Examination of the '5-2-1-0' Recommendations in Racially Diverse Young Children Exposed to Tobacco Smoke

PURPOSE

The '5-2-1-0' guidelines recommend that children: eat ≥5 servings of fruits/vegetables ('5'), have ≤2 hours of screen-time ('2'), have ≥1 hour of activity ('1'), and drink 0 sugar-sweetened beverages ('0') daily. The pediatric emergency department (PED) treats children at risk for obesity and tobacco smoke exposure (TSE). We examined body mass index (BMI), overweight, obesity, TSE, and '5-2-1-0' rates in children with TSE in the PED.

DESIGN

Cross-sectional study of PED children.

SETTING

The PED of a children's hospital.

SAMPLE

Children with TSE >6 months-5 years old (N = 401).

MEASURES

Sociodemographics, '5-2-1-0' behaviors, BMI, and cotinine-confirmed TSE.

ANALYSIS

Associations between '5-2-1-0' and sociodemographics were examined with logistic regression.

RESULTS

Mean (SD) age = 2.4 (1.6) years; 53.1% were Black; 65.8% had low-income; and 93.4% had TSE. Of 2-5-year-olds, mean (SD) BMI percentile was 66.2 (30.1), 16.1% were overweight and 20.6% were obese. In total, 10.5% attained '5', 72.6% attained '2', 57.8% of 2-5-year-olds attained '1', and 9.8% attained '0'. Compared to White children, "other" race children were more likely to meet '5' (aOR(95% CI):4.67(1.41, 5.45)); 2-5-years-olds (aOR(95%CI):0.60(0.38, 0.95)) and Black children (aOR(95%CI):0.36(0.21, 0.60)) were at decreased odds to meet '2' compared to younger or White children, respectively. Compared to younger children, 2-5-year-olds were at decreased odds to meet '0' (aOR(95%CI):0.08(0.02, 0.26)).

CONCLUSION

Racially diverse, low-income children with TSE had low '5-2-1-0' attainment. Interventions are needed to improve lifestyle habits in this population.

Assessment of Severe COVID-19 Outcomes Using Measures of Smoking Status and Smoking Intensity

Objective: Smoking status does not indicate the amount or length of tobacco use, and thus, it is an imperfect measure to assess the association between cigarette smoking and severe coronavirus disease 2019 (COVID-19) outcomes. This investigation assessed whether cigarette smoking status, intensity of smoking (i.e., average daily packs of cigarettes smoked), duration of smoking, and pack-years of smoking are associated with severe outcomes among adults diagnosed with COVID-19. Methods: We conducted a retrospective, cross-sectional study in which we identified consecutive patients diagnosed with COVID-19 at the University of Cincinnati healthcare system between 13 March 2020 and 30 September 2020 who had complete information on smoking status, severe COVID-19 outcomes, and covariates (i.e., demographics and comorbidities). We used logistic regression to evaluate the associations of smoking status and intensity of smoking with COVID-19 severity, defined as hospitalization, admission to intensive care unit (ICU), or death, adjusting for sociodemographics and comorbidities. Results: Among the 4611 COVID-19 patients included in the analysis, 18.2% were current smokers and 20.7% were former smokers. The prevalence of COVID-19 outcomes was 28.9% for hospitalization, 9.8% for ICU admission, and 1.4% for death. In the adjusted analysis, current smoking (AOR: 1.23, 95% CI: 1.02–1.49), former smoking (AOR: 1.28, 95% CI: 1.07–1.54), and pack-years of smoking (AOR: 1.09, 95% CI: 1.02–1.17) were associated with a higher prevalence of hospitalization. Average daily packs of cigarettes smoked was associated with a higher prevalence of hospitalization (AOR: 1.30, 95% CI: 1.10–1.53) and ICU admission (AOR: 1.23, 95% CI: 1.04–1.44). Conclusions: Smoking status, pack-years, and intensity of smoking were associated with hospitalizations in patients with COVID-19 and intensity of smoking was associated with ICU admission. The findings underscore the need for detailed information beyond smoking status when evaluating smokers with COVID-19 so that the potential for adverse sequelae may be optimally managed in at-risk patients.

Authoritative Parenting Behaviors and Marijuana Use Based on Age Among a National Sample of Hispanic Adolescents

Although numerous prevention efforts have been implemented, marijuana remains the most commonly used illicit substance among Hispanic adolescents nationwide. We sought to determine the influence authoritative parenting behaviors have on lifetime, past year, and past month marijuana use among Hispanic adolescents overall, and then based on age (i.e., 12-13, 14-15, and 16-17 years). We conducted a secondary analysis of the 2012 National Survey on Drug Use and Health (N = 3457). We performed a series of logistic regression analyses. Nearly one-fifth (19.5%) of Hispanic participants reported lifetime marijuana use, 14.5% reported past year use, and 7.5% reported past month use. Results indicated that Hispanic adolescents who are at significantly increased risk for reporting lifetime, past year, and past month marijuana use, were those who reported that their parents seldom or never performed the following behaviors: (1) checked if their homework was done, (2) helped them with their homework, (3) limited the amount of TV they watched, (4) told them they did a good job, and (5) told them they were proud of them. There were no relationships between adolescents' lifetime, past year, or past month marijuana use and whether their parents made their youth do chores or limited their time out on a school night. Regarding age, while results indicated that most authoritative parenting behaviors have a significant effect against marijuana use, the protective effect diminished with age, with the exception of the relationship between adolescents' past month marijuana use and whether their parents checked to see if their homework was done. Substance use prevention programs for this population should start in early adolescence and involve and educate parents on adopting authoritative parenting behaviors.

E-cigarette and marijuana use and the attainment of obesity prevention guidelines among U.S. adolescents

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Majority of U.S. youth still not meeting 5-2-1-0 obesity prevention guidelines.

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Current marijuana users did not meet screen time and physical activity guidelines.

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E-cigarette users met physical activity and screen time guidelines.

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Dual users are more likely to meet fruits and vegetables guidelines.

The study objectives were to examine the associations of exclusive and dual use of e-cigarettes and marijuana and the attainment of the “Let’s Go! 5–2-1–0” obesity prevention guidelines and perceptions of weight status among U.S. adolescents. Data from the 2017 Youth Risk Behavior Survey, a school-based nationally representative cross-sectional study, were analyzed (N = 12,578). Participants were categorized based on their past 30-day e-cigarette and marijuana use as: non-users, exclusive e-cigarette users, exclusive marijuana users, and dual users. Adjusted logistic regression models were conducted. Of adolescents, 5.2% were exclusive e-cigarette users, 10.3% were exclusive marijuana users, and 7.4% were dual users. Compared to non-users, exclusive e-cigarette users were more likely (aOR = 1.55, 95%CI = 1.16–2.07) to meet the physical activity recommendation. Compared to dual-users, exclusive e-cigarette users were more likely (aOR = 1.47, 95%CI = 1.10–1.97) to meet the screen time recommendation. Compared to non-users, exclusive marijuana users were at increased odds to meet the fruit/vegetable recommendation (aOR = 1.33, 95%CI = 1.03–1.71), but were at decreased odds to meet the sugar-sweetened beverages recommendation (aOR = 0.81, 95%CI = 0.65–0.99). Compared to exclusive e-cigarette users, exclusive marijuana users were less likely to meet the screen time (aOR = 0.71, 95%CI = 0.54–0.93) and physical activity recommendations (aOR = 0.60, 95%CI = 0.43–0.84). Compared with dual users, exclusive marijuana users were more likely (aOR = 1.38, 95%CI = 1.01–1.88) to perceive themselves as slightly/very overweight. Compared to non-users, dual users were less likely to meet the sugar-sweetened beverages recommendation (aOR = 0.63, 95%CI = 0.46–0.87). Adolescent current marijuana users and dual users were less likely to meet obesity prevention guidelines. Prevention efforts are needed to reduce e-cigarette and marijuana use and increase adherence to these guidelines.

Self-Perceptions, Normative Beliefs, and Substance Use Associated With High School Girls Comparing Themselves to Peers

BACKGROUND

We assessed whether self-descriptions, self-perceptions, perceived substance use of friends, and actual substance use were associated with high school girls' frequency of making social comparisons to peers.

METHODS

We analyzed data from the Adolescent Health Risk Behavior Survey data for 357 high school girls using multinomial logistic regression.

RESULTS

Compared to those who "never/rarely" made social comparisons, participants who self-described as fearing something constantly (p = .014) and forced to imitate the people they like (p = .009) were more likely to "usually" compare themselves to peers. Participants who described themselves as feeling forced to imitate the people they like (p = .022), were not the person they would like to be (p = .005), and did not remain calm under pressure (p = .010), were more likely to "often/always" make social comparisons. Participants who perceived themselves as unattractive (p = .034) and self-centered (p = .016) were more likely to "often/always" make social comparisons. Participants who perceived a larger proportion of friends use illicit drugs were less likely to "usually" make social comparisons (p = .027). Participants who perceived a larger proportion of friends drink alcohol were more likely to "often/always" make social comparisons (p = .018).

CONCLUSIONS

Girls who perceive and describe themselves more negatively are at increased odds of making social comparisons to peers.

Evaluation of tobacco screening and counseling in a large, midwestern pediatric emergency department

INTRODUCTION

The study objective was to assess tobacco screening and cessation counseling practices of pediatric emergency department (PED) and urgent care (UC) nurses and physicians, and factors associated with these practices. Secondarily, we assessed factors associated with performing tobacco smoke exposure reduction and tobacco cessation counseling.

METHODS

We conducted a cross-sectional survey of 30 PED/UC nurses and physicians working at one large, urban, Midwestern children’s hospital. Measures included current practices of performing the 5 As of tobacco counseling (Ask, Advise, Assess, Assist, Arrange), and attitude and practice factors that may influence practices.

RESULTS

Overall, 90.0% of participants had not received recent tobacco counseling training, 73.3% were unaware of the 5 As, and 63.3% did not have a standardized, routine screening system to identify patients exposed to secondhand smoke. The majority of participants reported that they: asked about patients’ secondhand smoke exposure status (70.0%) and parents’ tobacco use status (53.3%), and advised parental smokers to not smoke around their child (70.0%) and to quit smoking (50%). One in five participants reported they assessed smokers’ interest in quitting smoking, and 16.7% talked with smokers about cessation techniques and tactics; of these, 10% referred/enrolled smokers to the Tobacco Quitline or cessation program, and 6.7% made a quit plan or recommended nicotine replacement therapy medication.

CONCLUSIONS

Key findings identified are the need for professional tobacco counseling training, standardizing efforts during visits, and emphasizing pediatric patients’ potential health benefits. This information will be used for developing a PED/ UC-based parental tobacco cessation and child tobacco smoke exposure reduction intervention.

Exposure to Tobacco Smoke and Temperament among U.S. Children 0-5 Years Old

OBJECTIVES

This study examined the association between tobacco smoke exposure (TSE) and temperament among children 0-5 years old overall and within age groups: 0-2 and 3-5 years.

METHODS

Data were obtained from the 2017-2018 NSCH (N = 14,345). TSE status was defined as whether children lived with a smoker who: does not smoke inside the home (no home TSE) or smokes inside the home (home TSE). We conducted logistic regression analyses while controlling for covariates.

RESULTS

Overall, 12.5% of children lived with a smoker with no home TSE and 1.1% had home TSE. Children with home TSE were at increased odds to not always: be affectionate and tender (aOR = 1.74, 95% CI = 1.18-2.58), show interest and curiosity (aOR = 1.81, 95% CI = 1.23-2.68), and smile and laugh (aOR = 1.77, 95% CI = 1.13-2.77) than those with no TSE. Among 0- to 2-year-olds, those with home TSE were more likely to not always be affectionate and tender (aOR = 1.97, 95% CI = 1.04-3.74). Among 3- to 5-year-olds, those who lived with a smoker with no home TSE were more likely to not always: bounce back quickly (aOR = 1.21, 95% CI = 1.05-1.40) and smile and laugh (aOR = 1.26, 95% CI = 1.03-1.54), and those with home TSE were more likely to not always: show interest and curiosity (aOR = 2.24, 95% CI = 1.40-3.59) and smile and laugh (aOR = 2.43, 95% CI = 1.43-4.11).

CONCLUSIONS

Tobacco smoke-exposed children were at increased odds of not always demonstrating positive early childhood temperament behaviors, with 3- to 5-year-olds having more pronounced odds.

Concurrent E-cigarette and marijuana use and health-risk behaviors among U.S. high school students

The use of electronic cigarettes (e-cigarettes) and marijuana remain prevalent problems among adolescents nationwide. We assessed current (past 30-day) exclusive e-cigarette use, exclusive marijuana use, and concurrent use with unintentional injury and violent behaviors, alcohol and other drug use behaviors, and sexual behaviors among U.S. high school students. We analyzed 2017 Youth Risk Behavior Survey data including 12,578 high school students nationwide. Multivariable logistic regression models were performed to compare these health-risk behaviors among exclusive e-cigarette users, exclusive marijuana users, and concurrent users with non-users among the overall sample, and then to compare exclusive e-cigarette users and exclusive marijuana users with concurrent users among current users only. All models adjusted for adolescent sex, grade, and race/ethnicity, and other tobacco product use. Approximately 77% of students were non-users, 5.2% were exclusive e-cigarette users, 9.9% were exclusive marijuana users, and 7.8% were concurrent users. Compared to non-users, exclusive e-cigarette users and exclusive marijuana users were more likely to engage in most negative health-risk behaviors associated with unintentional injuries and violence, alcohol and other drug use, and sexual behaviors. Among current users only, exclusive e-cigarette users and exclusive marijuana users were at reduced odds of engaging in most of these health-risk behaviors when compared to concurrent users of both substances. The relationship between exclusive and concurrent e-cigarette and marijuana use and health-risk behaviors highlights the importance of comprehensive educational efforts during high school. Findings suggest need for more studies on influence of e-cigarette and marijuana use on injury and violence risk among youth.

Healthcare resources attributable to child tobacco smoke exposure

Background

Tobacco smoke exposure (TSE) places an economic toll on the U.S. healthcare system. There is a gap in the literature on pediatric emergency department (ED) and urgent care related healthcare costs and utilization specific to tobacco smoke-exposed patients. The objectives were to assess pediatric ED visits, urgent care visits and hospital admissions longitudinally, and baseline visit costs among tobacco smoke-exposed children (TSE group) relative to unexposed children (non-TSE group).

Methods and findings

We conducted a retrospective study using electronic medical records of 380 children ages 0–17 years in the TSE group compared to 1,140 in the non-TSE group propensity score matched via nearest neighbor search by child age, sex, race, and ethnicity. Linear and Poisson regression models were used. Overall, children had a mean of 0.19 (SE = 0.01) repeat visits within 30-days, and 0.69 (SE = 0.04) pediatric ED visits and 0.87 (SE = 0.03) urgent care visits over 12-months following their baseline visit. The percent of children with ≥ 1 urgent care visit was higher among the TSE group (52.4%) than the non-TSE group (45.1%, p = 0.01). Children in the TSE group (M = $1,136.97, SE = 76.44) had higher baseline pediatric ED visit costs than the non-TSE group (M = $1,018.96, SE = 125.51, p = 0.01). Overall, children had 0.08 (SE = 0.01) hospital admissions over 12-months, and the TSE group (M = 0.12, SE = 0.02) had higher mean admissions than the non-TSE group (M = 0.06, SE = 0.01, p = 0.02). The child TSE group was at 1.85 times increased risk of having hospital admissions (95% CI = 1.23, 2.79, p = 0.003) than the non-TSE group.

Conclusions

Tobacco smoke-exposed children had higher urgent care utilization and hospital admissions over 12-months, and higher pediatric ED costs at baseline. Pediatric ED visits, urgent care visits, and hospitalizations may be opportune times for initiating tobacco control interventions, which may result in reductions of preventable acute care visits.

High Cotinine and Healthcare Utilization Disparities Among Low-Income Children

INTRODUCTION

This study assesses the associations of child salivary cotinine, parent-reported smoking, and child tobacco smoke exposure with the number of child healthcare visits and hospital admissions over a 6-month period. This study also assesses the relationships between participant characteristics and child cotinine.

METHODS

Longitudinal data were evaluated from a sample of 313 clinically ill children aged 0-9 years who lived with a smoker and presented to a pediatric emergency department or urgent care in 2016-2018. In 2020, cotinine measurements were log transformed, and Poisson and linear regression were performed.

RESULTS

The majority of the children came from low-income homes (66.1%) and had public insurance/self-pay (95.5%). Child cotinine concentrations ranged from 0.1 to 332.0 ng/mL (geometric mean=4.8 ng/mL, 95% CI=4.1, 5.5). Poisson regression results indicated that each 1-unit increase of log-cotinine concentration was associated with an increase in pediatric emergency department visits over a 6-month period after the baseline visit, with an adjusted RR of 1.16 (95% CI=1.01, 1.34). Each 1-unit increase of log-cotinine concentration was associated with an increase in the frequency of hospital admissions over the 6-month period, with an adjusted RR of 1.50 (95% CI=1.08, 2.09). No differences were found between parent-reported smoking or child tobacco smoke exposure and healthcare utilization. Linear regression results indicated that children who were younger (β= -0.227, p=0.049), were White (geometric mean=5.5 ng/mL), had a medical history of prematurity (geometric mean=8.1 ng/mL), and had a winter baseline visit (geometric mean=6.5 ng/mL) had higher cotinine concentrations. Children living in apartments (geometric mean=5.5 ng/mL) and multiunit homes (geometric mean=5.5 ng/mL) had higher cotinine concentrations than those in single-family homes (geometric mean=3.6 ng/mL).

CONCLUSIONS

Routine biochemical screening could identify children who are in need of intensive tobacco smoke exposure reduction interventions.

Prevalence of Mental Health and Neurodevelopmental Conditions in U.S. Children with Tobacco Smoke Exposure

INTRODUCTION

This study investigated the prevalence and correlates of current mental health and neurodevelopmental conditions among U.S. school-age children with tobacco smoke exposure (TSE).

METHOD

Data from the 2016-17 National Survey of Children's Health were analyzed. Multivariable logistic regression analyses among 6-11-year-olds (n = 21,539) and among subsamples aged 6-8 years (n = 10,100) and 9-11 years (n = 11,439) were conducted.

RESULTS

Among 6-11-year-olds who lived with a smoker with no home TSE, the top mental health/neurodevelopmental conditions were other mental health conditions (22.1%), behavioral/conduct problems (21.7%), attention deficit disorder or attention deficit hyperactivity disorder (20.5%), depression (21.7%), and learning disability (19.3%). Children who lived with a smoker, with or without home TSE, were at increased odds of having anxiety problems, depression, attention deficit disorder or attention deficit hyperactivity disorder, behavioral/conduct problems, other mental health conditions, or learning disabilities. Many associations were more notable in younger children with home TSE.

DISCUSSION

TSE is associated with mental health and neurodevelopmental conditions. Interventions to decrease TSE are needed to protect children.

County-Level Characteristics Driving Malnutrition Death Rates among Older Adults in Texas

OBJECTIVES

This study aims to identify older adult malnutrition in Texas, examine county-level characteristics associated with crude malnutrition death rates, and describe assets and opportunities available to address and improve malnutrition among the older population.

DESIGN

Secondary data analysis using the Centers for Disease Control and Prevention's WONDER online database, the U.S. Census 2014-2018 American Community Survey, and the U.S. Department of Agriculture's Food Access Research Atlas data.

SETTING

All 254 counties in the state of Texas.

PARTICIPANTS

Individuals aged 65 years and older.

MEASUREMENT

The dependent variable was the proportion of county-level malnutrition crude death rates. Independent variables included Health Provider Shortage Area designations, rurality, poverty status, food access, age, race, ethnicity, and education.

RESULTS

The overall malnutrition crude death rate in Texas was 65.6 deaths per 100,000 older Texans, ranging from 0 to 414.46 deaths per 100,000 depending on the county. Higher malnutrition crude death rates were associated with non-metropolitan counties (P=0.018), lower education (P=0.047), greater household poverty (P=0.010), and low food access (P<0.001).

CONCLUSION

Socioeconomic disadvantages at the county-level appear to be one of the root causes of malnutrition crude death rates in Texas.

Costs to provide a tobacco cessation intervention with parents of pediatric emergency department patients

INTRODUCTION

Pediatric emergency department (PED) visits are opportune times in which to provide smoking cessation interventions for parents who smoke. This study reports on the costs of providing parental smokers who bring their children to the emergency setting, with a screening, brief intervention, and assisted referral to treatment (SBIRT) intervention, which includes counseling about tobacco cessation and nicotine replacement therapy.

METHODS

Cost data were collected during a randomized controlled trial with 750 parental smokers whose child was presented to a PED or pediatric Urgent Care unit with a potential tobacco smoke exposure-related illness. Interventionist training, screening, and SBIRT costs are reported from the organizational perspective (i.e. that of the providing hospital). A spreadsheet tool was created to allow for organizations to estimate their own costs based on their settings, for each aspect of the intervention.

RESULTS

The mean costs per parent included interventionist training, screening and enrollment, SBIRT delivery, distribution of take-home materials and nicotine replacement therapy, booster text messages, and follow-up phone contact. The total cost per parent was approximately $97. Varying the underlying cost assumptions led to total costs ranging from $85 to $124 per treated parent.

CONCLUSIONS

The emergency setting is an important locus of tobacco control that could have a large public health benefit to parents and children. The costs reported in this report and the accompanying spreadsheet tool will permit emergency settings to estimate the costs and assist with planning, staffing and resource allocation necessary to implement an SBIRT smoking cessation intervention in research-based and clinically-based cessation interventions into adult or pediatric emergency visits.

A Parental Smoking Cessation Intervention in the Pediatric Emergency Setting: A Randomized Trial

We examined the efficacy of a pediatric emergency visit-based screening, brief intervention, and referral to treatment (SBIRT) condition compared to a control condition (Healthy Habits Control, HHC) to help parental smokers quit smoking. We enrolled 750 parental smokers who presented to the pediatric emergency setting with their child into a two-group randomized controlled clinical trial. SBIRT participants received brief cessation coaching, quitting resources, and up to 12-weeks of nicotine replacement therapy (NRT). HHC participants received healthy lifestyle coaching and resources. The primary outcome was point-prevalence tobacco abstinence at six weeks (T1) and six months (T2). The mean (SD) age of parents was 31.8 (7.7) years, and 86.8% were female, 52.7% were Black, and 64.6% had an income of ≤$15,000. Overall abstinence rates were not statistically significant with 4.2% in both groups at T1 and 12.9% and 8.3% in the SBIRT and HHC groups, respectively, at T2. There were statistically significant differences in SBIRT versus HHC participants on the median (IQR) reduction of daily cigarettes smoked at T1 from baseline (−2 [−5, 0] versus 0 [−4, 0], p = 0.0008),at T2 from baseline (−4 [−9, −1] vs. −2 [−5, 0], p = 0.0006), and on the mean (SD) number of quit attempts at T2 from baseline (1.25 (6.5) vs. 0.02 (4.71), p = 0.02). Self-reported quitting rates were higher in SBIRT parents who received NRT (83.3% vs. 50.9%, p = 0.04). The novel use of the pediatric emergency visit to conduct cessation interventions helped parents quit smoking. The near equivalent abstinence rates in both the SBIRT and HHC groups may be due to underlying parental concern about their child’s health. Cessation interventions in this setting may result in adult and pediatric public health benefits.

Utilization of a Clinical Decision Support Tool to Reduce Child Tobacco Smoke Exposure in the Urgent Care Setting

BACKGROUND

Clinical decision support systems (CDSS) may facilitate caregiver tobacco screening and counseling by pediatric urgent care (UC) nurses.

OBJECTIVE

This study aimed to assess the feasibility of a CDSS to address caregivers' tobacco use and child tobacco smoke exposure (TSE).

METHODS

We conducted a 3-month prospective study on caregivers screened using a CDSS. Nurses used the CDSS to advise, assess, and assist caregivers to quit. We assessed caregiver sociodemographics, smoking habits, and child TSE.

RESULTS

We screened 185 caregivers whose children were exposed to TSE for study inclusion; 155 (84%) met the eligibility criteria, and 149 (80.5%) were included in the study. Study nurses advised 35.2% of the caregivers to quit, assessed 35.9% for readiness to quit, and assisted 32.4%. Of the 149 participants, 83.1% were female; 47.0% were white and 45.6% African American; 84.6% had public insurance or were self-pay; 71.1% were highly nicotine dependent; 50.0% and 50.7% allowed smoking in the home and car, respectively; and 81.3% of children were biochemically confirmed to be exposed to tobacco smoke. At follow-up (86.6% retention), 58.9% reported quit attempts at 3 months. There was a significant decrease in nicotine dependence and a significant increase in motivation to quit. Self-reported quit rate was 7.8% at 3 months.

CONCLUSIONS

An electronic health record-embedded CDSS was feasible to incorporate into busy UC nurses' workloads and was associated with encouraging changes in the smoking behavior of caregivers. More research on the use of CDSS to screen and counsel caregivers who smoke in the UC and other acute care settings is warranted.

Does marijuana use among African American adolescent males differ based on school factors?

Marijuana use among adolescents is a major public health problem. The purpose of this study was to examine whether past-year marijuana use among African American adolescent males differed based on age and school factors. Data from the 2015-2018 National Survey on Drug Use and Health (NSDUH) were analyzed. A national sample of African American students in grades 7 through 12 (n = 5,738) completed the survey. Results indicated that 14.7% reported using marijuana in the past year. Those at highest risk for past-year marijuana use were those who were male, were 16 to 17 years old, were in 9th through 12th grade, did not like going to school, and thought that most/all students in their grade used marijuana. Prevention professionals should consider the links among school attitudes, perceived social norms, and marijuana use when developing programs and interventions. Efforts are needed that are culturally competent and culturally sensitive to help reduce marijuana use rates among African American male adolescents. Future research is needed to further examine school perceptions and marijuana use among this population.

Family resilience and health among adolescents with asthma only, anxiety only, and comorbid asthma and anxiety

OBJECTIVES

The objectives were to examine the relationships between current asthma and anxiety and family resilience and overall health status in US adolescents.

METHODS

Data were from parents of adolescents (12-17 years) who completed the 2017-2018 National Survey of Children's Health (NSCH). Examined variables included: current asthma and anxiety diagnoses, family resilience, child health status, number of adverse childhood experiences (ACEs), family poverty, parent education, and child demographic factors. Multinomial logistic regression models were performed.

RESULTS

Findings indicated that compared to adolescents with high resilience scores, adolescents with anxiety only and comorbid asthma and anxiety were more likely to have moderate or low family resilience scores than adolescents with no asthma or anxiety. Compared with adolescents with an excellent/very good health status, youth with asthma only, anxiety only, and asthma and anxiety had higher odds of having good or fair/poor health status than adolescents with no asthma or anxiety. Among those with current diagnoses, adolescents with asthma only were less likely to have moderate and low resilience scores than adolescents with asthma and anxiety. Adolescents with asthma only and anxiety only were also at reduced odds to have good or fair/poor health status than those with comorbid diagnoses.

CONCLUSIONS

Results indicated that anxiety is linked to family resilience of adolescents with and without comorbid asthma. Experiencing a higher number of ACEs was a risk factor for lower family resilience scores and health status. Future research should consider the impact of other mental health problems and family resilience and health status.

Examining the Role of Weight Status and Individual Attributes on Adolescent Social Relations

PURPOSE

Weight stigmatization during adolescence may compromise the development of social relations important for the development. This study examined the associations between weight status and likelihood of nomination (indegree) for five different social network types-friendship, romantic, admiration, succeed, and popularity.

METHODS

Data for the study were from 1,110 tenth grade students (aged 11-19 years) from four high schools in one Los Angeles school district in 2010. Multiple Poisson regression analyses using generalized linear model were conducted to examine the relationship between weight status (underweight/normal weight/overweight measured with body mass index calculated from self-reported height and weight) and adolescents' indegree for the five different networks.

RESULTS

Obese adolescents were significantly less likely to be nominated as romantic interest (odds ratio [OR]: .29, 95% confidence interval [CI]: .19-42), admired (OR: .80, 95% CI: .65-.97), or popular (OR: .71, 95% CI: .57-.88) compared with their normal weight peers. Overweight adolescents were also less likely to be nominated as a romantic interest (OR: .57, 95% CI: .42-.78) or popular (OR: .67, 95% CI: .53-.84) compared with those who were normal weight. Underweight adolescents were also less likely to be nominated as friends (OR: .76, 95% CI: .60-98), someone admired (OR: .61, 95% CI: .42-.89), likely to succeed (OR: .62, 95% CI: .44-.87), or popular (OR: .40, 95% CI: .25-.64).

CONCLUSIONS

Our results suggest weight status is associated with being selected by peers into different types of adolescent networks. Underweight, overweight, and obese adolescents are at an increased risk for social isolation because of their weight. This may have a negative impact on their peer relations important for social development, self-esteem, and mental health.

Secondhand Smoke Exposure and Subsequent Academic Performance Among U.S. Youth

INTRODUCTION

Previous research shows the associations between secondhand smoke exposure and health consequences among youth, but less is known about its effect on academic performance. This study examines a dose-response relationship between secondhand smoke exposure and subsequent academic performance among U.S. youth.

METHODS

Data were from a nationally representative sample of youth non-tobacco users (aged 12-16 years) in Wave 2 (2014-2015) who completed Wave 3 (2015-2016) of the Population Assessment of Tobacco and Health Study (n=9,020). Past-7-day number of hours exposed to secondhand smoke at Wave 2 and academic performance at Wave 3 (1=Mostly As to 9=Mostly Fs) were assessed. Weighted multivariable linear regression models were used to examine the association between hours of self-reported secondhand smoke exposure at Wave 2 and academic performance at Wave 3 (1=Mostly Fs, 9=Mostly As), adjusting for covariates including sociodemographics, prior academic performance, internalizing and externalizing problems, and substance use problems. Analyses were conducted in 2019.

RESULTS

More than 30% of U.S. youth non-tobacco users were exposed to secondhand smoke in the past 7 days. Compared with unexposed youth at Wave 2, those who were exposed for 1-9 hours had poorer academic performance at Wave 3 (adjusted regression coefficient= -0.11, 95% CI= -0.18, -0.04), and those who were exposed for ≥10 hours at Wave 2 had even poorer academic performance (adjusted regression coefficient = -0.31, 95% CI= -0.45, -0.18).

CONCLUSIONS

A dose-response relationship was observed between secondhand smoke exposure and academic performance among U.S. youth. Reducing youth secondhand smoke exposure may promote academic performance and subsequent educational attainment.

Provision of free nicotine replacement therapy to parental smokers in the pediatric emergency setting

INTRODUCTION

Although the administration of free Nicotine Replacement Therapy (NRT) is effective in helping smokers quit, the feasibility, acceptability and safety of this practice have not been examined in the emergency setting of the pediatric emergency department (PED) or urgent care (UC). We examined the characteristics of parental smokers who were interested and eligible for free NRT during their child's emergency visit and the uptake, usage, and associated side effects of NRT use.

METHODS

We analyzed data from 377 parental smokers who were randomized to receive cessation counseling and free NRT as part of an emergency visit-based randomized controlled trial. Parents interested in NRT were screened for medical contraindications; eligible parents were given a 6-week supply of NRT patches or lozenges during their child's emergency visit and offered another supply 6 weeks later. We conducted Wilcoxon rank-sum tests and chi-squared tests to address our main study objective.

RESULTS

The majority of parents were female (87.5%), non-Hispanic Black (52.5%), and mean (SD) age was 33.1 (8.2) years. A total of 252 (66.8%) parents were interested in receiving NRT. Compared to uninterested parents, interested parents were more likely to: be older [33.6 (8.2) vs 31.9 (8.2), years]; be non-Hispanic Black (54.0% vs 49.6%); have older children [5.5 (5.0) vs 4.2 (4.6)]; have a higher readiness to quit [7.0 (2.4) vs 5.2 (2.6)]; and have a child being evaluated in UC compared to the PED (72.4% vs 56.5%). A total of 53 (21%) interested parents had >1 NRT contraindications. At 6 weeks, 94 (79.0%) parents reported some ≥NRT usage and 50 (53.2%) requested an additional 6-week supply. There were no serious adverse events and 5 (5.3%) reported minor side effects.

CONCLUSIONS

Parental smokers in the emergency setting are interested in receiving free NRT, the majority use it, and use is not associated with adverse side effects. The emergency visit may be an optimal time to offer NRT to parental smokers.

Screening, Counseling, and Health Care Utilization Among a National Sample of Adolescent Smokers

Our objective was to assess the association between cigarette smoking and tobacco use screening and advising to quit use by a clinician among adolescents nationwide. We also examined the relationships between smoking and health-related indicators and health care utilization. A secondary analysis of the 2017 National Survey on Drug Use and Health was conducted (N = 11 884). Ever smokers were less likely to be screened for tobacco use. Current smokers and those who were nicotine dependent were more likely to have been advised to quit use. Ever and current smokers were significantly more likely to report good/fair/poor health status, illness-related school absenteeism in the past 30 days, and were more likely to have had an emergency department visit or an overnight hospital stay. Standardized tobacco control efforts are needed in health care settings to support clinicians to screen all adolescents for tobacco use and advise every smoker irrespective of smoking frequency to quit use.

Tobacco Smoke Exposure, Respiratory Health, and Health-care Utilization Among US Adolescents

BACKGROUND

Tobacco smoke exposure adversely affects respiratory health. However, the effects of exposure on adolescents without asthma are not well known.

RESEARCH QUESTION

To what degree are biochemically measured and self-reported tobacco smoke exposure associated with pulmonary function and health-care utilization among US nonsmoking adolescents?

STUDY DESIGN AND METHODS

We analyzed 2007-2012 National Health and Nutrition Examination Survey data (N = 2,482). Tobacco smoke exposure was assessed with serum cotinine and self-reported home exposure. We built multiple regression, logistic regression, and Poisson regression models, depending on the outcome.

RESULTS

Approximately 3% of adolescents had high cotinine (3.00-15.00 ng/mL), 35.7% had low cotinine (0.05-2.99 ng/mL), and 10.9% had home exposure. Adolescents with high cotinine had significantly lower FEV₁% (mean, 97.4; SE, 2.09; β, -8.99; 95% CI, -15.64 to -2.33) and FVC% (mean, 97.4; SE, 2.06; β, -8.42; 95% CI, -14.74 to -2.11) than adolescents with no/minimal cotinine (< 0.05 ng/mL; mean, 101.0; SE, 0.45; mean, 99.9; SE, 0.46, respectively). Adolescents with high cotinine were less likely to have a past year health-care visit (adjusted OR [aOR], 0.57; 95% CI, 0.38 to 0.88), but more likely to have an overnight hospital stay (aOR, 4.82; 95% CI, 2.58 to 9.00), and at increased risk of having a higher number of overnight hospital stays (adjusted relative risk [aRR], 4.04; 95% CI, 2.27 to 7.21). Adolescents with low cotinine were less likely to have a health-care visit (aOR, 0.84; 95% CI, 0.71 to 0.99), but more likely to have an overnight hospital stay (aOR, 4.82; 95%CI, 2.58 to 9.00) than adolescents with no/minimal cotinine. Adolescents with low cotinine were at increased risk of having a higher number of health-care visits (aRR, 1.06; 95% CI, 1.02 to 1.11) and overnight hospital stays (aRR, 2.02; 95% CI, 1.46 to 2.81). Adolescents with home exposure had lower FEV₁% (mean, 99.9; SE, 1.17; β, -5.11; 95% CI, -9.26 to -0.96) and FVC% (mean, 100.0; SE, 1.16; β, -5.36; 95% CI, -9.30 to -1.42) than adolescents with no home exposure (mean, 101.0; SE, 0.38; mean, 100.2; SE, 0.39, respectively). Adolescents with home exposure were more likely to have an overnight hospital stay (aOR, 5.65; 95% CI, 3.66 to 8.73) and at increased risk of having a higher number of overnight hospital stays (aRR, 4.08; 95% CI, 2.76 to 6.03).

INTERPRETATION

Detectable serum cotinine levels and self-reported home exposure were distinctively associated with decreased pulmonary function and increased health-care utilization.

Electronic Health Record Classification of Tobacco Smoke Exposure and Cotinine Levels in Hospitalized Pediatric Patients

OBJECTIVES

Documentation of children's tobacco smoke exposure (TSE) in the electronic health record (EHR) can have important implications for clinical care. However, it may not be accurate if it is not based on biochemical assessment, the most reliable method of verifying TSE. Our objectives were to compare the accuracy of EHR classification of TSE with cotinine verification and to explore parent and child variables associated with biochemically verified TSE.

METHODS

Participants were 171 hospitalized pediatric patients (ages 0-17 years; mean age 5.1 [SD 3.7] years) who had EHR documentation of TSE and measured salivary cotinine. Children with cotinine levels >1 ng/mL were classified as having biochemical verification of TSE. Parents reported sociodemographic characteristics, and children's EHRs were abstracted for TSE status, past medical history, and diagnoses. We conducted χ² tests to assess the agreement between EHR classification of TSE status and cotinine levels. Then, we assessed the relationship between sociodemographic and clinical variables and cotinine using crude and adjusted logistic regression models.

RESULTS

Overall, 71% (121 of 171) of EHR classifications were correct on the basis of cotinine levels. Specificity analyses showed that 77% (53 of 69) were correctly identified as exposed to tobacco smoke. Sensitivity analyses showed that 67% (68 of 102) were correctly identified as unexposed. The negative predictive value was 0.61 (53 of 87); 39% (34 of 87) were misclassified as unexposed. The positive predictive value was 0.81 (68 of 84); 19% (16 of 84) were misclassified as exposed.

CONCLUSIONS

Almost 40% of children were misclassified in the EHR as unexposed to tobacco smoke. Biochemical verification should be used as part of universal TSE screening during pediatric hospitalizations.

Gender Differences in Socio-ecological Determinants of Alcohol Use Among Hispanic Adolescents

BACKGROUND

Compared to other racial groups, Hispanic/Latino(a) adolescents experience higher rates of alcohol (ab)use and alcohol-related problems. Evidence suggests there are gender differences in alcohol use patterns indicating the likelihood of gender differences in how various determinants influence alcohol use among the genders. Assessing the mechanisms that contribute to Hispanic adolescents' alcohol use requires an understanding of the multidimensional social and environmental processes that operate together to impact their alcohol use. In this study, we examined socio-ecological determinants of Hispanic adolescent alcohol use by gender.

METHODS

Data from 10th grade Hispanic/Latino(a) students (N = 781) from four high schools in Los Angeles were used to examine associations between socio-ecological characteristics and adolescent alcohol use by gender.

RESULTS

Overall, 37.5% of participants reported past 30-day alcohol use. Among boys, alcohol use was associated with intrapersonal (not qualifying for reduced lunch), interpersonal (mother's education and peer drinking), and institutional (alcohol-prone school club membership) determinants. Among girls, alcohol use was associated with intrapersonal (academic achievement) and interpersonal (parent and peer alcohol use behavior) determinants.

CONCLUSIONS

Prevention and intervention efforts need to take into consideration the gender differences in social-ecological risk and protective factors when designing educational or intervention programs and services targeted at Hispanic adolescents. This is crucial to addressing multi-component factors that influence their substance use behavior.

The Association of Environmental Tobacco Smoke Exposure and Inflammatory Markers in Hospitalized Children

Background: Environmental tobacco smoke (ETS) exposure is associated with altered cytokine levels in children. We sought to examine ETS exposure prevalence and the relationship between ETS exposure and cytokine levels in a sample of hospitalized children. (2) Methods: Inflammatory markers (IL-8, IL-1β, IL-10, and TNF-α) and cotinine were measured in saliva of hospitalized, nonsmoking children (N = 112). To assess the association between ETS exposure and immune system response, we built a multivariate regression model including the four inflammatory markers as the response variables and cotinine, age, sex, and discharge diagnosis as explanatory variables while assessing possible interaction effects. (3) Results: Mean age (SD) was 5.8(5.0) years; Geometric Mean (GeoM) cotinine = 1.8 [95% CI = 1.4–2.2]. Children with non-inflammatory other diagnoses had lower IL-10 (p = 0.003) and TNF-α (p = 0.009) levels than children with inflammatory other diagnoses. Children with asthma (p = 0.01) and bacterial illnesses and/or pneumonia (p = 0.002) had higher IL-8 levels. Independent of diagnosis, there was a significant curvilinear association between cotinine and IL-1β (p = 0.002) reflecting no association for cotinine levels <5 ng/mL and a positive association for >5 ng/mL. (4) Conclusions: Children with higher ETS exposure levels have higher IL-1β levels regardless of age, sex, and diagnosis. ETS exposure may increase pro-inflammatory immune responses in children and may interfere with native immune responses and the ability to heal and fight infection.

Self-Perceptions and Factors Associated With Being Put Down at School Among Middle and High School Students

This study assessed the prevalence of verbally being put down by others and intrapersonal and normative factors associated with being put down by others among middle and high school students. Students (N = 1,027) completed the Adolescent Health Risk Behavior Survey. Over 16% of participants reported being put down at school. Students who identified with the negative words confused, unattractive, dull, and careless and identified less with the positive words popular, smart, considerate, cool, and self-confident reported being put down by others. High school students were less likely to be put down. As students scored higher on the Negative Self-Description Scale, their odds of being put down increased. As students scored higher on the Positive Self-Description Scale, their odds of being put down decreased. Students who perceived their friends drinking alcohol regularly were less likely to be put down. Strategies to enhance self-perceptions to raise self-awareness and form healthy/positive identities are needed.

Tobacco Use Behaviors and Perceptions of Parental Smokers in the Emergency Department Setting

Background

More information is needed about modifiable child tobacco smoke exposure (TSE) patterns in racially diverse parental smokers to tailor interventions designed to help parents quit smoking and reduce their child's TSE. Our objectives were to determine whether there were differences in smoking and TSE patterns based on parental race and child age and whether these patterns differed based on child age within black and white parental smokers. Secondary objectives were to assess the relationship between parental perceptions about the effects of smoking and the benefits of quitting on their child based on child age, race, and reported TSE patterns and to examine biochemically verified TSE levels by child age, race, and parent-reported TSE patterns.

Methods

Participants (N = 415) were non-Hispanic black and non-Hispanic white parental smokers, mean age (standard deviation [SD]) = 31.2 (7.2) years, who visited the Pediatric Emergency Department (PED) or Urgent Care (UC) with their child, mean age (SD) = 4.7 (4.6) years. Parents reported sociodemographics, smoking, and child TSE patterns. We conducted chi-square tests, independent t-tests, and general linear regression models to answer our primary objectives and linear regression models to answer our secondary objectives.

Results

Parents were 56.1% non-Hispanic black; 87.5% women; mean (SD) number of cigarettes smoked/day was 10.5(6.8). A higher proportion of parents with younger children <3 years old reported smoking bans compared with parents with older children ⩾3 to <18 years old (41.3% vs 19.7%, P < .0001). Subsequent analyses revealed this pattern for both black and white parents. A total of 212 (51%) of children had biochemical assessment of TSE; 89.6% had detectable TSE. Younger children had significantly higher cotinine levels than older children independent of their race (P < .001).

Conclusions

Children of parental smokers who visit the PED/UC were highly tobacco smoke exposed. Both black and white parental smokers with younger children were more likely to enforce smoking bans, but younger children had higher TSE levels than older children. Interventions that target this group of parental smokers with younger children may be more effective than interventions geared to all parental smokers.

Characteristics of Daily E-Cigarette Use and Acquisition Means Among a National Sample of Adolescents

PURPOSE

To examine the relationship between several e-cigarette-related characteristics and daily e-cigarette use among adolescent current users.

DESIGN

Secondary analysis of 2016 National Youth Tobacco Survey data.

SETTING

United States middle schools and high schools.

SAMPLE

One thousand five hundred seventy-nine current e-cigarette users.

MEASURES

Daily e-cigarette use and e-cigarette flavors, brands, device type, and acquisition were measured.

ANALYSIS

Logistic regression and Poisson regression models were built.

RESULTS

A total of 13.6% of current users reported daily use. Results indicated that daily users were at increased odds of using all flavor types (all P < .001), with the exception of menthol/mint, and using a higher number of flavors than nondaily users (P < .001). Daily users were more likely to use Blu, eGo, Logic, Halo, NJOY, and another unlisted brand but less likely to report they did not know the brand used (all P ≤ .01). Daily users also reported using a higher number of brands than nondaily users (P < .001). Daily users were at increased odds of using marijuana/tetrahydrocannabinol (THC) oil wax as device ingredients (P < .001) and less likely to use only nicotine (P < .001) or unknown ingredients (P = .004). Daily users were more likely to acquire e-cigarettes from a vape shop, gas station/convenience store, Internet, mall/shopping center kiosk, drug store, grocery store, or other place (all P ≤ .01).

CONCLUSION

Comprehensive efforts are needed to reduce e-cigarette use and nicotine addiction among adolescents.

Tobacco smoke exposure disparities persist in U.S. children: NHANES 1999-2014

Tobacco smoke exposure (TSE) is a common modifiable hazard to children. The objective was to investigate how the prevalence of TSE varied from 1999 to 2014 among U.S. children and to calculate differences between sociodemographic characteristics and TSE by two-year increases. We also assessed associations between sociodemographics and TSE in 2013-2014. A secondary analysis of data from the National Health and Nutrition Examination Survey 1999-2014 was performed including 14,199 children 3-11 years old from nationwide. We conducted logistic regression analyses to assess TSE trends, and associations between sociodemographics and TSE in 2013-2014. TSE prevalence declined from 64.5% to 38.1% during 1999-2014 (a relative reduction of 44.4%). TSE declined among all sociodemographics. In 2013-2014, differences in TSE were found by race/ethnicity, family monthly poverty level [FPL], and house status. Non-Hispanic black children were 1.85 times more likely (95%CI[1.39-2.47]) to be exposed to tobacco smoke than non-Hispanic white children, whereas Non-Hispanic other (OR = 0.71, 95%CI[0.52-0.96]), Hispanic other (OR = 0.42, 95%CI[0.30-0.59]), and Hispanic Mexican (OR = 0.27, 95%CI[0.21-0.35]) children were at lower risk of exposure. Compared to those in the highest FPL category (>185%), children with FPL ≤130% were 3.37 times more likely (95%CI[2.73-4.15]) and children with FPL 131-185% were 1.80 times more likely (95%CI[1.31-2.49]) to be exposed. Children who lived in rented homes were 2.23 times more likely (95%CI[1.85-2.69]) to be exposed than children who lived in owned homes. Targeted tobacco control efforts are needed to reduce existing TSE disparities among children, especially those who are non-Hispanic black, low socioeconomic status, and live in rented homes.

Contribution of thirdhand smoke to overall tobacco smoke exposure in pediatric patients: study protocol

BACKGROUND

Thirdhand smoke (THS) is the persistent residue resulting from secondhand smoke (SHS) that accumulates in dust, objects, and on surfaces in homes where tobacco has been used, and is reemitted into air. Very little is known about the extent to which THS contributes to children's overall tobacco smoke exposure (OTS) levels, defined as their combined THS and SHS exposure. Even less is known about the effect of OTS and THS on children's health. This project will examine how different home smoking behaviors contribute to THS and OTS and if levels of THS are associated with respiratory illnesses in nonsmoking children.

METHODS

This project leverages the experimental design from an ongoing pediatric emergency department-based tobacco cessation trial of caregivers who smoke and their children (NIHR01HD083354). At baseline and follow-up, we will collect urine and handwipe samples from children and samples of dust and air from the homes of smokers who smoke indoors, have smoking bans or who have quit smoking. These samples will be analyzed to examine to what extent THS pollution at home contributes to OTS exposure over and above SHS and to what extent THS continues to persist and contribute to OTS in homes of smokers who have quit or have smoking bans. Targeted and nontargeted chemical analyses of home dust samples will explore which types of THS pollutants are present in homes. Electronic medical record review will examine if THS and OTS levels are associated with child respiratory illness. Additionally, a repository of child and environmental samples will be created.

DISCUSSION

The results of this study will be crucial to help close gaps in our understanding of the types, quantity, and clinical effects of OTS, THS exposure, and THS pollutants in a unique sample of tobacco smoke-exposed ill children and their homes. The potential impact of these findings is substantial, as currently the level of risk in OTS attributable to THS is unknown. This research has the potential to change how we protect children from OTS, by recognizing that SHS and THS exposure needs to be addressed separately and jointly as sources of pollution and exposure.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02531594 . Date of registration: August 24, 2015.

Nicotine on Children's Hands: Limited Protection of Smoking Bans and Initial Clinical Findings

Background:

Thirdhand smoke (THS) pollutants, such as nicotine, accumulate on the hands of children who live in homes with smokers and are exposed to secondhand smoke. Our objective was to examine whether levels of hand nicotine in exposed children are associated with demographics, environmental factors, and clinical findings.

Methods:

Participants were caregivers who smoke and children (mean age (SD) = 2.6 (3.7) years) who were part of an ongoing 2-group, randomized controlled trial of an emergency department–based tobacco cessation intervention (N = 104). The primary outcome measure was nicotine on the child’s hand. Caregivers reported demographics and smoking patterns; children’s medical records were abstracted for chief complaint, medical history, and diagnoses.

Results:

All children had detectable hand nicotine (geometric mean [GeoM] = 86.2 ng/wipe; range = 3.5-2, 190.4 ng/wipe). Children in the age group of 2 to 4 years old (GeoM = 185.6 ng/wipe) had higher levels than the children in the age groups of 0 to 1 (GeoM = 68.9 ng/wipe, P < .001), 5 to 9 (GeoM = 77.9 ng/wipe, P = .04), and 10 to 15 years old (GeoM = 74.2 ng/wipe, P = .048). Children whose caregivers smoked 6 to 14 (GeoM = 97.2 ng/wipe, P = .047) and 15 to 40 cigarettes/day (GeoM = 124.0 ng/wipe, P = .01) had higher levels than children whose caregivers smoked 1 to 5 cigarettes/day (GeoM = 59.7 ng/wipe). Children with 6 to 14 cigarettes/day (GeoM = 163.11 ng/wipe, P = .007) and 15 to 40 cigarettes/day (GeoM = 186.1, P = .003) smoked inside the home by all smokers had significantly higher levels than homes with 0 cigarettes (GeoM = 81.3 ng/wipe). Similar differences in hand nicotine levels were found for smoking frequency of all household members in any location. Children with complaints of cough/congestion (GeoM = 97.7 ng/wipe) had higher levels than those without cough/congestion (GeoM = 59.0 ng/wipe, P = .01).

Conclusions:

The high hand nicotine levels in children whose caregivers do not necessarily smoke indoor demonstrate that indoor smoking bans do not safeguard against THS exposure and the associations with increased home smoking activity indicate that hand wipes may be a noninvasive way to characterize children’s exposure. The findings of associated cough and congestion with higher THS levels need to be examined further.

Alcohol Advertising on Social Media: Examining the Content of Popular Alcohol Brands on Instagram

BACKGROUND

There is considerable evidence that exposure to alcohol marketing increases the likelihood of adolescents initiating and engaging in alcohol consumption. There is a paucity of research, however, specifically examining industry generated alcohol marketing occurring on social media/networking platforms.

OBJECTIVE

The purpose of this investigation was to analyze the content of promotional advertisements by alcohol brands on Instagram.

METHODS

For a 30-day period, Instagram profiles of 15 distinct alcohol brands were examined. Pictorial posts/updates from each profile were screen captured and individually documented. Approximately 184 distinct posts constituted our final sample. The Content Appealing to Youth Index was independently employed by two raters to assess each post. For each characteristic, Cohen's Kappa measures, and associated 95% confidence intervals, were calculated. Descriptive statistics were performed.

RESULTS

Posts increased throughout the week and peaked on Thursday and Friday. The production value of the posts examined was generally high, frequently featuring color, texture, shine, contrast, faces, and action. Character appeals and use of youth-oriented genres were uncommon. Many of the posts used product appeals and physical benefits to consumption. The posts also emphasized the following rewarding appeal characteristics: positive emotional experiences, achievement, individuality, and camaraderie. The most commonly coded risk-related feature was inappropriate use. Conclusions/Importance: This investigation represents an initial attempt to provide insights into the content alcohol brands are including in their promotional materials on social networking sites.

Heat-Related Training and Educational Material Needs among Oil Spill Cleanup Responders

Heat-related illness (HRI), injury, and death among oil spill cleanup responders can be prevented through training and educational materials. This study assessed heat-related training and educational materials currently used and desired by oil spill cleanup responders. A needs assessment was completed by 65 oil spill cleanup responders regarding their occupational heat-related experiences and training needs. Oil spill cleanup responders reported participating on average in 37 oil spill cleanup activities per year. Most reported experiencing additional HRI risk factors, such as high temperatures and humidity and wearing personal protective equipment and clothing ensembles, respirators, and personal flotation devices. Many reported experiencing symptoms of HRI (profuse sweating, headache, weakness, decreased urine output, high body temperatures) and experiencing heat exhaustion. Although multiple prevention controls were reported, only 1 in 4 reported using an acclimatization plan. The most common training delivery method and education received included just-in-time training and printed materials. The most desirable future training delivery methods and education products were smartphone or tablet applications, printed materials, and online training. Findings from this study may be beneficial to safety and health professionals and health educators, particularly those interested in developing heat stress training and educational materials for oil spill cleanup responders.

Adolescent Tobacco Smoke Exposure, Respiratory Symptoms, and Emergency Department Use

OBJECTIVES

Our objective was to examine the relationship between distinct tobacco smoke exposure (TSE) measures and TSE-related symptoms and emergency department (ED) and/or urgent care (UC) use among nonsmoking adolescents without asthma diagnoses.

METHODS

We performed a secondary analysis of 7389 adolescents who completed the Population Assessment of Tobacco and Health Study wave 2. Logistic regression and Poisson regression models were built.

RESULTS

Adolescents with TSE were at increased risk of reporting: shortness of breath, finding it hard to exercise, wheezing during or after exercise, and dry cough at night. Adolescents who lived with a smoker and had home TSE were at increased odds of reporting wheezing or whistling in the chest, and only adolescents with home TSE were at increased risk of reporting wheezing that disturbed sleep. Adolescents with TSE were less likely to report very good or excellent overall health and physical health but were more likely to report they sometimes, often, or very often missed school because of illness. Participants who lived with a smoker and had TSE ≥1 hour were more likely to have had an ED and/or UC visit. Participants with any TSE were at increased risk of having a higher number of ED and/or UC visits.

CONCLUSIONS

Different TSE measures uniquely increased the risk of TSE-related symptoms, but any TSE increased the risk of having a higher number of ED and/or UC visits. The providers at these high-volume settings should offer interventions to adolescents who are exposed to tobacco smoke and their families to decrease these symptoms and related morbidity.

National Institutes of Health Funding for Tobacco Control: 2006 and 2016

PURPOSE

The study objective was to describe and compare changes in newly funded National Institutes of Health (NIH) tobacco-related awards between fiscal year (FY) 2006 and FY2016.

DESIGN

Secondary analysis of NIH data.

SETTING

National Institutes of Health Research Portfolio Online Reporting Tool database was used.

SUBJECTS

National Institutes of Health tobacco-related awards newly funded during FY2006 and FY2016.

MEASURES

Search terms included tobacco, smoking, nicotine, secondhand smoke, and e-cigarettes. Grants and funding amounts were retrieved.

ANALYSIS

We calculated frequency distributions to determine the number and percentage of total NIH grants funded overall and by specific institute, and inflation-adjusted total and median funding amounts. We computed percentage differences in number of new grants, funding amounts, and percentage of funding allocated overall, and by institute.

RESULTS

There was a 187% increase in the percentage of total NIH funding allocated to new tobacco-related awards from 0.09% in FY2006 to 0.25% in FY2016. Total number of awards increased by 67% in FY2016 (n = 144; $56 015 931) compared to FY2006 (n = 86; $22 076 987), and there was a 154% increase in inflation-adjusted total funding for tobacco control. The top funding institutes were National Institute on Drug Abuse and National Cancer Institute; National Institute on Alcohol Abuse and Alcoholism was third in FY2006; and National, Heart, Lung and Blood Institute in FY2016. Research grants were the most frequently funded. Smoking cessation was a common topic area and increased by 64%.

CONCLUSION

NIH funding is critical for advancing the science of nicotine and tobacco research.

Predictors of Exclusive Breastfeeding for 6 Months in a National Sample of US Children

PURPOSE

To explore predictors of breastfeeding behavior and seek to replicate prior findings using a recent nationally representative United States (US) sample, which has not been done previously.

DESIGN

Secondary data analysis using the National Survey of Children's Health 2011 to 2012.

SETTING

Households in the 50 US states, the District of Columbia, and the US Virgin Islands.

PARTICIPANTS

Caregivers with a child between 6 months and 6 years of age (n = 26 552).

MEASURES

Caregiver-reported child breastfeeding behavior, child birth weight, child/maternal/family demographics, maternal physical and mental health, and household tobacco exposure.

ANALYSIS

A multinomial logistic regression explored whether child, maternal, and family characteristics predicted exclusive breastfeeding for 6 months or breastfeeding for a suboptimal duration.

RESULTS

Approximately 79% and 17% of the sample-initiated breastfeeding and exclusively breastfed for 6 months, respectively. Child ethnicity/race, maternal education, household tobacco exposure, family composition, and family income predicted odds of both exclusive breastfeeding for 6 months and breastfeeding for a suboptimal duration or not exclusively. Normal or high child birth weight and better maternal physical health predicted greater odds of exclusive breastfeeding for 6 months.

CONCLUSION

Rates of exclusive breastfeeding for 6 months remain low in the United States. Single-parent and step-families, lower income families, non-Hispanic black children, children with exposure to tobacco, and children of mothers with lower education are at greatest risk.

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.

Depression and Alcohol Use in a National Sample of Hispanic Adolescents

BACKGROUND

Underage alcohol use and depression remain public health concerns for Hispanic adolescents nationwide.

OBJECTIVES

The study purpose was to identify the profiles of depression among Hispanic adolescents who reported experiencing depressive symptoms in their lifetime and classify them into groups based on their symptoms. Based on classifications, we examined the relationship between past year alcohol use and severity of depressive symptoms while controlling for sex and age.

METHODS

A secondary analysis of the 2013 NSDUH was conducted among Hispanic adolescents from 12 to 17 years of age (n = 585) who reported experiencing depressive symptoms. Latent class analysis was used to identify latent classes of depressive symptoms among Hispanic adolescents. A zero-inflated negative-binomial regression model was used to examine the relationship between alcohol use and depressive symptoms.

RESULTS

"High depressive" and "moderate depressive" classes were formed. The items that highly differentiated among the groups were felt worthless nearly every day, others noticed they were restless or lethargic, and had changes in appetite or weight. There was a significant difference (p = 0.03) between the classes based on alcohol use; those in the moderate depressive class were 1.71 times more likely to be identified as not reporting past alcohol use. Results indicated the high depressive class was estimated to have 1.62 more days of past year alcohol use than those in the moderate depressive class for adolescents who used alcohol (p < 0.001). Conclusions/Importance: Study findings can be used to address these significant public health issues impacting Hispanic adolescents. Recommendations are included.

Tobacco Smoke Exposure Association With Lipid Profiles and Adiposity Among U.S. Adolescents

PURPOSE

We investigated the association between tobacco smoke exposure (TSE) as measured by serum cotinine and lipoprotein cholesterols and adiposity in adolescents.

METHODS

We performed a secondary analysis of 1999-2012 National Health and Nutrition Examination Survey data including participants 12-19 years old. We examined TSE: unexposed (<.05 ng/mL), passively exposed (.05-2.99 ng/mL), and actively exposed (≥3 ng/mL); lipid profiles: total cholesterol, high-density lipoprotein cholesterol (HDL-C), non-HDL-C, low-density lipoprotein cholesterol (LDL-C), and triglycerides; and adiposity: body mass index z-score (BMIZ), waist circumference (WC), and waist-to-height ratio (WHtR). Covariates were age, sex, race/ethnicity, income, diet, and physical activity. Multiple regression models were used to assess the association between TSE and lipid profile variables separately, and then TSE and adiposity measures separately, adjusting for covariates. We performed logistic regression to examine the association of TSE with body mass index and WHtR classifications.

RESULTS

Of the 11,550 participants, 41.7% were unexposed to tobacco smoke, 40.5% were passively exposed, and 17.8% were actively exposed. Compared with unexposed, participants with active TSE had lower total cholesterol, lower HDL-C, and higher triglycerides; higher BMIZ, higher WC, and higher WHtR; participants with passive TSE had lower HDL-C, higher total cholesterol, and higher LDL-C; higher BMIZ, higher WC, and higher WHtR. Participants actively exposed were at increased odds of being obese or WHtR ≥.65, and those passively exposed were at increased odds of being overweight, obese, or WHtR ≥.65.

CONCLUSIONS

Active TSE and passive TSE are differentially associated with factors within the lipid profile and adiposity, independent of covariates. TSE prevention efforts should start as early as childhood and continue throughout adolescence and adulthood.

Serum Cotinine and Hemoglobin A1c Among a National Sample of Adolescents Without Known Diabetes

Introduction

National data suggest tobacco smoke is positively associated with higher glycated hemoglobin (HbA1c) among adults. Our objective was to examine the association between serum cotinine and HbA1c among adolescents without known diabetes.

Methods

We assessed adolescents 12-19 years old (N = 11550) who participated in the 1999-2012 National Health and Nutrition Examination Survey. We applied sampling weights while performing multiple linear regression analyses.

Results

The prevalence of serum cotinine indicative of no tobacco smoke exposure (TSE, <0.05 ng/mL) was 43.2%, passive TSE (0.05-2.99 ng/mL) was 38.9%, and active TSE (>3 ng/mL) was 17.9% in our sample. Mean (± standard error) HbA1c in participants with no TSE was 5.16% (±0.01), passive TSE was 5.16% (±0.01), and active TSE was 5.14% (±0.01). No differences in HbA1c were found between TSE groups including sex, age, race/ethnicity, education, income, and physical activity or the fully adjusted model with waist circumference. We found cotinine × sex (p = .01) and cotinine × age (p = .02) interactions. There was an association between cotinine and HbA1c for males but not females. Within males, participants with cotinine ≥3 ng/mL (5.26 ± 0.02) had higher mean HbA1c than those with cotinine 0.05-2.99 ng/mL and <0.05 ng/mL (both 5.20 ± 0.01, p ≤ .02). The negative association between age and HbA1c was stronger for participants with cotinine ≥3 ng/mL than participants with cotinine <0.05 ng/mL.

Conclusion

No linear association was found between HbA1c and serum cotinine in adolescents overall after adjusting for potential confounders. Differences between TSE groups were found in males. Future research in adolescents should examine chronic TSE over time to examine the potential for development of type 2 diabetes.

Implications

TSE has been associated with increased risk for the development of type 2 diabetes among adults. It is unclear if this relationship holds in adolescents. We examined the association between serum cotinine and HbA1c in adolescents without known diabetes who completed the 1999-2012 National Health and Nutrition Examination Survey. Although no association was found between serum cotinine and HbA1c overall while controlling for potential confounding factors, we observed interaction effects that are indicative of TSE influencing HbA1c differentially by sex and age. Reducing TSE in adolescents should be a priority for future tobacco control efforts.

Dual- and Polytobacco/Nicotine Product Use Trends in a National Sample of High School Students

PURPOSE

The study purpose was to examine changes in patterns of ever and current dual- and polyproduct use over time and to examine demographic and modifiable risk factors including tobacco smoke exposure (TSE).

DESIGN

A secondary analysis of the 2013 to 2015 National Youth Tobacco Survey data.

SETTING

Nationwide high schools were selected.

SUBJECTS

A total of 31 022 high school students.

MEASURES

Ever and current (past 30 days) tobacco/nicotine product use, home tobacco/nicotine product use, TSE and e-cigarette vapor exposure, and demographic characteristics were measured.

ANALYSIS

Multivariable logistic regression and multinomial logistic regression models.

RESULTS

Of the students, 9.4% were ever dual users and 18.6% were ever poly users. Rates of ever/current use of e-cigarettes and hookah increased from 2013 to 2015 (all Ps < .001). In 2015, participants were 4.8 times (95% confidence interval [CI], 4.5-5.2) and 4.0 times (95% CI, 3.5-4.4) more likely to report ever/current e-cigarette use and 1.61 times (95% CI, 1.5-1.7) and 1.48 times (95% CI, 1.3-1.7) more likely to report ever/current hookah use. Participants reporting TSE were 15.4 times (95% CI, 11.5-21.0) more likely to report current poly use, and those with e-cigarette exposure were 10.4 times (95% CI, 7.8-13.8) more likely to report current poly use.

CONCLUSION

From 2013 to 2015, rates of ever and current use of e-cigarettes and hookah increased. Tobacco smoke and e-cigarette exposure were associated with higher rates of dual and poly use. Prevention efforts targeting these products are needed.