Validity of self-reported exposure to second-hand smoke in hospitality venues

Methodological guidelines for the estimation of attributable mortality using a prevalence-based method: The STREAMS-P tool

BACKGROUND

There is evidence of strong links between exposure to different risk factors and life-threatening diseases. Assessing the burden of a risk factor on the population's mortality due to a given disease provides a clear picture of these links. The estimation of attributable mortality to a risk factor is the most widely used procedure for doing this. Although different methods are available to estimate attributable mortality, the prevalence-based methodology is the most frequent. The main objective of this paper is to develop guidelines and checklists to STrengthen the design and REporting of Attributable-Mortality Studies using a Prevalence-based method (STREAMS-P) and also to assess the quality of an already published study which uses this methodology.

METHODS

The design of the guideline and checklists has been done in two phases. A development phase, where we set recommendations based on the review of the literature; and a validation phase, where we validated our recommendations against other published studies that have estimated attributable mortality using a prevalence-based method.

RESULTS

We have developed and tested a guideline that includes the information required to perform a prevalence-based attributable mortality study to a given risk factor; a checklist of aspects that should be present when a report or a paper on attributable mortality is written or interpreted and a checklist of quality control criteria for reports or papers estimating attributable mortality.

CONCLUSION

To our knowledge, the STREAMS-P is the first set of criteria specifically created to assess the quality of such studies and it could be valuable for authors and readers interested in performing attributable mortality studies or interpreting their reliability.

Association between Self-Reported Survey Measures and Biomarkers of Second-Hand Tobacco Smoke Exposure in Non-Smoking Pregnant Women

Second-hand tobacco smoke (SHS) causes adverse health outcomes in adults. Further studies are needed to evaluate psychosocial SHS exposure measures in comparison to SHS exposure biomarkers, particularly in pregnant women. This study aimed to compare self-reported SHS exposure to urinary cotinine levels in pregnant women. A cross-sectional correlation design was conducted using a convenience sample of 70 non-smoking pregnant women. Measures included self-reported questionnaires and laboratory confirmation of cotinine levels in the urinary samples. Multiple regression analysis was used to assess the correlation after controlling for potential confounding variables. The average level of urinary cotinine among non-smoking pregnant women was 6.77 ng/mL. Medium-strength correlations were found among psychosocial SHS exposure measures and urine cotinine levels. Questions regarding ‘instances of smoking in front of the individual’ and ‘subjective perceived frequency of SHS exposure in past 7 days’ are feasible items for pregnant women in clinics (particularly the first question). Hence, we suggest that these simple questions should be used to assist pregnant women in reducing the harm associated with SHS exposure.

Validity of self-reported indicators to assess secondhand smoke exposure in the home

INTRODUCTION

Questionnaires are widely used to assess secondhand smoke (SHS) exposure. However, the validity of self-reported SHS exposure indicators has been rarely assessed. We aimed to assess correlations, sensitivity, specificity, and predictive values between self-reported SHS exposure indicators and airborne nicotine concentrations.

METHODS

We performed a cross-sectional study with a convenience sample of 175 homes in Barcelona and Santiago de Compostela, Spain. Airborne nicotine samples were collected from participants' homes and a self-administered questionnaire was completed on SHS exposure in the home. Spearman correlations coefficients and sensitivity, specificity and predictive values were assessed between self-reported SHS exposure indicators and nicotine concentrations in the home.

RESULTS

All self-reported SHS exposure indicators correlated moderately strongly with airborne nicotine concentrations (Spearman correlations coefficient ranging from 0.58 to 0.65). Moreover, sensitivities and negative predictive values between self-reported indicators and the presence of nicotine in the home were below 66.4% while specificities and positive predictive values were over 78.4%. The "number of people usually smoking in the home" showed the best results (r_s = 0.65, p < 0.001; sensitivity = 50.4%, specificity = 95.2%, PPV = 95.0, NPV = 51.3).

CONCLUSIONS

The self-reported SHS indicators assessed in this study showed moderate and strong correlations, low sensitivities, and high specificities. Among them, the best results were obtained with the "number of people usually smoking in the home".

Validity of self-reported intensity of exposure to second-hand smoke at home against environmental and personal markers

The objective of this study was to assess the validity of two questions about the perception of intensity of exposure to secondhand smoke (SHS) at home using as a reference environmental markers (airborne nicotine and benzene) and biomarkers of exposure (cotinine in saliva and urine). This was a cross-sectional study in a convenience sample of 49 non-smoking volunteers. We found a high correlation between self-reported SHS exposure and airborne nicotine (r_sp=0.806, p<0.05), salivary cotinine (r_sp=0.752, p<0.05), and urinary cotinine (r_sp=0.626, p<0.05). We did not find differences between the score question and the conventional ones (p >0.05). In conclusion, the significant correlation of the two questions proposed with environmental markers and personal markers indicates their potential validity to assess exposure to SHS at home.

Secondhand Tobacco Smoke Exposure Associations With DNA Methylation of the Aryl Hydrocarbon Receptor Repressor

INTRODUCTION

Cigarette smoking is inversely associated with DNA methylation of the aryl hydrocarbon receptor repressor (AHRR; cg05575921). However, the association between secondhand tobacco smoke (SHS) exposure and AHRR methylation is unknown.

METHODS

DNA methylation of AHRR cg05575921 in CD14+ monocyte samples, from 495 never-smokers and 411 former smokers (having quit smoking ≥15 years) from the Multi-Ethnic Study of Atherosclerosis (MESA), was cross-sectionally compared with concomitantly ascertained self-reported SHS exposure, urine cotinine concentrations, and estimates of air pollutants at participants' homes. Linear regression was used to test for associations, and covariates included age, sex, race, education, study site, and previous smoking exposure (smoking status, time since quitting, and pack-years).

RESULTS

Recent indoor SHS exposure (hours per week) was inversely associated with cg05575921 methylation (β ± SE = -0.009 ± 0.003, p = .007). The inverse effect direction was consistent (but did not reach significance) in the majority of stratified analyses (by smoking status, sex, and race). Categorical analysis revealed high levels of recent SHS exposure (≥10 hours per week) inversely associated with cg05575921 methylation (β ± SE = -0.28 ± 0.09, p = .003), which remained significant (p < .05) in the majority of stratified analyses. cg05575921 methylation did not significantly (p < .05) associate with low to moderate levels of recent SHS exposure (1-9 hours per week), urine cotinine concentrations, years spent living with people smoking, years spent indoors (not at home) with people smoking, or estimated levels of air pollutants.

CONCLUSIONS

High levels of recent indoor SHS exposure may be inversely associated with DNA methylation of AHRR in human monocytes.

IMPLICATIONS

DNA methylation is a biochemical alteration that can occur in response to cigarette smoking; however, little is known about the effect of SHS on human DNA methylation. In the present study, we evaluated the association between SHS exposure and DNA methylation in human monocytes, at a site (AHRR cg05575921) known to have methylation inversely associated with current and former cigarette smoking compared to never smoking. Results from this study suggest high levels of recent SHS exposure inversely associate with DNA methylation of AHRR cg05575921 in monocytes from nonsmokers, albeit with weaker effects than active cigarette smoking.

Brief Counseling on Secondhand Smoke Exposure in Pregnant Women in Argentina and Uruguay

Argentina and Uruguay have a high prevalence of smoking during pregnancy, as well as of secondhand smoke (SHS) exposure. In this secondary analysis of a trial to implement brief smoking cessation counseling during antenatal care in Argentina and Uruguay, we aim to evaluate the effects of the intervention on the rates of self-reported SHS exposure at home and at work, and on attitudes recalled by non-smoker women enrolled in the intervention group compared with the control group. We randomly assigned (1:1) 20 antenatal care clusters in Argentina and Uruguay to receive a multifaceted intervention to implement brief smoking cessation counseling, which also included questions and counseling regarding SHS exposure, or to receive the standard of care. There was not a statistically significant difference between groups of the intervention’s effect (reduction of exposure to SHS) on any of the three exposure outcome measures (exposure at home, work or other indoor areas) or on the attitudes of women regarding exposure (avoiding breathing SHS and having rooms where smoking is forbidden). This analysis shows that we should not expect reductions in SHS exposure with this modest intervention alone. To achieve such reductions, strategies engaging partners and other household members may be more effective.

Second-hand smoke exposure in indoor and outdoor areas of cafés and restaurants: Need for extending smoking regulation outdoors?

Smoke-free legislation in indoor public places has concentrated smokers in the areas outside building entrances or other outdoor areas. This study assessed the drift of second-hand smoke between outdoor and indoor areas of cafés and restaurants in Barcelona, Spain, and characterized the exposure on outdoor terraces. Using a cross-sectional design, we monitored vapor-phase nicotine in indoor areas and outside entrances simultaneously (n=47), and on some outdoor terraces (n=51). We computed the median nicotine concentration and interquartile range (IQR) to describe the data and performed multivariate analysis to describe nicotine concentration and its determinants. The overall median nicotine concentration indoors was 0.65µg/m(3) (IQR: 0.29-1.17µg/m(3)), with significant differences based on the number of smokers at the entrance (p=0.039). At outside entrances, the overall median nicotine concentration was 0.41µg/m(3) (IQR: 0.21-1.17µg/m(3)). The nicotine concentrations indoors and at the corresponding outside entrances were not significantly different, and the multivariate analysis confirmed the relationship between these variables. On terraces, the overall median nicotine concentration was 0.54µg/m(3) (IQR: 0.25-1.14µg/m(3)), but it increased to 0.60µg/m(3) when a tobacco smell was perceived, 0.72µg/m(3) on closed terraces, 1.24µg/m(3) when there were >6 smokers, and 1.24µg/m(3) when someone smoked >20min. Multivariate analysis confirmed the outdoor terrace area, the season, the type of enclosure, and the number of smokers as the most relevant variables explaining nicotine concentration (R(2)=0.396). These findings show that second-hand smoke exposure exists in indoor areas due to smokers smoking at the outside entrances. In addition, exposure may occur on outdoor terraces when smokers are present and the terrace is enclosed to some extent. Thus, the current Spanish law does not fully protect non-smokers from second-hand smoke and supports extending regulation to some outdoor areas.

Monitoring asthma in childhood: management-related issues

Management-related issues are an important aspect of monitoring asthma in children in clinical practice. This review summarises the literature on practical aspects of monitoring including adherence to treatment, inhalation technique, ongoing exposure to allergens and irritants, comorbid conditions and side-effects of treatment, as agreed by the European Respiratory Society Task Force on Monitoring Asthma in Childhood.

The evidence indicates that it is important to discuss adherence to treatment in a non-confrontational way at every clinic visit, and take into account a patient's illness and medication beliefs. All task force members teach inhalation techniques at least twice when introducing a new inhalation device and then at least annually. Exposure to second-hand tobacco smoke, combustion-derived air pollutants, house dust mites, fungal spores, pollens and pet dander deserve regular attention during follow-up according to most task force members. In addition, allergic rhinitis should be considered as a cause for poor asthma control. Task force members do not screen for gastro-oesophageal reflux and food allergy. Height and weight are generally measured at least annually to identify individuals who are susceptible to adrenal suppression and to calculate body mass index, even though causality between obesity and asthma has not been established.

In cases of poor asthma control, before stepping up treatment the above aspects of monitoring deserve closer attention.

ERS review summarising and discussing the management-related issues regarding the monitoring of asthma in childhoodhttp://ow.ly/JfjGs

Relationship of secondhand smoke exposure with sociodemographic factors and smoke-free legislation in the European Union

BACKGROUND

To explore whether exposure to secondhand smoke (SHS) among non-smokers in the European Union (EU) showed any association with sociodemographic factors and/or the extent of national tobacco control policies.

METHODS

A secondary analysis was performed on data from 26 751 individuals ≥15 years old from 27 EU member states (EU MS), collected during the 2012 Special Eurobarometer survey (wave 77.1). Respondents were asked whether they had been exposed to SHS in eating or drinking establishments during the past 6 months, and/or in their workplace. Data on smoke-free policies were extracted from the European Tobacco Control Status Report and the European Tobacco Control Scale (TCS) in 2013.

RESULTS

In total, 29.0% of non-smoking participants reported being exposed to SHS in indoor areas. Males (vs. females) as well as individuals with difficulties to pay bills (vs. those with no difficulties), had significantly greater odds of being exposed to SHS in bars, restaurants and workplaces. For every unit increase of a country's score on the Smoke-free Component of the TCS (indicating greater adherence to smoke-free legislations) the odds ratio of reporting exposure to SHS was 0.82 in bars, 0.85 in restaurants and 0.94 in workplaces.

CONCLUSIONS

Differences in exposure to SHS clearly exist between and within EU MS, despite the fact that they all have signed the Framework Convention on Tobacco Control, with the burden found to disproportionally affect younger people and individuals with financial difficulties. Moreover, enforcement of smoke-free legislation was inversely associated with SHS exposure, highlighting the importance of enforcing comprehensive smoking bans.