS software v12.0 (SPSS Inc, Chicago, Ill). A 2-sided ␣ ⬍ .05 was considered statistically significant. RESULTS Of the 301 asthmatic subjects enrolled, 231 had persistent asthma symptoms and were included in this analysis (mean age 6.3 years). Table 1 shows the demographic characteristics of these children. The majority of the subjects were boys (60%), and 71% were enrolled in Medicaid. Fifty-five percent of the children were described as African American, and 31% described Hispanic ethnicity. The children were selected if they had persistent asthma symptoms, and more than one-third had severe persistent symptoms. Thirty-six percent of the children had a primary caregiver who smoked, and 48% lived with one or more smoker in the home. Table 2 describes the prevalence of smoking bans for households with and without smokers. Among all of the families, 71% banned smoking in the home, 74% banned smoking in the car, and 64% had a complete smoking ban in both locations. The presence of bans was significantly different among households with and without smokers. Among homes with smokers, only 51% had a home smoking ban, and 49% had a car smoking ban (compared with 90% and 91% of families with no smokers in the home, P⬍ .001). Additionally, children living in homes with
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Table 1. Population Demographics Characteristic Child demographics Male Sex Age, y 2–5 6–12 Race White African American Other Hispanic ethnicity Medicaid Child health Asthma severity Mild to moderate persistent Severe persistent Caretaker demographics Caretaker age, y ⬍30 ⱖ30 Caretaker education less than high school Household composition of single-parent family Smoking characteristics Primary caregiver smokers Smoker present in home other than primary caregiver Number of smokers in home 0 1 2 or more
n (%) (N ⫽ 231) 138 (60) 114 (49) 116 (50) 19 (8) 127 (55) 85 (37) 71 (31) 163 (71)
146 (63) 85 (37)
119 (52) 111 (48) 63 (27) 174 (75) 84 (36) 51 (22)
120 (52) 85 (37) 26 (11)
smokers were 10 times less likely to be protected by a complete smoking ban (odds ratio 0.10, 95% confidence interval 0.05– 0.19, P⬍ .001). There were no differences in any measure of smoke exposure among children with mild-moderate persistent asthma compared with children with severe persistent asthma (data not shown). Less than two-thirds of the children with severe persistent symptoms were protected by a complete smoking ban. Table 3 presents the percentage of caregivers who had received counseling from a health care provider in the past year regarding ETS exposure and smoking cessation. Most caregivers had been asked about smoke exposure in the home (82%). However, less had been asked about smoke in the car (40%) and only 58% of the caregivers had talked with a provider about decreasing ETS exposure. Most smokers were advised to stop smoking; however, less were offered resources to help them quit. The majority of caregivers felt very comfortable speaking with a health care provider about decreasing their child’s exposure to ETS.
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Table 3. Physician Counseling Regarding Environmental Tobacco Smoke (ETS) Exposure Characteristic
n (%)
Physician or nurse asked about smoke in home Physician or nurse asked about smoke in car Physician or nurse talked about decreasing ETS exposure Physician or nurse suggested you stop smoking (if smoker, n ⫽ 84) Physician or nurse offered resources to help stop smoking (if smoker, n ⫽ 84) Very comfortable talking with physician or nurse about decreasing ETS exposure
189 (82) 89 (40) 131 (58) 71 (84) 33 (40) 194 (86)
DISCUSSION These data demonstrate that many urban children with asthma are not living in smoke-free environments and likely are experiencing preventable morbidity. Overall, less than two-thirds of the children were protected by complete smoking bans. Exposure to smoke in the car was relatively common (26%), and is of particular concern because ETS in the car is significantly more concentrated than in a house. Although approximately 10% of children living with nonsmokers were exposed to ETS, the majority (60%) of children living with smokers were exposed to ETS. Exposure to ETS was common even among those children with the most severe symptom severity (40%). This is the first study of which we are aware to describe the prevalence of home and car smoking bans among children with documented persistent asthma as defined by national criteria. Further, the current study encompasses all families whether or not the primary caregiver or others in the home smoked. In this study, the prevalence of parent-reported smoking bans among children with asthma living with smokers was similar to that found in 2 other studies (41%26 and 47%28). We also found that 10% of children living with nonsmokers were exposed to ETS, presumably from persons visiting the home. Interventions targeting household ETS behaviors affecting young children with asthma can be effective in reducing children’s exposure to ETS,38 – 40 thus underscoring the importance of identifying children who are exposed and who would derive the greatest benefit from such interventions. The majority of caregivers in this study had been questioned by a health care professional about smoke exposure in the home. This is not surprising because all of the children in this study had documented asthma diagnoses and persistent symptoms, and all had access to a medical care provider (because they were recruited through the clinic). However, fewer caregivers had been asked about
Table 2. Smoking Bans in Households With and Without Smokers* Ban
Overall (N ⫽ 231)
Household With Smoker (n ⫽ 111)
Household With no Smokers (n ⫽ 120)
*OR (95% Confidence Interval)
P Value
Home ban Car ban Complete ban
165 (71%) 133 (74%) 148 (64%)
57 (51%) 37 (49%) 44 (40%)
108 (90%) 96 (91%) 104 (87%)
0.12 (0.06–0.24) 0.09 (0.04–0.21) 0.10 (0.05–0.19)
⬍.001 ⬍.001 ⬍.001
*Nonsmoking homes as reference.
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smoke exposure in the car, where exposure is more intense, or provided with suggestions to decrease exposure. Additionally, few of the smokers were offered resources to help them stop smoking. This may be related to more comfort among pediatricians for screening parents about smoking status, but less comfort with counseling about cessation.41 Other studies also have found significant room for improvement in provider counseling regarding smoke exposure.22–23,42 This is particularly pertinent because health care provider counseling regarding cessation can be effective in helping smokers quit.43– 45 From this study we conclude that a significant proportion of urban children with persistent asthma are not protected by smoking bans in their environment. Even those children with the most severe symptoms continue to experience exposure in various settings. This is highly relevant from the public health perspective because of the known detrimental effects of ETS, and the potential for smoking bans to lower children’s exposure to ETS. It may be possible to reduce smoke exposure by encouraging pediatricians to promote complete smoking cessation to family members at office visits,44 by teaching future pediatricians about routine tobacco counseling,23 and by implementing interventions to decrease ETS in the household.38 – 40 ACKNOWLEDGMENTS The research for this article was funded by grants from the Halcyon Hill Foundation, and the Robert Wood Johnson Foundation’s Generalist Physician Faculty Scholars Program. We thank George B. Segel, MD, for his insightful review of the manuscript, and Kathy Lynch, BA, for her help with manuscript preparation.
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12.
13. 14.
15. 16.
17.
18.
19.
20.
21.
22. 23.
24.
REFERENCES 1. Mannino DM, Homa DM, Redd SC. Involuntary smoking and asthma severity in children: data from the Third National Health and Nutrition Examination Survey. Chest. 2002;122:409 – 415. 2. Abulhosn RS, Morray BH, Llewellyn CE, et al. Passive smoke exposure impairs recovery after hospitalization for acute asthma. Arch Pediatr Adolesc Med. 1997;151:135–139. 3. Murray AB, Morrison BJ. Passive smoking and the seasonal difference of severity of asthma in children. Chest. 1988;94:701–708. 4. Strachan DP, Cook DG. Health effects of passive smoking. 6. Parental smoking and childhood asthma: longitudinal and case-control studies. Thorax. 1998;53:204 –212. 5. Oddoze C, Dubus JC, Badier M, et al. Urinary cotinine and exposure to parental smoking in a population of children with asthma. Clin Chem. 1999;45:505–509. 6. Chilmonczyk BA, Salmun LM, Megathlin KN, et al. Association between exposure to environmental tobacco smoke and exacerbations of asthma in children. N Engl J Med. 1993;328:1665–1669. 7. Weiss ST, Tager IB, Speizer FE, et al. Persistent wheeze: its relation to respiratory illness, cigarette smoking, and level of pulmonary function in a population sample of children. Am Rev Respir Dis. 1980;122:697–707. 8. Murray AB, Morrison BJ. Passive smoking by asthmatics: its greater effect on boys than on girls and on older than on younger children. Pediatrics. 1989;84:451– 459. 9. Canadian Paediatric Society Section on Allergy. Secondhand cigarette smoke worsens symptoms in children with asthma. Can Med Assoc J. 1986;135:321–323. 10. Institute of Medicine. Clearing the Air: Asthma and Indoor Exposures. Washington, DC: National Academy Press; 2000. 11. Murray AB, Morrison BJ. The effect of cigarette smoking from the
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mother on bronchial responsiveness and severity of symptoms in children with asthma. J Allergy Clin Immunol. 1986;77:575–581. Frischer T, Kuehr J, Meinert R, et al. Maternal smoking in early childhood: a risk factor for bronchial responsiveness to exercise in primary-school children. J Pediatr. 1992;121:17–22. Knight A, Breslin AB. Passive cigarette smoking and patients with asthma. Med J Aust. 1985;142:194 –195. Martinez FD, Antognoni G, Macri F, et al. Parental smoking enhances bronchial responsiveness in nine-year-old children. Am Rev Respir Dis. 1988;138:518 –523. Weitzman M, Gortmaker S, Walker DK, et al. Maternal smoking and childhood asthma. Pediatrics. 1990;85:505–511. Evans D, Levison MJ, Feldman CH, et al. The impact of passive smoking on emergency room visits of urban children with asthma. Am Rev Respir Dis. 1987;135:567–572. Mannino DM, Caraballo R, Benowitz N, Repace J. Predictors of cotinine levels in US children: data from the Third National Health and Nutrition Examination Survey. Chest. 2001;120:718 –724. Centers for Disease Control and Prevention. Cigarette smoking among adults—United States, 2002. MMWR Morb Mort Wkly Rep. 2004;53:427– 431. Weaver VM, Davoli CT, Murphy SE, et al. Environmental tobacco smoke exposure in inner-city children. Cancer Epidemiol Biomarkers Prev. 1996;5:135–137. National Institutes of Health. Guidelines for the Diagnosis and Management of Asthma. Expert Panel Report 2. NIH Publication 974051. Bethesda, Md: National Institutes of Health, National Heart Lung and Blood Institute; 1997. Frankowski B, Weaver S, Secker-Walker R. Advising parents to stop smoking: pediatricians’ and parents’ attitudes. Pediatrics. 1993;91:296 –300. Zapka JG, Fletcher K, Pbert L, et al. The perceptions and practices of pediatricians: tobacco intervention. Pediatrics. 2001;103:e65. Hymowitz N, Schwab J, Haddock CK, et al. The pediatric resident training on tobacco project: baseline findings from the Parent/Guardian Tobacco Survey. Prev Med. 2005;41:334 –341. Ashley MJ, Ferrence R. Reducing children’s exposure to environmental tobacco smoke in homes: issues and strategies. Tobacco Control. 1998;7:61–5. Greenberg RA, Bauman KE, Glover LH, et al. Ecology of passive smoking by young infants. J Pediatr. 1989;114:774 – 80. Wakefield M, Banham D, Martin J, et al. Restrictions on smoking at home and urinary cotinine levels among chidren with asthma. Am J Prev Med. 2000;19:188 –192. Johansson AK, Hermansson G, Ludvigsson J. How should parents protect their children from environmental tobacco-smoke exposure in the home? Pediatrics. 2004;113:e291– e295. Berman BA, Wong GC, Bastani R, et al. Household smoking behavior and ETS exposure among children with asthma in low-income, minority households. Addictive Behaviors. 2003;28:111–128. Norman GJ, Ribisl KM, Howard-Pitney B, et al. The relationship between home smoking bans and exposure to state tobacco control efforts and smoking behaviors. Am J Health Promot. 2000;15:81– 88. Pizacani BA, Martin DP, Stark MJ, et al. A prospective study of household smoking bans and subsequent cessation related behaviour: the role of stage of change. Tobacco Control. 2004;13:23–28. Farkas AJ, Gilpin EA, Distefan JM, et al. The effects of home smoking restrictions on quitting behaviours. Tobacco Control. 1999;8:261–265. Leung GM, Ho L, Lam T. Secondhand smoke exposure, smoking hygiene, and hospitalization in the first 18 months of life. Arch Pediatr Adolesc Med. 2004;158:687– 693. Gergen PJ, Fowler JA, Maurer KR, et al. The burden of environmental tobacco smoke exposure on the respiratory health of children 2 months through 5 years of age in the United States: Third National Health and Nutrition Examination Survey, 1998 to 1994. Pediatrics. 1998;101:E8. Schuster M, Franke T, Pham C. Smoking patterns of household
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members and visitors in homes with children in the United States. Arch Pediatr Adolesc Med. 2002;156:1094 –1100. Kattan M, Mitchell II, Eggleston P, et al. Characteristics of innercity children with asthma: the national cooperative inner-city asthma study. Pediatr Pulmonol. 1997;24:253–262. National Asthma Education Program. Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma. DHHS publication 91-3042. Bethesda, Md: US Department of Health and Human Services; 1991. National Asthma Education Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. NIH Publication 97-4051. Bethesda, Md: US Department of Health and Human Services; 1997. 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 2-year follow-up. Chest. 1997;111:81– 8.
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40. Borrelli B, McQuaid E, Becker B, et al. Motivating the parents of kids with asthma to quit smoking: preliminary findings from the PAQS Project. Paper presented at: Annual Meeting of the Society of Behavioral Medicine; 2004; Baltimore, Md. March 24-27, 2004. 41. Cabana MD, Rand C, Slish K, et al. Pediatrician self-efficacy for counseling parents of asthmatic children to quit smoking. Pediatrics. 2004;113:78 – 81. 42. Tanski SE, Klein JD, Winickoff JP, et al. Tobacco counseling at well-child and tobacco-influenced illness visits: opportunities for improvement. Pediatrics. 2003;111:e162– e167. 43. Wall MA, Severson HH, Andrews JA, et al. Pediatric office-based smoking intervention: impact on maternal smoking and relapse. Pediatrics. 1995;96:622– 628. 44. Fiore MC, Bailey WC, Cohen SJ. Treating Tobacco Use and Dependence Clinical Practice Guideline. Rockville, Md: US Department of Health and Human Services, Public Health Service; 2000. 45. Silagy C, Ketteridge S. Physician advice for smoking cessation. In: Cochrane Library. San Diego, Calif: Update Software; 1999.
tected 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.
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homes with smoking bans to which exceptions were made, and this observation has been substantiated in other studies.27,28 In addition to lowering children’s exposure to ETS, restrictions on smoking in the home also are associated with greater rates of cessation among smokers.29 –31 Overall, between 1/4 and 1/3 of all young children are exposed to ETS in their home, 32–34 and in the National Cooperative Inner-City Asthma Study, 59% of families reported at least one smoker in the home.35 Prior studies have shown the prevalence of smoking bans among children with asthma who live with a smoker is less than 50%.26,28 It is not clear to what extent smoking bans are used to protect children with persistent asthma, and whether pediatricians are taking advantage of their unique opportunity to counsel parents of children with asthma regarding ETS at office visits. The objectives of this study were 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 of children with asthma to implement smoking bans.
KEY WORDS: childhood asthma; environmental tobacco smoke; smoking bans Ambulatory Pediatrics 2006;6:115–119
nvironmental tobacco smoke (ETS) is associated with worsening symptoms and decreased pulmonary function among young children with asthma.1–10 Children with asthma who are exposed to maternal smoking have higher requirements for medications and more frequent visits to the emergency department.11–16 This is particularly pertinent for young urban children because they experience greater exposure to ETS compared with other children.17–19 Avoiding triggers, including ETS exposure, is recommended as an important component of asthma management,20 and pediatricians can play a key role in protecting children from tobacco exposure. However the majority of pediatricians do not routinely address smoke exposure at office visits,21,22 or offer cessation counseling to parents.22,23 Children most frequently are exposed to ETS in the home.24,25 Thus, one method to help reduce children’s ETS exposure requires parents to completely ban smoking in their home. A study by Wakefield et al 26 showed that children living in homes with absolute smoking bans had significantly lower levels of urinary cotinine (a quantitative measure of smoke exposure) than children from
METHODS Setting and Participants We conducted this study by using interview data from an office-based asthma intervention based in 3 urban pediatric clinics in Rochester, NY. We included children ages 2–12 years with physician diagnosed asthma who had asthma symptoms noted in their medical record within the previous 2 years. Children were eligible for enrollment if
From the Department of Pediatrics, University of Rochester School of Medicine and Dentistry and Golisano Children’s Hospital at Strong, Rochester, NY. Address correspondence to Jill S. Halterman, MD, MPH, University of Rochester School of Medicine, Box 777, Strong Memorial Hospital, 601 Elmwood Ave, Rochester, NY 14642 (e-mail: jill_halterman@urmc. rochester.edu). Received for publication August 3, 2005; accepted October 13, 2005.
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they arrived at the office for any scheduled visit with a physician or nurse practitioner. We included asthmatic children presenting to the office for any reason, including well-child care, asthma care, or care for another acute illness. A member of the study team approached the caregivers in the waiting room prior to the child’s office visit to offer participation in an intervention study to improve asthma care. From October of 2003 to August 2004, we approached 320 caregivers of children with asthma in the waiting room to elicit written informed consent and administer a brief written questionnaire, and 301 agreed to participate (response rate 94%). The questionnaire included inquiries about their child’s asthma symptoms, current medications, primary caregiver smoking status, number of smokers living in the home, smoking bans in the home and car, ETS counseling by a health care professional, and the family’s sociodemographic background. For this study we included only children with persistent asthma symptoms (n ⫽ 231) because we were particularly interested in smoke exposure among these symptomatic children. Asthma severity was assessed by parent report using criteria set forth by the National Heart, Lung, and Blood Institute.36,37 Persistent severity was defined as having daytime asthma symptoms ⬎2 times per week during the past 2 weeks, or nighttime asthma symptoms ⬎1 times per week during the past 2 weeks. The University of Rochester’s Institutional Review Board approved the study protocol. Definitions ETS Exposure We inquired about the smoking status of the primary caregiver (“How much does this child’s primary caregiver smoke? Never, occasionally or daily”; responses dichotomized as never vs. occasionally / daily), and the number of smokers living in the home (“How many people living in this child’s home smoke?”). We determined whether a household had a smoker in the home other than the primary caregiver on the basis of responses to the 2 questions above (primary caregiver smoking status and number of smokers in the home). We used a method of inquiry regarding smoking bans that was previously validated using children’s cotinine measurements.26 Parents were asked to choose from the following options to describe the situation regarding smoking in the child’s home: (1) smoking is allowed in any common room of the home, (2) smoking is limited to part of the house where the child rarely goes, or (3) there is no smoking inside at all. If the parent reported no smoking inside at all, we then asked if there were any exceptions to this situation. Only parents reporting no smoking inside the home with no exceptions were considered to have a complete smoking ban in the home.26 A similar mechanism of inquiry was used to determine the presence or absence of a car smoking ban. Among parents who owned a car, those reporting no smoking inside the car, with no exceptions to this situation, were considered
AMBULATORY PEDIATRICS
to have a complete car smoking ban.26 We defined a complete smoking ban as having no ETS exposure in any setting (home or car) with no exceptions. ETS Counseling We assessed a history of ETS counseling by health care providers by asking caregivers whether, in the past year, a physician or nurse ever; 1) specifically asked whether anyone in the child’s home smokes, 2) asked whether anyone smokes with the child in the car, and 3) talked about how to decrease the child’s exposure to smoke. The primary caregivers who smoked also were asked if a physician or nurse had ever suggested that they stop smoking and if a health care provider had offered them resources (e.g. referrals to programs, counseling, nicotine replacement) to help them quit smoking within the past year. Asthma Severity All of the children in this study had persistent asthma symptoms as defined by national criteria. We further categorized asthma severity as mild-moderate persistent (daytime symptoms more than 2x a week but not everyday/all the time and nighttime symptoms one or more times a week, but not frequently/every night) versus severe persistent (daytime symptoms everyday/all the time and/or nighttime symptoms frequently/every night).36,37 Analysis We used standard cross tabulations and 2 analyses to test for differences in proportions. Odds ratios and 95% confidence intervals were used to estimate risk. We performed all analyses by SPSS software v12.0 (SPSS Inc, Chicago, Ill). A 2-sided ␣ ⬍ .05 was considered statistically significant. RESULTS Of the 301 asthmatic subjects enrolled, 231 had persistent asthma symptoms and were included in this analysis (mean age 6.3 years). Table 1 shows the demographic characteristics of these children. The majority of the subjects were boys (60%), and 71% were enrolled in Medicaid. Fifty-five percent of the children were described as African American, and 31% described Hispanic ethnicity. The children were selected if they had persistent asthma symptoms, and more than one-third had severe persistent symptoms. Thirty-six percent of the children had a primary caregiver who smoked, and 48% lived with one or more smoker in the home. Table 2 describes the prevalence of smoking bans for households with and without smokers. Among all of the families, 71% banned smoking in the home, 74% banned smoking in the car, and 64% had a complete smoking ban in both locations. The presence of bans was significantly different among households with and without smokers. Among homes with smokers, only 51% had a home smoking ban, and 49% had a car smoking ban (compared with 90% and 91% of families with no smokers in the home, P⬍ .001). Additionally, children living in homes with
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Table 1. Population Demographics Characteristic Child demographics Male Sex Age, y 2–5 6–12 Race White African American Other Hispanic ethnicity Medicaid Child health Asthma severity Mild to moderate persistent Severe persistent Caretaker demographics Caretaker age, y ⬍30 ⱖ30 Caretaker education less than high school Household composition of single-parent family Smoking characteristics Primary caregiver smokers Smoker present in home other than primary caregiver Number of smokers in home 0 1 2 or more
n (%) (N ⫽ 231) 138 (60) 114 (49) 116 (50) 19 (8) 127 (55) 85 (37) 71 (31) 163 (71)
146 (63) 85 (37)
119 (52) 111 (48) 63 (27) 174 (75) 84 (36) 51 (22)
120 (52) 85 (37) 26 (11)
smokers were 10 times less likely to be protected by a complete smoking ban (odds ratio 0.10, 95% confidence interval 0.05– 0.19, P⬍ .001). There were no differences in any measure of smoke exposure among children with mild-moderate persistent asthma compared with children with severe persistent asthma (data not shown). Less than two-thirds of the children with severe persistent symptoms were protected by a complete smoking ban. Table 3 presents the percentage of caregivers who had received counseling from a health care provider in the past year regarding ETS exposure and smoking cessation. Most caregivers had been asked about smoke exposure in the home (82%). However, less had been asked about smoke in the car (40%) and only 58% of the caregivers had talked with a provider about decreasing ETS exposure. Most smokers were advised to stop smoking; however, less were offered resources to help them quit. The majority of caregivers felt very comfortable speaking with a health care provider about decreasing their child’s exposure to ETS.
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Table 3. Physician Counseling Regarding Environmental Tobacco Smoke (ETS) Exposure Characteristic
n (%)
Physician or nurse asked about smoke in home Physician or nurse asked about smoke in car Physician or nurse talked about decreasing ETS exposure Physician or nurse suggested you stop smoking (if smoker, n ⫽ 84) Physician or nurse offered resources to help stop smoking (if smoker, n ⫽ 84) Very comfortable talking with physician or nurse about decreasing ETS exposure
189 (82) 89 (40) 131 (58) 71 (84) 33 (40) 194 (86)
DISCUSSION These data demonstrate that many urban children with asthma are not living in smoke-free environments and likely are experiencing preventable morbidity. Overall, less than two-thirds of the children were protected by complete smoking bans. Exposure to smoke in the car was relatively common (26%), and is of particular concern because ETS in the car is significantly more concentrated than in a house. Although approximately 10% of children living with nonsmokers were exposed to ETS, the majority (60%) of children living with smokers were exposed to ETS. Exposure to ETS was common even among those children with the most severe symptom severity (40%). This is the first study of which we are aware to describe the prevalence of home and car smoking bans among children with documented persistent asthma as defined by national criteria. Further, the current study encompasses all families whether or not the primary caregiver or others in the home smoked. In this study, the prevalence of parent-reported smoking bans among children with asthma living with smokers was similar to that found in 2 other studies (41%26 and 47%28). We also found that 10% of children living with nonsmokers were exposed to ETS, presumably from persons visiting the home. Interventions targeting household ETS behaviors affecting young children with asthma can be effective in reducing children’s exposure to ETS,38 – 40 thus underscoring the importance of identifying children who are exposed and who would derive the greatest benefit from such interventions. The majority of caregivers in this study had been questioned by a health care professional about smoke exposure in the home. This is not surprising because all of the children in this study had documented asthma diagnoses and persistent symptoms, and all had access to a medical care provider (because they were recruited through the clinic). However, fewer caregivers had been asked about
Table 2. Smoking Bans in Households With and Without Smokers* Ban
Overall (N ⫽ 231)
Household With Smoker (n ⫽ 111)
Household With no Smokers (n ⫽ 120)
*OR (95% Confidence Interval)
P Value
Home ban Car ban Complete ban
165 (71%) 133 (74%) 148 (64%)
57 (51%) 37 (49%) 44 (40%)
108 (90%) 96 (91%) 104 (87%)
0.12 (0.06–0.24) 0.09 (0.04–0.21) 0.10 (0.05–0.19)
⬍.001 ⬍.001 ⬍.001
*Nonsmoking homes as reference.
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smoke exposure in the car, where exposure is more intense, or provided with suggestions to decrease exposure. Additionally, few of the smokers were offered resources to help them stop smoking. This may be related to more comfort among pediatricians for screening parents about smoking status, but less comfort with counseling about cessation.41 Other studies also have found significant room for improvement in provider counseling regarding smoke exposure.22–23,42 This is particularly pertinent because health care provider counseling regarding cessation can be effective in helping smokers quit.43– 45 From this study we conclude that a significant proportion of urban children with persistent asthma are not protected by smoking bans in their environment. Even those children with the most severe symptoms continue to experience exposure in various settings. This is highly relevant from the public health perspective because of the known detrimental effects of ETS, and the potential for smoking bans to lower children’s exposure to ETS. It may be possible to reduce smoke exposure by encouraging pediatricians to promote complete smoking cessation to family members at office visits,44 by teaching future pediatricians about routine tobacco counseling,23 and by implementing interventions to decrease ETS in the household.38 – 40 ACKNOWLEDGMENTS The research for this article was funded by grants from the Halcyon Hill Foundation, and the Robert Wood Johnson Foundation’s Generalist Physician Faculty Scholars Program. We thank George B. Segel, MD, for his insightful review of the manuscript, and Kathy Lynch, BA, for her help with manuscript preparation.
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