Assessing secondhand smoke exposure with reported measures

A Comparison of Measured Airborne and Self-Reported Secondhand Smoke Exposure in the MADRES Pregnancy Cohort Study

INTRODUCTION

Secondhand smoke (SHS) exposure during pregnancy is linked to adverse birth outcomes, such as low birth weight and preterm birth. While questionnaires are commonly used to assess SHS exposure, their ability to capture true exposure can vary, making it difficult for researchers to harmonize SHS measures. This study aimed to compare self-reported SHS exposure with measurements of airborne SHS in personal samples of pregnant women.

METHODS

SHS was measured on 48-hour integrated personal PM2.5 Teflon filters collected from 204 pregnant women, and self-reported SHS exposure measures were obtained via questionnaires. Descriptive statistics were calculated for airborne SHS measures, and analysis of variance tests assessed group differences in airborne SHS concentrations by self-reported SHS exposure.

RESULTS

Participants were 81% Hispanic, with a mean (standard deviation [SD]) age of 28.2 (6.0) years. Geometric mean (SD) personal airborne SHS concentrations were 0.14 (9.41) µg/m3. Participants reporting lower education have significantly higher airborne SHS exposure (p = .015). Mean airborne SHS concentrations were greater in those reporting longer duration with windows open in the home. There was no association between airborne SHS and self-reported SHS exposure; however, asking about the number of smokers nearby in the 48-hour monitoring period was most correlated with measured airborne SHS (Two + smokers: 0.30 µg/m3 vs. One: 0.12 µg/m3 and Zero: 0.15 µg/m3; p = .230).

CONCLUSIONS

Self-reported SHS exposure was not associated with measured airborne SHS in personal PM2.5 samples. This suggests exposure misclassification using SHS questionnaires and the need for harmonized and validated questions to characterize this exposure in health studies.

IMPLICATIONS

This study adds to the growing body of evidence that measurement error is a major concern in pregnancy research, particularly in studies that rely on self-report questionnaires to measure SHS exposure. The study introduces an alternative method of SHS exposure assessment using objective optical measurements, which can help improve the accuracy of exposure assessment. The findings emphasize the importance of using harmonized and validated SHS questionnaires in pregnancy health research to avoid biased effect estimates. This study can inform future research, practice, and policy development to reduce SHS exposure and its adverse health effects.

Characteristics of second-hand exposure to aerosols from e-cigarettes: A literature review since 2010

In recent years, the use of electronic vaping products (also named e-cigarettes) has increased due to their appealing flavors and nicotine delivery without the combustion of tobacco. Although the hazardous substances emitted by e-cigarettes are largely found to be much lower than combustible cigarettes, second-hand exposure to e-cigarette aerosols is not completely benign for bystanders. This work reviewed and synthesized findings on the second-hand exposure of aerosols from e-cigarettes and compared the results with those of the combustible cigarettes. In this review, different results were integrated based upon sampling locations such as residences, vehicles, offices, public places, and experimental exposure chambers. In addition, the factors that influence the second-hand exposure levels were identified by objectively reviewing and integrating the impacts of combustible cigarettes and e-cigarettes on the environment. It is a challenge to compare the literature data directly to assess the effect of smoking/vaping on the indoor environment. The room volume, indoor air exchange rate, puffing duration, and puffing numbers should be considered, which are important factors in determining the degree of pollution. Therefore, it is necessary to calculate the "emission rate" to normalize the concentration of pollutants emitted under various experimental conditions and make the results comparable. This review aims to increase the awareness regarding the harmful effects of the second-hand exposure to aerosols coming from the use of cigarettes and e-cigarettes, identify knowledge gaps, and provide a scientific basis for future policy interventions with regard to the regulation of smoking and vaping.

Perception of harm is strongly associated with complete ban on in-home cannabis smoking: a cross-sectional study

BACKGROUND

Perception of health risk can influence household rules, but little is known about how the perception of harm from cannabis secondhand smoke (cSHS) is related to having a complete ban on in-home cannabis smoking. We examined this association among a nationally representative sample of United States adults.

METHODS

Respondents were 21,381 adults from the cross-sectional Marijuana Use and Environmental Survey recruited from December 2019-February 2020. Perceived harm of cSHS exposure (extremely harmful, somewhat harmful, mostly safe, or totally safe) and complete ban of cannabis smoking anywhere in the home (yes or no) were self-reported. Logistic regression for survey-weighted data estimated covariate-adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association between perceived harm of cSHS and complete ban on in-home cannabis smoking. Stratified subgroup analyses (by cannabis smoking status, cannabis use legalization in state of residence, and children under age 6 living in the home) were conducted to quantify effect measure modification of the association between perception of harm and complete ban.

RESULTS

A complete ban on in-home cannabis smoking was reported by 71.8% of respondents. Eight percent reported cSHS as "totally safe"; 20.5% "mostly safe"; 38.3% "somewhat harmful"; and 33.0% "extremely harmful". Those who reported cSHS as "extremely harmful" had 6 times the odds of a complete ban on in-home cannabis smoking (OR = 6.0, 95%CI = 4.9-7.2) as those reporting smoking as "totally safe". The odds of a complete ban were higher among those reporting cSHS as "somewhat harmful" (OR = 2.6, 95%CI = 2.2-3.1) or "mostly safe" (OR = 1.4, 95%CI = 1.2-1.7) vs those reporting cSHS as "totally safe". In each subgroup of cannabis smoking status, state cannabis use legalization, and children under the age of 6 living in the home, perceived harm was associated with a complete ban on in-home cannabis smoking.

CONCLUSIONS

Our study demonstrates perceiving cSHS as harmful is strongly associated with having a complete in-home cannabis smoking ban. With almost a third of US adults perceiving cSHS as at least "mostly safe", there is strong need to educate the general population about potential risks associated with cSHS exposure to raise awareness and encourage adoption of household rules prohibiting indoor cannabis smoking.

Prevalence of Underreported Nicotine Exposure Among US Nonsmoking Adults: A Comparison of Self-Reported Exposure and Serum Cotinine Levels From NHANES 2013-2020

INTRODUCTION

Secondhand smoke (SHS) poses a significant health risk. However, individuals who do not smoke may be unaware of their exposure, thereby failing to take protective actions promptly.

AIMS AND METHODS

We assessed the prevalence of underreported nicotine exposure in a nationally representative sample of US nonsmoking adults using data from the US National Health and Examination Survey. Individuals with underreported nicotine exposure were defined as those who reported no exposure to all tobacco products (traditional tobacco, nicotine replacements, and e-cigarettes) or SHS, yet had detectable levels of serum cotinine (>0.015 ng/mL). We fitted logistic regression models to determine sociodemographic and chronic condition factors associated with underreported nicotine exposure.

RESULTS

Our analysis included 13 503 adults aged 18 years and older. Between 2013 and 2020, the prevalence of self-reported SHS exposure, serum cotinine-assessed nicotine exposure, and underreported nicotine exposure among US nonsmokers were 22.0%, 51.2%, and 34.6%, respectively. Remarkably, 67.6% with detectable serum cotinine reported no SHS exposure. Males, non-Hispanic blacks, individuals of other races (including Asian Americans, Native Americans, and Pacific Islanders), and those without cardiovascular diseases were more likely to underreport nicotine exposure than their counterparts. The median serum cotinine value was higher in respondents who reported SHS exposure (0.107 ng/mL) than in those who reported no exposure (0.035 ng/mL). We estimate that approximately 56 million US residents had underreported nicotine exposure.

CONCLUSIONS

Over a third of US nonsmokers underreport their nicotine exposure, underlining the urgent need for comprehensive public awareness campaigns and interventions. Further research into sociodemographic determinants influencing this underreporting is needed.

IMPLICATIONS

Understanding the extent of underreported nicotine exposure is crucial for developing effective public health strategies and interventions. It is imperative to bolster public consciousness about the risks associated with SHS. Additionally, surveillance tools should also incorporate measures of exposure to outdoor SHS and e-cigarette vapor to enhance the quality of data monitoring. Findings from this study can guide tobacco control initiatives and inform smoke-free air legislation.

Association between secondhand smoke exposure across the life course and depressive symptoms among Chinese older adults

BACKGROUND

There are limited data on the association between secondhand smoke (SHS) exposure across the life course and depressive symptoms among older adults. We aimed to investigate the association of childhood household SHS exposure, adulthood household SHS exposure, lifetime social SHS exposure, and their coexistence with depressive symptoms in older adults.

METHODS

Data were from the 2011-2012 and 2014 waves of the Chinese Longitudinal Healthy Longevity Survey. About 4000 participants (aged 60 years or older) were recruited in a randomly selected half of the counties and cities in China. Data on SHS exposure, past-year depressive symptoms, and covariates were collected using a questionnaire. The chi-square test (for categorical variables) and t-test (for continuous variables) were used to assess differences in the participant characteristics across groups of SHS exposures. We estimated the odds ratios (ORs) and 95 % confidence intervals (CIs) of depressive symptom according to different types of SHS exposure.

RESULTS

Childhood household SHS exposure (OR = 1.42, 95%CI = 1.22-1.66), adulthood household SHS exposure (OR = 1.41, 95%CI = 1.21-1.63) and lifetime social SHS exposure (OR = 1.35, 95%CI = 1.14-1.58) were associated with higher odds of depressive symptoms. Additionally, those with a higher SHS exposure score had higher odds of depressive symptoms (1 point: OR = 1.56, 95%CI = 1.22-2.00; 2 points: OR = 1.77, 95%CI = 1.39-2.25; 3 points: OR = 1.83, 95%CI = 1.45-2.31). The results were similar when stratified by lifetime nonsmoking, former smoking, and current smoking.

LIMITATIONS

Retrospective design may introduce recall bias.

CONCLUSIONS

SHS exposure was associated with higher odds of depressive symptoms in older adults, with the effect seeming to be addictive.

Comparison of secondhand smoking exposure between self-report and creatinine-corrected urine cotinine: Result from Korean NHANES 2009-2018

BACKGROUND/PURPOSE

Second-hand smoking (SHS) is usually examined by self-report (SR). However, there is a possibility that SR may not accurately measure SHS exposure. This study aimed to identify yearly trends and gender differences in SHS by SR and cotinine.

METHODS

We used data from the 2009-2018 Korea National Health and Nutrition Examination Survey (KNHANES) and included adults aged 19 years and older. We analyzed data of 47,907 respondents on SHS exposures in the past week and of 23,572 respondents who had both urine cotinine and creatinine measurements. SHS exposure was defined as those who answered 'yes' to whether or not they were exposed to smoking by SR. We performed descriptive analysis, Average annual percentage change (AAPC), and multiple regression analysis. All analyses were weighted reflecting the multi-stratified cluster sampling.

RESULTS

Exposure to SHS indoors at the work place (WSHS) (2009: 44.8%, 2018: 12.3%), indoors at home (HSHS) (2009: 14.1%, 2018: 3.9%), and indoors at public places (PSHS) (2013: 55.6%, 2018: 15.4%) decreased steadily over the years. WSHS and PSHS exposure was higher for males but HSHS was higher for females. However, the concentration of cotinine-to-creatinine ratio (Co/Cr) was higher among females regardless of SHS exposure status and environment. Multiple regression analysis showed that among males, the association between Co/Cr education level and WSHS was the strongest, and among females, the association was the strongest with HSHS. In addition, home exposure to SHS intensified the differences in Co/Cr levels between males and females.

CONCLUSION

Our study confirmed that cotinine-induced SHS showed different results by year and gender compared to SR. In particular, Co/Cr level in females was higher than in males regardless of exposure by SR, suggesting that SR did not correctly evaluate SHS. To reflect reality more accurately, biomarkers should be monitored along with SR.

Development of a risk prediction model to predict the risk of hospitalization due to exacerbated asthma among adult asthma patients in a lower middle-income country

BACKGROUND

Asthma patients experience higher rates of hospitalizations due to exacerbations leaving a considerable clinical and economic burden on the healthcare system. The use of a simple, risk prediction tool offers a low-cost mechanism to identify these high-risk asthma patients for specialized care. The study aimed to develop and validate a risk prediction model to identify high-risk asthma patients for hospitalization due to exacerbations.

METHODS

Hospital-based, case-control study was carried out among 466 asthma patients aged ≥ 20 years recruited from four tertiary care hospitals in a district of Sri Lanka to identify risk factors for asthma-related hospitalizations. Patients (n = 116) hospitalized due to an exacerbation with respiratory rate > 30/min, pulse rate > 120 bpm, O2 saturation (on air) < 90% on admission, selected consecutively from medical wards; controls (n = 350;1:3 ratio) randomly selected from asthma/medical clinics. Data was collected via a pre-tested Interviewer-Administered Questionnaire (IAQ). Logistic Regression (LR) analyses were performed to develop the model with consensus from an expert panel. A second case-control study was carried out to assess the criterion validity of the new model recruiting 158 cases and 101 controls from the same hospitals. Data was collected using an IAQ based on the newly developed risk prediction model.

RESULTS

The developed model consisted of ten predictors with an Area Under the Curve (AUC) of 0.83 (95% CI: 0.78 to 0.88, P < 0.001), sensitivity 69.0%, specificity 86.1%, positive predictive value (PPV) 88.6%, negative predictive value (NPV) 63.9%. Positive and negative likelihood ratios were 4.9 and 0.3, respectively.

CONCLUSIONS

The newly developed model was proven valid to identify adult asthma patients who are at risk of hospitalization due to exacerbations. It is recommended as a simple, low-cost tool for identifying and prioritizing high-risk asthma patients for specialized care.

Involuntary tobacco smoke exposures from conception to 18 years increase midlife cardiometabolic disease risk: a 40-year longitudinal study

Few population studies have sufficient follow-up period to examine early-life exposures with later life diseases. A critical question is whether involuntary exposure to tobacco smoke from conception to adulthood increases the risk of cardiometabolic diseases (CMD) in midlife. In the Collaborative Perinatal Project, serum-validated maternal smoking during pregnancy (MSP) was assessed in the 1960s. At a mean age of 39 years, 1623 offspring were followed-up for the age at first physician-diagnoses of any CMDs, including diabetes, heart disease, hypertension, or hyperlipidemia. Detailed information on their exposure to environmental tobacco smoke (ETS) in childhood and adolescence was collected with a validated questionnaire. Cox regression was used to examine associations of in utero exposure to MSP and exposure to ETS from birth to 18 years with lifetime incidence of CMD, adjusting for potential confounders. We calculated midlife cumulative incidences of hyperlipidemia (25.2%), hypertension (14.9%), diabetes (3.9%), and heart disease (1.5%). Lifetime risk of hypertension increased by the 2nd -trimester exposure to MSP (adjusted hazard ratio: 1.29, 95% confidence interval: 1.01-1.65), ETS in childhood (1.11, 0.99-1.23) and adolescence (1.22, 1.04-1.44). Lifetime risk of diabetes increased by joint exposures to MSP and ETS in childhood (1.23, 1.01-1.50) or adolescence (1.47, 1.02-2.10). These associations were stronger in males than females, in never-daily smokers than lifetime ever smokers. In conclusion, early-life involuntary exposure to tobacco smoke increases midlife risk of hypertension and diabetes in midlife.

Associations of timing, level, and pattern of secondhand smoke exposure with early alcohol initiation: A cohort study

BACKGROUND

Few studies explored the longitudinal link between early-life secondhand smoke (SHS) exposure and later alcohol initiation despite its risk for child behavioral difficulties. We examined the associations of the timing, level, and pattern of SHS exposure from pregnancy to childhood with early alcohol initiation and evaluated the sex differences in these associations.

METHODS

Data were from 16,440 participants of the Taiwan Birth Cohort Study conducted when the children were aged 6 months, 18 months, 3 years, 5.5 years, 8 years, and 12 years. Group-based trajectory modeling was applied to identified patterns of SHS exposure. A series of multiple logistic regression were conducted to examine study hypotheses.

RESULTS

Exposure to prenatal SHS was associated with an increased risk of early alcohol initiation (adjusted odds ratio [aOR] = 1.17, 95% confidence interval [CI] = 1.06, 1.30). Compared with the adolescents with a persistent-low-exposure trajectory, those who exhibited prenatal-high-decreasing (aOR = 1.18, 95% CI = 1.04, 1.35) or persistent-high-exposure (aOR = 1.27, 95% CI = 1.12, 1.45) patterns exhibited increased risks of early alcohol initiation. Those with higher cumulative levels of SHS exposure also exhibited an increased risk of early alcohol initiation (aOR = 1.03, 95% CI = 1.01, 1.04). Sex differences were also observed.

CONCLUSIONS

Varying timing, levels, and longitudinal patterns of SHS exposure during early life had differential effects on early alcohol initiation, with the effects differing by sex. Targeting SHS exposure while considering the nature of exposure and sex differences could help prevent and curb alcohol use in adolescents.

Cross-cultural adaptation of the Parental Perceptions of Children's Exposure to Tobacco Smoke instrument to the Brazilian context

OBJECTIVE

To perform a cross-cultural adaptation of the Parental Perceptions of Children's Exposure to Tobacco Smoke (PPE) instrument to the Brazilian context.

RESULTS

The cross-cultural adaptation process was performed in 10 stages. Four translators, eight specialists, and 35 primary care users participated in the study. Both translations were similar. The synthesis version that was back-translated was equivalent to the original. The committee of experts scored all items in the content validity index as 3 or 4, suggesting only small changes such as changing "photo" to "image" and "service balcony" to "service area". After the completion of the first sequence of pretests, some adjustments were required by the committee of experts for the second round. The form of application of the self-administered questionnaire for the interview was changed, the Likert scale was reduced from 7 to 5 points, and the option "I don't know" was added to questions 18, 19, and 20. After these adjustments, the instrument was well accepted by the study population and presented good internal consistency (Cronbach's α score = 0.82). The PPE instrument, which assesses the perception of parents about their children's exposure to cigarette smoke, was satisfactorily translated and adapted to the Brazilian context.

Childhood secondhand smoke exposure and respiratory disease mortality among never-smokers: the Japan collaborative cohort study for evaluation of cancer risk

BACKGROUND

The main source of secondhand smoke (SHS) exposure during childhood occurs at home due to close family members who smoke. This study examined the association between childhood SHS exposure and the risk of respiratory disease mortality among non-smoking adults.

METHODS

Data from 44 233 never-smoking Japanese men and women aged 40-79 years who participated in the JACC study between 1988 and 1990 were analyzed. The Cox proportional hazards model was used to calculate hazard ratios and 95% confidence intervals of respiratory disease mortality according to the number of smoking family members during childhood. Subdistribution HRs (SHRs) were calculated as a competing risk analysis.

RESULTS

A total of 735 deaths from respiratory diseases were documented in a median follow-up of 19.2 years. Living with three or more smoking family members during childhood was associated with a higher risk of respiratory disease mortality in adulthood among women; multivariable SHR compared with participants with no family member smokers during childhood was 1.60 (1.01-2.54) for participants with three or more family members who smoked during their childhood.

CONCLUSIONS

SHS exposure from three or more family members during childhood was associated with an increased risk of respiratory disease-related mortality in adulthood.

Tobacco smoke exposure, the lower airways microbiome and outcomes of ventilated children

BACKGROUND

Tobacco smoke exposure increases the risk and severity of lower respiratory tract infections in children, yet the mechanisms remain unclear. We hypothesized that tobacco smoke exposure would modify the lower airway microbiome.

METHODS

Secondary analysis of a multicenter cohort of 362 children between ages 31 days and 18 years mechanically ventilated for >72 h. Tracheal aspirates from 298 patients, collected within 24 h of intubation, were evaluated via 16 S ribosomal RNA sequencing. Smoke exposure was determined by creatinine corrected urine cotinine levels ≥30 µg/g.

RESULTS

Patients had a median age of 16 (IQR 568) months. The most common admission diagnosis was lower respiratory tract infection (53%). Seventy-four (20%) patients were smoke exposed and exhibited decreased richness and Shannon diversity. Smoke exposed children had higher relative abundances of Serratia spp., Moraxella spp., Haemophilus spp., and Staphylococcus aureus. Differences were most notable in patients with bacterial and viral respiratory infections. There were no differences in development of acute respiratory distress syndrome, days of mechanical ventilation, ventilator free days at 28 days, length of stay, or mortality.

CONCLUSION

Among critically ill children requiring prolonged mechanical ventilation, tobacco smoke exposure is associated with decreased richness and Shannon diversity and change in microbial communities.

IMPACT

Tobacco smoke exposure is associated with changes in the lower airways microbiome but is not associated with clinical outcomes among critically ill pediatric patients requiring prolonged mechanical ventilation. This study is among the first to evaluate the impact of tobacco smoke exposure on the lower airway microbiome in children. This research helps elucidate the relationship between tobacco smoke exposure and the lower airway microbiome and may provide a possible mechanism by which tobacco smoke exposure increases the risk for poor outcomes in children.

Prevalence and Impact of Asthma and Allergy on Daily Life, Health Outcomes and Use of Healthcare Services in Children: A Population-Based Study

INTRODUCTION

Studies on the prevalence of asthma and allergies often lack representation of the pediatric population, and their impact has not been examined using children without these diseases as a reference group. This study aimed to determine the prevalence of asthma and allergies in children under 14 years old in Spain and their impact on health-related quality of life, activities, healthcare utilization, and environmental and household exposure risk factors.

METHODS

Data came from a Spanish population-based representative survey of children aged <14 years (N=6297). A sample of controls (1:4) from the same survey was matched using propensity score matching. Logistic regression models and population-attributable fractions were calculated to determine the impact of asthma and allergy.

RESULTS

The population prevalence of asthma was 5.7% (95% CI: 5.0%, 6.4%), and of allergy was 11.4% (95% CI: 10.5%, 12.4. In children with lower percentiles of health-related quality of life (≤20th), 32.3% (95% CI, 13.6%, 47.0%) was attributed to asthma and 27.7% (95% CI: 13.0%, 40.0%) to allergy. Forty-four percent of restrictions in usual activity were attributed to asthma (OR: 2.0, p-value: <0.001), and 47.9% to allergy (OR: 2.1, p-value: <0.001). 62.3% of all hospital admissions were attributed to asthma (OR: 2.8, p-value: <0.001), and 36.8% (OR: 2.5, p-value: <0.001) of all specialist consults to allergy.

CONCLUSIONS

The high prevalence of atopic disease and its impact on daily life and healthcare utilization call for an integrated healthcare system focused on children and caregivers' needs with continuity of care across education and healthcare settings.

Global, regional, and national deaths, disability-adjusted life years, years lived with disability, and years of life lost for the global disease burden attributable to second-hand smoke, 1990-2019: A systematic analysis for the Global Burden of Disease Study

BACKGROUND

Smoke-free policies have led to a decline in smoking prevalence. Nevertheless, as the global population grows, more non-smokers are exposed to second-hand smoke (SHS) hazards. Mitigating SHS hazards requires a systematic analysis of the global disease burden attributable to SHS.

METHODS

Data on SHS was extracted from the Global Burden of Disease Study 2019. First, we measured the disease burden of SHS by the number of cases and age-standardized rates of deaths, disability-adjusted life years (DALYs), years lived with disability (YLDs), and years of life lost (YLLs) from 1990 to 2019. Second, trends in the disease burden of SHS in different periods were estimated based on the annual percentage change (APC) by joinpoint regression analysis. Finally, using histogram plots, world maps, Pearson correlation analysis, and population attributable fraction (PAF), we conducted a stratified analysis of SHS exposure by sex, age, geographic location, sociodemographic index (SDI) level, and disease.

RESULTS

The number of deaths caused by SHS remained stable between 1990 and 2019, and the number of YLDs more than doubled in three decades. In contrast, the number of DALYs and YLLs caused by SHS decreased. The declining trend in deaths (APC = -1.42 % [95 % UI -1.79 %, -1.05 %]), DALYs (APC = -1.91 % [95 % UI -2.15 %, -1.67 %]), and YLLs (APC = -1.28 % [95 % UI -1.93 %, -0.64 %]) had slowed down in recent years, while SHS-related YLDs were still increasing (APC = 1.84 % [95 % UI 0.74 %, 2.96 %]). From 2010 to 2019, we found that SHS exposure increased the risk of tracheal, bronchus, and lung cancer (PAF increased by 11.75 %), breast cancer (PAF increased by 5.36 %), diabetes mellitus (PAF increased by 8.24 %), and ischemic heart disease (PAF increased by 4.46 %). In addition, the disease burden caused by SHS was highest in middle SDI and low-middle SDI countries.

CONCLUSION

The global disease burden attributable to SHS is still severe, and policymakers need to implement more effective measures to reduce the harm of SHS.

A harm reduction model for environmental tobacco smoke exposure among Bangladeshi rural household children: A modified Delphi technique approach

This paper aimed to develop a harm reduction model to reduce exposure to environmental tobacco smoke among children of rural households in Bangladesh. A mixed-methods exploratory sequential design has been applied, and data has been collated from six randomly selected villages of Munshigonj district, Bangladesh. The research was divided into three phases. In the first phase, the problem was identified through key informant interviews and a cross-sectional study. In the second phase, the model was developed by focus group discussion, and in the third phase, the model was evaluated through the modified Delphi technique. The data was analyzed by thematic analysis and multivariate logistic regression in phase one, qualitative content analysis for phase two, and descriptive statistics in phase three. The key informant interviews showed attitude toward environmental tobacco smoke, lack of awareness, inadequate knowledge as a reason and smoke-free rules, religious beliefs, social norms, and social awareness as preclusion of environmental tobacco smoke. The cross-sectional study detected that households with no smoker (OR 0.006, 95% CI 0.002-0.021), high implantation of smoke-free household rules (OR 0.005, 95% CI 0.001-0.058), moderate (OR 0.045, 95% CI 0.004-0.461) to strong (OR 0.023, 95% CI 0.002-0.224) influence of social norm and culture along with neutral (OR 0.024, 95% CI 0.001-0.510) and positive (OR 0.029, 95% CI 0.001-0.561) peer pressure had been significantly associated with environmental tobacco smoke exposure. The final components of the harm reduction model consist of a smoke-free household, social norms and culture, peer support, social awareness and religious practice identified by the FGDs and modified Delphi technique.

Associations Between E-cigarettes and Subsequent Cocaine Use in Adolescence: An Analysis of the UK Millennium Cohort Study

INTRODUCTION

Nicotine exposure via early combustible cigarette smoking can prime the adolescent brain for subsequent cocaine use. However, there is limited evidence whether e-cigarette use, a nicotine delivery system that is increasingly popular among youth, is associated with later cocaine use. We examine the association between e-cigarette use by the age of 14 years and cocaine use by the age of 17 years.

AIMS AND METHODS

The Millennium Cohort Study is a nationally representative sample of 18 552 9-month-old children born between September 2000 and January 2002 in the United Kingdom. Follow-up interviews and surveys were collected from children and their caregivers at modal ages 3, 5, 7, 9, 11, 14, and 17 years. Our analytic sample included 340 youth who had used e-cigarettes by age 14 years (exposure variable), matched using coarsened exact matching, to 4867 nicotine naïve youth on childhood common liability confounders and demographics measured from infancy to age 11. The outcome was cocaine use by the modal age of 17 years.

RESULTS

Of the 5207 successfully matched youth, 7.6% of adolescent e-cigarette users by age 14 years used cocaine by age 17 years versus 3.1% of non-e-cigarette users. Multivariable logistic regression in the matched sample indicated that e-cigarette use by age 14 years was associated with 2.7 times higher odds of cocaine use by age 17 years (95% CI, 1.75 to 4.28).

CONCLUSIONS

These findings in a UK sample showed that e-cigarette use in early adolescence is associated with higher odds of cocaine use later in adolescence, similar to risks posed by tobacco cigarette smoking.

IMPLICATIONS

In this large-scale prospective cohort study (n = 5207), youth who had used e-cigarettes by the age of 14 years were matched to nicotine naïve youth on childhood common liability confounders and demographics measured from infancy to age 11 years (e.g. school engagement, risk-taking propensity, delinquency, peer and parental smoking, parental educational attainment). After matching, 7.6% of age 14 years e-cigarette users had subsequently used cocaine by the age of 17 years versus 3.1% of non-e-cigarette users. Although e-cigarettes are promoted as a strategy for nicotine-dependent users to reduce the harms of combustible cigarettes, the evidence here suggests that for nicotine naïve youth, they may increase the risk of subsequent cocaine use.

Concordance assessment through comparison with urine cotinine: Does self-report adequately reflect passive smoking?

INTRODUCTION

There is a paucity of studies evaluating passive smoking (PS) by comparing self-report (SR) and biomarkers. Our study aimed to confirm whether SR could accurately reflect PS compared to biomarkers, a golden standard for assessing the exposure of non-smokers.

METHODS

We used the 2014-2020 Korea National Health and Nutrition Examination Survey data and selected 29622 non-smokers aged >19 years as the study participants. The PS rate by SR was assessed during the last 7 days, and participants were interviewed to investigate their exposure at home, work, indoors, and in public places. In addition, participants having a limit of detection ≥0.5 ng/mL in urine cotinine (UC) was defined as the exposure group. All analyses reflected the weights of complex sampling. We first compared the rates of PS using biomarkers and SR, and then the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated based on biomarkers.

RESULTS

PS exposure by UC was the highest (44.4%), and the exposure by SR was significantly lower (5.1-29.5%). Kappa and sensitivity in PS in the indoor home (HPS) were lower than those in indoor workplaces (WPS) and indoor public places (PPS). Moreover, overall sensitivity and PPV were lower, and specificity and NPV were relatively higher in accuracy. Lastly, the sensitivity was poor, and the specificity was relatively good, which means that measurement by SR would identify people who were actually exposed to PS as non-exposed.

CONCLUSIONS

Despite exposure to PS, the use of the SR method is more likely to classify participants in the non-exposed group. Hence, to overcome measurement error in SR and reflect exposure in any place and setting, biomonitoring and SR should be performed.

Differences between Self-Report and Biomarkers in Smoking Indicators: The Necessity of Biomonitoring in Global Surveillance

Tobacco causes premature death through cardiovascular disease, cancer, and respiratory disease [...].

Secondhand Tobacco Smoke and Functional Impairments in Older Adults Living in the Community

BACKGROUND/AIM

There has been no comprehensive examination of the potential association of SHS with broad functional limitation assessment in older adults, where functional limitations are burdensome and challenging.

METHODS

We examined 2258 community-dwelling non-smoking older adults from the Seniors-Enrica-2-cohort. At baseline (2017) and follow-up (2019) grip strength was measured with a Jamar dynamometer, lower-extremity performance with the Short Physical Performance Battery (SPPB), overall physical function using the physical component summary (PCS) of the Spanish version of the SF-12, frailty with a Deficits Accumulation Index (DAI), and mobility limitations with the Rosow-Breslau scale. Baseline exposure to SHS was assessed by serum cotinine, and past exposure was self-reported. Cross-sectional analyses were performed using linear and logistic regression models, whereas functional performance changes were examined using repeated measures models with robust SE estimates.

RESULTS

Overall, the median (IQR) serum cotinine concentration was 0.079 (0.035-0.175) ng/ml, with 20 participants presenting concentrations ≥3 ng/ml. Compared to the unexposed, fully-adjusted models showed that the highest exposure group (≥0.239 ng/ml) presented lower grip strength (mean difference: -1.05 kg; 95% CI = -1.80, -0.31) and higher DAI scores (1.52; 95% CI = 0.38, 2.66) at baseline. Similarly, in models of self-reported past exposure, never-smokers who had lived with ≥2 smokers or been exposed to higher SHS cumulative doses showed lower baseline SPPB values, higher DAI scores, and higher prevalence of mobility limitations. In prospective analyses, those in the highest quartile of baseline cotinine presented harmful SPPB [-0.24 (-0.46, -0.02)] and DAI [1.28 (0.00, 2.55)] changes, and higher risk of mobility limitations [hazard ratio: 1.64; 95% CI = 1.01, 2.68] than the unexposed.

CONCLUSIONS

SHS exposure over the life-course and during old age may accelerate functional decline.

IMPLICATIONS

This manuscript provides a comprehensive examination of the relationship between secondhand smoke exposure and a broad range of functional limitations in older adults. Results show that: (i) non-smokers who had been exposed to higher cumulative doses of SHS in adulthood show worse physical function than non-exposed. (ii) Exposure to SHS during old age, as measured with cotinine concentrations, is associated with accelerated short-term functional declines. (iii) The effects of SHS are stronger among older adults with chronic morbidities. (iv) Results suggest that more efforts are needed to protect older adults from passive smoking, especially to those with chronic conditions because of their potential greater vulnerability to the effects of SHS.

Pre-conceptional and prenatal exposure to secondhand smoke and autism spectrum disorder: a national multi-center study in China

BACKGROUND

Despite extensive research evaluating the association between prenatal exposure to secondhand smoke (SHS) and the development of autism spectrum disorders (ASD), no study has investigated the association by considering the pre-conceptional period. This study aimed to investigate the associations of pre-conceptional and prenatal SHS exposure and the development of ASD among toddlers.

METHODS

In this cross-sectional study, parents of 6049 toddlers aged 16-30 months were recruited from 7 tertiary hospitals, 21 communities, and 7 kindergartens located in seven cities in six provinces from five geographical regions of China. We analyzed the associations of SHS exposure and the odds of ASD among toddlers in different exposure windows (pre-conceptional and/or prenatal periods). Data were analyzed from November 2021 to January 2022.

RESULTS

Among the 6049 toddlers included in the analysis [22.7 (4.1) months; 44.8% girls], 71 were identified and diagnosed with ASD. Compared with the unexposed toddlers, toddlers with pre-conceptional SHS exposure had higher odds of ASD (OR 2.30, 95% CI 1.36-3.84), while we observed a non-significantly positive association regarding prenatal SHS exposure. When considering both pre-conceptional and prenatal periods, toddlers who were continuously exposed to SHS during these two periods had higher odds than those without SHS exposure (OR 2.32, 95% CI 1.24-4.14).

CONCLUSION

We reported positive SHS-ASD associations when exposed during the pre-conceptional period and continuously exposed during pre-conceptional and prenatal periods, emphasizing the critical window of pre-conception for targeted intervention on smoking.

Exposure to melamine and its derivatives and aromatic amines among pregnant women in the United States: The ECHO Program

BACKGROUND

Melamine, melamine derivatives, and aromatic amines are nitrogen-containing compounds with known toxicity and widespread commercial uses. Nevertheless, biomonitoring of these chemicals is lacking, particularly during pregnancy, a period of increased susceptibility to adverse health effects.

OBJECTIVES

We aimed to measure melamine, melamine derivatives, and aromatic amine exposure in pregnant women across the United States (U.S.) and evaluate associations with participant and urine sample collection characteristics.

METHODS

We measured 43 analytes, representing 45 chemicals (i.e., melamine, three melamine derivatives, and 41 aromatic amines), in urine from pregnant women in nine diverse ECHO cohorts during 2008-2020 (N = 171). To assess relations with participant and urine sample collection characteristics, we used generalized estimating equations to estimate prevalence ratios (PRs) for analytes dichotomized at the detection limit, % differences (%Δ) for continuous analytes, and 95% confidence intervals. Multivariable models included age, race/ethnicity, marital status, urinary cotinine, and year of sample collection.

RESULTS

Twelve chemicals were detected in >60% of samples, with near ubiquitous detection of cyanuric acid, melamine, aniline, 4,4'-methylenedianiline, and a composite of o-toluidine and m-toluidine (99-100%). In multivariable adjusted models, most chemicals were associated with higher exposures among Hispanic and non-Hispanic Black participants. For example, concentrations of 3,4-dichloroaniline were higher among Hispanic (%Δ: +149, 95% CI: +17, +431) and non-Hispanic Black (%Δ: +136, 95% CI: +35, +311) women compared with non-Hispanic White women. We observed similar results for ammelide, o-/m-toluidine, 4,4'-methylenedianiline, and 4-chloroaniline. Most chemicals were positively associated with urinary cotinine, with strongest associations observed for o-/m-toluidine (%Δ: +23; 95% CI: +16, +31) and 3,4-dichloroaniline (%Δ: +25; 95% CI: +17, +33). Some chemicals exhibited annual trends (e.g., %Δ in melamine per year: -11; 95% CI: -19, -1) or time of day, seasonal, and geographic variability.

DISCUSSION

Exposure to melamine, cyanuric acid, and some aromatic amines was ubiquitous in this first investigation of these analytes in pregnant women. Future research should expand biomonitoring, identify sources of exposure disparities by race/ethnicity, and evaluate potential adverse health effects.

The Role of Ethnicity and Nativity in the Correspondence between Subjective and Objective Measures of In-Home Smoking

Studies are needed to understand the association between self-reported home smoking bans and objective measures of in-home smoking according to smokers' ethnicity/nativity. Data came from a trial that used air particle monitors to reduce children's secondhand smoke exposure in smokers' households (N = 251). Linear regressions modeled (a) full home smoking bans by ethnicity/nativity, and (b) objectively measured in-home smoking events, predicted by main and interaction effects of self-reported home smoking bans and ethnicity/nativity. Among smokers reporting < a full ban, US-born and Foreign-born Latinos had fewer in-home smoking events than US-born Whites (p < 0.001). Participants who reported a full smoking ban had a similar frequency of smoking events regardless of ethnicity/nativity. Results indicate that self-reported home smoking bans can be used as a proxy for in-home smoking. Establishing smoking bans in the households of US-born White smokers has the largest impact on potential exposure compared to other ethnicity/nativity groups.

Maternal Passive Smoking, Vitamin D Deficiency and Risk of Spontaneous Abortion

Background: Maternal passive smoking and vitamin D deficiency might elevate risk of spontaneous abortion. The study aimed to investigate the association of co-exposure to passive smoking and vitamin D deficiency with the risk of spontaneous abortion. Methods: A population-based case-control study was performed among non-smoking women in Henan Province, China, with 293 spontaneous abortion cases and 496 liveborn controls with term, normal birthweight. Results: Compared to women without exposure to passive smoking nor vitamin D deficiency, women with deficient vitamin D alone and women with exposure to passive smoking alone had increased risk of spontaneous abortion (OR = 1.76, 95%CI: 1.08~2.89; OR = 1.73, 95%CI: 1.11~2.69, respectively). The risk of spontaneous abortion was even higher for those with co-exposure to passive smoking and vitamin D deficiency (OR = 2.50, 95%CI: 1.63~3.84). A dose-response relationship was found of an incremental risk of spontaneous abortion with rising numbers of exposures to passive smoking and vitamin D deficiency (p < 0.001). Conclusion: Co-exposure to passive smoking and vitamin D deficiency was associated with an elevated risk of spontaneous abortion, and the risk of spontaneous abortion rose with rising numbers of exposures. Intervention programs need to specifically target the vulnerable groups of pregnant women with both malnutrition and unfavorable environmental exposure.

Association between objective measures and parent-reported measures of child tobacco smoke exposure: A secondary data analysis of four trials

INTRODUCTION

Tobacco smoke exposure (TSE) harms children and adults. Studies of childhood TSE exposure often relies on parental reports, but may benefit from objective measures. The objective of our study was to study the relationship between reported and objective measures of TSE.

METHODS

We analyzed data from four intervention trials, conducted in clinical or community settings, to identify objective measures most closely associated with parent-reported measures and the optimal set of parent-reported measures for predicting objective measures. We also assessed whether there was a learning curve in reported exposure over time, and the importance of replicate biomarker measures.

RESULTS

Correlations between objective and parent-reported measures of child TSE were modest at best, ranging from zero to 0.41. Serum cotinine and urinary cotinine were most strongly associated with parental reports. Parental questions most closely related to biomarkers were number of cigarettes and home smoking rules; together these formed the best set of predictive questions. No trial included all objective measures and all questions, precluding definitive statements about relative advantages. Within-subject repeatability of biomarker measures varied across studies, suggesting that direct pilot data are needed to assess the benefit of replicate measurements.

CONCLUSIONS

Improvements in objective and parent-reported child exposure measurements are needed to accurately monitor child TSE, evaluate efforts to reduce such exposure, and better protect child health.

Real-time feedback of air quality in children’s bedrooms reduces exposure to secondhand smoke

INTRODUCTION

Secondhand smoke (SHS) exposure creates health risks for non-smokers and is especially detrimental to children. This study evaluated whether immediate feedback in response to poor indoor air quality in children’s bedrooms can reduce the potential for SHS exposure, as measured by adherence to a World Health Organization (WHO) indoor air standard.

METHODS

Homes that contained children and an adult who regularly smoked inside (n=298) had an air particle monitor installed in the child’s bedroom. These devices measured the concentration of particulate matter (PM2.5) for approximately three months and, for half of the participants, immediately provided aversive feedback in response to elevated PM2.5. Hierarchical linear models were fit to the data to assess whether the intervention increased the probability that: 1) a given day was below the WHO guideline for daily exposure, and 2) a household established and maintained a smoke-free home (SFH), operationalized as achieving 30 consecutive days below the WHO guideline. The intervention’s impact was calculated as group-by-time effects.

RESULTS

The likelihood that a child’s bedroom met the WHO indoor air quality standard on a given day increased such that the baseline versus post-baseline odds ratio (OR) of maintaining indoor PM2.5 levels below the WHO guideline was 2.38 times larger for participants who received the intervention. Similarly, the baseline versus post-baseline OR associated with achieving an SFH was 3.49 times larger for participants in the intervention group.

CONCLUSIONS

The real-time intervention successfully drove clinically meaningful changes in smoking behavior that mitigated indoor PM2.5 levels in children’s bedrooms and thereby reduced SHS exposure. These results demonstrate the effectiveness of targeting sensitive microenvironments by giving caregivers actionable information about children’s SHS risks. Future extensions should examine additional microenvironments and focus on identifying the potential for SHS exposure before it occurs.

Factors Associated with Hemoglobin A1c Level Among Women Without Prior Diabetes Diagnosis in Rural Areas of Central South China: A Cross-Sectional Study

Background

Women in rural areas of China face the unique risk of developing diabetes, but data on the glycemic status among women without prior diabetes diagnosis in rural areas are lacking which may limit the decision-making for diabetes screening or prevention. This study was aimed to describe the glycemic status of women determined by hemoglobin A1c (HbA1c) and explore its associating factors.

Methods

A cross-sectional survey was conducted among women without prior diabetes diagnosis from two counties of rural areas in Central South China from July to October 2018. On the basis of the life course framework, data on socio-demographic, environmental health, genetic, biological (blood pressure, weight and height, lipids), psychosocial, and healthy behavioral factors were collected on site either through questionnaires or field measurements. The questionnaires included social-demographic sheet, Perceived Stress Scale, Self-efficacy scales for health-related diet and exercise behaviors, and Chinese Diabetes Risk Questionnaire. Generalized linear model analysis was performed to determine the associating factors of glycemic status, which was measured by HbA1c level.

Results

A total of 647 women were included in the study. The median age of women was 51.00 years (range 35–65 years). The median HbA1c level was 5.1% (interquartile range 4.6%-5.5%, range 4–13.6%), and 8.7% (n=56) of women were identified as elevated glycemic status (HbA1c>6%). Environmental health factors (eg, living in less-developed county [β=0.206, p=0.027]), biological factors (eg, higher body mass index [β=0.201, p=0.036], higher total cholesterol [β=0.097, p=0.040], history of gestational diabetes mellitus [β=0.722, p<0.001]), and psychosocial factors (eg, higher perceived stress [β=0.247, p=0.002]) were associated with higher HbA1c level.

Conclusion

This study reported 8.7% of elevated glycemic status among women without prior diabetes diagnosis in rural Hunan Province, China. After a comprehensive investigation based on a theoretical framework, living in a less-developed county of rural areas, having larger body mass index, higher total cholesterol, higher perceived stress, and a gestational diabetes mellitus history were identified as associating factors of higher HbA1c level. Professional support regarding weight control, blood lipid control, stress management, and the prevention of gestational diabetes mellitus should be recommended among this population, especially for women from less-developed counties.

Recombinant hepatitis B vaccine uptake and multiple sclerosis risk: A marginal structural modeling approach

BACKGROUND

There has been an ongoing debate regarding the association between uptake of recombinant vaccine against hepatitis B virus (HBV) and multiple sclerosis (MS) risk. This case-control study tested the hypothesis whether recombinant HBV vaccination status is causally associated with MS risk using targeted maximum likelihood estimation (TMLE) technique.

METHODS

Confirmed 110 MS cases and age (± 5 years), sex and nativity matched (1:1) 110 controls were enrolled. Data were collected on sociodemographics, environmental factors, history of vaccinations and past morbidities through face-to-face interview both from cases and controls. To estimate the causal parameters including marginal odds ratio (OR), causal relative risk (RR), causal risk difference (RD) and their 95% confidence intervals (CIs), we implemented case-control-weighted TMLE for a matched design that uses data-adaptive flexible stacked ensemble-based machine learning system namely Super Learner. Additionally, population preventable fraction (PPF) of MS risk was computed.

RESULTS

This study demonstrated a significant nonspecific protective effect of HBV vaccination against MS risk (marginal OR 0.44; 95% CI: 0.19-0.68; p = 0.006; causal RR 0.64, 95% CI: 0.46-0.89; p = 0.004). The significant causal RD showed that among the vaccinated 19% fewer MS cases occurred owing to their HBV vaccination (causal RD -0.19; 95% CI: -0.32 - -0.06; p = 0.014). In the source population, vaccination against HBV led to 17.4% reduced MS risk (PPF = 17.4%; 95% CI: 3.8%, 36.3%).

CONCLUSION

The results suggest a significant nonspecific protective effect of recombinant HBV vaccine against MS risk. Future studies may contemplate to confirm these results.

Interrelationship of Indoor Particulate Matter and Respiratory Dust Depositions of Women in the Residence of Dhanbad City, India

Women spend relatively more time in indoor environments in developing countries. Exposure to various indoor air pollutants leads them to higher health risks according to household air quality in which they reside. Particulate matter (PM) exposure with their exposure duration inside the household plays a significant role in women's respiratory problems. This study measured size-segregated particulate matter concentrations in 63 residences at different locations. Respiratory dust depositions (RDDs) for 118 women in their different respiratory regions like head airway (HD), tracheobronchial (TB), and alveolar (AL) regions for the three PM size fractions (PM₁₀, PM_2.5, and PM₁) were investigated. For different positions like light exercise and the sitting condition, RDDs values found for AL region were 0.091 μgmin^-1 (SD: 0.067, 0.012-0.408) and 0.028 μgmin^-1 (SD: 0.021, 0.003-0.126) for PM₁₀, 0.325 μgmin^-1 (SD: 0.254, 0.053-1.521) and 0.183 μgmin^-1 (SD: 0.143, 0.031-0.857) for PM_2.5, 0.257 μgmin^-1 (SD: 0.197, 0.043-1.04) and 0.057 μgmin^-1 (SD: 0.044, 0.009-0.233) respectively for PM₁ to females. RDDs values in the AL region significantly increase as PM₁₀ (11%), PM_2.5 (68%), and PM₁ (21%), confirming that for women, the AL region is the most prominent affected zone by fine particles (PM_2.5).

Thirdhand Smoke Knowledge, Attitudes, and Behavior: Development of Reliable and Valid Self-report Measures

INTRODUCTION

This study sought to provide essential tobacco control tools by testing the reliability and validity of new self-report scales developed to assess thirdhand smoke (THS) (ie, toxic tobacco residue) related knowledge, attitudes, and behavior (KAB).

AIMS AND METHODS

Items for the KAB scales were adapted from established secondhand smoke (SHS) measures, reviewed to support face validity, and tested in a longitudinal online survey evaluating THS health messages. Participants were California adults at risk of THS exposure. For 7 months, the three KAB scales were completed monthly, and data from the first (n = 1086), third (n = 315), and seventh (n = 301) month surveys were used in these analyses.

RESULTS

All three scales demonstrated consistent reliability and single-factor loading at all three timepoints for knowledge (αrange: .87-.90), attitude (αrange: .84-.87), and behavior (αrange: .80-.86). Similarly, analyses supported scale convergent validity (scale correlations rrange: .45-.85; all p values <.001), discriminant validity between smokers and nonsmokers (knowledge Cohen's drange: .57-.61, all p values <.001; attitude Cohen's drange: .78-.82, all p values <.001; behavior Cohen's drange: .90-.99, all p values <.001), and predictive validity (range R2KAB: .41-.48; all p values <.001).

CONCLUSIONS

KAB scales about THS provide new opportunities for tobacco control advocates and scholars to identify gaps in knowledge, misperceptions, and obstacles to behavior change in order to guide the design of novel tobacco control policies and interventions.

IMPLICATIONS

Numerous scales have been vetted as reliable and valid measures for assessing SHS-related KABs. Currently, standard measures of THS KABs are not available. This study tested three THS scales to fill this gap. The present findings provide tobacco control advocates, scholars, and practitioners tools for assessing KABs related to THS. This information is critical to development, implementation, and evaluation of novel tobacco control strategies.

Profiles of Nicotine and Cannabis Exposure among Young Adults with Asthma

There is a paucity of data on nicotine and cannabis use among young adults (YAs) with asthma. This study aimed to do the following among YAs with asthma: (1) describe YAs' active and passive exposure to nicotine and cannabis; (2) identify latent classes of active use of nicotine and cannabis; and (3) explore predictors of class membership (i.e., demographics, parental and friend use of nicotine and cannabis, and hours of environmental exposure to tobacco smoke, e-cigarette vapor, and marijuana smoke). YAs with asthma (N = 178) self-reported on nicotine and cannabis exposure and the included covariates. Latent class analysis was used to identify latent classes of lifetime nicotine and cannabis use. High rates of nicotine and cannabis use among YAs with asthma were found: 37% reporting a lifetime history of using both nicotine and cannabis. Regarding past year use, 25% had smoked cigarettes, 40% had used e-cigarettes, and 35% had used cannabis. Five classes of lifetime use were identified. The largest class was a non-user class (53%); the other four classes indicate concerning patterns of nicotine and cannabis use. The most consistent predictor of being in a class characterized by more nicotine and cannabis exposure (versus being in the non-user class) was past week exposure to cannabis smoke. This is the first study to identify classes of lifetime nicotine and cannabis use, and examine predictors of class membership, among YAs with asthma. There is a critical need to address environmental and active tobacco and marijuana exposure among YAs with asthma.

Exposure to second-hand smoke during early life and subsequent sleep problems in children: a population-based cross-sectional study

BACKGROUND

Previous studies have revealed that current secondhand smoke exposure showed highly suggestive evidence for increased risk of simultaneous sleep problems in children. Data on the associations between early-life exposure to SHS with subsequent sleep problems in children were scarce. We aimed to evaluate the associations of early-life SHS exposure with sleep problems in children.

METHODS

In this cross-sectional study, children were recruited from elementary and middle schools in Liaoning Province, China between April 2012 and January 2013. We assessed early-life SHS exposure (pregnancy and the first 2 years of life) via questionnaires. Sleep problems and different types of sleep-related symptoms were measured based on the validated tool of the Sleep Disturbance Scale for Children (SDSC). Generalized linear mixed models were applied to estimate the associations of early-life SHS exposure with sleep problems.

RESULTS

We included a total of 45,562 children (22,657 [49.7%] males; mean [SD] age, 11.0 [2.6] years) and 6167 of them (13.5%) were exposed to early-life SHS during both pregnancy and the first 2 years of life. Compared with unexposed counterparts, children exposed to early-life SHS had higher total T-scores of SDSC (β = 4.32; 95%CI: 4.06, 4.58) and higher odds of increased sleep problems (OR = 2.14; 95%CI: 1.89, 2.42). When considering different sleep-related symptoms, the associations between early-life SHS exposure and symptom of sleep-wake transition disorders (i.e., bruxism) were the strongest in all analyses.

CONCLUSIONS

Early-life SHS exposure was associated with higher odds of global sleep problems and different sleep-related symptoms in children aged 6-18 years. Our findings highlight the importance to strengthen efforts to support the critical importance of maintaining a smoke-free environment especially in early life.

Polyurethane-Based Face Mask as a Sampling Device for Environmental Tobacco Smoke

Environmental tobacco smoke (ETS), also known as secondhand smoking, contains human carcinogens associated with the development of many human diseases, including stroke, heart disease, leukemia, and lung cancer. Due to these adverse health effects, a sensitive and selective method is crucial for assessing the health impacts of ETS. While current methods to evaluate ETS exposure are either invasive or nonspecific and insensitive, in this study, we assessed the use of polyurethane foam face masks as a sampling medium to collect tobacco smoke-specific nicotine and nitrosamines for estimating personal exposure to ETS. This method was used in conjunction with tandem mass spectrometry coupled with isotope-dilution detection. After validation by comparison with the National Institute for Occupational Safety and Health standard method (NIOSH 2551) for nicotine, we quantitated ETS exposure in indoor and outdoor environments. The analysis shows the applicability of the method for monitoring nicotine down to ∼0.20 mg/m³ near an outdoor smoking hotspot and up to ∼5.2 mg/m³ in a room with burning cigarettes, all with a time resolution as short as 5 min. In comparison with the NIOSH method, the newly developed method is convenient, inexpensive, and does not require a personal sampling pump, thus can facilitate large-scale ETS exposure monitoring.

Associations Between Infant Developmental Delays and Secondhand Smoke Exposure Modified by Maternal Prepregnancy Overweight and Obesity Status

INTRODUCTION

Secondhand smoke exposure during pregnancy has long been associated with adverse health outcomes in children, but only a few studies have examined its effect modifiers. In this study, we applied effect modification analysis for maternal prepregnancy weight status on detrimental neurodevelopmental effect of secondhand smoke exposure during pregnancy and infancy in a nationwide representative population.

AIMS AND METHODS

Term singleton mother-infant pairs with nonsmoking mothers were included for main analysis (N = 15 987) from the Taiwan Birth Cohort Study (TBCS), and were further matched with propensity score (n = 5434). We extracted secondhand smoke exposure during pregnancy and infancy, and eight neurodevelopmental milestones from the responses in the baseline visit at 6 months, and 18-month follow-up of TBCS. The associations between secondhand smoke exposure and neurodevelopmental achievement were analyzed with multivariable logistic regression and Cox model. Propensity score weighting and matching were applied for high-versus-low analysis, and relative excess risk due to interaction were used to estimate effect modification.

RESULTS

Higher secondhand smoke exposure was associated with increased likelihood of delayed milestone achievement across gross motor, fine motor, language-related, and social-related domains. The associations in fine motor domains remained observable in propensity score-weighted and -matched models. We identified additive interaction with self-reported maternal overweight and obesity status before pregnancy in milestone development for walking with support, scribbling, and waving goodbye.

CONCLUSIONS

Secondhand smoke exposure during pregnancy and infancy were associated with delayed neurodevelopmental milestone achievement at 18 months, and the associations were modified by maternal prepregnancy overweight and obesity status.

IMPLICATIONS

The study results suggested the association between maternal secondhand smoke exposure during pregnancy and infancy and delayed fine motor and language-related milestone achievement at 18 months in multivariable, propensity score weighting, and matching populations. The results of positive effect modifications for maternal prepregnancy overweight and obesity status suggested the importance of concurrent interventions on smoke-free environment and maternal health during pregnancy.

Exposure to Secondhand Smoke at Home and Psychological Distress among College Students in China: The Role of Parental Attachment

This study examined the link between home SHS exposure and psychological distress among college students in China. Between July and September of 2020, 18-25-year-old students in three Chinese universities were invited to complete an online survey. Data from 872 respondents (mean age = 20.28) were analyzed. Psychological distress was assessed by the 10-item Kessler Scale. Home SHS exposure was assessed by the presence of smoking household members, hours of exposure, and exposure to the number of cigarettes smoked. Maternal and paternal attachment were assessed by the Inventory of Parent and Peer Attachment. Pairwise comparisons of sample characteristics were performed across never-smokers, triers (smoked one or two puffs), and smokers. Generalized linear regression models were constructed to assess the association. More smokers were exposed to home SHS or engaged in ever alcohol and other drug use than never-smokers. In never-smokers, exposure for <1 h/day or ≥3 h/day, or to 6-10 cigarettes/day was associated with increased psychological distress, but they were nullified after adjusting for parental attachment. In smokers, exposure to 6-10 cigarettes/day was associated with decreased psychological distress even after adjusting for parental attachment. Home SHS exposure is a risk factor for psychological wellbeing in never-smokers, the association with smokers warrants further study.

Home Smoking Bans and Urinary NNAL Levels to Measure Tobacco Smoke Exposure in Chinese American Household Pairs

Home smoking bans can reduce tobacco smoke exposure, but little is known about the impact for Chinese American household pairs. In this study of 202 household pairs with low acculturation, 53.9% reported a home smoking ban, 31.7% had inconsistent reports, and 14.4% reported no ban. With decreasing home smoking ban enforcement, more nonsmokers had tobacco smoke exposure (66.1%–86.2%) as measured by the tobacco-specific nitrosamine biomarker urine NNAL (4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol). Despite reported bans, about one-quarter of nonsmokers still reported tobacco smoke exposure at home (23.6%–30%) within the past 2 months and three-quarters reported outdoor exposure. In adjusted regression analyses of geometric mean NNAL ratios, nonsmokers in households with no ban had over two times higher levels than nonsmokers in households with a ban: adjusted log NNAL ratio = 2.70 (95% CI 1.21, 6.03). Higher smoker NNAL level and nonsmoker English fluency were also significantly associated with nonsmoker NNAL levels. Nonsmoker levels in households with an inconsistent ban were not significantly different compared to those with a ban. Although home smoking bans were generally associated with lower NNAL levels, tobacco smoke exposure in this immigrant population with low English proficiency was higher than that of the general population. From a health equity standpoint, there is a need for broader implementation and enforcement of comprehensive smoke-free policies.

Identifying the Best Questions for Rapid Screening of Secondhand Smoke Exposure Among Children

INTRODUCTION

Many children suffer from secondhand smoke exposure (SHSe), which leads to a variety of negative health consequences. However, there is no consensus on how clinicians can best query parents for possible SHSe among children. We employed a data-driven approach to create an efficient screening tool for clinicians to quickly and correctly identify children at risk for SHSe.

METHODS

Survey data from mothers and biospecimens from children were ascertained from the Neurodevelopment and Improving Children's Health following Environmental Tobacco Smoke Exposure (NICHES) study. Included were mothers and their children whose saliva were assayed for cotinine (n = 351 pairs, mean child age = 5.6 years). Elastic net regression predicting SHSe, as indicated from cotinine concentration, was conducted on available smoking-related questions and cross-validated with 2015-2016 National Health and Nutrition Examination Survey (NHANES) data to select the most predictive items of SHSe among children (n = 1670, mean child age = 8.4 years).

RESULTS

Answering positively to at least one of the two final items ("During the past 30 days, did you smoke cigarettes at all?" and "Has anyone, including yourself, smoked tobacco in your home in the past 7 days?") showed area under the curve = .82, and good specificity (.88) and sensitivity (.74). These results were validated with similar items in the nationally representative NHANES sample, area under the curve = .82, specificity = .78, and sensitivity = .77.

CONCLUSIONS

Our data-driven approach identified and validated two items that may be useful as a screening tool for a speedy and accurate assessment of SHSe among children.

IMPLICATIONS

The current study used a rigorous data-driven approach to identify questions that could reliably predict SHSe among children. Using saliva cotinine concentration levels as a gold standard for determining SHSe, our analysis employing elastic net regression identified two questions that served as good classifier for distinguishing children who might be at risk for SHSe. The two items that we validated in the current study can be readily used by clinicians, such as pediatricians, as part of screening procedures to quickly identify whether children might be at risk for SHSe.

Association of Prenatal, Early Postnatal, or Current Exposure to Secondhand Smoke With Attention-Deficit/Hyperactivity Disorder Symptoms in Children

IMPORTANCE

Few studies have investigated the association between the exposure window (prenatal, early postnatal, and current period) of secondhand smoke (SHS) and attention-deficit/hyperactivity disorder (ADHD) symptoms and subtypes in children.

OBJECTIVE

To evaluate the associations of prenatal, early postnatal, or current SHS exposure with ADHD symptoms and subtypes among school-aged children.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, 48 612 children aged 6 to 18 years from elementary and middle schools in Liaoning province, China, between April 2012 and January 2013 were eligible for participation. Data on SHS exposure and ADHD symptoms and subtypes for each child were collected via questionnaires administered to parents or guardians by school teachers. Data were analyzed from September 14 to December 2, 2020.

MAIN OUTCOMES AND MEASURES

The ADHD symptoms and subtypes (inattention, hyperactivity-impulsivity, and combined) were measured based on a validated tool developed from the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). Generalized linear mixed models were evaluated to estimate the association of SHS exposure with ADHD symptoms and subtypes.

RESULTS

A total of 45 562 participants completed the questionnaires and were included in this study (22 905 girls [50.3%]; mean [SD] age, 11.0 [2.6] years; 2170 [4.8%] with ADHD symptoms). Compared with their unexposed counterparts, children who were ever exposed (odds ratio [OR], 1.50; 95% CI, 1.36-1.66) or always exposed to SHS (OR, 2.88; 95% CI, 2.55-3.25) from pregnancy to childhood had higher odds of having ADHD symptoms and subtypes (ORs ranged from 1.46 [95% CI, 1.31-1.62] to 2.94 [95% CI, 2.09-4.13]). Compared with their unexposed counterparts, children with SHS exposure had higher odds of having ADHD symptoms when exposed in the prenatal period (OR, 2.28; 95% CI, 2.07-2.51), early postnatal period (OR, 1.47; 95% CI, 1.29-1.68), or current period (OR, 1.20; 95% CI, 1.09-1.31). Compared with their unexposed counterparts, children whose fathers smoked 10 or more cigarettes/d on both weekdays and weekends had higher odds of having ADHD symptoms and subtypes (ORs ranged from 1.48 [95% CI, 1.28-1.70] to 2.25 [95% CI, 1.29-3.93]).

CONCLUSIONS AND RELEVANCE

Being exposed to SHS from pregnancy to childhood was associated with higher odds of having ADHD symptoms and subtypes among school-aged children, and the associations were somewhat stronger for SHS exposure during prenatal and early postnatal periods. Our findings highlight the important public health implications of reducing SHS exposure, which may decrease the health and economic burdens of individuals with ADHD.

Occupational Exposure to Second-Hand Tobacco Smoke: Development of a Job Exposure Matrix

Exposure to second-hand tobacco smoke (SHS) in the workplace has been largely controlled in most workplaces in many countries that have adopted smoke-free laws and regulations. Workers in offices, bars, restaurants, and many other settings have experienced substantial reductions in the frequency and intensity of their exposure to SHS. While current exposure to SHS of most non-smoking adults arises from living with a smoker there are likely to be some jobs where non-negligible exposure to SHS continues to occur. This study describes the development of a simple job exposure matrix (JEM) for SHS exposure for the UK working population in 2020 and identifies that at least 1.04 million workers are likely to be exposed to SHS while performing their job. Occupations with the highest frequency and intensity of exposure include those where workers carry out work tasks in private, domestic settings: including care workers and home carers. This SHS-JEM provides a novel method for assessing occupational exposure to SHS in other countries, and can act as a tool to identify priorities for policies to protect those workers who continue to be at risk from SHS.

An examination of social and environmental determinants of secondhand smoke exposure among non-smoking adolescents

INTRODUCTION

Adolescents are at increased risk of secondhand smoke exposure (SHS) due to the limited control that they have over social and physical environments. Yet, knowledge regarding determinants of SHS among non-smoking adolescents is limited. This study identifies social and environmental factors associated with SHS among non-smoking adolescents.

METHODS

To be included, parents and adolescents (aged 11–17 years) of the Adolescents, Place, and Behavior Study had to have completed surveys between March 2019 and May 2020. Adolescents had to have not reported smoking within the past 30 days and provided a saliva sample assayed for cotinine (≤3 ng/mL). A series of stepwise linear regression models were fit to the data to identify social and environmental determinants of SHS, using log-transformed salivary cotinine.

RESULTS

Of the 105 adolescent and parent dyads included, 90.3% were African American, 26.9% of parents reported smoking, 33.3% resided in multi-unit housing, and 67.7% lived in homes where smoking was not permitted. Significant associations were found between parent tobacco use (β=2.56, SE=0.98, p=0.0082) and residing in multi-unit housing (β=1.72, SE=0.86, p=0.0460) with increased log-transformed cotinine levels among non-smoking adolescents. Adolescent age, gender, and race/ ethnicity, parental education, peer tobacco use, the number of adults and children in the home, average number of days of self-reported SHS within public spaces outside of the home, and home smoking policies were not significantly associated with cotinine.

CONCLUSIONS

Results emphasize the importance of reducing secondhand smoke exposure by reducing parental smoking and altering exposures within social and home environments. Parental tobacco use and residential setting should be considered when developing interventions to reduce secondhand smoke exposure among non-smoking adolescents.

Reliability and Validity of a Life Course Passive Smoke Exposure Questionnaire in an Australian Cohort From Childhood to Adulthood

OBJECTIVES

Life course exposure to passive smoke may predict health, but there are few validated measures. We tested the reliability and validity of a retrospective life course passive smoking questionnaire.

METHODS

Participants from the third follow-up of the Childhood Determinants of Adult Health study (2014-2019, ages 36-49 years) retrospectively reported mother/father/other household member smoking when living at home during childhood, including duration (years) and smoking location (never/sometimes/always inside house). The severity of exposure index (SEI; sum of mother/father/other years smoked multiplied by smoking location), cumulative years of exposure (CYE; sum of mother/father/other years), and total household smokers (THS) were derived. The reliability of retrospective passive smoking reports was examined with intraclass correlation coefficients (ICCs) using household smoking reported 34 years earlier in 1985 by participants when aged 7-15 years. Construct validity was examined by correlating retrospective passive smoking with participants' smoking in adulthood and lung function in childhood and adulthood.

RESULTS

Among 2082 participants (mean±standard deviation [SD], 45.0±2.5 years; 55.2% females), THS ranged from 0 to 5 (mean± SD, 0.9±1.0), CYE ranged from 0 to 106 (mean±SD, 10.5±13.9), and SEI ranged from 0 to 318 (mean±SD, 24.4±36.0). Retrospective measures showed moderate agreement with total household smokers reported in childhood (ICC, 0.58 to 0.62). The retrospective measures were weakly but significantly (p&lt;0.05) correlated with participants' smoking (r=0.13 to 0.15) and lung function (r= -0.05 to -0.06).

CONCLUSIONS

The retrospective passive smoking questionnaire showed reasonable reliability and validity. This measure may be useful for epidemiological studies.

Secondhand Smoke Exposure during Pregnancy and its Effect on Birth Outcomes: Evidence from a Retrospective Cohort Study in a Tertiary Care Hospital in Bengaluru

Context:

The effect of maternal smoking on birth outcomes is well-established, but the effect of maternal secondhand smoke (SHS) exposure is less clear, especially among Indian women.

Aim:

To evaluate the effect of SHS exposure during pregnancy on birth outcomes such as gestational age at birth, neonatal anthropometry, and Apgar score.

Setting and Design:

Retrospective cohort study at a tertiary hospital in Bengaluru.

Methods:

208 postnatal mothers: 104 each in “exposed” and “nonexposed” group, based on the history of SHS exposure during pregnancy. Sociodemographic and obstetric details were obtained by interview schedule and birth outcomes were obtained from patient charts.

Statistical Analysis:

Association of SHS exposure with birth outcomes was analyzed using inferential statistics such as Chi-square, t-test, and Mann–Whitney U-test, whereas the strength of association was expressed as relative risk with 95% confidence intervals. P < 0.05 was considered statistically significant.

Results:

SHS exposed and nonexposed groups were comparable with regard to potentially confounding socioeconomic and obstetric covariates. Babies born to SHS-exposed mothers had significantly lower mean birth weight, mean birth length, and mean birth head circumference by 172.5 g (P = 0.027), 1.6 cm (P = 0.001), and 1.1 cm (P = 0.001), respectively.

Conclusion:

Mothers exposed to SHS during pregnancy were twice likely to deliver low birth weight babies (relative risk [RR] = 1.9 [1.0–3.6], P = 0.02) and babies of low birth length (RR = 2.64 [1.4–4.6], P = 0.001) than unexposed mothers. With a significant risk of adverse birth outcomes found among mothers exposed to SHS during pregnancy, it is important that a “no tobacco smoke” environment at home should be recommended for pregnant women and their families.

Questionnaire-Based Environmental Tobacco Smoke Exposure and Hair Nicotine Levels in 6-month-old Infants: A Validation Study in Indonesia

Objectives. Using hair nicotine as the gold standard, this study aimed to establish cutoff points and validate the questionnaire-based environmental tobacco smoke (ETS) exposure and ETS statuses of Indonesian infants. Methods. A cross-sectional study design was conducted among families who were participants of the Peer Health Cohort Study in Jakarta, Indonesia. Households with 6-month-old infants joined this study. The presence and amount of ETS exposure were assessed by both questionnaire and hair sampling for nicotine determination. Head hair samples were collected from 102 infants and measured by optimized gas chromatography-mass spectrometry (GC/MS). Infants were grouped as ETS-exposed if they lived with at least 1 smoker at home. We used the receiver operating characteristic (ROC) curve to assess the sensitivity and specificity of cutoff values of hair nicotine. Results. There were 78 (76.5%) infants exposed to ETS based on the questionnaire. The nicotine concentrations in hair were significantly higher in infants with ETS exposure than in those without ETS exposure (P < .001). The area under the curve for nicotine was 0.774. A hair nicotine cutoff value of 2.37 ng/mg, with a sensitivity of 67.95% and specificity of 83.33%, was identified as the optimal cutoff value for separating exposed from non-exposed to ETS in infants. Conclusion. The hair nicotine value of infants aged 6 months is useful in confirming the questionnaire on smoking in the household and exposure to ETS. Moreover, it also could be used to distinguish ETS-exposed from non-ETS-exposed infants.

Evaluation of Secondhand Smoke Exposure in New York City Public Housing After Implementation of the 2018 Federal Smoke-Free Housing Policy

IMPORTANCE

Secondhand smoke (SHS) exposure is associated with many health conditions in children and adults. Millions of individuals in the US are currently exposed to SHS in their homes.

OBJECTIVE

To investigate whether a federal ban on smoking in public housing settings was associated with a decrease in indoor SHS levels in New York City public housing developments 12 months after the policy's implementation.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study tracked indoor air quality longitudinally from April 2018 to September 2019 and used difference-in-differences analysis to examine SHS exposure before vs after implementation of the 2018 federal smoke-free housing (SFH) policy in 10 New York City Housing Authority (NYCHA) buildings vs 11 matched low-income buildings not subject to the SFH policy (ie, Section 8 buildings).

EXPOSURES

Federal SFH policy implementation, beginning July 30, 2018.

MAIN OUTCOMES AND MEASURES

Comparison of nicotine concentration levels from passive, bisulfate-coated filters before vs 12 months after implementation of the federal SFH policy. Secondary outcomes included changes in particulate matter less than 2.5 μm in diameter, measured with low-cost particle monitors, and counts of cigarette butts in common areas.

RESULTS

Air quality was measured repeatedly in a total of 153 NYCHA and 110 Section 8 nonsmoking households as well as in 91 stairwells and hallways. Before the SFH policy implementation, air nicotine was detectable in 19 of 20 stairwells (95.0%) in NYCHA buildings and 15 of 19 stairwells (78.9%) in Section 8 buildings (P = .19) and in 17 of 19 hallways (89.5%) in NYCHA buildings and 14 of 23 hallways (60.9%) in Section 8 buildings (P = .004). Nicotine was detected less frequently inside nonsmoking apartments overall (26 of 263 [9.9%]) but more frequently in NYCHA apartments (20 of 153 [13.1%]) than in Section 8 apartments (6 of 110 [5.5%]) (P = .04). One year after policy implementation, there was no differential change over time in nicotine concentrations measured in stairwells (DID, 0.03 μg/m3; 95% CI, -0.99 to 1.06 μg/m3) or inside nonsmoking households (DID, -0.04 μg/m3; 95% CI, -0.24 to 0.15 μg/m3). Larger decreases in nicotine concentration were found in NYCHA hallways than in Section 8 hallways (DID, -0.43 μg/m3; 95% CI, -1.26 to 0.40 μg/m3).

CONCLUSIONS AND RELEVANCE

The findings suggest that there was no differential change in SHS in NYCHA buildings 12 months after SFH policy implementation. Additional support may be needed to ensure adherence to SFH policies.

Secondhand Smoking Among Children in Rural Households: A Community Based Cross-Sectional Study in Bangladesh

Objectives

This study aimed to determine the factors associated with reducing exposure to secondhand smoke among children in households of rural Bangladesh.

Methods

A cross-sectional study of 410 smokers and non-smokers, in 6 villages of Munshigonj district was conducted. Data were collected randomly using a self-administrative questionnaire. Differences between variables were assessed using Chi-square or Fisher's exact test (as appropriate). Univariate and multivariate logistic regression models were used to investigate associations. All results were presented as unadjusted and adjusted odds ratios with a 95% confidence interval. The level of statistical significance was reached when p < 0.05.

Results

A smoker in the household was determined to be a risk factor associated with exposure of other household members to secondhand smoke (p < 0.001). Higher education, strict implementation of household smoke-free rules, a higher influence of social norms and culture, as well as moderate knowledge on exposure to secondhand smoke were considered as preventive factors associated with exposure of others in the home to secondhand smoke.

Conclusion

Exposure to secondhand smoke is an extensive and preventable risk factor for children, and reducing exposure to secondhand smoke will have a largely positive effect in the community. An effective public health intervention model may reduce secondhand smoking.

Trends and patterns of second-hand smoke exposure amongst the non-smokers in India-A secondary data analysis from the Global Adult Tobacco Survey (GATS) I & II

Objectives

The primary objective of the present study was to compare the prevalence and patterns of second-hand smoke (SHS) exposure in the home, workplace, public places, and at all three places amongst the non-smoker respondents between the two rounds of Global Adult Tobacco Survey (GATS) in India. The secondary objectives were to assess the differences in various factors associated with SHS exposure among non-smokers.

Study design

This secondary data analysis incorporated data generated from the previous two rounds of the cross-sectional, nationally representative GATS India, which covered 69,296 and 74,037 individuals aged 15 years and above. Exposure to the SHS at home, workplace, and public places amongst the non-smokers were the primary outcome variables. Standard definitions of the surveys were used.

Results

The overall weighted prevalence of exposure to SHS amongst the non-smokers inside the home and public places reduced. In contrast, the prevalence in the workplace increased marginally in round II compared to I. The proportion of adults who were exposed to SHS at all three places did not change much in two rounds of surveys. A decrease in the knowledge of the respondents exposed to SHS at home and public places was observed about the harmful effects of smoking in round II. Age, gender, occupation, place, and region of respondents were found to be significant determinants of SHS exposure at all the three places on multinomial logistic regression analysis.

Conclusions

The study calls for focused interventions in India and stringent implementation of anti-tobacco legislation, especially in the workplaces for reducing the exposure to SHS amongst the non-smokers and to produce encouraging and motivating results by next round of the survey.

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.

Secondhand Smoke exposure and risk of Obstructive Sleep Apnea in Children

OBJECTIVES

Obstructive sleep apnea (OSA) has a prevalence of 4% in children. Few studies have explored the role of secondhand smoke (SHS) on OSA severity and have shown contradicting results. Most studies have focused on the effect of SHS on snoring. This study explored the association of SHS exposure and OSA severity in children aged 3-18 years.

METHODS

This is a retrospective single center IRB-approved study. Electronic Medical Records (EMR) were queried between 1/24/2015 and 1/24/2018 to obtain data on SHS exposure with standard questionnaires from perioperative database. SHS was analyzed as a binary variable and OSA was measured using obstructive apnea hypopnea index (OAHI) from polysomnography (PSG) as a continuous variable. Analyses were done on all children and in those with severe OSA (OAHI≥10/h) as a subgroup.

RESULTS

EMR query yielded 101,884 children of whom 3776 had PSG. Limiting baseline PSG in 3-18-year-old and reliable information on SHS yielded 167 analyzable children of whom 70 had severe OSA. Children exposed to SHS had significantly more public insurance than non-exposed (p < 0.0001). Among children with severe OSA, median OAHI was significantly higher in SHS exposed compared to non-exposed (29.0vs.19.5,p = 0.04), but not across all children. In multivariable analysis SHS exposure increased OAHI by 48% in severe OSA subgroup (95%CI: 8%-102%; p = 0.01) when adjusted for race, body mass index, and adjusted household income.

CONCLUSION

Children aged 3-18 years with severe OSA who were exposed to SHS were found to have 1.48 increase in odds of OAHI than those without SHS exposure. Results could be limited by retrospective nature of study and EMR tools.

A matched case-control study of risk factors associated with multiple sclerosis in Kuwait

Background

Genetic and environmental factors seem to have etiologic roles in multiple sclerosis (MS). Kuwait is regarded as medium to high risk country for MS. However, there is a paucity of published data on the risk factors for MS in Kuwait. Therefore, this matched case-control study examined the association between various factors including family history, stressful life events, exposure to tobacco smoke, vaccination history, comorbidities and MS risk in Kuwait.

Methods

Confirmed 110 MS cases and age (± 5 years), gender and nationality matched controls (1:1) were enrolled. A pre-tested structured questionnaire was used to collect the data through face-to-face interviews both from cases and controls. Conditional logistic regression was used to analyze the data.

Results

Among both cases and controls, majority were Kuwaiti (82.7%), and female (76.4%). Multivariable model showed that cases compared to controls were significantly more likely to have had a family history of MS (adjusted matched odds ratio (mOR_adj) = 5.1; 95% CI: 2.1–12.4; p < 0.001) or less likely to have been vaccinated against influenza A and B viruses before MS onset (mOR_adj = 0.4; 95% CI: 0.2–0.8; p = 0.010). None of the other variables considered were significantly related to MS status in this study.

Conclusions

Family history of MS had significantly direct, whereas, vaccination against influenza A and B viruses had inverse associations with MS status. Future studies may contemplate to verify the observed results.