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

The impact of exposure to tobacco smoke and e-cigarettes on asthma-related outcomes: Systematic review informing the EAACI guidelines on environmental science for allergic diseases and asthma

To inform the clinical practice guidelines' recommendations developed by the European Academy of Allergy and Clinical Immunology systematic reviews (SR) assessed using GRADE on the impact of environmental tobacco smoke (ETS) and active smoking on the risk of new-onset asthma/recurrent wheezing (RW)/low lung function (LF), and on asthma-related outcomes. Only longitudinal studies were included, almost all on combustion cigarettes, only one assessing e-cigarettes and LF. According to the first SR (67 studies), prenatal ETS increases the risk of RW (moderate certainty evidence) and may increase the risk of new-onset asthma and of low LF (low certainty evidence). Postnatal ETS increases the risk of new-onset asthma and of RW (moderate certainty evidence) and may impact LF (low certainty evidence). Combined in utero and postnatal ETS may increase the risk of new-onset asthma (low certainty evidence) and increases the risk of RW (moderate certainty evidence). According to the second SR (24 studies), ETS increases the risk of severe asthma exacerbations and impairs asthma control and LF (moderate certainty evidence). According to the third SR (25 studies), active smoking increases the risk of severe asthma exacerbations and of suboptimal asthma control (moderate certainty evidence) and may impact asthma-related quality-of-life and LF (low certainty evidence).

Avoidance of Inhaled Pollutants and Irritants in Asthma from a Salutogenic Perspective

Much is known about the role of aeroallergens in asthma, but little is described about the damage caused by inhaled pollutants and irritants to the respiratory epithelium. In this context, the most frequent pollutants and irritants inhaled in the home environment were identified, describing the possible repercussions that may occur in the respiratory tract of the pediatric population with asthma and highlighting the role of the caregiver in environmental control through a salutogenic perspective. Searches were carried out in the MEDLINE/PubMed, Web of Science, Lilacs and Scopus databases for articles considered relevant for the theoretical foundation of this integrative review, in which interactions between exposure to pollutants and inhaled irritants and lung involvement. Articles published in the last 10 years that used the following descriptors were considered: air pollution; tobacco; particulate matter; disinfectants; hydrocarbons, fluorinated; odorants; chloramines; pesticide; asthma; and beyond Antonovsky's sense of coherence. Exposure to smoke and some substances found in cleaning products, such as benzalkonium chloride, ethylenediaminetetraacetic acid and monoethanolamine, offer potential risks for sensitization and exacerbation of asthma. The vast majority of the seven main inhaled products investigated provoke irritative inflammatory reactions and oxidative imbalance in the respiratory epithelium. In turn, the caregiver's role is essential in health promotion and the clinical control of paediatric asthma. From a salutogenic point of view, pollutants and irritants inhaled at home should be carefully investigated in the clinical history so that strategies to remove or reduce exposures can be used by caregivers of children and adolescents with asthma.

Impact of Unmet Social Needs, Scarcity, and Future Discounting on Adherence to Treatment in Children With Asthma: Protocol for a Prospective Cohort Study

BACKGROUND

Asthma is one of the most prevalent chronic diseases of childhood and disproportionately affects children with lower socioeconomic status. Controller medications such as inhaled corticosteroids significantly reduce asthma exacerbations and improve symptoms. However, a large proportion of children still have poor asthma control, in part owing to suboptimal adherence. Financial barriers contribute to hindering adherence, as do behavioral factors related to low income. For example, unmet social needs for food, lodging, and childcare may create stress and worry in parents, negatively influencing medication adherence. These needs are also cognitively taxing and force families to focus on immediate needs, leading to scarcity and heightening future discounting; thus, there is the tendency to attribute greater value to the present than to the future in making decisions.

OBJECTIVE

In this project, we will investigate the relationship between unmet social needs, scarcity, and future discounting as well as their predictive power over time on medication adherence in children with asthma.

METHODS

This 12-month prospective observational cohort study will recruit 200 families of children aged 2 to 17 years at the Asthma Clinic of the Centre Hospitalier Universitaire Sainte-Justine, a tertiary care pediatric hospital in Montreal, Canada. The primary outcome will be adherence to controller medication, measured using the proportion of prescribed days covered during follow-up. Exploratory outcomes will include health care use. The main independent variables will be unmet social needs, scarcity, and future discounting, measured using validated instruments. These variables will be measured at recruitment as well as at 6- and 12-month follow-ups. Covariates will include sociodemographics, disease and treatment characteristics, and parental stress. Primary analysis will compare adherence to controller medication, measured using the proportion of prescribed days covered, between families with versus those without unmet social needs during the study period using multivariate linear regression.

RESULTS

The research activities of this study began in December 2021. Participant enrollment and data collection began in August 2022 and are expected to continue until September 2024.

CONCLUSIONS

This project will allow the documentation of the impact of unmet social needs, scarcity, and future discounting on adherence in children with asthma using robust metrics of adherence and validated measures of scarcity and future discounting. If the relationship between unmet social needs, behavioral factors, and adherence is supported by our findings, this will suggest the potential for novel targets for integrated social care interventions to improve adherence to controller medication and reduce risk across the life course for vulnerable children with asthma.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05278000; https://clinicaltrials.gov/ct2/show/NCT05278000.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/37318.

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.

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.