Health impact assessment of environmental tobacco smoke in European children: sudden infant death syndrome and asthma episodes

Estimating the number of children in households with substance use disorders in Germany

BACKGROUND

Parental substance misuse is reported to endanger the health and psychological development of children and adolescents. The aim of the present study was to address conceptual and methodological problems in estimating the number of children affected by parental substance misuse (CaPSM) and offer a novel approach based on survey data.

METHODS

Data came from the 2018 German Epidemiological Survey of Substance Abuse (ESA) among 18- to 64-year-olds (n = 9267) and from population statistics. DSM-IV diagnostic criteria were used to assess substance use disorder (SUD) related to tobacco, alcohol, cannabis, cocaine or amphetamine. Based on the number of household members, the number of children below age 18 years and the information on SUD status of the respondent living in this household, the number of children currently living in households with at least one member with SUD was estimated.

RESULTS

In 2018, there were 13,597,428 children younger than 18 years living in Germany. Of these, 6.9-12.3% (935,522-1,673,103) were estimated to currently live in households where at least one adult had a tobacco use disorder, 5.1-9.2% (688,111-1,257,345) in households where at least one adult had an alcohol use disorder and 0.6-1.2% (87,817-158,401) in households where at least one adult had a disorder related to the use of illicit drugs. The total number of children currently living with SUD adults in their household was estimated at 11.2-20.2% (1,521,495-2,751,796).

CONCLUSIONS

Available estimates are difficult to interpret and to compare due to a lack of clear case definitions and methodological approaches with various biases and limitations. Future estimates need to provide precise case definitions and standard approaches.

Passive smoking and cardiometabolic risk factors in Iranian children and adolescents: CASPIAN-V study

Background

Smoking behavior as a harmful trend among adolescents and young adults has increased over last two decades. Many children and adolescents are at the risk of "second-hand" smoking at home due to their exposure to parents' or siblings' smoking. These second hand smokers are called "passive smokers" and are at risk of several health complications like cardiometabolic risk factors.

Objectives

The present study aims to evaluate the association between passive smoking and increase of cardiometabolic risk factors in a sample of Iranian's children and adolescents, aged 7-18 years.

Methods

This multicenter cross-sectional study was carried out over 14,400 students (aged 7-18 years). Blood sampling were randomly collected from a sub-sample of 4200 selected pupils. According to their degree of exposure to smoke for both cigarette and hookah, water pipes that are used to smoke specially made tobacco that comes in different flavors, all participants were divided to the two separate groups of positive and negative exposure. Metabolic syndrome (MetS) is defined as a constellation of at least three out of five cardiometabolic risk factors, including abdominal obesity, elevated blood pressure, elevated fasting plasma glucose concentration, high serum levels of triglycerides (TG), and depressed high-density cholesterol (HDL-C) levels.

Results

The mean and standard deviation (SD) age of participants was 12.3 ± 2.24 years. 49.4% were girls and 71.4% of them were urban residents. The mean SD for BMI of participants was 18.5 (4.7) Kg/m2. The mean TG levels were considerably higher among passive smoker children and adolescents. MetS and being overweight were found to have a major association with passive smoking (OR 1.63 CI 95% 1.17-2.29 P Value 0.004 and OR 1.21 95% CI 1.06-1.37 P Value 0.004, respectively).

Conclusion

This study confirms that passive smoking or second-hand smoking is linked with the increased prevalence of cardiometabolic risk factors and places children and adolescents at a higher risk of being overweight. Preventive strategies could be incorporated against passive smoking to recognize it as a health priority among children and adolescents.

[Association between exposure to second-hand smoke and health status in children]

OBJECTIVE

This study aimed to estimate the association between second-hand smoke (SHS) exposure in children and asthma, wheezing and perceived health.

METHOD

A cross-sectional study based on a telephone survey was performed on a representative sample of 2411 children under 12 years old in Spain. Exposure to SHS in private and public settings, and the prevalence of asthma, wheezing and perceived poor health were described. The association between health indicators and SHS exposure was analyzed using multivariate Poisson regression models with robust variance according to age and educational level.

RESULTS

The prevalence of SHS exposure in children was 29.2% in private settings and 42.5% in public settings. There was no association between SHS exposure and asthma, wheezing and perceived poor health in children ≤5 years. In children aged 6-11 years with parents with primary/secondary education, presenting asthma (adjusted prevalence ratio [aPR]: 2.1; 95% confidence interval [95%CI]: 1.2-3.8) and worse perceived health (aPR: 1.6; 95%CI: 1.1-2.1) were positively associated with SHS exposure in private settings. In children with parents with university studies, a negative association between SHS exposure and asthma (aPR: .3; 95%CI: 0.1-0.7) and wheezing (aPR: 0.3; 95%CI: 0.1-0.8) was observed.

CONCLUSIONS

There are differences in the association between SHS exposure and asthma, wheezing and poor perceived health according to educational level. Interventions with an equity perspective aimed at reducing SHS exposure in childhood should be implemented.

Environmental Tobacco Smoke Exposure at Home and Attributable Problem Behaviors in Korean Children and Adolescents for 2012-2014 in a Nationally Representative Survey

BACKGROUND

This study aimed to examine the environmental tobacco smoke (ETS) exposure at home and associated problem behaviors in Korean children and adolescents.

METHODS

Approximately 2,167 children aged 3-18 years were included in the study after excluding 163 active smokers from the Korean Environmental Health Survey in Children and Adolescents (2012-2014). ETS data were obtained using a questionnaire; problem behaviors were measured using the Child Behavior Checklist administered to parents. The relationship between ETS exposure and problem behavior was evaluated using a survey regression model adjusted for region, age, sex, income, and father's education. The population-attributable fraction (PAF%) was calculated based on problem behaviors related to ETS exposure at home.

RESULTS

The rates of ETS exposure at home were 20%, 28%, and 39% in children aged 3-5, 6-11, and 12-18 years, respectively; ETS exposure at home was associated with behavioral problems: the exposed group having higher total behavioral problem score (95% confidence interval [CI]) than the non-exposed by 2.46 (0.60-4.32) and 2.74 (0.74-4.74) in children aged 6-11 and 12-18 years, respectively, with no significant association in those aged 3-5 years. The PAF% (95% CI) of total problem behaviors for ETS exposure at home were 2.68 (-10.11-17.78), 10.66 (3.25-17.55), and 11.62 (3.03-18.96) in children aged 3-5, 6-11, and 12-18 years, respectively. Children with externalizing problems had higher PAF% than those with internalizing problems.

CONCLUSION

In Korea, ETS exposure at home is associated with problem behaviors in children and adolescents with about more than 10% population attributable fraction.

Prevalence and factors associated with asthma in students from Montes Claros, Minas Gerais, Brazil

We investigated the prevalence of asthma and factors related to asthma development in schoolchildren aged 6 to 14, living in central and peripheral areas of the city of Montes Claros, Minas Gerais and who were registered with the Family Health Strategy program. Initially, a standard written questionnaire, based on ISAAC (International Study of Asthma and Allergies in Childhood), was administered to collect personal data, information regarding income, asthma prevalence, allergic rhinitis and eczema (N = 1,131). Secondly, a case-control study was performed by grouping the patients as either asthmatic (A; N = 172) or non-asthmatic (NA; N = 379). Potential factors associated with the occurrence of asthma were evaluated using the complementary questionnaire from ISAAC phase II. Skin tests for immediate hypersensitivity (STIH) and parasitological tests were also performed. The odds ratio, estimated by multivariate analysis, indicated that asthma cases were related to kindergarten attendance, household smoking, family history of asthma, rhinitis and positive STIH. It was concluded that, in the studied population, the prevalence of asthma was related to genetic predisposition, in addition to individual history, social demographics, exposure to pollutants such as tobacco smoke and a positive response to allergy testing.

Public Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke

Tobacco use and tobacco smoke exposure are among the most important health threats to children, adolescents, and adults. There is no safe level of tobacco smoke exposure. The developing brains of children and adolescents are particularly vulnerable to the development of tobacco and nicotine dependence. Tobacco is unique among consumer products in that it causes disease and death when used exactly as intended. Tobacco continues to be heavily promoted to children and young adults. Flavored and alternative tobacco products, including little cigars, chewing tobacco, and electronic nicotine delivery systems are gaining popularity among youth. This statement describes important evidence-based public policy actions that, when implemented, will reduce tobacco product use and tobacco smoke exposure among youth and, by doing so, improve the health of children and young adults.

Clinical Practice Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke

Tobacco dependence starts in childhood. Tobacco exposure of children is common and causes illness and premature death in children and adults, with adverse effects starting in the womb. There is no safe level of tobacco smoke exposure. Pediatricians should screen for use of tobacco and other nicotine delivery devices and provide anticipatory guidance to prevent smoking initiation and reduce tobacco smoke exposure. Pediatricians need to be aware of the different nicotine delivery systems marketed and available.Parents and caregivers are important sources of children's tobacco smoke exposure. Because tobacco dependence is a severe addiction, to protect children's health, caregiver tobacco dependence treatment should be offered or referral for treatment should be provided (such as referral to the national smoker's quitline at 1-800-QUIT-NOW). If the source of tobacco exposure cannot be eliminated, counseling about reducing exposure to children should be provided.Health care delivery systems should facilitate the effective prevention, identification, and treatment of tobacco dependence in children and adolescents, their parents, and other caregivers. Health care facilities should protect children from tobacco smoke exposure and tobacco promotion. Tobacco dependence prevention and treatment should be part of medical education, with knowledge assessed as part of board certification examinations.

Impact of smoke-free legislation on perinatal and infant mortality: a national quasi-experimental study

Smoke-free legislation is associated with improved early-life outcomes; however its impact on perinatal survival is unclear. We linked individual-level data with death certificates for all registered singletons births in England (1995–2011). We used interrupted time series logistic regression analysis to study changes in key adverse perinatal events following the July 2007 national, comprehensive smoke-free legislation. We studied 52,163 stillbirths and 10,238,950 live-births. Smoke-free legislation was associated with an immediate 7.8% (95%CI 3.5–11.8; p < 0.001) reduction in stillbirth, a 3.9% (95%CI 2.6–5.1; p < 0.001) reduction in low birth weight, and a 7.6% (95%CI 3.4–11.7; p = 0.001) reduction in neonatal mortality. No significant impact on SIDS was observed. Using a counterfactual scenario, we estimated that in the first four years following smoke-free legislation, 991 stillbirths, 5,470 cases of low birth weight, and 430 neonatal deaths were prevented. In conclusion, smoke-free legislation in England was associated with clinically important reductions in severe adverse perinatal outcomes.

Reducing tobacco smoke exposure in children aged below 4 years - a randomized controlled trial

OBJECTIVE

To explore the reach of a German population-based household sample using proactive recruitment and to test the efficacy of a behavioral change counseling intervention including feedback about children's urine cotinine level (CUCL).

METHODS

A randomized controlled trial (2008-2010) was conducted in households with at least one child aged below 4years and at least one current smoker. The study area comprised of 3570 households. A screening assessment was provided in 2641 households; 1282 included one current smoker and 852 completed the study protocol. The intervention group (IG; n=428) received feedback about CUCL and up to two counseling sessions. The control group (CG; n=424) received a leaflet. Assessments were provided at baseline and 12-month follow-up. Heckman's selection model analysis was used to consider the detection limit of cotinine in urine (10ng/ml).

RESULTS

CUCL below the detection limit in the IG was found in 43.2% at baseline and 44.6% at follow-up and in 44.8% of the CG at baseline and 47.2% at follow-up. The CUCL difference between follow-up and baseline was smaller in the CG than in the IG. The effect was not significant.

CONCLUSIONS

Data revealed a high reach of the target population but failed to identify an intervention effect. Clinical Trial Registration www.clinicaltrials.gov (NCT00647413).

Disease burdens from environmental tobacco smoke in Korean adults

In this study, we estimated the disease burdens attributable to environmental tobacco smoke (ETS) exposure in Korean adults in 2010 and analyzed the trend of that from 2005 to 2010. We obtained information on the study population from the 2010 Cause of Death Statistic and estimated the ETS-attributable fraction using data from the Korean Community Health Survey and the Korean National Health and Nutrition Examination Survey. The numbers of ETS-attributable deaths in female and male non-smokers were estimated to be 4.1 and 69.6% of the numbers of deaths attributable to current smoke, respectively. The deaths attributable to ETS were larger in female than in male non-smokers (710 vs. 420). The ETS-attributable deaths increased slightly in 2005-2008 but decreased in 2009-2010. The number of potential years of life lost from ETS was 9077.24 years in 2010. If there were no exposure to ETS in adult non-smokers, we would expect to see 1130 fewer deaths (9.9% of the deaths from current smoke). The results suggest that ETS poses considerable disease burdens for non-smokers, especially women, in Korea.

Addressing passive smoking in children

BACKGROUND

A significant number of parents are unaware or unconvinced of the health consequences of passive smoking (PS) in children. Physicians could increase parental awareness by giving personal advice.

AIM

To evaluate the current practices of three Dutch health professions (paediatricians, youth health care physicians, and family physicians) regarding parental counselling for passive smoking (PS) in children.

METHODS

All physicians (n = 720) representing the three health professions in Limburg, The Netherlands, received an invitation to complete a self-administered electronic questionnaire including questions on their: sex, work experience, personal smoking habits, counselling practices and education regarding PS in children.

RESULTS

The response rate was 34%. One tenth (11%) of the responding physicians always addressed PS in children, 32% often, 54% occasionally and 4% reported to never attend to it. The three health professions appeared comparable regarding their frequency of parental counselling for PS in children. Addressing PS was more likely when children had respiratory problems. Lack of time was the most frequently mentioned barrier, being very and somewhat applicable for respectively 14% and 43% of the physicians. One fourth of the responders had received postgraduate education about PS. Additionally, 49% of the responders who did not have any education about PS were interested in receiving it.

CONCLUSIONS

Physicians working in the paediatric field in Limburg, The Netherlands, could more frequently address PS in children with parents. Lack of time appeared to be the most mentioned barrier and physicians were more likely to counsel parents for PS in children with respiratory complaints/diseases. Finally, a need for more education on parental counselling for PS was expressed.

Towards estimating the burden of disease attributable to second-hand smoke exposure in Polish children

OBJECTIVES

To estimate the burden of disease attributable to second-hand smoke (SHS) exposure in Polish children in terms of the number of deaths and disability adjusted life years (DALYs) due to lower respiratory infections (LRI), otitis media (OM), asthma, low birth weight (LBW) and sudden infant death syndrome (SIDS).

MATERIALS AND METHODS

Estimates of SHS exposure in children and in pregnant women as well as information concerning maternal smoking were derived from a national survey, the Global Youth Tobacco Survey, and the Global Adult Tobacco Survey in Poland. Mortality data (LRI, OM, asthma, and SIDS), the number of cases (LBW), and population data were obtained from national statistics (year 2010), and DALYs came from the WHO (year 2004). The burden of disease due to SHS was calculated by multiplying the total burden of a specific health outcome (deaths or DALYs) by a population attributable fraction.

RESULTS

Using two estimates of SHS exposure in children: 48% and 60%, at least 12 and 14 deaths from LRI in children aged up to 2 years were attributed to SHS, for the two exposure scenarios, respectively. The highest burden of DALYs was for asthma in children aged up to 15 years: 2412, and 2970 DALYs, for the two exposure scenarios, respectively. For LRI, 419 and 500 DALYs, and for OM, 61 and 77 DALYs were attributed to SHS, for the two exposure scenarios, respectively. Between 13% and 27% of SIDS cases and between 3% and 16% of the cases of LBW at term were attributed to SHS exposure.

CONCLUSIONS

This study provides a conservative estimate of the public health impact of SHS exposure on Polish children. Lack of comprehensive, up to date health data concerning children, as well as lack of measures that would best reflect actual SHS exposure are major limitations of the study, likely to underestimate the burden of disease.

Secondhand smoke and asthma: what are the effects on healthcare utilization among children?

OBJECTIVE

This study aims to examine the associations between asthma, secondhand smoke exposure and healthcare utilization in a nationally representative sample of children.

METHODS

Data from 5686 children aged 0-11 years were analyzed. Healthcare utilization, asthma diagnosis and demographic information came from the 2001 and 2006 Medical Expenditure Panel Surveys. Secondhand smoke exposure was measured during the 2000 and 2005 National Health Interview Surveys. Multivariable regression models were used to determine the association between secondhand smoke exposure, asthma diagnosis and healthcare utilization (hospitalizations, emergency department visits, outpatient visits and prescription medication use).

RESULTS

Asthma modified the relationship between secondhand smoke exposure and hospitalizations, as exposure more than doubled the odds of hospitalization among children with asthma but had no effect on children without asthma. Secondhand smoke exposure increased the odds by 37% of emergency room visits (P<0.001), but was not associated with outpatient visits or medication use. Children with asthma had a higher odds of utilizing all healthcare services (P<0.001).

CONCLUSIONS

Secondhand smoke exposure was associated with a greater utilization of hospitals and emergency departments, and the effect on hospitalizations was most pronounced among children with asthma. Reducing secondhand smoke exposure would help to reduce the burden on the healthcare system, especially among children with asthma.

Relationship of environmental tobacco smoke to otitis media (OM) in children

INTRODUCTION

Many, but not all, studies have found a correlation between environmental tobacco smoke (ETS) and acute otitis media (AOM) and other adverse otologic outcomes. Given its high personal and societal costs and the divergent findings of the effect of ETS on middle ear disease, the aim of the current study was to assess the impact and possible determinant factors of ETS on recurrent (two or more) episodes of AOM.

METHODS

The study was performed at Heim Pal Children's Hospital, Ear, Nose and Throat (ENT) Department, Budapest, Hungary. Caregivers of a convenience sample of 412 children attending the ENT outpatient clinic were surveyed via a 22-item questionnaire regarding demographics, socioeconomics, and smoking behaviours of the child's family; as well as care-givers' self report of the number of AOM episodes of the child.

RESULTS

Of the 412 participants, 155 (38%) children's parents smoked. In bivariate analysis, two or more episodes of AOM correlated with reported hearing problems, day care enrolment, parental employment and increased age of the child. In multivariate logistic regression, parental smoking more than doubled a child's risk for recurrent AOM while increased maternal employment (e.g. part-time or full-time versus unemployed) boosted risk up to fourfold. Among children whose parents smoked, half-packs of cigarettes smoked per day and day care attendance doubled or nearly tripled, respectively, the risk of recurrent AOM episodes.

CONCLUSIONS

Childhood exposure to ETS is high among an ENT clinic population of Hungarian children. Such exposure correlates with AOM episodes, ENT operations and conductive hearing loss. Data such as these argue for strict laws smoke-free laws not only in Hungary, but also in Europe and around the world.

Second-hand smoke exposure and mitigation strategies among home visitation workers

OBJECTIVES

Protection of workers from second-hand smoke (SHS) in occupational settings is an important policy priority, yet little attention has been given to SHS protection for home visitation health workers, who number almost 2 million in the USA. Self-reported SHS exposure, SHS mitigation strategies and suggestions for further SHS exposure reduction approaches were obtained from home visitation health workers in Massachusetts.

METHODS

A cross-sectional survey was conducted among Massachusetts Early Intervention workers (N=316) at their state-wide conference in April 2010.

RESULTS

Eighty-three per cent of respondents reported at least 1 hour per month of SHS exposure, and 16% reported at least 11 hours per month. Nevertheless, only 22% of workers counselled clients on maintaining a smoke-free home. Fewer than 30% of workers had ever voiced concerns to their employing agency, and just 12% had raised their concerns directly with clients. Only 14% stated that their agency had rules designed to protect workers from SHS.

CONCLUSIONS

SHS exposure occurs frequently among home visitation health workers. The data point to a substantial population who are not protected from SHS exposure by formal policies.

Economic value of home-based, multi-trigger, multicomponent interventions with an environmental focus for reducing asthma morbidity a community guide systematic review

CONTEXT

A recent systematic review of home-based, multi-trigger, multicomponent interventions with an environmental focus showed their effectiveness in reducing asthma morbidity among children and adolescents. These interventions included home visits by trained personnel to assess the level of and reduce adverse effects of indoor environmental pollutants, and educate households with an asthma client to reduce exposure to asthma triggers. The purpose of the present review is to identify economic values of these interventions and present ranges for the main economic outcomes (e.g., program costs, benefit-cost ratios, and incremental cost-effectiveness ratios).

EVIDENCE ACQUISITION

Using methods previously developed for Guide to Community Preventive Services economic reviews, a systematic review was conducted to evaluate the economic efficiency of home-based, multi-trigger, multicomponent interventions with an environmental focus to improve asthma-related morbidity outcomes. A total of 1551 studies were identified in the search period (1950 to June 2008), and 13 studies were included in this review. Program costs are reported for all included studies; cost-benefit results for three; and cost-effectiveness results for another three. Information on program cost was provided with varying degrees of completeness: six of the studies did not provide a list of components included in their program cost description (limited cost information), three studies provided a list of program cost components but not a cost per component (partial cost information), and four studies provided both a list of program cost components and costs per component (satisfactory cost information).

EVIDENCE SYNTHESIS

Program costs per participant per year ranged from $231-$14,858 (in 2007 U.S.$). The major factors affecting program cost, in addition to completeness, were the level of intensity of environmental remediation (minor, moderate, or major), type of educational component (environmental education or self-management), the professional status of the home visitor, and the frequency of visits by the home visitor. Benefit-cost ratios ranged from 5.3-14.0, implying that for every dollar spent on the intervention, the monetary value of the resulting benefits, such as averted medical costs or averted productivity losses, was $5.30-$14.00 (in 2007 U.S.$). The range in incremental cost-effectiveness ratios was $12-$57 (in 2007 U.S.$) per asthma symptom-free day, which means that these interventions achieved each additional symptom-free day for net costs varying from $12-$57.

CONCLUSIONS

The benefits from home-based, multi-trigger, multicomponent interventions with an environmental focus can match or even exceed their program costs. Based on cost-benefit and cost-effectiveness studies, the results of this review show that these programs provide a good value for dollars spent on the interventions.

Passive smoking in babies: the BIBE study (Brief Intervention in babies. Effectiveness)

BACKGROUND

There is evidence that exposure to passive smoking in general, and in babies in particular, is an important cause of morbimortality. Passive smoking is related to an increased risk of pediatric diseases such as sudden death syndrome, acute respiratory diseases, worsening of asthma, acute-chronic middle ear disease and slowing of lung growth.The objective of this article is to describe the BIBE study protocol. The BIBE study aims to determine the effectiveness of a brief intervention within the context of Primary Care, directed to mothers and fathers that smoke, in order to reduce the exposure of babies to passive smoking (ETS).

METHODS/DESIGN

Cluster randomized field trial (control and intervention group), multicentric and open.

SUBJECT

Fathers and/or mothers who are smokers and their babies (under 18 months) that attend pediatric services in Primary Care in Catalonia.The measurements will be taken at three points in time, in each of the fathers and/or mothers who respond to a questionnaire regarding their baby's clinical background and characteristics of the baby's exposure, together with variables related to the parents' tobacco consumption. A hair sample of the baby will be taken at the beginning of the study and at six months after the initial visit (biological determination of nicotine). The intervention group will apply a brief intervention in passive smoking after specific training and the control group will apply the habitual care.

DISCUSSION

Exposure to ETS is an avoidable factor related to infant morbimortality. Interventions to reduce exposure to ETS in babies are potentially beneficial for their health.The BIBE study evaluates an intervention to reduce exposure to ETS that takes advantage of pediatric visits. Interventions in the form of advice, conducted by pediatric professionals, are an excellent opportunity for prevention and protection of infants against the harmful effects of ETS.

TRIAL REGISTRATION

Clinical Trials.gov Identifier: NCT00788996.